Patients with hidradenitis suppurativa (HS) may have a high risk for long-term opioid use, according to the findings of a recent study.1 The findings suggest screening for pain and opioid use may be warranted among this patient population, particularly those with other medical comorbidities, including depression.
The retrospective study, which included 22,277 opioid-naïve patients with HS and 828,832 controls, found patients with HS had 1.53 (95% CI, 1.20-1.95) higher odds of long-term opioid use compared with controls. Among patients with HS, higher odds of long-term opioid use was associated with ever smoking (odds ratio [OR] 3.64; 95% CI, 1.06-6.41), advancing age (OR 1.02 per 1-year increase; 95% CI, 1.00-1.03), history of depression (OR 1.97; 95% CI, 1.21-3.19), and baseline Charlson comorbiditiy index score (OR 1.15 per 1-point increase; 95% CI, 1.03-1.29). Specialties associated with the most opioid prescriptions in the study included primary care, anesthesiology/pain management, gastroenterology, surgery, and emergency medicine.
In an interview with The Dermatologist, lead author Sarah Reddy, BA, discussed the implications of these findings and what dermatologists should know when treating patients with HS who reported pain and/or opioid use.
The Dermatologist: Why did you and your team decide to perform this study? What results did you expect to find, and did any of the findings surprise you?
Reddy: We know that patients with HS experience chronic pain, and recent work by our group suggests that the majority of patients with HS rate their pain as at least moderate in severity.2 Pain management in HS is a challenge because patients experience significant diagnostic delays and often receive care from multiple specialists. For these reasons, we wanted to examine the risks of long-term opioid use in this susceptible population. This study seemed especially relevant in the context of the current opioid crisis.
We expected to find that patients with HS had increased risk for long-term opioid use compared with the non-HS population. However, we were surprised at how closely the incidence of long-term opioid use among patients with HS approximated that of other at-risk populations, including those with newly diagnosed musculoskeletal pain and surgical patients.
Also, we were surprised to find that HS disease duration and established dermatologic care were not associated with the risk of long-term opioid use. Disease duration is difficult to accurately measure with claims-based data. We could not control for disease severity, which may have affected our ability to detect an association between dermatologic care and opioid use.
The Dermatologist: How does this study highlight the connection between pain and HS, and the need for better treatment options that alleviate both the skin disease and other aspects, such as pain?
Reddy: Our study shows that patients with HS have a risk of long-term opioid use that is comparable to other high-risk groups, including patients with newly diagnosed musculoskeletal pain and patients undergoing surgery. The importance of monitoring opioid use in the latter groups is well-accepted, and our results suggest that patients with HS with exposure to opioids may need similar levels of monitoring.
Our findings support the importance of pain as a primary outcome in HS treatment studies. There are no established pain management protocols in HS, and further studies on the use and efficacy of non-opioid pain medication are needed.
The Dermatologist: What other research is needed to better support these patients and reduce the burden and risk of opioid use?
Reddy: Now that we can quantify the increased risk of long-term opioid use among patients with HS, we need to identify modifiable factors that lower this risk. Our study identified modifiable factors that were associated with increased risk of opioid use, including depression and tobacco smoking, but we did not find any that lowered the risk. Notably, established dermatologic care was not associated with lower risk of long-term opioid use. This may be because patients with HS who had dermatology encounters may have had more severe disease. Further studies that are able to directly control for disease severity are needed to evaluate the impact of established dermatologic care, as well as the efficacy of HS treatment modalities, in reducing long-term opioid risk.
The Dermatologist: What are your recommendations for providers, both in and outside dermatology, for incorporating your findings into their practice?
Reddy: Dermatologists regularly see patients with HS and have the greatest opportunity to identify those at risk for opioid misuse. Periodic screening for long-term opioid use may be cost effective and identifying at-risk patients has the potential for great benefit.
While patients with HS are at higher risk of chronic opioid use compared with controls without HS, the absolute risk is still relatively small. Non-dermatologist providers should be aware of the significance of pain in HS, as patients with HS have similar incidence of long-term opioid use as other well-studied, at-risk groups.
1. Reddy S, Orenstein LA, Strunk A, Garg A. Incidence of long-term opioid use among opioid-naive patients with hidradenitis suppurativa in the United States [Published online September 11, 2019]. JAMA Dermatol. doi:10.1001/jamadermatol.2019.2610
2. Garg A, Neuren E, Cha D, et al. Evaluating unmet needs in hidradenitis suppurativa: Results from the Global VOICE project [published online July 3, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.06.1301