Drug therapy for neuropathic pain

Coverage Decision

Tricyclic antidepressants, duloxetine, and gabapentin are covered for neuropathic pain (see definition below) when associated with a work-related condition or occupational disease. Pregabalin requires prior authorization. Unless it is prescribed for an FDA-approved indication, pregabalin can be covered for claim-related neuropathic pain only if the above formulary drugs have been tried and failed.

Certain formulations of capsaicin, menthol, and lidocaine are covered for localized neuropathic pain or when used as adjunctive therapy (check coverage status of specific products using our drug lookup tool).

Opioids do not have good quality evidence to support their use in the treatment of neuropathic pain. Coverage of opioids is subject to department guidelines and rules.

The treatment of trigeminal neuralgia is considered separately, as evidence supports use of carbamazepine and oxcarbazepine for this specific indication.

Prescribing of drug therapy to treat neuropathic pain should be consistent with FDA-recommended dosing guidelines and contraindications to use and should account for other patient-specific factors.

Neuropathic pain is pain that arises as a direct consequence of a lesion or disease affecting the somatosensory nervous system. Neuropathic pain is described as lancinating, paroxysmal, burning, constant, cramping; and evoked dysesthesia, allodynia, hyperalgia, or hyperpathia. Examples of neuropathic pain conditions or diseases that are known to cause neuropathy includes, but not limited to, spinal cord injury, cauda equina syndrome, phantom limb pain and traumatic nerve injury.

This coverage decision is based on a review of literature and evidence-based guidelines developed by: the International Association for the Study of Pain (IASP), Neuropathic Pain Special Interest Group, European Federation of Neurological Societies, Canadian Pain Society, and a collaboration between the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation.

Abbreviated list of literature reviewed, including current pain guidelines
  1. Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010;17:1113-23.
  2. Bril V, England J, Franklin GM, et al. Evidence-based guideline: treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011;76:1758-65.
  3. Derry S, Moore RA. Topical lidocaine for neuropathic pain in adults. Cochrane Database Syst Rev 2014;CD010958.
  4. Enke O, New HA, New CH, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. CMAJ. 2018;190:E786-93.
  5. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162-73.
  6. Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Eng J Med 2017;376:1111-20.
  7. McNicol ED, Midbari A, Eisenberg E. Opioids for neuropathic pain. Cochrane Database Syst Rev 2013;CD006146.
  8. Moulin DE, Boulanger A, Clark AJ, et al. Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society. Pain Res Manag. 2014;19(6):328-35.
  9. Neuropathic pain in adults: pharmacological management in non-specialist settings. NICE guideline (CG173). London (UK): National Institute for Health and Care Excellence; 2017. Available: www.nice.org.uk/guidance/cg173 (accessed on July 18, 2018).
  10. https://www.uptodate.com/contents/overview-of-the-treatment-of-chronic-non-cancer-pain (accessed on July 18, 2018).