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10 Articles in Volume 16, Issue #5
A Review of Skeletal Muscle Relaxants for Pain Management
Applying Kinesiology as a Multi-Prong Approach to Pain Management
Arachnoiditis: Diagnosis and Treatment
Bench to Bedside: Clinical Tips from APS Poster Presentations
Conversation With David Williams, PhD, President of the American Pain Society
Letters to the Editor: Prince Fentanyl Overdose, High-Dose Opioids, Mystery Care
Los Angeles Times Versus Purdue Pharma: Is 12-Hour Dosing of OxyContin Appropriate?
My Experience With OxyContin 12-Hour Dosing
Technology: Changing the Delivery of Healthcare
The Neuroscience of Pain

Letters to the Editor: Prince Fentanyl Overdose, High-Dose Opioids, Mystery Care

June 2016

Prince Died of Fentanyl Overdose

Practical Pain Management has had an overwhelming response to our report on the accidental overdose death of legendary musician Prince.1 Many of the comments are from chronic pain patients. The following is a selection of their comments.

I can definitely understand how Prince died from using fentanyl. I used the patches for years. I have lupus, rheumatoid arthritis, and fibromyalgia. Also, I had a cervical spine fusion. The patches are great, especially if you have multiple chronic pain problems. I was pain free for a long time, and then my body became immune to them. I was so tempted to double the dose, but after consulting with my pain management doctor, and reading up on fentanyl, I realized it could kill you instantly. I had to change pain medications; oxycodone, and other pain medicines, never did work as well as the patches did.

Janie Martin

Glad to see comments about people with chronic pain needing their prescribed opiates. People who live with daily pain need whichever opiate their well-educated doctor prescribes for them. If medications are not taken as prescribed, or medications are purchased by other avenues than prescription, it is wrong.People who suffer with conditions that require the use of opioids should not be looked down upon. Nor should their doctors’ hands be tied!

Sharon Hall

Please understand that much of the fentanyl that is being seen in these overdoses is not prescription grade, and doesn’t come from a patch or lollipop. It is “backyard grade” fentanyl that is being produced in illicit basement labs and sold as heroin or fentanyl. On a toxicological report, the 2 can’t be differentiated. Prince may have had a prescription for fentanyl due to previous [pain] issues, or he may have gotten it from the streets. More people are dying of fentanyl in my community than heroin, and it’s not from the patch.

Amanda Archer

High-Dose Opioids

I am the physician in charge of Kaiser’s pain management department in San Diego—we have over 650,000 members in the area.  

Our administration has asked our department to take over all patients who are taking more than 500 mg per day of morphine equivalents for their chronic pain, and their opiate refills.

Of course, most of these patients have been through our department at some time. I feel that having our department see these patients, and make opioid dosing recommendations and give advice (mostly about weaning), is support enough for the primary care physicians to refill these patient’s opiates according to any treatment plan.

The medical group wants us to assume all refills. Is it outside the standard of care for a primary care physician to refill high-dose opioid prescriptions under the guidance of a pain management doctor?

Michael Jaffe, DO

Physician In Charge

Integrated Pain Management

Physical Medicine and Rehabilitation

Kaiser Permanente

Dear Dr. Jaffe,

Your question and issue is most timely and critical. The timing of your situation, and many others, appears to be related to the new and widely-published Center for Disease Control and Prevention (CDC) guidelines on opioid prescribing.2

There are 2 major problems in pain management today:

1. All the new guidelines want a pain specialist to attend every patient who needs a daily morphine equivalent dosage of about 100 mg per day. The problem is simply that we don’t have enough pain specialists to go around.

2. We have many chronic pain patients who were started on high-dose opioids years ago, before we had alternatives such as neuropathic agents, low-dose naltrexone, ketamine, and neurohormones, etc. Many of these “legacy” patients are doing very well on their high-dose regimen and don’t wish to change. In addition, no party in pain management has found a consistent, reliable, and cost-effective way to reduce opioid dosages.

Let me say that having a primary care physician refill high-dose opioid prescriptions under a specialist’s guidance is not only a good “standard of care,” it is now, essentially, mandatory practice. We have no other option given the high number of legacy patients, and the growing shortage of pain specialists.

A couple of years ago, I personally became so inundated with legacy patients that I identified 3 primary care physicians in my local community who were willing to donate some of their practice time to see a limited number of high-dose opioid patients. We meet monthly for training and consultation. We have adopted standard forms and prescriptions. A great deal of training time has been dedicated to regulatory compliance and to prescription safety (risk vs benefits, drug screening, functional assessment).

Recently a colleague with a doctor of pharmacy degree (PharmD) has received his Drug Enforcement Agency (DEA) license, and is now part of our network and starting to see a few of the legacy, high-dose cases.

