Among the 5 high-quality and 2 moderate quality studies that met the inclusion criteria, oral narcotic medications are not an effective treatment to reduce pain and improve function in osteoarthritis of the knee (Serrie 2017; Afilalo 2010; Mayorga 2016; Fishman 2007; Fleischmann 2001; Burch 2007; Babul 2004). In fact, the use of narcotics to treat osteoarthritis of the knee is consistently associated with a significantly high risk of adverse events. Due to the lack of efficacy and increase of adverse event, we would recommend against the use of narcotics for the treatment of osteoarthritis of the knee. Given the effective and relatively safe alternatives of oral NSAIDs and acetaminophen, oral narcotics should be avoided when the provider is considering the recommendation of an oral medication.
Benefits/Harms of Implementation
The removal of oral narcotics from the medications prescribed in the treatment of osteoarthritis of the knee will have further beneficial effects if patients fail non-surgical management and eventually progress to replacement of the knee, as they have been associated with adverse events after surgery as well.
Outcome Importance
The most important consideration will be removal of oral narcotics from the medications prescribed in the treatment of osteoarthritis of the knee. This becomes particularly significant due to the rise of the opioid epidemic in the United States.
Cost Effectiveness/Resource Utilization
Evidence based decision-making in selecting the optimal systemic treatment for the treatment of symptomatic knee osteoarthritis should result in improved pain and function. For a given systematic treatments as effectiveness increases without raising the risk of adverse events so will its cost effectiveness. To date, the most cost-effective systemic treatment is still to be determined.
Acceptability
Due to the lack of efficacy and increase of adverse event, a recommendation against the use of narcotics for the treatment of osteoarthritis of the knee was made and this could present some resistance from patients who have failed oral NSAIDs and acetaminophen. Nonetheless, patients should be counseled on the risks associated with narcotics and their lack of efficacy for the purpose of treating knee osteoarthritis.
Feasibility
This recommendation may be implemented immediately having a potential positive impact in clinical practice.
Future Research
Most important future research will provide high quality investigation through either prospective randomized trials or prospective cohort studies to establish efficacy within specific subgroups and populations to tailor systemic medications increasing efficacy and decreasing risk of adverse effects.
- Afilalo, M., Etropolski, M. S., Kuperwasser, B., Kelly, K., Okamoto, A., Van Hove, I., Steup, A., Lange, B., Rauschkolb, C., Haeussler, J. Efficacy and safety of Tapentadol extended release compared with oxycodone controlled release for the management of moderate to severe chronic pain related to osteoarthritis of the knee: a randomized, double-blind, placebo- and active-controlled phase III study. Clinical Drug Investigation 2010; 8: 489รข505
- Babul N,Noveck R,Chipman H,Roth SH,Gana T,Albert K. Efficacy and safety of extended-release, once-daily Tramadol in chronic pain: a randomized 12-week clinical trial in osteoarthritis of the knee. J Pain Symptom Manage 2004;28(1):59-71.
- Burch, F., Fishman, R., Messina, N., Corser, B., Radulescu, F., Sarbu, A., Craciun-Nicodin, M. M., Chiriac, R., Beaulieu, A., Rodrigues, J., Beignot-Devalmont, P., Duplan, A., Robertson, S., Fortier, L., Bouchard, S. A comparison of the analgesic efficacy of Tramadol Contramid OAD versus placebo in patients with pain due to osteoarthritis. 2007; 3: 328-38
- Fishman, R. L., Kistler, C. J., Ellerbusch, M. T., Aparicio, R. T., Swami, S. S., Shirley, M. E., Jain, A. K., Fortier, L., Robertson, S., Bouchard, S. Efficacy and safety of 12 weeks of osteoarthritic pain therapy with once-daily tramadol (Tramadol Contramid OAD). 2007; 5: 273-80
- Fleischmann, R. M., Caldwell, J. R., Roth, S. H., Tesser, J. R. P., Olson, W., Kamin, M. Tramadol for the treatment of joint pain associated with osteoarthritis: A randomized, double-blind, placebo-controlled trial. Current Therapeutic Research - Clinical and Experimental 2001; 2: 113-128
- Mayorga, A. J., Wang, S., Kelly, K. M., Thipphawong, J. Efficacy and safety of fulranumab as monotherapy in patients with moderate to severe, chronic knee pain of primary osteoarthritis: a randomised, placebo- and active-controlled trial. International Journal of Clinical Practice 2016; 6: 493-505
- Serrie, A., Lange, B., Steup, A. Tapentadol prolonged-release for moderate-to-severe chronic osteoarthritis knee pain: a double-blind, randomized, placebo- and oxycodone controlled release-controlled study. Current Medical Research & Opinion 2017; 8: 1423-1432