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WHEN it comes to the treatment of osteoarthritis (OA), experts say there is currently a strong disconnect between evidence and practice.
Despite recommendations against using opioids for the treatment of OA, they are still regularly being prescribed for ongoing treatment.
In Australia, one study found that opioids were prescribed for 26% of hip osteoarthritis and 15% of knee osteoarthritis from 2010 to 2016.
However, a systematic review and meta-analysis published in the MJA has found that opioids may provide very small benefits and may also increase the risk of adverse events.
“The incidence of adverse events, including gastrointestinal and central nervous system effects, was higher for people receiving opioids than for those receiving placebo,” the authors wrote in the review.
Despite Royal Australian College of General Practitioners (RACGP) clinical guidelines released in 2018 strongly recommending against the use of opioids for OA, experts in the field say the review findings aren’t surprising.
According to rheumatology clinician researcher Professor David Hunter, there could be a variety of reasons why they are still prescribed so frequently.
“Clinicians are quite used to using opioids for pain. And they think that that could probably be translated to things like osteoarthritis. But by the same token, there’s similar evidence for back pain suggesting that opioids are not helpful and probably harmful,” he told InSight+.
“The other element here is that the marketing of these products is quite powerful. I don’t want to invoke us as being under the influence of the Sackler family (heirs to the OxyContin fortune) or Purdue Pharma (owned by the Sacklers) but I think there are some real elements to the marketing here that have been quite pervasive and quite strong.
“We have been using opioids for things they are probably not indicated for,” he said.
According to Professor Hunter, opioids should only be considered for acute pain, particularly post-operatively.
“A person comes in, they have an operation, they’re going to take a week or two to recover, and you give them something to help overcome the pain that they’re likely to experience post-operatively,” he said. “But for chronic pain conditions, the use of opioids is quite pervasive and problematic.”
One of the review authors, Dr Christina Abdel Shaheed told InSight+ that the way opioids are prescribed is concerning.
“If you think about the way that opioids are prescribed for chronic pain, a lot of the time a long-acting formulation is prescribed. You typically get a packet of 28 tablets and the individual might be asked to take that one tablet twice a day, for example. That’s already 14 days of use right there.
“You can expect up to a quarter of people who take that regimen to be still using an opioid one year later,” she said.
According to Professor Hunter, it doesn’t matter the type of opioid. They’re all equally problematic.
“There is some marketing going on at the moment to suggest that agents such as tramadol are likely less harmful and potentially more beneficial, but it’s been stated in the absence of solid evidence.
“Until there’s better trial evidence suggesting efficacy, they should stop marketing that as such, because the average person with osteoarthritis has the disease for 25 years. These have been demonstrated in acute pain trials to probably be efficacious in the order of 4 to 6 weeks.
“Over and above that, there is no good evidence to suggest they’re helpful for chronic pain conditions like osteoarthritis.
“I don’t think it matters which agent we’re talking about here. I think all opioid agents probably have similar tendencies to the same side-effect profile and dependency,” he said.
There are other treatment options, including surgery in final stage disease.
The MJA review only included randomised controlled trials in which the analgesic effect of an opioid was compared with placebo and did not include trials in which the effect of opioid therapy was compared with other treatments but not with placebo.
“Our findings indicate that opioids provide pain relief similar to that of paracetamol, and their benefit is almost half that achieved by NSAIDs (a conclusion, however, based on indirect comparisons), challenging beliefs that simpler analgesics are less effective than opioids for people with common musculoskeletal conditions,” the MJA review authors wrote.
The first step in the management of OA should always be non-pharmacological treatments such as exercise and a healthy diet, the authors wrote.
According to Dr Abdel Shaheed, more needs to be done to ensure clinicians and patients have the most effective strategies.
“What is needed are interventions to try and increase the uptake of the recommendations in the guidelines. Timely access to therapies, more educational strategies for clinicians and patients. All of these strategies can be integrated together, and evaluated in primary care to see if they reduce the use of opioids for those people who are using them in osteoarthritis,” she told InSight+.
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I was on Jurnista 64 mg for about a year then I was decreased by 8mg.
