Experts Warn Against Long-Term Use of Common Pain Pills



But they should — especially if they’re elderly.






“Physiological changes in the elderly affect the way drugs are absorbed and secreted and how the body responds to them,” said Dr. Keela Herr, a professor at the University of Iowa College of Nursing in Iowa City who researches pain management in the elderly and was involved in drafting the new guidelines. “Younger people can use this class of medicine with limited risks. In older persons, it’s a different story. Physical changes make them more sensitive.”

The geriatrics society’s new guidelines say NSAIDs should be considered “rarely” in the population of frail elderly people, and used “with extreme caution” and then only in “highly selected individuals.” For those patients with moderate to severe pain that diminishes the quality of life, opiates may be considered, the guidelines suggest, after both the patient and caregiver are screened for prior substance abuse.

It is the third revision of the guidelines, originally created in 1998 and updated in 2002. In this latest version, acetaminophen remains the top choice for chronic pain. But acetaminophen is a fairly weak analgesic, experts say.

“Opioids are, everyone agrees, probably the strongest pain medication you have,” said Dr. Roger Chou, a pain expert who was not involved in writing the new guidelines and believes decisions about opioid therapy must be made on a case-by-case basis. “The down side is the potential for abuse, and we’re seeing huge increases nationwide of reports about the misuse and diversion of prescription drugs and related deaths. . . .The concerns about opioids are very real.”

He argued that opioids must be prescribed very carefully, no matter what the age of the patient. Patients with chronic persistent pain will be on the drugs for a long time, because the pain usually does not go away, and they will also be at risk of developing other problems related to the medication, such as constipation, nausea and fatigue.

The guidelines are not meant to discourage the treatment of pain. On the contrary, chronic pain is rampant among the elderly, affecting an estimated 25 to 50 percent of elderly people living in the community and up to 85 percent of nursing home residents. Often caused by degenerative spine conditions, arthritis and cancer or cancer treatment, chronic pain takes a powerful toll on quality of life.

Untreated, chronic pain can disrupt sleep and affect mood, restrict mobility and lead to depression, anxiety and isolation, experts say. It can also contribute to falls, which lead to further complications and often death. Although non-drug treatments like physical therapy, cognitive behavioral therapy and other educational interventions are often helpful, adding drugs to the mix usually enhances treatment, experts say.

“There really continues to be a significant amount of unrecognized and untreated pain in older people, and it’s a huge problem,” Dr. Herr said. “A lot of people think that just because they’re getting older they’re going to have pain and just have to learn to live with it. That’s not the case.”

Pain cannot always be entirely eliminated, she added. “You can get to the point where it’s in the mild category — where it’s annoying but not causing such impairment that you can’t function and interact and do the things that are important.”

Comments are no longer being accepted.

What about medical marijuana for treatment of chronic pain in the elderly?

See: “Retirees demand marijuana.”

Who exactly are these frail, elderly people? Is there a recommended age for the new guidelines? Which NSAIDs are associated with which risks? What about older people taking low-dose aspirin to protect their hearts?

I have an older friend (in his seventies) who takes Oxycontin for neuralgia. His pain may be abated, but his mental functioning has taken a nosedive. What is worse — walking around in a fog all day or having an increased risk of gastric problems?

Hasn’t acetaminophen also been implicated in causing kidney problems in elderly people when taken every day for pain?

Ms. Rabin replies: Yes. Studies have found high doses of acetaminophen over many years can result in kidney problems. There is also a concern about long-term use causing liver failure if maximum recommended doses are exceeded.

Why do these articles always leave out some critical bits of information? In this case, the would be how the panel of experts defined the term, “the elderly.” In other words, at around what age do people need to start worrying about these side effects.

Ms. Rabin responds: Point taken. The guidelines are intended to apply to those ages 75 and older. We will update the story.

Nowhere does the article mention the use of so-called “regimen aspirin,” those 81mg, enteric coated aspirin recommended for heart health.

Is this still recommended, or included in the warnings?

Ms. Rabin responds: Many adults take a baby aspirin containing 81 milligrams once a day to prevent coronary heart disease, and the new guidelines do not suggest they stop doing so. In fact, the guidelines say that anyone taking other NSAIDs should also take baby aspirin to reduce cardiovascular risk. Baby aspirin contains only one-quarter the dose of a full aspirin, which contains 325 milligrams. And while baby aspirin is proven to confer heart protection, much higher amounts are used to to treat persistent round-the-clock pain, said Dr. Alfred Bove, president of the American College of Cardiology: “Don’t expect your arthritis to get better with one baby aspirin.”

