Treating Gout Flares with Opioid Therapy Links to Chronic Opioid Use

Patients with gout are 36% more likely to have chronic opioid use than patients without gout, according to recent research.¹

Painful gout glares often get treated with opioid therapy, even though opioids are not the preferred treatment. According to a 2019 study, over 28% of patients (n = 456) with acute gout received an opioid prescription. Not only that but over a quarter of the patients received opioid treatment for > 14 days. The study found patients were associated with being more likely to receive opioid treatment if they had diabetes, gout attacks affecting several joints, and opioid use prior to visiting the hospital.²

“We have a number of medications that can treat acute gout effectively, almost completely eliminating the need to use opioids,” wrote Deepan Dalal, MD, MPH, of Brown University Warren Alpert School of Medicine, in Providence. “The fact that 28% of patients are being treated with opioids, and many longer than 2 weeks, is alarming and provides an opportunity to reduce the burden of prescription opioids.”

Ultimately, treating gout glares with opioids can lead to a “gateway” to chronic opioid use. A new matched cohort study, led by Lindsay Helget, MD, of Nebraska Medical Center in Omaha, Nebraska, wanted to compare the risk of developing chronic opioid use in patients with and without gout. The team also examined the determinants of developing chronic opioid use in gout patients.1 The study was presented at the ACR Convergence 2023 on November 12, 2023.

Helget and colleagues collected their participants from national Veteran’s Health Administration data from January 1999 to January 2015 based on >2 ICD-9 codes for gout. The investigators matched patients with gout and without based on birth year, sex, Veteran’s Health Administration enrollment year. They followed the patients from index date until the first incident of chronic opioid use, death, or 5 years after the index date. Individuals who took opioids in the year before the index date were excluded.

The team considered chronic opioid use as 90 cumulative days of taking > 2 dispenses within 6 months and no gap for >32 days. To find associations of gout with chronic opioid use, the investigators used cumulative hazard curve and multivariable Cox proportional hazards regression. Covariates for both models included race (Black, African American, Other, Missing, White), comorbidities, body mass index, and smoking status (former, current, missing, or never). Other covariates in the study included age, index year, chronic lung disease, past myocardial infarction, cardiovascular disease, stroke, hypertension, diabetes, fracture, depression, stomach ulcer, or cancer.

Of 16.7 million patients, 6.9% of gout patients had chronic opioid use (n = 28,948), and 3.8% of the non-gout patients did (n = 137,497). The investigators found similar results when adjusting for covariates. Still, patients with gout were significantly more likely than non-gout parents to have chronic opioid use (hazard ratio [aHR] 1.36; 95% CI 1.34 – 1.39).

“In the [Veteran’s Health Administration] we found that patients with gout were 36% more likely than those without gout to initiate chronic opioid use, after accounting for potential confounders, despite opioids not being recommended for management of gout flares,” the investigators wrote. “Associations between patient characteristics and time-to-initiating chronic opioid use highlight potential gaps in care, particularly among underserved Black/African American and rural populations, as well as the potential for adequate urate control to reduce the risk of chronic opioid use in gout.”

References

1. ^{Helget L, England B, Roul P, Sayles H, Neogi T, O’Dell J, Mikuls T. Gout: A Gateway to Chronic Opioid Use? [abstract]. Arthritis Rheumatol. 2023; 75 (suppl 9). https://acrabstracts.org/abstract/gout-a-gateway-to-chronic-opioid-use/. Accessed November 20, 2023.}
2. ^{Are Opioids Being Inappropriately Prescribed To Treat Gout? EurekAlert! July 3, 2019. https://www.eurekalert.org/news-releases/557952. Accessed November 20, 2023.}