Talk:Neuropathic pain

Wiki Education Foundation-supported course assignment

This article is or was the subject of a Wiki Education Foundation-supported course assignment. Further details are available on the course page. Student editor(s): Kobefields, Stone-McQuaidT.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 05:10, 17 January 2022 (UTC)

Creating page

I've created this page, mostly from content removed from the Neuropathy article, as part of a reorganisation of the articles relating to neuropathy. I appreciate that further work is needed, and would welcome help in the form of comments or edits. Please see the recent discussion on the Peripheral neuropathy talk page. Neurotip (talk) 18:02, 22 November 2009 (UTC)

Stimulants

Stimulants like amphetamine and cocaine can have an analgesic effect and potentiate the analgesic effect of opiates, however tolerance is quickly developed.

I think there should be a new section like above, but the litterature I found didn't specifically mention neuropathic pain, but I'm pretty sure, that the sentence above is valid also for neuropathic pain. Here is link with lots of references: http://www.doctordeluca.com/Library/Pain/Pain-Amphetamines.htm Knowww (talk) 18:34, 24 March 2011 (UTC)

Dietary supplements

I'm concerned about the strength of the claims made for the efficacy of dietary supplements, particularly

A variety of essential nutrients including vitamins like thiamine (especially the benfotiamine form), pyridoxine, biotin, folic acid, methyl- or cyanocobalamin and vitamin E, minerals such as magnesium, zinc and chromium, the amino acids L-arginine and L-glutamine, and the omega-3 and omega-6 fatty acids, as well as a few non-essential nutrients like myo-inositol and taurine, have all been found effective in both alleviating pain symptoms and healing actual damage in different types of peripheral neuropathy. Additionally, antioxidants including alpha-lipoic acid, acetyl-L-carnitine, glutathione, and N-acetylcysteine have been found useful in a similar manner.

I'll be able to access the source in a week or so but, in the meantime, could the editor who authored this paragraph please double-check the source to make sure the paragraph accurately reflects the source? --Anthonyhcole (talk) 20:27, 13 May 2011 (UTC)

The ref does not say the above. Thus removed.--Doc James (talk · contribs · email) 20:52, 13 May 2011 (UTC)

What is it??

Hi. I just read the article and it doesn't actually say what neuropathic pain is. It starts off by saying what causes it, what it is associated with, the different people that are affected by it, what parts of the body, and so on. But it doesn't actually say, you "what is neropathic pain". I read the article and I have no idea. Can someone who knows add this to the article? — Preceding unsigned comment added by 122.249.84.227 (talk) 06:03, 6 June 2011 (UTC)

122.249.84.227 is absolutely correct, even today, years later. The article really does start off by what causes the condition, etc, but never buckles down to actually defining it. Would someone who knows please add a definition? Thank you, Wordreader (talk) 02:04, 1 December 2014 (UTC)

It's really quite complex, and a thorough study of neuropathy is needed to understand it, which means devoting oneself to reading several articles on the subject. I can only speak to my own neuropathies of both hands and feet caused by diabetes. In my case the basic explanation is that the higher general sugar levels in my bloodstream have damaged the myelin sheaths that protect the nerves, which is revealed at Neuropathy#Polyneuropathy. Bare, unprotected nerves send mixed messages to the pain centers of the brain, and since there is more than one kind of nerve (heat sensing, pressure sensing, etc.), there are several different types of pain at varying intensity levels. While this describes my own situation, it barely scratches the surface of all the possible explanations of what NP is, but it may begin to give some idea. – Paine Ellsworth ^CLIMAX! 11:17, 1 December 2014 (UTC)

Opioids

Our current content on opioids is not consistent with the published evidence; we must stress that the evidence for their use is supported by limited evidence - doi:10.1002/14651858.CD006146.pub2 (Cochrane review). JFW | T@lk 16:29, 3 September 2013 (UTC)

Lancet Neurology review of all pharmacotherapeutic agents for neuropathic pain doi:10.1016/S1474-4422(14)70251-0 JFW | T@lk 22:25, 26 January 2015 (UTC)

Cannabinoids section seriously out of date.

