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INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Pain is the most common symptom of patients with rheumatic disorders and can occur in both inflammatory and noninflammatory conditions. As a complex phenomenon with a strong subjective component, pain can be influenced by the nature of the underlying disease, personal predisposition (biologic and psychological), as well as environmental and psychosocial factors that impact the pain experience. In the management of patients with musculoskeletal disease, therefore, the characterization of pain (e.g., its onset, duration periodicity, and impact on functioning) is important in establishing the diagnosis and developing a comprehensive treatment plan to reduce pain and to improve quality of life.

Although rheumatologists diagnose and treat pain, they do not characterize themselves as “pain physicians.” Rather, in their professional identity, many rheumatologists consider themselves more narrowly as subspecialists who treat musculoskeletal disorders that have a component of acute and chronic nonmalignant pain. Furthermore, rheumatologists have traditionally approached pain from the perspective of the proximal causes of pain such as tissue injury and inflammation, and have concentrated therapy on reducing inflammation either locally or systemically. The therapies used have been predominantly pharmacologic and include nonsteroidal antiinflammatory drugs (NSAIDs), disease-modifying agents including biologics, and corticosteroids. Although commonly recommended, nonpharmacologic psychosocial interventions such as cognitive–behavioral therapy or body-based therapies including exercise are generally considered less effective by rheumatologists despite evidence that such approaches can be highly efficacious depending on the setting or disease (1–3).

For most conditions treated by rheumatologists, the etiology of pain has been conceptualized primarily in the context of events in peripheral tissue. As a result, rheumatologists have relied heavily on pharmacologic therapies directed at the immune system to control symptoms, especially in inflammatory disease. Correspondingly, for patients with major or irreversible tissue damage, whether arising in inflammatory or noninflammatory disease, surgery has been the mainstay of treatment, with pharmacologic therapy used as a transition until a definitive operation is performed. Given this approach, events in the central nervous systems contributing to the experience of pain have received less attention in treatment, with additional analgesic, psychosocial, or interventional therapies receiving neither extensive investigation nor widespread or appropriate use. This approach may limit the utilization of newer and multidisciplinary approaches to pain management in the care of patients with rheumatic disease as well as the conduct of cutting-edge pain research by rheumatologists.

To increase the understanding of a rheumatologist's role in pain management and the place of pain in the rheumatology research agenda, the Executive Committee of the American College of Rheumatology (ACR) established a task force whose goal was to consider these issues both at present and in the future as the field develops. This task force conducted literature reviews and practitioner surveys, and held face-to-face and telephone meetings to gauge the impact of a greater focus on pain management on practice, training, and education. At the heart of this task force's inquiry are the following types of questions: Are rheumatology health care providers optimally treating their patients' pain? How can rheumatologists and allied health professionals become better informed regarding the new research and clinical opportunities for pain management? What is the approach to patients with inflammatory disease who have responded to disease-modifying antirheumatic drugs (DMARDs) and/or a biologic agent but nevertheless have ongoing pain? What is the role of psychosocial and other nonpharmacologic interventions in the management of musculoskeletal pain?

The relevance of these issues is highlighted by a recent study of European rheumatoid arthritis (RA) patients indicating that two-thirds reported inadequate pain control (4). Indeed, despite advances in the management of rheumatic diseases, many patients believe that their physicians focus on the treatment of the underlying musculoskeletal disease and are not concerned with relieving pain itself (5). Although some patients may have this impression, the ACR, in its position statement on pain management in rheumatic diseases, nevertheless affirms that effective pain and symptom management is an ethical obligation of all health care providers and organizations.

The intent of the initiative is not to remake rheumatologists as pain specialists in general, but rather to increase their skill and expertise in the management of pain as it relates to a specific group of painful disorders. The goal of this report is to summarize the salient issues in treatment, research, and training considered by the task force to establish the foundation for ACR initiatives to enhance the effectiveness of rheumatologists and rheumatology health professionals in the diagnosis and management of pain associated with rheumatic diseases to improve patient outcomes.

CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Pain assessment.

