• Pain and Analgesic Use in Persons with Rheumatoid Arthritis
• How do Patients with RA Decide that a Treatment is Working?
• Ethnic Differences in Depression in Older Persons
• Perceptions Differences between Patients with RA and Their Life-Partner/Spouse

Pain and Analgesic Use in Persons with Rheumatoid Arthritis
Abstract 863 The Characteristics and Patterns of Analgesic Use in Rheumatoid Arthritis
Wolfe, F, Michaud K, Messer J.

Control of pain in persons with Rheumatoid Arthritis (RA) is a primary aim of therapy. For many, adequate pain relief occurs as inflammation is controlled; however, for some, analgesics also may be required to achieve adequate pain control. However, little is known about the prevalence and characteristics of analgesic use in persons with RA.

Methods: Data were derived from 10,002 persons enrolled in the National Data Bank (NDB) for Rheumatic Diseases. The NDB is a longitudinal study of RA in which patients with rheumatologist-diagnosed RA complete self-report questionnaires at 6-month intervals. All participants in this study had completed at least one biannual survey between January 1 1999 and June 30 2002.

Results:
Analgesic Use: When acetaminophen use was included in the analyses, 57.7% reported using no analgesics, 24.6% reported use of non-opiod analgesics and 17.7% used opiods. When analyses were restricted to prescription analgesics only, 73.6% reported using no analgesics, 8.7% reported using non-opiod analgesics and 17.7% used opiods. Results described below are restricted to the use of prescription analgesics.

Demographic Characteristics: Both opiod and non-opiod analgesic use were more common in women than men, although this association disappeared after controlling for disease activity. A non-linear association between age and analgesic use was observed, increasing to about age 50 and falling thereafter. Median income was lower in analgesic users as compared with non-users ($35,000 vs. $45,000, respectively). Analgesic users were also more likely to have had their disease longer and have more comorbidities. As compared to persons with a high school education, analgesic use was reduced among college graduates (OR 0.8; 95% CI 0.7, 0.9) and greater among those with 8-11 years of education (OR 1.3; 95% CI 1.1, 1.5).

Ethnicity: Analgesic use was similar among non-Hispanic whites, blacks, native Americans, Mexican Americans, Puerto Ricans and others, except for Asian Americans who used fewer analgesics.

Medical coverage and costs: As compared to individuals with private insurance, those receiving Medicare disability or Medicaid were twice as likely to use analgesics (OR 2.0; 95% CI 1.6, 2.7). Medicaid users were also more likely to use analgesics (OR 1.2; 95% CI 1.0, 1.3). Users of analgesics also reported increased medical costs; compared with non-analgesic users who incurred $3717 in total direct medical costs per 6 months, opiod users incurred $6246 in costs in the same period.

Disease activity, health status, and outcomes: As would be expected, a stepwise relationship was observed between analgesic use and type and more active RA, worse health status overall, and adverse outcomes. Pain intensity and number of painful joints was associated with analgesic use. A strong, linear association was observed between analgesic use and HAQ scores. Total joint replacement and receiving work or Social Security disability were also strongly linked with analgesic use. Similarly, analgesic use was strongly associated with prednisone use, followed by leflunomide and methotrexate.

Multivariate modeling: Pain, prednisone use, comorbidity and work disability were among the strongest predictors of analgesic use. However, psychosocial factors (i.e., depression, anxiety, and the MC score of the SF-36) were not significantly associated with analgesic use after controlling for important covariates (i.e., in the adjusted model). No conclusions about the use of analgesics and sex could be derived given the collinearity among key variables that are always increased in women. Education differences were no longer significant in the adjusted model.

Conclusion: In summary, analgesic use is relatively common with more than one quarter of RA patients, and nearly one fifth use prescribed opiods. Analgesic use is associated with functional and work disability and with disability medical insurance. Analgesic users have more active and more severe RA, as well as more RA treatments, especially prednisone. Persons who use analgesics also have higher costs and service utilization.

Editorial Comment: Given the high levels of pain reported by analgesic users and the primary role that pain plays in quality of life, more research is needed to determine if increased analgesic use would be of benefit for many persons living with RA.

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Patient perceptions of whether or not medications are safe and effective are intimately tied with decisions about whether to remain adherent to prescribed treatment regimens. However, little is known about how patients with RA arrive at decisions of whether or not treatment is working. Insights into how patients gauge the success of their treatments may facilitate RA management and medication adherence.

Methods: Hughes and colleagues conducted a series of focus groups in 5 cities in the UK. Participants were 39 patients (23 female; 16 male) with a mean age of 58 (range 29-81) and disease duration of 11 years (range 2-26). Persons of varying socioeconomic levels were included in the groups and asked, "How do you decide that a treatment is working?" Discussions were taped, transcribed and evaluated using standard methods of systematic qualitative analyses.

