Neuropathic pain (NP) is a prominent form of pain associated with a variety of diseases and conditions, including cancer, diabetes, herpes zoster, chronic back pain, and multiple sclerosis. A growing NP patient population, the significant percentage of patients refractory to treatment, a high rate of polypharmacy, and large unmet need, in balance with the availability of multiple generic analgesics and well-established treatment options, combine to make the NP market one of modest commercial opportunity for pain therapies, particularly those with novel mechanisms of action. Antiepileptic drugs (AEDs), such as Pfizer’s Lyrica (pregabalin) and gabapentin (Pfizer’s Neurontin, generics), and antidepressants, such as Eli Lilly’s Cymbalta (duloxetine, generics), are the most commonly used drugs in first-line treatment of NP. Among topical anesthetics, the 5% lidocaine patch (Endo’s Lidoderm, generics) has emerged as an early-line therapy for NP patients who present with highly localized peripheral pain; the newer Qutenza (Acorda Therapeutics’ 8% capsaicin patch) has seen limited uptake since its U.S. launch for PHN in 2010. Nevertheless, because no single therapy provides more than partial analgesia, NP treatment is characterized by a high rate of polypharmacy across several drug classes. Other drug classes frequently prescribed for this patient population include NSAIDs, dual-acting opioid analgesics (e.g., tramadol [generics], Nucynta ER [Depomed’s tapentadol ER]), and, for the most severe pain, opioid analgesics (e.g., oxycodone CR [Purdue’s OxyContin]).

For this report, we surveyed 49 primary care physicians (PCPs), 50 pain specialists, 51 neurologists, and 30 managed care organization (MCO) pharmacy and medical directors to assess their attitudes, expectations, receptivity, and reservations regarding current, recently approved, and emerging NP therapies (including Daichii-Sankyo’s AED mirogabalin, Pfizer’s AED pregabalin CR, BioDelivery Sciences International’s topical clonidine gel, Impax/Durect’s transdermal bupivacaine patch, Immune Pharmaceutical’s topical ketamine/amitriptyline cream [AmiKet], and Biogen’s oral subtype-selective sodium-channel antagonist CNV-1014802).

Questions Answered in This Report:

  • Understand surveyed PCPs’, pain specialists’, and neurologists’ current treatment of key NP populations (i.e., PHN, PDN, neuropathic back pain, post-trauma/postsurgical NP, HIV/AIDS-related NP, central NP, and neuropathic cancer pain). Which NP populations and pain severities are the different physician types treating? What are physicians’ first- and second-line treatment choices for these NP populations? How might use of key analgesic drug classes vary based on the physician specialty and/or patient population treated? What are physicians’ general impressions of key NP therapies with regard to clinical factors and reimbursement restrictions? What factors (clinical and/or non-clinical) are influencing their treatment decisions?

  • Examine surveyed payers’ current coverage and use of cost-containment strategies for marketed NP therapies. Which NP therapies are covered on managed care organization (MCO) pharmacy/medical directors’ largest commercial and Medicare PDP formularies, and on what tier are these therapies likely to be placed? What are the most common cost-containment strategies for expensive branded agents? How has availability of generic duloxetine and generic 5% lidocaine patch changed overall reimbursement of branded NP therapies? How do approvals for specific subtypes of NP affect overall reimbursement for NP? What are the most important clinical and non-clinical factors to payers when making reimbursement decisions for NP therapies? What are the preferred drug comparators when assessing therapies for various subtypes of NP?

  • Explore surveyed physicians’ and payers’ attitudes toward emerging therapies. How will surveyed physicians incorporate key emerging therapies into clinical practice, if at all? What factors are influencing physicians’ decisions to prescribe (or not prescribe) these agents? For which NP populations will they prescribe particular agents, and which current therapies are most at risk of losing share? How will MCO coverage, including formulary inclusion, tier placement, and reimbursement restrictions, impact the uptake of emerging therapies? How do expected tier placement and cost controls for these agents compare to those of long-standing current therapies?


This U.S. Physician & Payer Forum report contains insights from a survey of 150 physicians (49 PCPs, 50 pain specialists, 51 neurologists) and 30 MCO pharmacy/medical directors regarding physician and payer dynamics that affect prescribing practices for the treatment of NP in the United States. In this report, we explore the use, reception, and formulary status of key current and newer-to-market NP therapies by physicians (PCPs, pain specialists, and neurologists) and MCO directors across multiple NP populations and gauge payer and physician outlook toward key emerging therapies. By understanding the attitudes and expectations of prescribers and payers toward current and emerging NP therapies, stakeholders can gain an understanding of the complex and changing reimbursement climate for NP.

Markets covered: United States.

Primary research: Online survey of 49 PCPs, 50 pain specialists, 51 neurologists, and 30 MCO pharmacy or medical directors.

Epidemiology: 2015 prevalent cases of the following NP populations are presented: Neuropathic back pain, PDN, PHN, neuropathic cancer pain, HIV/AIDS-related NP.

Population segments: Where appropriate, our data and analyses are segmented by the following key NP populations: PHN, PDN, neuropathic back pain, post-trauma/postsurgical NP, HIV/AIDS-related NP, central NP (e.g., MS-related NP, stroke-related NP), neuropathic cancer pain.

Author(s): Bethany A. Kiernan, Ph.D.
Andrea (Buurma) Kravit