Pain caused by dysfunction or damage to the peripheral or central nervous system is typified by the symptoms described by patients with painful diabetic neuropathy, post-herpetic neuralgia and central poststroke pain. All these conditions are more common in the elderly.
Neuropathic pain has long been recognised as one of the more difficult types of pain to treat; however, with the current emphasis on providing a multidisciplinary assessment and approach to management, more patients will be offered relief of their symptoms and an improved quality of life.
Despite the use of combination drug therapy, adequate pain relief in the elderly is difficult to achieve without adverse effects. In an attempt to minimise these it is important to include non-drug treatment options in the management plan. Lifestyle changes and environmental modification, together with encouragement to adopt an appropriate exercise programme and an emphasis on maintaining mobility and independence should always be considered.
Interventional therapy ranging from simple nerve blocks to intrathecal drug delivery can be of value.
Drug treatment remains the mainstay of therapy. Tricyclic antidepressants such as amitriptyline, while having significant adverse effects in the elderly, have a number needed to treat (NNT) of 3.5 for 50% pain relief in diabetic neuropathy and 2.1 for 50% pain relief in postherpetic neuralgia.
The newer antiepileptic drugs, such as gabapentin, appear to have a better adverse effect profile and provide similar efficacy with the NNT for treating painful diabetic neuropathy being 3.7 and 3.2 for treating pain in postherpetic neuralgia.
As our understanding of the complexities of the pain processes increases, we are becoming more able to appropriately combine treatments to achieve not only improved pain relief but also improved function.
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in to check access.
Dr Ahmad has received no funding and has no conflicts of interest directly relevant to this manuscript. Dr Goucke has also received no funding and has served on medical advisory boards for Pfizer, MundiPharma and CSL.
Merskey H, Bogduk N. Classification of chronic pain. 2nd ed. Seattle (WA): IASP Press, 1994Google Scholar
Choi YK, Liu J. The use of 5% lidocaine for prolonged analgesia in chronic pain patients: a new technique. Reg Anesth Pain Med 1998; 23(1): 96–100PubMedGoogle Scholar
Saberski LR, Ahmad M, Fitzgerald JF. Cryoneurolysis and radiofrequency lesioning. In: Raj PP, editor. Practical management of pain. St Louis (MO): Mosby, 2000: 753–67Google Scholar
Bennett G, Serafini M, Burchiel K, et al. Evidence-based review of the literature on intrathecal delivery of pain medication. J Pain Symptom Manage 2000; 20(2): S12–36PubMedCrossRefGoogle Scholar
Anderson VC, Burchiel KJ. A prospective study of long-term intrathecal morphine in the management of chronic non-malignant pain. Neurosurgery 1999; 44(2): 289–300; discussion 300–1PubMedCrossRefGoogle Scholar
Lund C, Mogensen T, Hjortso NC, et al. Systemic morphine enhances spread of sensory analgesia during postoperative epidural bupivacaine infusion. Lancet 1985; 2(8465): 1156–7PubMedCrossRefGoogle Scholar
Dahl JB, Rosenberg J, Hansen BL, et al. Differential analgesic effects of low-dose epidural morphine and morphine-bupivacaine at rest and during mobilization after major abdominal surgery. Anesth Analg 1992; 74(3): 362–5PubMedCrossRefGoogle Scholar
Etches RC, Gammer TL, Cornish R. Patient-controlled epidural analgesia after thoracotomy: a comparison of meperidine with and without bupivacaine. Anesth Analg 1996; 83(1): 81–6PubMedGoogle Scholar
Sjoberg M, Karlsson PA, Nordberg C, et al. Neuropathologic findings after long term intrathecal infusion of morphine and Bupivacaine for ain treatment in cancer patients. Anaesthesiology 1992; 76: 173–86CrossRefGoogle Scholar
