Pain mechanisms for the practicing rheumatologist.

Pain in rheumatic diseases transcends the traditional nociceptive paradigm, incorporating complex interactions between nociceptive, neuropathic, and nociplastic mechanisms, as well as significant psychosocial factors. Advances in understanding chronic pain highlight the role of peripheral and central sensitization, and the emergence of nociplastic pain-a result of altered central nervous system processing. This modern perspective acknowledges the influence of mood disorders, environmental stressors, and cognitive patterns like catastrophizing, revealing the intricate interplay between biological, psychological, and social determinants of pain. Research emphasizes the brain's pivotal role in pain perception, underscoring the importance of comprehensive approaches that integrate medical, psychological, and social interventions to address the multifaceted nature of chronic pain in rheumatic diseases effectively.

Problems with opioids beyond misuse.

The U.S. is grappling with an opioid epidemic, with millions of adults on long-term opioid therapy (LTOT). Although patients often report pain relief and improved daily function with opioids, research shows no significant differences in short-term outcomes between opioid and non-opioid users, as well as no long-term opioid benefits. This scoping review aims to identify lesser-known side effects of long-term opioid use and increase awareness of them, allowing healthcare providers and patients to better assess the risks and benefits of opioid use. Our data search from PubMed and Google Scholar used keywords related to opioids, chronic pain, hypogonadism, endocrinopathies, cancer progression, cardiovascular events, renovascular events, sleep disturbances, mood disorders and others, narrowing down to English-language full articles published from January 2018 to April 2023. This review emphasizes the probable serious adverse consequences of long-term opioid use on various body systems in patients with chronic pain. Given the lack of long-term benefits and significant adverse effects, our review underscores the critical need for healthcare providers to include these risks in discussions with patients when considering the long-term use of opioid therapy.

Practical approaches for clinicians in chronic pain management: Strategies and solutions.

Effective management of chronic pain necessitates multidisciplinary approaches including medical treatment, physical therapy, lifestyle interventions, and behavioral or mental health therapy. Medical providers regularly report high levels of stress and challenge when treating patients with chronic pain, which recur in part due to improper education on contributors to pain and misalignment in patient and provider goals and expectations for treatment. The current paper reviews common challenges and misconceptions in the setting of chronic pain management as well as strategies for effective patient education and goal setting related to these issues. The paper also outlines key aspects of provider burnout, its relevance for medical providers in chronic pain management, and recommendations for burnout prevention in navigating issues of patient education and treatment planning.

Cost-related prescription non-adherence and patient-reported outcomes in systemic lupus erythematosus: The Michigan Lupus Epidemiology & Surveillance program.

OBJECTIVES: Medication access and adherence play key roles in determining patient outcomes. We investigated whether cost-related non-adherence (CRNA) to prescription medications was associated with worse patient-reported outcomes in a population-based systemic lupus erythematosus (SLE) cohort. METHODS: Sociodemographic and prescription data were collected by structured interviews in 2014-2015 from patients meeting SLE criteria in the established Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We examined the associations between CRNA and potential confounders such as sociodemographics and health insurance coverage, and outcome measures of SLE activity and damage using multivariable linear regression. RESULTS: 462 SLE participants completed the study visit: 430 (93.1%) female, 208 (45%) Black, and mean age 53.3 years. 100 (21.6%) participants with SLE reported CRNA in the preceding 12 months. After adjusting for covariates, CRNA was associated with both higher levels of current SLE disease activity [SLAQ: ß coeff 2.7 (95% CI 1.3, 4.1), p < 0.001] and damage [LDIQ ß coeff 1.4 (95% CI 0.5, 2.4), p = 0.003]. Race, health insurance status, and fulfilling Fibromyalgia (FM) Survey Criteria were independently associated with both higher (worse) SLAQ and LDIQ scores; female sex was further associated with higher SLAQ scores. CONCLUSION: Patients with SLE who reported CRNA in the previous 12 months had significantly worse self-reported current disease activity and damage scores compared to those not reporting CRNA. Raising awareness and addressing barriers or concerns related to financial implications and accessibility issues in care plans may help to improve these outcomes.

Identifying and Managing Nociplastic Pain in Individuals With Rheumatic Diseases: A Narrative Review.

Chronic pain is a burdensome and prevalent symptom in individuals with rheumatic disease. The International Association for the Study of Pain classifies pain into 3 descriptive categories: nociceptive, neuropathic, and nociplastic. These categories are intended to provide information about the mechanisms underlying the pain, which can then serve as targets for drug or non-drug treatments. This review describes the 3 types of pain as they relate to patients seen by rheumatology health care providers. The focus is on identifying individuals with nociplastic pain, which can either occur in isolation as in fibromyalgia, or as a comorbidity in individuals with primary autoimmune conditions, such as rheumatoid arthritis and systemic lupus erythematosus. Practical information about how rheumatology health care providers can approach and manage chronic pain is also provided.

