Opioids only modestly improve pain relief, function in OA, not QoL
ATLANTA — Among patients with osteoarthritis, opioids demonstrated only moderate benefit for pain and function, while contributing no notable benefit for quality of life or depression compared with placebo, according to a presentation at the 2019 ACR/ARP Annual Meeting.
“As we know, the major treatment hurdle for osteoarthritis is that we do not have any good disease-modifying drugs for this disease,” Raveendhara R. Bannuru, MD, PhD, FAGE, director of the Center for Treatment Comparison and Integrative Analysis at Tufts Medical Center in Boston, said during a press conference. “Without effective treatment, we are left to manage patients symptomatically and the most common thing we do is manage their pain.”
“One of the main culprits [driving opioid use] are chronic pain patients and one of the most highly prescribed conditions for opioids is osteoarthritis,” he said. “What we wanted to know is whether there is a therapeutic window that exists for opioids — a time period when efficacy of these drugs is peaked and safety [risk] is at its lowest level?”
To determine the long-term efficacy of commonly prescribed opioids, Bannuru and colleagues conducted meta-analyses of pain and function at 2, 4, 8, and 12 weeks among patients with OA, examining relevant safety outcomes for all opioids, as well as “strong” vs. “weak” opioids.
The researchers assessed MEDLINE and the Cochrane Database from inception to April 2019, actively seeking unpublished data. Bannuru and colleagues excluded studies using enriched enrollment or double-dummy design involving nonoral treatments in favor of randomized placebo-controlled trials assessing efficacy and safety of FDA-approved opioids in patients with knee and/or hip OA.
The researchers included 23 randomized controlled trials with 11,402 participants in their analyses. Patients’ mean age ranged from 54 to 67 years, with a mean BMI ranging from 28 to 34 kg/m².
According to study results, opioids exhibited only a small, statistically significant benefit for pain at each time point, with a similar impact on function at two, four, eight and 12 weeks. Although opioids were found to have no notable impact on quality of life or depression, patients who were prescribed opioids reported significantly higher quality of sleep.
“We did not find any effect on quality of life measures and we did not find any effect on depression,” Bannuru said. “We found a small improvement in sleep quality, but I would take that with a grain of salt and say that more research needs to go in there.”
Additionally, researchers reported that “strong” opioids had consistently less effect on pain than “weak” opioids; however, a meta-regression demonstrated that opioid dosage had no impact on pain relief (P = .09). Bannuru and colleagues noted that methodological bias “could have contributed to the poor performance of strong opioids,” or, alternately, that patients who received strong opioids were unable to achieve the optimal therapeutic dose.
With regard to safety, the researchers noted that strong opioids demonstrated consistently worse safety profiles than weak opioids, especially with respect to drug withdrawal symptoms (2.78 [95% CI, 1.41-5.49] vs. 1.06 [95% CI, 0.19-5.8]) and discontinuation due to adverse events (5.47 [95% CI, 4.63-6.47] vs. 2.77 [95% CI, 2.26-3.39]).
“A very interesting finding was that strong opioids consistently underperformed against weak opioids across all time periods,” Bannuru said. “One possible explanation we considered was that there was a dose relationship between the dose of opioid prescribed and the pain relief; we found a higher number of discontinuations due to adverse events among the strong opioid group so that almost doubled the number of patients who were prescribed strong opioids compared to weak opioids.”
He added, “What this tells us is that patients receiving strong opioids were probably not titrated to the therapeutic dose needed to achieve pain relief. We hope that our results will help patients and clinicians have these discussions about how to wisely use opioids.” – by Robert Stott
Osani M. Abstract #910. Is there any role for opioids in the management of OA? Presented at ACR/ARP Annual Meeting; Nov. 8-13, 2019; Atlanta.
Disclosure: Bannuru reports no relevant financial disclosures.