Pain Management Approaches in Patients with SLE

Dr Henry H Shen - a reprint from Lupus Foundation of America, Premiere Issue, fall 2003

Anyone who has been involved in the care of a patient who has systemic lupus erythematosus ( SLE ) knows that these patients often have complex and multiple problems.
Some of the difficulties which lupus patients face are accompanied by pain. An example of a controllable problem would be carpal tunnel syndrome due to active synovitis of the wrist. The patient who develops the rare complication of transverse myelitis or who develops avascular necrosis may end up with chronic pain.
The most common pain complaints voiced by SLE patients are due to active inflammation. Arthritis / arthralgias, pleuritic chest pain and pericardial pain are best treated with anti-inflammatory medications, antimalarials or, in severe cases, corticosteroids.
Patients with SLE also experience tissue damage, such as avascular necrosis, vasculitis or neuropathic dysfunction. The following addresses various treatment options for the pain associated with such damage.

Pharmacologic pain treatments

Opioids.

Morphine and other narcotics have been effective in treating many types of pain, In individuals with chronic pain, it is often better to place the patient on a long-acting narcotic preparation. This ensures that the patient always has an adequate blood level of an opioid. Patients who take short-acting opioids often have to wait for them to be absorbed before they experience relief, which may result in a cycle in which doses of pain medication must "catch up" to pain. It is important to emphasise that the use of narcotic medications does not automatically lead to addiction. In fact, addition rarely occurs in people who do not have a prior history of substance abuse.
Opioid medications have common side effects, which include, but are not limited to, constipation, nausea, vomiting, sedation, central nervous system impairment, and respiratory depression. There are four long-acting narcotics available to use in the United States at this time: time-release forms of morphine, oxycodone and fentanyl, as well as methadone, which has a half-life of more than 24 hours.

Antidepressants.

Antidepressants drugs have been shown to be effective in the treatment of neuropathic pain. The tricyclic antidepressants ( amitriptyline, nortriptyline, desipramine ) are associated with multiple dose-related side effects, which include dry mouth, drowsiness, dizziness, constipation, urinary retention, blurred vision, confusion, tachycardia and weight gain.
Selective serotonin reuptake inhibitors, or SSRIs ( fluoxetine, paroxetine, citalopram ), are reported to be effective in treating neuropathic pain, but clinical experience to date has been disappointing.
Venlafaxine is a newer antidepressant that has fewer side effects than the tricyclic antidepressants, and anecdotal experience so far suggests that it will be an effective medication for pain.

Anticonvulsants.

Anticonvulsant drugs have been used for years in the treatment of pain. Gabapentin is approved for the treatment of postherpetic neuralgia; however it has been successfully used in the treatment of many other pain states. Gabapentin may cause drowsiness or sometimes dizziness, but it is not associated with serious side effects.
Lamotrigine and topiramate are newer anti-epileptic drugs which appear to relieve pain in some individuals. <
Carbamazepine or its analog oxcarbazepine, as well as phenytoin are not used as often, due to inconsistent pain relief and some extremely rare but potentially serious side effects.

Antiarrhythmics and anti-spasmodics.

Another drug used for pain relief is mexiletine, an antiarrhythmic drug that is an oral analog of lidocaine. Its numerous side effects make it difficult to tolerate. Lidocaine is available in a transdermal patch, and some patients report marked relief.
Capsaicin is an extract from chili peppers. When first used, it may cause a temporary burning sensation, which abates if the product is used consistently.
The anti-spasm drug tizanidine has been reported to have analgesic properties separate from its muscle-relaxant effect. Its main side effect is sedation.

Chronic musculoskeletal pain in lupus
Many SLE patients seek a physician's assistance with joint pain, but the arthritis seen in SLE rarely causes permanent deformities. More common are fibro myalgic complaints. A small minority of individuals may have an inflammatory myositis, while others may develop avascular necrosis. Some of these individuals may benefit from surgery.
Those who have chronic musculoskeletal pain often develop a variety of other problems that tend to magnify their pain and impair their ability to function. These problems include the development of depression, deconditioning (due to limited physical activity), poor body mechanics, and maladaptive behavioural patterns. Such patients can be considered candidates for a multidisciplinary pain management approach.

