Ankylosing spondylitis is a type of inflammatory arthritis that mainly affects the spine. It typically causes chronic back pain and stiffness, but it can also affect other parts of the body.
The American College of Rheumatology do not recommend that people take opioid pain relievers to treat symptoms of ankylosing spondylitis (AS). Instead, they recommend treating active cases of AS with physical therapy or other medications. These may include nonsteroidal anti-inflammatory drugs (NSAIDs), tumor necrosis factor inhibitors (TNFis), or other disease-modifying antirheumatic drugs (DMARDs).
Opioids offer limited benefits for the treatment of AS while posing serious risks — including the risk that an individual will develop an opioid use disorder.
“Opioid medication has a role for managing short-term pain, for example, in the days after a surgery,” Dr. Eliana Cardozo, an assistant professor of rehabilitation medicine at Icahn School of Medicine at Mount Sinai in New York, told Medical News Today.
“But for more chronic illnesses, taking opiates for pain relief can lead to long-term opiate use, which we know has risks, including dependence, building up a tolerance to the medication, sedation, constipation, and more,” she continued.
Before choosing opioids to treat pain, doctors and people with AS may consider other treatment options. They can also discuss all of the potential benefits and risks of taking opioids.
An article published in the Annals of the Rheumatic Diseases reports how experts from the Assessment of SpondyloArthritis international Society (ASAS) and European League Against Rheumatism (EULAR) found that evidence on the efficacy of taking opioids to treat AS is “lacking.”
Those experts recommend that doctors only prescribe opioid pain relievers for lingering pain after someone has tried other recommended treatments for AS.
This aligns with recommendations from the Centers for Disease Control and Prevention (CDC). In their latest guidelines on opioid prescription, the CDC advise against prescribing opioids as a first-line therapy for chronic pain. They suggest that a doctor should only prescribe opioids right away if a person has active cancer or requires palliative or end-of-life care.
The CDC report that opioids have little short-term benefit and unclear benefits in the long run for treating chronic pain. The organization also warn that opioids carry the risk of severe side effects.
Despite the existence of guidelines that favor other treatments, a research study in The Journal of Rheumatology highlights that doctors prescribe opioids to people with AS with “disturbing frequency.”
That research team assessed 720 people aged 18 years and older from the Truven Health MarketScan Research database. They found that chronic opioid use was particularly high among people with AS who were Medicaid enrollees. Medicaid members were also less likely to be taking TNFis or other DMARDs than people with private insurance.
In another study, researchers aimed to find out more about the factors that contribute to opioid use among people with AS, including what other medications they take. They found that primary care providers or pain clinics were more likely to prescribe the drugs than arthritis specialists.
This suggests that many people with AS who take opioids may not be receiving specialty care for their condition. These people may benefit from receiving other treatments, such as NSAIDs and TNFis.
“Although opiates are not part of the recommended treatment guidelines for [AS], recent studies have shown that many patients are still treated with opiates for this condition in the United States,” Dr. Cardozo told MNT.
“This highlights an area where more education is needed for both patients and healthcare providers,” she added.
Opioids carry significant risks of side effects, some of which are very severe.
Common side effects of opioid use include:
- dry mouth
More serious potential side effects include:
- hormonal changes, including infertility and reduced sexual function
- breathing problems, such as respiratory depression
- heart problems, such as bradycardia
People who take opioid medications for extended periods may develop a tolerance to them. In some cases, they may experience increased pain or pain sensitivity while taking opioids.
People who take opioids may also become physically dependent on them. This can lead to the development of opioid use disorder, or “opioid addiction.” People may experience withdrawal if they stop taking opioids or suddenly reduce their dosage.
Taking too many opioids can also cause a nonfatal or fatal overdose.
Opioid use disorder occurs when a person develops a pattern of opioid use that interferes adversely with their day-to-day life.
A research review published in the journal Pain found that an estimated 8–12% of people who receive opioids for chronic pain develop an opioid use disorder.
People with opioid use disorder typically take opioids in larger doses or for more extended periods than their doctor prescribes. Some people may obtain opioids from family members, friends, or other illegal sources.
