Risky Painkillers Commonly Prescribed for Osteoarthritis

Nearly one-third of patients in one large health system get opioids, benzodiazepines

https://www.medpagetoday.com/meetingcoverage/aaos/78645

LAS VEGAS — Published guidelines warn that treating osteoarthritis (OA) with opioids and benzodiazepines can boost patients’ risk of falling. Nevertheless, physicians in a large health system were prescribing those drugs for the condition nearly a third of the time, often in the vulnerable elderly, according to a study reported here.

More alarmingly, 3% of the patients received concurrent prescriptions for opioids or benzodiazepines. This is “a significant and potentially deadly combination,” said the study’s lead author, Vignesh K. Alamanda, MD, an orthopedic surgery resident with Atrium Health, in a presentation at the 2019 annual meeting of the American Academy of Orthopaedic Surgeons.

He and his colleagues tracked 20,556 outpatient visits in the first half of 2016 in the Atrium Health system, which serves North and South Carolina. All of the patients had a primary diagnosis of osteoarthritis. In nearly 32% of the visits, patients were prescribed opioids and/or benzodiazepines, with hydrocodone-acetaminophen prescribed almost half the time.

More than 37% of patients who received a prescription were considered to be at risk for prescription misuse, judging by factors such as early refill (33%), positive toxicology screen (4%), and previous overdose (1%). Patients older than age 65 made up 43% of those who got the drugs.

“Deadly consequences have resulted from the increased utilization of prescription opioids and benzodiazepines,” Alamanda told MedPage Today in an interview after the presentation. “This is particularly important in the elderly population, who are especially at high risk for falls, constipation, and adverse medication reactions. Additionally, studies have shown worse outcomes in patients who are managed with opioids for their osteoarthritis who eventually undergo a total joint arthroplasty including experiencing increased length of stay, increased risk of revision, and poor postoperative pain control.”

A 2019 position statement by the American Association of Hip and Knee Surgeons states that “the use of opioids for the treatment of osteoarthritis of the hip and knee should be avoided and reserved only for exceptional circumstances.” A 2014 Cochrane Library review, meanwhile, found that opioids “have a small effect on pain or physical function” in OA.

“OA is a chronic disease, and the use of opioids is not recommended as it does not treat the problem. Over time patients can develop tolerance and increased risk or dependence and abuse,” said Vani J. Sabesan, MD, an orthopedic surgeon and shoulder/elbow sports medicine specialist at Cleveland Clinic Florida.

In contrast to opioids, there’s been little research interest in benzodiazepines in OA, although studies have suggested that they boost the risk of falls in the elderly, Sabesan explained. “There is some evidence that patients have a higher risk of opioid usage if they take benzos, and there is higher risk of abuse when taking both. Otherwise, not much else is out there.”

Sabesan cautioned that the new study is based on 3-year-old data. Awareness about the opioid risk has grown since then, she said, and new guidelines have appeared. “Strategies to improve compliance with evidence-based guidelines as well as alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis,” she said. “Primary care physicians and orthopedic surgeons need to be more aware, educate patients on the risks of opioids, and communicate with patients about better alternate methods of pain management.”

I find this almost humorous how they use certain words and phrases to make the statement sound REALLY BAD when using vague statements

take this statement: Published guidelines warn that treating osteoarthritis (OA) with opioids and benzodiazepines can boost patients’ risk of falling. the word CAN is a very VAGUE term unless it is followed by some numeric increase or percentage increase, other than that it is just a GUESS or an OPINION.

More than 37% of patients who received a prescription were considered to be at risk for prescription misuse, judging by factors such as early refill (33%), positive toxicology screen (4%), and previous overdose (1%). Patients older than age 65 made up 43% of those who got the drugs.

Early refills suggests that the pt may not have been prescribed a adequate dose of the opiate to help them obtain a acceptable level of pain.  Directions could have read every 4 hrs AS NEEDED and the prescriber presumed 4 doses/day and the pt took them around the clock because every 4 hrs suggest 6 doses in a 24 hr day – so a EARLY REFILL would have occurred.  Because neither the prescriber nor the pharmacist made it clear to the pt the expectation of the pt only taking 4 doses in 24 hr.   What does the term “positive toxicology screen” really mean… they were positive for the Hydrocodone and Benzo that they were taking ?

Over time patients CAN develop tolerance and increased risk or dependence and abuse

there is that vague word again CAN… expressing an opinion or belief and not really supported by FACTS

although studies have suggested that they boost the risk of falls in the elderly

There is another VAGUE word when describing the possibility of adverse pt outcomes

“There is some evidence that patients have a higher risk of opioid usage if they take benzos, and there is higher risk of abuse when taking both

Again no per-cent was stated… would 1% define SOME… would 0.5% defined SOME ? and there is a HIGHER RISK OF ABUSE… RISK and the reality of abuse is not the same

This article seems to try to give the impression that there is a problem with pts taking both HCD/APAP and a Benzo when in fact there was no real stats that they had or wished to publish because the numbers were so low that it would disprove their whole hypothesis