Yvonne C. Lee, MD, MMSc: Pain Mechanisms in Rheumatic Disease

In an interview with HCPLive Rheumatology, Yvonne C. Lee, MD, MMSc, associate professor of medicine (rheumatology) and preventive medicine (epidemiology) at Northwestern University, discusses her Congress of Clinical Rheumatology West presentation, “Pain Mechanisms in Rheumatic Diseases: Towards a Targeted Approach to Pain Management?” She explains how rheumatologists are focused on treating inflammation and the immune pathways, the targeted treatment approach, and promising advancements in pain research.

Yvonne C. Lee, MD, MMSc

Credit: IASP World Congress 2022

Can you provide a brief overview of the current state of pain management in rheumatic diseases?

Certainly, the current state of pain management in rheumatic diseases is still in its early stages. In rheumatology, our primary focus has been on treating inflammation and immune pathways, with the assumption that addressing these issues will also alleviate pain. In many cases, this approach works, as treating joint inflammation often leads to reduced pain. However, there's a significant proportion of patients who continue to experience pain despite successfully managing inflammation.

What are some common mechanisms underlying pain in rheumatic diseases?

The mechanisms underlying pain in rheumatic diseases are similar to those in pain categorization as a whole. The International Association for the Study of Pain classifies pain into 3 main categories: nociceptive pain, neuropathic pain, and nociplastic pain.

Nociceptive pain: This type of pain is akin to acute pain, such as when you injure yourself. In rheumatic diseases, nociceptive pain can arise from acute joint inflammation, where the pain serves as a protective mechanism.

Neuropathic pain: Neuropathic pain is caused by damage to nerves. Conditions like carpal tunnel syndrome or sciatica fall under this category.

Nociplastic pain: This is a newer classification, where pain isn't directly related to tissue or nerve damage but is thought to result from dysregulation in the central nervous system's pain regulation.

Your presentation mentions a targeted approach to pain management. Could you elaborate on how this approach applies to rheumatic diseases?

In rheumatology, we've been moving toward a targeted approach to treating rheumatic diseases in general. This approach involves understanding the specific pathways involved in diseases like rheumatoid arthritis (RA) and using medications that target those pathways. For example, we have biologics that block specific pathways, such as tumor necrosis factor inhibitors (TNFs) and interleukin-6 (IL-6) inhibitors. However, when it comes to pain management, particularly in the context of rheumatic diseases, the science of targeting pain pathways is less advanced.

While we have various painkillers like opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) that can address general pain, we haven't yet reached the level of targeting specific pain pathways as precisely as we have in treating the diseases themselves. Pain is a complex concept influenced by multiple factors and finding the right pathway or pathways to target can vary from patient to patient.

Are there any promising advancements or emerging treatments in pain research that you find particularly exciting?

Pain research has seen significant growth and interest over the past decade, and there are several exciting avenues being explored. One area of interest is non-pharmacologic interventions, especially in conditions like fibromyalgia and chronic pain. While these interventions may not be entirely new, their potential is being more thoroughly explored.

For instance, cognitive-behavioral therapy (CBT) has proven effective for certain types of pain. What's interesting is not just the intervention itself, but how it can be delivered. Can CBT be effectively delivered digitally or virtually to make it more accessible? Additionally, combining various interventions, such as CBT with graded exercise or sleep management, is gaining attention. The goal is to create multimodal treatment plans tailored to individual patients.

Are there any key takeaways that you’d like our audience to know?

It's important for rheumatologists to consider different types of pain, classify them into categories like nociceptive, neuropathic, or nociplastic, and understand which type predominates in a patient at a given time. Moreover, exploring non-pharmacologic therapies and finding ways to provide patients access to these treatments is crucial.

This transcript was edited for clarity.