Hormone Combo Reduces Pain, Opioid Dose in Intractable Pain

Nancy A. Melville

March 17, 2014

PHOENIX, Arizona — A novel hormone therapy combining oxytocin and human chorionic gonadotropin (hCG) shows the potential to improve pain while allowing for opioid dose reductions in patients with intractable pain, results of a preliminary study suggest.

Both hormones have been shown to have neurogenic and analgesic properties and have been linked anecdotally to reductions in pain and the need for pain medicine among pregnant women.

Lead author Forest Tennant, MD, a pain specialist with the Veract Intractable Pain Clinic in West Covina, California, said he was convinced to pursue the study after observing such patterns among his own patients.

"I would see pain patients whose pain would simply go away if they became pregnant, and even heroin and methadone addicts would not need the drugs when they became pregnant, so it has been clear something was going on with this physiologically," he told Medscape Medical News.

In the first trial of its kind, Dr. Tennant evaluated the effects of simultaneous administration of the oxytocin and hCG in 9 patients with intractable pain who were maintained on 1 or more long- and short-acting opioids.

The patients were treated with 25 to 500 units of hCG sublingually daily and 10 units of oxytocin sublingually 2 to 4 times daily.

At follow-up of 2 to 3 months, 7 of the 9 patients reported reductions in their opioid doses of 30% to 40%, reductions from baseline in pain and flare intensity, or an increase in the amount of time between flares.

The patients also reported varying improvements in energy levels, mental functions, mood, and libido.

Dr. Tennant said the patients were maintained on the therapy at 6 months and continued to report improvements.

"Most of these patients were taking opioid doses upwards of 200 mg a day and the doses are significantly down in all patients," he said. "Pain relief appears to be sustained."

Effects "Intriguing"

With the effects of opioids on the endocrine system well documented, the role of hormones in potentially offsetting the effects is intriguing, said Joseph Rabi, MD, from the University of Chicago, Schwab Rehabilitation Hospital, Illinois.

"It definitely is an interesting avenue to pursue," Dr. Rabi told Medscape Medical News.

"Prior to Dr. Tennant's study, I was only familiar with oxytocin being used on fibromyalgia patients without much success. In his study, patients were on an extraordinarily high amount of morphine equivalency dose of over 500 mg."

Opioids cause endocrinopathy by decreasing the release of luteinizing hormone, which is the pituitary analog of hCG, Dr. Rabi explained.

"In essence, the hCG given to the patients in this study counteracted the opioid's suppression of the hypothalamic tract," he said. "The way it caused the pain to decrease is still uncertain. It is an interesting study and further studies should be pursued."

Dr. Rabi noted that while pain specialists and primary care physicians are starting to become more aware of opioid endocrinopathy, they still may not encounter such cases very often.

"It is very unusual for a physician to encounter an obvious adrenal insufficiency patient with the symptoms of nausea, vomiting, hypotension in patients taking high-dose opioids," Dr. Rabi said.

"It is the subtle symptoms — fatigue, depression, decreased libido — that many pain specialists and primary care physicians overlook, but these symptoms are often seen in chronic pain patients."

"I believe pain physicians and primary care physicians should clinically screen for these symptoms if patients are taking 100 mg morphine equivalence a day," he concluded. "If patients do have these symptoms, a diagnostic work-up should be sought and treatment options should be considered weighing the risk and benefit of hormonal treatment."

Dr. Tennant and Dr. Rabi have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 30th Annual Meeting. Abstract 187. Presented March 6, 2014.

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