Talking about Pain

Susan Oliver, RN, MSc, Nurse Consultant Rheumatology, Devon
Original article: 10/10/2006
Reviewed: 22/09/2009
Next review due: 22/09/2012 

When we attend the doctor’s surgery we often have high expectations of the outcome, particularly as we are becoming increasingly well-informed ourselves about our healthcare needs. Yet it can be difficult because these high expectations come at a time when consultations are shorter and healthcare teams have a number of tasks they must make sure they do in the short time you are sitting with them. The doctor or nurse needs to check your current prescriptions, any other conditions that might affect your treatment and possibly even your latest blood tests! This all seems to be going on whilst you are hoping to explain what your pain is like and ask how to get some pain relief. There doesn’t seem much time to try and explain. This article includes:

•    How pain works
•    What affects your experience of pain
•    How to manage pain
•    How to describe your pain

Pain - an overview

We have all experienced pain at some time or other, but what do we mean by pain?

You may have read about ‘acute’ and ‘chronic’ pain. Acute pain is that quick needle prick that makes you jump and then the pain goes away after the injury. Chronic pain is sometimes defined as a pain that doesn’t go away after an injury. However, for many people with RA there is always a level of pain that you cope with and then on top of that may come painful episodes.

So why do I need to understand all this? Why can’t the doctor just treat my pain?

We know from research evidence that all of us only retain a small amount of the
information we are given at the consultation and sometimes we are just not ready to hear some information. So coming to terms with your condition can take time and it will also affect how you feel about your pain. Uncontrolled pain can cause a vicious cycle, (see right)

How you feel about your pain and how positive you are about controlling pain can be as powerful in managing the pain as some of the medications for pain!

Further reading:

•    Arthritis Research UK booklet- Pain and Arthritis

•    Arthritis Care - Coping with Pain

•    The British Pain Society – What is Pain? - patient information leaflet

First steps in achieving pain control

Pain control needs to be tailored to the individual person and their lifestyle, the level of pain experienced and, in some cases, how active the disease is at the time of the increase in pain.

We all have different ways of thinking about health, illness and sensations like pain. Most people have experienced some sort of pain before developing arthritis. It may be that the previous experience of pain can affect how you cope with the pain you experience with arthritis. Sometimes it can help to discuss how you see your RA and how you feel able to cope with the problems you experience. If you are seeing a consultant about your arthritis it should be possible to be referred to a specialist nurse or practitioner who can provide specific advice on pain control and education about your disease, as well as guidance on the tablets or treatments you might be prescribed.

How pain works

This section is going to describe the basic principles of how your body feels pain and how the body responds to pain sensations.

Let’s look at an example of how pain works as a process within the body. If you think about pricking your finger, this is where you get the pain sensation and a message is sent back quickly from your finger up to your brain and the brain responds by sending a message quickly back to say the pain is there, move your finger or take the needle out of your finger. But if you have a strong constant pain, the message from the nerve endings keeps sending up messages to the brain and the cycle of pain begins.

So why doesn’t the brain stop RA pain?

Sometimes the messages about the pain intensity that come from your nerve endings can be very high and the brain may only send a moderate response to that request to relieve the pain. This means perhaps that your body sent a message saying my pain is 100 out of 100 on a pain scale but the brain only seems to have received a message saying it is 85 out 100 in pain sensation. This is because other factors can affect that initial sensation of pain – for instance the body’s response to the injury may measure one scale – but your emotions at the time measure it much higher. For example, you have had a disturbed night and haven’t slept well, you wake early and get out of bed, you are upset because you have a busy and important day ahead of you and you are starting the day tired and, just then, you manage to knock your knee on the corner of the bed. Your emotions about not sleeping and the day will affect how badly you feel the pain, so you will consciously say to yourself ‘I feel that pain – it hurt an awful lot’ but your nerve endings and your brain may perceive less pain. We also all have different levels of pain tolerance, we are all unique, and certain events on any one day can affect your usual pain tolerance.

