People with hip or knee osteoarthritis (OA) use oral pain medications more often than nondrug pain treatments, such as physical therapy, knee joint injections and topical creams, according to an analysis of three clinical trials. That’s in spite of guidelines that recommend trying nondrug treatments before medications.
The analysis, which appeared recently in Arthritis Care & Research, looked at trials conducted by researchers at Duke University, the Durham Veterans Affairs (VA) Health Care System and the University of North Carolina at Chapel Hill, all in North Carolina. A total of nearly 1,200 patients ages 61 to 65 participated in the three studies. All participants had knee or hip OA, and most were overweight and treated by a primary care doctor. None got the minimum 150 minutes of physical activity a week recommended for good health.
Researchers found that 70 percent to 82 percent of the study participants took pills for pain, mainly nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, but sometimes other pain relievers such as acetaminophen (Tylenol) and opioids. Use of pain medications was more common among those with severe symptoms.
About 39 to 52 percent of the participants received physical therapy, half had corticosteroid or hyaluronic acid knee injections and 25 to 39 percent used topical pain creams.
American College of Rheumatology guidelines recommend nondrug therapies, including exercise and weight loss, as first-line treatments for OA. These can not only relieve pain and disability but also help delay further joint damage. Oral analgesics, including full-dose acetaminophen and prescription NSAIDs, can be used if the use of intermittent over-the-counter medications haven’t relieved symptoms, but they can’t stop disease progression and can cause side effects, including stomach bleeding, ulcers, high blood pressure and heart or kidney problems – all more common in older adults.
Most studies have found no evidence to support using opioids for chronic pain, and the Centers for Disease Control and Prevention (CDC) and many rheumatologists recommend against it. But nearly 30 percent of patients in the Durham VA Health System took opioids for arthritis.
The study didn’t look at past medical histories, so it’s not known if patients using medications had tried and failed other treatments. Still, while the proportion of patients using NSAIDs from each of the three studies is fairly similar and in line with the findings of earlier studies, the proportion of VA patients taking opioids for arthritis pain (almost 30 percent) is more than twice as high as the percentage used by participants in the other two studies (between 10 and 13 percent), says lead author Lauren Abbate, MD, a researcher with the VA Eastern Colorado Healthcare System in Denver and an emergency medicine specialist at the University of Colorado School of Medicine in Aurora.
Dr. Abbate speculates that veterans may have more severe arthritis pain or other injuries, or can’t take NSAIDs due to other health problems, such as kidney disease. But she also notes that earlier reports found high rates of opioid use for chronic pain among veterans, which eventually led the U.S. Department of Veterans Affairs to establish guidelines to reduce the use of opioids for chronic pain.
Race, sex and socioeconomic status seemed to play some role in the types of treatments patients received. For example, women and non-whites were more likely than white men to have physical therapy or use topical creams. But in general, Dr. Abbate concludes that there’s a gap between existing guidelines and how OA is treated in the real world, and that nondrug therapies for OA aren’t used nearly as much as they should be. She thinks closing that gap will lead to better care for all patients with arthritis.
The clinical guidelines from the American Academy of Orthopedic Surgeons recommend nondrug treatments along with medications, says Geoffrey Westrich, MD, an orthopedic surgeon and director of research of Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery in New York City. Those guidelines, similar to the ACR’s, recommend that patients with symptomatic knee arthritis “participate in strengthening their muscles, low-impact aerobic exercises, and physical activity consistent with national guidelines (a minimum of 150 minutes a week),” says Dr. Westrich, who was not involved in the study.
He adds that, although NSAIDs are also recommended for arthritis patients who can tolerate them, “physical therapy or a home exercise program with muscle strengthening may also help patients manage their pain, increase activity and potentially improve their quality of life.”
For patients with severe arthritis whose pain is not helped by conservative measures, he says, “joint replacement surgery may be the best option for permanent pain relief.”
Author: Linda Rath
- Exercise Benefits for Hip OA
- Strength Training for People with Arthritis
- 6 Exercises for Knee OA Pain
- Benefits of Weight Loss