Chronic Opioid Use in Fibromyalgia Syndrome

A Clinical Review

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


J Clin Rheumatol. 2013;19(2):72-77. 

In This Article

Time for an Evidence-based Approach

Although further research into the effects of chronic opioid use for FM is certainly desirable, the lack of economic impetus for the pharmaceutical industry makes them unlikely. Given the profound lack of controlled or anecdotal efficacy evidence supporting the use of opioids in FM, their prevalence as a treatment option is of great concern. Couple this lack of efficacy with the increasing armamentarium of drugs that do have evidence of safety and efficacy supporting their use and with the clear societal and personal adverse effects of chronic use of opioids, the prevalence of their use in FM becomes very troubling. Beyond all of these concerns, which are common to the treatment of most chronic nonmalignant pain conditions, the pathophysiology of FM, which is characterized by central pain amplification and the possibly increased risk for opioid-induced hyperalgesia associated with this amplification, makes the use of opioids in this condition ill advised.

From a practical perspective, not starting opioid treatment in FM patients is the preferred approach. Should rescue analgesics be required, tramadol is the agent whose efficacy is best supported by the literature. Even with tramadol, however, dose escalation should be avoided. Often, primary care physicians' prescribing opioids complicates treatment by specialist physicians including rheumatologists. Unfortunately, there are few data to suggest that patients started on approved medications for FM are successful in discontinuing opioids.[44] Educating patients on the potential problem of opioid-induced hyperalgesia, attempting dose reduction, and resisting increases in opioid dose are important steps toward reducing overuse of opioids in FM.