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10 Articles in Volume 13, Issue #10
Poor Adherence to Opioid Pain Management Regimens
A Practical Approach to Discontinuing NSAID Therapy Prior to a Procedure
Opioid-induced Osteoporosis: Assessing Causes and Treatments
Persistent Acute Lower Back Pain: The Importance of Psychosocial Evaluation
Research Advance Of The Year
A Day of Consulting in Rural America
Ask the Expert: Should You Test For and Treat Opioid-induced Hypogonadism?
Ask the Expert: Do NSAIDs Cause More Deaths Than Opioids?
News Briefs
Letters to the Editor

A Day of Consulting in Rural America

Due to a lack of pain specialists, primary care physicians in rural areas are being asked to manage increasingly complex pain patients.

America’s growing shortage of pain specialists, and now primary care physicians, is affecting the availability of pain treatment in many rural communities. This has become true in one rural community in Chino Valley, Arizona, approximately 90 miles northwest of Phoenix, where the primary care physicians are being tasked to become experts in chronic pain management.

At the invitation of these physicians, I travelled from Los Angeles County to this community to query, observe, examine, and advise on their problematic chronic pain cases. It didn’t take much persuasion to get me to undertake this task of hands-on, face-to-face consulting in a rural clinic. Why? I wanted to see for myself if my suspicion was correct—that primary care physicians are being forced to manage some severe, complex pain patients with little or no help from pain specialists and academic centers. I also wanted to know if some in-clinic, on-site training should be done to facilitate pain treatment in the primary care setting.

In this article I describe the problematic pain cases I evaluated, along with my analysis and primary recommendations. Hopefully, these assessments will help others who may have similar cases. I also summarize some of my personal observations to describe the plight of primary care physicians who must now shoulder the majority of medical management of some very severe, complex chronic pain patients.

Chino Valley Medical Center

Chino Valley, Arizona, is a town of about 20,000 people located about 15 miles north of Prescott. The primary industry in town is agriculture. Like in many Arizona towns, there has been a large influx of retirees from other states who have settled in the area in recent years. The Chino Valley Medical Center is essentially the only healthcare provider in the community (Figure 1). Seven primary care physicians and a nurse practitioner attend the clinic. Some of the physicians have retired to the area and work part-time. Because the center is “everything” and the “only thing” for medical care in this rural community, all ages, clinical problems, and third-party payment plans are accepted. No patient is turned away because they do not have anywhere else to go.

The physicians in this center had become very frustrated with a few of their chronic pain patients, who had seen pain specialists in Arizona, Nevada, and California. These referrals usually resulted in an interventional procedure such as an epidural injection being performed, with the patient being returned to the clinic for medical follow-up. The physicians in Chino Valley voiced no problem with the average chronic pain patient who had run-of-the-mill, mild to moderate pain from arthritis or neuropathies but wanted help in assessing and managing many of these intractable cases.

Troublesome Cases

On August 1, 2013, I saw 8 patients with chronic conditions that required sophisticated pain management. I will briefly describe the patients’ medical history and current pain management regimens. The intent of this article is not to detail dosages and any extraordinary findings as in the usual case report but to portray these patients as having a specific problem that is typical of the problematic, chronic cases now seen in primary care. I make no claims that my recommendations were optimal or the best-practice possible. Like any consultation, I gave it my best shot at that particular time and place. Please know that I physically examined and queried every patient, because I firmly believe you can’t properly evaluate, much less provide advice and teach, unless you’ve done an age-old history and physical (H&P).

Case 1

What Else Besides Standard Care?

A 31-year-old woman sustained a severe leg burn in childhood and developed diabetes and systemic lupus erythematosis as a teenager and young adult, respectively. She had seen multiple pain specialists and currently was being followed by a rheumatologist located 90 miles away in Phoenix. Her current medical regimen consisted of an antidepressant, bedtime sedative, long-acting oxycodone, and a short-acting hydrocodone/acetaminophen compound for breakthrough pain (Table 1). She had been treated previously with topical lidocaine patches, tricyclic antidepressants, and non-steroidal anti-inflammatory drugs (NSAIDs). Her pain was primarily articular, affecting multipl joints. She described her pain as constant and said she could sleep for only about 3 hours at a stretch.

