Persistent Opioid Exposure in Older Adults with Rheumatic Disease: National Patterns, Disparities, and Cross-Specialty Prescribing

Objective Estimate national prevalence of opioid use, including chronic and high-risk use, among older adults with rheumatic diseases; identify sociodemographic and clinical factors associated with chronic opioid use; and characterize prescribing patterns by clinician specialty in a contemporary Medicare-linked national registry cohort. Methods Cross-sectional analysis of the Rheumatology Informatics System for Effectiveness (RISE) registry linked to Medicare Part D (2016-2021). Patients were ≥65 years with qualifying rheumatic diagnoses and continuous Medicare enrollment in 2021. Opioid use was identified from Part D claims. Chronic use was defined as ≥90 days' supply in 2021. High-risk use was assessed using Office of Inspector General indicators. Generalized estimating equations modeled factors associated with chronic opioid use. Results Among 45,455 patients (mean age 75.8 years; 76.88% women), 43.13% filled ≥1 opioid prescription and 17.93% met criteria for chronic use in 2021. Very high-risk prescribing was rare (<1%). Chronic use was most prevalent in axial spondyloarthritis (axSpA; 26.19%) and least in polymyalgia rheumatica (11.58%). In adjusted analyses, axSpA (OR 1.63, 95% CI 1.35-1.98), fibromyalgia (OR 2.68, 95% CI 2.39-3.00), mood and anxiety disorders, higher comorbidity burden, American Indian/Alaska Native race, and greater socioeconomic deprivation were independently associated with chronic use. Non-rheumatology clinicians wrote most opioid prescriptions (62.60%) and more high-dose prescriptions (≥50 morphine milligram equivalents/day). Conclusion Opioid exposure remains common among Medicare-insured older adults with rheumatic disease, although very high-risk prescribing is rare. Coordinated, guideline-concordant pain management across specialties may help preserve appropriate opioid use for patients who may benefit while reducing avoidable long-term exposure.