Exploring factors which influence the prescription of medicines to manage neuropathic pain from the perspective of prescribers: a qualitative study
Authors: Mshelia C , Kennedy M C , McHugh G 
Published: March 2021

Abstract

Introduction
Neuropathic pain (NP) is estimated to affect about 8% of the population in the UK. NP is defined as ‘pain caused by a lesion or disease of the somatosensory nervous system’ (1). NP often results in alterations in the pain pathway caused by tissue and nerve damage leading to hypersensitivity, characterised by spontaneous pain (no stimuli exist but the organism feels pain), allodynia (painless tactile stimulus or warmth are perceived as pain) and hyperalgesia (painful stimuli make the organism feel pain of greater intensity) (2).
Most people present with neuropathic pain for the first time in primary care settings. It is important therefore, to understand the experiences of the prescribers who prescribe to this group of patients in order to highlight areas of good practice and to identify areas where support is required, and improvements need to be made.

Aim
To explore prescribers’ experiences of managing patients with neuropathic pain and the influence of these experiences on prescribing and treatment choices.

Methods
This study adopted a qualitative approach and obtained ethical approval. Purposive and snowball sampling methods were used to recruit General Practitioners (GPs), Advanced Nurse Practitioners (ANPs) and Pharmacist Independent Prescribers working in general practices in West Yorkshire. Semi-structured interviews were conducted face-to-face or by the telephone. The interviews took place between December 2019 and September 2020. The interviews were transcribed verbatim. Thematic analysis was used to identify key themes from the data. NVivo (version 12.6) was used to aid the analysis.

Results
21 healthcare professionals responsible for prescribing medication to people with neuropathic pain were interviewed (GPs = 10, ANPs = 6 Pharmacists = 5). Prescribers identified several factors which influence their prescribing and treatment choices. These factors were grouped into micro, meso and macro factors. Micro factors were prescriber related factors such as experience or training in pain management, support from colleagues and prescriber-patient relationship. Meso factors were related to the patient and included factors such as side effects, comorbid conditions and addictive tendency. Macro level factors were those related to the health system such as timely access to specialists, length of consultations and cost-effective prescribing. Table 1 provides some illustrative quotes from the prescribers. All prescribers reported to derive satisfaction from being able to successfully help their patients manage the NP symptoms but acknowledged that this was sometimes not possible.

Conclusion
This study found that the experiences of prescribers with regards to managing NP is more negative than positive. Prescribers highlighted the challenges of managing neuropathic pain in primary care settings. This is largely due to the complexities of the condition and of prescribing decisions as well poor treatment outcomes for patients. A study limitation is the generalisability of the sample with participants not representing more geographical areas. Prescribers require appropriate support and training in managing NP to build their confidence in making prescribing decisions. It is also important to ensure patients get timely access to pain specialists and pain management clinics for specialist treatment.

References
1. International Association for the Study of Pain (IASP). Taxonomy 2017 [Available from: https://www.iasp-pain.org/Taxonomy#Peripheralneuropathicpain.
2. Yan Y-y, Li C-y, Zhou L, Ao L-y, Fang W-r, Li Y-m. Research progress of mechanisms and drug therapy for neuropathic pain. Life Sciences. 2017;190(Supplement C):68–77.