Learning to "Live With" Chronic Pain: Lessons From Mrs. Tandy

Paul Arnstein, PhD, APRN, BC

Topics in Advanced Practice Nursing eJournal. 2007;7(1) 

In This Article

Overview of Chronic Pain

In general, chronic pain (lasting more than 6 months) is difficult to treat, with a 30% reduction in pain intensity considered to be a successful response to treatment.[6] First, clinicians must identify and treat the underlying cause of pain, then determine whether persistent pain is nociceptive or neuropathic in origin.[7] In general, chronic neuropathic pain is more likely to be reported as a sharp or burning and superficial pain, whereas chronic non-neuropathic pain is more likely to be described as deep and aching.[8] Other common descriptions of neuropathic pain include:

  • Shooting;

  • Stabbing;

  • Electric shock; or

  • Uncomfortable numbness.

Despite the perception that neuropathic pain is refractory to opioids, patients are more likely to respond to opioid analgesics than any other single agent.[9] In head-to head trials, no subclass of opioids (for example, long-acting vs short-acting), drug (for example, morphine vs fentanyl), or route of administration (for example, oral vs transdermal) has demonstrated superiority for chronic noncancer pain.[10]

Co-analgesic drugs are typically added to opioids and have analgesic benefits independent of the pain-relieving properties of opioids. Tricyclic antidepressants (TCAs) are effective treatments for neuropathic pain.[11] These agents have a long track record of successful research and clinical use[12] and may be the most effective agents to use for the treatment of painful diabetic neuropathy.[13] The American Geriatrics Society warns that because of the side-effect burden of these agents in older persons, the starting dose should be 10 to 25 milligrams (mg) per day at bedtime.[14]

The effectiveness of several other treatments for diabetic neuropathy has been demonstrated, but some of these are used "off-label," as the United States Food and Drug Administration has approved only 5 agents for the treatment of neuropathic pain (indicated by an asterisk)[15]:

  • Carbamazepine (Tegretol)*;

  • Duloxetine (Cymbalta)*;

  • Gabapentin (Neurontin)*;

  • Lamotrigine (Lamictal);

  • Pregabalin (Lyrica)*;

  • Venlafaxine (Effexor);

  • Topical lidocaine 5% patch (Lidoderm)*; and

  • Tramadol (Ultram).

Duloxetine, although approved for the treatment of painful diabetic neuropathy, has not been published in head-to-head trials to demonstrate its equality or superiority to TCAs. The adverse effects involving the gastrointestinal, neuropsychological, and hepatic systems,[16] as well as drug-drug interactions affecting the cytochrome (CY) P450, 1A2, and 2D6 isoenzymes,[17] suggest that more safety and efficacy studies need to be published before this drug can be used routinely, especially in older persons.

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