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

The findings warrant vigilance in practice of opioid prescribing for [rheumatoid and MSK conditions] since long term opioid therapy is associated with poor outcomes (eg, opioid dependence and opioid-related adverse events) [Yun-Ting Huang et al]

Each patient had been newly prescribed an opioid up to six months before, or any time after, their diagnosis from January 2006 to the 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-plus days’ opioid supply in the first year); or stringent (10 or more opioid prescriptions filled over more than 90 days, or 120-plus 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 per cent of whom transitioned to long term use under the standard, 11 per cent under the stringent, and 22 per cent under the broad definitions.  Most (97 per cent +) of new prescribing episodes meeting any of the definitions were captured by the broad definition. Just under half fulfilled all three. 

High rates among patients with fibromyalgia 

The highest proportion of long-term opioid users were patients with fibromyalgia – 27.5 per cent, 21 per cent, and 34 per cent for each of the respective definitions – followed by those with rheumatoid arthritis – 26 per cent, 18.5 per cent, and 32 per cent – and those with axial spondyloarthritis – 24 per cent, 17 per cent, and 30 per cent. The lowest proportion of ‘transitioners’ were among those with osteoarthritis: 16.5 per cent, 11 per cent, and 21.5 per cent, for each of the respective definitions.

The proportion of patients with SLE and fibromyalgia who became long term opioid users noticeably increased between 2006 and 2019, rising from 22 per cent to 33 per cent, and reaching 29 per cent in 2020.

'Consider non-drug alternatives' 

The researchers observed a statistically significant decreasing trend among patients with rheumatoid arthritis, although the overall proportion remained high at 24.5 per cent 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, say the researchers. 

‘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),’ Dr Huang and her colleagues warn. They advise clinicians to instigate medication reviews or de-prescribing and to consider non-drug treatments for pain relief to minimise the risks of ‘avoidable harms’ in this group of patients.

Factfile

People with rheumatic and MSK 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 see the full version of the article – titled 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 – click