Pain Medications Used by Persons Living With Fibromyalgia: A Comparison Between the Profile of a Quebec Sample and Clinical Practice Guidelines

Figures & data

Table 1. Sample characteristics.

Variables	Mean ± SD
Age (years)	53.7 ± 10.7
Range	28–76
Median (IQR)	53 (14)
Duration of pain (years)	19.4 ± 12.9
Range	3–64
Median (IQR)	15 (15)
	n (%)
Sex at birth^a,b
Women	60 (96.8)
Men	2 (3.2)
Education level
No high school diploma	2 (3.2)
High school diploma	13 (20.6)
Certificate or professional diploma	8 (12.7)
College education	18 (28.6)
University education	22 (34.9)
Employment status
Temporary or permanent disability related to pain	22 (34.9)
Disability for a reason unrelated to pain	3 (4.8)
Work full-time	12 (19.0)
Work part-time	5 (7.9)
Retired	15 (23.8)
Other	6 (9.6)
Self-perceived general health
Excellent	0
Very good	6 (9.5)
Good	24 (38.1)
Fair	26 (41.3)
Poor	7 (11.1)
Pain diagnoses other than fibromyalgia
Yes^c	28 (44.4)
No	35 (55.6)
Access to a pain clinic^b
Yes	11 (17.7)
No	51 (82.3)
Number of pain medications
1	2 (3.2)
2	3 (4.8)
3	5 (7.9)
4	9 (14.3)
5 or more	44 (52.4)
10 or more	6 (9.6)
Using physical or psychosocial treatments^b
Yes	55 (88.7)
No	7 (11.1)

^aNo participants reported a gender identity different from sex at birth (female or male).

^bMissing n = 1.

^cIncluding conditions such as arthrosis, arthritis, cervical hernia, headaches.

IQR = interquartile range.

Table 2. Medications used and perceived risk for people with fibromyalgia.

