Burden of OA-associated pain

Osteoarthritis-associated pain

Pain associated with osteoarthritis is significant and requires an alternative management approach

Osteoarthritis (OA) is the most common form of arthritis, estimated to affect 302 million people worldwide¹. The knees, hips and hands are the most commonly affected joints; knee and hip osteoarthritis rank highly as global causes of disability (eleventh highest) and chronic pain among older adults^1-3. OA may also lead to increased risk of all-cause mortality and the incidence of OA continues to rise due to both the ageing population and increased prevalence of obesity⁴.

Let’s meet our patient ‘Marie’. How does knee osteoarthritis affect her daily life?

Note: this is a theoretical case for educational purposes only. Marie has had osteoarthritis (OA) for a number of years and so we review her treatment and comment on how she might have been treated differently using the current guideline recommendations. At the bottom of the page, you will have the opportunity to complete a short quiz based on this case study.

Initial clinical presentation

• Female, 55 years old, obese (BMI 34 kg/m²)
• 3-year history of progressively worsening pain in both knees
• Knees stiff for about 20 minutes first thing in the morning and for a few minutes after getting up from a chair during the day
• Difficulty walking >30 minutes because of pain and swelling (limits recreational walking with friends)
• Symptoms exacerbated by kneeling, squatting or descending stairs (limits gardening and housework)
• Sitting, resting and reclining relieve pain, but becomes stiff if in one position for too long

• Symptoms worse on humid or cold days

Linear pain scales overused in osteoarthritis

Traditional linear pain assessment scales are sometimes overused in osteoarthritis and may not be fit-for-purpose in assessing patient QoL in the real world

Accurate pain assessment is the foundation of optimal management⁷. However, because pain is highly subjective, assessing severity can be difficult. Indeed, healthcare professionals (HCPs) and patients frequently differ in their perception of pain severity associated with a condition or extent of tissue damage⁸. In a study comparing patient–physician discordance in global assessment of patients with osteoarthritis  (OA) (n = 243) versus patients with rheumatoid arthritis (RA) (n = 216), patients with OA were more likely to be discordant with their rheumatologists than patients with RA with the most important explanatory variable for discordance being higher levels of pain⁹.

Current osteoarthritis treatments often ineffective

Current osteoarthritis pain treatments are often ineffective, which may lead to treatment escalation and use of controlled drugs associated with more serious side effects

An observational study in patients with knee osteoarthritis (OA) suggests that inadequate pain relief (IPR) is highly prevalent. Following a year of physician-prescribed treatment, 54% of patients reported IPR (moderate-to-severe pain)¹³. This suggests that currently prescribed pain treatments for knee OA are not meeting the needs of the majority of patients¹³.

Opioid addiction avoidable

Opioids offer only small benefits in terms of pain and function in osteoarthritis (OA) and do not improve quality of life or depression¹⁶

Socioeconomic burden of osteoarthritis

The socioeconomic burden associated with osteoarthritis pain is significant and underestimated

What is the economic burden of osteoarthritis (OA)? Given its high prevalence, OA incurs substantial health and societal costs, both directly (clinician visits, treatments, surgery) and indirectly (impaired work productivity and early retirement)³.

The costs associated with OA can be particularly significant for the elderly, who face potential loss of independence and a requirement for help with activities of daily living. While estimating costs is difficult, the US Bone and Joint Initiative (USBJI) has highlighted the enormous economic impact of OA in their 2018 Burden of Musculoskeletal Diseases report²¹:

• In 2008–14, per-person medical costs attributed to OA averaged $11,052 per-year
• In 2008–14, annual all-cause costs (both direct and indirect) attributed to OA and allied disorders averaged $486.4 billion nationally
• In 2013, there were 20.78 million ambulatory care visits and ~2.95 million inpatient hospitalisations for patients with OA and associated disorders

In Europe a 2013 review estimated that²²:

• the average total annual cost of OA per patient in Europe ranged from €1,330 to €10,452
• when considering only direct medical costs, the annual cost of OA ranged from €534 to €1,788
• in active patients, the indirect costs were much higher than the direct costs

