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Table 3 A selection of free text responses about a definition of refractory neuropathic pain

From: Towards a definition of refractory neuropathic pain for epidemiological research. An international Delphi survey of experts

“Pain that cannot be reduced to levels of 4 or less on a 1–10 scale after all available biomedical treatments have been given and adequate try”
“Does not respond to 3 different classes of neuropathic pain drugs (TCA,> gabapentin/ pregabalin/ opioid at established sufficient dose each for a sufficient time”
“Duration > 6 months and unresponsive or poorly responsive to gabapentin/ pregabalin, TCA, topical lidocaine patch, opioid”
“Persistent clinical relevant pain despite a proper trial of gabapentin or pregabalin and a tricyclic antidepressant or a serotonin noradrenalin reuptake inhibitor”
“When, after appropriate assessment and treatment, patients are still often distressed and/or have activity limitations due to their NP, and also have persistent symptoms of the type outlined above”
“Persists more than a year after original injury or lesion. Pain levels greater than 5/10 despite adequate trial with standard class 1 or 2 drugs. Pain significantly affects the quality of life, sleep and daily function despite adequate therapy with pharmacological agents, physical therapy and CAM therapies”
“Patients got insufficient pain relief after trying Pregabalin up to 450 mg/die, amitriptyline 1 mg per kilo, oxycodone 20 mg, or could not reach the target dosage because of adverse events. If patients have contraindications to a TCA antidepressant they should try duloxetine 60 mg or venlafaxine 225 mg. If patients have allodynia in a small area they should also try a lidocaine patch. If patients have Trigeminal neuralgia they should try none of the above; they should try oxcarbazepine up to 1600 mg or carbamazepine up to 1000 mg. If they can reach adequate dosage with either drug and still get insufficient pain relief they should be proposed surgery. Concerning the problem of combination therapy, I do not think we have enough evidence to ask for it. Perhaps it may be considered when adverse events prevent reaching the adequate dosage?”
“6 months history not responded to first line treatments (ie medication with lidocaine, anticonvulsants, antidepressants) significant disability and distress”
“All of the neuropathic pain beyond 3 months is chronic and all of the neuropathic pain that persists at level of 5/10 or higher even with a single or multiple treatment modalities is refractory”
“Resistant to any kind of pharmacological and nonpharmacological therapy, if the drugs and doses have been tested along the common guidelines (long and high enough)”