A large percentage of patients with end-stage knee, hip and spine osteoarthritis use opioids to manage their chronic pain, especially those who are younger or have symptoms of depression, according to new research findings presented this week at the 2017 ACR/ARHP Annual Meeting in San Diego.
Osteoarthritis, or OA, is the most common joint disease affecting middle-aged and older people. It is characterized by progressive damage to the joint cartilage-;the cushioning material at the end of long bones-;and causes changes in the structures around the joint. OA commonly affects the knees, hips, spine, hands and other joints.Use of prescription opioids for pain management is under scrutiny because of the potential risk of dependence, misuse and increased adverse events. A group of researchers in Canada conducted a study of 1,204 pre-surgical patients with knee, hip and spine OA to examine the rates of prescription opioid use, as well as any association between opioid use and various socio-demographic and health status characteristics.
"Growing evidence demonstrates little if any clinically significant benefit of opioids for OA pain, particularly when compared to other medications. There are growing concerns about the potential for misuse, dependency and increased adverse events, including opioid-related death. Limited published research in this area suggests that pre-operative opioid use may be associated with poorer clinical and patient-reported outcomes," said Y. Raja Rampersaud, MD, FRCS(C), a professor at the University of Toronto in the Divisions of Orthopaedic and Neurosurgery, and a lead author of the study. "Many pain management options for these patients are limited, ineffective, and/or risky. There really has been little progress in this area."
The study participants included 577 patients with knee OA, 459 patients with hip OA and 168 patients with spine OA. All were scheduled for surgery at a tertiary care hospital in Toronto. The study participants were of a mean age of 65.6 years and 55.5 percent were women.
Participants were given pre-surgery questionnaires to collect data on their opioid usage. They were asked if they used opioids for pain never, sometimes or daily. They were also asked if they used other medications for arthritis or joint pain, such as non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants or neuroleptics, and over-the-counter medications.
In addition to opioid use, variables in the questionnaire included age, sex and education level, body-mass index score, comorbidities, depressive symptoms according to the Hospital Anxiety and Depression Scale, and pain level measured on a 0-10 numeric scale for average pain experienced in the last week. The researchers used a multivariable logistic regression method to examine the associations between the patients' current reported opioid use with an outcome of sometimes/daily versus never and other variables.
The study's results showed that 15 percent of patients overall reported that they sometimes used opioids and an additional 15 percent reported daily use of these medications. Reported opioid use was highest among the spine OA patients at 40 percent and similar among knee and hip OA patients at 28 percent and 30 percent, respectively.
Women under the age of 65 reported the greatest overall opioid use, especially those with spine OA. The researchers also found that greater likelihood to use opioids was significantly associated with spine OA, younger age, obesity, the presence of fibromyalgia along with OA, greater depressive symptoms, greater pain and the current use of other prescription pain medications. The researchers concluded higher use of opioids among younger patients and those with greater depressive symptoms is especially concerning due to the possibility of opioid-related adverse effects.
"In both the U.S. and Canada, joint replacement and spine surgery for OA are the most common inpatient elective surgeries. Given the associated negative effects of opioids, we need to better understand the impact and means of mitigating adverse events associated with their use in end-stage OA, that is, the surgical population," said Dr. Rampersaud. "We found that those with the highest use also reported the highest levels of pain, suggesting that perhaps the opioids were not having their intended pain-reducing effect on all patients. Given the relative lack of efficacy, the simplest answer is to not start them on opioids to begin with, and if necessary, to do so for short durations at the lowest possible dose. Our findings demonstrated that pre-surgical opioid use is an independent predictor of a greater degree of pain at three months post-surgery. Once we have determined the impact on other outcomes such as perioperative adverse events, health care utilization and patient-reported outcomes, we aim to assess the efficacy of different pre-surgical pathways, including multimodality pain management strategies, that eliminate or reduce, in both dose and duration, opioid use in this population."