Diabetes Self-Management Blog

Pain researcher Rebecca Sudore, MD, says, “Adults living with Type 2 diabetes are suffering from incredibly high rates of pain, at levels similar to patients living with cancer.” Sounds awful. But what can we do about it? Actually, quite a bit.

Let’s look at medications first. Because chronic pain involves emotions, thoughts, stress, general health, and the entire body, there are at least six different categories of drugs that can help with pain. They include: narcotics, anxiolytics (“tranquilizers”), antidepressants, anti-inflammatories, medicines for seizures, and alternative treatments.

With all those choices, nobody should have to live in severe pain. Unfortunately, many doctors know little about pain treatment and care even less. “I can’t see it or feel it,” they reason. “How bad can it be?” Doctors are often more likely to worry about patients’ “drug seeking” than they are about relieving their pain.

So it helps if people know their possible treatments and ask for them. Here’s a brief run-down:

Narcotics (also called opioids) are derived from the opium plant or are chemical imitations of opiates. They include morphine, codeine, oxycodone, meperidine, methadone, and many, many more. They block receptors in brain cells that feel pain.

Narcotics can help people ignore or cope with pain signals, but they don’t calm the overactive pain nerves that send the chronic pain messages. Sometimes, they have to really knock you out before you get much pain relief. But for some people, narcotics are the best answer.

Unfortunately, narcotics have a bad rap, because users build up a tolerance to them. They can become addicted. Contrary to popular myth, these addictions are not that hard to break, if people have some other way of dealing with their physical and emotional pain. The difficult part is staying off the drug when you’re still hurting.

The legal sanctions and medical prejudice against narcotics keeps many people from getting relief. But it doesn’t hurt to ask.

Narcotics are sometimes used in combination with other classes of pain medicines. Side effects may include constipation, sleepiness, and difficulty urinating.

Anxiolytics are drugs that calm anxiety and tension. They relax muscles and frequently reduce pain. They include benzodiazepines, such as alprazolam (Xanax) and diazepam (Valium), buspirone (Buspar), and herbals, such as chamomile, Saint-John’s-wort, and kava.

Anxiety and fear are major contributors to chronic pain, so if you notice extra anxiety or tension, you might consider these drugs.

• Anti-inflammatories are where most pain treatment should start. Inflammation is a chemical process, in which hormone-like chemicals called prostaglandins make nerves more sensitive to pain signals. Non-steroidal anti-inflammatory drugs (NSAIDs) block prostaglandins and reduce pain.

Older NSAIDs include aspirin, ibuprofen, and nabumetone (Relafen). Newer ones like celecoxib (Celebrex) and rofecoxib (Vioxx) made a multi-billion dollar splash in the 90’s, because they don’t cause stomach problems the way the older ones do. But as often happens, they turned out to cause worse problems, such as strokes. Now, they are not as widely used as the older ones.

Acetaminophen (Tylenol) is sometimes classed as an anti-inflammatory and sometimes not. It has only mild action against inflammation, but can help relieve pain.

• Anti-seizure medicines are often very good for chronic pain. Why? Because chronic pain is sometimes caused by oversensitive nerves. Seizures are the extreme case of hyperactive nerves, so medications for seizures can also turn down pain.

The most effective seizure drugs for pain are probably gabapentin (Neurontin and others) and pregabalin (Lyrica). These are widely prescribed for pain. According to Wikipedia, they are considered to have low potential for abuse or for causing dependence. Gabapentin is available as a generic, while pregabalin is not. But pregabalin may be more effective for many people.

Older anti-seizure drugs such as phenytoin (Dilantin), carbamazepine (Tegretol), and valproic acid (Depakene) can also reduce pain, although perhaps not as much as the newer ones. They are all cheap and available, but sometimes cause side effects including nausea, vomiting, headache, and dizziness.

• Since depression almost always goes along with chronic pain, antidepressants often help. Drugs prescribed for pain include the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac and others) and paroxetine (Paxil and others).