Pain has been called the “fifth vital sign” by the American Pain Society, and its characterization and ascertainment of cause are essential in the evaluation of any patient with musculoskeletal disease presenting with pain. In view of the complexity of this symptom and its diverse causes, a biopsychosocial model of pain (6) may provide the best framework for a program of patient management that can involve a team approach and the use of diverse modalities. This model poses that pain is not only influenced by biologic, psychological, and social factors, but in turn, that the experience of pain can produce biologic, psychological, and social changes that potentially affect future responses to pain (6). Therefore, in the patient assessment, physical function, psychosocial function, and other aspects of quality of life should be determined, with the goal of identifying potentially modifiable and relevant factors. As is standard in the rheumatologic evaluation of patients with painful conditions, a thorough history and physical examination should focus on onset, pattern, duration, location, intensity, and characteristics of the pain, any aggravating or palliating factors, and the impact of the pain on the patient's quality of life (7, 8).

Medical and psychiatric comorbidities should be assessed in all patients reporting pain. These medical conditions may themselves be associated with pain (e.g., diabetic neuropathy) as well as affect the utilization of various pharmacologic and nonpharmacologic therapies. For example, the presence of hypertension, renal disease, or liver disease may limit the use of certain pharmacologic agents. Psychological factors can play a similar role in determining the severity and duration of pain. Therefore, depression and anxious mood are common in populations with persistent pain (9), and psychological factors are essential to understanding the persistence of pain in some cases (10).

In rheumatologic populations, psychosocial factors such as depression and pain catastrophizing (poor coping) in particular appear to be common and are highly associated with pain report (11, 12). Adding another level of complexity, both pain and psychiatric comorbidity can affect sleep quality, and conversely, sleep quality can affect both pain and psychiatric comorbidity. Because sleep difficulties are also frequently reported in rheumatologic populations (13), sleep is another critical target in the comprehensive assessment and treatment of pain. Therefore, the clinician should inquire about mood, sleep quality, role functioning, enjoyment of activities, coping, and relationships.

A quantitative measurement of pain is also important in pain management and can be accomplished using a variety of well-validated instruments. The selection of a tool should be based on the clinical setting (e.g., routine care or research) and patient characteristics (e.g., age, cognitive ability, functional status) (14). Examples of measurement tools include the Health Assessment Questionnaire, the Oswestry Disability Index, the Brief Pain Inventory, and the evolving Patient-Reported Outcomes Measurement Information System (PROMIS) tools (see below). Although such instruments can be incorporated into practice, a simple visual analog or numerical rating scale is often sufficient for determining the severity of pain and its response to therapy. Adding such simple scales for concurrent symptoms such as fatigue, sleep difficulty, and depression can assist in evaluating the multiple symptoms associated with pain.

Pain classification.

The pain associated with rheumatic disorders is difficult to characterize in simple categories. Damage to specific tissues results in pain of varying qualities. Examples of some of these rheumatic disorders and associated pain categories are listed in Table 1.

Table 1. Classification of rheumatic disease pain syndromes
1.Superficial somatic (skin, subcutaneous tissue)
 Autoimmune conditions (e.g., systemic lupus, vasculitis) with pain arising from the skin
2.Deep somatic (muscles, periosteum, ligaments, joints, vessels)
 Noninflammatory and inflammatory conditions of the peripheral joints
  Osteoarthritis
  Rheumatoid arthritis
  Spondylarthritis (e.g., seronegative spondylarthropathy, psoriatic arthritis)
  Crystal-induced disorders, including urate gout, calcium crystal–induced arthritis (e.g., pseudogout,  calcium phosphate arthritis, hydroxyapatite disease)
  Autoimmune conditions (e.g., systemic lupus, vasculitis) with pain arising from bone and joints
 Degenerative and inflammatory conditions of the tendons, ligaments, and bursae (e.g., rotator cuff  disorders, diabetic arthropathy)
 Degenerative and inflammatory conditions of the spine
  Spondylosis of the cervical, thoracic, and lumbar spine, including facet syndrome
  Postsurgical pain syndromes (e.g., failed back syndrome)
 Metabolic and other bone disease
  Osteoporosis of all forms
  Osteomalacia
  Paget's disease of bone and related secondary osteoarthritis
  Avascular necrosis of bone
3.Radicular (spinal nerve roots)
 Lumbar spinal stenosis, lateral recess impingement, disc compression
4.Neurogenic/central (peripheral/central nervous system)
 Neurogenic and neuropathic conditions of the extremities
  Causalgia/complex regional pain syndrome type II
  Thoracic outlet syndrome
  Entrapment neuropathies
  Other peripheral neuropathies
 Pain conditions related to central sensitization
  Fibromyalgia
  Myofascial pain syndromes
  Reflex sympathetic dystrophy syndrome/complex regional pain syndrome type I

Interdisciplinary team approach to rheumatic pain management.

