The case: Arthritis pain in his knees had left him unable to walk
Mr. N expertly steered his three-wheeled electric scooter into the exam room, then shook my hand, smiling.
"Everything's fine," he said, when I asked how he'd been doing.
But his face clouded over when I inquired specifically about his knees. They still hurt him most of the time, especially while standing. When using his walker to get around the house, he rated his pain as 9 out of 10.
Knee pain had been Mr. N's main medical concern for more than a year. X-rays had shown bad osteoarthritis in both knees, and his daily pain had left him unable to walk farther than across his living room. The orthopedic surgeons had recommended total knee replacements; although Mr. N was 82, he was otherwise in good health and seemed strong enough to handle the physical therapy that's needed to recover from joint surgery.
But Mr. N had refused surgery. "My cousin tried that, and it ended up almost wrecking his life."
So we had explored other ways to treat his nearly-disabling arthritis pain and improve his function. We had tried physical therapy. We had tried injections into his knees, first with hydrocortisone (an anti-inflammatory steroid), then with hyaluronic acid (which is supposed to help better cushion the knee bones).
Finally we referred him to a special arthritis clinic, staffed by rheumatologists. They confirmed that Mr. N had very advanced osteoarthritis of both knees. Because he wasn't willing to have surgery, and no other treatment options had helped, we'd have to focus on treating him with pain medications. Already acetaminophen and analgesic creams had had little effect. So the rheumatologists suggested a low-dose opiate, oxycodone.
Mr. N hesitated. "I don't want to take a strong pain pill like that. I don't want to get addicted."
The challenge: There's often no perfect solution to the problem of chronic arthritis pain
Surveys have found that almost one in four older adults is often troubled by moderate or severe pain. Pain from osteoarthritis, which is also called degenerative joint disease, is especially common as one ages and the cartilage cushioning the bones wears out. For many, it's mild. But for some, it can be severe. Even moderate pain can affect function: If the pain is worse with standing or activity, the person may be unable to participate in physical therapy or even take the short daily walks that are essential to maintaining basic strength and balance.
Patients, and sometimes doctors, often brush off arthritis pain. "It's just what happens when you get old," they say.
It's true that arthritis is a fact of aging for all but the luckiest among us. Still, in many cases better treatment of arthritis pain leads to real improvements in quality of life, especially in an older person's ability to stay active.
The trouble is, there's often no easy way to treat arthritis pain. Physical therapy requires time and dedication. Joint injections require regular trips to the doctor, and don't work for everyone. And studies have yet to establish that supplements, such as glucosamine chondroitin, definitely help.
Nor are there easy choices of oral pain medications. The American Geriatrics Society recommends starting with acetaminophen (brand name Tylenol), but it's only a mild painkiller and often doesn't provide sufficient relief. Non-steroidal anti-inflammatories drugs (NSAIDs) such as ibuprofen can be effective, but are riskier for older people.
The solution: Low-dose opiate often does the trick
To treat arthritis pain, geriatricians sometimes end up using low doses of opiates, i.e. painkillers such as hydrocodone, morphine, or oxycodone.
Like Mr. N, patients tend to resist this suggestion -- understandably. We've all heard about people becoming addicted to painkillers or otherwise being harmed by these headline-making drugs. And who wants to be on "strong medicines" that require a special prescription?
The truth, however, is that for most older people with bad arthritis pain, the benefits usually outweigh the potential risks. Here's what I explained to Mr. N:
Opiates are good at treating pain, and have very few interactions with other medications. Unlike NSAIDs, opiates don't affect kidney function, and won't increase the chance of life-threatening internal bleeding. When used as directed, the main side effect is constipation, but this can easily be managed with regular use of a laxative. The patient might experience a little nausea or drowsiness the first few times he tries the medicine, but this side effect usually goes away after a few days.
"But aren't these drugs dangerous?" he persisted. Well, it's true that when used improperly, opiates can cause problems. Taking too many pills at once can make a person unconscious and can slow one's breathing down to a dangerously low rate. This problem is uncommon, however, especially in people who are taking low doses. A recent study found that only about one in 500 people on low-dose opiates for non-cancer pain had a problem related to overdose. The study also found that overdoses were often linked to using additional drugs from different doctors, or other problem behaviors.
What's more, in older people with pain and no history of abusing alcohol or other drugs, the risk of addiction -- which means uncontrollable cravings and wanting increasing doses "“ is very small.
Mr. N agreed to try low-dose oxycodone twice a day for his knees. Two weeks later, he came back for a check-in. "My pain is better," he said, looking pleased. "Now when I stand up, my pain is only 6 out of 10. I've even been able to take short walks in my garden."
My prescription for caregivers: - Take osteoarthritis pain seriously, especially if it's bad enough to interfere with basic activities, like walking.
Make sure the person you're caring for has started with non-drug treatments for arthritis, like physical therapy and weight loss.
Know that finding a solution to chronic arthritis pain is often a process of trying different options, to see which treatment has the best balance of benefits versus risks.
Know that sometimes low-dose opiates can be a reasonable choice in an older person with daily arthritis pain. Addiction and overdose effects are rare if people are properly monitored.
If your loved one and doctor decide to give low-dose opiates a try, you can help monitor that they're not being abused by keeping track of how many pills are taken every day. You should also monitor for constipation.
After starting opiates, or any other drug to treat pain, make sure the person has a follow-up appointment within a few weeks. It's essential to check that the drugs are helping, and that there haven't been any concerning side effects.
If the patient is using the opiates more quickly than prescribed, is getting opiates from more than one prescriber, or may be abusing alcohol or other drugs, be sure to let the doctor know right away. Special care should also be taken with opiates' storage, to ensure they aren't stolen, resold, or misused by other people in the household or the patient's care circle.