Painful Progress

The problem with pain is that it is what we say it is. One patient may rate their pain a 10 (on a scale of 1 to 10, with 10 being the absolute worse), while a similar patient with similar pain may rate theirs as a two. And there is no objective way to tell the difference. Health professionals certainly don’t want to see their patients in pain and tend to prescribe the strongest medications that they believe are safe and effective.

Elderly patients with pain are particularly at risk for medication complications. A recent study reviewed antidepressant medications prescribed to many Medicare patients (average age of 80). The investigators tried to learn whether the patients refilled their antidepressant prescription—indicating ongoing use—or discontinued the medication altogether. The investigators also wanted to know if these patients were also taking other medications with the potential for harmful interaction with the antidepressants.

The study showed that 30% of those patients were also taking potent opioid pain medications for other conditions. These drugs have known interactions with antidepressants, causing a whole different set of adverse symptoms on their own. Apparently, these symptoms caused almost half of the patients in the study to stop taking the antidepressant.

Which leads us back to controlling the patient’s pain. Anti–inflammatory medications (think Ibuprofen, or naproxen) are effective for pain control without causing harmful medication interactions. We tend to discount these medications, believing that we need something stronger. We sometimes fail to appreciate the drug interactions that can result when using opioid pain medications. In elderly patients, these harmful interactions are distressing and dangerous.

We clearly need to understand how to treat pain safely and effectively in older patients. Starting with common over–the–counter medications is effective and much safer. Certainly we need more research, but for now starting low and going slow with pain medications makes the most sense.

About Steve P. Sanders

A general internist writing and sharing ideas and art.

One Response to “Painful Progress”

  1. During med school, the pharmaceutical prof sent us to the library to find out how pain meds were tested for effectiveness, why the difference in folks, and animals. I remember a dental school in California had a big grant, they put a sodering iron on the same tooth per patient, then turned it on with differing heats, some got placebos some got Darvon, I shivered with the thought of a red hot soldering iron in my mouth. I learned that endomorphins were the agent, all of us have differing levels naturally, pregnant women have high levels not just for pain but to reduce the fetus breathing. Now the trivia answer, on what animal can you operate without anesthesia, answer a camel, because of the endomorphin levels. Now you know the rest of the story. Happy New Year.

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