Pain Management in Rheumatology

Hello, I'm Christine Stamatos. I'm talking to you from Long Island, New York. I'm a nurse practitioner with Northwell Health and I have been running a fibromyalgia wellness clinic. So, I'm here — I was asked to talk about managing chronic pain in rheumatic disease. So, what I'm going to do today is I'm going to give you some highlights. I'm going to give you sort of my approach, my philosophy to approaching patients in rheumatology with rheumatic disease.

I want you to just stop and think for a second. I'm going to go through a slew of patients that you probably see in any given day. 37-year-old with severe foot pain and swelling, had a sudden onset, severe, third time in the past year, but only one joint involved. Another patient that day, 35-year-old with pain and fatigue all over. Severe morning stiffness, trouble using hands, swelling diffusely. Yet another patient on your schedule, 65-year-old with knee pain and fatigue. Pain is worse at the end of the day. A 24-year-old with a large swollen red hot knee and trouble walking. A 53-year-old that comes into the office with widespread pain, fatigue, and discognition everywhere.

These are very typical patients that we see in our day. And how we approach them, as you can tell, is likely going to be different. No two patients are going to be the same, but how we approach them should be the same.

I'm going to also talk — I wanted to give you a little bit of epidemiology. And as we work in rheumatology, we see patients with various conditions. Osteoarthritis — 16% of people with osteoarthritis live with chronic pain. 21 to 55% of patients with rheumatoid arthritis live with chronic pain. 36% of lupus patients live with chronic — I'm sorry, chronic pain. Scleroderma — up to 70% of patients live with chronic pain. And in the spondyloarthritides we don't have an exact number because of the diversity, but we know it takes upwards of 10 years to acquire a diagnosis, so we believe it's probably 50 to 70% of patients that live with these diseases have chronic pain.

And so how do we manage these patients? What is the best approach to make? And I think of Maslow's hierarchy, if you remember that from your days back in school. And for the most part, you have to address those physiologic needs at the bottom. And the physiological needs are taking care of — ensuring that you're addressing any inflammation, sleep, and mood. If you don't do those three things, you'll never be able to manage anyone's pain. We'll do that through a variety of disease-modifying agents, but often it's also some behavioral health issues and again, behavioral strategies in general.

So targeted pain management — the first thing you have to do is identify inflammatory versus non-inflammatory. Obviously inflammatory we're going to treat in one direction, non-inflammatory in another. So make sure that you do your basic labs looking for systemic inflammation.

Then we need to address sleep. So, every patient should be asked about their sleep. Do they have trouble falling asleep, staying asleep? If they have trouble falling asleep, what's the problem? Is it that they can't stop their mind? Or is it because they have too much myofascial pain, for example, in their upper back or neck or their lower back? Or do they have terrible joint pain that needs to be addressed? And then if you've figured out what the issues with falling asleep are, you need to then ask about, well, do you have any trouble staying asleep? And again, you want to ask why do you have trouble falling or staying asleep? If the issues are addressed and there's no trouble falling and no trouble staying asleep, but people say that they have non-restorative sleep, then you need to start thinking about sleep apnea, either central or obstructive sleep apnea.

So, we really need to tackle that sleep because even if you do everything right with regards to managing someone's inflammatory arthritis, but you don't address their sleep, fatigue will be severe and that will contribute to pain, and pain will be more significant than it should be even after you've controlled all the inflammation.

Sleep hygiene — I did just want to touch on that. Don't ever forget talking to your patients about sleep hygiene. I won't have time to go into it any more than that, but remember that the biggest issue that people have with sleep hygiene is that they use their phones or TVs right before bed. So tell your patients they should be avoiding any screen time for 30 to 40 minutes before sleep.

Next, I just want to make sure that you all address mood issues. So again, even if I control someone's inflammatory condition, if I have not addressed a mood problem, they're still going to end up complaining of chronic pain. So again I want to give you some of the epidemiology. So in rheumatic diseases we know that 21 to 83% of patients have some
depression. Um, 18 to 60% of people have anxiety and 30 to 50% of people have both, and up to 23% of our patients have PTSD. 21% of our patients have bipolar disease and up to 25% of our patients have substance abuse disorder. So there's lots of issues to consider. I would encourage you to make sure that you're having a PHQ or some kind of a depression assessment and some kind of an anxiety assessment for all of your patients at least once a year and with any significant change in treatment.

And then again, when I'm thinking about chronic pain, it's just I can't emphasize enough. It's more than just a scale of 1 to 10, a visual analog scale. In addition to the mood and the sleep issues, you have to identify whether there's other social determinants of health that need to be addressed. And I'm going to go through a little bit about that in showing you two patients that I sort of have tried to highlight to pull out these issues.