On physical exam, her pupil size was under 3.0 mm and slowly reactive, indicating good opioid response. Her blood pressure and pulse rate were normal. She felt she had a good quality of life—she was functional, driving a car, and carried out normal activities of daily living. She believed her pain treatment had been excellent, and she was grateful to her physicians and their “life-saving” care. She and her physician simply wanted to know if there was anything else that she might do to better her clinical condition. In particular, were there any measures that might be curative?

My Assessment

This patient had centralized pain (severe, intractable pain that started in the periphery and now resides in the central nervous system) and was receiving effective, standard pain care (Table 2). She had normal physical and mental functions, and a good quality of life. This case is typical of many chronic pain patients who are the beneficiaries of standard, symptomatic pain care. However, many patients want to know what can be done to enhance their care and permanently reduce their pain.

Since the patient had tried multiple pain treatments, the only thing I know that may achieve greater pain relief, reduce the need for opioids, and give some permanent relief is the use of hormone therapies (Table 3). First, I recommend a standard hormone panel that is widely available through commercial laboratories. If any hormones prove to be deficient, they should be replaced.1,2 Also, patients may wish to attempt a trial with the neurohormones, such as human chorionic gonadotropin and/or oxytocin. Hormone therapies are easy and inexpensive options to try in many of these worst-case scenarios.

For follow-up, I recommended monthly visits to the clinic and a focus on dietary supplements, stretching exercises, and emphasis on gaining an improvement in quality of life (and not necessarily complete elimination of pain). One might also advise the patient that she may require ongoing therapy with opioids or other analgesics. This should be done in consultation with her physician, who can properly monitor the patient for the emergence of side effects or aberrant behaviors. Often meeting with family members can allay fears of opioid misuse or abuse.

Case 2

Female with Low Testosterone

An intelligent, educated 54-year-old woman with an academic teaching background had undergone 4 lumbar spinal and 3 hip surgeries (bilateral). She described her spine and joint pain as constant and complained of persistent, excess heat (a typical manifestation of excess sympathetic discharge in patients with central pain). Also, she felt she was losing her memory. Her medications consisted of short-acting oxycodone (30 mg) taken 2 to 4 times a day, a muscle relaxant, and an occasional bed-time sedative. In the previous year, she had been found to have low serum testosterone levels, but her physician felt uncomfortable prescribing testosterone to a woman. The patient very much wanted to manage her pain with minimal opioid use. In the past, she had seen multiple pain specialists and tried a number of anti-inflammatory, antidepressant, and neuropathic agents, which provided no significant pain relief. Lumbar spine surgeries had been performed to treat a combination of osteoarthritis, stenosis, and herniated discs. Compliance with her medication regimen appeared good.

My Assessment

This patient had centralized pain and was not responding well to standard pain treatment with pharmacologic agents. Like many of today’s pain patients, she resisted taking opioids, which allowed her pain to excessively flare. Rather than start women on testosterone, I now recommend as first-line treatment a course of human chorionic gonadotropin (HCG) (125 units) given sublingually 2 times a day and supplemental dehydroepiandrosterone (DHEA) at a dosage of 50 to 100 mg a day. Serum testosterone levels in females usually will rise to normal within a month with this regimen. If they don’t, I then will resort to a standard, commercial testosterone preparation with a starting dosage that is ¼ the male dosage. The patient was informed that if her testosterone is brought into normal range she may get more pain relief and be able to reduce, but likely not eliminate, opioid use.

Case 3

New Patient With Chronic, Low Back Pain

A 46-year-old woman had developed persistent pain in her right lower back, buttock, groin, and thigh within the previous 6 months. She recently had visited an orthopedic specialist who had ordered magnetic resonance imaging (MRI) of her spine and hip, and suggested she may require surgery. Her lumbar spine MRI showed degenerative changes at the L2, 3, and 4, but the hip was normal. The orthopedists had prescribed ibuprofen, gabapentin, carisoprodol, and a lidocaine patch, all of which provided some relief. The patient was seeing her physician about the exact nature of her problem and, since she wanted to avoid surgery, she was asking what should she do now.

My Assessment

The physical exam showed that the patient listed to the right and had hypertrophy of the right paraspinal muscle group. She had normal range of motion of both arms and legs. These findings, along with her MRI, indicated to me that the patient had long-standing, chronic degenerative spine disease. She needed daily stretching exercises to prevent paraspinal muscle contractures, lest she be a candidate for invasive interventions and/or surgery. I gave the patient a trigger-point injection consisting of
2 mL of 1% xylocaine and 1 mL of betamethasone. The injection site was at the right base of the spine in the “corner” just above the site that the ischial bone and lumbar spine intersect.

