Editor's Memo
by Forest A. Tennant, MD, DrPH
 The physician who treats pain patients has to possess
some extra calling from above or within to relieve suffering. A simple desire to help
doesn't suffice. A lot of art is required to deal with the complexities of long term pain.
Helping the patient and their loved ones navigate through the horrors of disability,
hopelessness, remorse, financial hardship, and the healthcare bureaucracy requires the art
of perseverance and stubbornness, rather than science.
But, look yonder! Science is riding the good white horse and coming our way to help.
Highlighted in this issue are some new practical scientific findings. One of the new,
emerging laboratories, AIT of Indianapolis, that specializes in pain treatment is
reporting in this issue that hydromorphone (Dilaudid«) is a metabolite of high dose
morphine therapy. This is not surprising since opioids induce significant liver enzyme
activity. It may just well be that metabolite formation gives you two opioids for the
price of one which, in turn, may help explain why high dose, morphine therapy is so
terribly effective in many cases. Two other laboratories, Dominion and Ameritox, are also
joining us in advancing scientific education.
Also reported in this issue is a simple, but easily understood advance in epidural
intervention. By the use of a simple catheter and external infusion device, Dr. Mike
Shapiro has found a way to continuously bathe targeted tissue in the epidural space with
corticoids for three days. Corticosteroid contact at the target area appears to need a
longer stay than usually obtained with the standard epidural injection. Just as
long-acting "depo" corticoid preparations are required for painful trigger
points and joints, a longer time may be required to adequately treat peri-spinal tissues.
This advance should spread rapidly to eliminate some spine surgeries and reduce the need
for opioid administration.
There are scads of anecdotal reports regarding the use of herbal topicals. Finally
someone has decided to find out if the old, oily, smelly rubdown does anything. A group
from the University of Toronto led by Dr. Gordon Ko did a double blind study with a
concoction of six oils including aloe vera and camphor. And yes, there was significant
pain relief. We can now stop feeling guilty thinking that the cliche "rub this on and
you will feel better" just isn't a state of art. We now have a fragment of science to
back us up!
Herein is also reported the second edition of opioid blood levels in chronic pain
cases. This simple scientific survey shows that a single blood level can tell the
physician a great deal such as whether the patient is taking opioids as prescribed or if
the patient's blood level is high enough to be effective. Until such time as science gives
us a way to assess genotypes of enzymes which measure gastric absorption and rapid
metabolism of opioids, a periodic blood opioid level is an essential measurement in
chronic pain patients who require daily, high dose opioids.
Let's keep inviting science to the Art of Pain Medicine Festival.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— Jan/Feb 2006
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