Medications for Persistent Pain A Guide to Safe Use of Pain Medications for Older Adults HEALTH IN AGING Trusted Information. Better Care.

What is persistent pain? Persistent, or chronic pain, is pain that lasts for months or years. Persistent pain can involve: • Pain that lasts longer than usual after an injury or illness (for example, a broken bone or a viral infection) • Conditions that do not heal, such as arthritis or nerve damage Sometimes the pain may not have any clear physical cause at all.

Pain is a common problem for older adults. Pain at any age is usually a warning signal that something is wrong. Pain should not be tolerated as just a part of “growing older.” Your healthcare provider can assess your pain and decide the right treatment to relieve your pain. He or she will ask questions or observe your condition to understand your pain. You can help him or her by describing your pain as accurately as possible: • How severe is your pain? • Is it a stabbing, aching, or burning feeling? • Is it worse at a certain time of day or night? • What causes the pain? Is there a specific movement or activity that makes it feel worse? • Is there anything that helps the pain? • How does the pain impact your ability to do the things important to you?

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What are the 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, muscle problems, and back pain are especially widespread among older persons. But persistent pain can also have a variety of other causes. Here are some examples of disorders that can cause persistent pain:

Neuropathic (nerve) pain disorders • • • • •

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

Joint, muscle, and bone disorders • • • • • • •

Osteoarthritis (also known as degenerative arthritis) Gout Back and neck problems Osteoporosis (decreased bone mass) Fibromyalgia (a disorder associated with pain and tenderness of muscle and connective tissue) Muscle aches and pain Old injuries

Skin disorders • Diabetic skin ulcers • Shingles

Other disorders that can cause pain • Chronic headaches • Gastrointestinal, heart, or circulation disorders

Remember, persistent pain is not normal. Pain can affect many parts of your life. Persistent pain saps energy and disrupts sleep. It can interfere with work and leisure activities. You may have trouble taking a short walk and 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. Unrelieved pain can worsen other medical conditions, and make it even harder to stay healthy and positive.

Always tell your healthcare provider if you have pain that lasts for months. You do not need to live with untreated pain. H ealth in A ging F oun d ation

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How can your healthcare provider help? Your healthcare provider will select a specific medication and decide the best way for you to take your medication. • Around-the-clock doses of medication (Tylenol®, for example) may work better than waiting for pain to return and then taking another dose to control it. • Other medications are better when taken “as needed” when pain returns or before a painful activity, such as physical therapy. • Older persons are often more sensitive to the effects of medications. These effects can be helpful or unpleasant (the term for this is side effects).An important rule of prescribing pain medication for older persons is to “start low and go slow.” This means your healthcare provider will start you on a lower dose first. Then, he or she may go to a higher dose if needed to control your pain. • Sometimes, combining low doses of two different medications (for example) will be more helpful than a higher dose of just one medication. It may help to avoid side effects associated with higher doses.

Many treatments are available. Your healthcare provider will select a specific medication and decide the best way for you to take your medication. Medications are often used to control pain in older persons. There are safe and effective medications available, however use of any drug requires monitoring for effectiveness and possible side effects. Some are available over-the-counter (OTC) and others are available only with a prescription from your healthcare provider. For example, your healthcare provider may recommend around-the-clock medication, such as acetaminophen (Tylenol®).

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You can help your healthcare provider help you. Tell your provider whether your pain is controlled. If your pain is not controlled, your healthcare provider will be able to make changes. He or she may change the way or time you take the medication, or give you another medication. Even if pain does not disappear completely, it can be managed so you can do what is important to you. No one should be expected to live with uncontrolled pain. Be careful taking more than one medication. OTC and prescription medications can combine dangerously with one another. It can also be unsafe to mix medications 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 tell your healthcare provider about all medications you are taking, including OTC medications, nutritional supplements, and herbal remedies. Your healthcare provider and pharmacist will work with you to determine the safest and most effective medication(s) for your painful condition. Always report any side effects. It is very important that you discuss any side effects you experience with your healthcare provider right away. Remember, any medicines—even over-the-counter pain medicine—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. Others must be taken on an empty stomach, and some should be taken at bedtime. 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, the time, or the way a medication is taken. For example, such as taking it without or without food, or before bedtime can get rid of side effects. Some side effects will get better after a short time, while others continue while taking the medication. For example, constipation is a very common side effect that can be prevented by taking a laxative with your pain medication. If you tend to be constipated, tell your healthcare provider so that an appropriate medication can be prescribed.

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Medications for Persistent Pain Guide to Prescription and Over-the-Counter Pain Medications HEALTH IN AGING Trusted Information. Better Care.

This guide will help you learn about prescription and non-prescription (over-the-counter) pain medications. This listing of pain medications is designed to give brief information and examples of commonly used medications. There are other effective medications available that your healthcare provider can offer.Your healthcare 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 healthcare provider or pharmacist first.

