Opioids for the management of musculoskeletal pain

Currow, 2016Dowell, 2016Frieden, 2016Karanges, 2016Pilgrim, 2015Ray, 2016Schug SA, 2019Wiese, 2016

Opioids, including tramadol and tapentadol, are often used to treat musculoskeletal pain because of concerns about paracetamol efficacy and nonsteroidal anti-inflammatory drug (NSAID) adverse effects. However, opioids have a very limited role in the management of acute and chronic musculoskeletal pain because of modest benefits and a significant risk of harms. Harms of opioids include tolerance, dependence, inadvertent (potentially fatal) overdose, cognitive effects, falls, constipation, endocrinopathy, cardiovascular effects, fractures, dry mouth, anorexia, urinary retention and overflow incontinence, and pruritus. Opioids have also been associated with an increased risk of hospitalisation for serious infection in patients with rheumatoid arthritis, and a significantly increased risk of all-cause mortality in patients with chronic nonmalignant pain. Short-term adverse effects of opioids are summarised in Adverse effects with short-term use of opioids and long-term adverse effects of opioids are summarised in Adverse effects with long-term use of opioids.

Notwithstanding their modest benefits and significant risk of harms, opioids may be considered for severe musculoskeletal pain that is not relieved by other treatment (eg nonpharmacological interventions, paracetamol, NSAIDs, immunomodulatory drugs and analgesic adjuvants).

If musculoskeletal pain is severe enough to warrant opioids, this should flag that specialist referral may be appropriate. If opioids are used, they should be prescribed on a short-term trial basis as part of an overall pain management strategy, with clear goals and regular review of treatment response and adverse effects; see Parameters of an analgesic trial for chronic noncancer pain. Before starting an opioid, a plan for stopping ineffective therapy should be in place and discussed with the patient. If treatment response is inadequate, exercise caution before increasing the dose as there may be no added benefit and an increased risk of harms. For information on the harms associated with opioid use, see Opioid-related harms.

Prolonged use of opioids for severe persisting musculoskeletal pain should only be undertaken in consultation with a specialist to ensure that all alternative options have been explored and optimised. Most placebo-controlled trials of opioids in chronic pain have assessed only short-term effects, so evidence for long-term benefit is lacking. In patients with chronic pain, opioids may worsen pain and function, possibly by potentiating pain perception (see Neuroadaptive and physiological changes associated with opioid use)da Costa, 2014Krebs, 2018.

For patients already taking opioids, regular clinical review of the benefits and harms are recommended together with attempts at dose reduction and stopping therapy if possible.

For further discussion on the use of opioids for pain, see Opioids in pain management.