Indications for the use of cannabinoids / Indicação do uso de canabinoides

ABSTRACT BACKGROUND AND OBJECTIVES: The increasingly widespread use of cannabinoids in the management of acute and chronic pain generates an urgent need to study how cannabinoids act on CB1 and CB2 receptors and what their effects are on the organism. It is important to understand the difference in action between natural cannabinoids (cannabidiol, delta 9-tetrahydrocannabinol, cannabigerol, cannabinoil, terpenes) and synthetic ones, so that the appropriate choice is made in each case, and depending on the pathophysiology of pain, one or the other active is more indicated. CONTENTS: Studies collected in the Pubmed, Cochrane Library and Web of Science databases were analyzed. These studies focus were on natural cannabinoids (cannabidiol, delta 9-tetrahydrocannabinol, cannabigerol, cannabinoil, terpenes) and synthetic cannabinoids in the use for the treatment of chronic pain, their action on the endocannabinoid system through the activation of the CB1 and CB2 receptor and their effect after activating this receptor, aiming to compile which cannabinoid is more indicated in the treatment of pain pathology. CONCLUSION: The subject still requires much study and new articles are being published daily. The analysis of the studies must be carried out with criteria to evaluate their seriousness. The endocannabinoid system is closely linked to the treatment of chronic pain and some cannabinoids such as: cannabidiol, delta 9-tetrahydrocannabinol, cannabigerol, cannabinoil, as well as some terpenes are already considered important in the treatment of chronic pain inferring sparing effect of opioids, anticonvulsants, antidepressants among others.

RESUMO JUSTIFICATIVA E OBJETIVOS: O uso cada vez mais disseminado dos canabinoides no controle da dor aguda e crônica gera uma necessidade urgente do estudo de como os canabinoides agem nos receptores CB1 e CB2 e quais seus efeitos no organismo. É importante entender a diferença de ação entre os canabinoides naturais (canabidiol, delta 9-tetrahidrocanabinol, canabigerol, canabinol, terpenos) e os sintéticos, para que a escolha adequada seja realizada em cada caso, sendo que dependendo da fisiopatologia da dor é mais indicado um ou outro ativo. CONTEÚDO: Foram analisados estudos coletados na Pubmed, Cochrane Library e Web of Science. Os estudos se concentram em canabinoides naturais (canabidiol, delta 9-tetrahidrocanabinol, canabigerol, canabinoil, terpenos) e canabinoides sintéticos no uso para o tratamento da dor crônica, sua ação no sistema endocanabinoide através da ativação do receptor CB1 e CB2 e seu efeito após ativar esse receptor, visando compilar qual canabinoide é mais indicado no tratamento da patologia álgica. CONCLUSÃO: O assunto ainda requer muito estudo e diariamente novos artigos vem sendo publicados. A análise dos estudos deve ser realizada com critério para avaliar sua seriedade. O sistema endocanabinoide está intimamente ligado ao tratamento da dor crônica e alguns canabinoides como: canabidiol, delta 9-tetrahidrocanabinol, canabigerol, canabinoil, assim como alguns terpenos já são considerados importantes no tratamento da dor crônica inferindo efeito poupador de opioides, anticonvulsivantes, antidepressivos entre outros.

Comparative Study of 150 vs. 200 Units of Botulinum Toxin as Treatment for Vaginismus / Estudo comparativo de 150 vs. 200 unidades de toxina botulínica como tratamento para vaginismo

Abstract Objective To comparatively evaluate the outcome of treatment with 150 versus 200 units (U) of botulinum toxin in achieving pain-free intercourse and relieving muscle contraction in order to allow gynecological examination. Methods In this comparative prospective observational study, 99 patients with vaginismus were treated with botulinum toxin injections from September 2016 to August 2021. Diagnosis and grading of vaginismus severity were assessed using a Female Sexual Function Index (FSFI) questionnaire. Under local or general anesthesia, botulinum toxin diluted with preservative-free saline (150 U and 200 U) was injected into, above, and below the right and left bulbospongiosus muscle and the lateral submucosal areas of the introitus and perineal body using an insulin syringe. Patients were recalled after 2 weeks, and the postoperative outcome was recorded using a similar preoperative questionnaire. Results Overall, the mean age of patients was 30.2 years. The baseline and clinical characteristics were comparable between the 2 groups (p > 0.05). Significant improvements were seen in the pain and anxiety scores of finger penetration, dilator use, intercourse, and cotton swab in individual groups. The intergroup comparisons between 150 U and 200 U of Botox were not statistically significant (p > 0.05). Conclusion Low-dose Botox (150 U) is equally effective as high dose Botox injections (200 U) in vaginismus patients. Therefore, Botox-150 U can be used to treat vaginismus as an alternative to high doses of the same substance.

