Roderick A. Fields

Prescription Opioid Analgesic Use and Mortality in Systemic Lupus Erythematosus

Objectives This research investigated the prevalence of opioid analgesic use in patients with systemic lupus erythematosus (SLE). Methods This 5-year prospective cohort study of 275 SLE patients focused on prescription opioid use and 5-year outcome. Associations were determined with univariable regression analysis and then multivariable models were created to determine independent effects on dependent variables Results Prescription opioid use was common in SLE with 24% using opioid analgesics chronically and 76% not using opioids. Opioid users had a higher rate of tobacco use (p<0.01), cocaine use (p<0.002), mean pain scores (p<0.001), disease activity (SLEDAI-2K) (p<0.001), disease damage (SLICC/ACRDI) (p<0.001), non-adherence to medical therapy (p<0.01), and total deaths at 5 years (opioids: 48.0%, no opioids 19.0%, p<0.001). Logistic regression analysis predicting death revealed opioid use (hazard ratio 2.6, p<0.001) and SLEDAI-2K (1.1, p<0.001) respectively; and opioid use (hazard ratio 2.5, p<0.002), SLEDAI-2K (hazard ratio 1.1, p<0.001), and non-adherence (hazard ratio 1.6, p=0.11), respectively. Multivariable Cox Model analysis estimating probability of death with covariates: opioid use (hazard ratio 2.6, p<0.001) and SLEDAI-2K (hazard ratio 1.1, p<0.001); opioid use (hazard ratios 3.0, p<0.001), and cocaine use (hazard ratio 3.2, p<0.001). The Kaplan-Meir survival analysis revealed a significantly higher probability of death for SLE patients using opioid analgesics. Conclusions Prescription opioid analgesic use is common in SLE and is associated with markedly increased mortality. Preferably, non-opioid approaches to treat chronic pain should be used in SLE patients. Clinical trial registration number This was not a clinical trial. KEY MESSAGES: 1. Chronic opioid analgesic use is common in SLE (24%). 2. Opioid use is associated with greater disease severity, tobacco use, non-adherence, and increased mortality. 3. Opioids should be used cautiously in SLE; alternative non-opioid management of pain is recommended. ACKNOWLEDGMENTS AND FUNDING INFORMATION: This work was supported by US National Institutes of Health research grants to Dr. Sibbitt (R01 NS035708) and to the Clinical and Translational Research Center (UL1TR001449).

Glenohumeral Injection Using Anatomic Landmark Versus Sonographic Needle Guidance

Objective We hypothesized ultrasound (US) guidance improves outcomes of corticosteroid injection of the painful shoulder. Methods 30 patients with symptomatic shoulders due to osteoarthritis were randomized to glenohumeral injection with 3 milliliters of 1% lidocaine and 60 mg of triamcinolone acetonide using the anterior approach with 1) conventional anatomic landmark palpation-guidance or 2) US-guidance. Injection pain (visual analogue pain scale (VAS)), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next-injection, and costs were determined. Results Injection pain was less with US (VAS: 0.3±0.6 cm) vs. landmark-guidance (VAS: 1.4±2.4 cm, 95% CI of difference: 0.5<1.1<1.7, p=0.05). Pain scores were similar at 2 weeks: US: 2.2±2.4 cm; Landmark: 1.8±2.7 cm, 95% CI of difference: −2.2<−0.4<1.4, p=0.66 and 6 months: US: 5.8±2.8 cm; Landmark: 6.4±2.9 cm, 95% CI of difference: −0.4<0.6< 1.1, p =0.71. Therapeutic duration (US: 3.9±1.5 months; Landmark: 3.0±1.2 months, 95% CI of difference: − 1.4 <−0.9<−0.4, p=0.045) and time-to-next-injection (US: 8.1±3.5 months; Landmark: 5.7±2.9 months, 95% CI of difference: −3.6<−2.4<−1.3, p=0.025) were longer, and fewer injections per year (29% less) were required: US: 1.5±0.2 injections/year; Landmark: 2.1±0.2 injections/year (p<0.037; 95% CI of difference −0.9<−0.6<−0.3). However, cost/patient/year was modestly greater with US (US:

Compression-Assisted Arthrocentesis of the Knee as a Quality Improvement Intervention

318±89, Landmark:

Medical Nonadherence, Cannabis Use, and Renal Outcome in Systemic Lupus Erythematosis

301±67; p=0.28). Conclusion Anatomic landmark guidance in the short-term is equally effective as US for injection of the osteoarthritic shoulder and modestly less costly, however, US may reduce the need for repetitive injections by prolonging the therapeutic effect and thus time to next injection. IRB Statement This project was in compliance with the Helsinki Declaration, was approved by the Institutional Review Board (IRB) as ultrasound subset of a syringe safety trial (Human Research Review Committee approval 04-347), and was registered at ClinicalTrials.gov (Clinical Trial Identifier NCT00651625). The subjects gave informed consent to participate prior to all studies and interventions. Patient confidentiality was protected according to the U.S. Health Insurance Portability and Accountability Act (HIPAA) and all data was de-identified.

