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Leroux T, Ajrawat P, Sundararajan K, Maldonado-Rodriguez N, Ravi B, Gandhi R, Rampersaud R, Veillette C, Mahomed N, Clarke H. Understanding the epidemiology and perceived efficacy of cannabis use in patients with chronic musculoskeletal pain. J Cannabis Res 2024; 6:28. [PMID: 38961506 PMCID: PMC11220958 DOI: 10.1186/s42238-024-00231-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 04/11/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND The belief that cannabis has analgesic and anti-inflammatory properties continues to attract patients with chronic musculoskeletal (MSK) pain towards its use. However, the role that cannabis will play in the management of chronic MSK pain remains to be determined. This study examined 1) the rate, patterns of use, and self-reported efficacy of cannabis use among patients with chronic MSK pain and 2) the interest and potential barriers to cannabis use among patients with chronic MSK pain not currently using cannabis. METHODS Self-reported cannabis use and perceived efficacy were prospectively collected from chronic MSK pain patients presenting to the Orthopaedic Clinic at the University Health Network, Toronto, Canada. The primary dependent variable was current or past use of cannabis to manage chronic MSK pain; bivariate and multivariable logistic regression were used to identify patient characteristics independently associated with this outcome. Secondary outcomes were summarized descriptively, including self-perceived efficacy among cannabis users, and interest as well as barriers to cannabis use among cannabis non-users. RESULTS The sample included 629 patients presenting with chronic MSK pain (mean age: 56±15.7 years; 56% female). Overall, 144 (23%) reported past or present cannabis use to manage their MSK pain, with 63.7% perceiving cannabis as very or somewhat effective and 26.6% considering it as slightly effective. The strongest predictor of cannabis use in this study population was a history of recreational cannabis use (OR 12.7, p<0.001). Among cannabis non-users (N=489), 65% expressed interest in using cannabis to manage their chronic MSK pain, but common barriers to use included lack of knowledge regarding access, use and evidence, and stigma. CONCLUSIONS One in five patients presenting to an orthopaedic surgeon with chronic MSK pain are using or have used cannabis with the specific intent to manage their pain, and most report it to be effective. Among non-users, two-thirds reported an interest in using cannabis to manage their MSK pain, but common barriers to use existed. Future double-blind placebo-controlled trials are required to understand if this reported efficacy is accurate, and what role, if any, cannabis may play in the management of chronic MSK pain.
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Affiliation(s)
- Timothy Leroux
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada.
| | - Prabjit Ajrawat
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada
| | - Kala Sundararajan
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada
| | - Naomi Maldonado-Rodriguez
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada
| | - Bheeshma Ravi
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rajiv Gandhi
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada
| | - Raja Rampersaud
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada
| | - Christian Veillette
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada
| | - Nizar Mahomed
- The Arthritis Program, University Health Network, 399 Bathurst St, East Wing, 1st Floor, Room 1-436, Toronto, Ontario, M5T 2S8, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Madden K, Pallapothu S, Young Shing D, Adili A, Bhandari M, Carlesso L, Khan M, Kleinlugtenbelt YV, Krsmanovic A, Nowakowski M, Packham T, Romeril E, Tarride JE, Thabane L, Tushinski DM, Wallace C, Winemaker M, Shanthanna H. Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty. Pilot Feasibility Stud 2024; 10:30. [PMID: 38360686 PMCID: PMC10868001 DOI: 10.1186/s40814-024-01457-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA. METHODS This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use. DISCUSSION The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making. TRIAL REGISTRATION Prospectively registered in Clinicaltrials.gov (NCT04968132).
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Affiliation(s)
- Kim Madden
- Department of Surgery, McMaster University, Hamilton, Canada.
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada.
- Department of Health Research Methods, McMaster University, Hamilton, Canada.
| | | | | | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Moin Khan
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Adrijana Krsmanovic
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Matilda Nowakowski
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Tara Packham
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Eric Romeril
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Jean-Eric Tarride
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
- Center for Health Economics and Policy Analyses, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Daniel M Tushinski
- Department of Surgery, McMaster University, Hamilton, Canada
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Christine Wallace
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Harsha Shanthanna
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
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3
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Schnitzer TJ, Robinson RL, Viktrup L, Cappelleri JC, Bushmakin AG, Tive L, Berry M, Walker C, Jackson J. Opioids for Osteoarthritis: Cross-Sectional Survey of Patient Perspectives and Satisfaction. J Clin Med 2023; 12:jcm12072733. [PMID: 37048816 PMCID: PMC10095440 DOI: 10.3390/jcm12072733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/14/2023] Open
Abstract
Patients often take opioids to relieve osteoarthritis (OA) pain despite limited benefits and potential harms. This study aimed to compare cross-sectional perspectives of patients that were taking prescription opioid (N = 471) or nonopioid medications (N = 185) for OA in terms of satisfaction, expectations of effectiveness, and concerns. Patients prescribed opioids (>7 days) reported more prior treatments (2.47 vs. 1.74), greater mean pain intensity (5.47 vs. 4.11), and worse quality of life (EQ-5D-5L index value mean 0.45 vs. 0.71) than patients prescribed nonopioid medications (all p < 0.0001). Based on linear regression models adjusting for demographics and pain intensity, patients prescribed opioids were less satisfied with overall regimen (3.40 vs. 3.67, p = 0.0322), had less belief that medications were meeting effectiveness expectations (2.72 vs. 3.13, p < 0.0001), and had more concerns about treatments being "not very good" (3.66 vs. 3.22, p = 0.0026) and addiction (3.30 vs. 2.65, p < 0.0001) than patients prescribed nonopioid regimens. When the models were replicated for subgroups with ≥30 days' medication regimen duration, the findings were consistent with the main analyses. Patients have concerns about the risk of opioid addiction, but those with greater disease burden and more prior treatments continue taking opioid regimens.
