Oral Narcotics (Recommendation Against)
Oral narcotics, including tramadol, result in a significant increase of adverse events and are not effective at improving pain or function for treatment of osteoarthritis of the knee.

Rationale

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.