Steven A. King, MD, MS

After reading this article, clinicians should be able to identify the symptoms of fibromyalgia and have several options for distinguishing fibromyalgia from conditions with similar symptoms.

1. Recognize the difficulties in diagnosing fibromyalgia in the presence of mental disorders

2. Learn about the current recommendations for treating fibromyalgia

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Fibromyalgia (FM) is one of the most controversial diagnoses in the field of pain management. 

Some experts believe that it does not exist

 and actually represents an accidental or purposeful misdiagnosis of other conditions, while others believe that it is badly underdiagnosed.

The truth likely falls somewhere between these 2 extremes. FM is certainly a real syndrome, but it is also perhaps overdiagnosed, both because many physicians are unaware of the actual diagnostic criteria, and because there may be a desire to avoid diagnosing patients with other conditions that could explain the symptoms of FM—most notably mental disorders.

Over the years, the medical understanding of FM has evolved. It has gone from being viewed as a pain disorder to being considered a 

 that falls on a continuum, depending on the number and severity of the symptoms.

There are no universally agreed-upon definition diagnostic criteria for FM. At minimum, it is generally agreed that there is chronic pain spread throughout the body. However, even here there is some ambiguity. For example, the current 

International Statistical Classification of Diseases and Related Health Problems

 diagnosis for FM says it can be “an acute, subacute, orchronic” painful state, although it also describes FM as “a chronic disorder.”

What appears to have been the first attempt to develop formal diagnostic criteria was presented by 

 Because of the many competing definitions of FM that emerged over time, the 

American College of Rheumatology (ACR) sought to develop a clear set of diagnostic criteria

 The most significant criteria were that 1) generalized pain was present for at least 3 months; 2) the pain was present in at least 3 of 4 body quadrants; and 3) the patient had pain to pressure of up to 4 kg/cm2 as measured by an algometer at more than 11 of 18 points throughout the body.

The establishment of formal criteria resulted in FM being included as a diagnosis in the ICD in 1992. However, over the years, concerns grew about using these criteria, especially the identification of tender points, because it appeared that many physicians did not know how to accurately determine their presence or how much pressure to apply to elicit pain.

 The requirement for tender points was eliminated, and the ACR instead based the diagnosis primarily on 2 scales: The Widespread Pain Index (WPI) and the Symptom Severity scale (SS).

The WPI asks whether pain has been present during the previous week in 

 The SS scale consists of 2 parts: 1) asking about the presence and severity offatigue, waking feeling unrefreshed, and cognitive symptoms during the past week and scoring them on a 0 to 3 scale; and 2) asking about the presence of any of 41 potential symptoms, including depression, fatigue, constipation, diarrhea, rash, chest pain, and headaches during the previous week and adding the total number of symptoms to obtain a score.

American College of Rheumatology 2010 Diagnostic Criteria for Fibromyalgia

A diagnosis of FM requires either a WPI score ≥ 7 and SS ≥ 5 or a WPI between 3 and 6 and SS ≥ 7.

Since the development of the 2010 ACR criteria, the work group has published 2 revisions. The 2011 revision recommended 

 so that it could be self-administered by patients and not require physicians to determine the presence or extent of the severity of the pain.

 The 41-item checklist was replaced with a score representing the sum of scores for 3 items:headaches; pain or cramps in the lower abdomen; and depression symptoms. The authors created a fibromyalgia symptom scale that combined elements of the WPI and SS. It inquired about the locations of pain, the presence and severity of fatigue, the presence of pain or cramps in the lower abdomen, and the presence of depression and headaches.

The most recent suggested revisions were 

 The major recommended changes were that although FM could still be diagnosed with a WPI less than 7 and SS greater than 5 (the 2010 criterion), it could also be diagnosed with a WPI between 4 and 6 and an SS greater than 9. It also recommended adding criteria of generalized pain in at least 4 of 5 regions (leftupper, right upper, left lower, right lower, axial) with jaw, chest, and abdominal pain not included, and symptoms being present at a similar level for at least 3 months.

The greatest change in the 2016 revision was the recommendation that a diagnosis of FM should not require the exclusion of other illnesses that could present with similar symptoms.

