Opioids won't help arthritis patients long-term: study

by Amy Norton, Healthday Reporter

Opioid painkillers may temporarily ease the discomfort of arthritis, but they have no clear lasting benefit, a research review finds.

11 nov 2019--In an analysis of 23 clinical trials, researchers found that, on average, opioid medications were somewhat effective at easing pain in patients with osteoarthritis. That's the common form of arthritis in which cartilage cushioning the joints gradually wears down, leading to swelling, stiffness and pain.

But the trials found no evidence that opioids improved patients' quality of life or helped with their depression. And any benefits for pain seemed to wane with time.

"We found that the magnitude of these effects is small and continues to decrease over time," said lead researcher Dr. Raveendhara Bannuru. He is director of the Center for Treatment Comparison and Integrative Analysis at Tufts Medical Center, in Boston.

Treatment guidelines for chronic pain, other than cancer-related pain, already say opioids should be a last resort.

With osteoarthritis, Bannuru said, the drugs are only recommended if a patient has not gotten relief from other medical therapies, and if surgery—like knee or hip replacement—is not an option.

Instead, patients should try to exercise regularly and maintain a healthy lifestyle. As for medications, Bannuru said, topical versions of nonsteroidal anti-inflammatory drugs (NSAIDs)—like ibuprofen and naproxen—are a "first choice."

These creams or ointments help people avoid the side effects that can come with prolonged used of oral NSAIDs (such as Motrin, Advil, Aleve), Bannuru noted. Injections of hyaluronic acid, a substance in joint fluids, are another option, he said.

In addition, aerobic activity, like walking, and exercises that strengthen the muscles around the arthritic joint can be helpful, according to Dr. Steven Eyanson, a rheumatologist who was not involved in the study.

And if a patient is overweight, shedding some pounds can help ease pain and improve joint function, said Eyanson, a retired adjunct assistant professor at the University of Iowa in Iowa City.

"In the case of osteoarthritis, the benefits of therapy by opioid pain relief are very limited," Eyanson said.

Bannuru was scheduled to present the findings Saturday at the American College of Rheumatology's annual meeting, in Atlanta. Research presented meetings is generally considered preliminary until it is published in a peer-reviewed journal.

For the study, the researchers pooled the results of 23 previously published clinical trials that involved more than 11,400 osteoarthritis patients.

Overall, the investigators found, opioid treatment had a modest effect on people's pain over two to 12 weeks. At higher doses, the drugs were actually less effective, and carried a higher risk of side effects, such as nausea, constipation and diarrhea.

"In light of dependency concerns and the discomfort that many patients feel while taking the drugs, it would appear that there is no optimal therapeutic window for the use of oral opioids in osteoarthritis," Bannuru said.

The results come during a national crisis of opioid addiction that, according to government figures, is killing 130 Americans each day.

After years of skyrocketing, prescriptions for opioids—like OxyContin, Vicodin and Percocet—have been declining since 2012, according to the U.S. Centers for Disease Control and Prevention. In recent years, illegal opioids—like heroin and illicitly manufactured fentanyl—have become the biggest concern.

Still, prescription opioids were involved in 36% of opioid overdose deaths in 2017, the CDC says.

"We hope the results of our study will empower osteoarthritis patients to have informed discussions with their health care providers about the safest and most effective treatment options for their pain," Bannuru said.

Eyanson said that, to him, "the take-home messages are that opioids have limited benefit in osteoarthritis pain control, and have significant potential for risk."

Most osteoarthritis patients will benefit from a "more holistic approach"—including medication and non-drug therapies, and in some cases, surgery, he added.

More information: The Arthritis Foundation has more on treating osteoarthritis.

Study: Is There Any Role for Opioids in the Management of OA? (Abstract #910).

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Infection risk up for seniors with rheumatoid arthritis

Elderly adults with rheumatoid arthritis have a considerable risk of serious infection, with antirheumatic drug use increasing the risk, according to a study published online July 25 in Arthritis Care & Research.

07 aug 2012-- Elderly adults with rheumatoid arthritis have a considerable risk of serious infection, with antirheumatic drug use increasing the risk, according to a study published online July 25 in Arthritis Care & Research.

Jessica Widdifield, Ph.D., of University of Toronto, and associates examined the risk and risk factors for serious infection in a cohort of 86,039 patients with rheumatoid arthritis, aged 66 years or older, from Ontario health administrative data across 1992 to 2010.