Wagemans MF, van der Valk P, Spoelder EM, et al. Neurohistopathological findings after continuous intrathecal administration of morphine or a morphine/Bupivacaine mixture in cancer pain patients. Acta Anaesthesiol Scand 1997; 41: 103–8CrossRefGoogle Scholar
Dahm P, Lundborg C, Janson M, et al. Comparison of 0.5% intrathecal bupivacaine with 0.5% intrathecal ropivacaine in the treatment of refractory cancer and noncancer pain conditions: results from a prospective, crossover, double-blind, randomized study. Reg Anesth Pain Med 2000; 25(5): 480–7PubMedGoogle Scholar
Eisenach JC, DuPen S, Dubois M, et al. Epidural clonidine analgesia for intractable cancer pain. The Epidural Clonidine Study Group. Pain 1995; 61(3): 391–9PubMedCrossRefGoogle Scholar
Eisenach JC, Hood DD, Curry R. Intrathecal, but not intravenous, clonidine reduces experimental thermal or capsaicin-induced pain and hyperalgesia in normal volunteers. Anesth Analg 1998; 87(3): 591–6PubMedGoogle Scholar
Zuniga RE, Schlicht CR, Abram SE. Intrathecal baclofen is analgesic in patients with chronic pain. Anesthesiology 2000; 92(3): 876–80PubMedCrossRefGoogle Scholar
Bowersox SS, Luther R. Pharmacotherapeutic potential of Omega-conotoxin MV2A (SNX-111), and N-type neuronal calcium channel blocker found in the venom of Conus Magus. Toxicon 1998; 36: 1651–8PubMedCrossRefGoogle Scholar
Penn RD, Paice JA. Adverse effects associated with the intrathecal administration of ziconotide. Pain 2000; 85(1–2): 291–6PubMedCrossRefGoogle Scholar
Lauretti GR, Reis MP, Prado WA, et al. Dose-response study of intrathecal morphine versus intrathecal neostigmine, their combination, or placebo for postoperative analgesia in patients undergoing anterior and posterior vaginoplasty. Anesth Analg 1996; 82(6): 1182–7PubMedGoogle Scholar
Hood DD, Mallak KA, Eisenach JC, et al. Interaction between intrathecal neostigmine and epidural clonidine in human volunteers. Anesthesiology 1996; 85(2): 315–25PubMedCrossRefGoogle Scholar
Pellerin M, Hardy F, Abergel A, et al. Chronic refractory pain in cancer patients. Value of the spinal injection of lysine acetylsalicylate: 60 cases [in French]. Presse Med 1987; 16(30): 1465–8PubMedGoogle Scholar
Naji P, Farschtschian M, Wilder-Smith OH, et al. Epidural droperidol and morphine for postoperative pain. Anesth Analg 1990; 70(6): 583–8PubMedCrossRefGoogle Scholar
Wilder-Smith CH, Wilder-Smith OH, Farschtschian M, et al. Epidural droperidol reduces the side effects and duration of analgesia of epidural sufentanil. Anesth Analg 1994; 79(1): 98–104PubMedCrossRefGoogle Scholar
Bach V, Carl P, Ravlo O, et al. Potentiation of epidural opioids with epidural droperidol: a one year retrospective study. Anaesthesia 1986; 41(11): 1116–9PubMedCrossRefGoogle Scholar
Grip G, Svensson BA, Gordh Jr T, et al. Histopathology and evaluation of potentiation of morphine-induced antinociception by intrathecal droperidol in the rat. Acta Anaesthesiol Scand 1992; 36(2): 145–52PubMedCrossRefGoogle Scholar
Geurts JW, Kallewaard JW, Richardson J, et al. Targeted methylpredisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica, one year follow up study. Reg Anesth Pain Med 2002; 27: 343–52PubMedGoogle Scholar
Richardson J, McGurgan P, Cheema S, et al. Spinal endoscopy in chronic low back pain with radiculopathy a prospective case series. Anaesthesia 2001; 56: 454–60PubMedCrossRefGoogle Scholar
North RB, Kidd DH, Piantadosi S. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a prospective, randomized study design. Acta Neurochir Suppl 1995; 64: 106–8PubMedCrossRefGoogle Scholar
Harke H, Gretenkort P, Ladsleif HU, et al. Spinal cord stimulation in postherpetic neuralgia and in acute herpes zoster pain. Anesth Analg 2002; 94: 694–700PubMedCrossRefGoogle Scholar
Spincemaille GH, de Vet HC, Ubbink DT, et al. The results of spinal cord stimulation in critical limb ischaemia: a review. Eur J Vasc Endovasc Surg 2002; 21: 99–105CrossRefGoogle Scholar
Merry AF, Smith WM, Anderson DJ, et al. Cost effectiveness of spinal cord stimulation in patients with intractable angina. N Z Med J 2001; 114: 179–81PubMedGoogle Scholar
