Does Diabetes Hurt?

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In 2008, I wrote a fivepart series on chronic pain and diabetes. Pain hasn’t gone anywhere, and people still aren’t talking about it much. But new research is helping us understand pain better and treat it more effectively.

First the bad news — the amount of pain people with diabetes have is staggering. A study of over 13,000 adults with Type 2 diabetes by researchers in California found that nearly half report significant pain.

A University of California, San Francisco, press release stated, “Patients in the study reported significant pain and nonpain symptoms [such as insomnia and depression] across the entire course of the disease, among all age groups, with prevalence increasing as people neared the end of their lives.”

Lead author Rebecca Sudore, MD, said, “Adults living with Type 2 diabetes are suffering from incredibly high rates of pain, at levels similar to patients living with cancer.”

That phrase “similar to patients living with cancer” really threw me. I mean, cancer is awful, and often brings terrible pain, but people with cancer don’t have to do much besides fight to live and hope their treatments work. They can focus a lot of energy on reducing pain, and their doctors are likely to at least try to help.

But for people with diabetes, no matter how much pain they’re in, they still have to focus on controlling their blood glucose levels. Rather than figuring out, “how can I get comfortable?” they may have to make themselves less comfortable with fingersticks. They have to exercise and worry about what they eat. Their doctors don’t prioritize their pain or know what to do about it, if people even bother to tell them.

Chronic pain has been found to interfere with diabetes self-management in several ways. A 2005 study in the journal Diabetes Care reported, “Patients with chronic pain had poorer diabetes self-management overall and more difficulty following a recommended exercise plan and eating plan.” They also had a harder time taking medications correctly, probably because they were on so many medicines.

So what is causing all this pain? The most obvious answer is “peripheral neuropathy” (PN), damage to small nerves in the feet, hands, arms, and legs caused by high blood glucose levels. Pain expert Dr. Scott Fishman said, “Diabetes starves these tiny nerves. As a result, the nervous system becomes confused about what is and isn’t painful. Stockings, gloves — anything that that touches skin served by these tiny, hypersensitive nerves is going to send signals to the spinal cord, where they may be mistaken for pain.”

So diabetes directly causes PN pain. But a British study from 2006 found that, while over 26% of people with diabetes reported painful PN, 36.8% of subjects with diabetes reported other, nonneuropathic pain. Major categories of reported pain included back pain, headaches, and abdominal pain, but it seems people with diabetes have more pain in general. They also have more depression, which is often considered a form of “psychological pain.” Why should this be?

Studies show that the risk factors for chronic pain are similar (or the same) as those for diabetes. These include low social or economic status, membership in a discriminated–against group, a history of trauma, physical inactivity, relatively low self-confidence or self-esteem, and a lack of social support.

These mostly nonphysical factors play a big role in chronic pain, because pain is our bodies’ way of telling us when something is wrong. The body doesn’t have a whole lot of ways to communicate. Pain, fatigue, nausea, and maybe a couple of other symptoms are its only ways of getting our attention.

Pain may start with some signals sent by peripheral nerves. But these signals get mixed with emotions, and either amplified or turned down by anxiety, anger, grief, and stress. So the harder life, the more pain you are likely to feel.

Conversely, people who have relatively easy lives — with lots of money, love, meaning, pleasure — may not feel much pain in spite of having cancer, arthritis, or diabetes. Their nervous systems are turned down to a comfortably low level, not amped up to a level that makes everything hurt.

Fortunately, the many causes of pain in diabetes mean there are many ways to treat it. A variety of different classes of medications can help — not just narcotics, but medicines for seizures, depression, anxiety, and inflammation. I’m going to have to address those later, because I’m running out of space here.

For this week, I want to cite a nondrug approach to PN involving electricity. You may have heard of TENS (transcutaneous electrical nerve stimulation) systems. These are normally electrodes placed on the painful area. Gentle current is passed through them into the nerves, where they block pain signals. These units work well for many people.

A company called Neurometrix has come out with a system called the Sensus Pain Management Sytem, a box about the size of a glucose meter that you strap to your upper calves and use to control pain. When pain bothers you, you just push a button and the signals are largely blocked. It’s very new, but might be worth looking into.

There are many other things you can do about pain, but I would first like to know your pain experience. How big a role does pain play in your life? Does it interfere with other things? What have you been able to do about it?

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