Gout, the most common form of inflammatory arthritis, affects over 10 million people in the United States. Characterized by sudden, excruciating flares of debilitating joint pain and swelling, gout often drives patients to hospitals and clinics in search of relief. Unfortunately, opioids are not infrequently used for pain management in these settings. The U.S. continues to face a devastating opioid epidemic, with more than 100,000 overdose deaths in 2021 alone. While opioids may provide short-term pain relief, they carry significant risks, including dependence, overdose, and even potential paradoxical worsening of pain and inflammation. To date, there have been no large-scale investigations examining the frequency of chronic opioid use in patients with gout.
Our recent matched cohort study sought to examine the frequency of chronic opioid use in patients with gout using data from the Veterans Health Administration (VHA) between 2000 and 2020. The study included more than 419,000 patients with gout and 3.6 million matched controls without gout and followed patients for an average of 4.5 years. Our study found that gout patients were 30% more likely to receive chronic opioid prescriptions compared to non-gout patients, even after adjusting for other health conditions. Additionally, 6.9% of gout patients progressed to chronic opioid use during follow-up, versus 3.8% of controls. Certain subgroups faced greater risk or chronic opioid prescriptions, including women, smokers, underweight or obese patients, those with multiple comorbidities, and patients requiring rheumatology consultation. Adequate uric acid control (defined as a serum urate of ≤7 mg/dL) was associated with a lower likelihood of chronic opioid use.
Our study observations translate to one additional case of chronic opioid use for every 74 gout patients treated over five years. On a national scale, this could mean more than 165,000 gout patients in the U.S. transition to chronic opioid use each year. Our study highlights several critical issues for providers managing gout including the concept that opioid use intended for short-term pain control during a flare could potentially evolve into long-term usage. Given this concern, NSAIDs, colchicine, and corticosteroids should remain the cornerstone of care for gout flare management as outlined in the American College of Rheumatology guidelines (Fitzgerald et al, Arthritis Care and Res, 2020). Our study identified women, non-Hispanic Black patients, and those with high comorbidity burdens as being particularly vulnerable. These findings mirror existing disparities in gout care and suggest that opioid-related risks may compound these inequities. Patients achieving adequate serum uric acid targets were less likely to require chronic opioid prescriptions, reinforcing the importance of treat-to-target strategies that include the use of urate-lowering treatments such as allopurinol to achieve and maintain circulating uric acid levels below 6.0 mg/dL. Patients referred for specialist care were more likely to become chronic opioid users, likely reflecting greater gout severity seen in rheumatology clinics. This underscores the need for careful coordination of pain management strategies in complex cases.
There are a few practical steps that can be taken for the clinician treating gout flares. First, providers need to educate patients about safe and effective non-opioid options for managing flares. Other approaches include reinforcing the importance of urate-lowering therapy adherence and closely monitoring serum uric acid results to achieve target levels. It is also essential to address health disparities by ensuring equitable access to guideline-based care across patient populations. Finally, providers caring for patients with gout need to carefully consider the appropriateness of opioid prescriptions, particularly those at higher risk.
Our study demonstrates that gout results in more than intermittent flares of joint pain, also serving as a potential risk factor for long-term opioid use. We suggest providers avoid opioids whenever possible, optimize uric acid control, and remain vigilant in at-risk populations. By doing so, we can not only improve gout outcomes but also play a role in curbing the ongoing opioid crisis.
Dr. Helget is an Assistant Professor of Medicine in the Department of Internal Medicine at the University of Nebraska Medical Center (UNMC).
Dr. Helget completed her medical school training at UNMC followed by internal medicine residency at the Medical University of South Carolina. She then returned to UNMC to complete rheumatology fellowship and joined UNMC/Nebraska Medicine in 2021 as a staff rheumatologist where she remains active in education and patient care.