The patient felt immediate pain relief, confirming that the pain generation site was around the exit of nerves emanating from the lumbar spine. After the injection, I taught the patient and physician a set of stretch and hold exercises (range of motion) designed to prevent contractures of the right, paraspinal muscles. My basic exercise consists of having the patient raise her arms straight up and hold in that position for 15 seconds. Other arm length stretches also can be performed that put a force on the muscle groups that may scar, shrink, and form contractures. I always inform patients that stretch and hold exercises are the most essential measure for chronic, low back pain, and they must be done daily. The patients was told to continue her current medical regimen, immediately start daily stretch and hold exercises, and have regular follow-up visits with her primary doctor.

Case 4

Should Meperidine be Continued?

A 54-year-old man fell off a scaffold several years ago while working and severely injured his lower spine and pelvis (Figure 2). Over the past several years, he saw numerous pain and spine specialists who treated him with a variety of analgesics, corticoid spinal injections, and an implanted electrical spinal cord stimulator, which provided good relief. Unfortunately, about 2 years ago, he sustained a cervical neck injury in an automobile accident.

His spinal cord stimulator ceased working and he was started on a pain management regimen of oral meperidine (Demerol) at a dosage of 300 mg per day, which gave him pain relief. His primary doctor believed he should discontinue meperidine, since its metabolites may accumulate and cause seizures. After cessation of meperidine, his physician had tried numerous other opioids, including hydrocodone, oxycodone, and hydromorphone (maximum dosages were not provided), but they failed to provide enough pain relief to allow the patient to function normally. The patient claimed that without meperidine, he was bed- and couch-bound much of each day.

My Assessment

Decisions about using drugs that confer a high risk for complications, such as meperidine, carisoprodol, and methadone, often require a risk-benefit analysis. In my experience, meperidine seizures occur within a few weeks after initiating therapy in patients whose metabolism causes a toxic accumulation of meperidine metabolites. This patient had taken meperidine for over 2 years without incident. I have patients who have taken over 300 mg or more of meperidine a day for over 20 years without incident. I recommended that this patient go back on meperidine. In my opinion, the risk of the seizure from meperidine was outweighed by the improvement in quality of life. In practical pain management, high-risk treatments sometimes have to be used in lieu of another treatment. I recommend that a risk analysis and the basis for accepting the benefit of a risky treatment be clearly stated in chart notes. One also should consider adding gabapentin to offset the risk for seizures; educate the patient about need to avoid dehydration; and avoid any drugs that might enhance meperidine-normeperidine accumulation such as NSAIDs.

Case 5

Cervical Spine Pain and Hormone Deficiencies

A 49-year-old woman had symptoms of headaches, auras, and visual disturbances, which was originally diagnosed as multiple sclerosis. Rather suddenly she developed neck pain, and evaluation with MRI and neurologic consultation determined that she had severe cervical neck degeneration that required urgent surgery and implant of metal supports. Her pain is now constant and focused primarily in her head and neck. Multiple sclerosis has been ruled out. Her pain medications consist of a fentanyl patch (12.5 mcg), and hydromorphone (4 mg) for breakthrough pain. A hormone profile had been taken some months ago, which revealed low serum levels of adrenocorticotropin (ACTH), testosterone, and cortisol (<1.0 mcg/dL). No hormone replacement had been done to date due to uncertainty by the primary physician as to how to approach this problem.

My Assessment

Physical exam of the patient revealed hyperactive reflexes, hyperhidrosis, cold hands and feet, and a pupil dilated over 5.0 mm, indicating potential tolerance or reduced effect of pain medications. The patient and her husband were remarkably upbeat, grateful to have had excellent medical care, and thankful that she was alive because she had endured great periods of pain and suffering.

Uncontrolled, severe cervical spine pain may cause functional hypopituitarism with multiple low hormone serum levels.1,2 A low ACTH level suggests severe, unrelenting central pain.2 Cervical neck degeneration can occur without any known injury. It may be quite advanced before it manifests as pain. Besides head and neck pain, a fibromyalgia-like pain distribution (“all over”) may develop.

