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Reducing Chronic Opioid Risk Among Patients with Osteoarthritis

Australia sees almost 150 hospitalisations for opioid harms daily

Moreover, Amanda Roxburgh and colleagues (National Drug and Alcohol Research Centre, University of New South Wales) attribute 70% of opioid-related mortality in Australia to pharmaceutical opioids.2 This is part of a world-wide trend where high-income countries have seen a dramatic rise in opioid deaths over the past two decades.3,4 Australia has also seen a dramatic rise in the prevalence of knee arthritis, which stands out as an important risk factor for opioid use.

Among seniors, a knee osteoarthritis diagnosis more than doubles the likelihood of opioid use.5 Fortunately, physiotherapy ameliorates knee osteoarthritis progression while quickly reducing pain and improving function with effects comparable to surgery.6-8 Furthermore, patients referred to physiotherapy within their first year of symptoms achieve 21% better scores for pain and 28% better scores for function.9

These facts beg the questions, “Would physiotherapy reduce opioid risk for patients with knee osteoarthritis?” and “Could more prompt referrals improve the protective effect against chronic opioid use?” In February, the British Journal of Sports Medicine published the research with the answers.10 Deepak Kumar and colleagues analysed the Medicare and insurance records of more than 67,000 patients diagnosed with knee osteoarthritis. They found that the greater the time between diagnosis and physiotherapy referral, the greater the risk for opioid use and chronic opioid use. For instance, among opioid naïve patients, those referred to physiotherapy within one month had the lowest risk of chronic opioid prescriptions.

For later referrals, the risk of chronic opioid prescriptions increased by: 25% (1-3 months), 83% (3-6 months), 129% (6-9 months), and 150% (9-12 months). Last month, this bulletin reported the work of van Middelkoop et al., finding that patients achieve better outcomes with knee osteoarthritis when physiotherapy is initiated within one year of the diagnosis.9

This most recent publication by Kumar et al. further refines that observation to show that physiotherapy referrals within the first month of diagnosis protect patients best. The work of Kumar et al. adds to the findings of a 2018 study of nearly 150,000 back pain cases.11 Similarly, that study finds that physiotherapy on day-one of the back pain presentation reduces opioid use 89% compared to no physiotherapy. Later referrals to physiotherapy also reduce opioid use, but to a lesser degree. The current study’s results also align with the findings of various previous studies demonstrating how physiotherapy prescriptions protect patients from opioid risk. This applies to chronic conditions, injury management, and post-surgical care. For example, Brown-Taylor et al. recently published a scoping review of 30 studies.12 They find that repeated, professionally guided sessions of exercise therapy reduce opioid use 20% to 80% across all diagnoses studied to date.


1. Australian Institute for Health and Welfare (AIHW). Opioid harm in Australia and comparisons between Australia and Canada. Canberra, Australia: AIHW; 2018.

2. Roxburgh A, Hall WD, Dobbins T, Gisev N, Burns L, Pearson S, Degenhardt L. Trends in heroin and pharmaceutical opioid overdose deaths in Australia. Drug and Alcohol Dependence. 2017 Oct 1;179:291-8.

3. Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, Abbasi-Kangevari M, Abbastabar H, Abd-Allah F, Abdelalim A, Abdollahi M. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020 Oct 17;396(10258):1204-22.

4. World Drug Report 2021 (United Nations publication, Sales No. E.21.XI.8): res/wdr2021/field/WDR21_Booklet_2.pdf

5. Losina E, Song S, Bensen GP, Katz JN. Opioid use among Medicare beneficiaries with knee osteoarthritis: prevalence and correlates of chronic use. Arthritis Care & Research. 2021 Dec 17.

6. Katz J, Brophy R, Chaisson C, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. NEJM. Mar 19 2013; DOI: 10.1056/NEJMoa1301408.

7. Pinto D, Robertson M, Abbott J, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial. Osteoarthritis and Cartilage. 2013; joca.2013.06.014.

8. Fransen M, McConnell S, Harmer A, et al. Exercise for osteoarthritis of the knee. Br J Sports Med. 2015; 49 (24): 1554-1557.

9. van Middelkoop M, Schiphof D, Hattle M, Simkins JM, Bennell K, Hinman RS, Allen KD, Knoop J, van Baar ME, Bossen D, Wallis J. Exercise Therapy Compared To Usual Care In People With Early-Stage Knee Oa: An Individual Patient Data Meta-Analysis From The Oa Trial Bank. Osteoarthritis and Cartilage. 2023 Mar 1;31:S17.

10. Kumar D, Neogi T, Peloquin C, Marinko L, Camarinos J, Aoyagi K, Felson DT, Dubreuil M. Delayed timing of physical therapy initiation increases the risk of future opioid use in individuals with knee osteoarthritis: a real-world cohort study. British Journal of Sports Medicine. 2023 Feb 23.

11. Frogner BK, Harwood K, Andrilla CH, Schwartz M, Pines JM. Physical therapy as the first point of care to treat low back pain: an instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs. Health Services Research. 2018 May 23. DOI: 10.1111/1475-6773.12984

12.  L, Beckner A, Scaff KE, Fritz JM, Buys MJ, Patel S, Bayless K, Brooke BS. Relationships between physical therapy intervention and opioid use: A scoping review. PM&R. 2022 Jul;14(7):837-54

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