RSD Puzzle #086

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

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EPILEPSY, PAIN, MS

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RSD PUZZLE #86
Morphine Pump

In regard to Morphine pump, in our clinic we are following the largest series (that I know of) of the patients who have received Morphine pump treatment for RSD. The preliminary reports on 88 patients who have been followed for three years or longer are as follows:

1. The optimal dose of Morphine is anywhere from 4mg to 10mg per day. Below 4mg, the dosage is too weak. Over 14mg, the dosage is too strong and is accompanied by recurrence of pain rather than pain relief.

The number one cause of failure of Morphine pump has been addition of other drugs that mess up the function of the small doses of Morphine. These drugs consist of alcohol at any amount, and oral or skin patch intake of other Morphine agonists. For this reason, we have developed a routine practice of doing urine tests on the patients. If there is any other Morphine agonist medication in the urine, then we will not add Morphine to the pump any more. Such a patient is classified as a failure.

The success group which at the present time consists of approximately 80% of the patients treated by this method, are characterized by the pain severity dropping by 40-50% (usually the pain reduction from 7-8 down to 2-4). In addition, improvement of the quality of life such as return to part-time or full-time work, and better interpersonal relationship as well as improvement of depression-if to begin with the patient is depressed. If the patient is not depressed, then the improvement is measured by improvement of agitation, irritability, insomnia, etceteras.

Incidentally, on the subject of depression, Doctor Mary Lynch from Toronto, Ontario, has shown that RSD patients are no different than the general population in regard to their psychological profile[1]. On the other hand, the forth criteria of making the diagnosis of RSD is the fact that the pain is so severe that it is incompatible with normal sleep, happy and relaxed mood, and perfectly euphoric attitude. So, using the criteria #4 does not imply any insult to RSD patients.

Other causes of failure of pump are: lack of proper plasticity, meaning that unfortunately the treatment with the pump is done in patients who have had RSD for more than 5 years. After 5 years, the body does not have the power of healing to adjust to the foreign body of the pump or the spinal stimulator so the patient's body rejects the pump. The other causes of failure are infection or excessive scar formation (in less than 2% of such patients) or total intolerance of any dosage of Morphine in the spinal fluid.

Morphine pump is the best form of treatment for advanced, severe RSD patients as long as the patient and the doctor understand that the dosage of Morphine can not be mixed with other forms of strong pain medications.

In our study of application of ACTH for chronic pain, we measured the dosage of endorphines in the spinal fluid [2]. The patient's who take large dose of Morphine agonist have no endorphine in the spinal fluid. The use of ACTH increased the dosage of endorphine. The dosage of endorphine in the spinal fluid of the Morphine pump patients is low, but the endorphine is still present. Once the patient takes any strong pain medications by mouth, then the endorphine disappears. A usual dose of Morphine by mouth is over 100mg a day whereas, less than 1/10 of it is applied per day in the pump.

The patients who have the best results from the pump are the patients who get relief from 4mg to 7mg per day of Morphine.

This is the report of our experience with patients followed more than 3 years. In the past 1 year, we have had another problem. After the patient has had the pump treatment, there has been a lot more generous oral prescriptions of pain medications given to the patients just because of persistence of pain. As the result, the pump is tried, it doesn't work, and it has to be discontinued. It is not the pump that failed, but the lack of understanding of how important it is to provide a drip irrigation and extremely small doses of Morphine in the pump.

2. Regarding the question about Methadone and other drugs. Methadone should not be given with other strong Morphine agonists or antagonists. However, other medications can be given to the patient who is on Methadone such as NSAIDS calcium channel blockers, or antidepressants.

3. The reason the insurance providers are so adamantly against the pump is because of the point brought up on the fact that the patient is on the pump and also takes other pain medications. However, usually the patients who need the pump are work injury RSD patients. Usually by the time the patient needs the pump, the case is so-called settled, and the patient is disabled, so the patient is covered by Medicare. The Medicare does pay for the pump treatment.

What you need to remember is that there is no way you can get rid of the steel claws of the curse called RSD unless you are pain free. The pain free state can be achieved by the combination of antidepressants and proper pain medications, exercise and activity, proper diet, and proper nerve blocks-not the kind of nerve blocks that last only 1-2 days or 2-3 days.

Remember, it is not all in your head. It is all over your body. It starts from one extremity or one part of the body and if not properly treated, it spreads to the other parts of the body. Don't let anybody convince you to be treated exclusively by a psychiatrist or to "learn to live with your pain". Just remember you are not crazy. The pain of RSD is enough to drive anybody out of their mind but what I admire is the fact that RSD patients still keep their sanity.

H. Hooshmand, M.D.

1. Lynch ME: Psychological aspects of reflex sympathetic dystrophy : a review of the adult and pediatric literature. Pain 49:337-47 1992.

2. Hooshmand H: Chronic Pain: Reflex Sympathetic Dystrophy: Prevention and Management. CRC Press, Boca Raton FL. 1993.

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