A new expert guidance states that people with pain from diabetic neuropathy should seek treatment for sleep and mood disorders first, before they explore pain-relieving medication.

The new advice comes from The American Academy of Neurology (AAN), the leading professional society of neurologists and neuroscientists.

In treating patients with [painful diabetic neuropathy], it is important to assess other factors that may also affect pain perception and quality of life… Mood and sleep can both influence pain perception. Therefore, treating concurrent mood and sleep disorders may help reduce pain and improve quality of life, apart from any direct treatment of the painful neuropathy.

An accompanying press release stated, “a doctor should first determine if a person also has mood or sleep problems since treatment for these conditions is also important.”

Diabetic neuropathy is a type of nerve damage common in people with diabetes. Neuropathy can affect many parts of the body, including the digestive system, the heart, the eyes, the bladder, the sweat glands, and sexual organs.

The nerve damage that mostly affects the feet, hands, legs, and arms is referred to as peripheral neuropathy. This condition is often very uncomfortable, with patients feeling pain, tingling, burning, prickling, numbness, and complete loss of feeling in the extremities. Pain may be worse at night. These symptoms are generally noticed first in the feet.

To support the new recommendation, the guidance cites two studies: one showed that chronic back pain is significantly resolved by improved mood; the other that fragmented sleep significantly reduces pain tolerance. (There are many other studies in the scientific literature that offer similar conclusions.)

To put it simply, while mood or sleep do not actually address the root cause of painful diabetic neuropathy, they do significantly alter our perception of pain.

It stands to reason that a well-rested and happy person is better equipped to deal with chronic pain. If that sounds too obvious, consider that people with diabetes suffer from both depression (and related mental health issues) and sleep disorders far more frequently than average, and that these conditions far too commonly go unrecognized and untreated.

Disordered sleep is itself a complication of diabetes, and is actually a risk factor for cardiovascular disease. Likewise, depression is a huge problem in the diabetes community. Scientists have estimated that roughly 20-25% of people with diabetes experience depression. The prevalence of diabetes distress – a lower level of anguish tied specifically to the stress involved in managing this chronic condition – is even higher.

Not only do disordered sleep and mental health issues have a direct negative effect on pain tolerance and overall health, but they also negatively impact glycemic control. Because diabetic neuropathy is ultimately caused by high blood sugars, addressing sleep and mood problems can create a virtuous cycle of improvement.

For patients that require pharmaceutical relief, there are many options available. The new guidance directs doctors to offer one or more of the following prescription medications:

• Tricyclic antidepressants (TCAs)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs)
• Gabapentinoids
• Sodium channel blockers

Some of these drugs also have benefits for mood and sleep, which may partially explain how they work.

There are also many topical treatments for peripheral neuropathy, although the scientific proof of their efficacy is a bit murky. In the new AAN guidance,  four treatments were rated as “possibly more likely than placebo to improve pain.” Those treatments are:

• Capsaicin
• Nitrosense patches
• Citrullus colocynthis
• Glyceryl trinitrate spray

Another treatment people have found effective is exercise. A 2014 review concluded that “it is critical to understand that routine exercise may not only help prevent some of those causes [of neuropathic pain], but that it has also proven to be an effective means of alleviating some of the condition’s most distressing symptoms.” As a bonus, exercise is known to improve both mood and sleep, which means it should also help reduce the perception of pain, as explained above.

Like other complications, nerve damage is ultimately caused by chronic high blood sugar. About half of people with diabetes develop nerve damage. It can happen at any time but chances of developing nerve damage go up with age and the longer a person has diabetes. It is also more common in patients with obesity, high cholesterol, and high blood pressure. But it is never too late to improve blood sugar control.

The next time you see your healthcare provider, consider whether you should be discussing your sleep and mental health, in addition to your neuropathy pain and discomfort.