The Clinical journal of pain
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The rationale for improving analgesic therapy is presented. After reviewing the role of drug pharmacokinetic and pharmacodynamic variability in determining the quality of pain relief, newer developments in acute pain management are described: newer opioid and nonopioid analgesic drugs; alternative drug delivery systems; nonpharmacologic approaches, use of combination analgesic therapy. Finally, several possible future research trends in acute pain management are discussed.
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The development of an acute pain service in a community hospital is described. A plan of operation is proposed, including accurate record maintenance to avoid complications. Results are presented on over 10,000 patients treated by the acute pain service.
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In some forms of cerebrovascular disease, such as intracranial hemorrhage, headaches are well known as a prominent symptom and often are a valuable clue to diagnosis. There are difficulties, sometimes, in distinguishing between a small subarachnoid hemorrhage and a severe migraine headache, but these can be resolved using clinical observations, CT scan, and lumbar puncture. It seems less well known that headaches may accompany or precede cerebral thrombosis and embolism. When these headaches are recognized as a forerunner to stroke, they may allow an opportunity for preventive treatment.
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Headache is the most common complaint encountered in clinical practice. Approximately 45 million people in the United States experience chronic headaches. The management of migraine headache involves both pharmacologic and nondrug therapy. ⋯ Prophylactic therapy is focused on reducing the frequency and severity of the attacks. beta-Adrenergic blocking agents, such as propranolol, remain the primary agents for many migraine patients, although other drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), including ketoprofen, or calcium-channel blocking agents, such as verapamil, may be beneficial for many patients. For cluster headache and its variants, methysergide and corticosteroids are usually the drugs of choice. Patients with chronic cluster headache may achieve good results from long-term treatment with other therapies, including lithium carbonate, verapamil, and ketoprofen.
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Healing or successful intervention usually leads to the resolution of pain. However, in some patients biologic or psychologic symptoms associated with pain persist despite treatment or apparent healing. In cases in which the etiology is not known, persistent pain is categorized as a clinical syndrome known as "chronic pain." Organic, psychologic, and socioenvironmental factors contribute to the development of chronic pain. ⋯ Before successful management can begin, the major etiologic factors and sequelae of the chronic pain syndrome must be understood. Antidepressants, neuroleptics, anticonvulsants, nonsteroidal anti-inflammatory drugs, and hydroxyzine have been proven effective in the treatment of pain syndromes. The treatment of patients who present with chronic pain must be individualized based on a comprehensive understanding of the factors underlying the chronic pain syndrome of each patient.