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

Medical Management

The remainder of Mrs. Tandy's history and physical examination revealed no contraindications to a trial of opioid analgesics with carefully selected adjuvant medications for her neuropathic pain. She was started on low-dose oxycodone with acetaminophen (Percocet 2.5/325) 1 to 2 tablets every 4 hours as needed (≤ 8 per day with instructions to avoid other sources of acetaminophen). It was unlikely that she would experience the bothersome cognitive effects on this drug that she experienced on the Darvocet because oxycodone produces no norpropoxyphene, the toxic metabolite of propoxyphene that causes cardiotoxicity and neurotoxicity.[24] She overcame her reluctance to use opioids when she was told that this medication had the same potency or was only slightly stronger than 2 tablets of her acetaminophen with codeine, while being much less likely to cause the side effects that could limit its usefulness.

As is standard for all patients in the practice, Mrs. Tandy was instructed on how to keep a pain diary. She submitted to written questionnaires screening for depression, drug abuse, and physical mental functioning, and she participated in a urine drug screen. She also signed an opioid agreement with instructions to return for follow-up in 1 week.

Evaluation of this regimen at 1 week demonstrated that Mrs. Tandy's pain was slightly better (8/10 in intensity), which the pain diary linked to the timing of the medication administration. There were no physical or mental side effects reported, with stable vital signs and an absence of aberrant drug behaviors. The oxycodone dose was titrated (utilizing the 5/325 preparation of Percocet) , a bowel regimen was added, and adjuvant therapy was considered.

Adjuvant therapy. Although tricyclic antidepressants are typically used as first-line treatment for painful diabetic neuropathy,[11,13,25] a trial of gabapentin was used first for Mrs. Tandy because of its greater safety margin for older people. To minimize the risk of falls due to sedation or dizziness, she was started on 100 mg of gabapentin at bedtime, with instructions to add an afternoon pill in 3 days, then add a morning pill 3 days later before returning to the clinic the following week.

During the second week, she continued to improve (pain intensity cut to 7/10); however, the gabapentin trial failed because of intolerable side effects at subtherapeutic doses. She tried taking it twice a day a couple of times during the week, but each time she became dizzy and frightened of falling. After a screening electrocardiogram indicated a normal ST segment, a trial of nortriptyline 10 mg at bedtime was substituted, which also failed due to intolerable dry mouth and dizziness the next day.

A dose of 2 oxycodone/acetaminophen 5/325 mg tablets every 6 hours seemed to work best for her. At night, however, she was still awakened by her pain. The oxycodone preparation was helping to provide partial temporary relief, but was too short-acting to allow for sustained sleep.

Other adjuvant medications for neuropathic pain were tried in order of their anticipated safety and side-effect profiles. After a couple more failed trials, oxcarbazepine (Trileptal) 150 mg by mouth at bedtime was added, and the oxycodone/acetaminophen (5/325 mg) regimen was switched to controlled-release oxycodone (OxyContin) 20 mg twice daily. Oxcarbazepine has support for long-term safety and tolerability when used for painful diabetic neuropathy,[26] and was acceptable to Mrs. Tandy when titrated up by 150 mg per day added each week until reaching 600 mg twice a day. Combined with the changed opioid, this worked to lessen the burning character of her pain and reduced its intensity to 5/10. Mrs. Tandy also reported that she was sleeping much better and had considerably more daytime alertness. Concurrently, she had been enrolled in the 10-week Cognitive-Behavioral Pain Management Program led by a nurse practitioner, and was beginning to notice clinical benefits from that as well.[27]

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