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Sock's Toxicity And Drugs In RA:
Chronic Pain
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Why do people have so much trouble getting treated for their chronic pain? It's simple we don't have a lab test,an x-ray,or any other accurate test that tells physicians how bad the pain is. They have to believe the patient. For people who suffer from rheumatic diseases such as RA, Fibromyalgia and a myriad of other condition,there is no simple way to prove positively,pain is real.
 
It's not only rare or terminal conditions that are painful and disabling. Even chronic low back pain is a problem.  Proper pain relief comes from an understanding of the duality of pain. One definition is an unplesant sensory and emotional experience associated with actual or potential tissue damage. In other words pain affects attitude,and attitude affects pain . And plesant thoughts can cut some of the pain experience dramatically.
 
Your emotions can have a profound effect on your perception of pain. How your physician,family,friends react also change the pain experience. If a physician says,"I believe you",it elicits a positive response. If he says,"You're a faker,"this elicits a negative response and it only makes the pain worse. Simply having a physician's support can be a powerful pain reliever. We all know that arthritic pain is not that simple to solve but attitude helps. Pain management is a specialized  branch of medicine and more specialists are needed.

One of the more intriguing findings is that the body produces its own pain control substances known as endorphins. These chemicals actually block pain signals much as medications do. The challenge is how to activate them. Pain operates on several levels at once,physical,mental,and emotional and therefore treatment strategies also tend to be mutifaced.
 
Inflammation begins when a joint is injured in some way, Perhaps you have had a accident,twisted your ankle or something complex,like an automobile crash. The injury may be a result of an unknown origin.
 
What ever the cause,once the joint is injured,the immune system responds with inflammation. Blood vessels widen,or dilate,and blood and other fluids seep into the affected area. This increased blood flow allow rescue worker cells to travel quickly to the site of the injury. As blood flows into the tissue surrounding  the injury,the area becomes inflamed. The result is pain,warmth and the injured area will swell up.
 
The nerve endings have special receptors known as nociceptors that receive sensory information (touch,heat,cold etc.) and in turn send a signal to the brain for interpretation.  The sensory information is interpreted as pain when the communication becomes physically unplesant and emotionally distressing, anything from mild discomfort to teeth-grinding agony.
 
Nociceptors vary according to the location in the body and the type of communication that is sent to the brain. Many are located near the skin. Some are extremely sensitive and communicate everything from warmth to pressure. Other nerves react only to dramatic sensations such as burns and cuts. Other oarts of the body,notably tendons and blood vessels,have different types of noticeptors.
 
Nociceptors also respond to certain chemicals produced by the immune system , In an arthritic joint,an enzyme known as cyclooxygenase (Cox) gives rise to other chemicals known as prostaglandins. Once nociceptors in the area detect prostaglandins,a pain signal is sent to the brain. Recent research is uncovering other chemicals such as substance P that also seems to send pain signals to the brain. Others will be found.
 
Pain may also function as more than just your body's alert system,some think it actually plays an important part in the healing process. According to this theory,once inflammation,the body's response to injury,reaches a critical point,you will feel pain. And the chemicals involved in creating that painful sensation somehow also subdue inflammation before it continues unabated causing more harm then good.
 
In most forms of arthritis,the pain does not subside,but continues long after its usefulness is over"Alert-Danger-Something is wrong",the knee is screaming through the pain. And even if you rest the joint,take a pain medication,the pain may still be waiting for you once the drugs wear off.

Pain is one of the hallmark symptoms of arthritis. It may come and go as the arthritis goes into a flare or subsides in remission,but for most people with RA, it may never entirely disappear. We understand a little of how pain works,but not all by any means.
 
We have words to describe its effects,yet they can never entirely convey to someone else what we are feeling. And almost any two people will experience different levels or intensities of pain from virtually identical causes. Because of the individuality of pain,we may never fully understand exactly what some one else is going through.
 
Rheumatoid arthritis pain can be so intense and constant it dominates the patient's every waking moment and many a sleepness night, It has a purpose,as we've seen. All those overexcited nerve cells are racing to inform the brain that harm is being done to one (or more) of your joints. In response,the brain signals muscles in the affected area or areas to contract as a form of protection. The resulting painful spasms prevents the patient from using the joint/joints normally,while the body makes its mostly futile attempts to effect repairs.
 
Persistent,severe pain from rheumatoid arthritis requires a combination of therapeutic stratigies;no one pill or management technique is enough to provide non-stop pain relief. Arthritis medications are only one part of an overall strategy that will help reduce and cope with pain,improve joint function and daily-living activities,and learn to deal with emotional stresses that arthritis can impose.
 
Maintaining that multi-part strategy successfully is only possible the patient understand as much as they can about the disease and pain,how it can be treated,and what the patient can play in its relief. Not every strategy will be equally effective for everyone;the patient need to discover what works for him/she,combining different approaches to prolong pain relief
 
There's a lot to learn,but the more one understands about every aspect of the treatment plan,the more likelyhood one is to benefit from it. Knowledge is power. Learn to weild that power as an active participant of one's own treatment team Learn as much as possible about all the strategies available--whether they're medications or non-medicinal techniques.
 
That understanding is an important step toward one becoming an arthritis self-manager. As repeated over and over again early aggressive treatment to control the disease as early as possible is imperlative. An uncontrolled disease is a hallmark of a painful associated disease,in our case,rheumatoid arthritis.
 
If the source of pain isn't tended to by a professional,there's a heavy price to pay. Studies show that muscle tissue starts wasting away after only three to six days of inactivity-followed by a corresponding loss of strength and flexibility, which of course leads to more pain. Unchecked,the underlying disease process continues its dogged work,which increases the pain further. As already mentioned,persistent,severe pain from arthritis requires a combination of different strategies,a blend of different approaches that will help one prolong pain relief.
 
Chronic pain is a significant public health problem and frustrating to everyone affected by it. Psychiatrists offer skills with pharmacological and psychological treatments now recognized as effective in the management of chronic pain. Recent advances in the treatment of chronic pain include the diagnosis and treatment of psychiatric co-morbidity,the application of psychiatric treatments to chronic pain,and the development of interdisciplinary efforts to provide comprehensive health care to a patient suffering chronic pain.
 
