LBD, Tyenol and Opiates

Last week, we recommended against the use of NSAIDS for chronic pain. A little more about NSAIDs. Aspirin is probably the mildest of these and is still a possible option. Ibuprofen (Advil) is also fairly mild and if you are going to use these drugs at all, it is probably the best option. But first, try another old standby, acetaminophen (Tylenol). It is not an NSAID, and thus causes neither GI bleeding nor heart problems.

The UNC School of Medicine's protocol for treating a dementia patient's pain starts with the over-the-counter (OTC) drug, acetaminophen (Tyenol). It is considered by many to be the safest pain drug around, but only if it is used carefully. The recommended dose is up to two 325 mg tablets every 4 to 6 hours. The elderly, or anyone with LBD, should take about half that. Sadly, Tylenol is not a very powerful pain reliever and people tend to double up when they use it--which can lead to liver failure. In fact, acetaminophen overdose is the leading cause of acute liver failure in the US.

Another problem with both aspirin and acetaminophen is that they are often combined with other, less safe drugs. An example is Tylenol PM, which adds diphenhydramine (Benadryl), a serious anticholinergic drug. Be careful of any drug with initials after its name. This means other drugs have been added. Often these drugs are sedatives or anticholinergics, both of which can trigger LBD's drug sensitivities.

When a stronger pain reliever is needed, many doctors choose an opiate. By chosing one combined with acetaminophen, such as Percocet or Vicodin, they can use a smaller dose. However, opiates are addictive. You might say, "So what. If it helps the pain, he'll probably want it for the rest of his life anyway." But that isn't the way an addictive substance works. "Addictive" means that this is a drug that the body adapts to. As a person's body adapts, more of the drug is needed to provide the same amount of pain relief. Eventually, even large doses might not help. Opiates are fairly strong sedatives and are mildly anticholinergic. With the larger doses, sedative and anticholinergic symptoms like the following may appear:

• Constipation, which is likely already an issue for anyone with LBD.

• Sleepiness and additional confusion is common, with an increased the risk of fractures caused by falls.

• Disordered breathing, with slower or shallow breathing patterns, especially during sleep.

• Heart problems. Some opioids increase the risk of heart attack or heart failure. Ask the doctor about this before agreeing to any opiate drugs for your loved one.

Bottom line, opiates may work well for PwLBD, in carefully reduced, carefully monitored dosages for severe, short-term pain. However, they may be problematic when used for long term pain such as arthritis.

Reference:
Denham A. (2013) Pain Management in Dementia. University of North Carolina School of Medicine. July 10, 2013. https://www.med.unc.edu/pcare/files/pain-management-in-dementia

For information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson’s & Lewy BodyDementia

Helen and James Whitworth are not doctors. As informed caregivers, they share the information here for educational purposes only. It should never be used instead of a physician's advice.