Therapeutic “Tolerance” in Medical Pain Management

Editor’s Memo: We Need More “Tolerance” in Medical Pain Management

Every time I hear a clamor for dosage restrictions of opioids or hear such statements as “no one could possibly take that much medication,” I suspect the person uttering the statement is pretty ignorant about therapeutic tolerance and the legitimate need for opioid dosage escalation in selected patients.

What is Tolerance?

Let’s review. According to the American Pain Society, therapeutic tolerance is defined as “a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the opioid effects over time.”1 This is not to be confused with physical dependence or addiction, which are defined in the Table below.

tol-dep-addAnother confounding phenomenon is that of opioid-induced hyperalgesia (OIH).2-4 This is the phenomenon by which opioids actually increase a patient’s sensitivity to noxious stimuli and previously non-noxious stimuli (allodynia). The clinical reality of OIH is a topic of some controversy, with supporters and opponents on both sides.

Patients on long-term opioids must become tolerant to the sedating and depressant effect on the autonomic nervous system (blood pressure, pulse rate, pupil size, speech, and ambulation).

My main message is that physicians who medically manage pain patients must not only fully understand tolerance as applied to pain management, but also document that therapeutic tolerance has been achieved. What’s more, therapeutic tolerance must be continually documented and recorded. Why? Good patient care and legal protection.

A pain practitioner must document that he/she has achieved therapeutic tolerance and is safely prescribing opioids. Too many parties are more than eager to besmirch, denigrate, humiliate, and/or charge a pain practitioner who prescribes medicine to a pain patient.

there are many parties who zealously claim opioid over-prescribing and report such complaints to a state medical board or other government agency.

A pain practitioner can easily and routinely document the presence of therapeutic tolerance at each clinic visit so that the patient can safely take his or her medications.

“too much medicine” lowers the blood pressure, pulse rate, and slurs the speech,

The best way to document the presence of therapeutic tolerance is by obtaining a blood level for opioids when the patient has normal physiologic parameters, such as blood pressure, speech and ambulation, and simultaneously claims good pain control.

1 thought on “Therapeutic “Tolerance” in Medical Pain Management

  1. Pingback: Promoting Continuous Monitoring of Patients on Opioids | EDS Info (Ehlers-Danlos Syndrome)

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