Arthritis is at an all-time high in the United States and is expected to rise, increasing the potential for opioid overuse, according to Anne Schuchat, MD, the acting director of the CDC, who spoke during a teleconference.

Approximately one in four adults are diagnosed with some form of arthritis. The most common forms are osteoarthritis, rheumatoid arthritis, gout, lupus and fibromyalgia. The percentage of people whose lives are particularly limited has increased 20% since 2002, with 24 million adults claiming that their activities are limited by their arthritis (MMWR Morb Mortal Wkly Rep 2017;66:246-253).

“We are seeing this increase independent of aging of the population,” said Dr. Schuchat, who added that the limitations are preventing daily activities, such as the ability to lift a grocery bag, hold a cup of coffee or walk to a car. “Dealing with limited abilities can be frustrating and have a negative impact on the quality of life,” she said.

The CDC analyzed data from more than 100,000 respondents of the National Health Interview Survey interviewed between 2013 and 2015, and found that 54 million individuals have arthritis. That number is expected to grow to 78 million by 2040.

As the disease progresses and becomes more severe and painful, people are more likely to take opioids, which could contribute to the rising opioid epidemic. There are better ways to manage pain, Dr. Schuchat said.

However, there are more considerations than just opioid abuse, said Jeffrey Fudin, PharmD, FCCP, FASHP, DAAPM, a clinical pharmacy specialist in pain management and the director of the PGY-2 Pain & Palliative Care Pharmacy Residency at the Albany Stratton VA Medical Center, in New York. He said opioids should never be part of first line arthritis treatment, but be part of the treatment plan “depending on the severity of the arthritis.”

Toni Fera, PharmD, BSPharm, an independent health care consultant based in Pittsburgh, Pa., and an expert in opioid abuse and diversion, agreed, saying that drug therapy selection for patients with arthritis “should be evidence-based and use a stepwise approach.

“Due to the risks, opioids should be reserved for patients who don’t respond to or have contraindications to first-line therapies,” she said.

Dr. Fudin recognized the threat of opioid overuse and recommended minimizing that potential by administering opioids only when necessary and in appropriate dosages. However, he noted that in some cases “opioids aren’t necessarily the less safe option,” and that it may not be appropriate to try to decrease the use of opioids in treating arthritis. Because people with arthritis tend to fall into an older demographic, it’s best to give them as few drugs as possible, including nonsteroidal anti-inflammatory drugs (NSAIDs).

“Equally or more appropriate is to ask is, ‘What can we do to decrease NSAID use, particularly in an elderly population with several comorbid conditions and elevated risks for kidney dysfunction, GI bleeds, and various cardiovascular risks?’ People are wearing blinders because they’re really focusing on opioids when NSAIDs can be way worse,” he said.

NSAIDs are often more effective than opioids at relieving arthritic pain, particularly when the pain is caused by connective tissue inflammation. However, for patients with other health issues, such as uncontrolled hypertension, NSAID treatments could significantly exacerbate their conditions. It is therefore very important for medical providers to prescribe patient-specific treatments, and perhaps greater attention should be given to the negative effects of NSAIDs.
“Risks always have to be weighed against the benefits of therapy, particularly in elderly patients with arthritis, who may have multiple chronic diseases and who may be on multiple medications,” agreed Dr. Fera. “Care needs to be individualized, and patients need to be engaged in the discussion about the risks and the benefits of therapy if the physician feels use is warranted.”

Dr. Schuchat said physical activity could be the solution that many need, thereby reducing dependence on opioids and NSAIDs. Currently, one in three adults with arthritis reports being inactive, even though physical activity can decrease pain and improve function by almost 40%.

Because adults are significantly more likely to attend a disease management education program when encouraged by a health care provider, “we are asking providers to urge patients with arthritis to increase physical activity and strive for a healthier weight to ease joint pain, recommend patients attend proven education programs to learn about managing their condition, and consult the guidelines of the American College of Rheumatology or other professional organizations for treatment options,” Dr. Schuchat said.

“We are also asking for doctors and other providers to ask patients about any depression or anxiety, and offer care, treatment and links to services. We have found that one-third of adults with arthritis over age 45 report anxiety or depression,” she added.

Recommended physical activities include walking, biking, swimming, and participating in physical activity programs available in parks and recreation centers, YMCAs and other community organizations. The CDC estimated that health care costs could be reduced by $1,000 per person just by participation in physical activity programs.

“As payers and providers move to value-based payment models and population health management, organizations would be wise to consider the impact of arthritis as a co-morbidity of costly chronic diseases and create programs that support patient self management,” Dr. Fera said. “There is good evidence that self-management programs achieve better outcomes, and often, lower the costs of care.”

While only one in 10 people with arthritis participates in disease management education programs, the CDC report noted that patients with arthritis can reduce their symptoms by 10% to 20% by gaining skills to better manage their symptoms.

Dr. Fudin explained that managing pain, rather than just reaching for the prescription pad, is not emphasized enough in medical, nursing or pharmacy schools. “The first problem is that most colleges don’t have a dedicated staff member that exclusively specializes in pain management. The second problem is that if some general practice faculty members do teach pain management, it’s not prioritized.

“In a particular program, the number of hours dedicated to pain management is generally between zero to four hours. Comparatively, in the population as a whole, heart disease, cancer and diabetes combined have a lesser prevalence than patients with chronic noncancer pain. But in pharmacy school, they’ll spend a week on cancer therapy, a week on heart disease and one to two weeks on diabetes,” he added.

To facilitate this shift away from drugs and toward physical activity to ease arthritic pain, Dr. Fudin suggested that one effective method would be to mandate colleges and universities to cover pain management in more depth to raise awareness for future clinicians about the benefits and risks of various therapies.

A team approach needs to include the patient, Dr. Fera said. “The ideal program educates patients about safe medication use and reinforces the benefits of non-pharmacologic approaches, such as regular exercise. Often, patients need to modify behaviors and manage multiple health issues, and this takes ongoing support.”

Dr. Schuchat added: “When you’re in pain, exercise is often the last thing you want to do. Start small, by taking a short walk in the park, gardening or a lap in the pool. This can start patterns that can make a big difference in the long run.”

—Carina Elfving