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Affiliation(s)
- Thomas J Schnitzer
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Rebecca L Robinson
- Value, Evidence and Outcomes, Eli Lilly and Company, Indianapolis, IN 46285, USA
| | - Lars Viktrup
- Neuroscience, Eli Lilly and Company, Indianapolis, IN 46285, USA
| | - Joseph C Cappelleri
- Statistical Research and Data Science Center, Pfizer Inc., New York, NY 10017, USA
| | - Andrew G Bushmakin
- Statistical Research and Data Science Center, Pfizer Inc., New York, NY 10017, USA
| | - Leslie Tive
- Internal Medicine, Global Medical Affairs, Pfizer Inc., New York, NY 10017, USA
| | - Mia Berry
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
| | - Chloe Walker
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
| | - James Jackson
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
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4
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Schnitzer TJ, Robinson RL, Viktrup L, Cappelleri JC, Bushmakin AG, Tive L, Berry M, Walker C, Jackson J. Opioid Prescribing for Osteoarthritis: Cross-Sectional Survey among Primary Care Physicians, Rheumatologists, and Orthopaedic Surgeons. J Clin Med 2023; 12:jcm12020589. [PMID: 36675516 PMCID: PMC9864807 DOI: 10.3390/jcm12020589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
Opioids are often prescribed for osteoarthritis (OA) pain, despite recommendations to limit use due to minimal benefits and associated harms. This study aimed to assess physicians' practice patterns and perceptions regarding opioids by specialty one year following the Centers for Disease Control and Prevention (CDC) published guidance on opioid prescribing. The 139/153 (90.8%) physicians who reported prescribing opioids in the previous year reported decreased prescribing for mild OA (51.3%, 26.5% and 33.3% of primary care physicians, rheumatologists, and orthopaedic surgeons, respectively), moderate OA (50.0%, 47.1% and 48.1%) and severe OA (43.6%, 41.2% and 44.4%). Prescribing changes were attributed to the CDC guidelines for 58.9% of primary care physicians, 59.1% of rheumatologists, and 73.3% of orthopaedic surgeons. Strong opioids were mostly reserved as third-line treatment. Although treatment effectiveness post-CDC guidelines was not assessed, perceptions of efficacy and quality of life with opioids significantly differed across specialties, whereas perceptions of safety, convenience/acceptability and costs did not. Physicians generally agreed on the barriers to opioid prescribing, with fear of addiction and drug abuse being the most important. Across specialties, physicians reported decreased opioid prescribing for OA, irrespective of OA severity, and in most cases attributed changes in prescribing to the CDC guideline.
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Affiliation(s)
- Thomas J. Schnitzer
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Rebecca L. Robinson
- Value, Evidence and Outcomes, Eli Lilly and Company, Indianapolis, IN 46285, USA
- Correspondence: ; Tel.: +1-317-224-5833
| | - Lars Viktrup
- Neuroscience, Eli Lilly and Company, Indianapolis, IN 46285, USA
| | - Joseph C. Cappelleri
- Statistical Research and Data Science Center, Pfizer Inc., New York, NY 10017, USA
| | - Andrew G. Bushmakin
- Statistical Research and Data Science Center, Pfizer Inc., New York, NY 10017, USA
| | - Leslie Tive
- Internal Medicine, Global Medical Affairs, Pfizer Inc., New York, NY 10017, USA
| | - Mia Berry
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
| | - Chloe Walker
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
| | - James Jackson
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
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Atkins N, Mukhida K. The relationship between patients’ income and education and their access to pharmacological chronic pain management: A scoping review. Can J Pain 2022; 6:142-170. [PMID: 36092247 PMCID: PMC9450907 DOI: 10.1080/24740527.2022.2104699] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Nicole Atkins
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karim Mukhida
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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6
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Ross A, Gambrill V, Main C. Clinical Outcomes of Amniotic Membrane/Umbilical Cord Particulate in Spinal Disorders: A Retrospective Study. J Pain Res 2022; 15:3971-3979. [PMID: 36561643 PMCID: PMC9767063 DOI: 10.2147/jpr.s375201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Background Musculoskeletal spinal disorders significantly impact patient populations from everyday workers to military soldiers. Effective treatment is critical to minimize the time between injury and returning to work and daily activities. Injection of amniotic membrane/umbilical cord (AMUC) tissue has demonstrated great potential in reducing patients' pain and has become an increasingly popular treatment option for painful orthopedic disorders. Methods A single-center, retrospective study was conducted on patients diagnosed with musculoskeletal spinal disorders and subsequently treated with AMUC via epidural and facet injections. Demographics and outcomes related to pain were assessed. Pain was verbally reported by the patient on a scale of 0-10 where 0 indicated no pain and 10 indicated worst imaginable pain. Complications and adverse events were also reported. Results A total of 52 patients (average age 40.8 ± 9.6 years) were included in the analysis with diagnoses of spondylosis (n = 44), intervertebral disc degeneration (n = 31), radiculopathy (n = 18), stenosis (n = 2), or other conditions. The cohort's average baseline pain score was 4.9 ± 2.2 with a mean duration of symptoms for 54.2 months (range: 1-300 months). After AMUC injection, pain significantly decreased to 3.4 ± 2.3 at two weeks (p < 0.0001) and 3.5 ± 2.2 at 3-4 weeks (p = 0.0023). For the mean follow-up period of 10.6 ± 5.4 weeks, pain was reduced to 2.8 ± 2.1 (p < 0.0001 vs baseline). No significant complications or adverse events were reported. Conclusion Use of an injectable AMUC, such as CLARIX FLO, may alleviate pain in patients with painful spinal indications of various pathologies. This study provides further evidence of its safety and efficacy in epidural and facet injections. Further studies are warranted to verify these promising results.
