Opioid Use for the Treatment of Osteoarthritis of the Hip and Knee

Osteoarthritis of the hip or knee is a common condition affecting millions of patients. Symptoms may include stiffness, loss of mobility, as well as pain. How best to manage pain in the non-operative setting can be challenging and has been the subject of much debate.

Opioids are potent analgesic medications, that offer pain relief for severe acute pain such as pain associated with major trauma or surgery. Additionally, opioids are useful in some chronically painful conditions in situations with limited life expectancy (such as metastatic cancer). Traditionally, non-opioid analgesics such as acetaminophen and non-steroidal anti-inflammatory medications, modification of activities, weight loss (in patients who are overweight) and the use of an assist devices (such as a cane) have been the mainstay of nonoperative treatment for arthritis of the hip and knee. However, over the past three decades, the use of opioids for the nonoperative treatment of arthritic conditions has increased, with numerous negative consequences.

It is well recognized that the United States is in the midst of an opioid crisis. The US represents less than 5% of the world’s population yet consumes approximately 80% of the world’s prescription opioid production.⁽¹⁾ Moreover, the US ranks second only to Canada in per capita medical sector opioid consumption.⁽²⁾ In 2017, there were more deaths from opioid overdoses in the US than American deaths from the Vietnam, Afghanistan and Iraq wars combined.⁽³⁾

The root of this crisis is multifactorial. In a subset of patients, physicians may prescribe opioids to help patients with pain from chronic conditions, such as osteoarthritis, which unwittingly may contribute to an opioid dependency in these patients. The negative consequences of prolonged opioid use are well known. For patients who eventually choose to undergo hip or knee replacement surgery, these patients have difficulties with postoperative pain control, a higher risk of complications after surgery and potentially poorer long-term outcomes.^(4-6)

There is increasing evidence that opioids, when compared to non-opioid medications, do not provide superior long-term pain relief when used for the treatment of hip and knee arthritis.^(7-9) Hence, the use of opioid medications for treatment of hip and knee arthritis, especially prior to surgery must be questioned.

It is our position that the use of opioids for the treatment of osteoarthritis of the hip and knee should be avoided and reserved for only for exceptional circumstances. Opioids should not be used as a first line treatment for either acute or chronic symptoms of hip or knee osteoarthritis. When other non-opioid treatment modalities have failed and patients cannot undergo joint replacement surgery, opioid use may be considered in an extremely small subset of patients. These patients who are prescribed opioids for nonoperative treatment of osteoarthritis should be educated on the risks of prolonged opioid use including addiction and dependency. Additionally, the fewest number of opioids in the lowest dose, and for the shortest time possible should be prescribed. For patients who may require more prolonged opioid use, strong consideration should be given to referral to a pain management specialist. In addition, patients should be educated on safe storage of opioid pain medications and proper disposal when opioids are no longer needed. As an alternative to opioids, orthopaedic surgeons and other providers of musculoskeletal care should strongly consider the recommendations of the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines on nonsurgical treatment and non-arthroplasty treatment of hip and knee arthritis.⁽¹⁰⁾

References

1. Manchikanti L, Singh A: Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 2008;11(2 suppl):S63-S88. MedlineWeb of Science http://www.ncbi.nlm.nih.gov/pubmed/18443641
2. Kommenda N, Durkin E, Smears Why are more Americans than ever dying from drug overdoses? Thu 29 Nov 2018 07.32 EST. https://gu.com/p/a23mx?CMP=share_btn_link. https://www.theguardian.com/us-news/ng-interactive/2018/nov/29/usdrug-overdose-epidemic-opioids-crisis-getting-worse?utm_term=RWRpdG9yaWFsX0d1YXJkaWFuVG9kYXlVUy0xODExMjk%3D&utm_source=esp&utm_medium=Email&utm_campaign=GuardianTodayUS&CMP=GTUS_email
3. Holly Hedegaard, M.D., Arialdi M. Miniño, M.P.H., and Margaret Warner, Ph.D. Drug Overdose Deaths in the United States, 1999–2017. National Center for Health Statistics, Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db329.htm
4. Kim SC; Choudhry N; Franklin JM; Bykov K; Eikermann M; Lii J; Fischer MA; Bateman BT. Patterns and predictors of persistent opioid use following hip or knee arthroplasty. Osteoarthritis & Cartilage. 2017:25(9):1399-1406.
5. Smith SR; Bido J; Collins JE; Yang H; Katz JN; Losina E. Impact of Preoperative Opioid Use on Total Knee Arthroplasty Outcomes. J Bone Joint Surg – Am 2017:99(10):803-808.
6. Zarling BJ; Yokhana SS; Herzog DT; Markel DC. Preoperative and Postoperative Opiate Use by the Arthroplasty Patient. J Arthroplasty 2016:31(10):2081-4.
7. Katz JN; Smith SR; Collins JE; Solomon DH; Jordan JM; Hunter DJ; Suter LG; Yelin E; Paltiel AD; Losina E. Cost-effectiveness of nonsteroidal anti-inflammatory drugs and opioids in the treatment of knee osteoarthritis in older patients with multiple comorbidities. Osteoarthritis & Cartilage 2016:24(3):409-18.
8. Krebs EE; Gravely A; Nugent S; Jensen AC; DeRonne B; Goldsmith ES; Kroenke K; Bair MJ; Noorbaloochi. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018: 319(9):872-882.
9. Smith SR; Deshpande BR; Collins JE; Katz JN; Losina E. Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review. Osteoarthritis & Cartilage. 2016:24(6):962-72.
10. http://www.orthoguidelines.org/guidelines

Published January 2019