There has been plenty of more recent research, also the info on Sativex availability is out of date.--Penbat (talk) 15:35, 28 September 2014 (UTC)

Additionally, it conflates CBD with THC, and is now doubly out of date given the proliferation and wider OTC availability of CBD products. VxJasonxV (talk) 06:40, 11 October 2022 (UTC)

Trimmed primary source

I trimmed this. We should be using secondary sources per WP:MEDRS "In a study conducted by the University of California, San Diego and published in the American Pain Society's Journal of Pain, researchers found that cannabis provided at least the equivalent in pain reduction as other patients reported from using traditional neuropathic pain medication."

References

Doc James (talk · contribs · email) 15:43, 18 March 2015 (UTC)

I don't particularly agree with that guideline, especially when the study is performed by a reputable institution and by scholars who performed a scientific study of the subject. Also, since the author of the second source, Marie Veksler, did not participate in the study, then that is a secondary source that reports on the findings of, and supports, the primary source. Do you have any specific problems with that source? – Paine Ellsworth^CLIMAX! 10:04, 19 March 2015 (UTC)

This is popular press [1] What we are looking for is a review article. Or a positions statement by a nationally or internationally recognized body. Doc James (talk · contribs · email) 15:21, 19 March 2015 (UTC)

Sourcing is not OK per WP:MEDRS - we don't get to blow off policies and guidelines here. Paine Ellsworth please really do read MEDR - especially the definitions of primary, secondary in "Definitions" and the section on "Respect secondary sources". If you don't understand why current secondary sources are so important for health content, the lead of my too-long draft essay might help you -- see Why MEDRS? -- Jytdog (talk) 15:30, 19 March 2015 (UTC)

ill second that--Ozzie10aaaa (talk) 15:43, 19 March 2015 (UTC)

Since Google Scholar finds a number of review articles that cite this paper (http://scholar.google.com/scholar?cites=872360759358358409&as_sdt=5,44&sciodt=0,44&hl=en), there is really no justification for going against MEDRS here. Looie496 (talk) 15:51, 19 March 2015 (UTC)

If we know medical secondary sources exist, I don't see a reason to remove the content, per wp:preserve, our editing policy — assuming the primary source content that needs to be converted into secondary source supported material could or would be included in a featured article version of the topic. Such material can be tagged with {{npsn}}, a shortcut for Template:Primary source-inline, which appears as this:, instead of removed. I hope that helps. Biosthmors (talk) pls notify me (i.e. {{U}}) while signing a reply, thx 19:33, 19 March 2015 (UTC)

The two review articles identified by Web of Knowledge that cite the 2012 (actually published in 2013) source include The Effectiveness of Cannabinoids in the Management of Chronic Nonmalignant Neuropathic Pain: A Systematic Review By: Boychuk, Darrell G.; Goddard, Greg; Mauro, Giovanni; et al. JOURNAL OF ORAL & FACIAL PAIN AND HEADACHE Volume: 29 Issue: 1 Pages: 7-14 Published: WIN 2015 & Adverse Health Effects of Marijuana Use By: Volkow, Nora D.; Baler, Ruben D.; Compton, Wilson M.; et al. NEW ENGLAND JOURNAL OF MEDICINE Volume: 370 Issue: 23 Pages: 2219-2227 Published: JUN 5 2014. Hope that helps. Biosthmors (talk) pls notify me (i.e. {{U}}) while signing a reply, thx 19:47, 19 March 2015 (UTC)

The conclusion of the abstract of the 2015 review is "Cannabis-based medicinal extracts used in different populations of chronic nonmalignant neuropathic pain patients may provide effective analgesia in conditions that are refractory to other treatments. Further high-quality studies are needed to assess the impact of the duration of the treatment as well as the best form of drug delivery." Biosthmors (talk) pls notify me (i.e. {{U}}) while signing a reply, thx 20:03, 19 March 2015 (UTC)

The NEJM states "Marijuana has been used to relieve pain for centuries. Studies have shown that cannabinoids acting through central CB1 receptors, and possibly peripheral CB1 and CB2 receptors,63 play important roles in modeling nociceptive responses in various models of pain. These findings are consistent with reports that marijuana may be effective in ameliorating neuropathic pain,64,65 even at very low levels of THC (1.29%).66" The source "66" is Wilsey 2013. Biosthmors (talk) pls notify me (i.e. {{U}}) while signing a reply, thx 20:17, 19 March 2015 (UTC)

