Pain physician
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The role of nonspecific treatment effects in the outcomes of patients receiving interventions for pain has been the subject of controversy and interest. While the administration of placebo and its effects have been widely studied, the role of placebo and nocebo effects of active agents administered prior to or during interventional techniques has not been explored. ⋯ In patients undergoing interventional procedures, sodium chloride solution, midazolam, and fentanyl produced placebo effects in 13% to 15%, 15% to 20%, and 18% to 30% of the patients respectively. Similarly, a nocebo effect was seen in 5% to 8% of the patients in the sodium chloride group, 8% of the patients in the midazolam group, and 3% to 8% of the patients in the fentanyl group. It is concluded that positive and negative effects may be seen either with placebo or active agents in 13% to 30% of the patients.
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In the United States, physicians are faced with two opposing dilemmas in the treatment of pain - the potential for drug abuse and diversion, and the possible undertreatment of pain. While controlled prescription drugs such as narcotic analgesics, anxiolytics, antidepressants, stimulants, and sedative-hypnotics, play a legitimate role in managing chronic pain and other conditions, the illicit use of prescribed medicines is increasing at epidemic proportions. Diversion and abuse of prescription drugs is costly in terms of addiction, overdose, death, and related criminal activities, but chronic pain carries significant economic, social, and health impact as well. ⋯ President George W. Bush signed NASPER on August 11, 2005, and it became Public Law 109-60. Implementation of NASPER will improve patient care and reduce abuse and diversion of prescription controlled substances.
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Over 500,000 percutaneous disc decompression procedures have been performed in the past 20 years. Various percutaneous techniques include chemonucleolysis, percutaneous lumbar discectomy, and laser discectomy which have reported success rates in the 70% to 75% range. This retrospective evaluation of 49 patients who underwent nucleoplasty procedures for treatment of herniated discs, evaluates the effectiveness of nucleoplasty in the reduction of pain, improvement of functional activity, and reduction of pain medication. ⋯ Nucleoplasty should be used in those patients who fail conservative medical management including medication, physical therapy, behavioral management, psychotherapy, and who are unwilling to undergo a more invasive technique such as spinal surgery.
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The interscalene brachial plexus block (ISBPB) is a most reliable and commonly performed technique for regional anesthesia of the upper extremity. It has widespread clinical applicability, ranging from use for shoulder surgery as well as diagnostic and therapeutic uses in pain management. Traditional methods described for performing the ISBPB involve identifying surface anatomy landmarks. Unfortunately, in patients with less than ideal landmarks (those with short, thick necks and those lacking adequate muscle tone in the neck area) it becomes increasingly challenging to identify these landmarks. As a result there is greater uncertainty in accurately locating the brachial plexus, and consequently greater risk in performing the block. ⋯ It is concluded that this technique represents a safe, reproducible, and highly successful method for use by anesthesiologists and pain physicians alike.