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“Behind the dazzle of the search for diagnosis and cause, the fundamental concern of rheumatologists and their patients is pain.”

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Croft (1996)1

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Pain resulting from various bone and joint disorders, whether noninflammatory (e.g., degenerative joint disease, osteoarthritis [OA]) or inflammatory (e.g., rheumatoid arthritis [RA]), significantly reduces the quality of life in affected patients. Individuals with chronic pain often become depressed and socially isolated and experience functional decline and disability as well as morbidity and mortality associated with pain. Data on undertreatment of pain in patients with arthritis do not appear to be available. However, as many as 20% of patients with cancer may have inadequate pain relief even when World Health Organization (WHO) guidelines (the analgesic ladder)2 are used.3 Pain is frequently underassessed and undertreated in patients with arthritis4 and in elderly patients. A review of 15 studies of chronic pain in the elderly found a median point prevalence of 15% (range from 2% to 40%) and noted that there were no clearcut differences between estimates based on self-assessment and those made by physicians after clinical examination.5

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The medications for management of arthritis, especially acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are not completely satisfactory because of the high incidence of side effects, largely gastrointestinal (GI). As many as 20% of patients experience some toxicity,6 and 2% to 4% of chronic NSAID users develop upper GI bleeding, a symptomatic ulcer, or intestinal perforation each year, resulting in up to 200,000 hospitalizations and 20,000 deaths in the United States.7 Long-acting opioid formulations are an underutilized option. In addition, relief of pain may be complicated by age-related changes in organ function, because many patients with arthritis are older adults.

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It is important to recognize that the perception of pain caused by arthritis is complex. Trauma or inflammation can result in hypersensitivity at the affected site, which results in alternations of central nervous system processing and amplification of the pain that is perceived.4 Often there is a discordance between the pain reported and the degree and amount of tissue damage apparent to the examiner. Depression is associated with increased levels of pain and functional impairment. There are advantages to targeting both peripheral and central pain mechanisms. The analgesic and anti-inflammatory action of NSAIDs appears to result from a combination of peripheral and central effects.4

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The issues in managing pain, including arthritis-related pain, in older individuals has been outlined in clinical practice guidelines.8,9 Health care providers should aggressively treat the pain with analgesics and nonpharmacologic approaches10 while evaluating and alleviating the underlying cause of the pain. Monitoring side effects (especially with NSAIDs in older individuals) and using an objective measurement of patient response to pain (e.g., Visual Analog Scale or other validated pain scale) is essential with any analgesic regimen, from acetaminophen, aspirin, or another NSAID to a strong opioid.

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