Is Lidocaine A Cheap, Non-Opioid Alternative For Nerve Pain?

Today's post from clinicalpainadvisor.com (see link below) looks at lidocaine as an alternative to opioids for chronic (and especially neuropathic) pain. Traditionally, lidocaine has been used as a local anesthetic or numbing agent. It's cheap and arguably much more effective as a nerve pain blocker than many other drugs. It has side effects for some people but they are also generally less impactful than for instance Lyrica and other drugs used to treat neuropathic symptoms and it seems that it is quite effective in reducing nerve pain. So why isn't it much more widely prescribed? This article suggests a lack of research studies into practical application but otherwise can't really find a reason why it is seldom used. There are lidocaine patches that are commonly used as local anesthetics but research also seems to suggest that the patch's effects are much more systemic than providing local pain relief - giving more hope to neuropathy patients that it may be very suitable for their condition. Have you any experience of lidocaine for neuropathic pain...or have talked to your doctor about the possibility of using it? All personal experiences or links to further research will be useful to our community as a whole.

 

Reviewing the Effectiveness of Lidocaine for the Management of Chronic Pain 
Tori Rodriguez, MA, LPC  February 20, 2018

The authors conducted a review of research investigating the safety and efficacy of systemic lidocaine for the prevention and treatment of chronic pain. As many as 116 million adults experience chronic pain each year in the United States, and treatment for these individuals often includes opioids.1 However, the use of opioids for chronic pain is controversial, highlighting the need for nonopioid therapies for this patient population. 

The potential for intravenous (IV) lidocaine to reduce postoperative pain was first proposed in the literature in 1961.2 Multiple studies conducted since then have demonstrated support for this concept, and other research suggests that IV lidocaine may also be effective in the treatment of chronic pain.

Although there are limited data regarding the proposed mechanisms underlying these effects, findings indicate that IV lidocaine is “effective in the management of some neuropathic pain syndromes by modulating the ectopic neuronal discharges, thus decreasing hyperalgesia and the inflammatory response,” according to a paper published in 2017 in Anesthesiology and Pain Medicine.

“This effect is obtained through inhibition of the voltage-gated sodium channels, voltage-gated calcium channels, various potassium channels, N-methyl-D-aspartate receptors, glycine system, and G protein pathways.”

The authors conducted a review of research investigating the safety and efficacy of systemic lidocaine — delivered either intravenously or through a patch (5% lidocaine) — for the prevention and treatment of chronic pain. The literature search included relevant studies published through April 2016. Selected results are described below. 

Systemic lidocaine and postherpetic neuralgia (PHN). The 5% lidocaine patch received approval from the US Food and Drug Administration in 1999 for one specific indication — relief of pain in PHN — and studies have demonstrated its safety and efficacy in reducing PHN-related tactile allodynia.4 In some cases, the patch does not cover the entire affected area, suggesting that “the effect of lidocaine patch is most likely achieved through systemic absorption, rather than a local effect,” the authors wrote. 

A study reported in Pain in 2007 used functional magnetic resonance imaging to examine brain activity associated with PHN-associated spontaneous pain and how this activity is modulated by treatment with a 5% lidocaine patch.5 Spontaneous PHN pain was found to activate affective and sensory-discriminative areas, and this activity was found to be reduced after 2 and 3 sessions of treatment with the lidocaine 5% patch. 

Systemic lidocaine for other neuropathic pain syndromes. Multiple studies indicate that the 5% lidocaine patch may be effective in alleviating neuropathic pain in patients with a variety of conditions, including diabetic polyneuropathy, complex regional pain syndrome (CRPS), and postmastectomy-associated pain.6 In a double-blind placebo-controlled study, IV lidocaine led to a significant decrease in allodynia and hyperalgesia (caused by peripheral nerve injury) for up to 6 hours.7

Systemic lidocaine for low back pain and osteoarthritis. In a prospective trial of patients with moderate to severe low back pain who were treated with the lidocaine patch, results showed improved scores on the Neuropathic Pain Scale over for the length of the assessment period (2-6 weeks after treatment).8 The lidocaine patch was also found to improve pain in patients with osteoarthritis.9 

Intraoperative lidocaine and development of chronic pain. In a double-blind placebo-controlled trial, a 20-fold reduction in the relative risk for chronic postsurgical pain was observed following the administration of IV lidocaine in patients who had undergone mastectomy.10

In another placebo-controlled study, patients treated with IV lidocaine had lower pain scores and opioid requirements in the 48 hours after spine surgery than patients treated with placebo.11 Patients in the lidocaine vs placebo group also exhibited fewer complications in the 30 days after surgery and had higher scores on the 12-Item Short Form Survey.


