Access to the PPM Journal and newsletters is FREE for clinicians.
15 Articles in Volume 19, Issue #3
Analgesics of the Future: The Potential of the Endocannabinoid System
Buprenorphine: A Promising Yet Overlooked Tool
Chronic Pain and the Psychological Stages of Grief
Could a Personalized Approach to Therapy End the War on Pain?
Finally, A Systematic Classification of Pain (the ICD-11)
Hormone Therapy for Chronic Pain
How to Communicate with a Medical Marijuana Dispensary
Letters: Opioid Conversions; Scrambler Therapy for CRPS
MSK Pain: Time for an Enhanced Assessment Model
National Drug Use & Abuse Trends: Prescribed and Illicit
Neuroplasticity and the Potential to Change Pain Response
Should Emergency Naloxone Be in Schools?
Talking to Patients about Medical Cannabis
Utility of Pulsed Radiofrequency Ablation in Xiphodynia
When Opioid Prescriptions Are Denied

Letters: Opioid Conversions; Scrambler Therapy for CRPS

April/May 2019 PPM Letters to the Editor from practitioner peers and patients.
Page 13

Conversion Conundrum: Morphine to Methadone

Dear PPM,

While using your online opioid calculator, I converted 120 mg of morphine to methadone 18.6 mg. However, when I converted 90 mg of morphine to methadone, it reported 19.2 mg. Each time I chose no modification for incomplete tolerance. How can 90 mg of morphine convert to more methadone than 120 mg of morphine?

–E. Jay Fleming


Dear Mr. Fleming,

This is an excellent and very important question.The answer is simple, but the explanation is pharmcokinetically and mathematically complex.

In short, the higher the dose of morphine (or equivalent), the lower the dose of methadone is needed to replace it. This is a pharmacokinetic enigma and part of the reason why there are so many dosing errors, and even deaths when transitioning from full agonist opioids over to methadone. It also is further justification for a slow titration down from the parent drug (in this case, morphine) with a gradual increase of methadone.

I developed an equation several years ago that captures the conversion mathematically, but as you can see, it is quite complex. This is the equation utilized by the PPM Online Opioid Conversion Calculator. It is called the Methadone Fudin Factor and appears above. To learn more about the pharmacokinetic and mathematical detail, please refer to the paper: “Mathematical Model for Methadone Conversion Examined” in the PPM September 2012 issue.

–Jeffrey Fudin, PharmD

Scrambler Therapy for Complex Regional Pain Syndrome (CRPS)

Dear PPM,


The complex regional pain syndrome (CRPS) article by Don Goldenberg, MD, in the March issue (“Complex Chronic Pain Disorders”) was great until I saw the solutions offered for CRPS. It left me and others wanting more. I have personally seen hundreds of CRPS patients get significant pain relief with Calmare Pain Therapy,* a type of Scrambler Therapy.


This non-pharmacological, non-invasive neuromodulation approach has virtually no side effects. While I realize the medical community would like large, double-blind studies to validate this claim, the antidotal evidence (including from major hospitals and medical centers across the US) cannot be ignored in view of how horrific this disease is and how many patients have taken their own lives because they were without hope of ever getting pain relief. The status quo is not acceptable.

The medical community continues to fall short in treating chronic pain with very few options available. My observation is that the chiropractic community is ahead of the general medical community in treating chronic pain effectively. It is time to wake up and consider other alternatives.

It is time for value-based medicine. What is really working out there? There is too much focus on studies and not enough focus on what is actually working in practice. Large double-blind studies are producing few effective solutions, leaving best practice at prescribing anticonvulsants with 20% efficacy and a range of known side effects. This is no longer acceptable to anyone but the pharma companies.

I apologize if my tone is too candid but I see this situation first-hand every week and something needs to change. Too many lives are being lost or ruined with the current medical practice of treating  (more accurately, not treating) chronic pain. Thank you for considering my point of view.  

–T. Kocherhans
Author is
affiliated with InterWest Pain Solutions, LLC, which distributes Calmare.

Last updated on: May 3, 2019
Continue Reading:
Letters: The Word "Catastrophizing;" AIPM Ceases Operations; Patient Questions
close X