Intravenous high-dose methadone administered by patient controlled analgesia and continuous infusion for the treatment of cancer pain refractory to high-dose morphine.

The management of severe tumor-related pain in the patient with cancer may be problematic. Systemically administered opioids remain the cornerstone of treatment for moderate to severe cancer pain, while parenteral routes should be considered for patients who require rapid onset of analgesia, and for highly tolerant patients whose dose requirements cannot be conveniently administered. The use of intravenous methadone by patient controlled analgesia (PCA) is attractive for the management of severe, intractable cancer pain and may offer some advantages over morphine. We describe the safe and effective use of high-dose intravenous methadone by PCA and continuous infusion for a patient with intractable tumor-associated cancer pain who experienced inadequate pain control and dose-limiting side-effects with high-dose intravenous morphine.

Acute pain management in patients with prior opioid consumption: a case-controlled retrospective review.

The patient with a history of current opioid consumption presenting in the acute postoperative setting presents a challenge for pain management. Standard treatment dosages and strategies are often ineffective in providing pain relief. This retrospective case-control study reviews 4 years' experience of the Acute Pain Service (APS) at our institution providing care for 202 chronic pain and opioid-consuming (CPOC) patients, 6.6% of 3058 patients undergoing urologic, gynecologic, orthopedic and general surgical procedures. Controls matched for age, gender, date and type of surgery, and postoperative pain relief modality were found for 180 (89%) of these patients. Patients were provided patient-controlled analgesia (PCA), or epidural opioid analgesia (EOA with boluses of preservative-free morphine or bupivacaine (1:16% + 2 micrograms/ml fentanyl (B/F)). Records were reviewed for patient demographics, diagnoses, surgical procedures, pre-operative opioid use, days-on-service, analgesic requirement, pain scores and incidence of moderate/severe side effects. Patient demographics were similar between CPOC and control groups. When considering PCA alone, mean 24-h usage in controls was 42.8 (32.0) mg morphine (MS) equivalents differing significantly from CPOC patients' use of 135.8 (68.5) mg MS equivalents (P = 0.0001). EOA and B/F case studies showed similar results. Moderate sedation was experienced by 50% of CPOC patients receiving PCA. Differences in opioid usage, side effects, pain scores, sedation and prescribed treatment with anxiolytics were shown between CPOC patients and matched controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug utilization patterns in chronic pain patients.

In the population of chronic pain patients seen at multidisciplinary pain clinics, excessive and/or inappropriate medication use is a frequent problem. This study examined differences between chronic pain patients who used no addicting medication (30% of the sample of 131 patients), those who used narcotic but not sedative medications (33%) and those who used both narcotic and sedative medications (37%). Patients in the narcotic and narcotic-sedative groups had undergone significantly more pain-related hospitalizations and surgeries than those in the no addicting drugs group. Narcotic-sedative patients spent significantly more money on pain medication per month, reported significantly greater physical impairment, and had higher MMPI hypochondriasis and hysteria scores when compared to the other patients. The findings are interpreted in light of the hypothesis that certain patients show greater readiness to complain of and seek help for physical symptoms.

Self-reported vs. actual use of medications in chronic pain patients.

Inappropriate or excessive medication use is a commonly observed problem among patients with chronic pain. Comparing patients' self-reported drug use with actual observed drug use, this study examines the incidence, nature and magnitude of drug utilization in a selected population of pain patients and evaluates the reliability of patient estimates of their own drug use. The data support the clinical observation that patients with chronic pain tend to underestimate their medication use. This tendency is greater for narcotic analgesics than for a variety of other medications taken for pain and is greater for women than men.