Fibromyalgia and centralized pain in the rheumatoid arthritis patient.

PURPOSE OF REVIEW: Individuals with rheumatoid arthritis (RA) have traditionally been characterized as having nociceptive pain, leading to the assumption that effective immunosuppression should be enough to provide effective pain management. However, despite therapeutic advancements providing excellent control of inflammation, patients continue to have significant pain and fatigue. The presence of concurrent fibromyalgia, driven by augmented central nervous system processing and largely unresponsive to peripheral therapies, may contribute to this pain persistence. This review provides updates on fibromyalgia and RA as relevant for the clinician. RECENT FINDINGS: Patients with RA have high levels of concomitant fibromyalgia and nociplastic pain. The presence of fibromyalgia can lead to higher scores on disease measures, erroneously indicating that worse disease is presently leading to the increased use of immunosuppressives and opioids. Disease scores that provide a comparison between patient-reported and provider-reported and clinical factors may be helpful to indicate centralized pain. IL-6 and Janus kinase inhibitors, in addition to targeting peripheral inflammation, may provide pain relief by acting on peripheral and central pain pathways. SUMMARY: Central pain mechanisms that may be contributing to pain in RA are common and should be distinguished from pain directly arising from peripheral inflammation.

Recommendations for the Use of Nonsteroidal Anti-inflammatory Drugs and Cardiovascular Disease Risk: Decades Later, Any New Lessons Learned?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most prescribed pharmacologic therapies worldwide due to their therapeutic analgesic efficacy and relative tolerability. In the past several decades, various cardiovascular (CV) adverse events have emerged regarding both traditional NSAIDs (tNSAIDs) and cyclo-oxygenase 2 (COX-2) selective (coxibs). This review will provide an updated report on the CV risk profile of NSAIDs, focusing on several of the larger clinical trials, meta-analyses, and registry studies. We aim to provide rheumatologists with a framework for NSAID use in the context of rheumatologic chronic pain management. Recent findings: In patients with and without CV diseases, the use of NSAIDs, both tNSAIDs and coxibs, is associated with an increased risk of adverse CV events, myocardial infarction, heart failure, and cerebrovascular events. These CV risks have increased within weeks of coxib use and higher doses of tNSAIDs. The risk of adverse CV events is heterogenous across NSAIDs; naproxen and low-dose ibuprofen appear to have lower increased CV risk among NSAIDs. A variation in CV risk is associated with multiple factors, including NSAID class, COX-2 selectivity, treatment dose and duration, and baseline patient risk. Summary: Many important questions remain regarding the safety of NSAIDs and whether the culmination of research performed could inform us whether specific patient subtypes or NSAID class may have a more favorable profile. tNSAIDs such as naproxen and low-dose ibuprofen may have a lower CV risk profile, while coxibs have a more favorable GI risk profile. In general, any NSAID can be optimized if used at the lowest effective dose for the shortest amount of time, especially among individuals with increased CV risk.

Persistent hand pain despite adequate immunosuppression? The distinct value of occupational therapy in the era of biologics.

PURPOSE OF REVIEW: Despite the tremendous advancement in the use of biologics, many patients with inflammatory arthritis do not achieve remission, and the risk of joint damage remains high. A multidimensional approach to treatment is essential. Joint disease in the hands and wrists may prevent patients from performing daily and valued life activities. This review will discuss the role of occupational therapists in inflammatory arthritis, recent updates on joint protection and assistive devices, as well as highlighting adjunctive treatment options for rheumatologists to help patients manage their symptoms. RECENT FINDINGS: This article describes the meaningful role of occupational therapy and assistive devices in improving the outcomes for patients with inflammatory arthritis. We describe orthoses, assistive devices and adjunctive therapies utilized in inflammatory arthritis. We provide evidence supporting joint protection and occupational therapy as ways to help with these diseases. A multidisciplinary approach including the entire healthcare provider team, including occupational therapists, is essential to providing individualized treatment focusing on maximizing mobility in each patient's daily routine. SUMMARY: Although larger studies are needed, assessment by hand-certified occupational therapists for instruction in joint protection techniques, assistive devices and customized orthoses and devices are important adjuncts to pharmacologic management in inflammatory arthritis.

Pain Mechanisms in Patients with Rheumatic Diseases.

Patients with rheumatic diseases often have mixed pain states, with varying degrees of nociceptive, neuropathic, and nociplastic mechanisms, which exist on a continuum. When individuals with any chronic pain have a nociplastic component to their symptoms, they are less likely to respond to treatments (eg, injections, surgery, biologics, and opioids) that work better for acute or purely nociceptive pain.

