When Are Pain Medications Appropriate for Arthritis Patients?

Some arthritis patients try to do without pain medications (analgesic painkillers) because they fear becoming addicted. Are these patients doing more harm than good by avoiding pain medications? When is it appropriate for pain medications to be prescribed as part of the treatment plan for arthritis patients? Are pain medications appropriate as a long-term treatment or maintenance treatment, or should they only be used short-term?

Pain Is Often Poorly Managed

Most patients with rheumatic conditions experience pain or discomfort as a part of their condition. Recognition of patients' pain is an important aspect of patient care and is considered by the Joint Commission on Accreditation of Healthcare Organizations as the fifth vital sign. (Editor's note: the other four vital signs are blood pressure, core temperature, pulse, and respiration.)

Despite the fact that chronic pain adversely affects the quality of life of patients, it is often poorly managed.

Measures to Control Pain

Non-pharmacologic Measures

Non-pharmacologic measures to control pain include practitioner-administered treatments such as:

• meditation and relaxation
• hypnosis
• massage
• acupuncture
• exercise

Pharmacologic Measures

Pharmacologic treatments include:

• topical preparations
• herbal remedies
• dietary supplements
• anti-depressants
• muscle relaxants
• anti-convulsants
• NSAIDs (non-steroidal anti-inflammatory drugs)
• acetaminophen (Tylenol)
• narcotic (opioid) analgesics (painkillers)

Opioids

Due to their effectiveness, the use of opioids is a common therapy to treat musculoskeletal pain. Their use to treat musculoskeletal pain has doubled over the past 20 years. They can be quite useful to help control the pain of periodic flares. Some patients will find that they can be taken during the day and not cause drowsiness, while others will need to limit their use to evenings. Opioid therapy for long-term non-cancer musculoskeletal pain remains controversial due to insufficient evidence for effectiveness and concern over adverse effects, overdose, and misuse.  

Despite their benefits, there is a potential downside to the use of opioids. However, studies have not sufficiently assessed the risks of long-term use of opioids in patients with chronic musculoskeletal conditions. 

There has been a tendency to use stronger opioids such as hydrocodone (e.g., Norco) and morphine (MS Contin, Avinza), although tramadol (Ultram) is a weak synthetic opioid that has gained widespread use.

Side Effects

In addition, like many medications, side effects exist in addition to drowsiness and include nausea, constipation, and cognitive impairment. Many may cause withdrawal symptoms such as dizziness, anxiety, as well as other physical symptoms if stopped suddenly.

Scott J. Zashin, M.D., is a clinical assistant professor at the University of Texas Southwestern Medical School, Division of Rheumatology, in Dallas, Texas. Dr. Zashin also is an attending physician at Presbyterian Hospitals of Dallas and Plano. He is a fellow of the American College of Physicians and the American College of Rheumatology and a member of the American Medical Association. Dr. Zashin is the author of Arthritis Without Pain - The Miracle of Anti-TNF Blockers and co-author of Natural Arthritis Treatment.