Approach to managing acute neuropathic pain

Neuropathic pain is under-recognised as a component of acute pain. Prompt recognition is key to appropriate management, use of a screening tool (eg PainDETECT) may be helpful. Early management of acute neuropathic pain is crucial to reduce the pain experience, inappropriate use of opioids, and the likelihood of transitioning from acute to chronic pain.

Postoperative acute neuropathic pain can be managed pre-emptively in patients at significant risk of nerve injury during surgery (eg patients undergoing amputation) and this may reduce the likelihood of transitioning to chronic postsurgical pain. Regional anaesthesia and parenteral adjuvants (eg ketamine) are used perioperatively to prevent postoperative neuropathic pain.

For children and adolescents, seek specialist advice (eg paediatrician, specialist pain medicine physician) for the management of acute neuropathic pain¹; the benefit–harm profile of adjuvants is generally unfavourable (see Commonly used adjuvants in pain management).

In adults, gabapentinoids, tricyclic antidepressants (TCAs), or serotonin and noradrenaline reuptake inhibitors (SNRIs) are commonly used adjuvants for acute neuropathic pain. Adequate pain relief may take up to 1 week to achieve using oral adjuvants—gabapentinoids are preferred to TCAs and SNRIs because of their faster onset of action, but their use may be limited by potential harms. Consider a TCA or SNRI if a gabapentinoid is not appropriate (see Prescribing considerations for commonly used adjuvants in pain management in adults).

For patients with acute neuropathic pain in the community, doses of oral adjuvants are titrated slowly to reduce the incidence of adverse effects. For patients managed in hospital (eg major burns), doses are titrated quickly to achieve faster analgesia and adverse effects are managed simultaneously. For drug regimens, see:

Severe, acute neuropathic pain (eg neuropathic pain associated with major burns, traumatic plexus injury or amputation) should be treated in a hospital. Anaesthetists or pain specialists may use parenteral ketamine to rapidly establish analgesia—follow local protocols. Ketamine is stopped once analgesia from oral adjuvants is established. Opioids are not consistently effective for the management of severe, acute neuropathic pain and should only be used under specialist advice.

If a patient’s pain also has a nociceptive component, manage the nociceptive pain simultaneously; see mild, moderate, or severe, acute nociceptive pain for management.

Always have a plan for reassessment of acute neuropathic pain, and tapering and stopping adjuvants. Some nerve injuries (eg spinal cord injury) carry a high risk of transitioning to chronic neuropathic pain. For the management of chronic pain; see General principles of chronic pain management and The role of adjuvants for chronic noncancer pain.

¹ Specialist advice can be sought via phone or email; patients do not necessarily require referral to a specialist.Return