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High Rates of Inappropriate Opioid Use Found in SLE

A large proportion of patients with systemic lupus erythematosus (SLE) have been inappropriately prescribed opioids, researchers reported recently in the Morbidity and Mortality Weekly Report.

A large proportion of patients with systemic lupus erythematosus (SLE) have been inappropriately prescribed opioids, researchers reported recently in the Morbidity and Mortality Weekly Report.

Opioids are generally not indicated for pain in SLE or other rheumatic diseases because of limited efficacy and risks for addiction and adverse health effects.

This is of particular concern in individuals with SLE, because they are more vulnerable to some of the medical risks associated with long-term opioid use, such as myocardial infarction, immunosuppression, and osteoporosis. The elevated risk in SLE is due to both the underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies, according to lead author Emily C. Somers, Ph.D., of the division of rheumatology at the University of Michigan, Ann Arbor, and colleagues.

Moreover, they note, recent preliminary data suggest that opioids are associated with increased mortality in lupus.

Sources of pain in SLE can include active inflammatory disease resulting in peripheral pain such as arthritis, damage from the disease or its treatment, such as steroid-induced osteonecrosis or vertebral, or centralized pain disorders, such as fibromyalgia, which often co-occurs with SLE. Each of these needs to be accurately diagnosed in order to be appropriately treated, Somers and colleagues said.

“Given the risks for opioid therapy and the lack of pain efficacy data in SLE, it is important that clinicians managing SLE, including providers in [emergency departments], be aware of the potential adverse effects of opioid therapy in these patients, consider nonopioid pain management strategies, and be familiar with guidance for opioid tapering or discontinuation when patients are not achieving treatment goals of reduced pain and increased function or when otherwise indicated,” they wrote.

The study involved 462 patients with SLE from the population-based Michigan Lupus Epidemiology and Surveillance (MILES) Cohort and 192 individuals without SLE matched with the patients for age, sex, race, and county of residence.

In structured interviews conducted during 2014 and 2015, 31 percent of the SLE patients reported that they were currently using prescription opioids, compared with just 8 percent of those without SLE (P < 0.01). And among the 143 using prescription opioids, 68 percent had been using them for more than one year, and 22 percent were taking more than one opioid medication concomitantly.  
After accounting for demographic, psychosocial, and clinical factors, the odds of opioid use were more than three times greater for those with SLE (odds ratio 3.4, P < 0.001).

Prescription opioid use was also twice as common among individuals with SLE who had made at least one emergency department visit in the past year (odds ratio 2.1, P = 0.004).

And, for every one standard deviation increase in pain and physical function scores, the odds of opioid use were approximately 35 percent and 12 percent higher, respectively.

“The widespread and long-term use of prescription opioids among this cohort of patients with SLE was striking given lack of evidence regarding safety and efficacy of opioids for treating chronic pain associated with rheumatic disease,” Somers and colleagues write.

“Interventions to address opioid use in patients with rheumatic diseases will require a better understanding of pain management for patients with these complex, chronic conditions, whose sources of pain might be multiple, persistent, and severe, and which must be accurately diagnosed to be appropriately treated,” they conclude.