COMMENTARY

'Avoid Opioids to Treat Arthritis,' Says a Rheumatologist

'Rheumatologists Should Not Contribute to the Healthcare Crisis of Opioid Addiction'

Jonathan Kay, MD

Disclosures

January 03, 2018

Hello. I'm Dr Jonathan Kay, professor of medicine and the Timothy S. and Elaine L. Peterson Chair in Rheumatology at the University of Massachusetts Medical School and University of Massachusetts Memorial Medical Center, both in Worcester, Massachusetts. Welcome to my Medscape blog.

Recently, there has been a lot of discussion about the opioid epidemic in the United States. In fact, the President of the United States declared this a public health emergency. Patients with chronic pain have been treated with opiates, oftentimes with long-acting opiates administered more than the approved daily dosing. Individuals initially treated for medically indicated reasons, such as perioperative pain or following a sports injury, become addicted to opiates and, ultimately, acquire opiates either from physicians who are willing to prescribe them in large quantities, or they turn to street drugs, such as heroin, when they can no longer obtain [an opiate].

Part of the genesis of this opioid epidemic was the push to expand the market for OxyContin® in the early part of the 2000s to indications other than perioperative pain and cancer pain. The sales people for Purdue Pharma were encouraging physicians to use OxyContin® to treat pain in conditions such as arthritis and even fibromyalgia. Well, this was a big mistake.

Patients with inflammatory arthritis can and should be treated effectively with disease-modifying antirheumatic drugs (DMARDs). A patient with active synovitis can be treated very effectively with anchor drugs (eg, methotrexate) and, if necessary, targeted biological therapies. If patients with active synovitis are started on a narcotic analgesic medication, they become dependent upon the narcotic analgesic and then become narcotic-addicted individuals in addition to having inflammatory arthritis.

In my own practice, I avoid prescribing narcotic analgesics for this reason, and I aggressively treat to target to control the underlying disease. Patients with generalized pain amplification syndromes oftentimes have pain amplification as a result of an underlying sleep disturbance, which, when diagnosed, can be treated with effective control of their pain. Some patients have inadequately treated psychiatric disease, such as depression, which can be addressed with appropriate pharmacologic medication. Individuals with post-traumatic stress disorder should be treated (perhaps less effectively) with psychotherapy and medication.

Thus, opioids should not become part of the therapeutic armamentarium of rheumatologists, and patients with rheumatic diseases should be treated with medications directed toward treating the underlying disease. Rheumatologists should not contribute to the healthcare crisis of opioid addiction in the United States, but rather we should help to control underlying disease and reduce the need for opioid analgesics.

Thank you for your attention. I'm Dr Jonathan Kay. I look forward to seeing you again on Medscape.

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