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Non-Opioid TreatmentofPain and Inflammatory Conditions
JENNIFER ZAVALA, MSN, APRN, FNP -BC
RHEUMATOLOGY ASSOCIATES OF SOUTH TEXAS
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DisclosureI have relevant financial relationship with the products or services described, reviewed, or compared in this presentation.
◦ Contracted as a speaker for Amgen Pharmaceuticals
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Pain Classification Based on Pathophysiology*
NOCICEPTIVE PAIN
SENSORYHYPERSENSITIVITY
NEUROPATHICPAIN
Pain due to damage totissue due to trauma or
inflammation
Examples:Gout
Rheumatoid arthritisOsteoarthritis
Pain without identifiable nerve or tissue damage;
thought to be due to neuronal dysregulation
Example:Fibromyalgia
Pain due to damage to peripheral or central
nerves
Examples:Diabetic peripheral
neuropathyPost herpetic neuralgia
*Adapted from: Stanos S, et al. Postgrad Med. 2016; 128(5):502-515.
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Associated symptoms
Depression and Anxiety
Migraine or tension headache
GI problems: IBS and reflux
Irritable or over-active bladder
TMJ disorder
Widespread pain with muscle tenderness, sometimes joint and skin pain
Severe fatigue
Sleep problems
Difficulty with memory or thinking clearly
Fibromyalgia
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Primary vs SecondaryFibromyalgia
oPrimary Fibromyalgiao No associated disease or condition identified
oSecondary Fibromyalgiao Appears after or in conjunction with other medical problem
o Inflammatory or autoimmune disease (RA, Lupus, Ankylosing Spondylitis)
o Physical injury
o Other causes of chronic pain such as degenerative disk and joint diseases
o Obstructive Sleep Apnea and other sleep disorders
o PTSD (physical or sexual abuse)
oFibromyalgia mimickerso Hypothyroidism
o Multiple Sclerosis
o Polymyalgia rheumatica
o Inflammatory myopathies
o Myofascial pain syndrome
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Osteoarthritis
Mechanical Derangements
Osteonecrosis
Trauma
Sickle Cell Disease
Rheumatoid Arthritis
Gout
CPPD
Juvenile Chronic Arthritis
Bacterial Sepsis
Neisseria infections
Trauma
Hydroxyapatite
Systemic Lupus Erythematosus
Hypothyroidism
Hemophilia
Sarcoidosis
Palindromic Rheumatism
Familial Mediterranean Fever
Parvo B-19 virus
Hepatitis virus
Psoriatic Arthritis
Inflammatory Bowel Disease
Reactive Arthritis
Lyme’s Disease
Whipple’s Disease
Sjogren’s Syndrome
Leukemia
Syphilis
Tuberculosis
Ankylosing Spondylitis
Malignancies
Causes of Arthritis
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Inflammatory vs. Mechanical Pain
FEATURE INFLAMMATORY MECHANICAL
Morning stiffness > 1 hour ≤ 30 minutes
Onset Subacute Variable
Fatigue Significant Minimal
Nocturnal pain Moderate Mild
Activity ↓ symptoms ↑ symptoms
Rest ↑ symptoms ↓ symptoms
Systemic symptoms Yes No
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Rheumatoid Arthritis
Wrist
Shoulder
Elbow
Metacarpophalangeal
Joints
Metatarsophalangeal
Joints
Tarsal joints
Ankle
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Osteoarthritis
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Rheumatoid ArthritisExtra-articular Manifestations
Cutaneous Rheumatoid nodules
Ocular Corneal ulcers, episcleritis, scleritis
Respiratory Emphysema, pulmonary hypertension,
pulmonary fibrosis
Hematologic Felty syndrome, lymphoma, anemia,
thrombocytosis
Renal Interstitial nephritis, amyloidosis
Vascular Cutaneous arteritis, vasculitis
Neurologic Polyneuropathies
Cardiac Cardiomyopathy, pericarditis, valvular
heart diseaseAdapted from Williams EA, et al. Postgrad Med. 2003;114(5):19-28.