McQuay HJ, Moore RA. Using numerical results from systematic reviews in clinical practice. Ann Intern Med 1997; 126(9): 712–20PubMedGoogle Scholar
Collins SL, Moore RA, McQuay HJ, et al. Antidepressants and anticonvulsants for diabetic neuropathy and postherpetic neuralgia: a quantitative systematic review. J Pain Symptom Manage 2000; 20: 449–58PubMedCrossRefGoogle Scholar
Kvinesdal B, Molin J, Froland A, et al. Imipramine treatment of painful diabetic neuropathy. JAMA 1984; 251(13): 1727–30PubMedCrossRefGoogle Scholar
Sindrup SH, Ejlertsen B, Froland A, et al. Imipramine treatment in diabetic neuropathy: relief of subjective symptoms without changes in peripheral and autonomic nerve function. Eur J Clin Pharmacol 1989; 37(2): 151–3PubMedCrossRefGoogle Scholar
Young RJ, Clarke BF. Pain relief in diabetic neuropathy; the effectiveness of imipramine and related drugs. Diabetic Med 1985; 2: 363–6PubMedCrossRefGoogle Scholar
Sindrup SH, Gram LF, Brosen F, et al. The selective serotonin reuptake inhibitor paroxetine is effective in the treatment of diabetic neuropathy symptoms. Pain 1990; 42(2): 35–44CrossRefGoogle Scholar
Sindrup SH, Tuxen C, Gram LF, et al. Lack of effect of mianserin on the symptoms of diabetic neuropathy. Eur J Clin Pharmacol 1992; 43: 251–5PubMedCrossRefGoogle Scholar
Sindrup SH, Gram LF, Skjold T, et al. Clomipramine vs desi-pramine vs placebo in the treatment of diabetic neuropathy symptoms: a double-blind cross-over study. Br J Clin Pharmacol 1990; 30(5): 683–91PubMedCrossRefGoogle Scholar
Max MB, Lynch SA, Muir J, et al. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med 1992; 326(19): 1250–6PubMedCrossRefGoogle Scholar
Vrethem M, Boivie J, Arnqvist H, et al. A comparison a amitriptyline and maprotiline in the treatment of painful polyneuropathy in diabetics and nondiabetics. Clin J Pain 1997; 13(4): 313–23PubMedCrossRefGoogle Scholar
Sindrup SH, Bjerre U, Dejgaard A, et al. The selective serotonin re-uptake inhibitor citalopram relieves the symptoms of diabetic neuropathy. Clin Pharmacol Ther 1992; 52: 547–52PubMedCrossRefGoogle Scholar
Mendel C, Klein R, Campbell D, et al. A trial of amitriptyline and fluphenazine in the treatment of painful diabetic neuropathy. JAMA 1986; 255: 637–9PubMedCrossRefGoogle Scholar
Gomez-Perez FJ, Rull JA, Dies H, et al. Nortriptyline and fluphenazine in the symptomatic treatment of diabetic neuropathy: a double blind cross over study. Pain 1985; 23: 395–400PubMedCrossRefGoogle Scholar
Watson CP, Evans RJ, Reed K, et al. Amitriptyline versus placebo in postherpetic neuralgia. Neurology 1982; 32(6): 671–3PubMedCrossRefGoogle Scholar
Max MB, Culnane M, Schafer SC, et al. Amitriptyline relieves diabetic neuropathy pain in patients with normal or depressed mood. Neurology 1987; 37(4): 589–96PubMedCrossRefGoogle Scholar
Kishore-Kumar R, Max RB, Schafer SC, et al. Desipramine relieves postherpetic neuralgia. Clin Pharmacol Ther 1990; 47: 305–12PubMedCrossRefGoogle Scholar
Goodman LS, Limbird LE, Milinoff PB, et al., editors. 9th ed. Goodman and Gilman’s: The pharmacological basis of therapeutics. New York (NY): McGraw-Hill Professional, 1996Google Scholar
McQuay H, Carroll D, Jadad AR, et al. Anticonvulsant drugs for management of pain: a systematic review. BMJ 1995; 311(7012): 1047–52PubMedCrossRefGoogle Scholar
Saudek CD, Werns S, Reidenberg MM. Phenytoin in the treatment of diabetic symmetrical polyneuropathy. Clin Pharmacol Ther 1977; 22(2): 196–9PubMedGoogle Scholar
Chadda VS, Mathur MS. Double blind study of the effects of diphenylhydantoin sodium on diabetic neuropathy. J Assoc Physicians India 1978; 26(5): 403–6PubMedGoogle Scholar
Backonja M, Beydoun A, Edwards KR, et al. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus: a randomized controlled trial. JAMA 1998; 280(21): 1831–6PubMedCrossRefGoogle Scholar
Rowbotham M, Harden N, Stacey B, et al. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA 1998; 280(21): 1837–42PubMedCrossRefGoogle Scholar