With RA, the inflammation in your joints causes the body to launch an immune response – this is because the condition is caused by your own body attacking your own joints (recognising your own tissues as foreign – a bit like bacteria). As a result your joints become hot, swollen, difficult to move and painful. The nerve fibres around the joint send those important messages to the brain (via the ‘pain gate’). But the pain messages will be sent frequently and the body cannot adequately produce the chemical over prolonged periods of time to reduce the pain, and other factors will be making the pain worse (how you feel, how tired you are, how distressed you are with the level of pain you have and how much you are trying to do whilst your joints are painful). These things can amplify or increase the pain levels being sent to the brain.

In these circumstances the body needs help to damp down the pain sensations by using medicines and other methods that will help to bring down the pain messages.

Further reading:
•    NRAS article – What is RA?

•    ARUK booklet- Rheumatoid Arthritis 

Medications for pain

All pain relief medication should be taken at regular intervals when you are trying to get effective pain control. Many people make the mistake of only taking their tablets to relieve pain when the pain is very bad and then wonder why the tablets have not worked. The brain is sensitive to pain messages from the body and if you only take medication occasionally the brain will not be able to produce enough natural pain killer to 'turn off' the 'help I have pain' messages sent from the painful areas to the brain. Regular pain relief helps to break the cycle of pain messages going from the painful joints to the brain.

Further reading:
•    ARUK booklet - Pain and Arthritis

•    The Pain Relief Handbook by Dr C Wells & Graham Nown ISBN0-09-181371-9

When you have good pain control then you should gradually reduce the pain medications. You should think of it as:

1.    Step up - when the pain is beginning to be difficult to control - review your pain control strategies and increase medication (according to your doctor’s instructions)

and

2.    Step down - when the pain is well controlled, review how to gradually reduce your pain control medications and additional strategies (eg reduce resting time) and gradually continue to reduce them as long as the pain remains controlled.

Achieving pain relief

Many of the tips outlined below should also be used, as part of a complete strategy to reduce your pain. Applying a cold pack on its own to a very hot painful joint probably won’t achieve the level of pain control that you need but, combine that with regular pain control, and you might find this begins to work.

Analgesia (pain relief medications)

Note:  When discussing medications it is important to realise that the advice outlined in this article is only a guide. Any medications you take should be used according to the information leaflet provided by the manufacturer of the product and the advice of your own doctor or nurse.

You should not exceed the prescribed dose. Always check that you are safe and able to take the medications and there are no reasons discussed in the patient information leaflet that mean you should not be taking the medication. Make sure that the person prescribing the medications is aware of any other medications you take, including anti-inflammatory creams, alternative or complementary therapies.

Details of over the counter painkillers:

‘Simple’ analgesics:

These drugs are called ' simple' because they are made up of only one type of drug (eg paracetamol or aspirin).  A tried and tested effective 'simple' pain relief tablet is paracetamol. Aspirin is not usually advised because it can cause problems with some medications but also can be irritating to the stomach.

Examples:

• Paracetamol

• Aspirin

Creams/ patches:

These can be applied to painful joints, sprains and strains, particularly useful for smaller joints, eg knuckles.

NB: It is important to know that when creams are applied too frequently or liberally they can be absorbed by the body and have effects throughout. Some of the anti-inflammatory creams can be bought over the counter at the chemist. They have been shown to be effective for pain relief in the short term (up to two weeks).

There are also creams that reduce pain sensors on the skin and at the fine nerve endings which recognise the pain and reduce the pain message that the brain receives from the painful area. These creams can sometimes take several weeks before the pain relief is felt and when first used can cause an initial burning sensation. Some people find this counter irritant effect quite soothing and the burning sensation itself does reduce when you get used to the cream.