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Affiliation(s)
| | | | - Chris Main
- Midwest Bone & Joint Center, Macon, MO, USA,Correspondence: Chris Main, Midwest Bone & Joint Center, Macon, MO, USA, Email
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7
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Bernstein J, Rankin KA, Green T. Movement if Life-Optimizing Patient Access to Total Joint Arthroplasty: Alcohol and Substance Abuse Disparities. J Am Acad Orthop Surg 2022; 30:1074-1078. [PMID: 35442926 DOI: 10.5435/jaaos-d-21-00939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/07/2022] [Indexed: 02/01/2023] Open
Abstract
Alcohol use disorders (AUDs) and substance use disorders (SUDs) place patients undergoing total joint arthroplasty at notable risk for complications. AUD and SUD disproportionately affect vulnerable communities and often coexist. Following is a discussion of the presence of these disorders in vulnerable populations and approaches to screening for them to optimize care and reduce the risks of joint arthroplasty surgery. 25.1% of American adults report binge drinking in the past year, and 5.8% of American adults carry a diagnosis of AUD. Alcohol consumption and AUD disproportionately affect American Indians/Alaskan Natives, and heavy episodic drinking is highest in Latinx and American Indians. AUD is higher in those who are unemployed, have lower education level, and those who are single/divorced. Alcohol use in the preoperative period is associated with difficulty maintaining blood pressure during surgery, infections, wound disruptions, and increased length of stay. In addition, patients with AUD or unhealthy alcohol use have a greater comorbidity burden, including liver disease and dementia, that predisposes them to poor surgical outcomes. Optimization in these vulnerable populations include proper screening, cessation programs, psychosocial interventions, assessment of support systems, and pharmacologic interventions. 38% of adults battle a drug use disorder. Twenty-one million Americans have at least one addiction, but only 10% receive treatment. Rates of opioid use and opioid-related deaths have continued to rise. Recreational drug use is highest in American Indians. Marijuana use is highest in Black and Latinx lesbian, gay, and bisexual women. Overall, substance use is associated with depression and anxiety; discrimination based on race, ethnicity, sex, or sexual preference is also deeply interwoven with depression, anxiety, and substance use. Preoperative use of opioids is the number one predictor of prolonged chronic postoperative opioid use. Optimization in these vulnerable groups begins with appropriate screening, followed by psychosocial interventions, social work and substance abuse counseling, and pharmacologic therapies.
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Affiliation(s)
- Jenna Bernstein
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT (Bernstein and Rankin), and Virginia Mason Medical Center, Seattle, WA (Green)
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8
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da Costa BR, Pereira TV, Saadat P, Rudnicki M, Iskander SM, Bodmer NS, Bobos P, Gao L, Kiyomoto HD, Montezuma T, Almeida MO, Cheng PS, Hincapié CA, Hari R, Sutton AJ, Tugwell P, Hawker GA, Jüni P. Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: network meta-analysis. BMJ 2021; 375:n2321. [PMID: 34642179 PMCID: PMC8506236 DOI: 10.1136/bmj.n2321] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of different preparations and doses of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and paracetamol for knee and hip osteoarthritis pain and physical function to enable effective and safe use of these drugs at their lowest possible dose. DESIGN Systematic review and network meta-analysis of randomised trials. DATA SOURCES Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, regulatory agency websites, and ClinicalTrials.gov from inception to 28 June 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised trials published in English with ≥100 patients per group that evaluated NSAIDs, opioids, or paracetamol (acetaminophen) to treat osteoarthritis. OUTCOMES AND MEASURES The prespecified primary outcome was pain. Physical function and safety outcomes were also assessed. REVIEW METHODS Two reviewers independently extracted outcomes data and evaluated the risk of bias of included trials. Bayesian random effects models were used for network meta-analysis of all analyses. Effect estimates are comparisons between active treatments and oral placebo. RESULTS 192 trials comprising 102 829 participants examined 90 different active preparations or doses (68 for NSAIDs, 19 for opioids, and three for paracetamol). Five oral preparations (diclofenac 150 mg/day, etoricoxib 60 and 90 mg/day, and rofecoxib 25 and 50 mg/day) had ≥99% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. Topical diclofenac (70-81 and 140-160 mg/day) had ≥92.3% probability, and all opioids had ≤53% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. 18.5%, 0%, and 83.3% of the oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of dropouts due to adverse events. 29.8%, 0%, and 89.5% of oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of any adverse event. Oxymorphone 80 mg/day had the highest risk of dropouts due to adverse events (51%) and any adverse event (88%). CONCLUSIONS Etoricoxib 60 mg/day and diclofenac 150 mg/day seem to be the most effective oral NSAIDs for pain and function in patients with osteoarthritis. However, these treatments are probably not appropriate for patients with comorbidities or for long term use because of the slight increase in the risk of adverse events. Additionally, an increased risk of dropping out due to adverse events was found for diclofenac 150 mg/day. Topical diclofenac 70-81 mg/day seems to be effective and generally safer because of reduced systemic exposure and lower dose, and should be considered as first line pharmacological treatment for knee osteoarthritis. The clinical benefit of opioid treatment, regardless of preparation or dose, does not outweigh the harm it might cause in patients with osteoarthritis. SYSTEMATIC REVIEW REGISTRATION PROSPERO number CRD42020213656.
