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Hello, my name is Jennifer Grimmer. I am a nurse practitioner in the chronic pain clinic at Roswell Park Cancer Institute in Buffalo, New York. Today I will be speaking about neuropathic pain and cancer patients in the use of multi-model therapy to increase success.
Neuropathic pain is pain arising as a direct consequence of a lesion or disease, affecting the somatosensory nervous system. It is described as spontaneous, ongoing, or shooting pain and evoked amplified pain responses after noxious or non-noxious stimuli. The task force on cancer pain of the International Association for the Study of Pain estimates the prevalence of neuropathic pain in 24 countries to be 40% amongst severe cancer pain cases. The challenge with neuropathic pain is in proper identification of the neuropathic pain, and initiating targeted analgesic therapies.
There are several barriers to good neuropathic pain control. Reasons often include: inadequate pain assessment, inattention to underlying pain ideology, and possibly insufficient knowledge of effective drugs and clinical practice. Over the past several years, much of the research has focused on diabetic neuropathy and postherpetic neuralgia management. However, as of recent, more sound clinical trials have been done focusing on the use of adjuvant medications or other neuropathic pain syndromes.
In general, the NCCN guidelines state that cancer pain requires treatment with opioids. However, with neuropathic pain, every case should consider the use of adjuvant analgesic agents to appropriately target the neuropathic pain. In managing difficult pain management cases, always consider the patient you are treating. Consider the extent of their disease, pain diagnosis, behavioral and substance abuse history, and psychosocial concerns.
While guidelines state that opioids may be used for cancer-related neuropathic pain, we should be thinking about using adjuvants up-front. You could consider a trial of antidepressants such as the tricyclic antidepressants or the serotonin or epinephrine reuptake inhibitors, and/or a trial of anticonvulsant therapy which would include gabapentin and pregabalin.
You could also consider topical agents such as lidocaine, capsulation, or compound cream. And then you would consider a pain specialist referral for refractory pain. The NCCN recommends antidepressants and anticonvulsants as first-line analgesic agents for cancer-related neuropathic pain. Again, to appropriately use these agents, it is important to be thorough in your assessment of the patient's pain to determine the ideology. Titrate the medications until analgesic effect is achieved. Adverse effects become unmanageable or the maximum dose is reached.
This is the conclusion of my presentation, thank you.