These recommendations have yet to be formally adopted, and I have great concerns about allowing FM to be diagnosed along with other disorders that can cause widespread pain and other similar symptoms—most notably mental health disorders. I believe that FM is already overdiagnosed, and if it is diagnosed despite the presence of other conditions, then it could become the focus of clinical attention while other conditions that need to be treated may be largely ignored.

more recent proposal for diagnostic criteria

 was developed by ACTTION (an acronym for a public-private partnership of a study network for analgesic, anesthetic, and addiction and the US Food and Drug Administration [FDA]) and the American Pain Society (APS). It was published in 2019.

The ACTTION APS Pain Taxonomy criteria include (1) multisite pain defined as pain at 6 or more of a possible total 9 sites (head, left arm, right arm, chest, abdomen, upper back and spine, lower back and spine including buttocks, left leg, right leg); (2) moderate to severe sleep problems or fatigue; and (3) the pain and fatigue or sleep problems must have been present for at least 3months. Although the criteria note that the presence of another pain disorder does not rule out the diagnosis of FM, it does recommend a clinical assessment to evaluate for any condition that could account for the symptoms or contribute to their severity.

criteria for FM are largely descriptive, calling it “a chronic disorder of unknown etiology characterized by pain, stiffness and tenderness in the muscles of neck, shoulders, back,hips, arms, and leg. Other signs and symptoms include headaches, fatigue, sleep disturbances, and painful menstruation.” It also notes that it is characterized by “multiple points of focal muscle tenderness to palpation (trigger points)” and that “Fibromyalgia makes you feel tired and causes muscle pain and ‘tenderpoints.’”

Which set of criteria is the correct or best one remains an open question. When examining patients who I believe may suffer from FM, I have continued to examine for tender points in addition to using the WPI and SS scales. Mental disorders are possible etiologies for widespread pain but are commonly overlooked. With this in mind, I make sure to evaluate for their presence and donot, as is commonly done, simply write off depression and anxiety as only being due to the pain. Unfortunately, as most pain specialists in this country are anesthesiologists and FM has, for the most part, been considered the province of rheumatologists, careful evaluation for mental health disorders is likely to be rare.

The etiology of FM remains unclear. For decades, it was viewed as a musculoskeletal or rheumatologic disorder. More recently, it is being considered a neurologic disorder, in large part because the medications that were found to be most efficacious for treating FM were those that were also most effective for neuropathic pain syndromes.

The present thinking is that FM is most due to some form of central nervous system dysfunction, resulting in increased sensitization to pain.

 However, why it develops in certain individuals but not others largely remains a mystery.

Measurements of the prevalence of FM have varied because of the different diagnostic criteria used to diagnosis it. Estimates have varied from 

 Another major problem is that only about 25% of patients who report having FM have actually been diagnosed by a physician, and many of those who are diagnosed do not actually meet any formal diagnostic criteria for it.

, there is debate about the degree to which this is true.

 There is some concern that because women appear to be more likely than men to complain of pain to their health care providers, they are therefore more likely to receive the diagnosis.

There is also an ongoing debate about whether

 pain is taken less seriously in women than in men

 and whether women are more likely to be simply given the diagnosis of FM, rather than receiving a full work-up to determine the presence of any underlying conditions that might be causing the pain.

 Furthermore, the female-to-male ratio has varied widely depending upon which diagnostic classification has been employed.

Being middle-aged or older appears to increase risk. However, FM can occur at any age, and some reports suggest that a 

The presence of musculoskeletal disorders has also been reported to be a risk factor. However, there is the question of whether in at least some cases the symptoms of musculoskeletal disorders might be confused with those of FM. 

 include high body mass index (BMI), cigarette smoking, and performing heavy or repetitive work (

 (ie, each appears to be a risk factor for the other) between FM and migraine headaches, irritable bowel syndrome, gastroesophageal reflux disorder, and diabetes have been reported.

There are no objective tests to make the diagnosis of FM, so it is essentially a diagnosis of elimination, where other possible explanations for widespread pain are considered and ruled out. Because pain is such a common symptom, disorders of virtually every organ system can result in the 

Table 3. Conditions With Similar Presenting Symptoms

Many of these other conditions include symptoms that are not a part of FM and there are usually abnormalities on diagnostic tests. Notably, these include systemic inflammatory rheumatic diseases that, in addition to widespread pain, can present with 

 including skin rashes, vasculitis, and adenopathy, as well as with abnormal erythrocyte sedimentation rate and C-reactive protein, and joint abnormalities on radiographic imaging.