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Affiliation(s)
- Bruno R da Costa
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Tiago V Pereira
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Pakeezah Saadat
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Martina Rudnicki
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Ophthalmology, University College London, London, UK
| | - Samir M Iskander
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - Nicolas S Bodmer
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Department of Medicine, University of Zurich, Zurich, Switzerland
| | - Pavlos Bobos
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Western's Bone and Joint Institute, Western University, London, ON, Canada
| | - Li Gao
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | | | - Thais Montezuma
- Health Technology Assessment Unit, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | - Matheus O Almeida
- Health Technology Assessment Unit, Oswaldo Cruz German Hospital, São Paulo, Brazil
- Master Program in Physical Therapy, Universidade Ibirapuera, São Paulo, Brazil
| | - Pai-Shan Cheng
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cesar A Hincapié
- Department of Chiropractic Medicine, Faculty of Medicine, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Roman Hari
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Tugwell
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gillian A Hawker
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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9
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Baker JF, Stokes A, Pedro S, Mikuls TR, George M, England BR, Sayles H, Wolfe F, Michaud K. Obesity and the Risk of Incident Chronic Opioid Use in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2021; 73:1405-1412. [PMID: 32475039 DOI: 10.1002/acr.24341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/22/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study was undertaken to evaluate whether the rate of incident chronic opioid use is higher in obese patients with rheumatoid arthritis (RA). METHODS Participants with RA in the FORWARD databank were asked about their use of weak and strong opioid medications on semiannual surveys. Incident chronic opioid use was defined as new reported use extending over 2 contiguous surveys (~7-12 months). Cox proportional hazards models were used to evaluate associations between body mass index (BMI) at enrollment and incident chronic opioid use (overall use and strong opioid use). Models adjusted for demographics, smoking, disease duration, RA treatments, household income, and education level. The predicted 5-year cumulative incidence was calculated from Cox models. RESULTS Among 19,794 participants, 2,802 experienced an incident episode of chronic opioid use over 93,254 person-years of follow-up. Higher BMI was associated with higher risk of chronic opioid use. Severe obesity (BMI >35 kg/m2 ) was associated with a higher risk of overall use (adjusted hazard ratio [HRadj ] 1.74 [95% confidence interval (95% CI) 1.72-2.04], P < 0.0001) and strong opioid use (HRadj 2.11 [95% CI 1.64-2.71], P < 0.001) compared to normal BMI. This association was partially explained by greater comorbidity, pain, and disability in obese groups. The attributable risk for obesity was 15% of overall opioid use and 24% of strong opioid use. CONCLUSION Obesity is associated with a substantially higher risk of incident chronic opioid use. Approximately 1 in 4 cases of incident use of strong opioids may be attributable to obesity, suggesting a major public health impact. Interventions to prevent or reduce obesity could have an important impact on the use of opioids.
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Affiliation(s)
- Joshua F Baker
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia
| | - Andrew Stokes
- Boston University School of Public Health, Boston, Massachusetts
| | - Sofia Pedro
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | | | - Bryant R England
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Harlan Sayles
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Fred Wolfe
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Kaleb Michaud
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, and VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
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Pain Pharmacotherapy in a Large Cohort of Patients with Osteoarthritis: A Real-World Data Analysis. Rheumatol Ther 2021; 8:1129-1141. [PMID: 34106448 PMCID: PMC8380605 DOI: 10.1007/s40744-021-00329-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/27/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There is limited evidence on the consumption of analgesics in real-world large cohorts of patients with osteoarthritis (OA), especially in those with comorbidities. We aimed to characterize the use of pharmacological analgesic treatments, evaluate standardized comorbidity rates, and assess treatment trends. Our hypotheses were: (1) OA patients generally consume low and inconsistent pharmacological analgesic treatments; (2) analgesic treatment is often non-congruent with comorbidity-related safety concerns. METHODS The study was carried out at the second largest health maintenance organization in Israel. Members aged 18 years or above who were diagnosed with OA before December 31, 2018, were included. Information was obtained from the members' electronic medical record (EMR) including data on dispensed prescriptions, which were used to estimate analgesic consumption. RESULTS A total of 180,126 OA patients were included in our analyses; analgesics were dispensed to 64.2% of the patients, with oral NSAIDs and opioids dispensed to 34.1 and 22.9% of the OA population, respectively. Analgesic use increased with time lapsed from OA diagnosis (p < 0.001), up to a median of 59 days covered (IQR, 20-175) after 21 years. Rates of most comorbidities in the OA population were higher compared to the MHS general population. Patients with comorbidities used more NSAIDs and opioids compared to those without them. CONCLUSIONS Most OA patients use analgesics, usually oral NSAIDs. Analgesic use remains relatively low throughout the years, indicating that many OA patients are not being treated pharmacologically for pain on a regular basis. Despite having higher rates of several comorbidities compared to MHS general population, many OA patients are still treated with analgesics that can be associated with a worsening in comorbidity.
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Addressing National Opioid Prescribing Practices for Knee Osteoarthritis: An Analysis of an Estimated 41,389,332 Patients With Knee Arthritis. J Am Acad Orthop Surg 2021; 29:e337-e344. [PMID: 33591123 DOI: 10.5435/jaaos-d-20-00924] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/05/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Knee osteoarthritis (OA) is a chronic pathology that is treated across multiple specialties. Opioid prescribing practices for knee OA have not been described on a national level. The purpose of this study was to (1) investigate the trends in opioid prescriptions for knee OA, (2) characterize and identify predominant opioid based medications prescribed for knee OA, and (3) identify patient- and provider-related factors influencing opioid prescribing patterns in the treatment of knee OA in the outpatient setting. METHODS The National Ambulatory Medical Care Survey (NAMCS) was used to identify all patients in the United States who presented to an outpatient clinic for knee OA between 2007 and 2016. New opioid prescriptions were determined using a previously published algorithm. Generalized linear models were used to assess trends. RESULTS A total of 41,389,332 patients were included, of which 12.8% were prescribed an opioid-based medication. Opioid prescription rose from 2007/2008 to 2013/2014. Analysis of the opioid type demonstrated that the prescription of hydrocodone-based medication and "other" traditional opioids followed the aforementioned trends. However, tramadol prescription demonstrated a sustained increase throughout the years peaking at 2015/2016. Patient income in the lowest quartile, a worker's compensation status, and depression were independently associated with higher odds of opioid prescription for knee OA. CONCLUSIONS Opioid prescription for knee OA remains high. Decreases in traditional opioid prescription have been countered by increase in tramadol prescription. The risks and addictive potential of tramadol and patient and provider risk factors should be emphasized.