Practical management strategies for benign hypermobility syndromes.

PURPOSE OF REVIEW: Patients with symptomatic hypermobility syndrome such as hypermobile Ehlers-Danlos syndromes (hEDS) and hypermobility spectrum disorders (HSD) commonly present to rheumatologists with joint pain and functional disability. Providers often have difficulty with diagnosis due to a lack of knowledge on the range of associated manifestations and the available therapeutic modalities. This review will discuss recent updates on diagnostic measures and treatment options for rheumatologists to help patients navigate hEDS/HSD. RECENT FINDINGS: This article describes newer diagnostic measures and assessment of hEDS/HSD manifestations. Evidence supporting physical therapy and occupational therapy is provided, as well as recent updates on assistive devices, compressive garments, orthoses, and surgical interventions. Given patient heterogeneity specific guidance about the amount and type of therapies required to produce a beneficial effect is lacking. Treatment should be individualized, and many of the studies focus on regional joint complaints rather than a whole-body approach. SUMMARY: Physical therapy and occupational therapy remain the cornerstone of treatment.

Access and Cost-Related Nonadherence to Prescription Medications Among Lupus Patients and Controls: The Michigan Lupus Epidemiology and Surveillance Program.

OBJECTIVE: Medication access and adherence are important determinants of health outcomes. We investigated factors associated with access and cost-related nonadherence to prescriptions in a population-based cohort of systemic lupus erythematosus (SLE) patients and controls. METHODS: Detailed sociodemographic and prescription data were collected by structured interview in 2014-2015 from participants in the Michigan Lupus Epidemiology and Surveillance (MILES) cohort. We compared access between cases and frequency-matched controls and examined associated factors in separate multivariable logistic regression models. RESULTS: A total of 654 participants (462 SLE patients, 192 controls) completed the baseline visit; 584 (89%) were female, 285 (44%) were Black, and the mean age was 53 years. SLE patients and controls reported similar frequencies of being unable to access prescribed medications (12.1% versus 9.4%, respectively; P was not significant). SLE patients were twice as likely as controls to report cost-related prescription nonadherence in the preceding 12 months to save money (21.7% versus 10.4%; P = 0.001) but were also more likely to ask their doctor for lower cost alternatives (23.8% versus 15.6%; P = 0.02). Disparities were found in association with income, race, and health insurance status, but the main findings persisted after adjusting for these and other variables in multivariable models. CONCLUSION: SLE patients were more likely than controls from the general population to report cost-related prescription nonadherence, including skipping doses, taking less medicine, and delaying filling prescriptions; yet, <1 in 4 patients asked providers for lower cost medications. Consideration of medication costs in patient decision-making could provide a meaningful avenue for improving access and adherence to medications.

Prescription Opioid Use in Patients With and Without Systemic Lupus Erythematosus - Michigan Lupus Epidemiology and Surveillance Program, 2014-2015.

Rheumatic diseases are a leading cause of chronic, noncancer pain. Systemic lupus erythematosus (SLE) is a chronic autoimmune rheumatic disease characterized by periodic flares that can result in irreversible target organ damage, including end-stage renal disease. Both intermittent and chronic musculoskeletal pain, as well as fibromyalgia (considered a centralized pain disorder due to dysregulation of pain processing in the central nervous system), are common in SLE. Opioids are generally not indicated for long-term management of musculoskeletal pain or centralized pain (fibromyalgia) because of lack of efficacy, safety issues ranging from adverse medical effects to overdose, and risk for addiction (1,2). In this study of 462 patients with SLE from the population-based Michigan Lupus Epidemiology and Surveillance (MILES) Cohort and 192 frequency-matched persons without SLE, nearly one third (31%) of SLE patients were using prescription opioids during the study period (2014-2015), compared with 8% of persons without SLE (p<0.001). Among the SLE patients using opioids, 97 (68%) were using them for >1 year, and 31 (22%) were concomitantly on two or more opioid medications. Among SLE patients, those using the emergency department (ED) were approximately twice as likely to use prescription opioids (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.3-3.6; p = 0.004). In SLE, the combined contributions of underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies already put patients at higher risk for some known adverse effects attributed to long-term opioid use. Addressing the widespread and long-term use of opioid therapy in SLE will require strategies aimed at preventing opioid initiation, tapering and discontinuation of opioids among patients who are not achieving treatment goals of reduced pain and increased function, and consideration of nonopioid pain management strategies.

Patient Concerns and Perceptions Regarding Biologic Therapies in Ankylosing Spondylitis: Insights From a Large-Scale Survey of Social Media Platforms.

