Philip Mease, MD: The Patient Experience and Pathways of Pain in Rheumatic Disease

In an interview with HCPLive, Philip Mease, MD, clinical professor at the University of Washington School of Medicine and Director of Rheumatology Research at the Swedish Medical Center in Seattle, discussed his Rheumatology Winter Clinical Symposium (RWCS) presentation, “State of the Art: Pain (simple title, complex issue).”

Pain, a key issue for patients with rheumatic diseases, is generally ranked as one of the top complaints of disease experience.

“Rheumatologists aren't very well-trained in how to diagnose or assess pain and how to manage it,” Mease explained. “In particular, everyone has been [concerned about] the narcotic treatment of pain issue and how bad it is. Oftentimes, rheumatologists fearful that they're going to get patient requests to prescribe a narcotic analgesic.”

Increasingly, rheumatologists are choosing not to prescribe opioids to patients and are able to control the underlying disease and using non-narcotic analgesics for disease management.

Mease also discussed neurophysiologic pathways, including ascending nociceptive pathways that are mediated by neurotransmitters. Fibromyalgia, for example, is characterized by a permanent increase on the nociceptive side and a decrease in the inhibitory neuropeptide side.

“The whole area has gotten more sophisticated with identification of multiple neurotransmitters and that are involved both at the peripheral paint processing mechanisms and the central pain processing systems, including the role of microglia, which are kind of like macrophages to the central nervous system that influence our pain experiences,” Mease explained.

In addition to neurochemical aspects, other factors, such as a patient’s reaction to stressors and psychosocial adaptation, also influence the experience of pain at the central nervous system level. Nociceptive and neuropathic pain vary among individuals and result in a mixture of the two.

“A young person with rheumatoid arthritis or psoriatic arthritis is going to have peripheral nociceptive input going on from their inflamed joints, but some of them are going to have a certain amount of increase of central nociplastic pain as well,” Mease emphasized.