Literature Review Shows Options for Neuropathy in Long-Term Care

Abstract

The literature has imperfect but important messages for long-term care regarding neuropathic pain management: the long-term care population “can still benefit from careful opioid prescribing,” that nonpharmacologic therapies have a role, and that among the non-opioid pharmacologic options “gabapentin, pregabalin, venlafaxine, and duloxetine have the best evidence for benefit.” These are the messages that Julie K. Gammack, MD, CMD, took home from her review of the literature and shared at AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Annual Conference. “In the long-term care setting where we’re doing end-of-life [care] and palliative symptom management, there is a role, and evidence for that role, for multiple types of medicine, including opioids, antiepileptics, and antidepressants,” Dr. Gammack said. The 2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain targets primary care clinicians treating non-cancer chronic pain in outpatient settings outside of palliative and end-of-life care. Medical directors should take note, however, that surveyor guidance on pain (currently part of F-tag 309; after Nov. 28, F-tag 675) stipulates that pain management interventions must be consistent with “current standards of practice,” said Dr. Gammack, of the St. Louis University School of Medicine. Per the guidance, surveyors will look for pain management that treats underlying causes of pain, tries to prevent or minimize anticipated pain, considers nonpharmacological and complementary and alternative medicine interventions, monitors effectiveness and adverse consequences, and is communicated with the health care provider. “These are some of the components of the guidance for our recognition,” said Dr. Gammack, emphasizing that “facilities that are not communicating with the practitioner … might be reprimanded.” A systematic review and meta-analysis published last year in JAMDA on the treatment of pain in nursing home residents (14 trials) concluded that analgesics rather than nonpharmacologic treatments are the most effective options and should be considered the first-line therapy ( J Am Med Dir Assoc 2016;1163.e19–1163.e28). Nonpharmacologic approaches still have a place, however; small studies published in the past few years, for instance, have suggested that physical exercise and broader peer-led pain management programs have potential, Dr. Gammack said. Most if not all studies on opioids for neuropathic pain have been small and short (many less than 6 weeks) and have highlighted both the challenge of side effects and the importance of setting realistic expectations for pain management. The most recent Cochrane review and meta-analysis of opioids for neuropathic pain, published in 2013, covered 31 trials of 10 different opioids and showed at least 33% pain relief in 57% of participants receiving an opioid, vs. in 34% of those receiving placebo. The number needed to treat for an additional beneficial outcome was four (Cochrane Database Syst Rev 2013;8:CD006146). To achieve at least 50% pain relief, the number needed to treat was about six, and “for every six people who get benefit [the analysis shows] there are four who get a significant side effect,” Dr. Gammack said. Constipation was the most common adverse event, followed by drowsiness, nausea, dizziness, and vomiting. European observational research of a low-dose oral prolonged-released oxycodone/naloxone (not available in the United States) has shown larger reductions in chronic pain without discontinuation due to gastrointestinal side effects, she noted. The formulation has been studied in elderly patients with cognitive impairment who are naïve to opioids and have moderate-severe chronic pain and constipation (Clin Interv Aging 2016;11:641–649). Interestingly, Dr. Gammack said, a German meta-analysis of 10 randomized controlled trials examined whether opioids for chronic noncancer pain (including various neuropathic pain syndromes) were superior to nonopioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs). It concluded that there was no significant difference in pain reduction, but that nonopioid analgesics were superior in improving physical function (Schmerz [Pain] 2015;29:85–95). Separate Cochrane systematic reviews of oral NSAIDs for neuropathic pain and of acetaminophen with or without codeine or dihydrocodeine for neuropathic pain, meanwhile, have found insufficient evidence to support or refute their use. Of the antidepressants, studies in the last decade suggest that venlafaxine and duloxetine, although not indicated by the Food and Drug Administration for chronic pain management, are most likely to benefit patients with neuropathic pain. There is less clear evidence for tricyclic antidepressants, she said. Of the antiepileptic drugs, the quality of evidence for some degree of efficacy in diabetic neuropathy, postherpetic neuralgia, and other neuropathic pain syndromes is highest for gabapentin and pregabalin. “With careful monitoring, we can see some benefits of these medications,” Dr. Gammack said. Christine Kilgore is a freelance writer in Falls Church, VA.