The American Pain Society (APS) (2002) has published an excellent reference, Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. The clinical practice guideline is written for physicians, nurses, and other healthcare professionals who work with adults who have osteoarthritis (OA) or rheumatoid arthritis (RA) or with children who have JCA, and for pain specialists who are unfamiliar with treating arthritis pain. The guideline is based on the best scientific evidence available at the time of writing. For readers unfamiliar with the classification of evidence, an overview is given in chapter two with a detailed list of the studies used for research-based interventions.
The other six chapters concisely cover: (1) an overview of OA, RA, and JCA and related pain, (2) pain assessment, (3) management of pain in OA and RA, (4) treatment of pain in children and older adults with arthritis, (5) summary and comments, and (6) references. The book concludes with four appendices of (1) pain assessment instruments, (2) health status, function, and quality of life assessment instruments, (3) glossary, and (4) reviewers and consultants.
The most significant aspect of the guideline is the recommended use of opioids for pain in both children and adults with arthritis. Before the mid 1990s opioids were rarely used to treat chronic nonmalignant pain (CNP). That thinking is changing. In 1996, the APS and American Academy of Pain Medicine (AAPM) issued a joint policy stating that it is appropriate to use opioids in the management of CNP when other available management strategies have not provided adequate pain relief. However, that statement did not address the use of opioids in children with CNP.
Now the 2002 APS guideline states: "Opioids should be used for patients with OA and RA when other medication and nonpharmacologic interventions produce inadequate pain relief and the patient's quality of life is affected by the pain. Morphine, oxycodone, hydrocodone, or other new agonist opioids, as a single agent or combined with an NSAID (nonsteriodal antiinflammatory agents) or with acetaminophen, should be used for moderate to severe OA or RA pain that has not responded to other treatments" (p. 81). "In general, analgesia for children should be similar to that for adults who experience pain" (p. 124).
Since the use of opioids invariably raises the prevalent, but unfounded, fear of addiction, the guideline addresses this concern. It emphasizes that the prevalence of addiction is low in patients using opioids for pain without a preexisting substance abuse disorder. Those patients with a substance abuse problem require individualized treatment of their pain. The guideline does not address their pain management but recommends consultation from appropriate interdisciplinary specialists (p. 82).
Nurses caring for children in any setting - hospital, clinic, office, school, home - need to be aware of the expanded use of opioids to treat moderate to severe pain in children with JCA. JCA refers to a group of systemic inflammatory disorders, such as juvenile rheumatoid arthritis, that affects children younger than 16 years of age (approximately 285,000 children in North America). It is the most common chronic rheumatic condition and the fifth most common chronic disease of childhood. More conventional therapies, including cognitive behavioral techniques (distraction, relaxation, and guided imagery), physical and occupational therapy, joint injections, and sometimes surgery, are typically used with analgesics. Total pain control must address all sources of pain, including treatment and procedures. Children with JCA frequently need repeated blood tests, may receive subcutaneous or intramuscular (IM) injections of methotrexate or etanercept (Enteril, Enbrel) or intra-articular glucocorticoid injections. Puncture pain can be prevented with the use of topical anesthetics, such as EMLA or ionotophoresis (Numby Stuff). Adding 0.1 ml of lidocaine 1% to injectable gold can decrease IM injection pain (Kovalesky, Sherry, & Lehman, 1986).
November 17, 2002
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