Patients with rheumatic and musculoskeletal conditions vulnerable to long term opioid use

Up to 1 in 3 with rheumatoid arthritis or fibromyalgia starting an opioid for the first time may be at risk, warn researchers

Patients with rheumatic and musculoskeletal conditions are vulnerable to long term opioid use, with up to 1 in 3 of those with rheumatoid arthritis or fibromyalgia potentially at risk, suggest researchers at The University of Manchester The findings, published in the Annals of the Rheumatic Diseases show people with rheumatic and musculoskeletal conditions are often prescribed opioids to manage their pain, and a proportion of them will become long term users with the associated risks of dependence and harmful side effects, point out the authors.

It was based on over 841,000 anonymised medical records in Clinical Practice Research Datalink (CPRD), a primary care research database representative of the national population.

Most research defines long term opioid use as 90 or more days, although definitions in the scientific literature vary, and there are no contemporary estimates of the scale of long-term opioid use, they add.

To assess the proportion of patients transitioning to long term use among those newly started on an opioid, they drew on the anonymised medical records of 841,047 adults.

Each patient 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 had been followed up for at least a year.

Long term use was defined as either standard (3 or more opioid prescriptions issued within a 90-day period, or 90+ days’ opioid supply in the first year); or stringent (10 or more opioid prescriptions filled over more than 90 days, or 120+ days’ opioid supply in the first year); or broad (more than 3 opioid prescriptions at monthly intervals in the first 12 months).

In all, 1,081,216 new episodes of opioid use were identified among all the patients, just under 17% of whom transitioned to long term use under the standard, 11% under the stringent, and 22% under the broad definitions.

The highest proportion of long-term opioid users were patients with fibromyalgia--27.5% 21%, and 34% for each of the respective definitions-followed by those with rheumatoid arthritis--26%, 18.5%, and 32%---and those with axial spondyloarthritis--24%, 17%, and 30%.

The proportion of patients with SLE and fibromyalgia who transitioned noticeably increased between 2006 and 2019. In fibromyalgia patients this was 22% to 33%---reaching 29% in 2020.

Our study shows that a considerable proportion of patients with RMDs starting opioids for the first time, transition to long-term opioid use
A statistically significant decreasing trend was observed for patients with rheumatoid arthritis, although the overall proportion remained high at 24.5% 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.

This proportion could be as high as 1 in 3 for those with fibromyalgia or rheumatoid arthritis and 1 in 3.5 for those with axial spondyloarthritis using the broad definition, say the researchers.

Dr Joyce Huang, the research associate from The University of Manchester and first author said: "Our study does not intend to stigmatise patients who use opioids. We want to highlight the high frequency of long-term opioid use needs to be optimised and prevent people living with RMDs from opioid-related harm."

Dr Meghna Jani, an NIHR Advanced Fellow and Senior Lecturer at the Centre for Epidemiology Versus Arthritis, The University of Manchester was the Principal Investigator of the study. "Our study shows that a considerable proportion of patients with RMDs starting opioids for the first time, transition to long-term opioid use. In RMD patients this is much higher than people who are starting an opioid for non-cancer pain in general- our previous work has shown that this was around 1 in 7 people.

"Because long-term opioid therapy is associated with poor health outcomes, these findings warrant vigilance when prescribing these drugs. Long term use is particularly pronounced in fibromyalgia patients, who suffer chronic widespread pain for which there are no disease modifying treatment options. This is also more common than we initially thought, in rheumatoid arthritis and axial spondyloarthritis."

The authors advise prompt interventions such as medication reviews or deprescribing interventions in the community will ensure the appropriateness of long-term opioid therapy.

"Proactive consideration of non-pharmacological treatments for pain relief where appropriate would also be of benefit to reduce avoidable harm to these patients."

Deborah Alsina MBE, 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."

High frequency of long-term opioid use among patients with rheumatic and musculoskeletal diseases initiating opioids for the first time doi 10.1136/ard-2023-224118 is published in the Journal Annals of the Rheumatic Disease

The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care