UI - 000149

AU - Abram SE

TI - 1992 Bonica Lecture. Advances in chronic pain management since gate control. [Review]

AB - OBJECTIVE. Two pain treatment systems that developed soon after the publication of the gate theory are probably a direct result of its publication: neuraxial opiate administration and electrical stimulation of the spinal cord and peripheral nerves and receptors. Although the use of these modalities has become widespread in managing chronic pain, there is disagreement about their long-term efficacy. This presentation will attempt to review the data regarding the mechanisms of action of these modalities and their efficacy in treating chronic pain of malignant and nonmalignant origin. DATA SOURCES. Data were derived almost entirely from original articles reporting experimental data from both animal and human studies and from series of patients undergoing treatment with the modalities reviewed. STUDY SELECTION. Where possible, controlled studies were selected. However, much of the available data regarding treatment results are uncontrolled. DATA EXTRACTION AND SYNTHESIS. Selected data from studies that were felt to be reasonably well conducted are presented or summarized. Because of the lack of control groups in many of the clinical trials, meta-analyses were not carried out. CONCLUSIONS. Long-term spinal opiate administration has been shown to be more effective than systemic opiates in some patients with cancer pain, but often must be combined with local anesthetics to provide satisfactory pain relief. Loss of effect over time is a significant problem. Since the identification of spinal opiate receptors and the introduction of spinally administered narcotics, a number of other receptors that are important in both sensitization and suppression of pain projection systems have been characterized. Agonists and antagonists to many of these receptors are being developed, and a few are available for clinical trials. Long-term electrical stimulation of the spinal cord produces substantial analgesia below the stimulated spinal segments in some patients with chronic pain. Although initial results are usually encouraging, long-term efficacy may be disappointing. It is postulated that analgesia associated with spinal stimulation is associated with both stimulation of large fiber ascending tracts and blockade of spinothalamic pathways. Transcutaneous electrical nerve stimulation (TENS) has come into widespread use in managing chronic pain and has had limited trials in cancer pain patients. It is well accepted by patients and physicians, but clinical studies of long-term efficacy have yielded variable results. The analgesic action is probably the result of both large afferent fiber activation and blockade of peripheral nociceptors. [References: 99]

SO - Regional Anesthesia 1993;18:66-8

UI - 000146

AU - Bushnell TG

AU - Justins DM

TI - Choosing the right analgesic. A guide to selection. [Review]

AB - Pain is an unpleasant sensory and emotional experience, unique to each individual patient. In the dynamic processes of nociceptive stimulation, signal transmission, central decoding and interpretation there are many potential sites for pharmacological intervention, and there are many drugs which will produce analgesia. An analgesic 'ladder' has been proposed for rational pain relief in cancer and a similar concept should be used in all forms of acute and chronic pain. Continuing research and drug development undoubtedly extends our understanding, but consistent improvement in our clinical ability to relieve pain depends more on our willingness to consider the need of each patient individually, to tailor the drug, route and mode of administration to that patient's requirements, and then to monitor on the basis of the response of the patient to the treatment. [References: 27]

SO - Drugs 1993;46:394-40

TI - Decision-making in the opioid therapy of cancer pain: interim analysis of a prospective survey

(Meeting abstract)

AB - Sequential trials of opioid drugs or routes of administration are frequently required to optimize the balance between analgesia and adverse effects. Neither the clinical factors that determine the choice of drug or route nor the variability in patient (pt) response have been studied previously. To assess these phenomena, we are evaluating pts referred to the Pain Service using a new instrument completed by the treating physician that records reason(s) for referral, pain-related data, and reason(s) for change(s) in analgesic regimen. To date, 25 consecutive pts with advanced cancer (11 males and 14 females; median age 51 yr, range 31-82) have been followed until discharge (n=23) or death (n=2). The reason(s) for referral included uncontrolled pain despite analgesic therapy (68%), difficulties in pain assessment (33%), and analgesic toxicity with inadequate (33%) or adequate (11%) analgesia. All pts had received previous opioid trials (median 3, range 1-6). Following referral, a total of 45 changes in either drug, route, or both were evaluable. Two pts died and 13 were discharged during the initial therapeutic trial. Ten required additional trials to achieve an acceptable balance between pain relief and adverse effects: 5 required 2 trials, 2 required 3 trials, and 3 required 4 or more sequential trials. The major factors that influenced opioid selection were previously well tolerated (48%), no known prior dose-limiting toxicity (51%), and easy to titrate (56%).

Convenience of formulations (24%) was associated only with the selection of morphine, whereas concerns regarding renal function (8%) and drug metabolites (14%) were associated with the selection of hydromorphone. The major reasons for the choice of a parenteral rather than oral route were the need for very rapid analgesic effect (66%), inability to swallow (31%), impaired intestinal function (25%) and intolerance of po administered drugs (18%). In the 2 cases in which spinal route was selected, dose- limiting toxicity with systemic administration was the compelling consideration. In 6 cases, an initial parenteral route was changed to the oral route prior to discharge; the need for rapid analgesic effect was a reason for the first selection, and resolution of that need and improved convenience were the reasons for the change. This interim analysis illustrates (1) the large variability in response to different opioids and routes of administration; (2) the potential utility of sequential therapeutic trials; and (3) the likely existence of trends in the rationale for the selection of opioid therapies, enhanced understanding of which may improve therapeutic decision making AD - Pain Service AD - Dept. of Neurology AD - Memorial Sloan-Kettering Cancer Center AD - New York AD - NY 10021 UI - 93695900

SO - Proc Annu Meet Am Soc Clin Oncol 1993;12:A1502-A150

UI - 000147

AU - Dixon BA

TI - Institutional survey of nurse anesthesia practice in patients receiving opioids via patient-

controlled analgesia

AB - This preliminary study determined certified registered nurse anesthetist (CRNA) practice experience and educational needs in the preoperative evaluation of patients using patient-controlled analgesia (PCA) for chronic and cancer pain management. A convenience sample (N = 29) of CRNAs practicing in a university teaching hospital completed the surveys developed by the investigator. Survey items related to CRNA experience with management of patients using PCA preoperatively, PCA modes of opioid delivery, and use of adjuvant medication for chronic and cancer pain patients. Results of the study indicated that 79% of CRNAs reported experience in administration of anesthesia to one or more patients who used PCA preoperatively. However, only 32% of CRNAs surveyed reported knowledge of the modes of opioid delivery available. Results also indicated that 48% of CRNAs were not familiar with adjuvant medications (ie, tricyclic antidepressants, benzodiazepines, steroids, and anticonvulsants), which are often prescribed in combination with opioids in chronic pain management. The respondents reported use of a variety of methods in handling opioid and infusion devices for patients using PCA preoperatively. Fifty-two percent of CRNAs disconnected the infusion and discarded the opioid preoperatively. Fourteen percent reported leaving the PCA device connected to the patient for use perioperatively or for continued pain management postoperatively. Based upon the findings of this preliminary study, CRNA education in management techniques for the use of PCA infusions in chronic and cancer pain is recommended

SO - Nurse Anesthesia 1993;4:112-11

TI - Flupirtine. A review of its pharmacological properties, and therapeutic efficacy in pain states. [Review]

AB - Flupirtine is a novel non-opiate centrally acting analgesic agent with muscle relaxant properties, advocated for use in a number of pain states. Preliminary evidence suggests that flupirtine 100 to 200mg orally or 150mg rectally 3 to 4 times daily (maximum daily dose 600mg) is more effective than placebo in relieving moderate acute pain of various types. For the relief of pain due to surgery, traumatic injury, dental procedures, headache/migraine and abdominal spasms, flupirtine has proved at least as effective as the opiate analgesics codeine, dihydrocodeine and pentazocine, the nonsteroidal anti-inflammatory agents suprofen, diclofenac and ketoprofen, as well as dipyrone and paracetamol (acetaminophen). Although evidence to support a role in the treatment of chronic pain is limited, flupirtine has been found as effective as pentazocine in short term trials of patients with muscular or neuralgiform pain, dysmenorrhoea, soft tissue rheumatism or cancer pain. The safety profile of flupirtine has not yet been fully established, although initial evidence suggests that adverse reactions, while frequent, are usually minor in nature. The most common reactions are drowsiness, dizziness, dry mouth and various gastrointestinal complaints. In comparison with opiate drugs, flupirtine appears to produce fewer central nervous system effects, no respiratory or cardiovascular depression, and no overt tolerance or physical dependence on prolonged administration. If these initially favourable results are confirmed in larger long term trials, then flupirtine would appear to represent an effective analgesic for the relief of moderate pain, particularly that of musculoskeletal origin.

[References: 75]

SO - Drugs 1993;45:548-56

AU - Goldman B

TI - Use and abuse of opioid analgesics in chronic pain. [Review]

AB - Primary care physicians are frequently required to treat patients with chronic debilitating pain. Opioid analgesics can successfully manage chronic pain. To prescribe opioid analgesics effectively, physicians must identify appropriate patients. Several methods can be used to identify and distinguish appropriate patients, addicted patients, and for-profit drug seekers. [References: 15]

SO - Canadian Family Physician 1993;39:571-57

AU - Helme RD

AU - Katz B

TI - Management of chronic pain. [Review]

AB - The principles of chronic pain management in the elderly are the same as in younger people; whenever possible, the cause of the pain should be identified and eradicated. However, older people are more likely to suffer pain from incurable conditions, and the emotional component of the suffering may be considerable. Treatment options include analgesics, opiates, antidepressants and anticonvulsants as well as psychological strategies, physical strategies such as exercise and transcutaneous electrical nerve stimulation (TENS), and surgery. Improvement of function may be a more important treatment goal than relief of pain.

[References: 15]

SO - Medical Journal of Australia 1993;158:478-48

AU - Kerrick JM

AU - Fine PG

AU - Lipman AG

AU - Love G

TI - Low-dose amitriptyline as an adjunct to opioids for postoperative orthopedic pain: A placebo-controlled trial

AB - IN: U Minnesota Coll of Pharmacy, Minneapolis, US LA: English AB: Investigated the usefulness of a tricyclic antidepressant in the management of chronic pain. 28 patients (aged 38-79 yrs) undergoing surgery completed a randomized, placebo-controlled, double-blinded trial of 50 mg of amitriptyline (AMT) po HS on postoperative days 1, 2, and 3 while using patient-controlled morphine or meperidine analgesia. Visual analog and numerical verbal pain ratings, sedation scores, sleep quantity/quality scores, and sense of well-being scores were assessed twice daily on each of the days succeeding AMT/placebo use. AMT was no different than placebo in altering the majority of postoperative symptom variables studied in the sample study population but caused no significant adverse effects. There does not appear to be an opioid-sparing effect nor an improvement in general well-being. Results of this study do not support general use of AMT as a coanalgesic. (PsycLIT Database Copyright 1993 American Psychological Assn, all rights reserved) KP: adjunctive low dose amitriptyline with patient controlled morphine or meperidine analgesia; 38-79 yr olds with postoperative orthopedic chronic pain AN: 80-34733

SO - Pain 1993;52:325-33

AU - Kong H

AU - Raynor K

AU - Yasuda K

AU - Moe ST

AU - Portoghese PS

AU - Bell GI

AU - Reisine T

TI - A single residue, aspartic acid 95, in the delta opioid receptor specifies selective high affinity agonist binding

AB - The enkephalins, dynorphins, and endorphins are endogenous opioids which function as neurotransmitters, neuromodulators, and hormones and are involved in the perception of pain, modulation of behavior, and regulation of autonomic and neuroendocrine function. Pharmacological studies have defined three classes of opioid receptors, designated as delta, kappa, and mu. To investigate mechanisms by which agonists and antagonists interact with the delta opioid receptor, we have substituted aspartic acid 95 in the transmembrane segment 2 of the cloned mouse delta opioid receptor with an asparagine (D95N). The D95N mutant receptor had reduced affinity for delta receptor-selective agonists such as enkephalin, [D-Pen2,D-Pen5]enkephalin and [D-Ser2,Leu5]enkephalin-Thr6 such that it did not bind these peptides even at micromolar concentrations. The binding of delta-selective non-peptide agonists was also reduced. In contrast, the delta receptor-selective antagonists, such as naltrindole, the benzofuran analog of naltrindole, and 7-benyllidenenaltrexone, bound equally well to the wild-type and mutant receptor. Similarly, non-

selective opioid agonists such as bremazocine and buprenorphine, which interact with delta, kappa, and mu

opioid receptors, showed no difference in binding to the wild-type and mutant delta receptor. The D95N

mutant remained coupled to G proteins, and the receptor was functionally active since it mediated agonist

inhibition of cAMP accumulation. These results indicate that selective agonists and antagonists bind

differently to the delta receptor and show that Asp-95 contributes to high affinity delta-selective agonist

binding. The identification of a key residue involved in selective agonist binding to the delta opioid receptor

will facilitate the development of novel therapeutic reagents that can be used for the treatment of chronic

pain and other conditions.

