Adjunctive Behavioral Therapy for Chronic Pain: Answers for Patients With Neuropathy

Adjunctive Behavioral Therapy for Chronic Pain: Answers for Patients With Neuropathy

Adjunctive Behavioral Therapy for Chronic Pain: Answers for Patients With NeuropathyIt’s not hard to commiserate with another person’s pain, yet it’s nearly impossible to fully grasp the devastating impact of living with disabling pain every minute of every day. When such chronic pain is caused by nerve damage, the pain is amplified by frustration, as medication efficacy is hit-and-miss depending on the underlying condition.

When you counsel patients taking prescription medications to relieve neuropathy, talk with them about how their medication is working, then ask whether they’ve considered adjunctive behavioral therapy. Helping them develop multimodal therapy that combines medications with psychological intervention offers hope for better pain relief.

The Complex World of Neuropathy

Treating neuropathic pain is often a trial-and-error process as physicians must work with variables like diverse underlying conditions, pathophysiology that’s often undefined, the impact of central sensitization, and each person’s overall health and tolerance. The complexity of neuropathy—and a look into the patients you’ll encounter—is highlighted by this short list of acquired autonomic neuropathies:1

Primary acquired autonomic neuropathies:

  • Idiopathic distal small-fiber neuropathy – chronic peripheral somatic neuropathy affecting sudomotor fibers
  • Holmes-Adie syndrome – autoimmune-based neuropathy causing tonic pupils
  • Amyloid neuropathy – amyloidosis affects peripheral sensory, motor or autonomic nerves

Secondary acquired autonomic neuropathies:

  • Diabetic neuropathy – the most common cause of autonomic neuropathy—affects neurons differently, possibly due to individual sensitivity to oxidative stress
  • Uremic neuropathy – weakness and muscle cramps of extremities—occurs in 67 percent of uremic patients
  • Hepatic disease – autonomic neuropathy occurs in 48 percent of patients with primary biliary cirrhosis
  • Vitamin B12 deficiency – causes neuropathy and myelopathy in 41 percent of patients—8 percent have neuropsychiatric manifestations such as memory loss, depression, personality changes and paranoid psychosis2
  • Celiac disease – autonomic neuropathy is estimated to occur in half of adults with celiac disease, leading to presyncope and postural nausea
  • Rheumatoid arthritis and systemic lupus erythematosus – abnormalities of sympathetic postganglionic function is caused by numerous connective tissue disorders

Pharmacologic Recommendations for Neuropathic Pain

Medication is always first-line therapy because it’s imperative to alleviate pain as quickly and effectively as possible—not only to give the patient relief, but also to prevent permanent changes in the central nervous system that perpetuate chronic pain and hypersensitivity. The International Association for the Study of Pain recommends the following:3

First-line treatment:

  • Gabapentin – Gabapentin effectively relieves some types of neuropathic pain in a dose-dependent manner. Doses of 1200 mg or more effectively relieved neuropathic pain in some patients—35 percent achieved a high level of pain relief; half didn’t get any relief.4 Differences in results were attributed to varying types of neuropathy.
  • Pregabalin – Recommended for a variety of neuropathic pain conditions, including diabetic peripheral neuropathy, postherpetic neuralgia and fibromyalgia in a dose of at least 150 mg/day.5
  • Antidepressants – Serotonin-norepinephrine reuptake inhibitors, especially duloxetine, are effective for pain due to diabetic neuropathy and fibromyalgia; tricyclic antidepressants show positive results in the treatment of diabetic neuropathy, postherpetic neuralgia and painful polyneuropathy.

Second-line treatment

  • Topical lidocaine – Lidocaine may be first-line therapy for older adults and those who can’t tolerate first-line medications. Lidocaine 5 percent transdermal patch relieves painful peripheral neuropathies. Lidocaine gel is an acceptable alternative when the patch isn’t tolerated or too expensive.
  • Topical capsaicin – A single 30-minute application of capsaicin 8 percent patch significantly relieved painful diabetic peripheral neuropathy, according to a study in Drugs in January 2016.6
  • Tramadol – Tramadol remains a second-line recommendation for painful neuropathies.

