Multimodal Treatment Patterns for Osteoarthritis and Their Relationship to Patient-Reported Pain Severity: A Cross-Sectional Survey in the United States

Abstract

Purpose: The purpose of this study was to assess how patient-reported pain is related to osteoarthritis (OA) treatment patterns in routine clinical practice.

Patients and methods: Data were collected between February and May 2017 from 153 United States (US) primary care physicians, rheumatologists, and orthopedic surgeons. Each invited up to nine consecutive patients to rate their OA pain in the last week. Physicians provided demographic, clinical, and treatment information for patients, including nonpharmacologic therapies ever recommended, currently recommended over-the-counter (OTC) medications, and currently and ever prescribed medications for the management of OA. Findings for patients with mild (0─3), moderate (4─6), and severe current pain (7─10) were compared using appropriate statistics.

Results: Among the 841 patients (61% female; mean 65 years; 57% knee OA), 45% reported mild, 36% moderate, and 19% severe current OA pain. Current treatment modalities differed by pain severity (P<0.05). Most patients (70%) had been recommended nonpharmacologic therapy and 40% were currently recommended OTC medications. More patients with moderate (81%) or severe pain (78%) currently received prescription medications, with or without nonpharmacologic therapy, versus those with mild pain (67%). Overall, 47% of patients currently received just one prescription drug, while 49% had received one prescription drug ever. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common current (58%) and ever received (88%) prescriptions. Current NSAID prescriptions were not associated with pain severity. Acetaminophen recommendations, opioid prescriptions (current and ever), and multiple prescription medications tried were numerically highest in the severe pain group (all P<0.05 by pain severity). In all groups, >80% of treatment switches were due to lack of efficacy.

Conclusion: Real-life treatment patterns for OA in the US are significantly associated with current patient-reported pain. Combining nonpharmacologic and pharmacologic treatments is common but higher pain ratings are associated with multiple failed prescription treatments. Current use of acetaminophen and opioids, but not NSAIDs, increases alongside pain severity.

Keywords: nonprescription drugs; pain management; physicians; practice patterns; prescription drugs; therapeutics.

Figure 1

Percentage of Patients Currently Utilizing Nonpharmacologic and Pharmacologic Treatment by Pain Severity. Current treatment recommendations were collected from the treating physician. Patients reported their current osteoarthritis joint pain on an 11-point scale; 0–3=mild; 4–6=moderate; 7–10=severe. P value derived from the Pearson’s chi-squared test.

Figure 2

Nonpharmacologic Therapy Recommendations by Current Patient-Reported Pain Severity. Nonpharmacologic recommendations have been made (at any time, including the day of the office visit) to 67.5% of patients with mild, 66.9% with moderate, and 79.6% with severe current osteoarthritis pain (585/841 [69.6%] overall). P values compared across pain severity groups using the Pearson’s chi-squared test or the Fisher-Freeman-Halton test (FFH): lose weight P=0.0002, physical therapy P=0.0001, avoidance of painful activities P=0.0191, stick/cane P=0.0005, walker P=0.0029 (FFH), wheelchair P=0.0249 (FFH). All others were P<0.05 (cognitive behavior therapist/psychotherapist, hyponosis, patient forums/groups by FFH).