SO - Journal of Biological Chemistry 1993;268:23055-2305

UI - 000150

AU - Krames ES

TI - Intrathecal infusional therapies for intractable pain: patient management guidelines

AB - This article focuses on appropriate patient selection for and management of patients selected for

continuous spinal infusional opioid therapy. Patients with cancer-related pain who have undergone sequential

strong opioid drug trials, who have intractable, unmanageable side effects, and who have undergone a

successful spinal opioid efficacy trial are candidates for implantable spinal infusional therapy. Patients with

noncancer-related chronic pain, who have failed all conventional syndrome-specific therapies before

neuroablative surgical procedures, including sequential strong opioid drug trials, who have

intractable, unmanageable side effects, and who have undergone successful spinal opioid efficacy trial

are deemed candidates for implantable spinal infusional therapy. Patients with chronic noncancer-

related pain and patient with cancer-related pain who have life expectancies greater than 3 mo all have

implanted programmable infusion pumps. Patients with cancer-related pain who have life expectancies less

than 3 mo have implanted permanent epidural catheters connected to external pump systems. Management

guidelines for complications of therapy broadly categorized as surgical, mechanical, and pharmacologic are

presented.

SO - Journal of Pain & Symptom Management 1993;8:36-4

UI - 000151

AU - Lipchik GL

AU - Milles K

AU - Covington EC

TI - The effects of multidisciplinary pain management treatment on locus of control and pain beliefs

in chronic non-terminal pain

AB - OBJECTIVE: To determine whether chronic pain patients' beliefs and attributions about pain control

are amenable to change in a short-term inpatient multidisciplinary pain management program. DESIGN:

Non-randomized consecutive sample with prospective, before-after treatment. SETTING: Pain-

management, tertiary care center in a major U.S. city. PATIENTS: All adult patients (n = 50) who were

treated in an inpatient multidisciplinary pain management center were contrasted with those of a control

group of 46 adult patients who were treated in an outpatient pain center. OUTCOME MEASURES: Pain

Locus of Control Scale, the Pain Beliefs and Perceptions Inventory, subjective pain intensity, and medication

usage were measured before and after treatment. RESULTS: Statistically significant posttreatment changes

were found for the treatment group, but not the control group. Patients who completed the inpatient pain

management program reported significant decreases in subjective pain intensity despite discontinuation of

narcotic analgesics. Patients in the treatment group showed an increased sense of personal control over their

pain and substantial decreases in attributions of pain control to powerful others and chance. Patients in the

treatment group also showed a significant reduction in their endorsement of the belief that their pain was a

mysterious phenomenon. CONCLUSIONS: Chronic non-terminal pain patients' beliefs about pain and

attributions of pain control are amenable to change in a short-term inpatient multidisciplinary pain

management program. These results suggest that an intensive multidisciplinary program involving

psychotherapy might be more effective in treating chronic pain patients similar to those in this study than

outpatient treatment without psychotherapy.

SO - Clinical Journal of Pain 1993;9:49-5

UI - 000206

AU - Portenoy RK

TI - Therapeutic use of opioids: prescribing and control issues

AB - AB - [No Abstract Available] AD - Department of Neurology AD -Memorial Sloan-Kettering Cancer

Center AD - New York 10021 UI -94019720

SO - NIDA Res Monogr 1993;131:35-5

UI - 000254

AU - Weissman DE

TI - Doctors, opioids, and the law: the effect of controlled substances regulations on cancer pain

management

AB - AB - Opioids are underused by physicians for the treatment of cancer pain. Reasons for this include

excessive concern about opioid-induced respiratory depression, tolerance, and addiction, as well as the

impact of controlled substances regulations. The negative impact of controlled substances regulations on

patient care is not well understood. This paper reviews the historical basis and current structure of the

regulatory system. Four potential ways in which controlled substances regulations and policies can affect

medical care are discussed: (1) by placing restrictions on physician practice, (2) by affecting patient access to

opioids, (3) by stigmatizing patients, and (4) indirectly through physicians' perceptions of regulations,

resulting in modified medical practices. Physicians are urged to work with state regulatory agencies to

identify regulatory impediments to appropriate patient care. AD - Division of Cancer and Blood Diseases

AD - Medical College of Wisconsin AD -Milwaukee UI - 93235094

SO - Semin Oncol 1993;20:53-5

UI - 000154

AU - Wilder-Smith CH

TI - [Non-opioids in pain therapy: current perspectives]. [German]

AB - Increasing knowledge of the mechanisms underlying nociceptive processing are making a more

rationale approach to pain treatment possible. Recent research has confirmed relevant differences between

NSAIDs and the direct analgesic action of several psychotropic drugs. Alpha 2-adrenergic agonists are being

clinically tested and have shown considerable analgesic activity in various pain states. Simultaneous

treatment of pain with complementary analgesics, i.e. "balanced analgesia", seems to be a logical approach in

the light of the close interactions between the different nociceptive pathways. The indications for the use of

known analgesics in chronic pain therapy are insufficiently researched.

SO - Schweizerische Rundschau fur Medizin Praxis 1993;82:271-27

UI - 000172

AU - Zenz M

AU - Willweber-Strumpf A

TI - Opiophobia and cancer pain in Europe [see comments]

SO - Lancet 1993;341:1075-107

UI - 000155

AU - Beltrutti DP

AU - Ardizzone A

AU - Parola P

TI - Continuous spinal analgesia by means of micropumps[correction of micropumpus]: a report of

163 chronic pain patients

AB - Chronic pain in patients suffering from advanced cancer as well as unbearable chronic pain states

depending on non-malignant pathology have always represented a test bench to verify results of advanced

therapeutical programs as to more traditional approaches. The Authors present their experience resulting

from longterm spinal infusion with peridural catheters connected to portable micropumps for the continuous

administration of analgesic solutions. The availability of portable micropumps, a better understanding of

spinal opioid receptors and advances in pharmacokinetics of opiate analgesics led in these years to a

tremendous improvement of pain control possibilities and of the quality of life of patients.

SO - Panminerva Medica 1992;34:128-13

UI - 000194

AU - Brescia FJ

AU - Portenoy RK

AU - Ryan M

AU - Krasnoff L

AU - Gray G

TI - Pain, opioid use, and survival in hospitalized patients with advanced cancer

AB - AB - PURPOSE: Pain is a common and feared symptom for patients with incurable cancer.

Comprehensive assessment provides the foundation for effective pain management, and data that clarify the

relationship between pain and other relevant factors also facilitate this process. The main objective of the

study was to develop a clinical data base for advanced cancer patients and to survey data to determine (1)

pain severity at admission, (2) opioid use at admission, (3) change in opioid use during the hospital stay, and

(4) survival in the hospital. PATIENTS AND METHODS: Information was collected prospectively on

1,103 patients admitted and on 1,017 patients who died within 6 months of the study's end. Demographic

and clinical data were recorded 72 hours after admission and soon after death or discharge. RESULTS:

Seventy-three percent of patients had pain at admission. Cancer of the cervix was frequently (68%)

associated with severe pain, as were prostate (52%) and rectal/sigmoid tumors (49%). Severe pain was more

probable in those with bone metastasis, those admitted from home, and in those younger than 55 years of

age. The majority (71.7%) of patients had a stable dosing pattern, and only 4.2% of the patients required

dose increases of at least 10% per day. CONCLUSION: This study demonstrated the wide variability in

opioid doses required. No reliable predictor of opioid requirement was identified, and this lack of

predictability of cancer pain severity underscores the need for ongoing assessment. AD - Calvary Hospital

AD - Bronx AD - NY 10461 UI - 92092056

SO - J Clin Oncol 1992;10:149-15

UI - 000211

AU - Cherny NI

AU - Thaler HT

AU - Friedlander-Klar H

AU - Lapin J

AU - Portenoy RK

TI - OPIOID RESPONSIVENESS OF NEUROPATHIC CANCER PAIN: COMBINED ANALYSIS

OF SINGLE-DOSE ANALGESIC TRIALS (MEETING ABSTRACT)

AB - AB - Neuropathic pain resulting from damage to the central or peripheral nervous system is common

in cancer patients (pts). Controversy exists about the opioid responsiveness of this type of pain. Some

clinicians have suggested that these pains may be inherently resistant to opioid analgesia; others have

postulated that the neuropathic mechanism may relatively diminish the analgesic response. To assess these

hypotheses, we performed a combined analysis of the results from 4 controlled single-dose analgesic trials

performed from 1978 to 1982, with morphine or heroin at high and low doses. Analgesic response was

assessed serially over a 6-hr interval using a visual analog scale and was summarized as a total pain relief

(TOTPAR) score. A total of 194 pts with chronic cancer pain were included; there were 482 administrations

of study drug. Median age was 52 yr (20-79). Information about characteristics of pts' pain recorded at the

time of study was reviewed independently by 2 experienced pain clinicians who grouped each case according

to inferred pain mechanism (neuropathic, nociceptive or mixed) and the degree of confidence in the inferred

mechanism (definite vs probable/possible). When initial groupings differed, they were rereviewed with a

third investigator and disagreement was resolved by consensus. Cases were grouped as follows: nociceptive

pain only (n=210), neuropathic pain only (n=51) and mixed (n=221). Analgesic responsiveness was

evaluated comparing TOTPAR scores using the Student's t-test. TOTPAR for the entire group was not

predicted by the specific drug (morphine vs heroin), but the dose (high vs low) was a significant predictor of

TOTPAR. Placebo TOTPAR response was estimated at 5.1, significantly less than the mean observed with

any group. The primary analysis for the study compared analgesic response of pts having any neuropathic

component with those with only nociceptive pain. Results are presented in a table. In a covariate analysis

that adjusted for prior opioid exposure and other prognostic factors, the opioid responsiveness of

neuropathic pain was significant and was less than that of purely nociceptive pain. These data support the

postulate that opioid responsiveness is a continuum and that it is diminished by the neuropathic mechanism

AD - Pain Service AD - Dept. of Neurology AD - Memorial Sloan-Kettering Cancer Center AD - New

York AD - NY 10021 UI - 92682059

SO - Proc Annu Meet Am Soc Clin Oncol 1992;11:A1330-A133

UI - 000188

AU - Culpepper-Morgan JA

AU - Inturrisi CE

AU - Portenoy RK

AU - Foley K

AU - Houde RW

AU - Marsh F

AU - Kreek MJ

TI - Treatment of opioid-induced constipation with oral naloxone: a pilot study

AB - Opioids cause constipation by binding to specific opioid receptors in the enteric and central nervous

systems. First-pass glucuronidation limits systemic bioavailability of oral naloxone. This study was designed

to determine if oral naloxone could reverse opioid-induced constipation without precipitating abstinence or

recrudescence of pain in opioid-dependent individuals. Concentrations of unmetabolized and total naloxone,

including naloxone glucuronide, were measured by radioimmunoassay. A dose-related increase in symptoms

of laxation resulted in all three opioid-dependent patients studied that paralleled the increase in active and

total naloxone plasma levels. Withdrawal symptoms occurred with plasma naloxone area under the plasma

concentration-time curves above 550 ng.min/ml and with dosing intervals less than 3 hours. Peak plasma

levels did not predict withdrawal. Oral naloxone ameliorates opioid-induced constipation in opioid-

dependent persons. Titration of dose to a maximum of 12 mg at least 6 hours apart may be needed to avoid

adverse reactions.

