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The alarming statistics on prescription opioid overdoses are well known to medical professionals, thanks to the Centers for Disease Control and Prevention (CDC)’s widely cited finding that deaths from opioid analgesics have increased fourfold since 1999.1 Half of all fatal drug overdoses now involve opioids prescribed by a doctor.
Meanwhile, a lack of rigorous research demonstrating long-term effectiveness of opioids in relieving chronic, non-cancer pain contrasts with well-documented adverse events from these prescriptions, including opioid use disorder and resulting social problems, high rates of emergency room visits and hyperalgesia—even increased risk of nonvertebral fracture for rheumatoid arthritis (RA) patients on opioid analgesics.2
Many stakeholders in the opioid overdose epidemic, including the Drug Enforcement Administration, Surgeon General, Food and Drug Administration, law enforcement, legislators, hospitals and medical associations, are all saying the same thing: Doctors are writing too many opioid prescriptions.
So how are frontline providers responding? Opioids are still part of the analgesic armamentarium used by rheumatologists, and an individualized, evidence-based approach tailored to each patient is the recommended strategy. “But studies don’t have that much data to show that opioids help my patients,” says Philip J. Molloy, MD, FACP, a rheumatologist at Beth Israel Deaconess Hospital in Plymouth, Mass.
In 2015, more than 33,000 Americans died from overdoses of legal and illegal opioids. One-fifth of patients with non-cancer pain will receive an opioid prescription and one out of four who receives long-term opioid therapy in a primary care setting will struggle with addiction, according to the CDC. Problems from prescription drugs include patients taking drugs as prescribed but having adverse reactions, as well as using prescriptions for nonmedical reasons and diversion of prescribed drugs.
However, unaddressed chronic pain was described by the Institute of Medicine (IOM) in 2011 as another major public health concern—one costing between $560 billion and $635 billion per year in medical care, missed work and lost productivity.3 The IOM concluded that more than 100 million Americans suffer each year from chronic pain lasting 30 to 60 days or more. Musculoskeletal sources of pain are common, and many of those with chronic pain are patients with rheumatologic conditions who visit rheumatologists.
Concerns about untreated pain and the vast suffering it represents were behind a pendulum swing toward more aggressive treatment of pain over the past two decades. And now the pendulum has swung back to where the Centers for Medicare and Medicaid Services plans to drop some pain-related questions from its hospital patient satisfaction surveys out of concern that such questions have encouraged hospitals to overprescribe opioids. Others have sought to end Pain as a Fifth Vital Sign programs that routinely ask patients to rate their subjective experience of pain on a 0 to 10 scale. A California legislator in March proposed imposing a tax on opioid wholesalers for OxyContin and other opioids, with proceeds going to fund drug rehabilitation services.4
‘We understand the challenge of the difficult patient, & chronic, untreated pain is very real for some of our patients.’ —Ronald Rapoport, MD
What Is the Rheumatologist’s Role?
Rheumatologists confront these issues every day, says Ronald Rapoport, MD, chief of the Division of Rheumatology for Southcoast Health in Fall River, Mass. They try to resolve their patients’ pain by reducing the underlying disease with disease-modifying anti-rheumatic drugs and other treatments, he says. “We understand the challenge of the difficult patient, and chronic, untreated pain is very real for some of our patients.”
If the pain is primarily driven by inflammation, the rheumatologist may be the best person to address it, so much the better if the underlying disease can be reduced. But that’s not always clear, Dr. Rapoport says. “Let’s say I have a patient with osteoarthritis, complaining of back pain. Signs of physical changes on the X-ray don’t always correlate to the patient’s reported pain. The benefits of opioids for the majority of these cases seem to fade rather rapidly, as substantiated in the recent literature, while side effects mount. This puts us in a difficult situation where we just don’t have good options. Sometimes, the only thing that works is opioids,” he says.
“Pain is one of the most common reasons why people visit rheumatologists,” notes Yvonne C. Lee, MD, rheumatologist at Brigham and Women’s Hospital in Boston. “We are very focused on inflammation, but that may not be the only, or even primary, cause of their pain.” A lot of attention goes into trying to figure out what is the cause, and for a lot of patients it can be multifactorial.
“We need to make sure we’re not abandoning our patients or missing diagnoses that could mimic rheumatologic conditions and explain the source of pain,” she says. “It’s also important to emphasize that we’ll be there for them—we’ll work with them to overcome the hurdles. We don’t want to say we can’t use opioids at all. It’s important to evaluate risks and benefits for each patient.”
