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

Initial Assessment, Diagnosis, and Treatment Planning

Mrs. Tandy first presented as a well-dressed, meticulously groomed 76-year-old woman. Her response to the question, "What brings you here today?" was very telling of her personality.

Well...my feet were burning so badly, I was on my way to the doctor to tell him to cut them off. While waiting at the elevator I saw a sign for the Pain Medicine Department. I went and yelled at him for not referring me there years ago.

Her pain was described as a severe burning (10/10 in intensity) in a stocking distribution pattern bilaterally. A "stocking" or "glove" pattern of pain distribution is typical of peripheral diabetic neuropathy (present in 20% who have diabetes of ≥ 10 years' duration), which damages the peripheral ends of small somatosensory fibers.[18] Her pain had been constant for 6 years, gradually worsening over time. Although it was present around the clock, she was most bothered by the pain at night when it interfered with the onset and maintenance of sleep. The pain was worsened by: tight-fitting shoes, standing, or walking for too long. She tried cool soaks, acetaminophen, and ibuprofen, but nothing seemed to help.

Her doctor once prescribed propoxyphene napsylate with acetaminophen (Darvocet N-100), but it made her head feel "goofy" so she stopped. Next, she tried acetaminophen with codeine (Tylenol 3); however, the constipating effects were a problem and she found it never noticeably reduced her pain. Similarly, lidocaine 5% topical patch was ineffective against her pain. She did not want to take stronger opioids because of concern about addiction and "what [her] children might think about [her]."

Mrs. Tandy's past medical history was significant for:

  • Diabetes type 2 -- treated with oral medications;

  • Cataracts; and

  • Hypertension, controlled by an angiotensin converting enzyme (ACE)-inhibitor

Her adherence to the diabetic and low-sodium diet was poor, but she was very compliant, if not regimented, when it came to taking her medications.

Mrs. Tandy was a fiercely independent woman, adamantly denying the need for help with shopping, laundry, finances, or housework.

She lived alone in a modest apartment on a fixed income (husband's pension). She struggled financially to balance her need for medicine, food, and heat. Mrs. Tandy described her 2 daughters and 8 lovely grandchildren, who lived nearby but rarely visited. They had a falling out years earlier when she refused to place her bed-bound, abusive husband in a nursing home. She found support and companionship at the local senior center and dance club, and found strength in her faith community.

Mrs. Tandy was diagnosed as having painful diabetic neuropathy of her feet. We discussed her treatment options. She was reassured that surgical amputation or other invasive procedures were not indicated or appropriate, as they were unlikely to make her pain go away and could potentially create new pains and health problems for her.[19] At the very least, she needed to make lifestyle changes, including diet and exercise for optimal control of her diabetes, which was the underlying cause of her pain.

An integrated approach, using a combination of medications and nondrug interventions provided by a multidisciplinary team, was likely to be the most effective strategy for managing her chronic pain.[20] In this case, the team included a:

  • Nurse;

  • Psychologist;

  • Physician;

  • Nutritionist; and

  • Physical therapist.

Mrs. Tandy herself was an important member of the team, as her treatment success was going to depend to a large extent on her motivation to utilize self-initiated coping skills and adhere to the established medical regimen.[21]

Patient education measures were complex and would take several visits to provide; education was not merely a matter of giving Mrs. Tandy a handout, or trying to teach her everything in one session.[22] Additionally, Mrs. Tandy had biases or misconceptions about the use of strong opioids for severe pain that needed to be addressed in order to offer her an optimal medication management plan. Developing a sustained, trusting partnership with the healthcare team was important for Mrs. Tandy to make the necessary meaningful changes in her self-care practices.

Taking the first step toward change. A first step in planning was to ensure that she had realistic expectations of her course of treatment and disease trajectory. As was the case for her diabetes, the treatment of her chronic neuropathic pain required her to take responsibility for changing her diet and exercise patterns, while fine-tuning her treatment based on the results of self-monitoring activities. Also like her diabetes, her pain was a condition she would likely have for the rest of her life, with no magic pill or procedure that could make it completely disappear. A treatment would be deemed successful if it decreased her pain by a third.[23]

Resistance to opioid use. Strong opioids are often necessary, but when used alone, they are insufficient to treat pain as severe as Mrs. Tandy was experiencing. Her reluctance to use opioid pain relievers was addressed. We discussed the monitoring safeguards to detect and treat the emergence of an addiction disorder, carefully explaining that an addiction was possible, but extremely unlikely in her case. She was reassured to know that people could be treated with strong opioids without becoming addicts.

Setting goals. In setting preliminary treatment goals, Mrs. Tandy wanted to decrease her pain by at least 30% and be able to increase her activity tolerance from 30 minutes to 45 minutes. To accomplish this, the plan was to meet weekly for a month to refine her medical management and begin to alleviate her pain. She was very interested in participating in a 10-session treatment program, led by a nurse practitioner, that would teach her ways to cope better with her pain after she was stabilized medically. She enrolled in the program scheduled to begin 3 weeks into her medical management appointments.

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