Results: Two major themes emerged from these discussions. As expected, the first determinant of whether patients viewed treatments as successful revolved around symptom reduction including:

• Decreased pain (e.g., fewer painful joints and shorter flairs)
• Increased function and mobility (e.g., being able to accomplish tasks such as brushing teeth and dressing more easily)
• Return to activities that had been difficult to do
• Increased energy

• Feeling less self-aware of their disease
• Living more easily
• Not feeling ill

Patients were also asked about what constituted a minimally clinically important (or noticeable) difference in their disease. Once again magnitude of improvement viewed as meaningful varied with disease duration and in response to the variability of RA flares. Larger changes were required for persons with long-term RA to view treatment as successful. As one long-term RA participant noted:

I think as the arthritis progresses you dont recognize the small changes so much and you dont think they are as important. You just get used to putting up with aches and pain.

Conclusion: In summary, these data suggest that two important markers for patients in evaluating the effectiveness of their RA treatments are pain reduction and quiescence of their disease (i.e., having periods of time where individuals can "forget" they have RA.)

Editorial Comment: At this time, it is unclear how these subjective perceptions correlate with traditional biomarkers of disease activity. Thus, clinicians may wish to evaluate their patients priorities for assessing whether treatments are viewed as being successful. Future studies which include measures that capture the patients perspective of successful treatment may offer insights into enhancing patient satisfaction and ultimately increasing therapeutic adherence.

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Among several chronic diseases, depression is associated with greater impairments in functional status, increased morbidity and mortality. Underrepresented minorities who have arthritis have worse functional status than comparable non-Hispanic white (NHW) populations. Since arthritis and depression are independent risk factors for functional limitation, the investigators hypothesized that among persons with arthritis, depression would be a significant risk factor for developing functional limitations. In addition, they hypothesized that minority persons with arthritis would have a higher prevalence of depression and that ethnic differences in functional status of persons with arthritis may be partially explained by these ethnic differences in the prevalence of depression.

Methods: National data sample from the 1996 Health and Retirement Survey (HRS), n=7916 persons aged 54-65 were used in these analyses. The HRS includes a one-time measure of major depressive episodes using the short form of the World Health Organization's (WHO) Composite International Diagnostic Interview (CIDI-SF). The HRS has 669 Hispanic, 1288 African American (non-Hispanic) and 5815 White (non-Hispanic) adults. Measured variables include self-reported arthritis, ethnic background, and function (activities of daily living [ADLs]). CIDI-SF scores diagnose clinical depression when three or more symptoms are present. Functional limitiation was measured by one or more ADL limitations.

Results: Arthritis was reported in 49% of whites, 54% of African Americans (AAs), and 46% of Hispanics (Hs). As compared with whites, elderly minority persons with arthritis were more likely to be depressed than (Hs: odds ratio [OR]=1.40, 95% confidence interval [CI]=[0.99, 1.96], AA: OR=1.24, CI=[0.96, 1.96]) For all ethnic groups, depressed individuals with arthritis report ADL limitations more frequently than individuals without depression (Hs: 63% vs. 33%, AA: 54% vs. 30%, and NHW: 39% vs. 16%). As compared to NHWs, elderly minority persons with arthritis who were depressed were more likely to be functionally limited versus NHWs (Hs: OR=2.44, CI=[1.91, 3.11], AA: OR=2.59, CI=[1.88, 2.70]).

Conclusion: Results of this study are indeed worrisome. Depression appears to be more prevalent among elderly persons who are members of minority groups; the odds of being depressed are 40% greater in Hispanics and 24% greater among African Americans. Across all ethnic and racial groups, depression was also an important marker for higher ADL limitations in persons with arthritis. Elderly minority persons with arthritis experience greater impairments in functional status when they are depressed.

Editiorial Comments: Depression is a serious and potentially life-threating illness in elderly persons. Rates of suicide attempts are highest in elderly persons. Effective treatment for depression in the elderly exist. Many older patients believe that depression is tied to character weakness and is not deserving of treatment, or that their depression will go away with time. All patients who are potentially at risk should be screened for depression. (For more information see the NIH Concensus Statement on Diagnosis and Treatment of Depression in Late Life. NIH Consensus Statement Online 1991 Nov 4-6: [cited 2002 Nov 15];9(3):1-27. You can learn more about depression and arthritis by reading the article on Chronic Pain, Depression and Anti-Depressant on our website.

