Not all physicians agree with the panel’s decision. Many pain specialists contend that NSAIDs still have a place in the medicine cabinet. Some even argue that the recent emphasis on the dangers of NSAIDs has pushed the pendulum too far, causing physicians to overlook the potential risks of opioids.
“Personally I still [prescribe] NSAIDs, even in the older generation,” says Mehul Desai, M.D., a pain management specialist in Washington D.C. “I think all of this attention [on the harmful effects of NSAIDs], to some extent has been—I don’t want to say completely undue—I think it’s been overblown.”
Mark Fendrick, M.D., a researcher and physician at the University of Michigan, thinks using caution is appropriate, but he doesn’t agree that NSAIDs should be thrown out in favor of opioids for every patient of a certain age.
“The use of even low-dose narcotics in the elderly tends to be frowned upon in almost every situation,” Fendrick says.
If a patient has no other cardiovascular risk factors but has a history of stomach ulcers and gastrointestinal bleeding or takes blood thinners, for example, Fendrick feels a traditional NSAID along with a medication—like Nexium or Prilosec—that reduces gastric acid production is still warranted. For patients who do have cardiovascular risk factors such as high blood pressure or coronary artery disease, Fendrick argued, an NSAID like naproxen may still be safe. In most studies, the drug naproxen, found in the brand Aleve, caused a smaller increase of heart attack risk than other NSAIDs.
Addiction Risks Overstated?
Fendrick, like Desai, worries that the new guidelines proposed by the Geriatrics Society overlook the side effects and potential harm of opioids. Unlike acetaminophen (Tylenol’s generic name), which can damage the liver, or NSAIDs, opioids haven’t been linked with any long-term organ damage. But there are known side effects, including constipation, nausea, and sedation, that can cause problems for many people who take them.
“Particularly in the elderly population, there are concerns over sedation and neurological effects,” Desai says.
Opioids, which work by blocking pain receptors in the brain, also present a risk of abuse and addiction. They are considered one of the most commonly abused drugs in America, even among people over the age of 65. But Ferrell says the panel looked at the research and found that most people who become addicted to painkillers already had a history of substance abuse. And the relatively low rate of addiction and abuse among the elderly convinced the guidelines’ authors that opioids were safe.
Anderson, the pain management doctor, calls the fear of opioids a “faith-based system” that dates back to research on criminals from more than two centuries ago. The fact that opioids are heavily regulated, while some NSAIDs can be bought without a prescription, also contributes to a view among the public that NSAIDs are safer. But Anderson thinks opioids are often the better choice; he also says that most of his patients can be fully functional on the drugs.
Laura Johnson agrees. A patient of Anderson’s for several years, the 52-year-old Forest Lake, Minn., nonprofit director suffers from multiple sclerosis, fibromyalgia, migraines and arthritis. She uses a fentanyl patch that releases the narcotic throughout the day.