Prescription Opioid Use in Patients With and Without Systemic Lupus Erythematosus

Michigan Lupus Epidemiology and Surveillance Program, 2014-2015

Emily C. Somers, PhD; Jiha Lee, MD; Afton L. Hassett, PsyD; Suzanna M. Zick, ND; Siobán D. Harlow, PhD; Charles G. Helmick, MD; Kamil E. Barbour, PhD; Caroline Gordon, MD; Chad M. Brummett, MD; Deeba Minhas, MD; Amrita Padda, MD; Lu Wang, PhD; W. Joseph McCune, MD; Wendy Marder, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(38):819-824. 

In This Article

Discussion

In this study documenting the extent of prescription opioid use in patients with SLE, nearly one third of SLE patients in a well-characterized cohort used prescription opioids during 2014–2015, compared with 8% of frequency-matched persons without SLE. Approximately 70% of the SLE patients taking prescription opioids were on opioid therapy for >1 year. The higher odds of prescription opioid use among patients persisted after accounting for several factors in multivariable models. ED use in the last 12 months was associated with opioid use in both the total population and among SLE patients.

The widespread and long-term use of prescription opioids among this cohort of patients with SLE was striking given lack of evidence regarding safety and efficacy of opioids for treating chronic pain associated with rheumatic disease.[1,7] Particularly concerning is that some of the less appreciated medical risks associated with long-term opioid use, such as myocardial infarction, immunosuppression, and osteoporosis,[8] are potentially compounded in persons with SLE, whose baseline risks for these comorbidities are elevated because of the underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies. Further, recent preliminary data suggest that opioids are associated with increased mortality in lupus.

Whereas rheumatic diseases are a leading cause of chronic, noncancer pain,[7] data on opioid use and associated outcomes in persons with rheumatic diseases are limited. One recent study of Medicare beneficiaries with rheumatoid arthritis estimated regular opioid use (three or more filled prescriptions or one or more filled 90-day prescription per calendar year) at approximately 40%.[9] Together with the findings from this analysis, the prevalent use of opioids in at least two patient populations with rheumatic diseases supports the need for better understanding of prescribing patterns, risk factors associated with opioid initiation and long-term continuation, and pharmacoepidemiology related to adverse medical effects of opioids in these patients. Effective interventions in this population will need to couple tailored approaches for tapering and discontinuing opioids when indicated, along with prevention of opioid initiation and consideration of nonopioid pain management strategies.

Interventions to address opioid use in patients with rheumatic diseases will require a better understanding of pain management for patients with these complex, chronic conditions, whose sources of pain might be multiple, persistent, and severe, and which must be accurately diagnosed to be appropriately treated. Sources of SLE-related pain can include active inflammatory disease resulting in peripheral pain (e.g., arthritis), damage accrual attributable to the disease or its treatment (e.g., steroid-induced osteonecrosis or vertebral fractures), or centralized pain disorders, such as fibromyalgia, the prevalence of which is higher in patients with SLE than in the general population.[4]

The findings in this report are subject to at least five limitations. First, prescription data were self-reported, which limited the ability to examine sources of opioid prescribing or dosing patterns in more detail and could have been subject to underreporting attributable to social desirability bias. Second, since the original SLE registry reflected the demographics of southeastern Michigan (which is predominantly black and white), Asians, Hispanics, and other groups were not well represented, and results might not be generalizable to the wider SLE population. Third, this report addresses prescription opioid use, but information on other potential opioid sources is unavailable. Fourth, these data reflect 2014–2015; trends in opioid prescribing and usage might have changed since then. Finally, the cross-sectional nature of this analysis precludes assessing temporal relationships for factors associated with prescription opioid use. Strengths of this study include starting from a population-based SLE registry, inclusion of relatively large numbers of well-defined patients with SLE, comparing to age-, sex-, race-, and county-matched persons without SLE, and use of validated patient-reported outcome measures to assess psychosocial and lupus-specific factors in relation to prescription opioid use.

In conclusion, during 2014–2015, one third of patients in a SLE cohort in southeastern Michigan were using prescription opioids, most for longer than 1 year. Given the risks for opioid therapy and the lack of pain efficacy data in SLE, it is important that clinicians managing SLE, including providers in EDs, be aware of the potential adverse effects of opioid therapy in these patients, consider nonopioid pain management strategies, and be familiar with guidance for opioid tapering or discontinuation when patients are not achieving treatment goals of reduced pain and increased function or when otherwise indicated.[2]

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