The psychiatrist can provide expertise in the examination of mental life and behaviour,an understanding of the individual person and the systems in which they interact, and facilitate the intergreation of the delivery of medical care with other health care professionals and medical specialists. However,not everyone with chronic pain require psychiatric evaluation,which should be reserved for patients who have severe symptoms,multiple treatment failures,or problematic behaviors such as substance abuse or noncompliance. The majority can be treated by the primary physician.
 
Today's health professionals have numerous therapies at their disposal. The first criteria is to get the disease under control because when RA is under control, this means less inflammation and less pain. Inflammation and pain is indictive of a condition that is not controlled. This is accomplished through (DMARDs)disease modifying drugs.
 
Supplemental therapies may include some of the following,in certain patients--They are not for everyone with arthritis pain:
 
Behavioral therapies: Because the mind-pain connection is so strong, psychological counseling is often a component of the pain management package In particular cognitive behavioral therapy can help patients develop healthier and more productive thought patterns,emotions,and actions. Relaxation methods including bio-feedback,decrease anxiety and a more pain-free existence.
 
Nerve Block: Injections of local anesthetics into specific nerve bundles can suppress pain. The relief is usually temporary,but even the momentary respite helps patients to get relief from acute pain.
 
Implantable Devices: When pain doesn't respond to therapy,certain devices can be implanted through the skin to provide relief. Patients report satisfaction with the implanted pump,which delivers a tiny dose of opiate or other pain-killer directly to the spinal cord where pain is processed.
 
Opiates: There is a huge stigma attached to the use of morphine and its derivatives on the part of both physicians and patients. This aversion is unfortunate because opiates are the only drugs that provide effective relief for many patients with extreme chronic pain. The therapy program must be managed by a experienced,professional pain-management specialist found in specialized  pain clinics.
 
Studies have repeatedly shown that when prescription opiates are used under close supervision,the risk of addiction in patients with chronic pain is quite low,around 1 per cent. Keeping the risk of addiction low requires careful evaluation of a patient before and after starting opiates. When used correctly, opiates should liberate,not stupefy,the patient. If the use of opiates increases a patient's mobility,mood and motivation to return to activities he/she had abandoned because of extreme pain,then the drugs should be continued.
 
 To avoid blood levels of opiates,patients often prefer time-release formulations,which decrease the chances of becoming,overly sedated or high. Opiates are not for everyone and the pain-management specialist will determine who can be helped. Abuse can occur in any therapy, but no patient should be subjected to high- extreme- pain levels that normally can not be controlled with conventional therapy. The majority of RA patients will not be candidates for opiates therapy.
 
Terms such as addiction,misuse,abuse and dependendence have been inconsistently to describe various behaviours,making interpretation of many research studies difficult. Nonetheless,studies investigating the risk of opiod abuse have been encouraging. In one study of 12,000 medical patients treated with opiods only 4 patients without a history of substance abuse developed dependence on the medication.
 
Dependence,in this article, was defined as a psychological rather than physical dependence involving a subjective sense of need for a specific, psychoactive substance,either for its positive effects or to avoid negative effects associated with its abstinence. This now is the approved definition of the American Society of Addiction Medicine for psychological dependence. Dependence used alone should be reserved for physiological dependence that leads to a sterotyped withdrawal syndrome upon discontinuation of the medication, particularily in the field of pain medicine.
 
Other studies of chronic opiod therapy found that all patients who developed problems with opiod use had a prior history of substance abuse Even when the diagnosis of dependence is suspected in patients taking opiods for chronic pain,maladaptive behaviors such as stealing or forging prescriptions rarely occur.
 
In a randomized,double-blind,placebo controlled trial,controlled-release oral opiods were more effective than tricyclic antidepressants in decreasing the pain of post-herpetic neuralgia. Other studies have documented the presence of opioid receptors in the peripheral tissues activated by inflammation. These findings suggest a role for opiods in the treatment of chronic inflammatory diseases such as rheumatoid arthritis and connective tissue disorders.
 
In a study of patients attending a clinic specializing in pain management,almost 90 % of patients were taking medications. Opiod analegesics were prescribed to 70 % while antidepressants and benzodiazepines were being taken by only 25 % and 18 % respectively. In this population,12 % met DSM-111-R criteria(Diagnostic and Statistical Manual-111) for substance abuse or dependence, however, the misuse and abuse of medications was not limited to just psychoactive substances.
 
In a review of 24 studies of drug and alcohol dependence in patients with chronic pain,only 7 studies used standard accepted criteria for dependence and addiction. The prevelence of dependence/addiction in these studies ranged from 3.2-18.9 %. In a study of chronic low back pain patients,34 % developed a substance disorder,and in all case,history of substance abuse prior to study entry were found to be at increased risk for recurrence during treatment for chronic pain.
 
The mechanism of relapse back to substance abuse in these patients is not well understood and probably involves mutiple factors;however,a cycle of pain followed by relief after taking medications is an example of operant reinforcement of their future use. Therefore,if the patient has unresolved pain and perceives a lack of commitment to treatment by the physician,they are at high risk for relapse into substance abuse. The best prevention of relapse comes from aggressive treatment of pain and close follow-up to monitor the signs of relapse into dependence/addiction.
 
Opioids offer an appropiate and safe treatment when administered by a pain-specialist for some but not all patients with non-malignant chronic pain. Experimental research and clinical experience are needed to define those patients most likely to receive specific benefits from treatment with opiods.
 
The benefits of treatment are now being documented in controlled trials. Potential risks,including drug abuse and intolerable side effects seem to be manageable in most cases. Anyone with chronic pain who has failed traditional treatments should be considered for a trial of chronic long acting opiods. If they have neuropathic pain,then opiods are now worth considering as a first line choice, especially if the patient cannot tolerate antidepressants or anticonvulsants.
 
A recommendation approach is to start low and go slow with a willingness to increase the dose until the person becomes toxic or delirious, complains of intolerable side effects,or gets complete relief from pain. Because patients with chronic pain suffer many consequences of their illness,any treatment with the potential to improve their symptoms should be prescribed and the results carefully studied.
 
