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Popular Medications No Longer Recommended for Chronic Pain

New guidelines say opioids like codeine are safer for patients over 75.

When a group of leading geriatric physicians recently released new guidelines that called for virtually eliminating the use of popular medications like ibuprofen for people over 75 with persistent pain, Alfred Anderson, M.D., wasn’t surprised. A physician who specializes in pain management, Anderson thinks the risks of stomach bleeding and heart problems associated with ingredients found in medicines like Advil, Aleve and Celebrex make them less than ideal for treating chronic pain in older patients. Instead, the Minnesota doctor often prescribes narcotics known as opioids such as codeine and Percocet.

“Over the last 20 years, it’s been obvious to me that the safer of the medications is the opioids,” says Anderson, who sits on the board of directors of the American Academy of Pain Management. “If you compare them with NSAIDs, opioids typically don’t have any damage to the body that’s severe enough to create life-threatening situations.”

The guidelines, which the American Geriatrics Society will publish in August, advise doctors to recommend that their older patients try acetaminophen, like Tylenol, and if that doesn’t work, to prescribe opioids. “It is a major change,” says Bruce Ferrell, M.D., a University of California at Los Angeles geriatrician who chaired the panel for the American Geriatrics Society. “We’ve finally come to the conclusion that NSAIDs as a strategy for the management of chronic pain should really be used quite rarely.”

These new guidelines issued this month came just after the Food and Drug Administration announced stricter labeling requirements for these common, over-the-counter painkillers called NSAIDs (non-steroidal anti-inflammatory medications). The FDA now requires manufacturers to put a warning on the medication about the risks of gastrointestinal bleeding.

Although the Geriatric Society’s guidelines are specific to people age 75 and over, experts say people over age 50 should be aware of the risks as well and consult their doctors about the use of NSAIDs. For people over age 75, however, the panel said the medications should be used “rarely” and “with extreme caution.”

Although some of the side effects of NSAIDs, like gastrointestinal bleeding and kidney problems, have been known for decades, more recent research—and some high-profile recalls and lawsuits—put NSAIDs under the microscope of regulators and physicians.

Studies have linked ibuprofen and other traditional NSAID use to heart attack risk as well. In addition, NSAIDs, which work by reducing the production of hormone-like substances in the body that cause swelling and pain, appear to exacerbate high blood pressure and congestive heart failure. This also influenced the panel’s decision to recommend against their use for people over 75, who are already at high risk for cardiovascular problems, Ferrell says.

“This is the group of patients that has more trouble with [NSAIDs] than any group of patients,” he says. “The evidence is actually stronger than in the past that you really have to use these drugs with caution.”

Some Doctors Skeptical About Opioid Use for Pain

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