Chronic Opioid Use in Fibromyalgia Syndrome

A Clinical Review

Jacob T. Painter, PharmD, MBA, PhD; Leslie J. Crofford, MD

Disclosures

J Clin Rheumatol. 2013;19(2):72-77. 

In This Article

Abstract and Introduction

Abstract

Chronic opioid therapy in the treatment of chronic nonmalignant pain has increased drastically over the past decade. This is a worrisome trend in general, but specifically, given pathophysiologic characteristics seen in fibromyalgia (FM) syndrome patients, the use of this class of medication deserves special scrutiny. We first describe the current understanding of the etiology and pathophysiology of FM, including the role of genetic and environmental factors in the development of this syndrome. We then discuss the biologic effects of opioid use. Next, we review the pharmaceutical treatment options for FM, including 3 Food and Drug Administration–approved medications, and the evolution of treatment guidelines since 2004. We then highlight the various consequences associated with the mechanism of action of opioids and the specific concerns for FM patients.
Finally, summarizing the existing literature, we make the case that chronic opioid use is inappropriate in the treatment of FM because of the interaction of unique pathophysiologic characteristics of the patients and effects associated with chronic opioid use.

Introduction

According to Relieving Pain in America, a recent report published by the Institute of Medicine, pain is the leading affliction affecting Americans and costs the nation more than $635 billion annually in medical costs and lost productivity.[1] The institute stresses the importance of increased research into the translation of effective treatments into practice and into the occurrence and cost of pain.[1] Chronic pain research is a difficult endeavor due to the subjective and heterogeneous nature of the disorder. Fibromyalgia (FM) is an idiopathic, functional disorder characterized by chronic widespread pain and diffuse tenderness.[2] Fibromyalgia is the most common cause of widespread musculoskeletal pain,[3] affecting more than 6 million patients in the United States.[4] This syndrome is associated with significant clinical and economic burden to patients, the health care system, and society as a whole. Over the past decade, the worrisome trend of increased prescribing and utilization of opioids for the treatment of chronic nonmalignant pain, including in FM, has emerged.

There are several characteristics, both physiologic and clinical, that separate FM patients from those with other forms of chronic nonmalignant pain and these characteristics render chronic opioid use especially troubling. While the theoretical case, which is presented in detail in the following pages, is strong, there is a lack of evidence specifically comparing utilization and cost characteristics of FM patients using opioids chronically and those receiving evidence-based therapy. The hallmark symptom of FM is widespread pain; however, the syndrome is also characterized by fatigue, nonrestorative sleep, psychological distress, and cognitive difficulties.[5] There are many unanswered questions regarding both etiology and management of FM. the number of studies has increased in conjunction with the recent introduction of medications approved for the indication of FM, research addressing issues such as cost of care, off-label treatment patterns, or health care utilization for patients receiving medications other than those currently under patent is less than rigorous, outdated, or nonexistent. The purpose of this review was to describe FM and highlight the consequences of use of chronic opioid therapy for the symptomatic control of FM pain. Use of opioids in this disease state is of particular interest because of the lack of evidence supporting utilization and the growing concern over the clinical and societal consequences of use of these drugs. Many of these consequences are unique to or elevated in patients with FM when compared with those suffering from other nonmalignant pain syndromes.

We first describe the biologic effects of opioids. Then, we discuss diagnosis, burden of illness, and treatment options for patients with FM. Next, we highlight the various consequences of opioid use and their application to FM patients. Finally, summarizing the existing literature, we analyze the clinical decision to utilize opioids chronically in patients with FM.

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