Skip to main content

Mental health conditions and the risk of chronic opioid therapy among patients with rheumatoid arthritis: a retrospective veterans affairs cohort study

Clinical Rheumatology volume 39, pages 1793–1802 (2020)Cite this article

Abstract

Objective

Patients with rheumatoid arthritis (RA) often receive opioid analgesics for pain management. We examined the association between mental health conditions and the risk of chronic opioid therapy.

Methods

A retrospective cohort of veterans with RA initiating opioid use was assembled using Veterans Health Administration databases (2001–2012). Mental health conditions included anxiety (N = 1108, 12.9%), depression (N = 1912, 22.2%), bipolar disease (N = 131, 1.5%), and post-traumatic stress disorder (N = 768, 8.9%) and were identified by ICD coded diagnoses and use of specific medications. Cohort members were followed from opioid initiation through chronic opioid therapy, defined as the continuous availability of opioids for at least 90 days. Multivariable Cox proportional hazard regression models assessed the association between mental health conditions and chronic opioid therapy accounting for relevant covariates. Subgroup analyses examined whether the strength of the observed association varied by the duration of the initial opioid prescription.

Results

We identified 14,767 patients with RA with 22,452 episodes of opioid use initiation. Mental health conditions were identified in 8607 (38.3%) patients. Compared with patients without mental health conditions, patients with mental health conditions 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). The increased risk was highest for those with a history of opioid use disorder (aHR 1.94, 95% CI 1.09, 3.46) and also elevated for those with other substance use disorders (aHR 1.35, 95% CI 1.05, 1.73). Duration of the initial opioid prescription was independently associated with chronic opioid therapy, regardless of the estimated opioid daily dose.

Conclusions

History of mental health conditions and duration of the initial opioid prescription were associated with an increased risk of chronic opioid therapy among patients with RA.

Key Points
• Approximately a third of patients with RA are exposed to opioid analgesics.
• Patients with RA and history of mental health disease, especially substance use disorders, who initiate opioid use have an increased risk of chronic opioid therapy.
• This study provides insight in an underrepresented population of mainly male patients with RA.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. Centers for Disease Control and Prevention (2011) Overdoses of prescription opioid pain relievers - United States, 1999-2008. Morb Mortal Wkly Rep MMWR 60:1487–1492

    Google Scholar 

  2. Centers for Disease Control and Prevention (2016) CDC guideline for prescribing opioids for chronic pain - United States, 2016. Recomm Rep 1:1–49

    Google Scholar 

  3. Rudd RA, Seth P, David F, Scholl L (2016) Increases in drug and opioid-involved overdose deaths - United States, 2010–2015. MMWR Morb Mortal Wkly Rep 65:1445–1452. https://doi.org/10.15585/mmwr.mm655051e1

    Article  Google Scholar 

  4. Hoots B, Xu L, Kariisa M, et al (2018) 2018 Annual surveillance report of drug-related risks and outcomes - United States. Surveillance Special Report

  5. Hedegaard H, Miniño AM, Warner M (2018) Drug overdose deaths in the United States, 1999–2017, Hyattsville

  6. Guy G Jr, Zhang K, Bohm M et al (2017) Vital signs: changes in opioid prescribing in the United States, 2006–2015. Morb Mortal Wkly Rep 66:697–704

    Article  Google Scholar 

  7. Moore RA, Derry S, Aldington D, Wiffen PJ (2015) Adverse events associated with single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews. Cochrane Database Syst Rev 10:CD01140. https://doi.org/10.1002/14651858.CD011407.pub2

    Article  Google Scholar 

  8. McNicol ED, Midbari A, Eisenberg E (2013) Opioids for neuropathic pain. Cochrane Database Syst Rev:CD006146. https://doi.org/10.1002/14651858.CD006146.pub2

  9. Basurto Ona X, Rigau Comas D, Urrútia G (2013) Opioids for acute pancreatitis pain. Cochrane Database Syst Rev:CD006146. https://doi.org/10.1002/14651858.CD009179.pub2

  10. Manchikanti L, Fellows B, Ailinani H, Pampati V (2010) Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician 13:401–435

