Patients With Rheumatic and Musculoskeletal Conditions Vulnerable to Long-Term Opioid Use

Up to one in three with rheumatoid arthritis or fibromyalgia may be at risk, researchers warn

Patients with rheumatic and musculoskeletal conditions are vulnerable to long-term opioid use, with up to one in three of those with rheumatoid arthritis or fibromyalgia, who take these drugs for the first time, potentially at risk, suggest the findings of a research letter, published online in the Annals of the Rheumatic Diseases.

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 attendant risks of dependence and harmful side effects, the authors point out.

Most research defines long-term opioid use as 90 or more days, although definitions 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 anonymized medical records of 841,047 adults whose details had been entered into the Clinical Practice Research Datalink, a nationally representative UK-wide primary care research database.

Some 12,260 of them had been diagnosed with rheumatoid arthritis, 5,195 with psoriatic arthritis, 3,046 with axial spondyloarthritis, 3,081 with systemic lupus erythematosus, 796,276 with osteoarthritis, and 21,189 with fibromyalgia.

Each patient had been newly prescribed an opioid up to six months before, or any time after, their diagnosis between January 2006 and end of October 2021 and had been monitored for at least a year.

Long-term use was defined as either standard (three 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 three 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.

Most (97%+) of new prescribing episodes meeting any of the definitions were captured by the broad definition. Just under one-half fulfilled all three.

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 lowest proportion of transitioners were among those with osteoarthritis: 16.5%, 11%, and 21.5%, for each of the respective definitions.

The proportion of patients with systemic lupus erythematosus and fibromyalgia who became long-term opioid users noticeably increased between 2006 and 2019, rising from 22% to 33%, and reaching 29% in 2020.

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, one in five patients with fibromyalgia and one in six of those with rheumatoid arthritis or axial spondyloarthritis fulfilled definitions for long-term opioid use within 12 months of starting an opioid.

But this proportion could be as high as one in three for those with fibromyalgia or rheumatoid arthritis, and one in 3.5 for those with axial spondyloarthritis, using the broad definition, the researchers say.

“The findings warrant vigilance in practice of opioid prescribing for [rheumatoid and musculoskeletal conditions] since long-term opioid therapy is associated with poor outcomes (eg, opioid dependence and opioid-related adverse events),” they warn.

And they advise clinicians to instigate medication reviews or deprescribing and to consider nondrug treatments for pain relief to minimize the risks of “avoidable harms” in this group of patients.

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

Source: Annals of the Rheumatic Disease