Many With Controlled RA Experience Pain | Arthritis Information

Despite having clinically well-controlled disease, more than half of patients with rheumatoid arthritis experience moderate to severe pain, and few take the medications necessary to control it, according to findings from a prospective study.

Patients and rheumatologists share the responsibility for inadequate pain control, Dr. Mary-Ann Fitzcharles and her colleagues found. Rheumatologists tend to ignore pain in favor of focusing on disease control, whereas patients are afraid of the very medications that could help control pain, wrote Dr. Fitzcharles of McGill University in Montreal (J. Pain 2009;10:300–5).

“Both rheumatologists and patients have been lulled into believing that pain is simply part of the condition,” she said in an interview. “Our patients were very, very cautious about pain medication. They are scared of addiction, they dislike taking even more pills, and they worry about drug interactions, side effects and masking disease progression. We rheumatologists, on the other hand, focus predominately on trying to control the inflammatory disease. We have not appreciated the importance of pain to these patients and simply don't ask about it.”

The study comprised 60 patients with RA who attended a specialist rheumatology practice. In all, 54 (90%) were women; their mean age was 57 years. They had been diagnosed with RA for a mean of 14 years. Most (54, or 90%) were taking disease-modifying antirheumatic drugs.

Patients were asked to complete several questionnaires about pain and quality of life, including the Health Assessment Questionnaire, McGill Pain Questionnaire, and a visual analogue pain scale. They were also asked about potential barriers to pain control with medications.

A seeming contradiction appeared almost immediately, Dr. Fitzcharles said. Despite 39 (65%) patients' reporting satisfaction with their pain control, 28 (47%) reported a desire for additional pain relief, and 32 (53%) reported experiencing moderate to severe pain. Almost half (45%) reported that the pain caused them moderate to severe distress, and the same percentage reported that pain exerted a moderate to severe interference with their daily activities.

“This was most striking,” she said. “They believed their pain was controlled, yet they were still having pain. And most were not using any modality to reduce the pain. Of the 60 patients, only 4 were taking anything stronger than acetaminophen.”

Patients expressed a high degree of concern about taking pain medications. More than half of the group (55%) expressed at least three barriers to taking such drugs. In all, 48 (80%) were worried about the side effects; 38 (63%) disliked taking even more pills; 34 (57%) worried about drug interactions; 21 (35%) had concerns about addiction; and 16 (27%) thought that controlling pain might mask disease progression. The higher the patient's pain level, the more barriers the patient felt toward controlling that pain.

Patients with RA seem to believe that pain is “an inevitable symptom,” and that little can be done about it, Dr. Fitzcharles and her colleagues wrote. “The importance of pain may also take second place to other effects of RA, including the impact on self-esteem due to deformity, the systemic effects of fatigue and depression, and functional limitations due to mechanical joint dysfunction.”

Rheumatologists can—and should—do more to investigate pain in their RA patients, the authors said. Patients should be specifically questioned about pain, because many will not volunteer this information. It's also a good idea to explore their worries about pain medication.