Rheumatology News

R heumatology N ews • Vol. 4 • No. 1 • 2016 12 PAIN

Practice guideline released for treating opioid use disorder

As well, social and environmental factors should be assessed, to identify both barriers to and facilitators for addiction treat- ment in general and pharmacotherapy in particular. “At a minimum, psychosocial treatment should include the following: psychosocial needs assessment, supportive counselling, links to existing family supports, and referrals to community services.” Physicians should be prepared to collaborate with qualified behavioural health care providers, the guideline states. Urinary drug testing is recommended, both during the assess- ment process and frequently throughout treatment. Regarding treatment, the guideline recommends considering the patient’s preferences, past treatment history, and the treat- ment setting when deciding whether to prescribe methadone, bupenorphrine, or naltrexone. The treatment venue is as impor- tant as the specific medication selected. Office-based treatment, which provides medication prescribed either weekly or monthly, is limited to buprenorphine only. It might not be suitable for patients who regularly use alcohol or other substances. In contrast, treatment programs provide daily supervised dos- ing of methadone and, increasingly, buprenorphine. Methadone is recommended for patients who fail on buprenorphine or who would benefit from daily dosing and supervision. Naltrexone can be prescribed in any setting by any clinician, but prescribers must be aware that adherence to oral naltrex- one is generally poor, which often leads to treatment failure. Extended-release injectable naltrexone reduces but doesn’t elimi- nate adherence issues. Clinicians should reserve naltrexone “for patients who would be able to comply with special techniques to enhance their adherence, such as observed dosing.”

BY MARY ANN MOON Frontline Medical News From Journal of Addiction Medicine

pregnant women, patients with comorbid psychiatric disorders, and patients with chronic pain. The ASAM guideline specifically addresses these and other special populations (for example, adolescents, patients in the criminal justice system). It includes detailed sections on treat- ing opioid withdrawal and opioid overdose, as well as compre- hensive discussions of methadone, buprenorphine, naltrexone, and psychosocial therapies. The guideline offers numerous clinical recommendations regarding patient assessment and diagnosis. First, “addiction should be considered a bio-psycho-social- spiritual illness, for which the use of medication(s) is but only one component of overall treatment.” In addition to a thorough history and physical exam (including specific laboratory tests needed for this patient population), patients should undergo a mental health assessment with particular attention to pos- sible psychiatric comorbidities. And since opioid use often co-occurs with other substance-related disorders, “the totality of substances that surround the addiction” should be assessed before treatment is considered. Notably, the concomitant use of alcohol, sedatives, hypnot- ics, or anxiolytics with opioids can cause respiratory depression. Patients who use these agents may automatically require a higher level of care than that offered in typical primary care practices. At a minimum, psychosocial treatment should include the following: psychosocial needs assessment, supportive counselling, links to existing family supports, and referrals to community services.

T he American Society of Addiction Medicine has released a practice guideline to help clinicians evaluate and treat opioid use disorder, with the ultimate goal of getting more physicians to provide effective treatment. Effective treatment of opioid use disorder “requires skill and time that are not generally available to primary care doctors in most practice models,” so much of the treatment provided in primary care has been “suboptimal.” This has probably wors- ened what the United States Centres for Disease Control and Prevention has described as an epidemic of opioid misuse and related deaths, said Dr Kyle Kampman and Dr Margaret Jarvis, cochairs of the ASAM’s guideline committee. “At the same time, access to competent treatment is pro- foundly restricted because few physicians are willing and able to provide it,” they noted. This guideline “is primarily intended for clinicians involved in evaluating patients and providing authorisation for phar- macologic treatments at any level,” said Dr Kampman of the University of Pennsylvania, Philadelphia, and Dr Jarvis, of the Marworth Alcohol & Chemical Dependency Centre, an entity of the Geisinger Health System, Waverly, Pennsylvania. To develop the guideline, the committee – experts and researchers in internal medicine, family medicine, addiction medicine, addiction psychiatry, general psychiatry, obstetrics, pharmacology, and neurobiology, including some with allopathic or osteopathic training – first reviewed 34 existing clinical guidelines and 27 recent studies in the literature assessing medications used with psychosocial interventions. None of the existing guidelines included all the medications currently in use, and few addressed critical special populations such as

Dr Kampton disclosed research ties with Braeburn Pharmaceuti- cals; Dr Jarvis disclosed business ties with US Preventive Medicine.

