Drugs to Treat Neuropathic (Nerve) Pain
Many types of pain can occur in the body. Each type of pain is treated differently. Pain can range from uncomfortable to intolerable. It seems the most complicated of all is nerve pain. Nerve pain, medically called neuropathic pain, occurs when messages are not transmitted correctly in the body. The pain includes miscommunication of the nerves of the central nervous system, which includes the brain and spinal cord, although the result is felt in the body. Peripheral neuropathy is a neuropathic pain that arises in the nerves of the body or those outside of the central nervous system. Other, specific types of nerve pain include trigeminal neuralgia or nerve pain on one side of the face. Shingles (herpes zoster) is a nerve pain that follows the course of one of the spinal nerves that branch around the body.
Neuropathic pain can arise from nerve damage, compression, pinching, or nerves that are separated within the nerve body or separated from their connecting nerves. It can result from trauma or disease. Neuropathic pain is associated with brain injury, spinal cord injury, diabetes, alcoholism, multiple sclerosis, amputation, viruses such as shingles, infection, cancer, or vessel malformation, among many others, especially neurological diseases.
Some medications can affect nerves. Just because you take these medications does not mean you will develop neuropathy, but there is an association or increased risk. The medications include those taken for heart conditions (Amiodarone, Hydralazine, Perhexiline), some chemotherapy medications, drugs used to fight infection (Chloroquine, Dapsone, Isoniazid (INH), Metronidazole (Flagyl), Nitrofurantoin, Thalidomide), drugs for autoimmune disorders (Etanercept (Enbrel), Infliximab (Remicade), Leflunomide (Arava), seizure medications (Carbamazepine, Phenytoin, Phenobarbital), Disulfiram which is used to treat alcoholism, and drugs for HIV/AIDS (Didanosine (Videx), Emtricitabine (Emtriva), Stavudine (Zerit), Tenofovir and emtricitabine (Truvada), Colchicine for gout treatment, arsenic, and gold. Do not panic if you take any of these medications but speak with your healthcare professional about the signs of neuropathy so you can monitor your condition.
Neuropathic pain is a unique experience for each individual. There are similarities in cases, but two cases are rarely the same. This type of pain can range in intensity from a minor inconvenience to excruciating. The pain may be just in one body location, such as a toe or a location somewhere on the thigh or arm. However, it can be anywhere on the body. Neuropathic pain can include an entire body part, such as an entire leg, arm, and/ or torso. It can also be inside the body, such as a damaged spleen. Individuals will describe the pain as numbness, tingling, electrical shocks, cramps, weakness, prickling, sharp, jabbing, burning, throbbing, buzzing, humming, itching, and other terms. Sometimes the skin is sensitive to touch, the weight of clothes and bed linen, or even a breeze such as a furnace or air conditioning turning on can set off neuropathy.
Activities can be affected by neuropathic pain to the point where an individual does not move the affected body part to avoid triggering the pain. Internal body functions can also be upset in the form of abdominal cramps, impaired balance, and weakness.
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Reducing neuropathic pain includes treatment of metabolic issues, such as maintenance of blood sugar in diabetes care, and stopping alcohol or drug use, including nicotine, and other toxic chemicals, such as vaping. Medications may be changed to reduce or improve neuropathy. Eating a healthy, well-balanced diet and hydrating as your medical issues allow is important. Gentle exercise may be of benefit, and strenuous exercise is not helpful as overstimulation can trigger neuropathic pain.
There are medications that have been created specifically to treat neuropathic pain. These include gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica). Both medications are started at a low dose and increased over time to effectiveness. After an unpredictable amount of time on a stable dose, both will most likely need to be increased as the body becomes used to them. About one-fourth of individuals who begin these medications will have side effects for 8-9 days of blurred vision, dizziness, and difficulty swallowing. Once the 8-9 days are complete, these side effects resolve. Taking these medications before bed can reduce noticing some of the side effects.
Gabapentin and pregabalin are not interchangeable. If you decide you would like to change between the two, you must completely taper off the one you are on and, when completely off, titrate onto the other. It is critical not to stop suddenly, or cold turkey as suddenly stopping these medications can create significantly increased pain as well as difficulty in the effectiveness of the next medication.
