If you have rheumatoid arthritis, you’re probably well-acquainted with pain.
According to Stanford rheumatologist Dr. Stanford M. Shoor, “a majority of patients with RA suffer from some degree of pain.”
Rheumatoid arthritis is an incurable autoimmune disorder that produces inflammation throughout the body. It affects multiple organs and organ systems, like the heart, lungs, blood vessels and skin. But most people know RA as a disease that attacks the joints, causing painful swelling and stiffness that can ultimately damage and permanently deform them.
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Early and aggressive treatment of rheumatoid arthritis with powerful drugs has enabled many people with RA to avoid much of the tissue destruction that was common before the advent of these medications, which include disease-modifying anti-rheumatic drugs like methotrexate; biologics like etanercept, adalimumab and others; and corticosteroids.
According to Shoor, modern drug therapy has decreased overall disease activity, pain and stiffness in 50 to 75 percent of people with RA, and has caused the disease to go into remission — defined as the absence of any symptoms — in 10 to 25 percent.
Although this is good news, “a summary of several studies showed that between 44 and 60 percent of patients reported some degree of chronic pain despite the fact that the majority of them were in remission or a state of low disease activity,” says Shoor, who is a clinical professor of medicine and rheumatology at the Stanford School of Medicine.
“People with RA and other forms of chronic arthritis suffer daily,” says Shoor. “Many continue their daily activities despite pain. Perhaps because of this, and because [the pain] is chronic and not immediately life-threatening, there is less public and private support for the treatment of arthritis and rheumatic diseases than other more ‘dramatic or life-threatening’ diseases, such as heart disease and cancer. This is a shame because arthritis and chronic pain are at least as common, or perhaps more common, than other chronic diseases, and those who suffer from arthritis deserve and would benefit from more support,” he adds.
Pain can be acute or chronic. Acute pain is the result of an injury — like the pain you feel when you hit your thumb with a hammer or, in the case of RA, when you are experiencing a flare of the disease that causes sudden, temporary, painful swelling and stiffening of the joints.
Acute pain can last for minutes or weeks, depending on how long it takes for the injury to heal.
Chronic pain lasts for three months or more, often continuing long after the original injury has healed. “Chronic pain is fundamentally different from acute pain in that it is not the symptomatic response to injury, but is a disease in itself,” says Dr. Sean Mackey, who is chief of the Division of Pain Medicine and Redlich Professor of Anesthesiology, Perioperative and Pain Medicine, Neurosciences and Neurology at Stanford University.
“Chronic pain can persist for years and worsen with time, exacerbating an already devastating condition,” says Mackey, who is a past president of the American Academy of Pain Medicine.
Chronic pain can be devastating for a number of reasons. “[It] results in altered mood, sleep disturbances and stress. This can affect work and personal relationships and well-being ,” Shoor says.
The first step in treating chronic pain in people with uncontrolled RA is to get the disease under control as much as possible. In the short term, this can include the use of corticosteroids, either administered orally or by intramuscular injection, Shoor advises. In the long term, it may mean an adjustment in RA medications or even switching to a different drug.
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According to the Arthritis Foundation, it’s also important to develop a comprehensive pain management plan that targets the different factors influencing chronic pain. This might include drugs or other treatments designed specifically to treat pain, including over-the-counter nonsteroidal anti-inflammatory medications. In some cases, prescription opioids may be necessary to control pain.
“I would estimate that 10 to 25 percent of RA patients are on opioid analgesics,” Shoor says. “Although narcotic analgesics are not the first choice for pain, there are some patients who tolerate the drugs well, do not have a risk for or a history of substance abuse, do not suffer notable side effects and remain on a relatively low and stable dose.”
Medications for sleep may be indicated in the case of severe sleep disturbances, or even referral to a sleep specialist or clinic.
Exercise can also be helpful. “Numerous studies over a period of 20 years have shown that conditioning exercise can reduce pain by an average of 30 percent,” Shoor says. “The key to exercise success in pain is to start at a low level and work your way up slowly, to gradually increase your pain threshold without ‘paying for it’ the next day.”
Cognitive behavioral therapy can provide strategies to help cope with chronic pain, as can mindfulness-based stress reduction. “Distraction, relaxation, imagery, thought restructuring and other mental techniques can reduce pain by a modest degree,” Shoor advises. “Studies have shown that a patient’s belief that they can control the pain increases the chance that they will reduce pain,” he adds.
Antidepressants should be considered to treat the depression and anxiety that often accompany the pain of RA. In addition, according to the Arthritis Center at Johns Hopkins University, antidepressants are also effective, and often underappreciated, pain relievers.
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Eating a low-sugar Mediterranean-type diet that includes fish, vegetables, fruit, nuts and olive oil can reduce the overall inflammation of RA, which may decrease pain levels. Supplementation with fish oil and vitamin D may also be beneficial, according to Shoor, but he cautions that they should not take the place of conventional treatment with RA medications. “This can result in increasing disability and joint damage,” he warns.
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Pain Is All Too Common in People With Rheumatoid Arthritis originally appeared on usnews.com
