Editor's Memo
by Forest A. Tennant, MD, DrPH
 In this issue, Drs. Leong and
Royal provide a very fine and timely review of practical guidelines for opioid therapy of
chronic and intractable pain. They state that morphine, a derivative of opium, is the
“Gold Standard” for pain treatment. Opium, including its derivatives and
synthetic analogues, truly are the only real standard for pain care and will remain so.
Science has shown that these compounds are such “kissing cousins” of the
endorphins and other neuro-peptides that they are now referred to as “endogenous
opioids”. They work to relieve pain by attaching to and stimulating opioid receptors
in the central and peripheral nervous systems.
Beginning with Egyptian physicians thousands of years ago, advanced and caring
physicians have used opium to relieve pain and suffering. No medicinal compound can come
close to claiming the multitudes of saved lives and humane relief. Given the therapeutic
history of opioids, their non-scientific attack in the United States is perplexing,
because the number of abusers and addicts to opium derivatives throughout history have
been miniscule compared to the number of normal persons assisted by its humane, pain
relieving attribute. It is unclear why there is such an aggressive thrust to denigrate the
only agent that truly activates the receptors in the body that relieve severe pain.
The apparent widespread misunderstanding of opioids therapy among today's physicians is
astounding. Talk with 20 intractable pain patients and they will relate unbelievable
half-truths, misconceptions, misunderstandings, and misleading statements about opioids
that have been communicated to them by otherwise competent physicians.
Below are some samples of misstatements made to patients that have taken on a life of
their own — without the benefit of scientific and practical confirmation.
- Get off opioids, psychologic therapy will cure you.
- You'll have less pain if you detoxify from opioids.
- Get off your opioids so we can find out how much pain you really have.
- I can't give you a nerve block, injection, or physical therapy until you get off
opioids.
- Opioids cause too many side-effects but anti-inflammatory agents, anti-depressants, and
anti-epilepsy drugs are much safer.
- It's not safe to take so much opioid.
- You have to get off all opioids since you are pregnant or need surgery or dental
extraction.
- You'll get tolerant and opioids won't work (relieve pain) after awhile.
- You'll get addicted to opioids and never be able to get off.
Please examine the above examples. They are common day lingo that pain patients and
their families routinely hear from some MD’s. Lets face it, when intractable, severe
pain isn't curable by any known means, it certainly isn't going to go away with
psychotherapy, physical therapy, blocks, or detoxification. All these adjuncts can,
however, be very supportive and complement opioid therapy.
Perhaps the worst and most insidious myth that has recently been propagated is that
daily opioid dosages over 180 mg equivalent of morphine shouldn't be used since there is
no “validating outcome evidence.” This ignores the basic physiologic facts that
the pain-relieving effects of opioids are dependent upon their gastrointestinal
absorption, serum level, intra-tissue concentration, and stimulation of the MU opioid
receptor. Bottom line: there is no maximal opioid dosage as long as there is no functional
impairment. Physicians experienced in opioid therapy know that it starts at a low dosage
and progressively increases over time to whatever daily opioid load is required to
suppress pain and get the patient off the couch and onto the street of quality life.
There's no better standard!
— Forest A. Tennant, MD, DrPH
Editor in Chief
— Sep/Oct 2004
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