gabapentanoid, SNRI, or TCA for every patient with chronic pain?

[oreosandsake]

I have been reading some papers recently supporting the idea that any chronic pain state leads to/or is in part due to sensitization of the cns.

the gabapentanoids decrease the excitatory state in the CNS pain pathways.

NE plays a role in the inhibitory pain pathways, and 5HT probably to a much lesser extent

this is possibly one explanation for why duloxetine has been FDA approved for so many indications... (clinically, not financially)

what are your thoughts on giving these meds to all your patients with chronic pain -- non-neuropathic, non-classical sensitization states (fibromyalgia, etc)

would you give these to your patients with chronic OA, RA, or pelvic pain? should we spike the pain clinic water cooler with TCAs and gabapentin?

any one care to postulate if "pre-emptive" analgesia can prevent windup, development of central sensitization, or prevent acute pain developing into chronic pain? (not shown to help in PLP, but that is quite different...)

I have also read that opioids downregulate VG calcium channels in the dorsal horn. Thus, combination therapy of gabapentin and opioid having synergistic effect for pain. anyone using tapentadol off label for other neuropathic conditions? care to comment on efficacy for DPN, or other neuropathic pain?

please correct me if my science is off... just trying to learn!

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[Ducttape]

part of what is learned in a pain fellowship is: what medications would reasonably work for a particular condition. sounds like you are having a crisis in identity as a pain fellow.

you should be directing these questions towards your professors - i.e. what meds work and are appropriate for each particular condition. with all these questions, sounds like you either havent listened or they havent taught you. or maybe you are now exposed the influence of Big Pharma, and that they try to get everyone on some kind of drugs.

and while we can pontificate about particular meds or conditions, most of us believe that there is a role for specific medications for specific disease processes, not the garbage plate approach.

(ps the only treatment that is given to all my patients is recommendation of exercise and behavioral medicine therapy.)

 

[101N]

(ps the only treatment that is given to all my patients is recommendation of exercise and behavioral medicine therapy.)

Wisdom.

 

[Gauss]

you haven't been burned yet by pharma. We went through the vioxx & bextra mess. Got burned by the abuse deterrent opiates when they got reformulated or even pulled off market. I've seen way too many GI ulcers happen despite preaching they stop all nsaids except mobic or cox2's I prescribe because everyone takes advil thinking it's different.
rational polypharmacy sounds great in textbooks but ain't all that glorious in practice

 

[oreosandsake]

thank you for responding. I am not yet a fellow, and I still have a lot to learn.

I may not have put the argument clearly but I will try to clarify what I am asking.

ex: duloxetine, FDA approved for FM, chronic OA, DPN, "chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain"

some of these may be "neuropathic" but OA and chronic LBP is defnitely not classically so.

the MOA for this drug is thought that it acts centrally, on the inhibitory noradrenergic pain pathways, Thus, acting on the central sensitization. (TCA's, NRI's, and SNRI's work for pain, SSRIs don't)

in fibromyalgia, there is evidence for increased activity of substance P, and glutamate in the CSF --> excitatory NTs, and afferent pain pathways. thus, membrane stabilizers such as pregabalin decrease the activity of VG calcium channels and decrease the excitatory (depolarizing) pain inputs. Again, FDA approved indication.

combination therapy for neuropathic pain including opioids has been reported by many authors (Argoff, Backonja, gilron, and a cochrane review) http://www.ncbi.nlm.nih.gov/pubmed/22786518

tapentadol is FDA approved, first mu receptor agonist (and NRI properties) medication for DPN. I have no experience w/ this medication since none of my attendings use it. I am wondering what the SDN community's experience has been, and have they used this for other pain conditions.

regarding sensitization from other pain states, i believe some of these concepts are only now emerging.
ex: knee OA, central sensitization (CS)

http://www.ncbi.nlm.nih.gov/pubmed/22961435
http://www.ncbi.nlm.nih.gov/pubmed/20418016
http://www.ncbi.nlm.nih.gov/pubmed/15283455
http://www.ncbi.nlm.nih.gov/pubmed/23380268

there is also data supporting CS in pelvic pain, etc

I will ask my attending. I just emailed him, but I think I already know thoughts on this.

so, there are multiple questions.

1) Does the SDN community think that that there is a role for these type of medications for all/most/many patients with chronic pain? (gabapentin/pregabalin, TCAs, snri's, for knee OA, pelvic pain, abdominal pain, etc, etc?)


2) What is your experience with tapentadol. have you used it off label for other neuropathic or sensitization pain conditions?

thanks

 

[oreosandsake]

or maybe you are now exposed the influence of Big Pharma, and that they try to get everyone on some kind of drugs.

and while we can pontificate about particular meds or conditions, most of us believe that there is a role for specific medications for specific disease processes, not the garbage plate approach.

