Opioid use in Fibromyalgia Continues DespiteGuidelines That do not Support its Efficacy or Risk

Barbara K. Bruce, PhD; Madeleine E. Allman, MPH; Fernando A. Rivera, MD; Andy Abril, MD; Jessica M. Gehin, MS, RN; Loretta M. Oliphant, RN; Lisa M. Nordan, MBIT; Launia J. White, BS; Dayana Martinez, MHA; Shehzad K. Niazi, MD

Disclosures

J Clin Rheumatol. 2021;27(5):187-193. 

In This Article

Abstract and Introduction

Abstract

Background/Objective: The aim of this cross-sectional study is to determine the prevalence of opioid use in a large sample of fibromyalgia (FM) patients and examine the factors associated with opioid prescription/use despite multiple clinical guidelines that do not recommend opioid use in this population.

Methods: Data were collected from a convenience sample of 698 patients admitted from August 2017 to May 2019 into an intensive 2-day Fibromyalgia Treatment Program at a tertiary medical center in the United States after FM diagnosis. Patients were administered the Fibromyalgia Impact Questionnaire–Revised, the Center for Epidemiologic Study of Depression Scale, and the Pain Catastrophizing Scale upon admission to the program. Demographic information and opioid use were self-reported. Logistic regression analysis was utilized to determine associations between patient-related variables and opioid use in this prospective study.

Results: Of 698 patients, 27.1% (n = 189) were taking opioids at intake. Extended duration of symptoms (>3 years), increased age, higher degree of functional impairment, and increased pain catastrophizing were significantly associated with opioid use.

Conclusions: Opioids are not recommended for the treatment of FM under current guidelines. Greater burden of illness appeared to be associated with the prescription and use of opioids in this population. These findings suggest that some providers may not be aware of current recommendations that have been found to be effective in the management of FM that are contained in guidelines. Alternative approaches to the management of FM that do not involve opioids are reviewed in an effort to improve care.

Introduction

Fibromyalgia (FM) is a common disorder with a prevalence of 2% to 8% in the world population.[1–3] Approximately 5 million adults in the United States are affected by FM.[4] Despite its prevalence, diagnosis and management of FM remain a challenge for patients and providers. On average, patients consult with 3.7 specialists and have to wait more than 2 years for diagnosis.[5]

Fibromyalgia is often a debilitating disorder characterized by widespread pain, fatigue, sleep disturbance, cognitive difficulties, and an amplified sensitivity to sensory input considered to be centrally mediated.[6–9] Pain is considered to be the hallmark symptom of FM and generally includes chronic musculoskeletal pain.[10] The etiology of FM is not known, and there is no cure as yet. A definitive treatment does not exist, and a number of pharmacological and nonpharmacological treatments have been used to ameliorate the symptoms of this disorder. Many of the current treatments target pain and are directed at modulating central pain pathways to reduce the sensitivity that is characterized by hyperalgesia and allodynia. The most effective pharmacological treatments for acute nociceptive pain such as opioids have not been shown to work on centralized pain.[11,12]

Treatment guidelines recommend against the use of opioids in the treatment of FM because of their ineffectiveness in treating centrally mediated pain and because of the high risk of misuse, abuse, and dependence associated with chronic opioid use.[13] Opioid use disorder and overdose are occurring at high rates in the United States as a result of exposure to opioids that are often used long term in patients with chronic pain conditions.[14,15]

Evidence-based clinical practice guidelines have been developed by both national and international groups to assist health care providers in the treatment of patients with chronic pain generally and FM specifically. The Centers for Disease Control and Prevention (CDC) released guidelines in 2016 that were interpreted as significantly restricting the use of opioids for pain.[14] Significant controversy over these guidelines resulted in a recent clarification of their position noting that the guidelines were developed to implement safer prescribing practices particularly among primary care physicians who actually write the majority of prescriptions for opioids.[16]

A review of the guidelines developed by the American Pain Society, Canadian Pain Society, European League Against Rheumatism, and the Association of the Scientific Medical Societies in Germany provide some areas of agreement regarding the efficacy of treatment approaches.[17] First-line treatments for FM are nonpharmacological interventions that include education, exercise, and cognitive behavioral therapy.[2,17,18] Amitriptyline and multicomponent treatment are also strongly supported in these guidelines.

Nonetheless, opioid prescription/use remains high among FM patients despite strong recommendations against it.[11] Estimates of opioid prescription and use among patients with FM vary and have been increasing in recent years, ranging from 20.1% to 55.4%.[19,20] A recent study published in 2018 of 305 patients seen in a tertiary medical setting with FM found that 34.8% were taking opioids.[21]

Several factors have been found to be associated with opioid use in FM, including female sex, geographic variation (proxy for local contextual and structural factors such as information dissemination, local licensing and prescription laws, and health care facility–specific norms and procedures), psychological factors, history of opioid use/misuse/abuse, age, disability, depression, higher pain levels, socioeconomically more disadvantaged, obesity, and patient/physician preference.[22,23] A recent study found that FM patients being prescribed opioids have higher medical utilization and may have more severe illness.[21] However, study designs have not been rigorous and have included retrospective record review and a self-reported internet survey, often with limited sample size.[15,24–26]

Prescription of opioids for long-term use in chronic pain is associated with serious risk of opioid use disorder and overdose, which are occurring at high rates in the United States.[14,15] In light of high opioid misuse/abuse rates in the United States and current guidelines for the management of FM and the CDC's recent guidelines against opioid use in FM specifically and chronic pain management generally, it is important to examine the problematic use of any opioid in FM patients.[14] The current study was designed to examine the prevalence of opioid use in a large tertiary sample of FM patients and determine the factors associated with its use in an effort to understand and decrease the factors that place FM patients at risk of chronic opioid exposure.

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