Pain
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Case Reports
Difficult management of pain following sacrococcygeal chordoma: 13 months of subarachnoid infusion.
We report on a patient suffering severe pain following a long-standing sacral chordoma in whom management of therapy and pain was extremely difficult. Because orally administered morphine was observed to be ineffective in the early stages of treatment, we tried to achieve pain relief by using epidural morphine. This was also unsatisfactory. ⋯ Periods of analgesia were followed by occasional crises of intense sharp pain suggesting incomplete relief. No serious complications or meningitis occurred. This case emphasizes the difficulty in managing pain in this type of cancer.
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Hyperalgesia and allodynia in 4 cancer patients treated with morphine disappeared after discontinuing or substituting morphine with other opioid agonists. The first case describes a young female who developed hyperalgesia and myoclonus during intravenous morphine infusion. The hyperalgesia and myoclonus disappeared when the morphine administration was discontinued and she felt comfortable on small and sporadic oral doses of methadone. ⋯ The fourth case describes a boy developing hyperalgesia after high doses of oral and intramuscular morphine. The hyperalgesia disappeared after discontinuing morphine administration but withdrawal symptoms developed due to too small doses of methadone. Possible mechanisms of morphine-induced hyperalgesia are discussed.
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Seventeen drawings of localised low-back pain were analysed by two assessors using 4 systems. Three were grid-based systems and one was by computer. The mean area or 'extent' was calculated to be 7.7%, 4.7%, 3.6% and 2.3% of the body outline using 45, 200, 560 and 61,102 section analyses, respectively. ⋯ Correlation coefficients of extent between the systems varied from 0.46 to 0.94. Correlation was highest between systems of adjacent magnitude of sections. It is concluded that grid-based assessment of small areas overestimates the actual area of pain and this may account for the lack of sensitivity to change in clinical status.
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Prescribing long-term opioids for patients with chronic pain is controversial. The primary purpose of this study was to examine physicians' beliefs about and prescribing of the long-term use of opioids in the treatment of chronic pain patients. Concerns about regulatory pressure and appropriateness of education regarding opioids were also examined. ⋯ Differences were noted by region, specialty, and the requirement for the use of multiple prescriptions for schedule II drugs. Physicians in the Midwestern United States were the least likely to prescribe the long-term use of opioids. Rheumatologists and general practitioners were significantly more likely to prescribe long-term opioids than were surgeons, neurologists, or physiatrists and were more likely to emphasize the importance of symptom improvement as an appropriate goal even in the absence of functional improvements.(ABSTRACT TRUNCATED AT 250 WORDS)
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To address the mechanisms of hyperalgesia and dorsal horn plasticity following peripheral tissue inflammation, the effects of adjuvant-induced inflammation of the rat hindpaw on behavioral nociception and nociceptive neuronal activity in the superficial dorsal horn were examined in neonatally capsaicin-treated rats 6-8 weeks of age. Capsaicin treatment resulted in an 82% loss of unmyelinated fibers in L5 dorsal roots, a dramatic reduction of substance P-like immunoreactivity in the spinal cord, and a significant decrease in the percentage of dorsal horn nociceptive neurons that responded to C-fiber stimulation and noxious heating of the skin. The thermal nociceptive threshold was significantly increased in capsaicin-treated rats, but behavioral hyperalgesia to thermal stimuli still developed in response to inflammation. ⋯ There was no difference in stimulation-induced expansion of the receptive fields for WDR neurons between vehicle- or capsaicin-treated rats. An N-methyl-D-aspartate receptor antagonist, MK-801, attenuated the behavioral hyperalgesia and reduced the receptive field size of dorsal horn neurons in inflamed capsaicin- and vehicle-treated rats. The data suggest that while capsaicin-sensitive primary afferents may be involved in neuronal plasticity induced by peripheral tissue inflammation, changes in the capsaicin-insensitive WDR and NS populations are sufficient to produce thermal and mechanical hyperalgesia after the loss of capsaicin-sensitive primary afferents.