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Examining Clinical Predictors of Chronic Opioid use Among Patients with Rheumatoid Arthritis (RA)

Yvonne C. Lee, MD discusses the clinical predictors of chronic opioid use among patients with rheumatoid arthritis (RA), and what her research might mean for the future of pain treatments for RA patients.
Examining Clinical Predictors of Chronic Opioid use Among Patients with Rheumatoid Arthritis (RA)
Featuring:
Yvonne C. Lee, MD
Yvonne C. Lee, MDis a research professor and physician focused on understanding the pain experience in individuals with systemic rheumatic conditions, such as rheumatoid arthritis (RA), and to identify the relationship between these experiences and pain pathways. This research is important because it paves the way for the development of effective pain prevention and management strategies to improve the well-being of our patients.

Learn more about Yvonne C. Lee, MD
Transcription:

Melanie Cole (Host): Persistent opioid use among patients with rheumatoid arthritis has become a great medical concern. My guest today, is Dr. Yvonne Lee. She’s a rheumatologist and researcher at Northwestern Medicine. Dr. Lee, tell us about the opioid epidemic for patients with rheumatoid arthritis, it’s becoming a growing problem, correct?

Yvonne C. Lee, MD (Guest): Yes. In our study, we found that the prevalence of patient-reported opioid use rose from about seven and a half percent in 2002 to almost 17% in 2015. This is a problem because opioid use has as you know, many potentially devastating consequences due to misuse and overdose. In addition, studies have indicated that opioids are also associated with other serious health risks as well. For example, animal studies and in-vitro human studies have shown that certain opioids have immunosuppressive characteristics, and this is particularly concerning for patients with systemic rheumatic conditions such as rheumatoid arthritis who are at increased risk of infections due to both the autoimmune disease process itself as well as many of the medications that are used to treat these conditions. In fact, there was a recent paper published in Arthritis and Rheumatology in 2016 which showed that among rheumatoid arthritis patients, opioid use was associated with an increased risk of hospitalization for serious infections.

Host: Wow, that’s so interesting. Dr. Lee, is there evidence that opioids are efficacious for the treatment of pain?

Dr. Lee: So, opioids have been – I guess there is weak evidence that opioids are efficacious for the treatment of pain in RA. There have been a few studies on it. And it does show that compared to placebo, it does show improvements, though as with their use in other conditions for pain, the effect is actually pretty - relatively small and there are a lot of side effects. And so, while there is evidence for some efficacy, I would say that it’s not great. Certainly not a huge effect.

Host: Then tell us about your research that examines opioids and if you can share some patient characteristics.

Dr. Lee: Yeah. So, we examined trends in the prevalence of opioid use among rheumatoid arthritis patients between 2002 and 2015. And we also identified predictors of chronic opioid use over the same time period. And the data were from rheumatoid arthritis patients in the Corrona Registry. So, these were patients that were on average about 59 years old, mostly female, as is consistent with the overall rheumatoid arthritis population, mostly white and with a duration of RA of about five years, at median. And so, opioid use was gathered from patients self-reported surveys, so patients self-reported the opioid use. These were obtained at the time of doctor’s visits. We defined chronic opioid use as any opioid use reported during at least two consecutive doctor’s visits. And ultimately, we found that among rheumatoid arthritis patients, chronic opioid use doubled from 2002 to 2015 and that pain and antidepressant use were the strongest predictors of chronic opioid use. Some other predictors included things like rheumatoid arthritis disease activity, level of disability, and insurance status.

Host: What would you like us to learn from these key clinical predictors?

Dr. Lee: The strongest predictor was severe pain which in and of itself probably isn’t too surprising, however, it was interesting that this relationship was independent of rheumatoid arthritis disease activity. In other words, the association between pain and becoming a chronic opioid user wasn’t solely because these patients had uncontrolled inflammation from their rheumatoid arthritis. So, these patients may have had pain due to other causes as well.

I think another key finding was that there was this association between antidepressant use and chronic opioid use and we suspect that antidepressant use was serving as a proxy for the diagnosis of depression. In other words, it’s not really that the antidepressants in and of themselves increased one’s risk for becoming a chronic opioid user; rather it’s the underlying depression that increases the risk and this has been reported in studies of other chronic pain conditions as well.

Host: In your opinion, how do you feel we can curb the rise in chronic opioid use? What are some strategies you would like to put forward for control of rheumatoid arthritis disease activity and should management of pain and depression be research priorities, do you feel?

Dr. Lee: Yeah, those are great questions. So, I think with regards to kind of curbing this opioid epidemic, I think education is key. Education to both physicians as well as patients about how much effect they can actually expect to see from opioids, because I think there is a conception that these medicines are going to be able to cure my pain. I’m going to have no pain afterwards. When in reality, the effects are actually smaller than I think a lot of people think and then to really weigh that with the significant potential for harm, particularly the risk for misuse, abuse, as well as these other associated health risks such as the risk for infection. There’s another study that showed that in RA patients, there was an increased risk for fracture as well. So, I think education is key.

And then with regards to your question about the research priorities, I absolutely think that more research should go into looking for appropriate pain management strategies for people with rheumatoid arthritis as well as other systemic inflammatory conditions. Right now, I think rheumatologists tend to treat pain by treating inflammation, but it’s not always – the two aren’t always directly linked. And so, sometimes you can treat the inflammation, but the pain still won’t go away and so I think it’s really important to really be able to understand the pain, understand why patients are having pain because it can be very multifactorial and to be able to really target the pain mechanisms themselves rather than just targeting the inflammation and then hoping that it will solve the problem of pain as well.

Host: Dr. Lee, what does this mean for the future of pain treatments for rheumatoid arthritis patients and what would you like providers to know to help their patients? Maybe even give us some tips for non-opioid pain management.

Dr. Lee: Right. So, with regards to what this means for the future, I think really as I said before, there is a critical need for identifying new pain management strategies for pain in RA. I think that luckily, we are at a time where funding agencies such as the National Institute of Health, the NIH, have really begun to take notice of this issue and allocate the financial resources to developing these programs. For example, in April of this year, they just launched the HEAL initiative which stands for helping to end addiction long-term to really speed scientific solutions to stem the national opioid public health crisis. So, hopefully, we will be able to move away from the use of opioids to treat pain in RA and other chronic pain conditions, regardless of whether the origins of the pain themselves are inflammatory or not.

And then as for your question regarding what should providers know and what can we do to help our patients, I think our study really highlights the importance of evaluating and treating pain and mental health problems before prescribing opioid medications and in addition, to treating with the typical disease modifying anti-rheumatic drugs that we as rheumatologists are very familiar with that are targeted to treating inflammatory disease activity, but not necessarily pain. And I think also an evaluation of possible comorbid conditions should also be pursued. And if diagnosed, really treat accordingly preferably without the use of opioids.

Host: That’s great information. Thank you so much Dr. Lee, for joining us today and for explaining some of these clinical predictors of chronic opioid use among patients with rheumatoid arthritis. Thank you again. This is Better Edge, a Northwestern Medicine Podcast for physicians. For more information on the latest advances in medicine, please visit www.nm.org, that’s www.nm.org. This is Melanie Cole. Thanks so much for listening.