For the rheumatologist, the current approach to the treatment of pain can be divided into 3 general categories: nonpharmacologic, pharmacologic, and interventional, which can be used to various extents using a multimodal approach. Several medical organizations have developed guidelines for the management of chronic noncancer pain that include attention to patient populations (e.g., the elderly) that commonly seek the care of rheumatologists (15, 16).

Because of the multifactorial and dynamic nature of pain, interdisciplinary approaches are recommended for treating pain in rheumatologic populations in an integrated fashion (17–19). Based on a biopsychosocial model of pain, key factors to be addressed in pain management are represented by the acronym ExPRESS: Exercise, Psychiatric comorbidity, Regaining function, Education, Sleep hygiene, and Stress management (20). Ideally, comprehensive treatment is individualized based on the type of pain (e.g., nociceptive, non-nociceptive) and the ExPRESS factors requiring intervention. A rheumatologist's armamentarium should therefore include nonpharmacologic interventions such as physical therapy, patient education, occupational therapy, nutrition and weight control, patient self-management, and cognitive–behavioral therapy.

An integrated approach to pain management requires the participation of a variety of allied health professionals who work as a team with the rheumatologist to facilitate behavioral and cognitive approaches as described above. Potential team members may include a physical therapist and/or physiatrist, an occupational therapist, a psychologist and/or psychiatrist, a nurse practitioner or physician assistant, a pharmacist, a nutritionist/dietician, and a social worker. The team can focus on individual disease-specific treatment programs to determine the intensity of the involvement of each team member (21). Each program should have clearly stated short- and long-term goals because unrealistic goals may lead to patient disappointment and dissatisfaction. Once a plan has been initiated, the rheumatologist must regularly monitor the progress with validated instruments and adjust the plan accordingly. Interdisciplinary teams can more effectively address challenges common in pain management, such as opioid addiction, requests for disability, and maladaptive illness behavior.

Building these teams and developing treatment protocols using evidence-based interventions will require a paradigmatic shift in rheumatology education at the training and professional practice levels. The collaboration of rheumatologists with professionals specializing in pain in the fields of behavioral medicine and health psychology can facilitate this shift and promote innovative programs in clinical care, education, training, and research. Collaborative efforts of this kind have resulted in the availability of Web-based self-management programs that promote patient and health care provider education and standardization of integrative pain programs.

Pharmacologic therapies.

The approach to effective pain management should focus on the type of pain experienced by the patient. Since many rheumatologic conditions are inflammatory in nature, therapy should involve antiinflammatory and immunomodulatory agents such as the DMARDs, including the newer biologic agents. Furthermore, in patients with inflammatory and noninflammatory rheumatic diseases, central sensitization may contribute to chronic pain and represent a target for treatment. Central sensitization refers to increased spontaneous impulse activity of dorsal horn neurons and their enhanced responses to impulses in nociceptive and non-nociceptive primary afferent input. The consequences of central sensitization are hyperalgesia, allodynia, and spontaneous pain (see below). Available drug treatments for chronic pain include simple analgesics such as acetaminophen, salicylates and other NSAIDs, traditional opioid drugs, topical agents, and adjuvant agents (e.g., antidepressants, anticonvulsants) (22). Typically, the choice of a drug involves balancing the indications for treatment, the clinical efficacy of the drug, and its toxicity based on understanding their mode of action and consideration of patient comorbidities (Table 2) (15, 23). In addition, multimodal therapy, as used in RA, can be applied to other inflammatory diseases associated with pain.

Table 2. Pharmacologic strategies for pain management*
TargetDrug classMechanism of action
  • *

    NSAIDs = nonsteroidal antiinflammatory drugs; PG = prostaglandin.

