Pain Management & Treatments for PN

Acetaminophen

Acetaminophen is used to treat mild-to-moderate pain and reduce fever, but it is not very effective at reducing inflammation. Acetaminophen provides relief from pain by elevating the amount of pain you can tolerate before you experience the feeling of pain. The best-known brand of acetaminophen is Tylenol®, but there are also many generic versions available.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce pain, swelling, stiffness and inflammation. Two drugs in this category, ibuprofen and naproxen, also reduce fever. NSAIDs work by reducing the body’s production of prostaglandin, an enzyme that sends pain messages to the brain. When these drugs are taken regularly, they build up in the blood to levels that fight pain caused by inflammation and swelling, and also provide general pain relief.

There are several different types of NSAIDs:

• Aspirin (Bayer® Aspirin, Ecotrin®, Excedrin®, St. Joseph’s®, and many others)
• Ibuprofen (Advil®, Motrin®, and others)
• Ketoprofen (Orudis®)
• Naproxen (Aleve®)

Transcutaneous electronic nerve stimulation (TENS) is a method of therapy that may be used to treat nerve pain. It works by inhibiting pain signals from reaching the brain. It is a drug-free therapy that works by placing very small electrical impulses on specific nerve paths. The electrical impulses are delivered to the nerves through electrodes that are placed on the skin. Although it doesn’t work for everyone or all types of pain, TENS may be prescribed in combination with other treatments, primarily to provide relief from acute forms of nerve pain.

There are two alpha-2-adrenergic agonists that have some evidence as pain relievers: tizanidine (Zanaflex®) and clonidine (Catapres®). There are some studies showing that tizanidine can be effective for tension-type headache, back pain, neuropathic pain and myofascial pains. Clonidine has been used to treat neuropathic pain that is not responding to other treatment or therapy.

Corticosteroids are anti-inflammatory drugs that can be used to relieve severe pain associated with nerve irritation and inflammation. They may be taken orally, or injected directly into the areas of the body where there is pain. Coricosteroids can greatly reduce and may eliminate pain for extended periods of time.

COX-2 inhibitors are a relatively new type of nonsteroidal anti-inflammatory drug (NSAID)

that reduces pain and inflammation by blocking a specific enzyme (COX-2) in the body. COX-2 inhibitors are less likely to cause gastrointestinal problems or bleeding than traditional NSAIDs (e.g., aspirin or ibuprofen) and may be a safer alternative for certain patients. However, because COX-2 inhibitors do not inhibit blood clotting (thin the blood), as do other NSAIDs — especially aspirin — they should not replace aspirin as a heart treatment.

COX-2 inhibitors include:

• Celecoxib (Celebrex®)
• Rofecoxib
• Valdecoxib (Bextra®)

Intravenous immunoglobulin is frequently abbreviated as IVIg or IgG (for intravenous gamma globulin). This procedure is used in the treatment of immune system disorders. It also is performed to improve the immune system’s reaction to a serious illness. Concentrated antibodies collected from healthy individuals are put in a sterile solution and injected directly into a vein to help fight illness.

Limited evidence suggests that medical marijuana, which is prescribed by doctors and legal in selected states in the U.S. and some countries internationally, can reduce nausea and vomiting during chemotherapy, improve appetite in people with HIV/AIDS, and reduce chronic pain and muscle spasms associated with neuropathy. For more comprehensive information on the use of medical cannabis for neuropathic pain click here to read our five-part article on the subject.

Mexiletine (Mexitil®), an orally taken form of lidocaine, was originally approved to treat irregular heartbeats, but sometimes is effective in the relief of chronic nerve pain. Mexiletine reduces pain by adhering to peripheral nerves and reducing pain signals carried from the peripheral nerves to the central nervous system and brain. Over time, as mexiletine bonds to the peripheral nerves, the feeling of pain is diminished. Mexiletine is being used experimentally to treat pain associated with different kinds of peripheral neuropathy.

Narcotics, also known as opioids, are used to relieve severe and chronic pain. They are prescribed when other pain medications and therapies do not seem to work. These drugs are often used in combination with other medications such as antidepressants, anticonvulsants, and non-narcotic pain relievers. Opioids are the strongest pain medicines available and may become addictive if used on a long-term basis.

There are different types of opioids, which include:

Codeine
Hydrocodone
Hydromorphone (Dilaudid®)
Meperidine (Demerol®)
Methadone (Dolophine®)
Morphine (MS Contin® and others)
Oxycodone (OxyContin®)

Anesthetic nerve blocks are a method used to treat and understand the source of nerve pain. A patient receives an injection of an anesthetic directly into a bundle of nerves. The injection prevents the nerves from sending pain signals to the brain, thus providing temporary pain relief. If the nerve block works, it may help identify affected nerves and lead to better pain treatment.