SO - Clin Pharmacol Ther 1992;52:90-9

UI - 000164

AU - Dimski DS

AU - Hebert LA

AU - Sedmak D

AU - Ogrodowski JL

AU - Elkhammas EA

AU - Tesi RJ

AU - Gold M

AU - Courville CS

TI - Renal autotransplantation in the loin pain-hematuria syndrome: a cautionary note

AB - The current literature suggests that renal autotransplantation is nearly uniformly effective in

controlling the severe and debilitating pain of the loin pain-hematuria syndrome (LPHS). However, we

report two patients thought to have this syndrome in whom renal autotransplantation did not result in long-

term control of pain. In case 1, autotransplantation resulted in immediate cessation of pain; however, the

flank pain recurred 7 1/2 months later. The recurrent pain was also severe and debilitating, requiring narcotic

medications for control. In case 2, autotransplantation of the left kidney resulted in chronic pain in the left

pelvic area, the site of the autotransplanted kidney. In addition, the patient continued to experience chronic

discomfort in the left flank and along the flank incision. One year after autotransplantation, the patient still

requires multiple daily doses of narcotic medications for pain control. Our two patients represent the 13th

and 14th reported patients subjected to renal autotransplantation for management of LPHS. They represent

only the third and fourth reported patients with recurrence of pain after renal autotransplantation. Because

studies with negative results are less likely to be reported in the literature than studies with positive results, it

is possible that the literature overestimates the effectiveness of renal autotransplantation in the LPHS. To

assess the true effectiveness of renal autotransplantation in LPHS, a survey of patients with LPHS who have

undergone renal autotransplantation needs to be performed.

SO - American Journal of Kidney Diseases 1992;20:180-18

UI - 000016

AU - Eisele JH

AU - Grigsby EJ

AU - Dea G

TI - Clonazepam treatment of myoclonic contractions associated with high-dose opioids: Case report

AB - IN: U California-Davis, Sacramento, US LA: English AB: Presents the case of a 30-yr-old man with

chronic abdominal pain who was treated with high doses of iv hydromorphone and developed severe and

frequent myoclonic contractions. Several medications including lorazepam failed to control the contractions;

however, clonazepam in normal doses reduced the myoclonus dramatically. (PsycLIT Database Copyright

1992 American Psychological Assn, all rights reserved) KP: clonazepam; hydromorphone induced myoclonic

contractions; 30 yr old male with chronic abdominal pain; case report AN: 79-44237

SO - Pain 1992;49:231-23

UI - 000161

AU - Fishbain DA

AU - Rosomoff HL

AU - Rosomoff RS

TI - Detoxification of nonopiate drugs in the chronic pain setting and clonidine opiate detoxification.

[Review]

AB - Although the pain physician is most familiar with the treatment of the opiate withdrawal syndrome,

other drugs are abused by the chronic pain patient. The pain physician should then be familiar with the

withdrawal syndromes associated with other drug groups. The withdrawal syndromes associated with

hypnosedatives, psychotomimetics, nicotine, stimulants, ergot alkaloids, beta adrenergic blocking agents,

antidepressants, muscle relaxants, and alpha-adrenergic agonists are described. Drug detoxification protocols

for these drugs are reviewed. Additionally, the rationale for clonidine opiate detoxification is discussed, and

current clonidine detoxification protocols are reviewed. [References: 89]

SO - Clinical Journal of Pain 1992;8:191-20

UI - 000207

AU - Galer BS

AU - Coyle N

AU - Pasternak GW

AU - Portenoy RK

TI - Individual variability in the response to different opioids: report of five cases

AB - AB - Although it is widely appreciated that patients can demonstrate highly variable responses to

different opioid drugs, there have been few detailed descriptions of this phenomenon. To illustrate this

variability, we present 5 patients, 4 with cancer pain and 1 with non- malignant pain, who underwent dose

titration with more than 1 opioid and developed markedly different responses to each. In every case, dose

escalation led to successful treatment with 1 opioid and to intolerable side effects without adequate relief

with others. The existence of this individual variability in the response to different opioids has important

implications for both clinical practice and current understanding of opioid pharmacology in man. It

contradicts the view that any opioid is inherently more efficacious than any other, suggests that patients who

fail to obtain adequate pain relief at maximally tolerated doses of 1 opioid may benefit from an alternative

drug, and underscores the potential importance of genetic factors as a determinant of opioid response. AD -

Department of Neurology AD - Memorial Sloan-Kettering Cancer Center AD - New York AD - NY 10021

UI - 92278827

SO - Pain 1992;49:87-9

UI - 000019

AU - Hamilton J

AU - Edgar L

TI - A survey examining nurses' knowledge of pain control

AB - IN: Victoria General Hosp, Halifax, NS, Canada LA: English AB: Surveyed 318 nurses at an acute

care teaching hospital to identify their knowledge of pain assessment and management. Two pain

instruments by M. McCaffery et al (1990) were combined and adapted for use. The final instrument, the Pain

Control Survey, was administered to Ss. Ss lacked knowledge and understanding of opioid addiction,

equivalent dosing, properties of opioids, and differences in acute and chronic pain. No significant differences

were found in the scores by level of educational preparation or by years of experience. Presentation of the

results unit by unit demonstrated that the instrument was suitable as an educational tool as well as an

effective strategy to introduce Ss to nursing research. (PsycLIT Database Copyright 1992 American

Psychological Assn, all rights reserved) KP: knowledge of pain assessment & management with narcotic

opioid analgesics; nurses at acute care teaching hospital AN: 79-29038

SO - Journal of Pain and Symptom Management 1992;7:18-2

UI - 000165

AU - Litman RS

AU - Shapiro BS

TI - Oral patient-controlled analgesia in adolescents

AB - Adolescence is a time when concerns about independence and self-control are of paramount

importance. These developmental issues must be considered when planning treatment for adolescents with

acute or chronic pain. Patient-controlled analgesia (PCA) is a method of administering opioids that

reinforces patient autonomy. Traditionally, opioids given by PCA are administered via the intravenous or

subcutaneous route. Issues of autonomy and control, however, are no less important for patients receiving

oral opioids. To augment patient autonomy, we have provided oral medication kept at the bedside (oral

bedside PCA) for adolescents with diverse pain problems. We describe our selection criteria and methods for

using oral bedside PCA with adolescents and present 4 patients who used this method.

SO - Journal of Pain & Symptom Management 1992;7:78-8

UI - 000162

AU - McQuay HJ

AU - Jadad AR

AU - Carroll D

AU - Faura C

AU - Glynn CJ

AU - Moore RA

AU - Liu Y

TI - Opioid sensitivity of chronic pain: a patient-controlled analgesia method

AB - Twenty-two patients with chronic pain of malignant or nonmalignant origin were given intravenous

morphine by patient-controlled analgesia. A prestudy judgment was made from the characteristics of the pain

as to whether it was nociceptive or neuropathic. Analgesic efficacy was assessed by a nurse-observer;

adverse events were noted and plasma morphine and metabolitie concentrations measured. Three categories

of opioid response were distinguished. Good responders obtained > 70 mm relief on the visual analogue

scale, with minimal or manageable adverse events. Moderate responders obtained < 70 but > 30 mm relief

with more problematic adverse events, and poor responders had < 30 mm relief with troublesome adverse

events. This method for the study of opioid sensitivity allowed a wide dosage range to be studied. The

simultaneous analgesic and adverse event measurements showed that the spectrum of observed response was

wide, and response category could be judged for the majority by 4 h. In those with poor or moderate

response, adverse event severity limited further dose increment. The relationship between pain

characteristics and response showed that some pains judged to be neuropathic had a good response to opioid

(5/13), and some pains judged to be nociceptive did not (5/14). The study suggests that the pattern of

response is not as black and white as the prediction of good response from nociceptive pain and poor from

neuropathic pain would suggest, although nociceptive pain was more likely than neuropathic pain to show a

good response. For the moderate responders opioid titration may, in the absence of other effective

treatments, be useful, but the analgesic endpoint may not be totally satisfactory. The method provides an

operational definition of opioid sensitivity.

SO - Anaesthesia 1992;47:757-76

UI - 000169

AU - Moulin DE

AU - Johnson NG

AU - Murray-Parsons N

AU - Geoghegan MF

AU - Goodwin VA

AU - Chester MA

TI - Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use [see

comments]

AB - OBJECTIVE: To provide guidelines for the institution and maintenance of a continuous subcutaneous

narcotic infusion program for cancer patients with chronic pain through an analysis of the narcotic

requirements and treatment outcomes of patients who underwent such therapy and a comparison of the costs

of two commonly used infusion systems. DESIGN: Retrospective study. SETTING: Tertiary care facilities

and patients' homes. PATIENTS: Of 481 patients seen in consultation for cancer pain between July 1987

and April 1990, 60 (12%) met the eligibility criteria (i.e., standard medical management had failed, and they

had adequate supervision at home). INTERVENTION: Continuous subcutaneous infusion with

hydromorphone hydrochloride or morphine started on an inpatient basis and continued at home whenever

possible. OUTCOME MEASURES: Patient selectivity, narcotic dosing requirements, discharge rate, patient

preference for analgesic regimen, side effects, complications and cost-effectiveness. RESULTS: The mean

initial maintenance infusion dose after dose titration was almost three times higher than the dose required

before infusion (hydromorphone or equivalent 6.2 v. 2.1 mg/h). Eighteen patients died, and the remaining 42

were discharged home for a mean of 94.4 (standard deviation 128.3) days (extremes 12 and 741 days). The

mean maximum infusion rate was 24.1 mg/h (extremes 0.5 and 180 mg/h). All but one of the patients

preferred the infusion system to their previous oral analgesic regimen. Despite major dose escalations nausea

and vomiting were well controlled in all cases. Twelve patients (20%) experienced serious systemic toxic

effects or complications; six became encephalopathic, which necessitated dose reduction, five had a

subcutaneous infection necessitating antibiotic treatment, and one had respiratory depression. The

programmable

computerized infusion pump was found to be more cost-effective than the disposable infusion device after a

break-even point of 8 months. CONCLUSIONS: Continuous subcutaneous infusion of opioid drugs with the

use of a portable programmable pump is safe and effective in selected patients who have failed to respond to

standard medical treatment of their cancer pain. Dose titration may require rapid dose escalation, but this is

usually well tolerated. For most communities embarking on such a program a programmable infusion system

will be more cost-effective than a disposable system

SO - Canadian Medical Association Journal 1992;146:891-89

UI - 000015

AU - Ollat H

TI - Traitement pharmacologique de la douleur neuropathique. / Pharmacological treatment of

neuropathic pain

AB - IN: Association pour la Neuro-Psycho-Pharmacologie, Paris, France LA: French AB: Reviews the

recent literature on pharmacological treatment of neuropathic pain (i.e., chronic pain resulting from injury to

the peripheral nervous system and induced by functional changes in peripheral and central pathways). Drugs

currently prescribed for neuropathic pain are discussed in terms of their effectiveness, indications, and

mechanisms of action. Data are presented on the use of various antidepressants, opiates, and anticonvulsants

for different neuropathic pain syndromes (e.g., trigeminal neuralgia, diabetic neuropathy, and postherpetic

neuralgia). Preliminary data from new pharmacological approaches (e.g., capsaicin, local anesthetics, and

anti-inflammatory agents) are reviewed, and research recommendations are provided. (English abstract)

(PsycLIT Database Copyright 1993 American Psychological Assn, all rights reserved) KP: pharmacological

treatment & drug indications & mechanisms of action; chronic neuropathic pain resulting from peripheral

nervous system injury; research review AN: 30-86136

SO - Revue Neurologique 1992;148:521-53

UI - 000156

AU - Osipova NA

AU - Petrova VV

AU - Novikov GA

AU - Beresnev VA

AU - Sergeeva IE

AU - Dolgopolova TV

TI - [Norfin in oncological practice]. [Russian]

AB - A synthetic opiate agonist-antagonist norphin (buprenorphin) has been studied in 297 cancer patients

as an analgetic component of general anesthesia, in postoperative analgesia and in the treatment of chronic

pain syndrome. In modified neuroleptanalgesia based on norphin, diazepam, droperidol and N2O the patient

is more adequately prevented from surgical trauma than in conventional neuroleptanalgesia based on

fentanyl. This is confirmed by greater stability in circulation, metabolism and stress

hormone parameters, however this anesthesia technique is less manageable and may be accompanied by

prolonged postanesthesia depression of the central nervous system. Good results have been obtained when

norphin pills were used sublingually for the treatment of long-lasting intensive chronic pain syndrome in

incurable cancer patients. Norphin is no less effective than morphin, however, unlike morphin, it causes no

severe adverse reactions.

