Is there a “best” pain reliever for osteoarthritis?

Robert R. Edwards, Ph.D.

Contributing Editor

Osteoarthritis (OA) affects tens of millions of Americans and is a leading cause of disability and reduced quality of life across the globe. Other than joint replacement surgery, there is no known “cure” for OA, and most treatments focus on relief of symptoms such as pain. Often, the first step is non-medication-based approaches such as physical therapy, exercise, and weight loss. Most patients, however, will eventually use pain relievers such as non-steroidal anti-inflammatory drugs (NSAIDs). Other kinds of medication, such as opioids, have also been tested as treatments for OA, and there is ongoing debate about what treatments are best.

NSAIDs vs. opioids: Was there a clear winner?

A recent study compared oral NSAIDs and oral opioids for relief of osteoarthritis pain. Researchers at Harvard-affiliated Brigham and Women’s Hospital performed a meta-analysis (that is, they combined and summarized the results of numerous published studies). They included clinical trials in which patients with knee osteoarthritis (KOA) were chosen at random to receive treatment that lasted at least 2 months.

The researchers carefully chose which studies to include, and two members of the team independently reviewed each study and extracted the data. They selected studies that used a common, well-validated, and widely-accepted measure of pain (the WOMAC scale, which rates pain on a scale from 0 to 100). Data from over 5,500 patients were included, and the researchers found that, on average, oral NSAID treatment reduced pain by around 18 points on the WOMAC scale. Treatment with less potent oral opioids (such as tramadol) also reduced pain by around 18 points, and potent oral opioids (such as oxycodone) reduced pain by around 19 points on the WOMAC scale. Since, on average, patients started out with pain ratings of around 50-60 out of 100, each of these medications achieved around a 30% reduction in patients’ pain.

In short, each of these medications helped reduce pain, and their effects were about identical. The finding of a roughly 30% reduction in pain is very consistent with studies of many treatments for chronic pain. While we are fairly good at acute pain management, many chronic pain conditions such as OA, low back pain, and others are harder to treat effectively. Many researchers in the field believe that a multidisciplinary team (which includes health care providers with different backgrounds) working together to use a number of different approaches to manage pain offers the most effective way of managing chronic pain. And there is good evidence for the effectiveness of these kinds of treatments. For example, a patient with severe KOA might: be treated with NSAIDs prescribed by her primary care physician; see a physical therapist to work on strengthening and conditioning the leg muscles; receive occasional steroid shots in the knee to alleviate inflammation and pain in the joint; and see a nutritionist to help with diet and weight loss, which relieves pressure on the joint and can significantly reduce knee pain.

Working toward a personalized approach to pain management

This meta-analysis cannot tell us which of these types of medication (if any) should be prescribed for a particular patient. No study can. The person-to-person variation in the effectiveness of any KOA treatment is huge. One patient may get near-total pain relief while another is not helped at all. These findings do give clinicians a benchmark for the “typical” amount of pain relief that might be expected from these medications, and suggest that, since they work about equally well, the choice of which one to use will be influenced by considerations other than effectiveness. Providers and those suffering with chronic pain also need to weigh potential side effects. Treatment (especially long-term treatment) with oral NSAIDs can result in stomach problems like bleeding, ulcer, and stomach upset, as well as high blood pressure and kidney problems. Opioids can have side effects such as constipation, nausea, and drowsiness. As you are also likely aware, opioids are also associated with a risk of serious overdose and addiction.

Many of us in the field of pain management are hopeful that eventually we will be able to more effectively “personalize” pain treatment on the basis of an individual’s characteristics, and his or her likely responses to a particular treatment. It is worth noting that non-medication treatments such as exercise, weight loss, and improvements in diet generally have few or no side effects, and have benefits that extend beyond relief of knee pain (for example, improvements in heart health). For most people, these treatments should be included as a part of their multidisciplinary pain management program, regardless of the medication options being considered.

Comments:

  1. Bobbi A

    I was recently diagnosed with osteoarthritis of my hands for which the rheumatologist prescribed plaquenil. Has anyone else been prescribed this for oa, I am wondering if that is a typical treatment?

