European journal of pain : EJP
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Randomized Controlled Trial
Adding propacetamol to ketorolac increases the tolerance to painful pressure.
Combining an NSAID and paracetamol (acetaminophen) has in some studies given superior analgesia compared with the single drugs. In other trials no additive effect has been found. We have investigated the effect of this drug combination on the pressure pain tolerance threshold (PPTT), a reproducible correlate to clinical pain. The aim of this double blind, randomised, placebo controlled, crossover study was to evaluate the effect of i.v. propacetamol 2 g (= paracetamol 1 g) and ketorolac 30 mg, individually and in combination, on PPTT in 16 volunteers on four separate days. PPTT was measured 15 min before and at 45, 60, 90 and 150 min after the start of test drug administration. The pressure stimuli were applied on the base of a fingernail, increasing by 30 kPa/s until the pressure pain tolerance threshold was reached. For the total observation period (150 min), only the combination (propacetamol+ketorolac) increased significantly PPTT compared with baseline (P<0.04), while PPTT decreased significantly after placebo (P<0.01). The combination (propacetamol+ketorolac) and ketorolac alone increased PPTT compared with placebo (combination vs. placebo and ketorolac vs. placebo, P<0.001) and with propacetamol (combination vs. propacetamol and ketorolac vs. propacetamol, P<0.001). The combination was significantly better than ketorolac alone (P<0.04). After propacetamol 2 g, PPTT did not change significantly neither compared with placebo or baseline. ⋯ Tolerance to repeated painful pressure (PPTT) decreased after placebo. Ketorolac 30 mg caused an increase in PPTT compared with placebo but not with baseline. Adding propacetamol 2 g to ketorolac 30 mg significantly increased PPTT. These findings support the practice of combining paracetamol with an NSAID for relief of acute pain.
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Antidepressants are widely used to treat painful chronic rheumatic conditions but, contrary to neuropathic conditions, little is known about their true analgesic properties and value in these situations. Our group, which focuses on pain in rheumatology, aimed to develop recommendations for the use of antidepressants in rheumatology, based on evidence-based review of published data and expert opinion. ⋯ These recommendations for the treatment of painful rheumatological conditions with antidepressants were developed using evidence-based and expert consensus approaches and are the first of their kind in this field. Our review of the literature highlights the need for further, well-designed clinical studies of the use of antidepressants to treat painful rheumatological conditions.
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Plurisegmental endogenous pain inhibitory mechanisms related to diffuse noxious inhibitory controls (DNIC) were demonstrated in animal experiments to act on multireceptive neurons of the entire cord outside the conditioned segment without any side differences. Human experiments have demonstrated altered pain sensitivity to pressure, heat and electrical stimulation during heterotopic noxious conditioning stimulation (HNCS). The purpose of the study was to examine if side and/or time differences in pain thresholds and suprathreshold pain sensitivity for pressure and heat, respectively, could be detected during HNCS. ⋯ On the lastly assessed side only SPP and SHP increased significantly on both sides alike (p<0.02 and p<0.03, respectively), without magnitude differences between sides. During unilateral HNCS of the left arm, a time factor was demonstrated only for alterations in suprathreshold pain sensitivity, without any differences in magnitude between sides. Therefore, the results have implications for future design of HNCS-related experimental and clinical studies.
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The development of catheter associated granulomatous masses in intrathecal morphine therapy is an uncommon, but potentially serious problem. While these systems have historically been used in patients with short life expectancies, more recently patients with pain from a benign source have benefited from this therapy, and new complications are being encountered secondary to the patients' longer life spans. Morphine is the most commonly used intrathecal opioid and evidence exists that the formation of granulomatous masses are related to the use of higher doses. ⋯ Serial neurological examinations for new deficits may be performed and recorded during pump refill visits to recognize a granulomatous mass in its early stages. If an abnormality is identified, imaging studies are appropriate. Awareness of the condition and vigilance are the keys to successful management of this complication.
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Iatrogenic opioid addiction among chronic pain patients was the initiative for starting a methadone programme for pain patients at the University Hospital of Uppsala. The aims were to improve pain relief and quality of life in pain patients with problematic opioid use and to investigate background factors explaining problems with opioid use. ⋯ A structured methadone programme can be used for treating chronic pain patients with opioid dependence improving pain relief and quality of life. However, side effects and serious adverse events may limit the beneficial effects of the method.