Neuropathic pain results from damage to or dysfunction of peripheral nerves due to a variety of factors, such as the ones below.
Finding an excellent pain specialists who can really help! See below for my recommendations on pain specialists who also prescribe naltrexone and low dose naltrexone (LDN).*
Causes of Neuropathic Pain:
1. Idiopathic: meaning ..no know knows why
2. Previous virus or bacterial infection
-Herpes Zoster: this is well known as Post Herpetic Neuralgia
3. Metabolic disorder
-Diabetes: this is well known as peripheral neuropathy
-Diet: some suspect Gluten is triggering nerve inflammation in some patients
4. Toxins
-Chemotherapy: well known to cause potential nerve damage
5. Severe ischemic injury:
-Post Stroke: patients can have pain after loss of oxygen to area and in particular the brain.
6. Disc Herniation:
-This is well known to cause chronic pain that can radiate down the leg, arm, back area, etc.
7. Post Dental Surgery or procedure or dental nerve root infection or inflammation
-patients can have a chronic orofacial pain syndrome
8. Trauma:
-Trauma to an area is well known to potentially cause a chronic pain syndrome.
9. Inflammation
-Autoimmune disease: in some patients blood work will confirm this as the cause of chronic pain, but in other patients we are seeing NORMAL blood work but positive biopsies for Sjogren's syndrome for instance.Likely there is sub-clinical inflammation that is causing a chronic pain syndrome in patients who are the spectrum of early autoimmune disease or an unidentified inflammatory condition.
The frustrating issue is that despite over 50 years of research, there are not proven treatments to cure neuropathic pain which has been classified as a chronic and incurable disease (Ref 1).
For eye surgeons who are used to doing "just eye surgery," the tsunami of chronic eye pain if shocking many of us who find we are unable to "just do a procedure" and get rid of the pain. Chronic pain is more complex and requires a team of doctors to remove the cause of the pain or control the pain in patients in whom we cannot find or cure the underlying reason.
How do we determine if there is a chronic pain condition?
1. Pharmacological tests conducted by a pain specialist can include the following:
A. A saline control lidoocaine
IV infusion to test for neuropathic pain
(local anesthetic sodium channel blockade)
and phentolamine infusion to test for
sympathetically maintained pain (sympathetic
blockade): but this has been called into question in Reference 2 below as not really helpful...
B. A trial of antidepressants
and/or anticonvulsants:
C. Quantitative sensory testing provides
a standard set of validated neurosensory
measures to determine the presence of
neuropathy.
D. Facial thermography: highly
selective in thermal accuracy (100%), with
results showing the affected (painful) side
of the face to be hotter than the nonpainful
side (range 0.4 to 3.1ºC, mean=1.1 ± 0.8).22
E. Magnetic
resonance spectroscopy has shown that
patients with trigeminal neuropathy have a
significant reduction in the N-acetylaspartate
to creatine ratio, a biochemical marker of
neural viability, in the region of the thalamus
that also displays grey matter volume loss: but this is still experimentalTreating or "Managing" Neuropathic Pain
As with all disease process, most eye surgeons and doctors prefer or should prefer to try natural remedies first.
Natural compounds have been used in mild neuropathic pain with varying results.
Here are some options that have been used:
1. Topical capsaicin cream (0.025% and 0.075% capsaicin concentration;
TGA indicated for the treatment of postherpetic neuralgia).20
The cream is applied for five to 10 minutes twice daily for eight weeks to the painful oral mucosa. The capsaicin can cause an initial burning sensation in the first few days; this can be reduced by pretreating the mucosa with topical anaesthetic mouthwash (lidocaine 1%). There is some evidence for using
2.Topical ginger (containing gingerol) applied topically can work as antineuropathic.
3. Palmitoylethanolamide, an active compound from egg yolk and peanut oil, being effective in the treatment of neuropathic pain.31
4. For nerve compression:
-acupuncture, massaging, physical therapy, electric heat massagers have been used to help.
5. For Dry Eye Related Neuropathic pain:
-lid hygiene, warm compresses, non-preserved artificial tears, blinking exercises, lid massaging, high dose Omega 3, moisture chamber goggles, humidifier, anti-inflammatory diets, Lipiflow, Intense Pulse Light, Autologous Serum, Platelet Rich Plasma, --all try to noninvasively and naturally relieve pain. If these do not work or a patient does not mind using drugs, we try Xiidra, Restasis, Doxycycline pills, Punctal Plugs, Testosterone Cream, True Tear, Meibomian gland probing and expression, lid tarsorrhaphy if dryness is causing corneal abrasions or melts.