Examples:

• Ketoprofen (an anti-inflammatory cream)

• Capsaicin cream (reduces pain sensors)

Details of painkillers a doctor or nurse may prescribe:

Compound painkillers (i.e. made with 2 types of pain relief):

Some of these drugs are mixed with paracetamol or aspirin and a stronger form of pain control called an opioid. There are a number of different mixtures and these tend to have slightly more side effects than the simple analgesics. For many of the compound or pure opioid tablets, one of the most common side effects is constipation. It is worth being aware of this and, if you are taking regular compound pain relief, ensure you take regular bulk forming laxatives such as Ispaghula Husks (eg Fybogel) to avoid constipation. Always check with your doctor that this is safe for you to take. Other side effects can include nausea, vomiting and drowsiness.

Examples:

• Paracetamol 500mg with 8mg Codeine Phosphate (500mg/8mg = Co-Codamol 8/500)

• Paracetamol 500mg eith 30mg Codeine Phosphate (500mg/30mg = Co-Codamol 30/500)

• Paracetamol 325mg with 32.5mg dextropropoxyphene hydro-chloride Prescribed as Co-Proxamol

Opioid drugs:

Used to relieve moderate to severe pain. The dose and how often tablets should be taken will vary according to levels of pain. Your doctor or nurse will advise you on how to take this medication.

Opioid drugs are sometimes given on their own without paracetamol or aspirin.

Examples:

• Codeine Phosphate 30-60mg every four hours (according to Doctor’s prescription but usually to a maximum of 240mg per day)

• Tramadol 50-100mg 4 hourly (according to doctor’s prescription)

• Dihydrocedeine 30mg (frequency will vary according to levels of pain

• Tramacet Comprises 37.5mg tramadol hydrochloride and 325mg Paracetamol. 2 tablets not more than every 6 hours. Maximum 8 tablets daily.

Part simple/ part opioid compounds:

Medications that are part simple analgesic and part opioid based compounds (stronger than the simple analgesics).

NOTE: Co-proxamol is now only prescribed on a named patient basis. For further information on Co-proxamol, please click here.

Examples:

• Co-codamol (8mg codeine phosphate /500mg Paracetamol)

• Co-drydramol (10mg dihydrocodeine/500mg Paracetamol

• Tylex (30mg codeine phosphate/500mg Paracetamol)

• Co-proxamol (dextropropoxy-phenehydrochloride

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs):

There are lots of different types of these drugs and they are effective in reducing pain, especially pain that is experienced as a result of inflammation in your joints. Your doctor has to prescribe many of these drugs although one or two can be purchased at lower dosages over the counter (for example, ibruprofen). These drugs do have side effects (one side-effect is that they can cause stomach ulcers and bleeding).

Examples:

• Brufen 200mg four times a day

• Diclofenac 50mg three times a day

Further reading:
•    ARUK information leaflet on NSAIDs and Cox IIs.

•    The National Institute of Excellence (NICE) has produced guidance on the prescribing of COX II which is included in the NICE guidance on the management of osteoarthritis

•    ARUK leaflet on Drugs and Arthritis

Cox II (Cyclo-oxygenase Inhibitors) NSAIDs:

Cox II were developed to improve upon the risks related to taking what we now call ‘traditional NSAIDs’.  The main problem with traditional NSAIDs was a small but not insignificant risk of developing an ulcer or having a bleed from your stomach, particularly increased if NSAIDs were not taken with food or you had some underlying risks (such as history of peptic ulcers). However although COX IIs are safer if you did have  additional risks of stomach ulcers or have had a previous stomach bleed they have a lot in common with traditional NSAIDs too.  That is they still have other side effects related to the traditional NSAIDs (for example increasing the risk of cardiac problems if you had an underlying heart problem).   

In recent years there has been intense scrutiny on the newer COX II therapies and it has been only as a result of a greater understanding of how COX IIs work that we understand more about the older ‘traditional NSAIDs’ and how they work and the risks they also hold in relation to cardiac problems etc. There are now some concerns and a small level of uncertainty about all NSAIDs as to which is the best one to take. Having said this they are still an important and effective part of pain relief especially for people with RA. Often because of the issues outlined above doctors can be resistant to prescribing NSAIDs. However, it is important that you are given a full assessment of the potential risks and benefits of taking an NSAID and that you are enabled to make a fully informed decision about whether you elect to take an NSAID (or COXII).

