Chronic pain in rheumatology: Is it a problem of mind or body?
Click Here to Manage Email Alerts
This month, our featured roundtable assembled an esteemed panel of experts on pain to help unravel the complexities we face with our patients who have chronic unresponsive pain, often in the setting of systemic immune-mediated disorders.
The discussion highlights the challenges of management and underscores the legacy of toxicity and dependency, the limitations of opioids and the need for new ways of thinking and addressing the problem.
Image: Adobe Stock
I want to add my perspective on one controversial issue in this arena, namely how we view such patients as having a condition — ie, chronic pain — that is either emanating from some form of physiologic issue of the body — inflammation, mechanical stress, etc. — or the mind — emanating from some sort of perturbation of psychologic health.
As most will readily appreciate, it is not such a simple dichotomy, and now fortunately we appear on the verge of a much greater understanding of chronic pain, so let me continue.
If you are speaking to rheumatologists about uncontrolled chronic pain in patients with inflammatory arthritis, such as in the setting of rheumatoid arthritis, lupus or psoriatic arthritis, most will analyze this by questioning what type of therapy they are on, inquire as to what the tender and swollen joint counts are, and what are the acute phase reactants. If these indices are controlled, there is often a natural inclination to ask whether the patient has fibromyalgia, which I feel is logical.
In the setting of concomitant fibromyalgia, such patients will also often display varying degrees of fatigue, disturbed sleep and complaints of “brain fog,” often accompanied by a history of intercurrent mood disorders. Although fibromyalgia commonly occurs in isolation, rheumatologists are aware that it is over expressed in patients with a variety of immune-mediated diseases.
Unfortunately, and not infrequently, the pain of fibromyalgia is too often viewed by practitioners and many in the lay public as “nonorganic” or merely residing in the mind.
In some minds, it reflects some sort of weakness or inability to put up with the viscosities of daily life that we all experience. With this background, I will begin by casting my opinion that this later belief is both reductionist and pejorative to those who suffer with such pain. I also hold that in light of growing evidence from the fields of neuroscience, psychoneuroimmunology and pain science, the answer is far more complex. Fortunately for all, we appear to be on the horizon of a new integrated view of fibromyalgia, or what those in the pain field now call nociplastic pain.
For an in-depth and elegant discussion of the science, history and unmet needs of this reality, please read The Song of Our Scars: The Untold Story of Pain, an outstanding exploration of the chronic pain conundrum by Haider Warraich, MD — as well as my review of the book.
The brain and immune system, as I tell my patients, make up one organ with bidirectional communications linking pain perception, mood, consciousness, autonomic neuroregulation and inflammation. All pain, and especially chronic pain and suffering, is processed and experienced in the brain. To ignore this is to diminish the reality of how we all can and do ultimately suffer.
Helping patients understand this reality is, in my opinion, the gateway to engagement in what they really need — namely, multidisciplinary integrated and holistic adjunctive therapy, along with aggressive treatment of any underlying immune-mediated disorder, for chronic pain. Although far from meeting our national health care needs, such programs are becoming increasingly available, with, most notably, an excellent working model seen within the Veterans Affairs health care system.
Once patients are expunged of guilt and shown empathy for their suffering, they become more open to a greater understanding of mind-body interplay and are relieved to hear and understand that it is in some way not their fault, or that they are merely stressed or depressed. It’s all about biology!
Finally, I want to highlight a recent and very important work on this subject by José A.P. da Silva, MD, PhD, and colleagues (reference below), which proposes a working hypothesis of an integrative bio-behavioral model accommodating the role of psychosocial stress, mood, inflammation, autonomic processing and beyond, not only for fibromyalgia but also many other poorly understood disorders, which co-associate with or mimic fibromyalgia, including myalgic encephalomyelitis/chronic fatigue syndrome and long COVID. I hope you read it and would love your feedback.
Yes, in the end, chronic pain and suffering is all in our head, but we need new and creative ways think about it, communicate it to our patients, and address it. That’s my take. What is yours? Please share your thoughts with me at calabrl@ccf.org or at rheumatology@healio.com.
- Reference:
- Pinto AM, et al. Nat Rev Rheumatol. 2022;doi:10.1038/s41584-022-00873-6.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Collapse
Read more about
Click Here to Manage Email Alerts