Endocrine and infectious disorders, including thyroid abnormalities and hepatitis C, also present with additional symptoms and can be diagnosed with laboratory tests.

. These include statins, opioids, chemotherapeutic agents, and bisphosphonates.

 If patients are taking any of these, the pain would be considered likely to be secondary and, depending on the severity of the pain, alternative medications would be considered if available for the primary condition.

The most difficult disorders to differentiate from FM are mental disorders that also cause widespread pain. Obviously, there are no objective tests to make these diagnoses, which means that clinicians must consider and weigh which diagnosis is the most likely.

Widespread pain is a common symptom of both depressive and anxiety disorders. Also, both are often accompanied by disordered sleep, which itself can result in the symptoms of FM in healthy individuals. Because many patients with chronic pain suffer depression as a result of the pain, FM can be a primary disorder with depression secondary to it.

The best way to differentiate FM from a mental disorder is to determine whether the mental disorder preceded the onset of the pain, or whether the patient has a family history of mental disorders that might make them more prone to developing these conditions.

One of the many as-yet-unanswered questions about FM is whether certain mental disorders might predispose patients to developing it. Of recent interest is an association between posttraumatic stress disorder (PTSD) and FM with underlying childhood abuse.

 As with depressive and anxiety disorders, pain itself can be a symptom of PTSD. It is unclear whether patients with symptoms of this disorder and pain only are suffering from this or also have comorbid FM.

Psychosocial stresses are possible contributing factors in the development of FM or in the exacerbation of its symptoms. These stressors are often overlooked and therefore not addressed.

As with most types of chronic pain, FM can be difficult to treat, but a number of therapies have been shown to provide benefit. A 

 identified several that appear to be effective.

 With regard to medications, the classes of medications that seem to be most beneficial for FM are the serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants and central nervous system depressants, primarily anticonvulsants.

 for their use based on controlled studies (

Table 4. Treatment Strategies for Fibromyalgia

This fits with the medications currently approved by the FDA for the management of FM: the SNRIs venlafaxine and milnacipran and the anticonvulsant pregabalin. It should be noted that other medications in the same classes, most notably the tricyclic antidepressants (TCAs), especially amitriptyline, and other anticonvulsant medications, especially gabapentin (a gabapentinoid likepregabalin), have been found to be beneficial.

Whether the FDA-approved medications are more efficacious than others with similar modes of action is an open question, as there is scarce research comparing the various medications to oneanother. Most of the studies demonstrating the efficacy of these other medications were performed after the drugs were no longer under patent, so there was minimal financial benefit for manufacturers to formally seek approval of these for treatment of FM.

Whether amitriptyline is more effective for FM than other TCAs is also unknown. The strong sedative effect of this medication, which may be beneficial for sleep problems experienced by many with FM, may provide some advantage over less-sedating TCAs.

Nonsteroidal anti-inflammatory drugs may provide some benefit for FM but appear to less efficacious than the SNRIs and anticonvulsants. One class of medications that is frequently prescribed to patients with pain, opioids, appears to provide little benefit to FM patients. The risk for adverse events associated with the use of opioids, most notably opioid abuse, is considered to outweigh whatever benefit they might provide.

A limitation of virtually all the studies on medications is that most report short- or medium-term results, leaving open the question of long-term efficacy, which is an important issue, considering that FM is a chronic condition.

 Of the nonpharmacologic therapies, 2 appear to be 

 The first is aerobic exercise, which can be beneficial for many chronic painconditions. Unfortunately, because patients may experience increased pain as they begin to exercise, they may take this as a sign that the exercise is exacerbating the pain and thus an indication to do less exercise. It can be helpful for patients to work with physical and occupational therapists, as these professional can instruct patients in proper ways to exercise and encourage them to continue (even if they initially experience increased pain) and in methods to perform daily activities that are less likely to exacerbate the pain.

The second nonpharmacologic therapy is cognitive behavioral therapy (CBT). Patients with FM can often benefit from CBT by focusing on the ways pain and other symptoms interfere with their lives and addressing this.

Patients may resist referral for CBT out of fear that benefiting from any form of psychotherapy indicates their health care providers believe they are suffering from a mental disorder and therefore their pain is not real. Providers need to explain that undergoing CBT in no way discounts the presence of the pain and other symptoms.

A major benefit of both exercise and CBT is that they are essentially free from adverse events and therefore unlikely to exacerbate FM and symptoms, something that can occur withmedications.