It is incumbent on all of us to stop the hysteria surrounding the opioid issue and educate all parties that we are short on manpower, and that we have no magic answers to reducing opioid dosage in patients who were prescribed, in good faith, high-dose opioids a few years ago. In contrast to past years, we now have good alternatives to opioids, and today rarely have to go above 500 mg of daily morphine equivalents to help our patients.

Best wishes always,

Forest Tennant, MD, DrPH

Historic Injury

I work for the Howard Hughes Corporation, and I am a pain management patient. I read Dr. Tennant’s article about my old boss from the July/August 2007 issue of PPM.3 I can’t tell you how delighted everyone in my company was to read your article. It gave us a new perspective on the man.

It is with this in mind that I am writing to ask your opinion on a historical figure who suffered an accidental gunshot wound during a military expedition in the early 19th century. Perhaps you can shed some light as to what nerve damage and/or chronic pain he suffered from his wound.

I will give you a brief synopsis: His ranking was captain, 1st US Regiment Infantry. He suffered a gunshot wound to his buttocks; the bullet was a .53 caliber round shot from an 1803 short rifle. He was shot from approximately  100 feet (40 paces) away. The entrance wound was an inch below the hip joint; the bullet tore through his left buttock and exited his right buttock. He was hunting elk when he got shot. The bullet did not hit any bones, arteries, or internal organs. The wound was described as a “very bad flesh wound, cutting the cheek of the right buttock for 3 inches in length and the depth of the ball,” and “the stroke was very severe.”

After a month of lying facedown in a boat without medication, he recovered, and appeared to walk and run normally. The shot is considered a low-velocity impact by today’s standard, like being stabbed in the backside with a dull sword. As you read this, please keep in mind the principal mode of transportation back then.

I will convey a few more details: He was embarrassed and would not talk about his wound afterward. At the time it happened, he referred to it as being shot in the “thye.” He could not even bring himself to use the word “backside.” Physically, he was in superb shape and was all muscle. Besides horseback riding, his duties called for him to sit for long periods of time.

I am sure you will figure out who he was, but what I am after is a disinterested third-party expert opinion. You might be able to reclassify him as a pseudoaddict, but at this point it can only be a footnote in his biography. His ending was not a happy one, and I think this gunshot wound carried a little more gravitas than people think.

I am aware of your busy schedule but I hope you will find the time to think about this man’s case. History has labeled him a drug addict with a “dark side,” and I think it may be unjustified.

Thank you so much for your kind attention.

Sharon Diamandis

Howard Hughes Corporation

Dear Sharon,

Thank you for your comments about Howard Hughes and your “mystery” man, who I believe was Meriwether Lewis of Lewis and Clark fame. Lewis sustained his gunshot wound while on his famous expedition in 1806. He died about 3 years later, in 1809.

The trauma and wound sustained by Lewis could well have affected him long after the bullet went through his buttocks. He undoubtedly suffered some nerve damage, and it’s possible that the nerves never totally healed and left him with what is now called neuropathic pain. Your description of the gunshot wound and depth would certainly be consistent with neurologic damage.

Did he suffer pain afterward, and did his pain cause him to resort to the use of alcohol and opium? This is quite possible. Keep in mind that the use of opium was widespread and acceptable in the 1800s. Also, I doubt that an officer of his caliber and pride would complain much about pain.

It has been difficult to get a good feel for pain treatment relief in the 1800s. Few, if any, records were kept. Family diaries and memoirs have been one of the best sources. Do you know if Lewis ever complained about chronic pain?

Lewis was found dead from multiple gunshot wounds while traveling the Natchez Trace near Nashville, Tennessee. To this day, it is unknown whether his death was the result of suicide or murder.

In summary, it is possible that the gunshot wound Lewis suffered in 1806 caused him chronic neuropathic pain, which led to alcohol and opium abuse, depression, and suicide.

One of my personal motivations to bring pain care to patients was my long-ago observation that severe chronic pain is intolerable, and the sufferer will often resort to alcohol and drug abuse to find relief. Good pain care prevents a lot of alcohol and drug abuse.

Forest Tennant, MD, DrPH

Calmare Therapy

I would like to know more information about a procedure called Calmare therapy or scrambler therapy. Is it safe for a patient who was diagnosed with arachnoiditis in February? The patient is my daughter who is 33 years old.

Louise Tidd

Galloway, NJ

The Calmare therapy is a new electric current therapy. It determines the frequency and voltage of your own electricity and designs an electric current that is bioidentical to your own. A good poster was presented at the American Pain Society meeting.4 At this time, the “scrambler” sounds promising. If you try it, be prepared to stop it if you have side effects.

Forest Tennant, MD, DrPH

Last updated on: August 5, 2016
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