147426 tn?1317265632

General PrincipleS in Treating Neuropathic Pain

I just received this from Paindoc38.  These are really important principles and we see them broken every day.  Everyone who takes a medication for nerve pain should read this over and over.  I learned a bunch from this!


General tenants:

I.  Don't be in a hurry to get out of pain!

The medications that most successfully reduce neuropathic pain in terms of reducing pain severity, the quality of pain relief and durability of relief ALL take time to work.  An expectation that they will work like commonly used pain relievers (opioid medications: such as vicodin, codeine, etc) will result in PROFOUND DISAPPOINTMENT and more importantly may cause you to prematurely put aside one of the few medications that can produce long-term profound pain relief.  In other words an expectation that they will work like other common pain relieving meds will "burn" (cause you to reject) a drug that might--if used differently with different expectations—have been very successful.  This is for several reasons:

1)   Unlike the opioid medications where you take a little and they help a little; take more and they help more, many of these "anti-neuropathic" medications appear to exhibit a threshold effect in any given individual.  In other words a patient might feel no relief at 25 mg, or 50 mg, and then at 75 mg suddenly start to feel relief and then at 150mg feel profound relief.  So your initial experience of the drug may not reflect your subsequent experience.  You might then ask why not just start the higher dose?

2.  When started at "effective" doses these drugs usually create side effects that can be largely avoided by slowly titrating up from a much lower dose and allowing your body to accommodate to the effects of the medication.  In other words drug X may make you very nauseated if started at 60 mg a day, but if started at 20 mg a day, and then each week increasing the dose by 20mg until you get to 60 mg then nausea is very rare.  So it is better to start at a low dose and work your way up.  It is generally very difficult to talk someone into re-trying a drug they are convinced makes them puke (or be dopey etc.) because of their experience from previously taking it at too high an initial dose.

3.  There is some evidence that even though these drugs may exert some effect immediately at any given dose, the degree of pain relief may really build substantially over the first few weeks of treatment.  No-one has a real good explanation for this, but we wave our hands and talk about things like "central sensitization".

4.  Unlike penicillin where you can just pick the right dose—with all of these anti-neuropathic medications doses have to be significantly tailored to the individual. I don't know what dose may be too much for one person and not enough for another.  Essentially you have to test a given dose in a given person and then slowly change the dose to see at any given dose the degree of side effects and the degree of pain relief.

So the mantra is START LOW and GO SLOW!!!

START LOW  (start at a dose that you are really confident won't create side effects—usually a dose too low to be effective)

GO SLOW! ( increase the dose by small increments every few days or each week so that you plan to reach your target dose in a month to two months)

But GO! ( when you start one of these medications don't just pick a low dose and leave it there or decide that it doesn't work just because it isn't having an effect at that low dose) these medications should generally be slowly titrated up until either:

      a)  You are getting significant pain relief or you are reaching a dose defined by the medical literature to include some risk of sudden significant hazard (e.g. an arrhythmia that might occur without you feeling this adverse effect coming on slowly)


      b)  You start reaching dose-limiting side effects (e.g. the medication is making you feel too sleepy or too nauseated).

II.   Only Change One Thing at a Time.

People in pain want to get out of pain right now and for that reason are tempted to try multiple things at the same time.   When you run into side effects you don't know which intervention is causing the side effect, and if it works you don't know what works.  Slowly learning what works and what doesn't; and why things don't work (e.g. lack of efficacy versus overwhelming side effects) is important to eventually achieving success.

III.  Nothing Ventured, Nothing Gained.

It is okay to not like taking medications, but with chronic pain if you don't change something –a medication or something else—then nothing will change. .  And if you are in you have to be committed.  Taking these meds one day and skipping them the next because of frustration etc. will generally make you feel really bad.  So decide to give them a real 6 week trial, or decide that you are not ready—but don't do the half-measures thing.  They don't work when used this way and you wind up mis-educating yourself that these medications don't work when in reality they are not working because of the way you are using them.


9 Responses
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231441 tn?1333892766
This is excellent!  Needs to go with the general information files.

Helpful - 0
335728 tn?1331414412
This is an incredibly valuable piece of information and it should be made available to all!  Are you considering it for the Health Pages Quix?

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147426 tn?1317265632
Absolutely.  I was just making sure that everyone saw it first.  It is going under the TREATMENTS section.
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572651 tn?1530999357
Thanks for posting this - from personal experience with my heart meds for angina I know it has taken time (7-8 months)  to find the right combination and strength to effectively eliminate my chest pains.  It has tested my patience at times, but the idea that I couldn't  just dump drugs into my system without problems was pretty clear.  Thanks for sharing this. - Laura
Helpful - 0
428506 tn?1296557399
I was on neurontin earlier this year and am now on lyrica.

Just wanted to testify that my experiences are in agreement with the above.  I always started at a lost dose and worked up.  Though I got some relief in a few days, it does take longer to get the full effect.

I know at first I had a lot of Q's about the different ways to treat "normal" vs. neurogenic pain, this entry is wonderful in summarizing what to expect.

Thanks Quix & Paindoc38 !

Helpful - 0
198419 tn?1360242356
Thank you Quix, for reaching out to Paindoc!

Thank you Paindoc for providing us with this useful and important information!

Helpful - 0
195469 tn?1388322888
I am taking this to my prescribing doctor on my next appt. in a week.  She has been prescribing less and less pain medication per HOUR.  She has taken me from every 4 hours to ever 6 hours.  For whatever reason.  I have had huge re-bound pain.  This is NOT acceptable.  More pain is NOT an option.

Thanks so much for this article and thank you Paindoc.


Helpful - 0
428506 tn?1296557399
I wanted to share a story that I think is relevant to this thread.

This spring, I started having ear pain on both sides.  I was checked over and over for ear infections (to which I am prone), but was always clear.  I also had painful (burning/aching) paresthesias in my arms and legs that had started before the unexpained ear pain.  I tried OTC pain killers, but they did not touch these discomforts.  

I finally got an Rx for neurontin.  Almost immediately, I started sleeping better.  Then, a lot of my paresthesias were improved, and the ear pain was greatly reduced.

A few weeks later, I was feeling overall very good, my paresthesias were being well-controlled by the neurontin.  But then my R ear started to hurt again, very much so!  At first, I thought it was the same "unexplained" ear pain, just somehow still hurting through the medication.

But it was the ONLY pain I was feeling anywhere, and was only in one ear.  So I did go back to have it checked, and this time, it WAS infected.  I got anti-bacterial steroid ear drops, and then the pain quickly subsided.

So for me, this case really demonstrated how neuropathic pain and "regular" pain do NOT respond the same to medications.  I know this is a question that has come up on the forum before, so I thought I'd place it here.
Helpful - 0
334876 tn?1229979296
I had just seen my new neruo that had just moved here in town and I got too say that she asked me more Q about ms them my other one did that I know of in Anch and she is all ready ordering more mri's of my head with contrast on the 3.0 and was giving neuropathic pain killers but I'm still not to sure to take more meds as I seem to be on so many as it is, that I really just deal with the pain but now I'm not so sure and may be I will give it a try, but I really hate trying out new meds

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