Manchester — Opioid treatment of fibromyalgia more than quadrupled between 2006-2021, with a threefold increase in morphine and oxycodone, according to a longitudinal analysis of UK data across different rheumatic and musculoskeletal diseases (RMDs).
"A key finding was a 4.5-fold increase in fibromyalgia opioid users (from 17.7 to78.5/10,000 persons) between 2006 to 2021," said Joyce (Yun-Ting) Huang, PhD, an epidemiologist at the University of Manchester, who presented the findings at the British Society for Rheumatology (BSR) annual conference.
"We also found the strong opioids – morphine and oxycodone – increased threefold between 2006-2021 in fibromyalgia," she added. "However, reassuringly, there was no sudden increase in opioid prescribing during the pandemic in the UK."
She stressed that their study was not intended to stigmatise patients who use opioids. "We want to optimise opioid use for those in real need, and prevent opioid-related harm."
Fibromyalgia was found to have the highest opioid use in terms of morphine milligram equivalents (MME) per day, a standardised measure of the active opioid ingredient, which was consistently over 35 MME/day, closely followed by axial spondyloarthritis also at around 35 MME/day.
Impact of COVID on Opioid Prescribing 'Unknown'
Recent data show a significant increase in opioid prescriptions for non-cancer chronic pain in the UK, but there is very little evidence on the trends of opioid prescribing for patients with RMDs, including among different RMDs. "The impact of the COVID-19 pandemic on opioid prescribing in the UK is also unknown," said Dr Huang.
Interested in filling this research gap, Dr Huang's study aimed to investigate trends in opioid use between 2006 and 2021 across six RMDs: rheumatoid arthritis (RA), psoriatic arthritis, axial spondyloarthritis, systemic lupus erythematosus, osteoarthritis, and fibromyalgia, by analysing the number of adult users and prescribing patterns, including the impact of the COVID-19 pandemic on opioid prescribing.
Data on opioid users with RMDs were drawn from the UK Clinical Practice Research Datalink (CPRD) database between 2006 and 2021, excluding cancer patients, and standardised for age and sex.
The researchers found an overall increasing trend for opioid users across all RMDs, but this started to decrease after 2018 – of note, RA started to fall in 2019, psoriatic arthritis in 2020, axial spondyloarthritis in 2019, systemic lupus erythematosus in 2019, and osteoarthritis in 2018.
2021 NICE Guidelines Recommend Against Opioid Use in Fibromyalgia
Trends for use in fibromyalgia started to plateau after 2021. "Pre-pandemic, fibromyalgia showed an increasing trend [0.009, 95% CI=0.008 to 0.009] which started to decrease [-0.009; 95%CI=-0.011 to -0.006] during the pandemic," Dr Huang highlighted. "I don't expect this to go up given new NICE [National Institute for Health and Care Excellence] guidelines in 2021 recommending against opioid use in fibromyalgia."
"There have also been improvements in the diagnosis of fibromyalgia in the past decade, so the prevalence has increased, and because there are no effective DMARDs to treat it, people rely on painkillers," explained Dr Huang.
"Use of strong opioids, such as morphine and oxycodone, showed a clear three-fold increase in fibromyalgia," she reported, with morphine use increasing from 4%in 2006 to 13% in 2021, while oxycodone use rose from 1.5% in 2006 to 4.7% in 2021."
Finally, Dr Huang explored the variation in opioid use before and after the UK's COVID-19 pandemic by looking at trends between 2015 and 2021. With RA, the number of opioid users decreased five times faster during the pandemic (-0.005, 95% CI=-0.008 to -0.002) compared with pre-pandemic (-0.001, 95% CI=-0.002 to -0.001).
"There was no sudden increase in opioid prescribing during the pandemic, but the consistent of lack of rebound is probably associated with the reduced healthcare services across the UK," explained the researcher. "Theoretically, opioid prescribing trends might not decrease further in the future."
Psoriatic arthritis had a decreasing-to-flat curve (0.0010, 95%CI=0.0006,0.0015) pre-pandemic, which changed by -0.003 (95% CI=-0.006 to -0.0003) during the pandemic, resulting in a decreasing trend.
Vanessa Reid, a specialist clinical pharmacist from Manchester University NHS Foundation Trust, commented on the opioid study results: "A lot of NICE guidelines around opioid use have come out in the past few years, particularly with respect to osteoarthritis. This is an underlying trend [recent decrease] probably related to the pandemic with fewer GP visits, but I think the trend will reverse because patients are waiting longer for surgery," she said.
"Fibromyalgia is hard to treat and when faced with a patient in immense pain it is understandable that a doctor wants to give them a prescription, even though they are unlikely to work," added Ms Reid.
1 in 4 Patients Using Opioids Become Long-Term Users
Dr Gouri Koduri, a rheumatologist at Southend University Hospital, Essex, who moderated the session, also commented on the findings. "We thought that opioid prescriptions would go up during the pandemic because of patient concern around taking DMARDS due to immunosuppression increasing their risk of COVID, but these patients were also shielding more too. However, the risk was not as high as expected and these study data reflect this," she said.
Another study presented at the meeting by Carlos Raul Ramirez Medina, also from the University of Manchester, found at least 1 in 4 patients taking opioids had become long-term users with the first year of starting. "This is very concerning. In addition to pain relief, we need to address the psycho-social issues including sleep," remarked Dr Koduri. "These patients feel nobody is listening to them. Primary care needs to create clinics with psychologists, physiotherapists, and occupational therapists because these people knock on different doors."
Dr Huang, Mr Ramirez Medina, and other co-authors have no conflicts of interest to declare. Neither Dr Koduri, nor Ms Reid declared any conflicts.