Read on: danhwilliams.com

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So, paracetamol doesn't work for chronic joint pain.

Or, put another way, we might as well take a sugar pill.

Or better still, do something, anything else instead.

That evidence is clear.

So, is there any painkiller proven to work for joint pain...

 
Tramadol?

Jump quickly to the third line painkiller, tramadol.

This time the Cochrane review included 22 studies and 6,496 people with osteoarthritis. Good numbers yet again.

Does it work?

Tramadol showed ‘NO important benefit on mean pain or function’.

Same deal here. On a 100-point scale, people who took tramadol rated their pain as 50.3.

People who unknowingly took the placebo sugar pill rated their pain at 54.3.

On a (slightly odd) 0 to 1700 scale, physical function was 68 points lower in the tramadol group.

Not much difference and, again, NOT significant.

And, importantly, 17% more people suffered side effects- mainly nausea, dizziness, and tiredness- when taking tramadol.

The evidence here was downgraded to moderate quality due to 'risk of bias'.

Most of these trials were funded by the pharmaceutical industry.

That’s an important footnote in many drug trials. 

Two comprehensive, large-scale reviews.

I am, personally, not going to take paracetamol or tramadol for my hip pain… but what about anti-inflammatories?

 
Anti-inflammatories

Non-steroidal anti-inflammatories (NSAIDs) are usually prescribed as second line painkillers.

No Cochrane review this time.

However, a recent Lancet publication included 76 randomised trials with 58, 451 patients. Crumbs. Impressive numbers.

This time, NSAIDs did improve pain and function compared to placebo.

At last, a result!

Diclofenac 150 mg/day was the most effective.

However, side effects and safety needs ‘careful consideration’.

 
What about gels?

Then Cochrane looked at anti-inflammatory gels.

Diclofenac and Ketoprofen gel rubbed into the skin.

Both produced 50% pain relief in 60 to 63% of people...

...when used for 6 to 12 weeks in 8 studies by about 5000 people. Mainly in hand and knee osteoarthritis.

But hang on...

You guessed it, here comes placebo again...

48 to 50% of people got the same pain relief when rubbing in a placebo gel.

The equivalent of moisturiser.

Well, we do all feel better when we moisturise :)

There is a difference. But... 

7 to 10 people need treatment for one person to actually benefit.

 
We’ve seen that joint pain is all about inflammation.

So, it fits that anti-inflammatories help decrease that inflammation.

And for short periods of a few days that is what I might take.

And, therefore, that is what I recommend to my patients.

If your joint flares up (and you can)...


Take a short course of NSAID tablets 

Do NOT take paracetamol or tramadol for chronic joint pain.

And do NOT let painkillers distract you from doing what really works. This where all of our attention should be...

The traditional medical advice to rest and take painkillers for chronic osteoarthritis is at best incomplete, and at worst plain wrong.

The overwhelming evidence supports only a short course of non-steroidal anti-inflammatory painkiller. That’s it.

Personally, I’m doing what Valerie, the 73-year old Scillonian woman from Newsletter #012 did...

Wean off any painkillers and focus on what works.