Opioid-sparing Pain Management Strategies for Fibromyalgia

NICHOLAS PIARULLI, BS DAVID S. STOLZENBERG, D.O.

SUMMARY POINTS

• Fibromyalgia is a chronic pain disorder that is poorly understood.

• Opioids are not recommended for these patients but have been prescribed.

• While there is no cure for fibromyalgia, various treatment modalities exist for symptom management and relief.

• Research on many potential treatments has often been conflicting or lacking in quantity or quality.

ANALYSIS

Background

Fibromyalgia is a chronic pain disorder with a poorly understood pathophysiology (1). Women are more likely to receive a diagnosis than men, however, the exact skew is currently being disputed (2). Fibromyalgia is often preceded by a medical or traumatic event that leads to gradually accumulated pain symptoms. While the exact mechanism is yet to be understood, the currently accepted theory is that pain is amplified globally via modulations in the central nervous system (1).

Fibromyalgia cannot be diagnosed with any physiological testing. Rheumatologists have historically diagnosed this condition by assessing for pain across 18 anatomic tender points (3). However, more current data found this test to be unreliable. Additionally, with the added knowledge that fibromyalgia symptoms extend into mood, sleep, digestive, and cognitive dysfunction, an expanded diagnostic protocol was required. As a result, this anatomic tender point test has since been replaced with various pain, symptom, and quality-of-life measures (3).

Multiple treatment modalities exist for fibromyalgia, as there is no one treatment or cure for this disease. Opioids, however, are not generally recommended for chronic pain and specifically not for pain caused by fibromyalgia (4). Despite this, patients with fibromyalgia have been given opioids with the hopes of managing severe pain (3). Due to opioids’ potentially serious adverse effects such as addiction and overdose, non-opioid treatments are a priority for current and future fibromyalgia care.

Figure 1: Anatomic map of tender points historically used for fibromyalgia diagnosis. SEE ARTICLE from Mayo Clinic (1)

Findings

One widely explored category of methods for managing fibromyalgia symptoms is the use of physical therapy (5). Results vary by therapy modality. Aerobic exercise has been found to improve quality of life functions, however, there is a lesser improvement in pain (5). The efficacy of strength and flexibility exercises on pain relief has also been explored. While studies did find a moderate improvement in pain, the studies were lacking both in quantity and in methodological quality (5). Aquatic therapy is recommended for individuals suffering from more severe joint pain where high-impact land exercises can worsen symptoms (5). While massage therapy has mixed results, myofascial therapy specifically has been shown to improve pain and mood symptoms in patients with fibromyalgia (5). More studies are needed to further analyze the effects of physical therapy techniques on fibromyalgia-related pain. However, the quality-of-life improvements provided by these modalities, along with a lack of significant side effects, make physical therapy an important nonpharmacological treatment option.

Currently, pharmacologic interventions do not provide a cure for fibromyalgia. This is likely due to an incomplete understanding of its pathophysiology. Despite this gap in knowledge, there are pharmacologic interventions that have crossover effects that treat fibromyalgia symptoms. Tricyclic antidepressants, such as amitriptyline, help improve pain and sleep. Cyclobenzaprine, a muscle relaxant with strong tricyclic properties, has similar effects (3). Additionally, gabapentinoids, such as pregabalin and gabapentin, also improve similar symptoms (3). Serotonin-norepinephrine reuptake inhibitors, such as duloxetine, can improve symptoms of depression along with pain (6). When compared to opioids, these interventions have comparatively safer side effects, however, their potential side effects are still numerous. Dizziness, dry mouth, constipation, diarrhea, nausea, somnolence, headaches, and issues with cognition can all result from administering these medications (3). Less potent yet less efficacious medications may be administered if patients have more controlled pain symptoms, such as acetaminophen and nonsteroidal anti-inflammatory medications (3). Topical medications, such as lidocaine patches, may be applied for more localized pain (3).

