Since 2004, when the painkiller rofecoxib, or Vioxx, was taken off the market due to its link to a higher risk of heart attacks and strokes, people with arthritis increasingly have been prescribed opioid drugs for pain relief. A large study, however, shows that the increase in the use of opioid painkillers by people older than 65 with osteoarthritis, or OA, is associated with an increase in falls and fractures.

The study was presented at the American College of Rheumatology’s 2011 meeting in Chicago.

“While many patients have great benefit from opioid analgesics when used correctly with supervision, this study points out that they should not be considered as first line [treatment] necessarily, as the side effects in the elderly are worrisome,” says the study’s lead author, Lydia Rolita, MD, a geriatrician at New York University School of Medicine in New York City.

"In the elderly population, patients are already prone to diminished muscle tone and balance, and [opioids] can further impact these risk factors for falls by multiple mechanisms,” she explains, noting that opioids’ effect on the vascular system can result in orthostatic hypotension – a drop in blood pressure upon standing that causes dizziness – and their effect on the central nervous system can cause dizziness and impaired balance.

"Recommendations for chronic pain treatment should be re-evaluated," Dr. Rolita says.

Several major health organizations – including the American Heart Association and the American Geriatrics Society – issued the recommendations after the ban of Vioxx, which is a COX-2 inhibitor, a nonsteroidal anti-inflammatory drug, or NSAID. The recommendations call for the use of NSAIDs to be severely restricted due to side effects such as gastric bleeding and an increased risk of cardiovascular problems. These side effects are more common among older patients. NSAIDs include popular over-the-counter painkillers such as ibuprofen, or Motrin and Advil; naproxen, or Aleve; and aspirin. Prescription NSAIDs include diclofenac and ketoprofen; as well as the prescription COX-2 inhibitor celecoxib, or Celebrex.

To determine whether there is a link between opioid use and falls and fractures, Dr. Rolita and her colleagues first looked at the use of opioid painkillers in more than 10,000 people with OA older than age 65 both before and after Vioxx was pulled from the market.

From 2001 to 2004, the number of patients receiving a prescription for an opioid painkiller – sometimes called a narcotic painkiller – rose from 8 percent to 20 percent. By 2009, the number had doubled to 40 percent. The use of non-opioid painkillers declined throughout the study period.

At the same time, the rate of falls and fractures rose, from 1 percent in 2001 to 4 percent by 2009. People who fell tended to be older (in their 70s and 80s) and sicker, regardless of the type of pain medication they used, than those who didn't fall. But even when age and other illnesses were taken into account in the analysis, opioid painkillers were associated with a four-fold higher risk for falls than non-opioid painkillers.

"The increase in falls and fractures was strongly associated with the increased use of opioids as opposed to Tylenol or other pain medications," Dr. Rolita says.

The findings come at a time that the Centers for Disease Control and Prevention, or CDC, reports that the death toll from overdoses of prescription painkillers has more than tripled in the past decade, with more than 40 people dying every day from overdoses of opioids like hydrocodone, methadone and oxycodone.

The epidemic is blamed largely on misuse of prescriptions for nonmedical reasons, but increasing use of drugs for pain control is a contributing factor as well, according to the CDC.

That's all the more reason to take steps to reduce the use of opioid painkillers among older patients, according to experts. In elderly patients, who are prone to falls for other reasons, just taking opioid painkillers – not abusing them – is associated with more falls and fractures, says Eric Matteson, MD, chair of the division of rheumatology at the Mayo Clinic in Rochester, Minn. Dr. Matteson was not involved in the study.

The problem is that treatment options for people with chronic pain due to arthritis are limited. "If you take away opioids and NSAIDs, what's left?” he asks. “Tylenol (acetaminophen) … joint injections, and nonpharmacological measures such as acupuncture and weight loss."

Rather than eliminating NSAIDs and substituting opioids, Dr. Matteson says, NSAIDs need to used more judiciously.

"Instead of taking them every six to eight hours, as the label states, I tell patients to only take them when really needed for pain," he says. "Or, take a lower dose of an NSAID like Advil plus one Tylenol to get equivalent pain relief to two Advil tablets."

Scott Zashin, MD, who moderated a press conference in which the study results were discussed, has another suggestion: Keep an eye on the patient. He recommends that a family member or visiting nurse stay for a few days with an elderly patient starting a opioid painkiller to ensure the drug doesn’t make him confused or drowsy. And they should come back weekly to check on the patient.

Opioids should not be given "a totally bad rap," says Dr. Zashin, a clinical associate professor of medicine at the University of Texas Southwestern Medical School in Dallas. "They can be effective painkillers."