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10 Articles in Volume 17, Issue #7
Abuse-Deterrent Opioids: Why Rush to Judgment?
Alcohol Screen Recommended to Reduce Opioid-Induced Respiratory Depression Overdose
Ehlers-Danlos Syndrome: An Emerging Challenge for Pain Management
Guide to Laboratory Testing in Patients With Suspected Rheumatic Disease
Letters to the Editor: Arachnoiditis, Hormone Testing, Ehlers-Danlos Syndrome
Neurocognitive Disorders: Pain Expression in the Face of Mental Deficits
Preemptive and Preventive Analgesia for Chronic Postsurgical Pain
The Effects of Religion and Spirituality on Coping Efficacy for Death and Dying
Topical Nonsteroidal Anti-inflammatory Drugs and Nephrotoxicity: Is There a Safer Option?
Transformative Care for Chronic Pain and Addiction

Letters to the Editor: Arachnoiditis, Hormone Testing, Ehlers-Danlos Syndrome

An opportunity to learn what is on the minds of your colleagues and patients.

Need Reimbursement for Hormone Testing

In the last issue of Practical Pain Management, you recommended documentation for justification of morphine milligram equivalents (MME) over 90.1 In my experience, the genetic and functional hormone testing you recommend is either not readily available in the area where I practice or may not be covered by the patient’s insurance. In fact, I have had difficulty getting reimbursement for these tests. 

Has coverage determination changed? If not, how can we be expected to include evidence that is simply not, as a practical matter, available? 

Are there any clinical surrogates, such as close follow-up and serial observation during titration and over time that is acceptable? I use periodic serum levels in patients taking higher doses of long-acting opioid medications to correlate analgesic effect and to monitor for impairment.

Mitchel L. Galishoff, MD
Valley Medical & Surgical Clinic, PC
Valley, Alabama

Dear Dr. Galishoff,

First, I want to commend you for the selection and appropriate use of the clinical surrogates you shared.

Second, as for the questions that you raised about the utility of relying on results from genetic and functional hormone tests to guide your pain planning in patients with intractable pain and other chronic pain conditions, I have also experienced similar limitations in gaining insurer reimbursement when ordering these critical tests for my chronic pain patients. 

In order to continue ordering these tests to monitor patients with intractable pain,  I have negotiated a cash fee of $400-500 for a 16-panel genetic test with a private laboratory. For patients who want to continue at a higher-than-90 MME dose, at present, they will likely face some out-of-pocket costs.

The point you raise about the need for established (consensus) guidelines for high-dose opioid prescribing is not just a problem for you or me but extends to all pain practitioners; in fact, the impact has nationwide consequences. It was more than 18 months ago that the Centers for Disease Control and Prevention guidelines were published.2

At present, most states have also established a guideline for opioid prescribing. I can find lots of ceiling levels to stay under and tapering guidelines, but not a single government agency, including the Centers for Medicare & Medicaid, state medical board, professional organization, or insurer has proposed clinical criteria or offered recommendations for proper opioid prescribing when exceeding a 90 MME dosage. In the meantime, physicians like us who are treating patients daily for chronic pain will need to continue to share our experiences as to which patients remain on opioid levels above 90 MME and why. 

More importantly, we must take an active role in informing all concerned parties (ie, legislators, government leaders, patients, health care providers, and insurers) that some patients—particularly those with intractable pain or a chronic pain condition for which they have been well managed for many years—legitimately need more than 90 MME dose of opioids, and that the benefit of treatment far outweighs the risks of uncontrolled pain.

Forest Tennant, MD, DrPH

Readers ask Practical Pain Management about arachnoiditits, hormone testing, Ehlers-Danlos Syndrome.

Treating Adhesive Arachnoiditis

My sister was diagnosed with adhesive arachnoiditis nearly 20 years ago and now is essentially bedridden. Occasionally, we will attempt to move her to a wheelchair or encourage her to use a walker, but she finds these efforts too painful. As it is, she requires multiple doses of opioids daily, including intrathecal administration, in order to achieve some relief from the intractable pain. Even so, any lessening of her pain is minimal even with these treatments. 

Recently, I read an article in Practical Pain Management that mentioned using a combination of pentoxifylline and vitamin E to dissolve fibrotic scars and adhesions in patients who have adhesive arachnoiditis when given over a period of several months.3 Since we feel we have done everything possible to help her find better pain relief, I can’t help but wonder if it might possible for this treatment [of pentoxifylline and vitamin E] to give her more control over the pain.

Also, she lives in Wichita Falls, Texas, where finding a pain specialist for this type of condition is rare, so I wonder if this regimen is worth trying. Perhaps her primary care provider could be persuaded to follow the protocol since she really has nothing to lose and no other options.

