At the same time, pain specialists find it helpful to refer patients to rheumatologists if the pain seems to originate from a condition that seems less mechanical or osteoarthritic and more inflammatory, systemic or autoimmune in nature, says Stuart B. Kahn, MD, associate professor, rehabilitation medicine, Department of Orthopedics, Mount Sinai Medical School/School of Medicine, New York.
Rheumatologists should not ignore a patient’s pain complaints because they are out of the specialty’s wheelhouse, Dr. Borenstein says; instead, they should be proactive about referring to pain specialists.
The Challenges of Pain
Both rheumatologists and pain management specialists must help patients manage the challenges of chronic pain, which include impaired function at home and at work, as well as a greater risk for falls, says pain management specialist Fabian A. Ramos, MD, Ramos Center for Interventional and Functional Pain Medicine, with offices in Bradenton and Sarasota, Fla.
This lowered quality of life can commonly lead to depression, Dr. Smith says. “This can be very hard to treat, and inadequate treatment of depression frequently leads to inadequate treatment of pain,” he says.
Psychological issues are common in patients with pain problems, and this is often something that a comprehensive pain practice can help them better manage, Dr. Williams says. It can be difficult to let patients know that their pain may be reduced, but that it won’t always go away completely. “Patients with chronic pain need to know and understand that it’s often not about curing, but managing a pain problem,” Dr. Williams says.
Another treatment challenge is finding the right balance with certain medications, such as biologics, steroids or NSAIDs and combining that with the pain management specialists’ use of opiates and focal injection therapies, Dr. Kahn says.
Perhaps the biggest challenge with managing chronic pain patients is controlling opioid doses, Dr. Smith says. “Although many patients receive benefit from opioid therapy, these medications may be the biggest threat to our society’s overall well-being,” he says. “More young people die from opioid overdose than any other cause. Identifying the proper patients to use these medications, and discontinuing them when they are ineffective, is important,” he says. This often requires a multidisciplinary approach with communication among the pain physician, rheumatologist, addiction specialist, psychologist or psychiatrist, and a social worker, he added.
Dr. Smith prefers to try every modality possible, including more invasive procedures, before starting or escalating opioids, Dr. Smith believes.