Clinical Concepts — Current Comments

This section provides commentary on a variety of important subjects from experts in the pain management and/or addiction treatment fields. The viewpoints and opinions expressed are those of the authors, and do not necessarily reflect those of Pain Treatment Topics, our sponsors, or affiliate organizations.

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The OIH Paradox: Can Opioids Make Pain Worse?

By: Peggy Compton, RN, PhD, Pain Treatment Topics, August 2008.

Download PDF: http://www.pain-topics.org/pdf/Compton-OIH-Paradox.pdf (195 KB, 12 pp)

Healthcare providers are becoming increasingly aware that ongoing opioid therapy for chronic pain might paradoxically worsen the pain in some patients – a condition called Opioid-Induced Hyperalgesia or OIH. According to Peggy Compton, RN, PhD, author of this evidence-based review, present indications are that OIH does not arise in the majority of patients taking opioid analgesics, but when it does occur it can be difficult to manage.

It is essential that healthcare providers carefully monitor patients’ responses to opioid therapy and recognize that several conditions other than OIH – including worsening disease, opioid tolerance, withdrawal, pseudoaddiction, or addiction – can lessen opioid-analgesic effectiveness. In some cases, higher opioid dosing is needed; however, if OIH occurs, other strategies should be employed to provide pain relief. Strategies described in Compton’s review include keeping opioid doses as low as is clinically effective, the use of adjuvant medications, opioid rotation, and new applications of low-dose opioid antagonists.

Using Objective Signs of Severe Pain to Guide Opioid Prescribing

By: Forest Tennant, MD, DrPH, Pain Treatment Topics, June 2008.

Download PDF: http://pain-topics.org/pdf/Tennant-PainSigns.pdf (180 KB, 6 pp)

In this brief, ground-breaking paper, Forest Tennant, MD, DrPH, tells how uncontrolled severe pain can almost always be identified by objective physical signs that help practitioners to differentiate between drug-seekers and relief-seekers, as well as to determine if opioid dose is adequate. The fact is, he says, this sort of pain “usually produces more objective physical evidence of its presence than does the average case of diabetes or coronary artery disease.”

Uncontrolled pain stirs a physiologic response that can be clinically assessed via pulse rate, blood pressure, and pupil size. Less obvious, but still observable, are signs relating to how patients in pain seek positional relief, sensory avoidance, and pain distraction. Astute healthcare providers can use all of these measures to objectively determine if opioid analgesics are being properly prescribed, or if other pain relievers might be more appropriate.

Opioid-Induced Sexual Dysfunction: Causes, Diagnosis, & Treatment

By: Stephen Colameco, MD, MEd, Pain Treatment Topics, April 2008.

Download PDF: http://pain-topics.org/pdf/Colameco-Opioids-SexDysfunction.pdf (176 KB, 8 pp)

Sexual dysfunction is a common problem in patients with chronic pain. Yet, many suffer in silence, healthcare providers rarely ask patients about sexual concerns, and guidance literature on the subject is relatively scarce.

Ironically, considerable evidence suggests that long-acting opioids used on a daily basis for more than a month to help relieve chronic pain can have a number of adverse effects on human endocrine function leading to sexual dysfunction. This commentary by practitioner Stephen Colameco, MD, MEd, examines the causes and diagnosis of endocrine disorders related to opioid therapy. Recommended clinical approaches for the treatment of associated sexual dysfunctions are discussed, and it is hoped that through a better understanding of these issues opioid therapy can be more effectively used in the treatment of pain.

Should Opioid Abusers Be Discharged From Opioid-Analgesic Therapy?

By: Peggy Compton, RN, PhD, Pain Treatment Topics, January 2008.

Download PDF: http://www.pain-topics.org/pdf/Compton-OpioidUseProblems.pdf (220 KB, 11 pp)

“Any practitioner prescribing opioids for chronic use should be accountable for having a management strategy in place if addiction should become evident,” says Peggy Compton, RN, PhD. Providing daily opioid analgesics without suitable addiction expertise or support in place puts both the pain-management practitioner and patient at risk for poor outcomes.

Unfortunately, the clinical practice of discharging patients from opioid therapy when there are concerns about substance abuse or addiction can do significant harm; not just at the level of the individual, but also affecting families, the healthcare system, and society at large. Such practice should be avoided. Rather, thoughtful working partnerships between addiction and pain specialists should be developed, with the pain practitioner continuing treatment for pain while also playing a role in addiction treatment.

This does not require the pain-management practitioner to become an addiction specialist; however, pain practitioners should become involved in, rather than draw away from, addiction treatment for their patients with chronic pain who have need for such services. Such participation by pain practitioners not only enhances therapy for chronic pain but provides them a unique opportunity to help stem the significant public health problem of opioid addiction. In this essay, Compton outlines specific steps for any healthcare provider to follow.

Howard Hughes & Pseudoaddiction [A brief medical tutorial on a saga of intractable pain.]

By: Forest Tennant, MD, DrPH. By permission from Practical Pain Management. 2007(Jul/Aug);7(6).