Two kinds of drugs used as nerve blocks are:

Lidocaine
Bupivacaine

Are a type of antidepressant medication that may reduce neuropathic pain. These drugs affect the nerve cells in the brain and inhibit the reuse of specific neurotransmitters (dopamine, serotonin, and norepinephrine), which may alleviate depression by achieving a chemical balance in the brain.

Examples of norepinephrine reuptake inhibitors are:

Bubropion (Wellbutrin®, Wellbutrin SR®)
Ludiomil (Maprotiline®)

Plasmapheresis, a procedure that removes excess antibodies from the bloodstream, is used in the treatment of lupus and multiple myeloma. During this procedure, whole blood is removed from the body and the blood plasma and blood cells are separated. Antibodies are found in plasma, so the plasma is discarded. The blood cells are recombined with plasma substitute, or donor plasma, and may be returned to the body.

Are a new type of antidepressant drug that is used to treat pain caused by neuropathy. SSRIs restore the chemical balance in the brain’s nerve cells. Common SSRIs used to treat neuropathy pain include:

Paroxetine hydrochloride (Paxil®)
Fluoxetine (Prozac®)
Sertraline (Zoloft®)
Citaprolam (Celexa®)
Fluvoxamine (Luvox®)

Are a new type of antidepressant medication that may alleviate pain caused by neuropathy. These drugs affect the nerve cells in the brain and inhibit the production and release of specific neurotransmitters (serotonin and norepinephrine).

Examples of serotonin and norepinephrine reuptake inhibitors include:

Duloxetine (Cymbalta®)
Venlafaxine (Effexor®, Effexor XR®)

Are antidepressant medications that may relieve neuropathic pain. These drugs work to achieve chemical balance within the brain by increasing the levels of serotonin and norepinephrine available to transmit messages to other nerves.

Serotonin receptor modulators include:

Nefazodone (Dutonin®)
Trazodone (Desyrel®)

Topical medications are creams, ointments, gels, lotions or patches that you apply directly on your skin to provide relief from nerve pain and inflammation. The active drugs in these medications are absorbed through the skin and provide localized pain relief.

Two types of topical medications used to treat neuropathy pain are:

Local anesthetics
Analgesics (see over-the-counter options)
LOCAL ANESTHETICS
Local anesthetics are used to treat localized pain. They work by numbing the area and blocking the pain where they are applied. Some local anesthetics are:

EMLA – A prescription cream that numbs the skin within an hour of application and lasts for a few hours.
Lidocaine patch (Lidoderm®) – A prescription patch that is applied directly to the skin to relieve nerve pain.

Tramadol is a pain medication prescribed to treat moderate-to-severe acute pain. Its effectiveness in treating chronic pain is still being studied. It has properties similar to both opioids (narcotics) and antidepressants. Tramadol reduces pain by interfering with pain signals to the brain (like an opioid) and by affecting neurotransmitters (like an antidepressant).

Acupuncture is an ancient Chinese treatment that is performed today throughout the United States and Europe. Acupuncture involves inserting very thin needles into the body at specific points. Many people believe that acupuncture is an effective therapy to reduce pain. For some people with peripheral neuropathy, acupuncture acts as a complementary therapy because it may reduce the need to take pain-relieving drugs. Presently, research results are mixed as to whether or not acupuncture reduces chronic pain. A list of doctors that practice acupuncture is available from The American Academy of Medical Acupuncture.

Biofeedback is a therapy that uses an electrical machine to help you identify, monitor and learn to consciously manage your body’s physiological responses. It also can be used to learn relaxation techniques that can reduce stress, headaches and chronic pain.  Certified biofeedback therapists monitor the electronic equipment and train patients in the most effective techniques to control their specific symptoms.

Splints can be helpful for people suffering from muscle weakness as the result of peripheral neuropathy. Also, making ergonomic changes to one’s workplace may reduce the symptoms of carpal tunnel, and help alleviate the pain from peripheral neuropathy.

Relaxation techniques are designed to release tension that could make pain worse. A number of techniques exist including breathing exercises, visualization, meditation, massage, and yoga.

If you have a nerve disorder, a diet rich in certain nutrients can help. The food you eat can improve your nervous system’s functioning. Knowing which nutrients nourish your nervous system can help you lead a healthier life and reduce your chances of nerve-related problems.

