Study Demonstrates Reassuring Opioid Prescribing Trends Over Time and During COVID-19 Pandemic for RMDs

Study results published in Rheumatology (Oxford) reveal stabilization of opioid prescribing trends for rheumatic and musculoskeletal diseases (RMDs) over time, with a decrease in prescribing volume during the COVID-19 pandemic.

The opioid epidemic has become a public health crisis over the last 2 decades, with increased prescribing noted for noncancer chronic pain. Rheumatic and musculoskeletal diseases are of particular concern, as they are one of the most common indications for opioid prescriptions.

Investigators assessed opioid use trends from 2006 to 2021, as well as changes in types of opioid prescriptions, with a focus on the effects of the COIVD-19 pandemic on prescribing patterns.

Primary care electronic health records in the United Kingdom (UK) were accessed using the Clinical Practice Research Datalink (CPRD) database. Adult patients with any of the 6 most common RMDs (rheumatoid arthritis [RA], psoriatic arthritis [PsA], axial spondyloarthritis [AxSpA], systemic lupus erythematosus [SLE], osteoarthritis [OA], and fibromyalgia) who were prescribed an opioid within 6 months of RMD diagnosis were included in the study.

Patients reporting a new episode of opioid use within a 2-year time frame were considered new opioid users, while those with existing intermittent or persistent opioid use were considered persistent users.   

A total of 1,313,519 patients were included in the study. The majority of patients were diagnosed with OA (1,255,999 patients), while 66,944 patients were diagnosed with fibromyalgia, 36,932 with RA, 12,649 with PsA, 6811 with AxSpA, and 6423 patients with SLE. 

Among patients with RA, PsA and fibromyalgia, numbers of new opioid users trended upwards during the study period, increasing from 2.6/10,000 persons in 2006 to 4.5/10,000 persons in 2018 among patients with RA, and from 1.0 and 3.4/10,000 persons in 2006 to 1.8 and 8.7/10,000 persons in 2019 among patients with PsA and fibromyalgia, respectively.

A decrease in the number of new opioid users was observed during the remainder of the study period, with rates in August 2021 among patients with RA, PsA, and fibromyalgia to be 2.4, 1.2, and 5.9/10,000 persons, respectively.

The number of prevalent opioid users increased for all RMDs over time, with a plateau/decrease towards the end of the study period.

There was an increase in opioid use among patients with OA from 2006 to 2018, from 2006 to 2019 among patients with RA, AxSpA and SLE, and from 2006 to 2020 among patients with PsA.

Notably, patients with fibromyalgia showed the largest increase in prevalent opioid use, with a 4.5-fold increase from 17.7/10,000 persons in 2006 to 78.5/10,000 persons in 2021.

The investigators noted changes in prescribing patterns over time, with an increase in prescriptions for codeine among new users (~60% to ≥70% of all opioid use) from 2006 to 2021 for all RMDs.

There was a decrease in prescriptions for dihydrocodeine (~20% to ~10%) and tramadol (10-15% to <10%) during this same time period, while new users were prescribed morphine at a higher rate (<1% in 2006 to 3-5% in 2021).

Trends in prescribing patterns were similar among prevalent users throughout the study period. However, a more significant increase in prescriptions for strong opioids was found, with a 3- to 4-fold increase in prescriptions for morphine (2-4% to 9-13%), 2.5- to 5-fold increase for oxycodone (0.7-1.5% to 2.9-4.7%), and a 1.2- to 2-fold increase for buprenorphine (1.7-3.9% to 3.1-4.6%) from 2006 to 2021.

Although the total number of prescriptions among prevalent opioid users remained stable, all RMDs showed an increasing trend in number of morphine milligram equivalents (MME)/day between 2006 and 2021, with 26-27 MME/day to 33-35 MME/day among patients with inflammatory RMDs and SLE, from 23 MME/day to 30 MME/day among patients with OA, and from 29 MME/day to 37 MME/day among patients with fibromyalgia.

During the COVID-19 pandemic, a significant reduction in the average number of new opioid users was found among patients with OA.

The number of prevalent users with RA had the steepest decline during the pandemic, with prepandemic rates declining by -0.001 (95% CI, -0.002 to -0.001) per logarithm of the population to -0.005 (95% CI, -0.008 to -0.002) during the pandemic.

Number of MME/day among patients with fibromyalgia and OA were found to increase before the pandemic, while plateauing among patients with fibromyalgia (-0.065; 95% CI, -0.100 to -0.031), and decreasing among patients with OA (-0.031; 95% CI, -0.051 to -0.012) during the pandemic.

Limitations included the lack of data on opioids obtained in-hospital and over-the-counter, as the study focused on primary care prescriptions. Additionally, registration rates in the CPRD database are different across regions in the UK, potentially reducing generalizability.

The study authors concluded, “Despite the reassuring results of plateauing/decreasing trends for opioid users, our findings flag a warning that opioid prescribing in fibromyalgia and AxSpA may need to monitor closely in the clinical setting.”

Disclosure: One or more of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.