Letters to the Editor: Testosterone, Ultra-high Dose Opioids
Do you know what would be the incidence of testosterone deficiency in a 57-year-old male on chronic opioid use (OxyContin)?
—Carlos Omar Viesca, MD
Dear Dr. Viesca,
With any long-acting opioids, plan on 65% to 85% of patients having suppressed testosterone.1-6 The percentage of patients who have suppressed testosterone levels with intrathecal opioids is even higher and approaches 85%.1,6 In summary, long-term opioid use regularly suppresses testosterone production. Other hormones, particularly pregnenolone, dehydroepiandrosterone (DHEA), and cortisol, also may be suppressed.6 Long-acting and intrathecal opioids present the biggest problems.5
—Forest Tennant, MD,
The Taxing Challenges of Being a Pain Practitioner
Regarding the article "Ultra-high Dose Opioid Therapy: Uncommon and Declining, But Still Needed,"7 I just want to say: THANK YOU, THANK YOU, THANK YOU.
In my opinion, there is much unofficial maneuvering going on to the point where pain management is definitely under fire nowadays—and more so than I have ever seen in my entire career. I am dual trained in internal medicine and physical medicine and rehabilitation, and have been out of residency since 1992. I have been doing pain management exclusively for many years now. I seem to have become the "gatekeeper to hell."
I think the current issues challenging those of us who deal with these patients are mainly political.
The war on drugs hasn’t been much help—especially for those who advocate the dragnet strategy, which usually harms many innocent individuals. Adding sophists to the mix simply makes matters worse. Much is done via insinuation, innuendo, ambiguous board rules, etc.
Far too often people fail to identify the risk of decreased function due to inadequate chronic pain management. I thank you for elaborating those risks. There is no risk-free benefit to help address the "drug problem."
I myself do not know how much longer I can continue to do this type of practice. It is time consuming and much, if not most, of the time spent is not reimbursable. The reimbursement is insufficient compared with the costs of doing all the increasingly non-reimbursable tasks associated with pain management. The hassle factor has markedly increased over the last 2 years, most distinctly after President Obama’s recent declaration on the war on prescription drugs.8 Insurers want to reduce their costs on our non-reimbursable time. (And these outside entities can simply increase their rates next year to cover any of their overhead costs, whereas practitioners do not have the power to do so.)
As a personal example, I spent 2 hours on the phone with a fourth-party medicine management company, and my staff spent 10 hours on the phone with them, to get approval for a patient who had been functioning well on the same regimen for more than 5 years. When I put the pen to the paper and calculated it out, it looks more and more like I will actually lose less if I simply quit and go fishing.
—Roy Blackburn, MD
Oregon TLC Pain Management