An article in a newsletter published by the College of Physicians and Surgeons of Alberta (May 1, 2017) provides guidelines to physicians on safe prescribing of painkillers to seniors with non-cancer pain.
The article uses an example of John, a 78-year-old man who has experienced chronic low-back pain due to arthritis for several years, with gradual worsening over time. There is no indication John needs surgery.
John has several medical conditions that include mild cognitive impairment (problems with memory, language, thinking and judgment), high blood pressure, diabetes mellitus type 2, mild chronic renal impairment and falls.
His current medication regimen includes acetaminophen 500 milligrams (mg) when needed and naproxen 200 mg twice daily (over the counter supply). These painkillers do not relieve his pain. He wants a stronger medication.
As we know chronic pain is common in older adults. There are concerns regarding the potential adverse effects of painkillers in this population. But should we let them suffer? No. A person should be treated as a whole taking into consideration other medical problems.
Management of John’s pain includes appropriate assessment of the pain and other medical issues. That should include involvement of John’s family in the future management plan.
The article says, “Treatment-related goals should generally be directed toward improvements in function rather than in pain intensity as function-related goals are often more evident in patients with chronic pain.”
What kind of painkillers can we use safely?
Acetaminophen is the first line of treatment for older adults with mild-to-moderate pain. Acetaminophen at recommended doses is considered safe. Maximum recommended daily dose is 3,000 mg. Dose is lower if a person has liver disease or those who consume three or more alcoholic beverages daily. Acetaminophen should not be used if a person has severe liver failure.
Oral NSAIDs (non-steroidal anti-inflammatory drugs) are recommended to be used with caution and for the shortest time possible. This recommendation stems from the high risk of side effects, particularly with long-term use. It can adversely affect the stomach, heart and kidneys.
Topical NSAIDs, such as diclofenac gel, are generally preferred for localized musculoskeletal pain such as osteoarthritis.
Opioids (produces morphine like effect) use in older adults with chronic non-cancer pain has been associated with decreased pain intensity and improved function. However, there is a lack of data on long-term efficacy as existing studies have been only short-term. It is a narcotic and can cause confusion, increased risk of falls, fractures, hospitalization and mortality.
For mild to moderate pain, the recommendation is to use codeine or tramadol. Second-line opioid treatment for mild-to-moderate pain, and first-line for severe pain is morphine, oxycodone or hydromorphone.
Antidepressants should be used in patients who have co-existing depression and pain.
Non-pharmacologic Management
This involves a psychologists and a social worker. They can be helpful in terms of teaching coping strategies, providing emotional support and accessing appropriate programs. A physiotherapist can help with flexibility, balance and endurance exercises.
Pain management in the elderly with multiple medical conditions is not easy but a team effort can do a lot to help and relieve suffering.
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