MANCHESTER, United Kingdom—Osteoarthritis (OA) patients on British National Health Service waiting lists for hip or knee replacement surgery report constant pain during the time on waiting list, are prescribed analgesics at levels below those recommended in accepted guidelines, and have little exposure to information that might help them manage better during the waiting period, which can extend for more than a year for over one-quarter of patients, according to Gretl McHugh, PhD, and colleagues at the University of Manchester's School of Nursing, Midwifery & Social Work in Manchester, UK.¹

"Some 63 percent of patients experienced constant pain during their time on the waiting list. There was very poor information provision both on pain and how to manage osteoarthritis There was little use of health services and treatments for pain management by these individuals. Even though individuals consulted their General Practitioner (GP) for other health related problems, and despite reported difficulties in managing symptoms, they did not discuss their OA or pain during these consultations. Management of symptoms associated with end-stage OA are suboptimal," Dr. McHugh told CIAOMed.

High Pain Levels, Low Analgesic Use

Dr. McHugh recruited 105 patients from orthopaedic surgery waiting lists for primary knee replacement or primary hip replacement in the UK. The patients were interviewed at baseline and after 6 months on the waiting list and were sent a postal questionnaire at 3 months. The primary outcome measure was pain, measured by visual analogue scale (VAS) and by the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. The researchers also recorded us of medication and other health care services and treatments.

At baseline the mean levels of pain were 7.0 measured by VAS (indicating severe pain) and 11.2 on WOMAC. Most participants (74%) were taking analgesics more than once daily, but more than half of the 70% of patients who had consulted their primary care physician in the previous 3 months had not discussed either their pain or OA, and only 30% reported receiving information on OA. Physical functioning deteriorated significantly after 3 months on the waiting list (mean difference 4.8 on the WOMAC physical functioning scale). "As measured by VAS and WOMAC pain at baseline, 3 months, and 6 months, the majority of study participants was experiencing pain levels that were considered to be severe," the authors report.

Most patients were taking analgesics and/or NSAIDS more than once a day. Despite the high levels of pain reported on the WOMAC scale, 81% of patients were being managed with non-opioids and/or NSAIDs, which is step one of the World Health Organization (WHO) pain management ladder. Eighteen percent were taking weak opioids such as codeine or tramadol and NSAIDs. Thirty-one percent were taking one NSAID and one non-opioid.

"Despite an increase in pain levels as measured by VAS and WOMAC pain at 3 months (n=84) and at 6 months (n=47), there was little change in frequency of medication at 6 months. For the majority of participants (33, 70%), the frequency of taking pain medication at 6 months had not changed from that reported at baseline," Dr. McHugh reports.

At baseline, only 11 of patients reported receiving information on pain management at baseline: 5 from a pain specialist, 1 from their primary care physician and from a pain specialist, 2 from a physiotherapist,  from their primary care physician, and one from a health magazine. This did not change much while patients were on the waiting list: only 1 patient received information on pain management. "Most of the patients commented that, when they went to their GP because of pain, they were prescribed analgesics or NSAIDs but felt that they were never given an explanation on how to best manage their pain or what other treatments were available," Dr. McHugh says.

The  British national health service has set a "waiting list initiative" goal of reducing waiting time to 18 weeks by the end of 2008, but  in orthopedics, only 16 percent of patients were treated within 18 weeks. Over half wait for up to one year, 23% wait one to two years, and 3% wait more than two years.²

"It appeared that joint replacement was seen as a ‘cure' and participants were just waiting for their operation to get symptom relief. However, despite waiting list initiatives in England, there is still a wait for surgery with some individuals having to wait up to a year from referral to operation and others not being fit enough to have their operation. These findings suggest that management of symptoms associated with end-stage OA are suboptimal," the researchers conclude.

Although waiting list time is less extended in the U. S., the management of pain in patients with advanced OA is a growing problem.  Arthritis Foundation President John H. Klippel, MD, told CIAOMed, "This is a very important and largely not much talked about problem that will only worsen as the numbers of people with OA increases over the next two decades. Certainly we have a very similar if not identical problem in the US with wait times for total hip or knee replacement typically in the range of 3-4 months for the typical patient. Severe, progressive pain and the limitations it causes in advanced OA is a universal problem. I don't know that recognition or approach to this problem is any better or worse in the US, and there certainly are many opportunities to do a much better job of addressing the problem."

Dr. Klippel also said that while underutilization of analgesics in general  is a problem in advanced OA,  there is also a important role for the increased use of narcotics in select patients who are non-surgical candidates.

Reference

1. McHugh GA, Luker KA, Campbell M, et al. A longitudinal study exploring pain control, treatment and service provision for individuals with end-stage lower limb osteoarthritis. Rheumatology. 2007;46:631-637.
2. Hall C. Patients wait year for hip surgery. The Telegraph, December 21, 2006. Available at: http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/12/20/nhealth20.xml