Addressing arthritis pain without the opioids physicians 'love to hate'
SAN DIEGO — As the health care community moves away from opioids for pain management, a number of approaches may be set to fill the gap, according to a presentation at the 2019 Congress of Clinical Rheumatology West.
Jeffrey R. Curtis, MD, MS, MPH, of the University of Alabama at Birmingham, and a member of the Healio Rheumatology peer perspective board, described opioids as the drugs that rheumatologists “love to hate.” He addressed a host of topics pertaining to pain in rheumatology, from the relationship between disease and pain management to an overview of novel non-pharmacotherapeutic interventions.
“About two-thirds of our patients achieve DAS28 or CDAI remission, but they still have pain that routinely bothers them,” Curtis said. “Pain is not going away just because we have new and improved immune-based therapies.”
Curtis described a “gigantic amount of variability” from rheumatologist to rheumatologist with regard to opioid use, with data showing that 20% of patients in some practices receive them, compared with 80% of patients in other practices.
The question of efficacy also arose. “How well do they really work for long-term pain management?” Curtis said. “We have almost no data beyond 3 months. Why are people stuck on these medications for years and years?”
Pain measurement parameters may also be insufficient and, thereby, complicate pain management, according to Curtis. “A patient can choose three out of 10 on a visual analog scale, but your three may be different from my three,” he said.
With this in mind, novel methods for scoring pain are emerging. The NIH PROMIS Pain Interference Scale, the Widespread Pain Index (WPI), and symptom severity score all may have utility. “They are simple and can be deployed in clinics,” he said.
Looking beyond measurement, Curtis provided a review of some novel approaches to managing pain. Anti-nerve growth factor blockade is one potential method, along with vagus nerve stimulation. “With the vagal nerve approach, the side effects that we see with biologics or other pharmacotherapies are limited,” he said.
Although cannabis is gaining traction as legal impediments to its use are gradually being removed, a number of questions still remain. “We do not know what the biologic side effects are,” Curtis said. “The FDA has grudgingly acknowledged that CBD may be therapeutic, but, in general, the evidence is still not there yet.”
An additional concern for cannabis is the stigma surrounding its use. Despite the fact that many patients are using CBD and THC in their various forms, they often express unwillingness to discuss this with their clinicians for fear of being judged. “Rheumatologists must endeavor to maintain an empathetic relationship with their patients and avoid personal bias,” Curtis said.
As for additional modalities, Curtis suggested that mindfulness and meditation approaches should be considered. “We have seen evidence for short-term benefit,” he said.
In perhaps the most far-fetched idea, Curtis also said that virtual reality may have use in pain management. One simple approach is to use it to distract patients while changing the dressing on a wound.
“But we can also use VR to teach a patient how to do tai chi or yoga,” he said. He noted that many patients may live far from a place where these classes are taught, and that rheumatologists do not have time to instruct their patients in these techniques. “The pain reduction is mild, but if we can provide a patient with a 12-week course in yoga through a virtual reality machine, we may see some long-term lifestyle benefits.” — by Rob Volansky
Curtis JR. Changing trends in the use of opioids and other therapies for arthritis pain. Presented at: Clinical Congress of Rheumatology West. September 26-29, 2019; San Diego.
Disclosure: Curtis reports research grants and consulting fees from AbbVie, Amgen, BMS, Corrona, Janssen, Lilly, Myriad, Pfizer, Roche and UCB.