This patient clearly had central pain and urgently needed a higher opioid dose for pain control. Consequently, I recommended that the dosage of her fentanyl patch be increased and that hydromorphone be taken aggressively to prevent pain flares. Another recommendation was to get an up-to-date hormone panel to determine which hormones need to be replaced, because the patient will likely get more pain relief if serum hormones are brought into the normal range. In addition, hormone deficiencies may lead to multiple complications such as depression, hyperalgesia, fatigue, and muscle wasting.

Case 6

Poor Pain Control in Severe Ankylosing Spondylitis

The next case involved a 36-year-old woman with long-standing, documented ankylosing (rheumatoid) spondylitis. Her disease and pain had been centered in her lumbar spine for several years but recently started to affect her cervical spine. A mere glance at the patient revealed the stiffness (“freezing”) of her cervical spine—her neck was bent forward and she couldn’t raise her head (Figure 3). She was being followed be a rheumatologist and was maintained on adalimumab (Humira), a tumor necrosis factor-a inhibitor. The rheumatologist, however, left all pain management to her primary care physician. Her pain management plan consisted of 1 to 2 doses of oxycodone (15 mg every 4 to 6 hours). Her physician felt uncomfortable prescribing an opioid dosage above this level, and there were questions as to whether her insurance would pay for additional oxycodone.

My Assessment

In addition to severe cervical and lumbar pain, the patient bitterly complained about tooth and jaw pain. Periodontal infection and tooth decay were obvious, and she was being treated with antibiotics while awaiting tooth extraction.

Inadequate pain control was obvious because the patient’s pupils were overly reactive and dilated >5.0 mm. She also had hyperreflexia and hyperhidrosis. An immediate increase in pain relief was paramount in this patient. This could be obtained in a number of ways. Depending upon her insurance coverage, she could increase her oxycodone dose or add a second opioid such as hydrocodone, or morphine. A long-acting opioid would be a consideration if the short-acting opioids did not work and insurance coverage would pay for a long-acting agent. This patient’s severe dental erosion may have been in part due to recurrent hypercortisolemia, produced over time by her severe, uncontrolled pain. High serum cortisol may result in calcium reabsorption and cause the conditions of osteoporosis, dental erosion, and renal stones.3,4 In addition to better pain control, I recommended a hormone profile to determine if hypercortisolemia or a hormone deficiency such as testosterone, pregnenolone, or DHEA may be present and in need of replacement.

Case 7

Chronic Low Back Pain in Patient With Substance Abuse History and Little Money

A 45-year-old woman had reinjured her back a few months ago. She was taking hydrocodone/acetaminophen (10 mg/325 mg) 3 times a day. She stated that this wasn’t enough pain relief, but she had previously abused opioids and “became addicted.” She, therefore, didn’t want to take more opioids than she was already taking. Her pupil size was dilated and measured 4.0 to 5.0 mm in diameter, suggesting inadequate pain control.

The patient was diagnosed with chronic lumbar sprain, but there were no x-rays to be more definitive. She was vague about her substance abuse history, and in what little time I had to question her, I believed it to be benzodiazepine and oxycodone/acetaminophen abuse. In addition, she had marked reduction in the range of motion of her arms, listed to one side, and her right paraspinal muscle was hypertrophic. She could only lift her arms over her head about 50% of full range, and at this level experienced increased back pain. She could only bend over and dangle her arms about 70% of full range. These findings indicated that she had already developed contractures of her paraspinal muscles. The patient stated that prior physical therapy had hurt her.

My Assessment

Based on her poor range of motion, the patient was rapidly progressing toward a crippling back problem. I showed the patient simple range of motion exercises, and admonished the patient that they must be done daily to prevent contractures of the back muscles. The exercises primarily consist of raising arms and legs to stretch the paraspinal muscles, reduce and prevent contractures, and prevent worsening of pain. These exercises can be taught in less than 5 minutes and the patient can do them at home in less than 3 minutes.

Rather than increase her opioid dosage, I recommended promethazine, an antiemetic that has been shown to potentiate the effects of pain medications, with her opioid because she had previously had pain relief with this agent. Other agents with a low abuse potential include hydroxyzine, clonidine, and ibuprofen. Also, I recommended lidocaine gel for topical use and either an anti-depressant or neuropathic agent, whichever Arizona Medicaid might cover. Before trying invasive corticoid injections or surgery in chronic back patients without neurogenesis defects, my treatment strategy is the standard treatment regimen shown in Table 1. My ancillary in-clinic procedures usually include local (“trigger point”) corticoid injections, electromagnetic administration, and homeopathic injections.