• Establish your diet around vegetables, fruits, whole grains, legumes, omega-3 rich foods and lean protein sources
• Aim for 5-10 servings of colorful fruits and/or vegetables daily (phytonutrients). 1 serving = 1/2 cup for all other fruits and vegetables
• 1 medium fruit or vegetable, example apple, orange
• 1/4 cup dried fruit
• 3/4 cup juice
• Limit/avoid alcohol
• Toxic effect on nerve tissue
• Be aware of sodium; use <2,300 mg per day Lower saturated fats and trans fatty acids by choosing lean meats and poultry, and low-fat or non-fat dairy products
• Choose monounsaturated fats and polyunsaturated fats (from fish, nuts, and vegetable oils) in lieu of saturated and trans fats
• Choose/prepare foods and beverages with little added sugars/caloric sweeteners
  Anti-Inflammatory Eating

If you have a nerve disorder, a diet rich in certain nutrients can help. The food you eat can improve your nervous system’s functioning. Knowing which nutrients nourish your nervous system can help you lead a healthier life and reduce your chances of nerve-related problems.

• Establish your diet around vegetables, fruits, whole grains, legumes, omega-3 rich foods and lean protein sources
• Aim for 5-10 servings of colorful fruits and/or vegetables daily (phytonutrients). 1 serving = 1/2 cup for all other fruits and vegetables
• 1 medium fruit or vegetable, example apple, orange
• 1/4 cup dried fruit
• 3/4 cup juice
• Limit/avoid alcohol
• Toxic effect on nerve tissue
• Be aware of sodium; use <2,300 mg per day Lower saturated fats and trans fatty acids by choosing lean meats and poultry, and low-fat or non-fat dairy products
• Choose monounsaturated fats and polyunsaturated fats (from fish, nuts, and vegetable oils) in lieu of saturated and trans fats
• Choose/prepare foods and beverages with little added sugars/caloric sweeteners
  Anti-Inflammatory Eating

Low‐level, chronic inflammation lies so far below the skin’s surface that you can’t see it or feel it. It’s the result of an immune system in overdrive, damaging healthy tissue and leading to chronic illnesses. Follow these tips to help keep inflammation as low as possible:

Increase Omega–3 fatty acids:

• Use 1–2 Tbs. of flaxseed daily (grind the seeds for best effects)
• Eat 3–4 oz. of fatty fish at least 2 times per week. (e.g., wild salmon, halibut, mackerel, tuna)
• 3 oz. walnuts a day

Fiber and Antioxidants:

• Increase anti‐oxidants from fruits and vegetables (at least 5 daily)
• Eat foods that are more slowly absorbed into the blood stream (fruits, vegetables, nuts and beans)

Elevated blood sugar levels contribute to many chronic health conditions, including diabetic peripheral neuropathy. To help you maintain the best blood sugar level and manage your diabetes –

Know Your Carbohydrates!
Bread, cereal, pasta; starchy vegetables, like corn, peas, potatoes; dried beans, lentils, rice; fruits and fruit juices; milk, yogurt and other dairy foods; sweets, like cookies, candy, regular soda, sugar, syrup

Quality:
High fiber/whole grains, fruits, beans/lentils, low-fat dairy

Quantity:
Count your carbohydrates, label reading for serving size AND total carbohydrate
Plate method (1/2 plate veg, ¼ starch, ¼ lean protein)

Timing:
Spread out carbohydrate servings (3 small meals, 2-3 small snacks)

Often the medications and treatments that are used to fight chronic or life-threatening conditions, have a tendency for healthy cells to be affected, too, which may cause side effects. Some side effects may result to eating problems.

Nausea: 6-8 small meals, bland foods
Lack of appetite: Eat every few hours, fluids between meals
Unwanted weight loss: Add healthy fats (olive oil, nuts/seeds, avocado, olive)
Constipation: Increase fiber/fluids, regular meal times
Diarrhea: Limit milk products, small/bland/low-fat meals – easily digestible

Contributing factors to PN include vitamin deficiencies, traumautic injuries, diabetes, alcoholism, and others. Treatment may include managing underlying causes, physical therapy, medications and dietary changes. For best results seek guidance from your doctor.

Gluten: If you have a gluten allergy, celiac disease, consuming gluten can trigger and worsen your symptoms. Common sources include all food containing white, wheat, cake or baking flour. Look for products labeled ‘gluten free’.

