They determined that only 43% of RA patients who were prescribed opiates got that prescription from a rheumatologist. These are Medicare patients, who may have more than one medical problem, Dr. Curtis tells The Rheumatologist. There was also more than fourfold variability in opiate use between rheumatology practices, which the authors attribute to individual prescribing patterns, disease severity and the presence of other painful conditions suffered by patients.
“In sum, our results suggest substantial use of opioids in an older RA population despite societal concerns regarding potential overprescribing in recent years,” Dr. Curtis says. “I’d like to know more about how helpful this is long term.”
Rheumatology has an important role in complicated pain issues, as the population with rheumatologic condition grows and pain is a common, and often the leading, debilitating problem in these patients, says Perry Fine, MD, professor of anesthesiology at the University of Utah School of Medicine and a national expert in pain treatment.
“Opioids can be either life saving or life threatening, depending on the competence of the prescriber, reliability of the patient and the social sphere in which they reside, and the support systems—formal and informal—available to the patient in creating a safe and effective outcome. At the end of the day, good care requires all of the above, with a focus on patient selection, sound application of prescribing practices and ongoing monitoring of therapeutic effects versus adverse effects and risks,” Dr. Fine concludes in a recent email to The Rheumatologist.
“In other words, we have very few proven high-efficacy options, medical or nonmedical, for long-term management of severe, debilitating intractable pain, and none are risk free. We know from experience and limited literature that some carefully selected and followed patients do benefit from long-term opioid therapy when other approaches have failed,” he says. “In all cases, we must individualize care, taking into account risks of treatment vs. nontreatment, monitor outcomes carefully and closely to minimize risks, especially when using opioids.”
The Place of Interdisciplinary Pain Clinics
“If we have somebody who’s not getting relief at the analgesic doses we are comfortable in providing, do we push the dose until either the pain is relieved or side effects emerge?” Dr. Rapoport poses. “We all get patients in our office who come to the rheumatologist when something hurts. When do we decide to send them to a pain center?” There are too many patients who have chronic pain and need pain management, and they can’t all be sent to a pain center.
