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Best Practice Journal

Dear bpac,

It’s amazing how hard it is to let some things that you value, enjoy, and that have become motifs for what you do and who you are, finally go. But my medical life is in the past now. Almost exactly two years ago I took the decision not to renew my Practising Certificate, so I’ve been retired for that length of time. However, over all this time I’ve had the pleasure of continuing to receive all your wonderful stuff through the mail. I love reading it, rarely complete the quiz, and file it away in a part of my filing cabinet that says bpac, with a wistful “just maybe”.

At last I feel it only right to set the record straight as it were, and let you know of these changed circumstances. If this means, as I’m sure it will, the end of our association, sadly, so be it. I want to record my sincere thanks to you for providing what, over my last several years of practice, were some of my best references tools, and sources of excellent, reliable information. I’m sure bpac has made a huge difference to the New Zealand medical landscape.

Sincere thanks and warm regards

Dr Geoff Bradley, GP, Retired
Canterbury

Neuropathic pain

Dear bpac,

Thank you for producing such an interesting and useful magazine as “Best Practice”. I always enjoy reading it.

I have a slight issue with your management of neuropathic pain on page 14, in Issue 16, September 2008. If one followed the protocol for nortriptyline to the maximum of 75mg and then carbamazepine to the full dose, it would require 12 weeks which it is felt is too long.

Would it not be better to explain the side effects, but raise the doses much more quickly. In the same way as in a depressed patient you would not raise the nortriptyline over seven weeks?

GP, Wellington

Thank you for your question. In the management of neuropathic pain it is possible, and may be desirable, to escalate the doses more quickly than indicated in the article. So, why the cautious approach? To answer this, consider the contrasting therapeutic goals when prescribing for chronic pain and depression.

Firstly, in depression the aim is to reach the therapeutic dose as quickly as possible and then wait for the lag in clinical effect. The expectation is that at therapeutic doses the majority of patients will find relief from their symptoms but that at lower doses there will be no significant clinical effect. Thus, there is nothing to be gained by waiting at the lower doses and the dose should be raised to maximum as quickly as possible.

In contrast, chronic pain management,1 while including medication to reduce pain, also involves patient education regarding the natural history of their condition and explaining the realistic treatment expectations. The aim of pharmacological treatment is optimal pain control without troublesome side effects and this is best achieved by starting with a low dose and then increasing this slowly according to response and tolerance. This allows pain control to be assessed and even a partial response may significantly improve quality of life. Rapid dose escalation may not provide better pain control but a dose which is unnecessarily high is likely to be more poorly tolerated.

Not all neuropathic pain seen in general practice will fall into the chronic pain category. For example in newly diagnosed shingles it would be reasonable to increase the dose more rapidly with the aim of controlling pain in the shortest possible time. Similarly in palliative care rapid control of pain is often required.

Reference

  1. Gilron I, Watson PN, Cahill CM, Moulin DE, Neuropathic pain: a practicle guide for the clinician. CMAJ 2006;175(3):265-75.

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