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

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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.

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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.

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Authors and 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

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  1. Justin S. Liberman
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Corresponding author

Correspondence to Justin S. Liberman.

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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.

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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

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