Resumo Objetivo Avaliar comparativamente o resultado do tratamento com 150 versus 200 unidades (U) de toxina botulínica na obtenção de relações sexuais sem dor e no alívio da contração muscular para permitir o exame ginecológico. Métodos Neste estudo observacional prospectivo comparativo, 99 pacientes com vaginismo foram tratadas com injeções de toxina botulínica de setembro de 2016 a agosto de 2021. O diagnóstico e a classificação da gravidade do vaginismo foram avaliados usando um questionário Female Sexual Function Index (FSFI). Sob anestesia local ou geral, injetou-se toxina botulínica diluída em soro fisiológico sem conservantes (150 U e 200 U) nos músculos bulbo esponjoso direito e esquerdo e nas áreas submucosas laterais do intróito e corpo perineal, utilizando-se uma seringa de insulina. Os pacientes foram chamados após 2 semanas, e o resultado pós-operatório foi registrado usando um questionário pré-operatório semelhante. Resultados No geral, a média de idade dos pacientes foi de 30,2 anos. As características basais e clínicas foram comparáveis entre os 2 grupos (p > 0,05). Melhorias significativas foram observadas nos escores de dor e ansiedade à penetração com dedo, uso de dilatador, relação sexual e cotonete em grupos individuais. As comparações intergrupos entre 150 U e 200 U Botox foram não estatisticamente significativas (p > 0,05). Conclusão Botox de baixa dose (150 U) é tão eficaz quanto injeções de Botox de alta dose (200 U) em pacientes com vaginismo. Portanto, o Botox-150 U pode ser usado para tratar o vaginismo como alternativa às altas doses da mesma substância.

Pharmacological treatment of pain in pregnancy / Tratamento farmacológico da dor na gestante

ABSTRACT BACKGROUND AND OBJECTIVES: Non-obstetric causes of pain during pregnancy are very common and can be disabling if not treated properly. The objective of this study is to discuss the pharmacological treatment of pain during pregnancy with a focus on drug classification and pregnancy use, therapy options, teratogenicity, increased fetal malformations and gestational complications associated with the use of therapy CONTENTS: During pregnancy, the body goes through several anatomical and physiological changes. These changes can precipitate pain, which in some cases can lead to disability. In addition, pregnancy may exacerbate pre-existing painful conditions. The choice to prescribe a drug to a pregnant woman is difficult. The changes in the body of a pregnant woman influence drug absorption, distribution, metabolism, and excretion, and may alter the expected response. CONCLUSION: The risks and benefits of the drug for the mother and the child should be considered, weighing the risks of not treating the disease adequately during pregnancy.

RESUMO JUSTIFICATIVA E OBJETIVOS: As causas não obstétricas de dor durante a gravidez são muito comuns e podem ser incapacitantes se não forem tratadas adequadamente. O objetivo deste estudo foi discutir o tratamento farmacológico da dor durante o período gestacional com foco na classificação de fármacos e o uso na gravidez, opções de terapia, teratogenicidade, aumento de malformações fetais e complicações gestacionais associados ao uso da terapia. CONTEÚDO: Durante a gravidez, várias alterações anatômicas e fisiológicas ocorrem no corpo. Essas alterações podem precipitar a dor, que em alguns casos pode levar à incapacidade. Além disso, a gravidez pode exacerbar condições dolorosas pré-existentes. A escolha de prescrever um fármaco para uma gestante é difícil. As alterações gravídicas no corpo da gestante influem na absorção, distribuição, metabolismo e excreção dos fármacos, podendo alterar a resposta esperada. CONCLUSÃO: Deve-se considerar os riscos e benefícios do uso do fármaco para a mãe e filho, pesando-se os riscos de não tratar adequadamente a doença durante a gestação.

An integrated review on new targets in the treatment of neuropathic pain

Neuropathic pain is a complex chronic pain state caused by the dysfunction of somatosensory nervous system, and it affects the millions of people worldwide. At present, there are very few medical treatments available for neuropathic pain management and the intolerable side effects of medications may further worsen the symptoms. Despite the presence of profound knowledge that delineates the pathophysiology and mechanisms leading to neuropathic pain, the unmet clinical needs demand more research in this field that would ultimately assist to ameliorate the pain conditions. Efforts are being made globally to explore and understand the basic molecular mechanisms responsible for somatosensory dysfunction in preclinical pain models. The present review highlights some of the novel molecular targets like D-amino acid oxidase, endoplasmic reticulum stress receptors, sigma receptors, hyperpolarization-activated cyclic nucleotide-gated cation channels, histone deacetylase, Wnt/β-catenin and Wnt/Ryk, ephrins and Eph receptor tyrosine kinase, Cdh-1 and mitochondrial ATPase that are implicated in the induction of neuropathic pain. Studies conducted on the different animal models and observed results have been summarized with an aim to facilitate the efforts made in the drug discovery. The diligent analysis and exploitation of these targets may help in the identification of some promising therapies that can better manage neuropathic pain and improve the health of patients.