Antidepressants: Before the introduction of such antidepressants as Prozac, Paxial and Zoloft and collectively called selective serotonin reuptake inhibitor (SSRIs), there were tricyclic antidepressants,or TCAs. TCAs increase the body's own inhibitory (anti-pain) mechanisms that modulate pain. For unknown reasons, having nothing to do with their depression-lifting properties,tricyclics can be highly effective against headaches and neuropathic pain. Meanwhile,the SSRIs can be useful against the depression that accompanies pain.
 
Anticonvulsants: The anticonvulsants were developed to treat seizures. However,in some abnormal pain conditions,the nerve fibers become hypersensitive and start producing what amounts to mini-seizures,sending waves of pain racing to the pain. Anticonvulsants especially the latest addition to this class gabapentin,slow down nerve impules. A pain-clinic should be consulted.
 
Papers:--Are cannabinoids an effective and safe treatment option in the management of pain? *Pain Management Centre,Undercroft,South Block, Queen's Medical Centre----Another test report and viewpoint:
 
Objective: To establish whether cannabis is an effective and safe treatment option in the management of pain
 
Design: Systematic review of randomized controlled trials
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Data sources: Electronic databases Medline,Embase,Oxford Pain Database:
Study selection: Trials of cannabis given by route of administration (experimental  intervention) with any analgesic or placebo (control intervention) in patients with acute,chronic non-malignant,or cancer pain. Outcomes examined  were pain intensity,pain relief scores,and adverse effects. Validity of trials was assessed independently with the Oxford scale.
 
Data extraction: Independent data extraction; discrepancies resolved by consensus.
 
Data synthesis: 20 randomized controlled trials were identified,11 of which were excluded. Of the 9 included trials (222 patients),5 trials related to cancer pain,2 to chronic non-malignant pain,and 2 to acute postoperative pain. No randomised controlled trials evaluated cannabis; all tested active substances were cannabinoids. Oral delta-9-tetrahydrocannabinol (THC) 5-20 mg,an oral synthetic nitrogen analogue of THC 1 mg,and intramuscular levonantradol 1.5-3 mg were about as effective as codeine 50-120 mg,and oral benzopyranoperidine  2-4 mg was less effective than codiene 60-120 mg and no better than placebo. Adverse effects,most psychotropic,were common.
 
Conclusion: Cannabinoids are no more effective than codeine in controlling pain and have depressant effects on the central nervous system that limit their use. Their widespread introduction into clinicl practise for pain management is therefore undesirable. In acute post operative pain they should not be used. Before cannabiods can be considered for treating spasticity and neuropathic pain,further valid randomized studies are needed.
 
What is known on this topic: Three quarters of British doctors surveyed in mid 90's wanted cannabis available on prescription Humans have cannabinoid receptors in the central and peripheral nervous system.  In animal testing cannabinoids are analgestic and reduce signs of neuropathic pain.
 
The use of opiods for the treatment of non-inflammatory musculoskeletal conditions is more confusing. A randomized double-blind,placebo-controlled crossover study of oral controlled crossover study of oral controlled release morphine was performed in patients with chronic regional,soft tissue  musculoskeletal pain conditions that were resistant to codiene,NSAIDs and anti-depressants.
 
Although patients experienced a decrease in pain pain,they did not experience significant psychological or functional improvement. In contrast,another randomized,placebo-controlled trial in patients with chronic non-maligant pain found that treatment controlled-release codeine reduced pain as well as pain-related disability.
 
In July 20,2001 the Narcotics Control Regulations was amended and the Marijuana Medical Access Regulations act came into force. People who have terminal illness, whose life-span is less than 12 months and for those who have symptoms associated with certain medical conditions such as M.S., Cancer, Spinal Cord injury,AIDs/HIV infection,Epilepsey seizures and severe forms of arthritis etc., were allowed to apply for permission to use marijuana for pain relief. The federal government have built a remote underground farm for the production of the plant. The federal Health Minister has released a press statement reversing the decision.--8/14/02. The minister said further studies are required,to ensure safety to Canadians.
 
Acetaminophen is more of a pure anagesic or pain medicine and is not a NSAID. The good thing about it is it can be mixed with NSAIDs. Mixing of two different NSAIDs is not recommended ,each of them will work less well. So, one can take say Vioxx or Celebrex  (either one but not together) with acetaminophen and get extra pain relief.
 
If certain patient's don't respond well to the standard NSAIDs,or Cox-2 inhibitors,and if acetaminophen was added to that,a combinations of acetaminophen with a mild narcotic analgesic such as codiene can be used. Acetaminophen recently,has been shown by recent tests,regarding high doses--i.e., 2 to 4 grams of it per day,can actually cause bleeding ulcers and stomach problems at high doses,which is a new finding. It was previously though that acetaminophen was perfectly safe on the stomach.
 
Many other arthritis drugs,such as MTX may also contribute to stomach problems in some patients. Patients should be aware of possible habituation with narcotics based medication when they take them. Narcotic can dull the mind and cause constipation,which may be a problem especially with older patients With all the new drugs available RA patients should not require pain-killing, dangerous drugs such as the outlawed pain-killer such as OxyContin or opiates-generally,for arthritis pain relief. Tylonol has mutiple-strength tablets,with the stronger ones having codien-base in them. Tylonol is harder on the stomach vs acetaminophen.Vicondin,Lortab,Larcet are common drugs that mix with acetaminophen,but the physician should be consulted.
 
The patient must realize,when they start a NSAID ,that there is a posssible risk of bleeding ulcers and stomach problems. The Cox-2 type have a small chance that it may raise the blood pressure or affect the kidney. Darvon is a mild analgesic,used as a additive agent. Patients may mix it with NSAIDs,even Cox-2 type. There are Darvon compounds and Darvon can be mixed with acetaminophen,either at the pharmacy,or at home by the patient. It's commonly used.
 
Ultran or tramadol,which is the generic name and now a newer version called Ultracet,approved last August,which is actually a combination of tramodol or Ultram,or Ultram plus acetaminophen,again has been effective--it is a non-narcotic analgesic with less constipation problems,less central nervous system problems in older patients who have trouble with their head and feeling-like thinking work quite well. It can mix with present DMARD and NSAIDs. Either Ultram,or the newer Ultracet is a helpful agent in pain management.
 