Fibromyalgia has gone from being viewed simply as a pain disorder to being considered a complex, multisystem disorder, with widespread pain being only one of its symptoms. It is important to be aware of the diagnostic criteria for FM because other disorders, especially mental disorders, are not uncommonly misdiagnosed as FM. Finally, despite the variety of therapeutic optionsavailable, FM remains very difficult to treat.

is in private practice in Philadelphia, Pennsylvania.

“No one wants to look after the fibro patient.” Understanding models, and patient perspectives, of care for fibromyalgia: reviews of current evidence.

2. Galvez-Sánchez CM, Reyes Del Paso GA. 

Diagnostic criteria for fibromyalgia: critical review and future perspectives. 

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Two contributions to understanding of the “fibrositis” syndrome.

The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee.

6. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 

The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.

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Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia.

8. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 

2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria.

9. Arnold LM, Bennett RM, Crofford LJ, et al. 

AAPT diagnostic criteria for fibromyalgia.

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 Fibromyalgia as a chronic primary pain syndrome: issues to discuss.

12. Treede RD, Rief W, Korwisi B, et al. 

A review of the incidence and risk factors for fibromyalgia and chronic widespread pain in population-based studies.

14. Wolfe F, Walitt B, Perrot S, Rasker JJ, Häuser W. 

Fibromyalgia diagnosis and biased assessment: sex, prevalence and bias.

Sex differences in pain: a brief review of clinical and experimental findings. 

16. De Sanctis V, Abbasciano V, Soliman AT, et al. 

The juvenile fibromyalgia syndrome (JFMS): a poorly defined disorder.

17. Häuser W, Perrot S, Sommer C, et al. 

Diagnostic confounders of chronic widespread pain: not always fibromyalgia.

18. Häuser W. The importance of psychosocial factors in the etiology and management of fibromyalgia. 

19. Gota C, Kaouk S, Yassen K, et al. Relationship between a history of abuse and fibromyalgia symptoms and severity: data from the Cleveland Clinic Fibromyalgia Registry. Presented at: American College of Rheumatology Annual Meeting; November 8-13, 2019; Atlanta, GA.

20. Mascarenhas RO, Souza MB, Oliveira MX, et al. 

Association of therapies with reduced pain and improved quality of life in patients with fibromyalgia: a systematic review and meta-analysis.

Articles

This CME covers the ins and outs of fibromyalgia, and everything a mental health professional needs to know when dealing with it. 

Fibromyalgia: What It Is and How to Treat It

Most health care professionals are aware that medical care in this country varies a great deal based on the patients’ race and ethnicity. We only have to look at the current coronavirus disease 2019 (COVID-19) crisis, in which Black individuals have been 

 both in number of infections and deaths as a result of a myriad of psychosocial, genetic, and environmental factors.

On top of unequal access, some individuals hold discriminatory beliefs about pain experienced by individuals of different racial and ethnic groups. In 1892, S. Weir Mitchell, MD, the father of American neurology, wrote about the experience of pain in White people of Northern European ancestry in comparison with Black and Native American people. He stated, “In our process of being civilized, we have won, I suspect, intensified capacity to suffer. The savage does not feel pain as we do.”

This view of pain was often used to rationalize the mistreatment of enslaved and Native American people: when violence was inflicted on them, they did not suffer as White people did. Pre-Civil War, 19th century New Orleans physician Samuel A. Cartwright, MD, said he identified “dysaesthesia Aethiopis,” an inherited disorder specific to Black individuals that made them insensitive to pain.

These views were perpetuated solely based on racism, without any science to support them. However, we now know that genetics can play a significant role in disease. Different races and ethnicities can be more at risk for certain diseases, such as sickle cell disease among Black people and Tay-Sachs disease among people of Ashkenazi Jewish ancestry. Thus, there is still the question of whether pain is experienced differently by individuals from different backgrounds.

A complicating factor in this discussion is how the experience of pain is affected by culture. It is readily apparent that it is more acceptable in some cultures and societies, often based on race or ethnicity, to complain about pain. How much of this is due to actual differences in the pain experience versus cultural acceptability of reporting pain—nature versus nurture—remains unclear.

 the effects of race and ethnicity on the care individuals received for chronic pain.