Examples:

• Cox II selective anti-inflammatory drugs

Meloxicam 15mg once daily

• Cox II specific anti-inflammatory drugs

Celecoxib 200mg twice a day

Other helpful medication

In addition to the pain relief treatments above your rheumatologist or family doctor may have prescribed other medications. Some of the treatments will be to improve control of the disease and this should reduce the pain. Some treatment options may include:

1. Disease Modifying Drugs

The use of disease modifying drugs or biologic therapies to control the level of disease activity. For more information on RA medication, please see the drug directory page on the NRAS site.

Evidence strongly supports the use of these therapies to reduce the long term damage.  By reducing the disease activity the levels of pain are usually reduced.

2. Steroid treatments

a) For one or two painful swollen joints
Injections of steroid (for inflamed joints).

If the pain is chiefly in one or two painful joints it might be possible to consider an injection of steroid into the joint. Steroid can provide rapid relief of symptoms. It     is important to have information about these injections so you should speak to your doctor or nurse for advice, as they need to check that an injection would be suitable for you and give you benefit.

b) For more widespread pain and multiple swollen joints:
These include tablets, injections (can be injected into the large muscles of your bottom or top of leg) or infusions (a needle is inserted into a vein and a bag of fluid mixed with the steroid are given to you over a period of a few hours).  

Further reading:
•    Further reading: ARUK information leaflet on Local Steroid Injections

3. Some simple, non drug techniques for local pain control

These are options you can use any time of day or night and come with little if any risk!

Cold packs (or a bag of frozen peas) on hot and painful joints
Cold packs can be purchased over the counter and are usually put into the freezer. Some people can find them a little uncomfortable because they are so cold when on the painful area but usually find reasonable pain relief afterwards. They can be used frequently during the day and provided you do not damage the skin by putting the frozen pack directly in contact with your skin (it is best to have a fine cloth around the pack) they are very safe and without side effects.

Hot packs are often useful especially for stiff or aching joints and muscles. Hot baths can also be used to reduce pain and stiffness especially in the morning.
Again you must be careful that you do not damage your skin. Skin that is painful may not be able to recognise accurately when the heat is burning or damaging the skin. Make sure that you don’t let the pack get too hot and test the temperature before applying to a painful joint. As with cold packs, it would be advisable to wrap a fine piece of cloth around the pack. These packs are made from a range of products and can be heated in the microwave, but do make sure that you use the packs as advised by the manufacturers.

Other ways of reducing pain - non medication options

1. Transcutaneous Electrical Stimulation (TENS)

TENS machines have two small electrode pads that need to be attached to the skin. The TENS machine works by providing mild electrical impulses that stimulate the touch sensors in the skin reducing the pain messages to the brain. A small battery powers the electrical impulses, the level and type of impulses can be adjusted. TENS machines can be purchased from chemists. Although TENS machines may be useful to some people it might be worth taking specialist advice from the hospital physiotherapist/practitioner about whether you might benefit from using one. Research evidence to date has not proved conclusive evidence of the value of TENS for chronic pain.

Further reading:
•    Moore et al, 2003. Bandolier's Little Book of Pain, Oxford University Press.  ISBN 0-19-263247-7

2. Pacing, Rest and distraction

Pacing is a term used to modify the stress or workload levels on your joints as well as learning to rest yourself mentally and physically. It means finding ways in your life to balance times of work with times of rest. Painful joints may need some recovery time, for example changing tasks from standing or walking to sitting or lying down to read a book. This takes the weight off the joints and allows some of the muscles that have been doing most of the work to relax. Pacing also means recognising especially bad or difficult days and being flexible about how much you should do that day.

