Neuropathic pain is defined as a lesion or disease of the somatosensory system, and may involve the central or peripheral nervous systems. Treatment of neuropathic pain is a challenge for clinicians involved in affected patients' care. In 2007, the first guidelines for the treatment of neuropathic pain in the Canadian context were produced by the Canadian Pain Society. This update to these guidelines incorporates new evidence published since the first guidelines were released.

Neuropathic pain (NeP), generated by disorders of the peripheral and central nervous system, can be particularly severe and disabling. Prevalence estimates indicate that 2% to 3% of the population in the developed world suffer from NeP, which suggests that up to one million Canadians have this disabling condition. Evidence-based guidelines for the pharmacological management of NeP are therefore urgently needed. Randomized, controlled trials, systematic reviews and existing guidelines focusing on the pharmacological management of NeP were evaluated at a consensus meeting. Medications are recommended in the guidelines if their analgesic efficacy was supported by at least one methodologically sound, randomized, controlled trial showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment are based on degree of evidence of analgesic efficacy, safety, ease of use and cost-effectiveness. Analgesic agents recommended for first-line treatments are certain antidepressants (tricyclics) and anticonvulsants (gabapentin and pregabalin). Second-line treatments recommended are serotonin noradrenaline reuptake inhibitors and topical lidocaine. Tramadol and controlled-release opioid analgesics are recommended as third-line treatments for moderate to severe pain. Recommended fourth-line treatments include cannabinoids, methadone and anticonvulsants with lesser evidence of efficacy, such as lamotrigine, topiramate and valproic acid. Treatment must be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Further studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes, and treatment of pediatric and central NeP.

Study design: Clinical practice guidelines. Objectives: To develop the first Canadian clinical practice guidelines for treatment of neuropathic pain in people with spinal cord injury (SCI). Setting: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. Methods: The CanPainSCI Working Group reviewed the evidence for different treatment options and achieved consensus. The Working Group then developed clinical considerations for each recommendation. Recommendations for research are also included. Results: Twelve recommendations were developed for the management of neuropathic pain after SCI. The recommendations address both pharmacologic and nonpharmacologic treatment modalities. Conclusions: An expert Working Group developed recommendations for the treatment of neuropathic pain after SCI that should be used to inform practice.

Chronic pain, including neuropathic pain, has a high prevalence and, therefore, its management is an important public health issue. Aggressive management guided by pain specialists can provide adequate pain relief; however, delays in access to these specialists can negatively impact patient’s well-being. The economic value of managing chronic neuropathic pain in academic centres is discussed, in addition to determining the long term outcomes of this type of pain management.