Opioids: use in rheumatological diseases

Opioids: use in rheumatological diseases

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The use of opioids in acute musculoskeletal pain follows the same principles as for their use in any acute pain for which an identifiable cause has been established.

Opioid analgesics are necessary in the management of chronic pain in rheumatology in some circumstances. A major aim of their use is to relieve pain to an extent that allows increased mobility and participation in normal activities of daily living.

In rheumatology, opioids may be prescribed for pain that is unresponsive to paracetamol, NSAIDs, and disease-modifying drugs—for example, in late rheumatoid arthritis patients with severe joint deformities. There is evidence that the addition of codeine to paracetamol is more effective than paracetamol alone in the treatment of patients with osteoarthritis of the hip. Escalation of therapy may, however, be limited by adverse effects. Various other opioids have been trialled in the rheumatology setting, eg controlled-release oxycodone; however, their use is limited to specific conditions. Commencement of opioids in rheumatology patients should be done as part of an overall pain management strategy, and should involve consultation with the rheumatologist or other pain specialist.

Guidelines for the use of opioids in chronic noncancer pain have been developed.

Key issues to consider are:

• accurate diagnosis, including specialist assessment, of the underlying cause of the pain

• lack of adequate response, or a contraindication, to physical, surgical and other pharmacological treatments

• some assessment of psychological stability of the patient

• informed consent from the patient after discussion about assessment of efficacy and the risks of opioid treatment 

 

• limiting prescriptions and dispensing of opioids to the doctor(s) and pharmacy with whom the patient has frequent and long-term contact

• reassessment after a trial period of 4 to 6 weeks, and tapering and cessation of the drug if adverse effects outweigh the therapeutic benefits, or if treatment goals have not been reached.