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Lidocaine and postoperative pain. A Cochrane review of randomized placebo-controlled trials investigating perioperative IV lidocaine found sufficient evidence for the treatment's effectiveness in reducing pain for up to 24 hours after abdominal surgery, but not after other types of surgery.12

CRPS. In a small study of patients with CRPS treated with continuous subcutaneous 10% lidocaine infusion for 4 to 8 weeks, improvements in pain and range of motion were reported.13 

Doses and safety. There was substantial variation across studies regarding the optimal dose of lidocaine. In the CRPS study, for example, treatment effectiveness was achieved with serum levels maintained between 0.09 µg/mL and 8.06 µg/mL, with an average of 3.7 µg/mL.13 In another study, a dose of 1.5 mg/kg/hour was initiated preoperatively in patients undergoing major abdominal surgery and was continued until 1 hour postsurgery. The mean plasmatic level during surgery was 1.9 µg/mL.14 This approach controlled postoperative pain successfully for up to 72 hours. 

Across studies, systemic lidocaine was found to be safe overall, with infrequent and minor side effects. Dermal reactions after application of the patch are the most common adverse effect.

Taken together, the literature on the use of lidocaine for chronic pain treatment is promising. “A better understanding of [lidocaine's] mechanisms of action, required doses, and modality of administration, as well as lidocaine in clinical use, will help prevent the occurrence of chronic pain,” and will improve the pain and quality of life in individuals affected by chronic pain, the authors concluded. “Therefore, further research involving local anesthetics in different clinical scenarios needs to be performed.”
 
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References
Kandil E, Melikman E, Adinoff B. Lidocaine infusion: a promising therapeutic approach for chronic pain. J Anesth Clin Res. 2017;8(1):697.
Bartlett EE, Hutserani O. Xylocaine for the relief of postoperative pain. Anesth Analg. 1961;40:296-304.
Yousefshahi F, Predescu O, Asenjo JF. The efficacy of systemic lidocaine in the management of chronic pain: a literature review. Anesth Pain Med. 2017;7(3):e44732.
Davies PS, Galer BS. Review of lidocaine patch 5% studies in the treatment of postherpetic neuralgia. Drugs. 2004;64(9):937-947.
Geha PY, Baliki MN, Chialvo DR, Harden RN, Paice JA, Apkarian AV. Brain activity for spontaneous pain of postherpetic neuralgia and its modulation by lidocaine patch therapy. Pain. 2007;128(1-2):88-100.
Devers A, Galer BS. Topical lidocaine patch relieves a variety of neuropathic pain conditions: an open-label study. Clin J Pain. 2000;16(3):205-208.
Attal N, Rouaud J, Brasseur L, Chauvin M, Bouhassira D. Systemic lidocaine in pain due to peripheral nerve injury and predictors of response. Neurology. 2004;62(2):218-225.
Galer BS, Gammaitoni AR, Oleka N, Jensen MP, Argoff CE. Use of the lidocaine patch 5% in reducing intensity of various pain qualities reported by patients with low-back pain. Curr Med Res Opin. 2004;20 Suppl 2:S5-S12.
Gammaitoni AR, Galer BS, Onawola R, Jensen MP, Argoff CE. Lidocaine patch 5% and its positive impact on pain qualities in osteoarthritis: results of a pilot 2-week, open-label study using the Neuropathic Pain Scale. Curr Med Res Opin. 2004;20 Suppl 2:S13-S19.
Tiouririne M, Brenin D, Terkawi AS, Sharma S, Durieux ME, Thammishetti S. Perioperative lidocaine infusion reduces the incidence of post-mastectomy chronic pain: a double-blind, placebo-controlled randomized trial. Pain Physician. 2015;18(2):E139-E146.
Farag E, Ghobrial M, Sessler DI, Dalton JE, et al. Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiology. 2013;119(4):932-940.
Kranke P, Jokinen J, Pace NL, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev. 2015(7):CD009642.
Linchitz RM, Raheb JC. Subcutaneous infusion of lidocaine provides effective pain relief for CRPS patients. Clin J Pain. 1999;15(1):67-72.
Koppert W, Weigand M, Neumann F, et al. Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesth Analg. 2004;98(4):1050-1055. 

https://www.clinicalpainadvisor.com/chronic-pain/intravenous-lidocaine-patch-chronic-pain-neuropathic-pain-postsurgical-pain/article/744627/