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Acute and chronic joint pain

Strong opioids suitable for elderly patients 

A new Polish study shows that elderly people with chronic musculoskeletal pain often receive inadequate treatment and would benefit from strong opioids. The data was presented at the 1st Topical Symposium of the European Pain Federation EFIC, which focused on the subject of acute and chronic joint pain.

The study suggests that this situation does not change until patients are referred to specialised pain clinics. “Prior to referral, the patients receive systemic non-steroidal anti-inflammatory drugs (NSAIDs) all too often and opioids all too rarely. Yet the opioid buprenorphine, for instance, is a highly effective drug for combatting pronounced pain and is just as safe used on elderly patients as on younger ones,” said study author Dr Magdalena Kocot-Kepska from the Collegium Medicum of Jagiellonian University in Krakow, Poland.

In this study, researchers evaluated data from 165 patients over the age of 80 years who were referred to a pain clinic due to chronic complaints. A total of 70 per cent of this group consisted of patients suffering from chronic musculoskeletal pain. Six out of seven patients were women. Prior to admission to the clinics, 71 per cent of the patients were treated with NSAIDs. That was the case even though nearly all of these patients (95 per cent) suffered from cardiovascular diseases and these analgesics are not indicated in the case of cardiovascular problems. 

After being admitted to the pain clinic, 35 per cent were given strong opioids, but only one-in-five of these patients displayed slight side effects. 

 “A good deal of clarification and clear-cut treatment guidelines are still needed. The concerns about opioids and the excessive use of NSAIDs definitely have to be reconsidered, especially in elderly, most vulnerable patients,” Dr Kocot-Kepska concluded.

Weight loss reduces joint pain, Scottish study finds

Patients with osteoarthritis can reduce their pain level if they lose weight by means of diet and exercise, according to a Scottish study presented at the 1st Topical Symposium of the European Pain Federation EFIC on Acute and Chronic Joint Pain.

After losing weight, patients had to take steroidal anti-inflammatory drugs only three times a week instead of four times to combat breakthrough pain, according to the study authors.

In this study 30 people (12 men, 18 women) were examined to determine how programmed weight reduction would affect their pain level. For 14 weeks the study participants followed a diet and swam 30 minutes a day under the supervision of a physiotherapist. The participants weighed an average of 95 kilograms initially and the majority of them succeeded in losing about 6.7 per cent of their body weight. 

At the same time the pain level on the 10-point VAS pain scale fell from six to four points among the men and from seven to six points among the women.

EFIC has declared 2016 to be the European Year against Joint Pain. The goal of this information campaign is to focus on a health problem from which more than half of the worldwide population over age 50 suffers. Against this background, pain experts attending the Symposium, held in Dubrovnik on 21-23 September 2016, discussed the many current trends for understanding and treating pain caused by joint diseases. Topics covered in the Symposium included animal models of joint pain, inflammatory hyperalgesia, epidemiology and assessment of joint pain, back pain and the new NICE guidelines, acute joint pain and its management including pre- and post-operative pain treatment, and all aspects of treatment of chronic joint pain now and in the future.

“With the ageing of the European population, the prevalence of arthritis is expected to increase yearly. By the year 2030, an estimated 120 million (25 per cent of the projected total adult population) adults aged 18 years and older will have doctor-diagnosed arthritis. Two-thirds of those with arthritis will be women. Also by 2030, an estimated 60 million adults (37 per cent of adults with arthritis) will report arthritis-attributable activity limitations. These estimates may be conservative, as they do not account for the current trends in obesity, which may contribute to future cases of osteoarthritis,” commented European Pain Federation President Dr Chris Wells. 

New therapeutic strategies to combat joint pain

Using beta-blockers to combat pain instead of high blood pressure? Experts at the 1st Topical Symposium of the European Pain Federation EFIC on Acute and Chronic Joint Pain discussed the benefits of searching for a hidden analgesic effect in drugs used for other conditions and how patients are not all the same.

Joint pain continues to be one of the main reasons for persisting disablement, the Symposium heard. One explanation, among others, is that pain therapies available today do not always have the desired effect. Prof David Walsh, from the University of Nottingham, UK, discussed new developments in this area. “Researchers are currently investigating a number of interesting possibilities. The development of new drugs is an arduous process, however, we can most likely expect that NGF [nerve growth factor] blockers, a completely new class of painkillers, will be available for therapeutic practice in the foreseeable future,” Prof Walsh noted.

In the meantime, many clinical studies have shown that blocking NGF can have a positive effect on arthritis pain, back pain and likely also other types of pain. A recent study (Xu L, 2016), in which Prof Walsh was involved, shows in the animal model, for instance, that treatment with the anti-NGF antibody muMab911 mitigates pain responses in connection with arthritis, doing so without preventing cartilage damage and synovitis. This study also indicates that indirect effects on subchondral bone remodelling could also contribute to the analgesic effect of the NGF blockade. Other drugs in development that prevent NGF signalling might equally reduce arthritis pain. 

One research approach attempts to identify the mechanisms of pain and of pain transmission and then deactivate them – but only at the right places. Prof Walsh explained: “Without pain as a warning signal, people would be at constant risk of injury. That is why the experience of pain as a whole cannot be prevented.” A London team, which includes Prof Walsh, is identifying proteins that work as pressure sensors on nerves in the joint and play an instrumental role in the arthritis pain when joints move or on standing.

“To help people with joint pain more effectively, we need to recognise that not everyone is the same – for any one treatment people might either be responders for whom the analgesic works well or non-responders who might benefit more from other drugs,” he said.

A lot of research is now underway to determine how patients can best be clustered according to type of pain and to the mechanism behind that pain.

“The advantage of this approach is this: You are able to offer the patient a targeted therapy that brings about important relief that outweighs any likely side effects. I am firmly convinced that many of the drugs attested to be ineffective in the past might well have worked for some people, but those people were hidden in the clinical trials among the large group of persons for whom the drug didn’t work, or whose pain even got worse. If we could identify the group of people for whom a treatment will work, new effective treatment possibilities could be found for them quickly,” Prof Walsh emphasised.

Prof Walsh sees another future field of investigation in the identification of therapies from other indication areas whose analgesic benefits were heretofore unknown or not sufficiently known. For example, arthritis typically involves nociceptive pain triggered by mechanical stimuli. If common analgesics do not work, drugs for combatting neuropathic pain can help in many cases – quite unexpectedly.

Other examples might be beta-blockers, which have been prescribed for decades to combat high blood pressure. In the meantime, there is growing evidence that they can also affect the transmission of pain in certain people. Non-drug treatment approaches should also be revisited and tested, Prof Walsh stated. “In some circumstances, physical exercise or psychological interventions can be employed differently than before and efficiently for specific groups of people with arthritis pain. Here, too, we must filter out those patients who can benefit from certain psychological techniques or defined exercise programmes.”

For instance, patients who will continue to suffer severe pain after receiving a knee joint replacement can be predicted to a certain degree. Untreated depression is one of the predictors for postoperative problems. One reason, among others, may be that in some people the brain mechanisms active in connection with depression overlap with those that process pain. 

“It is therefore worthwhile looking into the question of whether antidepressants and cognitive behavioural therapy might also improve outcomes for some people needing joint surgery,” Prof Walsh concluded.

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