Acetaminophen Acetaminophen (ah-see-tah-MIN-oh-fen) 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 than other pain relievers if you use the right amount. Acetaminophen can cause problems if you: • Have liver disease (it may affect liver function) • Drink a lot of alcohol • Take it with other medications that can cause liver problems

Generic Name

Examples of Brand Names

Acetaminophen

Tylenol®, store brands

You should not take more than 3,000 milligrams of acetaminophen per day, unless under the care of a healthcare provider. Do not take more than one medicine at a time that contains acetaminophen in order to make sure not to take the wrong amount. Many prescription and over-the-counter medicines contain acetaminophen, including the following:

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Acetaminophen (continued) Medications that contain acetaminophen Generic Name

Examples of Brand Names

Oxycodone, acetaminophen

Endocet®, Percocet®, Tylox®

Hydrocodone, acetaminophen

Lortab®, Norco®,Vicodin®/Vicodin ES®/ Vicodin HP® Codeine, acetaminophen TYLENOL® with Codeine (Typically called TYLENOL® #2 or #3) Tramadol hydrochloride, acetaminophen Ultracet® This is not a complete list. Many other brands and prescription medications use acetaminophen as an active ingredient. Sometimes acetaminophen is listed as “APAP” on prescription bottles and labels. Also, some brands listed above have products that do not contain acetaminophen. Check your medicine before you take it to see if it contains acetaminophen, and talk to your healthcare provider or pharmacist if you are not sure if your medicines contain acetaminophen.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) NSAIDs are medications used to block pain. They are available both over-the-counter and with a prescription. If you are taking an NSAID on your own, it is important to let your healthcare provider know about this. At higher doses (available with a prescription), they are effective in reducing inflammation. Inflammation can cause pain. NSAIDs block the body’s production of certain substances that cause the inflammation. NSAIDs may be useful and necessary if taken for a very brief amount of time (a few days). However, even short-term use of NSAIDs can cause indigestion, bleeding, and easy bruising. Longterm use of NSAIDs is generally discouraged for older persons, because of risks of serious medical complications, including heart problems, stomach ulcers, and kidney problems. Risk of heart disease, including heart failure and heart attack, has been shown with high doses of NSAIDs, so it is important for your provider to carefully evaluate your risk and potential benefits.

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NSAIDs (continued) Generic Name(s)

Examples of Brand Names

Aspirin, ASA, acetylsalicylic acid (Dose greater than 81mg per day) Choline magnesium trisalicylate

Aspirin, Ecotrin®, Excedrin®, store brands Tricosal®,Trilisate®

COX-2 Inhibitors: celecoxib

Celebrex®

Salsalate

Disalcid®, Mono-Gesic®, Salflex®

Ibuprofen

Advil®, Nuprin®, Motrin®, Store brands

Naproxen

Anaprox®, Aleve®, Naprosyn®

Diclofenac

Cataflam®,Voltaren®

Nabumetone

Relafen®

Corticosteroids Corticosteroids, or glucocorticoids, are anti-inflammatory drugs. They are similar to hormones produced naturally in the body by the adrenal glands (triangle shaped glands located at the top of your kidneys). 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, for the dose may be changed to every other day instead of daily, to reduce the likelihood of side effects. Sometimes corticosteroids are given as a shot to try to target at the site of pain. This is one way to lower the common side effects, but still provide pain relief. Common side effects occurring with corticosteroids taken by mouth include: • • • •

Diarrhea or constipation Upset stomach Headache Increased appetite

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• Increased blood sugar • Insomnia • Anxiety/irritability/nervousness

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Corticosteroids (continued) People who take corticosteroids for a long time may develop osteoporosis (weakening of the bones). Your healthcare provider may want you to take calcium and vitamin D as well as another medication to prevent osteoporosis. Generic Name

Examples of Brand Names

Betamethasone

Celestone®

Dexamethasone

Decadron®

Cortisone acetate

Cortone®

Hydrocortisone

Hydrocortone®

Methylprednisolone

Medrol®

Prednisone

Deltasone®, Prednisone®, Orasone®

Prednisolone

Prelone®

Triamcinolone

Kenalog®

Opioids Pain medicines that contain opioid analgesics (also referred to as narcotics) can be used for treating persistent moderate-to-severe pain that impacts function and does not respond well to other medications and treatments. Deciding to use opioid medications should be based on a careful evaluation of risk and benefits. Some people still believe that there is a high risk of addiction with these medications. However, the risk is small for older adults when the medication is taken specifically to fight pain, there is no prior history of substance abuse, and there is careful monitoring of the benefits and adverse effects. The most common side effects of opioid use are drowsiness and constipation. The constipation typically does not go away with time, so many older adults may need a laxative. Opioids can also cause dizziness, upset stomach, confusion, and falls.