Download PDF: http://www.pain-topics.org/pdf/HowardHughesPseudoaddict.pdf (571 KB, 12 pp)

Howard Hughes was a flamboyant personality who pushed the envelope in aviation, film-making, and other industries. Despite great accomplishments he also was notorious for bizarre behaviors late in life, allegedly fueled by an addiction to pain relievers.

This fascinating analysis by Forest Tennant, MD, DrPH, who had unique access to Hughes’ medical records, makes a convincing case that underlying the glamour, glitz, sex, money, and politics surrounding Hughes life, there also was a grim and serious saga of intractable pain. Tennant explains how, following a plane crash in 1946 that inflicted severe injuries, Hughes survived another 30 years with physical agony that was, by today’s standards of care, poorly managed. This included average daily codeine doses of up to 3 grams, plus a host of other drugs. He died in 1976 due to anti-inflammatory agents that, over time, produced kidney failure.

Hughes' infamous refusal to brush his teeth, cut his toe or finger nails, brush his hair, or wear clothes were probably related to excruciating pain inflicted by these everyday activities (allodynia). He was labeled a drug addict at a time before pseudoaddiction was recognized as an iatrogenically induced quest for pain relief. There are many lessons to learn from this tragic case history, as Tennant clearly discusses what might be done differently today to alleviate the suffering of patients like Hughes and others with intractable pain, which is severe, constant, and largely incurable.

For further information on intractable pain, consult Tennant’s guide, Intractable Pain Patient's Handbook for Survival.
See details… >

Chronic Pain Conundrums in Primary-Care Practice

By: Penelope P. Ziegler, MD, FASAM, Pain Treatment Topics, July 2007.

Download PDF: http://www.pain-topics.org/pdf/Ziegler-ChronicPainPrimCare.pdf (99 KB, 5 pp)

Pain is the most common complaint that brings patients to private practice offices, outpatient clinics, or emergency rooms. Yet, it is one of the most challenging and frustrating problems for most primary-care providers to deal with in their patients. Partly, this is because pain is a subjective symptom, not an objective sign, and assessing these patients requires skills that many healthcare providers have not been taught or do not take time to use.

When pain is chronic, having been present for months to years, and a variety of efforts have failed to relieve it, the clinical challenge is even more difficult. Penelope Ziegler, MD, FASAM, discusses practical suggestions for improving overall management of these patients in primary-care settings and for helping to identify those who need referral for specialty consultation and treatment. When approached in a systematic manner – with written, structured Treatment Plans and clearly stated expectations – most patients with chronic-pain disorders can be treated effectively and primary-care professionals will find greater satisfaction in working with them

Maximizing Safety with Methadone & Other Opioids

By: Lynn R. Webster, MD, FACPM, FASAM, Pain Treatment Topics, July 2007.

Download PDF: http://www.pain-topics.org/pdf/Webster-MaximizingOpioidSafety.pdf (125 KB, 7 pp)

Opioids provide life-saving analgesia for the millions of persons suffering with chronic pain, yet overdose deaths are rising at an alarming rate, with methadone implicated to a disproportionate degree. “To stop the deaths, we must understand clearly what is causing them,” says Lynn R. Webster, MD, FACPM, FASAM – a widely published author who is board certified in anesthesiology and pain medicine, and also certified in addiction medicine. He is Medical Director at the Lifetree Clinical Research & Pain Clinic, President of the Utah Academy of Pain Medicine, and Chief of Anesthesiology at Health South Salt Lake Surgical Center.

Webster asserts that the medical establishment must urgently respond to any clinical misapplications of opioids, particularly methadone. These agents must be respected as powerful medications and careless prescribing or consuming of opioids can be lethal. In this commentary, he examines the problems, along with some possible causes and areas for further research, suggests precautions for practitioners, and provides guidance for better counseling of patients to maximize opioid safety.

CAUTION: Methadone HCl prescribing instructions (PI) were revised in October 2006. When starting opioid-naïve patients on oral methadone the usual induction dose is 2.5 to 10 mg every 8-12 hours, slowly titrated to effect – 30 mg/day maximum. Vigilance is necessary to avoid overdosage, taking into account methadone’s long elimination half-life. (The older PI allowed induction doses up to 80 mg/day, which could be hazardous.) < See revised PI >

Overcoming Opiophobia & Doing Opioids Right

By: Forest Tennant, MD, DrPH; Pain Treatment Topics, May 2007.

Download PDF: http://www.pain-topics.org/pdf/OvercomingOpiophobia.pdf (110 KB; 6 pp)

Only opioids can effectively treat significant pain from surgery, injury, and certain disease processes, according to Forest Tennant, MD, DrPH -- an outspoken practitioner and widely published author, with more than 30 years of clinical experience in pain management. He comments that opioids are the only class of drugs that directly enhance the body's natural endorphin system, and he proposes there is a need to overcome irrational arguments and fears, or opiophobia, hindering their prescribing. The clinical benefits of opioid therapy dwarf the clinical risks, he asserts.

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