Is Toradol (ketorolac) or a narcotic, such as morphine or oxycodone, the best option for severe back pain in a 90-year-old patient?

Severe Back Pain Management in a 90-Year-Old Patient

For a 90-year-old patient with severe back pain, avoid both Toradol (ketorolac) and narcotics as first-line therapy; instead, use scheduled intravenous acetaminophen every 6 hours as the primary treatment, with NSAIDs like ibuprofen added only if pain remains severe, while reserving opioids strictly for breakthrough pain at the lowest dose for the shortest duration. 1

Why Avoid Toradol in This Population

Ketorolac is particularly dangerous in elderly patients and should be avoided. The FDA label explicitly warns that elderly patients (≥65 years) receiving ketorolac at doses >60 mg/day have dramatically increased rates of clinically serious gastrointestinal bleeding—ranging from 2.8% to 7.7% compared to 0.4% to 4.6% in younger patients. 2 This risk escalates to 25% in elderly patients with a history of GI ulceration who receive high doses. 2

Additional concerns with ketorolac in the elderly include:

• Maximum duration of only 5 days for all ketorolac formulations combined, severely limiting its utility for ongoing pain management 2
• Acute renal failure risk, which is particularly problematic in elderly patients with age-related renal decline 3
• Delayed onset of action (30-60 minutes) with >25% of patients showing little to no response 4
• Increased cardiovascular and renovascular risks in this age group 1

Why Avoid Narcotics as First-Line

Opioid administration should be avoided in elderly trauma and pain patients due to high risk of serious complications. 1 Elderly patients face:

• Progressive morphine accumulation leading to over-sedation 1
• Respiratory depression 1
• Delirium 1
• Constipation and nausea as common side effects 1

The 2017 American College of Physicians guidelines found only small short-term improvement (approximately 1 point on a 0-10 pain scale) with strong opioids for chronic back pain, with moderate-quality evidence. 1

Recommended Treatment Algorithm

First-Line: Acetaminophen

• Administer intravenous acetaminophen 1000 mg every 6 hours regularly (not as needed) 1
• This provides effective and safe analgesia in elderly trauma patients 1
• Preferred over NSAIDs due to more favorable safety profile and low cost 1

Second-Line: Add NSAIDs if Needed

If pain remains severe despite acetaminophen, add oral ibuprofen 400 mg every 6-8 hours (maximum 3200 mg/day). 5

Before prescribing NSAIDs in a 90-year-old:

• Assess cardiovascular risk factors (hypertension, heart disease, stroke history) 1
• Assess gastrointestinal risk factors (prior ulcer, GI bleeding, concurrent anticoagulation) 1
• Co-prescribe a proton pump inhibitor for GI protection given the patient's age 1, 5
• Use the lowest effective dose for the shortest duration 1

NSAIDs provide more effective pain relief than acetaminophen alone but carry known GI and renovascular risks. 1 Moderate-quality evidence shows NSAIDs provide small to moderate pain improvement in chronic back pain. 1

Third-Line: Multimodal Approach

Implement a multimodal analgesic strategy including: 1

• Continued scheduled acetaminophen
• NSAIDs (if tolerated)
• Consider adding gabapentin 100-300 mg at bedtime, titrating to 900-3600 mg daily in divided doses for neuropathic component 5
• Regional nerve blocks if available and appropriate 1

Last Resort: Opioids for Breakthrough Only

Reserve opioids exclusively for severe, disabling pain uncontrolled by the above measures. 1

If opioids become necessary:

• Use the lowest effective dose 1, 6
• For the shortest period of administration 1
• Start with immediate-release oxycodone 5 mg every 4-6 hours as needed (not scheduled) 6
• Reduce doses progressively due to accumulation risk in elderly 1
• Monitor closely for sedation, respiratory depression, and delirium 1
• Reassess frequently and discontinue if ineffective after time-limited trial 1

Critical Pitfalls to Avoid

• Never use ketorolac for more than 5 days total (IV/IM plus oral combined) 2
• Never exceed recommended NSAID doses in elderly patients—the risk of serious GI bleeding increases exponentially with higher doses 2
• Never prescribe NSAIDs without assessing cardiovascular and GI risk 1
• Never use opioids as first-line in elderly patients with back pain 1
• Never continue opioids long-term without reassessment and consideration of alternatives 1

Special Considerations for Radicular Pain

If the back pain has a radicular (nerve root) component:

• Tricyclic antidepressants (amitriptyline starting 10-25 mg at bedtime) are first-line for neuropathic pain 5
• Duloxetine 30-60 mg daily shows small improvement in pain and function with moderate-quality evidence 1
• Gabapentin shows small, short-term benefits in radiculopathy 1, 5