The researchers identified 20,575 infections, for a rate of 46.4 per 1,000 person-years, with respiratory infection, herpes zoster, and skin/soft tissue infection being the most common. Factors that correlated with infection included higher comorbidity, rural residence, markers of disease severity, and history of prior infection. There was a several-fold increase in infection noted with the use of anti-tumor necrosis factor agents and disease modifying antirheumatic drugs (adjusted odds ratio ranging from 1.2 to 3.5), with the greatest effect seen for glucocorticosteroids (odds ratio ranging from 4.0 at low doses to 7.6 at high doses).

"While the relative risk of serious infection was elevated across all antirheumatic treatments, the message should not be that non-use is the way to reduce infection risk in seniors," the authors write. "Rather, seniors with rheumatoidarthritis have significant morbidity related to serious infections and require enhanced vigilance in the management of their pharmacotherapy and comorbidities."

More information: Abstract 

Incorporating education in exercise programs increases benefits for arthritis patients

COLUMBIA, Mo., 09 oct 2008– Arthritis is the nation's most common cause of disability. The number of adults with doctor-diagnosed arthritis is projected to increase to 67 million by 2030, and a large proportion of U.S. adults will limit their activity as a result, according to the Centers for Disease Control and Prevention. Now, in a new study, University of Missouri researchers found that adults with arthritis who received exercise interventions that included educational components significantly increased their physical activity levels and experienced improvements in pain and physical functioning.
"Many researchers examine the effectiveness of exercise classes to encourage people with arthritis to start exercising, but these studies don't examine what the classes are teaching people and if those people continue exercising after the class is over," said Marian Minor, professor in the MU Department of Physical Therapy in the School of Health Professions. "All exercise programs should include educational components that teach people how to stay active for life. We know from other studies that exercise reduces pain and improves physical functioning and mental health, but if people stop exercising, the benefits will go away."
The researchers found that patients with arthritis who learned exercise habits through physical activity interventions reported decreases in pain and increases in physical functioning, compared to patients who did not participate in interventions. Educational components helped patients maintain increased physical activity levels. Patients reported additional benefits, including increased muscle strength and better mental health, said Vicki Conn, lead author of the study, professor and associate dean of research in the MU Sinclair School of Nursing.
"Educational components can be incorporated into exercise programs in any setting that are currently suggested by physicians, nurses and other care providers," Conn said. "We found various tactics for educating patients that are effective, including one-on-one discussions with care providers or group interventions, providing self-monitoring advice, providing feedback to subjects regarding their performance, goal-setting, and problem-solving."
The researchers completed a meta-analysis incorporating data from 4,111 participants in 28 studies; participants included people with osteoarthritis, knee arthritis and rheumatoid arthritis. Only studies that measured physical activity after the completion of the intervention were included.
"Health care providers have a responsibility to educate patients and help them maintain effective physical activity habits. It is important that people diagnosed with arthritis have someone to look to for education and help with managing their symptoms. This is a public health priority, and health providers need to teach people to take control of their own health and improve their lives," Minor said.
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The study, "Physical Activity Interventions Among Adults with Arthritis: Meta-Analysis of Outcomes," was published in Seminars in Arthritis and Rheumatism. It was funded by a grant from the National Institutes of Health.

New study proves that pain is not a symptom of arthritis, pain causes arthritis

New treatments will seek to interrupt 'crosstalk' between joints and the spinal cord