SO - Anesteziologiya i Reanimatologiya 1992;:3-

UI - 000163

AU - Patterson KL

TI - Pain in the pediatric oncology patient

AB - Pediatric oncology nurses face many challenges in treating the pain associated with childhood cancer.

The type and severity of pain children with cancer experience varies from acute, short-term, procedure-

related pain to the progressive chronic pain associated with terminal illness. In addition, the unfounded fears

of using strong narcotic analgesics and the underutilization of psychological techniques to treat pain in

children limit the effectiveness of pain management. Armed with objective data, pediatric oncology nurses

can work with other members of the cancer treatment team to provide relief from the pain associated with

the diagnosis and treatment of childhood cancer.

SO - Journal of Pediatric Oncology Nursing 1992;9:119-13

UI - 000157

AU - Rothman RB

TI - A review of the role of anti-opioid peptides in morphine tolerance and dependence. [Review]

AB - Studies on the mechanisms of tolerance and dependence have mostly focused on changes at the

receptor level. These experiments, conducted with model systems ranging from clonal cell lines to whole

animals, have identified a number of important adaptive

mechanisms which occur at the receptor level. However, none of these adaptive mechanisms can completely

account for the phenomena which serve to define the state of morphine tolerance and dependence, especially

the observation that as an animal becomes more tolerant to morphine, less naloxone is required to trigger

withdrawal. The data reviewed in this paper provide strong support for the hypothesis that the brain

synthesizes and secretes neuropeptides which act as part of a homeostatic system to attenuate the effects of

morphine and endogenous opioid peptides. According to this model, administration of morphine releases

anti-opioid peptides (AOP), which then attenuate the effects of morphine. As more morphine is given, more

AOP are released, thereby producing tolerance to the effects of morphine. Cessation of morphine

administration, or administration of naloxone, produces a relative excess of anti-opioid, which is in part

responsible for the withdrawal syndrome. Since endogenous and exogenous antagonists might together

produce synergistic effects, less naloxone might be required to trigger withdrawal in the presence of higher

levels of AOPs. Although the study of AOP is in its infancy, a deeper understanding of the central nervous

system (CNS) anti-opioid systems may lead to new treatments for chronic pain, substance abuse, and

psychiatric disorders. [References: 114]

SO - Synapse 1992;12:129-13

UI - 000168

AU - Sagen J

TI - Chromaffin cell transplants for alleviation of chronic pain

AB - Treatment of intractable pain with parenteral, subarachnoid, or epidural narcotics is often

unsatisfactory due to tolerance and other systemic complications that accompany increasing dosages of these

drugs. Other disadvantages include the potential infections with implantable pumps and the inconvenience of

repeated narcotic administration. During the past several years, studies at the author's laboratory indicated

that transplantation of adrenal medullary tissue or isolated chromaffin cells into the spinal subarachnoid

space can significantly reduce pain in several rodent models without resulting in development of tolerance.

Adrenal medullary chromaffin cells were selected because they produce high levels of both opioid peptides

and catecholamines, agents that independently, and possibly synergistically, reduce pain when injected locally

into the spinal subarachnoid space. The adrenal medullary transplants survive for prolonged periods, and

continue to produce high levels of both catecholamines and met-enkephalin. These transplants reduce pain in

two rodent chronic pain models, an arthritis model and a peripheral neuropathy model, both of which closely

resemble human chronic pain syndromes. The success of the animal studies has led to initiation of human

clinical trials in patients with chronic cancer pain; results are promising.

SO - ASAIO Journal 1992;38:24-2

UI - 000166

AU - Smythe M

TI - Patient-controlled analgesia: a review. [Review]

AB - The patient-activated analgesic system was introduced in 1968. Early trials, although uncontrolled,

supported the safety and efficacy of patient-controlled analgesia (PCA) in several kinds of pain, such as that

relating to surgery, cancer, trauma, and obstetric procedures. In the past decade, prospective, randomized

trials have reported several advantages of PCA over conventional analgesia in the early postoperative period.

Although not supported by all controlled trials, they include improved pain relief, less sedation, lower level

of narcotic consumption, fewer postoperative complications, greater patient satisfaction, and improved

pulmonary function. Preliminary results in the management of chronic pain indicate that PCA can lead to

significant lifestyle improvements in ambulatory patients with cancer. The most significant, although

infrequent, adverse effect is respiratory depression, the majority of cases occurring in patients predisposed

secondary to concomitant illness or as a result of human error. The clinical use of PCA will likely see a

significant increase among persons with cancer, and an increase in epidural administration. The cost benefit

of PCA has yet to be assessed in inpatient and outpatient settings. [References: 114]

SO - Pharmacotherapy 1992;12:132-14

UI - 000159

AU - Sorensen HT

AU - Rasmussen HH

AU - Moller-Petersen JF

AU - Ejlersen E

AU - Hamburger H

AU - Olesen F

TI - Epidemiology of pain requiring strong analgesics outside hospital in a geographically defined

population in Denmark

AB - Based on obligatory notifications from pharmacies to the National Board of Health about prescription

of strong analgesics as well as questionnaires to the prescribing doctors, the occurrence and causes of pain

requiring strong analgesics outside hospitals were analysed over a period of one month in Denmark in a

limited population (480,000), corresponding to nearly 10% of the Danish population. During one month,

strong analgesics were prescribed to 0.2 per cent of the population. The commonest acute conditions were

back pain (23%) and trauma (17%). The commonest recurrent acute conditions were headache (25%) and

angina pectoris (17%). The commonest chronic non-malignant conditions were back pain (29%) and

pancreatitis (7%). The commonest malignant conditions were lung cancer (20%) and colorectal cancer

(14%). The commonest conditions indicated under the chronic pain syndrome were headache (33%) and

back pain (13%). Conditions requiring strong analgesics reflect to some extent the distribution of painful

conditions in the general population.

SO - Danish Medical Bulletin 1992;39:464-46

UI - 000160

AU - Terman GW

AU - Loeser JD

TI - A case of opiate-insensitive pain: malignant treatment of benign pain

AB - OBJECTIVE: We report the case of a woman with presumed cancer pain treated with escalating

doses of opiates despite no evident improvement in her pain and several deleterious side effects. PATIENT:

A 62-year-old woman with cervical myelopathy and a diagnosis of a spinal cord tumor was referred to the

University of Washington Medical Center complaining of chest tightness, multiple joint pains, nausea,

constipation, seizures and a deteriorating memory. At the time of admission she was confined to her bed

with a full-time attendant and was receiving 240 milligrams of intravenous morphine per hour for her pain.

INTERVENTION: Diagnostic studies failed to find any evidence of neoplasm and revealed only an old

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Subject: Re: Pain Medication #1

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hemorrhage within the cervical spinal cord. A program of increasing physical and occupational therapy and

decreasing opiate intake was initiated. RESULTS: Within a month the patient's pain complaints decreased,

as did the rest of her presenting complaints. Her activities of daily living greatly increased making attendant

care no longer necessary. CONCLUSIONS: This case report illustrates some of the hazards of opioid

therapy in the management of patients with chronic pain. Our patient's opiate therapy was expensive, gave

her undesirable side effects, and did not reduce her pain complaints or improve her function. In the treatment

of chronic pain, of noncancerous or cancerous origin, a) systemic opioids may not be effective in reducing

pain complaints in every patient, b) treatment efficacy evaluation should always include functional endpoints,

and c) nonefficacious treatments should not be continued indefinitely

SO - Clinical Journal of Pain 1992;8:255-25

UI - 000167

AU - Tobias JD

AU - Oakes L

AU - Austin BA

TI - Pediatric analgesia with epidural fentanyl citrate administered by nursing staff

AB - Even though epidural analgesia is effective and has advantages over conventional postoperative

analgesia, it is also labor intensive, requiring 24-hour supervision by an anesthesiologist. In an effort to

decrease the manpower requirements, some hospitals allow the nursing staff to administer epidural narcotics

to adult patients. In children, however, this practice has been limited. We retrospectively reviewed our

experience over 12 months with this procedure. Epidural catheters (caudal, lumbar, or thoracic) were placed

in 43 pediatric patients for acute and chronic pain management. All patients received a continuous epidural

infusion of bupivacaine hydrochloride with fentanyl citrate. Eleven (26%) of the 43 patients required

supplemental analgesia and were given 45 doses of epidural fentanyl. Adequate analgesia was achieved in all

patients. No intravascular or intrathecal injections were noted, nor did any inadvertent epidural injections of

medications occur. No patient had respiratory depression (respiratory rate less than 10% for age). We

believe epidural administration of fentanyl by a carefully educated nursing staff is safe and effective in

children.

SO - Southern Medical Journal 1992;85:384-38

UI - 000158

AU - Wilson JF

AU - Brockopp GW

AU - Kryst S

AU - Steger H

AU - Witt WO

TI - Medical students' attitudes toward pain before and after a brief course on pain [see comments]

AB - The effectiveness of a brief clinical and basic science seminar on pain for 1st year medical students was

examined by comparing attitudes about pain prior to the seminar to attitudes 5 months after the seminar. The

6-h course combined written materials conveying facts about behavioral, social and biological aspects of pain

with clinical observations of an acute and a chronic pain treatment team. Examination of responses to a

questionnaire assessing attitudes toward pain patients revealed that medical students have limited personal

experience with pain and medications for pain, and limited knowledge about pain. Pre-course attitudes

toward pain patients were dominated by perceived negative characteristics of pain patients and the belief that

working with such patients is difficult. Attitudes measured 5 months after the course reflected increased

complexity, greater emphasis that pain is real and not imaginary, and stronger belief that working with pain

patients is rewarding. Five months after the seminar, students reported more accurate estimates of the

frequency of problems with addiction stemming from acute pain treatment and exaggerated the prevalence of

pain problems in the society. The importance of integrating clinical and basic science experiences in order to

influence long-term clinical attitudes and produce lasting changes in clinically relevant knowledge is

discussed.

SO - Pain 1992;50:251-25

UI - 000173

AU - Zenz M

AU - Strumpf M

AU - Tryba M

TI - Long-term oral opioid therapy in patients with chronic nonmalignant pain

AB - In contrast to the use of opioids for the treatment of acute and chronic cancer pain, the administration

of chronic opioid therapy for pain not due to malignancy remains controversial. We describe 100 patients

who were chronically given opioids for treatment of nonmalignant pain. Most patients experienced

neuropathic pain or back pain. We used sustained-release dihydrocodeine, buprenorphine, and sustained-

release morphine. Pain reduction was measured with visual analogue scales (VAS), and the Karnofsky

Performance Status Scale was used to assess the patient's function. Good pain relief was obtained in 51

patients and partial pain relief was reported by 28 patients. Only 21 patients had no beneficial effect from

opioid therapy. There was a close correlation between the sum and the peak VAS values (r = 0.983; p less

than 0.0001) and pain reduction was associated with an increase in performance (p less than 0.0001). The

most common side effects were constipation and nausea. There were no cases of respiratory

depression or addiction to opioids. Our results indicate that opioids can be effective in chronic

nonmalignant pain, with side effects that are comparable to those that complicate the treatment of cancer

pain

SO - Journal of Pain & Symptom Management 1992;7:69-7

UI - 000017

AU - Zenz M

AU - Strumpf M

AU - Tryba M

TI - Long-term oral opioid therapy in patients with chronic nonmalignant pain

AB - IN: Universitatsklinik Bergmannsheil, Klinik fur Anaesthesiologie, Intensiv und Schmerztherapie,

Bochum, Germany LA: English AB: Chronically administered dihydrocodeine, buprenorphine, or morphine

to 100 patients (aged 29-81 yrs) with nonmalignant pain. Ss were administered the Visual Analogue Scale

