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Abstract
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Background and Aims Traumatic brachial plexopathies (TBP) can cause severe neuropathic pain (NP). Opioids are usually recommended second to fifth-line for NP due to significant side effects. TBP patients are at risk of prolonged opioid prescription due to chronic debilitating pain, associated psychological issues including depression and pain catastrophizing. However, TBP patients are commonly prescribed opioids for nociceptive pain caused by concurrent injuries. This case study looks at efforts to minimize opioid use in a young patient who suffered from a left brachial plexopathy and hip fracture following a road traffic accident.
Methods This involved reading published articles on TBP management, the patient’s journey with the acute pain service and discussions with his consultant-in-charge.
Results With daily reviews and re-education while on patient-controlled analgesia (PCA) fentanyl, he was weaned off post-operatively within a week and converted to oral oxycodone. The use of adjunct analgesia in accordance with published guidelines helped to improve NP control. Oxycodone was switched to Targin to reduce constipation risk while retaining analgesic effectiveness. Opioids including oxycodone and tramadol have clinical efficacy in relieving peripheral NP but are insufficient as sole analgesic agents. They are used in conjunction with first line drugs to optimize NP control. Studies recommend starting opioids within one hour of nerve injury to reduce risk of nociceptive hyperalgesia.
Conclusions First-line treatment with gabapentinoids, tricyclic antidepressants and topicals should commence to optimize NP control. If opioids are started, it should commence within one hour of nerve injury and weaned off once feasible. Regular reviews of opioid prescriptions are vital.
First line management for neuropathic pain
Second to Fifth Line Management for Neuropathic Pain
Analgesia administered during patients’ journey with Acute Pain Service