Chronic Pain Update 2013: New Data and Perspectives - Episode 6

Devising Treatment Plans for Postherpetic Neuralgia

In this brief brainstorming session, the physicians attempt to develop an appropriate treatment plan for postherpetic neuralgia (PHN) that considers medication side effects and potential combination therapies that would result in better patient outcomes.

Though he hesitates to offer a “boiler plate suggestion,” Christopher Gharibo, MD, recommends once-a-day Lidoderm with gabapentin for mild-to-moderate PHN pain, once-a-day gabapentin with tramadol for moderate PHN pain, and the moderate regimen with a narcotic or a long-acting opioid as needed for severe PHN pain.

In terms of educating a patient on the side effects of those medications, Joseph Pergolizzi, MD, says the once-daily dosage forms offer flexibility in terms of recommending administration times, such as instructing a patient to take the medication in the morning if it keeps him or her up at night. However, Pergolizzi also stresses the importance of “treating the patients in the biopsychosocial model” via non-pharmacological regimens, including coping.

“This is a disease of the elderly, by nature, and it’s very complex because they’re sensitive to the medications that we use,” Jeffrey A. Gudin, MD, adds. “Teaching them coping strategies, nonpharmacologic strategies — what can they do when their pain gets bad because we’ve maximized most of the medication?”

While moderator Peter Salgo, MD, notes that he keeps hearing from patients, “I don’t want you to teach me how to cope with my pain; you’re a doctor, make my pain go away,” Pergolizzi says that idea of a “magic bullet” remains a problem among medication-dependent US pain patients that reasonable medication tapering and titration may potentially correct.

“Tapering, as I mentioned with opioids, is something we’ve overlooked. Tailoring may be something with neuropathic pain that we’re just not doing well enough of a job,” Pergolizzi concludes. “So the titration and tailoring is extremely important.”