OPIOID medications may provide very small benefits for people with osteoarthritis, but also increase the risk of adverse events, according to a systematic review published today by the Medical Journal of Australia.
“Osteoarthritis affects more than 500 million people around the world, and it is a leading cause of disability, wrote the authors, led by Dr Christina Abdel Shaheed, an Academic Fellow at the University of Sydney, and Dr Wasim Awal from Griffith University.
“Non-pharmacological strategies, such as exercise and maintaining a healthy weight, are recommended for first line management, as are simple analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol (acetaminophen).
“However, advice on using opioid analgesics to treat the pain of knee and hip osteoarthritis is inconsistent; opioids are often prescribed, including for about 40% of people with knee osteoarthritis in the United States.”
Abdel Shaheed and colleagues conducted a systematic review and meta-analysis of randomised, placebo-controlled trials of opioid therapies for treating the pain of osteoarthritis, extracting pain, disability, health-related quality of life, and adverse events data from 36 eligible trials.
“The evidence from 19 trials (8965 participants) for very small medium term pain relief was low quality, as was that from 16 trials (6882 participants) for a very small effect on disability,” they reported.
“Opioid dose was not statistically significantly associated with either degree of pain relief or incidence of adverse events in a meta-regression analysis. Evidence that opioid therapy increased the risk of adverse events (risk ratio, 1.43) was of very low quality.
“Our review is the first systematic review of therapy for people with osteoarthritis to conclude that single ingredient opioid medications provide very small immediate, short- and medium-term benefits, and that opioid dose (in the range examined) may not influence pain relief in the medium term.
“This is in contrast to conventional thinking that higher doses are more beneficial, and our findings should discourage the prescribing of stronger opioid analgesics for people with severe osteoarthritis pain.
“Given their very small effects, the appropriateness of single ingredient opioids for managing osteoarthritis is debatable. Our findings also indicate that the association between opioid dose and medium-term risk of adverse events is unclear.”
Abdel Shaheed and colleagues did find that combinations of low-dose opioids and simple analgesics may have beneficial synergistic effects.
“For some people with osteoarthritis, short term use of these combination analgesics may be a reasonable option; however, this finding was based on a small number of studies.”
The authors concluded that:
“Opioid medications may provide people with osteoarthritis very small benefits but also may increase the risk of adverse events. The association between opioid dose, pain relief, and risk of adverse events requires further evaluation.
“Alternative pain management strategies for people with osteoarthritis should be investigated, as well as opioid-sparing and tapering strategies for those being treated with opioids.”
- Cate Swannell