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12 Articles in Volume 12, Issue #4
Causes of Postoperative Pain Following Inguinal Hernia Repair: What the Literature Shows
Persistent Postsurgical Pain
Managing Adverse Drug Effects in Pain: Focus on Triptans and NSAIDs
Nonsurgical Treatments for Ankle Arthritis
Opioid Disposal: Dos and Don’ts
Survey Shows More Education About Fibromyalgia Needed Among Healthcare Providers
Anxiety in a Headache Patient: Case Challenge
“Centralized Pain”: A New Consensus Phrase
Tooth Loss in the Chronic Pain Population
When Prescribed Opioids Go Unused
May 2012 Pain Research Updates
May 2012 Letters to the Editor

May 2012 Letters to the Editor

Bilateral Oophorectomy, Replacing Stimulants in Pain Treatment, and High-tech Scams

Pain and Bilateral Oophectomy

Dear Dr. Tennant,
I am writing to inquire about the relationship of chronic pain with bilateral oophorectomy. My patient is a 44-year-old white female who is experiencing uncontrolled joint pain since having a hysterectomy and bilateral oophorectomy. If that is the case, what do you suggest regarding hormone replacement?

Thank you.
—Azza Kenawy, MD
West Chester, Pennsylvania

Dear Dr. Kenawy,
Your patient, who had a bilateral oophorectomy and later developed uncontrolled joint pain, is an example of a patient who has heretofore been a mystery. Also, astute observers have often seen women develop worse pain following menopause. I suspect you are correct when you believe that her pain is related to a lowering of some serum hormone resulting from gonadal tissue loss.

One thing is abundantly clear: some hormones are pain protective and a deficiency results in pain. I recommend
your patients have their progesterone, pregnenolone, cortisol, and testosterone levels tested. Simply order an early morning, non-fasting blood specimen at your local lab. Testing results will help target therapy.

The most likely causative hormone for her increased pain is progesterone. My first encounter with progesterone’s pain relief occurred a few years ago when I visited a nurse practitioner and her pharmacist husband near Indio, California. They were successfully treating farm workers who had arthritis, particularly of the knee, with topical progesterone.

Several animal studies document progesterone’s pain protection and neurogenic effects.1-3 In addition to peripheral targets, progesterone has receptors in the central nervous system. Soldiers with pain who have returned from Iraq and Afghanistan show low levels of the progesterone metabolite allopregnanolone.4 I just presented my preliminary investigation with the use of progesterone in patients who have severe centralized pain. These were patients who had various peripheral pain conditions and required opioids. The majority of patients reduced their pain and opioid dosages when given the progestin medroxyprogesterone, either in topical or oral form.5,6

Progesterone, besides having its own neurogenic and pain-protective effects, metabolizes to dehydroepiandrosterone (DHEA), estrogen, and testosterone. These properties make it a prime, safe choice, particularly when used topically. My progesterone therapy is simple: I use the inexpensive and widely available progestin medroxyprogesterone, which metabolizes to plain progesterone.

In topical form, I mix 20 to 30 mg in 1 oz of a cream base. Patients can use it for pain flares or on a regular basis such as before bedtime. Orally, I start with 10 mg twice per day and work up to as much as 50 mg per day. I use it in men and women. If I don’t get a response within 60 days, I stop the treatment. The only side effect I’ve seen is menstrual bleeding in premenopausal women.

Besides progesterone, it may be that your patient would respond to any one of these hormones: pregnenolone,
testosterone, DHEA, or human chorionic gonadotropin (HCG). Pregnenolone has its own pain-protective effects and receptors throughout the body. It also metabolizes to progesterone and testosterone. HCG stimulates production of progesterone, estrogen, thyroid, and testosterone.

It is my early observation that some adjunctive hormone therapies will allow us to minimize the use of drugs prone to side effects and toxicity including the opioids and neuropathic agents. Also, I believe the early use of hormones such as progesterone may prevent the centralization of peripheral pain.

If you find some hormonal success with your patient, please share your experience.

Best wishes,
Forest Tennant, MD, DrPH

Replacing Stimulants in Pain Treatment

Dear Dr. Tennant,
I was impressed with your article on stimulants and opioids.7 This is frowned upon by the medical community, but I must admit, it makes a lot of sense. Many of my chronic pain patients (I am a human immunodeficiency virus specialist, too) have gained a lot of weight, have sleep apnea, are developing diabetes and hypertension from being overweight, have lower testosterone from obesity, and are not able to work out.

Stimulants would help them lose weight, get rid of the apnea, hypertension, and diabetes, I presume, based on your article. Stimulants would also help with reducing the opioid dose, perhaps?

My question, besides the amphetamines (I understand that the norepinephrine hormone is key. Is that right?), are there other medications that would have a similar effect (ie, venlafaxine [Effexor], a norepinephrine reuptake inhibitor, duloxetine [Cymbalta], which hasn’t had that great a track record with my patients, milnacipran [Savella])? Do they even come close to being as effective as the stimulants? Do you have any other suggestions for these metabolic syndrome patients who basically have become that way due to the opioids and inactivity? Do testosterone shots increase the weight gain? Is there any benefit from caffeine, gingko, or thyroid hormone?

(I think these may disrupt the pituitary axis, more than help, but I’m not sure.)

You seem to have a lot of experience. I need some wisdom and knowledge.