Next, you also want to ask about the impact of the pain on someone's quality of life. So if they say that they've got severe horrible pain, but they're still able to go to work and they're functioning, still able to socialize, still able to enjoy life, that's very different than the person who says that they have severe pain and they're stuck in bed and they haven't gone to work in the last two weeks. Those are two very different levels of pain. And it's important to understand the difference between the two. It's also important to get a family history, a trauma history, a full medical history as well.

So let me just give you two examples of patients. One is a 48-year-old with a BMI of 68 with widespread pain all over, came into my clinic with untreated psoriasis and hydronaiva, severe tricompartmental osteoarthritis of the knee, severe sleep apnea, works from home and is married happily.

And then a second patient — and again, as I'm talking about these patients I want you to think about all the different things that are probably going on with them. In the second case, it's a 54-year-old again with a BMI that's high at 48. She describes severe burning pain everywhere, stiffness and fatigue. She has poorly controlled psoriatic arthritis, type 2 diabetes and bipolar disease. She has a peripheral neuropathy. She's on disability for behavioral health issues, huge financial stressors, she has restless sleep, her husband is in jail at the time, and she doesn't drive. So if you think about how am I going to take care of these patients' pain, I have to think about so many different factors to get their pain under control.

I did want to highlight what to think about when you're worried about people who may go on to develop chronic pain and some of the modifiable and nonmodifiable factors. So nonmodifiable factors — we know women and of younger age, poor socioeconomic background, if there's a genetic history of chronic pain in the family, certain attitudes and beliefs. I don't know if you've ever heard of catastrophic thinking, but people who have catastrophic thinking tend to have a little bit more pain, history of abuse — so these are nonmodifiable causes for chronic pain.

And then there's a whole slew of modifiable causes. Let me just quickly go into the pain-prone phenotype. And I wanted to do this because I think it's important that you identify who your pain-prone patients are, because you want to really be aggressive at addressing all the different components of their pain in order to get them under control, so that they're not living with chronic pain despite taking care of whatever other condition they may have. So females, genetics, early life trauma — I can't emphasize enough, early life trauma is associated with a centralized pain processing problem — cognitions, as I mentioned the catastrophizing, and then exposures to certain stressors, psychological stressors, and often having a disease in one of our rheumatic diseases is something enough to turn some of these pain conditions on.

So my philosophy for pain is to: recognize that you have to identify the primary etiology of the pain, you have to understand that pain is individualized, and you have to understand that it doesn't take one pill to fix a problem. It's an armamentarium of approaches. And it's often a multitude of different strategies at any given time that it's going to take to get the pain under control.

The other really important point that I want to make — and this is sort of stating the obvious, and most of us know it — but the therapeutic relationship that you establish with your patients is probably as important, if not more important, than almost anything else that we can do for them.

I did want to just talk about briefly how hard it is to study pain. As you can imagine, I've just given you all these different reasons for problems in assessing and treating pain. And it's
because it's so diverse. As a result, it's hard to study pain, and studying pain has been a problem for years because of the heterogeneity of the patients, the multiple comorbidities. The fact that for most drugs, for example, you want to have a washout period, and that's hard to do in somebody who's living with chronic pain. Monotherapy is often a difficult thing to do, and almost all pain studies don't follow somebody past 12 months. So these are some of the challenges in being able to study chronic pain or pain in general.

I do want to make sure that you understand that there are different types of pain, and each different type of pain is treated in a different way. Right? So you have nociceptive pain, you have neuropathic pain, and you have hypersensitivity. The current term is nociplastic pain. Nociceptive pain is that immediate stimuli is triggered — the message goes to the brain, it says there's pain here. Nociceptive pain is inflammatory pain, bone fracture pain. Those are acute pain conditions that respond very well to anti-inflammatories and analgesics.

Neuropathic pain is when nerves are disrupted. So carpal tunnel syndrome, diabetic peripheral neuropathy, lumbar radiculopathy, any kind of nerve pain that's disrupted. Shingles is another example of neuropathic pain. And the way that we treat neuropathic pain is often different. Neuropathic pain does not respond as well to your standard analgesics, anti-inflammatories, even opiates. It responds far better to the gabapentinoid type of agents and some of the different CNS pharmacotherapy for psychiatric issues.

And then lastly, we have nociplastic pain or centralized pain. So this is when the pain processing has been completely disrupted and messaging is getting up to the brain at an excessive level, and then being able to modify that pain is disrupted for a whole number of reasons. And there's lots of really interesting information about that. But I just want you to understand that how we treat each of those different states does vary as well.

