Veterans With RA, History of Mental Health Conditions at Higher Risk for Chronic Opioid Therapy

^{By Julie Gould}

According to recent study findings, which were published online in Clinical Rheumatology, veterans with rheumatoid arthritis (RA) who also had a history of mental health conditions were at an increased risk of chronic opioid therapy.

The retrospective study, which was led by Justin Liberman, MD, MPH, assistant professor of Anesthesiology, Vanderbilt University Medical Center, and colleagues, observed a cohort of veterans with RA initiating opioid use was assembled using Veterans Health Administration databases from 2001 through 2012. Mental health conditions that were included in the study were anxiety, depression, bipolar disease, and post-traumatic stress disorder.

Dr Liberman and his colleagues identified 14,767 patients with RA with 22,452 episodes of opioid use initiation. Further, 8607 of the study participants identified mental health compared.

In order to better understand why veterans with RA and mental health conditions are at a higher risk of developing chronic opioid therapy compared to veterans with RA without mental health conditions, Veterans Health Today spoke with Dr Liberman.

Dr Liberman, completed Anesthesia residency at Virginia Mason Medical Center in Seattle, Washington. After residency, he completed the Veteran Affairs Quality Scholars Fellowship in Nashville Tennessee, and during his fellowship, he obtained a Masters of Public Health in epidemiology at Vanderbilt University. Currently, he serves as the Assistant Director of Quality and Patient Safety in the Department of Anesthesia at Vanderbilt University Medical Center.

What existing data led you and your co-investigators to conduct this research?

As an anesthesiologist I have always been interested in opioid use, opioid exposure, and how patients become chronic opioid users. I have performed prior research on opioid use in patients with heart failure (https://doi.org/10.1161/JAHA.118.010664). We were surprised that a very sick cohort of patients with congestive heart failure (CHF) were maintained on an opioid medication, even after hospitalization for acute CHF exacerbation. 

I was always interested to see historic common opioid prescribing practices while I was training. It was not uncommon for patients to receive 30-45 days of an opioid, like oxycodone, for a typical surgery. At this time, opioids prescriptions such as this were thought to be "safe," however we are currently seeing the impact this has had on public health and the current opioid crisis. 

Currently at Vanderbilt we are employing ERAS protocols looking to reduce, or eliminate, opioids given intraoperatively with great success. And only prescribing the minimum amount of opioids needed for patients after they complete surgery. 

I became interested in disease processes that have a high prevalence of opioid exposure. Rheumatoid arthritis was one such disease with over a third of patients diagnosed with RA will be prescribed an opioid in their life. Prior studies have shown an association between mental health disease (depression, anxiety) and opioid exposure. We were interested to see if this association was found in our cohort of Veterans with Rheumatoid Arthritis. 

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

Our study looked at the association between patients with Rheumatoid Arthritis, mental health disease and their risk of maintaining chronic opioid therapy, defined as the continuous availability of opioids for at least 90 days. 

We found Veterans with Rheumatoid arthritis and mental health conditions (defined as the presence of coded clinical diagnoses (ICD-9 codes), prescriptions for specific medications associated with mental health conditions or participation in psychotherapy) have a higher risk of developing chronic opioid therapy (469.3 vs 378.1 per 1000 person-years, adjusted hazard ratio [aHR]: 1.18, 95% CI 1.09, 1.29) compared to Veterans with Rheumatoid arthritis without mental health conditions.

In the assessment of individual mental health conditions and medications, non-opioid substance use disorder (aHR: 1.35; 95% CI 1.05 to 1.73), benzodiazepines (aHR: 1.13; 95%CI 1.01 to 1.27), non-benzodiazepine sedative hypnotics (aHR: 1.26; 95% CI 1.01 to 1.56), previous opioid use disorder (aHR: 1.94; 95%CI 1.09 to 3.46) , SSRIs (aHR: 1.11; 95% CI 1.00 to 1.24) and antipsychotics (aHR: 1.37; 95% CI 1.13 to 1.67) were significantly associated with an increased risk of  chronic opioid therapy.

The initial opioid prescription characteristics were also strongly associated with chronic opioid therapy. In multivariable analyses and compared to patients prescribed 0-7 days of opioid medication, patients prescribed 8-15 days of opioid medication had an aHR: 1.12 (95% CI 0.93 to 1.35), 16-29 days had an aHR: 1.52 (95% CI 1.16 to 2.01), and a 30 days’ supply had an aHR: 1.78 (95% CI 1.53 to 2.08).

What are the possible real-world applications of these findings in clinical practice?

Our study helps to promote increased emphasis on the examination of the past medical history of patients with Rheumatoid arthritis before prescribing opioid medications. 

Understanding how past medical history can contribute to chronic opioid therapy can reduce unwarranted opioid exposure and minimize the risk of chronic opioid therapy and its consequences. 

Additionally, further understanding on how initial prescriptions of opioid medication for acute pain episodes can shape patient behaviors is imperative to curb the national opioid epidemic. 

Do you and your co-investigators intend to expand upon this research

We have no plans at this time to expand upon this research but we hope it inspires others to look into this association more. 

Reference:

Liberman JS, D'Agostino McGowan L, Greevy RA, et al. Mental health conditions and the risk of chronic opioid therapy among patients with rheumatoid arthritis: a retrospective veterans affairs cohort study [published online ahead of print, 2020 Feb 8]. Clin Rheumatol. 2020;10.1007/s10067-020-04955-2. doi:10.1007/s10067-020-04955-2