  2. Jenny Dearborn

    I have bone to bone left knee and nearly same right knee. Hips hurt too. Now 70, but find whilst walking hurts cycling is better. Would appreciate any advice

  3. M.Stefan

    Does anyone have any experience with NSAID topical solution called diclofenac sodium 2% ? Pennsaid is one of the brand names. It is advertised for osteoarthritis knee pain. Expensive stuff. A friend used it for muscle tendonitis because he could not use oral NSAIDs due to GI issues, and for him, a little bit helped relieve the pain when it flared.

  4. Hanumantha Rao Yarlagadda

    My wife with KOA and before knee replacement surgery was prescribed paracetamol and tramadol combination drug with which she was not comfortable and the drug had to be withdrawn

  5. Adrienne in Providence RI

    By the way I am 218 lbs female.

  6. doris watson

    Has any one heard about the new studies being look at, using the rooster comb to replace loss cartilage?

    • Howard Lieberman, MD FACS

      I, at 82, have OA, mostly in the fingers and meta carpals bilaterally, with marked 65% limitation of movement, but especially in the middle finger proximal joints. That on the right was more painful, and did not respond to medication with Voltarin. X-ray showed fragmentation of the bone around the joint. So I decided to have surgery. The joint was replaced with a much lauded plastic joint, followed by physical therapy. It is 8 months now. I am assiduous in keeping up with the exercises. The pain is much less, and is responsive to transcutaneous analgesics and anti-inflammatories, but the motion is still markedly impaired, and is about the same as the other hand. No cure, but I won’t knock the procedure.

    • jim jacobson

      yes i recently got the “chicken” shot from an ortho doc for my knee! it took down the swelling & reduced the pain significantly! unfortunately i still have osteo arthritis in the knee so i live with that. Opiods help greatly & the constipation is handled with syllium supplements. i would recommend the shot although i noticed an irristible urge to crow @ sunrise!!

  7. Vic Gardiner

    I have bone to bone left knee and nearly same right knee. Hips hurt too. Now 70, but find whilst walking hurts cycling is better. Would appreciate any advice, vic

  8. Laszlo G Meszaros

    It might be worth trying glucoseamine + chondroitine + curcumine.

    • Anil

      You all write too much but biased.why no mention how bedt homeopathy help pain of any sorts to human being devoid of any side effect…

  9. robert l cabano

    hi — I am a 70 year old male retired construction worker — have OA in most of my joints — had left knee arthroscopic surgery (not successful) and right knee is close to bone on bone — have had cortisone shots in both knees and both shoulders(right shoulder is bone on bone) and the series of filler shots in right knee — both ankles are also very painful plus left hip joint and both hands have a lot of pain – also carpal tunnel ops both hands and some neck pain — aside from the shots I have used many types of prescribed narcotic meds over the last 15 years — as I have aged they seem to work less and have more bad side effects — have had many mri,s and cat scans and x rays also ,plus I suffer from coronary artery disease (have a few stents) –the onset of damp weather seems to make the OA worse — have recently started taking OSTEO BI FLEX , an over the counter medicine with very, very good results(was recommended by my family doctor) — a large reduction in knee and hip pain — I also take up to 4 Tylenol pills a day plus about 5 different meds related to the heart problems –the OSTEO BI FLEX doesn’t seem to help every joint , but the knees and hip pain reduction is amazing — the cortisone shots have also helped both shoulders , and its been over a year since those shots

  10. Linda Griego

    It’s amazing that so many of us suffering from OA have fought so long and gone through so much just to live a less painful life, especially taking all the medication we are forced to swallow. It gets old waking up in pain – at times so severe that I just wanted to stay under the warm covers and not come out until a real cure for osteoarthritis was on the horizon. But…we all know the truth about that one, it’s not in sight! Going on doxycycline has helped my hands, which had become so deformed at the knuckles. Even the cartilage on my right thumb was completely eaten away before the physical therapist noticed my thumb could bend in ways that reminded you of a horror movie! Sad truth is, there is NOTHING out there except compression gloves, to help arthritis or deforming and/or clenching fingers. I spent three years experimenting with every glove on the market and finally made my own only because I was scared to death of loosing my independence – one finger at a time. So…if anyone is interested I’d be glad to share with you what Straight Fingers has done for me and also let you know when we are hoping to offer them to the millions of arthritic hands around the world ~ to help you keep your independence one finger at a time ~ that would be so awesome!