And if I go back to those two case studies, both of the case studies I mentioned to you are mixed pain states. So you have in the first case study somebody who had the psoriasis that had never been diagnosed. She in turn had a case of inflammatory arthritis that was not being treated. She also has severe OA, tricompartmental. So those are nociceptive — sorry — nociceptive pain states, and as a result of living with that for a number of years she's gone on to develop a centralized pain or nociplastic pain state. And so how we're going to treat that is going to be different. And then in the other patient you had again a poorly controlled inflammatory state that needed to be addressed, and she had multiple behavioral health issues that needed to be addressed, and then the chronic stress was impacting her pain as well.

I really — probably if you walk away from anything else — it's going to be this tire analogy. Living life with chronic pain is like driving your car with your tires flat. This is not an analogy I came up with, but I've sort of morphed it. Penny Cowan is the founder, I should say, of the American Chronic Pain Association, and she describes that living with chronic pain is like driving your car with your tires flat. And when I talk to my patients I tell them you have to fill all four tires.

One tire is medical treatments. It's what we can do for you — drugs, injections, interventions. But that's only one tire. And if that's the only thing that you focus on, you're still probably not going to move smoothly through life.

The second tire is your physical strength and endurance. So that's the strength that you have in your body, the muscles that you maintain, the food you put into your body, the weight you maintain, the sleep that you get. It's your ability to restore your body. So if all of those different issues aren't being addressed, that's a whole tire that's flat.

The third tire is your social worth and value in this world and the need to make sure that you maintain that social value. It's the ability to still find joy in your relationships with other people. It's feeling like you're making a difference on the planet. So that's a whole tire.

And then the last tire is your own personal strategies — the ability to change the way you're thinking if you start thinking in a negative way, or the ability to pace yourself when you know you don't have the energy to get through a day and do what you used to do before you had a chronic pain condition. So these four things have to be addressed to run smoothly through life.

And when I talk to my patients, I say, "You're coming to us. We are going to help give you some direction, but it's really on you to be able to move forward to make these things happen for your life so that your
pain is controlled." And when it comes to pharmacotherapies, there are not any one drugs out there that fixes your problems. Um, you know, patients always ask me or people ask me all the time, how do you take care of fibromyalgia patients? What's your treatment approach? My treatment approach is very much an individualized approach based on all the questions I've already talked to you about. So no two patients are the same. Again, you need to identify if there's an inflammatory issue and treat that appropriately with DMARDs. You need to identify if there's a sleep problem and treat that ideally with nonpharmacologic therapies. But when that's not working, sometimes you need a bridge and use pharmacotherapy. Um, you need to treat any mood disorders. You need to also think about any GI or GU problems. So if someone has, you know, IBS and that's what's keeping them up at night, you need to maybe focus on ways to treat the IBS. If their problem is an interstitial cystitis and they have to void for, you know, five or six times at night, you need to treat that problem.

Um, and then pain, there's a whole slew of medicines that we can use very specifically for analgesia. There are also multiple interventional techniques that we have. Um, trigger point injections for muscles that are tense, and teaching patients how to do self-management for trigger points is also really important. Joint injections, tendon sheath injections, epidurals. Um, these are all different types of interventional strategies we use every day to manage chronic pain.

And then I just can't emphasize enough our need to be able to share with patients that there's lots they can do for themselves. So, there's uh wonderful sites for information about self-management for chronic pain. I've listed a couple of books on here. You can't see my slides, but um there's a new book that came out in 2024 that I absolutely love. It's called the Chronic Pain Reset Book, and that was written by Dr. Afton Hassett. She's a psychologist, a pain psychologist at the University of Michigan. University of Michigan is where most of the — some of the best science is coming out on chronic pain, and she's taken everything that she's learned over her career and put it into this book which is user friendly. It goes through case studies and then has um exercises for you to do to help learn what kind of strategies are going to work for me to help manage my pain.

Um, I also can't emphasize enough how helpful apps can be. So there's the Calm app, Insight Timer, and 10% Happier. These are just three of my favorites. There are over 350,000 apps, but these apps often can be used. I find that they're very very helpful for people that have issues with sleep. Um, you know, trouble falling or staying asleep. Using some of these different apps and listening to bedtime music or bedtime stories is often very helpful.

And then another resource I wanted you to walk away with is the University of Michigan's pain guide. So, if you go to their website, their pain guide gives patients self-management strategies. Um, you can also go to the Department of Health, which has a whole um self-management approach for chronic pain.

And I hope that I've given you sort of a broad overview. And the key that I wanted you to walk away with today is understanding that pain treatment is based on a diverse and complicated but easily attainable um evaluation of a patient in order to individualize the care that's needed for them. I thank you for your attention and if you have further questions, RheumNow is loaded with lots of good information and studies about any number of the things I've talked about today.