PeripheralCorticosteroidsAntiinflammatory/immunomodulatory
Biologic agentsAntiinflammatory/immunomodulatory
MixedNSAIDsInhibit PG production
Peripheral/centralLocal anestheticsBlock sodium channels
Muscle relaxantsInhibit motor neuron excitation
CapsaicinDepletes proinflammatory neuropeptides
CentralSimple analgesicsCentral inhibition of PG production
OpioidsOpioid-receptor agonists
AntidepressantsBlock serotonin/norepinephrine reuptake
AnticonvulsantsInhibit sensitization of pain neurons

The role of opioids in the management of chronic or persistent musculoskeletal pain remains an area of both controversy and uncertainty. Emerging understanding of opioid actions on alternate receptors that may mediate persistence of chronic pain raises further concerns surrounding opioid use in chronic pain conditions (24). At present, the education of physicians and other providers on opioid therapies in pain management appears at best limited in the curriculum of many rheumatology fellowship programs. Because of inadequate training, some rheumatologists may be reluctant to prescribe this therapeutic class on a regular basis. The prescription of opioids must be done thoughtfully, since patients who may receive the greatest benefit may also be the same as those who are likely to abuse these agents (25–29). Better understanding of the risks and benefits of opioids should be understood by all rheumatologists so that these medications can be safely, albeit selectively, used in patients with certain chronic rheumatologic disorders.

Interventional therapies.

Peripheral joint injections with corticosteroids have been a staple of interventional therapies for the rheumatologist. These injections can be performed in patients with a wide variety of inflammatory and noninflammatory conditions, with imaging by ultrasound guidance gaining increasing attention to achieve better localization and greater efficacy. The performance of other interventional therapies (e.g., epidural steroid injections) in the office setting may be considered by some rheumatologists, although such interventions require extensive training and experience. Although many rheumatologists may not be interested in the performance of these therapies themselves, they nevertheless should understand their benefits and risks and be able to recommend their use to patients on the basis of a solid grounding in the evidence in this field. The key in considering these options should include the comfort and skill level of the rheumatologist and the availability of other physician specialists to whom the rheumatologist may refer patients (30).

Special populations.

The treatment of pain in pediatric and geriatric populations involves special considerations because of diagnostic uncertainty and the complicated interplay of risks and benefits of existing therapy. In the case of children, for example, specific pain assessment tools and the use of opioids have been studied (31, 32), although more prospective trials are needed to determine optimal management.

In contrast to children, geriatric patients are challenging because they may have significant comorbidities, including cognitive impairment (33, 34). Nevertheless, the age of the patient, either young or old, should not prohibit the use of analgesic therapies, pharmacologic or nonpharmacologic.

RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Although pain is the presenting symptom for most individuals seeking care from a rheumatologist, rheumatologists typically have very little training in pain assessment or management. Even fewer perform research related to pain. Therefore, rheumatologists and rheumatology fellows may have limited experience in the design and conduct of basic or translational research addressing pain mechanisms in rheumatic diseases. Since such commonly studied processes (e.g., inflammation) may not be the drivers of symptoms and dysfunction in their patients, rheumatologists will need additional training in pain mechanisms to promote research bridging the gap between inflammation and tissue destruction, on the one hand, and the experience of pain and dysfunction, on the other hand.

As in the case of patient management, the development of a research agenda for pain in the rheumatic diseases requires an intellectual framework as well as an understanding of the current state of the field. The task force therefore reviewed current research in the field of pain as it may apply more specifically to the rheumatic diseases. As this review indicated, the past decades have witnessed significant advances in mechanisms of the neurobiology of pain, and this information needs to be translated into clinical practice so our diagnostic and treatment paradigms match current knowledge in the field. Important advances will be considered briefly as the basis for understanding future directions of pain research in rheumatology.

Basic science of pain.

Melzak and Wall were the first to challenge the notion of pain processing, when they proposed the “gate control” theory of pain in the 1960s (35). This theory posited that a sensory input from the periphery can be modulated at the level of the dorsal horn of the spinal cord, and that spinal influences can play a significant role in determining the presence or severity of pain. The advent of functional brain imaging led to the realization that, in addition to this strong spinal control of pain, supraspinal influences can also determine the presence and magnitude of pain. These findings indicate that control of pain occurs at a minimum of 3 levels in the nervous system: peripheral, spinal, and supraspinal.

Other research indicates that there are at least 3 different dimensions of pain sensed by cortical regions: 1) sensory (where it is and how much it hurts), 2) affective (the emotional valence of pain), and 3) cognitive (what people think about their pain). Because there are specific pain fibers in nerves as well as nonspecific pain pathways in the brain, the pain experience (especially in chronic rather than acute pain) is a result of a complex information processing network. Until recently, the primary targets for therapy for pain in the periphery were thought to be prostaglandins and bradykinin, since these mediators are released during different types of tissue injury and can elicit pain.

