The opioid pendulum: risks and benefits are a balancing act, reports Dr Meghna Jani
Musculoskeletal conditions are one of the most common reasons for prescribing opioid drugs such as codeine, tramadol, oxycodone and morphine. Whether it is knee pain, back pain, rheumatoid arthritis or fibromyalgia, it is likely that most of us know someone who has been on these pain medications.
Opioids are a broad group of drugs that act on areas of the brain and spinal cord to interfere with the transmission of pain signals. But what makes them effective for treating pain, at higher doses can also make them dangerous.
Opioid use and its related harmful effects have reached epidemic proportions in the US and Canada, with rising trends in the UK and other countries. However, there are limited options for pain relief and these drugs can be effective in the short-term.
Considered to be some of the strongest pain medicines available, opioids are used to treat pain after surgery, severe injury and cancer. Therefore, depriving everyone of opioids is not a solution. Balancing the benefit and harms and making informed decisions based on the scientific evidence is crucial, but how do we do this?
Current challenges
The opioid epidemic in North America has been one of the most high-profile public scandals of the 21st century. Millions of people were prescribed potent opioids without being informed of their short- and long-term risks.
The cultural and prescribing context in the UK is different, and people tend to be prescribed less potent opioids in the first instance. However, hospital admissions due to opioid-related harms, have still doubled over a decade.
Using anonymised electronic health records from around two million people in the UK, our work at The University of Manchester found that prescribing in the UK for non-cancer pain increased between 2006 and 2017. During that period there was a five-fold increase in codeine prescriptions, a seven-fold increase in tramadol prescriptions, and a 30-fold increase in oxycodone prescriptions for non-cancer pain.
People with musculoskeletal conditions are particularly vulnerable to opioid-related harm due to factors including older age, being on drugs that suppress the immune system and medication for other pre-existing health-conditions. Drug-interactions (when there is a reaction between two or more medicines leading to potentially more severe side effects) may be more common.
National bodies such as the National Institute for Health and Care Excellence (NICE), who publish guidance on the use of medicines, suggest opioids can be used infrequently for short-term pain relief in osteoarthritis. But they are no longer recommended for conditions such as fibromyalgia, as they were shown to be ineffective.
Long-term use
Given limited options for pain relief, it may be appropriate to take opioids in the short-term. But some people go on to use them long-term for a variety of reasons.
Long-term opioid use may be effective for some but can be associated with poor health outcomes including constipation, problems with concentration and cognition, increased risk of falls and fractures, and issues with breathing which can be life-threatening. There are emerging side effects to these drugs such as increased risk of infection, particularly concerning in people with musculoskeletal conditions who already have a lowered immune system. However, it is not currently possible to predict who may develop these side effects before they get their prescription.
At The University of Manchester, some of our recent work shows that in the UK, in patients with fibromyalgia and rheumatoid arthritis newly starting on an opioid, up to one in three people transition to long-term use. For conditions such as axial spondyloarthritis (an inflammatory arthritis that mainly affects the back), this was up to one in 3.5 to four people.
This means people with musculoskeletal conditions who are starting an opioid would greatly benefit from regular medication reviews in the community, proactive interventions to reduce pain without medications and early support to help manage pain.
The future
Opportunities such as new data sources, advances in methods and novel technology can allow important questions to be addressed that were not possible previously. At The University of Manchester, Centre for Epidemiology Versus Arthritis, we are working on understanding how best to optimise these medicines. It includes:
- Identify risk-factors and groups of patients where harms outweigh benefits;
- Understand what prescribing factors (ie dose, type and patterns of use) lead to side effects important to patients;
- Develop better understanding of the association of opioids and emerging side effects such as risk of infection and effect on cognition;
- Predict individual risk of opioid-related harms, to help answer the question “what is my personalised risk of developing these serious side effects?”;
- Learn more about the benefits and harms of these drugs directly from patients by using digital data from smartphones;
- Implement research findings in real-time in clinical settings, before a patient receives their first opioid prescription to promote safe prescribing.
The aim is that people, along with healthcare professionals, can make more informed shared decisions to decide if these drugs are right for them.
First published July 2023
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Dr Meghna Jani is an NIHR Clinician Scientist and Senior Lecturer at The Centre for Epidemiology Versus Arthritis, University of Manchester; the Capacity Building and Training Lead for the Rheumatic and Musculoskeletal Diseases Theme of the NIHR Manchester Biomedical Research Centre and Honorary Consultant Rheumatologist at Salford Royal Hospital.
