Medications for Persistent Pain An Older Adult s Guide to Safe Use of Pain Medications THE AGS FOUNDATION FOR HEALTH IN AGING
What is persistent pain? Introduction Persistent, or chronic pain, is pain that lasts longer than it should. Persistent pain can involve: Pain that lasts longer than you think it should (e.g., after a broken bone or another acute illness); or Conditions that do not heal, such as arthritis or nerve damage. Sometimes the pain may not have any obvious physical cause at all. A common problem for older adults Pain at any age is not normal. It need not be tolerated as just a part of growing older. Your health care provider can evaluate your pain and determine the right treatment to relieve your pain. Your health care provider will ask questions or observe your condition to understand your pain. You can help your health care provider by describing your pain as accurately as possible: Is it stabbing, aching, or burning? Is it worse at a certain time of day or night? What causes the pain a specific movement or activity? What, if anything, have you tried that helps the pain? 2
Many treatments are available Your health care provider has many ways to relieve your pain. Most commonly, medications are used to control pain in older persons. There are many safe and effective medications available. For example, your health care provider may prescribe around-theclock medication, such as acetaminophen (example, Tylenol ), to relieve mild-to-moderate muscle/ joint pain caused by arthritis. Other prescription medications are effective in treating pain that isn t relieved by this kind of medicine. Sometimes, persistent pain can be treated well without medications. Physical therapy, exercise, or fitness programs can improve strength and motion of your joints. Application of heat and cold to the painful area can also be helpful. Community programs can teach you about pain and help you cope with it. Often, medicines, together with other programs, will offer the best pain relief. Frequent causes of persistent pain in older people Persistent pain is more common in older people than in any other age group. Some reasons for this are obvious: conditions like arthritis, muscular problems, and back pain are especially widespread among older persons. But persistent pain can also have a variety of other causes. Joint, muscle, and bone disorders (osteoarthritis [also known as degenerative arthritis], gout, back and neck problems, osteoporosis{decreased bone mass}, fibromyalgia {disorder associated with pain and tenderness of muscle and connective tissue}, muscle aches and pain, old injuries). 3
Skin disorders (diabetic skin ulcers, shingles). Neuropathic (nerve) pain: diabetic nerve disorders; facial pain (such as trigeminal neuralgia); pain from a prior stroke; amputation (stump pain, phantom limb pain); pain after a viral infection (such as shingles) or after other illnesses. Chronic headaches, gastrointestinal, heart or circulation disorders. Pain Matters Remember, persistent pain is not normal. It can be treated effectively. Persistent pain saps energy and disrupts sleep. It can interfere with work and leisure activities. A short walk can become a challenge, making routine errands difficult or impossible. Simple chores can be just too much. Pain can cause depression. People coping with persistent pain tend to stay close to home. They may avoid social and family situations that they once enjoyed. Quality of life suffers. Unrelieved pain can worsen other medical conditions, and further eroding health and overall well-being. 4
Medications Can Help There are many effective and safe medications available for older adults with persistent pain. Your health care provider can prescribe the appropriate medication(s) once the pain has been evaluated carefully. Older adults who suffer from persistent pain frequently avoid physical activity. In addition to taking medication, your health care provider might suggest a program of moderate exercise to improve your physical condition. In fact, exercise helps to alleviate certain painful conditions, such as arthritis. The AGS Foundation for Health in Aging has a brochure, Rx: Exercise for Osteoarthritis, that may be helpful. Important Principles of Prescribing Medication for Pain Your health care provider will select a specific medication and determine the best way for you to take your medication. Around-the-clock doses of medication (Tylenol, for example) may be more effective than waiting for pain to return and then taking another dose of the medication to control it. 5