I disagree with Dr. Ferrell , the chair of the geriatrics panel, that made the recommendations. The problem is that one is only substituting side effects , rather than improving health outcomes. Consider Edna, an 85 year old with hip arthritis and osteoporosis. It is likely that ANY dose of narcotics, such as vicodin , or morphine, as the panel suggests could increase her risk for a fall that would result in a hip fracture, not a trivial event in this age group, when one considers that there is a 20 % mortality ( that’s deaths , not just increased morbidity ) is associated with the hospitalization and hip pinning surgery that would most certainly ensue. And this doesn’t even require a severe fall, just a “trip” on the edge of a carpet that was not seen, ( opiates also cause blurred vision, besides impaired balance and judgement ) . I would still say that NSAIDS ( motrin, diclofenac ) are safer in the elderly, GIVEN that these patients are followed and monitored frequently by a well qualified physician. The only risk that was previously unseen by geriatricians, is the vasospasm /thrombosis that some NSAIDs cause, ie, the newer , more recent nsaids such as celebrex. This is a yet unidentified risk as their adverse effects such as MI or stroke have yet to be elucidated…not enough research dollars…there is a spectrum of these nsaids , from the least likely to the most likely to cause heart attacks and stroke, that most people are not aware of…as a good physician !

I am in my mid 50’s with MS and was on very strong NSAID’s (both naproxen then nabumatone) for about 4 years for chronic leg pain. Turns out the pain was neurophathic and I now use Cymbalta and Lyrica with much better pain management and no more NSAID’s for me, only Tylenol on rare occasions. Blood pressure is much happier and no more acid reducers either. Much improved pain management helps with my sleep, ability to exercise and general well being.

Given the high number of elderly on aspirin therapy, this article would have been more helpful had it quantified “high does” as it relates to aspirin.

If they already know the potential hazard these drugs imply… why do they keep on letting them out on the market!?

Speaking as chronic pain patient with seever intractable chronic pain who thinks a broken wrist is a 2 out of 1-10 on the pain scale, they are OUT OF THEIR MINDS!

And just what happens to someone who is put on narcotics and then can’t afford to fill their prescription, eh? Narcotics ARE addictive. Ever hear of withdrawal?

When those on Medicare hit the dreaded doughnut hole in coverage after the first $2700 in drugs and now have to 100% of costs until the total in drugs reaches $4350, people go off their medications.

Maybe these so-called expets don’t mind walking around in a fog from narcotics, but I most certainly do! 1/4 of the lowest dose of narcotics leaves me unable to stay awake and forget functioning.

My wife went on low dose aspirin a month ago for it’s blood thinning properties. Already she is experiencing ulcer like symptoms. For my part, I’m prone to indigestion and so have never tolerated aspirin well. I have only a single kidney (renal cancer) so acetaminophen and ibuprofen are both problematic.
Two years I had transitory gout related to a radioactive dye used in an MRI. I visited two different doctors who offered no help at all. On the 3rd try, I met a wonderful doctor who understood that given the issues with my Kidney, typical gout medications and over the counter pain meds were not the answer. She prescribed a low dose narcotic. I refilled it once, the gout passed within a month and I have gone on with my life. Addiction should not be taken lightly, but we shouldn’t sacrifice our health, or live needlessly in pain, because of the hysteria whipped up by drug warriors. Alcohol is the most dangerous drug in America, yet somehow we manage to live with it. Doctors should be free to prescribe what works best for the patient without fear of Government interference.

As a person who has been living with chronic pain for many years as the results of 2 auto accicents (was in the wrong place at the wrong time), I’ve seen the downside to using prescription pain pills. It’s the cost!

Not the cost of the drugs, they are inexpensive, its the government regulations that say that only one month of pills can be prescribed at a time. This is unlike other meds where you can do one doctor visit and get a prescription for 6 months or a years worth of pills.

For the pain meds, the government requires that you see the doctor every month to get a prescription. The doctor visits cost a lot more than the medicine.

As most people who live with chronic pain will attest, they are NOT getting the meds to get high, they are getting them to be able to function.

Unfortunately, a few high profile case like Rush Limbaugh who have abused drugs make it expensive to the millions that just need relief so they can continue a “normal” life.

Yes, the pills have side effects but considering the alternative, they are pretty mild (considering the alternative).

If the government is serious about lowering the cost of medical care, they should look at all the millions of mandated, extra, doctor visits required by their own regulations.

One additional comment, Dr. Ferrell’s statemetn about addiciton in the elderly, ““You don’t see people in this age group stealing a car to get their next dose.”, is true , but misleading. I am surprised that a geriatrician would make that type of blanket statement…he should realize that the elderly are a DIVERSE poplulation of people, with varying levels of “skill”, often assumed by the younger to have forgotten them. There are nefarious octa and nonagenarians amongst the more benign ones, ,don’t forget!

. There is also more financial pressure on these elderly , thus making it more likely they would sell their narcotics, perhaps not to the usual drug pusher , but there are a number of unseen drug pushers, such as those in nursing homes, the “aides”, or food service personnel , for example, who would buy Edna’s 120 tablets of vicodin during her lunch, at bargain basement prices, and turn around and SELL them to minors at the high school next door.

I think this is a tremendously unhelpful set of recommendations. It is one thing to caution that great care needs to be taken with NSAIDS. But without offering a viable alternative (which opiates, quite frankly, aren’t), they’re essentially saying old people just have to suck it up and suffer. I don’t think that’s acceptable. The fact is that suggesting opiates as an alternative is farcical due to our government’s drug “issues” and its not-infrequent harassment of doctors who are prescribing and/or patients it feels are taking “too many” opiates. Unless and until the government stops that hostile behaviour, NSAIDS will remain a necessary risk that must be taken to manage pain.

