Evaluation and Treatment of Malignant Neuropathic Pain

BackgroundCancer-related neuropathic pain (CRNP) is difficult to identify, assess, and treat, often requiring higher analgesic needs and resulting in poorer outcomes.ObjectivesTo evaluate the effectiveness of guideline-directed therapy for CRNP in veterans treated at the West Palm Beach VA Healthcare System (WPB VAHCS) Hematology/Oncology Center and managed as outpatients by a pain and palliative care clinical pharmacy practitioner (CPP).MethodsThis quality assurance retrospective chart review included patients treated for CRNP with "Tier 1" medications (SNRIs, TCAs, or antiepileptics) and/or mixed-mechanism opioids (eg, buprenorphine, tramadol). Primary outcomes were changes in pain and PEG (Pain, Enjoyment, and General Activity) scores. Secondary outcomes included morphine equivalent daily dose (MEDD), emergency department (ED) visits, and medication trends. Data were collected from July 1, 2022, to June 30, 2024.ResultsAmong 144 patients screened, 119 were included. The average age was 70.9 years, and 93.3% were male. Following CPP intervention, pain scores improved from 4.90 to 3.61 (P < 0.001), and PEG scores improved from 6.34 to 4.53 (P < 0.001). Buprenorphine use increased at follow-up while gabapentin use declined. ED visits decreased by 21%, and cost per fill rose 63.5%.ConclusionsCPP-guided use of guideline-directed therapies significantly improved pain intensity and function in veterans with CRNP. Buprenorphine may reduce medication burden in geriatric patients with multimodal pain, reinforcing its value in structured palliative care models.