Awaywithpain.co.uk

Understanding NICE guidance
Information for people who use NHS services
Drug treatments for
neuropathic pain
This booklet is about the care and treatment of people with neuropathicpain in the NHS in England and Wales. It explains guidance (advice) from NICE (the National Institute for Health and Clinical Excellence). It is written for people with neuropathic pain but it may also be useful for their families or carers or for anyone with an interest in the condition.
This booklet gives details about the drugs (medication) that may be offered to people to help them manage their neuropathic pain. It describes the care that people can expect from their GP or as part of general hospital care. Pain clinics or other specialist clinics may offer other treatments thatare not described here.
The booklet is to help you understand the care and treatment options thatshould be available in the NHS. It does not describe neuropathic pain orthe tests or treatments for it in detail. Your doctor should discuss thesewith you. There are examples of questions you could ask throughout thisbooklet to help you with this. You can get more information from theorganisation listed on page 11.
Information about NICE clinical guideline 96
Issue date: March 2010
Choosing medication to help with neuropathic pain The advice in the NICE guideline covers:
It does not specifically look at:
• adults with neuropathic pain who are being treated in pain clinics • other (non-drug) treatments for neuropathic pain.
Information about NICE clinical guideline 96
Your careIn the NHS, patients and healthcare professionals have rightsand responsibilities as set out in the NHS Constitution(www.dh.gov.uk/en/Healthcare/NHSConstitution/index.htm). All NICEguidance is written to reflect these. You have the right to be involved indiscussions and make informed decisions about your treatment and carewith your healthcare team. Your choices are important and healthcareprofessionals should support these wherever possible. You should betreated with dignity and respect.
To help you make decisions, healthcare professionals should explainneuropathic pain and the possible treatments for it. They should coverpossible benefits and risks related to your personal circumstances. Youshould be given relevant information that is suitable for you and reflectsany religious, ethnic, or cultural needs you have. It should also take intoaccount whether you have any physical or learning disability, sight orhearing problem or language difficulties. You should have access to aninterpreter or advocate (someone who helps you put your views across)if needed.
Your family and carers should be given their own information and support.
If you agree, they should also have the chance to be involved in decisionsabout your care.
You should be able to discuss or review your care as your treatmentprogresses, or your circumstances change. This may include changingyour mind about your treatment or care. If you have made an ’advancedirective’ (have already given instructions) about any treatments that youdo not wish to have, your healthcare professionals have a legal obligationto take this into account.
All treatment and care should be given with your informed consent.
If, during the course of your illness, you are not able to make decisionsabout your care, your healthcare professionals have a duty to talk to yourfamily or carers unless you have specifically asked them not to. Healthcareprofessionals should follow the Department of Health’s advice on consent(www.dh.gov.uk/consent) and the code of practice for the Mental CapacityAct. Information about the Act and consent issues is available fromwww.publicguardian.gov.uk. In Wales healthcare professionals shouldfollow advice on consent from the Welsh Assembly Government(www.wales.nhs.uk/consent).
Information about NICE clinical guideline 96
Neuropathic painNeuropathic pain is a type of pain that is caused by damage or changesto nerves which mean that they don’t work properly. This is different frompain caused by damaged or inflamed tissue that gets better after a processof healing. Neuropathic pain can be present at the same time as paincaused by damaged tissues.
People with neuropathic pain sometimes describe the pain using wordslike shooting, stabbing, an electric shock, burning, tingling, tight, numb,prickling, itching or a sensation of pins and needles. The pain can comeand go, or be there all the time.
Neuropathic pain is associated with a number of conditions. Examplesinclude diabetic neuropathy (which is caused by damaged nerves in somepeople with diabetes), post-herpetic neuralgia (pain that some peoplehave after recovering from shingles) and trigeminal neuralgia (whichaffects the face). A common cause of neuropathic pain is a trappednerve, for example in the back or neck. Neuropathic pain can also occurafter a stroke, after amputation of an arm or a leg, and in people withcancer, multiple sclerosis and some other conditions.
Painkillers such as paracetamol, anti-inflammatory drugs (like aspirin andibuprofen) and codeine may not be effective in easing neuropathic pain,but other drugs are available that can help a person to manage their pain.
Questions you might like to ask your healthcare
team
• Please tell me more about neuropathic pain.