Dor crônica: manejo baseado nos mecanismos / Chronic pain: mechanism based management

A dor crônica (DC) é uma experiência sensorial e emocional desagradável e é definida por períodos contínuos ou persistentes de dor superior a três meses de duração. A classificação da DC, por seu mecanismo, permite um manejo mais adequado e eficiente. O presente trabalho objetiva revisar esta visão e analisar aspectos concernentes à essa questão.

Chronic pain (CP) is a multidimensional sensation with intrinsically unpleasant experiences. It is associated to uninterrupted or persistent periods of pain superior to e three months. CP is classified according to its mechanism, and this distinction is important to make the appropriate management of the condition. The goal of this assessment is to review such concept.

Pain Management with fentanyl transdermal and morphine subcutaneous injection for the patients with advanced liver cancer pain after intervention therapy / 药学实践杂志

Objective To evaluate the effects of fentanyl transdermal combined with morphine subcutaneous injection in the management of advanced liver cancer pain after intervention .Methods 166 patients who suffered from advanced liver canc-er and received intervention therapy in our hospital were divided into two groups .89 patients belong to the fentanyl transdermal combined with morphine subcutaneous injection treatment group .77 patients belong to the morphine subcutaneous injection treatment group .The pain score and the remission rate of the two groups were compared and analyzed statistically .Mean-while ,the side effects of each group were recorded .Results Pain score in the group with fentanyl transdermal and morphine treatment was significantly lower than morphine mono therapy .12 hours after intervention therapy ,(1 .97 ± 0 .56 for combina-tion treatment vs 3 .23 ± 1 .49 for morphine only group ,P<0 .05) .24 hours after intervention therapy ,(1 .63 ± 0 .44 for com-bination vs 4 .19 ± 1 .68 for morphine only group ,P<0 .01) .Similarly ,the remission rate of the fentanyl transdermal combined with morphine subcutaneous injection group improved significantly ,(92 .1% vs 76 .6% P<0 .05) 12 hours after intervention therapy ,and(97 .8% vs 70 .1% ,P<0 .05) 24 hours after intervention therapy .Conclusions The addition of fentanyl trans-dermal to morphine subcutaneous injection treatment significantly improve the pain remission rate for the patients with advanced liver cancer pain 72 hours after intervention therapy .

Astrocytic expression of GFAP and serum levels of IL-1ß and TNF-α in rats treated with different pain relievers

ABSTRACT Pro-inflammatory cytokines and glial cells, especially microglial cells, have been implicated in persistent pain sensitization. Less is known about the role of astrocytes in pain regulation. This study aimed to observe the expression of the astrocytic biomarker glial fibrillary acidic protein (GFAP) and the serum levels of interleukin 1 beta (IL-1ß) and tumor necrosis factor alpha (TNF-α) after short-term administration of central pain relievers in rats not submitted to noxious stimuli. Male Wistar rats were divided into five groups, receiving for nine days- (1) amitriptyline (Amt-10 mg/kg/day, by gavage); (2) gabapentin (Gb-60 mg/kg/day, by gavage; (3) methadone (Me-4.5 mg/kg/day, intraperitoneal route [IP]); (4) morphine (Mo-10 mg/kg/day, IP); or (5) 0.9% saline solution, IP. Brain samples were collected for immunohistochemical study of GFAP expression in the mesencephalon and nucleus accumbens (NAc). The area of GFAP-positive cells was calculated using MetaMorph software and serum levels of IL-1ß and TNF-α were measured by enzyme-linked immunosorbent assay. Serum TNF-α levels were decreased in the groups treated with Mo, Me and Gb, but not in the Amt-treated group. IL-1ß decreased only in rats treated with Me. The astrocytic expression of GFAP was decreased in the brainstem with all drugs, while it was increased in the NAc with Amt, Me and Mo

Prevalência e características de dor em pacientes internados em hospital português / Pain prevalence and characteristics in patients admitted to a Portuguese hospital