The public has high expectations for medical care—some of that pushed by pharmacy companies’ direct-to-consumer advertising, Dr. Molloy says. “Patients believe they have the right to be pain free. Well, sometimes we can’t get rid of the patient’s pain. That makes for some very difficult conversations. Those of us who are willing to treat this pain, we can’t do it all. It takes me a lot of emotional effort and time to take care of chronic pain patients. They are very needy. I’m a rheumatologist. I don’t want to be a pain specialist, and I don’t want to advertise myself as a pain doctor,” he says.
Opioids are for when benefits are expected to outweigh risks, based on a thorough evaluation of pain & its causes, & a thorough discussion with the patient of the risk & benefit—including dangers from polypharmacy & from the concurrent use of alcohol.
Not all practicing rheumatologists want to get involved with these patients, Dr. Rapoport says. In fact, some rheumatologists were reluctant to share their experience with pain treatment for this article. “As a rheumatologist, treating our patients’ pain is a necessary part of our practice. But if you become known in the community as a doctor who writes pain prescriptions, you’ll end up getting a lot of office visits for reasons other than pain control,” he says.
Other interventions with more supporting evidence deserve more attention from rheumatologists. Treatments ranging from biofeedback and hypnosis to cognitive behavior therapy have shown benefit—although they are often more expensive. “Nerve blocks and epidurals are poorly covered by insurance, yet I can write Percocet prescriptions all day,” Dr. Molloy says. Non-opioid pharmaceutical approaches receiving more attention recently include serotonin-norepinephrine reuptake inhibitors (SNRIs), such as pregabalin (Lyrica) and gabapentin (Neurontin), a medication used to treat epilepsy and neuropathic pain.
Tools for Managing Opioid Risk
Experts urge rheumatologists to familiarize themselves with the CDC’s March 2016 opioid prescribing guidelines, which recommend trying non-narcotic medications or treatments for pain first, except for active cancer treatment, palliative care or end-of-life care.5 Opioids are for when benefits are expected to outweigh risks, based on a thorough evaluation of pain and its causes, and a thorough discussion with the patient of the risk and benefit—including dangers from polypharmacy and from the concurrent use of alcohol.
Several other interventions recommended by the CDC and endorsed by medical societies are aimed at making opioid prescribing safer—for the patient, physician and society. First is opioid risk screening, which can help to determine which patients have a higher likelihood of abuse or misuse of narcotics. The evaluation incorporates coexisting psychological problems or a history of abuse, including family history. Those identified as higher risks may require greater care and attention from their physician, or opioids may not be a good choice for their pain.
If the rheumatologist intends to order an opioid, Dr. Rapoport recommends executing a signed pain agreement with the patient.6 “We want to take care of our patients, but we’re concerned about the risks of opioid analgesics. I say to my patients: ‘No. 1, I will be the only physician who can prescribe your pain medication, and I need to know which pharmacy you will be using.’ I have all of my patients receiving opioids sign this agreement.”
Dr. Rapoport also tells his patients that urine drug screening tests make for better outcomes for the patient and the doctor. If a drug comes up in the screening that should not be there, or if an opioid that was prescribed is not present, suggesting that it could have been diverted, the doctor can order a more formal test, called chromatography. But the quick-and-dirty four-minute urine cup test is accurate enough for everyday purposes.
Prescription drug monitoring programs (PDMPs), now established in almost every state, are statewide electronic databases that collect data on controlled substances dispensed in the state. By allowing the professional to review all of the patient’s opioid prescriptions from different providers, it helps to identify and deter or prevent drug abuse and diversion and encourage the identification, intervention and treatment of persons who are abusing prescription drugs. It takes some time to contact the PDMP for every patient who is on or about to start an opioid prescription, and the database may not help with patients who are getting additional prescriptions from another adjoining state.
Impact on Rheumatology Practice
What has been the impact of all this national attention to the overdose epidemic on practicing rheumatologists? In data presented at the 2016 ACR/ARHP Annual Meeting in Washington, D.C., in November, Jeffrey Curtis, MD, MS, MPH, from the Arthritis Clinical Intervention Program at the University of Alabama-Birmingham, and colleagues reported on a study of a cohort of 70,000 RA patients between 2006 and 2014. They found that rates of opioid prescribing went up slowly until peaking in 2010 and then started decreasing.7 The researchers also found evidence that physicians may be shifting their patients from stronger opioids to weaker ones, such as Tramadol.
