Pain and Its Impact on the Treatment of Rheumatic Disease:

Practical Advice on Pain Management

arthritissupport.com

12-19-2005, Source: John Wiley & Sons, Inc.
Pain and its impact on the treatment of rheumatic disease

New insights into pain mechanisms; Practical advice on pain management

Long treated as a side effect, pain is now widely recognized as an integral part of patient care. While the last decade has brought extraordinary advances in the unravelling of pain mechanisms at the molecular level, evaluating and alleviating pain remains an ongoing challenge for physicians, particularly rheumatologists. The December 2005 issue of Arthritis & Rheumatism (http://www.interscience.wiley.com/journal/arthritis) offers a timely examination of pain as it pertains to rheumatology practice.

"Rheumatologists are increasingly required to address pain as a specific symptom," notes leading author Mary-Ann Fitzcharles, M.D., of Montreal General Hospital, McGill University. "Pain management is no longer simply a quick fix with a single pill, but rather an approach to the patient as a whole biopsychosocial being."

What is rheumatic pain? How is it affected by inflammation? How is it linked to a patient's psychological state? Drawing on the latest research into this complex factor, Dr. Fitzcharles and her collaborators demystify both the process and the experience of pain for patients with rheumatoid arthritis (RA) and related diseases.

Pain mechanisms are not hard wired, but constantly in a state of change. But neurotransmitters and inflammatory molecules make rheumatic pain feel chronic. Rheumatic pain, as the authors explain, is transmitted by not only the central nervous system, but also receptors in the joint tissue and cartilage. Because rheumatic pain travels through small, slow-conducting fibers, it is perceived as a pervasive aching rather than as acute, localized stabs.

Inflammation also plays a role in activating pain pathways that usually lie dormant �?comprising as many as one-third of the total number of pain-transmitting nerves. What's more, molecular evidence suggests that stress and depression may increase a rheumatic patient's production of pain-provoking inflammatory agents.

How can a rheumatologist accurately assess a patient's pain? As Dr. Fitzcharles acknowledges, clinical evaluation of pain is difficult and subjective.

In addition to using time-honored tools �?namely, the visual analogue scale of pain severity and patient questionnaires �?in real-life practice, the rheumatologist must take cues from the patient during the interview and examination, heeding spontaneous movement, musculoskeletal structure, and verbal complaints, as well as consider the patient's psychosocial history and coping strategies.

Beyond the prescription of a pill, what works to relieve rheumatic pain? "There is no gold standard regarding the ideal management of chronic pain in rheumatic diseases," observes Dr. Fitzcharles. "Ideal pain management should encompass a wide range of both pharmacological and nonpharmacological interventions."

The authors culminate with a comprehensive review of complementary treatment approaches, including:

Exercise. According to studies, regular physical activity not only maintains muscle tone and helps to improve function, but also induces the production of endogenous opioids �?endorphins and other natural painkillers.

Herbal and dietary supplements. For example, decreased pain has been recorded among RA patients receiving supplementation with an omega-3 enriched diet for 12 months. This dietary change reduced the need for antirheumatic medication.

Topical applications. Used for centuries as home remedies, healing ointments have shown clinical promise for the care of rheumatic conditions. In one recent study, topical diclofenac performed as well as ingested diclofenac in relieving knee joint pain.

Opioid analgesics. The cornerstone of pain management in cancer, opioids are increasingly prescribed for patients with musculoskeletal pain. However, only limited data support the long-term use of opioids in patients with rheumatic pain. It is not clear, as yet, if opioids provide sufficient benefit to counterbalance the possible harmful effects.

"Rheumatologists will need to become familiar and comfortable with the use of newly developed strategies for pain management to ensure optimal treatment," Dr. Fitzcharles concludes. "Improved function and rehabilitation, and not simply palliation, should be the main goal of pain management in rheumatologic practice."

Article: "Pain: Understanding the Challenges for the Rheumatologist," Mary-Ann Fitzcharles, Abdulaziz Almahrezi, and Yoram Shir, Arthritis & Rheumatism, December 2005; 52:12; pp. 3685-3692.

Arthritis Care Falls Short for the Elderly

April 6, 2006, (HealthDay News) -- Many older Americans with arthritis aren't receiving the care they need, and when they do get medications to control their pain they often aren't told about the side effects of those drugs.

That's the conclusion of a new study in which doctors sat down and talked to patients about their care -- a departure for such research, which usually is based on information from insurance claims or medical records.

Of the 339 people aged 75 and older who were interviewed, they received the recommended care for osteoarthritis -- the most common form of the disease -- just 57 percent of the time. And only 44 percent were told about potential side effects of their medications.

That's an important omission because the frail condition of arthritis sufferers makes them vulnerable to drug side effects, said study author Dr. David A. Ganz, a research fellow in geriatrics at the University of California, Los Angeles.

The study, by researchers at Rand Health, the David Geffen School of Medicine at UCLA and the Greater Los Angeles VA Healthcare System, appears in the April 15 issue of Arthritis Care and Research.

One-third of the people in the study reported one of three major problems of old age -- falls, urinary incontinence or loss of mental function, Ganz said. Even over-the-counter medications such as acetaminophen can cause problems, with side effects such as kidney damage, stomach trouble and the risk of heart failure, he noted.

"The truth is that the side effects can be similar for all these drugs," Ganz said.

The new study is part of a larger effort to assess the quality of health-care offered to older people, and the results so far are somewhat discouraging, Ganz said. "We know that the quality of care for older people in general is not great," he said.

For arthritis, the researchers found that most of the people they interviewed were getting care from their family doctor. Only 12 percent reported having seen a rheumatologist in the previous year. When they were asked, "Did any doctor or nurse tell you about possible side effects?" a majority said, "No."

A big part of the problem is the assembly-line nature of many medical practices, Ganz said. "My take on it is that there are too many things going on at once," he said. When a frail, older person asks for help to relieve the pain of arthritis, the doctor often does it the easy way, he explained.

"But as you get old and frail and on more medications, the issue of side effects becomes more important," he said. "It's hard to make a conscientious effort when you see a patient every 15 minutes."

Part of the solution could rest with the patients themselves, Ganz said. "Part of the goal of writing this report is to make them aware from this end that they should ask simple questions, like, 'Doctor, what are the side effects of this medication?'" he said.

But the health-care provider has responsibilities, too, Ganz said. It's common for doctors to write a prescription on the computer, he said, and when writing such a prescription, the patient's potential vulnerability to side effects should be taken into account. "There should be a warning on the screen," he said.

 
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