    PubMed  Google Scholar 

  11. Trescot AM, Helm S, Hansen H et al (2008) Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines. Pain Physician 11:S5–S62 18443640

    PubMed  Google Scholar 

  12. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O'Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C, American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel (2009) Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 10:113–130. https://doi.org/10.1016/j.jpain.2008.10.008

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Manchikanti L, Ailinani H, Koyyalagunta D, Datta S, Singh V, Eriator I, Sehgal N, Shah R, Benyamin R, Vallejo R, Fellows B, Christo PJ (2011) A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain Physician 14:91–121

    PubMed  Google Scholar 

  14. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN (2011) Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 171:686–691. https://doi.org/10.1001/archinternmed.2011.117

    CAS  Article  PubMed  Google Scholar 

  15. Waljee JF, Cron DC, Steiger RM, Zhong L, Englesbe MJ, Brummett CM (2017) Effect of preoperative opioid exposure on healthcare utilization and expenditures following elective abdominal surgery. Ann Surg 265:715–721. https://doi.org/10.1097/SLA.0000000000002117

    Article  PubMed  PubMed Central  Google Scholar 

  16. Rogal S, Mankaney G, Udawatta V et al (2016) Association between opioid use and readmission following liver transplantation. Clin Transpl 30:1222–1229. https://doi.org/10.1111/ctr.12806

    CAS  Article  Google Scholar 

  17. Wiese AD, Griffin MR, Schaffner W, Stein CM, Greevy RA, Mitchel EF Jr, Grijalva CG (2018) Opioid analgesic use and risk for invasive pneumococcal diseases. Ann Intern Med 168:396–404. https://doi.org/10.7326/M17-1907

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wiese AD, Griffin MR, Stein CM, Mitchel EF Jr, Grijalva CG (2016) Opioid analgesics and the risk of serious infections among patients with rheumatoid arthritis: a self-controlled case series study. Arthritis Rheumatol 68:323–331. https://doi.org/10.1002/art.39462

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. Heiberg T, Finset A, Uhlig T, Kvien TK (2005) Seven year changes in health status and priorities for improvement of health in patients with rheumatoid arthritis. Ann Rheum Dis 64:191–195. https://doi.org/10.1136/ard.2004.022699

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. Curtis J, Fenglong X (2017) Changing trends in opioid use among patients with rheumatoid arthritis in the united states. Arthritis Rheumatol 69:1733–1740. https://doi.org/10.1002/art.40152

    CAS  Article  PubMed  Google Scholar 

  21. Goesling J, Henry MJ, Moser SE, Rastogi M, Hassett AL, Clauw DJ, Brummett CM (2015) Symptoms of depression are associated with opioid use regardless of pain severity and physical functioning among treatment-seeking patients with chronic pain. J Pain 16:844–851. https://doi.org/10.1016/j.jpain.2015.05.010

    Article  PubMed  Google Scholar 

  22. Seal K, Ying S, Cohen G (2012) Association of Mental Health Disorders with prescription opioids and high-risk opioid use in the US Veterans of Iraq and Afghanistan. JAMA 307:940–947. https://doi.org/10.1001/jama.2012.234

    CAS  Article  PubMed  Google Scholar 

  23. Halbert BT, Davis RB, Wee CC (2016) Disproportionate longer-term opioid use among U.S. adults with mood disorders. Pain 157:2452–2457. https://doi.org/10.1097/j.pain.0000000000000650

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  24. Nicassio PM (2010) Arthritis and psychiatric disorders: disentangling the relationship. J Psychosom Res 68:183–185. https://doi.org/10.1016/j.jpsychores.2009.09.008

    Article  PubMed  Google Scholar 

  25. Covic T, Tyson G, Spencer D, Howe G (2006) Depression in rheumatoid arthritis patients: demographic, clinical, and psychological predictors. J Psychosom Res 60:469–476. https://doi.org/10.1016/j.jpsychores.2005.09.011

    Article  PubMed  Google Scholar 

  26. Dickens C, Creed F (2001) The burden of depression in patients with rheumatoid arthritis. Rheumatology 40:1327–1330. https://doi.org/10.1093/rheumatology/40.12.1327

