Pain management for elderly patients — beyond opioids

Reviewed by a board-certified geriatric medicine specialist

Chronic pain affects more than half of older adults in the United States, yet it remains undertreated in this population because doctors and families alike are caught between the opioid crisis and the reality that pain ruins quality of life. The good news: effective non-opioid options exist, from topical treatments to nerve-targeting medications to behavioral approaches. Your parent does not have to choose between addiction risk and suffering.

Non-Opioid Medications, Topical Treatments, and Behavioral Approaches Give Most Older Adults Meaningful Pain Relief Without the Risks of Long-Term Opioid Use

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. According to the NIH, chronic pain contributes to depression, sleep disruption, reduced mobility, and increased fall risk in adults over 65. It affects 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. The CDC's 2022 clinical practice guidelines specifically note that non-opioid therapies should be preferred for chronic pain, but they also emphasize that pain in older adults should not go unaddressed. Your parent might be offered nothing, or told they're too old for pain medication, or prescribed something that doesn't work. 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 may 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 them a burden to doctors. They may 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 may 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 may 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 treatment. 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 effective 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. The American Geriatrics Society Beers Criteria lists oral NSAIDs as potentially inappropriate for adults 65 and older because of gastrointestinal bleeding risk, kidney damage, and cardiovascular effects. If your parent takes blood thinners, NSAIDs increase bleeding risk further. Some people take them anyway because the pain relief is worth it, but they do it under doctor supervision with frequent check-ups and time-limited courses.

Acetaminophen is safer for long-term use in many ways, but it has a ceiling dose. You can't just take more to get more pain relief. The FDA maximum for adults is 3,000 mg per day (some guidelines say lower for older adults), 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, the AGS recommends it as a first-line treatment because of its safety profile.

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 may help. Diclofenac comes as a gel that works through the skin, giving NSAID-level relief with far less systemic absorption. 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. The FDA has approved both for specific types of nerve pain, including diabetic neuropathy and postherpetic neuralgia. They work differently from NSAIDs, targeting the nerves directly. They can help many 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 regular application. 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 duloxetine has FDA approval for diabetic neuropathy, fibromyalgia, and chronic musculoskeletal 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 do 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 that nothing else matches. 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 may 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 may help. The risks are real though. The AGS notes that opioids cause constipation in up to 40 percent of older users, and that constipation can become dangerous enough to require hospitalization. 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 can be dangerous.

There's also the risk of overdose. Older adults metabolize medications differently. The NIH reports that adults over 65 have the highest rate of opioid-related emergency department visits per capita. A dose that's safe for a younger person may be too much. As your parent ages and gets frailer, they may 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 the most common and sometimes the worst side effect, and it's something you actively manage. Your parent should be on a stool softener and possibly a mild laxative while taking opioids. Increasing fiber and fluids helps. 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 on their own. 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 may need to try a few different approaches before finding what works. NSAIDs for a while to see if they help. Then adding topical treatments. 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.

Frequently Asked Questions

Is it safe for my parent to take ibuprofen every day for arthritis pain?
Daily NSAID use in adults over 65 carries real risk. The AGS Beers Criteria flags chronic oral NSAID use as potentially inappropriate for older adults because of gastrointestinal bleeding, kidney problems, and cardiovascular effects. Short courses under doctor supervision are sometimes reasonable, but long-term daily use should be a conversation with their doctor about safer alternatives like topical diclofenac or acetaminophen.

My parent's doctor won't prescribe anything stronger than Tylenol. What should I do?
Ask the doctor specifically what the treatment plan is. If acetaminophen alone isn't enough, there are many options between Tylenol and opioids: topical treatments, gabapentin for nerve pain, duloxetine for chronic pain, physical therapy, and injections. If the doctor isn't willing to explore these, a referral to a pain management specialist or geriatrician is a reasonable next step.

Can physical therapy help with chronic pain in older adults?
Yes. The NIH cites physical therapy as one of the most effective non-pharmacological treatments for chronic musculoskeletal pain. A physical therapist can design exercises to strengthen muscles around painful joints, improve flexibility, and reduce pain over time. Many insurance plans, including Medicare, cover physical therapy with a doctor's referral.

How do I know if my parent is in more pain than they're admitting?
Watch for changes in behavior rather than waiting for them to say something. Decreased activity, reluctance to walk or stand, changes in sleep patterns, irritability, loss of appetite, and withdrawing from social activities can all signal unmanaged pain. Ask specific questions about pain in different body areas rather than a general "how are you feeling."

Are opioids ever appropriate for an older adult with chronic pain?
Yes, in specific situations. When other treatments have failed and the pain is severe enough to affect daily function, carefully monitored low-dose opioid therapy can be appropriate. The CDC guidelines recommend that when opioids are used for chronic pain, the lowest effective dose should be prescribed, with regular reassessment. The decision belongs to your parent and their doctor, not to a blanket policy.