OBJECTIVE: Few studies have examined ankylosing spondylitis (AS) patients' concerns about and perceptions of biologic therapies, apart from traditional surveys. In this study, we used social media data to examine the knowledge, attitudes, and beliefs of AS patients regarding biologic therapies. METHODS: We collected posts published on 601 social media sites between January 1, 2016 and April 26, 2017. In each post, both an AS keyword and a biologic were mentioned. To explore themes within the collection of posts in an unsupervised manner, a latent Dirichlet allocation topic model was fit to the data set. Each discovered topic was represented as a discrete distribution over the words in the collection, similar to a word cloud. The topics were manually reviewed to identify themes, which were confirmed using thematic data analysis. RESULTS: We examined 27,416 social media posts and identified 112 themes. The majority of themes (n = 67 [60%]) focused on discussions related to AS treatment. Other themes, including the psychological impact of AS, reporting of medical literature, and AS disease consequences, accounted for the remaining 40% (n = 45). In discussions regarding AS treatment, most topics involved biologics, and most subthemes involved side effects (e.g., fatigue, allergic reactions), biologic treatment attributes (e.g., dosing, frequency), and concerns about use of biologics (e.g., increased cancer risk). Additional implicit patient needs (e.g., support) were identified using qualitative analyses. CONCLUSION: Social media revealed a dynamic range of themes governing AS patients' experience with and choice of biologic agents. The complexity of selecting biologics from among many such agents and navigating their risk/benefit profiles suggests the merit of creating online tools tailored to support patients' decision-making with regard to biologic therapies for AS.

Quantifying the Twitter Influence of Third Party Commercial Entities versus Healthcare Providers in Thirteen Medical Conferences from 2011 - 2013.

INTRODUCTION: Twitter channels are increasingly popular at medical conferences. Many groups, including healthcare providers and third party entities (e.g., pharmaceutical or medical device companies) use these channels to communicate with one another. These channels are unregulated and can allow third party commercial entities to exert an equal or greater amount of Twitter influence than healthcare providers. Third parties can use this influence to promote their products or services instead of sharing unbiased, evidence-based information. In this investigation we quantified the Twitter influence that third party commercial entities had in 13 major medical conferences. METHODS: We analyzed tweets contained in the official Twitter hashtags of thirteen medical conferences from 2011 to 2013. We placed tweet authors into one of four categories based on their account profile: healthcare provider, third party commercial entity, none of the above and unknown. We measured Twitter activity by the number of tweet authors per category and the tweet-to-author ratio by category. We measured Twitter influence by the PageRank of tweet authors by category. RESULTS: We analyzed 51159 tweets authored by 8778 Twitter account holders in 13 conferences that were sponsored by 5 medical societies. A quarter of all authors identified themselves as healthcare providers, while only 18% could be identified as third party commercial entities. Healthcare providers had a greater tweet-to-author ratio than their third party commercial entity counterparts (8.98 versus 6.93 tweets). Despite having less authors and composing less tweets, third party commercial entities had a statistically similar PageRank as healthcare providers (0.761 versus 0.797). CONCLUSION: The Twitter influence of third party commercial entities (PageRank) is similar to that of healthcare providers. This finding is interesting because the number of tweets and third party commercial entity authors required to achieve this PageRank is far fewer than that needed by healthcare providers. Without safety mechanisms in place, the Twitter channels of medical conferences can devolve into a venue for the spread of biased information rather than evidence-based medical knowledge that is expected at live conferences. Continuing to measure the Twitter influence that third parties exert can help conference organizers develop reasonable guidelines for Twitter channel activity.

Is content really king? An objective analysis of the public's response to medical videos on YouTube.

Medical educators and patients are turning to YouTube to teach and learn about medical conditions. These videos are from authors whose credibility cannot be verified & are not peer reviewed. As a result, studies that have analyzed the educational content of YouTube have reported dismal results. These studies have been unable to exclude videos created by questionable sources and for non-educational purposes. We hypothesize that medical education YouTube videos, authored by credible sources, are of high educational value and appropriately suited to educate the public. Credible videos about cardiovascular diseases were identified using the Mayo Clinic's Center for Social Media Health network. Content in each video was assessed by the presence/absence of 7 factors. Each video was also evaluated for understandability using the Suitability Assessment of Materials (SAM). User engagement measurements were obtained for each video. A total of 607 videos (35 hours) were analyzed. Half of all videos contained 3 educational factors: treatment, screening, or prevention. There was no difference between the number of educational factors present & any user engagement measurement (p NS). SAM scores were higher in videos whose content discussed more educational factors (p<0.0001). However, none of the user engagement measurements correlated with higher SAM scores. Videos with greater educational content are more suitable for patient education but unable to engage users more than lower quality videos. It is unclear if the notion "content is king" applies to medical videos authored by credible organizations for the purposes of patient education on YouTube.