Older Patients, Wiser Care

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

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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.