The Role of Medicines in Pain Control: Part 1

Older adults take more medicines and are more likely to have problems due to using them. Medicines should be avoided if possible. But pain is also more prevalent among seniors and medicines are the most effective way to control pain. This post will be part 1 about medications for chronic pain in older adults.

Let’s start with some basic concepts:

  • What works for one person may not work for another. The right medicines control pain without major side effects or adverse consequences. Some meds work for some people but not others. Some people have side effects, not others.
  • Pain should be treated before it’s severe. Delay in treating pain can result in repeated cycles of severe pain and strong pain killers. Pain is then in control. It’s better to be in control of chronic pain, avoiding severe pain, and avoiding the need to take stronger pills.
  • Milder pain relievers should be tried first. The World Health Organization recommends a ladder approach. Progress to stronger medicines only if needed.
  • Be careful when using long-acting medicines in older adults. Long-acting medicines are often prescribed to keep pain under continuous control. This makes sense but drug metabolism is slower with aging. This means that the drug can accumulate in the body over time. Side effects can come on gradually. Keep an eye out for this. Keep long-acting medicines at the lowest strength that is effective. One strategy is to use a long-acting medicine together with a shorter acting one.
  • A combination of medicines with different mechanisms of action is often useful.
  • A daily medication regimen is often needed. Chronic pain is a medical condition just like a high cholesterol. The goal with medications is to arrive at an optimal regimen that works for the person. Sometimes pain is more severe at certain times of the day or before certain activities. Provide pain relief before those times. The regimen should also include a “just in case” medicine. This is not used routinely but is one that can be relied on when pain is severe. It makes a difference for people to know that there’s something extra just in case.
  • Avoid excess alcohol. Alcohol increases the likelihood of adverse events with every class of pain medication.

Acetaminophen: “Pain Relief You Can Count On”, Partly True

Acetominophen has been the most common over-the-counter pain reliever since the 1970’s. (Outside the United States it is called paracetamol). The most well-known brand is Tylenol. It is the “#1 doctor recommended brand of pain reliever”. But how effective is it?

Acetaminophen is the first choice for mild to moderate pain in older adults. It is used for fever, transient headaches, muscle aches and joint pain. It is not very effective for other types of pain such as neuropathic or abdominal pain. For persistent pain, it must be taken frequently and at higher doses. “Extra-strength” means that it is the same product at a higher dose. Taken alone, it is ineffective for severe chronic pain.

Acetaminophen can be counted on because it is relatively safe and has few side effects. But extra care must be taken by patients on warfarin, a blood thinner. That’s because it can boost the effect of warfarin, resulting in more thinning of the blood. Be especially careful when starting or stopping acetaminophen. Warfarin is the only blood thinner that has this specific interaction with acetaminophen.

Although it is safe, acetaminophen at high doses can cause liver damage. For instance, taking more than 10 extra strength pills at once or 10 pills every day can be risky. Patients often unknowingly take high doses of acetaminophen. That’s because it is a component in many other medications. In addition, acetaminophen can worsen liver problems in people with preexisting liver disease. This is also true for people who drink too much alcohol. In these patients, the maximum safe daily dose can be less than four tabs per day.

It’s important to know what an NSAID is. Use with CAUTION

NSAID’s should not be used regularly in most older people with chronic pain. Regular use results in  injury to the stomach in more than 50% of patients.

“NSAID’s” are Non-Steroidal Anti-Inflammatory Drugs. They are called that because they are not steroids. Instead, they are a different class of drugs that also fights inflammation and pain. The classic NSAID is aspirin but there are many other ones. Ibuprofen is the most common over-the-counter NSAID in the United States. It is widely known by the brand name Advil.

The FDA states that NSAID’s should be used at the lowest effective dose for the shortest possible time. In reality,  they are now taken more frequently than any other pain medicine. NSAID’s are used regularly by as many as 30% of older patients. This is even though the risk of side effects increases with age.

Bleeding due to NSAID related ulcers can come on abruptly without warning. Many patients are surprised because there was no stomach upset before the bleeding. The longer NSAIDS are used, the greater the likelihood of stomach injury and bleeding. Many older adults take low dose aspirin or other “anti-platelet” drugs to prevent against heart disease or stroke. The probability of bleeding increases when these medicines are taken together with NSAIDs.

NSAIDS can cause other problems too. At higher doses, even short-term use can increase the risk of elevated blood pressure, kidney disease, stroke, heart failure or heart attack. In addition, NSAIDS increase the risk of bleeding in patients who are on anticoagulants or antiplatelet agents.

Adverse reactions vary a little bit with different NSAID’s. Celecoxib (Celebrex) is an  NSAID in which the risk of gastrointestinal problems is not quite as high. It is only available by prescription and is more costly than over-the-counter meds.

People commonly think that over-the-counter drugs are safe. This is often not true. I avoid using NSAID’s because I have seen too many GI bleeds. I sometimes prescribe it as a “just in case” medicine when pain is severe. Occasionally, an NSAID does turn out to be the best long-term drug for an older person with chronic pain. In this situation, the medication needs to be managed by a healthcare provider. An added medicine to protect the stomach is often used.

Bottom Line

Part 1 summarizes the pros and cons of widely used pain relievers. I hope it has some useful information. These medicines are seldom adequate for severe pain. Acetaminophen is safe and effective for mild to moderate pain. The more that an NSAID is used, the higher the likelihood of a gastrointestinal bleed. The risk is particularly high in frail older adults.

Part 2 will discuss opioids and other classes of medicines that are used for chronic pain.

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.

Posted in Caregiving, Dr. Warren, Geriatrics with Aloha.

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  1. Pingback: Part 2: I Need Something Stronger - Geriatrics with Aloha

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