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Rogers AH, Zvolensky MJ, Ditre JW, Buckner JD, Asmundson GJG. Association of opioid misuse with anxiety and depression: A systematic review of the literature. Clin Psychol Rev 2021; 84:101978. [PMID: 33515811 DOI: 10.1016/j.cpr.2021.101978] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 11/19/2020] [Accepted: 11/29/2020] [Indexed: 12/14/2022]
Abstract
The opioid epidemic is a public health problem associated with a host of negative outcomes. Although clinicians recognize covariation between opioid misuse with anxiety and depressive symptoms and disorders, research on this topic has only recently accumulated. Progress in this domain is impeded by the lack of systematic and integrative research to better understand and treat these co-occurring problems. This paper represents the first attempt to systematically review the empirical literature examining relations between opioid use and misuse, and anxiety and depression. In the first section, we define key terms and describe the article selection strategy. In the second section, we review the prevalence of anxiety and depressive symptoms among individuals who use and misuse prescription and illicit opioids. In the third section, we review the magnitude of associations between anxiety and depressive symptoms and disorders with opioid misuse, as well as highlight studies examining the longitudinal and temporal sequence of the relations between these variables. In the fourth section, we focus on experimental therapeutics, reviewing what is known about individual difference and transdiagnostic vulnerability factors for anxiety and depression that might contribute to opioid misuse and its symptoms. Finally, we discuss current knowledge gaps and present a heuristic model to guide future research.
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Affiliation(s)
- Andrew H Rogers
- Department of Psychology, University of Houston, Houston, TX, United States
| | - Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, TX, United States; Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, United States; HEALTH Institute, University of Houston, Houston, TX, United States.
| | - Joseph W Ditre
- Department of Psychology, Syracuse University, Syracuse, NY, United States
| | - Julia D Buckner
- Department of Psychology, Louisiana State University, Baton Rouge, LA, United States
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13
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van den Driest JJ, Schiphof D, de Wilde M, Bindels PJE, van der Lei J, Bierma-Zeinstra SMA. Opioid prescriptions in patients with osteoarthritis: a population-based cohort study. Rheumatology (Oxford) 2021; 59:2462-2470. [PMID: 31960046 PMCID: PMC7449800 DOI: 10.1093/rheumatology/kez646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/29/2019] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES To examine the incidence, prevalence and trends for opioid prescriptions in patients with OA. Furthermore, types of opioids prescribed and long-term prescription rates were examined. Finally, the patient characteristics associated with the prescription of opioids were assessed. METHODS A population-based cohort study was conducted using the Integrated Primary Care Information database. Incidence and prevalence of opioid prescriptions were calculated for the period 2008-2017. Logistic regression was used to assess which patient characteristics were associated with opioid prescriptions. RESULTS In total, 157 904 OA patients were included. The overall prescription rate remained fairly stable, at around 100 incident and 170 prevalent prescriptions per 1000 person years. However, the incident prescription rate for oxycodone increased from 7.1 to 40.7 per 1000 person years and for fentanyl from 4.2 to 7.4 per 1000 person years. The incident prescription rate for paracetamol/codeine decreased from 63.0 to 13.3 per 1000 person years. Per follow-up year, long-term use was found in 3% of the patients with incident OA. Finally, factors associated with more prescriptions were increasing age, OA in ≥2 joint groups [odds ratio (OR) 1.56; 95% CI: 1.51, 1.65] and the presence of other musculoskeletal disorders (OR 4.91; 95% CI: 4.76, 5.05). Men were less likely to be prescribed opioids (OR 0.78; 95% CI: 0.76, 0.80). CONCLUSION Prescription rates for opioids remained stable, but types of opioids prescribed changed. Oxycodone and fentanyl were increasingly prescribed, while prescriptions of paracetamol/codeine decreased. Since the benefit of opioids for OA pain is questionable and side effects are common, opioids should be prescribed with caution.
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Affiliation(s)
- Jacoline J van den Driest
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
- Correspondence to: J. J. van den Driest, Department of General Practice, Erasmus MC, Wytemaweg 80, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. E-mail:
| | - Dieuwke Schiphof
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marcel de Wilde
- Department of Medical Informatics Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Orthopedics, University Medical Center, Erasmus MC, Rotterdam, The Netherlands
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14
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Vina ER, Quinones C, Hausmann LRM, Ibrahim SA, Kwoh CK. Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis. J Rheumatol 2021; 48:1863-1870. [PMID: 33452165 DOI: 10.3899/jrheum.201133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA. METHODS A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables. RESULTS In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02). CONCLUSION Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.
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Affiliation(s)
- Ernest R Vina
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Cristian Quinones
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Leslie R M Hausmann
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Said A Ibrahim
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - C Kent Kwoh
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
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15
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Best TM, Petterson S, Plancher K. Sustained acoustic medicine as a non-surgical and non-opioid knee osteoarthritis treatment option: a health economic cost-effectiveness analysis for symptom management. J Orthop Surg Res 2020; 15:481. [PMID: 33076955 PMCID: PMC7574225 DOI: 10.1186/s13018-020-01987-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/27/2020] [Indexed: 12/24/2022] Open
Abstract
Background Patients diagnosed with osteoarthritis (OA) and presenting with symptoms are seeking conservative treatment options to reduce pain, improve function, and avoid surgery. Sustained acoustic medicine (SAM), a multi-hour treatment has demonstrated improved clinical outcomes for patients with knee OA. The purpose of this analysis was to compare the costs and effectiveness of multi-hour SAM treatment versus the standard of care (SOC) over a 6-month timeframe for OA symptom management. Methods A decision tree analysis was used to compare the costs and effectiveness of SAM treatment versus SOC in patients with OA. Probabilities of success for OA treatment and effectiveness were derived from the literature using systematic reviews and meta-analyses. Costs were derived from Medicare payment rates and manufacturer prices. Functional effectiveness was measured as the effect size of a therapy and treatment pathways compared to a SOC treatment pathway. A sensitivity analysis was performed to determine which cost variables had the greatest effect on deciding which option was the least costly. An incremental cost-effectiveness plot comparing SAM treatment vs. SOC was also generated using 1000 iterations of the model. Lastly, the incremental cost-effectiveness ratio (ICER) was calculated as the (cost of SAM minus cost of SOC) divided by (functional effectiveness of SAM minus functional effectiveness of SOC). Results Base case demonstrated that over 6 months, the cost and functional effectiveness of SAM was $8641 and 0.52 versus SOC at: $6281 and 0.39, respectively. Sensitivity analysis demonstrated that in order for SAM to be the less expensive option, the cost per 15-min session of PT would need to be greater than $88, or SAM would need to be priced at less than or equal to $2276. Incremental cost-effectiveness demonstrated that most of the time (84%) SAM treatment resulted in improved functional effectiveness but at a higher cost than SOC. Conclusion In patients with osteoarthritis, SAM treatment demonstrated improved pain and functional gains compared to SOC but at an increased cost. Based on the SAM treatment ICER score being ≤ $50,000, it appears that SAM is a cost-effective treatment for knee OA.
