Navigating Pain Management Prescriptions In Wound Care
“I find more often than not I use a combination of these medications to achieve a level of acceptable comfort,” says Dr. Brill.
The SNRIs, such as duloxetine or venlafaxine, are Dr. Suzuki’s second choice for neuropathic pain or as an adjuvant pain medication if the patient fails or is allergic to gabapentin or pregabalin. He notes that duloxetine now has a FDA indication for “chronic musculoskeletal pain,” although he says the black box warning for an increased propensity for suicide is an issue. Dr. Suzuki believes physicians used to prescribe tricyclic antidepressants such as amitriptyline often for diabetic neuropathic pain, but he almost never prescribes tricyclics because the side effects (such as dry mouth) are often intolerable in comparison to the mild drowsiness patients often encounter with gabapentin.
The topical application of adjunctive analgesics is very helpful for some patients and avoids problems of drug interactions and side effects that Dr. Jacobs notes can frequently lead to a reluctance to prescribe similar medications orally. He says gabapentin, ketamine, clonidine (Catapres, Boehringer Ingelheim), lidocaine (Lidoderm, Endo Pharmaceuticals), bupivacaine and other agents are useful in the management of symptomatic neuropathy. Dr. Jacobs notes that one may apply them as a compounded cream with very successful clinical results in many circumstances.
Dr. Jacobs advises remembering at all times that the anticonvulsants, antidepressants and other adjuvant analgesics utilized for symptomatic diabetic neuropathy are for relief of sensory symptoms and do not treat or reverse entrapment neuropathy, autonomic neuropathy or motor neuropathy. He adds that such agents do not reverse the ischemia, oxidative or nitrosative stress causing the neuropathy.
“We must remember that diabetic neuropathy is a metabolic disorder and correction requires metabolic correction,” says Dr. Jacobs. “I explain this to patients in detail and always combine agents such as anticonvulsants or antidepressants with supplements to reverse oxidative stress and assist in actual correction of the disease process.”
Common supplements for Dr. Jacobs include L-methylfolate, pyridoxal 5’ phosphate, methylcobalamin (Metanx, Pamlab) with adjuvant analgesics. He also will use alpha lipoic acid, L-carnitine and inositol.
Dr. Suzuki acknowledges some data showing that oral supplements of folic acid and alpha lipoic acid provide “meaningful” pain relief in diabetic neuropathy.1 However, he says those supplements would be the second line of treatment after gabapentin since it reportedly takes a few weeks of supplement use before patients can feel any pain relieving effect.2
“I know some neurologists swear by the topical capsaicin cream (Zostrix) for diabetic neuropathy but I haven’t had good luck getting the patients to apply it multiple times per day,” points out Dr. Suzuki.
Do you use oxycodone (OxyContin, Purdue Pharma) or other extended-release narcotics? Do you ever have a problem with prescribing these powerful opioids?
For the most part, if Dr. Lullove needs to use extended-release medications, he will always try to minimize the amount needed for the longest time. As he notes, the goal should be to sustain steady state levels in the blood so the patient does not have the peaks and troughs associated with conventional opioid medications. Ideally, he suggests matching the dosing schedules with the American Academy of Pain Management’s criteria for extended-release medications. Dr. Lullove notes that sometimes, the need for a “breakthrough” pain medication is necessary when using extended-release opioids due to the slow time release nature. Either way, Dr. Lullove says careful management and follow-up is necessary, and one should see patients no less than weekly in the first month of therapy during management.
Dr. Jacobs has found several opioid and opioid-like agents very helpful for the management of symptomatic diabetic neuropathy. Tapentadol (Nucynta, Janssen Pharmaceuticals) has recently received approval for the treatment of diabetic neuropathy. He notes that tramadol, with mu-2 receptor activity and some tricyclic activity, is also helpful to manage symptomatic neuropathy. He cites studies indicating that oxycodone is helpful for the management of neuropathic pain.3