Resting can sound difficult, especially if you are being asked to rest when you are experiencing pain, or have plenty of tasks that you want to do, but learning relaxation techniques can relieve tension and ultimately constant pain messages to the brain. Fatigue will affect how you perceive pain and how you cope with it. Learning ways to relax completely can be a real trial for some people, others are gifted at it! You need to find the best way to help you relax. Some people find certain types of music help, others like absolute quiet. It is useful to try resting on a bed for a short time each day when the pain is bad; lying in a dark room, without any additional noises or distractions. A short sleep may even be worthwhile. Set an alarm to ensure that you only sleep for a certain period of time so that over time you don’t lose your normal night sleep patterns.

With training and help to self manage your condition it is possible to find some techniques that help distract you from your pain. Often easier said than done but can be helpful, particularly if you recognise you are beginning to experience pain. Use some medication and non medical options and perhaps then listen to a relaxing piece of music, rest for 15 minutes on your bed or do a simple activity that you enjoy and are able to do with the discomfort. These may not work for you but other activities might. Self management programmes are designed to help you work through different ways of managing the challenges of RA, one important one is coping with pain.

At time of writing, an RA self-management programme is being trialled and it is hoped that this programme will be rolled out at the end of 2009.
 

3. Managing Fatigue

Fatigue is a very common symptom for those who are suffering with pain or difficult mobility problems. Fatigue can also be an added problem with inflammatory joint diseases such as Rheumatoid Arthritis, Psoriatic Arthritis and Ankylosing Spondylitis.

Fatigue is often not mentioned or fails to be recognised and sometimes you may feel that you are the only one who is exhausted and failing to cope.

Fatigue can be an indicator that the disease has become more active, particularly with diseases such as Rheumatoid Arthritis, and may be accompanied by increasing length of early morning joint stiffness. In addition fatigue can be as a result of anaemia.

Managing fatigue will be part of an overall strategy as highlighted in the same way as coping with pain. It will require a combined approach using rest, passive exercise and better pain control.

4. Swimming and Hot Baths

Water takes away gravity, resting your joints from their weight bearing work. It means that joints can move more freely and the muscles can have a greater degree of movement without taking any specific strain. Sometimes hydrotherapy treatments are offered to help your mobility and teach you how to improve the range of movements in your joints. These exercises can sometimes be continued in warm local swimming pools where local support may also be provided. You can find out about the availability of such facilities by contacting your local leisure centre or health club.

Hot baths help relaxation and give a sense of well being and pain relief. People who experience early morning joint stiffness often find taking their pain medication then getting into a hot shower or bath will help their pain control and reduce some of their stiffness.

5. Exercise

The balance of rest, relaxation and exercise can improve pain control and maintain mobility. For most types of arthritis exercise is essential. This is because joints and muscles need to move regularly and muscles need to maintain their muscle strength and bulk. Some of the pain experienced in arthritis is related to the stiffness that can be experienced following periods of inactivity or early morning stiffness (EMS).

The different types of exercise may vary according to the type of problems you have and the difficulties you are experiencing. If you are seeing a rheumatologist they will refer you to a physiotherapist to advise you on an exercise regime. However it is important to know whether you are doing 'active exercise' or 'passive exercise'.

a) Active Exercise
Active exercise is what most people do to keep fit and reduce weight. It
involves things like going for a walk or gardening. They often require the body and the joints to bear weight and work against a force - such as lifting or digging in a garden.

b) Passive Exercise
This is where the joints and muscles are worked but not against a specific weight or force. It involves moving the muscles and joints through a wide range of movements, this can be done while lying on the bed or sitting in a chair.

Further reading:
•    Exercise and RA by Lucy Darbyshire

•    Exercise and Arthritis booklet by Arthritis Care

•    ARUK Keep Moving poster
If you have any doubts about the safety of, or your ability to undertake, any exercise regime you should discuss this with your own doctor before starting an exercise programme.

6. Weight Loss

It is very difficult to lose weight, particularly when problems with mobility significantly reduce opportunities to undertake vigorous exercise regimes.
However, it is worthwhile knowing that people with arthritis who are overweight have greater damage to the joints and increased difficulties with mobility and exercising. Losing weight can be a very effective way to reduce your pain. It may be worth seeking advice about a suitable diet that will help you lose weight yet ensure you maintain a healthy balanced diet.

