The Clinical journal of pain
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The rationale for improving analgesic therapy is presented. After reviewing the role of drug pharmacokinetic and pharmacodynamic variability in determining the quality of pain relief, newer developments in acute pain management are described: newer opioid and nonopioid analgesic drugs; alternative drug delivery systems; nonpharmacologic approaches, use of combination analgesic therapy. Finally, several possible future research trends in acute pain management are discussed.
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Review Case Reports
Pharmacologic management of bone pain in the cancer patient.
Cancer patients may experience acute or chronic pain caused by tumor infiltration of pain-sensitive structures or related to surgery, radiation, and chemotherapy. Acute bone pain, with or without associated neurologic deficits resulting from tumor metastasis to bone and contiguous neural structures (e.g., large peripheral nerve trunks or the spinal cord), is a common cause of intractable pain in cancer patients. ⋯ Less commonly, invasive therapies, such as resection of vertebral body tumor with spinal reconstruction or pituitary ablation and intraventricular opioid administration (for diffuse bone pain), are offered. In this article I discuss current approaches to the management of pain in cancer patients, emphasizing current hypotheses on the pathogenesis of bone pain and the rationale for its pharmacologic treatment.
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Optimal care of surgical patients includes effective control of incisional pain. Attention is beginning to be focused on new in-hospital services created to improve the management of postoperative pain. Additional information regarding the organization and operation of this type of service, especially in the framework of a university hospital, is presented. The specific roles of an academic anesthesiologist involved in acute pain management are: to provide leadership by the development of effective services, to clarify through research optimal treatments, to train future practitioners in the management of acute pain, and to serve as a consultant for improving pain control for the whole medical community.
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Review Case Reports
The assessment and treatment of pain in the emergency room.
A broad spectrum of painful conditions presents to the modern emergency center (EC). The three most common categories are acute, self-limited disorders; chronic medical or surgical syndromes with acute exacerbation; and psychic pain syndromes in which the etiology cannot be easily ascertained. Many factors may differentiate pain from suffering, and physicians should educate patients not only about the nature of their condition and its prognosis, but also about anticipated discomfort. ⋯ Two special groups of patients, those with psychic pain syndromes and those with drug-seeking behavior, can create problems for the physician. Patients with chronic pain syndromes need special follow-up but do not benefit from additional analgesic drug therapy. Patients who seek and abuse drugs can be difficult to identify, may have true underlying medical pathology, and should not be given narcotic prescriptions.