  11. Mary Shenfield

    I would love to hear about them devise Steve Collins was referring to. I just had a knee replacement and I will do what ever can be do to save my other knee.

  12. Jerry Amos

    My finger joints were getting very sore and swelling. Tying shoe laces and even using knife and fork hurt, as well as keyboarding – I was working as a computer engineer and that’s a problem. The arthritis doctor diagnosed Heberden’s Nodes and recommended NSAIDS. He said they were not a cure just helped alleviate pain.

    Just at the same time – that was 20 years ago – glucosamine was being touted. Works for me. Hurting stopped. Joints stopped swelling and over time even a bit less. I’m 81. Carpentry, gardening, mechanical work no problem anymore. Well, of course don’t over do it. No NSAIDS.

    Reportedly glucosamine lubricates the insides of the joints so long as there is still cartilage there. It is not for bone on bone.

  13. George Elgass

    Opiates lost their effectiveness for my wife’s severe chronic back pain. After slowly being weaned down from the opiates, she was placed on generic Suboxone. This is a medication approved for addicts. However, it had been observed by some pain management doctors that some addicts who also had chronic pain received pain relief from this drug. Within a brief time my wife experienced quite amazing pain relief. This drug was very effective for many years until her death.

  14. Mimi

    I am a 70 year old female with degenerative osteoarthritis, have suffered because of this since my late 30’s, have undergone four back surgeries involving fusion of most of my spine. I’m on the verge of undergoing a fifth of the same type surgery. It scares me to undergo this again at my age, but have run out of options, including many, many steroid injections. The only problem I have with the 60mg of Oxcodone and 10mg of Oxycontin at bedtime which I take daily is the coñstant sleepiness. I would welcome another solution, but nothing else has come even close to helping at all. I can’t keep up with my housework or anything else because of the sleepiness which takes away my quality of life to the point of terrible depression.

  15. P Varjian

    Dear Readers & Doctors,
    For over 30 years, I have suffered with OA and now some of my joints are afflicted with inflammatory OA. I have lost a substantial amount of weight; had both knees replaced, one hip replaced, and now face replacement of my other hip and a reverse shoulder replacement – all due to osteoarthritis., not rheumatoid arthritis. My fingers are so swollen that I can no longer wear rings; have difficulty opening packages and, even typing.
    I exercise for 60 minutes per day, at 67 still work, and am still able to garden, shop, and enjoy many forms of recreation – all mildly, but at least I can still find some enjoyment in them.
    I have tried every drug in the medical books, worked with numerous PT people, rheumatologists, GPs, dietitians and nutritionists, in hopes that the next best cure would work. And, I have been responsible and cooperative with the medical practitioners. I don’t smoke, drink or take any recreational drugs – no combinations of anything not prescribed by my doctor.
    The only regime that has allowed me to continue enjoying any quality of life, for the past 20 years, has been the use of tramadol and ibuprofen on a regular basis. Now, with tramadol being categorized as a controlled substance my doctor has reduced my dosage, and expects me to feel as well as I did. Instead, my quality of life has been reduced because it hurts more to move even though I really try to “suck” it up and not complain.
    However, I, and many, many others are seriously affected in a negative way by those who take these drugs to get high, and politicians responding to a societal problem of drug abuse.
    I cannot change society’s complex drug abuse issues; however, I feel equally victimized because I am now categorized as an addict, when in reality the only effect I have ever received from taking my tramadol /ibuprofen mix has been a reduction of pain and some inflammation – no highs, no alterations in thinking.
    I respect everyone’s opinion on this subject, but believe that people such as myself, who truly are chronic pain sufferers have been abandoned by medical practitioners who have not tried walking in the shoes of one of their
    chronic pain patients and are more concerned about losing their licenses than treating their patients.
    I am tired of hearing about taking NSAIDS for severe OA. I cannot take enough to relieve my pain. I will continue to try every new form of treatment and hope that it helps, but I will guarantee to everyone reading my comments that my arthritis will continue to progress, and I will continue to feel worse, until I just can’t stand moving at all. I would prefer to have continual constipation than to die from the effects of NSAIDS and arthritis.
    In the meantime, while I am still able to write, I plan on pushing back on politicians who have forgotten the persuasive power of the baby boomer generation – many of whom are my peers in pain. Please let’s continue to push back for responsible pain management and make politicians realize that there is another side to this story of the war on opioids – there are other victims who are being denigrated by the harsh words, overly-strict government regulations and accusations of uncaring doctors and politicians. Sincerely,
    A Peer in Pain

