PALM SPRINGS, Calif. – Intractable pain patients on long-term, high doses of opioids should be screened for hormonal abnormalities, researchers said here.
In a small, long-term, single-clinic study, the majority of patients had, as expected, low testosterone -- but some also had abnormalities in cortisol and other hormones that may indicate an incomplete resolution of pain, according to Forest Tennant, MD, DrPH, of the Veract Intractable Pain Clinic in West Covina, Calif.
Action Points
- This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
- In this small study, patients with intractable pain maintained on opioids for 20 or more years had multiple hormonal abnormalities, both deficiencies and excesses.
Tennant reported the findings during a poster session at the American Academy of Pain Medicine meeting here.
"Physicians should do hormonal testing," Tennant told ľֱ. "If [patients'] pain is not controlled, despite what they say, it's going to show."
It's well known that chronic opioid therapy suppresses testosterone, but particularly severe intractable pain also has been thought to have effects on pituitary and adrenal hormones such as cortisol, corticotropin, and pregnenolone.
To assess potential hormone abnormalities in intractable pain patients who've been on long-term opioid therapy, Tennant studied 22 patients ages 47 to 71 who were on continuous opioid therapy for at least 20 years.
Their daily morphine equivalence doses ranged from 450 mg to 5,650 mg.
All patients had a morning blood draw to test for a panel of hormones, including cortisol, testosterone, pregnenolone, estradiol, ACTH, and follicle stimulating hormone.
A questionnaire was used to assess current health status, serious health problems associated with high doses of opioid therapy, and quality of life, and depression was assessed via the Beck Depression Inventory.
As expected, the majority of patients -- 54.5% -- had low testosterone (seven males and five females), Tennant said.
Almost a third (30%) had low levels of follicle stimulating hormone (three females and three males).
Tennant said in general, all patients reported good quality of life and little depression -- although the hormone levels appeared to tell a different story.
About 27% had high cortisol levels, 22.7% had highcorticotropin levels, and 18.2% had high pregnenolone levels. This may indicate that severe pain and its endocrine response "may not be sufficiently controlled by high doses of opioids," Tennant said.
"Patients may say they're fine, but they may not be sleeping, may not have a good diet," he told ľֱ.
He cautioned that these elevated hormone levels don't mean patients need more opioids: "It may mean they need an antidepressant or a muscle relaxant. The doctor needs to come up with a new strategy."
Tennant also warned that controlling hormone levels in long-term opioid therapy patients is a burgeoning area, but is worthy of note as some abnormalities can lead to larger problems. High cortisol, for instance, is tied to osteoporosis and vertebral collapse, he said.
Disclosures
Tennant reported no conflicts of interest.
Primary Source
American Academy of Pain Medicine meeting
Source Reference: Tennant FS "Endocrine abormalities after 20 years of opioid therapy" AAPM 2012; Abstract 248.