All these medications work,some of them better than others for different people in different situations. Always consult the physician before use. But like any medications side effects can occur. ---Dr. M. Schiff ----re:acetaminophen, analgesics.
 
Chinese proprietary medicine are very popular,and not only in the far east. A rheumatologist comments on a patient he has who uses them: " I did persuade her to bring me the package she uses,and printed on the side were the ingrediants of each tablet-a cortisone-like drug,two different NSAIDs (one restricted in Canada ) and a painkiller. Some of these ingrediants were in laughable low doses,others in doses higher than I would use. Similar preparations obtainable in Hong Kong and presumably contaminated have been linked to mercury,lead,cadium and arsenic poisoning."
 
"Periodically,I discover that a patient has obtained some arthritis remedy in Mexico,"he continues. "When these have been analyzed,they too invariably contained cortisone-like drugs an an NSAID-a combination for high risk"
 
Herbal remedies have been around for a long time. We need to know more about them. We need to isolate the chemicals unique to each herb and test them carefully,first in the laboratory and then in the clinic. We need regulation and control like drugs are treated in this country.
 
I was told that "thunder god vine" was dangerous and avoid it in a "high profile medical  publication".  The article cited bone density and other serious problems in some RA and Lupus patients who had been using them.
 
It  has now been tested in the lab and shown to keep immune cells from turning on the inflammation chain reaction (it may also have anti-cancer reactions). The leap from the lab is a big one, and manufacturing process is another. Can we be assured of non contamination,the right dose- purity ? Currently,the answer is no,in the majority of cases. In Germany they treat herbal products like we treat drugs,w.r.t. regulation.
 
 you have inflammatory arthritis or you're going through a periodic inflammatory phase of osteoarthritis,you're probably experiencing pain.
 
Since it usually takes al least two to four weeks before any NSAID begins to reduce inflammation-the source of the pain-patients will want something that will help in the interim. That's where straighforward analgesics-pain relieving medications,come in. For minimal to moderate pain,there are a number of over-the-counter formulations;for more severe pain,you may require prescription medication.
 
In the meantime,chart exactly how much pain you're experiencing. On a sheet of paper,draw a scale from 0 to 10,where 10 is the worst pain you've ever felt or can imagine.,then mark where you feel your present pain is. this allows you to measure whether you're getting better or worse by giving you a baseline reference point,and it provides your doctor with valuable information when prescribing your pain medication. If you're in a lot of pain,don't be bashful about asking your physician for strong medicine.
 
Once you've established your pain reference point,you can determine whether nonprescription medication will provide enough relief or whether you need stronger,prescription medication from your doctor. If,for example,your pain level is at 3 or below,try a nonprescription analgesic,or even a nonmedical approach (such as a ice bag). If the pain persists for more than seventyotwo hours or worsens,consult your doctor. But you be the judge;everybody experiences pain differently
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There are are many  nonprescription pain relievers for arthritis-acetaminophen (Tylenol,Panadol,Exdol etc.) ASA (Aspirin,Entrophe,Anacin etc.) and ibuprofen (Advil,Motrin etc.). They're more or less equally effective and well tolerated,provided you're not already taking prescription NSAID: ASA and ibuprofen are also anti-inflammatory medications and should't be taken in addition to a prescription NSAID,because of a slightly higher risk of side effects. If you are taking aan NSAID,acetaminophen is the preferred choice,because it can be safely combined with a prescrition NSAID for increased pain relief or for headaches and fever.
 
Acetaminophen is safe and effective,but it does have limits. You can take regular-strength tablets (325mg.) every four hours to a maximum of 12 in a 24-hour period,or extra-strength tablets (500 mg.) every six hours,to a maximum of 8 tablets in a 24 hour period. Be careful about exceeding those limits,a serious overdose can cause permanent liver damage If you find yourself repeatedly taking acetaminphen repeatedly than recommended,consult your doctor about a stronger pain medication.
 
One option is an acetaminophen formulation with codeine,which affects the central nervous system,reducing pain sensivity. It's most often available in combination with 325 mg. of acetaminophen and 32 mg of caffeine (the caffeine's to combat any drowsiness the codeine causes). Regardless of the brand,the amount of codiene ranges from 8 mg. per tablet in nonprescription formulations,such as Tylenol 1,Exdol-8,or Atasol-8,to 15 mg. of codiene in Tylenol 2,Tylenol 3 has 30 mg per tablet (which requires a prescription.
 
A common fear about pain relievers is addiction (codiene is a narcotic) even some doctors are wary about prescribing what some of their patients believe to be essential levels of pain-relieving medication. The important point is that pain medications only make pain more bearable-they don't treat the underlying cause. Make sure you treat the underlying cause. Make sure you also seek treatment for the real source of the pain. Certainly analgesics shouldn't be used to mask pain. If you feel no pain at all from an arthritic joint,you might bbe tempted to overuse it,causing irrepairable damage. Again,the best approach to controlling pain involves medication with complementary therapies and coping strategies (though if you're in extreme pain,your doctor can prescribe a limited course of a stronger pain reliever).
 
Clinical research shows that people who take a narcotic at a appropriate dose for their level of pain are at a very low risk of becoming addicted. Drug dependency is fuelled by a psychological cravings for the euphoric effects of certain narcotics,such as the opiates.
 
Although codeine is a narcotic,when its used solely for pain relief it rarely produces the "highs" that drug users seek-if anything,it tends to make life seem a little dull and colourless. Furthermore codiene is the weakest of all the narcotic agents and can be taken for relatively long periods of time without fear of addiction-particularily if you decrease your daily dose as your pain decreases over time.
 
Still concerned ? Then ask yourself these questions: If you're not in pain and you don't take the codiene,do you feel a need for it ? Do you require rapidly increasing does to control the same level of pain ? Do you get "high" when you take codiene ? Chances are, you answered "no" to all of these questions. If so,relax. You're not addicted to codiene.
 