03 oct 2008--Pain is more than a symptom of osteoarthritis, it is an inherent and damaging part of the disease itself, according to a study published today in journal Arthritis and Rheumatism. More specifically, the study revealed that pain signals originating in arthritic joints, and the biochemical processing of those signals as they reach the spinal cord, worsen and expand arthritis. In addition, researchers found that nerve pathways carrying pain signals transfer inflammation from arthritic joints to the spine and back again, causing disease at both ends.
Technically, pain is a patient's conscious realization of discomfort. Before that can happen, however, information must be carried along nerve cell pathways from say an injured knee to the pain processing centers in dorsal horns of the spinal cord, a process called nociception. The current study provides strong evidence that two-way, nociceptive "crosstalk" may first enable joint arthritis to transmit inflammation into the spinal cord and brain, and then to spread through the central nervous system (CNS) from one joint to another.
Furthermore, if joint arthritis can cause neuro-inflammation, it could have a role in conditions like Alzheimer's disease, dementia and multiple sclerosis. Armed with the results, researchers have identified likely drug targets that could interfere with key inflammatory receptors on sensory nerve cells as a new way to treat osteoarthritis (OA), which destroys joint cartilage in 21 million Americans. The most common form of arthritis, OA eventually brings deformity and severe pain as patients loose the protective cushion between bones in weight-bearing joints like knees and hips.
"Until relatively recently, osteoarthritis was believed to be due solely to wear and tear, and inevitable part of aging," said Stephanos Kyrkanides, D.D.S., Ph.D., associate professor of Dentistry at the University of Rochester Medical Center. "Recent studies have revealed, however, that specific biochemical changes contribute to the disease, changes that might be reversed by precision-designed drugs. Our study provides the first solid proof that some of those changes are related to pain processing, and suggests the mechanisms behind the effect," said Kyrkanides, whose work on genetics in dentistry led to broader applications. The common ground between arthritis and dentistry: the jaw joint is a common site of arthritic pain.
Study Details
Past studies have shown that specific nerve pathways along which pain signals travel repeatedly become more sensitive to pain signals with each use. This may be a part of ancient survival skill (if that hurt once, don't do it again). Secondly, pain has long been associated with inflammation (swelling and fever).
In fact, past research has shown that the same chemicals that cause inflammation also cause the sensation of pain and hyper-sensitivity to pain if injected. Kyrkanides' work centers around one such pro-inflammatory, signaling chemical called Interleukin 1-beta (IL-1β), which helps to ramp up the bodies attack on an infection.
Specifically, Kyrkanides' team genetically engineered a mouse where they could turn up on command the production of IL-1β in the jaw joint, a common site of arthritis. Experiments showed for the first time that turning up IL-1β in a peripheral joint caused higher levels of IL-1β to be produced in the dorsal horns of the spinal cord as well.
Using a second, even more elaborately engineered mouse model, the team also demonstrated for the first time that creating higher levels of IL-1β in cells called astrocytes in the spinal cord caused more osteoarthritic symptoms in joints. Past studies had shown astrocytes, non-nerve cells (glia) in the central nervous system that provide support for the spinal cord and brain, also serve as the immune cells of CNS organs. Among other things, they release cytokines like IL-1β to fight disease when triggered. The same cytokines released from CNS glia may also be released from neurons in joints, possibly explaining how crosstalk carries pain, inflammation and hyper-sensitivity back and forth.
In both mouse models, experimental techniques that shut down IL-1β signaling reversed the crosstalk effects. Specifically, researchers used a molecule, IL-1RA, known to inhibit the ability of IL-1β to link up with its receptors on nerve cells. Existing drugs (e.g. Kineret® (anakinra), made by Amgen and indicated for rheumatoid arthritis) act like IL-1RA to block the ability IL-1β to send a pain signal through its specific nerve cell receptor, and Kyrkanides' group is exploring a new use for them as osteoarthritis treatment.
The implications of this process go further, however, because the cells surrounding sensory nerve cell pathways too can be affected by crosstalk. If 10 astrocytes secrete IL-1β in response to a pain impulse, Kyrkanides said, perhaps 1,000 adjacent cells will be affected, greatly expanding the field of inflammation. Spinal cord astrocytes are surrounded by sensory nerve cells that connect to other areas of the periphery, further expanding the effect. According to Kyrkanides' model, increased inflammation by in the central nervous system can then send signals back down the nerve pathways to the joints, causing the release of inflammatory factors there.
Among the proposed, inflammatory factors is calcitonin gene related peptide (CGRP). The team observed higher levels calcitonin-gene related peptide (CGRP) production in primary sensory fibers in the same regions where IL-1β levels rose, and the release of IL-1β by sensory neurons may cause the release of CGRP in joints. Past studies in Kyrkanides reveal that CGRP can also cause cartilage-producing cells (chondrocytes) to mature too quickly and die, a hallmark of osteoarthritis.
Joining Kyrkanides in the publication from the University of Rochester School of Medicine and Dentistry were co-authors M. Kerry O'Banion, M.D., Ph.D., Ross Tallents, D.D.S., J. Edward Puzas, Ph.D. and Sabine M. Brouxhon, M.D. Paolo Fiorentino was a student contributor and Jennie Miller was involved as Kyrkanides' technical associate. Maria Piancino, led a collaborative effort at the University of Torino, Italy. This work was supported in part by grants from the National Institutes of Health.
"Our study results confirm that joints can export inflammation in the form of higher IL-1β along sensory nerve pathways to the spinal cord, and that higher IL-1β inflammation in the spinal cord is sufficient in itself to create osteoarthritis in peripheral joints," Kyrkanides said. "We believe this to be a vitally important process contributing to orthopaedic and neurological diseases in which inflammation is a factor."

