Articles: pain-management-methods.
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The role of antithrombotic therapy is well known for its primary and secondary prevention of cardiovascular disease by decreasing the incidence of acute cerebral, cardiovascular, peripheral vascular, and other thrombotic events. The overwhelming data show that the risk of thrombotic events is significantly higher than that of bleeding during surgery after antiplatelet drug discontinuation. It has been assumed that discontinuing antiplatelet therapy prior to performing interventional pain management techniques is a common practice, even though doing so may potentially increase the risk of acute cerebral and cardiovascular events. There are no data available concerning these events, specifically in relation to the occurrence of thromboembolic events, even though some data are available concerning bleeding complications. Even then, interventionalists seem to routinely discontinue all antithrombotic therapy prior to all interventional pain management techniques. ⋯ The results illustrate an overwhelming pattern of discontinuing antiplatelet and warfarin therapy as well as aspirin and other NSAIDs prior to performing interventional pain management techniques. However, thromboembolism complications may be 3 times more prevalent than epidural hematomas (162 versus 55 events). It is concluded that clinicians must balance the risks of thromboembolism and bleeding in each patient prior to the routine discontinuation of antiplatelet therapy.
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There are now several strong opioids available to choose from for the relief of moderate to severe pain. On a population level, there is no difference in terms of analgesic efficacy or adverse reactions between these drugs; however, on an individual level there is marked variation in response to a given opioid. ⋯ If personalized prescribing could be achieved this would have a major impact at an individual level to facilitate safe, effective and rapid symptom control. This review presents some of the recent positive advances in opioid pharmacogenetic studies, focusing on associations between candidate genes and the three main elements of opioid response: analgesic, upper gastrointestinal and central adverse reactions.
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Intrathecal drug delivery (IDD) continues to gain relevance as a beneficial tool for the treatment of cancer pain, spasticity, and chronic nonmalignant pain. This review includes advances in recommendations for the use of IDD for cancer pain, nonmalignant pain, and spasticity, as well as a new study of cerebrospinal fluid kinetics, updates in logistics, and recent reports of complications. ⋯ IDDS continues to play an important role in the management of severe intractable pain. However, the most important areas in need of advancement, outcome studies and new therapeutics, did not have any significant breakthroughs over the past year. There is some interesting preclinical work on new therapeutics but likely the translation into clinical practice will be challenging. More work is also needed on improving technologies that will result in less catheter breaks and disconnects.
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The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well informed decisions about health care and health policy. ⋯ The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national license to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online free through www.thecochranelibrary.com.
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Drug addicts often seek medical help for pain. Numerous fears and beliefs may hinder the recognition, evaluation, and management of pain in addicts. Nevertheless, the same fundamental principles apply to these patients as to other patients in terms of pain evaluation, analgesic selection, and dosage adjustment. ⋯ The use of strong opioids should be kept to a minimum (although this important rule may be difficult to follow, for instance in surgical emergencies). The best route of administration and galenic formulation vary with each individual situation but, in general, intravenous administration of strong opioids is highly undesirable. A treatment contract established with the patient is crucial and must indicate the nature of the drug or replacement agent used and the treatments given for pain control.