Cannabis and cannabinoids are under consideration for many pain conditions. Preliminary research on cannabis suggests that these compounds can help control chronic pain safely and effectively. This is in stark comparison to opioids which are considered effective only in small-dose treatment for acute severe pain (7,8). However, the efficacy of cannabis in treating fibromyalgia patients is currently unknown. The studies performed thus far are limited in quantity, are of poorer quality, and have mixed conclusions (8). Additionally, research challenges remain due to the legal classification of cannabis in the United States. More studies are needed to confirm whether cannabis can become a standard of care for fibromyalgia patients.

Alternative treatments have been found to have short-term efficacy for treating fibromyalgia pain in select cases. There is mixed evidence to say that acupuncture can aid in the treatment of short-term pain (9). Preliminary data also suggest cognitive behavioral therapy as a potential method to cope with pain, however not enough high-quality data has been gathered to make a definitive claim (10). Some nonspecific suggestions for fibromyalgia patients include maintaining a healthy diet/lifestyle, maintaining a regular sleep schedule, and managing stress effectively (1). Resources encouraged for patients include occupational therapy and psychological counseling to deal with any cognitive/mood symptoms (1).

Discussion

Many more research studies are needed for the development of more efficacious treatments for fibromyalgia. Curative treatment for fibromyalgia is unlikely to be established without a greater understanding of its pathophysiology. Therefore, the highest priority studies would be those that elucidate a more comprehensive neurobiological framework for fibromyalgia. This would allow for a more focused pharmacological and therapeutic treatment target in future studies. Additionally, research on cannabis use for fibromyalgia pain relief should also be prioritized. Success in these studies would mean that many fibromyalgia patients have an available treatment modality for managing their chronic pain symptoms until a curative treatment is discovered. Equal research efforts should be given to managing non-pain symptoms, such as cognitive difficulties, mood disturbances, insomnia, and migraines. Opioids should be avoided whenever possible due to their poor long-term efficacy and addictive potential. Patients should instead be prescribed treatments that improve symptoms and do not typically cause severe adverse reactions, such as physical therapy and non-opioid analgesics.

References

1. Fibromyalgia. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/fibromyalgia/diagnosis-treatment/drc-20354785. Published October 7, 2020. Accessed June 25, 2021.

2. Wolfe F, Walitt B, Perrot S, Rasker JJ, Häuser W. Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias. PLoS One. 2018;13(9):e0203755. Published September 13, 2018. doi:10.1371/journal.pone.0203755. Accessed June 25, 2021.

3. Bair MJ, Krebs EE. Fibromyalgia. Annals of Internal Medicine. 2020;172(5). doi:10.7326/aitc202003030. Accessed June 25, 2021.

4. Volkow N, Benveniste H, McLellan AT. Use and misuse of opioids in chronic pain. Annual Review of Medicine. 2018;69(1):451-465. doi:10.1146/annurev-med-011817-044739. Accessed June 25, 2021.

5. Araújo FM, DeSantana JM. Physical therapy modalities for treating fibromyalgia. F1000Research. 2019;8:2030. doi:10.12688/f1000research.17176.1. Accessed June 25, 2021.

6. Lunn MPT, Hughes RAC, Wiffen PJ. Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia. Cochrane Database of Systematic Reviews. 2014. doi:10.1002/14651858.cd007115.pub3. Accessed June 25, 2021.

7. Jensen B, Chen J, Furnish T, Wallace M. Medical Marijuana and Chronic Pain: a Review of Basic Science and Clinical Evidence. Curr Pain Headache Rep. 2015;19(10):50. doi:10.1007/s11916-015-0524-x. Accessed June 25, 2021.

8. Berger AA, Keefe J, Winnick A, et al. Cannabis and cannabidiol (CBD) for the treatment of fibromyalgia. Best Practice & Research Clinical Anaesthesiology. 2020;34(3):617-631. doi:10.1016/j.bpa.2020.08.010. Accessed June 25, 2021.

9. Zhang X, Chen H, Xu W, Song Y, Gu Y, Ni G. Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. J Pain Res. 2019;12:527-542. https://doi.org/10.2147/JPR.S186227. Accessed June 25, 2021.

10. Shipman L. CBT reduces pain-associated fmri signals. Nature Reviews Rheumatology.2016;12(10):560-560. doi:10.1038/nrrheum.2016.155. Accessed June 25, 2021.