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Inflammatory Back Disease(Seronegative Spondyloarthopathies)
◦ Ankylosing spondylitis
◦ Psoriatic arthritis
◦ Reactive arthritis
◦ Enteric arthritis◦ Crohn’s
◦ Ulcerative colitis
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Physical Exam
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Inflammatory Back DiseasePhysical ExamSacroiliac joint involvement◦ Pelvic compression
◦ Gaenslen’s test
◦ Patrick’s test
Progression of spinal disease / ankylosis◦ Schober’s test
◦ Occiput to wall test
◦ Chest expansion
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Sacroiliac Pain
Pelvic Compression Test
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Sacroiliac PainPatrick’s Test (FABER’s Test)
Gaenslen’s Test
Gaenslen’s test
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Progression of Spine Disease / Ankylosis
Schober’s Test
Occiput-to-Wall Test
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Inflammatory Lab Workup
oRF
oCCP
oESR and CRP
oHLA-B27
oANA, RNP, DSDNA, SSA, SSB
oCBC w/ Diff
oCMP
oUrinalysis
oHepatitis profile
oThyroid antibodies
oSTI panel
oParvo B19 antibody
oTSH, Free T4
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Radiographic Imaging
o X-ray of hands, feet, SI joints, cervical spine, lumbar spine, and/other affected joints
o MRI of affected joint with and without contrast
o Chest Xray
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Radiographic Data
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Radiographic DataSacroilitis◦ Bilateral and symmetric
◦ Involves lower 2/3 of SI joints
◦ Earliest changes on the iliac side of the SI joint◦ Sclerosis
◦ Pseudo-widening
◦ Erosions
◦ Complete ankylosis / fusion
◦ If xrays are normal◦ MRI
◦ CT
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Radiographic Data
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Classification Criteria for Osteoarthritis
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2010 ACR/EULARClassification Criteria for RA
JOINT DISTRIBUTION (0‐5)1 large joint 0
2‐10 large joints 1
1‐3 small joints (large joints not counted) 2
4‐10 small joints (large joints not counted) 3
>10 joints (at least one small joint) 5
SEROLOGY (0‐3)Negative RF AND negative ACPA 0
Low positive RF OR low positive ACPA 2
High positive RF OR high positive ACPA 3
SYMPTOM DURATION (0‐1)< 6 weeks 0
≥ 6 weeks 1
ACUTE PHASE REACTANTS (0‐1)Normal CRP AND normal ESR 0
Abnormal CRP OR abnormal ESR 1
≥6 = definite RA
What if the score is <6?
Patient might fulfill the criteria…
→ Prospectively over time
(cumulatively)
→ Retrospectively if data on all
four domains have been
adequately recorded in the past
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Persistent Pain
Psychological Stress
Other Psychological Stresses
Poor Sleep
Other Causes of Insomnia
Muscle Fatigue and Generalized Fatigue
Inactivity Weakness Weight
Gain
Muscle Tension
Other Causes of Pain
Other Physical Stresses
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Goals of Therapy
Relieve pain/inflammation
Halt disease progression◦ Prevent or halt joint damage with autoimmune disease
Maintain or improve function for activities of daily living and work◦ Prevent or limit work disability
◦ Maintain or maximize independence
Maximize quality of life
Minimize risk of therapy
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Treatment Guidelines Based on Pathophysiology
NOCICEPTIVE PAIN
Pain due todamage to
tissue due to trauma or
inflammation
SENSORYHYPERSENSITIVITY
Pain without identifiable nerve or
tissue damage; thought to be due
to neuronal dysregulation
NEUROPATHICPAIN
Pain due to damage to
peripheral or central nerves
NSAIDS and Acetaminiophen 1,2,6−8
(Steroids, DMARDs and Biologics may be
indicated for inflammatory diseases)
Anti-epileptic drugs