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Opioids (continued) Generic Name

Examples of Brand Names

Hydrocodone

Lorcet®, Lortab®, Norco®,Vicodin®, Vicoprofen® Immediate release: OxylR®, Percocet®, Percodan®, Tylox® Sustained release : OxyContin® Immediate release: MSIR®, Roxanol® Sustained release: Avinza®, Kadian®, MS Contin®, Oromorph SR® Embeda® Immediate release: Dilaudid®, Hydrostat®, Sustained release: Exalgo® Dolophine®

Oxycodone

Morphine

Hydromorphone Methadone Oxymorphone Transdermal fentanyl

Immediate release: Opana IR® Extended release: Opana ER® Duragesic®

Antidepressants Research has shown that some medications used for depression—called tricyclic antidepressant medications (TCAs)—seem to be helpful in controlling persistent pain. These medicines are especially helpful for pain caused by damage to nerves. 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 occur. You should not take TCAs if you: • Have narrow angle glaucoma • Are an older man with an enlarged prostate gland. This is because TCAs may cause serious problems with urinating. TCAs have some risky side effects and should be used very carefully in older patients. They can make you feel very sleepy and can make it difficult to think clearly. TCAs may also affect your balance and cause constipation. Some TCAs have more side effects than others. 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.

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Antidepressants (continued) Generic Name

Examples of Brand Names

Desipramine

Norpramin®

Nortriptyline

Aventyl®, Pamelor®

Duloxetine

Cymbalta®

Venlafaxine

Effexor®

Milnacipran

Savella®

Anticonvulsants Anticonvulsants are drugs that are normally used to control seizures in people who have epilepsy. They have been found to offer good pain relief with some types of stubborn nerve pain. Anticonvulsants can interact with other medications, so make sure your healthcare provider knows all medications you take, even over-the-counter medications. Common side effects include: • • • •

Nausea Drowsiness A sense of unsteadiness or dizziness A general feeling of ill health

Generic Name(s)

Examples of Brand Names

Gabapentin

Neurontin®

Pregabalin

Lyrica®

Antiarrhythmic Agents Antiarrhythmic agents are medications usually used to treat irregular heart rhythms. 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 (shaking). Serious side effects can occur in patients with heart disease. Generic Name(s)

Examples of Brand Names

Mexiletine

Mexitil®

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Muscle Relaxants Muscle relaxant drugs are sometimes used when muscle spasms are contributing to the pain. However, many of them are not very effective or have too many side effects. Muscle relaxant drugs should be started at a low dose. If needed, they can be increased gradually to avoid possible side effects such as dizziness, low blood pressure, or stomach upset. You should not suddenly stop taking muscle relaxants. These medications must be slowly decreased to avoid side effects. Muscle relaxants have been helpful for some patients with: • Severe nerve pain • Pain from multiple sclerosis • Other conditions in which nerves are damaged Generic Name

Examples of Brand Names

Baclofen

Lioresal®

Tizanidine

Zanaflex®

Skin Preparations If you have pain that is limited to a small area, you may get a great deal of relief from using medications that are put directly on the skin, such as a medicated patch. Placing the medication onto the skin where the pain is also helps avoid side effects that come from taking medications by mouth. You may have some skin reaction (itchiness or soreness) where the patch was placed. Other medicines applied to the skin (such as creams like menthol or capsaicin) may sometimes be helpful, but you should check with your healthcare professional first in order to avoid side effects. Generic Name

Examples of Brand Names

Lidocaine (topical)

Lidoderm 5%®

Capsaicin

Zostrix®

Diclofenac topical

Voltaren gel®

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Dual Mechanism Drugs These medications are called “dual mechanism” because they act like an opioid drug and as an antidepressant. If you take these medications, you need to be regularly checked by your healthcare provider for side effects linked to both types of pain medicines. For instance, tramadol may be constipating (like an opioid drug) and it also must be stopped gradually (like an antidepressant). Generic Name(s)

Examples of Brand Names

Tramadol

Ultram®, Ultram ER®

Tapentadol

Nucynta®

Other Medications A variety of other medications have been tried for pain relief, but there is not enough good proof that they are really effective or useful for older people. They may also have serious side effects, and if used, should be approached with caution. These include calcitonin, botulinum toxin, glucosamine, chondroitin, and cannabinoids. Glucosamine and chondroitin are both dietary supplements used to support joint health. Calcitonin helps strengthen bones. Even if they can be obtained without a prescription, you should always inform your healthcare provider if you are already taking any of these medications or if you wish to take any of them.

Combination Drug Products Many medications contain more than one active ingredient. 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.) • Always tell you healthcare provider before adding any medications to those you already take.

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The American Geriatrics Society The American Geriatrics Society (AGS) is dedicated to improving the health and wellbeing of older adults. With a membership of over 6,000 healthcare professionals, the AGS has a long history of improving healthcare for older adults. The Health in Aging Foundation The Health in Aging Foundation aims to improve the health of older adults by: • Providing health information to older adults and those who care for them; • Advocating on behalf of programs and policies that help older adults to lead healthy, active lives; and • Supporting research on the diseases and disorders of older adults.

Sources: AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc 2009; 57:1331-1334. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. DISCLAIMER: This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other healthcare provider. Always consult your healthcare provider about your medications, symptoms, and health problems.

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