JUSTIFICATIVA E OBJETIVOS: Os estudos de prevalência da dor apontam, sistematicamente, para valores elevados. Embora não comparáveis, a análise global permite inferir que em cada dois pacientes internados, um tem dor. Este estudo teve como principais objetivos determinar a prevalência da dor, suas características, tratamento analgésico e satisfação de usuários internados num hospital da Zona Centro de Portugal face à avaliação e tratamento da dor. MÉTODOS: Estudo transversal e observacional realizado com 141 pacientes, internados há pelo menos 24 horas, em unidades cirúrgicas e médicas (excluídos os não comunicantes), com idade média de 69 anos, de ambos os gêneros, a quem foi realizada uma entrevista após o cumprimento dos respetivos procedimentos formais e éticos. RESULTADOS: Obteve-se prevalência de dor nas 24 horas anteriores ao estudo de 52,5% (28,8% dor intensa). Na altura da entrevista, a prevalência diminuiu para 41,1% (2,7% de dor intensa). Os pacientes com mais dor estavam internados nos serviços cirúrgicos e o tipo de dor era sobretudo musculoesquelética. A maioria dos pacientes com dor esperou, no máximo, 10 minutos para lhe ser administrado um analgésico. Dos 57 que referiram dor no momento da coleta dos dados, 46 (80,7%) não desejaram outro fármaco e 91,3% mostraram-se satisfeitos com o seu tratamento. CONCLUSÃO: Nessa instituição houve prevalência e abordagem da dor semelhantes às da literatura, mas a dor ainda se encontra subtratada. Esses dados permitirão a definição e implementação de um programa de controle de dor mais dirigida e eficaz.

BACKGROUND AND OBJECTIVES: Studies on pain prevalence systematically point to high values. Although not comparable, a global analysis allows inferring that from every two hospitalized patients, one is in pain. This study aimed at determining pain prevalence, its characteristics, analgesic treatment and satisfaction of patients admitted to a hospital in the Center of Portugal with regard to pain evaluation and treatment. METHODS: This is a transversal and observational study with 141 patients admitted for at least 24 hours to surgical and medical units (excluded those unable to communicate), with mean age of 69 years, of both genders, who were interviewed after compliance with respective formal and ethic procedures. RESULTS: Pain prevalence in the 24 hours previous to the study was 52.5% (28.8% severe pain). During interviews, prevalence has decreased to 41.1% (2.7% severe pain). Patients with more severe pain were admitted to surgical services and pain was primarily musculoskeletal. Most patients with pain have waited no more than ten minutes before analgesics were administered. From 57 patients referring pain during data collection, 46 (80.7%) did not require a different drug and 91.3% were happy with their treatment. CONCLUSION: In this institution, there has been pain prevalence and approach similar to the literature, but pain remains undertreated. Such data shall allow the definition and implementation of a more focused and effective pain control program.

Clinical analysis of standardized drug treatment of cancer pain at the pain clinic / 中国肿瘤临床

Objective: To observe the efficacy and safety of analgesic drugs in the standardized treatment of cancer pain patients at the pain clinic. Methods: The data of 787 cancer pain patients and their corresponding prescriptions for cancer pain were collected from April, 2012 to April, 2013 at the pain clinic. The obtained information comprise of diseases that lead to cancer pain, cause of pain, pain intensity, and efficacy and side effects of medications. Diseases that caused cancer pain include 658 cases with primary malignant lung cancer. Results: Pain was mainly caused by primary lung cancer in 787 cancer-related patients. An analgesic drug, namely, oxycodone hydrochloride, was administered in 54.6% via single drug therapy. The daily dosage range of this drug was 20 to 90 mg/d in 280 cases. About 35.6% of the studied patients with a daily dosage of 90 mg/d or lower had their pain effectively managed. After the treatment, the number of cases with moderate to severe pain was reduced from 437 (55.5%) to 248 (31.5%). The oral administration of opioid oxycodone hydrochloride tablets ranked first among the prescribed drugs for cancer pain, and single-drug therapy was the choice of medication. The majority of patients had satisfactory pain-relief with a daily dosage of less than 90 mg/d upon the administration of oxycodone hydrochloride sustained-release tablets and morphine sulfate controlled-release tablets. Side effects included mild constipation, nausea, vomiting, dizziness, loss of appetite, urinary retention, somnolence, and so on. Intervention treatment was needed in most of the patients. Conclusion: Pain clinic is critical in the administration of standardized treatment for cancer pain in hospitals. The establishment of pain clinic ensures the standardized treatment of cancer pain.

