Practice Uncertainties

Which pain medications are effective for sciatica (radicular leg pain)?

BMJ 2017; 359 doi: (Published 12 October 2017) Cite this as: BMJ 2017;359:j4248

Re: Which pain medications are effective for sciatica (radicular leg pain)?

At primary care level we are on constant receipt of 'advice' from pain clinics, rheumatologists and all sorts to prescribe gabapentinoids for all sorts of reasons and usually the patient is under the expectation that these drugs will work. It is rare (in fact in my experience a never event) for the letter to include the comment that these medications might not work and if so stop them--rather to increase and increase the dose over months by which time the person taking does not know what they were like in the first place. I do agree on occasions they do work and work well.

For genuine radicular pain it also is probably important to do something that works before a chronic pain sets in - ie, MRI, possibly surgery, possibly nerve block--taking into account risk factors of smoking and not in work.

For narcotics, as primary care doctors we don't get to read the anaesthetic journals about narcotics with their science about pain enhancement dose responses, etc, and again the pain clinic approach is to up the dose then swap narcotic again without the possibility that narcotics won't work.

There was a time when pain clinics had a much more holistic approach, including accepting ways of living with symptoms - a much more honest reality than pretending we can cure things.

The BMJ continues to publish articles where the promotion of gabapentinoids is included without NNT or NNH or even licensed indications. Why?

Competing interests: No competing interests

14 November 2017
N John Sharvill
Deal Kent