 The review identified trends in the effects of race and ethnicity on the experience of pain and how it is treated. Among the multitude of previous studies, one can find many different results, ranging from race and ethnicity playing significant roles to playing virtually no role.

Some studies have reported that Black individuals and people who belong to certain ethnic minority groups have higher pain thresholds, while other studies have 

 Minority patients, especially those from groups in which there are relatively small numbers of represented physicians, may have their level of pain underestimated by their caregivers.

Race and Opioids: Lessons From the Civil War-Era Opioid Addiction Crisis

Several studies have examined affects of race or ethnicity on the prescribing of opioids for pain. The most common finding was that Black patients were less likely to be prescribed opioids than White patients; however, it is worth noting that 

 patients were less likely to receive opioids than non-Hispanic White or non-Hispanic Black patients.

 Furthermore, some studies found that Black patients who were prescribed opioids were monitored more closely for misuse than White patients.

In light of the prescription epidemic in this country, resulting in rising rates of misuse and overdoses, it could be argued that more restrictive prescribing and closer monitoring might be a positive thing. If so, Black patients might accidentally benefit from these prescribing patterns. However, there is no indication that physicians are more carefully looking out for their Black patients than for their White patients. Even if the result is positive, there is no apparent intent. Furthermore, research has shown that Black patients and non-White Hispanic patients may have a more difficult time than White patients filling opioid prescriptions, as pharmacies in their neighborhoods may carry 

Unfortunately, there has been a tendency to have limited participation of non-English speakers and immigrants in studies of 

, and this may have resulted in an unrepresentative sample. Considering that pain is a subjective complaint that must be self-reported, limited language skills could impair patients’ ability to convey the presence and severity of pain, all important factors in determining proper treatment protocols.

The extent to which race, socioeconomic status, and 

 contribute to the apparent discrepancies in the management of pain remains unclear. The issue of poor access to health care may extend beyond just the pain itself and may also affect the identification and treatment of underlying disorders that may be causing or exacerbating the pain. This includes mental health issues, most notably depressive and anxiety disorders, which can play important roles in the development and maintenance of 

It is not too surprising that so many factors may explain variances in pain among different racial and ethnic groups. We know that there are many elements involved in the development of pain, especially chronic pain, including genetic, cultural, psychological, and environmental influences. The importance of each factor can vary from individual to individual.

The authors of the current study noted that there are no easy answers to pain management discrepancies, especially between Black and White individuals in the United States. More research is needed to identify the reasons for these discrepancies and the best methods for addressing them. Physicians should be aware of biases, including unconscious ones, and the methods for assessing and managing pain, especially among patients who may belong to different racial and ethnic groups than they do. Viewing all patients as complex individuals whose pain may involve many factors is crucial.

2. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. In: Caplan AL, McCartney JJ, Sisti DA, eds. 

Health, Disease, and Illness: Concepts in Medicine

Racial and ethnic disparities in the treatment of chronic pain

4. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. 

5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. 

6. Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. 

Access to care for chronic pain: racial and ethnic differences

7. Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. 

Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting

8. Hollingshead NA, Vrany EA, Stewart JC, Hirsh AT. 

Differences in Mexican Americans’ prevalence of chronic pain and co-occurring analgesic medication and substance use relative to non-Hispanic white and black Americans: Results from NHANES 1999-2004

9. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. 

10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “

We don’t carry that”--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

Pain as a cultural construct considers conscious and unconscious biases, as well as methods for assessing and managing pain in all patient populations, including those with mental health challenges.

Race, Ethnicity, and Chronic Pain

The association between smoking cigarettes and the risk of developing serious and potentially fatal health problems (most notably cardiovascular diseases, pulmonary diseases, and cancer), has long been accepted fact. However, an additional health problem that may also be associated with smoking has often been overlooked: pain.

Two recent papers indicate a strong association between smoking and pain.

 Among the review’s important findings is that those who suffer from chronic pain are substantially more likely to smoke than are those who do not suffer from chronic pain. Although smoking rates continue to decline in the latter group, this does not appear to be occurring in those with pain.

Cigarette smoking has been cited as a risk factor for a wide variety of painful conditions, including back pain, 

, and diabetic peripheral neuropathy. Smoking appears to be associated with both the development and severity of pain.

The second paper specifically studied the most likely locations of pain among individuals who smoke. The 

 examined data from a 2003 to 2004 National Health and Nutrition Examination Survey, which contained data from comprehensive bodily pain questionnaires in addition to questions on other health issues, including tobacco use.

