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11 Articles in Volume 17, Issue #4
Algopathy—Acknowledging the Pathological Process of Pain Chronification
Are Abuse-Deterrent Opioid Products A Double-Edged Sword?
CMS Tackles Opioid Prescribing
How do you handle end-of-life care in a patient who does not know they are dying?
Letters to the Editor: Functional Medicine, Naloxone, Hormone Testing, CRPS
Look at the Patient’s Life Story, Then Implement a Management Plan
Myofascial Pain: Overview of Treatment Options
Pain in Parkinson’s Disease: A Spotlight on Women
Parkinson's Initiative—Women and PD Talk
Patient in Pain? When to Refer for Physical Therapy
Somatic Symptom Disorder: DSM-5's Removal of Mind-Body Separation

Letters to the Editor: Functional Medicine, Naloxone, Hormone Testing, CRPS

May 2017
Page 1 of 3

Functional Medicine

The case series using the functional medicine model was a very educational article.1 It would be useful to know about the cost and the possibility of insurance reimbursement for this pain management approach, so I might encourage my clients to consider this. I don’t expect that insurers in United States would cover tests or treatment provided by a functional medicine specialist. Also, how might I identify a naturopath who is well versed in these skills near my practice?

—Valerie M. Blais, BSN, LMT, CNT
Portland, Maine

Dear Valerie,

Actually, the current health care environment in the United States is uniquely situated to apply functional medicine into clinical practice. To my knowledge as a practicing physician, insurers reimburse many of the innovative functional tests typically requested. This is likely one of the contributing factors to the growing trend in referrals to functional medical specialists, more so in the US than in other parts of the world. However, according to the Institute for Functional Medicine, reimbursement by insurers is not typically granted for functional medicine testing at present, but this varies state by state and by specific insurer; patients should inquire about coverage prior to the doctor visit, and the physician may be able to assist in challenging the need for coverage.

There is a global movement toward systems biology as emerging data in genomics and metabolomics changes the one-size-fits-all medical model to a more predictive, personalized approach. Many centers, including the Cleveland Clinic, have recognized this paradigm shift and have incorporated the functional medicine model into their pain management programs.2

Training for naturopathic doctors (NDs) and medical doctors is available at the Institute for Functional Medicine in Washington, DC. Its website has a search tool to help you identify practitioners who have completed its courses. You can share this information with your patients.

Leigh Arseneau BSc, (hon.) ND

Practical Pain Management readers write in with their questions about hormone testing, functional medicine, CPRS.

Naloxone Risks?

It is my experience that there is an under-recognized risk of naloxone use in opioid-dependent patients, which was reinforced after I received 2 safety alerts—from Britain and Wales.3,4 How might I share this same warning with people in the US? I am concerned that many physicians do not address the chronic pain in patients who receive treatment in an acute setting for other medical crises. This means the pain condition is ignored, leading to extreme suffering and perhaps hastening a patient’s death, which I believe happened to my friend. I am aware of similar experiences, which have raised concerns about the legal and ethical issues surrounding withdrawal of essential pain relief without consent. In the case of my friend, her body will soon be autopsied—what might a pathologist look for to determine if pain was the cause of death?

—Richard Von Abendorff
London, United Kingdom

Dear Richard,

I’m delighted to hear that the England National Health Service has put out a safety alert to minimize the risk of distress and death from the inappropriate use of naloxone. As of now, I know of no such alerts in the United States, but I agree that it would be useful, and I am sorry to learn that your friend may have possibly lost her life to an inappropriate use of naloxone. I haven’t read any such reports in the United States, but I have received informal, unpublished reports.

First, the movement to give a naloxone kit to every pain patient is unwarranted. I have had health insurance companies urging me to prescribe a kit, which is quite expensive, for all my pain patients who have safely taken opioids for more than 20 years. One medical director of a prestigious health plan even went so far as to tell me that every patient who takes more than 100 mg of morphine equivalents a day will eventually overdose. Obviously, this medical director has never practiced pain medicine.

Your friend may be a victim of this ignorance. In my opinion, an opioid overdose worthy of naloxone has most of these physical findings:

  1. Miosis (pupil constricted under 3.0 mm (pinpoint) and non-reactive)
  2. Pulse rate 60 or under
  3. Blood pressure 90/50 mm Hg or less
  4. Respirations labored and under 10 a minute

Your friend may have arrived at a health care facility exhibiting symptoms of a disease or condition that was mistaken for an opioid overdose. The naloxone administration may have put her into a severe opioid withdrawal resulting in cardiac arrest. Unless all the physical signs noted above were present, she should not have been given naloxone—or she should have been given only a fraction (1/10 to 1/5) the usual dosage to assess if she may have overdosed.

Practical Pain Management has published articles about the cardiac hazard following a rapid withdrawal from opioids.5,6 During acute withdrawal, catecholamines rise rapidly in the serum, which can cause excess sympathetic activity. This spike in sympathetic activity constricts coronary blood vessels, which may produce an arrhythmia, infarction, or stroke. This is particularly true if the patient had underlying cardiovascular disease.

Do not look for answers from an autopsy, as it is unlikely for a patient who dies from cardiac arrhythmia to show any pathologic findings. If opioids are found in the blood, and absent any physical evidence for the death, the pathologist may declare an overdose.

Thank you for bringing this issue forward. 

—Forest Tennant, MD, DrPH

Hormone Testing

What type of doctor would you recommend I see for a hormone (metabolic) panel? I have already approached my primary care physician, my pain management doctor, my obstetrician/gynecologist, a dietician, a nutritionist, a psychologist, and a psychiatrist. They either told me that there is no need for such testing, or that my basic panel shows normal levels. However, I’ve been on opioid pain medication for 13 years, have had many steroid injections, and have taken oral steroids over the years.

Based on everything I have read about my symptoms, I am quite sure that my pain has affected my metabolism and disrupted my hormones, such as cortisol and adrenaline. No one will listen, but I am determined to find someone who will properly evaluate my hormone levels. Can you help?

—Bonnie Fricke
San Diego, California

Dear Bonnie,

Last updated on: September 27, 2017
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Myofascial Pain: Overview of Treatment Options

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