81 year old man with chronic pain: an integrative approach.
By Jacob Mirman, MD
Today I’ve been asked to consider an approach to treating pain in an 81 year old man who was in a bad auto accident 2 months ago and is currently recovering in a rehab facility. He had severe musculo-skeletal injuries as well as brain injury causing cognitive impairment. He is making good progress in treatment but appears to need some pain control medication because he has pains in his joints and possibly some injury sites.
Currently he is on gabapentin and naproxen for his pains, as well as pantoprazole to protect the stomach against naproxen side effects. We will first look at the current drugs.
Gabapentin is a drug that dulls perception in nerve cells. Therefore it often helps with pain. However, for the same reason it may cause some cognitive impairment, often similar to drinking alcohol. This is probably contraindicated in a person who already has cognitive impairment and we are hoping his brain will actually improve its function.
Naproxen is one of a group of non-steroidal anti-inflammatory drugs (NSAIDs). This group also includes drugs like ibuprofen, aspirin and others. These drugs work by interfering with prostaglandins. They are often quite effective in relieving pain. However, they all have issues. The best known side effect is causing stomach inflammation (gastritis) or stomach ulcers by interfering with the system of protection used by the healthy lining of the stomach against its own acid, also driven by prostaglandins. In some cases stomach lining may get damaged so severely as to cause bleeding. Thousands of people die each year in the US from this side effect of NSAIDs. This patient’s doctor thoughtfully added pantoprazole, and anti-acid drug, to protect against this side effect. However, NSAIDs have other side effects, some of which take long time to develop. They include irreversible chronic kidney failure sometimes ending in dialysis, elevated blood pressure, and they increase the risk of heart attacks three-fold. These are some of the most dangerous drugs in general use.
So we have a severely injured elderly man in need of some pain relief. What are the options?
Medical cannabis is hands down the safest and most effective pain medication I am aware of. While it does cause cognitive impairment in some people, it is usually possible to reduce and even eliminate this side effect by adjusting the ratio of THC to CBD in the cannabis product the patient is using. Cost and legal restrictions may prevent its use in many cases, but it is my first choice for fast and effective pain relief whenever possible. Another advantage of cannabis in this case is its ability to relieve anxiety and improve sleep.
Tylenol, an over-the-counter drug, may be an option. It is usually not as effective as NSAIDs, but in some cases it is effective enough. It also appears to be significantly safer.
Tramadol, an opioid-like drug, is very effective for pain relief. Most people tolerate it well. The most common side effect is constipation, but this can usually be mitigated by simple means like fiber, magnesium or Miralax. However, some people tolerate it poorly and develop nausea and other side effects. Cognitive impairment is not common but may happen. The main advantage of tramadol is fast and effective pain relief from each dose. As such, it can be used on as-needed basis. Because it is an opioid, it is always a good idea to take as little of it as possible.
Other opioids (narcotics) should be avoided in a case like this due to their side effects and addiction potential.
Supplements for Pain:
The two supplements work pretty well in chronic pain. They are safe. While medical cannabis is often quite expensive in effective doses, these supplements are much less expensive, so may be a good alternative. They can also be combined with other treatments. Some of our patients who could not tolerate cannabis in effective dose (rare, but it happens) did well on Curcumin or PEA. However, these supplements may not work as fast as some of the medications mentioned above and regular dosing is important.
Acupuncture is often useful for pain relief. Some physical therapy modalities also often work. Our patient is already receiving good PT.
Low Level Laser Therapy (LLLT) may be quite useful in a case like our patient for working on the injury sites and chronic joint pains. This would actually help healing, not just relieve pain. However, this modality is rarely available.
So what should we recommend in this case?
If cannabis is an option, it is definitely one to consider first.
I would try Tylenol 2-3 times to see if it works, and may continue if it does, as needed.
Tramadol is a good option for a strong pain killer if one is really necessary.
I would start the patient on PEA 2-3 times a day on regular basis. This may reduce overall pain level with time (1-4 weeks) and reduce the need for drugs, including cannabis. Curcumin is another option for regular ongoing treatment. However, because I have more experience with PEA, I would start it first.
If acupuncture or LLLT are available in this facility, I would definitely consider them as well.
Once another effective method is found, I would reduce and eliminate the currently used medications.