Pauline Anderson

October 03, 2016

SAN ANTONIO — Patients with severe chronic pain, including those with arachnoiditis, have low serum cortisol levels, a new study has shown.

Before prescribing opioids to such patients, clinicians should check cortisol levels, and if these levels are below normal, they should consider cortisol supplements, said Forest Tennant, MD, from Veract Intractable Pain Clinic, West Covina, California.

"One of my campaigns, which has been a voice in the wilderness, is that before you start anybody on opioids, you want to be checking their hormone levels, and if you bring them into normal range, you might not need the opioids," he told Medscape Medical News.

Dr Tennant presented his research here at the American Academy of Pain Management (AAPM) 2016 Annual Meeting. The academy recently changed its name to the Academy of Integrative Pain Management.

An extremely debilitating chronic pain condition, arachnoiditis is caused by injury to the arachnoid, one of the membranes that surrounds and protects the nerves of the spinal cord.

It is initially characterized by inflammation, and then by nerve root entrapment, bundling, and adhesion formation, followed by centralization of pain and overstimulation of the sympathetic nervous and hormonal systems, Dr Tennant noted.

Arachnoiditis "is probably the worst pain there is; it's humanity's worst pain," said Dr Tennant. He added that it is described as worse than cancer pain or the prolonged or excessive pain associated with complex regional pain syndrome, believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems.

"Some people who get this start off with the ordinary spine diseases — slipped discs, scoliosis, arthritis — or have horrible accidents after a spinal tap, or after an epidural delivery," said Dr Tennant. "But most cases have to do with the common degeneration of the spine."

Increasingly Common

Although it is considered a rare disorder, Dr Tennant is convinced arachnoiditis is more common than people think. He chalks this up to the fact that people are living longer and having more spinal surgeries.

And state of the art magnetic resonance imaging is making diagnosing arachnoiditis much easier, said Dr Tenant.

The current study included 202 subjects: 86 without a pain condition, 26 with arachnoiditis, and 90 with chronic intractable pain, defined by the authors as a constant, severe disabling pain causing changes in pulse rate, blood pressure, and adrenal hormone production.

Researchers collected blood samples from subjects and processed these to collect serum. Because cortisol levels are higher in the morning, and samples were collected at different times of the day, researchers used a computer program to convert the samples to a noon-time equivalent.

The study showed that nonpain subjects had a mean corrected serum cortisol level of 12.58 μg/dL, which, according to Dr Tennant, is well within the typical normal range. Patients with chronic intractable pain had a mean cortisol of 10.72 μg/dL, but those with arachnoiditis had a mean level of 6.52 μg/dL.

In his own clinic, Dr Tennant has seen cortisol levels in these patients drop down "to a trace."

Patients with arachnoiditis have often been treated with opioids, but these drugs can lower cortisol levels.

A better approach is cortisol supplements. "This helps because these patients don't have enough of their own cortisol to heal or to make their pain medicines work," said Dr Tennant. "Some corticoids get into the spinal fluid and are very therapeutic; you wouldn't want to try to treat some of these arachnoiditis patients without them."

Dr Tennant said he has reduced his prescribing of opioids to these patients by 50% in the last 2 or 3 years, "and I get referred the worst cases."

Without treatment, patients with long-term arachnoiditis can experience weight loss, muscle wasting, depression, apathy, hypotension, and even sudden death, according to Dr Tennant. He believes that many deaths attributed to opioid overdose are, in fact, caused by extremely low levels of cortisol.

Asked to comment, Robert Bonakdar, MD, director of pain management, Scripps Center for Integrative Medicine, La Jolla, California, said the study affirms that pain affects the endocrine system.

"We know that acute pain causes a stress response, and as pain becomes chronic, many patients will exhaust this important response," said Dr Bonakdar. "This depletion can help explain the fatigue, mood changes, and other nonpain comorbidities our chronic pain patients often exhibit."

Research looking at novel ways to help modulate adrenal response in the setting of chronic pain "would be ideal to reduce the consequences of this depletion," said Dr Bonakdar.

Dr Tennant is editor, Practical Pain Management, and a member of the Speaker's Bureau of Regenesis Biomedical, INSYS Therapeutics, and Ethos Laboratories.

American Academy of Pain Management (AAPM) 2016 Annual Meeting: Poster 5. Presented September 23, 2016.

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