(VAS), a performance status scale. Good pain relief was obtained in 51 Ss, and partial pain relief was

reported by 28 Ss. There was a close correlation between the sum and the peak VAS values, and pain

reduction was associated with an increase in performance. The most common side effects were constipation

and nausea. The case report of a 35-yr-old male is presented. Opioids can be effective in chronic

nonmalignant pain, with side effects that are comparable to those that complicate the treatment of cancer

pain. (PsycLIT Database Copyright 1992 American Psychological Assn, all rights reserved) KP: long term

dihydrocodeine or buprenorphine or morphine; pain relief & side effects; 29-81 yr olds with chronic

nonmalignant pain AN: 79-32549

SO - Journal of Pain and Symptom Management 1992;7:69-7

UI - 000022

AU - Abdelhamid EE

AU - Sultana M

AU - Portoghese PS

AU - Takemori AE

TI - Selective blockage of delta opioid receptors prevents the development of morphine tolerance and

dependence in mice

AB - IN: Alexandria U, Faculty of Science, Egypt LA: English AB: Studied the effect of the selective delta

antagonist naltrindole (NTI) and its nonequilibrium analog naltrindole 5'-isothiocyanate (5'-NTII) on the

development of morphine tolerance and dependence in male mice. Degree of morphine tolerance was

monitored by determining the ED-sub-5-sub-0 of morphine sulfate in a tail-flick antinociceptive assay;

degree of physical

dependence on morphine was assessed by estimating the amount of naloxone required to induce withdrawal

jumping. Both NTI and 5'-NTII suppressed the development of opiate tolerance and dependence in acute

and chronic models. The antagonists had no influence on the activity of the mu opioid receptor agonist

DAMGO. Thus, the inhibitory effect of NTI and 5'-NTII appeared to be due to their antagonist actions

solely on delta opioid receptors. Implications for the management of chronic pain are discussed. (PsycLIT

Database Copyright 1992 American Psychological Assn, all rights reserved) KP: naltrindole vs naltrindole 5-

isothiocyanate; development of morphine tolerance & dependence; male mice; implications for chronic pain

management AN: 79-00730

SO - Journal of Pharmacology and Experimental Therapeutics 1991;258:299-30

UI - 000116

AU - Boogaerts J

AU - Lafont N

TI - [Mechanism of action and clinical use of opioids administered by the peripheral perineural

route]. [Review] [French]

AB - Experimental studies have shown that opioids could produce two types of effect on neuronal

excitability. The first one, aspecific, is a local anesthetic action on the nerve fiber with a diminution of

sodium and potassium conductance. The second is specific: the sodium conductance lowering is due to a

linkage of the opioid with a receptor on the internal face of the membrane. Opioids could also migrate to the

posterior horn of the spinal cord after linkage with axonal receptors. Clinical studies have proved that

opioid injection in peripheral nervous trunks and specially in the brachial plexus produce a

prolonged analgesia status in the post operative period but also and mostly in the chronic pain. The

more liposoluble opioids like fentanyl and buprenorphine are the more effective. [References: 52]

SO - Cahiers d Anesthesiologie 1991;39:91-9

UI - 000117

AU - Eledjam JJ

AU - Viel E

AU - Bassoul B

AU - Bruelle P

TI - [Non-analgesic effects of opioids]. [Review] [French]

AB - The aim of the regional administration of opioids is to provide an efficient and prolonged analgesia.

Then, opiates can be useful for postoperative analgesia and for the treatment of chronic pain of malignant

origin. Analgesia is correlated with several adverse effects of which the most frequent are nausea and itching

and the most severe is respiratory depression. Beside the adverse effects, other properties of opiates could

be responsible of favourable effects which can be taken in advantage in specific indications. In the

postoperative period, epidurally administered opioid can attenuate the neuroendocrine and metabolic

responses to surgery and pain. This effect is responsible of a reduction of the resistance to insulin and of a

better nutritional balance, especially after major abdominal surgical procedures. Opioids also act by a

reduction of the motor functions of the bowel, which perhaps could reduce the incidence of anastomotic

breakdowns. Finally, other effects have been reported, as anecdotes, such as the treatment of spasm after

bilateral replantation of the ureters, neurologic bladder dysfunctions and enuresis. Spinal administration of

opioids has also been used as a treatment of premature ejaculation. [References: 41]

SO - Cahiers d Anesthesiologie 1991;39:111-11

UI - 000109

AU - Ferrell BA

AU - Ferrell BR

TI - Pain management at home. [Review]

AB - The management of chronic pain should be a priority in geriatric home care. Pain is a common

problem that has tremendous potential to influence the physical function and quality of life of elderly people

during their remaining years. The experience of pain and its management at home are not analogous to

institutional settings. Family and caregivers have important influences on pain management and may require

education and support for the long-term management of chronic pain patients. Existing pain management

strategies should be tailored to meet the special needs of geriatric patients and be sensitive to caregiver

concerns. Implications, indications, and applications for high-tech pain management strategies need to be

clarified for the management of older people at home. [References: 27]

SO - Clinics in Geriatric Medicine 1991;7:765-77

UI - 000122

AU - Fogel BS

AU - Fretwell MD

TI - Common mental health problems in geriatric practice. Part II: Insomnia, chronic pain, troubled

families, and other dilemmas

SO - Rhode Island Medical Journal 1991;74:68-7

UI - 000112

AU - Foldes FF

TI - Pain control with intrathecally and peridurally administered opioids and other drugs. [Review]

AB - Sharp pain is conducted rapidly by myelinated delta A fibers and diffused pain slowly by

nonmyelinated C fibers to pseudobipolar neurons in the posterior ganglion and

from there to neurons located in the posterolateral horn of the spinal cord. From here on nociferous impulses

are transmitted by excitatory peptides (e.g. substance P) or amino acids (e.g. glutamate, aspartate) through

interconnecting neurons of the pain pathways, primarily on the contralateral side, to the brain stem and from

there to the sensory cortex, where they are appreciated and acted upon. There are specific inhibitory

receptors located on axon terminals, near to the release sites of the excitatory amino acids and peptides.

Stimulation of these receptors by their appropriate ligands such as endogenous (e.g. enkephalis, endorphins)

or exogenous opioids, clonidine, serotonin, somatostatin inhibits the release of excitatory neurotransmitters

and relieves pain. There are at least 3 different opioid receptors, called mu-, kappa- and delta-receptors in

the spinal cord. These can be differentiated from one another by their specific affinity toward different

endogenous or exogenous opioids and the pure narcotic antagonist, naloxone. It appears that the nociferous

impulses transmitted by parallel pathways equipped with different inhibitory receptors have to be integrated

to produce pain sensation and partial inhibition of transmission in different pathways or complete inhibition

in one of the pathways may relieve pain. In recent years the concept of "selective spinal analgesia" has been

applied clinically for the relief of postoperative, obstetrical and chronic pain. At first it was expected that the

intrathecal or peridural administration of morphine will produce analgesia without the side effects of

systemically administered morphine. It soon became evident, however, that intrathecally and peridurally

administered morphine after several hours of delay reaches the fourth ventricle and by stimulating mu-

receptors may cause respiratory depression and other undesired effects (e.g. nausea, vomiting, pruritus).

Several different approaches are being investigated for the production of selective spinal analgesia without

side effects. They include: a. the use of more lipophilic, long-lasting opioids (e.g. lofentanil) which would be

almost completely absorbed by the spinal cord and therefore would not reach the medullary centers; b. the

development of opioids with specific affinity to kappa- and for delta- and little or no affinity to mu-

receptors, primarily responsible for side effects; and c. combining lower doses of opioid agonists with alpha

2-adrenergic agonists (e.g. clonidine) or with somatostatin. It is conceivable that in the not-too-distant

future, it will be possible to achieve through these measures, selective spinal analgesia without side effects.

[References: 68]

SO - Anaesthesiologie und Reanimation 1991;16:287-29

UI - 000118

AU - Forman WB

AU - Stratton M

TI - Current approaches to chronic pain in older patients. [Review]

AB - As the population ages, primary care physicians face an increasing number of individuals who suffer

from the effects of chronic diseases, including the accompanying chronic pain. This article reviews the

common causes of pain in the elderly and suggests a system for assessing its severity. Five different

approaches to treating pain in this population are outlined, as are guidelines for managing the potential side

effects of treatment. [References: 20]

SO - Geriatrics 1991;46:47-5

UI - 000171

AU - Hassenbusch SJ

AU - Stanton-Hicks MD

AU - Soukup J

AU - Covington EC

AU - Boland MB

TI - Sufentanil citrate and morphine/bupivacaine as alternative agents in chronic epidural infusions

for intractable non-cancer pain

AB - Intraspinal narcotic (usually intrathecal morphine) infusions with implanted pumps are increasingly

used in patients with intractable chronic pain not caused by cancer. In some patients, pain control is difficult

with infusions of morphine. Seven patients with diagnoses of arachnoiditis, epidural scarring, and/or

vertebral body compression fracture were treated with alternative solutions in an epidural route. For

maximal flexibility, Medtronic implanted programmable infusion pumps with catheters to T6-T10 were used,

and pain was monitored by verbal pain scales. In three patients, epidural infusions of morphine in 0.5%

bupivacaine (MS-MARC) resulted in little or no pain relief without significant side effects (e.g., headache,

nausea, or vomiting). In these same patients, epidural infusions of sufentanil citrate resulted in pain scale

reductions of 92%, 82%, and 40%, respectively, with no side effects. Four other patients found more

effective pain relief when switched from initial sufentanil citrate infusions to MS-MARC. Pain scale

reductions (with no side effects) were 92%, 76%, 59%, and 47% in these patients. Pain relief and minimal

side effects with sufentanil citrate is theorized to result from its higher lipophilicity promoting local

transdural diffusion to spinal cord and limiting upward diffusion to the brain stem. Sufentanil citrate is also

advantageous for programmable pumps because it is 100 times more potent than morphine and therefore

allows longer pump refill times and higher infusion doses. Although this study was done on a limited number

of patients, sufentanil citrate and MS-MARC in epidural infusions using programmable infusion pumps for

non-cancer patients provide significant alternative drug combinations and routes.

SO - Neurosurgery 1991;29:76-81; discussion 81-

UI - 000252

AU - Hogan O

AU - Weissman DE

AU - Haddox JD

AU - Abram S

AU - Taylor ML

AU - Janjan N

TI - EPIDURAL OPIATES AND LOCAL ANESTHETICS FOR THE MANAGEMENT OF

CANCER PAIN (MEETING ABSTRACT)

AB - AB - The Medical College of Wisconsin multispecialty cancer pain service reviewed its experiences

with epidural analgesia by retrospectively reviewing hospital/clinic charts from January 1987 through

December 1989. 1205 patients (pts) were admitted to the inpatient oncology service during the study period,

and epidural analgesia was used 16 times (15 pts, 1.2%). Indications for epidural analgesia included failure

of systemic opioids and other noninvasive drug and nondrug therapies per WHO guidelines. The mean pre-

epidural equianalgesic dose of im morphine was 300 mg/day. Temporary catheters were used to assess

response to epidural morphine; if no response bupivacaine was added; if no response the catheter was

removed; if analgesia was obtained the temporary catheter was replaced by a tunneled catheter for long-term

use. Analgesia was successfully obtained in 12/16 epidural attempts; 6 with morphine alone, 6 with morphine

plus bupivacaine. 4/16 attempts were discontinued due to unacceptable toxicity or technical problems.

Tunneled catheters were used for a mean of 83 days (range 6-965 days). Catheter problems included

malfunction (7), infection (4), injection pain (4), epidural hematoma (1), hyperesthesia (1). Epidural

analgesia is infrequently indicated, bupivacaine extends the efficacy of epidural analgesia and complications

are common AD - Medical Coll. of Wisconsin AD - Milwaukee AD - WI 53211 UI - 91672498

SO - Proc Annu Meet Am Soc Clin Oncol 1991;10:A1161-A116

UI - 000170

AU - Hoskin PJ

AU - Hanks GW

TI - Opioid agonist-antagonist drugs in acute and chronic pain states. [Review]

AB - The agonist-antagonist opioid analgesics are a heterogeneous group of drugs with moderate to strong

analgesic activity comparable to that of the pure agonist opioids such as codeine and morphine but with a

limited effective dose range. The group includes drugs which act as an agonist or partial agonist at one

receptor and an antagonist at another (pentazocine, butorphanol, nalbuphine, dezocine) and drugs acting as a

partial agonist at a single receptor (buprenorphine). These drugs can be classified as nalorphine-like or

morphine-like. Meptazinol does not fit into either classification and occupies a separate category.

Pentazocine, butorphanol and nalbuphine are weak mu-antagonists and kappa-partial-agonists. All three

drugs are strong analgesics when given by injection: pentazocine is one-sixth to one-third as potent as

morphine, nalbuphine is slightly less potent than morphine, and butorphanol is 3.5 to 7 times as potent. The

duration of analgesia is similar to that of morphine (3 to 4 hours). Oral pentazocine is closer in analgesic

efficacy to aspirin and paracetamol (acetaminophen) than the weak opioid analgesics such as codeine.