Some pain specialists find different antidepressants more helpful. The older MAO inhibitors, such as nortriptyline (Pamelor and others) often substantially reduce pain. The newer serotonin–norepinephrine reuptake inhibitors (SNRIs) work for many people. The drugs venlafaxine (Effexor) and duloxetine (Cymbalta and others) have shown good results in pain studies.

These drugs may take several weeks to start working. Side effects can include blurred vision, drowsiness, dry mouth, constipation, and weight gain.

• Alternative agents also work for many people. Popular ones include the following:

Arnica. An herb that comes from the Mountain Daisy. Arnica relieves swelling and pain. It can be rubbed on the painful area or taken by mouth.

Cannabis. If you live in a medical marijuana state, you might look into the pain-relieving and muscle-relaxing effects of cannabis. They have been shown in a number of studies. Cannabis oil applied to the skin is said to have no mental effects. You don’t get high, but inflammation and pain are reduced.

Other nondrug approaches include magnesium supplements to relax muscles, Chinese herbal medicine, capsaicin (chili extract), and many others, some of which you can see here.

That’s just the medicines that can help your pain. I haven’t even talked about physical therapy approaches like exercise, electrical nerve blocks or stimulators, Anodyne Therapy, or many others I discussed here and here. And improving glucose control often makes pain go away, especially the pain of neuropathy. So don’t forget that. But what has worked for you?

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Comments
  1. Getting my blood glucose in the lower 6% range has worked for me. When first diagnosed I couldn’t walk half a block due to pain. 20 years later, I can walk miles with no pain.

    Posted by Cal |
  2. I am dealing with severe pain in my legs, feet and hips. My doctor reluctantly prescribed Lyrica 13 months ago. I have had NO relief from the neuropathy pain in my feet. BUT… the pain in my neck, shoulders, spine and lumbar area have been greatly reduced. While not completely relieved, I can now at least function and participate in some of my family’s day to day activities. After some research, I believe the pain is from Fibromyalgia, but my doctor doesn’t believe that Fibromyalgia is a real disease. His thinking is that it’s just a made up disease that doctor use when they can’t explain, lessen or eliminate pain. Lately, I have just given up trying to function due to pain. My doctor suggested that I take a tranquilizer to eliminate my “depression”. I admit, it made me angry. I told him, I’m not depressed, I’m just sick and tired of feeling sick and tired. I don’t need a Happy Pill…. I need something for PAIN. Am I the only one that feels this way????

    Posted by Carol Cannon |
  3. Two observations and a question:

    1. Another area that is highly affected by chronic pain is one’s ability sleep. In my case, moderate pain and sleep deprivation have combined to be darn near debilitating at times, physically and mentally.

    2. An unfortunate fact is that for many of us a lot of these drugs are pretty much off limits, as it is illegal to drive or operate machinery while taking them, and we have to work. When I came back to work after surgery, I was taken off oxycodone & alprazolam and placed on tramadol, which dulls but does not relieve the pain. I’m getting by, but just. Some folks in similar situations tell me you eventually just get used to being in pain all the time. I’m not there yet.

    3. The question: Is chamomile or St. Johns Wort really comparable in a significant way to alprazolam? I know a cup of chamomile tea can be relaxing, but I’ve seen alprazolam have a near miraculous effect on people with panic attacks and other severe anxiety disorders. Again, this is a drug doctors are reluctant to prescribe due to its potential for recreational abuse.

    Thanks as always for your time and insight!

    Posted by Joe |
  4. I had gabapentin prescribed for foot and leg pain, and also restless legs syndrome. It did help relieve the pain, and also stopped the leg movements and allowed me to sleep. But, unfortunately, it also increased insulin resistance, and made me feel incredibly hungry ALL THE TIME, even when I had just eaten. I am a big person anyway, and this medication was making me so hungry I was gaining weight. I had to stop.

