The use of opioids in the treatment of osteoarthritis: When, why, and how?

Abstract

As life expectancy increases every decade, the incidence and prevalence of osteoarthritis (OA) also will increase. Despite progress in our knowledge of the pathophysiology of OA, the management of OA-mediated pain continues to challenge physicians. Concern regarding the cardiovascular effects of cyclooxygenase-2 inhibitors and the gastrointestinal and renal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) in general has limited the use of these medications in the management of chronic non-cancer pain. Appropriately dosed and monitored use of opioids for OA pain, when more conservative methods have failed, has potentially fewer life-threatening complications associated with it than the more commonly and often less successfully employed pharmacotherapeutic approaches to care. When used as part of a multimodal approach to pain control, opioids are a safe and effective treatment for joint pain, including that of OA. Patients for whom NSAIDs are contraindicated, or for whom combined acetaminophen, tramadol, and NSAID therapy is ineffective, may be started on low-dose opioids and titrated as needed and tolerated. Patient education and informed consent, exercise, complementary medicine, and the use of a controlled substance agreement increases the likelihood of patient compliance with treatment guidelines, improving functional capacity and quality of life.

Peri-operative Pain Management in Chronic Opioid Users and Unhabituated Patients

“…[1][2][3][4][5][6] Initially intended for the treatment of acute or terminal pain, opiates are increasingly common in the treatment of chronic non-terminal pain. Consequently, the use and potential abuse of prescription opiates have become widespread, and physicians increasingly encounter patients with a history of opiate use.…”

An update on the up and coming therapies to treat osteoarthritis, a multifaceted disease

“…Regarding opioids, their use is restricted to cases where NSAIDs/Coxibs cannot provide sufficient pain relief or where they are contraindicated due to underlying hypertension or hepatic or renal impairment. In such cases, they may represent an alternative (37,38), but adverse events such as nausea, constipation, dizziness, somnolence and vomiting may often cause patients to stop taking opioids (39). Furthermore, an increased rate of falls and fractures related to their long-term use is a main limitation (37,38).…”

Pharmacotherapy of Osteoarthritis

“…As part of a multimodal approach to pain control, opioids are often considered a safe, effective treatment for joint pain, including that of OA. 53 Patients for whom NSAIDs are contraindicated, or for whom combined acetaminophen, tramadol, and NSAID therapy is ineffective, may be started on low-dose opioids and titrated as needed and tolerated. 53 Various studies in OA patients have shown, not surprisingly, that opioid analgesics provide pain relief superior to that of placebo or NSAIDs 54 and that adding an opioid analgesic to an NSAID regimen provides better analgesia than the NSAID alone.…”

“…53 Patients for whom NSAIDs are contraindicated, or for whom combined acetaminophen, tramadol, and NSAID therapy is ineffective, may be started on low-dose opioids and titrated as needed and tolerated. 53 Various studies in OA patients have shown, not surprisingly, that opioid analgesics provide pain relief superior to that of placebo or NSAIDs 54 and that adding an opioid analgesic to an NSAID regimen provides better analgesia than the NSAID alone. 54,55 The authors of this review article have also found that this combination can be useful in properly selected patients.…”