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Multifaceted nature of pain in rheumatology requires pharmacologic, nonpharmacologic strategies
Elena Schiopu, MD, is an associate professor in the division of rheumatology at Michigan Medicine. She spoke with Healio about the rheumatologist’s role in pain management, the strategies used to address pain in patients with rheumatologic diseases and the unmet needs that patients and physicians face.
Can you describe the evolution of the rheumatologist’s role in pain management, from the description of “pain as the fifth vital” to now?
Pain is a constant concern in rheumatology clinics. It is an essential element of the patient-reported outcome measures (such as HAQ-DI or the Clinical Disease Activity Index), a substantial portion of our own assessment of the patient’s quality of life and one of the most reported chief complaints for our patients. Rheumatologists were initially “musculoskeletal” specialists, so any type of joint, tendon or muscle pain was our area of expertise. Initially – more than 2 decades ago, prior to the “modern era” of biologics and advanced immunological knowledge – our actions as healers were limited to exercise and rest, icing/warming the painful area and NSAIDs. Now, we’ve evolved to being “immunologists” and are able to manipulate the inflammatory burden, therefore addressing some of the pain that is defined as “inflammatory.” We also – and I think this is the most groundbreaking step in our evolution as far as “pain as the fifth vital” is concerned – learned about the multifactorial nature of pain and the relative contribution of central pain or central pain sensitization is to the patients’ overall pain complaint. “Fibromyalgia-ness” is not only present in patients with fibromyalgia syndrome, but also in the majority of inflammatory conditions as well. It does not respond to peripheral pain medications, or to immunosuppression, but it certainly contributes to the health care utilization burden and remains an important source of medical disability claims.
How is pain management structured in rheumatology?
Few other symptoms are as frustrating for both patients and rheumatologists as pain is and continues to be. While the immune manipulation armamentarium has evolved and sprawled, the pain interventions are stagnant. Pharmacological interventions are limited to NSAIDs, narcotics and central pain drugs, such as gabapentinoids and antidepressants. The non-pharmacological interventions, including physical therapy, multimodal pain strategies, cognitive behavioral therapy or mindfulness-based techniques, are dependent on individual motivation; they may also be cost-prohibitive or limited by access because of insurance benefits and providers. Rheumatologists are particularly limited in our interventions.
Additionally, a significant number of patients have pain from different conditions that require different pain strategies. For degenerative arthritis, NSAIDs and physical therapy would be indicated. For inflammatory arthritis, such as psoriatic arthritis or rheumatoid arthritis, immune modulation would be the solution. There’s also central pain sensitization, for which all of the above strategies have limited value. Figuring out the relative contribution of each type of pain to the overall pain burden could help customize the pain intervention, but our tools to accomplish that are also still under development. For example, though we can use self-reported measures to diagnose central pain, such as fibromyalgia, we cannot state that it represents 80% of the overall pain; further, we could only diagnose it if “no other condition” could explain the pain.
There is also the issue of a growing pain prevalence in the U.S. along with the increased regulatory burdens that limit clinicians’ face-to-face time with patients, which have resulted in widespread prescribing of narcotics. While there is still great debate about which patient is “fit” for narcotics, we noticed that, in general, musculoskeletal pain is not as responsive to narcotics, inflammation is not reduced and central pain gets worse, through hyperalgesia. I doubt there are patients in our clinics who would meet the cost – addiction, constipation and cognitive impact – vs. benefit ratio – modest pain relief in some patients – to justify narcotic use.
What nonpharmacologic strategies help manage pain?
Many nonpharmacological strategies exist. These strategies include exercise, from aerobic exercise that could reduce both mental stress, which acts as a pain amplifier, and inflammatory burden, to specific regional exercises. The use of local hot and cold therapy or other modalities that are used in physical therapy is another option. All of these are helpful, but they all require motivation, which is an important factor, and insurance benefits that cover physical therapy. I am personally a big fan of cognitive behavioral strategies, but there are very few psychologists available. Those who are usually work in large universities and insurances don’t routinely cover this strategy.
A significant percentage of knee pain could be reduced with weight loss if obesity is present – a 10% weight loss leads to a 50% reduction in pain – but that is another topic that is difficult to discuss and likely to create tension in the doctor-patient relationship. Intra-articular steroids, a decades-old intervention, is simply palliative – and possibly harmful.
Another issue is that “pain as the fifth vital” has been such a touted focus in U.S. health care that patients have grown to expect 100% resolution of their pain. Sometimes, that belief interferes with our ability to suggest non-pharmacological interventions; as physicians, we are expected to treat the pain, but we want to focus on the entire patient.
What are the greatest unmet needs regarding pain management for these patients?
I think a paradigm shift is needed in which both patients who experience pain and physicians who treat pain must accept that not all pain can be addressed. There is some pain that one must learn to tolerate or figure out how to prevent from interfering with quality of life. While there is no doubt that we need better pharmacological interventions, all drugs have side effects. I was excited about the interesting mechanisms of some of the nerve growth factor inhibitors and biologics for pain, but they come with the harsh price of neuropathic joints, much like the issue that patients with diabetes have. There is no free ride in pain pharmacology.
However, there is hope, as there is increased awareness of preventive strategies and adequate pain measurements that tease out the relative contribution of various forms of pain, whether it be nociceptive, neuropathic or central. More effort is also being put into moving away from narcotics and toward self-efficacy measures and non-pharmacological treatments.
Disclosure: Schiopu reports no relevant financial disclosures.