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10 Articles in Volume 17, Issue #8
A Fresh Look at Opioid Antagonists in Chronic Pain Management
Addressing Chronic Pain in the United States Armed Forces
Are biosimilars as effective as their biologic counterparts?
Integrative Pain Care: When and How to Prescribe?
Lady Gaga, Fame, and Fibromyalgia
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients.
Must-Have Devices for Your Pain Practice
Obsessive-Compulsive Disorder & Chronic Pain
Theory of Motivated Information Management and Coping With Death
United Nations Says Untreated Pain Is “Inhumane and Cruel”

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

I greatly appreciated the article “Justification of morphine equivalent opioid dosage above 90 mg”,1 given so many patients who are trying to cope with long-term and severe intractable pain.1 The justification protocol and the list of nine major diagnoses resonated with what I’ve experienced in my practice. The inclusion of genetic factors, complications, and the value of second opinions was well stated by the authors.

Letters to the Editor

However, two elements took away from the strength of the content when I shared the article with colleagues. All agreed that the editor’s disclaimer, “This is not PPM’s opinion nor have any studies been carried out to evaluate the risks to patients, and further investigation is warranted”, has appeared at the end of articles for future study and thrown out to the general scientific community for further scrutiny, which seemed inappropriate here.

Second, we all felt that the picture of the young woman could have been better chosen. Most of us guessed her to be under 20 years of age, looking despondent with hair flaring wildly, which did not properly represent someone in horrible, chronic intractable pain. 

I appreciate the opportunity to share some observations of an otherwise educational and worthy article in a fine journal.

Robert P. Skinner, PA

Pomona, California 

Dear Mr. Skinner,

As both the editor-in-chief and the author of the article, “Justification for Morphine Equivalent Dose (MED),”1 I welcome your keen observations with a bit of humility. While I did not have a hand in selecting the image for the article, I did approve the final layout, and I must admit that I did not pay sufficient attention to the picture, or to the editor’s disclaimer for that matter.

With regard to the disclaimer, you are quite right to point out that the article had nothing to do with evaluating risks to patients or studies that might pose a risk to participants. This paper was simply an overview of our group’s methodology for assessing which patients we believe warranted a MED of more than 80 to 90 mg daily.2

As for the lead image, it is quite evident that the young woman pictured was an inappropriate representation of this patient population since, as you indicated, most patients with intractable pain who require over 80-90 MED are past middle age and usually become alert, functional, and healthy when their MED is elevated to an effective level to meet their individual need.

Even more importantly, your point touches on a matter of greater concern. The media and the anti-opioid constituency have given the American public the mistaken idea that any pain patient who requires high-dose opioids is likely to be sedated and at high risk for overdose. I welcome the opportunity to refute this ill-conceived notion as there are a number of factors, including genetics, tolerance, and severity of the underlying cause of pain, among others that mitigate against a pain patient who requires more than 90 MED but for those who do require high-dose opioids, their need is real and a steady dosage over years has allowed them to regain their function without which they would face an unfavorable quality of life.1

Thank for your attentiveness to articles published in Practical Pain Management.

Forest Tennant MD, DrPH

Depressed Testosterone

A 53-year-old man came to me seeking pain relief. As I am looking to provide this patient with the most effective therapy, I would welcome your insights as assurance that my approach is reasonable.

As part of this patient’s examination, I obtained the following test results:

  • Pregnenolone: 46 ng/dL
  • Dehydroepiandrosterone sulfate (DHEA-S): 38 µmol/L  
  • Free Testosterone: 52.7 ng/dL
  • Estradiol-2: < 50 pg/ml  
  • Luteinizing hormone (LH) 1.5 mIU/ml
  • FSH 2.5 mIU/ml  
  • Human chorionic gonadotropin hormone (hCG): < 2 mIU/L
  • Cortisol 11.7 mcg/dL
  • Adrenocorticotropic hormone (ACTH): 11 pg/ml
  • Free Thyroxin 4 (FT4): 1.1 ng/dl
  • Total T3-triiodiothyronine (T3): 77 ng/dl

These tests were all done while the patient was fasting as an early morning draw. My assessment of these results is that the patient is experiencing testicular suppression with normal HPA/HPG and normal adrenals. However, the DHEA-S is elevated but it is not five times greater than normal, so I am wondering if this is due to the low free testosterone given that the ACTH is low normal, cortisol is in the mid-normal range, and LH is slightly low. Our lab doesn’t provide a total testosterone level when the numbers are low, defaulting instead to free testosterone. Would you concur with my evaluation?

Thank you for sharing your insights in support of my desire to learn more about managing patients with chronic pain challenges.

Darrel J. Brown, FNP-C

San Rafael, California 

Dear Mr. Brown,

I agree with your conclusions that this patient appears to present with testicular suppression, in which case I would agree with your recommendation to provide testosterone replenishment.

I understand your reticence to proceed without obtaining input on your pain management plan, as most pain practitioners do not consider ordering hormone blood tests given a lack of knowledge on interpreting and acting on the results. Let me offer you some reassurance that reviewing this patient’s hormones was a good step toward providing the best pain strategy.