The biggest problem with codiene is constipation (because it slows down the digestive tract). The best response is to increase your fibre and liquid intake You can try Metamucil,a nonabsorbed fibre,which may take a few days or a week to work but is an effective preventive (not a treatment) for most people. Psyllium,the active ingredient,is also available as Prodiem Plain,in chocolate mint,some people find it easier to tolerate. N.B. Don't take Metamucil WITH your medications,because they may pass right through your system with it,losing their effectiveness.
 
For the most part,stimulant laxatives aren't avisable,because the bowel can become "addicted" to them-i.e., it doesn't evacuate easily without them Glycerin suppositories are an alternative. Tyhey hydrate the bowel,helping to soften stools. Mineral oils aren't a good idea. They deplete the body of vitamin A,D,E,and K.
 
To some extent,everybody who has arthritis is going to suffer pain. How you meet the challenge of pain will in large part determine not only how well you cope with your illness but how much pain you experience
 
Different people react differently to pain and illness. Some become paralyzed. They sit at home,don't go out,become more and more aliented,depressed. Sit around with minimal physical activity. Other people say,'I can't let this pain get to me',and they go out and do all kinds of things,trying to prove to themselves that they can do it,and finally they crash. We should try to go the middle course,and utilize our good strategies and minimize our maladaptive strategies.
 
The first step is learning to understand and accept the pain. Easier said then done. But,only then can we begin to deal with it,establishing priorities and setting goals-taking resposibility about ourselves. There are skill we can learn that will help us to maximize our level of everyday functioning,but the first step is helping yourself. We have to be willing to take a close look at ourselves and our lifestyle and learn to accept our limitations.
 
In other words,you're going to have to learn to accept that there are certain things you can't do any longer. Activities that increase your pain will have to be modified or eliminated,and you may have to adopt practices that will maximize your ability to do the everyday things you have to do to maintain your altered self-image and self-respect.
 
Painkillers are a partial answer at best;they only mask the pain,and they can cause you harm by allowing you to do things that cause damage to arthritic joints,activities tht pain would"tell" you to avoid. No one expects someone with chronic pain to stop taking medications,but there are complements to drug therapy that help people take repossession of their lives.
 
The pain of arthritis has an insidious side effect. People suffering pain in a joint naturally want to avoid using it. When they do,the muscles and connective tissues surrounding the joint wither,contract and weaken. Disuse causes the joint to become progressively unstable and deformed,causing more pain.
 
This vicious cycle can end in serious incapacitation and can dim prospects for successful joint replacement surgery. In addition,incapacitation of a knee or hip joint can keep you getting the sort of exercise necessary for good health,
immunity,and vitality.
 
Exercise and various physical therapies have three purposes: to maintain the flexibility,stability,and strength of joint support structures;to promote overall health;and to prevent obesity or undue weight loss. Because effective physical therapy must be customized to individual circumstances a physiotherapist's help is preferable,or if that option is not available the Arthritis Society has books and videos to assist you.
 
Exercise can help maintain the normal range of motion in joints and enhance strength and endurance. Joint-stabilization exercises are of proven benefit. Physical therapy can improve physical functioning and limit pain by strengthening and stabilizing joints. Each patient's circumstances differ, therfore, help is a preference.
 
Acute,or "fast",pain feels specific,localized,and definable. Most of the pain in arthritis is chronic,or "slow",pain,which is controlled by the brain's limbic system. The limbic system is the center of emotions and instincts,which is why chronic pain has a emotional component. People respond to chronic pain in various ways,depending on their personalities. Some rreact with maladaptive behaviour,becoming sedentary,depressed,dependent on others,always seeking support and too reliant on pain medications. Arthritic patiens must be aware that chronic pain can have an effect on their emotions.
 
There are effective means of managing pain without overreliance on drugs. This does not imply any sort of moral or judgemental attitude toward analgesics. In cases of very serious,intractable pain,narcotics have unsurpassed analgesic effects and will not cause addiction when used with the guidance of a pain specialist. But such potent drugs are temporary methods of last resort.
 
Coginitive therapy is a concious effort to change one's attitude, It can be viewed as a sort of self-directed thought control,capable of changing old ways of thinking and feeling about things,including pain. Cognitive therapy is most effective when directed and supported by a trained therapist.
 
Autogenic training is a term that covers all the techniques designed to gain control over one's mental and nerve functions. Autogenic training includes such techniques as biofeedback,meditation,guided imagery,and progressive muscle relaxation.
 
These techniquew can produce measurable changes in skin temperature, electrical activity in muscles,and brain waves. One interesting biofeedback therapy helps patients gain control over tightness and pain through use of electromyograph machine,which provides readout of electrical activity in muscles.
 
Relaxation is the original,instinctive form of autogenic training. Among other effects,it produces desirable changes in brain waves and causes release of endorphins,which are endogenous (internally produced) chemicals with analgesic,mood-lifting effects.
 
There are many techniques for inducing relaxation,including meditation and biofeedback. It is important to learn to how to let go of negative thoughts and feelings about pain,which is not the same as adopting a fatalistic attitude. With assistance from medical personnel,trained in pain management,people can learn to control pain instead of  letting it control them. Family physicians are not trained in pain management,exercise or diet, but have a "working knowledge" about the topics to assist you if a specialist is not available.

Complementary Therapy:
 
EPA (eicosapentaenoic acid) is a polyunsaturated fat that is essential to human health. It belong to one of two main categoties of essential fatty acids,called omega-3 and omega-6 fatty acids. Certain fish fats are rich in EPA-an omega-3 essential fatty acid-and the body can also manufacture it from an omega-3 fatty acid called LNA (alpha-linolenic acid.
 
EPA is among the best researched and most widely promoted of all nutraceutical arthritis remedies. The bulk of the evidence indicates that it can provide modeate benefits for many people with rheumatoid arthritis.
 
How does EPA help ? Among other things,the body uses EPA to make prostaglandins that tend to dampen inflammation. the available evidence suggests that when arthritis patients increase the ratio of EPA or LNA in their diets-relative to meat,diary,and standard vegetable fats-painful inflammation gradually decline in intensity.
 
