Many patients with rheumatic and musculoskeletal diseases are prescribed opioids to manage their pain. Some of them transition to long-term opioid use, which carries the potential for dependence, abuse, and harm. A new study from the University of Manchester suggests that as many as 1 in 3 patients with rheumatoid arthritis or fibromyalgia newly-prescribed an opioid may be at risk of long-term use.
For the study, published online as a research letter in Annals of the Rheumatic Diseases, the research team set out to quantify the scale
of long-term opioid use across six rheumatic and musculoskeletal conditions.
They extracted data on adult patients with these conditions from the Clinical Practice Research Datalink. After excluding those with a prior cancer diagnosis, they had records on 841,047 patients. The cohort included 12,260 diagnosed with rheumatoid arthritis, 5195 with psoriatic arthritis, 3046 with axial spondyloarthritis, 3081 with systemic lupus erythematosus, 796,276 with osteoarthritis, and 21,189 with fibromyalgia.
In all, 1,081,216 new episodes of opioid use were identified – counting patients who had been newly-prescribed an opioid up to 6 months before, or any time after, their diagnosis between January 2006 and end of October 2021, and who had been monitored for at least 1 year.
Long-term opioid use was defined in three ways:
- Standard - 3 or more opioid prescriptions issued within a 90 day period, or 90+ days’ opioid supply in the first year
- Stringent - 10 or more opioid prescriptions filled over more than 90 days, or 120+ days' opioid supply in the first year
- Broad - more than 3 opioid prescriptions at monthly intervals in the first 12 months
Up to 1 in 3 Patients Became Long-Term Users
Almost all (97%) new prescribing episodes meeting any of the definitions were captured by the broad definition. Just under half fulfilled all three definitions. Among patients with new opioid prescriptions, 16.8% transitioned to long-term use under the standard definition, 11.1% under the stringent, and 21.9% under the broad definitions.
The highest proportion of long-term opioid users were patients with fibromyalgia: 27.4%, 20.9%, and 33.7% respectively for each of the definitions, followed by those with rheumatoid arthritis: 25.7%, 18.5%, and 32.3%, and patients with axial spondyloarthritis: 23.8%, 17.3%, and 29.6%, respectively.
Conversely, the lowest proportion of transitioners was among those with osteoarthritis: 16.4%, 10.7%, and 21.4%, for each of the respective definitions.
There were statistically significant increasing trends in long-term opioid use among patients with SLE and fibromyalgia, the team said. In particular, there was a noticeable increase among patients with fibromyalgia from 21.7% in 2006 to 33.0% in 2019 and 28.9% in 2020. In contrast, a statistically significant decreasing trend was observed for rheumatoid arthritis, although the overall proportion of patients becoming long-term users remained high (at 24.4% in 2020).
Under the stringent definition, 1 in 5 patients with fibromyalgia and 1 in 6 of those with rheumatoid arthritis or axial spondyloarthritis fulfilled definitions for long-term opioid use within 12 months of starting an opioid. Using the broad definition, the proportion was as high as 1 in 3 for those with fibromyalgia or rheumatoid arthritis, and 1 in 3.5 for those with axial spondyloarthritis, the researchers said.
They warned that their findings warranted "vigilance" in opioid prescribing for rheumatoid and musculoskeletal conditions, as "long term opioid therapy is associated with poor outcomes" such as opioid dependence and opioid-related adverse events.
"Health professionals should be aware of the high proportion of long-term opioid use in patients with rheumatic and musculoskeletal disorders," they said. "Introduction of prompt interventions, such as medication reviews or de-prescribing, to ensure the appropriateness of long-term opioid therapy, and proactive consideration of non-pharmacological treatments for pain relief, would also be of benefit to reduce avoidable harms in this patient population."
The impact of individual factors, including increasing age, comorbidities, socioeconomic status, and prescribing factors on long-term opioid use in these conditions "requires future dedicated evaluation", they noted.
Many Patients 'Dependent and Miserable'
Asked to comment by Medscape News UK, Dr Wendy Holden, medical advisor to Arthritis Action and honorary consultant rheumatologist, said: "Although shocking, it's not a surprise for doctors to discover that up to a third of patients with fibromyalgia and rheumatoid arthritis may be vulnerable to long term opioid use. Chronic pain can be a very challenging condition to manage, and many medicines frankly do not work very well.
"Opiates are often started in primary care for patients who present with pain that has not responded to simple painkillers such as paracetamol or anti-inflammatory medicines. Unfortunately, all opioids are extremely addictive and have significant side effects.
"The most recent NICE guidelines on osteoarthritis (October 2022) and chronic pain including fibromyalgia (April 2021), as well as the Royal College of Physicians' guidance on fibromyalgia (March 2022), no longer recommend opiates for these conditions. However, this message is still slow to take effect and as a result many patients who are long-term users remain dependent and miserable because of side effects."
Also commenting to Medscape News UK, Deborah Alsina, chief executive of the charity Versus Arthritis, said: "People with arthritis experiencing relentless and excruciating chronic pain are often desperate for pain relief, and it is sometimes appropriate for doctors to prescribe opioids in the short term. If people benefit from opioids, then they should be able to access these medicines.
"However, there are some who have a negative experience taking opioids, including risk of dependence due to long term use. Others have found that opioids make no difference to their quality of life, for good or bad.
"The decision to take any medicine should always be shared between a person and their doctor. This research can be used by doctors to inform people with arthritis of the possible benefits and risks of opioids and whether it is the right medicine for them."
This study was funded by FOREUM and the National Institute for Health and Care Research. The authors declared no conflicts of interest.