	Pain medication use, n (%)	Stratification of pain medication use (subgroups), n (%)			Perceived risk (0–10)
Medication subclass	Total sample (n = 63)	Fibromyalgia (n = 35)	Fibromyalgia and other diagnoses (n = 28)	P value (comparison between subgroups)	Median (IQR)
NSAIDs—Selective cyclooxygenase 2 inhibitors; e.g., celecoxib (Celebrex)	13 (20.6)	7 (20.0)	6 (21.4)	0.889	5.0 (6.5)
NSAIDs—Salicylates; e.g., acetylsalicylic acid (aspirin)	1 (1.6)	0	1 (1.6)	—	—
Other oral NSAIDs; e.g., ibuprofen (Advil, Motrin), naproxen (Naprosyn), diclofenac, ketoprofen, meloxicam, piroxicam	24 (38.1)	15 (42.9)	9 (32.1)	0.384	3.0 (7.0)
NSAIDs—Topical agents; e.g., diclofenac sodium (Pennsaid), diclofenac diethylamine (Voltaren Emulgel)	16 (25.4)	9 (25.7)	7 (25.0)	0.948	0 (0)
Various topical agents; e.g., various compounding preparations, ketamine cream, benzocaine, lidocaine (Emla), capsaicin (Zostrix), Antiphlogistine, Myoflex, Tiger Balm	16 (25.4)	7 (20.0)	9 (32.1)	0.271	0 (0)
Acetaminophen; e.g., Tylenol	46 (73.0)	30 (85.7)	16 (57.1)	0.011	0 (1.0)
Acetaminophen in combination with an opioid; e.g., acetaminophen with codeine (Triatec30, Empracet), with tramadol (Tramacet), or with oxycodone (Percocet)	10 (15.9)	6 (17.1)	4 (14.3)	0.758	5.0 (7.25)
Short-acting opioids; e.g., codeine, fentanyl, hydromorphone, morphine, oxycodone	15 (23.8)	7 (20.0)	8 (28.6)	0.427	4.0 (8.0)
Long-acting opioids; e.g., methadone, extended-release formulations (Codeine Contin, OxyContin, Hydromorph Contin, Jurnista, MS Contin, Duragesic)	5 (7.9)	1 (2.9)	4 (14.3)	0.162	2.0 (6.0)
Opioids associated with norepinephrine reuptake inhibition; e.g., tramadol, tapentadol	15 (23.8)	7 (20.0)	8 (28.6)	0.427	2.0 (7.0)
Partial opioid receptor agonists; e.g., buprenorphine (Butrans), butorphanol	3 (4.8)	1 (2.9)	2 (7.1)	0.580	7.0 (NA)
Opioids in combination with an opioid receptor antagonist; e.g., buprenorphine/naloxone (Suboxone), oxycodone/naloxone (Targin)	2 (3.2)	0	2 (7.1)	—	5.0 (NA)
Anticonvulsants—Calcium channel blockers (gabapentinoids); e.g., pregabalin (Lyrica), gabapentin gabapentin (Neurontin)	23 (36.5)	13 (37.1)	10 (35.7)	0.907	4.0 (8.0)
Anticonvulsants—Sodium channel blockers; e.g., oxycarbazepine, lamotrigine (Lamictal), phenytoin (Dilantin), carbamazepine (Tegretol)	0	0	0	—	—
Anticonvulsants—Other; e.g., levetiracetam (Keppra), topiramate (Topamax)	4 (6.3)	2 (5.7)	2 (7.1)	0.817	7.0 (7.5)
Antidepressants—SNRIs; e.g., duloxetine (Cymbalta), venlafaxine (Effexor XR)	35 (55.6)	23 (65.7)	12 (42.9)	0.070	3.0 (7.0)
Antidepressants—Selective serotonin reuptake inhibitors; e.g., citalopram (Celexa), escitalopram, fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)	7 (11.1)	4 (11.4)	3 (10.7)	0.929	0 (5.0)
Antidepressants—Serotonin reuptake inhibitors and 5HT2 receptor antagonists; e.g., trazodone	10 (15.9)	4 (11.4)	6 (21.4)	0.318	3.5 (7.25)
Antidepressants—Specific noradrenergic and serotonergic; e.g., mirtazapine (Remeron)	1 (1.6)	0	1 (3.6)	—	—
Antidepressants—Tricyclic; e.g., amitriptyline (Elavil), nortriptyline (Aventyl), desipramine	14 (22.2)	8 (22.9)	6 (21.4)	0.892	0 (5.25)
Antidepressants—Miscellaneous; e.g., bupropion (Wellbutrin)	8 (12.7)	6 (17.1)	2 (7.1)	0.282	0.5 (2.5)
Antipsychotics; e.g., aripiprazole, chlorpromazine, clozapine, haloperidol, olanzapine (Zyprexa), quetiapine (Seroquel)	10 (15.9)	5 (14.3)	5 (17.9)	0.700	1.5 (8.0)
Barbiturates; e.g., phenobarbital, primidone	0	0	0	—	—
Benzodiazepines; e.g., lobazam, clonazepam (Rivotril), alprazolam (Xanax), bromazepam, chlordiazepoxide, diazepam (Valium), flurazepam, lorazepam (Ativan), midazolam, oxazepam	17 (27.0)	7 (20.0)	10 (35.7)	0.163	0 (5.0)
Various anxiolytics, sedatives, and hypnotics; e.g., buspirone, hydroxyzine (Atarax), promethazine, zopiclone, zolpidem tartrate	5 (7.9)	1 (2.9)	4 (14.3)	0.162	0 (6.5)
Centrally acting skeletal muscle relaxants; e.g., cyclobenzaprine (Flexeril), methocarbamol (Robax)	16 (25.4)	8 (22.9)	8 (28.6)	0.605	5.0 (2.75)
GABA (Gamma-Aminobutyric Acid)-derivative skeletal muscle relaxants; e.g., baclofen (Lioresal)	0	0	0	—	—
Miscellaneous muscle relaxants; e.g., orphenadrine (Norflex)	0	0	0	—	—
Synthetic cannabinoid (by prescription); e.g., nabilone (Cesamet)	11 (17.5)	7 (20.0)	4 (14.3)	0.553	5.0 (6.0)
Medical/therapeutic cannabis; e.g., vaporized, vaped, oral, oromucosal, topical	22 (34.9)	15 (42.9)	7 (25.0)	0.140	3.0 (7.0)
Antimigraine agents—5HT-1 receptor agonists (triptans); e.g., sumatriptan (Imitrex)	11 (17.5)	5 (14.3)	6 (21.4)	0.458	1.0 (5.0)
Antimigraine agents—Calcitonin gene–related peptide antagonists; e.g., erenumab (Aimovig)	0	0	0	—	—
Antimigraine agents—Miscellaneous; e.g., pizotifen (Sandomigran)	1 (1.6)	0	1 (3.6)	—	—
Corticosteroids—Oral; e.g., prednisone, prednisolone	1 (1.6)	0	1 (3.6)	—	—
Clonidine (antihypertensive)	2 (3.2)	0	2 (7.1)	—	7.5 (NA)
Mexiletine (anti-arrhythmic)	0	0	0	—	—

NA = not enough data to generate an IQR.

