Clinical symposium: Pain in chronic rheumatic disease

Paivi Miettunen, MD, Roberta Schellenberg, MD

The American Pain Society has developed evidence-based guidelines for the management of pain in osteoarthritis, rheumatoid arthritis and juvenile chronic arthritis. The guidelines were formed by a multidisciplinary team and involved extensive literature and peer reviews. They are available at http://www.ampainsoc.org/pub/arthritis.asp

The goals of arthritis therapy are to:
 • Relieve pain and inflammation
 • Minimize the risks of therapy
 • Retard disease progression
 • Educate patients
 • Prevent work disability
 • Enhance quality of life
 • Promote functional independence.

The recommendations support the use of acetaminophen for mild/moderate non-inflammatory pain. For more severe pain, or with evidence of an inflammatory process, a COX-2 inhibitor is recommended as first line therapy. At any time in the management of pain, the following therapies may be initiated:
 •  Tricyclic antidepressants (TCAs)
 •  Hyaluronic acid or steroid injections
 •  Topical therapy
 •  Evaluation for surgery.

The Pain Society also evaluated the following modalities of therapy, which were not discussed specifically at this session:
 •  Physical therapy
 •  Adaptive interactions/psychological therapy
 •  Alternative/naturopathic therapy
 •  Surgery
 •  Nutritional therapy.

When pain is not controlled with adequate doses of acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDS), narcotic analgesia is indicated. The medications studied, using randomized controlled trails in osteoarthritis (OA) and rheumatoid arthritis (RA), include:
 •  Pentazocin
 •  Propoxyphen
 •  Tramadol
 •  Codeine.

None of these medications are significantly better than placebo and all are associated with significant side effects. Oxycodone has been reviewed in at least one study and found to be more effective than placebo in the treatment of OA-related pain. Oxycodone is equally efficacious in sustained release and immediate release forms, however, the sustained release form was associated with significantly less side effects.

A concern over addiction with narcotic analgesia was raised. Addiction was noted to be rare in patients with physiological pain. It was cautioned that some patients may exhibit APPROPRIATE drug seeking behaviour, if their pain is under treated. Like many other drugs we use (i.e. B-blocker, steroids), appropriate tapering of drug therapy is required.

Pain management in children should not differ in implementation from that of adults. As most children's arthritis is inflammatory, it may be permissible to use a NSAID as first line therapy. Children are often perceived to be unable to communicate the degree and location of their pain, but this can be overcome by the use of age appropriate pain assessment.

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This program has been provided through an unrestricted educational grant from McNeil Consumer Healthcare, the makers of TYLENOL*(acetaminophen).

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