The Pain of Rheumatology

Pain is the elephant in the middle of every rheumatology clinic, and it’s taking up a disproportionate amount of space. It is ever present and ever stubborn, and although everybody wants it gone, nobody is really certain about how to get rid of it. Thus, by default if not design, pain management is becoming an area of increasing research and clinical effort in rheumatology, according to Dr. Ronald Rapoport, director of the osteoporosis and research Center at Charlton Memorial Hospital in Fall River, Mass.

"Pain is the most common complaint of patients presenting to the rheumatology clinic, and it plays a central role in the clinical spectrum of rheumatologic conditions," Dr. Rapoport said. The challenge that time-crunched clinicians face, however, is that musculoskeletal pain across the range of rheumatologic conditions is typically not a consequence of the disease process alone, but rather is the result of a range of biologic, psychological, and social factors that, taken together, preclude easy assessment and treatment. If the pain of rheumatoid arthritis, for example, were simply secondary to inflammation, "then our jobs might be much easier: By treating the underlying manifestations of the disease, we would have a positive impact on the pain," he said. "The reality is that there’s much more to it than that."

In this month’s column, Dr. Rapoport discusses the challenge of rheumatologic pain and the integration of pain management into clinical practice.

Question: Why is rheumatologic pain so difficult to manage?

Dr. Rapoport: The reason is that we’re not just dealing with pain by itself. Halting disease progression is our main concern when we treat the majority of rheumatologic illnesses. If we are not able to control a patient’s pain, the odds of that patient’s returning are diminished, as is our plan of decreasing disease activity. The things we can do to help control pain may have no impact upon progression of the disease. We commonly use steroids as a bridge while we wait for disease-modifying antirheumatic drugs and biologics to have their effect. However, although these agents address pain quickly and effectively, they don’t really have a major impact on disease progression. Patients report feeling better on steroids, but the treatment does not slow or stop radiographic disease progression, which correlates better with future patient disability than does pain. Easing pain and stopping joint destruction often may not be achieved by the same therapeutic pathway.

Another obvious challenge is that ours is an aging population, and a patient’s complaint of pain may be associated with a number of conditions, rather than just the primary rheumatologic condition. A patient with rheumatoid arthritis may also have osteoarthritis or fibromyalgia, for example, and at times the pain associated with each condition may not be easily separable, so there are a lot of variables in the management equation.

Question: Are rheumatologists well equipped to deal with the complexity of chronic pain?

Dr. Rapoport: We are equipped to deal very specifically with pain that is aligned to the disease process, but in our training, there is no separate section on treating pain that is associated with the myriad other influences I mentioned. To treat pain optimally, rheumatologists have to learn about the pain pathways; how and where the various pain medications work; if, when, and in whom to start opioid therapy; whether to prescribe sustained-release or rapid-onset opioids; when and how to combine pharmacologic agents; and when and how to taper pain meds in the presence of improvements in disease progression.

On top of all of this, we must not be naive about the potential for abuse or misuse of pain medications. We need to determine which patients really need these pain meds and which might be abusing or diverting them. Frankly, even the most highly skilled rheumatologists may not always know the difference. This can be a major obstacle to pain management, because even though we all know that there are patients who do not have adequate pain control, there are also many patients who are abusing the potent pain medications. Differentiating between them is especially challenging among patients with significant arthritis.

Question: In recent years, novel pharmacologic agents have emerged that target various pain mediators as well as those that target nonpain symptoms that may inhibit pain secondarily. In your opinion, what have been some of the more important developments or breakthroughs in this regard?

Dr. Rapoport: The most significant advances have really been in the differentiation between pain states and the pathways associated with the different states. Researchers are working on uncovering and understanding the various pain pathways, with an eye toward interrupting the pain signals, in addition to focusing on the receptors and various channels.

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.

Pain is the elephant in the middle of every rheumatology clinic, and it’s taking up a disproportionate amount of space. It is ever present and ever stubborn, and although everybody wants it gone, nobody is really certain about how to get rid of it. Thus, by default if not design, pain management is becoming an area of increasing research and clinical effort in rheumatology, according to Dr. Ronald Rapoport, director of the osteoporosis and research Center at Charlton Memorial Hospital in Fall River, Mass.

"Pain is the most common complaint of patients presenting to the rheumatology clinic, and it plays a central role in the clinical spectrum of rheumatologic conditions," Dr. Rapoport said. The challenge that time-crunched clinicians face, however, is that musculoskeletal pain across the range of rheumatologic conditions is typically not a consequence of the disease process alone, but rather is the result of a range of biologic, psychological, and social factors that, taken together, preclude easy assessment and treatment. If the pain of rheumatoid arthritis, for example, were simply secondary to inflammation, "then our jobs might be much easier: By treating the underlying manifestations of the disease, we would have a positive impact on the pain," he said. "The reality is that there’s much more to it than that."

In this month’s column, Dr. Rapoport discusses the challenge of rheumatologic pain and the integration of pain management into clinical practice.

Question: Why is rheumatologic pain so difficult to manage?

Dr. Rapoport: The reason is that we’re not just dealing with pain by itself. Halting disease progression is our main concern when we treat the majority of rheumatologic illnesses. If we are not able to control a patient’s pain, the odds of that patient’s returning are diminished, as is our plan of decreasing disease activity. The things we can do to help control pain may have no impact upon progression of the disease. We commonly use steroids as a bridge while we wait for disease-modifying antirheumatic drugs and biologics to have their effect. However, although these agents address pain quickly and effectively, they don’t really have a major impact on disease progression. Patients report feeling better on steroids, but the treatment does not slow or stop radiographic disease progression, which correlates better with future patient disability than does pain. Easing pain and stopping joint destruction often may not be achieved by the same therapeutic pathway.