Perfil sócio-demográfico e clínico de uma coorte de pacientes encaminhados a uma Clinica de Dor / Socio-demographic and clinical profile of a cohort of patients referred to a Pain Clinic

JUSTIFICATIVA E OBJETIVOS: No Brasil há pouca informação do perfil dos usuários de Clinica de Dor e o impacto que esta demanda tem sobre a utilização dos serviços de saúde. O objetivo deste estudo foi identificar o perfil dos pacientes encaminhados a uma Clinica de Dor por meio de variáveis sócio-demográficas e clínicas obtidas em triagem específica, correlacionando estas variáveis ao tempo e intensidade da dor. MÉTODO: Estudo descritivo, exploratório de coorte transversal no qual foram incluídos 128 indivíduos, atendidos em ambulatório especializado no tratamento da dor. As variáveis independentes incluíram idade, gênero, estado civil, situação laboral, escolaridade, religiosidade, etnia, clinica que encaminhou, diagnóstico de origem, diagnóstico da Clinica da Dor, tempo e tipo de dor. Os instrumentos de avaliação foram uma ficha eletrônica e o exame fisico realizado por médico especialista em dor. A coleta de dados ocorreu no momento da primeira visita à clínica, antes da interação com qualquer provedor de cuidados de saúde. RESULTADOS: A prevalência de dor foi maior no sexo feminino (58,5%), nos casados (66,4%), nos inativos (62,5%) e naqueles com escolaridade média de 6,8 ± 3,5 anos. A maioria tem crenças religiosas (93,7%). O tempo médio de dor foi de 32,6 ± 21,9 meses. Houve correlação positiva entre intensidade e maior tempo de dor nas mulheres e nível educacional menor que 5 anos (p < 0,05). CONCLUSÃO: Os pacientes com dor crônica anteriormente sob os cuidados de outra especialidade encaminhados para uma Clinica de Dor, fornecem dados que podem contribuir para o controle da dor com alternativas terapêuticas mais eficazes, pela interação entre os conhecimentos dos diferentes profissionais.

BACKGROUND AND OBJECTIVES: There is little information in Brazil about the profile of Pain Clinic users and the impact of this demand on health services. This study aimed at identifying the profile of patients referred to a Pain Clinic using socio-demographic and clinical variables obtained by specific screening, correlating such variables to pain duration and intensity. METHOD: This is a cohort descriptive, transversal and exploratory study with 128 individuals seen by an outpatient setting specialized in pain management. Independent variables included age, gender, marital status, labor status, education, religiousness, ethnicity, clinic referring patients, original diagnosis, Pain Clinic diagnosis, pain duration and type. Evaluation tools were an electronic card and the physical evaluation performed by a pain specialist. Data were collected at first visit before the interaction with any health care provider. RESULTS: Pain was more prevalent among females (58.5%), married (66.4%), inactive (62.5%) and in those with mean school attendance of 6.8 ± 3.5 years. Most have religious beliefs (93.7%). Mean pain duration was 32.6 ± 21.9 months. There has been positive correlation between pain intensity and longer duration among females and educational level lower than 5 years. (p < 0.05). CONCLUSION: Chronic pain patients previously under the care of a different specialty and referred to a Pain Clinic supply data which may contribute to control pain with more effective therapeutic approaches, by the interaction of the knowledge of different professionals.

Characteristics and Treatment of Pain after Inflammatory Spinal Demyelination: 271 Cases Report / 中国康复理论与实践

@#Objective To explore the characteristics and treatment of pain after inflammatory spinal demyelination. Methods 271 patientssuffered from inflammatory spinal demyelination with pain were analyzed retrospectively. Results Acute radicular pain and Lhermitte'ssign were common in the acute pain syndromes. Individual therapy showed a benefit of decreased pain. Conclusion Pain is a commonclinical symptom of inflammatory spinal demyelination. Individualized therapeutic decisions could relieve symptom and improve outcome.

Advance in Pulsed Radiofrequency for Chronic Neuropathic Pain (review) / 中国康复理论与实践

@# Pulsed radiofrequency (PRF) which can form high voltage around the tissues by emitting pulsed electric current may affect activity of synapses and cytokine. It has many advantages, such as smaller trauma, easier manipulation, safer, better effect, and so on.

Effectiveness of a flow chart of medication for cancer pain treatment with controlled-release oxycodone tablets

<b>Purpose</b>: The effectiveness of a flow chart of medication for cancer pain treatment was investigated. This flow chart was developed at Sasebo Chuo Hospital, and calls for the early introduction of controlled-release oxycodone tablets in combination with prescribing of a rescue dose and agents to prevent adverse reactions such as nausea, vomiting, and constipation. <b>Method</b>: The flow chart was used with a group of 29 patients (FC group), but not with a group of 35 patients (non-FC group). The rate of titration, which was adjustment of opioid dosage to achieve cancer pain control, and time required to achieve titration were compared between these two groups. <b>Results</b>: The titration rate of the FC group was 93.1% and that of the non-FC group was 80.0%. Medication was changed to another opioid for 4 patients in the non-FC group because of nausea and vomiting. The time required to achieve titration was 3.8±2.2 days in the FC group and 5.3±3.0 days in the non-FC group, and a significant difference was noted (<I>p</I>=0.048). <b>Conclusion</b>: The use of this flow chart with its early introduction of opioid controlled-release oxycodone tablets appears to be effective in achieving cancer pain control at an early stage.

