Q My 74-year-old father has chronic pain from an old war injury that significantly affects his quality of his life. Yet his doctor doesn't want to prescribe anything stronger than over-the-counter medications for fear that his system won't be able to handle it. What should he do?
A As people age, they tend to react to medications differently because their metabolisms change. For instance, we often prescribe the opiate Darvocet to people who need something stronger than an anti-inflammatory because it's a fairly weak narcotic. But as people get older, the half life of the drug (meaning the time it remains in their system) increases, so if you're not careful it can accumulate in the blood, leading to psychiatric and neurological problems.
Another problem we see in the elderly is that many are on several medications, sometimes up to 15 different drugs. So doctors are often reluctant to add more drugs for an older person because we don't know how they will affect the person, particularly for those conditions in which we know the medication isn't going to change the course of the disease, like osteoarthritis.
The important thing is to sit down with the patient and talk about the pain, when it occurs and how bad it is. Sometimes you find that something like acetaminophen (Tylenol) will work, but patients have to understand that they have to take it consistently, several times a day, or the pain returns.
Having said that, if your father feels that his doctor is ignoring his concerns, or the pain is getting worse, it might be time to seek a second opinion. And don't discount opiates altogether; several studies find they can be safe in older adults. (24)
Q When is it time to find a pain specialist?
A If you're not getting enough pain relief from your primary care doctor or the pain has affected your life to the extent you are not able to do the things you used to do, it's time to see a specialist.
Unfortunately, there aren't many. So far, the American Board of Pain Medicine has certified just 1,700 doctors as pain specialists--about one for every 23,500 people who need care. (25)
What kind of specialist you need depends on your pain. If it's related to osteoarthritis, lupus or rheumatoid arthritis, for instance, you should see a rheumatologist. If your pain is chronic and unrelated to any underlying disease, then you might want to seek out a pain clinic.
(See Resources on page 4 for information on pain centers and specialists.)
--John Meyerhoff, MD
Rheumatologist and Assistant Professor of Medicine
Johns Hopkins University School of Medicine Baltimore, MD
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