Opioid use disorder puts people at heightened risk of severe side effects, including potentially fatal overdose. It can also adversely affect people’s mental health, their relationships, and their ability to fulfill responsibilities at school, work, or home.
Risk factors for opioid use disorder include:
- being young
- taking high doses of opioids
- taking opioids for an extended period
- having a personal or family medical history of substance use disorder
- having an underlying psychiatric condition, such as depression or bipolar disorder
“There’s been multiple studies that have shown that patients tend to underestimate the risk of becoming addicted to these medications,” Dr. Jenna L. Walters, an assistant professor of anesthesiology and pain medicine at Vanderbilt University Medical Center in Nashville, TN, told MNT.
“So, I think asking their doctor specifically if they have risk factors for developing an addiction is important,” she added.
If an individual develops opioid use disorder, the CDC advise that their doctor coordinates evidence-based treatment. In many cases, the treatment for opioid use disorder involves a combination of behavioral therapy and medication.
“Seeing a psychologist or a psychiatrist can be very helpful,” Dr. Walters said.
“There’s also support groups in the community that you can attend for free,” she continued, “and then, depending on how severe the addiction is, sometimes an addiction psychiatrist will choose to treat you with medication as well.”
Opioids slow breathing and heart function. Taking too many can cause a potentially fatal overdose.
The National Institute on Drug Abuse report that in 2017, an estimated 47,600 people in the U.S. died from a drug overdose involving opioids. In more than 17,000 cases, the overdose involved prescription opioids.
A nonfatal overdose can also have severe and potentially disabling consequences. For example, it may lead to:
- nerve damage
- reduced motor skills
- memory loss
- heart complications
- kidney failure
- fluid buildup in the lungs
People who take opioids are at increased risk of overdose if they:
- inject opioids
- take large doses of opioids
- take opioids in combination with other sedatives, such as benzodiazepines or alcohol
- have liver disease, kidney disease, lung disease, or sleep-disordered breathing
- have a psychiatric condition, such as depression
- have a history of substance use disorder
- take the drugs at an older age
The higher the dose of opioids that someone takes, the greater their risk of overdose.
Potential signs and symptoms of opioid overdose include:
- tiny pupils
- reduced consciousness
- slow, shallow breathing
- gurgling or choking sounds
- skin that is pale or cold
A person should contact the emergency medical services right away (i.e., call 911) if they suspect that someone is experiencing an opioid overdose.
While waiting for the emergency medical services to arrive, people may also administer an emergency medication called naloxone (Narcan) if it is available.
Over time, people who take opioids can become physically dependent on them. If they stop taking opioids or suddenly reduce the amount they take, they may experience withdrawal.
Potential symptoms of withdrawal include:
- hot and cold flashes
- trouble sleeping
- muscle pain
- runny nose
- watery eyes
Sometimes, withdrawal symptoms are mild, and a person can tolerate them without treatment.
In severe cases, doctors may recommend treatment with medications, such as codeine phosphate, clonidine (Catapres), buprenorphine (Subutex), or methadone (Dolophine).
Before taking opioids, doctors and people with AS can carefully consider the potential benefits and risks associated with these medications. In many cases, other treatments for AS are likely to provide more benefits with fewer risks.
The recommended treatment for active cases of AS includes physical therapy, NSAIDs, and TNFis or other DMARDs. In some cases, doctors may also recommend local corticosteroid injections or surgery.
If a person does take opioids, their doctor is likely to prescribe the smallest dosage possible to provide relief. They may also avoid prescribing opioids that contain benzodiazepines or other sedatives when possible.
After prescribing opioids, it is a good idea for doctors to monitor the person to check for side effects, opioid use disorder, and misuse of other drugs. If an individual suspects that they might be experiencing side effects or developing an opioid use disorder, they should let their doctor know right away.
“Regular checkins with your doctor are very important so that you can make sure that you’re using the medication appropriately, you’re not having side effects, and you aren’t showing signs that you could be developing an addiction,” Dr. Walters said.
“It’s really important that if you and your doctor decide that this is the right treatment for you, that you watch out for signs that you could be developing an addiction so that you can get treatment early,” she added.