It’s impossible to get through a day without hearing about or seeing an article focused on the current opioid crisis in the United States. The Centers for Disease Control and Prevention estimated that 32,445 Americans died from overdoses involving prescription opioid pain medications in 2016.1
It is no surprise that in the wake of the current environment and public outcry, draconian laws are being contemplated to restrict the abilities of many providers to prescribe opioids.
But then where does that leave us, the ones dealing with patients who have true and perhaps debilitating chronic pain? Hurdles are being thrown up by many insurance companies that I deal with. I have recently encountered plans who will pay for 1 week of opioids per month, or only one tablet a day instead of the three a day that the patient needs. The calls come in from the pharmacy telling us the limits that each patient’s insurance has put on opioids, which does not always align with the prescription that is written or the plan that our team of providers and the patient has agreed upon.
JP is one such recent patient of mine who is trapped in the current opioid rigamarole. He was diagnosed with rheumatoid arthritis (RA) 25 years ago at the age of 15. It has been a struggle to manage his disease and his pain for many years. The list of medications he has tried and failed due either to nonresponse or intolerable adverse effects is long and includes many of the nonbiologic and biologic disease modifying anti-rheumatic drugs we have at our disposal today.
JP’s history includes several episodes of pneumonia, including a single episode of bronchiectasis that resulted in a partial lobectomy. Recent lab results demonstrate positive anti-citric citrullinated protein levels, a positive rheumatoid factor, and low acute phase reactant levels (though within normal limits). X-rays are stable but demonstrate bilateral scaphoid erosions and radial joint space narrowing. JP typically has approximately 10 tender and 6 swollen joints, although he usually scores between 16 and 18 on a fibromyalgia tender point exam, reflecting significant myofascial pain.
In addition to our struggles controlling JP’s pain, his weight has become an increasingly more serious issue. In the last 2 years, JP has added approximately 90 pounds to his 6-foot frame, increasing his BMI from normal to obese (his most recent BMI was 33.6; anything over 30 is considered obese).2 JP’s Health Activity Questionnaire score has risen from 1.25 when he was
a healthy 160 pounds to 4.0 today.
Because of JP’s weight issues, we have been leery to add medications such as pregabalin that have been shown to result in weight gain. JP presents as the classic patient for whom opioids are necessary, fulfilling a number of the criteria providers should evaluate. These include the following (we use the acronym BESTO as a reminder of opioid risk):
Bone density: The more our patients remain sedentary, the less blood flows to their bones to maintain bone health. JP’s bone density T-score has decreased to -2.8, a substantial depletion for someone at such a young age. A T-score of -2.5 or worse is suggestive of osteoprosis.3
Electrocardiogram (EKG): Prolongation of the ventricular depolarization time increases the risk of mortality due to arrhythmia.4 JP’s QT interval has increased to 0.48 seconds, which is longer than the normal interval of between 0.36 and 0.44 seconds.
Sleep: Sleep is essential for the overall health of our patients. Poor quality sleep can result in respiratory depression, which prevents patients from being able to rest comfortably. JP reports that his sleep patterns are “broken”—possibly because his current opioids exacerbate respiratory depression5— and he finds a Continuous Positive Airway Pressure (CPAP) machine too uncomfortable.
Testosterone: In some patients suffering from chronic pain, testosterone levels drop, along with other endocrine functions such as cortisol, which in itself can help reduce pain.6 Low testosterone levels can also reduce a patient’s overall energy. JP has a testosterone level <200 ng/dL, well below the typically normal range for a 40-year-old male.
Obesity: Opioid-induced endocrinopathy can result in excess weight gain, depression, and fatigue. I have already spoken to JP’s weight issues earlier in this article. As detailed in this issue of Rheumatology Nurse Practice, excess adipose tissue, leptin, and adipokines can blunt
the effect of some biologic therapies used to treat RA such as TNF inhibitors.7,8 Obesity is also considered a negative predictor of response to biologic therapy in general.9
As with many of our patients with long-standing chronic pain, JP’s pain issues are being handled by a specialty pain management clinic. He has been on methadone 10 mg for several years, along with acetaminophen and hydrocodone 7.5/325 QID. Both clonazepam and tramadol were added in the last 16 months, putting JP on three different forms of opioids. JP’s visits to our clinic are rarely pleasant. He is unhappy that “YOU CANNOT CONTROL MY DISEASE!”
He is angry that his life revolves around pills and sleeping. His “self-management techniques” to control his pain are sedation and a total absence of recreational activities. We have tried arranging for physical therapy, but JP never goes because he is “too tired and hurts too much.” He even rejected a suggestion of in-home physical therapy.