    I do get some pain relief from Voltaren gel applied directly to the painful areas. When this is not enough, I use 5% lidoderm patches on the painful areas. Both help me a lot. Unfortunately, my use of the lidoderm patches is limited, because my skin is very sensitive, and I get itchy if I use them more than once or twice a week.

    Posted by Beth |
  5. Hi Carol

    I think your doctor is wrong about fibromyalgia not being real. But he is probably right about the antidepressant. They are not “happy pills.” They frequently help in chronic pain.

    I’m glad Lyrica is helping you. It’s great stuff. But it is not a “pain” medicine either. It’s for seizures. Chronic pain is a complicated condition and often needs several kinds of treatment. I’d give the depression medicine a try.

    This article might help you understand your pain better.

    Posted by David Spero RN |
  6. carol cannon,
    get a new doctor- in this day and age no one needs to suffer, always remember, less is more.
    the important task at hand is to have a good doctor who is well versed on medications that really work.It is the doctors job to diagnois your pain,the type of chronic pain that you are explaining to him and if appropriate, prescribe
    a medication so that you have relief of pain. without these steps you cannot have quality of life. I have had chronic pain since 1995, not from diabetes, from a vehical accident. I have been extremely lucky along the way to have had very good doctors.
    carol, goodluck to you and I hope you find some relief for your pain.

    Posted by karen jacobs |
  7. Beth,

    Glad to see you commenting again and sorry you are in so much pain. Thanks for the tip about the skin creams.

    Joe,

    I hadn’t thought about the operating machinery problem with these drugs. I will look into what is safe for driving, but there may not be much.

    I don’t think chamomile tea is equivalent to alprazolam or other BZD drugs. It’s just something that works for some people.

    Sleep is super important in pain. Insomnia is pain’s twin. You might ask your doctor about referral to a sleep specialist, or read some of the articles on our site about sleeping. Thanks for your kind words.

    David

    Posted by David Spero RN |
  8. Carol,I agree with Karen..Find a new doctor.Sometimes you have to take matters into your own hands.I have had severe Arhritis for over 30 years.It started in my late 20’s and my doctor at the time kept telling me to take a couple of asprin and relax.I was in severe pain for years.A pharmacist who was the husband of a friend finally told me about a good doctor who his customers raved about.I made an appointment and she diagnosed my condition in five minutes.I’m sure a good doctor can help.Don’t be afraid to speak up.Tell him or her exactely how you feel.In my case it was a female doctor who ended my years of severe pain.You like me may never be completely without pain but it can be managed.Don’t give up.I know it hurts but you have to keep moving.

    Posted by jack |
  9. None of the meds for pain work for me so I just have to endure. I do take meds at HS for Restless Legs and that at least lets me sleep. I think it is worth mentioning that taking more than 4,000mg of Tylenol can cause liver damage. Seems if isn’t one thing it’s another. Life can be challenging.

    Posted by Ferne |
  10. a homeopathic remedy that is a nerve tonic is HYPERICUM [ from St John's wort]. It can be taken a couple of times a day

    Posted by Peggy Brewster |
  11. I had diabetic neuropathic pain in my feet and legs so bad, I could barely walk. Gabapentin did not help. Lyrica provided some relief (I’m no longer taking it). The magic formula for me was as follows: CoQ-10 200mg per day, Vitamin B6 100mg twice a day, Potassium 99mg twice a day. I have been leg pain free for 6 years. Funny how none of these items are mentioned in the above article, but homeopathic (which is another word for completely worthless and ineffective) remedies are.

    Posted by Greg |
  12. What about using a pain cream from an accredited compounding pharmacy? “Transdermal Therapy” I understand they have the ability to make customized creams for customers.

    This way you can avoid taking narcotics/opioids and other oral medications and avoid the potential side effects. Some patients can’t handle opioids and other patients run the risk of becoming dependent or addicted to the narcotics. Also the drugs in the cream do not have to be metabolized by your liver and patient has control over which areas need treatment. There is also few to no side effects to these creams.

