The evolving picture around pain in rheumatic diseases, with multiple pain presentations, sleep disturbance, and depression, also warrants a generalized screening approach. “Rheumatologists, in the last couple years, are beginning to realize not all pain can be attributed to inflammation or damage in the periphery,” notes Dr. Clauw. “Patients often seek treatment for the one or two locations where the pain is more severe. If we don’t fully question patients about pain, we are missing the picture. We end up using peripherally targeted agents like antiinflammatory drugs and opioids without much success.” Using the fibromyalgia criteria as a general screening tool will help identify patients with types of pain that respond more to centrally activating agents like tricylic antidepressants, serotonin norepineprhine reuptake inhibitors, and anticonvulsants.
The revised criteria, particularly with the symptom severity scale, lend themselves to use as a follow-up tool for assessing medical management. Dr. Wolfe notes, “When patients come to us, we should be asking, How is the pain?, How is the level of fatigue?, [and] How is your sleep?” The widespread pain index and symptom severity scale enable the tracking of pain symptoms longitudinally. These scales help compensate for the lack of objective clinical measures for fibromyalgia.
Fibromyalgia in Primary Care Settings
Another major driver for revising the fibromyalgia criteria is to help primary care physicians appropriately diagnose and manage fibromyalgia. “Most rheumatologists know how to diagnose fibromyalgia with or without the new criteria,” Dr. Goldenberg says. He feels that fibromyalgia patients should be managed predominately by primary care, with rheumatologists serving as consultants.
The rheumatologist shortage is also a factor in the drive to shift fibromyalgia diagnosis and management to primary care, Dr. Clauw believes. “Not enough rheumatologists exist to take care of all the fibromyalgia patients. We need to help primary care physicians be able to identify fibromyalgia in routine clinical practice since the long-term management requires medication and multidisciplinary treatment that primary care physicians can easily do,” he notes. Since rheumatologists are unable to offer anything for medical management unique from primary care, Dr. Clauw feels that rheumatologists’ expertise and time can be better leveraged in caring for patients with rheumatologic conditions that require immunosuppressant drugs.
Dr. Clauw advocates promoting a model in rheumatology to get all physicians outside the specialty to start using the 2010 diagnostic tools as screeners. In this model, when general medicine colleagues identify people with elevated scores on the questionnaire, rheumatologists would consult on the first five to 10 patients to confirm the fibromyalgia diagnosis, exclusion of other musculoskeletal conditions, and management plan. By initially assisting nonrheumatologists in getting comfortable diagnosing fibromyalgia, rheumatologists would encourage general medicine colleagues to rely less on rheumatology referrals for fibromyalgia.
Patients often seek treatment for the one or two locations where the pain is more severe. If we don’t fully question patients about pain, we are missing the picture.
Response Beyond the Rheumatology Community
Opportunity as well as resistance to change categorizes the response among the primary care and psychiatry communities. “The disadvantage of the new criteria: It’s a change in thinking and new way of diagnosing fibromyalgia,” says Shay Stanford, MD, assistant professor in the department of family medicine who sees fibromyalgia patients at the Women’s Health Research Program Treatment Center at the University of Cincinnati.
