Background & Aims

Women during the (post)menopausal period often endure pain symptoms due to fluctuations in hormone levels. These pains commonly occur in the joints and are associated with increased diagnoses of musculoskeletal conditions. Guidelines from the National Institute for Health and Care Excellence (NICE) and agencies in the United States do not recommend opioid treatment to manage pains associated with musculoskeletal conditions (1, 2). Opioids have little to no effectiveness in treating musculoskeletal pains because of de-sensitivity to the medications over time, as well as the known risks associated with extended use (3, 4). However, general population observational studies have shown that these medications are prescribed for such conditions (3, 5, 6). No studies have yet focused on opioid prescribing rates for menopausal and postmenopausal women, despite women reporting higher and more severe levels of joint pain and receiving more musculoskeletal diagnoses, like fibromyalgia, compared to men (7).

Methods

This population-based drug utilization study identified women between the ages of 50 and 79 years with a newly diagnosed musculoskeletal condition who were prescribed opioids between 2010 and 2021 using IMRD-UK/THIN data (n=380,085). Women receiving palliative care were excluded from the cohort. Women entered the study on the date of pain diagnosis between their 50th and 80th birthdays and were censored at the date of death, practice transfer, or last data collection. Opioids (topical and oral formulations) include codeine, co-codamol, co-dydramol, dihydrocodeine, morphine, tramadol, buprenorphine, oxycodone, and fentanyl. Annual prescribing prevalence per 100 women was calculated using mid-year population estimates. Annual incident prescribing rates were calculated by dividing the number of women aged 50-79 with a first opioid prescription after musculoskeletal diagnosis by person-years-at-risk (PYAR). The average annual percentage change was assessed using linear regression.

Results

Annual prescribing prevalence decreased from 2010 to 2021 (23% to 14%). However, the annual incident prescribing rate of opioids remained steady from 2010 to 2021. The yearly incident prescribing rate, stratified by pain indication, showed that the highest number of new opioids were prescribed to women diagnosed with fibromyalgia. The IR of opioid prescriptions for fibromyalgia steadily increased from 2010 (184.4 [95% CI 163.3 to 208.3] per 1000 PYAR) to 2021 (259.6 [95% CI 226.4 to 297.8] per 1000 PYAR). The annual percentage change indicated an increased rate of new opioid prescriptions, 2.8% (95% CI 1.8 to 3.7), for fibromyalgia pain during the study period. Opioid prescriptions for women with polymyalgia rheumatica declined with an annual percentage change of -1.6% (95% CI -2.9 to -0.2), while those with osteoarthritis and rheumatoid arthritis had constant rates of opioid prescriptions (annual percentage change: -0.6% [95% CI -1.6 to 0.4] and -0.3% [95% CI -1.5 to 0.9] respectively) from 2010 to 2021. (Post)menopausal women with osteoporosis received the fewest new opioid prescriptions, maintaining a consistent annual percentage change from 2010 to 2021 (-0.9% [95% CI -1.7 to 0.01]).

Conclusions

(Post)menopausal women, defined by the ages of 50 to 79 years, received the highest number of new opioid prescriptions at an increasing rate if they had a diagnosis of fibromyalgia. Opioids are not indicated as a treatment regimen for fibromyalgia pains (8). Therefore, it is interesting to see that women of menopausal and postmenopausal age are receiving these medications for pain relief. More studies are needed to understand the effects of opioid use in women with musculoskeletal pains, specifically fibromyalgia, to understand the long-term effects associated with medication use.

Menopausal women report high levels of pain in the joints; this is a common complaint associated with midlife. However, the correct treatment for such pains depends on the practitioner seen. Women’s health specialists could prescribe hormone replacement therapy if accompanied by hot flashes, mood swings, and other bothersome symptoms associated with menopause. Pain specialists could prescribe different pain treatment regimens depending on the diagnosed joint condition and severity. These treatments include nonsteroidal anti-inflammatory drugs, bisphosphonates, or supplements. All guidelines for joint pains advise against the use of opioids. But, the results have shown that women are being prescribed opioids at high rates for musculoskeletal pain management, specifically for fibromyalgia pains. There is a need for awareness and reconsideration of prescribing patterns of opioids to women presenting with musculoskeletal pains.

References

  1. Painter JT, Crofford LJ. Chronic Opioid Use in Fibromyalgia Syndrome: A Clinical Review. JCR: Journal of Clinical Rheumatology. 2013;19(2):72-7.
  2. Chronic pain (primary and secondary) in 16s: assessment of all chronic pain and management of chronic primary pain [Internet]. NICE 2024 2021 [cited 02 May, 2024 ]. Available from: https://www.nice.org.uk/guidance/ng193.
  3. Busse JW, Wang L, Kamaleldin M, Craigie S, Riva JJ, Montoya L, et al. Opioids for Chronic Noncancer Pain. JAMA. 2018;320(23):2448.
  4. Dumas EO, Pollack GM. Opioid tolerance development: a pharmacokinetic/pharmacodynamic perspective. Aaps j. 2008;10(4):537-51.
  5. Huang YT, Jenkins DA, Peek N, Dixon WG, Jani M. High frequency of long-term opioid use among patients with rheumatic and musculoskeletal diseases initiating opioids for the first time. Ann Rheum Dis. 2023;82(8):1116-7.
  6. Sean B-T, David G-C, Nigel S. Trends in long-term opioid prescriptions for musculoskeletal conditions in Australian general practice: a national longitudinal study using MedicineInsight, 2012–2018. BMJ Open. 2021;11(4):e045418.
  7. Overstreet DS, Strath LJ, Jordan M, Jordan IA, Hobson JM, Owens MA, et al. A Brief Overview: Sex Differences in Prevalent Chronic Musculoskeletal Conditions. Int J Environ Res Public Health. 2023;20(5).
  8. Rivera J, Molina-Collada J, Martínez-Barrio J, Serrano-Benavente B, Castrejón I, Vallejo MA, Álvaro-Gracia JM. Opioids and fibromyalgia: frequency of use and factors associated with increased consumption in patients remitted to a tertiary care center. BMC Musculoskeletal Disorders. 2024;25(1).
  9. Ruschak I, Montesó-Curto P, Rosselló L, Aguilar Martín C, Sánchez-Montesó L, Toussaint L. Fibromyalgia Syndrome Pain in Men and Women: A Scoping Review. Healthcare (Basel). 2023;11(2).

Presenting Author

Emma Tillyer

Poster Authors

Emma Tillyer

PhD

University College London

Lead Author

Ruth Brauer

PhD

University College London

Lead Author

Yogini Jani

PhD

University College London and University College London Hospitals NHS Foundation Trust

Lead Author

Li Wei

PhD

University College London

Lead Author

Topics

  • Epidemiology