A few medical researchers have thought that vegetarian-type arthritis diets relieve symptoms of RA because because they automatically increase the ratio of polyunsaturated fats like EPA to saturated fats. One small contolled study, however,found no relationship between the changes in ratios of various ratios of fat in tissues and the degree of relief experienced by people eating vegetarian-style diets.
 
The supplemental sources of EPA-various types of fish and seed oils-range widely in cost ($12 to $120 per month) and usually take 3 months to produce benefits. You will want to know the pros and cons of each one,so I hope to take a closer look at the evidence in future articles. Be aware that every source of EPA takes three months or more to give noticeable therapeutic benefits.
 
Unrefined oils from flax are rich in an essentil omega-3 fatty acid called LNA (alpha-linolenic acid),which the body converts to EPA this conversion is not 100 % efficient,so these plant oils do not tise blood levels of EPA as much as encapsulated fish oils do,per  gram of oil ingested. The problem is that Americans' diets are very high in vegetable oils whose digestion uses up the same enzymes needed to convert LNA to EPA.
 
One study showed that when people taking flax  also cut back on their consumption of standard vegetable oils (corn,safflower,sunflower),their blood levels of EPA rose.
 
The unrefined,opaque-packaged canola oil sold in some health food stores is quite high in LNA,and it is much cheaper than flax. Standard,refined bramds of canola oil are processed for use in cooling are not reliable sources of intact LNA molecules that the body can convert to EPA.
 
Use unrefined canola oils for dressings amd oter uncooked dishes. Use olive oil or regular,refined canola oil for higher-temperture cooking An effective dose of EPA is 1.8 grams per day in capsule form or one tablespoon of cod-liver,flax oil,or hemp oil per day.(hemp is also known as marijuana,but the nutritional hemp oil sold in the U.S. is completely legal and nonpsychoactive-contains 2 % GLA)
 
Borage,black current,and evening primrose seeds are rich in an anti-inflammatory fat called GLA (gamma-linolenic acid). the clinical evidence in favor of GLA is less consistent than that favoring EPA,but several trials suggest that GLA-rich oils significantly alleviate joint tenderness and morning stiffness.
 
 If your present medication is working,it is better to stick to your present medication,but not all patients benefit from conventional medicine. GLA is relatively costly you will need to spend $100 per month. (1.4-2.8 grams daily dose)-which is 5 to 6 times the cost of the experimentally effective dose of flaxseed oil
 
The worry is manufacturing and distribution since these products are unregulated in most cases,purity,quantity and quality may present a problem.

Many patients have turned to alternate or complementary therapy for pain relief. Remember,that fish oil and GLA oils also have a potential side effect in that they're blood thinners.
 
So if one is taking say coumadin,or warfurin (blood-thinners) they need to be extra careful,when they start to take supplements that they are not adding another blood thinner that can cause problems especially,if minor surgery,or even in the case of dental care.
 
 Be careful with supplements and with herbs as one would with taking conventional drugs. Visit my other Ivillage site Rheumatoid Arthritis,re-Alternate therapy----herbal side effects,safe doses and possible serious drug interactions with other medicationsplus the added risks in even,minor surgery.
 
A question has been raised in the medical journal Lancet,whether Chondroitin sulphate in patients whose cartilage is being worn down either by RA or OA is really going to slow the disease process. More testing is to be done  through the NIH to answer the question "Does glucosomine help OA ?"
 
Even some doctors beleive they help in OA patients,but not RA. Some RA patients have "secondary" osteoarthritis through the ravages of RA. The NIH is also investigating the question whether Chondroitin sulphate may be a DMARD for OA. Many people are looking forward to the testing,and answer.
 
Experts in Complementary therapy suggest if one must use herbal remedy, avoid the ones from Asia because of possible contamination due to pollution and unregulation. Herbs are not regulated in most countries,including the US as well as supplements.
 
In Germany herbs are regulated by the government,just like drugs. The problem with supplements,aside of safety,we do not know what quantity ,or quality we are recieving because of unregulation,and that applies to the advertisement,as well as the reliability of the manufacturers themselves,not to mention drug interactions,again. Consider. that there are many varities of "arthritis" with different apllications in therapy,and results,some life threatening.
 
The NIH did a study on Vitamin C. Vitamin C is one of those Vitamins that,so- called "experts" recommended in mega-doses. More is not better,it can be harmful.
 
New information on a cellular messenger may lead to a powerful painkilling drug. MIT researchers recently reported online in the journal Psychopharmacology. Blocking a common signalling messenger between cells might shut down the chronic pain and inflammation that plagues millions,says author Lisa A. Teather,PHD-associate in the MIT Department of brain and Cognitive studies.
 
Teather studies platelet-activating factor (PAF),identified as a blood-clotting agent in the 1970's. It was later found to cause the buildup of prostaglandins,derivatives of fatty acids found in most body tissues. Excess prostanglandins are associated with chronic pain and inflammation.
 
PAF affects two kind of receptors. Teather believes that receptors within cells regulate prostaglandin production. Drugs such as ibuprofen and aspirin (NSAIDs) relieve pain by blocking the formation of prostaglandins. Researchers found that drugs interfere with PAF's block prostaglandin production and diminish pain and inflammation. Although these drugs are not now,used to treat inflammation or pain,one is in the herbal supplement ginko biloba (which has many undesireable,serious drug side effects and drug interactions).
 
 MIT has filed for patents on blocking PAF's as means for mediating inflammatory responses and alleviating pain. Animal studies have been performed. the researchers have no data on human-study,but they believe that blocking PAF might be effective in the treatment of certain forms of acute and chronic pain. "PAF controls many of the usual suspects in the inflammatory reaction",says Teather.
 
According to a study by researchers at the John Hopkins Universitity in Baltimore Maryland, a diet rich in soy appears to decrease inflammation induced pain in rats. The research,which was presented in March 15 at the Annual Metting of the American Pain Society in Baltimore,shows that rats with chronic pain resulting from inflammation-similar to pain cancer patients-were more tolerant to painful heat stimuli and had less swelling in the inflamed region, when fed a diet based on soy protein.
 
