Overcoming Pain

Why people experience chronic pain, and the power they have to de-intensify it.

Dr. Mark Borigini is a board-certified rheumatologist who has devoted his career to treating, and training others to treat, a wide variety of illnesses that cause chronic pain and disability. See full bio

July 17, 2009, Health

Opioids: An Endorsement for the Elderly

New guidelines for the older patient with chronic pain.

Recently, the American Geriatrics Society (AGS) suggested that chronic pain patients older than age 75 should avoid using nonsteroidal anti-inflammatory drugs (NSAIDs).

This is a new recommendation based upon revelations that have been with us most of the decade, regarding the serious cardiovascular and gastrointestinal tract risks associated with NSAID use. Also, it has been long known that the NSAIDs can worsen hypertension and renal function and congestive heart failure, particularly in the older population.

Thus, acetaminophen, commonly known as Tylenol, is the initial systemic therapy of choice for the older patient with chronic pain, assuming of course that the patient does not have serious liver disease. However, the AGS recommendations encourage the consideration of opioid drugs in the elderly individual with persistent pain. And persistent pain is a too-frequent symptom of the older patient, whether it be due to spinal degeneration , arthritis, nocturnal leg pain, or cancer.

The AGS believes that NSAIDs in many cases are associated with much more risk when compared to different opioid treatment strategies. Still, physicians must be vigilant for adverse events associated with opioid use, and for breakthrough pain.

Adverse events associated with opioids in the elderly include delirium, anorexia, nausea, vomiting and constipation.

But as with most aspects of medical care for most any age, treatment of the older patient with chronic pain requires an individualized approach, including psychological intervention and physical therapy, among others.