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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.

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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.

Last updated on: October 17, 2017
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Are biosimilars as effective as their biologic counterparts?