BETHESDA, Md. – The American College of Rheumatology has taken aim against pain.
"Most rheumatologists admit they’re inadequately trained in pain management, even though they’re taking care of pain in patients. ... We have to start early in the training of our fellows so they understand that treating pain is an important aspect of taking care of patients with musculoskeletal conditions. It isn’t just giving anti–[tumor necrosis factor] therapy," according to ACR president Dr. David Borenstein, who chaired a 15-member multidisciplinary pain task force.
Until formation of that task force and the eventual release of its report, the management of pain has not been a focus of rheumatology. This was the situation despite the fact that most patients seen in routine clinical rheumatology practice experience some degree of pain as a component of their illness.
While a significant proportion of patients with rheumatoid arthritis report inadequate pain relief (Ann. Rheum. Dis. 2004;63[Suppl 1]:432) few rheumatologists have adequate experience with non-opioid pharmacologic and non-pharmacologic modalities of pain management. These are areas the task force has targeted for improvement, said Dr. Borenstein of the department of medicine at George Washington University, Washington.
In a 2009 survey of 92 members of the Pennsylvania Rheumatology Society, the 60 respondents (65%) had been in clinical practice an average of more than 20 years, and their knowledge of pain management was largely self-taught. They reported that the majority of their patients had osteoarthritis, fibromyalgia, low-back pain, and other regional pain syndromes.
The most common inflammatory disorders were rheumatoid arthritis and microcrystalline disorders (for example, gout), affecting about 20% of all patients. Only a minority of their patients had connective tissue disease and other inflammatory conditions such as systemic lupus erythematosus, primary Sj?gren’s syndrome, myositis, or vasculitis. That may not be the case in academic settings, but it is in general community rheumatology practice, Dr. Borenstein pointed out at conference on pain and musculoskeletal disorders sponsored by the National Institutes of Health and the University of Michigan.
The rheumatologists reported that they see their professional role as evaluating, treating, and offering ongoing pain care for musculoskeletal disorders and that they felt comfortable leading a multispecialty team of health care professionals in the care of these patients. They were hesitant to prescribe opioids themselves, although they would do so if it were indicated.
A subsequent 2009 study of the entire ACR membership brought similar results, Dr. Borenstein noted.
The task force’s published report details the college’s initiatives with regard to pain management, aimed at "enhancing the effectiveness of rheumatologists and rheumatology health professionals in the diagnosis and management of pain associated with rheumatic diseases to improve patient outcomes."
Sections of the document summarize the extent of pain in rheumatic disease patients, the classification of rheumatic disease pain, and pharmacologic, nonpharmacologic, and interventional treatments. Also included is a section on pain research priorities and potential sources of research funding, from a rheumatology perspective (Arthritis Care Res [Hoboken] 2010;62:590-9).
Educational objectives include incorporation of pain management into fellowship training and increasing education of pain management at ACR instructional programs including the Annual Scientific Meeting. These programs would be aimed at both rheumatology fellows and those already in active practice, he said.
Dr. Borenstein has made this pain initiative a priority for his ACR presidency. "I guarantee this effort will be in place for at least a year as long as I’m president, and hopefully we’ll be able to continue this ongoing effort subsequently because I do think this organization has decided it’s really very important for the patients we care for."
Dr. Borenstein has received consultant fees, speaking fees, and/or honoraria of less than $10,000 each from Pfizer and King, and of more than $10,000 from Cephalon. In the published report, other members of the task force also disclosed relationships with a number of pharmaceutical companies.