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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.
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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). 

Last updated on: September 27, 2017
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