Editor's Memo
by Forest A. Tennant, MD, DrPH
 Physicians are like other
professionals in that we instinctively want to show our new clients, better known as
patients, that we are among the best. Unfortunately, this well-meaning drive can
inadvertently lead to disastrous consequences when treating a patient with severe acute or
chronic pain. When a physician attempts to change pain therapy too soon, too fast,
inadvertent harm may result. Awareness of this situation rekindled when the undersigned
recently was consulted about two intractable pain patients who changed physicians, and the
new physician immediately altered their opioid regimen. The unintended result was opioid
withdrawal and excruciating pain flare-ups. Immediately ensuing was a hypertensive crisis
with angina in one patient and a myocardial infarction in the other.
It is well to remember that uncontrolled pain, both acute and chronic, are malignant
stress syndromes that produce extremely high catecholamine serum levels. Cardiovascular
accidents and death are apparently common in uncontrolled pain. Vascular collapse or
stroke is probably a common mechanism of death in many painful, crisis situations —
including trauma and childbirth.
The rallying cry here is to refrain from fixing something that may not be broken. We
now know that there are multiple opioid receptor sub-types and great genetic variations in
peripheral nerve synapses. Consequently, pain control regimens tend to be very
individualized. While we all have our favorite opioids, anti-depressants, muscle
relaxants, and anti-inflammatory agents, we must not change treatments in a new patient
until we know the patient quite well and— over time — can determine just how
much pain the current treatment may suppress. Even though we may not much care for the
current pain treatment, it may have evolved over time with considerable trial and error.
Also, the patient may not always be cognizant of the true effectiveness of a given drug or
regimen. But, if a patient says something “works” stick with it until you can
figure out a better treatment. Ride a winning horse as long as possible!
— Forest A. Tennant, MD, DrPH
Editor in Chief
Please refer to the Nov/Dec 2004 issue for the complete text. In the event you need to order a back issue, please click here.
— Nov/Dec 2004
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