Featured contentOriginal researchGeographic Variation of Chronic Opioid Use in Fibromyalgia
Introduction
Fibromyalgia (FM) is an idiopathic, functional disorder characterized by chronic widespread myalgias and diffuse tenderness.1 Although the etiology of FM remains unclear, it is increasingly evident that disordered central pain processing is the primary source of the syndrome. FM is diagnosed in ∼5% of women2 and 1.6% of men3 (∼6 million patients) in the United States. Patients suffering from FM experience significantly increased health care utilization and costs compared with the general population.4, 5
Treatment of FM typically focuses on management of pain and lack of restorative sleep. Treatment is generally multimodal, consisting of pharmacologic agents, 3 of which are approved by the US Food and Drug Administration specifically for FM, and nonpharmacologic therapies found to be effective in randomized controlled trials such as aerobic exercise, tai chi, and yoga. One of the increasingly common therapy choices for FM pain is opioid analgesics, despite there being little evidence of efficacy supporting their use in FM patients and despite guidelines from professional societies specifically discouraging the use of these agents.6 Chronic opioid therapy for the control of chronic nonmalignant pain of many types has increased tremendously over the past decade.7 Even with the lack of evidence regarding efficacy and the unique pathophysiology of FM patients that make chronic opioid therapy especially troubling,8 the pattern of use in FM has mirrored that of use in other chronic nonmalignant pain conditions.9
The elevated rate of opioid use in FM is troublesome due to the lack of efficacy of these agents and to the myriad societal and individual adverse effects associated with their use.10 These effects include those commonly seen with acute use (constipation, pruritus, respiratory depression, nausea, vomiting, delayed gastric emptying, sexual dysfunction, muscle rigidity and myoclonus, sleep disturbance, pyrexia, diminished psychomotor performance, cognitive impairment, dizziness, and sedation) as well as chronic use (hormonal and immune effects, abuse and addiction, tolerance, and hyperalgesia) of this class of drugs. Opioid-induced hyperalgesia is of particular concern in FM patients because treatment with these medications may not only be inefficacious but also may result in the manifestation of a separate pain condition. Although opioid-induced hyperalgesia can occur in any patient treated with opioids, the dysregulated opioidergic pathways seen in FM patients is cause for increased concern.7
Geographic variation in care patterns is well documented for some disease states and medication classes. Significant differences in utilization rates between geographic regions has been shown in colorectal cancer,11 cardiac care procedures,12 antihypertensive medications,13 and stimulant agents.14 Review of the geographic literature regarding general opioid use finds considerable variation, with state-level factors explaining the majority of the different patterns.15, 16, 17, 18, 19
To the best of our knowledge, no studies have been published to date examining geographic variation in chronic opioid prescribing for patients with FM. The overall goal of the current study was to understand prescribing patterns that may explain the widespread utilization of a treatment choice that is not based on evidence of efficacy and that has the potential for significant harms. This study sought to answer 2 research questions. First, to what extent does geographic variation exist between states for chronic opioid utilization in patients with FM? Based on the literature examining acute opioid use, we expected that geographic variation would exist across states for chronic opioid prescribing for FM patients.15, 16, 20, 21 Second, what association is seen between contextual and structural factors and the rate of chronic opioid use at the state level? We predicted the current study results would generally mirror those of previous work in this area,15, 16, 20, 21 with the proportion of female patients and rate of previous illicit opioid use within a state being positively associated with chronic opioid use, and the presence of a state-level prescription monitoring program (PMP) and the prevalence rate of physicians in a state being negatively associated. In addition, we examined a new factor not previously studied in this literature: the prevalence of FM diagnosis within states.
Section snippets
Study Cohort Definitions
Our research team licensed deidentified patient health claims information for a large commercially insured population for the period January 1, 2007, to December 31, 2009. The dataset is a nationally representative sample of commercially insured patients across the United States and includes 15 million covered individuals. Data are collected at the patient level and linked across administrative and health data, including: administrative data (plan type, sex, age, and eligibility date spans),
Results
The analysis included 245,758 patients with a diagnosis of FM from the 48 contiguous states and Washington, DC. Of these patients, 11.3% received chronic opioid therapy during the study period (Table II). Most patients were female (70%), and the mean age was 44.7 years. Overall, patients received nearly 70 prescriptions per year, and ∼10% of these were for opioid medications. The average eligibility span for patients in the sample was ∼2 of the total 3-year study period. The national prevalence
Discussion
This study accomplished 2 research objectives. The first was to assess the level of geographic variation of chronic opioid use for patients with FM. We examined data within a large commercially insured population, extracting a sample with a diagnosis of FM. Using these data, we found that nearly 1 in 8 patients with FM were receiving chronic opioid therapy. This rate is similar to that seen in other studies of FM.31 Comparisons across states found a 5-fold difference between the most
Conclusions
Chronic opioid therapy for the treatment of FM and other types of chronic nonmalignant musculoskeletal pain is a practice based not on evidence but on other factors that have been heretofore unreported in the literature. The current study reports 1 set of characteristics that results in wide geographic variation in opioid use similar to that previously reported in other pain conditions. This large level of geographic variation suggests that the prescribing decision is based not solely on
Conflicts of Interest
Dr. Crofford serves as consultant for Glenmark Pharmaceuticals Ltd and receives research grant funding from Bioenergy, Inc. Dr. Painter and Dr. Talbert have indicated that they have no conflicts of interest regarding the content of this article.
