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Opioid side-effects 'outweigh benefits' in treating osteoarthritis

By Mark Pownall

Two new gold standard reviews have controversially called into question GP prescribing of opioids for osteoarthritic pain.

Reviewers for the Cochrane Collaboration concluded opioids should not be routinely used in osteoarthritis, even in patients in ‘severe' pain.

One of the reviews found the harmful side-effects of non-tramadol opioids outweighed their benefits, and that they should not be used routinely in knee and hip osteoarthritis.

The other - specifically on tramadol - found its efficacy was similar to paracetamol, but with more side-effects.

The first review, of 10 trials in 2,268 participants, found small improvements in pain and function for those treated with opioids compared with placebo.

It found little evidence that increasing dose, route of administration or duration of treatment improved pain relief and function.

Every twelfth patient treated with opioids had an additional adverse event compared with placebo, it reported.

Study leader Dr Eveline Nuesch, a research fellow in epidemiology at the University of Bern, Switzerland, said: ‘The small to moderate beneficial effects of non-tramadol opioids are outweighed by large increases in adverse events.'

The second review - of 11 trials in 1,019 patients – concluded: ‘Benefits of tramadol are comparable with paracetamol's, coupled with a less favourable safety profile.'

Dr John Dickson, a former GP and community specialist in rheumatology for Redcar and Cleveland PCT, was clinical adviser to NICE for its osteoarthritis guidelines. He said: ‘There are few trials to show opioids are any good in osteoarthritis and I don't use them much. But people tell us not to use NSAIDs and for GPs there is very little to offer these patients.'

He said use of opioids remained an option under NICE guidance, with alternatives being referral for a new knee or hip, or an NSAID.

Professor Philip Conaghan, professor of musculoskeletal medicine at the University of Leeds, criticised the quality of the trials analysed in the Cochrane reviews, and said the conclusions did not support a call to avoid opioids.

‘These are strong recommendations to make on the basis of combining findings from poor-quality trials of different opioids, at different doses that are not comparable,' he said.

‘All the evidence-based guidelines on osteoarthritis, from NICE to EULAR to the American College of Rheumatology, support use of opioids.'

‘Many of our patients with osteoarthritis do not get adequate pain relief from the core NICE approach of weight loss, education, exercise, paracetamol and topical NSAIDs, so to say opioids do not have a place is unbelievable.'

Osteoarthritis and opioids: what NICE says

Opioids are regarded as an option after lifestyle measures, and treatment with paracetamol and/or topical NSAIDs.

‘If paracetamol or topical NSAIDs are insufficient for pain relief…then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in elderly people.'

Source: NICE clinical guidelines 59

GP prescribing of opioids for osteoarthritic pain has been called into question

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