Are opioids used to treat lupus pain?

Opioid Use for Lupus Pain

Opioids are sometimes used for lupus pain in clinical practice, but they should not be considered first-line or routine therapy, as evidence shows lack of efficacy for chronic musculoskeletal and centralized pain conditions common in SLE, combined with significant safety risks. 1

Current Use Patterns in Lupus

• Approximately 31% of patients with systemic lupus erythematosus (SLE) use prescription opioids, compared to only 8% of matched controls without SLE. 2
• Among SLE patients using opioids, 68% use them for more than 1 year, and 22% are on two or more opioid medications concomitantly. 2
• Long-term opioid therapy (LTOT) occurs in 11-13% of SLE patients versus 1-3% of controls. 3

Why Opioids Are Not Recommended for Lupus Pain

Opioids are generally not indicated for long-term management of musculoskeletal pain or centralized pain (fibromyalgia) because of lack of efficacy, safety issues ranging from adverse medical effects to overdose, and risk for addiction. 2

• Evidence is limited or insufficient for improved pain or function with long-term opioid use for chronic pain conditions commonly seen in lupus, including fibromyalgia and chronic musculoskeletal pain. 1
• The CDC guideline explicitly states that opioids should not be considered first-line or routine therapy for chronic pain outside of active cancer, palliative, and end-of-life care. 1
• Expected benefits of initiating opioids for fibromyalgia (common in SLE) are unlikely to outweigh risks regardless of previous therapies used. 1

Specific Risk Factors in Lupus Patients

SLE patients face compounded risks from opioid therapy because the underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies already put them at higher risk for adverse effects attributed to long-term opioid use. 2

• SLE patients with fibromyalgia have 7.78 times higher odds of being on LTOT. 3
• Patients with chronic low back pain have 4.00 times higher odds of LTOT. 3
• Those with mood disorders have 2.76 times higher odds of LTOT. 3
• SLE patients using the emergency department are approximately twice as likely to use prescription opioids. 2

Recommended Approach to Lupus Pain Management

Prioritize disease-modifying therapies and nonopioid pain management strategies:

• Use immune-modulating agents to address underlying SLE disease activity, as disease-specific interventions can reverse or ameliorate pain. 1
• For neuropathic pain components, use tricyclic antidepressants, selected anticonvulsants, or transdermal lidocaine rather than opioids. 1
• For nociceptive pain exacerbations, NSAIDs can be used with appropriate monitoring for cardiovascular, renal, and gastrointestinal risks. 1
• Implement nonpharmacologic approaches such as exercise and cognitive behavioral therapy to reduce pain and improve function. 1

When Opioids Might Be Considered

If opioids are considered despite the above recommendations, they should only be used when:

• Expected benefits for pain and function clearly outweigh risks given patient-specific factors. 1
• The clinical context involves serious illness with poor prognosis for return to previous function, contraindications to other therapies, and agreement that the overriding goal is patient comfort. 1
• They are combined with nonpharmacologic therapy and nonopioid pharmacologic therapy. 1
• Treatment goals are established upfront, including realistic goals for pain and function, with consideration of how opioid therapy will be discontinued if benefits do not outweigh risks. 1

Monitoring Requirements if Opioids Are Used

• Evaluate benefits and harms within 1 to 4 weeks of starting opioid therapy or dose escalation. 1
• Reassess benefits and harms every 3 months or more frequently. 1
• Prescribe the lowest effective dosage and avoid dosages ≥50 morphine milligram equivalents per day when possible. 1
• Avoid concurrent opioids and benzodiazepines. 1

Key Clinical Pitfall

The most common pitfall is initiating opioids for chronic lupus-related musculoskeletal pain or fibromyalgia without recognizing that these pain types have insufficient evidence for opioid efficacy and high potential for harm. 1, 2 Addressing widespread opioid use in SLE requires strategies aimed at preventing opioid initiation and considering nonopioid pain management strategies. 2