If the pain is primarily driven by inflammation, the rheumatologist may be the best person to address it, so much the better if the underlying disease can be reduced. But that’s not always clear, Dr. Rapoport says. “Let’s say I have a patient with osteoarthritis, complaining of back pain. Signs of physical changes on the X-ray don’t always correlate to the patient’s reported pain. The benefits of opioids for the majority of these cases seem to fade rather rapidly, as substantiated in the recent literature, while side effects mount. This puts us in a difficult situation where we just don’t have good options. Sometimes, the only thing that works is opioids,” he says.
“Pain is one of the most common reasons why people visit rheumatologists,” notes Yvonne C. Lee, MD, rheumatologist at Brigham and Women’s Hospital in Boston. “We are very focused on inflammation, but that may not be the only, or even primary, cause of their pain.” A lot of attention goes into trying to figure out what is the cause, and for a lot of patients it can be multifactorial.
“We need to make sure we’re not abandoning our patients or missing diagnoses that could mimic rheumatologic conditions and explain the source of pain,” she says. “It’s also important to emphasize that we’ll be there for them—we’ll work with them to overcome the hurdles. We don’t want to say we can’t use opioids at all. It’s important to evaluate risks and benefits for each patient.”
The public has high expectations for medical care—some of that pushed by pharmacy companies’ direct-to-consumer advertising, Dr. Molloy says. “Patients believe they have the right to be pain free. Well, sometimes we can’t get rid of the patient’s pain. That makes for some very difficult conversations. Those of us who are willing to treat this pain, we can’t do it all. It takes me a lot of emotional effort and time to take care of chronic pain patients. They are very needy. I’m a rheumatologist. I don’t want to be a pain specialist, and I don’t want to advertise myself as a pain doctor,” he says.
Opioids are for when benefits are expected to outweigh risks, based on a thorough evaluation of pain & its causes, & a thorough discussion with the patient of the risk & benefit—including dangers from polypharmacy & from the concurrent use of alcohol.
Not all practicing rheumatologists want to get involved with these patients, Dr. Rapoport says. In fact, some rheumatologists were reluctant to share their experience with pain treatment for this article. “As a rheumatologist, treating our patients’ pain is a necessary part of our practice. But if you become known in the community as a doctor who writes pain prescriptions, you’ll end up getting a lot of office visits for reasons other than pain control,” he says.