References

1. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72(2):220–233.
2. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: Estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(7):1323–1330.
3. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr Cartil. 2019;27(11):1578–1589.
4. Bruyere O, Honvo G, Veronese N, Arden NK, Branco J, Curtis EM, et al. An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Semin Arthritis Rheum. 2019;49(3):337–350.
5. Brandt KD, Radin EL, Dieppe PA, Van De Putte L. Yet more evidence that osteoarthritis is not a cartilage disease. Annals of the Rheumatic Diseases. 2006;65(10):1261–1264.
6. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. The Lancet. 2019;393(10182):1745–1759.
7. Fink R. Pain assessment: The cornerstone to optimal pain management. Proc (Bayl Univ Med Cent). 2000;13(3):236–239.
8. Studenic P, Radner H, Smolen JS, Aletaha D. Discrepancies between patients and physicians in their perceptions of rheumatoid arthritis disease activity. Arthritis Rheum. 2012;64(9):2814–2823.
9. Castrejon I, Shakoor N, Chua JR, Block JA. Discordance of global assessment by patients and physicians is higher in osteoarthritis than in rheumatoid arthritis: a cross-sectional study from routine care. Rheumatol Int. 2018;38(11):2137–2145.
10. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form‐36 Bodily Pain Scale (SF. Arthritis Care Res (Hoboken). 2011;63(S11):S240–S252.
11. Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: What is moderate pain in millimetres? Pain. 1997;72(1–2):95–97.
12. Moore RA, Straube S, Aldington D. Pain measures and cut-offs - ‘no worse than mild pain’ as a simple, universal outcome. Anaesthesia. 2013;68(4):400–412.
13. Conaghan PG, Peloso PM, Everett S V, Rajagopalan S, Black CM, Mavros P, et al. Inadequate pain relief and large functional loss among patients with knee osteoarthritis: evidence from a prospective multinational longitudinal study of osteoarthritis real-world therapies. Rheumatology. 2015;54(2):270–277.
14. Mora JC, Przkora R, Cruz-Almeida Y. Knee osteoarthritis: pathophysiology and current treatment modalities. J Pain Res. 2018;11–2189.
15. da Costa BR, Nüesch E, Kasteler R, Husni E, Welch V, Rutjes AWS, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane database Syst Rev. 2014;(9):CD003115–CD003115.
16. Osani M, Lohmander S, Bannuru R. Is there any role for opioids in the management of OA? ACR Meeting Abstracts. 2019;910.
17. AAOS. Management of osteoarthritis of the hip companion consensus statements. Available at: https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the-hip/management-of-osteoarthritis-of-the-hip-companion-consensus-statements_3.13.17.pdf. Accessed 1 April 2020.
18. AAHKS. Opioids. Available at: http://www.aahks.org/position-statements/opioid-use-for-the-treatment-of-osteoarthritis-of-the-hip-and-knee/. Accessed 20 March 2020.
19. Alamanda VK, Wally MK, Seymour RB, Springer BD, Hsu JR, Beuhler M, et al. Opioid and benzodiazepine prescriptions for osteoarthritis remain prevalent. Arthritis Care Res (Hoboken). 2019;acr.23933.
20. Thorlund JB, Turkiewicz A, Prieto-Alhambra D, Englund M. Opioid use in knee or hip osteoarthritis: a region-wide population-based cohort study. Osteoarthr Cartil. 2019;27(6):871–877.
21. USBJI. Osteoarthritis. BMUS: The Burden of Musculoskeletal Diseases in the United States. Available from: https://www.boneandjointburden.org/fourth-edition/iiib10/osteoarthritis. Accessed 2 April 2020.
22. Hiligsmann M, Reginster J-Y. The economic weight of osteoarthritis in Europe. Medicographia. 2013;35:197–202.
23. Leardini G, Salaffi F, Caporali R, Canesi B, Rovati L, Montanelli R. Direct and indirect costs of osteoarthritis of the knee. Clin Exp Rheumatol. 2004;22(6):699–706.