In fact, there are many other peripheral “targets” that impact pain processing. Among recently defined systems for pain, the capsaicin/vanilloid receptor, transient receptor potential vanilloid 1, responds to both capsaicin and noxious heat and acidic pH. Blocking the activity of this receptor can reduce pain. Substance P and calcitonin gene-related peptide are neurotransmitters released by primary afferents that act locally both to cause neurogenic inflammation (e.g., warmth, redness, swelling) and to activate second-order neurons in the dorsal horn to augment pain transmission. Also, specific molecular channels are present on peripheral nerves, such as the tetrodotoxin (TTX)–resistant (Nav1.8 and 1.9) and TTX-sensitive (Nav1.7) sodium channels. Genetic studies have shown that a mutation that leads to loss of function of the Nav1.7 channel is associated with insensitivity to pain, whereas other mutations causing increased function lead to erythromelalgia or paroxysmal extreme pain disorder (36).

Acute or longstanding changes in many of the peripheral processes can lead to “peripheral sensitization,” wherein individuals experience increased pain to normally painful stimuli (hyperalgesia) or pain in response to normally non-painful stimuli (allodynia). Similarly, physiologic processes can lead to “central sensitization,” where the increased “volume control” on pain processing occurs in the central rather than the peripheral nervous system. The term central sensitization also refers to a specific type of spinal mechanism mediated by glutamate and substance P that leads to augmented pain processing at the level of the dorsal horn (37).

An important advance in the pain field has been the identification of supraspinal processes that influence the upward transmission of pain via pathways that descend from the brain to the spinal cord. These pathways are termed descending analgesic pathways. One set of these pathways primarily uses norepinephrine and serotonin as neurotransmitters, and the other uses endogenous opioids. These pathways can be attenuated in chronic pain states, as well as in individuals at risk for developing chronic pain. Testing the integrity of these pathways could be used clinically to identify subsets of patients with chronic pain who would preferentially respond to pharmacologic or nonpharmacologic interventions (e.g., with neurostimulatory devices) of one or the other of these pathways (38, 39). A more recent discovery is the presence of pathways that descend from the brain to the spinal cord and augment pain transmission, termed descending facilitatory pathways.

Genetics of pain perception.

As shown in recent studies, both the manner in which an individual experiences pain and the magnitude of the response to a given nociceptive stimulus may reflect a genetic “set point” in pain sensitivity as well as the extent of inflammation or damage in their peripheral tissues. For example, fibromyalgia is a condition characterized by severe and widespread pain in the absence of evidence of damage or inflammation in the tissues sufficient to explain the extent and severity of the pain symptoms. In these patients, the symptoms of fibromyalgia may be genetically determined and result from polymorphisms in genes for important receptors and signaling pathway. Candidate genes could be those responsible for catechol-O-methyltransferase (COMT), GTP cyclohydrolase 1, and the voltage-gated sodium channel Nav1.9, which can exert significant control in human pain perception (40–42).

The observations regarding the role of COMT are notable because of the relevance to human pain perception. Zubieta et al showed that the COMT Val158Met polymorphism in humans may influence differential pain sensitivity, working in part by modulating the endogenous mu-opioid system (43). Interestingly, the same Val158Met polymorphism is weakly associated with psychiatric disorders (44). Recently, Diatchenko and colleagues used haplotype analyses to identify 3 subsets of individuals based on 4 single-nucleotide polymorphisms (SNPs), termed low pain-sensitive (LPS), average pain-sensitive (APS), and high pain-sensitive (HPS) groups (45). These studies indicated that the subgroups are highly predictive of pain sensitivity on a variety of different experimental pain tasks (44). Moreover, in a prospective 3-year study of 240 individuals who were pain free at baseline, the development of temporomandibular joint disorder was 3 times as likely in HPS individuals as in the other groups (46).

Studies in animals provide further evidence for the influence of COMT on pain. In rats, animals with the LPS haplotype produced much higher levels of COMT enzymatic activity when compared with the APS or HPS haplotypes, and inhibition of COMT in the rat results in a profound increase in pain sensitivity. Finally, molecular studies have provided a biochemical basis for these differences because these synonymously coding SNPs, when combined into haplotypes, each led to a different RNA structure with markedly different activity (46).

