Neuropathic pain is notoriously variable in its severity and impact on patients, as well as in its response to treatment. Certain therapies for neuropathic pain have better evidence for their use; however, it is apparent that although some therapies provide relief for only a minority of patients, the relief may be significant. Without a trial of therapy, there is no way to know if that relief is achievable. Our treatment experiences have shown that occasionally unexpected benefit is obtained through a thorough investigation of all options, even in the setting of failure of those with the most compelling evidence or indication. Chronic neuropathic pain is generally best treated with regularly dosed medications, balancing efficacy and tolerability. Evidence supports first-line trials of anticonvulsants, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors, alone or in certain combinations. While opioid medications, particularly methadone, can be effective in treating neuropathic pain, they are best used only in refractory cases and by experienced clinicians, due to concerns for both short- and long-term safety. Some therapies have a long history of successful use for certain syndromes (e.g., carbamazepine for trigeminal neuralgia pain), but these should not be considered to the exclusion of other more recent, less-supported therapies (e.g., botulinum toxin A for the same), particularly in refractory cases. We find the principles of palliative care highly applicable in the treatment of chronic neuropathic pain, including managing expectations, mutually agreed-upon meaningful outcomes, and a carefully cultivated therapeutic relationship.