    CAS  Article  PubMed  Google Scholar 

  27. Zamora-Legoff JA, Achenbach SJ, Crowson CS, Krause ML, Davis JM 3rd, Matteson EL (2016) Opioid use in patients with rheumatoid arthritis 2005–2014: a population-based comparative study. Clin Rheumatol 35:1137–1144. https://doi.org/10.1007/s10067-016-3239-4

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chung CP, Rohan P, Krishnaswami S, McPheeters ML (2013) A systematic review of validated methods for identifying patients with rheumatoid arthritis using administrative or claims data. Vaccine 31(Suppl):K41–K61. https://doi.org/10.1016/j.vaccine.2013.03.075

    Article  PubMed  Google Scholar 

  29. Quinn PD, Hur K, Chang Z, Scott EL, Krebs EE, Bair MJ, Rickert ME, Gibbons RD, Kroenke K, D'Onofrio BM (2018) Association of mental health conditions and treatments with long-term opioid analgesic receipt among adolescents. JAMA Pediatr 172:423–430. https://doi.org/10.1001/jamapediatrics.2017.5641

    Article  PubMed  PubMed Central  Google Scholar 

  30. Quinn PD, Hur K, Chang Z, Krebs EE, Bair MJ, Scott EL, Rickert ME, Gibbons RD, Kroenke K, DʼOnofrio BM (2017) Incident and long-term opioid therapy among patients with psychiatric conditions and medications. Pain 158:140–148. https://doi.org/10.1097/j.pain.0000000000000730

    Article  PubMed  PubMed Central  Google Scholar 

  31. Braden JB, Russo J, Fan M-Y, Edlund MJ, Martin BC, DeVries A, Sullivan MD (2010) Emergency department visits among recipients of chronic opioid therapy. Arch Intern Med 170:1425–1432. https://doi.org/10.1001/archinternmed.2010.273

    Article  PubMed  PubMed Central  Google Scholar 

  32. Sullivan MD, Edlund MJ, Fan MY, Devries A, Brennan Braden J, Martin BC (2010) Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study. Pain 150:332–339. https://doi.org/10.1016/j.pain.2010.05.020

    Article  PubMed  PubMed Central  Google Scholar 

  33. Lin DY (1994) Cox regression analysis of multivariate failure time data: the marginal approach. Stat Med 13:2233–2247. https://doi.org/10.1002/sim.4780132105

    CAS  Article  PubMed  Google Scholar 

  34. Sekhri S, Arora NS, Cottrell H et al (2017) Probability of opioid prescription refilling after surgery: does initial prescription dose matter? Ann Surg 268:271–276. https://doi.org/10.1097/SLA.0000000000002308

    Article  Google Scholar 

  35. Calcaterra SL, Yamashita TE, Min SJ, Keniston A, Frank JW, Binswanger IA (2016) Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med 31:478–485. https://doi.org/10.1007/s11606-015-3539-4

    Article  PubMed  Google Scholar 

  36. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD (2007) Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain 8:573–582. https://doi.org/10.1016/j.jpain.2007.02.432

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK (2009) Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline. J Pain 10:131–146. https://doi.org/10.1016/j.jpain.2008.10.009

    CAS  Article  PubMed  Google Scholar 

  38. Paulozzi LJ, Strickler GK, Kreiner PW, Koris CM (2015) Controlled substance prescribing patterns — prescription behavior surveillance system, eight states, 2013. MMWR Surveill Summ 64:1–14. https://doi.org/10.15585/mmwr.ss6409a1

    Article  PubMed  Google Scholar 

  39. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN (2014) Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 348:g1251. https://doi.org/10.1136/bmj.g1251

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. Karch DL, Logan J, McDaniel D et al (2012) Surveillance for violent deaths--National Violent Death Reporting System, 16 states, 2009. MMWR Surveill Summ 61(6):1–43

  41. Shah A, Hayes CJ, Martin BC (2017) Factors influencing long-term opioid use among opioid naive patients: an examination of initial prescription characteristics and pain etiologies. J Pain 18:1374–1383. https://doi.org/10.1016/j.jpain.2017.06.010