Neither nalbuphine nor butorphanol is available as an oral

formulation. At usual therapeutic doses nalbuphine and butorphanol have respiratory depressant effects

equivalent to that of morphine (though the duration of such effects with butorphanol may be longer). Unlike

morphine there appears to be a ceiling to both the respiratory depression and the analgesic action. All of

these 3 drugs have a lower abuse potential than the pure agonist opioid analgesics such as morphine.

However, all have been subject to abuse and misuse, and pentazocine (but not the others) is subject to

Controlled Drug restrictions. Buprenorphine is a potent partial agonist at the mu-receptor, and by

intramuscular injection is 30 times as potent as morphine. A ceiling to the analgesic effect of buprenorphine

has been demonstrated in animals and it is also claimed in humans. However, there are no reliable data

available to define the maximal dose of buprenorphine in humans. A practical ceiling exists for sublingual use

in that the only available formulation is a 2 micrograms tablet and few patients will accept more than 3 or 4

of these in a single dose. The duration of analgesia is longer than that of morphine, at 6 to 9 hours. There

have been suggestions that buprenorphine causes less respiratory depression than morphine, but viewed

overall it appears that in equianalgesic doses the 2 drugs have similar respiratory depressant

effects.(ABSTRACT TRUNCATED AT 400 WORDS) [References: 118]

SO - Drugs 1991;41:326-34

UI - 000113

AU - Mendelson G

AU - Mendelson D

TI - Legal aspects of the management of chronic pain [published erratum appears in Med J Aust 1991

Dec 2-16;155(11-12):856]

AB - OBJECTIVE: To review the legal provisions which control the prescription of opioid analgesics in

Australia, and to summarise the areas in which practitioners who treat patients with chronic pain may expect

to become involved with the legal system. DATA SOURCES: The relevant legislation was reviewed, and a

selective review was undertaken of literature dealing with the legal aspects of pain and suffering which may

form a basis for personal injury claims. Case law which deals with issues of consent to treatment was also

examined. DATA SYNTHESIS: Statutory requirements which control the prescription of opioids were

summarised. Leading cases on patient consent were discussed to clarify for the practitioner the principles

which the Courts use in the assessment of the validity of the consent given by patients for treatment. The

assessment of the pain patient involved in litigation was briefly discussed. CONCLUSIONS: The

prescription and administration of opioid analgesics must be in accordance with the legislative provisions.

Treatment options must be discussed and explained to patients so that valid consent can be obtained.

Patients' questions must be answered in full, and documentation in the clinical record is required

SO - Medical Journal of Australia 1991;155:640-64

UI - 000110

AU - Merry AF

AU - Schug SA

AU - Richards EG

AU - Large RG

TI - Opioids in the treatment of chronic pain of nonmalignant origin

SO - New Zealand Medical Journal 1991;104:520-52

UI - 000121

AU - Pendergrass JS

TI - Epidural analgesia: a viable option for pain control

AB - Epidural analgesia is an important intervention for both acute and chronic pain management. It has

been in use since the early 1900s, but the technique using local application of opiate analgesics has only been

in use since the late 1970s (Moulin & Coyle, 1986). Today, many patients receive epidural analgesia for

postoperative pain control, and its use for acute or chronic pain management in a hospital, pain clinic, or

home setting also continues to increase. Epidural analgesia is also being utilized to manage acute pain in the

pediatric client. Epidural analgesia requires meticulous techniques, beginning with placement of the epidural

catheter and continuing with administration of medications and nursing management of the catheter. Nursing

assessment and development of protocols along with preoperative and postoperative patient and family

teaching are vital components of the total plan of care. The nurse practitioner (NP) or other health care

provider must be cognizant of safety considerations, whether in the hospital environment, pain clinic, or

home setting.

SO - Journal of the American Academy of Nurse Practitioners 1991;3:25-2

UI - 000119

AU - Pincus DF

TI - When and why I use pethidine

AB - Pethidine is a valuable drug in general practice. It is useful in the acute pain of trauma and renal or

biliary colic. It should be used by intramuscular injection, not orally. It should not be used for chronic pain,

malignancy, head injury, heart failure, undiagnosed acute abdominal pain and if opiate addiction is suspected

SO - Australian Family Physician 1991;20:392, 394-392, 39

UI - 000123

AU - Poniatowski BC

TI - Continuous subcutaneous infusions for pain control

AB - Chronic moderate-to-severe pain is a common problem that directly impacts on the quality of life of

the patient with a malignant neoplasm. It is estimated that pain is a major symptom in 70% of cancer

patients. Continuous subcutaneous infusion of opioids has proved to be an efficacious and safe method to

control the chronic pain of the home-bound and hospitalized patient. A wide variety of opioids can be used,

including morphine, hydromorphone, and methadone. The subcutaneous route offers economic as well as

physiologic advantages. The primary disadvantage to the system is volume limitations. Competent nursing

management of the subcutaneous infusion helps to maximize the effectiveness of the opioid, thereby

improving the patient's quality of life

SO - Journal of Intravenous Nursing 1991;14:30-3

UI - 000115

AU - Richlin DM

TI - Nonnarcotic analgesics and tricyclic antidepressants for the treatment of chronic nonmalignant

pain

AB - Chronic nonmalignant pain is often characterized by multiple treatment failures, a pattern of

maladaptive behavior, and depression. Often there is a history of inappropriate and excessive use of

medications for pain. Prior and ongoing use of narcotics and sedatives acts to compound and aggravate the

chronic pain syndrome. A first step in treatment is controlled withdrawal of these agents. Nonnarcotic

analgesics, NSAIDs, and tricyclic antidepressants are commonly employed in patients with chronic pain.

Effective use of these agents requires understanding of their pharmacokinetic and pharmacodynamic

properties. Use of a fixed-time schedule is necessary to achieve an effective, sustained therapeutic response.

Careful patient education and monitoring for side effects and toxicity are necessary, particularly in the

elderly and patients with coexisting medical disorders. Incidence of side effects and toxicity may be reduced

by choice of drug and modification of dosing regimen. Nonnarcotic analgesics, TCAs, and NSAIDs are

seldom effective by themselves in resolving the pain and distress of patients with chronic nonmalignant pain.

This is particularly true when maladaptive behavior coexists. A comprehensive multimodal pain management

program encompassing additional pain-relieving strategies and behavior-modifying techniques should be

considered and utilized in conjunction with medication.

SO - Mount Sinai Journal of Medicine 1991;58:221-22

UI - 000114

AU - Schug SA

AU - Merry AF

AU - Acland RH

TI - Treatment principles for the use of opioids in pain of nonmalignant origin. [Review]

AB - Inadequately treated acute and chronic pain remains a major cause of suffering, in spite of enormous

advances in pharmacology and technology. Opioids provide a powerful, versatile, widely available means of

managing this pain, but their use is too often restrained by ignorance and mistaken fears of addiction. The

management of postoperative pain (perhaps the most common form of acute pain) is traditionally attempted

with fixed dosages of analgesics by relatively unpredictable routes (e.g. oral, rectal and intramuscular).

Intravenous opioid infusions (an improvement) risk respiratory depression and require close monitoring and

titration. Patient-controlled analgesia (PCA), by contrast, permits the most efficacious medication (pure

opioid agonist) by the optimal route (intravenous) under direct control of the patient, and provides high

levels of satisfaction and safety. Ideally, any opioid use should be integrated with a wide spectrum of other

analgesic modalities in an anaesthesiology-based 'acute pain service'. The use of opioids for chronic pain of

nonmalignant origin remains controversial. There is a perceived conflict between patients' interests and those

of society. However, problems (such as tolerance, physical dependence, addiction and chronic toxicity),

anticipated from experience with animal experiments and pain-free abusers, seldom cause difficulties when

opioids are used appropriately to treat pain (so-called 'dual pharmacology'). With sensible guidelines, and in

the context of a multidisciplinary pain clinic, opioids may provide the only hope of relief to many sufferers of

chronic pain. [References: 88]

SO - Drugs 1991;42:228-23

UI - 000111

AU - Schwartz RH

AU - Johnson NP

AU - Hornung CA

AU - Phelps GL

AU - Berg EW

TI - Awareness of substance abuse in orthopedic patients: a survey of orthopedic surgeons

AB - We surveyed 178 orthopedic physicians in the Washington, DC, area to ascertain the effect on patient

care of previous education in the area of drug and alcohol issues. The return rate was 75%. Of the

respondents, 99% were male, average age was 46.7 years (+/- 9.3), and average number of years in practice

was 15.2 (+/- 9.6). A majority of respondents indicated that they did not have training in the abuse

potential of analgesics (92 [69%]), characteristics of benzodiazepine abuse (77 [58%]), or when to

seek the assistance of an addiction medicine specialist for patients with chronic pain (106 [80%]).

Only 41 (31%) of the orthopedists indicated that they inquire about alcohol and drug use before prescribing

opiates for more than a week. We offer suggestions for self-education for interested physicians

SO - Southern Medical Journal 1991;84:1455-145

UI - 000020

AU - Tennant F

AU - Shannon JA

AU - Nork JG

AU - Sagherian A

TI - Abnormal adrenal gland metabolism in opioid addicts: Implications for clinical treatment

AB - IN: Research Ctr for Dependency Disorders & Chronic Pain, West Covina, CA, US LA: English AB:

Examined whether methadone maintenance treatment (MMT) causes diminution of pituitary-adrenal reserve

or if that condition preexists in the heroin addict. Ss were 14 male heroin addicts who voluntarily sought

outpatient detoxification. Results indicate that most active heroin addicts have low adrenal reserve prior to

entering MMT. Chronic opioid administration may induce adrenal insufficiency or an addisonian state. There

is a need to normalize adrenal gland metabolism during treatment of heroin addicts. (PsycLIT Database

Copyright 1992 American Psychological Assn, all rights reserved) KP: abnormal adrenal gland metabolism

as preexisting condition vs methadone maintenance side effect; male heroin addicted patients in

detoxification AN: 79-24914

SO - Journal of Psychoactive Drugs 1991;23:135-14

UI - 000021

AU - Toro R

AU - Perez Infante M

TI - Treatment of chronic pain with LARQ 731, a new alternative to opiate analgesics

AB - IN: Inst Venezolano de los Seguros Sociales, Hosp General "Miguel Perez Carreno" Servicio de

Anestesiologia, Caracas, Venezuela LA: English AB: LARQ 731 (a drug combination of carisoprodol,

dipyrone, and salicylamide) was administered to 42 36-88 yr old patients with advanced cancer who

complained of severe pain and who required frequent medication with opiate analgesics. To test the

analgesic efficacy of the combination, the arm-cuff method was used before and after drug administration to

evaluate the pain threshold. A large increase in pain threshold after LARQ 731 administration was observed.

