Opioids for chronic nonmalignant pain. Choosing suitable candidates for long-term therapy.

Opioid maintenance analgesia for chronic nonmalignant pain can be successful in selected cases, but it is not a panacea for all pain, and management of patients using opioids can be an arduous process. A consistent and principle-based approach is recommended. Passion and chauvinism exist on both sides of the controversy and should be discouraged.

Following the clues to neuropathic pain. Distribution and other leads reveal the cause and the treatment approach.

Neuropathic pain can seem enigmatic at first because it can last indefinitely and often a cause is not evident. However, heightened awareness of typical characteristics, such as the following, makes identification fairly easy: The presence of certain accompanying conditions (e.g., diabetes, HIV or herpes zoster infection, multiple sclerosis) Pain described as shooting, stabbing, lancinating, burning, or searing Pain worse at night Pain following anatomic nerve distribution Pain in a numb or insensate site The presence of allodynia Neuropathic pain responds poorly to standard pain therapies and usually requires specialized medications (e.g., anticonvulsants, tricyclic antidepressants, opioid analgesics) for optimal control. Successful pain control is enhanced with use of a systematic approach consisting of disease modification, local or regional measures, and systemic therapy.

Institutionwide pain management improvement through the use of evidence-based content, strategies, resources, and outcomes.

The Agency for Health Care Policy and Research pain guidelines and implementation theories were used in this improvement initiative to ensure that evidence-based pain management reached every provider and patient in a large tertiary care hospital. Implementation strategies, products, and outcome measures are described for use in the clinical setting. Critical success factors and implementation barriers are also addressed.

Improving pain management after total joint replacement surgery.

PURPOSE: To test the effects of implementing evidence-based postoperative pain management content and strategies on patient, provider (nurse and physician), and fiscal outcomes. SAMPLE: 118 patients, 57 before and 61 after implementation, having total knee replacement (TKR) (54%) and total hip replacement (THR) (45%), and 28 orthopaedic nurses. METHODS: A research utilization approach with a pretest/posttest design was used. Independent variables (interventions) included evidence-based pain management content, education of care providers and patients, and system changes at the point of care. Dependent variables (outcomes) were patient perception of the postoperative pain experience, provider practice patterns, and length of stay (LOS). FINDINGS: The hypotheses of decreased provider use of meperidine and increased use of hydromorphone, i.v. route, pain plans of care, and nurse knowledge were supported. LOS was significantly reduced. The patient hypotheses decreased pain intensity and side effects and increased satisfaction and function were not supported. CONCLUSION: Methodical implementation of evidence-based pain management information changed practice and fiscal outcomes. Improvement in the patient perception of pain management was more difficult to achieve.

Complex regional pain syndrome.

The term "complex regional pain syndrome" encompasses causalgia and reflex sympathetic dystrophy. Symptoms of burning pain with autonomic and tissue changes begin shortly after an injury, usually to a distal extremity. The diagnosis is based on the history and the clinical findings. No confirmatory tests are available, although plain radiographs or a three-phase bone scan may be helpful in diagnosing some cases. Aggressive treatment, which may include sympathetic blockade, medications, physical therapy and psychotherapy, is essential for a favorable outcome. Despite treatment, many patients are left with varying degrees of chronic pain and disability.

Pharmacologic management of cancer pain in rural Minnesota.

Use of analgesic medications for cancer pain was assessed in six Minnesota communities. In our survey, cancer patients were treated primarily by family practice physicians. Approximately 70% were given one or more analgesics; 84% received a nonsteroidal antiinflammatory drug and 73% received an opioid. Most patients given an antiinflammatory drug received less than the maximal recommended dose for the drug. The most common opioid for cancer pain was oral morphine. Approximately 40% of the patients treated with opioids took the drug only when needed; the remainder took the drug around-the-clock, with or without additional opioids for breakthrough pain. Only 14% of patients who received analgesics received a coanalgesic and only 13% received a nonanalgesic adjuvant. The patterns of analgesic use in these communities corresponded well with accepted principles of cancer pain management: liberal use of opioids, use of oral morphine as the predominant agent, and avoidance of meperidine and opioid agonist/ antagonists.

The comparison of patients suffering from temporomandibular disorders and a general headache population.

The purpose of this study was to examine the possible association of signs and symptoms of temporomandibular disorders relative to headache. Fifty-six sequential patients referred to the Headache Institute of Minnesota for evaluation and treatment of migraine and tension headaches were examined for signs and symptoms of temporomandibular disorders. The results of the examination of headache patients were compared to patients suffering from myofascial pain dysfunction and/or TMJ internal derangements from the TMJ and Craniofacial Pain Clinic at the University of Minnesota. Finally the migraine and tension headache patients were compared to each other and an asymptomatic population. Results indicate that patients with temporomandibular disorders exhibit significantly more jaw dysfunction and pericranial muscle tenderness than migraine and tension headache patients. Migraine and tension headache patients were found to have similar amounts of pericranial muscle tenderness. Migraine and tension headache patients exhibited significantly more pericranial and neck muscle tenderness than a general population.

