Development of a telephone clinic for the management of neuropathic pain

      Pain that is neuropathic in nature is often difficult to treat, and requires combination therapy with medications from different classes with wide dose ranges and extended periods of titration. In 2010, the William S. Middleton Memorial Veterans Hospital Pain Committee developed an algorithm for the medication management of neuropathic pain which incorporated published treatment guidelines within the parameters of the VA formulary. The algorithm provides a recommended order of treatment as well as a table to guide dosing and titration. Subsequently, two quality improvement projects were undertaken to review the utilization of adjuvants for the treatment of neuropathic pain. Both studies demonstrated that the adjuvants recommended for the management of neuropathic pain often were not prescribed; or if prescribed, were under-dosed. In response, a new clinic was developed in September 2011: “Medication Management for Neuropathic Pain.” Presently, this is a consult service staffed by pharmacists who have training in pain management. Next steps will be to put in place templates and guidelines to allow nurse case managers to also assist with titration under physician orders based on the algorithm.