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Risky Painkillers Commonly Prescribed for Osteoarthritis

LAS VEGAS — Published guidelines warn that treating osteoarthritis (OA) with opioids and benzodiazepines can boost patients’ risk of falling. Nevertheless, physicians in a large health system were prescribing those drugs for the condition nearly a third of the time, often in the vulnerable elderly, according to a study reported here.

More alarmingly, 3% of the patients received concurrent prescriptions for opioids or benzodiazepines. This is “a significant and potentially deadly combination,” said the study’s lead author, Vignesh K. Alamanda, MD, an orthopedic surgery resident with Atrium Health, in a presentation at the 2019 annual meeting of the American Academy of Orthopaedic Surgeons.

He and his colleagues tracked 20,556 outpatient visits in the first half of 2016 in the Atrium Health system, which serves North and South Carolina. All of the patients had a primary diagnosis of osteoarthritis. In nearly 32% of the visits, patients were prescribed opioids and/or benzodiazepines, with hydrocodone-acetaminophen prescribed almost half the time.

More than 37% of patients who received a prescription were considered to be at risk for prescription misuse, judging by factors such as early refill (33%), positive toxicology screen (4%), and previous overdose (1%). Patients older than age 65 made up 43% of those who got the drugs.

“Deadly consequences have resulted from the increased utilization of prescription opioids and benzodiazepines,” Alamanda told MedPage Today in an interview after the presentation. “This is particularly important in the elderly population, who are especially at high risk for falls, constipation, and adverse medication reactions. Additionally, studies have shown worse outcomes in patients who are managed with opioids for their osteoarthritis who eventually undergo a total joint arthroplasty including experiencing increased length of stay, increased risk of revision, and poor postoperative pain control.”

A 2019 position statement by the American Association of Hip and Knee Surgeons states that “the use of opioids for the treatment of osteoarthritis of the hip and knee should be avoided and reserved only for exceptional circumstances.” A 2014 Cochrane Library review, meanwhile, found that opioids “have a small effect on pain or physical function” in OA.

“OA is a chronic disease, and the use of opioids is not recommended as it does not treat the problem. Over time patients can develop tolerance and increased risk or dependence and abuse,” said Vani J. Sabesan, MD, an orthopedic surgeon and shoulder/elbow sports medicine specialist at Cleveland Clinic Florida.

In contrast to opioids, there’s been little research interest in benzodiazepines in OA, although studies have suggested that they boost the risk of falls in the elderly, Sabesan explained. “There is some evidence that patients have a higher risk of opioid usage if they take benzos, and there is higher risk of abuse when taking both. Otherwise, not much else is out there.”

Sabesan cautioned that the new study is based on 3-year-old data. Awareness about the opioid risk has grown since then, she said, and new guidelines have appeared. “Strategies to improve compliance with evidence-based guidelines as well as alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis,” she said. “Primary care physicians and orthopedic surgeons need to be more aware, educate patients on the risks of opioids, and communicate with patients about better alternate methods of pain management.”

The study was funded by a Smith Arthritis Grant and the CDC.

Alamanda reported no relevant disclosures.

Sabesan disclosed research funding from Orthofix, Wright Medical, and LifeNet Health.