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Affiliation(s)
- Thomas M Best
- Department of Orthopedics, UHealth Sports Medicine Institute, University of Miami, Coral Gables, FL, USA.
| | | | - Kevin Plancher
- Orthopaedic Foundation, Stamford, CT, USA.,Department of Orthopaedics, Albert Einstein College of Medicine, New York, NY, USA.,Department of Orthopaedics, Weill Cornell Medical College, New York, NY, USA.,Plancher Orthopaedics & Sports Medicine, New York, NY, USA
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16
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Castellanos R, Tighe S. Injectable Amniotic Membrane/Umbilical Cord Particulate for Knee Osteoarthritis: A Prospective, Single-Center Pilot Study. PAIN MEDICINE 2020; 20:2283-2291. [PMID: 31418794 PMCID: PMC6830267 DOI: 10.1093/pm/pnz143] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the short-term safety and effectiveness of amniotic membrane/umbilical cord particulate (AMUC) in managing pain in patients with various severities of knee osteoarthritis (OA). DESIGN Single-center, prospective, investigator-initiated pilot study. SETTING Private practice. SUBJECTS A total of 20 knee OA patients aged ≥18 years were enrolled with pain >40 mm, as determined by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-A. METHODS Patients received an ultrasound-guided, intra-articular injection of 50 mg of AMUC particulate reconstituted in 2 mL of preservative-free saline. All patients were then monitored at six weeks, 12 weeks, and 24 weeks postinjection. Patients who did not show >30% reduction in pain received a second injection of AMUC at six weeks. WOMAC, Patient Global Assessment, medication usage, and magnetic resonance imaging (MRI) were assessed. RESULTS Knee OA pain significantly decreased from 74.3 ± 17.2 at baseline to 45.0 ± 25.4 at six weeks (P < 0.01), 35.4 ± 26.6 at 12 weeks (P < 0.001), and 37.4 ± 26.7 at 24 weeks (P < 0.001). This pain reduction was associated with a significant improvement in physical function (WOMAC-C) at all time points (P < 0.05) and stiffness (WOMAC-B) at 12 weeks (P = 0.01). Eleven patients received a second injection, which was significantly correlated with body mass index >30 kg/m2 (P = 0.025). MRI evaluation of the overall population revealed an improvement in the severity of bone marrow lesions in seven patients. No adverse events were observed. CONCLUSIONS AMUC particulate injection relieved pain and improved physical function in patients with symptomatic knee OA.
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Affiliation(s)
| | - Sean Tighe
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida.,TissueTech, Miami, Florida, USA
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17
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Delaney L, Gunaseelan V, Rieck H, Dupree JM, Hallstrom B, Englesbe M, Brummett C, Waljee J. High-Risk Prescribing Increases Rates of New Persistent Opioid Use in Total Hip Arthroplasty Patients. J Arthroplasty 2020; 35:2472-2479.e2. [PMID: 32389404 PMCID: PMC8289485 DOI: 10.1016/j.arth.2020.04.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The association between surgeon prescribing practices and new persistent postoperative opioid use is not well understood. We examined the association between surgeon prescribing and new persistent use among total hip arthroplasty (THA) patients. METHODS A retrospective analysis of Medicare claims in Michigan was performed. The study cohort consisted of orthopedic surgeons performing THAs from 2013 to 2016 and their opioid-naïve patients, aged >65 years. High-risk prescribing included high daily doses, overlapping benzodiazepine prescriptions, concurrent opioid prescriptions, prescriptions from multiple providers, or long-acting opioid prescriptions. The occurrence of a preoperative prescription, initial prescription size, and 30-day prescription dosage were examined as individual exposures. Surgeons were categorized into quartiles by prescribing practices, and multilevel hierarchical logistic regression was used to examine associations with postoperative new persistent opioid use. RESULTS Surgeons exhibited high-risk prescribing for 66% of encounters. Patients of surgeons with the highest rates of high-risk prescribing were more likely to develop persistent use compared with patients of surgeons with the lowest rates (adjusted rates: 9.7% vs 4.6%, P = .011). Patients of surgeons with initial prescription sizes in the "high" (third) quartile (adjusted odds ratio, 2.91; 95% confidence interval, 1.53-5.51), and of surgeons in the "highest" (fourth) quartile of 30-day prescription dosage (adjusted odds ratio, 1.93; 95% confidence interval, 1.03-3.61), were more likely to develop persistent opioid use compared with patients of surgeons with low initial and 30-day prescription sizes, respectively. CONCLUSION The development of persistent opioid use after surgery is multifactorial, and surgeon prescribing patterns play an important role. Reducing prescribing and encouraging opioid alternatives could minimize postoperative persistent opioid use.
