Nationally, opioid use and addiction are drawing increased scrutiny. An increase in the number of overdoses and addiction to heroin and prescription pain relievers in the past decade has been attributed in part to increased prescribing of opioids for the treatment of pain by physicians. National trends suggest the rate of opioid prescribing plateaued in 2010–11 and then declined. Nevertheless, continuing concerns regarding opioid prescribing have spurred major initiatives across multiple federal agencies.
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What is unknown is whether patterns of opioid receipt among patients with well-defined medical causes of chronic pain follow similar national patterns. For example, the prescribing and opioid use patterns in patients with inflammatory arthritis, such as rheumatoid arthritis (RA), have not been well characterized.
Effective pain control is often the highest priority of patients with RA. This study examined trends over time and variability in individual physician prescribing of opioids in the short and long term.
Methods & Results: The authors identified a cohort of RA patients based on 2006–2014 Medicare data and evaluated longitudinal time trends in regular use of opioids. They tested three main hypotheses: 1) that opioid use in patients with RA would follow national trends, 2) that patients with fibromyalgia and depression would be more likely to receive opioids, as would white patients, and 3) that after controlling for patient characteristics, individual rheumatologist prescribing of opioids for their RA patients would vary significantly, and that this interprovider variability would identify a class of “high opioid prescribers.”
The researchers identified 97,859 RA patients meeting the eligibility criteria. The mean age of the patients was 67 years, 80% were female, 82% were white, and 12% were African-American. The most commonly used opioids were those that combined acetaminophen with hydrocodone or propoxyphene. Regular opioid prescribing increased slowly but peaked in 2010 before propoxyphene was withdrawn from the market. Following the withdrawal of propoxyphene, receipt of hydrocodone and tramadol increased commensurately, and overall opioid use declined only slightly.
Factors associated with regular use of opioids included younger age, female sex, African-American race, back pain, fibromyalgia, anxiety and depression. Variability between U.S. rheumatologists (n=4,024) in prescribing of the regular use of opioids for their RA patients was high: 40% of the patients with RA used prescription opioids regularly. In almost half of the patients, at least some opioid prescriptions were written by a rheumatologist, and 14% received opioids that were co-prescribed concurrently by more than one physician.