Percutaneous Laser Disc Decompression for Treatment of Lumbar Discogenic Pain / 中国康复理论与实践

@# Objective To investigate the therapeutic effect of percutaneous laser disc decompression on lumbar discogenic pain.Methods56 patients with lumbar discogenic pain were treated with percutaneous laser disc decompression with Nd:YAG laser(wavelength 1064 nm).They were followed up for more than 3 months with Macnab criteria.ResultsAll the patients were followed up.At the end point of postoperative 3 months,32 patients had an excellent outcome,20 were good,3 patients were fair,1 patient were poor.No complication(infection and nerve injury)had been observed.ConclusionPercutaneous laser disc decompression is a safe,little invasive and effective treatment modality for lumbar discogenic pain.

Dolor en el trauma térmico / Pain in thermal trauma

La máxima agresión física que puede sufrir un ser humano son las quemaduras. Actualmente, en Chile se hospitalizan alrededor de 9.000 personas al año por quemaduras, con una tasa de mortalidad que ha ido en disminución en los últimos 20 años, por lo tanto la cantidad de pacientes sobrevivientes va en aumento. La IASP (Internacional Association for Study of Pain) definió el dolor en quemados como: "un dolor agudo y grave, que se produce al sufrir una quemadura y luego continuo con exacerbaciones que declinan gradualmente". El dolor en el trauma térmico está siempre presente, es de intensidad severa y prolongada en el tiempo, con una alta prevalencia de dolor crónico. Se sabe que el aumento en la intensidad se debe a que las quemaduras dañan gran cantidad de nociceptores, produciéndose una amplificación de la respuesta al dolor. Los opioides son el principal pilar en el tratamiento farmacológico. Es fundamental el buen manejo del dolor, para evitar el dolor patológico que aumentará el dolor crónico y con ello el desmedro de la vida personal de nuestros pacientes. Desafortunadamente el subtratamiento es una realidad, produciendo directamente un retraso en la recuperación de sus quemaduras y en la inserción social y laboral.

Burns are the greatest physical aggression that a human being can experience. In Chile, approximately 9000 patients are hospitalized annually due to burns, with a mortality rate that has decreased progressively in the last 20 years, which means that the amount of survivors is increasing. The IASP (International Association for Study of Pain) has defined pain in the burn patient as "an acute and severe pain produced by a burn that later continues with exacerbations that gradually decline". Pain in thermal trauna is always present, of severe intensity and prolonged in time, with a high prevalence of chronic pain. It is Known that the increase in intensity of pain is due to the damage of a great number of nociceptors, that produces an amplification of the response to pain. Opioids are the mainstay of pharmacologic treatment. Appropriate management of pain is fundamental to avoid pathologic pain that will increase the chronic pain and deteriorate the quality of life of our patients. Unfortunately undertreatment is a reality, retarding the healing of the burn wound, and the social and workplace reintegration.

Farmacoeconomia da terapia analgésica utilizada na dor pós-operatória / Pharmacoeconomics of analgesic therapy used in postoperative pain