And now I am on 32 mg and I will see the specialist on Monday 27th March 2023.
I am hoping to be taken off the drug.
After reading about this it’s me to a tee.
I am happy to try and get off this drug.
If I had read this sooner I would of wanted to get rid of them all together.
My GP wanted me to get off them a long time ago but I was conditioned that I needed them.
I wished I would of listened to my GP and got off them.
Interesting that you get a LOT more opiate prescriptions in areas where patients can’t afford out of pocket fees, and fewer in areas where there are better alterative treatments (exercise-based treatments, which are much more effective). However, Australia’s health system discriminates against patients of exercise-based practitioners and provides much lower Medicare rebates, so the majority of fees need to be paid out of pocket. Part of the solution would be to provide equity for exercise-based practitioners so that more people could afford to see them, instead of seeing “free” practitioners (Emerg Depts and bulk-bill GPs) who prescribe free opiates. https://threadreaderapp.com/thread/1178930821010358273.html
I have treated hundreds of elderly patients with different opioids at different doses. In general, they work well and help them to reduce their pain. They usually stay around the same dose for years and years with no complications. I have had many with advanced dementia and altered behaviour that once I commence them on opioids their behaviour improves significantly and remain at the same dose of the opioid.
I basically never prescribe NSAIDs because 99% of the time are contraindicated in elderly patients.
To #7 Anonymous…. I got your beat there….I have had 14 total surgeries on my back and neck….13 of them on my low back. Not bragging but with all the surgeries its very difficult to find a modality that will work. My total number of surgeries its standing at 21. Sure wish I could turn back time. Government always wants to be in control when it comes to healthcare. They should be concerned about issues that have bad results from some of their bad decisions.
Think maybe the issues are….hmmm. Bad decisions….
Lets put the right issues in the right place and bad issues in a bad place. Problem is….some people are just prone to addiction. No amount of treatments or ways to combat it will change what is going on with their problems. Let go, let God. That’s all I have to say about this issue.
Opiates are great on a short term basis. But OA is long term and therein lies the problem. The Targin 2.5/1.25 you initiated the patient on will be increased in a a few weeks to 5/2.5, in three months expect to prescribe 10/5; by the end of the year we can hope to add on PRN endone and perhaps Targin now at 20/10 and a really problematic drug dependent patient. It’s a slippery slope and I refuse to have a bar of it. I have seen many GPs and practices use this medication to increase patient numbers. Nothing healthier for a practice bottom line than a steady stream of opiate dependent patients.
Please, everyone, read the actual study.
Firstly, ALL of the evidence in this systemic review is low or very low quality. Do you make treatment decisions based on very low quality evidence? I don’t.
Also, the longest treatment length was 16 weeks. This is hardly long term, its medium term.
There were NO instances of dependence, overdose or death, yet these are constantly mentioned. pure scare tactics.
Low dose opioids combined with simple analgesics (oxycodone and paracetomol, codiene and ibuprofen) achieved very good pain relief. SEe the quote from the study, below.
“However, combinations of low dose opioids with simple analgesics may have beneficial synergistic effects. For example, the 95% confidence intervals for the pain relief achieved by low dose codeine with ibuprofen and low dose oxycodone with acetaminophen included large effects (more than 30 points).”
I’m heartened to see that many in this comment thread are not fooled and their real-world experience tells them that opioids are not only safe and effective for some patients, but life-changing, even life-saving.
Please read the full study, and the supplementary info. Its extremely eye opening. Dont deny patients who are in terrible pain a treatment that works well for them. There are few treatments for very painful osteoarthritis. Blanket bans on opioids is not good science, not good medicine.
In an ideal world, by all means cease opioids but that leaves a number of OA patients stranded when NSAIDS and regular paracetamol are not enough. Quality of life first. As a sufferer and user, I suggest the EXPERTS should be OA pain sufferers! They would better understand what it is like to not be able to get the pain ‘out of your face’ so that you can get on with your day. Sitting and moaning and getting depressed is not the answer, as not everyone can afford to head to the hydrotherapy pool three times a week! Even then, there are times when getting to sleep is difficult because of the pain. What then? A dependency on hypnotics?