    Dru Edrinton

Dear Dru,

Until now, an accurate diagnosis of adhesive arachnoiditis (AA) has been all but elusive. Unfortunately, the circumstances facing your sister are not so unusual. In fact, there are countless individuals who are in severe pain and confined to a bed, wheelchair, walker, or couch, unknowingly due to the pain and limitations that develop in patients who have arachnoiditis. 

Arachnoiditis is an inflammatory disorder of the spinal canal lining and nerve roots of the cauda equina that may stay active for a lifetime. Since she has had the disease for a while, she should be afforded every chance to lessen her pain, which need not be limited to symptomatic opioids.

For the treatment of AA In my practice, we recommend neuroinflammatory agents and an intermittent low-dose corticosteroid (dexamethasone or methylprednisolone). 

 Unfortunately, there isn’t an easy answer for the use of a combination of pentoxifylline and vitamin E in late-stage disease. The treatment appears safe and may be recommended for a 6- to 8-week trial. In fact, the protocols that have been developed can be done by any physician, so you might discuss all the options to assess which may be best for your sister. There are a few patient case studies in Practical Pain Management that you might share with your sister’s doctor to gain further insights about effective pain management approaches, which be elucidating. These patient cases can be found at AA Patient Case Studies.

 Forest Tennant, MD, DrPH

Treating for Ehlers-Danlos Syndrome

I am a primary care physician who wishes to find a better treatment for a patient with Ehlers-Danlos Syndrome (EDS). In particular, I would be interested in hearing your thoughts and/or experience with regard to the use of oxytocin for pain in these patients.

Andrew Fedorowicz, MD
Semper Healthcare
Denver, Colorado

Dear Dr. Fedorowicz,

Your inquiry about the appropriate use of oxytocin for EDS is most timely as it is the focus of this month's Editor's Memo. EDS is a progressive, degenerative connective tissue disorder that causes microtears in multiple organs. It is common to see EDS patients entering their teens or twenties who then develop severe pain. 

I believe we have finally arrived at a point where we have sufficient understanding of the underlying pathology of EDS to treat it with a more informed approach. Oxytocin appears to work on neurons in and around the spinal cord-brain region, making it an effective nonopioid therapy, which should be adopted more readily and more widely used.

To date, I have found oxytocin to be quite effective in relieving pain in patients with EDS. In addition, oxytocin may confer a neuroprotective effect given its antineuroinflammatory properties. If you decide to prescribe oxytocin for your current EDS patient, I suggest a starting dose of 20 units given sublingually. Typically, the concentration I titrate up to is 40 units per milliliter. If necessary, the dosage can be increased up to about 80 units safely, and it can be given as often as every 4 to 6 hours. 

Another therapeutic approach that has been beneficial in my clinic is the use of human chorionic gonadotropin, human growth hormone, and nandrolones in some EDS patients. The purpose of these hormones is to not only inhibit deterioration but, hopefully, to provide regeneration of some tissues.

Forest Tennant, MD, DrPH

Testosterone and Arachnoiditis

I am a primary care provider who just started to see a patient with a recent diagnosis of has been diagnosed with AA. When testing her hormone levels, the testosterone fell in the normal to a slightly low range. Might I consider providing supplemental hormone therapy in order to improve her response to pain management? If not yet, at what point would it be most appropriate to begin hormone treatment in the kind of patient?

Deirdre Donovan, MD
Downtown Family Healthcare
Charlottesville, Virginia

Dear Dr. Donovan,

I have been observing a great deal of interest in and confusion about the use of hormone testing and supplementation to improve pain management.

There are fundamentally 2 forms of hormone treatment:

  1. Hormone replenishment as indicated by serum levels
  2. Hormonal stimulation of tissue regeneration

The relevance of restoring serum testosterone levels to the recommended levels to gain optimal pain control is still poorly appreciated. Testosterone aids central nervous system receptor activity helps control neuroinflammation and has an anabolic effect on central and peripheral nerve tissue. 

Any pain patient who presents with a low serum testosterone will usually complain of poor pain control and little effectiveness or relief from taking analgesic medication. Other common symptoms of low testosterone in a pain patient are fatigue, lack of energy, and excessive pain flares.

Now the good news—clinical experience in treating arachnoiditis is starting to accumulate, and clinical observations are supporting the beneficial effects of testosterone. Other hormones that operate within the spinal canal may promote positive nerve plasticity and possibly foster the healing of the arachnoid lining.

While the only information you shared about this patient is that she has AA and possibly has a slightly lower than desirable testosterone level, there would be no downside in attempting to replenish this hormone to restore serum levels to normal and to see if this therapy improves her response to pain therapy.

 Forest Tennant, MD, DrPH


Last updated on: September 27, 2017
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