Both gabapentin and pregabalin treat neuropathic pain and seizures. Gabapentin also is used to treat shingles, restless leg syndrome, and diabetic neuropathy. Pregabalin is also used to treat fibromyalgia and anxiety. Both reduce the way messages of pain are sent to the brain, which reduces the perception of pain.
Prior to taking these medications, tell your healthcare professional all the other medications you take including over-the-counter and supplements. Gabapentin and pregabalin can react with many medications, over-enhance the effectiveness of medications, and some medications can counter effect these nerve pain medications. You may need to alter some of your regular medications to different times, for instance, magnesium affects the function of gabapentin and pregabalin, so it may need to be omitted or taken two hours before these medications. Your healthcare provider will help you manage your medications, but they need to know everything you take.
There are other drugs that help nerve pain. Other anti-epileptic (anti-seizure) medications can be used to treat nerve pain, for example, carbamazepine (Carbatrol, Tegretol). Antidepressants also help treat nerve pain, such as amitriptyline and duloxetine and others. Both anti-epileptic and antidepressants are given in lower doses for nerve pain treatment. These lower doses may not be effective treatments for seizures and depression. It is interesting to note that individuals who already take the medication in doses needed for seizures and depression treatment have less nerve pain.
Treatments applied directly to the skin over the area of nerve pain can be helpful. These include capsaicin cream (a product made from chili peppers that numbs the area) and lidocaine (anesthetic) patches. In mild cases of nerve pain, this may be the chosen treatment to reduce the pain in a particular area. Transcutaneous electrical nerve stimulation (TENS) is a low-level electrical stimulation delivered through a patch on the skin that breaks the pain message. As the intensity is low, individuals with sensation can use this treatment for nerve pain. Percutaneous electrical nerve stimulation (PENS) is a low-level electrical stimulation but with more intensity as it includes a needle in the area of the nerve pain.
Other therapies include acupressure and acupuncture to treat the pain. These also help to break up the stimulus of pain. Nerve blocks, the injection of an anesthetic into the painful nerve source of pain, will stop pain for a short period of time. This lasts for hours or, in some procedures, days. A pain pump consists of a small tube under the skin to deliver anesthetic for several days. Nerve blocks also block function by the nerve. Therefore, when a nerve block is done, you may see less function in that body part until the nerve block wears off.
As nerve pain can disrupt your daily life, some individuals will use biofeedback to learn to relax their muscles. Others will use distraction and relaxation techniques to help control their pain. You can use these approaches along with other treatments.
Often opioids are prescribed for nerve pain, but these do not treat the issue of nerve pain. They make you tired and sleepy, so you do not feel the pain as intently, but you are also unable to perform other activities. Opioids are not recommended for the treatment of nerve pain. There is extensive research concerning their addictive properties. Many reading this blog are taking these medications. Do not stop them without speaking to your healthcare professional to avoid sudden withdrawal and that ability to effectively treat your pain with other medications as mentioned previously. Individuals often ignore this advice and decide to go cold turkey. I have yet to meet a person who did not severely regret this decision. It is not a matter of willpower. It is how the drug changes your body’s functions. Slow tapering off the medication as prescribed by your healthcare professional is necessary.
Nerve pain is unusual in that, over time, it can resolve. Sometimes when people taper off a drug, they find their nerve pain is gone. Then they do not need to start a new medication. There is no predicting if or when this will happen, but it is comforting to know that it can. Most likely, the medication has re-educated the nervous system not to recognize the pain. And that is a good day. Nurse Linda
Pediatric Consideration:
Children and teens may not complain of pain as they may not know life without it or may not have the developmental abilities to express their situation. As parents, you know your child best so if you feel your child is having pain, be sure to discuss the issue with their healthcare professional.
Gabapentin and pregabalin are available for children and teens, but their dosage is created individually for them by weight. The same is true for anti-epileptic and antidepressant medications. Children have equal options for comfort. Nurse Linda