• Are there any support organisations for people with • Can you provide any information for my family/carers? Information about NICE clinical guideline 96
Choosing medication to help with neuropathic painWhen you talk with your doctor (or other healthcare professional) about medication to help with your neuropathic pain, they should tell you about the benefits and possible side effects of the different drugs, and explain why a particular drug is being offered. They should advise you about ways of managing both the pain and any side effects of treatment.
They should also explain that other (non-drug) treatments are available Your doctor should ask you about your preferences, and about anything else that might influence the choice of medication. This could include your day-to-day work and leisure activities, any physical or mental health problems you may have, and any other medication you are taking.
If you are already having treatment for neuropathic pain and this is helping you, you should be able to continue with that treatment.
If your neuropathic pain is severe or is having a significant effect on your daily life, or the health problem that has caused your pain has got worse, your doctor may offer you an appointment at a pain clinic and/or another specialist clinic. Healthcare teams in pain clinics have a lot of experience inhelping people to manage this sort of pain.
Information about NICE clinical guideline 96
First treatmentsTo begin with, your doctor should usually offer you a drug calledamitriptyline or one called pregabalin. Both of these drugs are takenorally (as tablets or syrup).
But if you have painful diabetic neuropathy, you should usually be offereda drug called duloxetine rather than amitriptyline or pregabalin. If youcan’t take duloxetine for medical reasons (for example, if you have liverdisease or severe kidney disease, or you are taking certain other drugs),you should be offered amitriptyline instead.
Whichever drug you take, you should usually be started on a low dose,which is then increased gradually over time. This means that it might besome weeks before you get the full benefit. The dose should be increaseduntil there isn’t any further improvement. Some people find that thedose can’t be increased any more because they get unpleasant side effectsthat don’t get any better. Your doctor should explain the reasons for thegradual increase in dose, and give you written information aboutdoses if possible.
Is the treatment working?
Soon after you start treatment with a new drug, your doctor should
check whether it is suitable for you. They should ask you whether you are
having any side effects. They may consider offering you a different dose,
or changing the treatment.
You should see your doctor regularly for as long as you are takingmedication for neuropathic pain. At each visit your doctor should askyou whether, and by how much, your pain has improved. They shouldalso talk with you about your mood, whether you are sleeping well andhow you are feeling generally. This includes whether you have been ableto get back to something like your normal life and start doing thingsagain that you had to stop because of the pain (such as jobs around thehouse, work, driving and social activities). You should also talk about anyproblems you have had, such as side effects of the medication. Yourdoctor may suggest that you keep a diary to remind you about howyou have felt.
Information about NICE clinical guideline 96
If you are taking amitriptyline and it is helping with the pain but theside effects are a problem, your doctor may offer you nortriptyline orimipramine tablets instead. These drugs work in a similar way toamitriptyline but have different side effects that may be less of a problemfor some people.
If the drug you are taking is helping you, and side effects aren’t asignificant problem, you should continue with the treatment. After awhile your doctor might suggest a trial to see whether you can managewith a lower dose, because this can help with any side effects. The dosewill be reduced gradually to make it less likely that you will be affectedby symptoms that can occur when a drug is stopped suddenly (theseare sometimes called ‘discontinuation’ or ‘withdrawal’ symptoms).
Sometimes neuropathic pain can improve enough for drug treatmentto be stopped altogether.
Amitriptyline, duloxetine, imipramine and nortriptyline can be usedto treat depression (they are sometimes called antidepressants).
Pregabalin is an anti-epileptic (anticonvulsant) drug that is sometimesused to treat epilepsy. These drugs can also help people withneuropathic pain (or other types of pain) to manage their pain. Thiseffect is separate from their action in treating depression or epilepsy.
Information about NICE clinical guideline 96
Questions about medication
• What are the possible benefits and risks of taking this
• What sort of improvements might I expect in my symptoms • When should I start to feel better, and what should I do if I • What are the possible side effects, and what should I do if I get • Why are you offering me an antidepressant (or an anti-epileptic • Why is the dose being increased (or decreased)? • How long will I need to take the medication for? • Might I have problems when I stop taking the medication? Information about NICE clinical guideline 96
What if my pain doesn’t improve?You may find that your neuropathic pain is still causing you problems even though the dose of the first drug has been increased as much as it can be. Your doctor may offer you a different drug after discussing the options with you. They should also talk with you about whether to carryon taking the first drug if you start taking a new one. They may suggest that you take the new drug as well as the first one to begin with, and then gradually reduce the amount of the first drug. This can help to control your pain when you are changing treatments.
