Managing Arthritis

Experts answer tough questions about pain treatments 

A man discussing with his doctor

Chronic pain is something that most people living with arthritis are all too familiar with. This article is the last of a three-part series on communicating about arthritis pain — one of the most common symptoms that impacts daily living and quality of life. Here, you can find our previous articles, offering tips on how to talk about arthritis pain in daily life and talking about arthritis pain with healthcare providers.  

In the last article, we learned how to have an effective conversation about arthritis pain with your healthcare provider. But even when you have a great relationship with your family doctor, nurse practitioner, pharmacist or rheumatologist, talking about pain medication can be uncomfortable. There can be a stigma - you might have concerns about being seen as drug-seeking or overreacting. 

We talked to two top experts in pain management — Dr. Mary Ann Fitzcharles, a rheumatologist and McGill University researcher with an interest in chronic pain in rheumatic disease, and Dr. Andrea Furlan, a University Health Network physician and researcher focused on pain management. Here's what they had to say. Remember, though, there's no one-size-fits-all solution — this article is not medical advice, and you need to talk to your physician about your particular situation. 

How long can I use over-the-counter pain medications for?  

Common over-the-counter, non-prescription pain relievers include NSAIDs (non-steroidal anti-inflammatory drugs, such as ibuprofen and naproxen), acetaminophen, muscle relaxants, and topical creams. "These medications are safe to take for a long time — months or years — if they are kept within the reasonable maximum dose and if the person doesn't have any risk factors for complications," says Dr. Furlan, noting that your healthcare provider will need to monitor your health, such as checking liver enzymes if you are taking acetaminophen or monitoring your kidneys, stomach and bowels if you are taking NSAIDs. 

Is one better than the other for longer-term use? "Absolutely not," says Dr. Fitzcharles. "It is totally dependent upon the characteristics of the person, the co-associated health issues, and what works best for an individual." 

Are opioids ever the right choice for arthritis pain? 

Opioids like codeine or morphine are intended for acute, short-term situations, such as recovering from surgery. They are not recommended as a first-line treatment or for long-term treatment of arthritis pain. But there are certain circumstances where they might be prescribed.  "All opioids are not the same," notes Dr. Fitzcharles. "And it's no question that patients with pain need to carry on their life. They need to have quality of life. There are ample studies now indicating that perhaps small doses of milder opioids [such as codeine] do in fact, afford some degree of pain relief and improve quality of life." She gives the example of a person with severe osteoarthritis in the knee or hip who is facing a long wait time for surgery.  

"I'd say the most acceptable use of opioids now is for a short period of time," says Dr. Furlan, adding that three to seven days of opioid use during episodes such as a pain flare, after a procedure or doing an activity that has exacerbated your pain may be reasonable. 

If I'm taking opioids for arthritis pain, will I get addicted? If I stop, will I go through withdrawal? 

"If they take opioids every day, 100 per cent of people will become physically dependent, which is not the same as addiction," says Dr. Furlan. "It doesn't take too long — a couple of days or weeks and they are dependent." Why? Opioids reduce pain by binding to opioid receptors in your central nervous system, and the body opens more receptors as it receives more of this medication, she says. When those receptors are expecting those molecules and don't get them, people experience withdrawal symptoms, and this is how physical dependence develops. 

"Typical symptoms of opioid withdrawal include stomach pains, muscle pain, diarrhea, vomiting, agitation and difficulty sleeping," Dr. Furlan explains. These symptoms are definitely unpleasant but should subside within a few days or weeks, depending on how long you have been taking opioids. Ask your healthcare provider about ways to manage symptoms, such as over-the-counter loperamide for diarrhea or melatonin for insomnia. 

Addiction to opioids is a psychiatric disease, where someone will continue taking the opioids despite the negative physical, mental and social consequences. "Physical dependence is necessary for the person to become addicted, but not everybody who is physically dependent has addiction," says Dr. Furlan. 

Can pain medications stop working for me?  

"You can absolutely develop a tolerance to opioids, so that you need a higher dose to have an effect," says Dr. Fitzcharles. "We don't have definite evidence that you develop tolerance to other agents sometimes used to treat arthritis pain, such as some anticonvulsant drugs, acetaminophen, or some of the antidepressants," she says. "But it might be that as the disease changes and/or joint damage progresses, pain increases with it." Pain may also grow due to pain sensitization, an aspect of chronic pain where the nervous system becomes overactive, sensing pain where it would not have before.  

Can I combine over-the-counter pain medications with my usual prescription treatment plan when it's really bad? 

Dr. Furlan believes that non-prescription pain relievers can be combined with a prescription, but it should not always be the first response for chronic pain. "Think about a toolbox where medication is only one of the tools. You should have other tools in the toolbox that you try first. I talk about the five M's of self-management tools: movement, mind-based interventions [such as meditation], other modalities [like heat or cold therapy], manual therapies, and medications. I teach my patients to think in this order, because by the time they try the second or third approach, they may not need the additional medication."  

Dr. Fitzcharles shares that it is common to combine over-the-counter and prescription medication. She says,"I want to emphasize that it's so important to have an open dialogue with your healthcare professional so we really understand what people are taking and the amount that they're taking, as well as the dose of agents that are being used so we can be alert to drug interactions." 

Does using medical cannabis for arthritis pain lead to side effects? 

The short answer is yes, medical cannabis can have side effects, although it depends on the person. "The side effects are very much dependent upon the amount of tetrahydrocannabinol (THC), which is the psychoactive agent. And it can have very, very different effects on different people. Even tiny doses can cause difficulty with cognition [such as reaction time while driving] or difficulty with psychomotor activity like balance," says Dr. Fitzcharles. 

Dr. Furlan adds that while cannabidiol (CBD, a non-euphoric cannabis chemical) can help some people with anxiety and sleep, if it's smoked, the damage to lungs is comparable to smoking nicotine cigarettes. She adds, "We know that prolonged use of cannabis affects people's cognition, memory, and thinking in the long term." 

If my pain stops, should I stop taking pain medications?  

It depends on your condition. For example, if you have ankylosing spondylitis, it's probably necessary to continue taking your anti-inflammatory medications, says Dr. Furlan. However, if you have been managing osteoarthritis with lifestyle factors like exercise and food choices and you're feeling better, you can reduce or stop your medication to see how you do. 

As always, it's important to talk to your healthcare provider.  "When we are managing people with chronic pain, what we hope is to be able to dampen the pain condition, and perhaps try to reset what has gone out of whack. The objective is to not have to use the same amount of medication continuously," says Dr. Fitzcharles. "And it's really important for patients and healthcare professionals to revisit, at every single visit, the need for continued medication."  

What's one thing you wish more arthritis patients knew about pain medications? 

"There are different types of pain, their mechanisms are different, and they're treated differently," says Dr. Furlan. "Ask your doctor, 'do you think this is nociceptive pain [from injury or damage], neuropathic pain or nociplastic pain? so I can seek the right treatment.' That will help your doctor to help you." 

Dr. Fitzcharles says, "Pain medications are not a magic potion. And what we always say is, use what you need, but get away with as little as possible." 

With these answers to some tough questions, we hope this article generates helpful and productive conversations with your healthcare providers. 

We hope that this three-article series has provided you with valuable tips on how to communicate about arthritis pain in useful ways as it is a core and chronic symptom of this disease. You can also learn more about living with arthritis pain in our comprehensive Arthritis Pain Management Guide