Grorsen K, Schott C, Herman R, et al. Gabapentin in the treatment of painful diabetic neuropathy: a placebo controlled, double blind crossover trial. J Neurol Neurosurg Psychiatry 1999; 66: 251–2CrossRefGoogle Scholar
Morello CM, Leckband SG, Stoner CB. Randomized double blind study comparing the efficacy of gabapentin with amitriptyline on diabetic peripheral neuropathy pain. Arch Intern Med 1999; 59: 1931–7CrossRefGoogle Scholar
Wright JM, Oki JC, Graves III L. Mexiletine in the symptomatic treatment of diabetic peripheral neuropathy. Ann Pharmacother 1997; 31(1): 29–34PubMedGoogle Scholar
Oskarsson P, Ljunggren JG, Lins PE. Efficacy and safety of mexiletine in the treatment of. painful diabetic neuropathy. The Mexiletine Study Group. Diabetes Care 1997; 20(10): 1594–7PubMedCrossRefGoogle Scholar
Stracke H, Meyer UE, Schumacher HE, et al. Mexiletine in the treatment of diabetic neuropathy. Diabetes Care 1992; 15(11): 1550–5PubMedCrossRefGoogle Scholar
Kalso E, Tramer MR, McQuay HJ, et al. Systemic local-anaesthetic-type drugs in chronic pain: a systematic review. Eur J Pain 1998; 2(1): 3–14PubMedCrossRefGoogle Scholar
Raffa RB, Friderichs E, Reimann W, et al. Opioid and non-opioid components independently contribute to the mechanism of action of tramadol and ‘atypical opioid analgesics’. J Pharmacol and Exp Ther 1992; 260: 275–85Google Scholar
Harati Y, Gooch C, Swenson M, et al. Double-blind randomized trial of tramadol for the treatment of the pain of diabetic neuropathy. Neurology 1998; 50(6): 1842–6PubMedCrossRefGoogle Scholar
Sindrup SH, Andersen G, Madsen C, et al. Tramadol relieves pain and allodynia in polyneuropathy: a randomised, doubleblind, controlled trial. Pain 1999; 83(1): 85–90PubMedCrossRefGoogle Scholar
Portenoy RK, Foley KM, Inturrisi CE. The nature of opioid responsiveness and its implications for neuropathic pain: new hypotheses derived from studies of opioid infusions. Pain 1990; 43(3): 273–86PubMedCrossRefGoogle Scholar
Watson CP, Babul N. Efficacy of oxycodone in neuropathic pain: a randomized trial in postherpetic neuralgia. Neurology 1998; 50(6): 1837–41PubMedCrossRefGoogle Scholar
Cheville A, Chen A, Oster G, et al. A randomised trial of controlled release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty. J Bone and Joint Surg 2001; 83-A: 572–6Google Scholar
The Capsaicin Study Group. Treatment of painful diabetic neuropathy with topical capsaicin: a multicenter, doubleblind, vehicle-controlled study. Arch Intern Med 1991; 151(11): 2225–9CrossRefGoogle Scholar
Low PA, Opfer-Gehrking TL, Dyck PJ, et al. Double-blind, placebo-controlled study of the application of capsaicin cream in chronic distal painful polyneuropathy. Pain 1995; 62(2): 163–8PubMedCrossRefGoogle Scholar
Bernstein JE, Korman NJ, Bickers DR, et al. Topical capsaicin treatment of chronic postherpetic neuralgia. J Am Acad Dermatol 1989; 21 (2 Pt 1): 265–70PubMedCrossRefGoogle Scholar
Watson CP, Tyler KL, Bickers DR, et al. A randomized vehicle-controlled trial of topical capsaicin in the treatment of postherpetic neuralgia. Clin Ther 1993; 15(3): 510–26PubMedGoogle Scholar
Zhang WY, Li Wan Po A. The effectiveness of topically applied capsaicin: a meta-analysis. Eur J Clin Pharmacol 1994; 46: 517–22PubMedCrossRefGoogle Scholar
Rowbotham MC, Davies PS, Fields HL. Topical lidocaine gel relieves postherpetic neuralgia. Ann Neurol 1995; 37(2): 246–53PubMedCrossRefGoogle Scholar
Rowbotham MC, Davies PS, Verkempinck C, et al. Lidocaine patch: double-blind controlled study of a new treatment method for post-herpetic neuralgia. Pain 1996; 65(1): 39–44PubMedCrossRefGoogle Scholar
Devers A, Galer BS. Topical lidocaine patch relieves a variety of neuropathic pain conditions: an open label study. Clin J Pain 2000; 16: 205–8PubMedCrossRefGoogle Scholar
Graziotti PJ, Goucke CR. The use of oral opioids in patients with chronic non-cancer pain: management strategies. Med J Aust 1997; 167(1): 30–4PubMedGoogle Scholar