(ps the only treatment that is given to all my patients is recommendation of exercise and behavioral medicine therapy.)

you haven't been burned yet by pharma. We went through the vioxx & bextra mess. Got burned by the abuse deterrent opiates when they got reformulated or even pulled off market. I've seen way too many GI ulcers happen despite preaching they stop all nsaids except mobic or cox2's I prescribe because everyone takes advil thinking it's different.
rational polypharmacy sounds great in textbooks but ain't all that glorious in practice

okay, i think i get what you are trying to say now.

pharma/hypothesis comes up with these theories, but they don't always pan out so well once put into practice?

I guess this is still the question I am asking. what are your thoughts re these theories..

 

[clubdeac]

Sure, there is a place for most of these meds in most pain conditions. In fact, when you get into practice you will realize that you'll have to try a lot of different "tools" in your toolbox before finding the right combo. I will say however, I rarely have a patient return after being placed on cymbalta, lyrica, pamelor or whatever and say "OMG doc, you changed my life!". That is not the case after an ESI, nerve block or RFA. Much more rewarding results....

 

[Ducttape]

"Theories" that have been propogated and promulgated over the past 20 years:

1. There is no ceiling or upper limit to opioid dosing

2. Pseudoaddiction

3. Pseudoaddiction is to be countered with as much medication as necessary to overcome it

4. There is insufficient opioid prescribing in the US

5. Oxycontin is safe, effective, and allows people to get their lives back


thats just a few of the ones that have not panned out over the past 10-15 years

 

[emd123]

"Theories" that have been propogated and promulgated over the past 20 years:

1. There is no ceiling or upper limit to opioid dosing

2. Pseudoaddiction

3. Pseudoaddiction is to be countered with as much medication as necessary to overcome it

4. There is insufficient opioid prescribing in the US

5. Oxycontin is safe, effective, and allows people to get their lives back


thats just a few of the ones that have not panned out over the past 10-15 years

Agree completely, but I think trying adjuvants such as gabapentin, lyrica, cymbalta, savella, TCAs on patients that have failed other treatments is pretty low risk in general, and reasonable off label. A trial of these is way lower risk an opiate trial or high dose opiates. That being said, putting "every chronic pain patient on them" is just not how a Medicine works. There is no treatment that everyone should get. I wish my job was that easy.

 

[Dr. Ice]

part of what is learned in a pain fellowship is: what medications would reasonably work for a particular condition. sounds like you are having a crisis in identity as a pain fellow.

you should be directing these questions towards your professors - i.e. what meds work and are appropriate for each particular condition. with all these questions, sounds like you either havent listened or they havent taught you. or maybe you are now exposed the influence of Big Pharma, and that they try to get everyone on some kind of drugs.

and while we can pontificate about particular meds or conditions, most of us believe that there is a role for specific medications for specific disease processes, not the garbage plate approach.

(ps the only treatment that is given to all my patients is recommendation of exercise and behavioral medicine therapy.)

How many of your patients actually follow through with behavioral medicine therapy?? If a lot, then thats a utopia I would love to join...

 

[Ducttape]

How many of your patients actually follow through with behavioral medicine therapy?? If a lot, then thats a utopia I would love to join...

few do. the motivated ones that, as anticipated, are the ones that seem to do better.


for the others, it provides me with something to discuss each time i see them.

 

[101N]

This has been pretty thoroughly studied, roughly 1/3rd of CNP & somatizing patients will 'accept' CBT.
Turk has written alot about this and using the MPI as a screening device the aceptors are the adaptive copers.

Gatchel uses the MPI to screen patients in his program. IMO MPI scoring should be be mandatory prior to
any comprehensive pain rehabilitation program. Those who fall in the dysfunctional and interpersonally distressed catagories should be offered CBT in those areas PRIOR to involvement in a multidisciplinary program.

 

[Axehandler]

I make cbt a mandatory part of a multimodal treatment plan, patients that refuse to do that don't stay on opiates. I don't let anyone pick and choose what treatments they "want" off the menu if they want to employ opiates in their plan. If they self select for another doctor that expects less of them that is up to them but I don't have any interest in creating "deadenders" and frankly those patients who choose their own plan don't get better. I suspect the reason lots of our patients are where they are is because we continue to give them the idea that once they take the right medicine the problem will be fixed. Meds are way over emphasized on most treatment plans and this leads right into the classical conditioning model Pavlov warned us about.

 

[SeniorWrangler]

Sometimes the patients who need CBT the most are the ones who won't do it.
I think adjuvants are worthwhile as part of a comprehensive treatment plan for many pain patients, just giving somebody a script for Gabapentin and seeing them back in a month has very low yield in my experience. But honestly, it's not so much that adjuvant meds are great, but that chronic opioids are so lousy.

 

[EdPierce]

sometimes these meds really help people, so you just want to have patients try it and see if it works. that is true for all the medicines in chronic pain, just give it a try. usually it does not work, has some side effects, and you go on to the next one until you either find one that works or you have exhausted everything (usually except opiods)

 

[Bsb2015]

I have been reading some papers recently supporting the idea that any chronic pain state leads to/or is in part due to sensitization of the cns.

the gabapentanoids decrease the excitatory state in the CNS pain pathways.

