What is the best management plan for an elderly patient presenting with neck pain, currently taking baclofen, GABA (Gamma-Aminobutyric Acid), and Tylenol (acetaminophen)?

Management of Refractory Neck Pain in an Elderly Patient

The current regimen of baclofen, gabapentin, and acetaminophen should be reassessed and optimized, with baclofen likely discontinued due to limited evidence for neck pain and high risk of adverse effects in elderly patients, while maximizing acetaminophen dosing to 3000 mg daily in scheduled doses and considering topical analgesics before escalating to other systemic therapies. 1

Immediate Medication Review and Optimization

Discontinue or Taper Baclofen

• Baclofen has minimal evidence for analgesic efficacy in neck pain and should not be used as a primary analgesic in elderly patients. 1
• Baclofen is a GABA-B agonist indicated primarily for spasticity from central nervous system injury, not musculoskeletal pain. 1
• The evidence for baclofen in pain is limited to anecdotal reports and one controlled trial in trigeminal neuralgia—not neck pain. 1
• Common side effects of dizziness, somnolence, and gastrointestinal symptoms are particularly problematic in elderly patients and increase fall risk. 1
• If discontinuing baclofen after prolonged use, taper slowly to avoid withdrawal symptoms including delirium and seizures. 1

Optimize Acetaminophen Dosing

• Increase acetaminophen to scheduled dosing of 650-1000 mg every 6 hours (maximum 3000 mg per 24 hours in elderly patients ≥60 years). 2, 3
• Scheduled dosing every 6 hours provides superior and consistent pain control compared to as-needed administration. 3
• The maximum daily dose should be reduced from 4000 mg to 3000 mg in elderly patients to minimize hepatotoxicity risk. 2, 3
• Explicitly counsel the patient to avoid all other acetaminophen-containing products to prevent exceeding the daily maximum. 2, 3

Reassess Gabapentin Dosing

• Gabapentin is appropriate for neuropathic pain but has limited evidence for pure musculoskeletal neck pain. 1
• If neck pain has a neuropathic component (burning, shooting, electric-like quality), continue gabapentin with proper dose titration. 1
• Start with 100-200 mg/day and escalate incrementally, monitoring for side effects of somnolence, dizziness, and mental clouding. 1
• Effective doses typically range from 900-3600 mg/day in divided doses, though elderly patients may respond to lower doses. 1
• Adjust dosing for renal function, as gabapentin is renally cleared. 1

Add Topical Analgesics as First-Line Adjunct

Topical NSAIDs (Preferred Option)

• Add topical diclofenac gel or topical salicylates (Salonpas) to the affected neck area for localized pain relief with minimal systemic absorption. 2, 4
• Topical NSAIDs provide therapeutic local concentrations while avoiding gastrointestinal bleeding, renal toxicity, and cardiovascular risks associated with oral NSAIDs in elderly patients. 2, 4
• No drug-drug interaction exists between topical salicylates and oral acetaminophen. 2
• The primary adverse effect is skin irritation at the application site. 2

Alternative Topical Options

• Lidocaine 5% patch can be considered for localized neck pain, though evidence is strongest for postherpetic neuralgia. 1
• The lidocaine patch has ease of use, absence of systemic toxicity, and lack of drug interactions. 1
• Topical capsaicin 8% patches have established efficacy for neuropathic pain and may be considered if neuropathic features are present. 1

If Pain Remains Inadequate: Multimodal Escalation Algorithm

Consider Duloxetine for Neuropathic Features

• If neck pain has neuropathic characteristics (radiating, burning, shooting), add duloxetine 30 mg daily for 1 week, then increase to 60 mg daily. 1
• Duloxetine is the only drug with large randomized trial evidence showing moderate clinical benefit in neuropathic pain. 1
• Duloxetine is preferred over tricyclic antidepressants in elderly patients due to better tolerability. 1

Avoid Oral NSAIDs

• Oral NSAIDs should be avoided in elderly patients (≥60 years) due to increased risk of gastrointestinal bleeding, renal insufficiency, and cardiovascular complications. 1, 3, 4
• If oral NSAIDs become absolutely necessary, use the lowest effective dose for the shortest possible time with mandatory co-prescription of a proton pump inhibitor. 3, 4

Reserve Opioids as Last Resort

• Reserve opioids only for breakthrough pain at the lowest effective dose for the shortest duration, as part of a multimodal approach. 3
• Opioids increase risk of falls, cognitive impairment, constipation, nausea, and delirium in elderly patients. 3
• If opioids are necessary, start with tramadol 50 mg or low-dose oxycodone 2.5-5 mg, and initiate prophylactic laxatives immediately. 3, 5

Critical Monitoring and Safety Considerations

Hepatotoxicity Monitoring

• Monitor liver enzymes (AST/ALT) regularly for patients on long-term acetaminophen therapy, particularly at maximum doses. 3, 4
• Avoid concurrent alcohol use, which increases hepatotoxicity risk even at therapeutic acetaminophen doses. 3

Fall Risk Assessment

• Many of the current medications (baclofen, gabapentin) are associated with greater risk for falls in older persons. 1
• Assess mobility, balance, and home safety when prescribing sedating medications. 1
• Side effects such as somnolence, dizziness, and mental clouding are common with gabapentinoids and can be very problematic in older patients. 1

Polypharmacy Review

• Discontinue herbal supplements and multivitamins that add complexity and cost without evidence of benefit. 1
• Review all medications for anticholinergic burden, which causes CNS impairment, delirium, falls, and urinary retention in elderly patients. 1

Non-Pharmacological Interventions to Combine

• Physical therapy with gentle range-of-motion exercises and postural training. 5, 6
• Heat or cold therapy applied to the affected area. 5
• Transcutaneous electrical nerve stimulation (TENS) for localized pain relief. 5
• Cognitive-behavioral therapy for chronic pain management and coping strategies. 5, 6

Common Pitfalls to Avoid

• Do not continue baclofen simply because the patient is already taking it—there is no evidence supporting its use for neck pain in elderly patients. 1
• Do not prescribe "muscle relaxants" (cyclobenzaprine, methocarbamol, carisoprodol) believing they relieve muscle spasm—their effects are nonspecific and they carry high anticholinergic burden in elderly patients. 1
• Do not assume gabapentin is appropriate for all neck pain—it is indicated primarily for neuropathic pain, not pure musculoskeletal pain. 1
• Do not add oral NSAIDs before maximizing acetaminophen and topical therapies—the systemic risks far outweigh benefits in elderly patients. 2, 3, 4
• Do not escalate to opioids without first optimizing non-opioid multimodal analgesia. 3, 5