Another obvious challenge is that ours is an aging population, and a patient’s complaint of pain may be associated with a number of conditions, rather than just the primary rheumatologic condition. A patient with rheumatoid arthritis may also have osteoarthritis or fibromyalgia, for example, and at times the pain associated with each condition may not be easily separable, so there are a lot of variables in the management equation.

Question: Are rheumatologists well equipped to deal with the complexity of chronic pain?

Dr. Rapoport: We are equipped to deal very specifically with pain that is aligned to the disease process, but in our training, there is no separate section on treating pain that is associated with the myriad other influences I mentioned. To treat pain optimally, rheumatologists have to learn about the pain pathways; how and where the various pain medications work; if, when, and in whom to start opioid therapy; whether to prescribe sustained-release or rapid-onset opioids; when and how to combine pharmacologic agents; and when and how to taper pain meds in the presence of improvements in disease progression.

On top of all of this, we must not be naive about the potential for abuse or misuse of pain medications. We need to determine which patients really need these pain meds and which might be abusing or diverting them. Frankly, even the most highly skilled rheumatologists may not always know the difference. This can be a major obstacle to pain management, because even though we all know that there are patients who do not have adequate pain control, there are also many patients who are abusing the potent pain medications. Differentiating between them is especially challenging among patients with significant arthritis.

Question: In recent years, novel pharmacologic agents have emerged that target various pain mediators as well as those that target nonpain symptoms that may inhibit pain secondarily. In your opinion, what have been some of the more important developments or breakthroughs in this regard?

Dr. Rapoport: The most significant advances have really been in the differentiation between pain states and the pathways associated with the different states. Researchers are working on uncovering and understanding the various pain pathways, with an eye toward interrupting the pain signals, in addition to focusing on the receptors and various channels.

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.

Pain is the elephant in the middle of every rheumatology clinic, and it’s taking up a disproportionate amount of space. It is ever present and ever stubborn, and although everybody wants it gone, nobody is really certain about how to get rid of it. Thus, by default if not design, pain management is becoming an area of increasing research and clinical effort in rheumatology, according to Dr. Ronald Rapoport, director of the osteoporosis and research Center at Charlton Memorial Hospital in Fall River, Mass.

"Pain is the most common complaint of patients presenting to the rheumatology clinic, and it plays a central role in the clinical spectrum of rheumatologic conditions," Dr. Rapoport said. The challenge that time-crunched clinicians face, however, is that musculoskeletal pain across the range of rheumatologic conditions is typically not a consequence of the disease process alone, but rather is the result of a range of biologic, psychological, and social factors that, taken together, preclude easy assessment and treatment. If the pain of rheumatoid arthritis, for example, were simply secondary to inflammation, "then our jobs might be much easier: By treating the underlying manifestations of the disease, we would have a positive impact on the pain," he said. "The reality is that there’s much more to it than that."

In this month’s column, Dr. Rapoport discusses the challenge of rheumatologic pain and the integration of pain management into clinical practice.

Question: Why is rheumatologic pain so difficult to manage?

Dr. Rapoport: The reason is that we’re not just dealing with pain by itself. Halting disease progression is our main concern when we treat the majority of rheumatologic illnesses. If we are not able to control a patient’s pain, the odds of that patient’s returning are diminished, as is our plan of decreasing disease activity. The things we can do to help control pain may have no impact upon progression of the disease. We commonly use steroids as a bridge while we wait for disease-modifying antirheumatic drugs and biologics to have their effect. However, although these agents address pain quickly and effectively, they don’t really have a major impact on disease progression. Patients report feeling better on steroids, but the treatment does not slow or stop radiographic disease progression, which correlates better with future patient disability than does pain. Easing pain and stopping joint destruction often may not be achieved by the same therapeutic pathway.

Another obvious challenge is that ours is an aging population, and a patient’s complaint of pain may be associated with a number of conditions, rather than just the primary rheumatologic condition. A patient with rheumatoid arthritis may also have osteoarthritis or fibromyalgia, for example, and at times the pain associated with each condition may not be easily separable, so there are a lot of variables in the management equation.

Question: Are rheumatologists well equipped to deal with the complexity of chronic pain?

Dr. Rapoport: We are equipped to deal very specifically with pain that is aligned to the disease process, but in our training, there is no separate section on treating pain that is associated with the myriad other influences I mentioned. To treat pain optimally, rheumatologists have to learn about the pain pathways; how and where the various pain medications work; if, when, and in whom to start opioid therapy; whether to prescribe sustained-release or rapid-onset opioids; when and how to combine pharmacologic agents; and when and how to taper pain meds in the presence of improvements in disease progression.

On top of all of this, we must not be naive about the potential for abuse or misuse of pain medications. We need to determine which patients really need these pain meds and which might be abusing or diverting them. Frankly, even the most highly skilled rheumatologists may not always know the difference. This can be a major obstacle to pain management, because even though we all know that there are patients who do not have adequate pain control, there are also many patients who are abusing the potent pain medications. Differentiating between them is especially challenging among patients with significant arthritis.

Question: In recent years, novel pharmacologic agents have emerged that target various pain mediators as well as those that target nonpain symptoms that may inhibit pain secondarily. In your opinion, what have been some of the more important developments or breakthroughs in this regard?

Dr. Rapoport: The most significant advances have really been in the differentiation between pain states and the pathways associated with the different states. Researchers are working on uncovering and understanding the various pain pathways, with an eye toward interrupting the pain signals, in addition to focusing on the receptors and various channels.

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.