The Mother Was In Pain. Why Were Pain Meds Withheld?


Last updated: January 29, 2010
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The case: A well-intentioned family

Mrs. L's adult daughter Kate accompanied her to a follow-up appointment, as usual. Today however, it was clear there was some tension between them. Mrs. L, a well-dressed 94-year-old widow, was in generally good health except for having arthritis in her major joints, which had been bothering her more and more. This day, before my patient could speak, Kate pulled a bottle of acetaminophen out of her purse. "Doctor, Mother insists it's okay to take these four times a day for her achy knees, but I'm pretty sure that's too much. I'm trying to limit her to one a day because, as I keep trying to tell her, I've heard how Tylenol is hard on the liver."

Mrs. L winced. "But I'm in pain. Doctor, didn't you tell me to take it with every meal if I needed it?" This wasn't the first time this year I'd heard this family debate.

The challenge: Acetaminophen can be both safer and less safe than you might think

Better known through the brand name Tylenol, acetaminophen has long been the geriatrician's first choice to treat aches and pains, mainly because for older adults, at usual doses it's much safer than other over-the-counter painkillers such as ibuprofen and aspirin. Acetaminophen got a bad rap last summer, however, when an FDA advisory panel [voted to ban] (http://www.nytimes.com/2009/07/01/health/01fda.html) drugs such as Vicodin and Percocet. These drugs combine acetaminophen with stronger, opiate-type painkillers. The main reason given for the ban was concern about the risk of liver toxicity due to accidental acetaminophen overdose.

Understandably, many of my family caregivers were left confused about how to treat their loved ones' chronic aches: Is acetaminophen safe or not?

For older people who don't have liver problems, experts widely believe that up to 3000 milligrams (mg) of acetaminophen per day is safe, even if one takes this amount every day. That's equivalent to 9 tablets of regular acetaminophen (which is usually 325mg/tablet). To put this amount in perspective: For decades the safe daily limit of acetaminophen was set at 4000mg/day. The FDA is now considering reducing this number but has not yet proposed a new limit, so in the meantime many doctors have adopted 3000mg/day as a reasonable safer alternative. If Grandpa is having some of his usual arthritis pains in his knees, it's fine to give him two tablets of regular-strength Tylenol with every meal. Unlike the pain relievers ibuprofen (Advil), naprosyn (Alleve), or celecoxib (Celebrex), acetaminophen won't harm the kidneys, won't raise blood pressure, won't cause internal bleeding, and won't interact with his other medicines.

Liver damage, however, is a possibility "“ though only if you were to regularly take a lot of acetaminophen. In people with normal livers, up to 3000mg per day of acetaminophen (that's 9 325mg tablets a day, remember) is incredibly unlikely to cause damage, even if taken daily for weeks or months. For those who worry, it's also fairly easy to check on how the liver is doing with a simple blood test. Balance that against the benefit, which is possible relief from an arthritic back or achy knees. Since regular acetaminophen only provides pain relief for about four hours, most people need to take it more than once a day to get reasonable relief throughout the day.

So why would the FDA be concerned about accidental acetaminophen overdose? Because it does happen. Although it's more typical for me to see older people who don't take enough pain medicine, there are always a few who pop more pills than I recommend. They mistakenly conclude that if a few doses help soothe the pain, maybe even more doses will make it go away altogether.

The other big way people consume too much acetaminophen (more than the safe daily limit) is in the form of the many combination medicines that include acetaminophen. These medicines include not only the frowned-upon Percocet and Vicodin, but also many over-the-counter cold and/or flu medicines, such as Theraflu (which can contain up to 1000mg acetaminophen per single dose). Often people don't realize that these medicines contain acetaminophen, and so accidentally overshoot the daily safe limit.

Caregivers also may have heard that acetaminophen isn't safe for people who drink alcohol, since daily alcohol can also affect the liver. Although this concern is legitimate, studies have found that [even alcoholics are usually safe taking up to 2000mg of acetaminophen per day] (https://www.caring.com/questions/faq-what-pain-relievers-are-safe-for-drinkers).

The solution: Understand how to use acetaminophen in older adults

I assured Mrs. L's daughter Kate that I was glad my patient had a concerned caregiver. But after I explained the benefits and risks of the drug, Kate agreed with me that trying up to 3000mg of acetaminophen per day was by far the safest and kindest thing to do for her mother's arthritis. We also reviewed the key steps every caregiver should take to maximize safety when using acetaminophen.

My prescription for caregivers:

  • Know that for older people, acetaminophen is generally the safest first choice for treatment of mild-to-moderate pain due to arthritis or other conditions. Ibuprofen and other over-the-counter anti-inflammatories are more likely to cause harm to older adults.
  • Check with the doctor and confirm that it's okay for your loved one to take up to 3000mg of acetaminophen per day, for chronic aches and pains. Be sure to mention if you have any concerns about the person's drinking.
  • Get in the habit of looking at the labels of all over-the-counter pain and cold medicines to identify which ones contain acetaminophen. Try to avoid using more than one medication containing acetaminophen at the same time.
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14 Comments So Far. Add Your Wisdom.

