Tennant Blood Study: Preliminary Report
by Forest Tennant, MD, DrPH
 Many physicians throughout the United States have begun therapeutic
blood monitoring of chronic pain patients who require opioids. The motivations for this
endeavor are multiple:
1. Monitor compliance with prescribed opioids;
2. Determine if tolerance and an adequate level of opioids are present in the blood to
control pain;
3. Determine if the opioid dosage is appropriate since some patients malabsorb or too
rapidly metabolize opioids.
Two major problems have emerged involving opioid blood levels. The standard published
ranges of blood levels for opioids—originally established for non-tolerant, acute
pain patients suffering, for example, from post-operative or dental pain—are
erroneously being applied to tolerant, chronic pain patients. Table 1, a reference,
depicts the published blood levels for non-tolerant patients and can be compared to
collected data of this study. To control pain, many opioid-tolerant, severe chronic pain
patients may require significantly higher daily opioid dosages for a lifetime. Second,
some physicians have been accused of inducing an overdose death strictly based on a high
opioid blood level taken at autopsy when, in fact, the patient was tolerant and required
the high blood level for adequate pain relief. Death, in fact, was likely due to a
cardiovascular or other adverse event.
To resolve these problems and enhance pain care, Practical Pain Management
journal has asked a group of physicians to send us blood levels on their chronic pain
patients who take opioids. We have chosen to publish preliminary survey results to provide
at least some objective clinical data to guide physicians in improving their clinical care
and protecting themselves from unscientific claims. Additionally, when completed in
mid-2006, this survey will be made available to enforcement agencies, the legal community,
state medical boards, and others who need to understand the scientific metabolism and
pharmacology of chronic opioid administration.
Be clearly advised that this survey is not meant to determine optimal testing
methodology or therapeutic agent. Physicians participating in this survey selected their
own local, commercial laboratory resource. While we have requested that opioid blood
levels be optimally done two hours post dose, there is no assurance of this time frame.
Also, the survey asked for daily opioid dosage and simple patient functions rated simply
as fully functional, able to drive, and/or able to work or volunteer. Full functionality
is generally characterized as patients being ambulatory and able to bathe, feed, and
clothe themselves.
Many physicians have related to us that the lack of data involving blood levels in high
dose opioid patients is essentially at a crisis level, given the large number of
physicians who have been falsely accused of wrongdoing. Consequently, we present here
preliminary data. This data is preliminary only in the sense that the first batch of cases
received are presented herein. Many more cases have been received and will be entered into
these Tables and published in upcoming issues of PPM. Experienced intractable
pain physicians will find no surprises in these reported levels of opioids required for
pain relief and restoration of functionality to chronic, severe pain patients.
This study’s results, presented here and in the future, will be summarized by
opioid. Within the next six months we will compile all data into a ready-to-use reference.
In all cases, the titration instructions for each respective opioid must be followed
carefully to ensure safety and efficacy.
We invite comments and experiences with opioid blood levels.
Acknowledgement
Special thanks to Dr. Lawrence Probes for his assistance in compiling the data.
Forest Tennant, MD, DrPH is an internist and addictionologist who specializes in
the research and treatment of intractable pain at the Veract Intractable Pain Clinics in
West Covina, California. Address any correspondence to Dr. Forest Tennant, 338 S. Glendora
Avenue, West Covina, CA 91790-3043; 626-919-7476; fax 626-919-7497; Editor-In-Chief@PPMjournal.com.
References
1. Baselt RC. Disposition of Toxic Drugs and Chemicals in Man, 5th Ed. Chemical Toxicology
Institute. Foster City, California, 2000.
2. Goldman L and Ausiells D. Reference Intervals and Laboratory Values in Cecil Textbook
of Medicine, 22 ed. Eds, Saunders, Philadelphia, 2004.
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— Nov/Dec 2005
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