    • George Elgass

      Perhaps you can find a different doctor who will prescribe what you need, especially since you have experimented with the lower dose. Seems ridiculous that your own doctor won’t do it. I could understand that he/she might want to write the scrip for a lower total quantity (given the recent increase in abuse) but leave your daily dosage as it was. Good Luck

      • Maggie Mahar

        As we grow older, our doctors should be less concerned about
        addiction –and more concerned about whether we are in pain.

        But I fear that your doctor is more concerned about protecting himself (covering his ass) against a possible( but very unlikely) lawsuit and less concerned about protecting you against pain..

        I agree with the other commenter who suggested that you should find another doctor.

        If you can find a support group for this type of
        arthritis, they might well be able to recommend someone.

        Clearly, you are not looking for a “recreational drug” — having
        arthritis is very tough, and you deserve help.

        Good luck

        Magge Mahar (author of Money-Driven Medicine)

      • Control your pain

        Stop blaming the doctors. We have been vilified for prescribing opioids for chronic pain. There are powerful groups of legislators, administrators, and a few physicians who believe opioids should NEVER be used for chronic pain. What’s more, insurance plans change their coverage based on the guidelines, which now recommend we prescribe opioids as little as possible.

        Nevermind that insurance does not cover the non-pharmacologic treatments which work (cognitive behavioral therapy and mindfulness based stress reduction training? Ha!) and charges a high copay for PT, making it out of reach for many. In addition, PT has become an assembly line process where patients rarely get the tailored *exercise instruction* and home exercise program training that is the mainstay of effective PT. Giving a handout on the last day is not enough.

        In addition, the DEA and our medical boards watch us closely. If we do not follow the opioid prescribing guidelines it is our licenses on the line. If I risk that for a few patients then it compromises my ability to care for all the rest.

  16. Steve Collins

    G’day Robert,

    I’m based in Phoenix, AZ and I was referred to your article this morning. I don’t want to be crass and use this response to advertise a device we are manufacturing in the US that will deal effectively with OA and other chronic ailments (drug-free). My e-mail address is provided (to you) if you are interested to know more. Dr. Joe Shurman, Chairman at Scripps Pain Clinic in San Diego has joined our team because of his emphatic belief in the efficacy of our device. We have a “launch” press release issuing this coming Wednesday (6th April) and I would be happy to include you in the recipient list.

  17. George Frangogiannis

    I am 60 years old, practice horseback riding, jogging and long walks almost every day.
    I find that ω3 helps a lot in osteoarthritis related pains, a daily dose of 2000 mg. has helped me a lot. I do not need to take any pain killers.

  18. Kenneth Price, Ph.D.

    Let’s see: Opiates, the greatest pain killer known to man have side effects of nausea and constipation. NSAID’s cause kidney damage, stomach ulcers, liver damage (not mentioned in the article) and death, especially when ingested with a sufficient amount of alcohol. I have yet to find a patient with chronic pain who prefers death over constipation. It is true that long term use of opiates also depresses testosterone and often leads to gynecomastia, an unpleasant side effect among men, albeit preferable to liver destruction and death – caused by heavy, long-term use of NSAID’s (in particular Acetaminophen). If God hadn’t wanted men to take opiates He wouldn’t have put opiate receptors in our brains. This war on opiates for chronic pain is not based on medicine; it’s based on politics. Shameful.

