What prompted this question was that I had a hangnail on the little toe of my left foot last night that was catching on the sheets. Being too lazy to get out of bed to clip it, I grabbed hold of it and attempted to rip off the nail portion while keeping the toe portion intact. I failed miserably. I’m proud of myself for not screaming and waking up the wife and kids. Somehow I still fell asleep. It’s probably because of the NyQuil I took for my cold. Anyway, this morning I awoke with my little toe glued to the sheet with dried up blood. Come to think of it, my wife will not be too happy when she finds out that I bloodied up the new sheets.
I came limping into the office and told my co-worker what happened. She admonished me and told me about a friend’s cousin who did this and got his little toe infected. It got to the point that they had to amputate his little toe. And then she mentioned that he might have phantom limb pain for the rest of his life. Since my little toe has begun to swell a little bit, I now have this fear. Hence, the question in the title. It just now hit me that my laziness is making this potentially worse. I was supposed to do laundry last night but didn’t. So this morning I had to recycle a pair of socks that I wore earlier in the week. Clean socks would have probably helped to prevent an infection. I guess when it rains, it pours.
Geez, don’t scare him even more. Neuropathic pain (which includes phantom pain) is hard, but not impossible to treat. Certain medications seem to be more effective than others. Low level anti-depressants, interestingly enough, are pretty effective, as are some anti-convulsants. I have also seen methodone used for neuropathic pain with good results. Most folks with amputations have more phantom sensation than phantom pain, and they just learn to ignore it.
Unless you are diabetic, you are highly unlikely to lose a toe to infection. I bet the stats are something like 99.99% of the people who have toes amputated are diabetics and the others are those who lose them to frostbite.
Am I that boring? Actually, I wasn’t THAT worried about it. If I was, I’d be at the doctor’s. I just wanted to give a background on the question, and perhaps provide some amusement at my expense.
In my experience, and in the general experience in chronic pain literature, the opiates are pretty crappy for chronic neuropathic pain. There’s usually some initial relief, but then the patient rapidly gets habituated, and the dose goes up even as it becomes less and less effective. Finally the patient suffers all the side-effects of high-dose opiate use (constipation, physical dependence, somnolence, difficulty urinating) and still seems to hurt just as much as before.
I had one patient who came to me on 800 mg of morphine and 400 mg of methadone a day for neuropathic pain, and was still so incapacitated by the pain that he couldn’t/wouldn’t walk.
I’ve had fair luck with tegretol, and even better luck with gabapentin, along with elavil, stretching exercises, biofeedback, relaxation therapy, and positive reinforcement. The abovementioned patient was mobile and only on 160 mg of methadone a day after 4 months of tapering and other therapeutic modalities. He left my practice after that and I’m not sure how he fared.
Opiates don’t work well on phantom limb and neuropathic pain. I’d say they help 25 per cent or fewer of the population. I like Qadgop’s suggestions on better treatments. Since many of these treatments are painkillers, I’d say “yes”.
Sorry for not answering sooner–the thread got away from me. I worked with a physician once who used methadone with SCI patients who had neuropathic pain. She gave it to a few patients for whom gabapentin didn’t work. She gave them pretty high doses for a few weeks, then tapered off. This was on an inpatient SCI rehab basis, by the way, probably a few weeks after the injury. I remember it working really well with one patient who had a significant hx of alcohol use, but denied other drug use. I don’t remember how well it worked with the others, though, and it wasn’t something she did often.
Neuropathic pain is not imaginary. It is pain that is generated by a problem with nerves. For example, in phantom pain, the nerves have been severed. The weird-seeming part is that sometimes the person “feels” the pain in the non-existant foot, because that is what the nerves are transmitting to the brain. Neuropathic pain is common in back injuries when the nerves are damaged. It is usually felt as tingling or burning pain.
As Brynda said, neuropathic pain is quite real. It’s most common causes are real disease and injuries, such as alcoholism, amputation, nerve root compressions or pathologies (like pinched nerves in the neck or back, trigeminal neuralgia, shingles), cancer chemotherapy (which damages nerves as well as cancer cells, but whatcha gonna do?), diabetes (one of the biggies), HIV infections, multiple sclerosis, or any traumatic injury to nerve root or trunk.
It runs a gamut of pain sensations, from tingling, burning (imagine molten lava), aching, throbbing, to “it just hurts!” It’s tough to treat (but not impossible) and does not respond well to opiate narcotics. If I were to choose one to use after having exhausted a number of other methods first, methadone would be the one I’d pick, but I’d not do so quickly or gladly.
Basically, neuropathic pain sucks. And, inadequately treated acute pain, such as from a severe injury, surgery, or infection, can turn into neuropathic pain.
I will use high doses of opiate painkillers to treat acute pain adequately, even in the worst heroin junkie. Doing so will often prevent chronic pain syndromes later.
Just wanted to post a thanks to you, QtM, for what you said about treating pain adequately. One of my biggest frustrations as a psychologist working with medically-ill or injured patients is that their pain is often inadequately treated.
I noticed that when I took naproxen for occasional lower back pain, it helped with the “phantom itch” I experience in my amputated little finger. I thought it was something I would just have to live with and I was doing a good job of adapting to it, so I only take it if it’s really bothersome. I have two rather prominent neuromas on the stump that my doctor says are the culprit that may require further surgery at some point. He seemed surprised when I told him that the naproxen helped.
Thanks for the scoop on neuropathic pain. I have one relative (an alcoholic) who suffers from this, and one other relative (doesn’t drink, no diabetes, no injury) who suffers terribly from it, but who I also think is a hypochondriac…goes to the doctor all the time, but has lead an extremely clean life. But who I think is depressed.
I had a pinched Sciatic nerve and the OxyContin they had me on was fairly useless for the nerve pain. It punched through the Oxycontin buzz like tissue paper.
My doctor recently put me on Lidocaine patches for muscle pain in my back-- they work like a charm. She told me that she’s prescribed them for a lot of different types of pain with pretty good results. One patient of hers has ultra-sensitive skin (very painful to the touch) on a portion of his body and the patches relieved that. (There was no true organic cause such as an injury for it-- just screwed up nerves.)
Is that the same kind of pain we’re talking about? Would Lidocaine patches help with phantom pain? (I’m very interested because a co-worker had a finger amputated because of MS, and if you think it might help her, I’d suggest she ask her doctor about it.)
I’ve recently read two books by neuropathologist (?) V. S. Ramachandran - Phantoms in the Brain and A Brief Tour of Human Consciousness.
In both, he describes a non-drug, non-surgical treatment for phantom limb pain that appears to work exceedingly well. Because the pain appears to be caused by a problem with neural remapping of the parietal lobe after amputation - where areas such as the face are remapped over the original neural connections that correspond to the amputated hand or arm - and the brain experienced feedback that it could not parse, Ramachandran experimented with a perceptual treatment that involved the patient putting his good arm and phantom arm into a box with a mirror. When the patient looked down into the box, he saw his good arm and the arm’s reflection as if it were his missing arm. The patient followed several symmetrical exercises that provided enough visual and proprioceptive feedback to the brain that the problem was solved and the phantom limb pain in most cases disappeared.
Fascinating stuff. His writing is clear, warm, and filled with anecdotes that made my jaw fall open in amazement.
Juggernaut, put some antibiotic ointment on your toe, soak it when you get home, and if it doesn’t clear up in a couple of days, see a doc. And don’t PICK at it anymore, 'kay?
Actually, I wasn’t THAT worried about it. If I was, I’d be at the doctor’s. I just wanted to give a background on the question, and perhaps provide some amusement at my expense.