Johns Hopkins Pain Physician: on the Need for an Inter-Disciplinary Approach to Pain Management
Pain specialists are important allies to rheumatologists in addressing patients' persistent pain.
Though pain is the most common concern among patients with rheumatic diseases, one study reported insufficient pain control in two-thirds of those with rheumatoid arthritis.1 Even when disease activity is well-controlled, many patients have persistent pain that requires additional treatment approaches.
According to the National Pain Strategy released in March 2016 by the Office of the Assistant Secretary for Health at the US Department of Health and Human Services, effective pain control strategies “emphasize shared decision-making, informed and thorough pain assessment, and integrated, multimodal, and interdisciplinary treatment approaches that balance effectiveness with concerns for safety.”2 To that end, pain specialists are important allies to rheumatologists in addressing patients' persistent pain.
To learn more about the role of these specialists in managing pain associated with rheumatic diseases, Rheumatology Advisor spoke with Steven P. Cohen, MD, director of the division of pain medicine and professor of anesthesiology and critical care medicine, physical medicine and rehabilitation, at the Johns Hopkins University School of Medicine. Dr Cohen is a member of the National Institutes of Health (NIH) Task Force on pain, and contributed to the development of the National Pain Strategy.
Rheumatology Advisor (RA): What is the nature of collaboration between pain specialists and rheumatologists, and at what point should rheumatologists refer a patient for further care to a pain specialist?
Steven P. Cohen, MD: There is not much collaboration at the level of education. Unlike neurologists, physiatrists, psychiatrists, and radiologists, pain physicians don't have to rotate through rheumatology as part of their training–and vice versa–but we conduct weekly meetings with internists about how to manage difficult patients.
We are generally called in to help manage difficult patients who have failed to respond to conventional and conservative therapies, including those with opioid escalation and those who might be candidates for procedural interventions.
RA: What are common interventions on the part of the pain specialist for these patients?
Dr Cohen: Injections, to include intraarticular injections and increasingly, radiofrequency denervation. These are warranted for patients who have failed conservative therapy. In the case of radiofrequency ablation, in people who have responded to positive prognostic or diagnostic blocks.
RA: What are some examples of integrative or alternative medicine approaches used for pain in these patients?
Dr Cohen: Alternative procedures, like conventional ones, are best done in people with localized pain that fits an anatomical pattern–for example, knee pain from arthritis or pain shooting into the leg from a herniated disc impinging on a nerve root. These might include spinal manipulation or craniosacral therapy for spine pain, acupuncture, Calmare®, and many others.
RA: There is growing awareness of the importance of psychological factors in the individual experience of pain.3 What is the role of psychology in the treatment of patients with chronic pain?
Dr Cohen: It is well known that people who have chronic pain are more likely to be depressed and anxious, but what is sometimes not known, is that people who are depressed and have an anxiety disorder or other psychiatric condition, are more likely to develop chronic pain after an injury.
Moreover, people who have poorly controlled psychiatric conditions are less likely to respond to treatments, which is why they are not usually enrolled in clinical trials. Some psychological approaches that could be helpful include cognitive behavioral therapy and biofeedback.
RA: What are important topics for future consideration in the realm of pain management?
Dr Cohen: As [a member] of the NIH Task Force on pain, I would say that one of the things that's important to show is that an interdisciplinary model and a multimodal approach are effective and cost-effective, as they certainly are expensive.
As the number and price of injections and the use of biological therapies continue to soar, we need more research on cost and comparative-effectiveness. It is widely acknowledged that interdisciplinary pain treatment is more effective than treatment by a single specialty, but this needs to be employed judiciously, and continued treatment should be based on the patient's response rather than standardized recommendations such as a series of 3 injections, for example.
At some point, there will be individualized care based on pharmacogenomics and phenotyping which should improve care and resource utilization.
Specialties that can become board-certified in pain medicine now include radiology, anesthesiology, physical medicine and rehabilitation, psychiatry, and neurology, but there are many doctors who have trained in internal medicine as well.
Pain medicine cuts across specialties, and as such it is important to recognize that each of the specialties has something unique to offer.
Summary and Clinical Applicability
Good control of disease activity is often insufficient to resolve pain in patients with rheumatic disease. Referral to a pain specialist may be indicated when patients are unresponsive to conservative or conventional treatments.
Dr Cohen discloses being a former advisory board member for Halyard, a manufacturer of radiofrequency ablation products.
- American College of Rheumatology Pain Management Task Force. Report of the American College of Rheumatology Pain Management Task Force. Arthritis Care Res (Hobolen). 2010; doi: 10.1002/acr.20005.
- National pain strategy: a comprehensive population health level strategy for pain. The Interagency Pain Research Coordinating Committee (IPRCC). Available at: from https://iprcc.nih.gov/docs/DraftHHSNationalPainStrategy.pdf. Accessed August 16, 2016.
- Darnall BD, Scheman J, Davin S, et al. Pain psychology: a global needs assessment and national call to action. Pain Med. 2016; 17(2): 250–263.