Rice's report fits very well with a recent American Academy of Neurology review of postherpetic neuralgia treatments. That study was led by Richard M. Dubinsky, MD, MPH, of the University of Kansas Medical Center.
"There are many treatments that work quite well and are well tolerated," Dubinsky tells WebMD. "The best are the tricyclic antidepressants, followed by opioids. Some people benefit from the lidocaine patch or capsaicin."
What should a patient try first? Dubinsky says that treatment must be individualized, and that a doctor's advice -- early on -- is crucial. The most important first step, he says, is to find out what drugs a patient is able to take. That decision is based on the patient's health, other current medications, and the side effects a patient has from certain drugs.
"If there are no contraindications, and the pain is debilitating, I would start a patient with tricyclic antidepressants," Dubinsky says. "If the pain is not that debilitating, I would try the lidocaine patch first. And if there is a contraindication to tricyclic antidepressants, I would go with opioids. This decision has a lot to do with what patients can tolerate."
If these individual medications don't work, Dubinsky would try a combination of tricyclic antidepressants and opioids. Such powerful combinations have powerful side effects, and he warns patients and doctors to plan for them in advance.