neuropathy: psych meds vs. pain management meds

Question

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 "firery 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, Valume, 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

Answer

There are some psychiatric medications that are used as adjunctive treatments for neuropathic pain. Those most commonly used in practice are antidepressants (amitriptyline,imipramine, desipramine, nortriptyline and doxepinand) and anticonvulsants, (carbamazepine, valproic acid, gabapentin). I haven't seen any literature on topiramate.

The SSRI anitdepressants are less well studied for pain management. I know of some evidence that paroxetine is effective for this purpose, but haven't seen any studies with sertraline.

Valium is usefull for pain secondary to muscle spasm, but probably not for neuropathy.

As for the physician who is against narcotic analgesics, there is no good reason for this position. Neuropathy is an extremely painful and potentially diabling condition. It should be aggressively treated with available analgesics, which should include opioid analgesics (eg. oxycodone, morphine, methadone, fentanyl, etc.), if necessary. Failure to adequately treat pain is cruel and unnecessary.

I don't know what HAART regimen your client is on, but it should also be remembered that some of the NRTI's may cause neuropathy as well, eg. didanosine (ddI), zalcitabine (ddC), and stavudine (d4T).