Nonsteroidal Anti-Inflammatory Drugs and Opioids in Postsurgical Dental Pain.

Postsurgical dental pain is mainly driven by inflammation, particularly through the generation of prostaglandins via the cyclooxygenase system. Thus, it is no surprise that numerous randomized placebo-controlled trials studying acute pain following the surgical extraction of impacted third molars have demonstrated the remarkable efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, etodolac, diclofenac, and ketorolac in this prototypic condition of acute inflammatory pain. Combining an optimal dose of an NSAID with an appropriate dose of acetaminophen appears to further enhance analgesic efficacy and potentially reduce the need for opioids. In addition to being on average inferior to NSAIDs as analgesics in postsurgical dental pain, opioids produce a higher incidence of side effects in dental outpatients, including dizziness, drowsiness, psychomotor impairment, nausea/vomiting, and constipation. Unused opioids are also subject to misuse and diversion, and they may cause addiction. Despite these risks, some dental surgical outpatients may benefit from a 1- or 2-d course of opioids added to their NSAID regimen. NSAID use may carry significant risks in certain patient populations, in which a short course of an acetaminophen/opioid combination may provide a more favorable benefit versus risk ratio than an NSAID regimen.

Chemotherapy-evoked painful peripheral neuropathy.

Vincristine and paclitaxel, two of the most effective drugs in the battle against cancer, produce a dose-limiting neurotoxicity that sometimes presents as a painful peripheral neuropathy. For the first time, investigators have been able to produce these chemotherapy-evoked painful peripheral neuropathies in the laboratory rat. These new models have already begun to elucidate the causes of the neuropathic pain associated with these antineoplastic drugs, which will now make it possible to search for effective ways to prevent and treat it.

Evidence for opioid variability, Part 1: A biological perspective.

The interplay of biological and pyschosocial factors explain the unique individual differences in opioid requirements that occur among postoperative patients. Nurses must be familiar with the physiologic mechanisms that influence opioid analgesia. Despite growing evidence that doses of opioid analgesics needed to achieve pain relief vary significantly from patient to patient, standardized dosing regimens continue to drive administration of medications for postoperative pain. In this article, evidence-based literature related to the biologic factors that contribute to differences in responses to opioid medication will be examined. Content will assist the Perioperative Nurse to recognize the pharmacology of opioid analgesics and the scientific basis for differences in the body's ability to metabolize and excrete opioids. These differences include age, gender, genetic predisposition, type of surgical procedure, preexisting pain, and prior or concurrent opioid use. Specific terms are introduced and defined to increase understanding of opioid variability.

Evidence for opioid variability, Part 2: Psychosocial influences.

There is substantial evidence to show that certain biological and psychosocial factors affect opioid requirements after surgery. In fact, evidence suggests that individuals are much more likely to be different rather than similar in how they sense pain, react to it and respond to therapy. In an earlier report (Seminars in Perioperative Nursing 10:3-16, 2001), we examined research related to the biological differences that explain variability in postoperative opioid use and defined relevant terminology. Here, we discuss the evidence that links psychosocial experiences to postoperative analgesic outcomes and pain, which include psychological states of patients, cultural influences and attitudes, and beliefs and biases held by both patients and health professionals. Content will assist perioperative nurses to understand the characteristics of their patients and circumstances that place patients at risk for needing increased analgesia or experiencing poor pain control. As perioperative nurses strive to integrate research into practice, it will be important to examine the results of research studies and to determine the usefulness of this information in developing individualized plans for postoperative pain management.

The relationship of gender to pain.

Gender differences have been identified in the perception of pain intensity for both acute and chronic pain and with responses to analgesics. Women seem to show lower pain thresholds, a greater ability to discriminate painful sensations, higher pain ratings, and a lower tolerance for pain. Although some pain syndromes, such as facial pain, are more common in women, gender-related responses to pain are not completely consistent. The study of gender differences in relation to pain is relatively new, yet promising. This article reviews the evidence for how gender may play a role in reports of pain intensity, measurements of patient responses, and differences in response to pain therapies. Literature that addresses pain perception and response in acute and chronic nonmalignant and cancer pain states, experimentally induced pain, and responses to analgesics are reviewed in terms of their relationship to gender. Although there are conflicting results for experimental and clinical studies, there is agreement among investigators that certain factors, such as perceptual ability and physiologic mechanisms, do explain gender-related differences to pain and its treatment. Gender is an important variable and should be taken into account in both research and the clinical practice of pain management.

Sedation and analgesia for oncological patients undergoing interventional radiologic procedures.

Patient-specific factors and knowledge of drug therapy direct CS and analgesia practices for oncology patients undergoing interventional radiologic techniques. Nurses caring for oncology patients in this setting must understand the effects of cancer on anatomic structures and physiologic functions. Variability in responses to pain and drug therapy observed among oncology patients necessitates the need for highly individualized plans of care that sometimes deviate from standard CS and analgesia procedures. Therefore, sedation and analgesia policies that apply to oncology patients must include flexible dose ranges for drugs such as opioids and benzodiazepines and guidelines for titrating these drugs to optimal effects. Although frequent assessments of pain using subjective reports remain the most valid indicators of adequate pain control, familiarity with radiologic interventions and responses of anatomic structures to various types of noxious stimuli allows the nurse to anticipate aspects of procedures known to be painful. Attention to symptom management both during and after the procedure is critical because patients with progressive cancer may present with significant physical and psychological alterations. In summary, CS and analgesia practices for oncology patients are based on sound pharmacologic principles and influenced by myriad factors that can be considered only in the context of the patient's own uniqueness and experiences.

Quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower-extremity amputation.

One hundred nine patients with long-bone fracture nonunion, chronic refractory osteomyelitis, and posttraumatic amputation were evaluated to assess the impact of chronic disability on the quality of life. The quality of life parameters were defined by a functional assessment instrument, the Arthritis Impact Measurement Scale (AIMS), and a Psychosocial Adjustment to Illness Scale (PAIS). A spouse PAIS self-report instrument was administered to assess the psychosocial adjustment of spouses or significant others. A final questionnaire was developed to determine the reasons, in order of their importance, for either continuing medical therapy or accepting amputation. The PAIS scores differed significantly between osteomyelitis patients and nonunion or amputation patients. The presence or absence of pain produced significant differences in AIMS and PAIS scores of nonunion and osteomyelitis patients. Subscale analysis of AIMS scores showed significant differences among the three groups with respect to health perception and scale of orthopaedic problem. The osteomyelitis patients were more severely affected than the nonunion or amputation patients. The PAIS was unable to detect any statistically significant differences in psychosocial adjustment of the spouses of patients in each of the three population groups. The most frequent reason for continuing medical and surgical management of nonunion and osteomyelitis was hopeful expectation for cure. The group who chose amputation did so in an attempt to put an end to the need for medical and surgical treatment. Differences in psychosocial and functional ability were related to disease diagnosis, pain, status of fracture healing, and timing of amputation. This study provides further insight into the quality of life experience for patients with long-term orthopaedic problems.

Interpleural analgesia for the management of postoperative pain.

Interpleural analgesia offers effective postoperative pain control and can enhance patient participation in pulmonary care regimens. Nurses play a vital role in the management of these patients by assisting with interpleural analgesia administration and monitoring patient outcomes.