Guideline sources The following summarized guidelines for the evaluation and management of chronic arthritic pain are prepared by our editorial team based on guidelines from the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the European League Against Rheumatism (EULAR 2018), the Canadian Medical Association (CMA 2017), and the Center for Disease Control (CDC 2016). 1 2 3 4 5 5 5 Definition Chronic arthritic pain is a combination of musculoskeletal pain arising from tissue destruction and mechanical changes to cartilage, bone, and soft tissues, which is associated with sleep disturbance, mood disorder, and fatigue. 5 Epidemiology Chronic arthritic pain is caused by an interplay of both nociceptive (inflammatory) and non- nociceptive (neurogenic) pain mechanisms. 5 Disease course https://web.pathway.md/diseases/rechi3n67ZUsw2urk 1/5 6/29/23, 3:51 AM Chronic arthritic pain Pathway Disease persistence and progression leads to sleep disturbances, fatigue, mood changes (depression and anxiety), and reduced quality of life. 5 Guidelines 1. Diagnostic investigations Pain assessment: Assess the following elements as part of the initial evaluation: patient's needs, preferences and priorities regarding pain management and important activities, values and goals in daily life patient's pain characteristics including severity, type, spread and quality previous and ongoing pain treatments and the perceived efficacy current inflammation and joint damage as sources of pain, and whether these are adequately treated pain-related factors that might need attention. B 2. Medical management General principles: initiate pharmacological and joint-specific pain treatment, if indicated, according to established recommendations for the disease being treated. Show 2 more Stepped care approach: Offer a personalized management plan to the patient with the aim of reducing pain and pain-related distress and improving pain-related function and participation in daily life. A stepped-care approach may include: in step 1, education and self-management support in step 2, one or more treatment options by a specialist in step 3, multidisciplinary treatment. B Analgesic therapy: As per CMA 2017 guidelines, implement nonpharmacologic therapy and non-opioid analgesics as first-line treatment for patients with chronic non-cancer pain, rather than performing a trial of opioids. A As per CDC 2016 guidelines, implement nonpharmacologic therapy and non-opioid analgesics as first-line treatment for chronic non-cancer pain. Consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, consider combining with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. B Cannabinoids: offer cannabinoid-based medicines as an adjunct to chronic pain management in patients with arthritic conditions not achieving adequate response with other modalities. B https://web.pathway.md/diseases/rechi3n67ZUsw2urk 2/5 6/29/23, 3:51 AM Chronic arthritic pain Pathway 3. Nonpharmacologic interventions Orthotics: provide a prescription for orthotics if indicated. If a patient has pain during activities of daily living which impedes functioning, orthotics such as splints, braces, gloves, sleeves, insoles and shoes, daily living aids such as a tin opener, an assistive device such as a cane or rollator, or ergonomic adaptation at home and workplace can be offered. Consider referral to the occupational therapist if the patient desires assistive support. A Psychosocial interventions: provide psychological or social interventions if indicated. Consider providing basic social and psychological management support or referral to a psychologist, social worker, self-management support programme, CBT or multidisciplinary treatment, if there are indications that social variables or psychological factors interfere with effective pain management and functional status. Discuss treatment options with the patient and the patient's primary care physician if depression and anxiety is present. A Sleep interventions: provide sleep interventions if indicated. Inquire about causes if sleep disturbance is reported and offer basic education about good sleep hygiene practices. Refer to a therapist or programme aimed at restoring sleep, or to a specialized sleep clinic if sleep remains severely disturbed. B Weight loss: advise weight loss if indicated. Explain to the patient that obesity can contribute to pain and disability. Discuss accessible weight management options with the patient or refer to a dietitian, psychologist, community lifestyle services or bariatric clinic/surgery for appropriate specialized weight management support. A 4. Patient education General counseling: Provide patient education, and ensure all patients have an easy access to: educational materials with general healthy lifestyle advice psychoeducation by the health professional online or face-to-face self-management interventions. A 5. Follow-up and surveillance Indications for specialist referral: consider multidisciplinary intervention if monotherapy has failed or if several concurrent treatments are indicated (e.g., to treat psychological distress in combination with a sedentary lifestyle). C Clinical findings Symptoms Past medical history Joint swelling Chronic disease Muscle cramps Inflammation https://web.pathway.md/diseases/rechi3n67ZUsw2urk 3/5 6/29/23, 3:51 AM Chronic arthritic pain Pathway Painful joints Integument exam Stiffness Weakness Skin tenderness Musculoskeletal exam Joint effusion Limping Studies 2002 Celecoxib vs. diclofenac in arthritis with recent ulcer bleeding In patients with arthritis and a recent history of ulcer bleeding, celecoxib was noninferior to diclofenac plus omeprazole with respect to the rate of probability of recurrent bleeding during the 6- month period. Chan FK et al. N Engl J Med. 2002 Dec 26. References 1. Alan D Bell, Caroline MacCallum, Shari Margolese et al. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions. Cannabis Cannabinoid Res. 2023 Mar 27. Open 2. Geenen R, Overman CL, Christensen R et al. EULAR recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018 Jun;77 6 797 807. Open 3. Busse JW, Craigie S, Juurlink DN et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189 18 E659 E666. Open 4. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. JAMA. 2016 Apr 19;315 15 1624 45. Open 5. Mary-Ann Fitzcharles and Yoram Shir. Management of Chronic Pain in the Rheumatic Diseases with Insights for the Clinician. Ther Adv Musculoskelet Dis. 2011 Aug; 3 4 179 190. Open 6. American Academy of Pediatrics. Choosing Wisely AAP recommendations. Choosing Wisely. 2019. Open 7. Nicola Veronese, Emanuele Cereda, Stefania Maggi et al. Osteoarthritis and mortality: A prospective cohort study and systematic review with meta-analysis. Semin Arthritis Rheum. 2016 Oct;46 2 160 167. Open 8. Azad Mohammed, Taraf Alshamarri, Temilayo Adeyeye et al. A comparison of risk factors for osteo- and rheumatoid arthritis using NHANES data. Prev Med Rep. 2020 Dec; 20 101242. Open 9. Mary-Ann Fitzcharles, Yoram Shir. Management of chronic pain in the rheumatic diseases with insights for the clinician. Ther Adv Musculoskelet Dis. 2011 Aug;3 4 179 90.2011 Aug;3 4 179 90. Open https://web.pathway.md/diseases/rechi3n67ZUsw2urk 4/5 6/29/23, 3:51 AM Chronic arthritic pain Pathway 10. Kurt Kroenke, Erin E Krebs, Matthew J Bair. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. Gen Hosp Psychiatry. May-Jun 2009;31 3 206 19. Open 11. Manfred Harth, Warren R Nielson. Pain and affective distress in arthritis: relationship to immunity and inflammation. Expert Rev Clin Immunol. 2019 May;15 5 541 552. Open 12. Ewa M Roos, Nigel K Arden. Strategies for the prevention of knee osteoarthritis. Nat Rev Rheumatol. 2016 Feb;12 2 92 101. Open 13. Shayan Senthelal, Jinpu Li, Amandeep Goyal et al. Arthritis. In: StatPearls Internet]. Treasure Island FL StatPearls Publishing; 2021 Jan. 2020 Aug 10. Open https://web.pathway.md/diseases/rechi3n67ZUsw2urk 5/5