Editor's Memo
by Forest A. Tennant, MD, DrPH
 Lost in all the condemnations,
proclamations, and recommendations about pain treatment these days is a most basic
scientific fact about pain. Its first and foremost impact, other than agony, is its
dramatic, aggressive assault on the cardiovascular system. Check with your neighborhood
medical consultants: 5th grade students. The boy who encounters a splinter and the girl
playing hopscotch who twists her ankle will both tell you that their pain causes their
heart to race. Better yet, go to your ultimate peer review consultant: your grandmother.
She well remembers the stories and days when women commonly died due to the pain of
childbirth when the heart stopped or a brain stroke occurred. Thank God we now have
opioids, channel blockers, and muscle relaxants—if only those who regulate or pay for
them will let physicians prescribe them!
Ignorance about the cardiovascular consequences of pain is profound even among some
learned pain specialists. First, some basics. Acute and chronic pain, being the ultimate
stress, causes a flood of adrenalin and related compounds to be released from the adrenal
and pituitary glands. The most obvious, discernable, and easily measured consequences are
an elevated pulse rate and blood pressure. Secondary physiologic consequences of excess
adrenalin in the blood may include, in the short run, hypoglycemia, exhaustion, fatigue,
and anorexia. In the long run, lipid abnormalities, cardiomyopathy, stroke,
arteriosclerosis, and heart failure. Perform a little test to demonstrate the
consequences. Check the pulse rate on the next patient you encounter who complains of
constant, severe pain. Don’t be surprised to find a resting pulse rate over 100 per
minute. It’s shocking, but many under-treated, intractable pain patients maintain
pulse rates over 88 and sometimes over 120. This editorial was, in part, motivated by a
“failed back surgery-autoimmune-tried everything-consulted everybody” patient
now on two opioids who just e-mailed me telling me her pain is poorly controlled and
accompanied by a house-bound state and her at-home pulse rates over 110. Naturally, pulse
rates this high call for more aggressive pain control such as another epidural, dosage
increase, or an ancillary pharmacologic agent. Bottom line is that effective pain
treatment must strive to bring pulse rates and blood pressure into normal ranges.
Cardiovascular consequences, including heart stoppage, stroke, or heart failure, are
among the most common, if not the most common, causes of death in chronic and intractable
pain patients. Clearly, pain will aggravate any pre-existing cardiac, lipid, or diabetic
condition. One of the travesties of scientific ignorance is that a number of physicians
have been erroneously accused of malpractice after one of their pain patients died. Too
often coroners and other onlookers jump to the false conclusion that pain medication and
an “over-prescribing” doctor cause the death when in actuality the patient died
a cardiovascular death from under-controlled pain. Just as in childbirth, a sudden severe
pain flare can cause excess adrenalin output, cardiovascular collapse, with sudden death.
Another common cardiac manifestation is unrecognized congestive heart failure. It can
cause sedation and sleepiness and can easily be confused with medication overdose. The
treatment here is digitalis rather than Naloxone!
Without question, detoxification and withdrawal of medications from a bonafide,
intractable pain patient may come to rank as one of the great medical frauds of the 21st
Century. The notion that intractable pain patients are somehow better off with no
medication and debilitated with pain is absurd and dangerous. Pain patients and families,
in order for some outfit to make the big detox bucks, have actually been told that opioids
and other medications are the cause of pain and that the patient will be “cured”
by detoxification. Many intractable pain patients have died of cardiovascular collapse
when their pain flared during too aggressive withdrawal from medication. Any ethical
physician who attempts detoxification of a chronically medicated pain patient must monitor
the pulse rate and blood pressure and be prepared to cease withdrawal and reinstate
medication if the pulse rate or blood pressure rise.
Regular pulse and blood pressure monitoring should be routine practice in pain
treatment, and patients and families should self-monitor at home in severe pain cases.
This author recommends that pulse rates be kept below 88, and pain treatment should
progressively and aggressively increase in intensity to bring the cardiovascular system
into normal homeostasis with a pulse rate of 68-76. Without good cardiovascular control,
the lifespan of an intractable pain patient will be cut short.
The author now recommends that intractable pain patients and their families buy a
$30.00 at-home pulse and blood pressure monitor and provide a monthly report on the
results. There simply isn’t a cheaper, better, and objective marker of uncontrolled
pain than a pulse rate.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— Sep/Oct 2005
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