    • Jen Godwin

      Your comment deserves a round of applause for clarifying the advantages of opioids vs NSAIDs and delivering to those who demonize the use of opioids for chronic pain a much needed dose of reality. My husband, who has anaphylactic allergies to NSAIDs and aspirin, suffered greatly from several severe pain conditions and while treated by a “pain management” doctor, and was coerced into agreeing to years of damaging steroid injections in turn for opioid prescriptions. We finally found a doctor who refused to play God and assume he knew what levels of opioids would relieve the pain. Although shrewd, (he had us in his office once a week for a year before relaxing to monthly check ups), his willingness to get to know and listen to my husband gave us five additional years of running our business. Now that my husband has advanced cancer, it’s becoming increasingly difficult to get his class 2 Rx’s filled. Everyone is afraid of losing their licenses due to the witch hunts by overly zealous regulators spurred on by Politicians who demonize this medicine. They truly make me sick – I wish for all of them years of untreatable severe chronic pain and I’m not proud of feeling so angry about this. We’re dreading the day when the politicians completely ban this class of medicine from the market – and they will soon unless more people like Dr. Price speak out.

      • Amelia Lee

        ?➕? to both Dr Price and Mrs Godwin!

      • Elizabeth

        I totally agree. Those irresponsible abusers are making us all pay with pain and lack of care.

      • Anne

        Thank goodness for reasonable doctors who listen and understand individual patient needs. Not everyone who has reached a point in their pain management plan where they need opiads is a drug addict.

      • Katharine Anderson

        Jen: I have noticed much more restrictive “laws” about a migraine Rx I take. It is the only med that obliterates my migraine. It took a century of suffering and research to discover and develop and yet it has now become much harder to access! Makes no sense.

      • Pamela Buckland

        Hello Jen; I, too, suffered terribly from long and frequent attacks of migraine from a very young age. Naturally, no one believed I was really feeling all that bad. As you may remember, it was believed(for what strange reason I do not understand)that an 11 year old child did not get migraine! Perhaps I just wanted attention. When I was in my teens I attempted to get help and was turned away because we young folk only wanted to get high(high?) on opiates. Now, our politicians are so excited about being ‘bi-partisan’ that once again they are doing that idiotic ‘mandatory’ dance! What is wrong with these fools? What is wrong with US that we habitually reinstate them? Please do write and call etc. to remind them how bloody stupid it is to by-pass a judge and, once more, fill prisons with non-offenders who will be suffering Baby-Boomers and the thinking, sympathetic medical folk who tried not to poison them with NSAIDS!

    • Maggie Mahar

      If god wanted wanted men to use opiates????

      What century are you living in?

      Assuming that there is a caring god, obviously he would want us to take advantage of any effective pain-reliever that is developed.

  19. C. Wilson

    And, what about PRP (Platelet Rich Plasma) and Stem Cell Therapy for painful arthritic joints??

    On March 23, 2016, the Mayo Clinic presented a Webinar entitled,
    “Stem Cell Therapy and Growth Factors for Osteoarthritis: Hope or Hype,” and the Mayo Clinic is now scheduling appointments. . . . I will not attempt to post a link, but if you search for “Mayo Clinic Connect,” it will appear in your search engine with 6 subheadings. One of the subheadings is “Webinars.” So, you can find the free webinar from there and view it for yourselves.

  20. harold jitschak bueno de mesquita

    Why are glucosamine and chondroitin with or without MSM not mentioned, for the knee at least?
    I don’t need any double blind studies after having treated tens [and probably over a few hundreds of patients over the many years with these compounds and also heard the results of many patients which bought them self these compounds.
    I validate these data far more than any computer search .
    The only problem is that the treatment is an ongoing one and most people get problems again after stopping these supplements for a while, even a week or so [we know this in Israel as many religious people stop these supplements during Pesach which is not strictly necessary according to Jewish law]
    An answer form Harvard would be appreciated.

    • Pamela Buckland

      Because, Harold, it is no help when there is no more cartilege left to lubricate. I am over 60 now and have had to use opiates for migraine, RLS, and, now, ruined joints. It is the only thing that helps without making me ill, and, I have NEVER found myself in danger of becoming addicted! That, above all, is what worries me about all these antsy politicians and their unthinking Mandatory ideas for ‘fixing’ things. They have ruined many lives and now…our Doctors?