Disability In Older Adults With Arthritis And Differences Among Racial Groups

02 Aug 2007 Arthritis is common among elderly Americans, and as the population ages it is expected to increase. At the same time, disability is increasing in patients with arthritis and the racial/ethnic composition of the U.S. is changing; minority populations are forecasted to increase from 30.6 percent of the population in 2000 to 49.9 percent by 2050. A new study published in the August issue of Arthritis Care & Research examined the rates at which different racial groups develop disability, how differences between groups can be accounted for, and the significant risk factors that predict the development of disability among older adults with arthritis.. Led by Jing Song of Northwestern University Feinberg School of Medicine in Chicago, IL, researchers examined data from the 1998-2004 Health and Retirement Study (HRS), a national study of noninstitutionalized older Americans. Using information from 1998, 2000, 2002 and 2004, their analysis included 7,257 respondents who reported arthritis and were initially disability free. The group was comprised of 85.5 percent whites, 9.3 percent African Americans, 2.4 percent Hispanics who spoke Spanish and 2.9 percent Hispanics who spoke English. Respondents were questioned as to whether they had arthritis, and disability was established by an inability (after the initial interview) to perform at least one task in the activities of daily living (ADL) as defined by the HRS: dressing, walking across a room, getting in or out of bed, bathing, eating and toileting. The results showed that 1 out of 6 people reported disability in at least one ADL task over the 6-year follow-up period, but there were substantial differences across race/ethnicity groups. The rates of ADL disability among African Americans and Hispanic/Spanish were almost twice that of whites; Hispanic/English had rates similar to whites. The study differentiated between Hispanics who spoke English and those who spoke Spanish in order to consider whether adapting to a new culture (as measured by language) can affect health status. The authors note that language barriers may limit educational and occupational choices, and social stress related to poverty may contribute to the greater disability experienced by the Hispanic/Spanish group. The study investigated the influence of health and medical access on racial/ethnic differences in developing disability and found that the differences were due to other chronic health conditions, functional limitation (such as an inability to walk several blocks), and health behaviors (such as smoking, alcohol consumption and regular exercise). Medical access also substantially influenced differences in the development of disability. In addition to having fewer economic resources, minorities were more likely to be uninsured or rely on Medicaid coverage. The authors note that lack of private insurance may indicate poorer quality of health care received and that those with lower tier health plans commonly have fewer choices regarding health services, which can compromise their quality of care. The authors acknowledge that the study included self-reported arthritis, did not include information on the severity of the condition, and that the findings might have been influenced by unmeasured factors such as occupation, job demands, poorer living conditions and segregation. Nonetheless, the results showed that among older adults with arthritis, differences among racial groups in developing disabilities was largely due to differences in health status and medical access. "At the clinical level, not only should treatment of comorbid conditions be considered, but also disease prevention, prevention and treatment of functional limitations, and promotion of healthy behaviors should be a priority for all patients with arthritis to prevent the development of disability," the authors conclude. "Future research should be directed at how to more effectively deliver such programs especially to minority populations."----------------------------Article adapted by Medical News Today from original press release.---------------------------- Article: "Racial/Ethnic Differences in Activities of Daily Living Disability in Older Adults with Arthritis: A Longitudinal Study," Jing Song, Huan J. Chang, Manasi Tirodkar, Rowland W. Chang, Larry M. Manheim, Dorothy D. Dunlop, Arthritis Care & Research, August 2007; (DOI: 10.1002/art.22906). Source: Amy Molnar John Wiley & Sons, Inc.

