Some chronic pain can be managed without drugs

Pain is associated with stress, depression, anxiety, poor sleep, and an overall reduction in quality of life for many patients with rheumatic and musculoskeletal diseases. A panel of experts reviewed nonpharmacological options for managing pain on Saturday, Nov. 6, in Not Another Pill! Integrative Pain Management Approaches. This and other ACR Convergence 2021 sessions can be viewed by registered meeting participants through March 11, 2022.

When tailoring a pain management regimen for a patient, the rheumatologist should assess the individual’s needs, preferences, and priorities; pain characteristics; previous and ongoing pain treatment; and inflammation and joint damage, said Rinie Geenen, PhD, Professor of Clinical Psychology, Utrecht University, the Netherlands. Dr. Geenen was involved with the development of the European Alliance of Associations for Rheumatology (EULAR) recommendations for management of pain in inflammatory arthritis and osteoarthritis around a patient-centered framework.

“The focus should be on health-related quality of life such as well-being and functioning, not only as maintaining variables but also as outcomes of pain management interventions,” he said.

Shared decision-making should be used to establish a personalized pain management plan, he advised. Management options could include physical activity, assistive devices, psychological and social interventions, sleep hygiene practices, weight management, and pharmacological and joint-specific management. However, the quality of evidence supporting the effect some of these interventions have on pain, if available, is low to moderate, Dr. Geenen said, citing a need to improve the methodological quality of treatment outcome studies.

“Chronic pain does have a significant cost, and we need to keep that in mind when we deal with our patients,” said Christine Stamatos, DNP, ANP-C. “For the most part, over 50% of our patients with chronic pain suffer from fatigue and sleep disorders, 40-44% of people can’t think straight, and 20-30% of people suffer from anxiety and depression.”

Stamatos, Assistant Professor, Hofstra Northwell School of Graduate Nursing, and Director, Fibromyalgia Wellness Center, Division of Rheumatology, Northwell Health, used case studies to illustrate targeted therapies for addressing the cause of pain. When working with patients to identify pharmacologic and nonpharmacologic treatment for pain, she begins with Maslow’s hierarchy of needs.

“I tell them that unless we control your inflammation, your sleep, and your mood, nothing that we do is going to work,” Stamatos said.

Many people with chronic pain experience sleep disturbances such as disordered sleep waves and lack of refreshed sleep, she explained. More than 90% of patients with fibromyalgia report excessive daytime fatigue.

Stamatos recommended a four-pronged, patient-centered approach to pain management that addresses medical treatments; physical strength and endurance; social support and worth; and coping strategies and self-management.

“If you miss any one of those four elements, then you’re not going to be moving smoothly through life,” she said.

There is evidence-based support for behavioral interventions to manage pain. Afton Hassett, PsyD, Associate Professor of Anesthesiology, University of Michigan, outlined five of the most common: behavioral therapy, cognitive therapy, mindfulness-based therapies, acceptance and commitment therapy, and positive activity intervention.

“Psychiatric comorbidities are very common among rheumatologic populations — depression and anxiety — and these can be well treated with behavioral interventions,” she said. “Things that people think, like pain catastrophizing, or ways they behave, like fear avoidance, are also types of processes that can be addressed with behavioral therapies.”

Behavioral interventions also can be used to help patients more effectively cope with their disease, to address sleep problems, and to facilitate increased physical activity. Behavioral therapy is among the oldest of these interventions. The behavioral therapist’s toolkit includes relaxation strategies, exposure techniques, systematic desensitization, and problem solving.

“The main target for behavioral therapies is to increase functioning by decreasing behaviors that get in the way of a good functional status,” Dr. Hassett said.

Positive activity intervention is among the most recent additions to the armamentarium. A meta-analysis recently published in the journal Chronic Pain shows these approaches, which could include acts of kindness, savoring a beautiful day, and creating meaning in life, resulted in reduced pain intensity and negative emotions and increased positive emotions compared to controls.

“These can be powerful tools even though they seem fun,” Dr. Hassett said.