Managing Musculoskeletal Pain in an Elderly Woman

ABSTRACT

Musculoskeletal conditions are common and a major cause of chronic pain; more than nine million people in the UK are affected by arthritis alone. Successful treatment of pain can lead to increased physical activity with consequent improvement of muscle tone around the affected joints. In older patients with multiple comorbidities, fewer therapeutic approaches or surgical interventions tend to be indicated. Where opioid therapy is unsuccessful, possible strategies include opioid rotation and/or changing route of administration.

KEYWORDS :

• arthritis
• musculoskeletal
• opioid
• pain
• rotation
• route of administration

COMMENTARY FROM ITALY

Maurizio Cutolo

This case report presents a condition of highly symptomatic and particularly diffuse osteoarthritis (OA), of a severity that is fortunately quite rare in the clinical experience of rheumatologists. The therapeutic management of the patient has clearly been deficient in the previous 30 to 40 years, resulting in the present severe and progressive clinical status of this patient.

As consequence of several stratified comorbidities, and in view of the age of the patient, few therapeutic approaches and/or surgical interventions are available without severe contraindications and associated adverse effects. The presence of a normal ESR in a 76-year-old woman is unusual, considering that ESR, a nonspecific marker of inflammation, would usually be altered in conditions ranging from infections to simple localized inflammatory reactions. However, chondrocalcinosis, at least in such severe and diffuse OA, should be suspected and checked carefully, which can be done easily via x-ray. Microcrystalline arthritis often characterizes such patients (pseudogout).

Of course, the final approach where there are contraindications to the use of specific therapies is to treat just the symptom of articular “pain.” In this case, once the diagnosis of myeloma or polymyalgia rheumatica was excluded and x-rays confirmed clear OA lesions, the use of painkillers such as opioids should alleviate some pain, but may also provide an acceptable level of control with fewer side effects for the patient. The physician must always follow the Hippocratic Oath, namely primum non nocere (“first, do no harm”).

COMMENTARY FROM THE NETHERLANDS

Jan H. Vranken

In 1986, the World Health Organization (WHO) published a three-step analgesic ladder¹ that, depending on individual pain intensity, progresses from nonopioid analgesics to weak opioids to strong opioids. However, there is a debate as to whether the second step of the WHO analgesic ladder, comprising opioid analgesics such as tramadol, codeine, dihydrocodeine, and dextropropoxyphene, is still needed for the treatment of chronic pain. Additionally, codeine is a weak opioid and its usefulness in pain management is further limited due to side effects, especially constipation. With this in view, a direct move to the third step of the ladder can be feasible and may reduce pain scores—but also requires careful management of side effects.

In this patient, a switch to transdermal administration of opioids was made resulting in an improved pain management. Although oral remains the preferred route of administration, alternative routes (sublingual, transdermal) are available and provide clinicians with the means to treat patients who cannot take oral medications because of head, neck, mouth, or bowel lesions. In addition, transdermal opioids have been increasingly used for the treatment of chronic pain because of perceived advantages to their side effect profile.

When patients experience either insufficient analgesia or problematic side effects following opioid administration, it may be worthwhile trying another opioid. Sequential trials of different opioids—opioid rotation—can help identify the most favorable drug. Variability in analgesic or adverse effect response to different opioids is relatively common and is probably due to incomplete cross-tolerance. Indications for opioid rotation include poorly controlled pain with unacceptable adverse effects, refractory pain, and difficult pain syndromes. Alternatively, switching to transdermal, rectal, nasal, parenteral, or neuraxial administration may improve analgesia with less accumulation of metabolites and consequent toxicity.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Notes

Maurizio Cutolo, MD, is Professor of Rheumatology, and Director, Research Laboratories and Academic Unit of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy (E-mail: [email protected]).

Jan H Vranken, MD, is an anesthesiologist and Coordinator, Pain Relief Unit, Medical Center Alkmaar, Alkmaar, The Netherlands (E-mail: [email protected]).