Primary care physicians are at the forefront of fibromyalgia management, and deservedly so, a pain management expert said at a Meet-the-Experts Program entitled “Case Studies in Fibromyalgia: Connecting the Dots from Diagnosis to Pain Management” held in conjunction with PAINWeek 2008.
“That’s just as it should be,” moderator Kevin L. Zacharoff, MD, an anesthesiologist and pain management consultant in Setauket, New York, noted. He is also the co-author of “The PAINEDU Manual: A Pocket Guide to Pain Management.”
“While fibromyalgia patients may be referred to specialists like rheumatologists, neurologists, pain experts, and psychiatrists, it is primary care doctors who are best suited to manage most fibromyalgia patients,” he said.
Among the reasons:
— Primary care doctors (more often than specialists) have the requisite tools for assessing and treating fibromyalgia patients.
— Fibromyalgia is not a static condition but is characterized by symptoms that may peak and trough. No physician knows the patient better than the primary care doctor, who is responsible for the patient’s overall health care and has an ongoing relationship with the patient. The specialist, in contrast, manages only a “component” of the patient’s health care and has only a “finite” relationship with the patient. The primary care doctor is thus the best “point person” for this disorder.
— There is a shortage of specialists equipped to manage fibromyalgia.
In order to firmly establish the diagnosis of fibromyalgia, a variety of other conditions first need to be ruled out, Dr. Zacharoff noted. These conditions include rheumatologic and musculoskeletal disorders that can be excluded on the basis of objective measures such as imaging studies, laboratory testing, or physical examination. If these tests produce negative results, the primary care physician then relies on findings of the physical examination and patient history to make a diagnosis. These findings commonly include the presence of tender points at specified sites, such as the neck, back and shoulders, widespread pain, insomnia, fatigue, digestive discomfort, loss of appetite, increased sensitivity, and malaise.
“While these symptoms may point to a variety of other problems, what will ‘clinch the deal’ is the patient’s response to trials of various treatments (both pharmacologic and non-pharmacologic) directed at a diagnosis of fibromyalgia,” noted Dr. Zacharoff. “It is also important to recognize that a diagnosis of fibromyalgia is not usually possible during a single office visit but rather over the course of several visits,” he added.
When should a fibromyalgia patient be referred to a specialist? According to Dr. Zacharoff, the timing of a referral is fairly straightforward. “As with other medical conditions, patients should be referred when the limitations of the primary care physician have been surpassed,” he said. “For example, when the primary care doctor no longer feels comfortable treating the patient or when a long-term treatment plan agreed upon by the physician and patient is unsuccessful – these are a ‘flip switch’ that it’s time for a referral to a specialist.”
Finally, the noted pain expert called for increased physician education about fibromyalgia directed at medical students and practicing physicians. “Although pain is the most common reason patients schedule an appointment with their physician, pain management gets short shrift in medical school and afterwards in continuing medical education. It’s definitely an oxymoron.”
Overall, fibromyalgia affects an estimated 2% to 4% of the general U.S. population, which translates into about six million people. The condition is more common in women than in men and tends to increase with age.
The program was supported by Forest Laboratories. Additional panelists in the program included Bill McCarberg, MD, Founder of the Chronic Pain Management Program at Kaiser Permanente in San Diego, California and adjunct assistant clinical professor at the University of California, San Diego School of Medicine, and Brian Walitt, MD, assistant professor of medicine at Georgetown University Medical Center in Washington DC and Associate Director in the Section of Rheumatology at Washington Hospital Center.
Written by Jill Stein
Jill Stein is a Paris-based freelance medical writer.