Pain relief guidelines for osteoarthritis ‘need revision’
By Sally Robertson, medwireNews Reporter
12 March 2013
J Am Geriatr Soc 2013; Advance online publication

medwireNews: The current practice of prescribing narcotic analgesics as pain relief for individuals with osteoarthritis (OA) may need reconsideration, suggest US researchers.

A study of elderly adults (aged 65-89 years) with OA who were prescribed pain relief medications between 2001 and 2009 showed that as the amount of prescriptions for opiate analgesics increased, so did the proportion of people who experienced a fall or fracture.

Moreover, individuals prescribed narcotic analgesics accounted for the majority of the increase in the proportion of falls and fractures after 2004, when their use was recommended in place of antiinflammatory drugs.

"Cyclooxygenase 2 (COX-2)-selective nonsteroidal anti-inflammatory drugs (NSAIDs) were initially hailed as a significant advance for the treatment of pain when first introduced in 1999…," remark Lydia Rolita (Albert Einstein College of Medicine, New York) and team, "but after 5 years of use, certain COX-2-selective agents were associated with a significant risk for cardiovascular disease, leading to withdrawal of some of these agents at the end of 2004."

In addition, the American Geriatrics Society guidelines for pain relief in older adults were altered to reflect these concerns and recommended the use of opiates in place of both COX-2-selective inhibitors and NSAIDs.

As reported in the Journal of the American Geriatrics Society, the researchers analyzed medical records available for a 9-year period (2001-2009) for individuals with a diagnosis of OA.

The researchers report that in 2001, only 61 (1.6%) of 3731 individuals were prescribed narcotic analgesics, compared with 3329 (30.2%) of 11,012 participants in 2009.

In contrast, the proportion of participants who received prescriptions for COX-2 selective agents peaked at 10% in 2004, and then rapidly declined to 4% in subsequent years.

In 2001, almost all participants received a prescription for NSAIDs. However, this declined by approximately 25% by 2004 and remained at this rate for the remainder of the study period.

The researchers report that a significantly greater proportion of participants in the post-COX-2 study period (2005-2009) experienced falls and fractures than in the earlier time period, at 10% versus 2%. And participants who received narcotic analgesics were significantly more likely to experience a fall or fracture in both study periods than those who received COX-2 or other NSAIDS.

Overall, after adjustment for age and comorbidities, participants who received a narcotic analgesic were at a 3.3-fold and 4.1-fold greater risk for falls and fractures compared with participants who received a COX-2 inhibitors or other NSAIDs, respectively.

The researchers say the findings "suggest an unintended consequence of adoption of a change in treatment practices without due consideration of potential side effects."

They conclude: "The current guidelines for the treatment of pain, which include first-line prescription of narcotics, should be reevaluated."

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