by European League Against Rheumatism

Credit: CC0 Public Domain

Fentanyl, tramadol or tilidine: New European figures show that even in Europe increasingly more people are taking opioids for pain connected with rheumatic and musculoskeletal diseases. Current analysis from Catalonia, Spain convincingly shows that the consumption of opioids in patients with osteoarthritis (OA/arthrosis) in 2007 to 2016 increased from 15 to 25 percent in all patients recorded. The survey is based on the health data (SIDIAP, System for the Development of Research in Primary Care) of 80 percent of the population of the Spanish autonomous region which is roughly six million patients. The European League Against Rheumatism (EULAR) is indicating in the course of its annual European E-Congress of Rheumatology 2020 the growing risk of opioid abuse in Europe and calls for measures to use these analgesics more safely. EULAR 2020 takes place from 3 June 2020 as an online congress due to the Covid-19 pandemic.

Opioids are strong analgesics. Around 70 percent of opioids are prescribed in Germany for patients with chronic non-tumour associated pains. According to guidelines, they can, inter alia, be used for chronic osteoarthritis (arthrosis) pains for a four- to twelve-week course of therapy. "There is an adequate, scientific evidence basis for effectiveness and safety for this indication", says Professor Ulf Müller-Ladner, EULAR Past Chair of Standing Committee on Clinical Affairs and Medical Director of the Rheumatology and Clinical Immunology Department of the Kerckhoff Clinic in Bad Nauheim, Germany. Then, however, they should stop being taken, as these pain relievers have strong side effects: Nausea, vomiting, chronic constipation, but also dizziness and fatigue. However, the greatest risk with them is their effects on the central nervous system, which are sometimes mood-enhancing and sometimes levelling effects. "This accounts for their strong addiction potential: For most patients, the physical withdrawal is therefore the most difficult", according to Müller-Ladner, former President of the German Rheumatology Society (DGRh).

Women (four percent more affected than men), the elderly (ten percent more than young people) and socially disadvantaged individuals (six percent more affected compared to the most privileged groups of the population) have a particular risk for addiction/dependency on opioids in the Catalonia study. Similarly, one percent more rural residents take opioids compared to urban residents. Junqing Xie from the University of Oxford, and lead author of the study says: "Taking opioids, in particular strong opioids, has substantially increased in recent years in patients newly suffering from osteoarthritis". Precautions must urgently be taken so that these medications are prescribed safely. This applies in particular for older women who live under difficult social conditions.

Furthermore, a current study from Iceland shows that the taking of opioids is frequently not discontinued even after the source of pain has gone, but rather their consumption actually increases. Therefore, in patients with inflammatory joint diseases, the dose of their opioids actually increases, instead of them being discontinued, even after treatment with precise, effective anti-inflammatory agents such as TNF inhibitors. "It is a matter of urgency", says EULAR President Professor Iain B. McInnes from Glasgow, Scotland, UK. Opioid addiction has now become a significant problem there.

The risk of physical and psychological addiction development is, however, low when opioids are used as intended. "Therefore, we would like to raise awareness of a responsible approach both by the prescribers and also the patients", says Professor John Isaacs from the University of Newcastle, UK, who is currently the EULAR Scientific Committee Chair. "In order to alleviate chronic pain, medications should in any case only be part of a comprehensive therapy programme, in which doctors, psychologists and physiotherapists work together". If doctors prescribe opioids in exceptional situations, the therapy trial should swiftly end if it proves ineffective or the effect diminishes.

More information: Temporal trends of opioid use among incident osteoarthritis patients in Catalonia, 2007-2016: a population-based cohort study, Xie et al., DOI: 10.1136/annrheumdis-2020-eular.3070

Initiating TNF inhibitors in inflammatory arthritis does not decrease the average opioid analgesic consumption. Olafur Palsson et al. DOI: 10.1136/annrheumdis-2020-eular.2587

Provided by European League Against Rheumatism