A study in Arthritis & Rheumatism (47) showed that within a large osteoarthritis (OA) database, like all others who had previously found a very weak association between the degree of OA of the knee or hip and pain, these authors noted that the individuals with the 158Met COMT variant had an almost 3 times higher risk for hip pain as compared with the Val/Val genotype. Female carriers drove this effect. Women with the 158Val allele were 4.9 times more likely to have pain, although in both genotype groups radiographic damage to the hip was present. This sex difference is notable since the expression of COMT is inducible by estrogen and may contribute to certain “phenotypic” characteristics that differ in women and men, including pain sensitivity (47).

Functional imaging.

Functional magnetic resonance imaging (MRI), positron emission tomography (PET), and proton spectroscopy (H-MRS) are techniques that can provide a noninvasive assessment of pain processing in individuals. These techniques have been used to corroborate the large differences in human pain sensitivity seen between individuals as well as to document pathologic states such as hyperalgesia and allodynia. These techniques allow visualization of how much pain an individual is experiencing, rather than relying entirely on self-report. For example, Coghill and colleagues showed that a number of brain regions seem to “code” for the sensory dimension of pain. Within the normal population, individuals who are more sensitive to pain show greater neuronal activations in these regions with the same objective intensity stimulus (48). Other studies have shown augmented pain processing on functional MRI in conditions such as fibromyalgia or low back pain, where individuals may be more sensitive to pain throughout their bodies (49, 50). Moreover, PET and H-MRS can actually measure the levels of specific neurotransmitters in the brain, and perhaps even the spinal cord (51, 52). These imaging techniques are now being used by pharmaceutical companies and academia for the development of new analgesics (53).

Clinical trials/therapeutic development.

In rheumatology, acute pain can result from many conditions such as bursitis, tendonitis, fracture, crystal-induced disease, and the initial manifestations as well as flares of RA or systemic lupus erythematosus. While starting acutely, these conditions can become persistent and undergo transition to a chronic state. Chronic pain, originally defined as pain lasting longer than 6 months, is now described as pain that lasts longer than the temporal course of the natural healing associated with a particular injury or disease process. The process for the transition of an acute pain process is clinically important and has been recognized as a focus of research in the National Institutes of Health (NIH) Road Map for Medical Research call for Transformative R01 grant applications.

Future research on pain will increasingly involve individualized approaches to understand this symptom and develop interventions for long-term treatment or prevention of disease (54). To improve outcomes, therapy will need to recognize the mechanisms that cause individual variability and develop integrated approaches to improve treating pain in both adults and children with rheumatic diseases. Importantly, this approach must incorporate an understanding of any proposed therapies in terms of the balance of risks and benefits. Although analgesics have traditionally been viewed in terms of medications taken on a regular basis, usually orally, the potential for analgesic treatments has expanded to include biologics and psychosocial interventions such as cognitive–behavioral therapy.

Rheumatology is uniquely poised to evaluate the benefits and risks of analgesics. Novel research could, for example, assess the risks and benefits of the agents currently employed to treat the pain such as NSAIDs, and opioid-related analgesics in comparison with cognitive–behavioral therapy. In this regard, therapeutics may be used in various combinations over time in a way that confounds an understanding of their toxicity. For both practice and research, development of an ACR Therapeutic Index for analgesics could be valuable to inform prescribers and patients about the overall effectiveness and risks associated with any particular therapeutic intervention.

In the conduct of innovative trials, adaptive trial design allows the use of information gathered during the initial period of the clinical study to modify subsequent periods of the trial without undermining the validity and integrity of the trial. The information could be data collected from related studies or data collected from within the study. Such considerations may lead to changes in the study end point, recalculating and amending sample sizes, reevaluation of the control groups, or even alteration of the key assessments required to confirm the methodologic and/or statistical hypotheses stated in the initial study protocol. This flexibility in clinical trials could improve the quality, speed, and efficiency of decision making in understanding and treating pain in patients with rheumatic diseases. The adaptive trial design approach may have particular advantages in small population studies, as well as in exploratory and large population studies. Adaptive design appears to be best suited for dose escalation trials and for phase III trials where sample reestimation may be required.

