• Tissue damage is not necessary for patients with rheumatic diseases to experience pain.
• Pain management in rheumatology requires a multimodal approach.

HUNTINGTON BEACH, Calif. — Rheumatologists should be open to antidepressant use or referral to psychiatry for patients experiencing chronic pain, according to a presenter at the Congress of Clinical Rheumatology West.

“Pain affects one in five individuals in the U.S. and is disabling for 8% of the population,” Traci J. Speed, MD, PhD, director of the Pain Treatment and Chronic Pancreatitis Pain programs at Johns Hopkins Medicine, told Healio in an interview. “Individuals with rheumatic diseases are more likely to experience pain than the general population, even when the disease is in remission. It is important to use a whole-person approach to complex pain because pain affects one’s whole life.”

According to Speed, pain is not merely a physical sensation.

“It is also the emotional response to that physical sensation,” she said. “The physical and emotional aspects of pain can negatively impact one’s occupation, relationships and identity.”

Tracking down the source of pain can be problematic for physicians, Speed added.

“Pain can be generated and amplified by many etiologies, especially in rheumatic diseases,” she said. “The arrows between mind and body go both ways. So, treating pain and improving patients’ quality of life involves addressing the underlying medical and psychiatric conditions that amplify pain.”

Quantifiable evidence of disease processes may not be necessary for patients to experience pain, according to Speed.

“Pain is a real disease and can occur with or without tissue damage,” she said. “Our nervous systems are intertwined, so complex pain management requires a neuromodulatory approach to reset the central, peripheral, autonomic and enteric nervous systems.”

The goals of pain management should include improving function, quality of life, longevity and comfort, Speed said. The tools used to achieve these goals can vary from patient to patient, and may include psychotropic medications like antidepressants, selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors.

Speed discussed these medications in the context of the relationship between depression and pain.

“Depression is a treatable disease that can amplify pain,” she said. “Although the treatment of depression and other psychiatric conditions is important in the management of pain, it is important for patients and physicians to remember that pain is not just a symptom of depression. Treating depression can help pain and treating pain can help depression.”

Efficacy of psychotropic medications can depend on several factors, including the patient’s condition, the type of medication used, access, adherence, the prescribing provider and sociocultural factors.

In the case of an inadequate treatment response, Speed suggested that referral to psychiatry may be necessary. A psychiatrist should also be involved if the patient experiences suicidal ideation, mood instability, or antidepressant-induced hypomania or mania.

“Pain is multifactorial and takes a multimodal interdisciplinary approach,” she said. “Treatment requires a comprehensive approach that identifies and addresses the multiple underlying causes and amplifiers of pain.”

Traci J. Speed, MD, PhD, can be reached at speed@jhmi.edu.