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Affiliation(s)
- Lia Delaney
- University of Michigan School of Medicine, Ann Arbor
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor
| | - Heidi Rieck
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor
| | | | - Brian Hallstrom
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor
| | - Mike Englesbe
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor,Michigan Surgical Quality Collaborative, Ann Arbor
| | - Chad Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor,Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor,Michigan Surgical Quality Collaborative, Ann Arbor
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18
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Are medical comorbidities contributing to the use of opioid analgesics in patients with knee osteoarthritis? Osteoarthritis Cartilage 2020; 28:1030-1037. [PMID: 32387761 DOI: 10.1016/j.joca.2020.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although opioid analgesics are not generally recommended for treatment of knee osteoarthritis (OA), they are frequently used. We sought to determine the association between medical comorbidities and self-reported opioid analgesic use in these patients. METHODS This cross-sectional study recruited patients referred to two provincial hip and knee clinics in Alberta, Canada for consideration of total knee arthroplasty. Standardized questionnaires assessed demographic (age, gender, income, education, social support, smoking status) and clinical (pain, function, total number of troublesome joints) characteristics, comorbid medical conditions, and non-surgical OA management participants had ever used or were currently using. Multivariable Poisson regression with robust estimate of the standard errors assessed the association between comorbid medical conditions and current opioid use, controlling for potential confounders. RESULTS 2,127 patients were included: mean age 65.4 (SD 9.1) years and 59.2% female. Currently used treatments for knee OA were: 57.6% exercise and/or physiotherapy, 61.1% NSAIDs, and 29.8% opioid analgesics. In multivariable regression, controlling for potential confounders, comorbid hypertension (RR 1.18, 95% CI 1.02-1.37), gastrointestinal disease (RR 1.31, 95% CI 1.07-1.60), depressed mood (RR 1.25, 95% CI 1.05-1.48) and a higher number of troublesome joints (RR 1.04 per joint, 95% CI 1.00-1.09) were associated with opioid use, with no association found with having ever used recommended non-opioid pharmacological or non-pharmacological treatments. CONCLUSIONS In a large cohort of patients with knee OA, of 12 comorbidities assessed, comorbid hypertension, gastrointestinal disease, and depressed mood were associated with current use of opioid analgesics, in addition to total burden of troublesome joints. Improved guidance on the management of painful OA in the setting of common comorbidities is warranted.
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Delaney LD, Clauw DJ, Waljee JF. The Management of Acute Pain for Musculoskeletal Conditions: The Challenges of Opioids and Opportunities for the Future. J Bone Joint Surg Am 2020; 102 Suppl 1:3-9. [PMID: 32251126 PMCID: PMC8272973 DOI: 10.2106/jbjs.20.00228] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➢ Opioid use for chronic and acute musculoskeletal pain is common.➢ Orthopaedic surgeons are frequent opioid prescribers.➢ Opioids are commonly prescribed for acute pain, with high variation.➢ Opioid alternatives for acute pain are effective, and the incorporation of multimodal pain management in the perioperative period can decrease opioid use.➢ Although opioids are effective for the management of acute musculoskeletal pain, the morbidity and mortality related to opioid analgesics reinforce the need for robust, evidence-based guidelines.➢ Providers should evaluate patient risk preoperatively, should prescribe judiciously with multimodal pain management plans, and should integrate a preoperative discussion on opioid usage.➢ Future research should include procedure-specific pain management strategies, as well as the comparative efficacy of pharmacologic and nonpharmacologic methods of pain management.
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Affiliation(s)
- Lia D Delaney
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Daniel J Clauw
- Departments of Anesthesiology (D.J.C.), Internal Medicine (D.J.C.), Psychiatry (D.J.C.), and Surgery (J.F.W.), University of Michigan, Ann Arbor, Michigan
- Chronic Pain and Fatigue Research Center, Ann Arbor, Michigan
| | - Jennifer F Waljee
- Departments of Anesthesiology (D.J.C.), Internal Medicine (D.J.C.), Psychiatry (D.J.C.), and Surgery (J.F.W.), University of Michigan, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
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Iolascon G, Ruggiero C, Fiore P, Mauro GL, Moretti B, Tarantino U. Multidisciplinary integrated approach for older adults with symptomatic osteoarthritis: SIMFER and SI-GUIDA Joint Position Statement. Eur J Phys Rehabil Med 2019; 56:112-119. [PMID: 31742367 DOI: 10.23736/s1973-9087.19.05837-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Multidisciplinary approach to osteoarthritis (OA) in older patients, whose functional decline is multifactorial and who present with multiple symptoms, has been long advocated, but it is still seldom implemented in daily practice. Therefore, further indications for the management of OA are eagerly awaited and should consider the specific clinical features of this population, including the presence of frailty and comorbidities. This clinical approach should be based both on well-grounded evidence and practical experience of experts in OA management. This manuscript comments the multidisciplinary integrated approach for OA management in the older population, according to the opinion of a multidisciplinary Panel of Experts. This project was developed by a Steering Committee, which consisted of three experts that were identified by the Italian Society of Physical and Rehabilitation Medicine (Società Italiana di Medicina Fisica e Riabilitativa, SIMFER) and the Italian Society for Unified and Interdisciplinary Management of Musculoskeletal Pain and Algodystrophy (Società Italiana per la Gestione Unificata e Interdisciplinare del Dolore muscolo-scheletrico e dell'Algodistrofia, SI-GUIDA). The Steering Committee identified key evidence on the management of OA in the older through systematic research in MEDLINE and EMBASE, selected the most relevant paper among those identified, and defined some questions concerning current unmet needs in the management of symptomatic OA in the older accordingly. The Panel discussed the identified evidence and questions during two meetings. The discussion was used to generate seven statements with relevance to clinical practice. In conclusion, older adults with symptomatic OA present multiple concomitant issues, including other diseases, marked pain, poly-pharmacy, and often poor psychological and/or socioeconomical status. According to the above-described evidence, it is crucial that the approach to those patients is multidisciplinary and based on the use of dedicated tools. A combination of exercise, mechanical support and properly selected analgesic treatment will greatly help the management of the OA patient, improving at the same time his/her quality of life.