7. The Use of Aids (walking sticks, joint protection, footwear)

For healthcare professionals, encouraging individuals to use various aids or assistive devices is often the hardest thing to achieve, yet it is one of the simplest ways of reducing fatigue, improving mobility, reducing pain and protecting joints. This is partly because most of us simply do not wish to consider the use of any form of aid, seeing it as recognition of a problem or as 'giving in'. Yet the use of some equipment can be liberating, allowing more energy and time for other activities. Coming to terms with using any form of aid is often most effective when supported by help and advice from a member of the multidisciplinary team.

Walking Aids
The way we use our body and our joints is taken for granted when everything works well. When a joint fails or is painful it is common for people to continue to walk, go up and down stairs etc but with pain and increasing difficulty. It is often achieved without the use of aids but usually is achieved at the cost of the other joints having to take the extra weight. This means that other joints will take the weight but not in a way that they are designed to. This means the weight will be distributed differently and add an extra load to healthier or less painful joints.

An example of this is when you have a painful knee. To continue to walk you protect the painful joint by throwing your weight onto the 'good' knee. This results in your body changing the mechanics of how you position your back before movement, distributing the weight onto the 'good' knee joint. The good knee has to cope with the abnormal load by distributing the force through other joints. This can result in not only a painful knee but in addition a painful ankle or hip too. To minimise the risk of this a walking stick could help by taking some of that additional load and maintaining a better body posture. When the knee settles and pain and function improves you can then put the walking stick away.

8. Joint Protection

Some types of arthritis or functional problems can be improved with the use of joint protection. It is quite common for people who have some types of arthritis (eg rheumatoid arthritis) to be assessed by an occupational therapist or rheumatology practitioner. The therapist or practitioner will assess the activities you undertake and see where stress on joints can be reduced to protect the joints and keep them in their normal alignment. The process of assessment will often include providing practical advice on how to avoid abnormal stresses or forces on the joints and can include additional pieces of equipment such as kettle tippers, reducing the need to lift a full kettle of water. When joints are more effectively protected pain can be reduced.

The occupational therapist can provide information on the benefits of splinting and how to protect your joints.

Further reading:
•    NRAS- The Role of the Occupational Therapist 

•    ARUK Looking after your joints when you have arthritis

9. Footwear

Podiatrists are specialists trained in managing foot problems and other difficulties related to the foot and diseases that affect the feet. For many forms of arthritis early practical advice on footwear can be very effective. Our joints work as shock absorbers taking up the impact and reducing the force applied to the joints. When we are young there is a tissue called cartilage that lines all healthy joints and is nice and spongy and provides an effective cushioning for movement. As we grow older this cartilage becomes less flexible and in osteoarthritis may become worn away allowing two joints to move against each other without the cushioning effect of cartilage. One way of improving the 'shock absorber' or cushioning effects that used to be achieved by our young healthy joints is to ensure that shoes have good cushioning included in them. Trainers are a good example of cushioning support that a shoe can provide.

However, there are a number of problems that might be experienced with different types of arthritis. A thorough foot assessment often proves very useful. The assessment will look at whether the arch support of your foot is maintained, and that you are bearing you weight down effectively onto your ankle and foot. Sometimes the use of an arch support can be very effective.

Further reading:
•    NRAS The Role of the Podiatrist

•    ARUK Feet , Footwear and Arthritis

10. Complementary or Alternative Therapies

Anyone with a chronic illness, whatever that illness, will be enticed by the vast array of products that promises a cure or relief of pain when traditional medicine has failed to provide the same promise.

It is natural to seek other solutions and find a way to resolve some of the difficulties that arthritis might put in your way. It is not possible to cover the complete range of complementary therapies available and some outlined on this page are used to provide examples.

The term complementary or alternative therapy is used to describe various types of non-medical treatments.

