Articles: opioid-analgesics.
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At present, intramuscular application of opioids given on request is the most widespread form of postoperative analgesia. This method is widely recognized as often being inadequate, however. As advanced techniques of pain management, such as patient-controlled analgesia, are not generally available, the question arises as to whether non-opioid analgesics should routinely be used in order to improve this situation. ⋯ Despite these results, it must be borne in mind that most studies have been carried out on patients of ASA groups I and II and that conclusions drawn from the literature are not necessarily representative for the elderly and for patients with organ failure. Alternative substances have received relatively little attention. Of these, the pyrazolone derivative, metamizol, may well prove to be of value for patients in whom the use of NSAIDS is contraindicated or relatively ineffective such as after biliary tract surgery.
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Despite widespread knowledge about many aspects of pain relief and the availability of appropriate opioid analgesics, inadequate pain management of cancer patients remains pervasive. The reasons can be classified into three categories: (1) societal barriers: (some health care providers still classify patients requiring "atypical" pain control as actual or potential drug abusers and continue to be affected by the deep-rooted negative image of opium and its misuse throughout history), (2) knowledge deficits (care givers often do not recognize the need for individualized treatment in accordance with the specific pain syndrome, the profile of the patient, the appropriate analgesic regimen, or the route of dosing; in addition, physical dependence, addiction, and tolerance are often regarded as synonymous and not clearly distinguished from one another), and (3) influence of governmental regulations (because drug regulatory guidelines concerning opioids are often vague and ambiguous, physicians are uncertain about what constitutes legitimate opioid use and fear regulatory and legal sanctions when prescribing opioid analgesics in higher than "normal" amounts; as a result, pain is often undertreated). It is imperative that we strive to overcome these barriers and correct societal biases and misinformation in order to create a more rational plan for effective cancer pain management in which opioid analgesics are utilized appropriately.
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Neurogenic pain (encompassing all types of neuropathic and central pain) is discussed. Experimental work is presented in a model in which the rat sciatic nerve is loosely ligatured. In painful human neuropathies, tricyclic antidepressants have been found to be effective in proportion to the degree they facilitate monoaminergic activity. ⋯ In nociceptive pain, recent findings in humans emphasize the importance of both the retroinsular (SII) and the anterior cingulate cortices in the conscious appreciation of pain. Opioid studies have revealed individual differences in the metabolism of morphine to its 3- and 6-glucuronosides; patients with nociceptive pain who respond poorly to morphine or diamorphine probably have a high 3:6 ratio. It has been pointed out that methadone may be useful in such cases, as it is not broken down to glucuronosides.