Condition · ICD-11 8B93
Neuropathic pain
Reviewed by Dr. Placeholder B (HPCSA MP0XXXXX · Pain Medicine) · Last updated · Published
Neuropathic pain is pain caused by damage to the somatosensory nervous system — burning, electric-shock, tingling, or stabbing sensations that are often disproportionate to any external trigger. Common causes include diabetic peripheral neuropathy, post-herpetic neuralgia, post-surgical nerve injury, and chemotherapy-induced neuropathy. First-line pharmacotherapy includes gabapentin, pregabalin, duloxetine, and tricyclic antidepressants. Cannabinoid-based therapy — typically balanced THC:CBD formulations — has a relatively strong evidence base for neuropathic pain and is considered in South Africa under Section 21 when conventional agents have been inadequate or poorly tolerated.
What the evidence says
Andreae et al (2015) meta-analysed five randomised trials of inhaled cannabinoids in chronic neuropathic pain and found a clinically meaningful benefit over placebo (number-needed-to-treat around 5–6). The Cochrane review noted modest improvements in pain and sleep, offset by adverse effects. The Canadian Pain Society and EAN list cannabinoids as a late-line option after first- and second-line agents have failed. Neuropathic pain is the cannabinoid-indication with arguably the most consistent RCT support in the chronic-pain space.
How the doctor will evaluate you
The consulting doctor will ask for a clear clinical picture — underlying cause of the neuropathy (HbA1c if diabetic; shingles history if post-herpetic; chemotherapy regimen if oncology-related), a current neuropathic-agent list with doses and trial durations, and sensory-symptom mapping (burning vs electric vs numbness). Balanced THC:CBD products are the most common choice; pure CBD has weaker evidence for neuropathic pain specifically.
Drug-interaction considerations
Patients on gabapentin or pregabalin tolerate cannabinoids reasonably well, but additive sedation is common in the first weeks. Duloxetine and amitriptyline combinations warrant closer attention. THC can increase heart rate — relevant for patients with existing cardiac conditions. As always, concurrent opioid use is reviewed, and dose-reduction is discussed rather than additive prescribing.
When to see a doctor urgently
- New motor weakness, bladder/bowel dysfunction — suggests compressive lesion, needs urgent review
- Fever with back pain — exclude discitis / abscess first
- Unexplained weight loss — exclude malignancy first
- Cardiac disease and THC — additive tachycardia risk
- Uncontrolled diabetes — optimise glycaemic control alongside, not instead of, symptomatic treatment
If any of the above apply, seek in-person medical care — do not wait for a remote Section 21 consultation.
The South African Section 21 pathway
Neuropathic pain is one of the better-evidenced Section 21 indications in SA. Applications are stronger when supported by a clear underlying diagnosis and a documented trial of first- and second-line neuropathic agents (gabapentin, pregabalin, duloxetine). Authorisations are time-limited and reviewed at renewal.
Frequently asked
- Will cannabinoids replace my gabapentin?
- Not automatically. The doctor may keep your current regimen and add a cannabinoid as an adjunct, or propose a structured taper if the combined effect is better. Changes are staged — not all at once.
- How long before I know if it works?
- Neuropathic pain is typically reviewed 4–6 weeks after dose stabilisation. If there is no measurable benefit on the pain score or on function by then, the doctor will usually discontinue rather than persist.
- Does this work for diabetic neuropathy specifically?
- There is evidence that cannabinoids help various forms of peripheral neuropathy including diabetic. The key prerequisite is that you are optimising glycaemic control in parallel — treating symptoms without addressing glucose is not sustainable.
Related conditions
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