Rheumatologist Kelly Weselman, MD, FACR, recently had a patient who was struggling with pain associated with shingles. The woman was already on an opioid, but it wasn’t helping. She adamantly asked for another opioid—a stronger opioid.
“I explained to her that opioids weren’t appropriate,” says Dr. Weselman, who is also chair of the ACR’s Committee on Communications & Marketing and a frequent speaker on opioid issues. “She needed a neuropathic type of pain medicine. So, I gave her something completely different, and she was OK with that because I took the time to explain why I was giving her [the medication] I was giving her.”
Amid an ongoing, national opioid crisis, rheumatologists in the U.S. find themselves struggling with how best to prescribe opioids for their patients—and how best to use alternative treatments and narcotics.
The answers aren’t easy, but to Dr. Weselman, a practicing rheumatologist for WellStar Health System in Smyrna, Ga., the first alternative to simply prescribing opioids is changing the mindset that opioids are always the best answer.
“It is important, first of all, to identify what the likely source of the pain is,” she says. “There is neuropathic pain, bone pain, muscle pain, inflammatory pain. There’s mechanical pain; there’s psychogenic pain. Trying to get at the root of the pain is important in terms of deciding the most appropriate way to treat it.”
The hunt for the underlying cause of pain can take some time, says rheumatologist Jonathan Greer, MD, president of Arthritis and Rheumatology Associates of Palm Beach, Fla. Example: A patient with an elevated calcium level may be in pain and asking for treatment. But if the patient has parathyroid gland hyperactivity, “[if] you remove the offending parathyroid gland, the calcium levels go down and the chronic pain they’re experiencing goes away,” he says.
“A patient may have underlying malignancy that we’re not aware of,” Dr. Greer adds. “And we have to maintain a proper index of suspicion where this is concerned, [because] chemotherapy may be a more appropriate treatment. Alternatively, the patient may have chronic hepatitis C infection, which can lead to chronic musculoskeletal pain. As we now have great antiviral therapies, which are potentially curative, you may be able to relieve their pain there, as well.”
Alternatives
Dr. Greer says that treating arthritis, particularly osteoarthritis (OA), has its own challenges.
“OA has no treatments that modify the course of the disease [and reverse the damage],” he says. “All the treatments out there for OA are there to help symptoms and function. … So for OA, we’ll try anti-inflammatory medications. We’ll try injections of corticosteroids. We’ll try other non-medical, alternative therapies that can be very effective. Non-medical therapies include things, [such as] physical therapy, meditation, yoga, tai chi, which can be very, very helpful in relieving many types of chronic pain.”
Dr. Greer also recommends certain antidepressant medications, which “are used commonly for off-label chronic pain indications. Duloxetine, in particular, has indications approved by the FDA for chronic osteoarthritis pain and chronic fibromyalgia pain, along with the indication for depression and anxiety,” he notes.
Dr. Weselman says that, generally speaking acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are a good start. For neuropathic pain, other types of medicine may be more appropriate, such as gabapentin, Lyrica and amitriptyline.
“Inflammatory pain is going to respond better to anti-inflammatories and acetaminophen,” she adds. “Muscular pain is going to respond better to, perhaps, muscle relaxers. There’s a whole host of medications [that are not opioids] we can use to treat various types of pain. I think it’s important that we have that discussion with the patient, because I think patients think of pain medicine as being opioids, and if they don’t get an opioid, their pain isn’t being addressed.”
Dr. Weselman says the use of herbal supplements is a relatively unclear area, because not enough clinical evidence exists to support their efficacy. Dr. Greer says it’s a similar conundrum with medical marijuana, which may help alleviate pain in some patients, but needs additional study.
Challenges
Both rheumatologists agree there are times when the use of opioids is justified and necessary. But those situations are the doctor’s call—not the patient’s. One part of successfully using alternatives to opioids is ensuring patients feel their pain is being addressed.
In recent years, that’s been a trickier situation, because patients who use medical websites often feel they have a practical degree in pain management before a rheumatologist has spoken with them.
Dr. Google is always a problem, Dr. Greer notes. “Often, we have to do some myth debunking and spend a great deal of effort counseling the patient,” he says. “When it comes to chronic pain management, rheumatologists have an obligation to discuss with the patient that whatever treatment we give is designed to try to reduce their pain to a manageable level—but not eliminate pain entirely. I don’t think it’s realistic or appropriate to say we can get rid of all of your pain if it’s chronic.”
Dr. Greer, whose goal is to have patients report their pain level as 5 or lower on a 10-point scale, says it can be difficult when a patient he does not believe opioids are appropriate or has already been prescribed opioids by other rheumatologists—particularly patients diagnosed with fibromyalgia.
“I try to avoid using any opioids in a new fibromyalgia patient. Unfortunately, a whole cadre of patients with [fibromyalgia] who are already on opioids, come into my practice,” he says. “I insist they see pain management for those treatments, because they’re very, very difficult to manage, and it is a challenge trying to get [patients] off opioids at that stage.”
A Pain Agreement
When a patient takes opioids for an extended period of time, Dr. Greer uses a patient pain agreement—he’s careful to never call it a contract. The agreement “lists and defines what the expectations [of opioid use] are.” The agreement states only one doctor prescribes opioids for the patient and the patient must come to regular office visits. They must submit to pill counts and random drug screenings and agree not to sell or otherwise divert the medication.
In 30 years of using the agreement, Dr. Greer says patients have refused to sign this agreement on only two occasions.
“I tell them, ‘the agreement is there to protect you, the patient, [to ensure] you’re taking [opioids] appropriately. And if anyone questions your use of opioids, you have this agreement, signed, that says you’re going to take it the way you should be,’” he says. “It’s really to protect you, as well as the physician, to make sure we’re doing things for the right reasons.”
Dr. Weselman says deciding what alternatives to use—when alternatives are applicable—is a process that takes diligence. Both she and Dr. Greer note that sometimes consulting with a pain-management specialist is helpful.
“It requires really understanding what the underlying process is, what the diagnosis is, what’s driving the pain,” she says. “It’s getting to know the patient and understanding whether they have coexistent anxiety, insomnia, depression—what’s going on in their life. Because all of that affects patients’ pain levels and their ability to cope with it. All of that takes a lot of time.”
Richard Quinn is a freelance writer in New Jersey.