Refined grains are highly glycemic meaning they have a dramatic impact on your blood sugar. Being able to control your blood sugar is the number one strategy to prevent neuropathy associated with diabetes. To improve the glyceminc impact of your diet, replace refined grains with whole grains.

Added sugars add flavor but few nutrients. Nutritional deficiencies can lead to neuropathy symptoms. Choose nutritious foods like fruits, vegetables and whole grains.

Saturated fat, prevalent in fatty meats and dairy products, can cause inflammation and an increased risk for type 2 diabetes. For enhanced wellness, replace fatty protein sources with lean alternatives and eat moderate amounts of healthy fat sources.

Source: LiveStrong.com

Below is a list of supplements for your nervous system.

Disclaimer: Dietary supplementation should NOT be initiated without the supervision of a qualified physician. Check with your doctor before you begin. Several of these supplements may have adverse effects.

ALPHA-LIPOIC-ACID

• Has been studied for treatment of diabetic neuropathy
• Anti-inflammatory effects, reduces oxidative stress
• Several studies show improvement in neuropathy symptoms with long term use
• According to one study taking 600 mg orally each day provides optimal risk-to-benefit ratio

ACETYL-L-CARNITINE

• Shown in clinical trials to be effective for diabetic neuropathy
• In studies of chronic peripheral neuropathy patients treated with 500-1,000 mg 3 times daily showed improvements in pain and improved sensation in fingers and toes
• Studies of other types of neuropathy have shown mixed results

VITAMIN D

• Studies have identified vitamin D deficiency as a risk factor for diabetic neuropathy
• Several trials showed improved pain levels in patients with diabetic neuropathy, with one study using an oral dose of 50,000 IU of vitamin D3 weekly
• Benefit of supplementation is less clear for patients with neuropathy and normal vitamin D levels

VITAMIN B1

• Studies have shown diabetic patients are more vulnerable to vitamin B1 deficiency
• Vitamin B1 deficiency can cause peripheral neuropathy
• Taking vitamin B1 600 mg/day can help improve pain in patients with diabetic neuropathy

VITAMIN B12

• Vitamin B12 deficiency can cause neuropathy
• Vitamin B12 deficiency is not uncommon in the USA, particular in older individuals when absorption declines
• In one study of patients with diabetic neuropathy and normal B12 levels, taking vitamin B12 500 mg 3 times daily helped improve symptoms of neuropathy after 4 months

VITAMIN B6

• Vitamin B6 toxicity and vitamin B6 deficiency can cause peripheral neuropathy
• Eating a balanced diet including foods high in B6 (salmon, poultry, chickpeas, dark leafy greens, bananas, cantaloupe) helps prevent vitamin B6 deficiency in most individuals

VITAMIN E

• Powerful antioxidant that reduces levels of free radicals and oxidative stress
• Studies showed a beneficial effect on the incidence and symptoms related to chemotherapy-induced peripheral neuropathy for patients taking vitamin E 300-600 mg/day

OMEGA-3 FATTY ACIDS (FISH OIL)

• High quantities in cold-water fish (salmon) and widely consumed for anti‐inflammatory powers

Essential fatty acids and important component of cell membranes, myelin sheath that protects nerves
Studies are underway (estimated completion date 2025-2026) to determine whether fish oil supplements can be effective in treating diabetic peripheral neuropathy

REFERENCES:

Chen, Jie, et al. “Vitamin E for the Prevention of Chemotherapy-Induced Peripheral Neuropathy: A Meta-Analysis.” Frontiers in Pharmacology, vol. 12, 2021, https://www.frontiersin.org/articles/10.3389/fphar.2021.684550.

Didangelos, Triantafyllos, et al. “Vitamin B12 Supplementation in Diabetic Neuropathy: A 1-Year, Randomized, Double-Blind, Placebo-Controlled Trial.” Nutrients, vol. 13, no. 2, Jan. 2021, p. 395, https://doi.org/10.3390/nu13020395.

Rowin, Julie. “Integrative Neuromuscular Medicine: Neuropathy and Neuropathic Pain: Consider the alternatives.” Muscle & Nerve, vol. 60, no. 2, 2019, pp. 124–36, https://doi.org/10.1002/mus.26510.

Yorek, Mark A. Effects of Fish Oil ± Salsalate on the Omega-3 Index and the Circulating Lipodome of Omega-3 Polyunsaturated Fatty Acid Metabolites in Patients With Type 2 Diabetes and Diabetic Neuropathy. Clinical trial registration, NCT05169060, clinicaltrials.gov, 6 Jan. 2023, https://clinicaltrials.gov/ct2/show/NCT05169060.