Safest, Most Effective Medications for Spine-Related Pain in Older Adults?

Megan Brooks

July 11, 2022

Some medications are safer and more effective than others for treating spine-related pain in older patients, a new comprehensive literature review suggests.

Investigators assessed the evidence for medications used for this indication in older adults by reviewing 138 double-blind, placebo-controlled trials.

Among their key findings and recommendations: acetaminophen has a favorable safety profile for spine-related pain but nonsteroidal anti-inflammatory drugs (NSAIDs) have greater efficacy.

However, NSAIDs should be used in lower doses in the short term, with gastrointestinal precaution, the researchers note.

Corticosteroids have the least evidence for treating nonspecific back pain, they add.

"Most older people experience neck or low back pain at some point, bothersome enough to see their doctor," co-investigator Michael Perloff, MD, PhD, Department of Neurology, Boston University School of Medicine, Massachusetts, said in a news release.

"Our findings provide a helpful medication guide for physicians to use for spine pain in an older population that can have a complex medical history," Perloff added.

The results were published online June 27 in Drugs and Aging.

Recommendations, Warnings

With the graying of the US population, spine-related pain is increasingly common, the investigators note.

Medications play an important role in pain management, but their use has limitations in the elderly, owing to reduced liver and renal function, comorbid medical problems, and polypharmacy.

Other key findings from the literature review include that although the nerve pain medications gabapentin and pregabalin may cause dizziness or difficulty walking, they also have some demonstrated benefit for neck and back nerve pain, such as sciatica, in older adults.

These agents should be used in lower doses with smaller dose adjustments, the researchers note.

They caution that the muscle relaxants carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine should be avoided in older adults because of their association with risk for sedation and falls.

"Rational Therapeutic Choices"

Three other muscle relaxants ― tizanidine, baclofen, and dantrolene ― may be helpful for neck and back pain. The most evidence favors tizanidine and baclofen. These should be used in reduced doses. Tizanidine should be avoided in patients with liver disease, and for patients with kidney disease, the dosing of baclofen should be reduced, the investigators write.

Other findings include the following:

  • Older tricyclic antidepressants should typically be avoided in this population because of their side effects, but nortriptyline and desipramine may be better tolerated for neck and back nerve pain at lower doses.

  • Newer antidepressants, particularly the selective serotonin-norepinephrine reuptake inhibitor duloxetine, have a better safety profile and good efficacy for spine-related nerve pain.

  • Traditional opioids are typically avoided in the treatment of spine-related pain in older adults, owing to their associated risks.

However, low-dose opioid therapy may be helpful for severe refractory pain, with close monitoring of patients, the researchers note.

Weaker opioids, such as tramadol, may be better tolerated by older patients. They work well when combined with acetaminophen, but they carry the risk for sedation, upset stomach, and constipation.

"Medications used at the correct dose, for the correct diagnosis, adjusting for preexisting medical problems can result in better use of treatments for spine pain," co-investigator Jonathan Fu, MD, also with the Department of Neurology, Boston University School of Medicine, said in the release.

"Rational therapeutic choices should be targeted to spine pain diagnosis, such as NSAIDs and acetaminophen for arthritic and myofascial-based complaints, gabapentinoids or duloxetine for neuropathic and radicular symptoms, antispastic agents for myofascial-based pain, and combination therapy for mixed etiologies," the investigators write.

They also emphasize that medications should be coupled with physical therapy and exercise programs, as well as treatment of the underlying degenerative disease process and medical illness ― while keeping in mind the need for possible interventions and/or corrective surgery.

The research had no specific funding. The investigators have reported no relevant financial relationships.

Drugs Aging. Published online June 27, 2022. Abstract

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