6. For chronic dental pain: a dental stent or mouth guard can be constructed by a dentist.
Prescription Medicines for Neuropathic Pain:
1. First-line medicines:
1) Antidepressants:
A. Tricyclic Antidepressants:
-can start with 25 mg for neuropathic pain: low doses ususally give less side effects, such as dry mouth, drowsiness, dry eye, weight gain.
If a patient is having terrible pain that he or she cannot sleep, we first get the pain under control before worrying about the worsening dry eye these medications can cause. It can be a Catch 22 with these medications but is important to find a non-narcotic to get rid of the pain to allow one to sleep. Lack of sleep or insomnia also worsens dry eye.
a. Amitriptyline
b. Nortriptyline
c. Dothiepin
B. Selective serotonin and norepinephrine reuptake inhibitor (SNRI)
a. Duloxetine
b. Venlafaxine
2) Anticonvulsants:
a. Gabapentin (aka GABA)
b. Pregabalin
c. Carbamazepine: this is used in trigeminal neuralgia: another reported rare risk is below
d. Sodium valproate (aka oxcarbazepine: usually prescribed by neurologists): this is used off label for neuropathic pain
3) 5% lidocaine patches over pain area, such as in post herpetic neuralgia
2. Second-line medicines:
1) Opioids including tramadol and morphine: which we try to avoid at all costs as they are very addictive.
3. Other: rarely used;
a. For eye pain:
Topical application of naltrexone hydrochloride (NTX), an opioid antagonist: has been used in Ref 3 below, but it is hard to get.
Low Dose Naltrexone LDN 1.5mg-4.5mg per day is sometimes used for Neuropathic Eye Pain, but side effects can limit effectiveness: side effects can include nightmares, insomnia, nausea. More on LDN below **
b. For other neuropathic pain: Mexiletine, a nonselective sodium channel blocker used for cardiac arrhythmias
b. Stellate ganglion blocks with bupivacaine or guanethidine
For Severe Breakthrough Pain: Recommend hospitalization under the care of a pain clinic team for close supervision of use of IV opioids, antineuropathics and NMDA antagonists (ketamine).
Psychological and Behavioral Management of Pain:
Psychological treatments are crucial for many patients with chronic pain. Anxiety and depression is common in patient struggling with chronic pain. Psychiatric diagnoses have been reported in 72% of patients with chronic pain conditions. The presence of negative thoughts of anxiety, despair, depression increases pain intensity in patients with acute postoperative pain.
Maintaining physical activity, social activities (especially with loved ones and friends), and even maintaining work schedules with its set order and plan of life likely helps prevent full focus on the chronic pain condition: though trying to limit electronic screen time or have more breaks is recommended.
Cognitive behavioral therapy can be helpful in pain rehabilitation.
Thus a recommended Overall Plan with treating chronic pain conditions could be:
1. Explaining pain cause as best as possible
2. Try Natural treatments including prayer, meditation, relaxation, mindfulness
3. If natural options do not help, try Rx options under careful observation for side effects
4. Discuss and planned physical activity with pain specialist
5. Discuss psychological distress with PCP, MD, or pain specialist.
6. Support restoration of social roles as best as can.
7. Encourage active self-management strategies to help wean patients off medications over time.
*Pain specialists in area:
1. Dr. Akshay Garg - Capital Interventional Pain & Spine Center
How to Find Pain Specialists Prescribing LDN
- LDN Research Trust Prescriber List: The LDN Research Trust offers a searchable directory of physicians, physician assistants, and nurse practitioners worldwide who prescribe LDN. This is a key resource for finding providers knowledgeable about LDN for pain management. You can access it at ldnresearchtrust.org under their Prescriber List. Note that the Trust does not verify credentials, so you should confirm the provider’s qualifications.
- LDNscience Directory: Another free, searchable directory of LDN prescribers is available at ldnscience.org. This can help you locate specialists in your area.
- Compounding Pharmacies: Pharmacies like VLS Pharmacy, CareFirst Specialty Pharmacy, or The Chemist Shop (listed in the previous response) often work with physicians who prescribe LDN. Contacting them for recommendations can lead to local specialists.
