Part 2: I Need Something Stronger

My elderly mom has pain in her calves and feet. She uses Tylenol® every day but some days the pain is so bad that she doesn’t leave the house. Like many frail adults, my mom has chronic pain that has an impact on her quality of life. What would help her? …. Is it time to try cannabis?

The last post was about first-line medicines for chronic pain. Acetaminophen is safe and effective for mild to moderate pain. NSAIDs sometimes work better but have more side effects, particularly among seniors. What’s next when more pain relief is needed?

I’m not depressed. I have pain. It’s not just in my head.

A good next step is an antidepressant. People don’t like to be told that pain is “just in the head” and due to depression. However, despite their name, antidepressants can also relieve pain. Some antidepressants adjust imbalances in serotonin and norepinephrine. These chemicals impact mood but also have important effects on chronic pain pathways. Pain and depression can also exacerbate each other. An antidepressant treats both.

Antidepressants should be used together with other medicines to relieve pain. In addition, antidepressants are not all equally effective. Duloxetine  (Cymbalta®) is FDA-approved for both neuropathic pain and chronic musculoskeletal pain. Neuropathic pain is pain caused by nerve injury. Shingles and diabetic neuropathy are examples of nerve injury.

Antidepressants do not bring immediate improvement to pain. Instead, they have a gradual impact on pain. They sometimes cause gastrointestinal discomfort. For that reason, start with a low dose after supper or before sleep. Gradually increase the dosage to allow the body to adjust. Decreases in dose should also be gradual. A good goal is moderate pain relief. A higher dose increases the likelihood of side effects.

Medicines that are FDA-approved for seizures are widely used for pain control. Is that good?

My mom has seen a variety of specialists for the pain in her feet. Inevitably, one of them prescribed low-dose gabapentin (Neurontin®). I know that the pain has been bothering her a lot and I thought that was a reasonable decision. She’s tried it for over a month now. She doesn’t think it has decreased the pain. Fortunately, she hasn’t had noticeable side effects. The doctor has told her it’s ok to stop.

It was reasonable to prescribe a trial of gabapentin. Gabapentin belongs to a class of drugs called gabapentinoids. They are one of several classes of drugs that are FDA-approved to prevent seizures. These medicines decrease the excitability of nerve cells. Pain reduction can be as much as 50% for neuropathic pain. However, the usefulness for pain unrelated to nerve injury is controversial.

Gabapentinoid use has gone up dramatically among older adults. 9% of adults over age 70 have used this class of medicine. Geriatricians are very concerned about this. Gabapentinoids are widely viewed as an alternative to narcotics. But they are increasingly used together with narcotics. This can be dangerous. They have side effects such as nausea, confusion, incoordination/falls, and fatigue. These side effects can occur even at low doses among frail seniors. In addition, the drug can accumulate in the body over time.

Other medications that should be avoided

Muscle relaxants are problematic for seniors, especially for those at risk for confusion. Even one dose can cause confusion, but the risk increases with prolonged use. They are sometimes necessary for conditions such as spastic paralysis. However, they should not be used for chronic pain in older adults.

Anti-anxiety medicines should be avoided for chronic pain. Medicines such as lorazepam (Ativan®) are sometimes used for muscle spasm. However, 10-20% of falls among seniors are associated with the use of this class of medicine.

Is it time for my mother to try cannabis?

My mother has never used cannabis in her life. Should she now? 30% of people with chronic pain have used cannabis for pain relief. This includes a surprisingly large number of older adults. 8% of seniors have used cannabis in the past year and use is increasing. One study indicates that cannabis is well tolerated among older adults. However, there is no data about use in the frail older person. Among these patients, I’m particularly concerned about the risk of confusion. Drug interactions are not well understood.

Does cannabis relieve pain? This is controversial and may depend on the type. There are two classes of cannabis products, marijuana/THC and cannabidiol/CBD. Marijuana/THC results in a “high” but CBD does not. There’s some evidence that THC is helpful for pain relief, especially neuropathic pain. There is less evidence that CBD is useful for pain relief. Some articles are attached below.

Cannabis products are still illegal in some states. However, the U.S. Drug Enforcement Agency will soon reclassify cannabis. It will no longer be in the class of the most dangerous drugs. It will be classified as a drug with medical uses. Healthcare providers still cannot prescribe them for pain control. It is not available in pharmacies yet. As a result, cannabis is available in regulated dispensaries in most states. Quality control is inconsistent. Cannabis products come as drops, gel chews, capsules, syrups, topical oils, creams, and sprays. And of course, they can be smoked. If tried, these products should be started at the lowest dose possible. The only cannabis product I would try for my mom is a CBD cream. These creams often have a menthol balm which could help. The National Institutes of Health has a nice summary about cannabis but, as noted, federal regulations are soon changing. 

What’s next for Mom?

I think a good option for my mother is a trial of an antidepressant even though she isn’t depressed. The next step could be a combination of low-dose antidepressant and low-dose gabapentin. These medicines impact different components of the pain mechanism and might work together. But more medicine also increases the risk of side effects and drug interactions. The risk must be weighed against the potential benefit. Every patient is different. Consult with your healthcare provider. Remember to review medicines for side effects and interactions. Mom is also getting relief from things other than medicines. This will be discussed in a future post.

Warmest Aloha,

[email protected]

PS: I say it over and over again: There’s no one more important than the caregiver in the daily life of a frail person.

Related Articles

Health Effects of Cannabis and Cannabinoids – PDF

JAMA Network Cannabis – PDF

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