Anonymous said over 3 years ago

Thank you SO MUCH for this article. I have metastatic cancer, but feel quite healthy at 83, although I know not how long that will continue. My daily problem at this time is chronic moderate to severe sciatica and pelvic joint pain from various forms of degenerative disc disease. I have restisted submitting to daily pain reliever i.e. acetamenephin fearing addiction and/or building up tolerance. THIS ARTICLE finally has convinced me that IT'S PERFECTLY O.K.....I really appreciate this article and all the comments.


Anonymous said almost 4 years ago

Awesome Post. I add this Post to my bookmarks.


Anonymous said almost 4 years ago

Very Interesting Information! Thank You For Thi Information!


about 4 years ago

my doc prescribed me 9 10/325 norcos per day 270 per month is that to many along with 5 excedrins per day ?


Anonymous said about 4 years ago

I just sent this post to a bunch of my friends as I agree with most of what you're saying here and the way you've presented it is awesome.


Anonymous said about 4 years ago

I've been visiting your blog for a while now and I always find a gem in your new posts. Thanks for sharing.


over 4 years ago

My husband has been taking 500mg tylenol (up to 6 tabs a day) for years, and he just a liver panel done, and he was A-Ok. He drinks beer ocassionally too.


over 4 years ago

i lve in pain every day.if you did you would take what ever you could to have a good day if my liver is going to give out then maybe that is what is written for my life to be.i lost my wife of 33 years to cancer the last few months were bad.for her and myself.to watch someone you love live in pain is just wrong.life is short why let the person you love live like that.when you get that old or in poor health you will do what ever you can to stop the pain and to heck with what my or your kids think.....


over 4 years ago

My mother is 95 with dementia. I believe she needs to take tylenol for her arthritis. She complains about knee pain on a daily basic, but will not take them. I try to sneak them in with her daily meds by breaking them in half or crushing them. It drove both my brother and I nuts, so we stopped giving them to her. Maybe I should keep trying. Any suggestions are helpful. Thanks


Anonymous said over 4 years ago

IMHO, once someone gets to their mid 70s, have their wits about them, have treatable medical conditions but find themselves in pain - I say, give them the pain relief. And barring liver disease to begin with, give them what they need to function comfortably. The stress pain causes on major systems can be tremendous, not to mention result in many false alarms re: heart attacks. My dad's lower back pain is so bad (arthritis, stenosis, degen disks) he would get tremors and clutch his chest when his lumbar vertabrae made contact. It would be worse if his GERD kicked in too. Ended up in the ER twice, being sent their by day care staff unfamiliar with these episodes. I finally found staff members at the VA who understood pain management - and frankly agreed that at 87 with AD and acute cardio issues, lumbar injections every 3 months were in order. At his age, the risk/reward makes sense...and may contribute to prolonging his current steady state in early stage 6. These shots, combined with 6 Tylenol 3s spaced four times a day, seem to make him more mobile, improved his balance and stopped the slide into depression and anger. Lorazepam also reduced his obsessing about his back. And its at least making it tolerable to live with him for now. Point is, there are a lot of tools, mostly medication, some therapy that can help. And for heaven's sake, if your mom is still mentally sharp and in her 80s, why risk putting her over the edge mentally by being rigid on her physical comfort? But I'd stick with acetominophen...the others have too many interactions with many drugs, and Tramadol can also not play well with other drugs affecting the Central Nervous System (CNS).


Anonymous said over 4 years ago

My 89-year old mom taks Tramadol 50 mg every four hours and takes Extra Strength Tylenol (Rapid Release) in addition to that several times a day. Is that safe, and if so how many Tylenol is safe. I don't want her to be in pain but also don't want her high powered narcotics with their side effects


over 4 years ago

Since my elderly aunt died of an accidental overdose of Tylenol (she DID have extensive liver damage and I don't know why she even had it prescribed], I would STRONGLY reccommend blood tests before using it. Any medication can be dangerous but to be fair, if she hadn't had the liver problems, she would have been OK.


Caring.com User - Leslie Kernisan, M.D.
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over 4 years ago

Thanks for that comment and for sharing your experience. A little pain medicine can certainly make a big difference in the life of an older person. However, ibuprofen and naprosyn (brand names Advil and Alleve) are over-the-counter anti-inflammatories, which are risky for an older person to take regularly. More detail on this issue is here: www.caring.com/questions/over-the-counter-anti-inflammatory-safety Ibuprofen and naprosyn were used (and still are!) by doctors and nurses for a long time. But because of safety issues, in May 2009 the American Geriatrics Society announced that these drugs should only be used in the elderly as a last resort, and under careful supervision.


over 4 years ago

AS A NURSE FOR 28YRS. ONE OF THE THING I SAW THE MOST WAS UNDER TREATMENT OF PAIN;I WAS ALSO VERY INVOLVED CARING FOR BOTH MY PARENTS BEFORE THEY PASSED-IF SOMEONE IN THEIR 90'S ARE LUCID AND TELL YOU THEIR IN PAIN-THEY ARE,MANY WAYS TO ADDRESS THIS MAYBE GIVE ONE ALEIVE A DAY OR ADVIL 1 AT 8AM 1 AT 8PM-LOTS OF WAYS TO SOLVE THIS-GODSPEED


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