WP:Secondary does not mean independent. A person who didn't participate is independent. In the absence of transformative thought (such as, but not limited to, a meta-analysis), the independent source is not actually secondary. Independent primary sources are often valuable, but they have more limited value for claims of efficacy. WhatamIdoing (talk) 03:20, 20 March 2015 (UTC)

The medical knowledge represented here is both admirable and appreciated; however, it appears that there is something to be learned here about this encyclopedia project. The so-called "consensus" in WP:MEDRS cannot be sustained as follows:

• Policy: "Unless restricted by another policy, reliable primary sources may be used in Wikipedia", and the last I checked, policies are not overridden by guidelines.
• Guideline: "Ideal sources for biomedical assertions include general or systematic reviews in reliable, third-party, published sources, such as reputable medical journals", and this is the main guideline on the subject.

This policy and guideline represent the community consensus regarding all articles on Wikipedia. There are good reasons for this community consensus. The so-called "consensus" in WP:MEDRS is more like an "anti-consensus", isn't it? It flies slap in the face of the community consensus. By being more restrictive, that medical anti-consensus makes it easier to introduce POV into medical articles. In this case the bias is against a perfectly good report in a medical journal about how cannabis, when distributed safely by medical professionals (implication) is just as effective for neuropathic pain as the dangerous, addictive opioids that are presently given to people. Arguably, there seem to be secondary sources available in this instance, but how many other times has this bias been introduced? Such bias goes against one of the five pillars of this project, and should be fought tooth and nail. I myself am getting too old to fight these fights, so I leave it here in good hands. (If any of that sounded patronizing, it most assuredly was not meant that way and only meant with the highest esteem for the medical profession.) – Paine Ellsworth^CLIMAX! 12:11, 22 March 2015 (UTC)

this is not the place to have the general discussion. please bring up your issues at WT:MEDRS. Thanks. I will say that every policy (WP:OR, WP:NPOV, WP:VERIFY) and the general RS guideline WP:RS) says that we should rely on secondary sources. yes these policies and the RS guideline - and even MEDRS - say that primary sources may be used, but you have provided no reason as to why their use is justified here. "may' is not a license to use primaries whenever you want. Jytdog (talk) 12:46, 22 March 2015 (UTC)

This had to be brought up HERE in order to countermand usage of the anti-consensus that was cited. And apparently you haven't actually read WP:MEDRS, which clearly states (against policy and community consensus): Primary sources should generally not be used for medical content. This flies in the face of both the policy and the main guideline I cited, which makes your argument above ill-formed, inaccurate and improper, thank you! Instead of grasping at straws, you might try to listen and understand. – Paine Ellsworth^CLIMAX! 15:01, 22 March 2015 (UTC)

nope, you make it even more clear here that you are arguing with a guideline itself. that guideline has the same status as WP:RS - also a guideline. You cannot change a guideline the level of an article. Again, if you want to use a primary source anywhere in WP, you need to bring a good reason to do so. You are not dealing with that with regard to this instance; that is what this Talk page is for. Again, WT:MEDRS is thataway if you want to challenge the guideline. If you want to discuss whether MEDRS contradicts WP:OR, WP:NPOV, or WP:VERIFY at a higher level, the place to do that, would be at that policy Talk page. Jytdog (talk) 15:27, 22 March 2015 (UTC)

I do not dispute that the place to actually challenge the guideline is on the talk page of the guideline. Nor did I ever indicate such a preposterous thing as you imply (that it should be argued here). The medical guideline was cited as a reason not to use a perfectly good primary source in accord with both the main guideline and the policy I cited above. So it is also appropriate to bring up this discrepancy here on the talk page of the article where the dispute first began with the out-of-hand removal of the cited text. If I argue with a guideline here it is because I specifically do not like to refer to someone as incorrect (except perhaps someone who argues inaccurately). I usually prefer to focus on what is right and wrong rather than on "who" is right and wrong. Anyway, you are fighting a lost fight, because it appears that the obvious must take place. A specific guideline cannot override a general community consensus nor can it override a policy. Therefore, the primary source in this case should not be disallowed. That source is usable in any applicable article on Wikipedia – and that's policy. – Paine Ellsworth^CLIMAX! 16:23, 22 March 2015 (UTC)

no policy or guideline says that primary sources should be used - they say may. in other words, it is conditional. so again, what is the reason to use this one here? Jytdog (talk) 16:25, 22 March 2015 (UTC)

