Study assesses opioid usage patterns in patients with lupus

Systemic lupus erythematosus (SLE)—a challenging autoimmune disease most common in women of childbearing age—can cause many problems in the body, including chronic pain.

Typical pain management strategies are not always available to patients with lupus. For example, patients with kidney problems being treated with steroids cannot use non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. As a result, different pain management strategies, including opioid therapy, may be needed.

A Mayo Clinic cross-sectional study in a population-based setting aimed to better understand rates of opioid use among patients with SLE and the factors behind their use. The paper is published in The Journal of Rheumatology.

The researchers note that when deciding to use opioids for chronic pain, it is important to consider the benefits carefully and whether they outweigh the risks. These risks include the long-term effects of opioids, including the risk of opioid use disorder along with the opioid overdose epidemic.

The researchers examined data on 465 patients with lupus and 465 patients without lupus. Subjects were drawn from the Lupus Midwest Network (LUMEN), a population-based registry of a 27-county region in Southeast Minnesota and Southwest Wisconsin within the Rochester Epidemiology Project (REP).

The study focused on prescription medications for oxycodone, morphine, hydromorphone, oxymorphone, fentanyl, meperidine, codeine, tramadol, methadone and hydrocodone. The study defined long-term opioid therapy as a prescription lasting more than 90 days or involving more than 10 continuous prescriptions.

"Before our study, there was little information about the use of opioid therapy by patients with systemic lupus erythematosus," says lead author Gabriel Figueroa, M.D., a research fellow in the Division of Rheumatology.

Researchers found that 13% of patients with systemic lupus erythematosus received opioid therapy compared to 3% of the non-systemic lupus erythematosus population. One out of 10 patients with SLE were on long-term opioid therapy, with a median duration of more than 1.5 years.

"Perhaps the most surprising finding was that arthritis, one of the symptoms that cause pain in lupus, was not associated with the use of opioid therapy," says corresponding author Ali A. Duarte Garcia, M.D., a rheumatologist and director of Mayo's Lupus Clinic. "The associations were with other chronic conditions that occur more frequently in lupus."

While the study did not find an association between increased opioid use and either inflammatory arthritis or renal involvement, it did reveal unexpected links with those having a history of acute pericarditis, pleural or pericardial effusion. It also found that patients with mood disorders like depression and anxiety, fibromyalgia, chronic low back pain, and hip or spine fragility fractures were more likely to receive long-term opioid therapy. Other key findings include:

• 44% of patients with lupus who were on long-term opioid therapy also had comorbid fibromyalgia, a rheumatic condition, compared to 5% of people without lupus.
• 66% of the patients with lupus on long-term opioid therapy had a concurrent mood disorder, compared to 30% without lupus.

Dr. Figueroa says that health care providers should be aware of these associations and exercise caution when prescribing analgesics, including opioids, to people with lupus.

"We believe that since different mechanisms in lupus could produce pain, it is important to give specific treatment to the source of the pain besides giving medications for pain relief," says Dr. Figueroa.

He emphasized the importance of a continuous dialog between the patient, their primary care physician and rheumatologist to consider alternative pain management strategies.

"While we, as rheumatologists, primarily manage the inflammation caused by lupus, it is becoming clear that a holistic approach is needed to address the needs of these patients," says Dr. Duarte Garcia.

Dr. Figueroa and Dr. Duarte Garcia note that non-pharmacological approaches like cognitive-behavioral, physical and psychological therapy can also help patients manage chronic pain along with other individual treatment options to improve their overall health and quality of life.