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Intractable Pain

Protocols for a lifetime of pain management for patients suffering constant, incurable, excrutiating, unrelenting pain
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Hormone and Neurotransmitter Replacement

This emerging aspect of IP treatment is promising. Testosterone deficiency appears very prevalent in males and females, so serum testosterone concentration should be determined. Opioids may cause gonadal suppression, and it is possible that pain, per se, may contribute to hypogonadism.5 The authors routinely determine serum pregnenolone concentration, since it is the precursor of all sex and glucocortioids, as well as being a neurotransmitter. If it is low, pregnenolone supplements are administered. Gamma-Aminobutyric Acid (GABA) is a major neuroinhibitor in spinal cord and peripheral nerves. IP may deplete these neurotransmitters, so daily supplements are a safe, inexpensive adjunct that many patients anecdotally believe assist overall pain control. Research shows that IP over-stimulates the hypothalamus-pituitary-adrenal axis, which initially causes over-secretion of pituitary and adrenal hormones, but uncontrolled, chronic IP may also cause suppression of cortisol and other adrenal hormones which may require replacement for pain control, health maintenance, and proper immune function.6

The Drug-Abusing Patient

Unfortunately some drug addicts insinuate their way into IP treatment programs by feigning pain. Others may have some legitimate pain, but exaggerate complaints to obtain opioids and other drugs. These abusers reveal themselves by such behavior as requesting early medication refills, “losing” medication, selling or sharing medication, and non-compliance with program rules. Regardless of pain severity, a patient who abuses or diverts opioid drugs or fails to follow program rules cannot be managed for a lifetime in an IP program. The authors recommend that, once identified, individuals with abusive tendencies with opioids be referred to the local methadone maintenance program for daily narcotic administration. Once their addiction or abuse is stabilized by methadone maintenance, pain treatment measures may then be instituted.

Clinic Setting for Lifetime IP Treatment

The challenge to pain practitioners is to establish outpatient, clinical settings which can provide lifetime medical management of IP. Proper treatment over the lifetime of the patient will require a number of different interventions, including medication, physical therapy, psychologic support, spiritual awareness, and palliative care.7 Table 4 summarizes the dimensions of care required for successful lifetime management of IP.

Elements of Lifetime IP Treatment
  • Monthly, out-patient visit
  • Opioid therapy for baseline and breakthrough pain and emergency flares
  • Stretching and strengthening exercises
  • Prostheses for musculo-skeletal degeneration
  • Topical analgesics
  • Hormone and neurotransmitter replacement
  • Family, social, and spiritual support
  • Patient self-help group
  • Out-of-home vocation or hobby activities
  • Weight control

Table 4.

IP clinical treatment sites should be in the community where the patient resides so that patients can avail themselves of community resources. IP patients should be encouraged to join a self-help support group or, if not locally available, form their own group. Although technical, sophisticated medication and therapies are essential for IP treatment, the most important element of IP treatment is continuity of care for a lifetime.

Last updated on: August 10, 2017
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