- Pain Management Clinics: Clinics specializing in chronic pain, especially those focusing on non-opioid treatments, are more likely to prescribe LDN. Look for providers affiliated with integrative or functional medicine practices.
I do not the below MDs but have heard from some patients that they do prescribe LDN.
Notable Pain Specialists Prescribing LDN
- Dr. Norman J. Marcus – Norman Marcus Pain Institute
- Location: New York, NY
- Details: Dr. Marcus, affiliated with Weill Cornell Medicine, has conducted observational studies on LDN for chronic musculoskeletal pain, noting its efficacy at doses ranging from 0.1 to 4.5 mg. His institute focuses on personalized pain management and LDN titration to find the maximally effective dose.
- Contact: (212) 532-7999 or visit normanmarcuspaininstitute.com
- Conditions Treated: Chronic musculoskeletal pain, fibromyalgia, neuropathic pain.
- Dr. David Borenstein – Manhattan Integrative Medicine
- Locations: Boca Raton, FL, and New York, NY
- Details: A functional medicine practitioner specializing in LDN for chronic pain, autoimmune diseases, and immune disorders. He tailors LDN doses after detailed patient evaluations and is recognized as a top LDN specialist in Florida and New York.
- Contact: (754) 247-0122 (Boca Raton) or (212) 262-2412 (NYC); visit davidborensteinmd.com
- Conditions Treated: Fibromyalgia, CRPS, neuropathic pain, autoimmune conditions.
- Dr. Neel Mehta – Weill Cornell Medicine Pain Management Team
- Location: New York, NY
- Details: Dr. Mehta and his team have explored LDN for chronic pain, reporting over 50% pain relief in some patients at doses as low as 0.1 mg. They collaborate with the LDN Research Trust and focus on non-opioid pain management.
- Contact: Visit weillcornell.org for appointment details.
- Conditions Treated: Fibromyalgia, neuropathic pain, inflammatory conditions.
- Bellevue Pain and Wellness PLLC
- Location: Bellevue, WA (serving Seattle, Kirkland, Redmond, and surrounding areas)
- Details: This clinic offers LDN for chronic pain conditions like fibromyalgia, CRPS, migraines, and diabetic neuropathy, especially for patients unresponsive to traditional treatments. They work with compounding pharmacies to source LDN.
- Contact: (425) 998-7884 or visit bellevuepainwellness.com
- Conditions Treated: Fibromyalgia, CRPS, migraines, neuropathic pain.
- Dr. Scott Zashin
- Location: Dallas, TX
- Details: A rheumatologist who has prescribed LDN since its early studies for fibromyalgia and other inflammatory pain conditions. He starts patients at 0.5–1.5 mg, titrating up to 4.5 mg, and monitors for side effects like vivid dreams.
- Contact: Visit scottzashinmd.com or call for inquiries.
- Conditions Treated: Fibromyalgia, rheumatoid arthritis, CRPS.
Notes on LDN for Pain Management
- Prescription Process: LDN requires a prescription and is typically compounded at doses of 0.5–4.5 mg, as standard naltrexone comes in 50 mg tablets. Specialists often start with a low dose and titrate up over weeks to minimize side effects like vivid dreams or insomnia.
- Conditions Treated: LDN is most commonly prescribed for fibromyalgia, CRPS, neuropathic pain, and inflammatory conditions like Crohn’s disease or multiple sclerosis. It may take 1–3 months to see effects, and it’s not effective for everyone.
- Contraindications: LDN should not be taken with opioids (e.g., tramadol), as it blocks opioid receptors, potentially causing withdrawal. Patients must be opioid-free for 7–10 days before starting.
- Finding Local Providers: If none of these specialists are near you, contact the LDN Research Trust or LDNscience for local recommendations. You can also ask local compounding pharmacies for referrals to prescribers they work with.
- Contact LDN Resources: Use the LDN Research Trust or LDNscience directories to find prescribers. You can also email the LDN Research Trust at info@ldnresearchtrust.org for assistance.
- Verify Credentials: Always check a provider’s qualifications and experience with LDN, as its use for pain is off-label and requires expertise.
