June 24, 2022

Is there a “best” painkiller for osteoarthritis?

ARCHIVED CONTENT: As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of publication or last revision of each article. Nothing on this site, regardless of date, should ever be used as a substitute for direct medical advice from your physician or other qualified clinician.

Osteoarthritis (OA) affects tens of millions of Americans and is a leading cause of disability and reduced quality of life worldwide. Other than joint replacement surgery, there is no known “cure” for osteoarthritis, and most treatments focus on relieving symptoms such as pain. Often the first step is non-drug approaches such as physical therapy, exercise, and weight loss. However, most patients will end up using pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs). Other types of drugs, such as opioids, have also been tested as treatments for osteoarthritis, and there is an ongoing debate about which treatments are best.

NSAIDs versus opioids: was there a clear winner?

A recent study compared oral NSAIDs and oral opioids for osteoarthritis pain relief. Researchers at Harvard-affiliated Brigham and Women’s Hospital performed a meta-analysis (that is, they combined and summarized the results of many published studies). They included clinical trials in which patients with knee osteoarthritis (KOA) were randomly selected to receive treatment lasting at least 2 months.

The researchers carefully selected the studies to include, and two team members independently reviewed each study and extracted the data. They selected studies that used a common, well-validated and widely accepted measure of pain (the WOMAC scale, which rates pain on a scale of 0 to 100). Data from over 5,500 patients was included, and the researchers found that, on average, treatment with oral NSAIDs reduced pain by about 18 points on the WOMAC scale. Treatment with less potent oral opioids (such as tramadol) also reduced pain by about 18 points, and potent oral opioids (such as oxycodone) reduced pain by about 19 points on the scale WOMAC. Since, on average, patients started out with pain ratings of about 50 to 60 out of 100, each of these drugs reduced patients’ pain by about 30%.

In short, each of these drugs helped reduce pain and their effects were about the same. The finding of about a 30% reduction in pain is very consistent with studies of many chronic pain treatments. Although we are quite good at managing acute pain, many chronic painful conditions such as osteoarthritis, low back pain and others are more difficult to treat effectively. Many researchers in the field believe that a multidisciplinary team (which includes healthcare providers from different backgrounds) working together to use a number of different approaches to managing pain offers the most effective way to manage pain. Chronic Pain. And there is good evidence for the effectiveness of these types of treatments. For example, a patient with severe KOA could: be treated with NSAIDs prescribed by their primary care physician; see a physical therapist to work on strengthening and conditioning leg muscles; occasionally receiving steroid injections into the knee to relieve inflammation and pain in the joint; and see a nutritionist for help with dieting and weight loss, which relieves pressure on the joint and can significantly reduce knee pain.

Towards a personalized approach to pain management

This meta-analysis cannot tell us which of these types of drugs (if any) should be prescribed for a particular patient. No study can. The variation from person to person in the effectiveness of any KOA treatment is huge. One patient may get almost total pain relief while another gets no relief at all. These results give clinicians a benchmark for the “typical” amount of pain relief that can be expected from these drugs, and suggest that since they work about as well, the choice of which one to use will be influenced. by considerations other than efficiency. . Providers and people with chronic pain should also weigh potential side effects. Treatment (especially long-term treatment) with oral NSAIDs can lead to stomach problems such as bleeding, ulcers, and stomach pain, as well as high blood pressure and kidney problems. Opioids can have side effects such as constipation, nausea, and drowsiness. As you probably also know, opioids are also associated with the risk of serious overdose and addiction.

Many of us in the pain management field hope to eventually be able to more effectively “personalize” pain treatment based on an individual’s characteristics and their likely responses to a particular treatment. It should be noted that non-drug treatments such as exercise, weight loss and improved diet usually have few or no side effects and have benefits that go beyond pain relief. to the knee (for example, improvements in heart health). For most people, these treatments should be part of their multidisciplinary pain management program, regardless of the drug options being considered.

As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of the last revision or update of all articles. Nothing on this site, regardless of date, should ever be used as a substitute for direct medical advice from your physician or other qualified clinician.

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