Opioid Use in Rheumatoid Arthritis

Abstract and Introduction

Abstract

Purpose of review: The opioid epidemic remains prominent in both the medical literature and popular media. Rheumatologists are among the physicians at the forefront of the epidemic because of the prominent role of pain in rheumatoid arthritis (RA) and the limited options for treatment of pain. The purpose of this review is to provide an update on the trends of opioid use among patients with RA, to discuss the various mechanisms of RA pain, review the available evidence for opioid efficacy in RA, and to promote a guideline for best practices in opioid prescribing.

Recent findings: Recent cohort studies have estimated that up to 40% of patients with RA are regular users of opioids, and the effects of disease-modifying antirheumatic drugs are minimal in reducing opioid use. Although the literature supports the efficacy of short-term opioids for the improvement in pain, long-term use is associated with reduced efficacy and increased safety concerns.

Summary: Although the data supporting the use of long-term opioid use in patients with RA is poor, rheumatologists can adhere to best practices for determining when and if initiation of opioids is appropriate. Identification of the nature of the pain can help determine the appropriate course of treatment.

Introduction

Rheumatoid arthritis (RA) is the most common autoimmune inflammatory arthritis and is estimated to affect up to 1% of adults globally.^[1] Pain is a nearly universal feature of RA, and pain can persist despite appropriate treatment with disease-modifying antirheumatic drugs (DMARDs).^[2] Although pain treatment strategies above and beyond effective disease control vary among rheumatologists, the limited number of alternatives often prompts patients and physicians to consider the potential role of opioids as part of RA management.

However, concern over opioid use has garnered national attention over the past decade, and a commission to combat drug addiction and the opioid crisis was established by the President of the United States (US) in March, 2017.^[3] From 2006 to 2010, annual opioid prescribing rates in the United States increased from 72.4 to 81.2 prescriptions per 100 persons, and then decreased to 70.6 per 100 persons from 2012 to 2015.^[4] To better estimate the prevalence of opioid use, misuse, use disorders, and the motivations for misuse, the 2015 National Survey on Drug Use and Health was conducted on noninstitutionalized US adults.^[5] This face-to-face, household interview survey was completed by 51 200 persons. Overall, 37.8% reported any use of opioids over the prior 12-month period. Of those reporting opioid use, 12.5% reported misuse of opioids, which was defined as use without a prescription, for a reason other than as directed, or in a greater amount, frequency, or duration than prescribed. Inadequate relief of physical pain was the most cited reason for opioid misuse (63.4%). Given that RA patients may experience chronic and sustained pain beginning at a young age and extending over a lifetime, these concerns related to opioid use are particularly salient in this disease.

In this article, we will review the various mechanisms of action of pain in RA, discuss the prevalence and patterns of opioid use specifically among RA patients, review the efficacy of opioids for RA pain, and consider safety concerns regarding opioid prescribing. Finally, we will review the best practices in opioid prescribing relevant to rheumatologists who choose to utilize opioids (key points).