The role of opioid analgesics in rheumatoid disease in the elderly population

Narcotic analgesics

There is documentation of the use of opium derived products in the ancient history of the Assyrians: the Egyptians; in the sixth century AD by the Roman Dioscorides; and by Avicenna (980-1037). Reference to opium like products is made by Paracelsus and by Shakespeare. Charles Louis Derosne and Fredrich Wilhelm Adam Serturner isolated morphine from raw opium in 1802 and 1806 respectively, and it was Sertürner who named the substance morphine, after Morpheus, the Greek God of dreams. By the middle 1800s, Opium and related opioid derived products were the source of a major addiction in USA, and to some extent in the United Kingdom. Opioid products are of major therapeutic value in the treatment of pain from injury, post surgery, intractable pain conditions, and some forms of terminal cancer.

Association of Rheumatoid Arthritis with Opioid Pain Medication Overuse among Persons Exposed to the 9/11 World Trade Center Disaster

We examined the association of post-9/11 rheumatoid arthritis (RA) diagnosis with opioid pain medication overuse among enrollees in the World Trade Center Health Registry (WTCHR). Opioid overuse was defined as the self-reported intake of prescribed opioids at a higher dosage or more often than directed in the last 12 months on one of the two most recent WTCHR surveys (2015-2016, 2020-2021). Post-9/11 RA was ascertained through self-reports and subsequently validated following medical record release by the enrollees' physicians or medical records review. We excluded those with self-reported RA that was not validated by their physicians and those who did not report being prescribed opioid pain medication in the last 12 months. Multivariable log-binomial regression was conducted to examine the relationship between post-9/11 RA diagnosis and opioid pain medication overuse, adjusting for sociodemographic characteristics and 9/11-related posttraumatic stress disorder (PTSD) symptoms. Of the 10,196 study enrollees, 46 had confirmed post-9/11 RA. The post-9/11 RA patients were mostly females (69.6% vs. 37.7%), less frequently non-Hispanic White (58.7% vs. 73.2%) individuals, and less often had attained a higher level of education (76.1% vs. 84.4%) compared to those without post-9/11 RA. Opioid pain medication overuse was significantly associated with a post-9/11 RA diagnosis (Adjusted Risk Ratio: 2.13, 95% CI: 1.44-3.17). More research is needed to better understand the use and management of prescribed opioids among WTC-exposed individuals with RA.

Opioids for nonmalignant pain

Pain is the most common symptom in the world for which patients seek professional help. Opioids offer an appropriate and safe treatment for some but not all patients with nonmalignant chronic pain. Potential risks, including drug abuse and intolerable side effects, appear to be manageable or even preventable in most cases. Patients with persistent rheumatic pain who have failed traditional treatments should be considered for long-acting opioids. Opioids are best administered in the framework of weighing the good against the bad in each patient, recognizing the potential morbidity and sometimes mortality in untreated patients who have severe and disabling pain daily.

Polypharmacy among people with rheumatoid arthritis: the role of age, disease duration and comorbidity

BACKGROUND

People with rheumatoid arthritis (RA) often have comorbidities with associated disability and complex medication regimens. Little published evidence exists about why people with RA require so many medications, although it is logical to hypothesize that this may relate to older age, longer duration of RA, more active RA, worse functional disability and a greater number of comorbidities.

OBJECTIVES

We set out to quantify polypharmacy in RA and identify its predictors in an observational cohort.

METHODS

The case notes of 348 people receiving secondary care for RA were reviewed to record polypharmacy. The 28-joint Disease Activity Score (DAS28) was calculated and the Health Assessment Questionnaire (HAQ) and the Self-administered Comorbidity Questionnaire (SCQ) were completed.

RESULTS

The mean total number of medications was 5.39, with a maximum of 16; of these, a mean of 2.41 medications were directly for RA. A mediational relationship was identified: older age and longer RA duration were significant predictors of a greater total number of medications, but these relationships were explained by the greater number of comorbidities in older participants and those with longer RA duration. Polypharmacy was not related to RA activity or functional disability.

