A new role for opioids in the treatment of arthritis

Arthritis, rheumatic diseases, spinal and peripheral joint disorders share in common a legacy of chronic pain. At the turn of the millennium, nonsteroidal anti-inflammatories (NSAIDs) had replaced aspirin as the agents most commonly used to deal with rheumatic symptoms, including pain. Paracetamol (acetaminophen) was the most common alternative analgesic for minor pain. Opioids were most commonly used on an ad-lib basis, usually for 'breakthrough' pain. However, neurobiological research has confirmed the basis for 24-hour around-the-clock complete suppression of chronic nonmalignant pain. This avoids the 'wind up' that leads to intractable pain progression. Proper monitoring, in the absence of the end organ toxicity seen with NSAIDs, allows a change in direction to opioids for arthritis for more severe pain. This requires understanding the responsibilities of maintaining opioids, in properly selected patients, based upon host response and informed consent. Under such circumstances, evidence-based trials support the use of stronger opioids in recalcitrant chronic pain of arthritis. Thus, we endeavour to better fulfill our Oath of Hippocrates: 'to relieve pain and suffering'.