|a Neste estudo estimou-se o custo direto da terapia analgésica utilizada durante o período do pós-operatório (PO) e realizou-se a análise farmacoeconômica dos esquemas analgésicos administrados a pacientes submetidos à cirurgia eletiva, no 1º dia de PO de. Analisaram-se 166 prontuários de pacientes que, no período de 01 de janeiro de 1997 a 31 de dezembro de 1998, realizaram hemorroidectomia em um Hospital Geral e Privado do município de São Paulo. Os dados provenientes da população possibilitaram traçar o perfil da prescrição analgésica, identificar os esquemas terapêuticos e caracterizar o comportamento álgico dos pacientes. Para realização da análise minimização de custo e custo-efetividade, inicialmente, foram identificados os 5 esquemas analgésicos mais utilizados na prática clínica: propoxifeno 231 mg +aspirina 935 mg + cetoprofeno 200mg (DOL1A+PROF2A), cetoprofeno 300mg (PROF1B), codeína 120mg + paracetamol 2.000mg (TYL1A), codeína 120mg + paracetamol 2.000mg + cetoprofeno 200mg (TYL1A+PROF2A) e codeína 90mg + paracetamol 1.500mg + cetoprofeno 200mg (TYL1B+PROF2A); em seguida estimaram-se seus custos e respectivas efetividades, que foram medidas utilizando-se dois critérios: os registros de escapes de dor e o consumo de analgésico opióide (AO) no regime se necessário (RSN). Os resultados mostraram que o custo direto total da terapia analgésica de R$ 14.062,15 foi composto pelo regime de horário (66,77%) e regime se necessário (33,23%) e que a categoria procedimento da administração de medicamentos, realizada pela enfermagem, representou 46,99% do custo total da terapia. Os esquemas DOL1A+PROF2A e TYL1A apresentaram efetividades semelhantes e superiores aos demais, que resultaram em 30,00% de pacientes sem registro de escapes de dor nas 24 horas do 1ºPO. Na comparação destes esquemas pela análise minimização de custo o padrão TYL1A mostrou menor custo (R$19,57). O custo-efetividade médio demonstrou que o ) TYL1A foi o esquema mais efetivo e que apresentou o menor custo por paciente sem registro de escape de dor (R$65,23). Em relação à análise dos esquemas utilizando-se o critério consumo de AO no RSN verificou-se que os 5 esquemas apresentaram efetividades distintas, sendo o TYL1A+PROF2A o mais efetivo, seguido do TYL1A, com respectivamente 59,50% e 50,00% dos pacientes que não consumiram AO no RSN nas 24 horas do 1ºPO. O esquema de melhor relação custo-efetividade médio foi o TYL1A (R$39,14) seguido do TYL1A+PROF2A (R$45,74). A análise incremental apontou que o esquema TYL1A+PROF2A expressa um custo adicional de R$80,53 para se obter um benefício extra de efetividade. As análises farmacoeconômicas mostraram que a escolha do esquema analgésico mais adequado deve contemplar, além dos aspectos econômicos e clínicos das opções terapêuticas, a disponibilidade de recursos da instituição.

This study estimated the direct cost of analgesic therapy used during the postoperative (PO) period and performed a pharmacoeconomic analysis of the analgesic therapies administered to patients who underwent elective surgery on the first postoperative day. One hundred and sixty-six patient's records were assessed from January 1st, 1997 to December 31st, 1998. All these patients underwent hemorrhoidectomy in a Private General Hospital of the County of São Paulo. Population data allowed us to draw analgesic prescription profile, identify therapeutic strategies and characterize patient's breakthrough pain. At first, the 5 most used analgesic therapies in clinical practice which were propoxyphene 231 mg + aspirin 935 mg + ketoprofen 200 mg (DOL1A+PROF2A), ketoprofen 300 mg (PROF1B), codeine 120 mg + acetaminophen 2000 mg (TYL1A), codeine 120 mg + acetaminophen 2000 mg + ketoprofen 200 mg (TYL1A+PROF2A), and codeine 90 mg + acetaminophen 1500 mg + ketoprofen 200 mg (TYL1B+PROF2A) were identified in order to perform cost-minimization and cost-effectiveness analyses. Afterwards it was estimated their cost and effectiveness which were measured by two criteria: breakthrough pain registers and supplementary consumption of opioid analgesics (OA). Results showed that the total direct cost of analgesic therapy of R$ 14,062.15 included around the clock method (66.77%) and rather than as need method (33.23%) and also that the medicine administration procedure category performed by the nursing staff represented 46.99% of the total cost of the therapy. The DOL1A+PROF2A and TYL1A therapies showed similar and higher effectiveness than the others, resulting in 30% of the patients without breakthrough pain registers during the first 24 hours of PO. When comparing these therapies by cost-minimization analysis, TYL1A therapy was less costly (R$19.57). The mean cost-effectiveness showed that TYL1A was the most effective therapy and showed the lowest cost per patient without breakthrough pain register (R$65.23). Regarding therapy analysis by applying supplementary OA consumption criterion, it was observed that the 5 therapies showed different effectiveness, considering that TYL1A+PROF2A was the most effective, followed by TYL1A, with respectively 59.50% and 50% of the patients who did not take supplementary OA in the first 24 hours of PO. The therapy that showed the best mean cost-effectiveness ratio was TYL1A (R$39.14) followed by TYL1A+PROF2A (R$45.74). The incremental analysis found that TYL1A+PROF2A has an additional cost of R$80.53 in case an extra benefit of effectiveness is needed. The pharmacoeconomic analyses showed that for the most suitable analgesic therapy choice, not only should economic and clinical aspects of therapeutic choices be taken into account but also resources availability of the institution.

