Pain expert Professor Michael Cousins warns that patients are not getting access to “some extraordinarily good options” for the management of chronic neuropathic pain because of a lack of awareness within the medical community.
“There is no doubt there is too much prescribing of opioids, but why is there so much inappropriate prescribing? The healthcare teams prescribing them haven’t been educated appropriately about other options in the management of chronic pain,” says Professor Cousins, a Sydney pain medicine specialist and researcher who chaired the executive committee that produced the Australian National Pain Strategy.
The National Pain Strategy calls for a multidisciplinary approach to the assessment and treatment of chronic pain, including the education of primary carers in key strategies that are now available in tertiary pain centres.
“GPs are central to preventing the process of chronification - the transition from acute to chronic pain. But there are options if you get [to it] early,” says Professor Cousins, author of Fast Facts: Chronic and Cancer Pain.
He says GPs may not be aware of the novel invasive treatments being performed in tertiary pain centres that are improving the management of patients with chronic neuropathic pain.
Professor Cousins shares eight of the most promising treatments: 
- Treatment: Intraspinal drug administration (ISDA)
Patient type or condition: Usually used for cancer pain that is unresponsive to multimodal systemic pharmacological treatment and other non-invasive treatments.
How it works: Opioid or other drugs are used as spinal analgesics, usually via a percutaneous intrathecal catheter or an epidural system. Implanted programmable pumps can also be used.
Discussion: The efficacy of this frequently used procedure has been confirmed in a recent clinical trial for the management of chronic non-cancer pain. 
- Treatment: Neurolytic celiac plexus block
Condition: This procedure is suitable for patients with intractable abdominal pain due to upper abdominal malignancies.
How it works: Neurolytic block is carried out at the level of the celiac plexus or splanchnic nerves.
Discussion: This treatment provides immediate relief for 70–94% of patients. It is administered by anaesthetists, requiring a high level of expertise, and is routinely carried out with fluoroscopy or CT scan. 
- Treatment: Neurodestructive neurosurgical procedures
Condition: Cordotomy is an important option for patients with intra-pelvic cancer involving soft tissues and the lumbosacral plexus.
How it works: A lesion is created in the spinothalamic tract to interrupt pain transmission.
Discussion: These techniques are now used less frequently due to the advent of ISDA and other regional anaesthetic techniques, but in those patients whose cancer pain cannot be controlled, anterolateral spinothalamic cordotomy can provide pain relief lasting up to a year or more, says Professor Cousins. He warns that this procedure requires considerable skill and is offered by only a few centres. Mirror image pain may develop on the opposite side of the body after variable periods of time. 
- Treatment: Radiofrequency lesioning
Condition: Suitable for patients with severe low back pain associated with osteoarthritis of facet joints (mechanical low back pain).
How it works: This treatment destroys sensory nerve endings in the joints of the spine and is performed as an outpatient procedure.
Discussion: When used correctly, 70 to 80% of patients will experience a good block of the selected nerve for six to nine months.  Clinical data suggest this method is most effective in chronic pain syndromes such as radicular pain and peripheral neuropathies. 
- Treatment: Neuromodulation
Condition: Acute and chronic pain including neuropathic pain, back pain, muscle pain, headaches and migraines.
How it works: Nerve activity is altered or modulated by delivering electrical or pharmaceutical agents directly to the target area.
Discussion: Patients often use simple interventions such as icing and TENS to cope with mild to moderate nociceptive pain. Bio-electrics is emerging as a promising field. 
- Treatment: Spinal cord stimulation (SCS)
Condition: Neuropathic pain including chronic neck and back pain.
How it works: An electrical current is delivered near the spinal column via programmable subcutaneous generator in the upper buttock or abdomen.
Discussion: This technique has been used for more than 40 years, but only about 40% of patients respond, with an about 40% reduction in pain. Recent improvements in the technique have been achieved through a ‘closed loop’ system that provides continuous and instantaneous adjustment of the SCS. Also, high frequency stimulation and burst stimulation have been reported to be successful in over 80% of patients, with much larger reductions in pain than previously reported. 
- Treatment: Peripheral nerve stimulation (PNS)
Condition: Good results observed in intractable migraine, occipital neuralgia and post inguinal herniorrhaphy neuropathic pain.
How it works: Similar to SCS, electrodes are placed in proximity to peripheral nerves, for example the greater occipital nerve for migraine and occipital neuralgia.
Discussion: Patient selection is important. This method has however been shown to be useful in decreasing severe pain in the distribution of the peripheral nerve. 
- Treatment: Sacral nerve stimulation (SNS)
Condition: Currently used widely by urologists and colorectal surgeons for conditions such as incontinence, SNS is gradually being used more for pain conditions such as perineal pain, bladder pain (‘interstitial cystitis’) and pelvic pain (e.g. pudendal canalstenosis).
How it works: An electrical current is delivered to the sacral nerves.
Discussion: The results for SNS in patients with neuropathic pelvic pain have been mixed, partly due to problems with anchoring the sacral electrodes. However, improvements in the technique mean it has the potential to transform the lives of patients with extreme chronic pelvic pain, says Professor Cousins. 
This content was independently produced by Cirrus Media with a sponsorship from Pfizer Australia.
References available upon request