—Photo by Masterfile

When a group of leading geriatric physicians recently released new guidelines that called for virtually eliminating the use of popular medications like ibuprofen for people over 75 with persistent pain, Alfred Anderson, M.D., wasn’t surprised. A physician who specializes in pain management, Anderson thinks the risks of stomach bleeding and heart problems associated with ingredients found in medicines like Advil, Aleve and Celebrex make them less than ideal for treating chronic pain in older patients. Instead, the Minnesota doctor often prescribes narcotics known as opioids such as codeine and Percocet.

“Over the last 20 years, it’s been obvious to me that the safer of the medications is the opioids,” says Anderson, who sits on the board of directors of the American Academy of Pain Management. “If you compare them with NSAIDs, opioids typically don’t have any damage to the body that’s severe enough to create life-threatening situations.”

The guidelines, which the American Geriatrics Society will publish in August, advise doctors to recommend that their older patients try acetaminophen, like Tylenol, and if that doesn’t work, to prescribe opioids. “It is a major change,” says Bruce Ferrell, M.D., a University of California at Los Angeles geriatrician who chaired the panel for the American Geriatrics Society. “We’ve finally come to the conclusion that NSAIDs as a strategy for the management of chronic pain should really be used quite rarely.”

These new guidelines issued this month came just after the Food and Drug Administration announced stricter labeling requirements for these common, over-the-counter painkillers called NSAIDs (non-steroidal anti-inflammatory medications). The FDA now requires manufacturers to put a warning on the medication about the risks of gastrointestinal bleeding.

Although the Geriatric Society’s guidelines are specific to people age 75 and over, experts say people over age 50 should be aware of the risks as well and consult their doctors about the use of NSAIDs. For people over age 75, however, the panel said the medications should be used “rarely” and “with extreme caution.”

Although some of the side effects of NSAIDs, like gastrointestinal bleeding and kidney problems, have been known for decades, more recent research—and some high-profile recalls and lawsuits—put NSAIDs under the microscope of regulators and physicians.

Studies have linked ibuprofen and other traditional NSAID use to heart attack risk as well. In addition, NSAIDs, which work by reducing the production of hormone-like substances in the body that cause swelling and pain, appear to exacerbate high blood pressure and congestive heart failure. This also influenced the panel’s decision to recommend against their use for people over 75, who are already at high risk for cardiovascular problems, Ferrell says.

“This is the group of patients that has more trouble with [NSAIDs] than any group of patients,” he says. “The evidence is actually stronger than in the past that you really have to use these drugs with caution.”

Some Doctors Skeptical About Opioid Use for Pain

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.

“I would be in a wheelchair without this medication,” Johnson says. “I use them very responsibly. I baby-sit my granddaughters, I drive my car. If you saw me, you’d never know I was on them.”

Johnson also uses Celebrex, a prescription NSAID, but only occasionally when her arthritis flares up. Anderson requires her to keep track of how often she takes the NSAID, and he has advised her against taking it every day.

Common Sense Solutions

For most people, physicians say, occasional NSAID use shouldn’t be a problem, as long as they follow dosage directions. There is no specific “safe” time period or dose—some people have stomach problems after a few days, others can tolerate NSAIDs for weeks—so physicians recommend consulting your doctor and watching for symptoms of possible complications, such as blood in your stool or an upset stomach. Aspirin is also an NSAID, but it’s unique because it doesn’t increase the risk of heart problems. The new guidelines are not meant to change doctor’s recommendation about taking baby aspirin for heart protection.

Although there is no absolute consensus, physicians agree that NSAID use should be watched carefully, especially among older patients with complicated medical histories.

In general, experts say, NSAIDs should be used periodically for arthritis flare-ups or acute problems. And patients on opioids need to start off on a low dose and slowly adjust it to find the dose that controls the pain but doesn’t impair daily function.

For people without liver problems, trying Tylenol first is recommended by most doctors. Trying nonpharmacological methods, from acupuncture to electrical nerve stimulation, might be an option as well.

Patients with severe pain may be willing to risk taking a medication that effectively treats their pain.

Research shows that NSAID use can cause people to have a significantly increased risk of gastrointestinal bleeding, especially among those over 75; some studies indicate that the risk of stomach bleeding may be as high as 15 times greater for someone on NSAIDs. But while the risk increases on NSAIDs, it still remains relatively low—in most studies, fewer than 5 percent of NSAID users had stomach bleeding. But that number increases as the number of risk factors—including age—increases. Similarly, some studies of the cardiovascular risk of NSAID use show a significant increase—even doubling the risk of heart attacks and other cardiovascular events. Once again, though, because the general risk of having a heart attack is relatively low, the increased risk may not be as scary as that statistic makes it sound.

“NSAIDs can be tolerated as long as they’re taken for comparatively short periods of time,” Anderson says. “[But] I’ve got patients that come in here and they’re taking 12 Aleve a day and they wonder why their stomach hurts.”

Experts on both sides of the issue agree that the best solution is for patients with chronic pain to discuss medications with their physician before using them regularly, even if they are over-the-counter drugs.

“The way I look at it, it comes down to the individual,” says Stephen Setter, an assoiate professor of pharmacology at Washington State University who specializes in geriatrics. “I think we’re making up ground for all the years that people took [NSAIDs] at any dose and any frequency. Now we know that is potentially detrimental, particularly as we age.”

Michael S. Gerber is a paramedic and writer based in Bethesda, Md.