Third-line treatment:

  • Opioids – Except for tramadol, opioids have been dropped to third-line treatment due to concerns about abuse and overdose.
  • Botulinum toxin type A – Newly added to the recommendations, injections of BTX-A show efficacy for treating post-herpetic neuralgia and peripheral neuropathic pain.7

Overview of Cognitive Behavioral Therapy

It’s not easy to tell patients that medication alone isn’t sufficient, but it’s imperative to help them formulate realistic expectations and guide them to other treatment options. When used as adjunctive therapy, cognitive behavioral therapy (CGT) is one of the standard treatments added to the medication regimen. Substantial evidence supports CBT’s ability to reduce pain and boost coping skills in a variety of chronic pain syndromes including fibromyalgia. Even though few studies have explored CBT’s efficacy for painful neuropathy, those focusing on chronic neuropathic pain following spinal cord injury suggest it yields positive results.8

Many roadblocks may stop patients from getting CBT, such as stigma, lack of insurance, inability to cover costs and even a shortage of therapists. But another factor also has a big impact—most patients don’t understand what behavioral therapy is or how any type of “talk therapy” could possibly help with physical pain. Here’s a rundown so you’re prepared to counsel patients when the issue comes up.

CBT is based on the concept that experiences form core cognitive beliefs, then those thought patterns generate automatic behavioral, emotional and somatic responses. When patients live with pain, they develop negative thinking patterns that subsequently make the pain worse by increasing their perception of pain. They may take an isolated excruciating incident that occurred while shopping and unconsciously begin to believe they’ll have the same pain every time they leave the house. They’ll focus on the negative—understandably so considering the extent and persistence of their pain—and make every decision based on this learned pattern, whether it’s accurate or not.

When patients enter CBT, they have to be motivated and prepared to actively participate. They’re not going to sit and talk with a therapist—they will work to break the cycle. They’ll identify specific problems, learn to recognize negative or defeating thoughts, challenge those assumptions, and come up with an alternative response that enables them to become more functional. Successful programs set specific goals, are time limited, and teach coping skills and relaxation techniques. They also incorporate education about pain pathways and central sensitization.9  By taking it one step at a time, CBT helps patients:

  • Reduce the impact of pain on daily life
  • Learn skills for better coping with pain
  • Improve physical and emotional functioning
  • Reduce reliance on pain medication

Cognitive Behavioral Therapy as Part of Multimodal Treatment Relieves Pain

As you have the opportunity to counsel patients with chronic neuropathic pain, talk about the efficacy of their medication and offer them the hope that adding CBT to their treatment plan can make a big difference. The truth is that they must somehow learn to live with the pain—every tool you can give them brings them closer to living the best life possible.
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Show 9 footnotes

  1. “Autonomic Neuropathy,” May 2016,
  2. “Vitamin B-12 Associated Neurological Diseases,” August 2016,
  3. “Feeling the Burn: Updated Treatment Recommendations,” September 2016,
  4. “Gabapentin for Chronic Neuropathic Pain and Fibromyalgia in Adults,” April 2014,
  5. “Pregabalin: Latest Safety Evidence and Clinical Implications for the Management of Neuropathic Pain,” February 2014,
  6. “Capsaicin 8 Percent Patch: A Review in Peripheral Neuropathic Pain,” January 2016,
  7. “Safety and Efficacy of Repeated Injections of Botulinum Toxin A in Peripheral Neuropathic Pain (BOTNEP): A Randomised, Double-Blind, Placebo-Controlled Trial,” May 2016,
  8. “Cognitive-Behavioral Therapy for Individuals With Chronic Pain,” February 2014,
  9. “Behavioral Medicine: How to Incorporate Into Pain Management,” September 2016,

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