What to Do About Chronic Pain in Older Adults

When you’re younger, it may be easier to shrug off pain or work through it. The old expression, No pain, no gain is the mantra of many athletes. But as we get older, pain has a way of getting us down faster and keeping us there longer. We don’t bounce back like we used to. This is especially true when pain is present.

Older adults often find that managing the chores and activities of daily life are a challenge enough without pain being added to the mix. Suddenly, making a cup of tea can become impossible — much less preparing a nutritious meal. Sleep is disrupted, thinking becomes cloudy, and the affected adult is no longer getting out with other people. Persistent pain in this age group can create a steady decline in physical and cognitive function.

What can be done about it? Medications are one possibility but knowing what to take and when to take it can be another difficult hurdle to jump. In this special edition, the American Geriatrics Society’s Guidelines for Pharmacologic Therapy are reviewed. The specific focus is on medications for chronic pain in older adults. Chronic (or persistent) pain is defined as pain that lasts more than three months. Older adult refers to men and women 65 years old and older.

The next logical question is, What medications are available and who should take them? Pain medications including acetaminophen (Tylenol), nonsteroidal antiinflammatories (NSAIDs), opioids (narcotics), adjuvant (additional other) analgesics, topical analgesics (rub on creams and gels), and other drugs are discussed. Here’s a brief summary of each class of drugs.

  • Acetaminophen (Tylenol): Safe and effective, the first choice of drug for pain relief. Patients should not take more than a total of 4 grams each day. Anyone with liver disease or who abuses alcohol cannot take this drug.
  • Nonsteroidal antiinflammatories (NSAIDs): More effective than acetaminophen for chronic inflammatory pain but with possible gastrointestinal problems. Should not be used by anyone with an active stomach ulcer, kidney disease, or heart failure. Patients on NSAIDs must be monitored carefully for any signs of adverse effects.
  • Opioids (narcotics such as Lortab, OxyContin, Percocet or Percodan, Morphine): Anyone who has not responded to acetaminophen or NSAIDs and who has moderate to severe pain that affects daily function should be considered for opioid pain relievers. Newer and better drugs of this type are available that are safe and effective. Opioids should only be prescribed and monitored by knowledgeable physicians with experience using these drugs.
  • Adjuvant analgesics: refers to drugs developed for some other purpose than pain relief but useful for persistent pain. Includes some anticonvulsants, antiarrhythmics, and antidepressants. Used most often for people with fibromyalgia, nerve pain, chronic and severe back or bone pain, and headaches. Often prescribed along with other pain relievers.
  • Topical analgesics including lidocaine, NSAIDs, and capsaicin: Available as a patch or topical gel, these medications are useful in controlling nerve pain. Patients with diabetic neuropathies or chronic musculoskeletal problems seem to benefit the most. Patients must avoid use around open wounds or mucous membranes and stop use if a skin rash develops.

    Patients should be warned to expect a burning sensation when using capsaicin. Unlike lidocaine, which is a numbing agent, capsaicin produces a counter irritant. The mild burning sensation draws blood to the area and improves circulation needed for local healing.

  • Other drugs: Efforts are ongoing to find other drugs that might be useful in controlling or managing various types of chronic pain. For example, muscle relaxants, oral (systemic) corticosteroids, calcitonin, and bisphosphonates have been used as a second-line treatment approach after some of these other, less risky medications. When it comes to pain control, much more research is needed to understand what works and why.

    One of the problems in prescribing pain medications for older adults is their unwillingness to take them. Often, they suffer in silence and refuse to see a doctor or mention their pain. They may believe that their symptoms are just part of aging. Unidentified or undertreated pain can spiral into a worse problem with additional complications if and when it is not addressed early on.

    Physicians are faced with the challenge of finding the right medication in the best possible dosage for a wide range of different problems. There can be joint pain from arthritis, muscle cramping associated with restless legs syndrome, or nerve pain from shingles. They must watch out for the adverse effects that can occur when patients are already taking multiple different medications for other problems like high blood pressure or diabetes.

    There’s also the problem of how older adults metabolize drugs. They don’t always break drugs down the same way or at the same speed as younger folks. The result can be overdosing or underdosing. Either way, there is less than optimal results. And finally, not all older adults are able to report pain verbally. Strokes, dementia, Alzheimer’s, and other conditions can leave patients without the ability to speak or communicate their problems and/or needs.

    The authors of this special edition hope that reviewing updated guidelines established by the American Geriatrics Society (AGS) will benefit professionals who are working with older adults. Recommended starting doses are provided for each drug. Whenever possible, other nondrug methods of pain management should be encouraged. This may include physical therapy, cognitive behavioral therapy, and complementary and alternative medicine (e.g., acupuncture, chiropractic, massage, Reiki, therapeutic touch, BodyTalk).

    Special instructions are offered when necessary such as how to monitor patients and what types of adverse effects to watch out for. With so many elderly people in the American population and a high incidence of pain among this group, this updated set of guidelines is a valuable tool for pharmacists, primary care physicians, and geriatricians (physicians who specialize in working with older adults).