Pain is probably the most important patient-reported outcome in rheumatology. As noted above, there are at least 3 dimensions of the pain experience: sensory, affective, and cognitive. PROMIS, an NIH-funded Roadmap initiative (online at: www.nihpromis.org), is a state of the art assessment tool based in item-response theory (IRT) that evaluates the different aspects of pain beyond a simple numerical rating scale. PROMIS has developed IRT-calibrated banks of items/questions that measure in adults the domains for pain impact, behavior, and quality; similar IRT-calibrated item banks are being developed for pain in children and parent-proxy domains. The pain impact and behavior banks in adults can be administered in all facets of clinical care and research (e.g., office setting or a clinical study) as a traditional pen and paper short form or via a computerized adaptive testing format. All of these domain banks are available at the Assessment Center, which can be accessed through the PROMIS Web site (online at: www.nihpromis.org). PROMIS offers the potential not only to improve patient-reported outcome assessment in rheumatology now, but also to facilitate research toward improved patient-reported outcomes in the future.

Special issues in children.

Although often viewed in terms of adults, chronic pain occurs in children and is a significant yet underexplored area of research. Persistent pain is common in children with juvenile inflammatory arthritis (JIA) and other musculoskeletal conditions, and may be partly responsible for the adverse psychosocial effects and functional disability associated with these diseases. Estimates have suggested that up to 86% of children with JIA report mild to moderate pain (55), with nearly half continuing to experience mild to moderate pain 5 years after disease onset (56). In a long-term followup study of pain in children with JIA, one-third of patients continued to report severe pain as adults (57). Pain in children with arthritis is particularly worrisome because it may contribute to poor physical and psychosocial outcomes such as academic delays and reductions in social and physical activities (58–60). Research on children with arthritis has found that daily pain intensity predicts limitations in both school and social activities (58). Persistent pain in the context of childhood arthritis or other chronic rheumatic conditions needs to be a focus for expanded research.

ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

An essential element of the initiative in pain management is the development of an organizational plan and structure to assess the interest of the members, determine the scope and direction of future activities, and develop a plan for both short- and long-term objectives, including the resources involved. In the past, the ACR has created initiatives to advance care in specific areas (e.g., bone disease), but the implications of a pain management initiative are perhaps greater for the membership since they could have an impact on the identity of rheumatology and the patterns of practice.

As an important first step in the initiative, the ACR should perform a member survey and conduct focus groups to assess current practices and to provide a platform for future activity. Types of information that will be obtained include, as examples, the number and types of patients with painful disorders seen, the current way in which these disorders are evaluated and managed, the frequency of visits, the utilization of different medications (e.g., opioids) and the understanding of their mechanisms of actions and their effects, the utilization of different procedures such as spinal injections, the community resources available, the attitude of members to the concept of a pain management initiative, and the types of information and learning activities in which they are interested.

An initial pain management survey has been completed by the Pennsylvania Rheumatology Society under the guidance of a member of the task force (TS). The response rate of 65% (60 of 92 rheumatologists) is a representative sample of members of the ACR who are in clinical and academic settings. The survey findings reveal that many rheumatologists have been in clinical group practice for 20 years or longer and have been self-taught in regard to pain management. The majority of patients they evaluate and treat have noninflammatory conditions such as OA, osteoporosis, fibromyalgia, and low back pain, as well as other regional and chronic pain disorders. The most common inflammatory disorders are RA and microcrystalline diseases, comprising approximately 20% of patients. Connective tissue diseases and other inflammatory arthritides make up a minority of a usual rheumatologist's practice population. According to this survey, rheumatologists believe that their professional role is to evaluate, treat, and offer pain management care for patients with musculoskeletal disorders. Rheumatologists are comfortable in leading a team of other subspecialty physicians and allied health professionals in the care of these patients. In contrast, rheumatologists are hesitant in prescribing opioids for their patients but will offer these medicines as part of therapy when indicated.

The structure of this initial questionnaire has highlighted the general questions that would serve as a pain management survey for the entire ACR membership. With information from the larger survey available, the Pain Initiative Task Force could present a strategic action plan, in addition to an initial position statement, to the Board of Directors (BOD) for discussion and approval. As part of this approval, the BOD should establish an ongoing structure (e.g., task force) to oversee subsequent activities. This structure would involve members of the ACR and the Association of Rheumatology Health Professionals (ARHP) and coordinate subsequent activities; these activities would include the following: 1) to develop a strategic plan with short-term and long-term objectives, including a timeframe for implementation, 2) to identify relevant ACR and ARHP committees to be involved in implementation, 3) to identify necessary resources, and 4) to provide relevant information to include in the ACR and ARHP strategic plans. Once this initial phase of the initiative is completed, the BOD will give approval and provide resources for full implementation.

