Dennis C. Ang, MD, MS, on Managing Persistent Pain in Rheumatologic Conditions
In the United States, more than 7 million adults have an inflammatory rheumatic condition.1 With many rheumatologic conditions, chronic pain is an ongoing concern, in which peripheral nerves, joints, muscles, or skin can be affected.
Currently, safe and effective pain therapies are limited, creating challenges for rheumatologists in the management of persistent pain.
Rheumatology Consultant caught up with with Dennis C. Ang, MD, MS, chief of the Section of Rheumatology and Immunology at Wake Forest Baptist Health in North Carolina, who discussed the rheumatologists’ role in managing a patient’s pain and the need for more therapeutic options.
Rheumatology Consultant: Pain associated with rheumatic diseases is a significant problem. How has the management of pain in this patient population evolved over time?
Dennis Ang: There are 2 types of pain associated with rheumatic diseases. For inflammatory pain, management has evolved significantly over time with the explosion of different effective biologic agents, albeit expensive, in treating inflammatory arthritis such as rheumatoid arthritis. On the other hand, the management of noninflammatory pain has not evolved much. The scientific community is still in search of a medication that is efficacious and nonaddicting at the same time.
RHEUM CON: There are pharmacological and nonpharmacological options for treating pain. How can a rheumatologist decide which option is best for a patient?
DA: The decision rests on both the physician and the patient. For a highly motivated patient, a self-management approach, such as relaxation, stress management, activity pacing, cognitive restructuring, exercise, physical therapy, and orthotics, is the preferred option for chronic noninflammatory pain. For patients who prefer a pharmacologic approach, medications such as nonsteroidal anti-inflammatory medications, muscle relaxants, anticonvulsants, antidepressants, and topical agents can be used for a short period of time. For the rare patients with moderate to severe pain requiring opioid medication, rheumatologists should consider referral to a pain specialist.
RHEUM CON: What challenges exist in treating and managing a patient’s pain?
DA: Firstly, we do not have an objective measure to assess response to medication. We rely completely on self-report. Secondly, we currently have very limited effective and non-addicting drug options for pain control. And thirdly, third-party payers do not pay for non-pharmacologic treatment options such as counseling, acupuncture, or other alternative treatment approaches.
RHEUM CON: What key takeaway should rheumatologists remember when managing pain in a patient with a rheumatic disease?
DA: There are a few important points to remember. The rheumatologist should pay attention to the psychosocial situation of the pain patients. Treatment of pain should not rely on medication alone. Rheumatologists should also be aware of all the available non-pharmacologic treatments to offer their patients. We also need to remember that most pain patients are not drug or opioid seekers.
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Reference:
Helmick CG, Felson DT, Lawrence RC. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Arthritis Rheum. 2008;58(1):15-25.