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supply restriction on drug purchasing. The importance of drugs being available for those living with RA should not be underestimated, considering it affects 458,000 Australians (1.9 per cent of the population). Arthritis and musculoskeletal problems accounted for 13 per cent of the total burden of disease in 2015, and in 2016-17 there were 13,213 hospitalisations for RA, a rate of 54 per 100,000 population. In 2015-16, these conditions cost the Australian health system an estimated $12 billion, representing 9.6 per cent of total disease expenditure. Stigma of opioid use problematic Another problem of drug availability has been restrictions on access to opioids, given that arthritis in general, including RA and osteoarthritis, has been among the leading conditions for which opioids have been prescribed and used, Ms Marine says. The pain of RA is well known. In 2017- 2018, 68 per cent of surveyed people with RA experienced ‘moderate’ to ‘very severe’ pain in the four weeks before being interviewed. People with RA were 30 per cent more likely to have had severe or very severe bodily pain in the previous four weeks compared with those without the condition at 10 per cent. This makes it unsurprising that opioids are often prescribed for the condition, characterised as it is by pain and functional limitations occurring soon after the onset of the disease and worsening with time. Joint damage in the wrist is reported as the cause of most severe limitation, even in the early stages of RA. When it comes to osteoarthritis and backache, Ms Marine highlights that the evidence suggests opioids are of limited benefit, which itself is likely to be outweighed by the potential harms of the drug. “In fact, the Royal Australian College of General Practitioners’ guidelines on osteoarthritis don’t recommend opioids at all,” she said. “And yes, there’s been a lot of concern as to how patients have been taken off opioids, with some complaining that they’ve been stigmatised and made to feel like criminals for asking for pain relief. “However, opioids can be an important part of a pain management plan for many people, and it’s vital that people can still access these products if necessary.” Ms Marine says the crisis around opioids reverts “to some extent” to the failure of effective pain management services in Australia, including the management of the pain that comes with osteoarthritis. “This is because there’s still much defeatism around osteoarthritis, with the myth being that it’s an inevitable affliction as people get older and that there’s not much that can be done about it,” she said. “However, that’s not the case. Therefore, encouraging people to more proactively manage the condition is very important. To do this, we have a lot of information and available resources to help manage osteoarthritis on our website.” BONES AND JOINTS 51 with the normal conclusion being that ‘I’d better not use my joints so I can preserve them for longer’. “That’s exactly the wrong message, as physical activity is imperative for better health outcomes, with specific exercises strengthening joints and counteracting muscle wasting. This needs to be underscored by pharmacists, as many people are still not getting it.” She cites a number of reviews that have highlighted the benefits of physical activity for patients with osteoarthritis being equivalent to those from non- steroidal anti-inflammatories. “Well, that’s quite a significant pointer as to the importance of exercise as a management strategy – obviously, keeping in mind that many will use painkillers or anti-inflammatories to help relieve the pain so that they can exercise,” Ms Marine said. Regardless of how people get to it, Ms Marine emphasises that the first line of treatment for the management of osteoarthritis is physical activity, weight loss and a short trial of paracetamol. “And it doesn’t have to be huge weight loss: just a loss of five to 10 per cent of body weight can make for a significant improvement in symptoms,” she said. “In fact, every extra kilogram of weight a person carries can add an extra 4kg of pressure to their weight bearing joints. That means a substantial reduction in pressure if a person loses just 3kg to 5kg.” She says people with osteoarthritis usually have comorbidities, with high blood pressure being one of the most common. This, she says, can be combatted through general good health and physical fitness. “And general good health is intrinsically tied in with diet,” Ms Marine said. “There’s not a lot of evidence that shows that eating a particular food is good or bad for a patient, but certainly it appears that the Mediterranean diet can help those with arthritis and for general good health.” Pharmacist input on the ground Pharmacists and their assistants can do so much to encourage people with arthritis in terms of exercise and diet, Ms Marine says. “Just take osteoarthritis as one example – they can direct patients with the condition to Arthritis Australia’s website that contains a lot of TO PAGE 52 “There’s still much defeatism around osteoarthritis, with the myth being that it’s an inevitable affliction as people get older and that there’s not much that can be done about it. However, that’s not the case.” Proactive osteoarthritis management Ms Marine underscores that osteoarthritis is the most common type of arthritis, with more than two million people in Australia living with the condition. Many myths surround it, the main one being that it’s caused by wear and tear, she says. “As research into the condition advances, it’s clear that’s not the full story,” she said, “and certainly not the case. In fact, osteoarthritis is now known to be a breakdown in the repair processes of a joint. “The joints are always repairing themselves. Sometimes that process can get overwhelmed by an injury or perhaps by repeated overuse, and that’s what causes a problem. And it’s not just cartilage that’s affected, but the whole joint, including the bone, and all ligaments and muscles – so our understanding of osteoarthritis is improving. “And I guess that’s really important because one of the mainstays of managing osteoarthritis is actually exercise. That seems counterintuitive, RETAIL PHARMACY ASSISTANTS • OCT 2020