Non-Opioid Treatment of Pain and Inflammatory Conditions · Rheumatoid arthritis Osteoarthritis Pain without identifiable nerve or tissue damage; thought to be due to neuronal dysregulation

Non-Opioid TreatmentofPain and Inflammatory Conditions

JENNIFER ZAVALA, MSN, APRN, FNP -BC

RHEUMATOLOGY ASSOCIATES OF SOUTH TEXAS

DisclosureI have relevant financial relationship with the products or services described, reviewed, or compared in this presentation.

◦ Contracted as a speaker for Amgen Pharmaceuticals

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.

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

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

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

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

Rheumatoid Arthritis

Wrist

Shoulder

Elbow

Metacarpophalangeal

Joints

Metatarsophalangeal

Joints

Tarsal joints

Ankle

Osteoarthritis

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.

Inflammatory Back Disease(Seronegative Spondyloarthopathies)

◦ Ankylosing spondylitis

◦ Psoriatic arthritis

◦ Reactive arthritis

◦ Enteric arthritis◦ Crohn’s

◦ Ulcerative colitis

Physical Exam

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

Sacroiliac Pain

Pelvic Compression Test

Sacroiliac PainPatrick’s Test (FABER’s Test)

Gaenslen’s Test

Gaenslen’s test

Progression of Spine Disease / Ankylosis

Schober’s Test

Occiput-to-Wall Test

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

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

Radiographic Data

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

Radiographic Data

Classification Criteria for Osteoarthritis

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

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

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

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

Healthy Lifestyle Modifications

Rest

Braces / splinting

Joint protection devices

Assistive devices

Appropriate exercise

Good nutrition, weight loss

Stress reduction

Cognitive behavioral therapy

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

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)

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)

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

Medications

oTopicalsoNSAIDsoAnalgesicsoCorticosteroids

SystemicIntra-articular

oDisease modifying anti-rheumatic drugs (DMARDs)

oBiologics◦

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

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

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

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

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

NSAIDSOver the Counter

oIbuprofenoMotrin ®

oAdvil ®

oNuprin ®

oCombination medicationsoExcedrin ® (Acetaminophen, Caffeine

and Aspirin)

oBC Powders ® (Aspirin, Caffeine and salicylamide)

oAspirinoBayer ®

oEcotrin ®

oBufferin ®

oAnacin ®

oNaproxenoAleve ®

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

Corticosteroids

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®

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)

Tramadol

Ultram ® 50 mg

Ultracet ®(tramadol / acetaminophen) 37.5 mg / 325 mg

Ultram ER ® 100 mg, 200 mg, 300 mg

CNS Active Medications

Tricyclic Antidepressants (TCAs)

Serotonin Reuptake Inhibitors (SSRIs)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Anticonvulsants

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®)

CNS Active Medications

Serotonin / Norepinephrine Reuptake Inhibitors◦ Venlafaxine (Effexor®)

◦ Duloxetine (Cymbalta®)

◦ Milnacipran (Savella)®

◦ Atomoxetine (Straterra)

◦ Desvenlafaxine (Pristiq)

◦ Levomilnacipran (Fetzima)

Anticonvulsants◦ Gabapentin (Neurontin®)

◦ Pregabalin (Lyrica®)

Sleep Medications

Zolpidem (Ambien®)

Zaleplon (Sonata®)

Temazepam (Restoril®)

Eszopiclone (Lunesta®)

Ramelteon (Rozerem®)

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

SURGERY

o Severe pain is the main indication for surgery oDisrupts life significantly

oAssociated with a disability

oSevere night pain or rest pain

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.