New figures a “wake up call” for opioid overuse in arthritis patients

Inappropriate prescribing of opioids for patients with arthritis is putting Australia on track for an opioid crisis to match that already occurring in the US, rheumatologists say.

Their warning follows new figures showing a rising trend for opioid use in osteoarthritis in Australia, and in particular before joint replacement surgery.

An analysis of Medicare, PBS dispensing and GP prescribing data found that almost one in five patients with osteoarthritis had used opioids for analgesia. If current trends continue, opioid usage levels will treble from 1 million to 3 million prescriptions a year by 2030/31, the study authors estimated.

The findings, published in Osteoarthritis and Cartilage, also found that 10% of all opioids prescribed in Australia were for OA-related pain,  with 20% of GP encounters for hip OA and 10% for knee OA resulting in an opioid script.

A separate study in the same journal showed that nearly half of OA patients had opioids prescribed before joint replacement in 2012, which was a 30% increase for total knee replacement and a 20% increase for hip replacement surgery since 2001.

The figures were cause for concern given that opioids had only limited benefit for chronic OA and a high risk of adverse effects, especially in a mostly elderly population, an accompanying commentary said.

“The skyrocketing use of opioids and its adverse consequences for patients and society call for a pause to quantify this burden in the setting of OA and reflect upon the role (if any) of opioids in the treatment of OA patients,” it suggested.

Dr Sam Whittle, a senior consultant rheumatologist at the Queen Elizabeth Hospital in Adelaide and treasurer of the Australian Rheumatology Association, told the limbic that the projections should be a “wake up call” for the speciality.

“It’s important we act in some way that prevents these predictions from coming true. If things were to increase from here we are looking at a major problem”.

Dr Whittle said the rise in opioid use in arthritis had been driven by a “well intentioned” move in the early 2000s towards prescribing opioids for non-cancer pain as a means to avoid using NSAIDs. It has taken another decade to realise they are not only associated with harms, but often not effective.

“As a profession we were unintentionally complicit in driving this use of opioids and setting the expectation we could treat chronic MSK pain with pharmacotherapy.

“Now we’re all scrambling as fast as we can to reverse that trend. Because if that trend continues the epidemic is only going to get worse. We need to act fast.”

Dr Whittle said for now at least, pharmacotherapy “is only really a small part of managing chronic pain, and it’s a message that’s hard to sell because we don’t have good alternatives. Exercise, CBT are effective but not effective in the same way”.

“We live in this state of hope we will develop much more effective pharmacotherapy and even disease modifying OA drugs in the near future.

“But in the meantime, we need to be absolutely certain that we aren’t allowing our patients to come to harm from medications that are not particularly effective and which have substantial harms and opioids are the poster child of that class of drugs.”

In the journal commentary, rheumatologists speculated that the rise in opioid use in OA was being driven by pharmaceutical company promotion, doctors’ and patients’ frustrations from insufficiently controlled pain, and underuse of non-drug interventions such as weight loss and exercise.

And overuse of opioids extended to rheumatoid arthritis, according to Dr Bethan Richards, head of the rheumatology department at Sydney’s Royal Price Alfred Hospital. She noted that despite huge gains with disease modifying agents, in one study showed 56% of patients using them still reported moderate to severe pain.

And data from the ARA database showed than on average almost one in three RA patients used opioids between 2001-2015, and 20% used strong opioid such as oxycodone or fentanyl.

Dr Richards said that avoiding an opioid epidemic would require a multi-pronged approach, involving doctors re-evaluating how they prescribe and also resetting patients’ expectations and government investment into more physical therapy and healthy lifestyle programs.

Opioids were useful as a short-term treatment of end-stage arthritis and post operatively, but beyond that it was unlikely they would be suitable to manage RA-related pain.

“What many of the patients are telling us is [opioids] are not working, and if you keep increasing the dose you can actually increase levels of pain,” she said.

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