Pain and pain killers: the falls tradeoff.
In their insightful review about falls prevention in community dwelling older people, Vieira and colleagues  list pain (such as lower limb pain or foot pain) as a risk factor for falls. In this regard, the association between pain and falls is well known and backed by data from large cohorts of patients .
Drugs (and other treatments) can reduce pain and thus pain appears a “modifiable risk factor for falls” . In this scenario, the reduction of pain not only improves older people's quality of life, but also reduces their risk of falls.
However, the efficacy of acetaminophen, i.e. the common first-line therapy for chronic pain, has been recently questioned  and oral non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended for long-term use in the elderly . Opioid analgesics are effective for chronic pain , but opioids are a falls risk factor per se , possibly because of their sedative effect. Moreover, opioids are associated with some other important adverse events in elderly patients . Finally, adding (at least) a new pill for pain control increases the total number of drugs (at least) by one and the use of more than three drugs is a risk factor for falls by itself .
I feel it is important to emphasise one major point raised by Vieira and colleagues. The multifactorial assessment and intervention for fall prevention in older people should also cover the “systematic assessment and management of pain” . Pain assessment and management is taken into consideration only by a minority of guidelines for falls prevention among older people, as effectively shown by Figure 2 of the review by Vieira et al.. Research is needed to find the best possible compromise between oral drugs for pain and fall risk in older people. Effectiveness in fall prevention of topical drugs and non-pharmacological therapies with recognised efficacy in pain control (such as topical NSAIDs  and strength training  in osteoarthritis) remains to be clarified as well.
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Competing interests: No competing interests