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Hormone Treatments in Chronic and Intractable Pain

An Emerging Practice
Page 3 of 4

Human Growth Hormone (HGH)

Human growth hormone achieved great notoriety a few years ago when frail, elderly men benefited from its administration. It is now marketed and labeled for cachexia in AIDS. So effective is growth hormone in stimulating tissue growth in adults that it is highly sought after by athletes. Be advised that internet sales and non-prescription products which claim to be growth hormone are probably, in most cases, frauds or releasing agents. A number of compounds including dopamine, clonidine, arginine, and GABA will release growth hormone from the pituitary. Some astute physicians are now administering dopamine agonists to fibromyalgia and other pain patients to release growth hormone. They report a positive clinical response. Growth hormone is released from the pituitary in pulsatile fashion, so a test for deficiencies requires a 24 hour collection or challenge with a releasing measure such as insulin-induced hypoglycemia.29,30 Although some severe, intractable pain patients have started HGH treatment, there is, as yet, no data to show effectiveness in reducing pain or ameliorating the underlying causative condition.

HGH is extremely expensive, but its allure is compelling. So much so that patients hear about it and request it. Their rationale is, of course, that HGH may regrow their damaged nerves and other tissues. To date there is no evidence to support this perception, and systematic studies will be needed to determine if this hope can be realized.

Gamma Amino Butyric Acid (GABA)

GABA is the main inhibitory transmitter within the central nervous system.31,32 It is clear that ample intraneuronal stores of GABA are essential for pain control, particularly neuropathic pain. A number of agents commonly used to treat neuropathic pain or provide muscle relaxation — including baclofen, gabapentin, tiagabine, and the benzodiazepines — provide their pharmacologic effects by enhancing GABA activity by a variety of mechanisms.

GABA in the cerebral spinal fluid is reduced in a number of neurologic disorders including Huntington’s disease, dementia, cerebellar cortical atrophy, multiple sclerosis, epilepsy, and Parkinson’s Disease.15 While GABA deficiency is not yet well documented in severe pain states, the close clinical resemblance of these neurologic conditions and severe, intractable pain makes deficiency a reasonable conclusion. GABA causes dopamine and growth hormone release.4

Pure GABA can be ingested orally to act as an adjunct to other treatment agents. While oral GABA may not consistently cross the blood-brain barrier in large quantities, it freely enters the spinal cord and exerts significant effects on peripheral nerves and spine.32,33

GABA appears to be primarily produced in the central nervous system and secreted into the blood.33 Serum concentrations are quite constant between sexes and at all times of day. GABA clearly has peripheral activity and functions as a hormone.32,33 For example, there are GABA receptors in the ovary.33 Orally-ingested GABA may produce a temporary niacin-like flush, but is has no other known side-effects or complications. Daily dosage ranges from 1500 to 4500mg a day. Many chronic or intractable pain patients report enhanced pain control with GABA. GABA treatment of brain neurons in elderly monkeys prevents dementia.34 It may well be that GABA administration in humans may prevent central, spinal, or peripheral nerve degeneration, but this remains to be proven.

Testosterone

In many pain practices testosterone replacement is becoming routine in male and female chronic and intractable pain patients. These patients have low serum testosterone levels and report decreased libido, energy, wasting, and a poor feeling of well-being.35,36 It appears that intractable pain may suppress adrenal testosterone production, and any use of opioids by oral, dermal, or intrathecal routes may further suppress total testosterone levels.10,11,36,37 Opioids appear to suppress pituitary follicle stimulating hormone (FSH) which reduces testicular and ovarian production of sex hormones.10,11 It is easy to screen for testosterone deficiency in pain patients. Table 3 shows a simple screening test for low testosterone. Once suspected, a single blood sample can be used to confirm hypotestosteronemia. While high dosages of testosterone may have many serious side-effects including hyperlipidemia, hepatitis, cardiac hypertrophy, and possibly cancer, the dosages of testosterone recommended on the labels of all testosterone replacement products is quite low and safe. If an excess of testosterone is given, patients will usually develop acne at which time the dose can be lowered or temporarily discontinued. Testosterone replacement and maintenance of a normal serum concentration appears critical in male and female pain patients. Pain control, depression control, energy, libido, and muscle construction are all dependent upon testosterone.35,38 Consequently, testosterone testing and treatment of deficiencies should become routine in pain treatment. Also, the positive clinical effects noted with DHEA, androstenedione, and HCG are, at least in part, related to their ability to raise serum testosterone levels.

Testosterone Screening Test
  YES NO
1. Do you have a decrease in sex drive? q q
2. Do you have a lack of energy? q q
3. Has your strength or endurance decreased? q q
4. Have you lost weight? q q
5. Are you enjoying life less? q q
6. Are you sad or grumpy? q q
7. Are your erections or orgasms less strong? q q
8. Have you noticed a recent deterioration in your ability to
play sports? q q
9. Do you fall asleep after dinner? q q
10. Has your work performance decreased lately? q q
If you answer yes to question 1 or 7 or at least three of the other questions, you might have low testosterone levels.

Table 3. Testosterone Screening Test (Reprinted with permission of Solvay Pharmaceuticals)

Cortisol

The relationship of cortisol to pain control is critical, and the monitoring of serum cortisol should be routine in management of intractable pain patients. It has been understood for over 30 years that severe, intractable pain alters corticoid serum levels.5-9

Last updated on: May 16, 2011
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