Pain Relief for the Elderly

Pain is a big problem for elderly people, with one recent study suggesting that almost half of older folks live daily with moderate or severe pain.  Medications derived from opium, called opiates, or chemically similar to opiates, known as opioids, are very effective pain relievers and have been thought to be safe in older people.  Now two studies in this week's Archives of Internal Medicine throw cold water on that longstanding belief.

One of the studies compared the safety of several different pain relievers in elders with arthritis, while the other looked at the relative safety of a number of opioids in people with pain not related to cancer.  As Rick points out in this week's podcast, after initial safety studies in very early clinical trials, the real data comes out in what are called 'post-marketing surveillance studies.'  These collect information after a drug, treatment or device has been approved and is now turned loose in the real world.  Often effects not seen in the few thousands of people studied in clinical trials emerge when hundreds of thousands of folks are taking a drug or receiving a treatment.

The perfect example for this topic of pain relief is Vioxx, one of a class of medications known as 'cox-2 inhibitors' because they inhibit an enzyme known by this abbreviation.  It was only when millions of prescriptions for Vioxx had been written that increased risk for cardiac events was seen with this medication, resulting in its withdrawal from the market.  Now both these studies, looking at data from Medicare populations in two US states, found that compared to nonsteroidal antiinflammatory drugs (NSAIDs) or cox-2 inhibitors, opioids were associated with more adverse events requiring hospitalization and an increased risk of death, and even among the opioids significant differences were found in rates of adverse events and risk of death.

Well.  What these results clearly do is point to a need for more robust clinical trials specifically designed to tease out the factors related to adverse events and death when these medications are employed.  Rick opines that identifying the risk factors could help design interventions or strategies to reduce the risk.  Here's my opinion:  just as is the case with Vioxx, which was extremely effective in reducing pain, the relative risk and the absolute risk are very different.  The spin is that Vioxx increased the risk of cardiovascular events by 100%!!!!  Yes, but the absolute risk went from 2 in 1000 to 4 in 1000 people.  So if you asked me, a person at extremely low risk for a cardiovascular event, if I was willing to accept that risk, I would say YES.

If older people who are dealing with significant pain are given a choice, after being informed of the facts, I believe many of them would make the trade.  The issue may be framed this way:  I can give you a very effective pain reliever but it may shorten your life, or I can potentially prolong your life but you will be in considerable pain.  Hmmmm. Clearly a frank and informative discussion between patient and physician is indicated, as well as those aforementioned clinical trials.

Other topics this week include optimal timing of thyroid medication,  interventions to increase rates of colorectal cancer screening and the clinical significance of masses found incidentally in the adrenal gland, also in Archives of Internal Medicine.  Until next week, y'all live well.

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TENS Machines & Pain Relief Blog - LGMedSupply » Blog Archive » Can Elderly Patients Use TENS Pain Units Safely?
October 23, 2012 at 5:12 pm

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carolyn kline August 18, 2013 at 9:58 pm

Indeed Vioxx and the like were very effective..but they are off the market. All of the OTC pain meds are now thought to be very dangerous for those of us over 65. My Drs.have tried to push opioids which I will not take since I still drive a car and like to be alert for conversation with my family and friends. Indeed the OTC's have done a number on my "insides". Bring back Vioxx etc. I won't sue...I'll just be happy to not be in pain. Medical plans such as Kaiser refuse to give good pain meds to folks my age. What to do?

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Bruce Wilson February 3, 2011 at 4:00 pm

I wonder about causality on these findings. I would imagine people who were sicker in general would also wind up being prescribed more powerful pain medication. Their worse outcomes might be the result of a worse baseline condition instead of effects of the drugs themselves.
If it weren't for post marketing monitoring we wouldn't know about Vioxx, but are we sure this comparison is valid.

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Banjo September 3, 2011 at 4:06 pm

Wonderful expalantion of facts available here.

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