Opioid side-effects 'outweigh benefits' in treating osteoarthritis

Many patients benefit from a home based exercise routine backed up by periodic visits to a physio or chiropractor for mobilisation/ manipulation. These resources are often under utilised in the management of OA. Chiropractor, Brighton, private practice

I have widespread o-a, mainly as a result of joint damage caused by being struck by lightning in '83 (though I'd developed o-a in my left hip 8 years earlier). I find opioid analgesics (DHC) very effective in muting my often severe pain - the side effects I can live with. All my meds cause side-effects to a degree, but so what? As always, medication is a trade-off between benefits and problems, and for me, at least, the benefits of DHC far outweigh any problems (the worst of which is constipation, which is manageable). I'm with Prof. Conaghan on this (I'm sure he'll be relieved!).

Of course the fat should be thin, and of course they should take more exercise, but patients tell us that Co-dydramol, Co-codamol (and Co-proxamol) are better than Paracetamol alone. The 'be thin and suffer' message is not sustainable.

Surely the adverse effects of oral NSAIDs, which would be pretty much the only alternative when paracetamol didn't work, would be far greater?

This is an interesting review. The conclusion is somewhat severe for patients with pain due to osteoarthritis. The issue in the clinic is of the individual rather than the 'average' that results from these analyses. Every prescription, particularly for older people, is a balance of the benefits versus the risks of adverse events. In older people nonpharmacological recommendations are important but in practice pharmacological adjuvant therapy is often needed for adequate analgesia and to maintain quality of life. For many older people with osteoarthritis, it is not so much the placebo that is the useful comparison, rather the paracetamol and oral nonsteroidal anti-inflammatory drugs. The last Cochrane review (Towheed 2006) on this subject found that oral NSAID's were marginally more effective than paracetamol without increased safety concerns in the studies of short duration which were highly selective. That review goes on to point out 'This conclusion may not be generalizable to the clinical setting where a heterogeneous patient population (some of whom who may have significant baseline risk factors for NSAID toxicity) is being managed. Risk factors for upper GI bleeding in patients treated with NSAIDs include age > = 65 years, history of peptic ulcer disease or of upper GI bleeding, concomitant use of oral glucocorticoids or anticoagulants, presence of comorbid conditions (Gabriel 1991, Lanza 1998). Risk factors for NSAID-induced reversible renal failure in patients with intrinsic renal disease include age > = 65 years, hypertension and/or congestive heart failure, and concomitant use of diuretics and angiotensin-converting enzyme inhibitors'. These comments allied to the cardiovascular concerns for NSAID's in this age group do mean that consideration of opioid medication is often necessary and when carefully evaluated this option is needed to provide meaningful pain relief, as suggested in the international and NICE guidelines.