They determined that only 43% of RA patients who were prescribed opiates got that prescription from a rheumatologist. These are Medicare patients, who may have more than one medical problem, Dr. Curtis tells The Rheumatologist. There was also more than fourfold variability in opiate use between rheumatology practices, which the authors attribute to individual prescribing patterns, disease severity and the presence of other painful conditions suffered by patients.
“In sum, our results suggest substantial use of opioids in an older RA population despite societal concerns regarding potential overprescribing in recent years,” Dr. Curtis says. “I’d like to know more about how helpful this is long term.”
Rheumatology has an important role in complicated pain issues, as the population with rheumatologic condition grows and pain is a common, and often the leading, debilitating problem in these patients, says Perry Fine, MD, professor of anesthesiology at the University of Utah School of Medicine and a national expert in pain treatment.
“Opioids can be either life saving or life threatening, depending on the competence of the prescriber, reliability of the patient and the social sphere in which they reside, and the support systems—formal and informal—available to the patient in creating a safe and effective outcome. At the end of the day, good care requires all of the above, with a focus on patient selection, sound application of prescribing practices and ongoing monitoring of therapeutic effects versus adverse effects and risks,” Dr. Fine concludes in a recent email to The Rheumatologist.
“In other words, we have very few proven high-efficacy options, medical or nonmedical, for long-term management of severe, debilitating intractable pain, and none are risk free. We know from experience and limited literature that some carefully selected and followed patients do benefit from long-term opioid therapy when other approaches have failed,” he says. “In all cases, we must individualize care, taking into account risks of treatment vs. nontreatment, monitor outcomes carefully and closely to minimize risks, especially when using opioids.”
The Place of Interdisciplinary Pain Clinics
“If we have somebody who’s not getting relief at the analgesic doses we are comfortable in providing, do we push the dose until either the pain is relieved or side effects emerge?” Dr. Rapoport poses. “We all get patients in our office who come to the rheumatologist when something hurts. When do we decide to send them to a pain center?” There are too many patients who have chronic pain and need pain management, and they can’t all be sent to a pain center.
Pain specialists emphasize the value of a multidisciplinary team approach to managing difficult pain cases as practiced at pain centers, often with multiple modalities that may include opioids, but also interventional procedures, such as epidurals. But patients may not always have access to such centers, their insurance may not cover the visit, and some centers may focus on interventional procedures at the expense of other modalities, Dr. Rapoport explains.
Ravi Prasad, PhD, associate chief of the Division of Pain Medicine at Stanford Medicine, Palo Alto, Calif., says the interdisciplinary approach to managing difficult pain, using the biopsychosocial framework practiced at Stanford’s pain clinic, is essential for challenging pain cases. The pain physician, physical therapist and psychologist on the interdisciplinary team bring together medical interventions, physical reconditioning and psychological and behavioral approaches to help patients get their pain under control. Pain centers may also bring in other specialties such as acupuncture.
“We need to recognize that acute and chronic pain are different, so the way we treat them should be different—and we need to make that clear to our patients. Acute pain often has an identifiable cause and a fixed end point, whereas chronic pain is influenced by multiple factors and can be ambiguous,” Dr. Prasad says.
“We do three-part evaluations, sit down and come up with comprehensive recommendations. Then we meet with the patient and walk them through the plan. There may not be a cure for their chronic pain condition, but nonpharmacologic strategies and techniques can help improve physical function and overall quality of life. The more we can step in early on and help patients learn to live with their pain, [the more they have] permission to move forward with their lives.”
Larry Beresford is a freelance medical journalist in Oakland, Calif.
References
- Paulozzi LJ, Jones CM, Mack KA, Rudd RA, et al. Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999–2008. Division of Unintentional Injury Prevention, National Center for Injury. Prevention and Control, Center for Disease Control and Prevention. MMRW. 2011 Nov 4;60(43):1487–1492.
- Acurcio FA, Moura CS, Bematsky S, et al. Opioid use and risk of nonvertebral fractures in adults with rheumatoid arthritis: A nested case-control study using administrative databases. Arthritis Rheumatol. 2016 Jan;68(1):83–91.
- Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint For Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011.
- Bollag S. California lawmaker proposes tax on OxyContin, other opioids. San Jose Mercury News. 2017 Mar 2.
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016 Mar 18;65(1):1–49.
- Hariharan J, Lamb GC, Neuner JM. Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. J Gen Intern Med. 2007 Apr;22(4):485–490.
- Curtis J, Xie F, Smith C, et al. Changing patterns over time in opiate use among U.S. rheumatoid arthritis patients [abstract 3086]. Arthritis Rheumatol. 2016;68(suppl 10).
