COMMENTARY

Managing Pain in Rheumatologic Conditions

Stephen Paget, MD

Disclosures

March 06, 2015

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I am Dr Stephen Paget, physician-in-chief emeritus at the Hospital for Special Surgery, and professor of medicine at the Weill Medical College of Cornell University, both in New York City.

I want to talk about pain from a rheumatologist's point of view. While I am not a pain specialist, at Hospital for Special Surgery we deal with many kinds of pain, either surgical pain or pain related to various types of arthritis.

First let me say this: I believe patients when they tell me they have pain. I say that because some physicians do not believe all patients when they say they have pain. They may believe that patients are malingering or are magnifying pain that does not really exist. I take patients' complaints at face value because I do not believe anyone makes up pain. Do emotions help to magnify pain? Yes, so we have to consider that, but it makes the pain no less real.

My first job as a rheumatologist is to determine whether a patient has some type of arthritis. Then, having differentiated the various types of arthritis to make a specific diagnosis, my job is to find the best possible therapy for that person, given their general medical status.

How to Manage Active Inflammatory Disease Plus Complicated Pain Scenarios

Let's talk about inflammatory joint diseases. One of the more common inflammatory joint diseases is rheumatoid arthritis. Patients present with symmetric inflammation of the small joints of the hands and feet. They have fatigue. A significant percentage of them will have positive serologic tests. They will be anemic with a thrombocytosis and a high sedimentation rate. There is no doubt in my mind that they have active inflammatory disease that needs to be controlled.

The rheumatologist in me must choose a medication regimen that will control the patient's pain and inflammation as quickly as possible. If the patient has severe active inflammation, when I start a disease-modifying drug such as weekly methotrexate, I may also give the patient a short course of steroid to bring down the thermostat, calm the inflammation, and allow the methotrexate to work because it cannot pull uphill in the setting of very, very bad inflammation.

Patients do not read the books, however; they do not have simple presentations. They have various other problems. Some will have low back pain; some of them will have fibromyalgia. You have to incorporate all of these concurrent problems into your decision-making. I may want to treat the inflammatory problem, but sometimes the fibromyalgia comes along for the ride, and in actuality their low back problem also has to be addressed in a slightly different way.

As I said, I am a rheumatologist, not a pain specialist, but it is not at all uncommon in people with progressive joint damage to have severe pain that is unresponsive to the medicines I have used for their rheumatoid arthritis. These patients need better pain control. That is why we have a whole service of pain specialists who I work with very closely. We use various modalities to try to control pain. If the patient has a back problem, we may use epidural steroids. If it is fibromyalgia, we can use one of the FDA-approved medications for that. Sometimes acupuncture is necessary. Thus, we need to have a multimodality approach to pain because any given person can have complex pain problems that all need to be addressed at the same time.

This is Dr Stephen Paget for Medscape. Thank you for listening.

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