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Opioid Use Common for Pain in Multiple Sclerosis

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With chronic pain common among people with multiple sclerosis (MS), approximately 20% of patients report opioid use ― despite warnings that the drugs are generally not recommended for the management of chronic pain and ongoing concerns of addiction, new research shows.

“This high level of opioid use supports that better pain management treatment options, including non-pharmacological options, are needed for people with multiple sclerosis and pain,” write the authors of the study, presented at the virtual Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) 2021.

Previous research has shown that more than 50% of people with MS report chronic pain that is serious enough to interfere with daily activities, employment, and quality of life. Many with MS report that pain is one of their worst symptoms, the authors note.

With surprisingly few studies evaluating opioid use in the MS population, Cinda L. Hugos, PT, an associate professor of neurology with the VA Portland Health Care System and the Department of Neurology, Oregon Health and Science University, Portland, Oregon, and colleagues investigated the issue in a sample of patients participating in a US multisite MS fatigue management trial conducted between 2013 and 2014.

Of the 281 participants with MS in the study, 58 patients (20.6%) reported using prescription opioids.

Among them, most ― 44 (76%) ― reported regular daily use, 10 (17%) reported using the drugs only as needed, three (5%) reported only short-term use, including after recent injury or dental surgery, and one provided incomplete information.

Those who reported opioid use had significantly worse fatigue scores on the Modified Fatigue Impact Scale (P = .015) and worse pain scores (P < .0001).

There were no significant differences in terms of age (mean age, 53 years), gender (69% female), or race (in both groups, about 76% were White).

No significant differences were seen in disability or depression scores in the opioid users vs nonusers.

“In this sample of people with multiple sclerosis who self-reported fatigue and volunteered to join a MS fatigue management research study, more than one in five reported using prescription opioids and nearly one in six used opioids daily,” the authors write. “Opioid users had more pain and fatigue than non-users.”

In commenting on the study for Medscape Medical News, Jeffrey Cohen, MD, president of ACTRIMS, said that the findings are consistent with his observations that “in the general population, opioids often are used to treat chronic pain in people with MS.”

But they’re not getting the drugs from his clinic. “We do not prescribe opioids in our clinic, referring such patients to a chronic pain program,” Cohen said. “However, there clearly is need for better treatment options.”

A previous study on opioid use by people with MS, published in 2015, found even higher rates ― 42% reported having ever used opioids, and 38% reported currently using opioids.

Although reports of opioid use by patients with MS have been lacking, more has been published on the emerging use of cannabis-related products. One recent study showed that nearly half of people with MS reported using a cannabis-based therapy for nerve-based pain and sleep disturbances.

Although cannabis is considered safer than opioids, the authors note that it has its own significant drawback ― a “paucity of provider guidance.”

“The range of perceived benefits and potential differential effects of THC and cannabinoid highlight the need for personalized, evidence-based guidelines regarding cannabinoid use,” they write.

Stretching Program for Spasticity Shows Benefits

With spasticity representing a key contributor to MS pain and affecting more than 80% of people with MS, Hugos and her colleagues are developing an alternative to medication ― a nonpharmacologic stretching regimen called Spasticity: Take Control” (STC).

Based on evidence-based strategies for the treatment of spasticity in MS, the program involves exercises with daily routines of 15 to 20 minutes over 6 months.

In a pilot study of 66 patients, also presented at the ACTRIMS meeting, the investigators report that the program showed significant reductions in pain severity and interference, measured with the Brief Pain Inventory – Short Form, compared with a control consisting of range of motion instruction over 6 months.

The study also offered important insights on the specific areas of pain. Among those who reported chronic pain (42% in the STC group and 63.3% in the range-of-motion group), the pain was most frequently reported in the lower back (74.3%), legs (68.6%), or lower back and legs (88.6%).

Hugos noted that the findings suggest a potentially important nonpharmacologic alternative to spasticity-related pain in MS.

“Stretching is the cornerstone treatment for spasticity from all causes, but there is very little information on stretching exercises in MS or any other conditions,” Hugos told Medscape Medical News.

“[Our] pilot study is the first and only study using a standardized, daily stretching exercise program to treat MS spasticity,” she said.

“A fully powered study is needed to better understand the impact of different types of exercise on pain severity and interference in multiple sclerosis,” she noted.

Hugos has received consulting fees from Greenwich Biosciences, Evidera, and Techspert.io. Cohen has received personal compensation for consulting for Adamas, Atara, Bristol-Myers Squibb, Convelo, MedDay, and Mylan.

Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) 2021: Abstracts P221, P222. Presented February 25, 2021.

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