Background Opioid analgesic prescription represents a growing problem in many countries with increased opioid-related overdoses and deaths being reported. In rheumatology setting, strong opioids are considered poorly effective and not recommended as first line treatment in pain management.
Objectives The aim of this study was to investigate rheumatologists' opioid prescribing patterns, demographic and practice characteristics, in relation with beliefs about prescription appropriateness and risks of opioids use.
Methods We conducted a nationwide survey with a 47-item questionnaire. The questions were developed by the French Study Group on Rheumatic Pain (CEDR), focusing on opioid prescription and pain training Questionnaires were mailed and e-mailed to every registered rheumatologist in France, with the help of French Rheumatology Society. Answers were anonymous.
Results 2490 questionnaires were sent, response rate was 33.7% (n=839), mean age 50,4 years, 49,2% were men, 33,6% had exclusive hospital practice, 65,4% reported having no special education on pain. Of these 58 (6.9%) self-reported never prescribing opioids in non-cancer pain.
Specific pain assessment was performed by 66,1% of rheumatologists to initiate, modify or maintain opioid prescription. It was significantly more frequent in young rheumatologists (<40 years), in women, in hospital practice and after special education on pain.
Main indications for opioids were: acute radicular pain (93,1%), vertebral fracture (91,4%) and acute back pain (67,1%). Only 1% would consider prescribing opioid in fibromyalgia.
Morphine and/or oxycodone were first line treatments for 613 prescribers (78,5%), fentanyl, hydromorphone and buprenorphine only for 168 prescribers (21,5%). The average starting daily dose was 45mg morphine equivalent, 80% (n=625) described a mean of 1.2 months testing period for opioid efficacy. 42% (n=328) reported a ceiling daily dose of 100mg/day morphine equivalent above which they stop increasing prescription. 70,3% reported screening for opioid misuse risk before initiating treatment.
Specific training on pain was significantly associated with opioid testing period (p=0,006); screening for risk of misuse at initiation (p<0,0001) and at continuation (p<0,0001).
Opioid side effects were prevented in 69,8% with a laxative and in 62,1% with anti-vomiting treatment. Prescribers with pain training prescribed more frequently laxative (p=0,015) and anti-vomiting treatment (p=0,0003).
Conclusions To our knowledge, this is the first national survey on trends in strong opioid prescriptions concerning rheumatologists. French rheumatologists are more likely to prescribe opioids in acute pain conditions at low dose, without exceeding the recommended 200mg daily dose for non-cancer pain, together with side effects prevention. Morphine sulfate is the first drug choice. Impact of pain education in rheumatologists' opioid uses is important, and emphasizes the need to include systematically pain training in rheumatology core curricula.
French rheumatologists have mostly a safe and careful prescribing pattern of opioid in non-cancer pain. Mostly they abide by national and international recommendations.
Disclosure of Interest None declared