You're at the train station, sitting on a hard, cold bench with your foot tucked under you. Absorbed in your newspaper, at first you barely notice the numbness. Then, as you leap up to catch the train, you realize your foot has fallen asleep. You limp forward on your numb appendage, bracing yourself for the inevitable tingling, burning, stabbing pain, which will signal that your blood-deprived nerve endings are screaming back to life.
Neuropathic pain feels a lot like this. Neuropathy, from the Greek words neuro (nerve) and patheia (or pathos, meaning a disorder of), is an umbrella term that covers several conditions affecting the nerves.
Neuropathic pain can be difficult to diagnose and tricky to treat. It's most often a symptom of an underlying problem like diabetes, alcoholism or autoimmune disease. Neuropathy can also be caused by vitamin-B deficiency, tumors, infections, cancer treatments and certain hereditary disorders. Thirty percent of neuropathies are caused by diabetes; 40 percent are caused by other underlying conditions [source: Crosta]. In these cases, addressing the underlying cause will generally improve or relieve the neuropathy.
In almost 30 percent of neuropathic pain cases, however, the underlying cause of the pain is unknown [source: Crosta]. In these instances, and in situations where treatment of the underlying cause doesn't relieve the pain, other treatments are necessary. We'll explore five of them in this article.
Find out how antidepressants and anti-seizure medications help improve neuropathic pain next.
Sometimes, treating the underlying cause doesn't relieve neuropathic pain, or no underlying cause can be found. In these cases, doctors prescribe medications to relieve neuropathy symptoms. Antidepressants (tricyclics and SNRIs) and anticonvulsants are considered first-line treatments for neuropathy pain.
SNRIs (serotonin-norepinephrine reuptake inhibitors) like Cymbalta (duloxetine) and Effexor (venlafaxine) and tricyclics like Elavil (amitriptyline) work by blocking proteins that act as re-uptakers, thereby increasing serotonin and norepinephrine levels. No one knows why, but patients with chronic pain often have low levels of these neurotransmitters. Therefore, taking drugs that increase these agents can be effective in decreasing pain. SNRIs are a newer class of drugs and have fewer side effects than the older tricyclics.
Anticonvulsants like Gabapentin prevent calcium from entering neurons and triggering a biochemical reaction that can result in neuropathic pain [source: Jeffries]. Studies show that about 43 percent of neuropathy patients who took Gabapentin at doses of 1200 milligrams or more showed moderate improvements, and one in three patients showed a substantial benefit [source: Moore, Wiffin, Derry and McQuay]. Gabapentin's main side effects are drowsiness, dizziness and diarrhea.
Neither tricyclics nor SNRIs work in every case. For cases where medications don't work or aren't effective enough, topical treatments may also be indicated. We discuss those next.
Even though anticonvulsants and antidepressants can treat neuropathic pain, about half of those who take them will not see any improvement [source: Moore, Wiffin, Derry and McQuay]. In these cases, topical pain relievers might help.
Lidocaine is one that has been around since the 1940s. It's so well-known as an analgesic that Meredith Grey, the protagonist of the popular television show "Grey's Anatomy," is quoted as saying, "I'm having a miscarriage. I need Lidocaine." in the nail-biting season six finale [source: Grey's Anatomy]. Lidocaine works on neuropathic pain by blocking voltage-gated sodium channels. Typically, it's prescribed in 5 percent patches. Up to three patches can be applied topically on a localized painful area and worn for 24 hours.
Capsaicin poses an alternative topical treatment. The active ingredient in capsaicin is derived from chili peppers, and capsaicin patches and creams are widely available over the counter for the deep-heating treatment of minor muscle pain. The dosages required for the treatment of chronic neuropathic pain, however, are much higher and require a prescription. In one study, patients applied a single high-dose (8 percent) capsaicin patch. Thirty-three percent of patients reported a 50 percent reduction in pain. Fifty percent reported at least a 30 percent reduction. The positive effects of the patch lasted around 12 weeks [source: Gever].
For cases where topical treatments don't provide enough relief or where neuropathic pain is random or not localized, patients may want to try something a little crazier than a cream.
Television shows like "Weeds" poke fun at so-called "medical" marijuana, inferring that it has more in common with reefer madness than real medicine. Nevertheless, as of this writing, medical marijuana is legal in 16 U.S. states as well as Washington, D.C., and six more states have pending legislation for the legalization of medical marijuana.
The reported benefits of cannabinoids, of which THC (the main psychoactive compound in marijuana) is one, have been confirmed in multiple randomized trials. A recent review concluded that 15 out of 18 trials showed that cannabinoids provided a significant pain-relieving effect when compared with a placebo. Cannabinoids were also shown to improve sleep [source: Lynch and Campbell].
The study of cannabinoids and why they work on chronic pain, including the neuropathic variety, is a hot topic among today's pharmacological researchers. Current studies are looking at cannabinoid receptors and ligands in the human body to try and provide a scientific explanation for why medical marijuana is effective in reducing pain.
Like all the other treatments for neuropathic pain, however, medical marijuana may only partially relieve the pain. In one Canadian study, patients who smoked medical marijuana reported their neuropathic pain level at 5.4, whereas patients who were given the placebo reported pain levels of 6.1 [source: Lowry]. If medical marijuana doesn't provide the necessary relief, more traditional analgesics may be indicated. We discuss the pros and cons of painkillers next.