Rats on the soy protein had significantly less swelling in their paws and a higher tolerance to heat,than the casein-fed animals. Diet did not affect the rats reaction  to pressure stimuli. According to a university news release,these results are consistent with previous research showing consumption of a soy-containing diet suppressed the development of pain following nerve injury.
 
Further studies will determine if a soy diet can reduce the opiod doses necessary for treating chronic pain,and,therefore,side effects related to the medication.

A rheumatologist-investigor comments at a seminar on complementaty therapy involvement in rheumatoid arthritis,along with questions and reply: Moderator lecturer; "Let's look at the relationship between diet and rheumatoid arthritis a little bit more.
 
"It's most important to note that the avoidance of certain foods that claim to promote or exacerbate disease symptoms are just that. They're claims, and there's not adequate scientific evidence to support these claims.
 
And that's not to say that an individual might benefit from these dietary alterations, but to broaden that scope and apply it to the general arthritis population is really inappropriate. "Avoidance of certain foods that claim to promote or exacerbate disease symptoms are just that. They're claims."
 
"Some people claim certain  foods that are commonly indicted, so to speak, for causing these disease exacerbations, and dairy products comes high on the list. And just to give some scope as to how few individuals are actually affected by that, there's only one case report in the literature of a patient with juvenile rheumatoid arthritis that had exacerbation of disease symptoms related to ingestion of milk.
 
So, again, to date, there are few scientific rigorous studies that have been conducted to authenticate that certain foods cause or prevent arthritis."
 
"It's difficult because we are all exposed to many kinds of foods, especially when we eat prepared foods because we don't know exactly what's in them. Generally, if you find a specific food or food group that makes you worse, then eliminating that with discussion with your registered dietitian and physician would be appropriate."
 
"An elimination diet is something that can be implemented in order to pare out what might be causing these allergies or food sensitivities. An elimination diet -- and to underscore the fact that it's important to have a trained healthcare professional -- a physician, a dietitian -- to oversee this elimination diet."
 
"An elimination diet typically takes several months to do appropriately. It's conducted by eliminating or pulling out of the diet foods that are thought to cause food allergy or intolerance and then over the course of time once you've seen an outcome in terms of if it improves disease symptoms or whatever, then they would reintroduce that and see if the symptoms return.
 
So, it's done in a very systematic, scientific way in a fairly controlled manner, and so it's important if you want to implement this type of an elimination process to pare out what foods might be giving one problems, to do it in a very specific way and not just by happenstance in order to really be able to determine the outcome and be able to interpret those results."
 
Question:
There's been a lot of focus on fat in the American diet in the past decade. What are some of the current recommendations about the amount and types of fat that Americans should eat?
 
"Typically, the American diet is as much as 40 to 50 percent of total calories ingested come from fat sources."  "The American diet is notorious for its increased fat composition. Typically, the American diet is as much as 40 to 50 percent of total calories ingested come from fat sources.
 
The important thing to keep in mind is not only to reduce it down to 30 or 35 percent of total calories but to also look at the composition of the types of fat included in that 30 to 35 percent. The goal is to minimize saturated and even polyunsaturated fats and to also replace those polyunsaturated/saturated fats with mono-types of fats, and monounsaturated fat examples are like canola or olive oil, and to also to decrease the amount of cholesterol intake to a maximum of 300 milligrams a day."
 
"There have been some studies, and they're actually very well-done clinical trials where they've taken patients with rheumatoid arthritis and they've given them omega-3 fatty acid or placebo pills, and they've been able to show that the patients given the omega-3 fatty acids versus the placebo did much better.
 
They actually used the patients as their own controls because what they did is cross them over, meaning that after a certain number of months the patients on omega-3 fatty acid would stop and then get placebo, unknown to either the physician or rheumatologist or the patient, and the patients getting placebo would get omega-3 fatty acid. [Omega-3 fatty acid is] a fish oil that's rich in tuna fish and mackerel among other fishes [and] that seems to benefit patients with arthritis including rheumatoid arthritis."
 
The investigator-scientist continues: "The use of fish oil supplements appears to be most potentially useful in the early stages of disease, and it's unknown if it affects disease progression." 
 
"The use of fish oil supplements or these omega-3 fatty acids appears to be most potentially useful in the early stages of disease, and it's unknown if it affects disease progression. Some of the pitfalls in prescribing and utilizing fish oils is that there's no universal standardized dose. In most of the clinical trials the dosage has been approximately three grams per day.
 
And fish oil that's sold as a dietary supplement can be packaged in varying dosages, so you may have to take between 10 and 15 capsules a day. There are side effects that have been reported in the use of fish oil, and most commonly are gastrointestinal symptoms such as diarrhea or nausea or abdominal cramping, but usually not so great as to discontinue supplementation in most instances."
 
"Dietary supplements, and one being fish oils but [there are] many others; they're not federally regulated by the government like drugs, and therefore there's no insurance that the levels of active ingredient are what is stated on the ingredient label and the purity, to be free of contaminants.
 
In the case of fish oils, the fish in and of themselves, especially cold-water fish that are high in omega-3s, can have toxins like mercury or dioxins or CBs in the product, and so contamination is a potential concern."
 
"So, none of these supplements are guaranteed, and in a recent independent product review of 20 different fish oils that are [currently] available, six were found to be inadequate in their levels of omega-3s. And two of these stated, and I thought this was quite interesting, that on the label it stated that the potency of the product had been tested and verified.
 
And also take into account that there are really no long-term safety and efficacy trials that have been conducted on the use of fish oils."
 
Question:
Would that mean the consumer just say ? "Okay, I'm going to eat a variety of fish occasionally and in moderation and just make that part of a balanced diet as a way to get some of those oils and just hope for the best"?
 
The rheumatologist continues:
"I think it's partly appropriate to go ahead and include fish regularly in your diet. Two to three times a week would be desirable, but the point being with the possible variation in potency of the different supplements of fish oil, it's hard then to improve symptoms through the fish oil when there is this variance.
 
 So, it's a bit questionable and a bit of a dilemma when we talk about the use of any dietary supplements."
 
"The studies that I discussed were for signs and symptoms, again meaning swelling of the joints and pain and how patients felt. There were no long-term x-ray studies to show that this was truly slowing the x-ray damage and destructive changes of rheumatoid arthritis.
 
