The use of analgesics in the management of pain in rheumatic diseases.

Pain punctuates everday life. A telephone survey found that 46% of respondents experienced severe pain at some time in their lives, with nearly half of these episodes attributed to chronic backaches and one third to "arthritis." 20 In the United States alone, more than 75 million people have some form of recurrent or persistent pain. 34 Not surprisingly, people spend billions of dollars each year to purchase over-the-counter (OTC) analgesics such as acetaminophen, aspirin, ibuprofen, naproxen, and medicated creams. Rheumatologists and other physicians add to these expenditures when they prescribe billions of dollars worth of nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and opioids to control pain. Patients may develop pain from ongoing inflammation or tissue damage. This type of pain originates from peripheral nociceptive input and usually responds to conventional analgesic therapy. Neuropathic pain arises from damage to the nervous system and responds poorly to conventional analgesics. Chronic fibromyalgic pain derives from unknown mechanisms. Its treatment often includes NSAIDs, antidepressant drugs, and skeletal muscle relaxants, but clinical improvement is unpredictable, despite intensive pharmacotherapy. In a rheumatologist's office, pain frequently dominates the clinical encounter. The physician listens attentively while the patient describes the pain, interjecting questions for clarification. The purpose of a careful history and physical examination is to classify the pain according to its bodily cause, intensity, frequency, duration, and time course, concentrating initially on the physical factors. Astute physicians recognize too the complexity of pain and probe further to ascertain its modulation by behavioral factors and psychosocial stresses. Pain may mean something quite different to the patient than to the physician. It may not only cause physical distress but also engender fear from uncertainty about its cause or potential crippling effects. Persons suffer to a lesser or greater extent depending on their ability to cope with the pain and its treatment. Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it. 33 Failure to recognize this dualism between mind and body can limit the effectiveness of treatment. Pain management requires an integrated approach consisting of pharmacotherapy, physical and psychosocial therapies, and procedural interventions. Our purpose here is to review analgesic therapy of musculoskeletal pain, focusing on the use of acetaminophen, NSAIDs, centrally acting skeletal muscle relaxants, antidepressants, topical counterirritants, and opioid analgesics. We discuss the pharmacology of commonly prescribed analgesic drugs and the scientific evidence supporting their use in rheumatological disorders. Finally, we utilize this knowledge to develop a stepwise treatment approach for treating musculoskeletal pain, amalgamating recommendations based on scientific evidence, insights gained from treating other causes of pain, and practical clinical experience.