Narcotics and Rheumatic Diseases: A Good Mix?

Abstract & Commentary

Synopsis: A retrospective review of narcotic use in patients treated in a rheumatology clinic found substantial efficacy, no trend toward higher doses or increased frequency of use over time, and a reassuringly small number of patients with addictive behavior.

Source: Ytterberg SR, et al. Arthritis Rheum 1998;41: 1603-1612.

When narcotic drugs are being considered for use in patients who have neither self-limited nor terminal illnesses, patients and their physicians have concerns about adverse effects including: addiction, constipation, the increased risk of falls, and other accidental injuries due to drowsiness. Physicians must also worry about illegal diversion of narcotic drugs and may fear loss of license or other sanctions if their prescribing is found only to be supporting addicts' "habits." Ytterberg and colleagues retrospectively reviewed narcotic drug use in 266 patients seen in a rheumatology clinic in a university medical school affiliated Veterans Affair Medical Center. The patients had an mean age of about 61 years and nearly all were men. A variety of musculoskeletal problems were represented, chiefly rheumatoid arthritis, spondyloarthropathies, and a variety of connective tissue diseases. Only 1-3% of patients surveyed had osteoarthritis. Forty five percent of all patients seen in rheumatology clinic during the 3 years had received at least one prescription for narcotics, 53% of those used the drugs on a short-term basis (less than three months), and 47% received them on a long term basis (³ 3 months). Two hundred sixty-six patients who received prescriptions for narcotics were surveyed by telephone and were asked about pain relief, side effects, and substance abuse ("street" drugs and alcohol). Most patients received prescriptions for either codeine or oxycodone. Pharmacy records were reviewed and medical records were reviewed for patients who had an escalation in dose of more than the equivalent of 60 mg of codeine per day to identify the reason for the increased dose. Using a 0-10 scale for pain before and after analgesic use, patients reported a mean of about 8 before and 3.6 after a dose of analgesic. Side effects were reported by almost 40% of patients with nausea and constipation being the most frequent complaints, followed by sleepiness and other non-specific sleep, mood, and equilibrium disorders. Of all those receiving narcotics, 32 had escalations in dosage. Of these, 12 patients had temporary escalations related to surgical procedures, trauma, or worsening of their diseases, while one patient's dose increase was unexplained. Twenty patients had dosage escalations that continued. Of these, 14 increases were ascribed to disease progression or intercurrent illnesses such as herpes zoster, two required joint arthroplasty, one had trauma, and three were unexplained. Of the four patients with unexplained dosage escalations, all had behaviors noted that were consistent with abusive use including drug seeking behavior, reported intoxication by family members, and asking multiple physicians for an increased dose or an earlier than expected request for new prescription. These patterns of abusive behavior were not strongly correlated with prior history of drug or alcohol abuse. Ytterberg et al conclude that risks of abuse and addiction are exaggerated and that narcotic analgesics are underutilized in patients with chronic rheumatic diseases.

Comment by Jerry M. Greene, MD, FACR

The findings of this retrospective study are reassuring, especially the small number of patients (4 of 266) whose increased demands for narcotic analgesics were indicative of drug addiction and abuse. On the other hand, each of the four patients identified as exhibiting drug-abuse behavior had a legitimate painful illness for which a narcotic analgesic was prescribed. One fears that prescribing narcotics on a chronic basis for a single patient who then demonstrates drug seeking or other addiction behavior could be a license-losing, potentially career-ending mishap. However, certain situations make use of narcotic analgesics an attractive alternative for patients with arthritis. For example, in my opinion, the risk of bleeding with the combination of NSAIDs and warfarin anticoagulation outweighs the small risk of addiction. The pain of many rheumatic diseases may be well controlled with a tailored anti-inflammatory and disease-modifying regimen, including, perhaps, low dose prednisone. But when anti-inflammatory treatment is ineffective or inappropriate and narcotic drug therapy is contemplated, the results of Ytterberg and colleagues can be shared with patients as part of the process of informed consent. The reportedly low risk of addiction in this patient population may allay patients' fears, allowing cautious use and providing needed pain relief.

Only four patients had unexplained escalation in narcotic use and all four demonstrated addictive behaviors such as seeking early prescriptions or increased dosage, or soliciting multiple physicians for narcotics.