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Adding an antidepressant or anxiolytic to the mix can work wonders for the patient with chronic nonmalignant pain. The tricyclic group of antidepressants (amitriptyline, nortriptyline, etc.) has been frequently used by physicians for pain prophylaxis. Although dosages vary from those used to treat depressive illnesses, these medications provide mild sedative effects for patients with chronic pain and can lead to improved sleep and function. Desipramine, a less sedating tricyclic agent, can be particularly effective for patients who wish to lessen their pain but avoid the drowsiness associated with other antidepressant medications. A newer agent, venlafaxine, “is just as efficacious against neuropathic pain as the tricyclic antidepressants, with fewer adverse effects.”⁴

Another group of agents being used for pain treatment and prophylaxis includes anticonvulsant therapy (gabapentin, topiramate, divalproex sodium, etc.) or other central nervous system drugs, such as nefazodone hydrochloride (Serzone). Gabapentin, in particular, is thought to work at the cellular level by hyperpolarizing nerve fibers so that depolarization of nerve pathways (required for transmission of pain signals) is slowed or impaired. Gabapentin is relatively nontoxic and can be combined with other agents without the fear of a drug reaction. Dosages of gabapentin have been well-tolerated up to 3,600 mg daily, although patients with renal compromise are restricted to much smaller amounts of the drug.

Conditioning, however, represents perhaps the most important aspect of treatment for chronic nonmalignant pain. Patients in pain often cope by stopping or restricting their movements. This can be detrimental to optimal functioning in the long run. While seeking analgesic treatment, patients need therapy to get them moving again or to return them to their work environments, where they can begin to feel useful and productive. This is an especially difficult step to encourage, and patients may need the benefit of so-called work-hardening programs, which use an interdisciplinary approach to pain treatment. These programs work with numerous types of pain patients, monitoring their drug therapies while enlisting the help of physical and occupational therapists, as well as psychotherapists.

What the future may hold

While we may be a long way from finding a cure for chronic nonmalignant pain, research holds promise for patients with this type of unremitting pain. Studies regarding the use of preemptive analgesia are well under way. Preemptive analgesia employs preoperative and intraoperative use of analgesic agents to reduce the risk of developing neuropathic pain in the first place. This is an important concept to remember when nurses treat preoperative patients who experience pain. Research suggests effective pain treatment in the preoperative phase goes a long way toward reducing problems with pain at a later date.

Developing an understanding of chronic nonmalignant pain assists nurses in assessing and treating patients more effectively. Knowledge also promotes compassion, for this group of patients can be difficult to treat, particularly when nothing seems to be effective to reduce their pain. Newer and more efficacious pain treatment options are surely on the horizon. Until then, nurses require skill, understanding, and tenacity to master this complex phenomenon.

Diane M. Goodman, RN, C, CCRN, is a clinical educator, patient care services, and pain resource nurse at Lake Forest Hospital, Ill.

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References

1. Marcus D. Treatment of chronic nonmalignant pain.
Am Fam Physician. 2002;61(5):1331-1338.

2. Meldrum M. A capsule history of pain management. JAMA. 2003;290 (18):2470-2475.

3. Ballantyne J, Mao J. Opioid therapy for chronic pain. N Eng J Med. 2003;350:840-842.

4. Vastag B. Scientists find connections in the brain between physical and emotional pain. JAMA. 2003;290(18):2389-2390.