Opioid (opiate) analgesia for neuropathic pain

There is currently a consensus that opioid analgesia is moderately effective in neuropathic pain (1).

Studies have shown (1):

• intramuscular morphine or diamorphine are effective in cancer-related neuropathic pain
• oxycodone is effective in post-herpetic neuralgia
• tramadol is effective in diabetic neuropathy

A systematic review revealed that tramadol is an effective treatment for neuropathic pain (2).

A further systemic review revealed that short-term studies provide only equivocal evidence regarding the efficacy of opioids in reducing the intensity of neuropathic pain, whereas intermediate-term studies demonstrate significant efficacy of opioids over placebo, which is likely to be clinically important (3).

NICE suggest that tramadol should only be considered if acute rescue therapy (short-term use only) is needed (4)

• from previous guidance (5)
  • for tramadol as monotherapy, start at 50 to 100 mg not more often than every 4 hours, with upward titration if required to an effective dose or the person's maximum tolerated dose of no higher than 400 mg per day. If tramadol is used as combination therapy, more conservative titration may be required

For NICE guidance regarding management of chronic pain (pain that lasts for more than 3 months) then see linked item.

In this guidance (6), NICE state that opioids should not be initiated to manage chronic primary pain in people aged 16 years and over.

Reference:

1. Drug and Therapeutics Bulletin (2000). Drug treatment of neuropathic pain; 38(12):89-93.
2. Duhmke R et al. Tramadol for neuropathic pain. Cochrane Database Syst Rev 2004; (2): CD003276
3. Eisenberg E et al. Opioids for neuropathic pain. Cochrane Database Syst Rev. 2006 Jul 19;3:CD006146. Review.
4. NICE (July 2019). Neuropathic pain (adults) - pharmacological management (non-specialist settings)
5. NICE (March 2010). Neuropathic pain (adults) - pharmacological management (non-specialist settings)
6. NICE (April 7th 2021). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain