Editor's Memo
by Forest A. Tennant, MD, DrPH
 Diagnoses Is By Physical
Examination, Not Pill Count
The ugly battle in pain treatment today is the hue and cry about
“over-prescribing” and “over-medicating.” This claim is made daily by
those who wish pain treatment an untimely death or desire that pain-treating doctors be so
suppressed and subdued they will never write another prescription.
The clinical diagnosis of “over-prescribing” or “over-medicating”
must be done like any other medical diagnosis. Any term which denotes the presence of
excess drug influence requires a basic physical examination of physiologic body functions:
gait, mental alertness, speech, pupil size and reaction, muscle coordination, blood
pressure, pulse rate, and reflexes. For example, if there is excess influence of opioids
in the blood stream the result is slow speech and gait, droopy eye lid, constricted,
non-reactive pupil, slowed reflexes, and lowered blood pressure and pulse. The presence of
opioid as the causation of these physical, tell-tale signs is confirmed by blood or urine
analysis. This simple physical screen and body fluid confirmation is now standard practice
by highway patrolmen throughout the United States to detect a “drugged” driver
who has taken an excess of drugs. Simply put, if a policeman can scientifically determine
drug influence why can’t physicians?
So why is this long-known, basic diagnostic method to detect excess drug influence
rejected in the pain field? Simple. Bias, greed, and ignorance which abounds aplenty. Just
give a biased regulator, insurance company, or physician a pill count above some
ill-conceived, magical number implanted in their mind, and they will yell at the top of
their lungs, “over-prescribing” and “over-medicating.” Amazingly, one
can’t lose a driver’s license unless a physical examination and confirmatory
body fluid test scientifically documents excess drug influence, but a physician can lose a
medical license at the hands of a pill counter who has never even seen the patient. A pill
count doesn’t even prove the patient has taken a medication. Only a body fluid
analysis can determine this and only a physical exam can determine excess medication and
drug influence.
Tolerance to opioid medication is hardly a secret. There are numerous cases of pain
patients taking a daily morphine equivalence of 10,000mg with no physiologic evidence of
excess drug influence or impairment. Furthermore, a patient in pain often assimilates
administered opioids without producing physiologic impairment — including respiratory
depression.
The habit of calling physicians “over-prescribers” and
“over-medicators” by the pill counters is not only an unfair and unethical
condemnation of caring physicians, it is an inhumane affront to suffering patients.
Let’s call it straight. There is no upper limit on the amount or number of different
opioids or pills prescribed for pain relief as long as the administration of the
medication does not produce physiologic abnormalities as diagnosed by a face-to-face,
hands-on physical examination.
The idea of systemic medication, of course, is to achieve a high enough blood level to
saturate opioid receptors in the brain, spinal cord, and periphery. Given that many
commercial opioid preparations are only available in relative low dosages — such as
10mg methadone tablets or 1600mcg fentanyl lozenges — a lot of dosages may be
required in a 24 hour period to achieve an effective, minimal opioid blood level. Is a
physician to say that a patient can only have pain relief for a few hours a day?
Intrathecal administration is done to achieve brain saturation of opioid receptors,
because pills cannot accomplish a high enough blood level.
It’s time we stop this absurdity and “just say no” to pill counters who
make unsubstantiated claims of “over-medication” or “over-prescribing”
when they haven’t even seen the patient, much less conducted the physical examination
required to make a claim of excess drug influence.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— March 2005
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