Identifying Depression in Older Patients. The Geriatric Depression Scale (GDS) is an effective self-administered questionnaire that does not rely on somatic symptoms and can be used to screen for depression in older persons. It can be easily administered in office and clinical settings and takes 8-10 minutes to complete. A short-form version is also available.

The GDS is in the public domain and can be copied and used freely. Translations exist in Chinese, Danish, Dutch, French, French Canadian, German, Greek, Hebrew, Hindi, Hungarian, Icelandic, Italian, Japanese, Korean, Lithuanian, Portuguese, Rumanian, Russian, Spanish, Swedish, Thai, Turkish, Vietnamese, Yiddish. (Copies of other language versions are available at http://www.stanford.edu/~yesavage/GDS.html.)

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Many factors influence an RA patientsperception of their disease and related outcomes. Little is known about the congruence between patient and spouse/life-partner perceptions, or congruence of psychosocial dimensions between patient and their health care providers.

Methods: Le Parc and colleagues evaluated results from a cross-sectional mail survey of RA patients enrolled in the Association Franaise des Polyarthritiques database. In the database of 7702 persons, most (81%) were female, with an average age of 57 years, mean age of RA onset of 41.5 years and a Mean HAQ score of 1.1. Of the 7702 patients who completed questionnaires, 4002 (52%) provided the name of their partner and 2834 of these partners completed the telephone interview. In total 5564 (72%) of the patients provided the name of their physician and 1918 providers responded to the mail questionnaire. The questionnaires and phone interviews included items related to the physical psychological and social outcomes of RA. Agreement between patients and life-partner-spouse and patients and doctors were studied separately. Agreement was calculated using percentage agreement and kappa coefficients. (Since all kappas coefficients were very close to % agreement scores, only % agreement values are reported.)

Results:
Between patients and their life partner/spouse, there was substantial agreement between RA patients and their spouses regarding perceptions of pain intensity (89%) and associated characteristics such as variability (91%), unpredictability (79%), improvement with medication (77%), and negative impact on relationship (74%). Very good agreement for the evaluation of psychological outcomes was also observed between patients and partners ranging from 80-84% for negative feelings (e.g., too much effort to do simple things, worried about RA, frustrated, sad, unable to plan). Very good agreement was also observed between patients and partners on the effects of RA on their relationship with others (e.g., rejected or excluded, humiliated, dependant, etc.) Slightly less agreement was observed between patients and partners concerning positive aspects of RA ranging from 75% (expected less of self; accepting constraints) to 79% (more attentive to others).

Between patients and their physicians, there was almost perfect agreement on physical difficulties such as pain (99%) and fatigue (93%). Percent agreement between RA patients and their physicians on pain intensity and related characteristics was also high and closely paralleled those between patients and spouses, with estimates ranging from 93% for pain intensity to 76% for negative impact on relationship. Very good agreement was reported on joint deformities (82%) and sleeping problems (75%). In contrast, only poor to fair agreement was reported between patients and their physicians on several key psychosocial difficulties. For instance, 50% agreement was reported on relationship with family, 29% agreement or emotional or sexual difficulties, 29% agreement housing not adapted to handicap, 21% with medical insurance difficulties. A notable exception to the pattern of poor concordance on psychosocial variables was with anxiety and depression, where there was 79% agreement between patients and physicians.

Finally, patients and physicians expressed relatively high agreement regarding their perception of patient education. 87% agreement was reported on receiving information about prescribed medications and 73% agreement was reported about the side effects of medications. However, only 65% agreement was indicated for discussions about new treatments currently available, and only 53% agreement for discussions about risks and benefits of medications.

Conclusion:In summary, in this cross-sectional study of persons enrolled in a French RA database, there was very good overall agreement between patients and their partners on several psychosocial dimensions. Similarly, there was substantial agreement between physicians and their patients concerning physical difficulties related to RA such as fatigue, pain, and joint deformities. However, it is clear that many important aspects of patients psychological and social problems related to RA are not recognized by their doctors.

Editorial Comments: This lack of awareness has the potential to seriously undermine RA management. Effective partnerships between physicians and their patients result from a relationship where the clinicians recommendations reflect a clear understanding of the patients needs and the context in which he or she lives (e.g., home life, job, family relationships). In addition, if patients perceive that their physicians do not fully appreciate the impact of their disease on their lives, they may be less trusting of (and ultimately less adherent to) their prescribed therapeutic regimen. Patient-centered communication strategies that focus on understanding the patients experience of their disease and their care have been shown to enhance the clinicians understanding of the psychosocial impact of chronic illness across several diseases. Since psychosocial impact of RA play a major role in predicting disability and impaired quality of life, more attention to factors such as the impact of RA on psychological and social functioning in research and clinical settings may offer opportunities to improve treatment adherence and related health outcomes.

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