**LDN Notes:
Low-dose naltrexone (LDN) is used off-label for conditions like chronic pain, autoimmune disorders, and certain cancers, so the types of medical doctors (MDs) who may prescribe it depend on their specialty and the patient’s condition. I used to prescribe LDN pills and eye drops but I had one patient who began to have terrible nightmares while on LDN requiring close follow up. My team could not handle the paper work involved in getting LDN drops though information is noted below so we had to stop prescribing LDN.
Always consult a qualified MD like the ones below to determine if LDN is appropriate for your condition, as prescribing requires careful medical evaluation.
Below is a list of MD specialties that are most likely to prescribe LDN based on its applications.
- Pain Management Specialists: Treat chronic pain conditions like fibromyalgia, complex regional pain syndrome (CRPS), and migraines, where LDN has shown promise as an anti-inflammatory and pain modulator.
- Rheumatologists: Manage autoimmune and inflammatory conditions such as rheumatoid arthritis, lupus, and fibromyalgia, where LDN may help reduce inflammation and symptoms.
- Neurologists: Prescribe LDN for neurological conditions like multiple sclerosis (MS) or neuropathic pain, as it may reduce neuroinflammation and improve quality of life.
- Gastroenterologists: Use LDN for inflammatory bowel diseases like Crohn’s disease or ulcerative colitis, where it has shown benefits in mucosal healing.
- Oncologists: May consider LDN for certain cancers, as it can modulate immune function and potentially affect tumor growth, though this is less common and typically adjunctive.
- Internal Medicine Physicians: Generalists who treat a wide range of chronic conditions, including autoimmune diseases, chronic fatigue syndrome, and fibromyalgia, may prescribe LDN after evaluating its suitability.
- Family Medicine Physicians: Similar to internists, they manage diverse conditions and may prescribe LDN for patients with chronic pain, autoimmune issues, or other off-label uses.
- Integrative or Functional Medicine Specialists: Focus on holistic approaches and are often more open to off-label LDN use for conditions like myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), autoimmune diseases, or immune modulation.
- Psychiatrists: Occasionally prescribe LDN for mental health conditions or alcohol use disorder, though this is less common unless combined with chronic pain or autoimmune overlap.
- Endocrinologists: May use LDN for autoimmune thyroid conditions like Hashimoto’s thyroiditis, adjusting doses carefully due to potential thyroid interactions.
Notes:
- LDN is not FDA-approved for these off-label uses, so prescribing depends on the physician’s familiarity with the drug and the evidence for its efficacy.
- Any licensed MD can legally prescribe LDN, but those listed above are more likely due to their specialties aligning with LDN’s therapeutic applications.
- Patients often need to consult compounding pharmacies, as LDN requires custom low doses (0.5–4.5 mg) not commercially available.
- Physicians should ensure patients are opioid-free for 7–10 days before starting LDN to avoid withdrawal.
Low-dose naltrexone (LDN) eye drops are not commercially available as FDA-approved products and must be obtained through specialized compounding pharmacies with sterile facilities. Below is a list of pharmacies known to compound LDN eye drops, based on available information:
- VLS Pharmacy & New Drug Loft
- Location: United States (specific locations not listed, but they serve prescribers nationwide)
- Details: Offers naltrexone ophthalmic solutions in strengths like 0.1%, 0.2%, and 0.3% for conditions such as neuropathic corneal pain, dry eye disease, and diabetic corneal complications. They emphasize sterile compounding and use high-quality pharmaceutical-grade APIs from PCCA.
- Contact: Visit newdrugloft.com or complete their new account form for prescribers.
- CareFirst Specialty Pharmacy
- Location: Licensed in over 50 states, based in the US
- Details: Known for compounding LDN in various forms, including potential ophthalmic solutions, though not explicitly advertised. They require a prescription and have experience with sterile compounding.
- Contact: Visit cfspharmacy.pharmacy or contact for a quote.
- The Chemist Shop
- Location: Long Island City, Queens, NY
- Details: A nationally accredited pharmacy and LDN Research Trust member, specializing in custom LDN formulations. While not explicitly listed for eye drops, their sterile compounding capabilities suggest they can produce LDN eye drops upon request.
- Contact: Visit thechemistshoppharmacy.com or call for inquiries.
- **Other Comp - Details: The LDN Research Trust provides a searchable list of compounding pharmacies worldwide knowledgeable about LDN, some of which offer sterile compounding for eye drops. Pharmacies like Belmar Pharma Solutions, Town & Country Compounding, and Sweetgrass Pharmacy are mentioned for LDN but not specifically for eye drops, though they may offer them with the right facilities.
