Editor's Memo
by Forest A. Tennant, MD, DrPH
 The title of this editorial was stimulated by a
patient I saw a few days ago in a pain clinic that I attend one week out of each month.
She was a woman I had accepted on referral about three years ago with out-of-control
systemic lupus, insulin dependent diabetes, and a spine that had gone south. Aggressive
opioid therapy was initially directed at all her neuropathies and arthropathies with
little thought about the daily corticoids and insulin needed to control her underlying
problems. Today, however, after three years of aggressive pain treatment, she has stopped
prednisone and insulin. She’s hardly an isolated case. Physicians throughout the
country are routinely seeing patients who are aggressively treated for pain and who cease
all kinds of disease-control medications. Included are many potent medications with far
more complications than opioids such as hypertensives, anti-psychotics, triptans, immune
suppressives, and anti-inflammatories, to name a few.
Simply, pain control stabilizes any concomitant or underlying disease. No wonder.
Uncontrolled pain has profound, negative effects on hormone levels, including contisol
adrenaline and immune suppression. Recent studies show that uncontrolled pain may cause
microscopic, neuroanotomical changes in peripheral nerves and spinal cord, and even
cortical atrophy which is visible on brain scans. Severe pain, including pain flares in a
chronic patient, can rev up blood pressure and pulse to the point of sudden death by
cardiac arrest or stroke. Given all of pains’ proclivity to negatively affect the
total body, the severe, intractable pain patient is fundamentally in a catabolic, dying
state.
The miraculous ability of pain control to stabilize underlying diseases has been lost
on insurance companies, regulators, and even families and physicians of pain patients. As
aggressive pain control sets in, patients begin to eat, sleep, mobilize, and socially
interact. They stop hounding emergency rooms, hospitals, and all kinds of expensive
practitioners. Lots of ineffective and ancillary medications are stopped. My bet is that
aggressive pain control, despite the relatively high cost of some interventions and drugs,
reduces the overall cost of medical care.
The message here is simple. Aggressively treat pain with specific, known measures and
analgesics rather than throw the PDR and the kitchen sink at the patient. Control the pain
and the concomitant psychiatric and physical ailments that may befall the patient will
stabilize. Let’s quit trying to treat the patient in reverse, otherwise we just go
backwards.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— March 2006
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