Treating RA During the "Opioid Crisis"

I’ve had rheumatoid disease (arthritis) for more than 30 years, and I’m very interested in how the “opioid crisis” affects patients like myself. So, I’ve been reading articles in rheumatology journals and websites that offer physicians up-to-date advice on how to treat the joint pain this incurable autoimmune disease causes.

Backward advice on dealing with RA pain

I’m struck by how backward the advice in these articles seems to me, and how they manage to barely notice the very large elephant in the room: opioids.

Usually, they suggest treating the disease itself with traditional and biologic disease-modifying anti-rheumatic drugs (DMARDs) as the first line of attack. This makes obvious sense. If you can get the rheuma-dragon to fall asleep in his cave, he won’t be out marauding the village (the patient) and chewing up the patient’s joints. But what happens when the disease-dragon doesn’t respond to the drug, or when it doesn’t respond as well as hoped? And let’s not forget that even when RD is well-controlled, it may still cause symptoms, including sometimes serious pain.

The unstable and at times unhelpful ladder approach to RA pain management

These articles don’t mention that. But they do address ways to treat RD pain, and that’s good. Except…

OTC pain relievers

To relieve RD joint pain, these articles suggest over-the-counter oral analgesics like acetaminophen, topicals such as capsicum or menthol-based salves, paraffin baths, hot/cold packs, TENS units, etc. If those are unsuccessful, they say to try…

Alternative/psychological therapies

These include mindfulness meditation, Cognitive Behavioral Therapy, and other mental health therapies, including one-on-one and group psychological and/or support therapy. Any or all of these might be used alone or in combination with physical therapy, weight loss therapy, acupuncture, yoga, and the above listed OTC analgesics.

Next-to-the-last resort…

If the stubborn patient is still in pain, physicians are counseled to use non-steroidal anti-inflammatory drugs (NSAIDs) to relieve it. But medical science has learned that some of these drugs can cause stomach tears and bleeding or even heart attacks. So, doctors are exhorted to prescribe them with caution, and for the shortest time possible.

Try an opioid…yes or no?

Some of the articles I’ve read end with NSAIDs, which seems disingenuous. If there are potent, effective drugs in our pain treatment arsenal, why not use them? Why leave people to suffer in pain?

And this is why I call this advice to rheumatologists backward. Most of these articles mention, briefly, the use of opioids for very short periods at low doses—or not at all. Yet for last 3,000 years or so, opioids have been the most potent and successful pain relievers known to humankind. Prescribed and monitored with care, opioid analgesics such as hydrocodone, oxycodone, and others are safe and work well. They may quickly if temporarily, tame RD pain from rampant and awful to moderate and manageable for those who suffer with it.

Is it possible that opioids are good at controlling RA pain?

We know the truth…

Physicians know how well opioids work. Yet because of the current “opioid crisis” in the US, and the wide misinterpretation of the CDC Guideline for Prescribing Opioid Analgesics for Chronic Pain (March, 2016), many of them have lowered doses or denied their RD patients access to opioids, citing the imminent dangers of addiction and/or overdose, or frustration with new and confusing government regulations and paperwork regarding prescribing and oversight. What some don’t tell their patients is that they fear losing their practices to the overzealous, misinformed U.S. Department of Justice and the DEA (Drug Enforcement Agency).

The dangers of addiction and overdose, at least as regards to prescribed opioids, are overblown. In fact, the vast majority of opioid overdose deaths have been and continue to be from illicit drugs like heroin and fentanyl, and from those and prescribed opioids taken in combination with other drugs, like alcohol or benzodiazepines. In addition, the data cited in the guideline regarding opioid overdose deaths per year were numerically incorrect, a fact the CDC recently admitted (but hasn’t tried very hard to publicize).

A misinterpretation of opioid prescription guidelines

Words matter

But just as importantly, the guideline (which is just that, not a law) was misinterpreted by physicians, government agencies, and the media. It didn’t instruct physicians to force their patients onto lower opioid doses or to deny them the drugs altogether. It merely suggested that physicians try other therapies before prescribing opioids, given their inherent dangers, and that they prescribe the lowest dose for the shortest time possible. Notably, the guideline instructed physicians to consider individual patient needs and left prescribing higher doses, using opioids for longer periods, to their discretion.

Opioids can relieve chronic pain

Finally, although the guideline authors state that opioids don’t work for chronic pain, the fact is that there have been very few studies done on long-term opioid use for chronic pain, and those were small and inconclusive.

As hundreds of thousands of chronic pain patients could tell them—including me—opioids do help relieve chronic pain. (A caveat: Not everyone responds well to them, and in some people, they cause unpleasant side-effects, like drowsiness, nausea, or constipation, that make them unusable.)

Although temporarily soothing, none of the other pain-relieving methods mentioned above are very effective at relieving the recurring joint pain caused by rheumatoid disease. Many of them require a lot of time, effort, and/or money. And most are still not covered by health insurance companies.

Taking a closer look at the opioid crisis, keeping in mind the need of those who need them for pain relief

Let’s turn this around

I think its time for our rheumatologists and the U.S. government to take another look at opioids. That a very small percentage of Americans do become addicted to illicit and abused opioids, and that thousands of them overdose and die every year, is a terrible tragedy. But at this moment, there are other thousands of people needlessly suffering from chronic pain because of the “opioid crisis” and being stigmatized as “addicts.” We, as a nation, need to work harder at stopping the inflow of illicit opioids. But we also need to make sure that we’re not targeting the wrong group of people and creating a new crisis—a chronic pain crisis--in the process.

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