The Dos and Don'ts of Pain Management for Elderly Adults

How to help with pain relief with an eye toward addiction risks
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The opioid epidemic that has struck communities across the United States is raising concerns among many patients and caregivers about using certain pain medications. And while it may come as a surprise, even elderly patients can be at risk of addiction and overdose from taking opioids. In fact, from 1993 to 2012, the number of hospitalizations for opioid overuse among people over 65 increased five-fold.

Opioid medications have been over-prescribed by many doctors in recent years, but experts stress that there’s still a role for the drugs in treating pain for some patients.

Still, elderly patients and their caregivers should be mindful of the risks and take steps to find alternatives to opioids when available. But while the danger of opioids is clear, many people have been left wondering what exactly those alternatives are.

Work with a doctor for a pain management plan

Experts say that pain management plans should be tailored to individuals, since everyone has different needs and responds differently to treatments. This can be difficult for some health care providers, who may want to use the same approach for the same problem each time, and frustrating for patients who find that their doctor’s recommendations aren’t working at first.

“We have to provide an unbiased attitude as providers, but we have to, if one thing doesn't work, try something else,” says Geralyn Frandsen, Assistant Director of Nursing at Maryville University in St. Louis and an expert in pharmacology.

“We also have to make sure we're educating the family and any significant friends,” she says.

Frandsen says that in addition to prescription medication, patients may respond well to non-pharmacological techniques, such as physical therapy, massage, applying heat or cold and even visual or musical therapies. These techniques can complement medication.

Doctors also have a variety of choices for pain relieving medications beyond opioids, and what works best will depend on the patient and what kind of pain they’re coping with.

Know what kind of pain you're dealing with

Frandsen also says it’s important for doctors to know what kind of pain the patient is suffering from and how severe it is. And for that reason, it’s important for patients to be able to identify it and describe it to their doctor.

For example, patients suffering from neuropathic pain – a sharp, electrical pain that can be caused by spinal cord injuries, multiple sclerosis or diabetes – might be better treated with a nonsteroidal anti-inflammatory medication like ibuprofen or aspirin, Frandsen says.

“You have to look at what type of pain they're having and whether an opioid is really the right answer,” she added.

Robert Alesiani, chief pharmacotherapy officer of Tabula Rasa HealthCare, recommends treating some localized pain, like shoulder pain or joint pain, with a topical applied to the site of the pain or a corticosteroid injection.

“That can often times ease the pain associated with the joint pain without resorting to an opioid,” he says.

For symptoms of conditions like arthritis, he also suggests physical therapy.

“Physical therapy is one of the first things I will mention to a nurse, especially things like arthritic pain,” Alesiani says. “Getting some increased range of motion can help a lot with that.”

Patients are also often asked to rate their pain on a scale from one to 10. Alesiani says that it’s important for doctors and patients to adjust expectations for treatments. He says that rather than setting a goal of eliminating pain, perhaps the goal of treatment should be to reduce it to a more manageable level.

When opioids are the best choice

With all of the attention on the risk of overdose and addiction from opioids, experts also stress that there are many instances when opioids are the best option.

For example, for end-of-life care, opioids are highly recommended. Since there’s no long-term risk of developing an addiction, the goal is only to make the patient more comfortable until they die.

Alesiani says that for patients suffering from terminal cancer, for example, “I never discourage them from taking what they need to be comfortable.”

Opioids are also effective in treating pain for cancer patients, but Alesiani said he has changed his philosophy over the years for how much to rely on opioids in those circumstances.

“I used to always think if we can cure the cancer, I can get them off the drug, because they're taking the drug because they're in pain over the cancer,” he said. “From what we've seen and what I've read in the literature, we kind of missed the ball there and it’s something we should have been keeping a closer eye on over time.”

But he adds that the answer isn’t to eliminate opioids entirely for these patients, nor to remove doctors’ ability to prescribe them, but instead to watch whether patients are becoming more tolerant of the drug and developing a dependence.

Understand how medications can interact

As with any medication you’re considering taking, it’s important to keep in mind how it might interact with other medications, diet or even your own body. Conflicts in medications can especially be a problem for older adults as they are often taking more than one. For caregivers, keeping track of them all can be a daunting task.

Alesiani’s company creates software products to gather data on potential issues with a medication regimen and find ways to avoid conflicts, such as spacing out certain medications throughout the day.

For example, anti-depressants like Prozac can interfere with the efficacy of some opioid pain medication, leading patients to believe that it’s not working. If they take more of the opioid and go off of the Prozac, it could lead to an overdose.

Alesiani also points out that some patients may lack certain enzymes needed for some opioid pain medications to be effective. Even dietary choices, like drinking grapefruit juice, can also affect these enzymes. And some herbal supplements, such as St. John’s wort, can limit the efficacy of pain medication as well.

Don’t leave unused opioids around the house

In March, Texas A&M University formed a multidisciplinary task force to research the opioid epidemic and its impact on Texas, including examining its impact on older adults and their families.

Michael Ellis, a task force member and clinical associate professor of oral and maxillofacial surgery, said that in dentistry, too, doctors are re-examining whether they have overprescribed opioids for pain.

He says research has shown that alternating between drugs with acetaminophen and those with ibuprofen can be just as effective as opioids in treating pain. For many young patients, their first exposure to opioids comes from a dental procedure like getting their wisdom teeth removed.

And if opioids are used for a short time, often a prescription contains too many pills, which might be left in a medicine cabinet and later abused, Ellis says. He encourages anyone with unused medication to safely dispose of it.

Scott Morris

Scott Morris is an independent journalist whose award-winning reporting has appeared in numerous publications such as local wire service Bay City News and more recently in outlets like the East Bay Express, Hoodline and Oakland Magazine. See full bio