Tennant Blood Study First Update
Presented here is the first update of tables showing opioid blood levels along with basic information about each patient. The next issue of Practical Pain Management will publish the second and final update. Physician readers are encouraged to immediately send us additional cases. Call or email for a survey form (see contact information for Dr. Tennant, below) or simply follow the table format and forward results to us. A comprehensive list of physician contributors to the study will be listed with the final update.
The Tables published here are for clinical and medicolegal reference and specifically address opioid-tolerant patients, that is those patients who have been safely titrated up to a level of opioid consistent with reducing their pain and improving their day to day functionality.
Stimuli for this survey are:
1. Claims of mis-prescribing by physicians based solely upon a blood level;
2. Education of all concerned parties that a periodic opioid blood level is essential to the clinical monitoring of persistent pain patients who require high dose, long-term opioid administration.
While most patients listed in these Tables were determined to be functional, ambulatory, able to drive, and even work by a single physician's observations, it is abundantly clear that opioid tolerance exists in these patients. Most patients in these Tables take a daily opioid dose that would generally be considered high, with accompanying blood levels that clearly exceed those labeled as toxic to non-tolerant patients. There is no better way to determine the presence of opioid tolerance than to determine that physiologic functions such as ambulation, alertness, speech, pupil reaction, and vital signs are normal in the face of a significant opioid blood level. Physicians are encouraged to document the presence of opioid tolerance by blood test and physical assessment in every long-term, high-dose patient.
It is to be noted here that a quantitative urine analysis for opioids does not document tolerance. Only the presence of opioids in bloodwhen physical functions are normalvalidate tolerance. Documentation of tolerance by use of a blood level not only tells the physician that the patient has likely complied with prescribing instructions for a considerable time period, but it also provides legal protection should an opioid blood level be taken after an auto accident or death.
Forest Tennant, MD, DrPH is an internist and addictionologist who specializes in the research and treatment of intractable pain at the Veract Intractable Pain Clinics in West Covina, California. Dr. Tennant has conducted research on intractable pain and written extensively on the subject. He is also Editor in Chief of Practical Pain Management journal. Address any correspondence to Dr. Forest Tennant, 338 S. Glendora Ave. West Covina, CA 91790-3043; 626-919-7476; fax 626-919-7497; EditorInChief@PPMjournal.com.
Please refer to the Jan/Feb 2006 issue for the complete text. In the event you need to order a back issue, please click here.