British journal of anaesthesia
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Review Meta Analysis
Acute pain: combination treatments and how we measure their efficacy.
Perioperative analgesic strategies are frequently tested using analgesic consumption as an outcome measure. This outcome measure is intuitive and superficially attractive, but has not been evaluated rigorously. Flaws in its use may be one explanation of continuing controversies surrounding the efficacy of analgesic strategies tested by this method. ⋯ Sedation, dizziness, and vomiting were significant problems in pooled analysis. Analysis according to similarity of pain scores did not clarify whether perioperative gabapentin is useful in perioperative care. More rigorous examination of analgesic consumption as an outcome measure is needed, to establish whether achieving similar pain scores is as important as this paper claims and to determine those features of the analgesic delivery system, adverse effects, and other factors which may interfere with analgesic consumption as an outcome measure.
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Significant advances in the assessment and management of acute pain in children have been made, and are supported by an increase in the availability and accessibility of evidence-based data. However, methodological and practical issues in the design and performance of clinical paediatric trials limit the quantity, and may influence the quality, of current data, which lags behind that available for adult practice. Collaborations within research networks, which incorporate both preclinical and clinical studies, may increase the feasibility and specificity of future trials. ⋯ Chronic pain in children has a negative impact on quality of life, resulting in social and emotional consequences for both the child and the family. Despite age-related differences in many chronic pain conditions, such as neuropathic pain, management in children is often empirically based on data from studies in adults. There is a major need for further clinical research, training of health-care providers, and increased resources, to improve management and outcomes for children with chronic pain.
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In the past ten years there has been recognition that chronic post-surgical pain is a significant problem. This is a complex area of research and although the quality of studies has improved many difficulties remain. ⋯ Severe acute postoperative pain emerges as a factor that we may be able to influence. There is a need for education of the medical profession and the general public, so that effective measures are introduced and unnecessary and inappropriate operations minimized.
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Advances in cannabis research have paralleled developments in opioid pharmacology whereby a psychoactive plant extract has elucidated novel endogenous signalling systems with therapeutic significance. Cannabinoids (CBs) are chemical compounds derived from cannabis. The major psychotropic CB delta-9-tetrahydrocannabinol (Delta(9)-THC) was isolated in 1964 and the first CB receptor (CB(1)R) was cloned in 1990. ⋯ They are currently licensed as antiemetics in chemotherapy and can be prescribed on a named-patient basis for neuropathic pain. Future selective peripheral CB(1)R and CB(2)R agonists will minimize central psychoactivity and may synergize opioid anti-nociception. This review discusses the basic science and clinical aspects of CB pharmacology with a focus on pain medicine.
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Older adults with persistent pain are not simply a chronologically older version of younger pain patients. Pain-related disability in older adults may be driven by pain 'homeostenosis', that is, diminished ability to effectively respond to the stress of persistent pain. Some of the comorbidities of ageing that can contribute to pain homeostenosis include cognitive and physical impairments, increased sensitivity to suprathreshold pain stimuli, medical and psychological comorbidities, altered pharmacokinetics and pharmacodynamics, and social isolation. ⋯ Specifically, we discuss age-related changes in the brain (both normal and pathological) and in pain physiology; changes in experience and expression of pain that occur with dementia and contribute to pain homeostenosis; and unique aspects of age and pain-associated psychological function and their contribution to disability. We also present data demonstrating changes in brain morphology and neuropsychological performance that accompany persistent non-malignant pain in older adults and the treatment implications of these brain changes. Finally, preliminary data are presented on the efficacy of mindfulness meditation, a treatment that has been examined explicitly in older adults and targets optimizing brain function and descending inhibition.