Serotonin-Norepinephrine reuptake inhibitors
Tricyclic anti-depressants1−5
Opioids when other treatments are NOT effective2,3,5,7,11−14
Opioids should be avoided9−10
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Healthy Lifestyle Modifications
Rest
Braces / splinting
Joint protection devices
Assistive devices
Appropriate exercise
Good nutrition, weight loss
Stress reduction
Cognitive behavioral therapy
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Weight Loss and Diet
10 lb weight loss reduces risk of knee OA by 50%
Decreases stress on weight-bearing joints
Weight loss diet◦ Low carbohydrate and sugar◦ Low fat◦ Adequate protein intake
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Non-Medication TreatmentMay Be Beneficial
Relatively inexpensive◦ Massage
◦ Heat application
◦ Ice application
Expensive◦ EMG biofeedback
◦ Hypnotherapy
◦ Cognitive behavioral therapy
◦ Acupuncture
◦ TENS (Transcutaneous electrical nerve stimulation)
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Physical and Occupational Therapy
oTeach appropriate exercisesoImproves ability to perform daily activities
oImproves joint range of motion and muscle strength
oReconditioning
oProper use of heat and cold
oPrinciples of wise joint use and energy conservation
oProvide assistive devices (canes, walkers, braces)
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SupplementsFish oils
◦ 3000-4000 mg daily
◦ Reduces inflammation and morning stiffness . Important for brain function and may inhibit RA development
Curcumino 500-1000 mg twice a day
o Relieve pain and inflammation. May help lower uric acid, digestive aid and appetite stimulant
Melatonin ◦ 1g to 5 mg at bedtime
◦ Aid in sleep
Ginger◦ 2 g in three divided dose
◦ Decrease joint pain and inflammation in people with RA and OA
Glucosamineo 1500 mg
o Slows deuteriation of cartilage, relives OA pain and improves joint mobility
Chondrotin sulfateo 800-1200 mg daiy in 2 to 4 doses
o Reduces pain and inflammation, improves joint function and slows progression of OA
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Medications
oTopicalsoNSAIDsoAnalgesicsoCorticosteroids
SystemicIntra-articular
oDisease modifying anti-rheumatic drugs (DMARDs)
oBiologics◦
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TOPICAL AGENTS
oCreams, rubs, ointments or sprays
oTemporarily relieves the pain of OA
oTopical Agentso Salicylateso Skin irritantso Capsaicino Lidocaine o NSAIDso Combinations medicationso Topical CBD oil
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TOPICAL AGENTS (Over the Counter)
oSalicylates (Aspercreme®, Myoflex®)o decrease the ability of the nerve endings in the skin to sense pain
oSkin irritants / Menthol (Bengay®, Mineral Ice®)o stimulate nerve endings to feel cold, warmth or itching
o distract attention from the actual pain
oCapsaicin (Zostrix®, Capzaicin P®)o substance found in the red chile pepper
o reduces substance P, which sends pain signals to the brain
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TOPICAL AGENTS (Prescription Medications)
oVoltaren Gel® (diclofenac)o 2 – 4 grams applied to affected area four times a day
o Not to exceed 32 grams per day
oPennsaid ® (diclofenac)o 1-2 pumps twice a day
oFlector Patch® (diclofenac)o Apply patch to area twice a day
oLidoderm Patch® (lidocaine)o Apply 1 – 2 patches to affected areas for 12 hours then remove for 12
hours
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NONSTEROIDAL ANTI-INFLAMMATORY DRUGS(NSAIDS)
o Relieve joint pain, stiffness and swelling
o Increased risk for side affects with increased age
o Increased side affects compared to acetaminopheno Gastrointestinal: most common
o Kidney
o Skin rashes
o Central nervous system (headache, dizziness)
o Cardiovascular risk
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Risk Factors for aNSAID Gastrointestinal Complication
