Osteoarthritis (OA) affects nearly 27 million Americans, or about 12% of US adults.1 As the average age of the population increases, the prevalence and burden of this debilitating disorder continue to rise.2
The American College of Rheumatology (ACR)’s guidelines for the medical management of OA of the hip and knee, last updated in 2000,3 focus on controlling pain and improving function and health-related quality of life while minimizing the toxic effects of therapy. The guidelines recommend tramadol—an atypical opioid with 2 distinct mechanisms of action4—for moderate-to-severe pain in OA patients who either have contraindications to COX-2 inhibitors and non steroidal anti-inflammatory drugs (NSAIDs) or have failed to respond to previous oral therapy. Patients with severe pain who don’t respond to or are unable to tolerate tramadol may be candidates for more traditional opioid therapy, the guidelines indicate.3
In recent years, however, the use (and abuse) of opioids has skyrocketed. Between 1997 and 2007, US per capita retail purchases of hydrocodone and oxycodone increased 4-fold and 9-fold, respectively.5 In a similar time frame (1996-2006), the number of deaths from opioid overdose more than tripled, going from 4000 to 13,800 annually.6 Not surprisingly, the use of narcotics for noncancer pain remains controversial.7,8 But inadequately treated pain continues to be a serious public health problem, as well.9
How this series can help you
This is the third in a series of articles based on the findings of the Cochrane Musculoskeletal Group (CMSG). One of the largest groups in the Cochrane Collaboration, the CMSG synthesizes the results of clinical trials to determine whether interventions for the prevention, treatment, and rehabilitation of musculoskeletal disorders are safe and effective. In this installment, the reviewers use detailed analysis, as well as a case study, to bring their findings to the attention of family physicians in a practical, clinically relevant context.
In 2006 and 2009, respectively, the Cochrane Collaboration published systematic reviews of tramadol (for OA in any joint)10 and other oral and transdermal opioids (for OA of the hip or knee).11 The reviewers’ findings, presented here along with data from more recent trials, can help ensure that you prescribe opioids for patients with OA only when their use is clinically appropriate and evidence-based. We’ve also included a case study (see page 211), so you can assess your knowledge and clinical skills.
How would you treat this patient?
CASE Carol J, an active 72-year-old, was diagnosed with OA in her right hip 5 years ago. Now she reports that the pain is getting progressively worse, making it harder and harder to turn over in bed at night or get in and out of the car. The pain is particularly bad at night, Carol says, and she’s had interrupted sleep for months. The patient has taken acetaminophen for the pain since her OA diagnosis, but now finds the analgesic is ineffective, even at the maximum dose of 4 g per day.
Carol has hypertension, which was difficult to manage until she began taking a combination ACE inhibitor/diuretic. She also has moderate renal impairment and mild chronic obstructive pulmonary disease, which limits her exercise tolerance. Nonetheless, she continues to smoke. The patient lives with and cares for her husband, who has Alzheimer’s disease, and worries about her ability to continue to care for him.
What are her treatment options?
Full-dose acetaminophen is no longer helping Carol, and NSAIDs are contraindicated because she takes an ACE inhibitor/diuretic and has moderate renal impairment. Increasing exercise will be a challenge. You strongly encourage her to stop smoking, emphasizing that this is particularly important to reduce the risk involved with any future joint replacement surgery.
Oral dosing options for the patient include:
- prescribing tramadol, starting with a low-dose immediate-release formulation taken one hour before bedtime (The controlled-release formulation is not advisable, given her age and renal function.) or
- adding a traditional opioid, eg, codeine 30 to 60 mg every 6 hours as needed, to her regular acetaminophen regimen.
Codeine and hydrocodone are available in combination preparations with acetaminophen, which may be convenient for some patients. However, hydrocodone was not one of the opioids tested in the trials included in the Cochrane reviews, and evidence of its use in OA is lacking.
Intra-articular corticosteroid injection, performed under imaging guidance, is another option for Carol. You explain that although there have been no studies of intra-articular corticosteroid injections for OA of the hip, these are used occasionally and may provide short-term symptom relief.7
You emphasize that surgery is likely to give her the best long-term outcome. In view of the patient’s circumstances and the need to care for her husband, however, you prescribe tramadol 50 mg at night. (Because of Carol’s age, renal impairment, and the possible adverse effects, it’s wise to start with a low dose and titrate upwards.) You warn her of the risks associated with opioids and advise her to alert your office staff if she experiences any adverse effects.
Before the patient leaves, you arrange an orthopedic consult and schedule a return visit for the following week. At your urging, she agrees to look into respite options for her husband.