Pain in hospitalized patients with medical illnesses.

To evaluate the prevalence of pain in hospitalized patients with medical illness, we retrospectively reviewed the records of 313 consecutive admissions to the medical service of the Hennepin County Medical Center. Of the 224 eligible patients, 157 (70.1%) experienced nonprocedural pain on presentation or in the hospital, and pain was the chief complaint of 34.8%. In order of frequency, the most common types of pain were headache, cardiac pain, abdominal pain, noncardiac chest pain, joint pain, and hepatic pain. Female patients were more likely to have pain complaints, especially headache and joint pain. Patients with pain tended to be older, but this did not reach statistical significance. Among patients with pain, no quantitative assessments of pain intensity were documented in the medical record by any caregiver. This study underscores both the high prevalence of pain and the lack of pain assessment among patients hospitalized for acute medical illnesses. Adequate evaluation and management of pain should be considered as an important part of quality care.

Exertional Headache.

In brief Exertional headaches can occur brief dynamic efforts such as running and swimming. They can also stem from static exertion such as weight lifting. Described here are two patients who experienced headaches of sudden onset while waterskiing. The headaches recurred with other forms of exertion. Both patients had normal neurologic examinations and CT scans. After avoiding aggravating activities and taking nonsteroidal anti-Inflammatory medication as necessary, the patients' headaches gradually resolved.

Diabetic neuropathy. Helping patients cope with their pain.

Diabetic neuropathy may have a metabolic or an ischemic origin, and the pattern of nerve damage varies by cause. Treatment should address the underlying cause. Patient reassurance, relaxation techniques, glucose control, use of tricyclic antidepressants or anticonvulsants, and surgical decompression for entrapment neuropathy are currently the mainstays of treatment. Physicians must reassure these patients that neuropathic pain is temporary.

Cocaine-related vascular headaches.

The records of 21 patients admitted to hospital from January 1985 to December 1988 for acute headache associated with cocaine intoxication were reviewed. Fifteen patients were identified who experienced headaches with migrainous features in the absence of neurological or systemic complications. None of them had a history of cocaine-unrelated headaches or a family history of migraine, and all had a favourable outcome. Three possible mechanisms of cocaine-related vascular headaches are discussed which depend on the interval between cocaine ingestion and development of the headache. We postulate that acute headaches following cocaine use may relate to the sympathomimetic or vasoconstrictive effects of cocaine, while headaches following cocaine withdrawal or exacerbated during a cocaine "binge" may relate to cocaine-induced alteration of the serotoninergic system.

Comparison of single-dose meperidine, butorphanol, and dihydroergotamine in the treatment of vascular headache.

We treated 64 emergency room patients with a primary vascular headache with dihydroergotamine (DHE), meperidine, or butorphanol. Post-treatment pain scores were lowest in the DHE group (p less than 0.01). Eight of 21 patients receiving DHE had greater than 90% reduction in pain compared with three of 19 patients receiving butorphanol and none of 22 receiving meperidine.

Control of pain in cancer patients.

Almost three quarters of patients with cancer have severe pain, from invasion of the cancer itself, from effects of therapy, or from causes unrelated to the cancer (but often exacerbated by it). With the proper pain-management strategy, however, pain can be controlled in most patients. The analgesic ladder for pain control, promoted by the World Health Organization, begins with a nonnarcotic agent, progresses to a weak narcotic plus a nonnarcotic, and finally reaches a strong narcotic. Adjuvant agents, which increase the analgesic potency of the drug being used, may be added at any level. The most common reasons for inadequate pain control in cancer patients are incorrect narcotic dosing and incorrect switching from one narcotic to another and from one route of administration to another. Factors that influence pain management (eg, fear, anxiety, sleep disturbance) should be treated as well with appropriate medications, behavioral therapy, counseling, hypnosis, and other supportive techniques. These points are illustrated in the case report (see box, page 328).

Effect of acupuncture on experimentally induced itch.

We evaluated the effect of acupuncture on histamine-induced itch and flare in healthy volunteers (n = 25) and compared it with the effect of a pseudo-acupuncture procedure and of no-intervention in a single-blind randomized cross-over study. A cumulative itch index is defined and was found to be smaller with acupuncture than with either pseudo-acupuncture (p less than 0.02) or with no-intervention (p less than 0.005). The duration of itching was shorter with acupuncture than with either pseudo-acupuncture (p = 0.006) or with no-intervention (p less than 0.001). In addition, maximal flare area was decreased with acupuncture compared with pseudo-acupuncture (p less than 0.04) and with no intervention (p = 0.003). Acupuncture had little or no effect on the itch onset time or on the maximal itch intensity after intradermal injection of histamine. Measurements of itching correlated poorly with measurements of flare size in all three experimental groups. Acupuncture appears to be an effective inhibitor of histamine-induced itch and flare. Moreover, acupuncture points displayed specificity in that needling near-by, non-acupuncture sites resulted in greater itching and larger flares.