Rheumatologist=Pain Doctor?

As I mentioned in my December column, to advance rheumatology we need to be proactive in meeting the needs of our patients. Reaching this goal requires that rheumatologists recognize the degree of pain our patients experience with the rheumatic diseases we treat them for. A survey was sent to the ACR membership, and 66% of the respondents stated that they consider themselves the physicians who are responsible for the evaluation, treatment, and follow-up of their patients’ pain. However, a significant proportion of the survey respondents indicated that their knowledge of pain medicine was not adequate to treat their patients effectively. I know there are some of us who don’t see ourselves as “pain doctors,” but whether we accept the title or not, we must acknowledge that caring for our patients appropriately requires treating their pain.

Consider Pain Management for Our Patients

The ACR has developed initiatives to address our members’ need for information on pain management, including educational sessions at the ACR/ARHP Annual Scientific Meeting and a position statement from the Pain Management Task Force that I chaired. The task force was formed based on a request from the membership, and its charge was to address the current status of pain management in the areas of basic and clinical research and clinical practice as it pertains to rheumatology. In addition, the task force considered the impact of increasing the importance of pain management on the ACR, including its educational and research programs. For example, the 2011 ARHP Clinical Focus Course will focus on pain management to help rheumatology health professionals be more effective in treating patients’ pain. Participants completing this course will learn about the latest thinking regarding the pathophysiology of pain, comprehensive pain assessment, and how to incorporate into clinical practice evidence based pain management strategies that are guided by the mechanistic characterization of pain.

Another initiative happened in December 2010 when the ACR participated as a facilitator of the National Institutes of Health (NIH) Pain and Musculoskeletal Disorders: Translating Scientific Advances into Practice Conference. This first-of-its-kind conference for researchers and clinicians was organized to stimulate conversation between individuals who care for pain patients with musculoskeletal disorders and researchers who study pain in its multiple forms. The conference opened with introductions by directors of four NIH Institutes who welcomed over 200 attendees. A wide variety of interesting topics were included, such as pain pathways, the interface between pain inflammation and cellular alarmins, animal models of pain, genetic markers of pain, functional neuroimaging techniques of pain, the PROMIS Outcome Measure system, dangers of opioid therapy, and novel nonpharmacologic treatment interventions. Of particular interest to rheumatologists were three speakers who discussed the many issues concerning pain for multiple demographics, including women, children, and those from lower socioeconomic backgrounds. “Women are at greater risk for the development of painful rheumatic disease,” stated speaker Lesley Arnold, MD, professor of psychiatry at the University of Cincinnati, who reviewed the endocrinologic and psychologic factors that increase the prevalence and intensity of pain in women compared with men. Pain is also a significant problem for children with juvenile idiopathic arthritis. Many of these children grow up to be adults with musculoskeletal pain. Laura Schanberg, MD, co-chief of the division of pediatric rheumatology at Duke University in Durham, N.C., cited literature that demonstrated increased levels of pain to thermal and mechanical stimuli in adults who were traumatized by painful procedures or accidents as children. Carmen R. Green, MD, professor of anesthesiology, obstetrics and gynecology, and health management and policy at the University of Michigan in Ann Arbor, highlighted racial and ethnic disparities in pain care. Many of our rheumatic diseases occur in patients of color with lower socioeconomic background. Minority patients are less likely to have pain recorded, receive less pain medication, and have decreased health due to pain. It doesn’t matter which demographics your patients fit into, pain management needs to be considered if we are to offer the best care possible to all our patients.

Pain as a Subspecialty?

Organized medicine is starting to take a more serious view of pain management. In November 2009, the ACR participated in the American Medical Association National Pain Medicine Summit convened through its Pain and Palliative Medicine Specialty Section Council. In the published Summit Report, the group stated that it wants to advocate for better pain care for patients and request additional funding to increase pain research.¹ The group also recommended changes within the structure of organized medicine to have pain medicine recognized as a separate specialty; the group believes that pain should be treated as a disease. While I agree that pain management does need to be a priority in patient care, I am unconvinced that all the proposed tactics from the summit are the best way to address it. Physicians and health professionals do need better education on pain, including its mechanisms and corresponding therapies. Additional funding for increased pain research is also appropriate. I have misgivings about establishing a separate specialty of medicine where knowledge of joint and bursal injections is listed 24th on a list of 32 items important to a pain medicine specialist, as it is in the Summit Report. Arthrocentesis is an essential technique for the care of patients with rheumatic disease. There should not be a tug of war as to who should be the appropriate provider of that service. Currently, however, the Summit Report is a proposal, not a reality.