Compounding Pharmacists Provide Targeted Hormone Replacement for Pain Management
The burning pain of inflammation as arthritic joints break down, sharp stabs of lower back pain and the deep body-wide aches from fibromyalgia are only three examples of excruciating pain that quite literally bring patients’ lives to a halt. These patients don’t know that their pain—and the opioids they take to relieve the pain—lead to hormone deficiencies. The complex but well-defined role of hormone replacement for pain management is finally making its way into the mainstream. Compounding pharmacists can take a lead role by discussing bioidentical hormone replacement with patients, which has an optimal safety profile for treating pain.
Pain Management and the Endocrine System
The relationship between pain and the endocrine system—and the impact of opioids—has been well documented for years, yet hormone replacement only recently found a seat at the table of pain management. Whether this change was fueled by advances in research, the desperate need for treatment options amidst an opioid epidemic, or both, it’s time to integrate hormone testing and replacement into pain relief regimens.
The hormones corticotropin, pregnenolone, cortisol and testosterone are essential for relieving pain, as their actions promote cellular healing, lower inflammation, mediate receptor binding and control nerve conduction. Acute pain stimulates the hypothalamic-pituitary-adrenal system, so serum levels of hormones increase. Chronic severe pain has the opposite effect. It suppresses the HPA axis and serum levels drop. The first hormones depleted are usually pregnenolone or DHEA, which subsequently makes testosterone levels go down. If severe pain persists, cortisol may drop dangerously low. Without normal levels of these vital hormones, analgesic agents such as antidepressants, opioids and neuropathic agents fail to relieve pain.1
To make matters worse, opioids also suppress hormone production. Any opioid can have this effect, but long-lasting and intrathecal opioids are more likely to diminish hormones. When serum levels of opioids stay constant, the HPA axis can’t return to normal functioning and hormones stay depleted. Testosterone levels are most often affected by opioids, but cortisol, pregnenolone and DHEA also suffer.
- About 75 to 85 percent of patients taking long-acting and intrathecal opioids have suppressed testosterone.
- Hormone suppression begins in the first 90 days after opioid therapy starts.
- Serum levels of hormones can stay low as long as the patient takes opioids.
Outreach Tips for Patients Taking Pain Medications
Assess for androgen deficiency: Patients often don’t report symptoms because they assume the problem is a side effect of opioids. Ask them about signs of androgen deficiency:2
- Fatigue and decreased energy
- Depression and irritability
- Decreased libido
- Decreased bone density
- Erectile dysfunction
- Decreased lean muscle mass
- Increased visceral fat
- Decline in concentration and memory
- Sleep disturbances
Recommend hormone testing: When you fill prescriptions for pain medications, especially opioids, take a minute to explain their impact on the endocrine system and how it affects pain treatment. Any patient in constant pain, whose pain is poorly controlled or who suffers from pain-induced insomnia regardless of taking opioids should have their hormone levels tested. In addition to determining whether they need hormone replacement or possibly more aggressive pain management, a hormone test can also help separate legitimate patients from those seeking drugs.
Compounded Bioidentical Hormones Provide Safe Option
The good news is that hormone replacement for pain management has picked up speed in recent years, which is at least partly fueled by new hormone formulations and clinical reports that hormone replacement enhances pain relief, improves functional abilities and minimizes the need for opioids, according to Forest Tennant, MD, DrPH and Jeffrey Gudin, MD in the April 2016 issue of Practical Pain Management.3 When tests reveal hormone deficiencies of cortisol, DHEA, estradiol, pregnenolone, progesterone or testosterone, replacement therapy should start with a low dose and be titrated up over six to eight weeks.
Compounding pharmacists should reach out to collaborate with physicians who may hesitate to prescribe bioidentical hormones. As it turns out, they provide an optimal safety profile for pain management, said Tennant and Gudin. Their advice to reduce or stop sub-replacement hormones once normal serum levels are achieved—and the patient’s pain is under reasonable control—reflects the U.S. Food and Drug Administration’s recommendation to use bioidentical agents at the lowest effective dose for the shortest time needed. Just keep in mind that the nature of chronic pain may demand long-term hormone therapy. Be sure to counsel patients about compounding sublingual, topical and other forms of testosterone to meet their individual needs.
Compounding Pharmacists Are Key Collaborators
The expertise of compounding pharmacists makes a significant difference for patients struggling to treat chronic pain, especially if they take opioids. When you intervene to assess patients or to work with doctors who may not be aware of the safety and benefits of compounded bioidentical hormones, the advice you offer and the subsequent treatments prescribed can be the key that enables patients to overcome pain and return to a productive life.
Pharmaceutica North America provides high-quality bulk pharmaceuticals and over-the-counter products for pain management. Contact us today to talk about how we can support you, your pharmacy and patients.
- The Physiologic Effects of Pain on the Endocrine System,” December 2013, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4107914/ ↩
- Opioid-Induced Androgen Deficiency: Pharmacist Counseling Points,” September 2015, http://www.pharmacytimes.com/contributor/jeffrey-fudin/2015/09/opioid-induced-androgen-deficiency-pharmacist-counseling-points ↩
- “Hormone Testing and Replacement: Status Report 2016,” April 2016, http://www.practicalpainmanagement.com/resources/diagnostic-tests/hormone-testing-replacement-status-report-2016 ↩