Articles: analgesics.
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The method for cancer pain relief proposed by the World Health Organization (WHO) consists of guidelines for a three-step treatment, from non-opioids to weak and then strong opioids, according to need. Adjuvant drugs can be added to each step. This report presents the 2-year experience of the WHO Collaborating Centre at the National Cancer Institute of Milan in the use of this method. ⋯ Neurolytic procedures had to be used in 29%. The authors conclude that analgesics, as proposed by WHO, are the most suitable treatment arm in controlling pain in palliative treatment for advanced cancer patients. Lack of availability or underuse of opioids constitute the real obstacle to the application of this method.
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Current use of opioids in anaesthesia is reviewed with particular emphasis on the use of opioids in anaesthetic doses, techniques that recently have become popular in cardiovascular anaesthesia. A major benefit of opioid anaesthesia (particularly fentanyl) is the cardiovascular stability which obtains during induction and throughout operation, even in patients with severely impaired cardiac function. Anaesthetic doses of morphine are associated with a higher incidence of cardiovascular disturbances and other problems. ⋯ High doses of opioids can reduce or prevent hormonal and metabolic responses to the stress of surgery. Even very large doses of fentanyl or its new analogues do not prevent marked increases in plasma catecholamine concentrations in response to cardiopulmonary bypass. The reduction in hormonal and metabolic stress response does not appear to continue postoperatively.
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Relief of pain after surgery remains poor for the majority of patients. The pain is unpleasant, and is associated with arterial hypoxaemia, venous thrombosis, myocardial ischaemia and a more florid hormonal response to surgery. Regional analgesia, systemic, subarachnoid or extradural opioids and antiprostaglandin drugs are all used to treat pain after surgery. ⋯ Intravenous administration avoids both problems and excellent results have been obtained using Patient Controlled Analgesia devices, but these machines are expensive. A simple regimen suitable for application to large numbers of surgical patients is required. Continuous infusion of fentanyl 100 micrograms h-1 IV begun two hours before surgery and supplemented by a single bolus dose of fentanyl 100 micrograms IV provided an effective background of analgesia.
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Small doses of epidural and intrathecal opioids produce effective and prolonged analgesia postoperatively, although the quality of analgesia does not differ from when conventional routes are used. The different opioids differ only in the speed of onset and duration of action, and in the incidence of side-effects. 'Minor' complications such as nausea, vomiting, pruritus and retention of urine are relatively common. ⋯ It is commoner after morphine and after intrathecal administration, and is also associated with advanced age, concomitant use of other central depressant drugs, respiratory disease and large doses. Because of the potentially lethal nature of this complication, it is recommended that the epidural and intrathecal routes of administration are used only when patients can be closely and constantly observed postoperatively.
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Concomitant administration of flupirtine maleate at a single low dose (15 mg/kg, mice; 35 mg/kg, rats) with a wide range of doses of each of the peripherally acting analgesics enhanced the antinociceptive activity of paracetamol, acetylsalicyclic acid and ibuprofen in the acetic acid writhing test, acetylsalicylic acid in the hot plate test and paracetamol, acetylsalicyclic acid and ibuprofen in the Randall-Selitto test. The concomitant administration of a single low dose of the peripherally acting analgesics (at about 1/2 ED50) with a wide range of doses of flupirtine maleate resulted in enhancement of flupirtine maleate analgesic activity by paracetamol (in the hot plate and Randall-Selitto tests), acetylsalicyclic acid (in the acetic acid writhing test), ibuprofen (in the Randall-Selitto test) and indomethacin (in the acetic acid and Randall-Selitto tests). Thus flupirtine maleate enhanced the analgesic activity of paracetamol, acetylsalicyclic acid and ibuprofen in mice and rats. Each of the peripherally acting analgesics enhanced the analgesic activity of flupirtine maleate in one or more of the analgesic tests used.