Intended for healthcare professionals

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Clinical Review State of the Art

Neuropathic pain: mechanisms and their clinical implications

BMJ 2014; 348 doi: (Published 05 February 2014) Cite this as: BMJ 2014;348:f7656

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Re: Neuropathic pain: mechanisms and their clinical implications

I would like to congratulate the authors for putting together useful summary of our current knowledge regarding neuropathic pain and which I hope will be of educational value to health care professionals who do not have the time to delve into the complexity of pain. I hope that readers will now realise how the multitude of transmitters and receptors involved in this pathophysiological condition explains why no single drug consistently helps patients who have their own individual biological polymorphisms and psychosocial backgrounds. Hence the succinct title of a previous paper published in the BMJ in 2013 "Expect analgesic failure; pursue analgesic success" [1].

The authors of this current state of art review have made some comments about high dose intravenous ketamine infusions, their side effects and the lack of long term outcome data. Whilst not a randomised controlled study, I would like to bring to their attention and to readers in general, my experience with using low dose sublingual ketamine in a heterogeneous group of patients, reflecting over 200 patient years of experience of using this treatment modality in a fashion that is more practical than inducing a ketamine coma in an attempt to reboot the central nervous system.Whilst clearly sublingual ketamine treatment is a therapy that has not been consistently helpful, for a small group of patients, it has.The complex pathophysiology underpinning the neuropathic pain state as outlined in this review may explain why this is the case.

[1] Moore et al Expect analgesic failure; pursue analgesic success
BMJ 2013;346:f2690 (last accessed 16 2 14)

[2] Jaitly Sublingual Ketamine in chronic pain : Service evaluation by examining over 200 patient years of data
Journal of Observational Pain Medicine – Volume 1, Number 2 (2013) ISSN 2047-0800 (open access)[]=26 (last accessed 16 2 14)

Competing interests: Over the years I have attended meetings and had lunches/dinners sponsored by a range of pharmaceutical firms and equipment manufacturers.

16 February 2014
Varun K Jaitly
Consultant Anaesthetist with an interest in Chronic Pain
Wrightington Wigan and Leigh NHS Foundation Trust
Department of Anaesthesia, Royal Albert Edward Infirmary, Wigan Lane, Wigan WN1 1NN