Nearly 10% of Medicare beneficiaries with knee osteoarthritis report chronic opioid use
Click Here to Manage Email Alerts
As many as 9% of Medicare beneficiaries with knee osteoarthritis use opioids chronically, while 21% are occasional users, according to data published in Arthritis Care & Research.
“U.S. opioid prescription practices have contributed to the ongoing opioid epidemic by increasing the individual risk of developing opioid use disorder and the community risk of illicit sharing of these medications to non-prescription receivers,” Elena Losina, PhD, of Brigham and Women’s Hospital, in Boston, and colleagues wrote. “An estimated 9.9 million persons misused prescription opioids in 2018 in the U.S., and drug overdoses led to over 67,000 deaths in 2018 alone.”
“Opioid prescriptions for musculoskeletal pain contribute substantially to this reported misuse,” they added. “The increased awareness of the risks associated with opioid use and the impact that opioid prescriptions have on the national epidemic provide context for the importance of understanding the trends over time and risk factors of chronic opioid use in persons over 65 years of age with knee OA.”
To examine the prevalence of opioid use, and characterize the risk factors of said use, among patients with knee OA, Losina and colleagues studied data from the Medicare Current Beneficiary Survey. According to the researchers, the survey features a nationally representative sample of Medicare beneficiaries, including individuals aged 65 years and older as well as younger enrollees with disabilities, and links expenditures and payment sources to various types of health coverage. A total of 3,549 beneficiaries with knee OA, who participated in survey years 2003, 2006, 2009, 2011, 2013, 2015 and 2016 were included in the analysis.
Losina and colleagues collected data on demographics, marital status, comorbidities, insurance and prescription medication coverage from the survey and linked Medicare claims. In addition, they included all prescription records classified as an opioid and stratified patients into three groups based on use. Patients who received zero opioid prescriptions per year were classified as “non-users,” while those who received one to five prescriptions annually were “occasional users” and those with six or more were “chronic users.” Lastly, the researchers used multivariable logistic regression models, with a Generalized Estimating Equation, to find correlates of chronic opioid use.
According to the researchers, 9% of the included patients were classified as chronic opioid users, while 21% were occasional users. Meanwhile, the multivariate analysis found that non-Hispanic ethnicity (OR = 4.8; 95% CI, 2.2-10.2), divorced status (OR = 2.3; 95% CI, 1.5- 3.5, compared with married status), Medicaid eligibility (OR = 1.9; 95% CI, 1.3-2.7), depression (OR = 1.9; 95% CI, 1.5-2.5), COPD (OR = 1.9; 95% CI, 1.4-2.5) and an inability to walk without assistive devices (OR = 2.4; 95% CI, 1.5-3.7, compared with no walking difficulty) were independently associated with chronic opioid use.
“Although the current treatment guidelines of both the Osteoarthritis Research Society International (OARSI) and the American College of Rheumatology do not recommend opioid use for knee OA pain management, our findings suggest opioids are still being prescribed,” Losina and colleagues wrote.
“In addition to identifying correlates of opioid use in the Medicare beneficiary knee OA cohort, we reported a rise in overall and chronic opioid use from 2003 to 2013 followed by a decrease in use from 2013 to 2016,” they added. “This promising trend aligns with reports elsewhere of opioid use and misuse in the general U.S. population. Finding alternative pain management treatments for these at-risk patients prior to surgery could lead to better outcomes and lower likelihoods of future opioid overuse, and could reduce the effect that knee OA related opioid prescriptions have on the national opioid epidemic.”
Perspective
Back to Top
David A. McLain, MD, MACR, FACP, FRCP
The pendulum swings in medicine, often from one extreme to the other. The use of opioids for musculoskeletal pain has been controversial from the beginning. The most prevalent causes of non-cancer chronic pain include back pain, fibromyalgia, osteoarthritis and headache. Rheumatologists regularly see patients with all these, except headaches.
Over half of the expenditures for opioids nationally are related to musculoskeletal pain. Some of the toughest patients are the so-called “failed back” patients who have been in the medical system for years and have had multiple procedures and, as they age, also have OA, degenerative disc disease and spinal stenosis, and end up in the rheumatologist’s office. The ACR guidelines on the treatment of OA of the hand, hip, and knee recommend tramadol, a non-opioid-derived synthetic opioid; they are conditionally against non-tramadol opioids.
At a recent meeting, one of my colleagues commented, “In my generation, we were taught not to use opioids in rheumatology. What about grandma with significant OA, and contraindications to NSAIDs, who breaks her hydrocodone 5 mg tablets in half, taking a half tablet in the morning to get her going and a half tablet at night to help her sleep? Is that unreasonable or dangerous?” This is a good question.
In my generation, we were exposed to the marketing of opioids with pain scales – often as exam room props that were gifted by pharma – with the idea that it was “malpractice not to treat pain” and that “pain was the fifth vital sign”. We would try and relieve most of the patient’s pain first by treating the underlying disease, but with the use of opioids if all else failed. The latest goal, in contrast, is 30% relief of the patient’s pain.
We have seen mortality in patients taking NSAIDs for osteoarthritis; but are NSAIDs more dangerous than opioids in OA and do they cause more deaths than opioids? We know that NSAIDs cause ulcers and gastrointestinal bleeding, renal failure, and an increase in cardiovascular disease.
In a 46-year-old head-to-head retrospective analysis published in Archives of Internal Medicine, Daniel H. Solomon, MD, MPH, and colleagues demonstrated an overall mortality incidence rate of 48/1,000 person-years for patients taking non-selective NSAIDs compared with 75/1,000 person-years with opioids. The type of opioid, the extent of disease in the groups, length of exposure, and other significant variables were unknown or not analyzed, but suggests that opioids are not as safe as NSAIDs in OA.
The pendulum has swung against the use of opioids, but it seems there is still a place for them in rheumatology. As hard as we try to avoid their use, we have patients for whom opioids improve the quality of their lives and until something better comes along, should be considered medically necessary.
Collapse
Read more about
Click Here to Manage Email Alerts