Tennant Blood Study — First Update
by Forest Tennant, MD, DrPH
 Presented here is the first update of tables showing opioid blood
levels along with basic information about each patient. The next issue of Practical
Pain Management will publish the second and final update. Physician readers are
encouraged to immediately send us additional cases. Call or email for a survey form (see
contact information for Dr. Tennant, below) or simply follow the table format and forward
results to us. A comprehensive list of physician contributors to the study will be listed
with the final update.
The Tables published here are for clinical and medicolegal reference and specifically
address opioid-tolerant patients, that is those patients who have been safely titrated up
to a level of opioid consistent with reducing their pain and improving their day to day
functionality.
Stimuli for this survey are:
1. Claims of mis-prescribing by physicians based solely upon a blood level;
2. Education of all concerned parties that a periodic opioid blood level is essential to
the clinical monitoring of persistent pain patients who require high dose, long-term
opioid administration.
While most patients listed in these Tables were determined to be functional,
ambulatory, able to drive, and even work by a single physician's observations, it is
abundantly clear that opioid tolerance exists in these patients. Most patients in these
Tables take a daily opioid dose that would generally be considered high, with accompanying
blood levels that clearly exceed those labeled as “toxic” to non-tolerant
patients. There is no better way to determine the presence of opioid tolerance than to
determine that physiologic functions such as ambulation, alertness, speech, pupil
reaction, and vital signs are normal in the face of a significant opioid blood level.
Physicians are encouraged to document the presence of opioid tolerance by blood test and
physical assessment in every long-term, high-dose patient.
It is to be noted here that a quantitative urine analysis for opioids does not document
tolerance. Only the presence of opioids in blood—when physical functions are
normal—validate tolerance. Documentation of tolerance by use of a blood level not
only tells the physician that the patient has likely complied with prescribing
instructions for a considerable time period, but it also provides legal protection should
an opioid blood level be taken after an auto accident or death.
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. Dr. Tennant has conducted research on intractable pain and
written extensively on the subject. He is also Editor in Chief of Practical Pain
Management journal. Address any correspondence to Dr. Forest Tennant, 338 S. Glendora Ave.
West Covina, CA 91790-3043; 626-919-7476; fax 626-919-7497; EditorInChief@PPMjournal.com.
Please refer to the Jan/Feb 2006 issue for the complete text. In the event you need to order a back issue, please click here.
— Jan/Feb 2006
The full article is now available as a PDF and may be
purchased for $5 and downloaded immediately:
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