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Patients Who Require Ultra-high Opioid Doses

The goal of ultra-high dosage therapy is to relieve pain and improve function in those chronic pain patients that are profoundly ill, impaired, and/or bed- or house-bound, without producing sedation.
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Traditional surgical treatments aim to rectify the anatomic position and to correct the carpal instability to prevent degeneration of the wrist. Presumably, the same occurs with prolotherapy to the wrist. The goal of the prolotherapy treatment is to eliminate pain and prevent further degeneration by stimulating the injured ligament(s) to heal. If the arthritic process has progressed, prolotherapy helps to stabilize the unstable joints. Unlike wrist fusion, however, prolotherapy for chronic wrist pain, as indicated in this study, helps improve range of motion, not diminish it. Because this subgroup study population of only five patients that looked to prolotherapy as an alternative to a surgery had great results with prolotherapy, further research is warranted into using prolotherapy as an option to wrist surgeries such as arthrodesis.

Tolerance

Tolerance is defined as the need for an increased dose to get the same effect. Tolerance quickly develops (within days) to the sedative and nauseating effects of opioids, but typically not to the constipating effect of the drugs. It is a myth that tolerance to the pain-relieving effect of opioids is to be expected.11 A need for increasing the dose early on in treatment is far more likely to result from increased activity and is a highly desired outcome of treating pain. It is not true that patients on high doses of opioids necessarily require ever-increasing doses, as clinicians who treat noncancer pain with opioids have learned. Many patients who require over 1000mg of morphine equivalents a day reach a plateau dosage after titration and may remain in a relatively constant dosage range, albeit high, for many years.12 Increased pain after months or years is more likely to be due to disease progression rather than a late development of tolerance.

Who Should Treat Ultra-High Opioid Patients?

Since these patients require very close monitoring and family involvement, the authors don’t recommend that they be treated in settings or practices that intermingle other types of patients. Ultra-high dose opioid treatment must be closely monitored. The authors are aware of physicians who block off time periods (i.e. one day a week) to attend to such patients.

Complications of Treatment

The major complication of ultra-high dose opioid therapy is testosterone suppression in males and some females. Patients may require testosterone replacement. Suppression of serum cortisol, pregnenolone, and estrogen, however, seldom occur. Sudden suppression of adrenal corticoids in an opioid-maintained patient is usually accompanied by nausea, weakness, and drop in blood pressure. In these cases, hormone replacement may be necessary if opioids are still required to suppress pain.

Last updated on: December 20, 2011
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