Dick Blumenthal May 6, 2009 · 2:35 pm

Like other commentators, the article fails in several respects. It may be reporting what the panel has stated, but the reporter should have raised the question of who the”elderly” are, how this warning relates to the blood thinnig properties of aspirin in particular, and what many have said are the multiple positive effects of aspirin

Acupuncture coverage by Medicare is long overdue. Though it might cost a surgeon or two a renovation of the rec room, it will help seniors stay off drugs and save ALL that money, get healthier, more energetic, have less pain, and even be clear-minded, as well as sleeping better. Imagine that, and it’s cheap, compared to all those visits to all those doctors all day long.

How about it? People, start writing all your representatives to get coverage of acupuncture by Medicare. Now!

I vote for grass, At least the buzz is nice …

letsBsafeNotSorryUSA May 6, 2009 · 2:53 pm

Hasn’t acetaminophen also been implicated in causing liver damage in chronic use?

Regarding stomach ulcers associated with aspirin, I though enteric coated aspirin which prevents digestion in the stomach reduces or eliminates this problem. The aspirin is absorbed in the intestines.

Americans need to look to Asian medicine including Ayurvedic Medicine of India, Chinese Medicine (including acupuncture which uses no medicines), herbal medications used in Europe and South America, and even physical therapy (exercise, hot and cold therapy). Then there are electrical stimulation treatments, massage therapy, and other healing arts.

Opiates do not sound like a great alternative. As noted earlier, elderly people are at risk for falling and hip and other trauma such as a blow to the head. Bumping into things and causing embolisms is not great as this can lead to heart attack, stroke and deep vein thromboses which can result in legs or feet being amputated.

By the way, acetaminophen can be combined with aspirin or other NSAIDs to reduce the amount of the latter that is needed to produce pain relieve. Advantages of NSAIDs over acetaminophen include their anti-inflammatory properties which are beneficial for joint diseases and may reduce risk for heart attack, as well as their anti-clotting abilities which also reduce heart attack and stroke risk.

Joanna Cumberland May 6, 2009 · 3:02 pm

Something to think about when you pop advil

Vic the Brooklynite May 6, 2009 · 3:18 pm

Food for thought, but there’s no specific mention of what they are talking about, when they say high doses. Besides being opinionated, I’m a fiftyish athletic type, who is starting to get the pains from my very active lifestyle. I’m also a believer from research, and my own experience, that the old standby derived from the bark of the willow trees, that substance with the trade name of “Aspirin” is still the best and safest thing, especially compared to what’s out there, including that thing called “Tylenol”.
My question is simple, what’s a high dose of Aspirin over time, because now and then, and it’s becoming more now, I take a 325mg. tablet?!

It is beyond me why anyone of any age has to risk destroying their stomach, liver, and kidneys trying to manage intractable pain.

It lived with three months of unbearable pain until I finally had an MRI and was diagnosed with a herniated disk in my neck. A single shot of steroids fixed the nerve inflammation and I can only hope that the months of around the clock ibuprofen did not do any damage to my liver or kidneys. My stomach is shot, I am hoping time will heal all wounds, but it is a sad story that none of the doctor’s I saw would prescribe me *anything* to relieve my pain.

Yes, some people will abuse narcotics (just like some people abuse alcohol). The vast majority of people do not abuse narcotics, and there is no rational reason that they should they suffer for the sins of the few.

I had severe pain from osteoarthritis in my knees bilaterally for 10 + years. I took Vioxx for many years, as nothing else would help my pain. At age 60 I had bilateral knee replacements which have been remarkable for me. The Vioxx turned out to be a major health hazard which did not affect me, thank goodness. The question is, what don’t we know about the future effects of what we are taking.
This is why I question the HPV vaccine. I believe that issues will arise that will qualify who should take various medications. This will only happen in time.
The gastroenterologist told my husband no more Nsaids as he has slight gastric erosions. So for pain, I massage the areas for him. He has realized that the pill is more harmful than the result would justify.
Be smart..there are often many other options.Be careful and do question and listen to your doctor.

The American Geriatrics Society has issued guidelines but doesn’t cite the science behind their decision. Have there been studies to examine the effects of NSAIDS vs. narcotics on morbidity and mortality in people over the age of 75?

What’s the real agenda behind the announcement?

Ms. Rabin replies: Your question about the evidence is a good one. Unfortunately, not many studies on this subject have included people ages 75 and older. The sparsity of evidence regarding this population was acknowledged by the guideline writers.

What is “high dose”. 800 mg.per day of ibuprofen? 1600 mg.? More?

once again, we see the results of the obdurate refusal of insurance-driven, Big Pharma-driven medicine to consider non-drug alternatives. Acupuncture and acupressure and, in some cases, massage may be effective for at least some types of chronic pain, but it remains unavailable to most people, especially the elderly who depend upon Medicare.
and the elderly are among the most vulnerable to adverse side effects from almost any drug.
Go figure.