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neuropathy: psych meds vs. pain management meds
Sep 12, 2003

I am an HIV Case Manager and am looking for some advice in a complex situation regarding neuropathy. My client who is sitting here with me has been experiencing "fiery painful feeling from his feet up his legs to his extremities, up his arms, and up his face, flu-like feeling w/o a fever." He has been followed closely by his PCP and ID specialist since 2000 and by his neurologist since 2001. His PCP is against pain management and narcotics, and his neurologist is prescribing pysch meds, including Zoloft, Neurotin, Valium, Vicodin, Topamex, etc for his neuropathy. However, my client states his pain gets worse, he is sleeping little to nothing w/ sporadic awakenings. His PCP doesn't want to switch his anti-viral regimen b/c it works. While my client is sober and in recovery, he also knows that pain management might be the only option to maintain a functional lifestyle. Any advice would be greatly appreciated as we try to balance the line between a PCP who is against narcotics and a neurologist who just prescribed less Vicodin this month and will prescribe more pysch meds (Zoloft) as time goes on.

Sleepless in Salem

Response from Dr. Conway

Dear Sleepless:

I congratulate the PCP (which I assume is primary care physician) on avoiding narcotics here. They almost never work in the long term, and carry a significant risk of addiction.

If there are any medications in the regimen that are exacerbating the condition and credible alternatives that would be as effective exist, these should be considered. I would leave this to the PCP to address.

In terms of pharmacologic approach to the condition, I am a strong advocate of non-narcotic analgesics, Neurontin, Tegretol and some antidepressants, such as Elavil. One of the main problems I often see is a failure to push the Neurontin to high enough doses. I have used as much as 1200 mg tid with good results.

The use of other antidepressants such as Zoloft is less proven, but may be worth a try. The temporary use of other mood altering agents may be indicated, but ONLY TEMPORARILY, to address the emotive component of the condition while waiting for the intervention directed against the neuropathy to work.

The key here is persistence, teamwork and an aggressive approach to care WHICH DOES NOT INCLUDE NARCOTICS.



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