Pain management for elderly patients — beyond opioids

This article is for informational purposes only and does not constitute medical, legal, or financial advice. Please consult appropriate professionals for guidance specific to your situation.

Pain in older adults is one of those things everyone talks around. Your parent might mention it casually, almost as if it's just part of getting old, something they're supposed to accept. "Oh, my knee hurts. That's just what happens." When you push to help them manage it, they might wave you off. They don't want to be a burden. They're afraid of addiction. They think pain medication is for cancer patients or surgery recovery, not for the chronic ache that's been with them for years. I spent months listening to my dad minimize his back pain before I understood that he thought complaining made him weak.

The truth is that untreated chronic pain in older adults is common and makes everything harder. It affects their sleep, their mood, their willingness to move around and exercise. It can contribute to falls because they're moving carefully to avoid pain. It makes them isolated because they don't want to go places or do things with others. When you help your parent manage pain better, you're not just making them more comfortable. You're making life better in ways that spread far beyond the pain itself.

The problem is that pain management in older adults has gotten complicated. For decades, doctors prescribed opioids somewhat freely for chronic pain. Then the addiction crisis happened. Now doctors are often overcautious, leaving elderly patients undertreated. Your parent might be offered nothing, or told they're too old for pain medication, or prescribed something that doesn't work well. You're left figuring out how to actually help.

Understanding Pain in Older Adults

Chronic pain is different from acute pain. Acute pain is what you get after surgery or from an injury. It hurts, you take pain medication for a while, and then you heal. Chronic pain is ongoing, sometimes for years. Arthritis, back pain, neuropathic pain from diabetes, cancer pain, post-operative pain that never fully resolved. Your parent might be dealing with multiple sources of pain at the same time. The pain is real, and it's not going away.

Older adults often minimize their pain because they've learned it's expected. They grew up in an era when you just pushed through. They think complaining is weak or will make you a burden to doctors. They might not realize how much their pain is affecting their life because the change happened gradually. What used to be easy now requires planning, and they've adapted by doing less. They might not connect their low mood to the fact that they're in pain every day.

Sometimes you need to specifically ask your parent about pain in different areas. Does their knee hurt? Their neck? Their lower back? Do their feet hurt when they walk? Is there a time of day when pain is worse? Some pain is worse in the morning after lying down all night. Some is worse after activity. Some is constant. Your parent might not think to tell the doctor about all of it unless you help them make a list.

The distinction between chronic pain and acute pain matters for how to treat it. Acute pain needs stronger medication to stop it quickly. Chronic pain needs something you can take every day without serious side effects, because you're taking it for months or years. This is why opioids, which are great for acute pain but dangerous for long-term use in older adults, aren't usually the answer anymore. You need different approaches.

Non-Opioid Options

NSAIDs like ibuprofen and naproxen work well for some kinds of pain, but older adults have to be careful. These medications can damage the stomach and cause bleeding, especially with long-term use. They can affect the kidneys, which are already working harder in older age. If your parent takes blood thinners, NSAIDs increase bleeding risk. Some people take them anyway because the pain relief is worth it, but they do it under doctor supervision with frequent check-ups.

Acetaminophen is safer for long-term use in many ways, but it has a ceiling dose. You can't just take more and more to get more pain relief. Your parent's doctor will recommend a dose, and going higher won't help more, it will just increase liver risk. For some types of pain, acetaminophen doesn't work as well as NSAIDs. But for mild to moderate pain, it's often worth trying first because it's safer.

Topical treatments like creams and patches containing capsaicin, menthol, or lidocaine can help with localized pain. If your parent's knee or lower back hurts, rubbing a cream on that area might help. Diclofenac comes as a gel that works through the skin. Heat and cold can work too. Some people find that a heating pad helps back pain, or ice helps swollen joints. These aren't dramatic, but they can take the edge off.

For neuropathic pain, the burning or tingling pain that comes from nerve damage, NSAIDs and acetaminophen often don't work. This is where medications like gabapentin or pregabalin come in. These are also used for nerve pain from diabetes, shingles, or other causes. They work differently than NSAIDs, targeting the nerves directly. They can help a lot of people, though they sometimes cause dizziness or drowsiness, especially when your parent first starts them.

Topical capsaicin works specifically for nerve pain by depleting substance P, the chemical that transmits pain signals. It causes a burning feeling when you first use it, which is strange, but that subsides with use. For someone with localized nerve pain who can't tolerate other medications, capsaicin is worth trying.

Antidepressants, especially duloxetine and venlafaxine, are used for chronic pain conditions. They weren't designed for pain, but they're effective for nerve pain, fibromyalgia, and some types of chronic pain. Your parent might already be on an antidepressant for mood, and if so, the doctor might choose one that also helps with pain.

The Opioid Question

When might opioids still make sense for an older adult? Cancer pain is a clear example. If your parent has metastatic cancer causing severe pain, opioids provide relief. They also need careful monitoring and other medications to help with side effects like constipation, which is severe with opioids. But the benefit is clear.

Severe pain from acute injuries might also warrant short-term opioid use. If your parent breaks a bone or has surgery, opioids for a few weeks after the procedure are reasonable. The risk of addiction in this short window is low, and pain control matters for healing.

Chronic non-cancer pain is more complicated. Your parent might have severe arthritis pain or pain from another condition that doesn't improve with other treatments. Opioids might help. The risks are real though. Opioids cause constipation, which can be severe enough to be dangerous in older adults. They cause dizziness and increase fall risk. They can cause confusion and cognitive changes. If your parent is on other medications that affect the brain, adding opioids might be dangerous.

There's also the risk of overdose. Older adults metabolize medications differently. A dose that's safe for a younger person might be too much. As your parent ages and gets frailer, they might need less medication even as they're taking more medications. This is why doctors are cautious.

If your parent does take opioids, monitoring is essential. Is the medication helping their pain? Are they able to do more? Or are they just more sedated without real pain improvement? Are they having side effects that are worse than the pain relief? Regular check-ins with the doctor are needed to make sure the medication is still working and still making sense.

Constipation is probably the worst side effect, and it's something you actively manage. Your parent should probably be on a stool softener and maybe a mild laxative while taking opioids. Increasing fiber and fluids helps too. Staying active helps. But constipation can still become dangerous. If your parent hasn't had a bowel movement in days, hasn't eaten because they're nauseated, or is having severe cramping, this needs medical attention.

Your parent should never increase their own opioid dose or take them more often than prescribed. If the pain isn't controlled, that's a conversation with the doctor, not a reason to adjust medication. You need to know what their prescription is and watch for signs of overuse, including drowsiness that seems excessive or mood changes.

Pain management in older adults requires creativity and patience. Your parent might need to try a few different approaches before finding what works. NSAIDs for a while to see if they help. Then maybe adding topical treatments. Maybe trying gabapentin if nerve pain is involved. Your job is to help them try things, monitor what helps, and communicate with the doctor about what's working and what isn't. Your parent deserves to have pain managed. They don't deserve to suffer because everyone is afraid of opioids. They also don't deserve unnecessary risks from medications that aren't helping. The answer is usually somewhere in the middle.

How To Help Your Elders provides educational content for family caregivers. This is not a substitute for professional medical, legal, or financial advice. Every family situation is different — what works for one may not work for another.