Fibromyalgia found in 20% with spondyloarthritis; could affect management decisions

of the investigators, is the first “to evaluate the prevalence of FM in a population of patients with SpA with regard to the fulfilment of the ASAS classification criteria.” FM patients had as expected a significantly higher rate of either history of depression, or use of psychotropic drugs or strong opioids, compared with patients without FM (67% vs 35%; P < 0.01). Rates of exposure to treat- ment with different drug types (nonsteroidal anti-inflammatory drugs or conventional an- tirheumatic disease-modifying drugs) did not differ between those with and without FM, but FM patients switched significantly more often from their first TNFi (15.2% vs 4.0%) and used it for a significantly shorter mean duration (1.7 vs 3.5 years). The percentage of patients still taking their first TNFi after 2 years also was significantly lower among FM patients (28.1% vs 41.7%). Within the entire cohort, FM patients more often had enthesitis (59.5% vs 39.0%, P = 0.01), a higher total Bath Ankylosing Spondylitis Disease Activity Index (4.7 vs 2.6; P < 0.01), higher global visual analog scale (5.9 vs 3.0; P < 0.01), and higher Bath Ankylos- ing Spondylitis Functional Index (4.8 vs 2.0; P < 0.01). The authors suggested that FM patients’ higher rates of peripheral symptoms and enthesitis may warrant the use of the FiRST questionnaire in clinical practice before start- ing a TNFi in SpA patients to detect poten- tially coexisting FM.

BY JEFF EVANS Frontline Medical News From Arthritis Research & Therapy

T he presence of fibromyalgia in patients who are undergoing treatment of spondy- loarthritis (SpA) is associated with higher measures of disease activity and shorter dura- tion of first-time treatment with tumour necro- sis factor inhibitors, according to results of a study measuring the impact and prevalence of fibromyalgia coexisting with SpA. The results confirm “that the existence of concomitant FM [fibromyalgia] in SpA might complicate the evaluation of treatment re- sponse and [suggest] that coexistence of FM should be carefully screened when initiating a TNFi [tumour necrosis factor inhibitor] and/or evaluating its treatment effect, especially in the presence of peripheral and/or enthesitic symp- toms and in the presence of very severe disease activity and patient-reported scores,” wrote Dr Natalia Bello and her colleagues at Cochin Hospital, Paris ( Arthritis Res Ther 2016 Feb 9;18:42. doi: 10.1186/s13075-016-0943-z). They recruited patients fromCochin Hospi- tal, a tertiary care facility, and its rheumatology department’s outpatient clinic. Rather than use the 1990American College of Rheumatol- ogy (ACR) classification criteria of FM or the 2010 ACR or modified 2010 ACR diagnostic criteria, which were developed for research and classification purposes, the investigators diagnosed FM based on a score of 5 or 6 on the six-question, self-reported Fibromyalgia Rapid Screening Tool (FiRST), which has 90.5% sensitivity and 85.7% specificity for FM. Patients’ SpA diagnoses were made by their

arm criteria alone has been controversial, the investigators said, mainly because it does not require an objective sign of inflammation (abnormal C-reactive protein or presence of inflammatory lesions seen on MRI of the sacroiliac joint) or structural damage in the sacroiliac joint seen on pelvic radiographs. But at least in this study there was no difference in FM prevalence in regard to whether patients met either the imaging and clinical arms of the ASAS classification criteria for axial SpA or both. The study, according to the best knowledge

rheumatologists. Overall, 30% of the cohort was female and had a mean age of 43 years. The overall FM prevalence in the cohort was 21.4% (42 of 196 patients) and did not differ significantly according to whether the patients met either the clinical or imaging ASAS (As- sessment of Spondyloarthritis International Society) criteria (21.3% vs 18.8%, respectively) or whether they did or did not fulfil the ASAS criteria (21.1% vs 30.0%, respectively). Previous studies have shown the preva- lence of FM at 12.6–15.0% in SpA patients. Classifying axial SpA based on the clinical

The authors had no conflicts of interest to de- clare.