Opioid Use Trends Down in Last Decade for Rheumatic Diseases

Titilola Falasinnu, PhD

Credit: Stanford Medicine

A recent study has found that the use of non-opioid pain management modalities has increased or stabilized while opioid and nonsteroidal anti-inflammatory drugs (NSAID) use has declined in patients with autoimmune rheumatic diseases.¹

“Data for the management of pain in autoimmune rheumatic diseases are scarce, particularly for less common diseases such as Sjögren’s syndrome and systemic sclerosis, with much of the recent literature focusing on opioid use and misuse. Clinical guidelines for the management of pain in people with autoimmune rheumatic diseases are dated and do not reflect contemporary trends in pain management, such as the shift away from chronic opioid use,” lead investigator Titilola Falasinnu, PhD, Assistant Professor of Medicine (Immunology and Rheumatology), Stanford Medicine, and colleagues wrote.¹

Falasinnu and colleagues conducted an analysis on data from patients with newly diagnosed ankylosing spondylitis, psoriatic arthritis (PsA), rheumatoid arthritis (RA), Sjögren’s syndrome, systemic sclerosis, or systemic lupus erythematosus (SLE) from the Merative Marketscan Research Databases from 2007 to 2021. These data included deidentified inpatient and outpatient health encounters with employment-sponsored health insurance claims in the USA. Participants had only minimal occurrences of multiple overlapping conditions, and the investigators included only the initial recorded diagnosis for each patient. They analyzed the association between the annual incidence of patients treated with opioids, anticonvulsants, antidepressants, skeletal muscle relaxants, NSAIDs, topical analgesics, and physical therapy in the year following diagnosis with outcomes adjusted for age, sex, and region.

"...the use of multiple non-opioid treatment modalities has increased, including physical and occupational therapy, anticonvulsants, topical analgesics, and psychosocial treatment.² However, little is known about recent changes in the use of alternative chronic pain treatment modalities in people with autoimmune rheumatic diseases. Such knowledge will be fundamental for updating chronic pain treatment guidelines in rheumatology,” Falasinnu and colleagues wrote.¹

The analysis included 141,962 patients with ankylosing spondylitis (n = 10,927), PsA (n = 21,438), RA (n = 71,393), Sjögren (n = 16,718), SLE (n = 18,018), or systemic sclerosis (n = 3468), most of whom were women (n = 107,475; 75.7%). The investigators found that the overall rate of opioid use rose by 4% each year until 2014 (adjusted odds ratio [aOR], 1.04 [95% CI, 1.03–1.04]) and then fell by 15% annually after 2014 (aOR, 0.85 [95% CI, 0.84–0.86]).

Physical therapy usage increased by 5% each year up to 2014 (aOR, 1.05 [95% CI, 1.04–1.06]), followed by a slight annual decline of 1% after that (aOR, 0.99 [95% CI, 0.98–1.00]). Anticonvulsant use grew by 7% annually until 2014 (aOR, 1.07 [95% CI, 1.07–1.08]) and remained stable afterward (aOR, 1.00 [95% CI, 0.99–1.00]). Prior to 2014, the incidence of NSAID use rose by 2% each year (aOR, 1.02 [95% CI, 1.02–1.03]), but it decreased by 5% annually after that (aOR, 0.95 [95% CI, 0.95–0.96]). These trends were consistent across genders, with the exception of NSAID use before 2014 (P = .02) and topical analgesic use after 2014 (P = .0100). A sensitivity analysis found that the number of autoimmune rheumatic diseases did not significantly change these findings.¹

Falasinnu and colleagues noted variations in pain management practices across different autoimmune rheumatic diseases. In ankylosing spondylitis, PsA, and RA, the prescribing rates for NSAIDs were highest, followed by opioids, while prescriptions for antidepressants, anticonvulsants, and topical analgesics were lower. Patients with Sjögren’s syndrome and systemic sclerosis had lower rates of opioid and NSAID prescriptions compared to those with ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis. However, systemic sclerosis patients had the highest opioid usage among pain management options, with rates ranging from 20–40%. Pain management trends were similar for systemic lupus erythematosus (SLE) and Sjögren’s syndrome.¹

Notably, patients with ankylosing spondylitis experienced the largest decline in opioid prescriptions after 2014, with a 17% annual decrease, while systemic sclerosis patients saw a 10% decrease. Patients with RA had the highest increase in anticonvulsant prescriptions prior to 2014 (10% annually), whereas systemic sclerosis patients saw no significant change during that time. Although the annual incidence of antidepressant prescriptions decreased for most conditions after 2014, it increased by 5% for systemic sclerosis patients, though this change was not statistically significant. No differences were observed in the use of skeletal muscle relaxants, NSAIDs, topical analgesics, or physical therapy when analyzed by condition.1

In comparison, among 639,850 patients with osteoarthritis and 3,277,292 patients with hypertension, a greater proportion of those with autoimmune rheumatic diseases and osteoarthritis received pain management prescriptions compared to hypertension patients. Additionally, opioid prescriptions decreased across all disease groups since 2014.¹

“In conclusion, our administrative claims study highlights a shift towards increased use of non-opioid pain management modalities and a decline in opioid and NSAID prescriptions among patients with newly diagnosed autoimmune rheumatic diseases in the USA, reflecting changes possibly influenced by policy shifts and updated clinical guidelines. However, further research is warranted to assess the long-term effect of these trends on patient outcomes and to address gaps in pain management strategies for less prevalent conditions such as Sjögren’s syndrome and systemic sclerosis,” Falasinnu and colleagues concluded.¹

REFERENCES

1. Falasinnu T, Lu D, Baker MC. Annual trends in pain management modalities in patients with newly diagnosed autoimmune rheumatic diseases in the USA from 2007 to 2021: an administrative claims-based study. Lancet Rheumatol 2024; 6: e518–27. doi: 10.1016/ S2665-9913(24)00120-6

2. Frank JW, Carey E, Nolan C, et al. Increased Nonopioid Chronic Pain Treatment in the Veterans Health Administration, 2010-2016. Pain Med. 2019;20(5):869-877. doi:10.1093/pm/pny149