'Life is not a chemical deficiency': Exploring opioid use in rheumatology practice
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With judicious use, opioids may, in fact, have a role in managing chronic pain in the rheumatology setting, according to a presenter at the 2020 Congress of Clinical Rheumatology-West.
“The root, long-term cause of the opioid crisis is based on trying to reduce pain, rather than trying to improve functioning” in patients with chronic conditions, said Daniel Doleys, PhD, director and owner of The Doleys Clinic in Birmingham, Ala.
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The opioid crisis in the U.S. may be a misnomer, Doleys said. “What we have is a crisis of drugs and alcohol,” he said, suggesting that careful pain management with FDA-approved opioids can be effective, while management of the myriad complications of life with a chronic disease with agents found outside of the clinic may not.
“Life is not a chemical deficiency,” Doleys said. “Clinicians and patients tend to view life stresses and difficulties as a problem that needs to be addressed chemically and with other means.”
That said, Doleys acknowledged the pain experienced by rheumatology patients, and that psychological and psychosocial factors play into that pain. “Chronic disease invokes a lot of responses in patients and their family members,” he said, noting denial, fear, anxiety and depression among them.
Moreover, he cited data showing that psychological distress and mood disorders may account for more than 80% of flares in patients with chronic diseases. “This leaves us in a situation where our patients are suffering chronic and disabling pain, wondering what to do,” he said.
Further research into questions pertaining to opioids is the key to understanding the exact role they should have in the clinic, according to Doleys.
One area of consideration is the impact of the drugs on the immune system. For example, while morphine has been shown to reduce natural and adaptive immunity, while buprenorphine may not have the same effect. “Maybe try to prescribe opioids that have no known impact on the immune system,” Doleys said.
Another consideration pertains to increasing tolerance with prolonged therapy. “Higher doses become necessary to produce analgesia,” Doleys said.
In response to this phenomenon, opioid tapering became part of clinical practice. Doleys suggested that rheumatologists who feel the need to reduce opioid doses in their patients should be cautious about how they approach this. “In the real world, opioid tapering is often forced,” he said. “Clinicians will tell patients: We are going to start tapering you whether you like it or not.”
Data have shown that about half of patients experienced worsening pain when their opioids were reduced or discontinued, according to Doleys. “Eliminating or reducing [opioids] does not always produce a positive outcome,” he said.
Patient selection is also critical in achieving optimal outcomes in prescribing opioids, according to Doleys. Those with a history of addiction, impulsiveness, incarceration, gambling or failure to follow other instructions are likely poor candidates for opioid therapy.
While opioid prescriptions peaked in 2010, the rheumatology community is trying to find the sweet spot of effective pain management without the issues of addiction or withdrawal. “It is clear that these substances are being used in clinical practice to treat chronic pain,” Doleys said. “We have to try to find a meaningful approach to treatment.”
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Doleys D. Treatment of Chronic Pain in the Rheumatology Practice. Presented at: Congress of Clinical Rheumatology-West annual symposium; October 8-11, 2020 (virtual meeting).
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