Health and Access to Care Help Explain Differences in Arthritis Disability Risk

CHICAGO, July 30 -- Racial and ethnic differences in the rate at which older adults with arthritis become disabled may be largely a function of overall health and access to care, researchers found.
In a study of older Americans with arthritis, African-Americans and Spanish-speaking Hispanics were nearly twice as likely as English-speaking Hispanics and whites to develop limitations in activities of daily living over a six-year period, said Jing Song, M.S., of Northwestern University here, and colleagues.
Together, comorbid conditions, functional limitations, and health behaviors accounted for more than half of the excess risk among the minority groups, they reported in the August issue of Arthritis Care & Research.
Health insurance and other medical access factors, such as education and income, were substantial mediators of differences as well, they noted.
Previous studies had discovered racial and ethnic disparities in risk of disability in this population, but the reasons behind it were not clear.
So, the researchers analyzed data from the nationally-representative sample of 7,257 participants in the larger Health and Retirement Study who self-reported arthritis and were initially disability free.
The study surveyed adults 51 and older about arthritis and ability to perform activities of daily living (dressing, walking across a room, getting in or out of bed, bathing, eating and using the toilet) in 1998, 2000, 2002, and 2004.
Most of the cohort was white (85.5%), 9.3% were African-American, 2.4% were Hispanics who spoke Spanish, and 2.9% were Hispanics who spoke English. The average age at baseline was 66.7.
The researchers distinguished between language groups for Hispanic participants as a proxy for acculturation.
After six years of follow-up, 17.7% of participants had developed disability in at least one activity of daily living.
The six-year incidence rates were:
28.0% among African-Americans (adjusted hazard ratio 1.94 versus whites, 95% confidence interval 1.51 to 2.38).
28.5% among Spanish-speaking Hispanics (adjusted HR 2.03 versus whites, 95% CI 1.35 to 2.71).
19.1% among English-speaking Hispanics (adjusted HR 1.41 versus whites, 95% CI 0.82 to 2.00).
16.2% among whites.
Overall, health factors -- chronic comorbidities, functional and physical limitations, smoking, alcohol use, exercise, and weight -- appeared to explain the majority of the excess risk among minorities. The findings were:
Adjusting for health factors reduced risk among African-Americans by 55% (adjusted HR 1.42).
Adjusting for health factors reduced risk among Spanish-speaking Hispanics 60% (adjusted HR 1.41).
Adjusting for health factors among English-speaking Hispanics left risk essentially unchanged (adjusted HR 1.42).
Each health factor explained 28% to 35% of excess risk for African-Americans and Spanish-speaking Hispanics.
Likewise, medical access factors -- education, income, net wealth, and health insurance -- explained a substantial proportion of excess risk. Adjusting for medical access reduced hazard ratios by 60% for African-Americans, 95% for Spanish-speaking Hispanics, and 73% for English-speaking Hispanics.
But controlling for health factors and demographics, medical access reduced risk only an additional 12% for African-Americans (adjusted HR 1.31), 20% for Spanish-speaking Hispanics (adjusted HR 1.20), and 24% for English-speaking Hispanics (adjusted HR 1.32).
Furthermore, controlling for the other risk factors eliminated most medical access factors as significant predictors of developing disability. Only enrollment in Medicaid (adjusted HR 1.65) and Medicare or other public health insurance (adjusted HR 1.41) remained significant.
The reason for differences between language groups among Hispanics may be related to "disadvantages stemming from limited educational and occupational choices, and social stress related to poverty," the researchers noted.
However, the language differences may also reflect a different cultural paradigm for health and illness, they cautioned. Other unmeasured factors may have contributed to disability in the other groups as well, such as occupation and its demands, living conditions, and segregation, they added.
Song and colleagues also acknowledged that the study had no information on disease severity and relied upon self-reporting.
Nonetheless, "at the clinical level, not only should treatment of comorbid conditions be considered, but also disease prevention, prevention and treatment of functional limitations, and promotion of healthy behaviors should be a priority for all patients with arthritis to prevent the development of disability," the investigators concluded.
The study was supported in part by the National Institute for Arthritis and Musculoskeletal Diseases and National Center for Medical Rehabilitation Research. The researchers provided no information on conflicts of interest.Primary source: Arthritis & Rheumatism (Arthritis Care & Research)Source reference: Song J, et al "Racial/Ethnic Differences in Activities of Daily Living Disability in Older Adults With Arthritis: A Longitudinal Study" Arthritis Rheum 2007;57:1058-1066.