The Challenge of Managing Pain in Multiple Sclerosis

Pain is a common symptom in patients with multiple sclerosis (MS), with some studies showing that clinically significant pain associated with their disease is experienced by more than half of patients with MS. This pain is often neuropathic and/or musculoskeletal in origin and can severely impact the patient’s quality of life. Clinicians who treat patients with MS should be aware of the central role of pain in MS and take a comprehensive approach to pain relief that includes pharmacologic and nonpharmacologic interventions.

At the 2013 Annual Meeting of the Consortium of Multiple Sclerosis Centers, Marie Moore, ARNP, a nurse practitioner with The James Norton MS Center in Carolina Medical Center, Charlotte, NC, presented an overview of her experiences in managing pain in multiple sclerosis.

While tricyclic antidepressants are an affordable option, Moore said she does not select this class of drugs very often because higher doses are really needed for norepinephrine-focused pain relief. Instead, Moore said she generally favors the serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine as being the most useful for immediate pain relief in patients with MS. An additional desirable effect of SNRIs is that they are “not too sedating,” said Moore.

She also reviewed several anticonvulsants that can be used to manage pain in this patient population. Gabapentin is the most commonly prescribed anticonvulsant used for pain relief. Another commonly used anticonvulsant is pregabalin. Moore said both of these are primarily metabolized in the kidney and present almost no drug contraindication issues. However, they cause sedation and less commonly also lead to weight gain. She noted that neuropathic pain is frequently worse at night, so clinicians should consider administering these medications before bedtime. Carbamazepine is another option, but is used less frequently for a variety of reasons. Moore said these medications are potentially associated with birth defects and dramatically reduce the effectiveness of oral contraceptives, so the patient should be made aware of this to avoid birth defects and unwanted pregnancies.

Although opioids have been increasingly prescribed over the past decade for pain relief, Moore noted that they have a minimal effect on CNS pain and are not recommended for treating MS pain. She said that the data “clearly demonstrate that opioids are effective in the short term for treating MS pain, but not so much in the long term,” and stressed that it is imperative that clinicians who prescribe opioids “know the expectations of regulatory authorities.” To help curb the growing prevalence of opioid misuse and diversion, individual states have created drug-monitoring programs that clinicians can access in order to find out if patients have been prescribed controlled substances by other providers.

Although medical cannabis is legally available for medical use in 18 states, Moore said that the use of cannabinoids to treat MS “is a loaded and complex issue,” with some clinicians reporting cognitive impairment and other benefits in treated patients. Moore noted “there is definitely a slightly increased risk for cancer” associated with smoked forms of cannabis.

Moore said there are highly effective topical medications that are useful for localized pain in MS, such as myofascial pain and lower back pain. They can be prepared at the local compounding pharmacy and come in multiple forms including patches and gels. Sometimes however, these topical drugs can be prohibitively expensive.

She warned that reduced functioning correlates in MS should be a red flag for healthcare practitioners. When a patient refrains from movement because of chronic pain, this can lead to a downward spiral that can make the situation worse.

There are also a variety of non-pharmacologic management options that can be tremendously beneficial for some patients with MS who are experiencing pain. These include exercise, acupuncture and acupressure, message, stretching for spasticity, and cooling. It is important that patients become active participants in using resources such as using physical therapists to help them to increase their exercise tolerance. Moore reminded the audience that “exercise is the body’s natural pain killer. It produces endorphins that can be helpful.”

In closing, she said, “It is important that we as practitioners help turn the tide, helping the patient to develop their own tools for managing pain.”