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More than a Quarter of Patients With OA Still Receive Opioids
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Despite recommendations against their use, nearly 27% of patients with osteoarthritis still receive opioids and benzodiazepines, with about 36% of such individuals demonstrating at least one risk factor for prescription misuse, according to data from a large health care system published in Arthritis Care & Research.
“The last 2 decades have seen significant increase in the prescription of opioids and benzodiazepines in the United States, and physicians treating musculoskeletal conditions and injuries have played a significant role,” Vignesh K. Alamanda, MD, of the Carolinas Medical Center, Charlotte, North Carolina, and colleagues wrote. “Opioid overdoses were involved in more than 43,349 deaths in 2016, representing a fivefold increase since 1999. Deadly consequences have resulted from the increased utilization of prescription opioids and benzodiazepines.”
“Evidence-based guidelines do not support long-term improvements in pain or function in patients with osteoarthritis (OA) when treated with opioids,” they added. “Clinical Practice Guidelines released by the American Association of Orthopaedic Surgeons (AAOS) in 2017 recommend against the use of the opioid pain medication for the treatment of osteoarthritis.”
To evaluate the prevalence of patients with OA who receive opioids and benzodiazepines, as well as to describe the risk factors for prescription drug abuse among these patients, Alamanda and colleagues conducted a retrospective cohort study at a large health care system. The researchers examined ED, urgent care and outpatient encounters between January and December 2016, focusing on primary diagnoses of knee, hip, shoulder, wrist, ankle, elbow or other joint-related OA. A total of 58,603 such encounters were identified, of which 31,123 were included in the final analysis after excluding cancer outpatient procedures.
The researchers collected demographic and prescription data, and recorded patientspecific risk factors. They also performed a descriptive analysis to characterize patients who received prescription opioids, as well as those who did not.
According to the researchers, nearly 27% of the encounters included in the final analysis included the patient receiving a prescription for opioids and benzodiazepines. Of these, 43% involved patients aged older than 65 years. The most commonly prescribed medication, representing 34.4% of encounters, was hydrocodone-acetaminophen, and 53% of prescriptions were written by pain specialists. Among patients who received opioids and benzodiazepines, 35.5% demonstrated at least one risk factor for prescription misuse, the most common being “early refill” and a history of receiving three or more prescriptions in the past month.
“Despite practice guidelines suggesting otherwise, opioids are being used for management of osteoarthritic pain,” Alamanda and colleagues wrote. “Additionally, significant amounts of these medications are being prescribed both to groups potentially at risk for misuse as well as the elderly. Alternative treatment modalities to opioids including the use of non-steroidal anti-inflammatory medications and acetaminophen, cryotherapy and cognitive behavioral therapies should be implemented to help manage symptoms.” – by Jason Laday
Disclosures: Alamanda reports no relevant financial disclosures. Please see the full study for additional authors’ disclosures.
Perspective
Back to TopMark D. Harris, MD, FACR
In 2017, the U.S. Department of Health and Human Services declared a public health emergency in response to the emerging opioid epidemic. Their 5-point strategy to combat the opioid crisis included a call for further research on the topics of pain and addiction.
Alamanda and colleagues contributed to this body of research with a study of >30,000 outpatient osteoarthritis encounters over a 1-year period, revealing that nearly 27% of patients received a prescription for an opioid or benzodiazepine. Most alarmingly, 3% of the patients received concurrent prescriptions for both classes of medications.
Tracking closely with the increased use of opioid analgesics over the last two decades has been a similar increase in benzodiazepine use, with the number of prescriptions increased by 67% from 1996 to 2013. The combination of benzodiazepines and opioids is a potent and potential lethal combination. More than 30% of all opioid overdoses also involve the use of benzodiazepines, and overdose deaths are 10 times higher in patients receiving benzodiazepines with opioid therapy compared to opioids alone. In a 2015 Veteran’s Health Administration study, nearly half of all Veterans who died from opioid overdoses also received prescriptions for benzodiazepines.
Opioids and benzodiazepines now carry an FDA “black box” warning, highlighting the dangers of concomitant use of these medications. Our current prescription medication crisis may be better thought of as a Polypharmacy Epidemic, as Dr. Alamanda’s study emphasizes.
Prescription opioid volumes peaked in 2011 and have declined by nearly 30%, but with such attention appropriately focused on opioid prescriptions, we need to remain vigilant of the risk of exposing patients to other sedating medications — not only benzodiazepines, but muscle relaxants, gabapentinoids or other CNS depressants.
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