Managing pain should be more than ‘hammering patients with immunomodulatory medications’
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SCOTTSDALE, Ariz. — Understanding the science of pain can help rheumatologists better manage fibromyalgia and other chronic conditions, according to a presenter at the Basic and Clinical Immunology for the Busy Clinician symposium.
“Many rheumatologists just don’t want to deal with pain,” Philip J. Mease, MD, of the Swedish Medical Center and the University of Washington, in Seattle, told attendees. “They are really not taught to comprehensively understand pain.”
According to Mease, the common perception among many rheumatologists is that most pain is nociceptive, meaning that it comes from inflammation.
“We are beginning to learn that this is not true,” he said.
A better understanding, based on the current data, involves three types of pain, including nociceptive, neuropathic and nociplastic, according to Mease.
“These are the three key buckets of the pain mechanism,” he said.
Nociceptive pain is what most rheumatologists address when they think about the inflammation in the joints of their patients, Mease said.
“This is what we tend to think about,” he added.
Neuropathic pain, meanwhile, occurs when the nerve itself is damaged. It is most relevant to patients with fibromyalgia and requires the most explanation to rheumatologists, according to Mease.
Lastly, nociplastic pain is that which “arises from altered nociception despite no clear evidence of disease or lesion of the somatosensory system causing the pain,” Mease said, quoting the International Association for the Study of Pain definition.
This definition was amended in 2021 to consider comorbidities such as sleep disturbance and fatigue.
“When we think of fibromyalgia, we think of nociplastic pain plus sleep disturbance, fatigue, dyscognition and additional somatic symptoms,” Mease said.
Although nociplastic pain often underlies all fibromyalgia, Mease stressed that, at any time, a patient may experience any of the three types of pain.
According to Mease, further investigation of the neurological components of pain has revealed that many patients with fibromyalgia have continued activation of certain neural networks that signify pain to the brain.
“It was never at rest,” he said. “At a neurophysiologic, level they are intrinsically different than a normal individual.”
Consequently, rheumatologists should approach the management of chronic pain in a more complex way, Mease said.
“What we are trying to do is understand how much of the reduction in pain is occurring as a result of reduction in inflammation,” he said. “It is important for us to think beyond just hammering our patients with immunomodulatory medications.”
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Mease PJ. Advances in Fibromyalgia: Science and Care. Presented at Basic and Clinical Immunology for the Busy Clinician, Feb. 17-18, 2024; Scottsdale, Arizona (hybrid meeting).
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