Editor's Memo
by Forest A. Tennant, MD, DrPH
 When you step back and analyze
all the background noise, lobbying, and pressure being applied to pain specialists these
days, one can only conclude that each of these ear-shattering proclamations is saying
there’s only “One Way” and that’s “My Way.” Put another way,
some third-party payors, government agencies, and competing treatment interests are
vigorously committed to persuading pain specialists that their own way is best. Although
there are obvious financial interests in some of these proclamations, there also appears
to be an element of emotion. Is it possible that the trend to tailor-make a treatment for
each specific patient is a deep-down threat to the heart and soul of those who champion
robotic medicine and drive-by treatment? Send me your answer!
The fact is that adequate treatment of chronic pain patients demands a treatment plan
of great individuality and may change over time. Perhaps no other field of chronic medical
care demands such tailor-making. Some innovative compounding pharmacies are now available
at the local community level thanks to a growing number of pharmacists who haven’t
forgotten the old mortar and pestle and are capable of formulating a tailor-made compound
that works in a given patient to get the job done. Sometimes it’s not a manufactured
pill that works but a tailor-made liquid, injection, topical, suppository, or sub-lingual
preparation that carries the day.
For the very best, most potent, tailor-made solutions, we now have a few specialty
pharmaceutical companies who prepare intrathecal medications in a wide variety of dosages
and combinations. Innovative physicians are learning that unique combinations of, for
example, clonidine and hydromorphone, may be just the ticket for a difficult patient.
Rather than give up on an intrathecal implant, physicians should consult the specialist
companies who make intrathecal medication and try some innovative dosages or combinations
before declaring the pump useless. For example, the undersigned was recently referred a
patient whose physician had given up because the meperidine in the pump had
“stopped” working.
We physicians have a job ahead of us in educating all concerned parties that
practically all opioids can be administered by the sub-lingual or suppository routes and
that many topical opioids and other medications, such as anti-inflammatory agents or
muscle relaxants, may provide significant local pain relief.
Despite best efforts, some desperate, suffering pain patients may require implanted
injection lines or external infusion devices. Although we may have thought that patient
controlled analgesia (PCA) is now a well-accepted technique, don’t be surprised if
some third party carrier tells you that your tailor-made injection, catheter, or
sub-lingual prep is simply too ineffective, too dangerous, and too ridiculous to replace
two aspirins and a good night’s sleep. When you get such a response, please try to
find the name of the medical director, or at least a pharmacist or nurse, and drop them a
line supporting your patient (i.e. their client) as to the benefits of a tailor-made
treatment relative to reducing hospital stays and lowering costs—to say nothing about
humanitarian relief. Also, let all parties know that off-label treatment is the rule, not
the exception in our business. Try to educate them about multiple receptor sites,
achieving an adequate blood or intrathecal level of any pharmaceutical, and that failure
to properly treat severe pain wreaks havoc with the cardiac and adrenal systems. It’s
time to let all concerned parties know that the pain specialty thrives and achieves great
patient care utilizing specialty, tailor-made medications and routes of administration.
—Forest A. Tennant, MD, DrPH
Editor in Chief
— Jul/Aug 2006
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