THERE MAY BE ABUSE OF OPIOIDS, BUT THE PERSONAL EXPERIENCE IS CONTRA TO WHAT THE LITERATURE SAY. I AM SURE IF WE ARE TRUE TO OURSELVES OPIOIDS DO WORK BETTER THAN ANY OTHER IN REAL LIFE. THE ISSUE IS THE PROBLEM OF DEPENDANCE AND THE STIGMA ASSOCIATED WITH IS AND NOW CLEARLY DOCTORS ARE TALKING AGAINST BECAUSE OF FEAR OF REPERCUSSIONS ON THEIR PRACTICE AND THEIR REGISTRATION. I DO NOT BELIEVE IN THE INDISCRIMINATE USE. BUT IN A GROUP OF PATIENTS MAY BE THE ONLY TOOL TO GET THEM A GOOD QUALITY OF LIFE. CONSISTENTLY I SEND PATIENTS TO PAIN ZPECIALIST THEY COME BACK WITH MORE OPIOIDS.
I have degenerative arthritis bone spurs and disc issues. Was prescribed Tramadol in 1995 still take it today as needed. Tramadol has given me a life with less pain. NSAIDS previosly given had caused heart problems arrhythmia and water retention in lower extremities. While I believe oxycodone is harmful my success with Tramadol is undeniable. I am not addicted as the barbiturate was removed yet this Tramadol is mistakenly being lumped in with ‘opioids’ and all laws governing opioids. Which is wrong.
I agree we need to be cautious, but I have had patients with definite benefit from opioids (Tramadol, Norspan, palexia) used at minimum doses, and reviewed frequently. I often find they stop their medications of their own accord when/if their pain reduces. Not all patients can use NSAIDs especially the elderly, and they often come back saying the paracetamol hasn’t helped. It isn’t “one size fits all”.
I’ve been dealing with multiple bilateral shoulder surgeries then multiple surgeries in my heal that I shattered I have degenerative bone disease, CRPS,osteoarthritis and osteoporosis. This all started when I was 36 now I’m 46. In that 10 years I’ve had 17 surgeries and multiple procedures. I’ve tried everything for the pain and the only thing that works is opioids. I ended up getting a pain pump and it’s amazing the difference it has made. To take patients off of opioids that need them is wrong. The Stigma that you are assigned for having to take opioids is wrong. Do you ask a Diabetic when they will get off insulin or a Cancer patient when they will stop chemo or radiation treatments? No you don’t. Everyone assumes the person on pain medication is just an addict. When in fact they are dependent on them to function in their daily lives. And addict uses drugs for the euphoric feeling and someone dependent on them needs them to maintain a somewhat normal life
I’ve taken these for a number of years for OA in spine. But now find they just take the edge off and dont give the relief they used to. But to not get that bit of relief would put me over the edge. Pain is so bad on days, so I up the number of doses. Would love to know what else would help. Cant exercise because of pain, cant walk stand or sit for too long without pain. Some days I wish I wasnt around.
Doctors and Pharmacists, when they become patients themselves, suddenly become quite keen on effective pain relief. I wonder how many of the experts and authors of these guidelines would be happy to be blanket-banned from receiving narcotic analgesics themselves for a chronic painful condition.
I’ve a few patients in GP who seem to benefit from low dose buprenophine patch with no discernible side-effects; they are socialising and mobilising more, their dose stays stable for years. Is this really so bad?
We run the risk that patients will use OTC ant-inflammatories , ibuprofen and diclopheac , etc etc , easily obtained without prescription , leading to peptic ulcers and bowel perforation , hypertension , stroke and ami, renal failure.
Opiate use alleviates the risks of NSAID abuse especially in elderly populations where they are prescribed more and nsaid risk is higher,In the 1980s therw was a higher use of nsaids and patients presented regularly at AE departnments with GIT bleeds , hypertensive crises etc .We risk a return too this state of affairs with a blanket ban on opoiates.
Several points ….
1. As others have noted, pain is poorly managed in Australia because safe, effective and affordable options aren’t available to all patients.