Many complementary therapies have not been studied to ensure they are safe and effective or have been inadequately researched from a scientific point of view. There is now great interest in undertaking research projects to help healthcare professionals and individuals with arthritis understand more about the risks and benefits of complementary therapies. Not only to see how effective these alternative therapies are but also to see the problems people experience when taking these therapies. The cost of most complementary therapies comes directly out of the pockets of the individual consumer and these costs need to be measured against benefits of the therapy.

It is important that you discuss with your doctor or nurse what you would like to take – particularly as some of these products can interact with prescribed medicines. Always remind any healthcare professional you see of the products you are using to self medicate, including complementary therapies.

Acupuncture
Studies for RA have shown no benefit from acupuncture for pain relief. There are different schools or 'styles' of acupuncture. Acupuncture is the use of special needles to stimulate 'acupuncture points' that reduce pain sensations. It is suggested from some small research studies that acupuncture might provide some pain relief to some people with osteoarthritis. It is often needed on a regular basis for pain control.

Aromatherapy
Aromatherapy is the use of massage and essential relaxing oils. It is important that if you have any painful or unstable joints you check with your doctor before having a massage and you tell the practitioner giving the massage that you have arthritis (and the type of arthritis you have) and any particular joint problems you have. If you are receiving tablets from your doctor it is always worth letting your doctor know you are having aromatherapy.

Homeopathy
When an analysis of a number of small research studies were reviewed homeopathy demonstrated no significant benefit to patients with arthritis. However, further large scientific research studies need to be undertaken to thoroughly evaluate any possible benefits.

Food Supplements
When considering herbal remedies or food supplements it is important to remember that there have been some deaths as a result of the side effects of herbal medication, or interactions with traditional medicines prescribed by a doctor. Always make sure that you check with your doctor if you are taking additional medicines and let them know what other complementary therapies you are taking.

Glucosamine and Chondroitin
Firstly it is important to know that there are different types of glucosamine, glucosamine sulfate and glucosamine hydrochloride. In addition there are a number of different manufacturers and different qualities, all of these issues make it difficult to evaluate the use of glucosamine. There is an additional complication when evaluating glucosamine and chondroitin together.

There have been a number of large scientific studies examining the benefit of glucosamine against non-steroidal anti-inflammatories (or sometimes against no other treatment). Most studies so far on the use of glucosamine have shown some modest benefit in the form of pain relief for some, but not all, patients with osteoarthritis participating in the trial. The benefits were more likely to be achieved if the dose of glucosamine was 1500mg daily although the tablets can vary in strength and purity. The long term risk and benefits of treatment are yet to be studied.

In some studies side effects from glucosamine have included stomach pain, tenderness, heartburn, diarrhoea and nausea. There is no evidence to support the use of glucosamine for rheumatoid arthritis.

It is important that your doctor knows you are taking glucosamine because the side effects experienced may be considered to be as a result of your other medications.  

The benefit of chondroitin sulphate still needs to be studied in large groups of patients although early research suggests that chrondroitin (at doses of between 800-1200mg a day) gave some pain relief for osteoarthritis which was better than no treatment and reduced the need to use other forms of pain relief such as NSAIDs.

These products are sold as food supplements and as such are not regulated as a medicine and dosages may vary. If you take glucosamine (1500mg a day) for three months and achieve no improvement in pain relief it may not be of value to continue.

Cannabis
The non pharmaceutical cannabis product is currently an illegal drug and has been used by some individuals for pain control and reduction of spasms or convulsions. In its current form (unregulated and non legal status) there are a number of problems for patients with arthritis. Firstly, taken in cigarette form the inhaled cannabis has the potential to affect your lungs in a similar way to tobacco, particularly with the amount required on a regular basis to achieve an effective level of pain control.

A recent study of a cannabis based medicine (Sativex) used to treat the pain of RA showed promising early results with benefits seen in reduction in pain. Further large studies need to be undertaken.

Further reading:
•    ARUK Complementary Therapies and Arthritis

•    Sense About Science have useful literature on how to make sense of the portrayal of science and research in the media

References available on request

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