o Age > 60o Previous gastrointestinal ulcer or bleedo Steroid useo Poor overall healtho Aspirin useo Coumadin / anticoagulation therapy
Think Celecoxib or NSAIDs + PPI
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NSAIDSOver the Counter
oIbuprofenoMotrin ®
oAdvil ®
oNuprin ®
oCombination medicationsoExcedrin ® (Acetaminophen, Caffeine
and Aspirin)
oBC Powders ® (Aspirin, Caffeine and salicylamide)
oAspirinoBayer ®
oEcotrin ®
oBufferin ®
oAnacin ®
oNaproxenoAleve ®
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NSAID CLASSES
Propionic
Acids
Indoles Oxicams Phenylacetic
Acids
Salicylates Non-acidic Cox - 2
Selective
Ibuprofen
Naproxen
Ketoprofen
Oxaprozin
Indomethacin
Tolmetin
Sulindac
Piroxicam
Meloxicam Diclofenac Aspirin
Salsalate*
Trisalicylate*
Nambumetone Celecoxib
* Non-acetylated Salicylates less GI mucosal damage and blood loss. No inhibition of Platelets aggregation
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Corticosteroids
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ACETATMINOPHENoRelieves pain
oDoes not reduce swelling or inflammation
oDose: 1 gram 3 times a day oTylenol, Extra strength Tylenol and Tylenol Arthritis®
oAspirin-Free Anacin®
oPanadol®
oExcedrin Aspirin free®
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TramadolUsed for moderate to moderately severe pain
Dual mechanism of action◦ binds opiod receptors◦ inhibits reuptake of norepinephrine and serotonin
May cause drowsiness, nausea or constipation
May lower seizure threshold when used with◦ Antidepressants◦ Cyclobenzaprine (Flexeril)
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Tramadol
Ultram ® 50 mg
Ultracet ®(tramadol / acetaminophen) 37.5 mg / 325 mg
Ultram ER ® 100 mg, 200 mg, 300 mg
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CNS Active Medications
Tricyclic Antidepressants (TCAs)
Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Anticonvulsants
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CNS Active MedicationsTricyclic Antidepressants oAmitriptyline (Elavil®)
oNortriptyline (Pamelor®)
oDesipramine (Norpramin®)
oImipramine (Tofranil®)
Serotonin Reuptake Inhibitors ◦ Fluoxetine (Prozac®)
◦ Sertraline (Zoloft®)
◦ Paroxetine (Paxil®)
◦ Citalopram (Celexa®)
◦ Escitalopram (Lexapro®)
◦ Trazodone (Desyrel®)
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CNS Active Medications
Serotonin / Norepinephrine Reuptake Inhibitors◦ Venlafaxine (Effexor®)
◦ Duloxetine (Cymbalta®)
◦ Milnacipran (Savella)®
◦ Atomoxetine (Straterra)
◦ Desvenlafaxine (Pristiq)
◦ Levomilnacipran (Fetzima)
Anticonvulsants◦ Gabapentin (Neurontin®)
◦ Pregabalin (Lyrica®)
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Sleep Medications
Zolpidem (Ambien®)
Zaleplon (Sonata®)
Temazepam (Restoril®)
Eszopiclone (Lunesta®)
Ramelteon (Rozerem®)
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Autoimmune / inflammatory arthritis Treatment
o DMARDs
oMethotrexate
oLeflunomide
oSulfasalazine
oHydroxychloroquine
o Biologic DMARDs
o Adalimumabo Etanercepto Certolizumab pegolo Golimumabo Infliximabo Abatacepto Rituximabo Tocilizumabo Anakinrao Tofacitinib
DMARDs = Disease Modifying Anti-Rheumatic Drugs
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SURGERY
o Severe pain is the main indication for surgery oDisrupts life significantly
oAssociated with a disability
oSevere night pain or rest pain
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References
Dalal, Deepan S. (2019). https://www.The-Rhemmatologist.org
https://www.rheumatology.org.
https://www.researchgate.net somatic symptoms of FMS.
Klippel, John H. (2008) Primer on the Rheumatic Diseases (13th edition). Springer.
Klipple, John H. Rheumatology, (3nd edition). Mosby.
Sterling G. West. (2015) Rheumatology Secrets (3rd edition). Elsevier.