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.
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 Regular opioid prescribing increased slowly but peaked in 2010 before propoxyphene was withdrawn from the market.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.
Conclusions: In the U.S., opioid use in older patients with RA peaked in 2010 and is now declining slightly. Withdrawal of propoxyphene from the U.S. market in 2010 had minimal effect on overall opioid use, because propoxyphene use was replaced by increased use of other opioids. Opioid use varied considerably by state, suggesting that some regional variability may be attributable to state regulations in opioid prescribing.
The study’s results suggest substantial use of opioids in a population of older RA patients despite societal concerns regarding potential overprescribing in recent years. Rheumatologists played a significant prescribing role, although co-prescribing was relatively common.
Rheumatologists and other clinicians caring for patients with RA face a significant dilemma precisely because the options for treating pain remain problematic. The proven benefits of opioids for the treatment of RA-related pain, as well as other types of musculoskeletal pain syndromes, are restricted to trials of shorter duration, tend to be modest in magnitude and include the risk of side effects. The benefits of nonpharmacologic treatments are similarly modest in magnitude and limited to short-duration studies.
Although the current findings are insufficiently granular to prove inappropriate practice, they do raise concerns for practitioners.
Excerpted and adapted from:
Curtis JR, Xie F, Smith C, et al. Changing trends in opioid use among patients with rheumatoid arthritis in the United States. Arthritis Rheumatol. 2017 Sep;69(8).