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“I refer patients to pain management when there is no underlying inflammatory condition, usual pharmacologic treatment has failed, and the patient may need chronic treatment with opioid analgesics or may need epidural spine injections, nerve blocks and other invasive procedures that are not in the rheumatology domain,” says Petros Efthimiou, MD, FACR, associate chief of rheumatology, New York Methodist Hospital, and associate professor of clinical medicine and rheumatology, Weill Medical College of Cornell University, New York.
Patients with chronic spine problems are also often referred to pain specialists, says rheumatologist David G. Borenstein, MD, clinical professor of medicine, The George Washington University Medical Center, and partner, Arthritis and Rheumatism Associates, Washington, D.C. Although a rheumatologist could possibly treat the problem, they would likely not have the same in-depth knowledge of pain treatments that a pain specialist has, he says.
“Non-rheumatologic back pain, such as degenerative disc disease and lumbar radiculopathy, is the bread and butter of pain medicine and also occurs in patients who have rheumatologic disease,” says anesthesiologist and chronic pain physician P. Joshua Smith, MD, Hickory, N.C.
Even after inflammation is controlled, some patients with autoimmune conditions need help to control pain due to joint alterations that can affect the spine and other parts of the body, says Orrin M. Troum, MD, Providence Saint John’s Health Center, Santa Monica, Calif. Dr. Troum will start with analgesic treatment, such as over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), but some patients don’t want to take those due to bad press about serious side effects, he says. He’ll work his way up the pain medication scale, but at a certain point, he feels more comfortable referring them to a pain management specialist.
Rheumatologists should consider the variety of specialists in their area who can manage pain in different ways, including anesthesiologists, physiatrists, rehabilitation medicine specialists and neurologists, in addition to pain management or pain medicine specialists, Dr. Troum says. Each specialist may have a slightly different treatment approach.
Another good reason to refer patients to pain specialists is that many offices have comprehensive care to tackle pain problems, including physical therapy, mental health professionals, and even individuals adept in areas like massage, functional rehabilitation, biofeedback or acupuncture, says Vernon Williams, MD, neurologist and founding director of the Kerlan-Jobe Center for Sports Neurology and Pain Medicine in Los Angeles. These practices can educate patients about non-pharmacologic therapies that will help get pain under control.
At the same time, pain specialists find it helpful to refer patients to rheumatologists if the pain seems to originate from a condition that seems less mechanical or osteoarthritic and more inflammatory, systemic or autoimmune in nature, says Stuart B. Kahn, MD, associate professor, rehabilitation medicine, Department of Orthopedics, Mount Sinai Medical School/School of Medicine, New York.
Rheumatologists should not ignore a patient’s pain complaints because they are out of the specialty’s wheelhouse, Dr. Borenstein says; instead, they should be proactive about referring to pain specialists.
The Challenges of Pain
Both rheumatologists and pain management specialists must help patients manage the challenges of chronic pain, which include impaired function at home and at work, as well as a greater risk for falls, says pain management specialist Fabian A. Ramos, MD, Ramos Center for Interventional and Functional Pain Medicine, with offices in Bradenton and Sarasota, Fla.
This lowered quality of life can commonly lead to depression, Dr. Smith says. “This can be very hard to treat, and inadequate treatment of depression frequently leads to inadequate treatment of pain,” he says.
Psychological issues are common in patients with pain problems, and this is often something that a comprehensive pain practice can help them better manage, Dr. Williams says. It can be difficult to let patients know that their pain may be reduced, but that it won’t always go away completely. “Patients with chronic pain need to know and understand that it’s often not about curing, but managing a pain problem,” Dr. Williams says.
Another treatment challenge is finding the right balance with certain medications, such as biologics, steroids or NSAIDs and combining that with the pain management specialists’ use of opiates and focal injection therapies, Dr. Kahn says.
Perhaps the biggest challenge with managing chronic pain patients is controlling opioid doses, Dr. Smith says. “Although many patients receive benefit from opioid therapy, these medications may be the biggest threat to our society’s overall well-being,” he says. “More young people die from opioid overdose than any other cause. Identifying the proper patients to use these medications, and discontinuing them when they are ineffective, is important,” he says. This often requires a multidisciplinary approach with communication among the pain physician, rheumatologist, addiction specialist, psychologist or psychiatrist, and a social worker, he added.
Dr. Smith prefers to try every modality possible, including more invasive procedures, before starting or escalating opioids, Dr. Smith believes.
“It’s become clear in this day and age of more abuse that only one physician should be prescribing opioids,” says Dr. Borenstein, former chair of the American College of Rheumatology’s Pain Management Task Force. Communication among physicians is crucial to keep tabs on what medications—opioid or otherwise—a patient is using, he says.
It’s also crucial to determine which patients truly would benefit from opioids, Dr. Borenstein says. For example, opioids would “just be a Band-Aid” for someone with swollen, inflammatory joints, he says.
In certain states, such as California, medical marijuana is becoming part of the treatment mix, albeit not an area where many rheumatologists are venturing, Dr. Troum says. Although he tells curious patients that he thinks medical marijuana can be useful for certain conditions, he also lets them know he does not prescribe it, and he refers them to a pain management specialist. “I could have a line out the door, but I’m busy enough. Maybe there are others [in rheumatology] with an interest in it,” he says.
Looking Toward Advances
There have been certain advances in pain medicine that rheumatologists should be aware of, specialists says. One of these is radiofrequency ablation, which is a treatment option for patients with chronic knee pain. “The procedure typically provides greater than 50% less pain for anywhere between six and 18 months,” Dr. Smith says. “Patients undergoing this procedure are able to enjoy an improved quality of life, because they are able to return to church, group activities, chores, etcetera,” Dr. Smith says. This same procedure can be used for the hip, sacroiliac joints and the spine.
“In trained hands and in selective patients, radiofrequency ablation can deliver reliable improvement of facet/joint spine pain,” Dr. Ramos says.
Another area advancing pain treatments is the use of stem cells to treat avascular necrosis of the hip and other areas, Dr. Ramos says.
Other advances that benefit rheumatologic patients and may be promising in the future include long-acting opiates, especially in the form of patches, and platelet-rich plasma treatment and other restorative injectables, which are all being used more frequently in the osteoarthritis population, but need to be studied more in the systemic inflammatory population, Dr. Kahn says.
Vanessa Caceres is a medical writer in Bradenton, Fla.