2. Decisions on management should be evidence-based not based on expert opinion.
3. Clinical trials don’t always translate to the real world as well as the ivory-tower types think.
4. Management of any condition should be tailored to the individual patient. A one-size-fits-all, public-health-based approach leaves many patients on their own with their problems.
5: The anti-opioid rhetoric we hear these days is as political and biased as big pharma drug marketing.
As a post trauma patient, on 2 occasions I was prescribed 1) pethidine and 2) codeine when pain was not an issue. As a GP I thought codeine was hardly addictive. I got no thanks from several “straight laced” ladies who couldn’t get off panadeine forte, despite surgical cures.
I take Palexia 50mg daily with good effect. Have been on them for several years. I adjust the time taken according to activity. I used to take NSAIDS but they sent my blood pressure up. It’s so difficult to get cortisone injections although these have good effect for several months to years. I do watch my diet, weight, and do exercise several times a week! It would be awful to be without pain relief!
This obssession with opioids is ridiculous. For years people have had good relief from chronic pain using opioids. The alternatives do not work long term. I have had several patients sent to pain clinics, all happy to go – “interesting” they say, “met people made friends but effective for my pain – not at all”.
If you want GPs to stop long term opioid meds, make all but 1 week authority only, with the same restrictions as say, Esomeprazole, which so few people die from, but which is so hard to provide 6 months of treatment for ( you can’t).
Try increasing access to public non medication treatments as mentioned above.
Hospitals use opioids to get people home and don’t stress that they must be only very short term.
It has been near impossible to access reliable physio, exercise classes, dietitians (to lose weight) etc during COVID and even in “normal times” the services are hard to access, limited duration and financially inaccessible to many people – will someone invest in these services long-term? This is the best option for so many reasons yet I fear the government see the cost of medication as less so opt for that
Pain specialists are still prescribing opioids for severe OA. Some pts can’t take nsaids due to CKD. SNRIs can relieve chronic MSK well, ? anti inflammatory action.Spme pts are taking CBD oil and say it relieves their pain. Is there a pain specialist or geriatrician willing to comment on here?
I agree wholly in principle we should avoid opioids in treatment of chronic pain and in particular osteoarthritis. However there is a small cohort of patients who have experienced long term disabling chronic pain (mainly lumbar) and have been severely disabled from working, walking and minor sports for years. This small cohort have maintained a remarkably improved quality of life (over years) without dose escalation on low dose (eg Targin 10/5) dosage). This is despite physio, recommended useless paracetamol 4G daily etc.. yoga etc, etc.
Previously they have experienced deconditioning, depression, insomnia and poor quality of life as a consequence. Their lives have been revolutionized (for years) by the addition of a small dose of opioid.
I do disagree with the title (“Stop prescribing opioids say the EXPERTS”). Inflexibility is dangerous. Unfortunately there have been doctors who have prescribed frequently, stupidly and indiscriminately which has led to abuse and this has correctly led to condemnation. However this widespread abuse has led some to obsession against ALL opioid prescribing. This attitude is not good for ALL patients.
Agree – making access to physical therapies more affordable will be effective and cost-effective in the longer term.
So many older people with osteoarthritis can’t afford even the gap with the subsidy of a care-plan, and this is limited to only 5 services per year.
Our regional hospital had a system where everyone who was referred for joint surgery received physiotherapy first, and many no longer needed surgery; those he did benefitted from the pre-hab. Win- win!
Opioid medication is good for short term relief of pain and distress (the psychotropic effect is the reason those who deliberately abuse opioid substances do so).
The long term effects have a gradual, subtle and inconspicuous onset, so escape attention.
These include not only Opioid Induced Hyperalgesia, GIT dysfunction and Endocrine suppression, but the sedation which may be low level but still disabling. This cannot be reliably assessed at an interview, as it is the level of arousal / attention when NOT stimulated that leads to poor judgement and misadventures.
The associated reduction in activity becomes serious as it continues, adding to the pain by de-conditioning, so further reductions in activity, especially serious for less-than-robust elderly, signalling a direction along a pathway down and out.
Other means for people to manage their lives with pain, which can be reduced by these means, are available and required.