No significant changes were found in routine laboratory examinations, blood pressure, heart, or breathing

rate. (PsycLIT Database Copyright 1992 American Psychological Assn, all rights reserved) KP: carisoprodol

& dipyrone & salicylamide; analgesic efficacy & pain thresholds; 36-88 yr old cancer patients with severe

pain AN: 79-10330

SO - Current Therapeutic Research 1991;49:187-19

UI - 000018

AU - Verhaag DA

AU - Ikeda RM

TI - Prescribing for chronic pain. Special Issue: Prescription drug issues: Public policy and clinical

practice

AB - IN: Medical Board of California, Sacramento, US LA: English AB: Offers guidelines in the following

areas for physicians who treat patients with chronic intractable pain with opiates: history and medical

examination, diagnosis/medical indication, written treatment plan with recorded measurable objectives,

informed consent, periodic reviews and modifications, consultation, and record keeping. (PsycLIT Database

Copyright 1992 American Psychological Assn, all rights reserved) KP: opiate prescription guidelines for

chronic pain patients; physicians AN: 79-32546

SO - Journal of Psychoactive Drugs 1991;23:433-43

UI - 000024

AU - Weingarten MA

TI - Chronic opioid therapy in patients with a remote history of substance abuse

AB - LA: English AB: Presents 2 cases of male patients with a history of substance abuse who were

successfully maintained on narcotics for chronic pain problems, without escalation of dose or abuse. It is

suggested that the criteria proposed by R. K. Portenoy (see PA, Vol 77:23432) for institution of narcotic

maintenance in chronic pain patients should not be considered absolute. (PsycLIT Database Copyright 1991

American Psychological Assn, all rights reserved) KP: chronic narcotic therapy; chronic pain; male patients

with history of substance abuse; case reports AN: 78-16376

SO - Journal of Pain and Symptom Management 1991;6:2-

UI - 000255

AU - Weissman DE

AU - Joranson DE

AU - Hopwood MB

TI - Wisconsin physicians' knowledge and attitudes about opioid analgesic regulations

AB - AB - [No Abstract Available] AD - Division of Cancer and Blood Diseases AD - Medical College of

Wisconsin AD - Milwaukee 53226 UI - 93118350

SO - Wis Med J 1991;90:671-67

UI - 000253

AU - Weissman DE

AU - Joranson DE

AU - Hopwood M

TI - THE INFLUENCE OF DRUG REGULATIONS ON OPIOID ANALGESIC PRESCRIBING

PRACTICE (MEETING ABSTRACT)

AB - AB - 200 Wisconsin Mds chosen at random were mailed a survey in June 1990 to assess

knowledge/attitudes concerning regulatory law. 90 surveys (45%) were evaluable for review, including

internists (27), surgeons (25), family practitioners (19), other (19). MDs had poor knowledge of drug

schedule and number of allowable refills of seven different opioids. 32% of MDs did not know that an

emergency supply of a schedule II drug could be prescribed by telephone. MDs were very concerned about

possible investigation when using opioids: 15, 17 and 19 times more concerned about prescribing morphine,

hydromorphone and methadone, respectively, than when prescribing codeine with acetaminophen. MDs

were 8 times more concerned about possible investigation when using opioids to treat chronic cancer pain

than when using opioids for acute pain and 20 times more concerned if the patient had a history of drug

abuse, even with a 'real' reason to have pain. MDs were less concerned about investigation than about

addiction, tolerance or respiratory depression. Wisconsin MDs have serious concerns about using opioid

analgesics and poor knowledge of regulatory laws. Education is needed to lessen these fears, especially as

they apply to the treatment of cancer-related pain AD - Medical Coll. of Wisconsin AD - Milwaukee AD -

WI 53211 UI - 91672474

SO - Proc Annu Meet Am Soc Clin Oncol 1991;10:A1129-A112

UI - 000120

AU - Yue SK

AU - St.Marie B

AU - Henrickson K

TI - Initial clinical experience with the SKY epidural catheter

AB - The new SKY epidural catheter was evaluated, based upon information collected about implant and

use of 53 catheters by 51 patients. Catheters were used to treat chronic pain of a malignant (n = 25) and

nonmalignant (n = 28) origin. Of 3450 treatment days, 89% occurred at home. Mean catheter use for

malignant and nonmalignant conditions were 58.6 and 76.3 days/patient, respectively. Visual analogue pain

scores in the first wk after implant indicated 79% of patients achieved good to excellent pain relief. Clinical

impressions indicated this group achieved substantial long-term pain relief. No serious complications were

observed. Two types of leakage required removing 5 catheters, prompting changes that eliminated

subsequent leakages of both types. Accidental patient retraction and subcutaneous infection each required a

catheter removal. No subarachnoid or epidural infections occurred. The SKY catheter proved to be safe and

reliable. Therapy was cost-effective, since patients achieved substantial pain relief while treated at home

SO - Journal of Pain & Symptom Management 1991;6:107-11

UI - 000174

AU - Zenz M

AU - Sorge J

TI - Is the therapeutic use of opioids adversely affected by prejudice and law?. [Review]

SO - Recent Results in Cancer Research 1991;121:43-5

UI - 000142

AU - Allen A

TI - Notes from the annual meeting of the American Society of Anesthesiologists

AB - Several important developments were reported at the 1989 Annual Meeting of the American Society

of Anesthesiologists: (1) a computerized machine called HealthQuiz asks patients health questions, and in

less than 10 minutes provides a printout of answers, a summary of symptoms, and a list of suggested

laboratory tests; (2) a simple device provides continuous measurements of a critically ill patient's oxygen and

carbon dioxide levels; (3) near-infrared reflectance is a new technique that may provide the first accurate

real-time measurement of critical oxygen levels in the brain; (4) pulse oximeters may provide false readings

in patients who smoke cigarettes; (5) a new test may accurately predict the survival chances of a child in a

coma; (6) the fastest growing subspecialty in anesthesiology is chronic pain management clinics; (7) alpha-2

adrenergic agonists improve pain relief without the unwanted side effects of narcotics; (8) clonidine appears

to suppress the dangerous shivering that often occurs in postanesthesia patients; (9) flumazenil was

successfully tested as an agent to reverse the drowsiness caused by midazolam; and (10) ephedrine

minimizes nausea and vomiting in patients undergoing ambulatory surgery

SO - Journal of Post Anesthesia Nursing 1990;5:96-10

UI - 000136

AU - Cole L

AU - Hanning CD

TI - Review of the rectal use of opioids. [Review]

AB - The rectal route for the administration of opioid analgesics is often forgotten by physicians seeking

alternatives to the oral route. This article reviews the physiology of rectal drug absorption and such data as

exists on the different opioids that have been administered by this route. Conventional fatty-based

suppositories have a place in the management of chronic pain but the variability in dissolution and drug

absorption limit their usefulness. Recently, sustained release vehicles have become available that offer the

prospect of the attainment of steady analgesic drug concentrations with once or twice daily dosing. Early

studies with the morphine hydrogel suppository suggest that it may be capable of fulfilling this prospect.

Their inherent safety, as dose-dumping is impossible, will make them suitable for use in the home.

[References: 43]

SO - Journal of Pain & Symptom Management 1990;5:118-12

UI - 000201

AU - Coyle N

AU - Adelhardt J

AU - Foley KM

AU - Portenoy RK

TI - Character of terminal illness in the advanced cancer patient: pain and other symptoms during

the last four weeks of life [see comments]

AB - AB - There is a great variability among advanced cancer patients in the experience of symptoms and

their impact on life's activities. A subgroup of difficult patients particularly tax the clinical skills and

compassion of practitioners. Although the need for information about these patients is evident, their

characteristics have not been explored heretofore. We describe our experience with such patients, a group

referred to the Supportive Care Program of the Pain Service at Memorial Sloan-Kettering Cancer Center.

Prevalence of pain and other symptoms, patterns of opioid use and routes of drug administration, and the

prevalence of suicidal ideation and requests for euthanasia are discussed UI - 90270702

SO - J Pain Symptom Manage 1990;5:83-9

UI - 000127

AU - Devulder J

AU - De Colvenaer L

AU - Rolly G

AU - Caemaert J

AU - Calliauw L

AU - Martens F

TI - Spinal cord stimulation in chronic pain therapy

AB - Spinal cord stimulation was undertaken in 45 patients referred to the University Hospital in Ghent.

Failed back surgery was the major indication for implantation. Raynaud's phenomenon, causalgia,

polyneuropathy, phantom limb pain, and diverse causes were the other indications. Before neurosurgical

implantation of the system, a percutaneous epidural trial procedure was performed. The efficacy of the

implanted stimulation system was estimated by considering the use of medication and the patients' personal

appreciation of the obtained pain relief. Thirty-five patients experienced very good pain relief. Only two

patients needed further narcotic analgesics. Eight patients stopped using the stimulation system. To ensure

good results, strict selection criteria and many surgical reinterventions seemed to be necessary. Although

spinal cord stimulation is a nonablative technique, many complications may occur

SO - Clinical Journal of Pain 1990;6:51-5

UI - 000131

AU - Eriksen J

AU - Jensen NH

AU - Frolich S

TI - [Why are chronic pain patients given opioids via injections? (letter)]. [Danish]

SO - Ugeskrift for Laeger 1990;152:3181-318

UI - 000135

AU - Finley RS

TI - Pain management with spinally administered opioids. [Review]

AB - The use of spinally administered opioids to manage pain is discussed. Central action on opioid

receptors of the substantia gelatinosa allows opioids to be administered spinally for pain originating

anywhere inferior to the cranial nerves. Spinal opioids are most commonly administered for intractable

midline sacral and perineal pain. The best candidates for spinal opioids are patients in whom appropriate

"conventional" therapy no longer provides adequate relief, patients who experience severe adverse effects

from conventional therapy, and patients for whom alternative anesthetic procedures are inappropriate or

have failed. A reasonably safe initial dose is morphine sulfate 1 mg intrathecally. The availability of

preservative-free, concentrated morphine sulfate enables larger doses to be safely and comfortably

administered. Increased dosage requirements may result from tolerance, progression of disease, increased

systemic absorption, or slippage of the catheter tip. As with systemically administered opioids, care must be

exercised when discontinuing spinal opioid therapy. Adjuvant drugs used with spinal opioids include

systemically administered analgesics, antidepressants, corticosteroids, and spinal local anesthetics. The

administration of spinal opioids with systemic opioids or other CNS depressants may result in excessive

sedation, respiratory depression, nausea, vomiting, constipation, pruritus, and other adverse effects. Spinally

administered opioids can be used to manage severe chronic pain effectively, safely, and comfortably.

[References: 29]

SO - American Journal of Hospital Pharmacy 1990;47:S14-S1

UI - 000143

AU - Gostomzyk JG

AU - Heller WD

TI - [Long-term use of narcotics in pain therapy]. [German]

AB - From 1. 1. 1976 to 30. 6. 1987, a total of 25,611 prescriptions for narcotics were obtained from

pharmacies by 4131 persons living in a town of 250,000 inhabitants in the Federal Republic of Germany.

2412 patients (58.4%) had been prescribed narcotics on only one occasion, 3178 patients (76.9%) over a

limited period of six months, presumably for acute pain. Only 520 patients (12.6%) received, over a period

of at least six months, five or more narcotic prescriptions per six months. Reasons for the latter prescriptions

were malignant tumours in 273 (6.6%) and chronic pain due to benign diseases in 144 (3.5%). In 21 patients

(0.5%) the narcotic dosage had risen over two years, presumably because of the development of tolerance.

19 patients had been on narcotics for at least eight years, without their doctor diagnosing addiction. The

data suggest that, in prescribing narcotics for patients with incurable disease, the risk of addiction should

play no role

SO - Deutsche Medizinische Wochenschrift 1990;115:763-77

UI - 000133

AU - Hansberry JL

AU - Bannick KH

AU - Durkan MJ

TI - Managing chronic pain with a permanent epidural catheter

SO - Nursing 1990;20:52-5

UI - 000141

AU - Hassenbusch SJ

AU - Pillay PK

AU - Magdinec M

AU - Currie K

AU - Bay JW

AU - Covington EC

AU - Tomaszewski MZ

TI - Constant infusion of morphine for intractable cancer pain using an implanted pump [see

comments]

AB - In the past, pain control for chronic pain syndromes using narcotic infusion has been carried out

primarily via the intrathecal (subarachnoid) route. This report presents one of the first large series of

terminally ill cancer patients with intractable pain treated with continuous epidural morphine infusions by

means of implanted pumps and epidural spinal catheters. The purpose of the study was to demonstrate that

the epidural route is effective with minimal complications, and that screening with temporary epidural

catheter infusions results in a high rate of subsequent pain relief. A multidisciplinary team (neurosurgeon,

anesthesiologists, psychiatrists, oncologists, and nurse clinicians) evaluated and treated all of the patients

studied. Percutaneous placement of temporary epidural catheters for a trial assessment was performed by the

anesthesiologists. Pain evaluations were conducted independently by psychiatrists using both verbal and

visual analog scales. From 1982 to 1988, 41 (59.4%) of 69 patients evaluated for eligibility experienced

good pain control during trial assessment and were subsequently implanted with Infusaid infusion pumps.

Preinfusion pain analog values were 8.6 +/- 0.3 and postimplantation values at 1 month were 3.8 +/- 0.4 (p

less than 0.001). Over this same 1-month period. requirements of systemic morphine equivalents decreased

by 79.3% with epidural infusions as compared to preinfusion requirements (p less than 0.001). There were

no instances of epidural scarring, respiratory depression, epidural infections, meningitis, or catheter

blockage. One patient developed apparent drug tolerance and three patients required further catheter

manipulations. This series strongly suggests that significant reductions in cancer pain can be obtained with

few complications and a low morphine tolerance rate using chronic epidural morphine infusion.