And the fellows in Washington at the FDA are trying to decide whether some of these over-the-counter preparations need to be better regulated so that when one does buy, say, omega-3 fatty acid and you think you're buying three grams of it, you know you're really getting three grams."
 
Question:
What about other kinds of fat, flax seed oil or even the seeds themselves? Any recommendations there?
 
"Well, just to give you a backdrop as to what's beneficial about these different types of plant oils, flaxseed being one, others being evening primrose, borage oil, even black currant seed oil may have a different type of essential fatty acid, gamolenic acid. And this is thought to be anti-inflammatory, and the studies are more minimal."
 
"There're fewer of these studies than clinical trials using fish oil, and dosaging is a bit more questionable as to what should be recommended as dosage. But there is scientific evidence that these plant oils may be beneficial in terms of an anti-inflammatory response."
 
Question:
How many cans of tuna fish do you have to eat to get three grams of omega-3 fatty acid?
 
Reply:
I think it's about five or six.
 
"Tuna's not your best bet. It is mackerel, and salmon. Those are the heavy hitters, and then tuna's a little lower on the list. So, it's like those cereal commercials. You've got to really stack it up and eat quite a bit to get just a minimal recommended dose of three grams.
 
Comment:
So, we might gain a bit of weight eating five cans of tuna fish a day.
 
Reply:
Unfortunately, especially if it's oil-based, which would be more beneficial omega-3 fatty acid-wise, but not in terms of calorie content.
 
Question:
What about vegetarian diets? They're typically lower in fat than the American diet in general. Would vegetarian diets be good for people with RA?
 
Answer:
Well, this is subject to personal preference and perhaps a bit controversial, but you are right on the money in terms of vegetarian diets are typically low in fat. Because? Because they eliminate animal products, and what is the greatest contributor to the diet of saturated or animal fats?
 
And that's meat protein from animals. And so the reduction of that may help to better balance the reduction of N6 types of saturated fatty acids.

The increased intake of plants and vegetables and maybe even fish and those types of things may increase not only the omega-3 fatty acid intake but also the antioxidant intake with increased fruits and vegetables and overall may have a beneficial effect for patients with arthritis. And that is more anecdotal.
 
There have been some small trials that have shown improvement, but it's unknown the sustained effect of vegetarian diets. And also to say that vegetarian diets are typically lower in calories because it's a lower amount of fat than the typical American diet, and so that again as we have been saying may be beneficial for patients with rheumatoid arthritis.
 
"Many patients with RA read about fad diets, either in written or electronic publications such as magazines or Internet, especially chat sites, and they wonder if these fad diets and nutritional supplements that are recommended will really work to improve their disease.
 
Question:
What kind of advice should we give to people with arthritis, especially rheumatoid arthritis, regarding these kinds of diets they read in magazines and on the Internet and the supplement information?
 
Reply:
"If it sounds too good to be true, it's probably not true." 
 
Comment:
This is a great question and one that I commonly encounter and often discuss with patients, and it's how to go about interpreting nutrition information from all the wide variety of sources that you've mentioned. So, let me just go through what are some of the hallmarks of nutritional fads or quackery, and the first one being if it sounds too good to be true, it's probably not true.
 
The second is that oftentimes this [information] infers a distrust of current methods of medical practice or it also infers suspicion of the regular food supply, and therefore you need alternatives, and then they list different types of food products.
 
"Another one is to take into account that many of the stories or anecdotes that are given are testimonials, and they don't have scientific evidence backing them. And also it's easy to get fake credentialing, to say that you're a nutritionist and hang your shingle in mail-order catalogs, so you can be fooled in terms of fake credentialing as to who may have the authority to lend sound nutritional information.
 
And the other item is that sometimes in these chat rooms or in the lay literature, they refer to studies that are unpublished, and they refer to these results, and they're cited, but they can't be critically examined because they haven't be published. So, that makes for difficulties in terms of being able to tell, and these are all items that should make you suspicious of nutritional information.
 
"If I go a step further, how do you go about identifying valid nutrition information; results obtained by conducting properly designed scientific experiments are those that are typically valid. Also that again, as I said, to recognize anecdotal or testimonial evidence.
 
We also realize and recognize that scientists who conduct animal research but don't apply their findings to humans should be a bit suspect in terms of valid results. And those that limit the sample of research participants to very few, which we've mentioned in many of these different types of dietary-related trials, it makes it very difficult to generalize those results to the entire population of patients with arthritis."
 
Question:
I'm wondering if you've noticed that people come to you with questions about diet, and especially those food fad things, like all of a sudden everybody asking about the high protein diet or something else that's popular?
 
Reply:
"Most people don't want arthritis. They specifically don't want rheumatoid arthritis, and they would love to find the food or the easy-to-fix cause that would make them all better."  "That's very common. I think most people don't want arthritis. They specifically don't want rheumatoid arthritis, and they would love to find the food or the easy-to-fix cause that would make them all better
 
. So, people do come to my practice at the Denver Arthritis Clinic commonly with in hand either a printout from the Internet or something in a magazine."
"And I would really reiterate what was said before, and that is that we need as physicians and rheumatologists to then say, "Let's look at the data or the information behind this and see if it's in what's called a peer-review journal," meaning that some people who really know the field such as a nutritionist,who would have looked at this information and said, "Yes, this is really worth publishing and looking at."
 
So, again, it is a common experience.
 
Question:
We've been talking about the benefits of diet, but now what would you recommend to a patient to actually achieve a healthy diet?
 
Reply:
"Try to increase your increase of fruits and vegetables to a minimum of five servings a day." 
 
"The first is to try to increase your increase of fruits and vegetables to a minimum of five servings a day. Another handy nutritional recommendation is to eat in moderation, which is not very well defined, but to try to limit your calorie intake so that it's not in excess of your expenditure, so you have to think about patients with rheumatoid arthritis who have some joint difficulties that might make physical activity reduced or difficult to take on, and therefore you have to adjust calorie intake with energy expenditure.
 
And those are really the two big ones that I would promote in terms of achieving a sound nutritional diet and also adequate weight maintenance."

Link National Pain Association