IQR = interquartile range.

The cells with dashes designate drug subclasses for which no p-value could be calculated because they were used by 0% of the study participants.

Table 3. Comparisons with guideline recommendations.

	Proportion of users in our study	Quebec Ministry of Health “Algorithm for the Management of Fibromyalgia”^Citation2	“Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome”^Citation8	AHRQ—Systematic review^Citation25,Citation32	Evidence-based recommendations
Medication subclass	n (%)	—	—	—	—
Antidepressants—Tricyclic	14 (22.2)	Strongly recommended	Recommended	Amitriptyline has no clear effect	Cochrane systematic review^Citation42: amitriptyline recommended but diminished pain only for a minority of patients
Antidepressants—SNRIs	35 (55.6)	Recommended	Recommended	Duloxetine and milnacipran are recommended (effect on pain quality of life). There is limited evidence on mid-term effects	Cochrane systematic review^Citation34: duloxetine is recommended; dose of 60 or 120 mg per day (18 studies)
Antidepressants—Selective serotonin reuptake inhibitors	7 (11.1)	Recommended (sertraline, paroxetine, and fluoxetine) if intolerant to SNRI antidepressants	Recommended	—	Cochrane systematic review^Citation41: no statistical or clinal improvement in pain, fatigue, and sleep. Effective for depression in this population
Anticonvulsants—Calcium channel blockers (gabapentinoids)	23 (36.5)	Recommended	Recommended starting with a low dose and then increasing (effect on pain, sleep, general condition)	Small improvement in short-term pain. Pregabalin associated with improved pain, pain response, and sleep interference (not anxiety or depression). Gabapentin has a positive effect on pain but not on quality of life	Cochrane systematic review^Citation33: pregabalin is safe and effective. Not enough evidence for gabapentin. For other anticonvulsants: not enough evidence for lacosamide and levetiracetam
Anticonvulsants—Sodium channel blockers	0 (0)	—	—	—	Cochrane systematic review^Citation38: lamotrigine is not recommended Cochrane systematic review^Citation39: carbamazepine could be effective for some persons, but lack of evidence
Opioids associated with norepinephrine reuptake inhibitor	15 (23.8)	Recommended for exacerbations	Recommended (pain and quality of life) for moderate to severe pain not relieved by other approaches	Lack of knowledge (one trial showing positive effect of tramadol on pain)	No Cochrane systematic review
Antipsychotics	10 (15.9)	—	—	—	Cochrane systematic review^Citation37: quetiapine can be considered for a time-limited period (4–12 weeks) for patients with major depression (reduce pain, sleep problems, depression and anxiety)
Medical/therapeutic cannabis	22 (34.9)	—	—	—	Cochrane systematic review^Citation36: no data available
Centrally acting skeletal muscle relaxants	16 (25.4)	—	Cyclobenzaprine is recommended (effect on general improvement, sleep, fatigue, depression)	Cyclobenzaprine has no clear effect	No Cochrane systematic review
Synthetic cannabinoid (by prescription)	11 (17.5)	—	May be considered, especially if sleep disorders; lack of knowledge	—	Cochrane systematic review^Citation36: two studies. Lack of knowledge to conclude
Acetaminophen	46 (73.0)	Recommended for other conditions such as osteoarthritis	Recommended at low dose (hepatotoxicity); lack of knowledge	—	No Cochrane systematic review
NSAIDs	34 (54.0)	Recommended for other conditions such as osteoarthritis	Recommended at low dose and for a short time, especially if osteoarthritis	Significant risk of adverse effects (serious gastrointestinal, liver dysfunction, and cardiovascular adverse effects)	Cochrane systematic review^Citation11: no efficacy of NSAIDs compared to placebo (six RCTs)
Various anxiolytics, sedatives, and hypnotics	5 (7.9)	—	—	—	No Cochrane systematic review
Opioids	21 (33.3)	To avoid because of the risk of misuse and overdose	Not recommended because of adverse effects. May be used in some cases according to clinical judgment; lack of knowledge	Lack of knowledge	Cochrane systematic review^Citation35: no RCT on oxycodone to reduce pain in fibromyalgia. Need for studies
Benzodiazepines	17 (27.0)	To avoid (risk of dependence)	—	—	Cochrane systematic review^Citation40: no RCT on clonazepam to reduce pain in fibromyalgia

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