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  42. Deyo RA, Hallvik SE, Hildebran C, Marino M, Dexter E, Irvine JM, O'Kane N, van Otterloo J, Wright DA, Leichtling G, Millet LM (2017) Association between initial opioid prescribing patterns and subsequent long-term use among opioid-Naïve patients: a statewide retrospective cohort study. J Gen Intern Med 32:21–27. https://doi.org/10.1007/s11606-016-3810-3

    Article  PubMed  Google Scholar 

  43. Scherrer JF, Svrakic DM, Freedland KE, Chrusciel T, Balasubramanian S, Bucholz KK, Lawler EV, Lustman PJ (2014) Prescription opioid analgesics increase the risk of depression. J Gen Intern Med 29:491–499. https://doi.org/10.1007/s11606-013-2648-1

    Article  PubMed  Google Scholar 

  44. Edlund MJ, Martin BC, Devries A, Fan MY, Braden JB, Sullivan MD (2010) Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: The TROUP Study. Clin J Pain 26:1–8. https://doi.org/10.1097/AJP.0b013e3181b99f35

    Article  PubMed  PubMed Central  Google Scholar 

  45. Singh JA, Holmgren AR, Noorbaloochi S (2004) Accuracy of veterans administration databases for a diagnosis of rheumatoid arthritis. Arthritis Care Res 51:952–957. https://doi.org/10.1002/art.20827

    Article  Google Scholar 

  46. Curtis JR, Westfall AO, Allison J, Freeman A, Kovac SH, Saag KG (2006) Agreement and validity of pharmacy data versus self-report for use of osteoporosis medications among chronic glucocorticoid users. Pharmacoepidemiol Drug Saf 15:710–718. https://doi.org/10.1002/pds.1226

    Article  PubMed  Google Scholar 

  47. West SL, Savitz DA, Koch G, Strom BL, Guess HA, Hartzema A (1995) Recall accuracy for prescription medications: self-report compared with database information. Am J Epidemiol 142:1103–1112. https://doi.org/10.1093/oxfordjournals.aje.a117563

    CAS  Article  PubMed  Google Scholar 

  48. Daubresse M, Chang H-Y, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC (2013) Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care 51:870–878. https://doi.org/10.1097/MLR.0b013e3182a95d86

    Article  PubMed  Google Scholar 

Download references

Funding

This work was supported by a CSR&D investigator-initiated grant from the Veterans Health Administration [I01CX000570-06]; National Institutes of Health - National Institute on Aging [R01AG043471 to C.G.G]; J.S.L was supported by the VA Quality Scholars Program. The funders of the study had no role in the study design, data analysis, data interpretation, or writing of the report. The corresponding author had final responsibility for the decision to submit for publication.

Author information

Affiliations

  1. Veteran Affairs Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA

    Justin S. Liberman, Robert A. Greevy, Marie R. Griffin, Christianne L. Roumie & Carlos G. Grijalva

  2. Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA

    Justin S. Liberman

  3. Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Lucy D’Agostino McGowan

  4. Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA

    Robert A. Greevy

  5. Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA

    James A. Morrow, Marie R. Griffin & Carlos G. Grijalva

  6. Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA

    Marie R. Griffin & Christianne L. Roumie

Authors
  1. Justin S. Liberman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lucy D’Agostino McGowan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Robert A. Greevy
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. James A. Morrow
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Marie R. Griffin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Christianne L. Roumie
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Carlos G. Grijalva
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Justin S. Liberman.

Ethics declarations

Conflict of interest

CGG has received consulting fees from Pfizer, Sanofi-Pasteur, and Merck, and received research support from Sanofi-Pasteur, Campbell Alliance, the Centers for Disease Control and Prevention, National Institutes of Health, The Food and Drug Administration, and the Agency for Health Care Research and Quality. LDM has received consulting fees from Acelity. The other authors declare that they have no conflicts of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(DOCX 33.8 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Liberman, J.S., D’Agostino McGowan, L., Greevy, R.A. et al. Mental health conditions and the risk of chronic opioid therapy among patients with rheumatoid arthritis: a retrospective veterans affairs cohort study. Clin Rheumatol 39, 1793–1802 (2020). https://doi.org/10.1007/s10067-020-04955-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10067-020-04955-2

Keywords

  • DMARDs
  • Mental health
  • Opioid analgesics
  • Rheumatoid arthritis