Other medications are more appropriately taken as needed when pain returns. Older persons are more sensitive to medications, both the helpful effects and the side effects. An important principle of prescribing pain medication for older persons is to start low and go slow. This means your health care provider will start you on a lower dose and proceed to a higher dose as needed to control your pain. Sometimes, combining low doses of more than one medication will be more helpful than a higher dose of just one medication. It may help to avoid side effects associated with higher doses. Your health care provider depends on you! You need to tell your provider whether your pain is controlled. If your pain is not controlled, your health care provider will be able to make the appropriate adjustments. He or she may change the way or time you take the medication, or prescribe another medication. Even if pain cannot be eliminated, it can be controlled. No one should be expected to live with uncontrolled pain. Examples of commonly prescribed pain medications Acetaminophen (Tylenol ) Nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen [Motrin ], naproxen [Naprosyn ]) 6
COX-2 inhibitors (celecoxib [Celebrex ]) Corticosteroids (prednisone) Opioids (also known as narcotics hydrocodone plus acetaminophen [Vicodin ], oxycodone plus acetaminophen [Percocet ]) Antidepressants (nortriptyline [Pamelor ], desipramine [Norpramin ]) Anticonvulsants (seizure medications that are used for pain carbamazepine [Tegretol ], gabapentin [Neurontin ]) Antiarrhythmics (mexiletine [Mexitil ]) Others (local anesthetics, topical agents such as capsaicin [Zostrix ] and lidocaine [Lidoderm]) Medication interactions: Safety is in your hands Over-the-counter and prescription medications can interact dangerously with one another. They can also interact with nutritional supplements, herbal medicines, and even certain foods and beverages. Certain medical conditions also make some medications less safe to use than others. It is very important that you inform your health care provider about all medications you are taking, including overthe-counter medications, nutritional supplements, and herbal remedies. Your health care provider and pharmacist will work with you to determine the safest and most effective medication(s) for your painful condition. 7
MYTHS ABOUT PAIN MEDICATIONS There are many myths about taking opioid pain medications. Some patients are afraid of taking opioid pain medications because they think they will become addicted. Even some health care providers are hesitant to prescribe opioids for pain control for the same reason. Taking opioid medication for pain carries an extremely small risk of addiction, especially for older adults. For long-term pain relief, opioids have fewer side effects than NSAIDs. The following section explains addiction, tolerance, and physical dependence. Addiction The risk of becoming addicted to opioid pain medications is very slight. True drug addiction is characterized by extreme craving for the drug for nonmedical reasons; not for pain relief but to alter the mood. Taking opioid medications for pain is not the same as taking drugs to get high. Appropriate pain control provided by opioid medications will allow a person suffering with severe pain to enjoy a better quality of life. 8
Tolerance Tolerance to an opioid pain medication means that there is a decrease in the effects of the drug at a given dose in both pain control and side effects. For example, if a medication causes nausea, those unpleasant feelings may decrease over a few days. If pain control is decreased and a higher dose of the medication is needed, this is usually because the disease has progressed and the pain has worsened, or secondary to the development of tolerance to the opioid pain medication. This does not necessarily mean the patient is seeking for more drugs. Physical Dependence Physical dependence means that the body has adapted to the opioid medication. This is a normal response, much as a patient with diabetes is physically dependent upon insulin. Stopping an opioid medication abruptly will cause symptoms of withdrawal (such as sweating, rapid heart beat, and diarrhea). If the opioid medication is no longer needed or must be stopped, the health care provider will have to lower the dose over time so not to precipitate withdrawals in the patient. 9
10 SIDE EFFECTS It is very important that you discuss any side effect(s) you experience with your health care provider right away. Remember, any medicines even over-the-counter pain relievers can cause side effects. Some of the most serious side effects are caused by non-prescription medications. It is also important to follow the instructions provided by the pharmacy when taking your medications. Some medications should be taken with food while others must be taken on an empty stomach, and some should be taken at bedtime. The most common side effects of opioid pain medications are constipation, nausea, and sedation (drowsiness). If you experience any of these side effects, talk to your health care provider. These unpleasant side effects can be managed. Just because you may experience an unpleasant side effect from your medication doesn t mean that your other choice is to live with pain! There are many pain medications available. Sometimes, just changing the dose or the time it is taken (without or without food; before bedtime, for example) can eliminate side effects. Constipation is a very common side effect that can be prevented by taking a laxative along with your pain medication. If you are prone to constipation, make sure your doctor is aware of this so that an appropriate medication can be prescribed.
