Journal of pain and symptom management
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J Pain Symptom Manage · Feb 1990
Comparative StudyEpidural versus intrathecal morphine-bupivacaine: assessment of consecutive treatments in advanced cancer pain.
Twenty-five patients with multifocal and multitype (somatic, visceral, and neurogenic) advanced cancer pain who experienced severe pain despite extradural (ED) morphine and bupivacaine were converted to intrathecal (IT) morphine and bupivacaine. The consecutive ED and IT periods (2-174 days, median = 50 days, and 1-305 days, median = 37 days, respectively) were assessed in clinical terms (daily analgesic dosages giving acceptable pain relief and quality of life expressed as sleeping hours and walking/daily activities). With the IT treatment, the total (all routes) opiate consumption and the daily doses of spinal morphine and spinal bupivacaine decreased significantly at the beginning of the treatment compared to the ED period, and continued to be significantly reduced for up to 1 wk for spinal opiate and bupivacaine and 6 mo for total opiate. ⋯ Subsequently, lower daily volumes and higher concentrations were needed for IT administration of the drugs. During the first month of the IT treatment, sleeping and walking scores improved compared to ED treatment. Thus, the IT treatment gave more satisfactory pain relief, and--because of lower daily doses and volume--proved to be more suitable for treatment at home (continuous infusion from external pumps) than the ED treatment.
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J Pain Symptom Manage · Feb 1990
Comparative StudyPalliative care in a cancer center: results in 1984 versus 1987.
We reviewed the charts of 48 consecutive patients treated by our Palliative Care Team (PCT) during 1984 and compared these results with 50 consecutive patients treated during 1987. The composition of the PCT did not change between 1984 and 1987. The median equivalent daily dose of parenteral morphine (MEDD) before referral, after initial treatment by the PCT, and at the maximum prescribed by the PCT were 43 mg, 48 mg, and 96 mg in 1984, respectively, versus 60 mg (p less than 0.03), 60 mg (p less than 0.03), and 120 mg (p less than 0.12) in 1987, respectively. ⋯ Poor pain control after the initial treatment was observed in 42% of patients in 1984 versus 26% in 1987 (p less than 0.01). Our results suggest that patients are being treated more aggressively by their physicians before referral to the PCT in 1987, that our PCT is using more aggressive initial treatment than in 1984, and that, notwithstanding these changes, there is still a significant proportion of patients in whom pain cannot be controlled before death. These results suggest that more research is necessary to better define intractable pain syndromes and develop adequate treatments for them.
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J Pain Symptom Manage · Feb 1990
Comparative StudySubarachnoid and epidural calcitonin in patients with pain due to metastatic cancer.
Nine patients with metastatic cancer who had pain refractory to traditional treatments received a subarachnoid injection of salmon calcitonin. Eight of the nine patients reported pain relief after subarachnoid injection varying from 1 hr to 5 days. Four of the responding patients subsequently received an epidural injection of salmon calcitonin, and two of these patients reported pain relief. Although many patients experienced pain relief, nausea and vomiting appeared to be a significant side effect, occurring in seven out of nine patients.
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The problem of undertreatment of acute postoperative pain has been documented in many studies. This article reviews this evidence and defines the problem of undertreatment as a group of attitudes about pain treatment that originate with deficiencies in knowledge and skills and lead to the development of inappropriate behaviors on the part of health care professionals, patients, and health care system administrators. The correction of these attitudinal barriers to appropriate pain management will require education about opioid pharmacology, newer techniques of opioid administration, and the value of appropriate treatment to the individual patients and the health care system as a whole. Emerging Comprehensive Acute Pain Management Services will play a role in this education and in the standardization of postoperative pain treatment.
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This review draws on data obtained in the cancer pain, nonmalignant pain, and addict populations to examine critically the major issues raised by the use of chronic opioid therapy in nonmalignant pain. The available evidence suggests that there is probably a selected subpopulation of patients with chronic nonmalignant pain who may obtain sustained partial analgesia without the development of toxicity or the psychologic and behavioral characteristics of addiction. Future discussions of this approach must adequately define the terminology of addiction and strive to distinguish medical considerations from the societal and regulatory influences that may affect prescribing behavior. Those who treat patients with chronic pain must actively participate in these discussions lest decisions with enormous impact on patient care be made solely by those whose primary responsibility is the elimination of substance abuse.