- Contact: Check ldnresearchtrust.org for their pharmacy list or contact them for recommendations.
Notes:
- You’ll need a prescription from a healthcare provider for LDN eye drops.
- Contact these pharmacies directly to confirm availability, as sterile compounding for eye drops is niche and not all pharmacies offer it.
- In the UK, LDN eye drops are currently unavailable due to high sterile compounding costs.
- For additional pharmacies, the LDN Research Trust’s pharmacy list or a local compounding pharmacy with sterile capabilities may be viable.
Reference:
1. A.B. O’Connor, R.H. Dworkin
Treatment of neuropathic pain: an overview of recent guidelines
Am J Med, 122 (2009), pp. S22-S32
2. Review Article | August 2009
Despite the growing body of literature on intravenous infusion tests, there has been no previous attempt to systematically review the available evidence. The purpose of this article is to provide readers with an evidence-based framework outlining the rationale and existing literature on previously described intravenous infusion tests, along with informed conclusions regarding the validity and predictive value of these tests.
There are limited data available examining the use of intravenous analgesic testing. For all of these tests, there is simply not enough available evidence to make definitive conclusions regarding their predictive value. On the basis of the available evidence, this systematic review demonstrates that intravenous analgesic tests have limited overall clinical utility in selecting patients for long-term treatment with specific oral analgesic agents.
Dry eye reversal and corneal sensation restoration with topical naltrexone in diabetes mellitus.
Abstract
OBJECTIVE:
To determine if topical application of naltrexone hydrochloride (NTX), an opioid antagonist, restores tear production and corneal sensation in rats with diabetes mellitus.
METHODS:
Type 1 diabetes was induced with streptozotocin in rats. Tear production was measured by the Schirmer test, and corneal sensitivity, by an esthesiometer. Eye drops of 10(-5)M NTX or sterile vehicle were administered either once only or 4 times a day for 1 or 5 days; a single drop of insulin (1 U) was given once only.
RESULTS:
Dry eye and corneal insensitivity were detected in the diabetic rats beginning 5 weeks after streptozotocin injection. One drop of NTX or 4 times a day for 1 or 5 days reestablished tear production and corneal sensitivity within 1 hour of administration. The reversal of dry eye lasted for up to 2 to 3 days depending on drug regimen, but restitution of corneal sensation lasted for 4 to 7 days. Topical application of 1 eye drop of insulin restored corneal sensitivity within 1 hour and lasted for at least 2 days. In contrast, 1 eye drop of insulin did not increase tear production at 1, 24, or 48 hours compared with diabetic animals receiving sterile vehicle.
CONCLUSION:
Topical treatment with NTX normalizes tear production and corneal sensitivity in type 1 diabetic rats.
CLINICAL RELEVANCE:
Topical application of NTX to the ocular surface may serve as an important strategy for treating dry eye and corneal anesthesia in diabetes. Its effect, if any, in other forms of decreased corneal sensitivity and/or dry eye should be investigated.
-------
Rare risk with chronic carbamazepine
-------
Rare risk with chronic carbamazepine
Am J Ophthalmol Case Rep. 2016 Oct; 3: 31–33.
Published online 2016 May 28. doi: 10.1016/j.ajoc.2016.04.010
PMCID: PMC5757391
PMID: 29503903
Pediatric conjunctival lymphoma associated with oral carbamazepine use
Abstract
PURPOSE:
To report a case of a pediatric patient diagnosed with conjunctival lymphoma associated with oral carbamazepine use.
OBSERVATION:
An 11-year-old boy who presented with 5-month history of a small nasal conjunctival mass in the left eye that failed therapy with topical corticosteroids. Upon excision and molecular analysis, diagnosis of Follicular Lymphoma was favored. The patient was healthy and did not have any known risk factors except for a history of epilepsy treated with systemic carbamazepine.
CONCLUSION AND IMPORTANCE:
We report a case of a rare childhood conjunctival lymphoma. Conjunctival lymphomas may masquerade as chronic conjunctivitis, or scleritis that fail therapy with topical corticosteroids. Furthermore, our patient did not have any known risk factors such as old age, systemic lymphoma or immunosuppression. The patient did have a history long-term use of systemic carbamazepine. This is to our knowledge the first case conjunctival lymphoma that may be associated to the use of carbamazepine.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.