Few people think twice about taking aspirin or ibuprofen. But for those 75 and older, the high doses needed to treat chronic pain may be so dangerous that patients may be better off taking opioids instead, an expert panel has found.
New pain management guidelines issued by the American Geriatrics Society late last month removed those everyday medicines, called Nsaids, for nonsteroidal anti-inflammatory drugs, from the list of drugs recommended for frail elderly adults with persistent pain. The panel said the painkillers should be used "rarely" in that population, "with extreme caution" and only in "highly selected individuals."
Acetaminophen (like Tylenol) remains the top choice for treating chronic pain, but for those patients unable to get relief, the next step on the ladder is opioids, the guidelines say — as long as patients and their caregivers are screened for previous substance abuse.
The recommendation, which is already proving controversial, was made even though Nsaids are known to be fairly effective for chronic inflammatory pain conditions that often plague older adults, and even though opiates can be addictive.
"We've come out a little strong at this point in time about the risks of Nsaids in older people," said Dr. Bruce Ferrell, a professor of geriatrics at U.C.L.A. who is chairman of the panel. "We hate to throw the baby out with the bathwater — they do work for some people — but it is fairly high risk when these drugs are given in moderate to high doses, especially when given over time.
"It looks like patients would be safer on opioids than on high doses of Nsaids for long periods of time," he continued, adding that for most older people, the risk of addiction appears to be low. "You don't see people in this age group stealing a car to get their next dose."
But experts on pain say that it is difficult to make generalizations and that extreme caution must be used in prescribing opioids, no matter what the age of the patient.
"We're seeing huge increases nationwide of reports about the misuse and diversion of prescription drugs and related deaths," said Dr. Roger Chou, a pain expert who was not involved in writing the guidelines for the elderly but directed the clinical guidelines program for the American Pain Society. "The concerns about opioids are very real."
There is also a concern about side effects that may be associated with opioid use, including respiratory problems, constipation, fatigue and nausea, Dr. Chou said.
Many of the panelists reported having financial ties with drug manufacturers, but the chairman, Dr. Ferrell, said that he had no conflicts of interest regarding the medications under discussion and that the guidelines were peer-reviewed.
Dr. Ferrell acknowledged that scientific evidence on addiction among the elderly was limited because few studies focus on people 75 and older. The risks of Nsaids include ulcers and gastrointestinal bleeding and, with some drugs, an increased risk of heart attacks or strokes. The drugs do not interact well with medicines for heart failure and other conditions, and may increase high blood pressure and affect kidney function, experts said.
The guidelines are not meant to discourage the treatment of pain. Experts involved in developing the guidelines say chronic pain takes a huge toll on the elderly and too often goes untreated.
The new guidelines are also not meant to affect recommendations about taking baby aspirin to protect the heart; the amount of aspirin — 81 milligrams — is very small, a quarter of the dose contained in an adult pill.