Acknowledgments
The current project was supported by the National Center for Research Resources (UL1RR033173) and the National Center for Advancing Translational Sciences (UL1TR000117) which supports Dr. Crofford and Dr. Talbert. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Dr. Painter was responsible for the literature search, figure creation, study design, data collection, data interpretation, writing. Dr.
References (36)
- et al.
Understanding fibromyalgia: lessons from the broader pain research community
J Pain
(2009) - et al.
Antihypertensive medication use in the Department of Veterans Affairs: a national analysis of prescribing patterns from 2000 to 2002
Am J Hypertens
(2004) - et al.
Are hospital services rationed in New Haven or over-utilised in Boston?
Lancet
(1987) - et al.
Geographic variation in opioid prescribing in the U.S.
J Pain
(2012) Developments in the scientific and clinical understanding of fibromyalgia
Arthritis Res Ther
(2009)- et al.
Epidemiology of fibromyalgia
Curr Pain Headache Rep
(2003) - et al.
Testing an instrument to screen for fibromyalgia syndrome in general population studies: the London Fibromyalgia Epidemiology Study Screening Questionnaire
J Rheumatol
(1999) - et al.
Characteristics and healthcare costs of patients with fibromyalgia syndrome
Int J Clin Pract
(2007) - et al.
The London Fibromyalgia Epidemiology Study: direct health care costs of fibromyalgia syndrome in London, Canada
J Rheumatol
(1999) - et al.
Management of fibromyalgia syndrome
JAMA
(2004)
Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain
J Pain
Chronic opioid use in fibromyalgia: a clinical review
J Clin Rheumatol
Adverse effects of chronic opioid therapy for chronic musculoskeletal painNature reviews
Rheumatology
Is spending more always wasteful?The appropriateness of care and outcomes among colorectal cancer patients
Health Aff (Millwood)
Impact of underuse, overuse, and discretionary use on geographic variation in the use of coronary angiography after acute myocardial infarction
Med Care
Geographic variation in the prevalence of stimulant medication use among children 5 to 14 years old: results from a commercially insured US sample
Pediatrics
Geographic variation in the prescription of schedule II opioid analgesics among outpatients in the United States
Health Serv Res
Geographic variation in opioid prescribing for acute, work-related, low back pain and associated factors: a multilevel analysis
Am J Ind Med
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The Influence of Opioids on Transcutaneous Electrical Nerve Stimulation Effects in Women With Fibromyalgia
2022, Journal of PainCitation Excerpt :Additional pharmacological strategies for the management of fibromyalgia may include anticonvulsants, antidepressants, alpha-2-delta ligands, anxiolytics/hypnotics, muscle relaxants/antispasmodics, central nervous system stimulants, analgesics, triptans, steroids, and opioids.58 Pain management guidelines23,3619,27 and peer-reviewed publications34,39,43,44,62,68 have mixed recommendations for the use of opioids in individuals with FM with some guidelines specifically recommending Tramadol. While the primary reason for the prescription of opioids is pain relief, side effects and potential negative consequences of opioid use may outweigh potential benefits in long-term pain management.
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2019, International Journal of Drug PolicyCitation Excerpt :Regarding the population demographics, this study found that female gender was associated with higher opioid utilization. This result is similar to a study exploring variation in opioid prescribing and its associated factors among patients with fibromyalgia (Painter et al., 2013). However, this is in contrast to the study conducted by Degenhardt et al. (2016) in Australia which showed that male gender was related to higher opioid utilization (Degenhardt et al., 2016).
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2016, Mayo Clinic ProceedingsCitation Excerpt :Cautioning health care providers about the misuse of opioids in FM may be the best approach to changing current practice habits. The study by Painter et al49 reporting significant geographic variation in opioid prescribing for FM suggests an important role for physician education. This study also found a negative correlation of opioid use with a greater regional International Classification of Diseases FM diagnosis.
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