Mental Health History May Be Associated With Increased Chronic Opioid Therapy Risk in RA

hands with rheumatoid arthritis holding pills
hands with rheumatoid arthritis holding pills
Researchers examined the association between mental health conditions and the risk for chronic opioid therapy in patients with rheumatoid arthritis.

Patients with rheumatoid arthritis (RA) with a history of mental health conditions are at increased risk for chronic opioid therapy, according to study results published in Clinical Rheumatology. Longer duration of initial opioid exposure also predicted later chronic opioid therapy use.

Investigators conducted a retrospective cohort study of adult veterans with RA using data abstracted from the Veterans Health Administration databases between 2001 and 2012. Patients were followed up from initiation of opioid use, defined as first exposure to opioid prescription. The primary outcome measure was chronic opioid therapy, defined as continuous availability of opioid medications for ≥90 days. Cox regression models were constructed to assess the association between mental health conditions and chronic opioid therapy. Mental health conditions were identified from a medical record review; conditions of interest included anxiety, depression, bipolar disorder, and posttraumatic stress disorder (PTSD). Cox models were adjusted for relevant covariates, including demographics, comorbid chronic conditions, baseline pain scores, and other medication use. Subgroup analyses were conducted based on duration of initial opioid exposure.

The study cohort included 14,767 patients with RA, among whom 22,452 episodes of opioid use initiation were observed. Mental health conditions were highly prevalent: 1108 (12.9%) reported anxiety; 1912 (22.2%) reported depression; 131 (1.5%) reported bipolar disorder; and 768 (8.9%) reported PTSD. Patients with mental health conditions were at greater risk for developing chronic opioid therapy, with an adjusted hazard ratio (aHR) of 1.18 (95% CI, 1.09-1.29). The rate of chronic opioid therapy during follow-up was 469.3 per 1000 person-years among patients with mental health conditions. Among patients without mental health conditions, this rate dropped to 378.1 per 1000 person-years. Duration of initial opioid exposure was positively associated with later risk for chronic opioid therapy. Increased risk for chronic opioid therapy was observed in patients prescribed 8 to 15 days (aHR, 1.12; 95% CI, 0.93-1.35), 16 to 29 days (aHR, 1.52; 95% CI, 1.16-2.01), and 30 days (aHR, 1.78; 95% CI, 1.53-2.08) of opioid medication compared with patients prescribed 0 to 7 days of opioid medication at initial exposure.

Exposure to benzodiazepines, nonbenzodiazepine sedative hypnotics, selective serotonin reuptake inhibitors, and antipsychotics also predicted increased hazard of chronic opioid therapy. Similarly, prior nonopioid and opioid substance use disorders were strongly associated with chronic opioid therapy risk.

Overall, the study results suggested that mental health history should be carefully considered before opioid prescribing. Initial opioid prescriptions should be limited in duration to prevent later chronic opioid use.

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In terms of study limitations, investigators noted that opioid use and adherence could not be directly ascertained from pharmacy records. In addition, no information was available on RA severity, which may have had an effect on risk for chronic opioid use.

“Further understanding on how initial prescriptions of opioid medication for acute pain episodes can shape patient behaviors is imperative to curb the national opioid epidemic,” the researchers concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Liberman JS, D’Agostino McGowan L, Greevy RA, et al. Mental health conditions and the risk of chronic opioid therapy among patients with rheumatoid arthritis: a retrospective veterans affairs cohort study [published online February 8, 2020]. Clin Rheumatol. doi:10.1007/s10067-020-04955-2