The Clinical journal of pain
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Optimal care of surgical patients includes effective control of incisional pain. Attention is beginning to be focused on new in-hospital services created to improve the management of postoperative pain. Additional information regarding the organization and operation of this type of service, especially in the framework of a university hospital, is presented. The specific roles of an academic anesthesiologist involved in acute pain management are: to provide leadership by the development of effective services, to clarify through research optimal treatments, to train future practitioners in the management of acute pain, and to serve as a consultant for improving pain control for the whole medical community.
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Review Case Reports
The assessment and treatment of pain in the emergency room.
A broad spectrum of painful conditions presents to the modern emergency center (EC). The three most common categories are acute, self-limited disorders; chronic medical or surgical syndromes with acute exacerbation; and psychic pain syndromes in which the etiology cannot be easily ascertained. Many factors may differentiate pain from suffering, and physicians should educate patients not only about the nature of their condition and its prognosis, but also about anticipated discomfort. ⋯ Two special groups of patients, those with psychic pain syndromes and those with drug-seeking behavior, can create problems for the physician. Patients with chronic pain syndromes need special follow-up but do not benefit from additional analgesic drug therapy. Patients who seek and abuse drugs can be difficult to identify, may have true underlying medical pathology, and should not be given narcotic prescriptions.
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Recent research advances indicate that specialized neural pathways are involved in the encoding of pain sensations and that these pathways are sensitive to changes in stimulus features, such as intensity, quality, duration, and location. It has also been established that there are three major families of opioid peptides in the brain: the enkephalins, the dynorphins, and the endorphins. In addition to these opioid peptides, other neurochemicals such as serotonin and norepinephrine play a role in the modulation of signals related to tissue damage. ⋯ Opioid drugs are administered into the membranes surrounding the spinal cord to provide long-lasting pain relief. Peripherally acting opioid drugs may represent a new functional class of analgesics devoid of the undesirable side effects of centrally acting opioids. Tricyclic antidepressant drugs are used in the treatment of neuropathic pain, based on their effects on noradrenergic and serotoninergic pathways in the central nervous system.
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Within acute pain management, as within any rapidly expanding field of therapeutic endeavor, novel treatment modalities may on occasion overreach their scientific foundations. In general, a cautionary theme is expressed regarding the utilization of various therapies, lest their overzealous clinical implementation jeopardizes the advancement of this highly promising field. ⋯ The subject of dosing for acute pain conditions with opiates via the epidural route versus intravenous opioid administration is discussed from the perspectives of practicality and risk/benefit assignments. The advisability and means of using demand-mode techniques in order to resolve the central issue of inherent benefits of opioid administration via one route or another is also presented.