 The study compared 1054 participants who smoked tobacco with 1316 participants who did not.

Those who smoked were found to be more likely to suffer chronic pain. Although the likelihood of pain was increased throughout the body, the study found that spine pain, and especially low back pain, had the strongest association with smoking. The second strongest association was between 

 and smoking. Smoking was also associated with both trunk pain, which included the chest and abdomen, and limb pain. (All statistical associations were drawn from Smuck et al.

This is an interesting and perhaps an unexpected finding. Because of the association between smoking and cardiovascular and cerebrovascular problems, it is easy to see why headaches would be fairly common among individuals who smoke. However, it might be reasonably expected that pain in the trunk and 

 would be more common than pain in the spine. The authors suggest that vascular factors may play a greater role in back pain than is often thought.

, which are becoming more popular, are any less associated with pain than traditional cigarettes remains an unanswered question.

From personal experience treating patients with chronic pain who also smoke, I know that helping them with smoking cessation attempts can be challenging. Although most patients are often well aware of the risks associated with smoking, their pain and its impact on their lives may make it more difficult for them to quit. Their pain may make them feel restricted, and their ability to participate in previously enjoyable activities is limited. Smoking is among the few such activities in which they can still indulge. They may also feel that smoking helps them cope with the pain.

 may have some analgesic effects, but abstaining from smoking may 

 individuals to suffer hyperalgesia, a lowering of the pain threshold.

 Thus, those who smoke may receive temporary relief from tobacco use, and their pain may get worse when they try to stop.

Additionally, depression and anxiety are frequent 

 among those with chronic pain, and their presence can also contribute to the challenge of getting patients to stop smoking.

Ultimately, all evidence points to the importance of convincing patients with chronic pain who also smoke that tobacco is not helpful. Indeed, tobacco may be significantly exacerbating their pain and adding to their misery.

The multitude of challenges can understandably make it difficult to persuade patients with chronic pain to stop using tobacco. Unfortunately, only a 

 of studies have sought to investigate the best treatments for attaining this goal.

Although no single optimal treatment has yet been identified, it appears that while nicotine replacement therapy can be useful, the 

 that are most successful are those that address both the pain and the smoking using psychotherapeutic interventions.

 In this way, treating tobacco use disorder and comorbid chronic pain is similar to the treatment of pain and iatrogenic opioid use disorder, where both problems must be managed together to be successful in treating either.

Of course, this raises the important issue of who treats pain and how it is treated. (For more information on psychiatry and pain, see 

Psychiatric TimesTM November 2020 Special Report

For the most part, the management of chronic pain has been under the aegis of anesthesiology, followed by physiatry and neurology, with psychiatry far down the list. However, the order of these specialties would be reversed if we asked which is best able to aid in smoking cessation. One doubts that there are many anesthesiologists, physiatrists, or neurologists who have expertise in treating patients with nicotine addiction.

As a result, it is difficult for patients with chronic pain who smoke to find health care professionals qualified to treat both issues. If it appears to patients that smoking and pain are 2 separate problems that require different medical specialties to treat them, it may make it more difficult to convince them that the issues are actually entangled. Nonetheless, the evidence suggests that managing 1 issue may aid in managing the other.

This article was posted ahead of print on November 11, 2020, and has since been updated. -Ed

Pain, nicotine, and tobacco smoking: current state of the science

2. Smuck M, Schneider BJ, Ehsanian R, et al. 

Smoking is associated with pain in all body regions, with greatest influence on spinal pain

Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers

Nicotine withdrawal and stress-induced changes in pain sensitivity: a cross-sectional investigation between abstinent smokers and nonsmokers

Anxiety and depression in bidirectional relations between pain and smoking: implications for smoking cessation

A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions

7. Hooten WM, LaRowe LR, Ditre JW, et al. 

Effects of a brief pain and smoking cessation intervention in adults with chronic pain: a randomized controlled trial

Two recent papers look at the subtle and surprising links between smoking and pain in different parts of the body. 

Steven A. King, MD, MS

Articles

Fibromyalgia: What It Is and How to Treat It

Race, Ethnicity, and Chronic Pain

Pain and Smoking: Is There an Association?

Psychiatry’s Role in the Management of Chronic Pain

Mind-Body Therapies for the Management of Pain: How Effective Are They?

Pain and Dementia