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Guide To Prescription And Over-the-Counter Pain Medications This guide will help you learn about prescription and non-prescription ( over-the-counter ) pain medications. The listing of pain medications that follows is designed to give brief information and examples of commonly used medications. There are other effective medications available that your health care provider can offer. Your health care provider and pharmacist will explain how the medication works and discuss any precautions or side effects with you. Any time you consider starting or stopping a medication, whether it is prescription or over-the-counter, always consult your HEALTH CARE PROVIDER OR PHARMACIST first. Acetaminophen Acetaminophen can relieve mild-to-moderate pain caused by some common conditions such as arthritis and low back pain. Acetaminophen may also be much safer for older adults. Acetaminophen can cause problems with liver function in persons with liver disease, persons with harmful alcohol use, and if taken with other medications that can cause liver function problems. Generic Name Acetaminophen Examples of Brand Names Tylenol, Tempra, store brands 12
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) (Prescription and non-prescription) NSAIDs block pain. At higher (prescription) doses, they are effective in reducing inflammation. This is important in relieving painful symptoms. NSAIDs block the body s production of certain substances that cause the inflammation. NSAIDs are relatively safe medications, especially at lower doses. But, they can have more side effects and may interact with other medications and medical problems you may have. NSAIDs can cause indigestion, bleeding, and easy bruising. When taking NSAIDs for a long period, your health care provider will monitor your condition for the development of side effects. Newer NSAIDs, called COX-2 inhibitors, can also cause kidney problems and problems for people with high blood pressure or heart disease. Generic Names Aspirin, ASA, acetylsalicylic acid (Dose greater than 81mg per day) Choline magnesium salicylate COX-2 Inhibitors: celecoxib Salsalate Ibuprofen Naproxen Examples of Brand Names Aspirin, Ecotrin, Excedrin Store brands Trilisate Celebrex Disalcid, Salflex Advil, Nuprin, Motrin, Store brands Anaprox, Aleve, Naprosyn 13
Corticosteroids Corticosteroids, or glucocorticoids, are antiinflammatory drugs. They are similar to hormones produced naturally in the body by the adrenal gland. Corticosteroids have been used for more than 50 years to treat many medical conditions, such as rheumatoid arthritis and asthma. Corticosteroids are strong medications that are very effective in reducing inflammation. They are especially useful for short-term treatment of severe pain associated with many different inflammatory conditions. When used for short periods, corticosteroids have few side effects. When used for longer periods, they may be prescribed for every other day instead of daily, to reduce the likelihood of side effects. Common side effects occurring with oral steroids include diarrhea or constipation, nausea, headache, and appetite changes. Glucose intolerance (diabetes) can also result. People who take these medications for a long time may develop osteoporosis. Your health care provider may want you to take calcium and Vitamin D as well as another medication to prevent osteoporosis. Generic Name Betamethasone Cortisone Dexamethasone Hydrocortisone Prednisone Prednisolone Examples of Brand Names Celestone Cortone Decadron Hydrocortone Deltasone Prelone 14
Opioids Pain medicines that contain opioid analgesics (also referred to as narcotics) are among the best tools for treating persistent moderate-to-severe pain that does not respond well to anti-inflammatory medications. Opioid medications may also have fewer risks when taken for a long time. Some people still believe that there is a danger of addiction with these medications. But, the risk is extremely small for older adults, when the medication is taken specifically to combat pain. The most common side effects of opioid use are drowsiness (especially when the medication is first started) and constipation. Generic Name Tramadol Hydrocodone Oxycodone Morphine Examples of Brand Names Ultracet, Ultram Lortab, Vicodin, Vicoprofen, Norco OxyContin, Percocet MS Contin, Oromorph, Roxanol Antidepressants Research has shown that tricyclic antidepressant medications (TCAs) seem to be helpful in controlling persistent pain. It is especially helpful for pain caused by damage to nerves. It is not known exactly why these medications are effective in blocking pain. When used to treat pain, TCAs are prescribed in much smaller doses than when used to treat depression. As with any medication, side effects can 15
occur. Patients with narrow angle glaucoma should not take TCAs. Research has also shown that older adults with persistent pain often become depressed. There are many medications available to treat depression, and unless it is treated, it may be difficult to control pain. If you feel depressed, it is very important to discuss this with your doctor. Generic Name Desipramine Nortriptyline Examples of Brand Names Norpramin, Aventyl, Pamelor Anticonvulsants In some types of stubborn nerve pain, anticonvulsants have recently been found to offer substantial pain relief. With the exception of gabapentin, anticonvulsants can interact with other medications, so make sure your health care provider knows all medications you take, even overthe-counter medications. Common side effects include nausea, drowsiness, a sense of unsteadiness, and a general feeling of ill health. Carbamazepine may also affect liver function. The effectiveness of carbamazepine may diminish over time. Generic Name Carbamazepine Clonazepam Gabapentin Examples of Brand Names Carbatrol, Tegretol Klonopin Neurontin 16
