Amount Of Pain Medication Research Articles

Effectiveness of Transforaminal Epidural Steroid Injections in Patients with Degenerative Lumbar Scoliotic Stenosis and Radiculopathy

The use of epidural steroid injections as a treatment for patients with degenerative lumbar scoliotic spinal stenosis and radiculopathy has received sparse attention in the literature. Even though it has been reported that patients with scoliosis may respond differently than other patient groups to conservative therapeutic interventions for low back pain and radiculopathy, patients with scoliosis have rarely, if ever, been excluded from clinical studies of epidural steroid injections. To date, there are no studies investigating the efficacy of fluoroscopic transforaminal epidural steroid injections as a treatment for patients with radiculopathy and radiographic evidence of degenerative lumbar scoliotic stenosis. To evaluate the effectiveness of fluoroscopically guided transforaminal epidural steroid injections as a conservative treatment for patients with degenerative lumbar scoliotic stenosis and radiculopathy. Retrospective case series. The study was performed in an academic outpatient physical medicine and rehabilitation spine practice. Participants included 61 patients with radiographic evidence of degenerative lumbar scoliotic stenosis and radiculopathy. Patients who had undergone at least one fluoroscopic-guided transforaminal epidural steroid and anesthetic injection were included. Numeric Rating Scale (NRS) for worst pain experienced, North American Spine Society (NASS) satisfaction scale, amount of pain medication used, and adapted Stucki questionnaire to assess function and pain status. We obtained follow-up on 52 (85.2%) of 61 included patients. We defined a successful outcome as a patient who was both satisfied with his or her results and experienced at least a 2-points improvement in NRS, Summary Pain, and Summary Function scores. Using these criteria for success, 59.6% of our patients had a successful outcome at one week post-injection, 55.8% at one month post-injection, 37.2% at one year post-injection, and 27.3% had a successful outcome at two years post-injection (p < 0.01). Fluoroscopic transforaminal epidural steroid injections appear to be an effective nonsurgical treatment option for patients with degenerative lumbar scoliotic stenosis and radiculopathy and should be considered before surgical intervention.

Poster 141: Are Fluoroscopic transforaminal epidural steroid injections an effective treatment in patients with degenerative lumbar scoliosis and radiculopathy?

Objective: To evaluate the effectiveness of fluoroscopic transforaminal epidural steroid injections as a conservative treatment for patients with degenerative lumbar scoliosis and radiculopathy. Design: Retrospective follow-up study. Setting: Academic outpatient physiatric interventional spine practice. Participants: 62 patients with radiographic evidence of degenerative lumbar scoliosis and complaints of radiculopathy. Intervention: At least 1 fluoroscopic transforaminal epidural steroid injection. Main Outcome Measures: Numeric rating scale (NRS) for worst pain experienced, North American Spine Society (NASS) Satisfaction Scale, amount of pain medication used, and the Adapted Stucki Questionnaire (ASQ) to assess function and pain status. Results: We obtained follow-up on 52 (82.5%) of 61 included patients. We had an average follow-up time of 85.5 weeks (range, 20–152wk), and performed an average of 1.3 injections per patient. We defined a successful outcome as a patient who was both satisfied with his/her results and who experienced at least a 2-point improvement in NRS and ASQ summary pain and summary function scores. Using these criteria for success, 59.6% of our patients had a successful outcome at 1 week postinjection, 55.8% had a successful outcome at 1 month postinjection, 55.8% had a successful outcome at 1 month postinjection, 44.2% had a successful outcome at 3 months postinjection, 37.2% had a successful outcome at 1 year postinjection, and 27.3% had a successful outcome at 2 years postinjection ( P<.01). In addition, 14 (27%) of our patients had complete symptom relief for an average of 1.5 years. Conclusion: Fluoroscopic transforaminal epidural steroid injections are an effective nonsurgical treatment option for patients with degenerative lumbar scoliosis and radiculopathy and should be considered before surgical intervention.

Assessment of Pain Caused by Invasive Procedures in Cancer Patients

Invasive procedures are commonly required in the diagnosis and management of cancer in adults. However, little is known regarding the prevalence and severity of procedure-related pain in this patient population. This prospective study was conducted to determine the frequency and types of invasive procedures performed in a large comprehensive cancer center, the intensity of pain associated with these procedures, the types of periprocedural analgesics administered, and how these patients would like their procedural pain to be managed in the future. During a 6-week period, 102 cancer patients were interviewed immediately after undergoing an invasive procedure. They were asked to rate the pain they experienced before, during, and after their procedure using a verbal descriptor scale (VDS) ranging from 0 to 10. They also were asked if they would want more, less, or the same amount of pain medication if they were to undergo the same procedure again. The most frequently performed procedures were bone marrow aspirates and biopsies (68%), lumbar punctures (14%), and placements of central venous catheters (10%). The average pain rating during these procedures was 4.2 (standard deviation [SD], 3.0). However, 26% of patients experienced severe pain (VDS score > or = 7) during the procedures. Twenty-four percent of patients surveyed received conscious sedation for their procedure. There was no statistical relationship between patients' pain ratings and their satisfaction with the pain control they received during the procedures. This study represents the largest descriptive study of procedural pain in adult cancer patients. As more than 50% of these patients experienced moderate to severe pain during procedures, further studies are needed to improve the control of procedure-related pain in patients with cancer.

