Far from 'the promised land': Managing expectations for patients with chronic pain
Conveying the efficacy of pain management approaches may help rheumatologists better manage their patients’ expectations and long-term pain relief, noted a presenter at the 2021 Congress of Clinical Rheumatology-East.
David Cosio, PhD, MS, of the Jesse Brown VA Medical Center in Chicago, aimed to help rheumatologists address chronic pain by any means necessary. “We know there are resources out there, but when I speak to providers, they tell me, ‘I don’t have access to those resources,’” he said.
Before starting a patient on a pain management regimen, it is important for clinicians to understand that most pain management strategies — from opioids to yoga — are likely to yield only around a 30% to 60% reduction in pain. “What do your patients want when they come in?” Cosio said. “They want 100% [reduction]. Education needs to occur to manage expectations.”
Cosio covered five categories of pharmacotherapeutic pain relief: NSAIDs, anticonvulsants, antidepressants, topical agents and muscle relaxants.
NSAIDs may have utility for muscle and back pain but not for neuropathic pain, according to Cosio.
He added that the argument for antidepressants has some basis in physiology. “The same part of the brain that is responsible for pain is also responsible for the way we feel,” he said. “They may do the trick. We see improvement.”
While there are some experts who see anticonvulsants as “the promised land,” Cosio believes they come with some issues. “They are expensive,” he said. “And there are a lot of pills to take.”
Muscle relaxants should be used as an adjuvant therapy, according to Cosio. “They should not be first line,” he said.
Topicals like capsaicin and lidocaine can offer some relief in specific areas like lower back pain, Cosio added.
Regarding injectable steroids, Cosio was clear in his position. “We use a lot of injections in the U.S.,” he said. “This is not international practice. The evidence is not supporting how we are using them.”
Cosio voiced a similar opinion about surgical interventions. “Surgery is not the treatment for pain,” he said. Rather, surgery may be used to repair underlying anatomical issues that are causing pain, but he stressed that pain is likely to persist after surgery.
If there is a reliable way to mitigate pain, it is movement. “I have yet to meet a doctor who says that exercise is not effective for chronic pain,” he said.
The issue is not with efficacy, it is that many insurance carriers do not cover gym memberships and other types of exercise-based interventions.
Cosio then addressed the broad topic of complementary medicine and integrative health, first noting that this is the new nomenclature for what used to be called “alternative medicine.” He added that Americans spend some $50 billion a year in these approaches. “If we are spending that much money, I want to know why,” he said.
This $50 billion figure has important implications for rheumatologists, according to Cosio. “Whether you know it or not, your patients are using complementary and integrative health,” he said. “It would behoove rheumatologists to know about it.”
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Cosio D. Emperor’s New Clothes: Multimodal Engagement & Improving Access to Care. Presented at: Congress of Clinical Rheumatology-East annual symposium; August 12-15, 2021 (hybrid meeting).