Already stated (and there is no "may" in the main guideline passage I cited). – Paine Ellsworth^CLIMAX! 17:02, 22 March 2015 (UTC)

your quote from RS is cherry picked. the whole section from RS (which doesn't dominate MEDRS but is parallel as both are guidelines) says "Ideal sources for biomedical assertions include general or systematic reviews in reliable, third-party, published sources, such as reputable medical journals, widely recognised standard textbooks written by experts in a field, or medical guidelines and position statements from nationally or internationally reputable expert bodies. Being a "medical source" is not an intrinsic property of the source itself; a source becomes a medical source only when it is used to support a medical claim. It is vital that the biomedical information in all types of articles be based on reliable, third-party, published sources and accurately reflect current medical knowledge." Compare the bolded text to what you find here: Wikipedia:Identifying_reliable_sources_(medicine)#Definitions. You will see those are secondary or tertiary sources. Jytdog (talk) 17:33, 22 March 2015 (UTC)

Support for the MEDRS guideline is substantial and widespread it represents a broad consensus. Even if use of a primary source is allowable under general PAG the core policies clearly point to using the highest quality sourcing available. Rationale to support the use of a primary source needs to be provided. Contested content or inclusion of a source needs consensus support. Policy based rationale for using this primary source seems lacking in this discussion. Solid policy based rationale for MEDRS in general has been presented extensively (on the relevant talk page and elsewhere) many of the reasons supporting MEDRS in general apply to this article. PAG is clear in putting forth the concept that the highest quality encyclopedic content supported by the strongest most appropriate sources for an encyclopedia are the goal and intent of WP. Where is a policy based rationale for not using the best possible source? If primary sources produce notable, important knowledge that is sustained under scrutiny it will be covered in MEDRS quality sources and then become appropriate content for an encyclopedia. - - MrBill3 (talk) 04:26, 23 March 2015 (UTC)

Okay, I'm wrong – all of you are right. All of you seem intent on rationalizing away the fact that MEDRS restricts an earlier community consensus in both policy and guideline. You appear to be so deathly afraid of OR that you are willing to eliminate perfectly good and valid information sources out-of-hand. No checking them to see if they are good sources, just delete them with no attempt to see if they're valid, which goes against policy, the main guideline and a much broader community consensus than could possibly be had by a specialty guideline. It is not right for a specialty guideline to restrict a policy nor a main guideline. That's not how Wikipedia works. The moment one learns to read with understanding, that will be the THE moment. You're not arguing with me, you're arguing with policy, the main guideline and the long-standing community consensus behind those. I'm getting too old for this. Feel free to do what you "may". I'm done. – Paine Ellsworth^CLIMAX! 06:27, 23 March 2015 (UTC)

Scrambler therapy

Just what is wrong with this link:

• Sparadeo F, Kaufman C, D'Amato S (2012) Scrambler therapy: an innovative and effective treatment for chronic neuropathic pain'' Journal of Life Care Planning Vol 11 No 3 pp3-15

and plenty more in scrambler therapy ? --Penbat (talk) 18:05, 7 April 2015 (UTC)

our guideline for sourcing health content is WP:MEDRS. Please read it. If you don't understand something there, please let me know. (the source you provide above, is a WP:PRIMARY source as defined in MEDRS) Jytdog (talk) 18:09, 7 April 2015 (UTC)

It is a primary source yes. Doc James (talk · contribs · email) 00:24, 12 November 2016 (UTC)

Opiods Section- Fentanyl

I am thinking of adding this 2016 cochrane review into the article http://www.cochrane.org/CD011605/SYMPT_fentanyl-neuropathic-pain-adults Potential addition: "There is no clear evidence suggesting that fentanyl gives pain relief to people with neuropathic pain." OR "It is unknown if fentanyl gives pain relief to people with neuropathic pain."