CONCLUSIONS

Polypharmacy is common among people with RA and associates with older age and longer RA duration through a greater number of comorbidities. Regular review of the full treatment plan of individuals with RA by pharmacists and other health professionals specializing in rheumatology, to weigh the benefits and risks of each medication and their interactions in light of RA activity and comorbidities, is advocated.

[Effectiveness of a pharmaceutical care unit for the control of severe chronic pain]

INTRODUCTION

The effectiveness of a pharmaceutical care unit was assessed within a staged program for non-malignant severe chronic pain control in a multidisciplinary pain management unit at Consorcio Hospital General Universitario, Valencia, Spain.

MATERIALS AND METHODS

One hundred and fifty patients with clinical indication for a major opioid were included in WHO's third analgesic rung by our medical team following careful triage. The pharmaceutical care unit, or phase II, monitored dosage titration for pain stabilization with absence of side effects, as well as the onset of subsequent chronic therapy.

RESULTS

Upon program completion 75% of patients had their pain under control, having required 22.7 days on average for opiate dose titration. Mean daily dose was 22.3 mg, and constipation was prophylactically managed from the start. Fifty-nine percent of patients received subsequent chronic therapy with fentanyl transdermal patches at 25 microg/h; 10% followed suit with oral morphine solution, and 6% with controlled-release morphine. Twenty-five percent of the remaining patients had relevant events during the therapy titration stage, which led to therapy discontinuation and discharge because of lack of therapeutic effectiveness. After 24 months 70% of patients were still on initial doses.

CONCLUSIONS

The effectiveness of our unit was demonstrated by the achievement of the program objectives.

Underutilisation of Opioids in Elderly Patients with Chronic Pain

The impact of poorly managed chronic pain on the quality of life of elderly patients and the problems related to its management are widely acknowledged. Underutilisation of opioids is a major component of poor pain management in this group of patients, despite good evidence for the effectiveness of opioids and published guidelines directing their usage. Reasons for this underutilisation are, among others, poor assessment of pain in this age group; fear of polypharmacy and opiophobia; and avoidance of opioids because of concerns about tolerance, physical dependence, addiction and adverse effects. This review suggests approaches to overcome these barriers to opioid usage, such as regular pain assessments, education to overcome opiophobia, rational prescribing, utilisation of less conventional opioids and non-oral routes of administration, avoidance of inappropriate opioids, opioid rotation, and education about managing or preventing adverse effects, the reasons why opioid therapy may be unsuccessful, and the effects of psychological factors on the pain experience. This more rational and knowledge-based approach to the use of opioids in the management of chronic pain in the elderly population should correct the current problems with underprescribing in this age group.

Transdermal fentanyl for the treatment of pain caused by rheumatoid arthritis

This study evaluated transdermal fentanyl (TDF) for the treatment of pain from rheumatoid arthritis (RA) which was not adequately controlled by nonopioid analgesics and/or weak opioids. Following 1 week of optimization of current analgesic medication, patients (n = 104) started 28-day treatment with 25 microg/h of TDF, with the option to up-titrate until adequate pain control was achieved. Metoclopramide was taken during the 1st week and as needed thereafter. Eighty-four patients completed the treatment phase, and 42 entered the 1-week tapering-off phase. The most frequently used maximum dose was 25 microg/h. The number of patients with pain control increased, particularly in the 1st week of treatment (33% to 77%), to 88% on day 28. From baseline to endpoint, there were reductions in pain (P < 0.001), including in "pain right now" at 24 h, and in degree of pain (mean reduction from "severe" to "moderate"), improvements in function (majority of items in the Health Assessment Questionnaire) (P < 0.001), and in quality of life (Short Form 36 physical P < 0.001, mental P < 0.05). Treatment was assessed favorably: > or = 78% would recommend it. Transdermal fentanyl should be considered in treatment programs for patients with RA.