Description
- Abstract:
- Autoimmune conditions are often associated with pathological pain, leading to high rates of opioid use, particularly among older adults. Current clinical guidelines for the treatment of autoimmune diseases emphasize detailed pathways for disease modifying therapy (DMT) use, reserving biologic DMTs (bDMTs) for individuals who do not achieve treatment targets on standard therapies. However, symptoms such as pain often extend beyond the clinical markers used in treat-to-target approaches, and there are no clear recommendations for pain management beyond reducing disease activity. Understanding the dynamic between bDMT initiation and opioid use in older adults with autoimmune diseases is critical for optimizing treatment strategies, improving clinical outcomes, and minimizing the potential harms associated with opioid use in this vulnerable population. This dissertation uses a cohort of U.S. Medicare fee-for-service beneficiaries initiating a bDMT for rheumatoid arthritis (RA), multiple sclerosis, systemic lupus erythematosus (SLE), ulcerative colitis, or Crohn's disease between 2008 and 2019 to explore the bidirectional relationship between bDMT initiation and opioid use. Chapter 1 is descriptive and assesses trends in analgesic use among older adults with autoimmune diseases initiating a bDMT, examining whether opioid and other analgesic use change following initiation. We found that bDMT initiation did not significantly reduce analgesic use for most autoimmune conditions. In many cases, the incidence of opioid use increased in the year after initiation and only SLE patients saw a small but significant decrease in the year post-initiation. Chapter 2 focuses on individuals with RA and examines the effect of bDMT initiation on opioid discontinuation among prevalent opioid users. Using a target trial emulation, we assessed the effects of bDMT versus leflunomide initiation and found no significant difference in the likelihood of opioid discontinuation among prevalent or chronic opioid users. Chapter 3 evaluates the comparative effects of opioid versus non-steroidal anti-inflammatory drug (NSAID) use on bDMT discontinuation and switching in individuals with RA. Employing a target trial emulation study and the clone-censor-weight approach, we compared two sustained regimens for pain management: initiating opioids or NSAIDs within three months of bDMT initiation. We found that sustained opioid use was associated with a 51% higher risk of bDMT discontinuation at 12 months compared to NSAID use, although the risk of therapy switching was similar between groups. These findings underscore the need for improved pain management strategies in older adults with autoimmune diseases. Specifically, this work highlights that: 1) opioid use is high across autoimmune conditions and is greater, on average, after the initiation of a bDMT, (2) bDMT initiation does not significantly alter opioid discontinuation in prevalent or chronic opioid users with RA, and (3) opioid use is associated with a higher risk of bDMT discontinuation compared to NSAID use in older adults with RA. In conclusion, pain management for individuals with autoimmune diseases, particularly RA, is more than a function of treating the underlying condition. Rheumatologists must carefully balance effective pain management with maintaining good bDMT adherence, especially for those requiring opioids for pain relief. Future research should evaluate additional safety outcomes associated with the concurrent use of opioids and bDMTs, given its high prevalence and clinical significance.
- Notes:
- Thesis (Ph. D.)--Brown University, 2025
Citation
Buxton, Meghan Cupp,
"Treating pain in autoimmune disease: concurrent use of opioids and biologic disease modifying therapy"
(2025).
Epidemiology Theses and Dissertations.
Brown Digital Repository. Brown University Library.
https://repository.library.brown.edu/studio/item/bdr:9srznku7/
