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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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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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