Acute pain and persistent peripheral, articular pain tend to respond to NSAIDs and classic opioids, whereas it appears that the central pain conditions may respond best to the central nervous system neuromodulating agents, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) and anticonvulsants.
The key is finding out the source of the patient’s pain and whether there is more than one condition to be addressed. In most cases, polypharmacy for pain control is the rule rather than the exception. Rheumatoid arthritis is a prime example. When we control disease activity and inflammation, sometimes the pain diminishes in a fashion that you would expect, but sometimes it doesn’t. In the latter case, searching for the etiology of the pain and considering an alternative agent is imperative.
Question: The prescription of long-term opioids for chronic, nonmalignant pain is increasingly common, but rheumatologists still grapple with fears of regulatory pressure and the possibility of abuse or diversion. What are some practical measures that can be easily implemented in the clinic to optimize the benefits of these drugs while minimizing the risks?
Dr. Rapoport: Before prescribing these drugs, take the time to explain how they work, the possible side effects, and details of the clinic protocol, such as the need for periodic urine testing. I also tell patients that there is only one health care professional who can write their pain medication prescription, and that no one will write a prescription at 5:00 pm on Fridays. It is also a good idea to have a written agreement – not a "contract," which implies legality – to be signed by the patient and the prescribing clinician that outlines the expectations. It can be time consuming, but it’s very important.
Question: Where, if anywhere, does medical marijuana fit into the mix?
Dr. Rapoport: Most of us – even those of us who were in college in the 1960s and 1970s – are not sure what to do with this yet. Many patients say it works. They are very convincing and very demanding, and they may be very right. But the legality of this is still murky, and the evidence is not totally clear. Most of what we have to go on is anecdotal, and in science that’s not enough. The majority of the patients using cannabis and seeking it do not have inflammatory arthritis. They are chronic pain patients who have exhausted most options. Even so, most of us are on the fence, neither rejecting nor embracing it until there are more data.
Question: Given the complexity of chronic pain, are rheumatologists the best specialists to manage it, or would patients be better served by referral to pain specialists?
Dr. Rapoport: This is a difficult question. I think rheumatologists are not necessarily the best clinicians for this aspect of care, for a number of reasons. First, most of us have an interest in the science associated with rheumatologic disease, and to the degree that pain is an outgrowth of this, it falls under our umbrella. Certain extra-articular pain states – such as neuropathic pain or pain associated with psychosocial factors related to disability – are outside of our domain and often would be best addressed by a pain specialist or primary care physician.
The problem is that these distinctions are not always clear. For example, a patient might present with lower back pain. It could be muscular, it could be discogenic, or it could be arthritis. I’m not sure a rheumatologist’s time, which is already at a premium, is best spent trying to figure this out and how to manage it, especially considering the prevalence of patients with lower back pain. We need to share the burden of these patients.
Question: Are there currently any guidelines or accepted algorithms or hierarchies for pain management in rheumatology, or are rheumatologists in practice flying solo?
Dr. Rapoport: I am unaware of any official guidelines for the treatment of pain in rheumatologic diseases in general or diseases such as rheumatoid arthritis in particular. A number of published articles suggest certain approaches, but beyond that, it’s up to clinicians to get an overall feel for their patients’ pain and its causes, and to proceed accordingly. This is where the art of being a doctor trumps most everything else.
Dr. Rapoport is medical director of phase III clinical research at the Truesdale Clinic Inc., in Fall River, Mass. Dr. Rapoport disclosed financial relationships with Abbott Laboratories, Amgen, Covidien, Forest Laboratories, Lilly, and Pfizer.