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General Principles in Neuropathic Pain

General principles for treatment of neuropathic pain

Consider the use of the assessment approaches and tools discussed in the relevant page on our site.

Treating neuropathic pain is different to pain from muscles, bones , organs etc. The basic principles are given below:

  • The drugs are given on a regular basis and not ‘as required’.
  • They may need to be titrated against response and side effects. If pain relief is experienced at a low dose then there is no need to increase to a higher dose.
  • It is impossible to predict which drug and what dose will help a particular patient therefore trail and error is the approach adopted.
  • A combination of drugs may be more effective than single treatment eg antidepressant + anticonvulsant. This is generally the case if each class only provides partial relief.
  • There is no evidence to guide which drugs to use first so the advice in our pathway is opinion only.
  • If drugs are useful they probably will need to be taken on a long term basis.

Principles of managing ongoing analgesic therapy include the 4 'A's:

  • Analgesia − is the medication still providing useful pain relief?
  • Adverse effects − what side effects is the patient experiencing and can these be managed more effectively?
  • Activity – does the patient maintain suitable physical and psychosocial functioning?
  • Adherence – is the patient taking medication as agreed in the management plan?




After starting or changing a treatment, it is important to perform early clinical review of dosage titration, tolerability and adverse effects to assess suitability of the chosen treatment.

Perform regular clinical reviews to assess and monitor effectiveness of chosen treatment.  Include assessment of:

  • Pain reduction
  • Adverse effects
  • Daily activities and participation (such as ability to work and drive)
  • Mood (in particular, possible depression and/or anxiety
  • Quality of sleep
  • Overall improvement as reported by the person


Some patients may have been on drugs used to treat neuropathic pain for a considerable time, and locally there is a drive to review these patients to assess the effectiveness and potential adverse effects of these drugs.  This offers potential advantages for patients in reducing side effects, as well as gains for the health community particularly in avoiding wasting resources on expensive drugs such as pregabalin and lidocaine patches.  

Guidance of review of such patients, specifically on long-term pregabalin, are currently being trialled and a copy of this is posted here.


Key principles of care in the NICE 96 guidelines

Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, including at initial presentation and at the regular clinical reviews, if:

  • they have severe pain or
  • their pain significantly limits their daily activities and participation or
  • their underlying health condition has deteriorated.

Continue existing treatments for people whose neuropathic pain is already effectively managed.

Address the person’s concerns and expectations when agreeing which treatments to use by discussing:

  • the benefits and possible adverse effects of each pharmacological treatment
  • why a particular pharmacological treatment is being offered
  • coping strategies for pain and for possible adverse effects of treatment
  • that non-pharmacological treatments are also available in non-specialist settings and/or through referral to specialist services (for example, surgical treatments and psychological therapies).

When selecting pharmacological treatments, take into account:

  • the person’s vulnerability to specific adverse effects because of comorbidities
  • safety considerations and contraindications as detailed in the SPC
  • patient preference
  • lifestyle factors (such as occupation)
  • any mental health problems (such as depression and/or anxiety)
  • any other medication the person is taking.

Explain both the importance of dosage titration and the titration process, providing written information if possible.

When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms.

When introducing a new treatment, consider overlap with the old treatments to avoid deterioration in pain control.

After starting or changing a treatment, perform an early clinical review of dosage titration, tolerability and adverse effects to assess the suitability of the chosen treatment.

Perform regular clinical reviews to assess and monitor the effectiveness of the chosen treatment. Each review should include assessment of:

  • pain reduction
  • adverse effects
  • daily activities and participation (such as ability to work and drive)
  • mood (in particular, whether the person may have depression and/or anxiety)
  • quality of sleep
  • overall improvement as reported by the person.








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Pain Service Website, Gloucestershire Hospitals NHS Foundation Trust
Webmaster Dr J G de Courcy, Consultant in Pain Medicine and Anaesthesia
email: pain.webmaster[at]

Page updated 15/02/2016