Editor's Memo
by Forest A. Tennant, MD, DrPH
 The spiritual song for which this
editorial is titled couldn't be more fitting for opioid pain treatment. Effective pain
control, especially for intractable constant pain, is entirely dependent upon achieving
and maintaining a minimal opioid blood level. Physicians throughout the United States are
beginning to monitor opioid blood levels in their pain patients, and Dr. Lawrence Probes
initiates the subject in this edition of Practical Pain Management.
A physician can learn a good deal from an opioid blood level and thus better treat the
patient. First, if the opioid is present, the patient is clearly taking the prescribed
drug and not diverting it. Second, if the level is reasonably high and the patient shows
no evidence of sedation or neurologic impairment, the patient is clearly tolerant to
opioids and can safely perform motor functions such as driving. Third, a critical
determination — which can be assessed by an opioid blood level — is whether or
not the patient is malabsorbing opioids or is a rapid metabolizer. Consequently, the best
time to take an opioid blood level is 1 to 2 hours after the patient has ingested their
usual dosage. Malabsorption and rapid metabolism are very common conditions in ill,
chronic pain patients and major reasons for the necessity of high dosages and use of
multiple opioids for adequate pain control.
What is not yet known are the therapeutic levels for good pain control. As Dr. Probes
points out, the opioid blood levels in opioid-tolerant, severe pain patients must be
considerably higher than the usual published therapeutic blood levels. In this regard
there is widespread confusion. Published ranges for opioid blood levels are for
non-tolerant, acute pain patients. Most of the published ranges have been determined in
non-tolerant, post-surgical patients and not severe, chronic, or intractable pain
patients. This fact has occasionally led to false accusations of malpractice when triple
or higher blood levels of opioids compared to therapeutic ranges in non-tolerant persons
have been found at autopsy or after an automobile accident.
Although it is clear that effective pain control in severe chronic or intractable cases
may require opioid blood levels two or more times that of published therapeutic opioid
levels in non-tolerant patients, just what ranges are common in tolerant, chronic or
intractable cases is unpublished. Consequently, this journal desires to collect and
publish opioid blood levels in tolerant pain patients.
The significance of blood level monitoring as stated above is a view shared by many
prominent pain physicians. Acknowledgement of that and a clear understanding of the levels
required in specific cases can be achieved through anecdotal and statistical data. Little
exists at this time and this publication will accept the task of collecting that data.
We are asking for your participation. Joining us in this effort will not only benefit
your colleagues and the entire pain management community, but will provide you with tools
for better treatment. The data collected will be published in Practical Pain Management
and you will be listed as one of the participants in the study.
There is no cost and no fixed commitment. We are looking for physicians anxious to
contribute to this effort. Ultimately, we plan to publish the data in a stand-alone
document and full credit will be given to all participants.
Please fill out the postage-paid card between pages 62 and 63 to indicate your desire
to be part of the program.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— Apr 2005
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