There is a subset of patients with FMS/MFPS that do respond to a combination of opiates in moderate stable doses and adjunct medications, however the evidence for enhanced functionality and/or reduced pain due to these medications is difficult to find. Of concern, is opiate induced hyperalgesia as noted in the articles below, in which patients and animal models show increases in pain on mere touching of the skin. This is typically what I see in many FMS/MFPS patients treated with chronic opiates. There is very little literature support for chronic opiate therapy, and almost no support for high dose opiate therapy in these patients. Dosage reductions of narcotics will indeed trigger massive increases in pain, and therefore produces both anger and fear as a predictable response. They do not understand the narcotics may actually be inducing some of the hypersensitivity to touch or movement induced pain as opiates are known by the general population to elicit pain relief in acute pain situations. The treatment of chronic pain populations with opiates for more than a month leads to hypersensitivy and tolerance (see the article below). What is disturbing is that in some animal models the neuroplasticity that accompanies NMDA receptor other calcium related peptide activations seems to be unidirectional: ie. the spinal neurophysiology changes become permanent. This would explain the maintenance of hypersensitivity in some patients when taken off narcotics and why opiate holidays do not work.
As for patients that need further neurodiagnostic workups but cannot afford them, there are a few options: 1. some hospitals have "charity" foundations that provide support for indigent services 2. one may perform epidurography or selective nerve stimulation in the office as a quick and dirty means of diagnosis 3. you can help patients engage in application for social programs such as Medicare, that will subsequently pay for the majority of the costs of diagnostic imaging 4. have the patient shop around for diagnostic imaging services or even better, do it yourself and tell the centers they must meet the lowest price in order to have the patients referred to them. I found a CT of the thorax in my area ranged from $840 to $2100 for exactly the same scan. I was able to negotiate with a center that typically charges $1550 to drop their price to the $840 price of the lowest center.
5, although current fluoroscopy reimbursement for the 76000 survey code is not cost effective, in 2008 it will be cost effective, paying over $100 for the code. This may be helpful in ruling out at least spondylolisthesis, fx, etc.
J Pain. 2006 Jan;7(1):43-8.
Opioid tolerance and hyperalgesia in chronic pain patients after one month of
oral morphine therapy: a preliminary prospective study.
Chu LF, Clark DJ, Angst MS.
Department of Anesthesia, Stanford University School of Medicine, CA 94305, USA.
There is accumulating evidence that opioid therapy might not only be associated with the development of tolerance but also with an increased sensitivity to pain, a condition referred to as opioid-induced hyperalgesia (OIH). However, there are no prospective studies documenting the development of opioid tolerance or OIH in patients with chronic pain. This preliminary study in 6 patients with chronic low back pain prospectively evaluated the development of tolerance and OIH. Patients were assessed before and 1 month after initiating oral morphine therapy. The cold pressor test and experimental heat pain were used to measure pain sensitivity before and during a target-controlled infusion with the short-acting mu opioid agonist remifentanil. In the cold pressor test, all patients became hyperalgesic as well as tolerant after 1 month of oral morphine therapy. In a model of heat pain, patients exhibited no hyperalgesia, although tolerance could not be evaluated. These results provide the first prospective evidence for the development of analgesic tolerance and OIH by using experimental pain in patients with chronic back pain. This study also validated methodology for prospectively studying these phenomena in larger populations of pain patients. PERSPECTIVE: Experimental evidence suggests that opioid tolerance and opioid-induced hyperalgesia might limit the clinical utility of opioids in controlling chronic pain. This study validates a pharmacologic approach to study these phenomena prospectively in chronic pain patients and suggests that both conditions do occur within 1 month of initiating opioid therapy.
Neurosci Lett. 2006 Mar 20;396(1):44-9. Epub 2005 Dec 15.
Opioid receptor-mediated hyperalgesia and antinociceptive tolerance induced by sustained opiate delivery.
Gardell LR, King T, Ossipov MH, Rice KC, Lai J, Vanderah TW, Porreca F.
Department of Pharmacology, College of Medicine, University of Arizona Health Sciences Center, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA.
Opiates are commonly used to treat moderate to severe pain and can be used over prolonged periods in states of chronic pain such as those associated with cancer. In addition, to analgesic actions, studies show that opiate administration can paradoxically induce hyperalgesia. At the pre-clinical level, such hyperalgesia is associated with numerous pronociceptive neuroplastic changes within the primary afferent fibers and the spinal cord. In rodents, sustained opiate administration also induces antinociceptive tolerance. The mechanisms by which prolonged opiate exposure induces hyperalgesia and the relationship of this state to antinociceptive tolerance remain unclear. The
present study was aimed at determining whether sustained opiate-induced
hyperalgesia, associated neuroplasticity and antinociceptive tolerance are the result of specific opiate interaction at opiate receptors. Enantiomers of
oxymorphone, a mu opioid receptor agonist, were administered to rats by spinal infusion across 7 days. Sustained spinal administration of (-)-oxymorphone, but not its inactive enantiomer (+)-oxymorphone or vehicle, upregulated spinal dynorphin content, produced thermal and tactile hypersensitivity, and produced antinociceptive tolerance. These results indicate that these pronociceptive actions of sustained opiate administration require specific interaction with opiate receptors and are unlikely to be the result of accumulation of potentially excitatory metabolic products. While the precise mechanisms, which may account for these pronociceptive changes remain to be unraveled, the present data point to plasticity initiated by opiate receptor interaction.
