Drug therapy for pain
It is uncommon to find a pain-relieving medicine that relieves all arthritis pain for any one person. The aim is to help control the pain so it has less effect on what you can do. The medicines commonly used to treat the pain associated with arthritis, are:
Painkillers (also called analgesics) reduce pain but do not have any effect on inflammation. The most widely-used painkiller is paracetamol. Paracetamol is safe in doses up to 4 grams daily and rarely causes side-effects. One paracetamol tablet will contain 500mg of paracetamol – up to eight tablets can be taken in any 24-hour period, but these must be spaced out over the day, with one or two tablets taken at each dose and a gap of at least four hours between doses. Taking more than this or consuming large amounts of alcohol with paracetamol can lead to permanent liver damage. Paracetamol is often used in combination with other medicines such as NSAIDs and opiates.
Watch the video below to see Prof. Woolf (consultant rheumatologist) talk about taking pain killers
Non-steroidal anti-inflammatory drugs (NSAIDs, anti-inflammatories)
Anti-inflammatories work in a different way to paracetamol and are able to reduce both pain and inflammation. They will not slow down or stop the progression of inflammatory arthritis. They are often used as the first treatment for inflammatory arthritis. They are also used when starting other treatments such as DMARDs which can take longer to start working. You can expect to start getting pain relief with the first dose of an anti-inflammatory, but it may take up to two weeks for there to be any effect on inflammation.
There are many different anti-inflammatories, but the most widely-used are ibuprofen, naproxen and diclofenac. Celecoxib and etoricoxib are also anti-inflammatories but work in a slightly different way to the others.
The dose is different depending on which anti-inflammatory you are prescribed. Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them. Different anti-inflammatories are available as tablets or capsules, and some can be used topically – they come as creams, gels, or sprays that are applied to the affected joints. If you have lots of joints affected by arthritis, taking anti-inflammatory tablets or capsules will probably be more effective, but if only a couple of joints are a problem then a topical anti-inflammatory may be suitable. You should not use topical and oral anti-inflammatories together.
While most people can take anti-inflammatories without any problem, they may not be suitable if you have a history of heart, stomach, or kidney problems. If you are taking low-dose aspirin, discuss with your GP whether you should use an NSAID. Anti-inflammatories can interact with other medicines so you should always check with your doctor, pharmacist, or nurse before using anti-inflammatories if you are taking any other medicines. To avoid causing serious side-effects, anti-inflammatories should be taken in the lowest effective dose for the shortest period of time possible.
Using anti-inflammatories can increase the risk of serious stomach problems, such as bleeding from the gut. For this reason, they must always be taken with or just after food. If you are likely to be taking anti-inflammatories for a long time you will probably be prescribed another medicine to protect your stomach. If you develop any new symptoms like indigestion or dark stools (poo), or an existing stomach problem gets worse while taking anti-inflammatories, you should contact your doctor for advice. Although these problems are serious they do not happen very often. Research has shown that if two to three thousand people take anti-inflammatories, one of these people will have a serious stomach bleed. Medicines like etoricoxib and celecoxib are less likely to cause these problems.
Anti-inflammatories are also known to cause problems with blood pressure, and can also increase the risk of heart attacks, stroke and kidney problems if they are taken regularly for a long time. Your doctor may want you to have blood tests to keep an eye on your kidney function and will also check your blood pressure regularly.
Corticosteroids, also known as ‘steroids,’ help reduce pain, stiffness and swelling. Corticosteroids are often administered when your doctor thinks inflammation is playing a big role in your pain. They are usually used when anti-inflammatories fail to provide relief. They can be given by mouth, or injected into a muscle to have a body-wide effect if many joints are affected. If only one or two joints are affected, it may be possible to inject steroids directly into the joint.
Steroids usually work very quickly, often improving pain and other symptoms within a few days. They are usually only used on a short-term basis as they can have serious side effects if used for more than a few months. These can include weight gain, osteoporosis (weakening of the bones), easy bruising, muscle weakness and thinning of the skin. They can also make diabetes and glaucoma (an eye disease) worse. Steroids can also sometimes cause mood changes.
Steroids can weaken your immune system, so if you become unwell you should seek advice from your doctor promptly. You should also see your doctor if you come into contact with anyone that has chickenpox or shingles.
Steroid tablets are usually taken as a single dose in the morning, as they can make it difficult for you to sleep if taken later in the day. While taking steroids it is important you do not stop taking them suddenly (unless advised to do so by your doctor). If you have been taking them for more than a few weeks, the dose will need to be reduced gradually to stop your arthritis flaring up when they are stopped.
There are two main types of opioid; weak opioids include codeine, dihydrocodeine and tramadol; the strong opioids include morphine and fentanyl. These can all be used alongside paracetamol and anti-inflammatories, and combination products containing paracetamol and codeine (co-codamol) or dihydrocodeine (co-dydramol) are available. These are usually taken by mouth, though patches containing fentanyl or buprenorphine are available and might be used if patients need regular opioids to manage their pain.
Unlike anti-inflammatories, which work in the joints themselves, opioids work in the central nervous system. Doses of these medicines are usually increased in a step-wise manner to get a balance between pain reduction and unwanted side-effects. The common side-effects of this class of medicines are constipation, nausea and drowsiness. High fibre diet and laxatives may be useful if the medicines are helping pain but causing constipation. Drowsiness may be helpful if the medications are used at night in people with sleep disturbance due to pain, but care must be taken during daytime activities such as driving. The term “opioids” is often associated with fears of addiction. However many patients use these medications for chronic pain without becoming addicted.
Combinations of the above drugs may be useful in some patients since the drugs work in different ways, for example, combining an NSAID and an opioid analgesic. For certain types of pain, antidepressants or antiepileptic medicines may sometimes be used – research has shown that these medicines can be effective for certain types of pain in people who do not have depression or epilepsy.
Some common questions
When is the best time of day to take my painkillers?
This very much depends on the sort of pain you are experiencing, and whether it is there most of the day or only at certain times. It is also easier to prevent pain than get rid of it once it has started. If you have pain most of the time, you may need to take painkillers or anti-inflammatories regularly throughout the day to have a constant pain-relieving effect.
If you only have pain at certain times of the day you should take your painkillers as and when needed. However, if certain activities tend to worsen your pain, you may wish to take painkillers 30 to 60 minutes beforehand to reduce the pain you experience.
If you find that your symptoms are worse first thing in the morning, it might be worth trying to take an anti-inflammatory shortly before you go to bed – if you do this, remember to have some food at the same time; this doesn’t need to be a meal so a light snack such as a piece of fruit or some crackers or biscuits would do.
Are the side effects worse than the benefit?
No, not in most people. You will only be taking them if you are having pain that is affecting what you want and need to do. You should only be using them if they are giving some worthwhile pain relief. Most people do not get any side effects.
Will my body get used to them?
Paracetamol and anti-inflammatories will always work just as well no matter how long you take them for. What does sometimes change is the severity of pain and the painkiller may no longer be effective enough for the more severe pain. Some people can get used to opiates and may need to adjust the dose to manage their pain.
I do not want to be addicted to them
People who use painkillers for arthritis pain do not get addicted to the types of painkillers used. Even if you need strong opiate painkillers for severe pain, it is very unusual to become addicted to them. The main thing is to not use a painkiller stronger than you need, or for longer than it is needed.