Physicians Prescribe Too Many Opioids for Osteoarthritis

Allison Shelley

October 22, 2018

Study presenter Wenhui Wei, PhD, senior director at Regeneron Pharmaceuticals, told Medscape Medical News that more than half of the nearly 143,000 patients in the insurance claims database who were being treated with opioids for osteoarthritis pain did not appear to be managed appropriately. (Camera work by John Gress; video edit by John Rodriguez)

CHICAGO — New data reinforce the need for physicians to evaluate the use of opioids to manage pain in patients with osteoarthritis. Study results, presented here at the American College of Rheumatology 2018 Annual Meeting, cast a shadow on higher-intensity regimens and identify criteria for flagging problems.

The treatment of joint pain, the primary symptom of osteoarthritis, must be adequate but should not expose patients to unnecessary risks, lead investigator Nathaniel Katz, MD, from Tufts University School of Medicine in Boston, and his colleagues point out in their abstract.

But there are inconsistencies in recommended treatment approaches, and data on whether osteoarthritis pain is appropriately managed in clinical practice, particularly in patients treated with opioids, are lacking.

"Opioids are not contraindicated in OA, but their positive risk–benefit balance depends upon appropriate use, which is often not the case," Katz told Medscape Medical News.

The team drew on the experience of clinical experts who manage osteoarthritis to study the prevalence of inappropriate pain management in a real-world setting and developed criteria to identify it.

Criteria for Potentially Inappropriate Opioid Pain Management
Clinical Category Definition
Multiple opioids At least four prescriptions for unique opioids in any 90-day period
Early refills At lease one opioid prescription fill when more than 10% of an existing prescription should be available
Excessive postsurgical opioid use Opioid prescription fill more than 90 days after surgery
Concomitant long-acting opioid use At least two occurrences — during any period of at least 7 days — of overlapping prescription fills for unique long-acting opioids
History of substance abuse Opioid prescription despite a history of substance abuse
Postindex opioid abuse At least one diagnosis of opioid abuse disorder after receiving opioids
History of opioid abuse At least one diagnosis of preindex opioid overdose
Opioid overdose At least one diagnosis of postindex opioid overdose

Their analysis of an insurance claims database showed that patients on double-barreled long- and short-acting opioid regimens were at highest risk for inappropriate pain management, 83% met the criteria for inappropriate pain management, and 32% on intermittent daily doses of opioids were considered at risk for inappropriate management.

Of the more than 40,000 patients in the study cohort who used nonopioid analgesics, 15% appeared to be overusing them, reported investigator Wenhui Wei, from Regeneron Pharmaceuticals in Tarrytown, New York.

And 14% of patients were using too many osteoarthritis-related medical services, he added.

In another poster presented during the same session, more than one-quarter of a cohort of 2220 patients with osteoarthritis referred for knee replacement were using opioid analgesia.

"Unfortunately, many patients on opioids have already missed the boat and are dependent," said investigator Lauren King, MD, from the University of Toronto.

In addition to not taking recommended therapies, these patients were not pursuing weight loss, exercising, or engaging in physiotherapy. "It was concerning to see so many patients referred for surgery and so few of them exercising or losing weight," she told Medscape Medical News.

King and her colleagues will now study postsurgical outcomes to see how patients fare in the long term.

The opioids study was funded by Regeneron and Teva. Katz serves as a consultant for Regeneron and Teva. Wei is an employee of Regeneron. King has disclosed no relevant financial relationships.

American College of Rheumatology (ACR) 2018 Annual Meeting: Posters 440 and 442. Presented October 21, 2018.

Follow Medscape Rheumatology on Twitter @MedscapeRheum and Allison Shelley @allishelley



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