Opioids & Rheumatic Disease

For individuals living with rheumatic disease, chronic pain can be one of the more difficult symptoms to manage – leaving individuals to search for therapies and medications to live a more comfortable life.

For some, opioids may be a helpful solution, but this option comes with risks.

Chronic Pain in Rheumatology

Rheumatic diseases may be a cause of pain, some more acute or flare driven and other more chronic pain, or pain that lasts more than 3 months. Some of the chronic pain syndromes are challenging and somewhat taboo to diagnose and manage, leaving some patients to question “who is managing this chronic pain?”

Given the high prevalence of chronic pain in individuals with rheumatic disease, you may think that opioids are prescribed often, and perhaps they were 10-15 years ago when the risks for opioid medications were not well understood. There has now been a shift in the pendulum, where opioids are rarely prescribed and are hard for even established and long-standing, opioid-dependent patients to access. Understanding this issue is especially challenging for patients that have noted improvements in function, quality, and pain while taking opioid medications with few or any perceived side effects.

Risks of Opioids

While opioids may help to manage the pain, rheumatology providers (MDs, nurse practitioners, physician assistants) recognize that there are risks associated with these medications and may be hesitant to prescribe. Rheumatology healthcare providers must thoroughly review all health conditions, alternatives tried, and have a comprehensive risk-benefit conversation with the patient prior to prescribing an opioid. These tasks all require time, which may be compounded by a shortage of rheumatology providers and clinical support.

However, there are many reasons, including a provider’s aversion to risk, that opioids are not prescribed often in rheumatology practice. Reasons range from opioids potentially making chronic pain worse (opioid-induced hyperalgesia), risk for patient overdose and death, provider hesitancy, litigation potential, and practice norms.

Limited Access

Limited access to opioids likely stems from internal provider conflict and increasing regulations from all levels (local, state, and federal). The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain is an example of regulation that has been revised in response to difficulties noted, including misapplication of the guidelines, “inconsistent and inequitable access to effective pain management solutions, and reducing opioid use through diverse approaches while ensuring appropriate pain management.” The impact of regulations on individuals in need of treatment are important to address moving forward.

Internal provider conflicts may also play a role. Many rheumatologists may be hesitant to prescribe due to difficulties with diagnosis, ownership of chronic pain management, lack of opioid prescribing education, and clinically speaking, implementing risk-reducing strategies (opioid mitigation strategies) and difficult patient conversations.

Future Considerations

Improving the health care system for individuals with rheumatic disease and addressing rheumatology provider challenges with opioid prescribing will require multiple strategies.

These could include:

• Improving provider education and confidence in the management of opioids and chronic pain at all levels
• Increasing provider time with patients for shared decision making
• Continued training of new rheumatology physicians and advanced practice providers (nurse practitioners and physician assistants)

In rheumatology, many of our patients have chronic, hard to manage autoimmune diseases. Some may have deformities and chronic pain that need ongoing pain management. As chronic syndromes necessitate patient-provider relationships that are typically long-standing, similar but different to a primary care provider in focus, it is reasonable for a rheumatology provider to consider opioids as part of a holistic management plan when appropriate. However, given the complexity of many of our autoimmune conditions, it may not be feasible for all opioids and chronic pain to be managed by the rheumatologist unless the constraints noted earlier, including time, support, education, and practice norms are addressed.