What is the best approach to manage physical pain in patients undergoing refeeding in eating disorder treatment?

Management of Physical Pain During Refeeding in Eating Disorder Treatment

Tricyclic antidepressants (TCAs) are an efficacious treatment for physical pain experienced during refeeding in eating disorder treatment, starting at a low dose (e.g., 10 mg amitriptyline once daily) and titrating slowly to a maximum of 30-50 mg once daily. 1

Understanding Pain During Refeeding

Physical pain during refeeding in eating disorder patients commonly stems from:

• Gastrointestinal discomfort due to reintroduction of food
• Functional dyspepsia symptoms
• Visceral hypersensitivity
• Central pain processing alterations

First-Line Approaches

Non-Pharmacological Interventions

• Soft-tissue mobilization techniques for physical discomfort 2
• Cognitive behavioral therapy (CBT) to address pain catastrophizing and develop coping skills 2
• Relaxation training to reduce autonomic arousal related to pain 2
• Mindfulness-based stress reduction for in-the-moment pain observation 2
• Distraction techniques during pain episodes 2

Pharmacological Management

1. Proton Pump Inhibitors (PPIs)

   • Efficacious for functional dyspepsia symptoms during refeeding
   • Use lowest effective dose 1

2. Histamine Receptor Antagonists

   • May be efficacious for functional dyspepsia during refeeding
   • Well-tolerated option 1

3. Tricyclic Antidepressants (TCAs)

   • Start at low dose (10 mg amitriptyline once daily)
   • Titrate slowly to maximum 30-50 mg once daily
   • Requires careful explanation of rationale to patient 1

4. For Acute Pain Episodes

   • Acetaminophen at appropriate weight-based dosing 2
   • NSAIDs may be used cautiously for short-term pain management if no contraindications exist 2

Special Considerations During Refeeding

Refeeding Syndrome Risk Management

• For high-risk patients, start nutritional therapy with low caloric input (5-15 kcal/kg BW per day) 1
• Increase calories step by step over 5-10 days according to individual risk 1
• Maintain protein content at least 1 g/kg actual BW/day if BMI is below 30 1

Avoiding Harmful Interventions

• Opioids should not be prescribed for pain during refeeding 1
  • Can lead to addiction
  • May paradoxically amplify pain sensitivity
  • Associated with poorer long-term outcomes 1

Monitoring and Follow-Up

• Maintain a pain diary to identify triggers and patterns 2
• Document effectiveness of interventions 2
• Schedule regular follow-up appointments to assess treatment efficacy 2
• Ensure clear communication between all healthcare providers involved in care 2

Important Caveats

• Early weight gain is important for long-term recovery 3
• Recent evidence supports higher calorie refeeding approaches under close medical monitoring 3, 4
• The risks of "underfeeding syndrome" should be considered alongside refeeding syndrome 3
• Multidisciplinary care is essential during refeeding, with nutritional rehabilitation and psychological support 3

Remember that effective management of persistent pain requires a collaborative, empathic patient-provider relationship 1. Explaining the neurobiological mechanisms of pain to patients can help improve their understanding and acceptance of treatment approaches.