  21. Judy Elmore

    I started having achy joints when I was in my 30’s and by 45 was taking diclofenac sodium/misoprostol because aspirin upset my stomach. I had major lower back surgery at 59 with rods and pins and another back surgery at 62. I went through months of PT but was still in a great deal of pain. I was actually considering suicide when I was sent to a pain clinic a year later. They put me on Morphine Sulfate 20 mg, twice daily and after 10 years of treatment I am now taking 30 mgs twice daily. I am still far from pain free, but I can at least garden and keep my house clean. I don’t know what I would have done without the wonderful Doctors and nurses at the pain clinic.

  22. LARRY CHRISPYN

    Yes, Turmeric is wonderful for so many things. I take 6 capsules when I wake up. I used to put it in my 4 gallons of Green Tea with Ginger and other herbs. I had to cut down to only 6 capsules so it does not interfere with Iron absorption. This is not an issue for many, but I was anemic and my doctor told me to take iron. She said that taking turmeric in the morning was fine.

  23. Roberta Privette

    I would like to know about cannabis (pot) for treating the pain.

    • manuel tarsha

      please let me know what replies you get. I am considering moving to a different state, because of the side effects of the various meds.
      Thank you

    • Adrienne in Providence RI

      I have av410,lb friend sears by it. So years ago I got a state issued card and then there were no compassion centers to get the stuff so I never tried it. He is in another state than me. Let me know your responses results as well. I understand you get no high when you do it medicinally.

  24. Diane Oakes

    I have found that taking Turmeric capsules and or drinking Turmeric tea help tremendously. It totally keeps me from having to take medication. Also, going to the gym helps.

    • Mary Campbell

      I’ve had osteoarthritis most of my adult life, and have had two related surgeries. I too have found turmeric capsules very helpful. On the evidence of what happens when I run out and am too busy for a couple of days to re-stock, I’d say they give me about 30% pain relief, just like the costlier, kidney-damaging drugs discussed in this article. I also agree that a regular gym habit helps a lot: thanks to the 2nd of my surgeries this winter I can again judge its helpfulness by contrast to what happened when I had to stop, 3 months ago: ouch! But while many people don’t have time for a regular habit of working out (including me, often), everyone has time to take a turmeric capsule with meals.

    • Dr Gerrit Rian Cloete

      The use of fresh Tumeric and Finger roots works for me . I also use a Tumeric powder mixed with A combination of Green and Rooibos tea. Black Pepper added , helps the resorption.
      Paracetemol does not work , best painkillers for me are Optoids. But use a lot less , after started with my Tumeric about a year ago.
      As a Retired Dentist , I suffer from Neck , lower back and knee problems. But then I Walk 60 min a day , swim 4 times a week . For 66 , I am resonabally fit.
      Conclusion, I believe that the use of the Turmeric and Ginger have improved my mobility , and I use a lot less painkillers .

      • Adrienne in Providence RI

        Would you be so kind as to tell us the mg or mcg of each, Turmeric aND Ginger, Black pepper, etc. You take And how often, aka dosing you take daily? I am 50 and suffer OA in the knees, back, and right hip and am quite limited as to activities daily. I am AMAZED at the people responding to this article that are 20+ years my senior still able to exercise an hour or more each day, when I am lucky to be able to do 1/2 that! Currently on 4X a day of 800 mg GABAPENTIN + 1000 mg Tylenol generic. I get better results than with opiods like morphine sulfate 15mg 2x a day, which leaves me lethargic. I love ibuprofen 800 mg but get burn out of stomach when use it daily. Currently trying snail amount of Turmeric + 3 grams plus daily of omega 3’s. The omega do help a little. I find slight results with osteo-bi-flex when taken a long time ago. Getting sick of waking at midnight to pain or agony so young.

      • Adrienne in Providence RI

        I am 218 lb female.

    • Martha Bullock

      Yes, I started taking turmeric capsules because I really didn’t want to take NSAIDs regularly, as they can have significant longterm effects.
      There are, I believe, studies of curcumin, the essential ingredient of turmeric, which are confirming its benefits. I take one 500 mg. capsule each day, and the effect on achiness in my hands is very noticeable.
      And, I also walk a lot – good for my arthritic knees, and do hand exercises. Less – if at all possible – is more!