Case 8

Progressive Chronic Regional Pain Syndrome (CRPS)

A 19-year-old man had a congenital lower leg deformity that required surgery in childhood. Unfortunately, CRPS developed after the surgery. Over the years, his pain progressed up the leg and to the contralateral leg. His arms and shoulders are now painful. The patient’s parents had taken him to numerous pain specialists around the country and sought consultation from a number of prestigious university centers. None of the numerous standard medications including anti-inflammatories, anti-depressants, muscle relaxants, and neuropathic agents, had helped relieve his pain or stopped progression of his disease. An implanted spinal cord stimulator and topical ketamine also failed to bring relief. The patient had a recent kidney stone. His mother was a pharmacist who had observed that her son didn’t receive any pain relief from most opioids including hydrocodone and oxycodone. However, he did respond to oral hydromorphone (Dilaudid) 6 mg 3 times a day, which controlled his pain well enough for him to attend college. The patient and parents weren’t looking for “cure” but something that would stop disease progression.

My Assessment

The patient was a very intelligent college student. He was accompanied by his most concerned, caring, and adoptive parents. Physical exam revealed a heavy-set patient with a cervical fat pad. His skin was warm and touchable without allodynia. Pupils were 2.0 mm in diameter and slow reacting indicating good pain relief with hydromorphone.

Most opioids are metabolized by one or more of the cytochrome P (CYP)450 isoenzyme. Hydromorphone, however, is not, suggesting that the patient might have a CP450 polymorphism. This would explain why hydromorphone was effective, while hydrocodone and oxycodone were not. I suggested the patient be tested to help identify other opioids that would be most effective.

His weight, cervical fat pad, and recent renal stone suggest he may have hypercortisolemia.3,4 Because he has take opioid for several years, he may also have hormone abnormalities. I recommended my standard hormone profile to determine if any hormone replacement such as testosterone or pregnenolone was needed. I also suggested to the patient and parents that systemic ketamine may be worth a trial. Also, I informed them that I have some CRPS patients who appear to have stopped progression of their disease with the neurogenic hormones, HCG and oxytocin. I emphasized that hope shouldn’t be thrown away as scientific knowledge about CRPS and is accumulating.

Personal Observations

Primary care physician are being required to manage some very serious and complex pain patients without the benefit of formal training, or any obvious consultation from pain specialists. Much to their credit, the PCPs in Chino Valley Medical Center had care and concern for their patients, and had obviously spent time studying the fundamentals of standard, pharmacologic pain care including the pharmacologic concepts involving neuropathic agents, anti-depressants, and bedtime sedation. They clearly understood the use of long- and short-acting opioids; however many were fearful of the risk of overdose related to the use of long-acting opioids. Consequently, questions to me were two-fold:

  • Am I doing the right thing?
  • What more can I do to help our pain patients?

The opioid dosages required and used by these PCPs were not particularly high, partly because these physicians know how to use the new standard, step-ladder model of pain treatment by first starting with anti-inflammatory, antidepressant, neuropathic, and other non-opioid agents.

Hopefully, I passed on a few clinical points to enhance their standard care:

  • One is that range-of-motion, stretching exercises are fundamental to low back care. If not done, paraspinal muscle contractures may occur that cause immobility and even more pain.
  • Adequate pain relief and opioid dosage can be fairly well determined by the finding of normal pupil size, blood pressure, and pulse rate. For example, if the pupil size is >5.0 mm in diameter and the blood pressure or pulse rate is elevated, the opioid dosage needs to be increased.
  • Hormone testing and replacement is a new but very useful adjunct to standard care. It is now easy to obtain a hormone profile from any commercial laboratory.

Summary

Many primary care physicians are becoming, by necessity, chronic pain specialists. The aging population, life-extending treatment of chronic diseases such as diabetes and arteriosclerosis, and emergency trauma services are all contributing to a high prevalence of chronic pain patients in primary care. As the cases here show, some very severe, complex, pain patients must rely on care from their PCP because there simply aren’t enough pain specialists to go around. My most pleasant and educational visit to Chino Valley, Arizona also tells me that I and other pain specialists should avail our selves to on-site, clinical training to assist PCPs in the management of complex pain patients.

Last updated on: December 3, 2013
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