Controle da dor pós-operatória: comparação entre métodos analgésicos / Postoperative pain relief: comparision among analgesic methods

Neste estudo, comparou-se o alívio da dor, a ocorrência de efeitos colaterais, o consumo de analgésicos, regular e complementar, e os custos do tratamento analgésico, em doentes submetidos a diferentes métodos de analgesia pós-operatória. Analisaram-se 403 prontuários de pacientes que, no período de janeiro de 1997 a dezembro de 1998, receberam analgesia pós-operatória sob a responsabilidade do Serviço de Terapia da Dor de um hospital geral e privado de São Paulo. Os métodos analgésicos utilizados foram a Analgesia Controlada pelo Paciente, por meio de bomba de infusão, e analgesia peridural convencional, por meio de seringa. De acordo com o método de analgesia recebido, formaram-se 5 grupos: infusão intravenosa contínua associada a bolo (IVC+B), infusão intravenosa somente em bolo (IVB), infusão peridural contínua associada a bolo (PC+B), infusão peridural em bolo (PB), infusão peridural em bolo por meio de seringa (PS). Os doentes dos 5 grupos não diferiram quanto à idade e ao sexo, diferiram quanto ao porte da cirurgia a que se submeteram e não foi possível compará-los quanto ao tipo de cirurgia. A maioria (92,9 %) dos doentes referiu ausência de dor ou dor leve, considerando-se todos os métodos analgésicos. Maior ocorrência de dor moderada a intensa foi observada no método PS e a maior e a menor média de intensidade de dor nos métodos IVC+B e PC+B, respectivamente. Essas diferenças foram estatisticamente significativa (p<0,05). Efeitos colaterais ocorreram em 44,8% dos doentes, perfazendo média de 0,72 por doente. Do conjunto de doentes estudados, a náusea e o vômitos foram os efeitos colaterais mais freqüentes (31,7% e 18,1%, respectivamente). Observou-se predomínio de prurido (p<0,001), no método PS, e retenção urinária (p=0,002), nos métodos PB e PC+B. A diferença quanto ao uso de analgésicos opióides de modo regular (maior consumo na via peridural) deveu-se às característica da via. ) Não houve diferença quanto ao número de analgésicos complementares utilizados. O método PS foi o mais barato, equivalendo a 51,6% do preço dos métodos mais caros (PC+B e PB). Visto que a magnitude da dor foi pequena, as diferenças observadas entre os métodos, possivelmente, apresentaram pequena expressão clínica. As diferenças de custo entre os métodos foram significativas, o que talvez possa ser fator importante na escolha da terapia.

This study compared the relief of pain, the occurrence of side effects, the regular and supplementary consumption of analgesics, and the costs of analgesic treatments among patients submitted to different methods of postoperative analgesia. 403 medical records of patients receiving postoperative analgesia in the period from January 1997 to December 1998 at the Pain Therapy Service of a private general hospital in the city of São Paulo were analyzed. The analgesic methods utilized were the Patient-Controlled Analgesia by means of infusion pump and the conventional peridural analgesia by means of syringe. Five groups were formed, according to the method of analgesia the patients received: continuous intravenous bolus-associated infusion (IVC+B), in-bolus only intravenous infusion (IVB), continuous peridural bolus-associated infusion (PC+B), in-bolus peridural infusion (PB), and in -bolus peridural infusion by means of syringe (PS). Patients in the 5 groups did differ as to age and sex, but they differed as to the size of the surgery they have been submitted, but it was not possible to compare them in relation to the type of surgery. Most of the patients (92,9%) reported lack of pain or slight pain, considering all the analgesic methods. The highest occurrence of moderate-to-intense pain was found in the PS method, whereas the highest and lowest average of pain intensity were found in the IVC+B and PC+B methods, respectively. These differences were statistically significant (p<0.05). 44,8% of the patients had side effects, representing a 0.72 average per patient. From the total universe of patients in the study, nausea and vomit were the most frequent side effects (31.7% and 18.1%, respectively). A prevalence of itching (p<0.001) in the PS methods and urine retention (p=0.002) in the PB and PC+B methods was found. The difference found regarding the use of opioid analgesics on a regular basis (highest consumption in intravenous route than in peridural route) results from features of the route. No difference was found as to the number of supplementary analgesics utilized. The PS method was the less expensive, corresponding to 51.6% of the price of the more expensive methods (PC+B and PB). Since pain magnitude was small, the difference among the methods found in the study had possibly low clinical significance. Cost differences among the methods were significant, which may be an important factor determining the choice for a certain therapy.