Articles: opioid.
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Objective. Intrathecal opioid/local anesthetic mixtures are a popular alternative in contemporary treatment of chronic nonmalignant pain. Unfortunately, its use is based solely on retrospective studies or anecdotal reports. ⋯ Addition of bupivacaine to the intrathecal opioid failed to produce significant improvement in pain control. Conclusion. At currently used doses, intrathecal opioid bupivacaine mixtures are not more efficacious in the treatment of chronic nonmalignant pain than opioid alone.
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Naturally occurring opiates (endorphins) diminish testosterone levels by inhibiting both hypothalamic gonadotrophin releasing hormone production and testicular testosterone synthesis. Heroin addicts treated with a single daily dose of methadone and nonaddicts receiving continuous intrathecal opioids quickly develop low luteinizing hormone and total testosterone levels. A similar pattern was sought in men consuming commonly prescribed oral opioids. ⋯ Either TT or E(2) level was subnormal in all 28 men consuming the equivalent of 100 mg of methadone daily and in 19 of 26 (73%) consuming smaller opioid doses. Eighty-seven percent (39 of 45) of opioid-ingesting men who reported normal erectile function before opioid use reported severe erectile dysfunction or diminished libido after beginning their opioid therapy. Commonly prescribed opioids in sustained-action dosage forms usually produce subnormal sex hormone levels, which may contribute to a diminished quality of life for many patients with painful chronic illness.
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Objective. This article presents an overview of the use of intrathecal bupivacaine (with and without opioid), focusing on laboratory data and clinical use for chronic pain. Some background on epidural use is included to support the intrathecal literature. ⋯ In addition, outcome studies are needed specifically to differentiate use of intrathecal bupivacaine based on the source and mechanism of pain. Conclusions. While there are few long-term randomized prospective studies at this point, we conclude that intrathecal bupivacaine appears to be a safe and efficacious treatment in both cancer and noncancer pain.
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Rofecoxib was the first specific inhibitor of cyclooxygenase-2 (COX-2) approved for the treatment of acute pain. It has been shown to provide analgesia that is significantly better than placebo and has an onset of action and efficacy similar to that of traditional nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen. In addition, the analgesic efficacy of rofecoxib has been demonstrated to be superior to that of the opioid combination of codeine 60 mg/acetaminophen 600 mg in an acute dental pain model. ⋯ Rofecoxib is a safe and highly effective alternative to previously available NSAIDs and should be considered for the treatment of acute pain conditions in adult patients, especially those at risk for developing gastrointestinal complications. It is preferred in the perioperative setting because of its analgesic efficacy and lack of platelet effects. Because of its more favorable gastrointestinal toxicity profile compared with nonselective NSAIDs, rofecoxib is safer in patients, especially older patients, for whom chronic anti-inflammatory or analgesic therapy is indicated.
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The implantation of a drug (opioid) infusion system catheter at the level of the cisterna magna, connected to an implanted programmable pump (Synchromed pump, 8611-H, Medtronic, Minneapolis, MN) is the procedure we use most commonly for the treatment of craniofacial and upper cervical pain. Our implantation technique, which we consider simple and easy to perform, is discussed in this article. Our results have been extremely encouraging, without untoward effects occurring. Adverse effects are prevented by the close proximity of the catheter tip to the pain receptors.