Persistent pain in the older adult. What should we do now in light of the 2009 American Geriatrics Society Clinical Practice Guideline?

The recent publication of revised guidelines for the management of persistent pain in the older adult (American Geriatric Society, 2009) has posed a dilemma for clinicians. In essence, these revised guidelines now downplay the use of nonsteroidal anti‑inflammatory drugs (NSAIDs) relative to prior year’s recommendations. The strong recommendation for caution when employing NSAIDs is because of the numerous, well‑documented, potential adverse effects including renal failure, stroke, hypertension, heart failure exacerbations, and gastrointestinal complications. Nevertheless, physicians still have a substantial arsenal for combating chronic pain due to such conditions as degenerative arthritis and back problems. Options for intervention include physical therapy, topical nonsteroidals, capsaicin, topical lidocaine, intra‑articular therapies, and judicious use of narcotics. In the future, cyclooxygenase‑inhibiting nitric oxide-donating drugs may represent a technical improvement in the toxicity profile of traditional NSAIDs.