How High Is Too High? 


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In Virginia, several years ago, an outstanding pain physician by the name of William Hurwitz had to close his office.  And, through a total travesty of justice, he was imprisoned.  He was not a bad physician.  In fact, Dr. Hurwitz is smart, caring and one of the most knowledgeable physicians in the area of pain management I have ever met. He had to close his office because of the government.  Why were they after him?  In part, it was because of the dosages of medicine he routinely prescribed for long standing pain patients.  Whereas, the usual dosages of medication is in the tens of milligrams, Dr. Hurwitz would use grams of medication.

“Oh my God” some might say.   Surely these patients are using the medications to get high.  Or worse, they might be selling it. 

Perhaps some patients were doing the wrong thing, but Dr. Hurwitz will say his patients required this dosage.  And there are many physicians that would agree with him.

One of the problems that a patient on chronic opiate medication develops is tolerance.  The medication no longer works as well as it once did.  There are many who maintain that tolerance should be dealt with by an increasing the dose of medication.  As long as the dose is increased slowly, there is no intoxication, no mental impairment and no danger.  Many doctors have found that there are patients who only obtain relief at extreme dosages.

Of course, such dosage requires dispensing hundreds of pills at a time.  One danger is that the patients may not be sincere.  Sometimes these medications are diverted to others for recreational drug use.  And sometimes, it is only the patient abusing the meds, staying at home, and knocking themself out.

Addiction is always a risk but if a patient really requires such a dosage, medication should be prescribed despite risk of misuse.  So the question becomes whether such high doses are occasionally needed.   If a person, who  had been ok on a certain dose of medication, comes in saying it no longer works well, should we keep increasing the dose? 

I do not believe so.  My experience with such patients is limited to three or four patients that I have pushed to extremely high doses.  I have not seen a benefit.  Certainly for a short period they felt better but then tolerance sets in again.  I have never seen any long-term improvement. In fact they complain of as much pain as they did when taking less medication. 

I have also weaned many people from high dosages of medication.  They have become more involved in work and family activities.  They have not experienced significant increases in pain.  They are usually happier.

There is an established belief that presence of pain prevents the development of tolerance.  My clinical experience supports this concept.   A large dose of medication given when there is severe pain does not cause sedation and intoxication; the same dose would cause sedation/intoxication if it were taken in the absence of pain.  Unfortunately, I am unaware of studies clarifying this phenomenon

Severe pain prevents tolerance.  Mild pain does not.  If I try to give enough of the medication to eliminate the pain, soon the pain returns.  However, when I give just enough to take off the edge, the more limited relief is much  longer lasting. 

It seems as if there has to be a cerrtain level of subjective pain.  Attempts to reduce the pain below this level by increasing the dosage may have initial success but soon the pain return to that same level, only at a higher level of tolerance.  If the medication dose is increased because of emotional issues, the same thing happens.

Another reason a high dose may be started is that, at the outset of treatment,  lower doses are ineffective.  In other words, the patient was never comfortable until a high dose was given.  This is a very appropriate reason to use a high dose but only to a point.  However, if there is little or no relief after a significant dose of opiate has been given, it is incorrect to keep increasing the dose.  Something is wrong. The pain may not be opiate responsive or there may be other issues with the patient.

I tended to limit my medication to no more than the equivalent of 300-400 mgs/day of morphine. 

I need to stress that many, many doctors disagree with me and that we are taught there should be no upper limit to medication.  Keep increasing the medication as a way to overcome tolerance.  They would say that there are many patients who have needed increasing doses to stabilize long-term.  However, after achieving this stability, they were functional throughout. 

Many others doctors agree with me.

Who is right?  Are some docs turning a blind eye to the problems the medication is causing?  Am I just nervous about treating such patients?   Perhaps both things are true.  Until appropriate studies can be done showing that such treatment works, clinical biases, anectodal experiences and prejudice will determine what treatments are given

Meanwhile, Dr. Hurwitz became a target of law enforcement for his style of practice.  Therefore, until an authoritative body endorses this style of practice, I will avoid such treatment.

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