Pain Relief: Part One

By Henry Schneiderman MD,
Vice President for Medical Services and Physician in Chief, Hebrew Health Care

This is the first in a series of posts, providing medical and wellness advice for the intelligent non-technical reader, who is either elderly himself or herself, or involved in the care of an older person.  These are not intended to replace, and must not be used instead of conversation and consultation with your doctor, who will know particulars of your body and your case that may call for different specific choices for care.

I’ve chosen “pain” for the first in the series, because every person has pain at various points in life. The first issue is always to have a diagnosis that explains the pain. That will dictate whether treating this symptom is a correct and safe first approach, or needs to be combined with other testing or intervention. A knee that has hurt for the last 30 years is likely arthritic and does not usually require new testing unless suddenly worse. By contrast, new acute pressure under the breastbone requires immediate medical attention; simply using pain medicine to ease such chest pain would be a poor choice reminiscent of the old cliche of poor medical practice. “Take two aspirin and call me in the morning.”

Whenever it is possible to alleviate or eliminate a source of pain, that is a preferred course of action: If an arthritic hip hurts whenever one walks, for example, one continues pain medicine to take the edge off, uses exercises from physical to strengthen the muscles that stabilize the joint, and if the situation does not become tolerable, one consults an orthopedic surgeon about whether surgical total hip replacement is indicated.

Two responses to pain make no sense but are extraordinarily common:

1. To limit one’s activity to avoid pain-this sets up a vicious cycle of weakening.
2. To believe that there is a virtue and medical soundness in “toughing it out.”  Living with pain that could be helped does not ennoble anybody. Such a choice sets up consequences including loss of strength and mobility, depression, sleep disturbance, and increased susceptibility to a whole gamut of purely physical ailments.

Acetaminophen (sold as Tylenol among other brands) is a wonderful pain medicine. With it or any other medicine, one has to get AHEAD of pain; catching up with pain is more difficult and more miserable than staying ahead. A great starting regimen is two extra strength caplets, for a total dose of 1000 mg. This is done four times daily; the doses should be as widely spaced as possible, regardless of food in the stomach for instance, first thing on arising, 1:00 p.m., 6:00 p.m. and last thing at bedtime.

Unless you have liver problems or are taking two or more drinks of alcohol a day, this dosage is safe regardless of age, at least for the short-term. At the end of a full week of taking such doses unfailingly ” avoiding the pitfall of skipping a dose because you have felt well, it’s time to ask yourself if your pain has fallen to zero. The scale is “0 is no pain, 1 is the least pain, 10 is the worst pain of your life.” If you are at zero or a low number that is comfortable for you, you can cut back to three times daily and repeat the question a week later.

If on this second follow up, you find that most of the time you are comfortable, you can cut back to twice daily, ideally at a 12 hour spacing, which keeps the blood level of the medicine as constant as possible. This regimen can be kept up as long as needed. It has the further advantage that if you need a booster dose now and then ” for instance, an hour before an exertion that routinely makes a joint ache more ” the total daily dose stays under 3 grams a day for long term safety. If you know in advance that you’ll need the booster, arrange the other doses so that there is at least five hours between any two doses.

If you drink two alcoholic drinks a day or more, or if you have known liver problems, you’ll need to consult your own physician about what it is the maximal safe daily dose over the long term for you. Acetaminophen is very safe when used wisely, but a leading poison when deliberately overdosed: I’d be mortified if any reader of this column accidentally took too much.

Next time, I will share why I do not prescribe Motrin, Advil, Ibuprofen, or Aleve to anybody over the age of 50, even if he or she is on a stomach-protecting medicine; and why I am so set against even the reputedly safer “COX-2 selective” agents such as celecoxib (celebrex) and Bexxtra. I’ll also reveal why I do not recommend aspirin for pain relief, notwithstanding the prominent television ads for this, and notwithstanding how enthusiastically and often I prescribe a single baby aspirin a day for preventing heart attacks, strokes, and perhaps even colon cancer.

I will conclude with the latest deeply encouraging information about morphine, a wonderful pain medicine (by mouth, no more need for injection) not just at the end of life ” the setting we all think about when we hear the word morphine ” but also in the midst of life, and for all kinds of pain including severe arthritis.

As you’ll see, I believe it’s high time for all of us “mature over 50” persons to avoid some widely used medicines. At the same time, we need to grow more comfortable and at ease about a drug that has had undeserved bad press, fear of addiction and of side effects, but that is in fact is a perfect solution much more often that we might think.

One thought on “Pain Relief: Part One

  1. Thank you Dr. Schneiderman for a superb post – you have clearly explained some key mistakes we all make, and as an ibuprofen user (under age 50) I look forward to your next post, as I worry what I’ll do when I’m over 50!

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