As pain practitioners, we are not looking to practice endocrinology or take risks, as we are not replacing hormones. Rather, we may respond to depressed hormone levels by providing low- dose replenishment. There is a difference. Hormone replacement, as practiced by an endocrinologist, is substituting hormones due to a diseased or nonproducing gland, whereas in pain practice, we are supplementing a hormone that is suppressed by chronic pain and/or the medications the patient is taking to control pain.

Your query affords me the opportunity to encourage all pain practitioners to consider prescribing hormones in low dosages. The reason stems from our understanding that opioid receptors are stimulated by testosterone. In the case of low serum pregnenolone, estradiol, progesterone, DHEA, and cortisol, we want to replenish any of these hormones so as to suppress neuroinflammation and reduce fatigue and depression. The goal in regulating hormones in pain medicine is to restore enough hormone to ensure that the pain medications are able to deliver maximal analgesic effect. As a basic protocol, I recommend replenishing any hormones that appear low for only 3 days a week to start. If the patient wants to try more, the prescription can be raised to five days a week. Since we are only replenishing deficient hormones, this can be safely stopped and restarted, using intermittent administration as needed.

Most of my chronic pain patients who have been receiving hormone replenishment routinely report they do better in many ways, including lesser need for opioids.

Forest Tennant, MD, DrPH

Proper Opioid Tapering

I am grateful for your recent article on proper opioid tapering.3 Many of my colleagues admit to having little understanding regarding the best approach (ie, who or when) to taper patients off opioids.

 The Centers for Disease Control and Prevention apparently is now estimating that 25% of patients on chronic opioid analgesic therapy (COAT) have an opioid use disorder. In a review paper I wrote, the estimate I found was closer to 20%.4 Statistics aside, I expect you will agree that it is important to assess each patient against the criteria for an opioid use disorder (OUD) prior to introducing the need to taper their opioids. As you indicated, many of our colleagues are unfamiliar with these criteria and think that an assessment of opioid use is pertinent only for patients with a history of criminal or other sociopathic behavior. In my view, no pain practitioner should remain uninformed, and at the very least, patients can be referred for a formal evaluation by any practitioner who feels uncertain about the process. I say this because the risks of taking someone off of agonist therapy who has a confirmed OUD are well documented and rather striking. Yet laws are being issued in Washington, DC, that make the main goal of OUD treatment one of abstinence.

   I’ve been wondering if diversion therapy poses a greater risk for patients who are properly being monitored and treated for an OUD than a patient on high-dose COAT therapy? I suspect that the patient who has an OUD is much more likely to protect their “supply,” and given the current climate surrounding use of opioids, all patients with chronic pain regardless of diagnosis may be pushed to stockpile their analgesia given financial and regulatory concerns. It also has been my experience that another risk factor for diversion—codependence—is also quite common in patients with chronic pain as well as those patients with substance use disorders (SUD); and who can blame them?!

While we well know of the challenges required in managing patients with SUDs and severe or prolonged pain conditions, I have found that when these patients are provided proper structure and support, as well as a modicum of respect, the outcomes are quite rewarding and outpatient care effective. I would add that in most other “civilized” countries, a general practitioner manages these issues quite fine without interference from the Drug Enforcement Agency, and without the rate of overdoses, diversion, and other complications so apparent in the United States. Finally, I argue that the major consequences associated with opioid prescribing are largely culturally induced. 

 To enhance the competency for assessing and managing OUD, pain practitioners would benefit from a formal workshop or presentation on this topic. In addition, it seems we must begin to better inform our lawmakers about the best practices for managing pain patients. How might we jump-start these needed actions?

J. Kimber Rotchford, MD, MPH

Port Townsend, Washington

Dear Dr. Rotchford,

Your perspective on the challenges we are facing is very accurate. Opioid-maintained patients who have indicated a proclivity to use opioids other than prescribed should raise a red flag to their pain practitioner; the best course of action is to see these patients frequently and to lower their dosages very slowly.

For practitioners who remain cautious or uncertain, I offer my old standard method for knowing whether the opioid dosage is too high, too low, or whether a taper is going too fast—check the patient’s pupils and pulse. Uncontrolled pain and opioid withdrawal both stimulate the autonomic nervous system. When over-stimulated, the pupils will dilate to over about 5.0 mm in diameter and the pulse rate will rise to over 100 beats per minute. Other less objective physical signs may also occur including diaphoresis, piloerection, and hypertension. It’s a safe bet that simply by monitoring pupil size and pulse rate, any clinician will be able to assess when the patient is getting the right opioid dose to adequately manage their pain.

In fact, I have begun to send my patients home with finger pulsometers and instructions to check their pulse at least twice a day and to keep the pulse rate above 64 but under 100 beats a minute.

In my opinion, practitioners have begun to rely too much on pain scores and the patient’s verbal responses, rather than utilizing simple, objective measures of autonomic function to adjust opioid dosages, including dosages during a tapering program.

I welcome and support your efforts to inform insurance companies of the limitations of basing opioid abuse risk by information on claims (ie, # of Rxs filled), which prohibits patient with legitimate pain conditions from receiving proper pain treatment. It has become evident that some insurers prefer to place profits ahead of safety and humanitarian relief.  We physicians, as distasteful as it may be, must be ready to “say no” to legislators and insurers, for the welfare and safety of our pain patients.

Keep up your good work.

Forest Tennant, MD, DrPH

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