Patients with rheumatoid arthritis, PsA, AS ‘stuck in a cycle of long-term opioid use’
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Key takeaways:
- Opioid use in ankylosing spondylitis, psoriatic arthritis and rheumatoid arthritis were elevated in the 12 months before and after diagnosis vs. matched controls.
- Findings point to need for safer, more effective pain management strategies.
Patients with rheumatic diseases demonstrate a high reliance on opioids around the time of diagnosis, and significant numbers of patients were not on appropriate treatment in the year afterward, according to data in Clinical Rheumatology.
“A subset of people living with ankylosing spondylitis, psoriatic arthritis and rheumatoid arthritis may be stuck in a cycle of long-term opioid use without receiving the proper treatment for the inflammation underlying their conditions,” Jeffrey L. Stark, MD, vice president and head of medical immunology at UCB Pharma, in Smyrna, Georgia, told Healio. “The initial symptomatic treatment can delay getting a diagnosis, which likely exacerbates the issue over the long term.”
Previous work by the research team found disproportionately high rates of opioid use among patients with AS, including many on no disease-modifying treatment at all, Stark added. To examine opioid use in the year before and after diagnosis in a variety of rheumatic diseases, Stark and colleagues conducted a retrospective cohort study separately analyzing two U.S. data sources: Medicaid and IBM MarketScan Commercial Claims and Encounters (CCAE).
The researchers examined patterns of exposure to opioids, as well as appropriate therapy per U.S. guidelines, across three mutually exclusive cohorts comprised of incident cases of AS, PsA and RA between 2010 and 2017. Opioid use and treatment were analyzed based on claims in the 12-month periods preceding and following diagnosis. For comparison with the wider population, each patient was matched with three randomly selected patients without their incident disease.
The CCAE population included 5,769 patients with AS, 10,880 with PsA and 91,722 with RA. Among these patients, 42.4%, 45.2%, and 46.3%, respectively, had a rheumatologist visit at baseline or index. The Medicaid population, meanwhile, included 337 patients with AS, 530 with PsA and 7,369 with RA.
According to the researchers, both data sources demonstrated higher prevalence of opioid claims among the disease cohorts, across both baseline and follow-up periods, vs. matched comparators. Patients with AS had the most long-term and chronic opioid use in follow-up vs. matched comparators. Following diagnosis, patients with PsA saw the largest increase in appropriate treatment.
Prevalence ratios for chronic opioid use in follow-up, vs. comparators, in the CCAE population were 3.82 (95% CI, 3.51-4.15) for AS, 2.41 (95% CI, 2.25-2.58) for PsA, and 3.22 (95% CI, 3.15-3.28) for RA. Meanwhile, prevalence ratios for long-term opioid use in follow-up were 3.51 (95% CI, 3.25-3.79) for AS, 2.25 (95% CI, 2.11-2.40) for PsA, and 2.99 (95% CI, 2.94-3.05) for RA. Furthermore, there were no claims for guideline-appropriate therapy during follow-up among 36.4% of patients with AS, 29.5% with PsA and 44.4% with RA in CCAE data.
Per Medicaid data, chronic opioid use frequency at baseline ranged from 21.8% to 25.4% in PsA- and RA-matched comparators, respectively. However, the researchers found even higher frequencies in the disease cohorts, ranging from 31.3% in PsA to 45.7% in AS. Throughout follow-up, prevalence ratios for opioid use vs. comparators were 2.21 (95% CI, 1.9-2.58) for AS, 1.82 (95% CI, 1.58-2.1) for PsA, and 1.98 (95% CI, 1.92-2.04) for RA. Prevalence ratios for long-term opioid use were 2.05 (95% CI, 1.77-2.39) for AS, 1.81 (95% CI, 1.58-2.07) for PsA, and 1.93 (95% CI, 1.87-1.99) for RA.
Meanwhile, 30.6% of patients with AS, 36.6% with PsA and 65.4% with RA had no claims for appropriate therapy in the Medicaid data.
“The situation presents a dual problem,” Stark said. “Not only are there significant risks associated with long-term opioid use, but there’s also a missed opportunity to apply treatments that could potentially slow down or even halt the progression of the disease. These findings are crucial for clinicians and patients, and highlight the importance of talking to patients about their symptoms and the prioritization of disease-modifying therapies.”
Stark emphasized a need for “better education, diagnosis and adherence to professional society guidelines” to reduce chronic opioid use with rheumatic diseases.
“Further research should focus on raising awareness of treatment patterns in AS, PsA and RA, and assess over time to see if there has been a shift from using opioids to manage pain to using disease-modifying therapies,” he added.
Perspective
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Coming from the world of pediatric rheumatology, where the use of opioids for pain control is rare and reserved for the most severe cases, I was curious to see how prevalent the use of opioids was in the adult world. I suspected the use would be higher and the results of this study confirmed by suspicions.
The analysis of the data also confirmed my fear that patients with Medicaid had a higher percentage of opioid use than those with commercial insurance.
However, what did surprise me was the continued use of opioids after diagnosis and initiation of appropriate treatment for the patient’s rheumatic disease, as well as the number of patients using opioids as monotherapy. Further analysis of the data indicated that, for patients exposed to treatment based on the latest guidelines, the incidence of opioid use declined.
Whether in the pediatric or adult world, we need to improve our efforts at advocating for easier access to rheumatology specialists, take seriously our patients’ complaints of pain, and continue to educate them on pain management strategies and the dangers of prolonged opioid use. Such efforts will not only help improve the lives of our patients, but it may also even put a dent in the opioid crisis in our country.
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