Because of his reliance (and, in our opinion, over-reliance) on opioids to control his pain, our office has submitted numerous authorizations to enroll JP in a drug addiction program and place him in an environment that empowers him to take ownership and control of his disease. Of course, whenever we suggest this to JP, he always tells us that “If I didn’t need these medications, why was I given them in the first place?” It’s a fair argument, and one that is difficult to counter (a quick aside: JP’s initial pain management clinic is no longer in our referral base due to their unusually high rate of dispensing opioids).
With a significant recorded history of RA, it is unquestionable that JP has real pain that needs to be treated. Our clinic does our best to help manage JP’s inflammation, currently treating him with tocilizumab 800 mg monthly—the maximum allowable dosage for someone of JP’s weight—as well as sulfasalazine 1 g BID. While his disease has remained relatively stable, we have not been able to reach our Treat to Target goals with JP.
Most of my conversations with JP revolve around the fact that he needs to take ownership of his disease and not rely entirely on a pharmacologic solution for his issues. Because JP has a significant amount of myofascial pain—which unfortunately often pairs with joint stiffness and synovitis—encouraging him to incorporate some sort of daily movement into his regimen is vital.10 We recently were able to take JP off of clonazepam with the blessing of his new pain management clinic, which at least is a small step in the right direction. We also continue to urge JP to enter a drug rehabilitation clinic to regain control of his disease and his life (currently unemployed,
JP has a daughter he sees twice a month after a traumatic divorce). My hope is that, with a continuous dose of positive reinforcement and reassurance that his RA is not irrevocably out of control, JP will eventually take some steps to help himself. He assured me at the end of his last office visit that he would visit the pain rehabilitation facility.
JP is not an easy patient for many reasons, and certainly challenges the skills and patience of our team. Obese patients are typically our patients who complain of pain to the greatest extent, and JP is no different. While we have done a good job of managing his RA, his life and overall health have nonetheless spiraled out of control. It has often been a frustrating battle with more lows than highs, but our office remains upbeat in helping JP to recapture his life.
Jacqueline Fritz, RN, MSN, CNS, RN-BC, is Owner and Coordinator of Education at the Medical Advancement Center in Cypress, CA. Her primary responsibility is working as an advance practice nurse for a large rheumatology practice where she is involved in patient visits, research programs, and infusion center coordination. In addition, she enjoys speaking, teaching, and learning about immunology.
1. Seth P, Rudd RA, Noonan RK, Haegerich TM. Quantifying the epidemic of prescription opioid overdose deaths. Am J Public Health. 2018;108(4):500-502.
2. Center for Disease Control and Prevention. Defining Adult Overweight and Obesity. 2018; Available at www.cdc.gov/obesity/adult/defining.html. Accessed July 7, 2018.
3. National Osteoporosis Foundation. Bone density exam/testing. Available at www. nof.org/patients/diagnosis-information/bone-density-examtesting/. Accessed July 7, 2018.
4. Monitillo F, Leone M, Rizzo C, Passantino A, Iacoviello M. Ventricular repolarization measures for arrhythmic risk stratification. World J Cardiol. 2016;8(1):57-73.
5. van der Schrier R, Roozekrans M, Olofsen E, et al. Influence of ethanol on oxycodone-induced respiratory depression: a dose-escalating study in young and elderly individuals. Anesthesiology. 2017;126(3):534-542.
6. Brownlee KK, Moore AW, Hackney AC. Relationship between circulating cortisol and testosterone: influence of physical exercise. J Sports Sci Med. 2005;4(1):76-83.
7. Singh S, Facciorusso A, Singh AG, et al. Obesity and response to anti-tumor necrosis factor-alpha agents in patients with select immune-mediated inflammatory diseases: A systematic review and meta-analysis. PLoS One. 2018;13(5):e0195123.
8. Gremese E, Tolusso B, Gigante MR, Ferraccioli G. Obesity as a risk and severity factor in rheumatic diseases (autoimmune chronic inflammatory diseases). Front Immunol. 2014;5:576.
9. Heimans L, van den Broek M, le Cessie S, et al. Association of high body mass index with decreased treatment response to combination therapy in recent-onset rheumatoid arthritis patients. Arthritis Care Res (Hoboken). 2013;65(8):1235-1242.
10. Andersson ML, Svensson B, Bergman S. Chronic widespread pain in patients with rheumatoid arthritis and the relation between pain and disease activity measures over the first 5 years. J Rheumatol. 2013;40(12):1977-85.