Physical occupational and vacational therapy
Physical therapy and a regular exercise program are key components in the rehabilitation of patients with chronic musculoskeletal pain. Normal joint function requires adequate muscle strength, endurance and range of motion. A gradual and gentle exercise program often works well in this group. A variety of approaches, such as modified yoga-based exercise or tai chi have been used with success.
Most lupus patients can regularly perform stretching exercises; however they may need to temporarily reduce or modify a more active program during a flare. A physical therapist with experience helping patients with inflammatory forms of arthritis can be of great help in determining the proper level of exercise.
Registered occupational therapists ( OTRs ) assist people with physical problems, some of which are associated with pain. An occupational therapist can recommend assistive devices and practical modifications in the home or workplace. They also can teach proper body mechanics, energy conservation measures, joint conservation measures, and other approaches to maximise function despite a person's pain and anatomical abnormalities.
Vocational rehabilitation counsellors offer job training for people who are unable to continue working at their current jobs because of illness or illness-related conditions, such as a sun-sensitive farmer or an administrative assistant who can no longer type due to hand deformities. In some cases, advisors will recommend that patients seek further education. Vocational rehabilitation services are available through both private and public agencies.

Displacing the pain
Patients who add one or more of the following psychological components to their pain management plan often can lessen the impact of the physical discomforts :

• Distraction can decrease a person's awareness of pain by directing the attention to something other than the discomfort; for example, listening to music, watching TV or movies, and engaging in hobbies, group activities or volunteer activities.
• Relaxation techniques are widely accepted as effective self-improvement techniques. Relaxation not only reduces painful muscle spasms but also helps patients to deal with pain and other aspects of living with lupus. Techniques include meditation, self-hypnosis and other stress-reduction methods. These skills can be acquired via self­help books, tapes, or with the help of an instructor.
• Imagery involves the person imagining his or her pain and discomfort, and using the power of thought to "destroy" the problem. Done for 15 minutes two or three times a day while listening to calming music, imagery can become an effective way to take away the pain for a period of time.
• Rest is vital to a body that is trying to heal. Rest allows tissues and joints to get the time they need to repair themselves. Poor sleep also contributes to fatigue and a sense of not feeling well. According to New York rheumatologist and researcher Dr. Robert G Lahita, people with lupus should get at least seven hours of sleep per night. When necessary, sleep medications can be prescribed.
• Heat can be applied locally when a joint or muscle is painful. Daniel J Wallace, MD, who isa practicing rheumatologist in Beverly Hills, CA, says that moist heat, such as a hot tub, Jacuzzi, shower or bath, is superior to dry heat. It is important to note that care must be taken when using this method if the individual has circulatory or sensory deficits.
• Biofeedback teaches a person to alter certain body functions, such as blood pressure, with the use of electronic monitoring. Psychologist Robert H Phillips, PhD, founder of the Centre for Coping in Long Island, NY, reports that biofeedback has been used to reduce pain in certain symptoms of lupus, such as Raynaud's phenomenon, but has not been well studied for use in relieving other types of pain.
• Acupuncture has a long history as a treatment for pain in Eastern medicine and has gained status for relieving pain in the West. However, studies in lupus have not been done.
• Chiropractic adjustments that relieve muscle spasms and backache might help make a person with lupus more comfortable. Chiropractic approaches should be considered only in conjunction with proper medical treatment and probably provide symptomatic relief at best.

Depression in people with lupus
When people are depressed, they spend more time thinking about how they are feeling and their awareness of their pain can be heightened. Dr Wallace points out that depression is the most common coping problem in people with lupus.
Psychotherapy and counselling can help people with chronic illness like lupus verbalise and work through feelings of denial, anger, fear or frustration about impairments or limitations brought on by the illness. Counselling can also help people learn methods of coping with their illness and gain a sense of control in their new life with lupus. Some patients join support groups and find the perspective that only a fellow patient can provide to be invaluable in the struggle to cope with and manage their illness.
Medication, stress-reduction techniques, treatment for depression, increased physical activity, improved body mechanics, positive behavioural patterns - the multiple therapeutic options outlined in this brief overview should serve to emphasize the need for a coordinated approach in successfully treating the lupus patient with chronic pain.
 

Disclaimer :
The Lupus Group of W.A. (Inc.) does not recommend or endorse any products, drugs, treatments, procedures, medical or health professional in this article. We suggest you discuss this information with your doctor or specialist.