NE plays a role in the inhibitory pain pathways, and 5HT probably to a much lesser extent

this is possibly one explanation for why duloxetine has been FDA approved for so many indications... (clinically, not financially)

what are your thoughts on giving these meds to all your patients with chronic pain -- non-neuropathic, non-classical sensitization states (fibromyalgia, etc)

would you give these to your patients with chronic OA, RA, or pelvic pain? should we spike the pain clinic water cooler with TCAs and gabapentin?

any one care to postulate if "pre-emptive" analgesia can prevent windup, development of central sensitization, or prevent acute pain developing into chronic pain? (not shown to help in PLP, but that is quite different...)

I have also read that opioids downregulate VG calcium channels in the dorsal horn. Thus, combination therapy of gabapentin and opioid having synergistic effect for pain. anyone using tapentadol off label for other neuropathic conditions? care to comment on efficacy for DPN, or other neuropathic pain?

please correct me if my science is off... just trying to learn!

Was looking through posts. Not sure if your question got answered or your experience has changed. A lot of colleagues do -rx gaba/Lyrica/TCA etc for OA- you can have central sensitization with OA.

 

[Orin]

I try to disentangle spontaneous from nociceptive pain for patients. The basic science folks tell me that arthritis, inflammatory or otherwise, appears to have a neuropathic component that responds to those agents. The way I understand it is simply that if the patient's knee hurts when they don't move, then there like is a neuropathic component. If they can get it in a comfortable position where it doesn't hurt at all, then it's probably more mechanical and would do less well with the neuropathic agents.

I generally also tell learners/patients that Duloxetine has an FDA indication for chronic musculoskeletal pain, so either way it's a win.

 

[willabeast]

I am retired. Did a lot of basic research on this topic a long time ago. Try the following .
If the pain (any pain) is burning try a tricyclic first. If the pain is electrical or shooting go with whatever anti-convulsant has the least potential for bad side effects first. It is OK to be on both if patient has both types of pain. . If pain is achy, try an anti-inflammatory first, for chronic use i would go with turmeric + glucosamine. the reason the glucosamine studies in the USA failed to show benefit is IMHO they were not done correctly.

 

[Bsb2015]

I am retired. Did a lot of basic research on this topic a long time ago. Try the following .
If the pain (any pain) is burning try a tricyclic first. If the pain is electrical or shooting go with whatever anti-convulsant has the least potential for bad side effects first. It is OK to be on both if patient has both types of pain. . If pain is achy, try an anti-inflammatory first, for chronic use i would go with turmeric + glucosamine. the reason the glucosamine studies in the USA failed to show benefit is IMHO they were not done correctly.

Did you ever use alpha lipoic acid? Saw some threads utilizing it for neuropathic pain. If so, patients did well?

 

[raptor5]

How many of your patients actually follow through with behavioral medicine therapy?? If a lot, then thats a utopia I would love to join...

We have our own Pain Psychologist and mandate it for all patients on COT.

 

[Ducttape]

I find little benefit using purely patient’s description of pain to decide meds. Most can only say “it hurts”...

Exposing ppl to meds that won’t help expose them to side effects.

If you determine the cause of the pain is neuropathic (radic) then gaba and nortrip worth a try. If axial back pain or joint pain, I have seen gabapentin not work so often that I don’t bother.

Most of the time, while telling ppl cymbalta is approved for musculoskeletal pain, a lot of the benefit prob relates to the mood altering effects.

 

[willabeast]

Did you ever use alpha lipoic acid? Saw some threads utilizing it for neuropathic pain. If so, patients did well?

Never used ALA enough to evaluate. Did have one fellow that failed everything except fish oil. Fish oil was the answer. Only reason i remember him was that i was so surprised it worked. I think that he had a diabetic neuropathic pain. Bottom line - worth trying but i am unable to evaluate effectiveness. BTW when using TCAs i always checked the QT interval on EKG and tried to keep the dose low enough that no one could blame me for an arrythmia. If dose escalated documented discussion and message to PCP.

 

[willabeast]

I find little benefit using purely patient’s description of pain to decide meds. Most can only say “it hurts”...

Exposing ppl to meds that won’t help expose them to side effects.

If you determine the cause of the pain is neuropathic (radic) then gaba and nortrip worth a try. If axial back pain or joint pain, I have seen gabapentin not work so often that I don’t bother.

Most of the time, while telling ppl cymbalta is approved for musculoskeletal pain, a lot of the benefit prob relates to the mood altering effects.

//I find little benefit using purely patient’s description of pain to decide meds. Most can only say “it hurts”...// I think you are mainstream on that belief.

 

[SommeRiver]

You know what I use all the time? Gabapentin, regardless of the etiology of their pain, especially if they have sleep dysfxn. If SE present themselves we stop it. Gabapentin 100mg HS in my pt population is pretty good. The other medications mentioned here have their own little niche and occasionally work. The bottom line is we all do things a little differently bc pain is an emotional experience that is individualized and demographics matter. Inner city Atlanta behaves differently to a "work injury" than rural Georgia.