—Robert Shankerman, MD
Chief Medical Officer
Clinica Sierra Vista
Bakersfield, California

Dear Dr. Shankerman,
The simultaneous use of stimulants and opioids dates back to the 1890s when physicians at the Royal Brompton Hospital in London believed that opioids without stimulants were less effective.8 Only later did hard science support the concomitant use of stimulants and opioids when double-blind clinical trials in humans showed heightened analgesia when the two were combined. 9 Also, animal studies show that endogenous opioids and amphetamines operate independently to provide enhanced analgesia.10

You well describe why stimulants make a lot of sense. In early historical writings, there is mention that stimulants may counter the sedative effects of opioids.11 The problem with stimulants is that the ones that best potentiate analgesia and neutralize opioid side effects are abusable; they are amphetamine, dextroamphetamine, methamphetamine, and methylphenidate. In my experience, old-fashioned dextroamphetamine best minimizes opioid complications while enhancing analgesia. Given the potential abuse problem with stimulants that truly potentiate analgesia and reduce opioid complications, they can only be given to very trustworthy patients who are being monitored quite closely. Given the abuse potential of many stimulants, a number of compounds have been tried to substitute for the “real McCoy.” They usually fall short, however, in providing long-term stimulant activity.

Fundamentally, the drugs for depression, narcolepsy, and attention deficit disorder are all designed to enhance dopamine and norepinephrine activity. The new opioid, tapentadol (Nucynta) has norepinephrine activity. It may truly combine opioid and stimulant activity. Caffeine and the classic weight control stimulants phentermine and phendimetrazine are stimulants with dopamine-norepinephrine activity and they provide mild analgesia and potentiation of opioids. I personally like to use phentermine and phendimetrazine in obese pain patients.

Thank you for having the fortitude to describe the very common multi-problem pain patient that we physicians have to deal with on a daily basis. The vocal critics of our various pain treatments—be it opioids, interventions, electromagnetic measures, or nutrition—fail to realize that these common multi-problem pain patients need all the tools we can muster, including stimulants.

Best wishes always,
—Forest Tennant, MD, DrPH


Duping Pain Doctors with High-tech Scams

Dear Dr. Tennant,
I am concerned regarding how we physicians are being fooled by many electronic medical records (EMR) systems that state we can use e-scripts for controlled substances when, in fact, it is only accessible to physicians in Texas, California, Maryland, and Virginia.

I was falsely led to believe (as I am sure other interventional pain doctors were) by our EMR system provider that if we paid $1,000, we would be able to get e-scripts and stop using our prescription pads.

The fact of the matter is that when I researched this, there is considerable misunderstanding and finger pointing as to why this e-script is not truly ready for pain doctors.

From what I gathered in speaking to the head attorney at the Board of Pharmacy in Charleston, West Virginia, is that e-scripts are under the domain of the Drug Enforcement Administration (DEA) and the company that my EMR system provider uses has, in fact, complied with the DEA requirements for doing online controlled substances.

The problem is that pharmacies like Walgreens, CVS, and others are not getting involved with controlled substances and I could not get a straight answer from the head attorney in West Virginia.

Do you have any insight into this problem for the other 46 states whose pain doctors are unable to prescribe narcotics with e-scripts?

Thanks for your attention.
—Roland F. Chalifoux, Jr, DO
Wheeling, West Virginia

Dear Dr. Chalifoux,
There are truckloads of companies selling some high-tech deal that is supposedly going to save a practicing pain doctor time and money and, in the process, somehow improve “quality of care.”

While you were duped about the “not-yet-ready” e-script deal, just about all of us, including yours truly, have been duped in recent years by a company that’s hawking a high-tech product. Here’s a partial list of other such scams: copy machines, faxes, telephones, credit card terminals, EMR, computerized billing, accounting, and personnel software. More than one doctor has been suckered into a high-tech heat and air conditioning or security system that never seems to work.
Addressing your situation, simply know that the use of computerized Internet prescriptions for controlled substances just isn’t ready. Controlled drugs are a federal issue and until the federal government and all the states agree on a single system, I say keep writing by hand.

Here’s a fact you should know: the computer and Internet industry was the seventh biggest lobbying spender among all industries and special interest areas in Washington, DC, in 2010.12 All the calls for EMR, computerized billing systems, and prescription services, etc, have a political back drop of private companies and government agencies that encourage or coerce physicians to expend money on unneeded high-tech deals.

Be careful. We all know that reimbursement rates will likely go down, not up. Our so-called recession recovery is fragile at best. Don’t spend money on high-tech stuff at this time unless you really can count more dollars coming in than you will spend on some new-fangled idea.*

My last thought is this: a physician in practice is a small business. We have all the regulatory, political, and personnel haggles applicable to a retail store. I highly recommend that pain practitioners join their local Chamber of Commerce, Better Business Bureau, and the National Federation of Independent Business. We need to admit to ourselves that we are small businesses that big government, big industry, and big everybody else believes are there for easy picking. Maybe we were rolling in dough in the distant past, but not now. All of us have been taken. Let’s get as good at protecting our shrinking dollars as we are at pain care.

—Forest Tennant, MD, DrPH

*Editor's Note: The federal government passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, which will make available $27 billion in incentive payments over 10 years for clinicians and hospitals who use EMR to improve delivery of patient care. Through Medicare, that equals up to $44,000 per clinician (or up to $63,750 per clinician through Medicaid).
Last updated on: June 19, 2012
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