Letters to the Editor from August 2012
Dear Dr. Tennant,
I have been reviewing the information you have published in reference to topical opioids.1 I understand the concentrations you have used but I was not able to determine daily dose. I suspect it must vary from patient to patient, but could you indicate a range of how long 1 oz of morphine or oxycodone should last the average patient? How much do you dispense at a time? Do you establish an upper limit for daily use? Or do you allow the patient to determine their limit?
CW Jasper, MD
Dear Dr. Jasper,
Your questions about topical opioids are most cogent. We usually issue an 8 oz jar and instruct the patient to massage enough into a pain site to relieve pain. Frankly, I don’t really know how much cream base to apply at each application. Fortunately, seldom do topical opioids enter the blood stream, so they are quite safe and side effect free.
We initiate topical opioid use when pain flares occur. As you are aware, however, patients have a mind of their own; some begin to use it at bedtime or on a regular daily schedule. We see no reason to limit their use, because topical opioids often lower a patient's use of systemic opioids.
Most interesting is that topical opioids don’t relieve pain in all patients, and some patients with centralized pain report the best results. I theorize that the sympathetic efferent electrical signals that emanate from the central nervous system in centralized pain and which give the perception of pain in a local area are subject to good control by topical opioids and carisoprodol.2,3 Since Dr. Luigi Galvani discovered in the 1700s that frogs given opioids did not die when shocked with electricity, opioids have been known to calm electrical charges.
Some patients may not respond to topical opioids because there are no receptors to attach to in their local pain site. Although we know that opioid receptors propagate in inflamed tissue, we know little about the rate, density, or physiologic functions of these receptors.4,5
Please let us know your experience with topical opioids.
Best wishes always,
Forest Tennant, MD, DrPH
HCG Dosing Guidelines
Dear Dr. Tennant,
I’ve read with great interest your articles on testosterone, human chorionic gonadotropin (HCG), and pain. This is an area that has been of interest to me but has received little attention until you have addressed it. The May issue of Pain Medicine looks at testosterone replacement therapy, but not at its effects on pain.6
Interestingly, in Florida, where I used to live, there are quite a few “rejuvenation clinics,” which are on the fringe, but may also be addressing an important issue.
Testosterone replacement has always been difficult because of the poor routes of administration. I am interested in trying HCG after reading your pieces.
There is a sublingual compounded HCG available. Have you tried that route of administration? Also, can you provide me with some general guidelines on dosing? How do you monitor therapy and adjust doses on subsequent visits?
Thank you for your continued thought-provoking and insightful writing. It is rare these days.
Daniel A. Graubert, MD
Dear Dr. Graubert,
Thanks for your interest in HCG, testosterone, and other neurogenic hormones. As time goes by, these agents are proving to have a most critical role in pain management.
You are certainly correct when you say that testosterone replacement is problematic. The commercial preparations are somewhat expensive and difficult to consistently administer. HCG can easily be compounded by any of the many local pharmacies that now practice compounding. I have sublingual HCG made in a 250 unit per mL bottle of 30 to 50 mL. I start with 1 mL per day and let the patient titrate upward to a maximum of 750 units per day. It can be used by itself or with testosterone administration.
The key to replacing testosterone, cortisol, and pregnenolone is to simply obtain serum levels every 3 to 4 months. To get adrenal or gonadal suppression, one will have to use dosages at least twice that required for replacement. Sub-replacement dosages appear effective in many pain patients. Your safety valve to prevent any hormonal complications is simple blood testing to keep the hormone levels in the normal range.
Forest Tennant, MD, DrPH