Intended for healthcare professionals

Rapid response to:

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

Rapid Response:

Re: Neuropathic pain: mechanisms and their clinical implications

Dear Editors

Various rapid responses to this article on the definition of neuropathic pain illustrate the problem of definition and differentiation of pathomechanics of pain production.

I would not be surprised if doctors who have similar experience in pain medicine differ in the diagnosis of neuropathic pain in the same patient

I am, however, alarmed by the number of patients who I inadvertently see through various orthopaedic clinics who are on Pregabalin for back pain; in Australia Pregabalin is on subsidised prescription schedule (PBS - Pharmaceutical Benefits Schedule) specifically for "refractory neuropathic pain not controlled by other drugs".

By these accounts, it appears that an alarmingly high number of back pain cases would be neuropathic in nature, if the indications for subsidised prescription are valid. And yet, a quick casual history (incooperating painDETECT) and a review of back x-ray support a diagnosis of back pain from degenerative facet joint arthritis without radiculopathy. Admittedly, a detailed history and medical record review was not undertaken so it is unclear to me the basis of decision-making leading to the provision of this drug by the prescribing doctors, most of whom are primary care providers and not pain specialists.

Given the various uncertainties in the definitions of neuropathic pain even amongst pain medicine practitioners, I am concerned that the trend in prescription of drugs like Pregabalin is not based on accurate or informed diagnosis, rather the fashion of the day and the reported improvement of symptoms in these patients with chronic back pain are in fact from secondary effect of Pregabalin, including anxiolytic and possible mood modulation effects.

Competing interests: I am not involved in long term management of chronic back pain (neuropathic or otherwise)

19 March 2014
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia