Ask the Expert: Pain Persists in Spite of High-dose Opioids
QUESTION: A 50-year-old man with degenerative disk disease and two failed lumbar surgeries continues to complain of back pain that is 8 to 9 out of 10 on a visual analog scale. He is currently on a 100-mcg/hr fentanyl patch every other day plus 60 mg of oxycodone every 4 hours for breakthrough pain. I have tried rotating him to other opioids, but he complains or experiences side effects. My instinct says something is not right, but the prescription monitoring program reports show that he is not getting opioids from any other prescriber. His urine screens are consistent, and there are no overt red flags for abuse. I have discussed with him discontinuing his opioids, but he says, “This is the only thing that helps me.” He works full time as a school teacher, drives a car, and walks his dog. What do you suggest for a patient who keeps complaining of severe pain, even with a high opioid dose?
ANSWER: Additionally, is the patient on a regular home exercise program? How often and for how long does he walk the dog? If he hasn’t been to physical therapy (PT) in a while, it would be worth while for him to go to PT and develop a stretching and muscle-strengthening home regimen, along with suggestions for how best to bend over, lift things, etc. Also, stress, depression, and anxiety can worsen pain. A psychological evaluation would be helpful to see whether emotional and psychological issues are present; if so, these might be helped by therapy and antidepressants. Because degenerative disk disease can be progressive it might be a good idea to have his lumbar spine imaged, if it’s been more than a few years, to be sure there is nothing that might benefit from a surgical procedure. You might consider referring the patient for consultation with an anesthesiologist pain specialist to see whether a spinal cord stimulator or intrathecal pain pump would benefit him. Also, has this patient had his testosterone level checked? Hypogonadism can decrease muscle strength and well being as well as sexual function. Most men on moderate-to-high doses of opioids have subnormal testosterone levels and can benefit from testosterone replacement.