By Phoebe Starr
New Orleans, LA—The role of opioids in the management of patients with rheumatoid arthritis (RA) is controversial. A 2011 Cochrane Review showed insufficient evidence to support the role of weak opioids in this setting for >6 weeks, or for the role of strong opioids (Whittle SL, et al. Cochrane Database Syst Rev. 2011;[11]:CD003113). Against this background, a small study suggests that adjuvant opioids provided effective pain relief and improved physical function, with no evidence of misuse, diversion, or laboratory abnormalities in older patients with RA-associated pain. This retrospective study was presented at the 2013 American Pain Society annual meeting.
“To date, there is no reported study on the long-term outcomes of opioids used in combination with antirheumatic drugs [ARDs] in older adults. Our study sought to evaluate the long-term efficacy and safety of adjunctive opioids in older persons with pain from RA,” said lead investigator, Shirley Albano-Aluquin, MD, Rheumatologist, Penn State University College of Medicine, Hershey, PA.
A total of 20 participants (aged ≥60 years) were seen from 2006 through 2012 and managed by 1 rheumatologist with geriatric training. The patients had moderate-to-severe RA pain, as reflected by a score of ≥5 on the 0 to 10 Numerical Pain Scale (NPS).
Opioids were started in patients receiving background therapy with ARDs. At baseline, 30% were receiving nonsteroidal anti-inflammatory drugs, 35% neuromodulators, 45% methotrexate, 50% corticosteroids, and 40% biologics.
Of the 20 patients, 16 were women, and the mean disease duration was approximately 10.6 years. The mean number of comorbidities was 4.8, including hypertension (85%), osteoarthritis (100%), neuropathic pain (30%), stenosis (10%), and osteoporotic fracture (20%).
Five patients were treated with Schedule II short-acting morphine, oxycodone, and acetaminophen; 1 received Schedule II long-acting morphine, oxycodone or fentanyl plus Schedule III/IV hydrocodone, tramadol or codeine; 3 received Schedule II long-acting plus short-acting opioids; and 11 received Schedule III/IV opioids only. Sixteen (80%) patients received a total daily dose of 120-mg morphine equivalents or less, whereas 4 (20%) received 120-mg morphine equivalents or greater.
At early (median, 4 months) and late (median, 11 months) follow-up, 42% and 47%, respectively, achieved pain improvement of ≥30% (NPS30). NPS responders were more frequently anti-CPP positive; 78% of responders were anti-CCP positive versus 22% of nonresponders. NSP30 responders also had higher baseline pain scores compared with nonresponders (median, 8.6 vs 6.2, respectively). In 56% of responders, oxycodone with or without acetaminophen was used.
On the Health Assessment Questionnaire Disability Index, improvement was seen in 27% at early assessment and in 46% at late assessment. A ≥50% response on the RA Clinical Disease Activity Index (CDAI50) was achieved in 5% at both follow-up assessments.
Only 1 serious adverse event was reported. There was no evidence of opioid abuse.
Dr Albano-Aluquin said that these results in patients with significant comorbidities and significant arthritis-related pain and functional impairment suggest that opioids were successful at relieving pan and improving function over the long-term.