As the initiative matures, the dissemination of new information will occur regularly in various media and venues of communication, including The Rheumatologist and the ACR Web site. Furthermore, there should be a concerted effort to develop a plan to increase the content on pain management for the Annual Scientific Meeting. Consideration should be given by the Quality of Care Committee to the development of practice recommendations for rheumatic disease pain management.

Since pain is a cross-cutting topic that will be considered by other scientific and medical disciplines, it will be important to develop strategies for collaboration and interaction. To accomplish this goal, it will be important 1) to identify and form alliances with other organizations, scholarly societies, and groups, including patient organizations, to promote clinical care, training, and research on pain; 2) to identify individuals and programs within the government (NIH, Veterans Affairs, Department of Defense, Centers for Disease Control and Prevention, etc.) and industry to form alliances in the development of innovative, multidisciplinary programs in research and clinical care; 3) to begin communication with granting organizations to promote interest and facilitate pain-related research as it relates specifically to the rheumatic diseases; and 4) to establish the presence of the ACR and ARHP in other organizations involved in research on pain or its management.

ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

A major aspect of the pain initiative will be to develop intellectual and scholarly resources on pain and its management that can be used for the education of members as well as incorporation into training programs. Included in this development are the following: 1) to design a curriculum for members that is available in various print and electronic formats; 2) in concert with training program directors, to develop a curriculum for incorporation into training programs; 3) to interface with the American Board of Internal Medicine to determine the scope of training that will be part of rheumatology training programs and develop appropriate models to assure acquisition of appropriate skills; 4) to provide training opportunities for those individuals wishing more expertise with procedures; and 5) to explore the development of new training models for fellowship programs to incorporate training related to pain, including issues of dual boarding.

At present, the number of rheumatologists in this country is limited and it is therefore essential to assure an adequate work force to promote an increase in activity in pain management by members of the specialty. It will be critical to obtain regular feedback from the members and engage members in the pain management initiative in a manner consistent with their practices and philosophies. Similarly, it will be critical to develop patient education material and resources for use in the practices of rheumatologists and other providers. This material may need to expand in the future on the basis of new and existing modalities and also provide information on local community resources.

The Pain Management Task Force recognizes that some rheumatologists may wish to limit their role in certain areas (e.g., performance of certain procedures) that may require either more extensive training or fundamental changes in the structure of their practices. As cognitive specialists, rheumatologists may be less inclined to perform procedures themselves and have been trained in programs where such procedures are rarely if ever performed by rheumatologists. Nevertheless, rheumatologists should recognize the importance of providing information for their patients on the value of such procedures and ways to have them done locally.

Also of concern is the lower level of compensation for cognitive versus procedural interventions for the treatment of pain in patients with rheumatic disease. These economic issues may make it more difficult to care for patients with pain who require more education and counseling time. As such, it will be important to develop patient education material to facilitate discussions on the course of disease, risk, and benefits of available treatments and choices among therapeutic options to alleviate symptoms and promote function. The effect of health care reform on the relative value of cognitive and procedural medicine as it pertains to patients with rheumatic disease remains to be determined.

SUMMARY

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

The next few years in medicine will be a time of incredible change, and the organizational structure (e.g., task force) overseeing the pain initiative should regularly monitor the activities of the initiative, survey members, and report back to the BOD. The initiative has an impact on the identity of the specialty of rheumatology and it is essential that it is supported by the members and has the resources, both intellectual and financial, to assure its success.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Borenstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Borenstein, Altman, Bello, Chatham, Clauw, Crofford, Croft, Hassett, Kozin, Pisetsky, Richardson, Schanberg, Starz, Witter.

Acquisition of data. Borenstein, Bello, Starz, Witter.

Analysis and interpretation of data. Borenstein, Altman, Bello, Croft, Hassett, Pisetsky, Starz.

REFERENCES

  1. Top of page
  2. INTRODUCTION
  3. CLINICAL ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASE
  4. RESEARCH ASPECTS OF PAIN MANAGEMENT IN RHEUMATIC DISEASES
  5. ACR ORGANIZATIONAL ISSUES FOR THE PAIN MANAGEMENT INITIATIVE
  6. ACR ACTIVITIES ON EDUCATION AND TRAINING IN PAIN
  7. SUMMARY
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES