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Update on Chronic Neuropathic Pain Medications

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Presentation on theme: "Update on Chronic Neuropathic Pain Medications"— Presentation transcript:

1 Update on Chronic Neuropathic Pain Medications
Joyce Côté, BSc Pharm ACPR Pharmacist, Chronic Pain Centre January 16, 2013 Calgary Neuropathy Association Presentation

2 Outline Medication Goals and Patient’s Toolbox Antidepressants
Anticonvulsants Opioids Cannabinoids Medical marijuana

3 Goals of Medication Therapy
30% pain relief may be expected Increase function Balance pain relief with acceptable side effects It is important to be realistic about how much pain relief you would expect to get with medications. Unfortunately, there is no “magic pill” that will take away all your pain. Often, only 30% pain relief would be expected with the use of medications. For example, if you have severe pain, it might be reasonable to decrease that pain from severe to moderate, perhaps from 9/10 down to 6/10 on the pain scale that we saw on the previous slide. We also hope to increase your level of function with medications, so that you are able to do more of the day-to-day activities you used to do before you were in pain. Because all medications can cause side effects, we need to balance your pain relief with side effects that are acceptable to you.

4 Patient’s Toolbox Knowledge Medications Nutrition Self-Monitoring
Although medications can be helpful, you can see that they are not likely to completely take away all your pain. So it is important to note that medications are only one tool in your toolbox. Your other tools may include knowledge, nutrition, rehabilitation and exercise, and most-importantly self-management skills, which include self-monitoring, pacing, relaxation, self-talk and communication. Self-Monitoring Pacing Relaxation Self-Talk Communication Rehabilitation Self-Management


6 Antidepressants – Tricyclic
Amitriptyline (Elavil®), Nortriptyline (Aventyl®), Desipramine (Norpramin®) 1st line for neuropathic pain Increase levels of serotonin and norepinephrine May also be helpful for sleep, mood, and migraine prevention Side Effects: Drowsiness, dizziness, blurred vision, constipation, difficulty urinating, weight gain

7 Amitriptyline Alberta Blue Cross – Regular Benefits 10 mg tablet $0.06

8 Nortriptyline Alberta Blue Cross – Regular Benefits
10 mg capsule $0.09 25 mg capsule $0.18

9 Desipramine Alberta Blue Cross – Regular Benefits 10 mg tablet $0.38


11 Antidepressants – SNRI
SNRI = Serotonin and Norepinephrine Reuptake Inhibitor Increase serotonin and norepinephrine Venlafaxine (Effexor®), duloxetine (Cymbalta®) Side Effects: Nausea, headache, increased blood pressure Withdrawal effects are common with venlafaxine

12 Venlafaxine Alberta Blue Cross – Regular Benefits
37.5 mg capsule $0.35 75 mg capsule $0.70 150 mg capsule $0.73

13 Duloxetine Health Canada Indications Major depressive disorder
Diabetic peripheral neuropathic pain General anxiety disorder Fibromyalgia Chronic low back pain Osteoarthritis of the knee (July 2012)

14 Duloxetine Alberta Blue Cross – Regular Benefit 30 mg capsule $1.88


16 Antiepileptics – 1st Line
Gabapentin (Neurontin®), pregabalin (Lyrica®) 1st line for neuropathic pain Side Effects: Drowsiness, dizziness, unsteadiness, unable to think clearly, weight gain

17 Gabapentin Alberta Blue Cross – Regular Benefits 100 mg capsule $0.16
Alberta Blue Cross – Not Benefits 600 mg tablet ~$1.30 800 mg tablet ~$1.74

18 Pregabalin Health Canada Indications Diabetic peripheral neuropathy
Postherpetic neuralgia Spinal cord injury neuropathic pain Fibromyalgia

19 Pregabalin Alberta Blue Cross – Not Benefits 25 mg capsule ~$0.85
Generics expected to be available ~Sept 2013


21 Antiepileptics – Other
Topiramate (Topamax®), lamotrogine (Lamictal®), carbamazepine (Tegretol®), oxcarbazepine (Trileptal®), divalproex (Epival®)

22 Topiramate (Topamax®)
Also useful for prevention of migraine headaches Side Effects: Drowsiness, dizziness Memory difficulties, confusion Loss of appetite, nausea Burning/tingling/numbness in hands/feet

23 Topiramate Alberta Blue Cross – Regular Benefits 25 mg tablet $0.48
50 mg tablet (PMS Only – pale yellow) $1.07 100 mg tablet $0.91 200 mg tablet $1.36 15 mg sprinkle capsule $1.17 25 mg sprinkle capsule $1.23


25 Opioids Canadian Opioid Guidelines
“Opioids showed only small to moderate benefits for neuropathic pain.” Some opioids are marketed specifically for neuropathic pain due to additional mechanisms of action Tramadol Tapentadol Methadone

26 Opioids Common side effects:
Drowsiness, dizziness, nausea, constipation, itching Serious side effects: Breathing slows down Long-term complications: Sleep apnea Decrease in sex hormones Opioid-induced hyperalgesia

27 Tramadol Long-Acting Also increases serotonin and norepinephrine
Ralivia® Tridural® 25% immediate-release Zytram XL® Durela®) 17 to 25% immediate-release

28 Ralivia® 100 mg tablet ~$1.32 200 mg tablet ~$2.39

29 Tridural® 100 mg tablet ~$1.26 200 mg tablet ~$2.31 300 mg ~$3.26

30 Zytram XL® 75 mg tablet ~$0.91 100 mg ~$1.18 150 mg ~$1.71

31 Durela® 100 mg capsule ~$1.22 200 mg capsule ~$2.23

32 Tapentadol CR (Nucynta CR®)
Moderate-severe pain Mu-opioid agonist plus norepinephrine reuptake inhibition (NRI) Possibly better GI tolerability Possibly more norepinephrine-like side effects Maximum dose

33 Tapentadol CR Alberta Blue Cross – Not a Benefit 50 mg CR ~$1.03

34 Methadone (Metadol®) Two distinct indications: Pain
Opioid-dependence / addiction For pain: Opioid activity Serotonin and norepinephrine reuptake inhibition NMDA receptor antagonist NMDA = N-methyl-D-aspartate

35 Methadone Long-acting Inexpensive Electrocardiogram required
Requires frequent monitoring while adjusting the dose Lots of drug interactions Risk of overdose is higher Physician requires a special license

36 Methadone Alberta Blue Cross – Regular Benefit 1 mg tab $0.17
1 mg/mL oral solution $0.10/mL 10 mg/mL oral solution $0.37/mL

37 cannabinoids

38 Cannabinoids Nabilone (Cesamet®), tetrahydrocannabinol-cannabidiol (Sativex®) Side effects: Drowsiness, dizziness, unsteadiness, dry mouth

39 Nabilone (Cesamet®) Health Canada indicated for nausea and vomiting associated with chemotherapy Studied in fibromyalgia (1 mg twice daily x 4 weeks) Studied in diabetic peripheral neuropathic pain (1-4 mg/day x 9 weeks)

40 Nabilone Alberta Blue Cross – Regular Benefits
0.5 mg capsule $3.10 (generic $1.17) 1 mg capsule $6.21 (generic $2.33)

41 Tetrahydrocannabinol-cannabidiol (Sativex®)
Spray under tongue or inside cheek Usually 8 sprays/day Alberta Blue Cross – Not a Benefit Vials of 48 sprays = ~$125

42 Medical marijuana

43 Medical Marijuana Health Canada:
“Marijuana is not an approved therapeutic product” “Its safety and efficacy have not been established” “Use… involves risks to health, some of which may not be known or fully understood”

44 Medical Marijuana What it does:
Often produces euphoria, relaxation, time-distortion, perception of enhanced sensory experiences, and loss of inhibitions What the active ingredients might be: Tetrahydrocannabinol (THC) Cannabinol Cannabidiol

45 Medical Marijuana What the other ingredients might be:
There may be more than 60 other cannabinoids Many of the substances found in tobacco smoke have been found in marijuana smoke

46 Medical Marijuana Warnings: Heart disease
Asthma, chronic obstructive pulmonary disease Alcohol/drug abuse or dependence Serious mental disorders Administration by smoking is not recommended Some people use in food, tea, or with a vaporizer May impair your ability to drive Can last up to 24 hours after consuming

47 Medical Marijuana Side Effects:
Mood reactions such as anxiety, paranoia, agitation, amnesia, delusions or hallucinations Fast heartbeat Facial flushing or red eyes Dizziness or feeling faint Long-Term Complications: Wheezing or chronic cough if smoked May impair short-term memory, attention, and concentration

48 Medical Marijuana Drug Interactions
Any drugs that slow down the central nervous system, causing drowsiness E.g. sleeping pills Antiviral drugs used in the treatment of AIDS

49 Medical Marijuana Application Process Two Categories
Category 1 – specialist not needed Category 2 – specialist required Authorization renewal required yearly Marihuana Medical Access Division: or

50 Medical Marijuana Distribution
Delivery every month by courier to your home or doctor’s office Cost 30 seeds = $20 Dried marijuana = $5/gram

51 Medical Marijuana College of Physicians and Surgeons of Alberta Jan 2012: “marijuana remains an illegal drug; one that is not on any formulary and one that has no human evidence as to efficacy, dose or safety.” “In the absence of evidence as to efficacy, we will continue to counsel our members not to authorize (or ‘prescribe’) [medical marijuana] for medical purposes.”

52 Medical Marijuana Proposed changes December 16, 2012
Removes Health Canada as a gatekeeper Doctors fill out a medical document similar to a prescription No specialist consult doctor required Patients takes document to a licensed producer Removal of home production

53 Medical Marijuana Canadian Medical Association:
“There’s a huge potential for harm to patients and the federal government’s decision is equivalent to asking doctors to prescribe while blindfolded.”

54 Medical Marijuana Currently > 26, 000 patients across Canada with authorized use (<500 patients in 2002) Cost will increase to ~ $8.80/gram (from $1.80 to $5/gram) Federal Health Minister Leona Aglukkaq: “Individuals will be able to choose their licensed producer based on strength, price, quality and customer service”

55 Medical Marijuana Health Canada will keep its current contract until March 31, 2014 to continue current patients Health Canada will align the price of its own supply once licensed producers are approved No new applications after October 1, 2013 April 1, 2014: Health Canada would no longer produce/sell marijuana

56 Medical Marijuana Producers are subject to security requirements, inspections, and good manufacturing practices Indoor production site (not a private residence) Restricted access 24/7 camera security system and alarm system Valid security clearance Notify local police, fire, and government officals

57 Medical Marijuana Government’s goal is to have new guidelines by March 31, 2013, and full implementation by April 2014 Canadians have the opportunity to comment before Feb 28, 2013. Comments or concerns you might have regarding the proposed changes can be submitted to Health Canada via

58 Topical analgesics

59 Topical Lidocaine 5% ointment commercially available, 30 grams
Applied 3-4 times daily as needed Requires prescription May be compounded with other drugs and using different bases Alberta Blue Cross – Regular Benefit $0.15/gram topical ointment

60 Topical Capsaicin Capsaicin 0.075% cream (Zostrix HP)
Painful diabetic foot neuropathy Applied four times daily regularly Decreases pain intensity Well tolerated after initial few days Available over-the-counter ~$31 per 60 grams Clinical Reviews: Diabetic Neuropathy Clinical studies demonstrate the effectiveness of the active ingredient present in Zostrix® Diabetic Foot Pain Relieving Cream in treating diabetic foot pain when used as part of a treatment regiment under the supervision of a physician. The effectiveness of treating diabetic foot pain is one reason why Doctors and Pharmacists recommend Zostrix®. Below we briefly review a key clinical study highlighting the effectiveness of 0.075% Capsaicin Cream in relieving diabetic foot pain. Study references are also provided if you wish to read the published article in its entirety. Treatment of Painful Diabetic Neuropathy with Topical Capsaicin Study Description: A multicenter study was conducted to establish the efficacy of topical 0.075% capsaicin cream in relieving the pain associated with diabetic neuropathy. 252 patients were enrolled in an 8 week randomized, double-blind trial study, comparing 0.075% capsaisin with a placebo. Capsaicin or the placebo cream was applied to painful areas four times per day for 8 weeks in patients randomly assigned to one of the two groups. Patients returned at weeks 2, 4, 6 and 8 weeks for efficacy and safety evaluations during the treatment period. Key Findings: Pain intensity and relief were recorded at 2-week internals using physician’s global evaluation and visual analog scales. Analysis at final visit for 252 patients showed statistical significance favoring capsaicin compared with placebo for the following: 69.5% vs 53.4% pain improvement by the physician’s global evaluation scale, 38.1% vs 27.4% decrease in pain intensity, and 58.4% vs 45.3% improvement in pain relief. Capsaicin was well tolerated, and study results suggest that topical capsaicin cream is safe and effective in treating painful diabetic neuropathy. Reference: The Capsaicin Study Group. Treatment of Painful Diabetic Neuropathy with Topical Capsaicin: a multicenter, double-blind, vehicle-controlled study. Arch Intern Med. 1991; 151:

61 Topical Ketamine Requires a triplicate prescription
Needs to be made by a compounding pharmacy Helpful for: Allodynia (pain produced by a stimulus which does not normally cause pain, e.g. light touch) Hyperalgesia (increased sensitivity to pain)

62 Patient resources

63 Patient Resources Chronic Pain Centre Public Lectures Introduction to pain This is your body Medications The role of exercise in managing pain Attention and memory Nutrition Pacing in pain management Anxiety, depression and chronic pain Sleep Understanding medical investigations and the health care system

64 Pain Resources Canadian Pain Coalition
Conquering Pain for Canadians booklet Pain Resource Centre

65 Thank You!

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