Nearly 25% of strong opioid use in RA may be attributed to obesity
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Nearly a quarter of strong opioid use among patients with rheumatoid arthritis is potentially attributable to obesity and its associated comorbidities, according to data published in Arthritis Care & Research.
“Chronic opioid use has been recognized as an important public health problem, and patients with arthritis commonly experience chronic pain that can lead to the use of these drugs,” Joshua F. Baker, MD, MSCE, of the University of Pennsylvania and the Philadelphia VA Medical Center, told Healio Rheumatology. “It's important to understand what factors lead to chronic use of opioids in order to learn how we might prevent this outcome.”
To analyze whether the rate of incident chronic opioid use is higher among patients with obesity in the rheumatoid arthritis population, Baker and colleagues studied data from Forward, The National Databank for Rheumatic Diseases. According to the researchers, Forward is a patient-based multi-disease, multi-purpose rheumatic disease registry with patients enrolled from community-based rheumatology practices across the United States, and followed-up with bi-annual questionnaires. Focusing on data from Jan. 1, 1999, to Feb. 28, 2019, the researchers included 19,794 individuals with RA in their study.
All Forward participants had been asked about their use of weak and strong opioid medications. Baker and colleagues defined chronic opioid use as new reported use extending through two contiguous follow-up questionnaires — roughly a period of 7 to 12 months. The researchers used Cox proportional hazards models to examine associations between baseline BMI and incident chronic opioid use, as well as predict 5-year cumulative incidence. These models adjusted for demographics, smoking, disease duration, RA treatments, household income and education level.
Investigators reported that 2,802 of the included participants experienced an episode of chronic opioid use during a total of 93,254 person-years of follow-up. Higher BMI was associated with a higher risk for chronic opioid use. For example, severe obesity — defined as a BMI greater than 35 kg/m2 — was associated with a higher risk for both overall opioid use (HR = 1.74; 95% CI, 1.72-2.04) and strong opioid use (HR = 2.11; 95% CI, 1.64-2.71), compared with the normal BMI range. Ultimately, the attributable risk linked to obesity was 15% for overall opioid use, and 24% for strong opioid use.
According to Baker and colleagues, this association was partially due to greater comorbidity, pain, and disability in patients with obesity.
“These findings are significant because they suggest that interventions to prevent or reverse obesity in this population would have an important effect on reducing the use of these drugs in the long-term,” Baker said. “These observations therefore add to the already substantial evidence that the obesity epidemic needs greater public health attention. They also further highlight that obesity remains an important and common problem in patients with rheumatoid arthritis with important long-term implications for health.”
Perspective
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Teri Puhalsky, RN, CRNI
Obesity is a preventable public health crisis. Obesity-associated inflammation is just one of the many serious health concerns facing our autoimmune patients; many are also at risk for major cardiometabolic diseases and certain forms of cancer.
Rheumatoid patients who are overweight and obese are at a higher risk for chronic opioid use to control their chronic pain. While there is no one optimal way to help our patients with their pain, awareness, education, and management must be discussed, implemented, and evaluated at regular intervals. Patients need to fully understand the effects and risks of long-term opioid use.
Weight control, food alternatives, complementary medicine and relaxation techniques should be interventions that are part of a holistic care plan for pain and inflammation management. Our highest-risk patients, those with a BMI >35kg/m2, need to be a priority for collaboration with other health care professionals to manage their pain and control inflammation before the use of prescription opioids becomes their only solution.
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David A. McLain, MD, FACP, FACR
How does obesity impact our rheumatoid arthritis patients? Prior studies have shown a poorer response to some biologic DMARDs with more treatment failures in obese patients. We know from the literature and our own experience that our obese patients have more osteoarthritis of the knees and lumbar spine, more comorbidities, more disability and more pain. Usually they are not able to exercise and often need a higher MME for pain relief.
Another analysis of opioid use in RA found that chronic pain, higher disease activity, antidepressant use, and greater disability were all associated with a higher rate of chronic opioid use. This present study using Fred Wolfe’s Forward database found that severe obesity (BMI >35 kg/m2) was associated with chronic opioid use and with strong opioid use — ‘strong’ being defined as any opioid stronger that hydrocodone.
Addressing severe obesity in our RA patients is difficult. I have had some success in referring them for a gastric sleeve after they have failed dieting. In some patients, this has been life changing. The best success has been with a bariatric surgeon that continues to follow these patients chronically with weight and diet monitoring as the surgery alone often has diminishing returns over time.
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