Rheumatoid arthritis is a systemic, inflammatory, autoimmune disorder. Inflammation causes redness, warmth, and swelling of the joints. Pain comes from the inflammation of the joints and tendons. Physicians seek to combat the inflammation at each phase of the immunologic process with:
It's important that the cause of any pain be identified, if possible. People with RA can have pain from many other causes, just as anyone without RA does, and those causes need to be identified and treated, in hopes of curing or controlling the problem without long-term pain medication.
Nonetheless, people with RA still may have chronic pain, as well as acute severe pain episodes, either due to flares or to post-surgical pain. However, pain is often under-reported by patients and/or trivialized as a symptom by physicians.
This is changing, because the Federal government now has a new standard of pain care. It requires physicians to ask patients what they are feeling and what medications they are using, and to do something about the pain – in the same way they check your vital signs (temperature, pulse, and blood pressure) and do something if the signs are abnormal.
Pain Management Programs
Further, major hospitals have been developing dedicated pain management programs. For example, here at the Hospital for Special Surgery we have an acute pain service, which is part of the Anesthesia Department. It includes nurses and anesthesiologists who see you for the first few days after surgery and then transition you to milder medicine that your physician takes care of or a stronger medicine that would be managed by a chronic pain physician. We also have a pain center that manages a lot of outpatients, many of whom have rheumatoid arthritis, who arrive by referral from their rheumatologist or surgeon.
The decision to refer to a pain management specialist has to do with the patient and the comfort level of the physician caring for the patient, based on the doctor's experience with these medications and perception about how the patient is doing. Pain management specialists tend to see patients whose pain has not improved and whose doctors have tried different approaches and can't figure out why the patient has not improved on the more commonly used medications.
Descriptions of Pain
Because pain is so subjective and varies so much from one person to another, it's important for you to be as specific as possible in describing your pain to your physician. Consider the following issues.
Is it a deep aching, throbbing, gnawing or dragging pain? If so, it's probably what doctors call nociceptive – nerve endings are being injured by some ongoing disorder, such as arthritis. For example, when a joint is being destroyed, the little nerve endings in the body sense that and send a normal pain message just as if it would if you cut your hand – a normal transmission of pain. Or you may have perioperative pain as you recuperate from joint surgery. These are normal, acute types of pain. Nociceptive pain tends to respond well to routine analgesics, such as NSAIDs and opioids that act in the brain.
On the other hand, is it burning, shooting, or tingling pain? If so, it's probably neuropathic pain – caused by abnormal processes that may persist after an injury or disease; nerves that constantly transmit pain become trained, through cellular changes, to transmit pain messages in the absence of an ongoing disorder. In such chronic pain, the symptoms become "imprinted" on your nervous system, which remembers what pain feels like and continues to send those messages, for example, beyond when your surgeon thinks you should be having pain post-operatively. Neuropathic pain responds to so-called adjuvant drugs that affect the brain's perception in unexplained ways. These include antidepressants and antiseizure drugs.
It can be useful to keep a pain diary for a week before seeing your doctor. Note when pain occurs, where it hurts, what it felt like, what you were doing when it hit, how severe it was on a 1 to 10 scale, and what you did to try to reduce the pain and the result of what you did.
The Use of Opioids and Pain Management
After surgery, some patients may be prescribed prescription pain medications – either intravenous or in pill form – to treat acute pain during their recovery. Sometimes, anesthetic medications, such as long-acting peripheral nerve blocks, are used in tandem with opioid therapy to help alleviate this short-term pain. This multimodal approach to pain management can help reduce the amount of opioids required. Opioid medications used to treat acute pain are prescribed for a short-term period immediately following surgery.
Because of the link between opioid use and tolerance, dependence and addiction, opioids are used sparingly as a treatment for both acute and chronic pain. In addition, opioid therapy is not suggested for use in alleviating chronic pain, since long-term opioid use can lead to the development of opioid-induced hyperalgesia (an increased sensitivity to pain). Pain management physicians now use a multidisciplined approach and incorporate many different pain relief techniques to treat chronic pain.
The Range of Pain Medications
Most people can find some medication that they can tolerate and that gives them very good relief. However, your need for pain medication – and the type that gives you relief – may change over time. You need to have a plan for dealing with the different types of pain you have:
Your doctor should work with you to have a "plan b" – with medications to institute – when such acute severe pain arises. Here's the range of medications from which your doctor may choose:
About the Living with RA Workshop at Hospital for Special Surgery
Summary written by Diana Benzaia, reviewed by Dr. Philip Wagner and Dr. Seth A. Waldman.