    Posted by Kenny |
  13. Carol,i agree with the others-get a new doctor. Fibromyalgia is real and don’t let anyone tell you different. Too many times people are afraid to speak up or question their doctors methods/advice/whatever and they shouldn’t be-it’s your body and your life and a good doctor will want you to question them or get a second opinion. hope you find some relief-good luck.

    Posted by gary |
  14. I appreciate everyone’s comments. My pain in my handa fingers and feet are so bad that I cry at times. The tests showed that I also have carpel tunnel that is effecting nerve damage in my right hand. I tskr gsbsprntin 300 3 times a day but need 600 at night to sleep. I find that using magnesium is good, and hot hand and foot baths help so I have a pedi and manicure monthly. I use on my fingars and hands and feetan cuticle oil by avani really helps and has 4 different oils and dead sea salts. Massages help from my neck, arms and hands. Mt doctors are supportive, and know its from my chemo cancer treatment as well as diabeted. remember the glass is half full.

    Posted by nora |
  15. A couple comments about this informative article that has gotten many comments. First nortriptyline is not an MAO inhibitor. It should not be taken with MAO inhibitors.

    Second, new recommendation for Tylenol is no more than 3000 mg a day rather than 4000 mg so it is even more restrictive than one of your readers noted. With some single dose packets containing two 650 mg caplets, it is easy to see how people may end up taking too much. The reader is correct about the possibility of liver damage and it can happen in a pretty short time frame.

    Thanx for the article. We have come a long way with pain management, but some have a long way to go. It can still be very difficult to get help with this issue whether acute or chronic.

    Posted by BK CDE |
  16. I suffer from bad pain over my whole body (yes my MD says, it’s Fibromyalgia) that is worse in my legs. I am on a significant dose of Neurontin (yes one of its side effects is weight gain). It’s not enough most times so I add cherries (yes they can relieve pain), Topricin cream (new but it helps a lot), Roobios tea to help calm me down at bedtime. I found these alternative things in various health food stores. My doctor was/is clueless. You have to be pro-active for you own health; because some doctors only believe in the medicine/medical aspects of care & not the alternatives. Also, my Tens machine helps when pain is REAL bad.

    Posted by Kathy McGlone |
  17. I’m 42 year old t2 diabetic, a1c is 7. I suffer from horrible migraines during my monthly cycle. This month I’m on five days straight of migraine. Last month three days. The month before 11 days ( I had a period lasted 11 days) . I also have what my doctor diagnosed shoulder bursitis. I have had 8 months of non stop shoulder pain. Some days are not to bad, other days the pain is non stop throbbing that can last 3 days. I also have a bulging disk L4 and L5 that now has arthritis. I was diagnosed with type 2 diabetics at 27 year’s old and 118 lbs at 5′ 5″ tall.
    No matter what doctor I see they rarely prescribe any pain medication. My nurologist ( saw her for migraines ) claimed I had rebound headaches and to take nothing for weeks then take Motrin 800 mg for every 8 hours. I have had kidney issues with my diabetes year’s aging and was told not to take anti inflammatory meds unless doctor prescribed. I take a antidepressant .5 mg of xanax. I have pain almost daily, severe pain ten day per month. I am very depressed that I am in pain and I cannot enjoy life like I use to. Each year I do less and less fun things with my children. I feel sad and tapped out. I want to enjoy my family, job, and mostly my children, and grandchild. But since people have been over prescribed pain meds in large doses at pain clinics and sell them I am no longer allowed a quality life with my family. What can I do to get some help. It seem it may be the only way to get help is to buy medication from the people that creating this problem. I won’t do this but I can understand the temptation. I feel like life is joyless when I have uncontrolled pain. How can get any help?

    Posted by Holli |
  18. Holli,

    I would search on the Net for a pain specialist. There are probably many medical and nonmedical options you have not tried. Wishing you relief soon.

    David

    Posted by David Spero RN |

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