There is no doubt that opiates will reduce almost most any kind of pain, including neuropathic pain. However, drugs like oxycodone, oxycontin and morphine carry risks that make some patients reluctant to use them and some doctors reluctant to prescribe them.
In general, opiates are considered a second or third-line treatment for neuropathic pain. Sometimes doctors will issue a short-term prescription for opiates in conjunction with first-line treatments since drugs like tricyclics, SNRIs and anticonvulsants can take several days to become effective. In cases where first-line treatments are ineffective, scheduled long-acting opioids like fentanyl patches or extended-release oxycodone are preferred over shorter acting agents [source: Jeffries]. This is because with any chronic pain, it is best to stay on top of the pain rather than to try and tough it out and only take medication when the pain gets really bad.
Side effects of opiates include drowsiness, constipation, nausea and, with elderly patients, an increased risk of falls or cognitive problems. Some studies have shown the risk of misuse or addiction to be as high as 50 percent [source: Jeffries]. Opiate alternatives such as methadone and tramadol have also been shown to work in treating neuropathic pain; both are thought to carry a lower risk of dependence than traditional opioids.
If opiates don't work for you, or if you're dubious about using addictive medication long-term, there are also alternative therapies to consider. We talk about acupuncture and other alternative treatments next.
A number of alternative treatments and non-Western healing practices are currently being evaluated to objectively gauge their effectiveness in treating many conditions including neuropathy. One of the most promising is acupuncture. Acupuncturists believe that vital energy ("Qi") traverses the nervous system along specific pathways called meridians and channels. By inserting thin needles into specific areas of the body, acupuncturists seek to stimulate qi and bring vital energy back into balance. The Chinese have practiced acupuncture for thousands of years. Although Western researchers can't yet explain how it works, studies have shown that it can be effective in relieving some types of pain. One 2010 study showed acupuncture to be more effective than traditional medication in relieving peripheral neuropathy pain induced by chemotherapy drugs [source: Zhongguo].
The Northern California Chapter of the Neuropathy Association has published a guide to complementary and alternative treatments for neuropathy. Among the treatments listed are alpha-lipoic acid (a universal antioxidant), Bowen therapy (a type of massage) and IVIG (intravenous immunoglobulin therapy), as well as many folk remedies such as borage oil, primrose oil and nettle footbaths. Though there is little scientific evidence supporting these treatments, they are recommended anecdotally by members of NCCNA support groups. Be sure to always discuss alternative treatments with your doctor before experimenting with complementary therapies.
Neuropathy is a big subject, with multiple possible causes and treatments. Find additional information and more great links on the next page.
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More Great Links
- "Complementary and Alternative Treatments for Neuropathy." Northern California Chapter of the Neuropathy Association. September, 2008. (October 13, 2011.) http://www.pnhelp.org/index.php/download_file/view/116/
- Crosta, Peter. "What is Neuropathy?" medicalnewstoday.com. April 29, 2009. (October 3, 2011.) http://www.medicalnewstoday.com/articles/147963.php
- Gever, John. "AAPM: High-Dose Capsaicin Patch Tolerable Long-Term for Neuropathic Pain." MedPageToday.com. February 3, 2009. (October 3, 2011.) http://www.medpagetoday.com/MeetingCoverage/AAPM/12720
- Jefferies, Kristen. "Treatment of Neuropathic Pain." Medscape. 2010. (October 3, 2011). http://www.medscape.com/viewarticle/730671
- Lindsay, Tammy J., et al. "Treating Diabetic Peripheral Neuropathic Pain." American Family Physician. July 15, 2010. (October 13, 2011) http://www.aafp.org/afp/2010/0715/p151.html
- Lowry, Fran. "Smoking Marijuana Eases Chronic Neuropathic Pain." Medscape Today. August 30, 2010. (October 13, 2011) http://www.medscape.com/viewarticle/727702
- Lynch, Mary E. and Campbell, Fiona. "Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials." British Journal of Clinical Pharmacology. October 11, 2011. (October 13, 2011) http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2011.03970.x/abstract
- Moore, RA, et al. "gabapentin for chronic neuropathic pain and fibromyalgia in adults." The Cochrane Library, 2011, Issue 3. (October 3, 2011.) http://www.update-software.com/BCP/WileyPDF/EN/CD007938.pdf
- Mross, Kerriann. Internist, Johns Hopkins Community Physicians. Personal Interview. October 6, 2011.
- Richemier, Steven. "Understanding Neuropathic Pain." SpineUniverse.com. 2000. (October 3, 2011.) http://www.spineuniverse.com/conditions/understanding-neuropathic-pain
- "Sanctuary; Death and All His Friends." Grey's Anatomy. Television show. Season 6, episode 23. Aired May 20, 2010. (October 3, 2011) http://abc.go.com/shows/greys-anatomy/episode-detail/sanctuary-death-and-all-his-friends/440238
- Zhongguo, Zhen Jiu. "Clinical Randomized Controlled Study on Acupuncture for Treatment of Peripheral Neuropathy Induced by Chemotheraputic Drugs." PubMed. June 30, 2010. (October 13, 2011) http://www.ncbi.nlm.nih.gov/pubmed/20578381