Experts Warn Against Long-Term Use of Common Pain Pills

http://newoldage.blogs.nytimes.com/2009/05/06/experts-warn-against-long-term-use-of-common-pain-pills/?_r=1

Aspirin and ibuprofen are staples in just about every medicine chest and first aid kit. They’re sold over the counter, and they’re not expensive. Most people don’t think twice about taking them.

But they should — especially if they’re elderly.

Last week, an expert panel of American Geriatrics Society pretty much bumped all non-steroidal anti-inflammatory drugs, or NSAIDs, off the list of medicines recommended for adults ages 75 and older with chronic, persistent pain. Long-term use of drugs like ibuprofen, naproxen and high-dose aspirin is so dangerous, the panelists said, that elderly people who can’t get relief from alternatives like acetaminophen may be better off taking opiates, like codeine or even morphine.

All this despite the fact that NSAIDs are known to be effective for chronic pain conditions that often plague older adults — and despite the fact that 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, chair of the panel that made the recommendations and a professor of geriatrics at the University of California, Los Angeles. “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 if given over time.”

“It looks like patients would be safer on these opioids than on high doses of NSAIDs for long periods of time,” he said, adding that for most elderly, 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.”

The risks from chronic use of NSAIDs are myriad. They can cause life-threatening ulcers and gastrointestinal bleeding, a side effect that occurs more frequently and with greater severity as people age. Some NSAIDs may increase the risk for heart attacks or strokes, and they don’t interact well with drugs used to treat heart failure. They can make high blood pressure worse, even uncontrollable, and impair kidney function. And the list of potentially hazardous interactions with other drugs is a long one, experts say.

“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.”