The prevalence of anticardiolipin antibodies in a healthy elderly population and its association with antinuclear antibodies.

Objective The present study reports the introduction of mechanical compression of the knee for arthrocentesis as quality improvement intervention in a procedure clinic. Methods 430 consecutive symptomatic osteoarthritic knees underwent arthrocentesis followed by corticosteroid injection (1mg/kg of triamcinolone acetonide). The first 215 consecutive knees underwent conventional arthrocentesis and injection; the quality intervention of a mechanical compression brace was introduced, and the next 215 consecutive knees underwent mechanical compression-assisted arthrocentesis follow by injection. Pain scores, arthrocentesis success, fluid yield, time-to-next-intervention, injections/year, and medical costs were measured. Results No serious adverse events occurred in 430 subjects. Diagnostic synovial fluid (≥2 ml) was obtained in 9.3% (20/215) without compression and 40.9% (88/215) with compression (p=0.00001, z for 95% CI= 1.96, Pierson). Mechanical compression was associated with a 231% increase in mean arthrocentesis volume: compression 5.3±11.2 ml, conventional 1.6±6.4 ml (CI of difference 2.0 <3.7< 5.4; p=0.00001). Time-to-next-intervention after compression-assisted arthrocentesis was longer: 6.9±3.5 months compared to conventional: 5.1±2.7 months (p<0.00001, 95% CI of difference 1.2 <1.8< 2.3). Mechanical compression was associated with a reduction in the number of corticosteroid injections administered per year: mechanical compression: 1.7±0.9 injections/year; conventional: 2.4±0.5 injections/year (p<0.00001, 95% CI of difference −0.83 < −0.70< −0.56). Mechanical compression did not increase overall yearly costs associated with management of the symptomatic knee (mechanical compression:

Neuropsychiatric lupus erythematosus, cerebral infarctions, and anticardiolipin antibodies.

293.30/year/knee, conventional:

Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance

373.29/year/knee) (p<0.0001, 95% CI of difference 47 <80< 112). Conclusions Routine mechanical compression of the knee for arthrocentesis and injection is an effective bioengineering quality improvement intervention in a procedure clinic.

Improvement in diagnostic and therapeutic arthrocentesis via constant compression

Background/Objective Non-adherence to recommended medical therapy has been associated with poorer outcomes in systemic lupus erythematosus (SLE). The present research investigated the association of medical non-adherence and cannabis use on renal outcomes of SLE. Methods This was a prospective 5-year longitudinal outcome study of 276 female SLE patients 30.4% who chronically used medical cannabis and 69.5% who did not. Outcomes were determined at 5 years after enrollment in the study. Results Cannabis use in SLE patients was associated with an increased prevalence of neuropsychiatric SLE (p<0.05), opioid analgesic use (p<0.01), cigarette smoking (p<0.001), and non-adherence to the medical regimen (non-cannabis: 3% non-adherence vs. cannabis use: 95% non-adherence, p<0.001). Within the 5-year period, the cannabis group demonstrated a 53% increase in mortality (p=0.12) and 127% increase in end-stage renal disease requiring dialysis (p<0.001). With logistic regression analysis adjusting for SLE disease activity (SLEDAI-2K), cannabis use was an independent predictor of end-stage renal disease: Odds ratio 2.65 (CI 1.32 – 5.32, p<0.01). Adjusting for SLE disease damage (SLICC/ACR-DI), cannabis use remained an independent predictor of end-stage renal disease: Odds ratio 2.0 (CI 1.26 – 6.23, p<0.01). With multivariable analysis adjusting for non-adherence, the effect of cannabis on end-stage renal disease could be largely attributed to an increase in non-adherence to medical therapy. Conclusions Non-adherence to recommended therapy and medical cannabis use are associated with a significant increase in the development of end-stage renal disease in SLE.