Review supports move away from OA ‘analgesic ladder’

A review that finds opioids and NSAIDs provide similar pain relief in people with OA is further evidence that we should move away from the concept of an ‘analgesic ladder’, an expert says.

The exploratory network meta-analysis by researchers from the Brigham and Women’s Hospital in Boston involved 27 treatment arms (9 celecoxib, 4 non-selective NSAIDS diclofenac, naproxen and piroxicam), 11 less potent opioids (tramadol) and 3 potent opioids (hydromorphone, oxycodone).

It showed that after adjusting for pain at baseline the average reduction in WOMAC pain achieved by non-selective NSAIDs and less potent opioids was – 18 points and for more potent opioids was -19.

“As it is likely that most patients considering opioids have previously taken NSAIDs our analyses provides a practical way of describing the extent of pain relief a patient can expect with opioids,” the study authors wrote in Osteoarthritis and Cartilage.

Rheumatologist and pain expert Dr Sam Whittle from the Royal Adelaide Hospital said the findings provided further evidence that we should move away from the concept of the ‘analgesic ladder’ in the management of OA pain.

“We have an array of options, most of which aren’t that effective, that can be discussed between doctor and patient, taking into account individual goals, comorbidities and risks” he told the limbic.

“The idea that there is a natural progression to opioid analgesia in this setting should be strongly discouraged,” he said.

One of the issues with studies like the current one was the extent to which the findings can be used to inform decision-making in the real world.

“All analgesic studies of this nature have relatively low generalizability, mainly due to short duration and the various exclusions that are inherent in randomised controlled trials such as comorbidities and concurrent therapies,” he said.


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