If you want to try a different drug your doctor may offer you the following: • If you have been taking amitriptyline, nortriptyline or imipramine, you • If you have been taking pregabalin, you should be offered amitriptyline.
(If amitriptyline helps you but side effects are a problem, nortriptylineand imipramine are possible alternatives – see page 7.) • If you have been taking duloxetine and are going to stop taking it, you should be offered either amitriptyline or pregabalin instead.
• If you are going to carry on with duloxetine and start taking a second drug as well, this should be pregabalin.
If at any stage your pain has got worse despite treatment, your doctor mayoffer you an appointment at a pain clinic and/or another specialist clinic.
Information about NICE clinical guideline 96
Some people find that their pain still causes them significant problems even after trying the treatments described in this booklet. If this happensto you, you should be offered an appointment at a pain clinic and/or While you are waiting for your appointment, you may be offered a drug called tramadol (a type of opioid – see the box below) instead of, or as well as, the other medication you are taking.
If you are unable to take oral medication (tablets or syrup) for medical reasons or because you have a disability, your doctor may offer you a treatment called lidocaine. Lidocaine is a local anaesthetic, which is applied to the skin on a patch (like a plaster) and works on the area You should not be offered other opioids (such as morphine or oxycodone) for your neuropathic pain unless you have been assessed in a specialistclinic. But drug treatments that have been started by doctors in aspecialist clinic can continue to be prescribed by your GP. You should havea written ‘care plan’ that gives details of the treatments you are havingand who is providing them. Your GP should keep a careful eye on anyside effects.
Tramadol, morphine and oxycodone are drugs called opioids. Opioidsare commonly used to treat pain, and vary in strength. As with manydrugs, people may experience side effects when taking opioids. Also,some people who need to take opioids for a long time are seen by aspecialist because these drugs can be habit-forming. You shouldtalk to your doctor about any concerns you might have. But somepeople find that opioids suit them and help to make their painmore manageable.
Information about NICE clinical guideline 96
More informationThe organisation below can provide more information and support forpeople with neuropathic pain. NICE is not responsible for the quality oraccuracy of any information or advice provided by this organisation.
• Pain Concern, helpline: 0844 499 4676 NHS Choices (www.nhs.uk) may be a good place to find out more. Yourlocal patient advice and liaison service (usually known as ‘PALS‘) may beable to give you more information and support. You should also contactPALS if you are unhappy with the treatment you are offered, but youshould talk about your care with a member of your healthcare team first.
If your local PALS is not able to help you, they should refer you to yourlocal independent complaints advocacy service. If you live in Wales youshould speak to NHS Direct Wales for information on who to contact.
Information about NICE clinical guideline 96
About NICENICE produces guidance (advice) for the NHS about preventing, diagnosing and treatingmedical conditions. The guidance is written by independent experts including healthcareprofessionals and people representing patients and carers. They consider the evidence onthe condition and treatments, the views of patients and carers and the experiences of doctors,nurses and other healthcare professionals. Staff working in the NHS are expected to followthis guidance.
To find out more about NICE, its work and how it reaches decisions, seewww.nice.org.uk/aboutguidance This booklet and other versions of the guideline aimed at healthcare professionals are availableat www.nice.org.uk/guidance/CG96 You can order printed copies of this booklet from NICE publications (phone 0845 003 7783 oremail publications@nice.org.uk and quote reference N2116). The NICE website has a screenreader service called Browsealoud, which allows you to listen to our guidance. Click on theBrowsealoud logo on the NICE website to use this service. We encourage NHS and voluntary organisations to use text from this booklet in their owninformation about neuropathic pain. National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn, London, WC1V 6NA; www.nice.org.uk
ISBN 978-1-84936-190-3N2116 10k 1P Mar 10 National Institute for Health and Clinical Excellence, 2010. All rights reserved. This material may befreely reproduced for educational and not-for-profit purposes. No reproduction by or for commercialorganisations, or for commercial purposes, is allowed without the express written permission of NICE.

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