“I refer patients to pain management when there is no underlying inflammatory condition, usual pharmacologic treatment has failed, and the patient may need chronic treatment with opioid analgesics or may need epidural spine injections, nerve blocks and other invasive procedures that are not in the rheumatology domain,” says Petros Efthimiou, MD, FACR, associate chief of rheumatology, New York Methodist Hospital, and associate professor of clinical medicine and rheumatology, Weill Medical College of Cornell University, New York.
Patients with chronic spine problems are also often referred to pain specialists, says rheumatologist David G. Borenstein, MD, clinical professor of medicine, The George Washington University Medical Center, and partner, Arthritis and Rheumatism Associates, Washington, D.C. Although a rheumatologist could possibly treat the problem, they would likely not have the same in-depth knowledge of pain treatments that a pain specialist has, he says.
“Non-rheumatologic back pain, such as degenerative disc disease and lumbar radiculopathy, is the bread and butter of pain medicine and also occurs in patients who have rheumatologic disease,” says anesthesiologist and chronic pain physician P. Joshua Smith, MD, Hickory, N.C.
Even after inflammation is controlled, some patients with autoimmune conditions need help to control pain due to joint alterations that can affect the spine and other parts of the body, says Orrin M. Troum, MD, Providence Saint John’s Health Center, Santa Monica, Calif. Dr. Troum will start with analgesic treatment, such as over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), but some patients don’t want to take those due to bad press about serious side effects, he says. He’ll work his way up the pain medication scale, but at a certain point, he feels more comfortable referring them to a pain management specialist.
Rheumatologists should consider the variety of specialists in their area who can manage pain in different ways, including anesthesiologists, physiatrists, rehabilitation medicine specialists and neurologists, in addition to pain management or pain medicine specialists, Dr. Troum says. Each specialist may have a slightly different treatment approach.
Another good reason to refer patients to pain specialists is that many offices have comprehensive care to tackle pain problems, including physical therapy, mental health professionals, and even individuals adept in areas like massage, functional rehabilitation, biofeedback or acupuncture, says Vernon Williams, MD, neurologist and founding director of the Kerlan-Jobe Center for Sports Neurology and Pain Medicine in Los Angeles. These practices can educate patients about non-pharmacologic therapies that will help get pain under control.