Anesthesiology and psychiatry input, along with temporary catheter infusion screening and quantitative pain

evaluations using analog scales, are essential

SO - Journal of Neurosurgery 1990;73:405-40

UI - 000138

AU - Juul A

AU - Pedersen AT

TI - [Endogenous opioids and their therapeutic use in the treatment of pain]. [Review] [Danish]

AB - Cancer patients with chronic pain and obstetric patients have participated in clinical trials of the

analgesic effects of endogenous opioids. It is possible to achieve adequate relief of pain in these patients

following epidural or intrathecal administration of endogenous opioids. Further investigations are required.

[References: 30]

SO - Ugeskrift for Laeger 1990;152:372-37

UI - 000023

AU - Kennedy JA

AU - Crowley TJ

TI - Chronic pain and substance abuse: A pilot study of opioid maintenance

AB - IN: U Colorado School of Medicine, Addiction Research & Treatment Services, Denver, US LA:

English AB: Presents a pilot study of methadone maintenance treatment for 4 patients (aged 27-38 yrs) with

both chronic pain and substance abuse. The study evaluated the program's ability to attract and hold patients,

the methodology for assessing change, and the problems and pitfalls. Weekly random urinalysis, weekly

psychotherapy, and quarterly self-report tests of pain, mood, and function were used to evaluate change.

Three patients remained in treatment for 19-21 mo. Two stopped needle use and substance abuse, and the

3rd stopped cocaine use and abusing the medical system to obtain opioids. All Ss appeared to have improved

functionally. (PsycLIT Database Copyright 1991 American Psychological Assn, all rights reserved) KP:

methadone maintenance; substance abusing 27-38 yr olds with chronic pain AN: 78-16651

SO - Journal of Substance Abuse Treatment 1990;7:233-23

UI - 000125

AU - King SA

AU - Strain JJ

TI - Benzodiazepine use by chronic pain patients

AB - Of 114 patients presenting to the Pain Management Service at the Mount Sinai School of Medicine

with chronic pain, 38% (N = 43) were taking one or more benzodiazepine drugs at the time of the initial

assessment. The majority of patients were chronic users, with 14% (N = 6) having taken the medications for

1-2 years and 46% (N = 20) for 2 years or longer. Ninety-three percent (N = 40) of those given a

benzodiazepine drug stated that it was initiated after the onset of pain. Although 86% (N = 37) were using

the medication (all or in part) to improve sleep, they continued to report as many problems with sleep as the

nonbenzodiazepine group did. Other drugs prescribed concurrently with the benzodiazepine drugs were

narcotic drugs (58% of patients), antidepressant drugs (32%), nonsteroidal antiinflammatory agents (26%),

and others (16%). Benzodiazepines have been reported to provide little therapeutic benefit to chronic pain

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patients, and may even exacerbate their symptoms. We have shown that benzodiazepine drugs are frequently

prescribed for long-term use, for sleep, and in conjunction with narcotic drugs. Such use is contrary to

generally accepted guidelines

SO - Clinical Journal of Pain 1990;6:143-14

UI - 000134

AU - Koeller JM

TI - Understanding cancer pain. [Review]

AB - The pathogenesis of cancer pain, the incidence of pain associated with specific types of malignant

tumors, and the nature of acute and chronic pain are discussed, and alternative delivery systems for pain

management are described. More than 80% of cancer patients with advanced metastatic disease suffer

moderate to severe pain. Most cancer pain is caused by direct tumor infiltration; approximately 20% of

cancer pain may be attributed to the effects of surgery, radio-therapy, or chemotherapy. The incidence of

cancer pain is related to tumor type; 70% or more of patients with tumors of the bone, cervix, and ovaries

suffer cancer-related pain, while only 5% of patients with leukemia have pain. Pain is defined by the organs

involved. Somatic pain is usually dull and well localized; visceral pain is generalized and difficult to describe.

Other types of pain, including deafferentation pain and referred pain, are particularly difficult to manage.

Cancer pain may be acute or chronic. The latter may cause psychological reactions that make effective

treatment more challenging. Opiate analgesic agents, administered by the epidural or intrathecal routes,

block pain more selectively and produce fewer adverse reactions than systemic analgesic agents. The

duration and onset of analgesia depend on the lipophilicity of the agent used. Because pain is the most

common complaint of the patient with cancer, clinicians should be aware of the range of pharmacologic and

nonpharmacologic analgesic modalities available to them. Familiarity with newer modalities and delivery

routes, such as spinal administration of opiate analgesics, is recommended. [References: 6]

SO - American Journal of Hospital Pharmacy 1990;47:S3-S

UI - 000139

AU - Lee TL

AU - Kumar A

AU - Baratham G

TI - Intraventricular morphine for intractable craniofacial pain

AB - This case management report on a patient with advanced craniofacial neoplasm discusses the

successful treatment of chronic pain by the cortical intraventricular narcotic administration. A previously

treated patient with surgery and radiotherapy for carcinoma of the palate developed severe intractable pain

despite high dose oral morphine therapy. Investigations revealed that neoplasm had reoccurred with

extensive infiltration. Intraventricular morphine therapy was discussed and accepted by the patient and

family. A ventricular shunt with an Ommaya reservoir was inserted under local anaesthesia. Preservative-free

morphine sulphate in increasing doses of 0.25 to 1 mg was administered, once daily, which kept the patient

in a pain-free state. The treatment was initiated in the hospital and continued at home till the demise of the

patient on the 9th week. The home care was provided by the nurses of Home Nursing Foundation and

Singapore Cancer Society under physician supervision. There were no complications which had been

reported in the literature, observed in the management of this patient

SO - Singapore Medical Journal 1990;31:273-27

UI - 000124

AU - Lipman AG

TI - Clinically relevant differences among the opioid analgesics. [Review]

AB - The mechanism of action of opioids and clinically relevant differences among the opioid analgesics are

described. Both endorphins (endogenous morphine-like substances) and exogenous opioids (opium alkaloids

and their derivatives) bind to opioid receptors in the human central nervous system to provide analgesia and

other effects. Some drugs, such as morphine, are true agonists, i.e., they bind to and activate receptors.

Some are partial agonists, binding to part of the receptor and causing effects that are similar to, but perhaps

less pronounced than, the effects produced by agonists. Others are antagonist, i.e., they bind to the receptor

but do not cause the associated effects. Some drugs, termed agonist-antagonist opioids, act as antagonists at

one type of receptor and agonists at another type of receptor. True agonists tend to have relatively straight-

line dose-response curves; in other words, their effect increases with increasing doses over a broad dosage

range. Partial agonists and agonist-antagonists tend to have ceiling effects; that is, they do not have the

broad dosage range of drugs such as morphine, methadone, hydromorphone, and other "strong" opioids.

This fact mediates against the use of partial agonists and agonist-antagonists in cancer patients who have

chronic pain that may increase as the disease progresses. Three major factors that should be considered

when a drug is selected for clinical use are (1) relative affinities for the different opioid receptor types, (2)

pharmacokinetic characteristics that influence onset and duration of action, and (3) whether the opioids are

strong or weak. For treatment of cancer pain, drugs with long durations of action are

preferable.(ABSTRACT TRUNCATED AT 250 WORDS) [References: 11]

SO - American Journal of Hospital Pharmacy 1990;47:S7-1

UI - 000128

AU - McKinney MW

AU - Londeen TF

AU - Turner SP

AU - Levitt SR

TI - Chronic TM disorder and non-TM disorder pain: a comparison of behavioral and psychological

characteristics

AB - The purpose of this paper is to determine whether patients with chronic temporomandibular disorder

(TMD) pain manifest behavioral, experimental, and psychological characteristics similar to patients with

other chronic pain illnesses. The Chronic Pain Battery (CPB), a multidimensional assessment tool for chronic

pain patients, was used to compare several important variables between 78 TM disorder (TMD) patients and

98 non-TMD chronic pain patients. The study found that chronic TMD patients had lower "usual" pain

intensity and suffering levels, fewer vegetative symptoms associated with depression, higher pain tolerance,

less impairment of activity, more hope about treatment outcome, lower health care system utilization, but

higher reported stress levels than non-TMD chronic pain patients. The two groups manifested no significant

differences in use of narcotics, sedatives, and sleeping pills; levels of depression, anxiety, somatization,

hostility, or psychoticism; illness behavior reinforcement in their social surroundings; or ratings of problems

with work, family, self-esteem, or suicidal impulses. These findings suggest that chronic TMD pain patients

(with a symptom duration of over six months) are behaviorally and psychologically similar to non-TMD

chronic pain patients, but that they differ in their perceptions of their disorder, rendering them less

handicapped by their problems. Psychological, social, and behavioral treatment methods useful for treating

chronic pain syndrome may thus also be applied along with dental therapy for optimal treatment of TMD

associated with chronic pain

SO - Cranio 1990;8:40-4

UI - 000130

AU - Morawetz RF

AU - Schreithofer D

AU - Bostjancic G

AU - Walter MH

AU - Namestnik E

AU - Benzer H

TI - [The multidisciplinary outpatient pain clinic in relation to anesthesia. An important task for the

anesthesiologist]. [Review] [German]

AB - Anesthesiologists have always played a leading role in research into pain and its treatment. Their

efforts, however, have been focused on acute or postoperative pain problems. It was the American

anesthesiologist John J. Bonica who fought for an increased interest in chronic pain. The establishment of

the first Multidisciplinary Pain Center at the University of Washington in Seattle, the foundation of the

International Association for the Study of Pain (IASP) and Melzack and Wall's now 25 year old gate control

theory were the driving forces behind rapid developments in research and treatment in the area of chronic

pain. The realization that chronic pain was the most frequent cause of disability in the United States also

gave an impetus for new efforts in treatment. The classic anesthesiological topics, such as operative

anesthesia emergency medicine and intensive care, have been extended to include acute pain services and

chronic pain treatment facilities. This reflects the understanding that anesthesiological knowledge and

techniques can be valuable to patients in severe acute pain and those in lingering long-term chronic pain

phases. Anesthesiologists are skilled in the use of opioid narcotics and in the administration of strong

analgesics. Many severe pain problems can be solved by correct use of the analgesic regimen. Special ways

of administering narcotic analgesics, such as epidural infusion or patient-controlled analgesia, have already

alleviated the pain problems of many patients. Anesthesiological techniques are also crucial in diagnosis.

Sequential differential blockade and simple nerve blocks can be helpful in the diagnosis and classification of

the pain problems. Anesthesiological contributions to a chronic pain service are not restricted to medical

interventions. Organizational skills are also needed for efficient running of multidisciplinary pain treatment

facilities. Clinical practice in surgical anesthesia means that anesthesiologists are experienced in

interdisciplinary work and familiar with the advantages and dangers of team work. Despite international

acceptance of the multidisciplinary approach to chronic pain, there is still a lack of appropriate facilities in

the German-speaking countries, and we consider it important that anesthesiologists commit themselves to

increasing general awareness of what is needed. [References: 45]

SO - Anaesthesist 1990;39:456-46

UI - 000129

AU - Osipova NA

AU - Novikov GA

AU - Ziai GR

AU - Mel'nikova ZL

TI - [Tramal in the treatment of acute and chronic pain syndromes in cancer patients]. [Russian]

AB - The study of 65 cancer patients has demonstrated the advantages and disadvantages of tramal as an

agent used for the relief of acute and chronic pain syndrome. In 18 patients tramal was used in postoperative

analgesia, in 17 patients it was used for the treatment of chronic pain syndrome. It has been shown that in

the postoperative period tramal has no noticeable advantages over promedol. However, tramal had definite

advantages over other opiate agonists when used for the treatment of chronic pain syndrome in incurable

cancer patients. Thus, the data obtained show that tramal, a synthetic analgesic of a new generation, has no

dangerous side effects, is effective in a convenient, non-invasive drug form, interacts well with non-narcotic

and supplementary agents and causes no clinical signs of drug tolerance or addiction in prolonged

application

SO - Anesteziologiya i Reanimatologiya 1990;:55-5

UI - 000144

AU - Payne R

TI - Medication-induced performance deficits: analgesics and narcotics

AB - Pain is the most common medical complaint, and analgesic drugs are often used for its management.

Seven out of 10 Americans took nonprescription pain relievers in the last year. Analgesics are classified as

nonnarcotics (acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs), narcotics (which include

the morphine-like drugs), and analgesic adjuvants (a heterogeneous group of drugs, including antihistamines,

phenothiazines, anticonvulsants, calcium channel blockers, and tricyclic antidepressants), which may have

intrinsic analgesic efficacy for specific p