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Affiliation(s)
- Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, Luigi Vanvitelli University of Campania, Naples, Italy -
| | - Carmelinda Ruggiero
- Orthogeriatric Service, Geriatric Unit, Gerontology and Geriatrics Section, Department of Medicine, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Pietro Fiore
- Physical and Rehabilitation Medicine-Unipolar Spinal Unit, Consorziale Polyclinic Hospital, Bari, Italy
| | - Giulia L Mauro
- Unit of Physiatry and Rehabilitation, Paolo Giaccone University Hospital, Palermo, Italy
| | - Biagio Moretti
- Clinic of Orthopedics and Traumathology, Policlinico University Hospital, Bari, Italy
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Cho SK, Jung SY, Choi S, Im SG, Kim H, Choi WS, Jang EJ, Sung YK. Factors related to the use of opioids as early treatment in patients with knee osteoarthritis. Arthritis Res Ther 2019; 21:222. [PMID: 31685008 PMCID: PMC6827242 DOI: 10.1186/s13075-019-2004-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/13/2019] [Indexed: 01/10/2023] Open
Abstract
Objective To examine factors related to the use of opioids as an early treatment option for knee OA patients Methods Using the Korean nationwide claim database, we selected knee OA patients between 2013 and 2015. Among them, patients without any claim of knee OA for 2 years before the index date were included as our study population. We analyzed their first claim for prescriptions, including tramadol and stronger opioids, at the index date of each patient. Using a multinomial model, we identified factors associated with the early use of tramadol and stronger opioids in knee OA patients. Results Among a total of 2,857,999 knee OA patients, 12.2% (n = 348,516) were treated with opioids as their first treatment. However, the prevalence of stronger opioid use was only 0.07% (n = 1972). Male sex (OR 1.28 in tramadol, OR 1.13 in stronger opioids) and comorbidities with depression (OR 1.05, 1.46), low back pain (OR 1.13, 1.30), intervertebral disc disorder (OR 1.11, 1.40), and spinal stenosis (OR 1.27, 1.55) were the factors for the early use of tramadol or stronger opioids in knee OA patients. Patients in a tertiary referral hospital tended to use tramadol or stronger opioids than those in clinics (OR 1.04, 56.63, respectively). Conclusion In Korea, 12.2% of knee OA patients were treated with opioids as an early treatment, and tramadol was used more commonly than stronger opioids. Male sex and having comorbidities such as depression or musculoskeletal disease are patient factors associated with the early use of opioids in knee OA patients.
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Affiliation(s)
- Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, 222-1 wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, 84, Heukseok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea
| | - Seongmi Choi
- Department of Statistics, Kyungpook National University, 80, Daehak-ro, Buk-gu, Daegu, 41566, Republic of Korea
| | - Seul Gi Im
- Department of Statistics, Kyungpook National University, 80, Daehak-ro, Buk-gu, Daegu, 41566, Republic of Korea
| | - Hyoungyoung Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, 222-1 wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Woo Seok Choi
- Department of Statistics, Kyungpook National University, 80, Daehak-ro, Buk-gu, Daegu, 41566, Republic of Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, 1375, Gyeongdong-ro, Andong-si, Gyeongsangbuk-do, 36729, Republic of Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, 222-1 wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
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Canizares M, Power JD, Rampersaud YR, Badley EM. Patterns of opioid use (codeine, morphine or meperidine) in the Canadian population over time: analysis of the Longitudinal National Population Health Survey 1994-2011. BMJ Open 2019; 9:e029613. [PMID: 31345978 PMCID: PMC6661673 DOI: 10.1136/bmjopen-2019-029613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE This study aimed to investigate cohort effects in selected opioids use and determine whether cohort differences were associated with changes in risk factors for use over time. DESIGN This study presents secondary analyses of a longitudinal survey panel of the general population that collected data biannually. SETTING Data from the Canadian Longitudinal National Population Health Survey 1994-2011. POPULATION This study included 12 542 participants from the following birth cohorts: post-World War I (born 1915-1924), pre-World War II (born 1925-1934), World War II (born 1935-1944), Older Baby Boom (born 1945-1954), Younger Baby Boom (born 1955-1964), Older Generation X (born 1965-1974) and Younger Generation X (born 1975-1984). MAIN OUTCOME Responses to a single question asking about the use of codeine, morphine or meperidine in the past month (yes/no) were examined. RESULTS Over and above age and period effects, there were significant cohort differences in selected opioids use: each succeeding recent cohort had greater use than their predecessors (eg, Gen Xers had greater use than younger baby boomers). Selected opioids use increased significantly from 1994 to 2002, plateauing between 2002 and 2006 and then declining until 2011. After accounting for cohort and period effects, there was a decline in use of these opioids with increasing age. Although pain was significantly associated with greater selected opioids use (OR=3.63, 95% CI 3.39 to 3.94), pain did not explain cohort differences. Cohort and period effects were no longer significant after adjusting for the number of chronic conditions. Cohort differences in selected opioids use mirrored cohort differences in multimorbidity. Use of these opioids was significantly associated with taking antidepressants or tranquillisers (OR=2.52, 95% CI 2.27 to 2.81 and OR=1.60, 95% CI 1.46 to 1.75, respectively). CONCLUSIONS The findings underscore the need to consider multimorbidity including possible psychological disorders and associated medications when prescribing opioids (codeine, morphine, meperidine), particularly for recent birth cohorts. Continued efforts to monitor prescription patterns and develop specific opioid use guidelines for multimorbidity appear warranted.
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Affiliation(s)
- Mayilee Canizares
- Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - J Denise Power
- Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Y Raja Rampersaud
- Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Elizabeth M Badley
- Arthritis Community Research and Evaluation Unit, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
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