Antiarrhythmic Agents One of these, mexilitine, is helpful in controlling persistent pain, especially nerve pain and pain caused by touch. Common side effects include nausea and tremors. Serious side effects can occur in patients with heart disease. Generic Name Mexilitine Examples of Brand Names Mexitil Combination Drug Products Many medications contain more than one active ingredient and many medications contain acetaminophen (the ingredient in Tylenol ). Not knowing the ingredients in each medication you take can be dangerous. For example, if you take Tylenol for a headache while you are taking a cold medication that contains acetaminophen, you may be getting too much acetaminophen. Check the active ingredients of every medication that you take, including nutritional supplements (vitamins, herbal health supplements, etc.). Be sure to check with your health care provider before adding any medications to those you already take. The Older Adult: Special Considerations Compared to young people, older adults may be more sensitive to the effects of pain medications. In older adults, over-the-counter pain medications can cause more significant side effects than prescription medications if not carefully monitored. 17
Unfortunately, older adults also tend to experience side effects more frequently. These guidelines will help to make sure you get the most benefit from your medications while avoiding side effects: 1. Keep a medication diary. Make a list of every prescription medication and/or over-thecounter drug or health product that you take, including natural (herbal or homeopathic) medicines, with their dosages. Even common herbal remedies like St. John s Wort can cause serious drug interactions when taken with certain prescription medicines. Have your list handy whenever you visit your health care provider or pharmacist. Tell your health care provider if you ve skipped some doses or stopped taking any medicines. Keep the list in your wallet or purse so it s available in an emergency. 2. Keep a daily pain diary. A pain diary is very important, especially when starting or adding a new pain medication. Expect a trial period. This will let you and your health care provider find the best dosages and combinations for your condition. A pain diary is available at: www. healthinaging.org. 3. Use a pain scale to rate the level of your pain. This will help your health care provider determine the most effective treatment for your pain. A pain scale is included in the pain diary at: http://www.healthinaging.org/public_education/ pain/my_pain_diary.pdf. 18
4. Use only one pharmacy for all your prescriptions. By having a complete record of all your prescriptions, the pharmacist can alert you or your health care provider to possible interactions. 5. Make sure your health care provider is aware of any illnesses, chronic conditions, allergies, or surgery that you ve had. A complete history is crucial in order to avoid possible drug-disease interactions, particularly if you ve ever had kidney or liver disease. 6. Be sure to report any side effects, even something you may consider minor, to your health care provider. Include how long they lasted, how severe, and what medications you were taking at the time. Your health care provider needs to know about it. 7. Take care of your bowel function while taking opioid analgesics. Fresh fruits, vegetables, and other forms of fiber will prevent constipation caused by opioids. Stool softeners and stimulant laxatives are usually needed, as well. 8. The combination approach: medications for pain work best when combined with other treatments, such as stress-reduction techniques, exercise, and psychological or social programs. Ask your health care provider for referrals in your community. 9. Optimal pain control requires regular reassessment. Schedule a follow-up appointment before you leave your health care provider s office. 19
The American Geriatrics Society The American Geriatrics Society (AGS) is dedicated to improving the health and well-being of older adults. With a membership of over 6,000 health care professionals, the AGS has a long history of improving health care for older adults. THE AGS FOUNDATION FOR HEALTH IN AGING The AGS Foundation for Health in Aging The Foundation for Health in Aging (FHA) builds a bridge between the research and practice of geriatrics health care professionals and the public. FHA advocates on behalf of older adults and their special needs through public education, clinical research, and public policy. The AGS Foundation for Health in Aging The Empire State Building 350 Fifth Avenue, Suite 801 New York, New York 10118 212-755-6810 1-800-563-4916 FAX 212-832-8646 e-mail: staff@healthinaging.org www.healthinaging.org This guide is based on the American Geriatrics Society s clinical practice guideline for health care providers, The Management of Persistent Pain in Older Persons (J Am Geriatr Soc 2002; 20; 6:1-20). It is intended to help older adults and their caregivers better manage persistent pain in consultation with their physicians and other health care providers.