Medically Speaking - Living with neuropathic pain
Neuropathic pain, is commonly known as phantom pain, root pain or “spook pyn”. It is commonly seen in patients that have suffered a spinal cord injury, diabeties, undergone an amputation and now a growing number of patients with HIV/AIDS suffer from significant neuropathic pain as well. When one speaks about pain, the clinician must distinguish between neuropathic pain and nociceptive pain as the treatment of the two differs considerably.
In this issue we will deal mainly with neuropathic pain. In neuropathic pain, the painful symptoms include both spontaneous pain, occurring with no apparent stimulation which can be continuous and intermittent, and evoked pain. Neuropathic pain is defined as pain that arises as a “direct consequence of a lesion or disease affecting the somatosensory system”. Neuropathic pain differs from nociceptive pain with respect to causes, mechanisms, symptomatology and different therapeutic approaches required for successful management.
Terms commonly used to describe painful and unpleasant sensations in people with neuropathic pain include burning, shooting, and electric shock-like pain. A number of altered, but not unpleasant, sensations are also described. These include tingling, the sensation of ants crawling over the skin, and pins and needles. Neuropathic pain can be evoked by normal, usually non-painful stimuli. For example, a light breeze blowing over the skin, skin contact with clothing and temperature change. However, normal painful stimulus (e.g. pinprick) can evoke a heightened pain sensation as well. These symptoms are quite different to those described as aching, throbbing etc. in patients with normal pain (Nociceptive pain).
The burden of neuropathic pain for the patient is substantial. Neuropathic pain is associated with psychological distress, physical disability and reduced overall quality of life. The problem is further compounded by the fact that globally, and often in South Africa, neuropathic pain is often underdiagnosed and inappropriately treated. This exacerbates the weight of this already debilitating condition. There appears to be a lack of education and awareness among physicians, including specialists, leading to sub-optimal identification, assessment and management of Neuropathic pain. Unfortunatly, referrals to pain specialists often come too late. Even in specialist centres a multidisciplinary approach is not always taken.
In the first instance it is important to make the right diagnosis and here an informed clinician should carefully find out what the symptoms felt by the patient are. Once neuropathic pain is suspected, treatment should commence on appropriate medications which are specific to the treatment of this type of pain. Classically, neuropathic pain will not respond to medications prescribed for nociceptive pain management. It is important too, to realise and accept that although neuropathic pain can be treated, it is unlikely that the pain will be completely removed. However studies indicate that the intensity of the pain can be reduced by up to 35 to 40%. The treatment of neuropathic pain involves the step wise use of a number of drug options that need to be carefully monitored by the clinician. There needs to be 100% commitment on the patient’s behalf. Treatment may be required on a chronic basis.
In most patients treatment on the appropriate drugs will provide a measure of relief where the patient is satisfied with the reduction in pain. However, unfortunately, even with optimal drug management, a certain percentage of patients will continue to suffer severe and ongoing homeopathic pain. These patients require specialist referral to pain clinics where various surgical options can be explored.