Musculoskeletal and Pain Management
Osteoarthritis and Osteoporosis
Osteoarthritis management centers on exercise, weight management, topical NSAIDs, and acetaminophen, with intra-articular glucocorticoids for flares. Oral NSAIDs should be used at the lowest dose for the shortest duration because of GI bleeding, renal injury, and cardiovascular risk; add a proton pump inhibitor or misoprostol when NSAIDs are unavoidable in high-risk patients, and avoid them in heart failure, CKD, and anticoagulation where possible. Osteoporosis treatment includes bisphosphonates, denosumab, and anabolic agents; ensure calcium and vitamin D adequacy, and remember denosumab must not be stopped abruptly without transition because of rebound vertebral fracture risk.
Pain Assessment
The older adult may underreport pain or present with agitation or withdrawal. Use structured tools, including scales for those with cognitive impairment. The WHO analgesic ladder still frames stepwise therapy, but in older adults start at the lowest effective dose and extend intervals.
Opioids and Adjuvants
Opioids relieve moderate-to-severe pain but carry constipation, sedation, falls, and respiratory depression risk. Always co-prescribe a bowel regimen. Avoid meperidine (neurotoxic metabolite) and use caution with codeine and tramadol because of variable CYP2D6 metabolism and serotonergic or seizure risk. Adjuvants include gabapentinoids for neuropathic pain (dose-adjust in renal impairment), topical lidocaine, and duloxetine.
Traps
Stems may pair an NSAID with an ACE inhibitor and diuretic - the "triple whammy" for acute kidney injury. Another trap is stopping denosumab without a plan, or adding an opioid without a laxative.
Rule of Thumb
For any new opioid in an older adult, prescribe a stimulant laxative concurrently and reassess function and falls at follow-up; if pain is neuropathic, consider a topical or adjuvant agent before escalating opioids.