2019 ACR/ARP Annual Meeting
Managing Pain in Rheumatology: Learning From the Opioid Epidemic
A presentation titled “In the Rheum: Pain Management During an Opioid Crisis” was given by Anupam B. Jena, MD, PhD, Harvard Medical School, on November 12 at the 2019 ACR/ARP Annual Meeting in Atlanta, GA. The session focused on various aspects of opioid prescribing in the era of the opioid epidemic and lessons that might be applied in rheumatology.
Following the discussion, our featured expert, Leonard H. Calabrese, DO, who attended this session, was interviewed by Conference Reporter Editor-in-Chief Tom Iarocci, MD. Dr Calabrese’s perspectives on this session and on the topic of opioids in rheumatology are presented here.
“Overall, things seem to be moving in the right direction. I think that we will see less opioid abuse in the future—whether it is attributed to people being monitored more closely, the fact that they do not want to put up with the regulatory burden that attends opioid use, or a mixture of factors, including an awareness of abuse potential.”
There is no simple answer or linear solution to explain how we got to this terrible state of a national epidemic of opioid use in the United States. The theories that have been proposed include overzealous marketing by pharmaceutical companies, the codependent role of national health care quality initiatives in emphasizing pain as the fifth vital sign, increasing demands on providers to provide pain relief, and a societal laissez-faire attitude toward substance use.
I am impressed by a recent analysis by Day and Curtis that shows that a substantial percentage of patients with rheumatoid arthritis (RA) may be on long-term opioids. Further, Jorge et al presented findings from their population-based cohort study in the United Kingdom in abstract 2048 at the 2019 ACR/ARP Annual Meeting, which revealed a substantial rise in the rates of opioid prescriptions among those with rheumatic disease from 2000 to 2016. I think that we all have to ask ourselves why this happens in rheumatology. Historically, our patients have had great demands for analgesia, and our therapies were largely ineffective in controlling inflammation in diseases such as RA up until the last 2 decades. Today, however, we treat RA early and aggressively. In our practice, I do not see the penetration of opioids into the RA population, and we do not have the rates of opioid use that are documented in some of the analyses that I have seen. Moreover, people are responding to this epidemic in different ways. In moving about the country, I have learned that some large and prominent practices now inform all patients up front that absolutely no prescriptions for opioids will be written by the practice. In my experience, younger practitioners are among the most reluctant to start any patient on opioids, and I think that is a good development.
In the 2019 ACR/ARP Annual Meeting presentation by Dr Jena, a variety of sources of data were considered in an attempt to gain additional insights into the drivers of opioid prescribing. One analysis seemed to suggest that opioid prescribing rates increase when clinicians are extremely busy and during patient encounters that occur later in the day. The latter, it was theorized, might reflect the effect of fatigue on the provider’s opioid prescribing practices. In explaining observations such as these, a number of factors may be at work.
From the patient’s perspective, they have likely learned that there is a need to present a convincing case regarding the need for analgesia. From the provider’s perspective, I would imagine that the lack of time and/or resources to approach the patient holistically on this subject would be a challenge. Without the necessary time, support, and infrastructure, a succinct conversation with the patient might convey an unintended message such as, “You are going to live in chronic pain for the rest of your life - period.” That patient who does not have access to some of these holistic pain programs that emphasize mindfulness, adjunctive stress relief, and mind-body therapies is more likely to get a prescription. Today, we are more cognizant of these adjunctive therapies, and I think that patients are responding in kind.
Additionally, my sense is that many of the patients who remain on chronic opioids are those who have been on them for years. It might be easy today to criticize how they initially came to be prescribed opioids. However, with the introduction of controlled distribution and checking and rechecking with providers, practices have some patients who have been taking their opioids responsibly for a decade or longer, and it is not an easy thing to suddenly tell these patients that their current opioid prescription will be their last. I am glad to see that patient advocacy has emerged in this area. Patients who have never demonstrated any abuse or diversion, for example, should not be treated as drug abusers.
Overall, things seem to be moving in the right direction. I think that we will see less opioid abuse in the future—whether it is attributed to people being monitored more closely, the fact that they do not want to put up with the regulatory burden that attends opioid use, or a mixture of factors, including an awareness of abuse potential.
Day AL, Curtis JR. Opioid use in rheumatoid arthritis: trends, efficacy, safety, and best practices. Curr Opin Rheumatol. 2019;31(3):264-270.
Jena A. In the rheum: pain management during an opioid crisis. Session presented at: 2019 American College of Rheumatology/Association of Rheumatology Professionals Annual Meeting; November 12, 2019; Atlanta, GA.
Jorge A, Lu N, Choi HK. Opioid prescription use among patients with rheumatic disease: a population based cohort study [abstract 2048]. Arthritis Rheumatol. 2019;71(suppl 10). https://acrabstracts.org/abstract/opioid-prescription-use-among-patients-with-rheumatic-disease-a-population-based-cohort-study/. Accessed November 20, 2019.
Lee YC, Kremer J, Guan H, Greenberg J, Solomon DH. Chronic opioid use in rheumatoid arthritis: prevalence and predictors. Arthritis Rheumatol. 2019;71(5):670-677.
Whittle SL, Richards BL, Husni E, Buchbinder R. Opioid therapy for treating rheumatoid arthritis pain. Cochrane Database Syst Rev. 2011;(11):CD003113.
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