Prescription trends and clinical decision-making in neuropathic pain pharmacological treatment : results from a cross-sectional survey by the spanish pain society

Abstract

Background: Neuropathic pain (NP) is a complex chronic condition with limited therapeutic effectiveness. Despite multipledrug classes and international guidelines, real-world adherence remains inconsistent, and data on prescribing practices amongpain specialists is scarce.Methods: We conducted a nationwide cross-sectional survey among members of the Spanish Pain Society in May 2025. A struc-tured 62-item questionnaire assessed prescribing habits, decision-making criteria, guideline adherence, dosage patterns, and therecognition and management of tolerance. Sociodemographic and professional data were also collected.Results: A total of 220 pain specialists (52% female) completed the survey; 28% had over 20 years of clinical experience.Satisfaction with current pharmacological options was modest, with 52% reporting dissatisfaction or indifference. Prescribing was mainly guided by clinical experience (43%) and guideline recommendations (36%). Gabapentin (45%) and pregabalin (40%)were the most frequent first-line choices, followed by tricyclic antidepressants (amitriptyline; 9%), duloxetine (5%) and venla-faxine (1%). Tramadol dominated second-line use (65%), followed by capsaicin (22%) or lidocaine (5%) patches. Half of the par-ticipants reported tolerance, typically after 3–12 months, managed mainly by dose escalation or switching drug classes. Dosagepractices for gabapentinoids and antidepressants showed marked heterogeneity, with frequent deviations from recommendedtitration protocols.Conclusions: NP management in Spain shows variability and partial alignment with international guidelines. Gabapentinoids,tricyclic antidepressants and duloxetine remain preferred treatments, but reliance on personal experience and awareness oftolerance hinder evidence-based practice. Quantifying Spanish pain specialists' views on tolerance supports calls for nationalconsensus, better dosing education and further research to harmonise care and improve outcomes.Significance: This nationwide survey provides the first systematic assessment of neuropathic pain management in Spain, re-vealing marked variability, only partial adherence to international guidelines, and persistent reliance on clinical experienceover evidence. It confirms gabapentinoids, tricyclic antidepressants and duloxetine as preferred treatments, identifies continuedtramadol use despite conflicting recommendations, and quantifies for the first time clinicians' perception and management oftolerance. These findings fill a major evidence gap and directly inform future national consensus, educational initiatives andclinical practice improvement

Gebro Pharma provided financial support for the survey