The Clinical journal of pain
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Physicians have in their armamentaria of drugs and techniques sufficient methods of relieving postoperative pain to maintain an analgesic state in postsurgical patients. The extent of the problem, and the options available, are discussed and described.
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The three general methods of treating pain are pharmacologic, physical and psychological. The goal of medical management of the patient with pain and inflammation is to relieve these symptoms with minimal side effects and inconvenience. Pain associated with inflammation may be relieved with nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin. ⋯ Relatively small doses of epidural or intrathecal opiates can also be used to achieve postoperative pain relief. Thus, treatment for orthopaedic pain begins with NSAIDs, followed by an oral opiate combined with acetaminophen, aspirin, or another NSAID. If these regimens are ineffective, oral opiates followed by parenteral opiates may be tried.
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Review Case Reports
Pharmacologic management of bone pain in the cancer patient.
Cancer patients may experience acute or chronic pain caused by tumor infiltration of pain-sensitive structures or related to surgery, radiation, and chemotherapy. Acute bone pain, with or without associated neurologic deficits resulting from tumor metastasis to bone and contiguous neural structures (e.g., large peripheral nerve trunks or the spinal cord), is a common cause of intractable pain in cancer patients. ⋯ Less commonly, invasive therapies, such as resection of vertebral body tumor with spinal reconstruction or pituitary ablation and intraventricular opioid administration (for diffuse bone pain), are offered. In this article I discuss current approaches to the management of pain in cancer patients, emphasizing current hypotheses on the pathogenesis of bone pain and the rationale for its pharmacologic treatment.
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A significant percentage of chronic headache sufferers use excessive quantities of substances for relief. Drug dependency is frequent in these patients. Patients have an impaired lifestyle, sustain organ system damage, may suffer a withdrawal syndrome, and continue to have headaches. ⋯ The mechanism of substance abuse may be related to repeated use of substances that reinforce behavior and stimulate brain reward systems. Treatment includes comprehensive diagnostic workup, withdrawal of the agent, and use of headache preventives. beta-Adrenergic blockers, tricyclic antidepressants, monoamine oxidase (MAO) inhibitors, and nonsteroidal anti-inflammatory agents may be of value. Behavior modification and dietary counseling are also helpful.
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Psychological factors are known to increase the severity and intensity of headaches. When they are shown to be present, an appropriate psychiatric diagnosis is the Diagnostic and Statistical Manual's (DSMIII-R) category of psychological factors affecting physical condition (code no. 316.0). ⋯ The factors overlap and intertwine in the average headache patient. Attention to these factors in a systematic way should enhance our understanding and treatment of the chronic headache patient.