Chronic Overlapping Pain Conditions Common in People With Rheumatic Disease

Chronic overlapping pain conditions (COPC) are a common problem among people with rheumatic diseases according to a recent paper in ACR Open Rheumatology.

Of the 5,992 rheumatology patients included in the study, 846 had psoriatic arthritis (PsA), 2,605 had rheumatoid arthritis (RA), 956 had Sjögren syndrome, 975 had systemic lupus erythematosus, and 610 had systemic sclerosis. A range between 36-62% of patients in the study had a COPC diagnosis. Rates were higher among Black patients and those using public insurance. Patients with one or more COPC were more likely to report depression and anxiety, as well as more frequent emergency department visits, surgeries, and hospitalizations.

First study author Titilola Falasinnu, PhD, is an epidemiologist and assistant professor of medicine (immunology and rheumatology) with Stanford Medicine in California. She recently discussed the study and its findings with the Reading Room. The exchange has been edited for length and clarity.

What key question was the study designed to address and why?

Falasinnu: People living with autoimmune rheumatic diseases (ARDs) such as lupus, RA, and PsA face many health challenges -- including unpredictable disease flares and organ damage. Chronic pain often compounds these challenges, and often takes many forms including arthritis, headaches/migraines, and abdominal pain.

Scientists and clinicians do not fully understand the mechanisms that cause pain in autoimmune rheumatic diseases. Pain is one of the most under-addressed complaints in patients with rheumatic diseases. Pain researchers identified 11 painful conditions named COPCs, which include fibromyalgia, irritable bowel syndrome, and chronic low back pain.

As the number of COPCs increase in a patient, so does the likelihood of disability and psychological problems. COPCs are also associated with fatigue, mood, and sleep disturbances.

In this study, our goal was to estimate the burden of COPCs in patients with ARDs. This knowledge will be foundational in developing more effective management options for chronic pain in patients with ARDs and improve their quality of life and function.

How would you summarize the study's key findings, particularly related to people with PsA?

Falasinnu: Our findings suggest that COPCs are strikingly common among patients with rheumatic disease and are associated with lower quality of life and greater healthcare needs.

We found high prevalence of COPCs in all six ARDs that we studied. About 44% of patients with PsA were diagnosed with at least one COPC. The most common COPC was chronic low back pain, followed by migraine and fibromyalgia. In PSA, chronic low back pain was present in 30% of patients, migraines were present in 14% of patients, and fibromyalgia was present in 9% of patients.

You found evidence of a higher burden of COPCs among certain segments of the population. What did you find in this area?

Falasinnu: We found stark health disparities in the burden of COPCs among patients with rheumatic diseases. As expected, COPCs were more prevalent in women, because a few of these conditions can only occur in the female sex (e.g. vulvodynia and endometriosis). We also found higher prevalence of COPCs in older patients, Black patients, those with higher body mass index, and individuals on public insurance.

We need more research to understand the drivers of chronic pain in different patient populations, particularly women, racial minorities, and older individuals. We also need better understanding of the unique needs of different patient groups so that we can develop treatments and interventions targeted to those needs.

In light of these findings, what suggestions might you have for rheumatology practices?

Falasinnu: Millions of people have COPCs. We urgently need guidelines for the management of chronic pain in these conditions to address the individual needs of patients from a biopsychosocial perspective, where the physical and emotional well-being of patients are prioritized.

This requires an interdisciplinary approach where multiple specialties work in concert with the rheumatologists to address the complex needs of patients with COPCs.

Read the study here and expert commentary on the clinical implications here.