I could also add this sentence onto the fentanyl page. Thanks! JenOttawa (talk) 21:07, 11 November 2016 (UTC)

We tend not to use the word "suffer" so adjusted to match. Looks good otherwise. I like the second personally. Doc James (talk · contribs · email) 00:08, 12 November 2016 (UTC)

I would prefer "unclear" rather than "unknown". Axl ¤ [Talk] 10:27, 12 November 2016 (UTC)

Great suggestions. Thanks. JenOttawa (talk) 12:24, 12 November 2016 (UTC)

Anticonvulsants

The article currently states that

"Pregabalin and gabapentin are first-line medications for diabetic neuropathy.[citation needed] "

What type of citation would be appropriate here? I could use systematic reviews and change it to:

Pregabalin and gabapentin may reduce pain associated with diabetic neuropathy.

Thanks. JenOttawa (talk) 16:41, 3 January 2017 (UTC)

Given the conclusions from the two papers:

Pregabalin has proven efficacy in neuropathic pain conditions and fibromyalgia. A minority of patients will have substantial benefit with pregabalin, and more will have moderate benefit. Many will have no or trivial benefit, or will discontinue because of adverse events. ...

and

There was no top tier evidence that was unequivocally unbiased. Second tier evidence, with potentially important residual biases, showed that gabapentin at doses of 1200 mg or more was effective for some people with some painful neuropathic pain conditions. The outcome of at least 50% pain intensity reduction is regarded as a useful outcome of treatment by patients, and the achievement of this degree of pain relief is associated with important beneficial effects on sleep interference, fatigue, and depression, as well as quality of life, function, and work. About 35% achieved this degree of pain relief with gabapentin, compared with 21% for placebo. Over half of those treated with gabapentin will not have worthwhile pain relief. Results might vary between different neuropathic pain conditions, and the amount of evidence for gabapentin in neuropathic pain conditions except postherpetic neuralgia and painful diabetic neuropathy, and in fibromyalgia, is very limited.The levels of efficacy found for gabapentin are consistent with those found for other drug therapies in postherpetic neuralgia and painful diabetic neuropathy.

I think your proposed wording is fine, and your proposed sources are fine, too - as is the NICE guideline suggested by Bondegezou below. Thanks for picking this up. --Anthonyhcole (talk · contribs · email) 17:24, 3 January 2017 (UTC)

You could also cite the NICE guidance at https://www.nice.org.uk/guidance/cg173 and https://pathways.nice.org.uk/pathways/neuropathic-pain#content=view-node%3Anodes-pharmacological-treatment-for-all-neuropathic-pain-except-trigeminal-neuralgia . The latter states, "Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)". Bondegezou (talk) 17:20, 3 January 2017 (UTC)

Amitriptyline and duloxetine are antidepressants and are covered in the next section. --Anthonyhcole (talk · contribs · email) 17:43, 3 January 2017 (UTC)

Thanks for the feedback. I appreciate your time. JenOttawa (talk) 19:44, 3 January 2017 (UTC)

• might try [2]Medicines used to treat neuropathic pain section...IMO--Ozzie10aaaa (talk) 11:01, 4 January 2017 (UTC)

ref

References

Rewrite

Hi guys,

I think this page needs a significant rewrite as there are many mistakes in the mechanistic part, for instance, those are not the definitions of peripheral or central sensitisation and I think the spinal cord is misunderstood here. I also think the treatments are unbalanced. Reading the page you might be led to believe that things like neuromodulation are mainstream treatments. I think the discussion over treatments might be somewhat wrong footed, my opinion that doctors try many available treatments for neuropathic pain because our understanding remains limited and we don't have the right tools. It is very difficult to perform a trial in the field because there are limited groups of patients. I think this all needs to be mentioned, because I foresee situations where a doctor who has exhausted first and second line medications who wants to be creative with a patient finds it difficult with this article. To make it even more complicated, I think there are even a group of patients who would uniquely benefit from a placebo. Maybe it is better to discuss in general terms with a few references to the agents that have been 'particularly' successful, although I'd note even the best agent has a NNT of 4!

I will put a version in my sandbox. For Now I will remove the mechanisms section. It will take quite some time to rewrite that section fully, however, those mechanisms are too controversial to be included, I think they are based on quite a fundamental misunderstanding of each of those concepts PainProf (talk) 18:36, 27 May 2020 (UTC)

References

Bad picture

The picture in this article is a person with shingles. It's hard to illustrate pain, but a pic of shingles lesions is not a great choice.174.56.45.216 (talk) 05:57, 19 June 2020 (UTC)