The association between knee temperature and pain in elders with osteoarthritis of the knee: a pilot study.

Osteoarthritis is a highly prevalent, disabling condition that causes significant pain and suffering among older adults. Cognitively impaired elders are as susceptible to osteoarthritis as their peers. However, since they have diminished ability to communicate their pain, an alternative method to detect osteoarthritis pain in cognitively impaired elders is urgently needed. Because the late stages of osteoarthritis involve joint inflammation with a mild increase in local temperature, skin surface temperature might reasonably be expected to serve as a proxy measure of osteoarthritis pain. If knee surface temperature could be shown to predict pain in cognitively intact elders, it could be used as a proxy measure of pain for cognitively impaired elders. To test this, the study reported here assessed the relationship between knee surface temperature and pain in cognitively intact elders with osteoarthritis of the knee. We recruited 12 cognitively intact elders with documented osteoarthritis of the knee who lived in retirement apartments. Elders' pain and knee temperature were measured three times on three separate occasions. Osteoarthritis pain of the knee was measured using the Knee Pain Scale and the Western Ontario and McMaster Osteoarthritis Index pain subscale. A YSI Model 4000 Dual Channel Display Telethermometer was used to measure knee temperature. We found no significant associations between knee temperature and any of the pain measures used, with one exception. However, body mass index, amount of pain medication used and activity level observed during the interview were significantly related to elders' pain. Knee temperature does not appear to predict knee pain in elders with osteoarthritis of the knee. Body mass index, use of pain medication and activity level are better predictors of this.

Abuse liability in opioid therapy for pain treatment in patients with an addiction history.

Patients may present to physicians with complaints of acute or chronic pain. Some of these patients will have a history of addiction to drugs or alcohol, and a few will have active addiction. Controlled-substance prescriptions, especially opioid pain medications, can be very beneficial for treatment of pain in patients. There are clear differences between physical dependence on medication, active addiction, addiction in remission, and pseudoaddiction. A search of the medical literature revealed different rates of addiction in patients with chronic pain because different criteria were used to define addiction and the types of chronic pain. It appears that rates of addiction in patient populations with chronic pain are no different than rates of addiction in the general population, according to some recent studies. "Drug-seeking behavior" may be seen with either active addiction or pseudoaddiction. A way to distinguish between these conditions is by giving the patient more pain medication and observing the patient's pattern of behavior. Some patients may be at higher risk to abuse prescription opioids, and some types of drug-seeking behavior may be more predictive of active addiction than pseudoaddiction. General guidelines can improve physicians' comfort level in prescribing opioids for patients with chronic pain, even those with a history of addiction. These include using a medication agreement or contract, setting appropriate goals with the patient, giving appropriate amounts of pain medication, monitoring with drug screens and pill counts, and documenting the case carefully. Even patients with a history of addiction can benefit from opioid pain medications if the patients are monitored appropriately.

Opioid Treatment of Chronic Pain in Patients with Addiction

Patients with a history of drug or alcohol addiction may present to physicians with pain complaints. The medical literature is weak on the treatment of pain with opioids in patients in recovery or active addiction. This is because inconsistent criteria were used to define addiction and the types of chronic pain. There are clear differences between physical dependence, tolerance, and addiction. Addiction is different from pseudoaddiction and must be determined by the patient's behavior after appropriate pain management. Long-acting opioids are often the medications of choice for moderate to severe pain control. Short-acting opioids can be used for breakthrough pain. There are many other medications that can enhance pain control as adjunctive analgesics. Drug-seeking behavior may be seen with either active addiction or pseudoaddiction, or as part of deviant behavior such as drug diversion. A way to distinguish between these conditions is by giving the patient appropriate pain medication and observing the pattern of behavior to determine which is causing the drug-seeking behavior. Safe prescribing of medications with abuse potential includes use of a medication agreement, setting goals with the patient, giving appropriate amounts of pain medication, monitoring with pill counts and drug screens, and careful documentation. Even patients with a history of addiction can benefit from opioid pain medications if monitored appropriately.

Differences between the sexes in post-surgical pain

It has been shown that women have a lower pain threshold and lower tolerance to some forms of experimental pain then men. However, the evidence that clinical pain is perceived differently by the two sexes is not yet as strong. The placement of intraoral implants is a highly controlled surgical procedure that we have used to investigate this possibility. Forty-eight edentulous (without teeth) subjects (27 females), aged from 35 to 63 years, received two titanium implants in the anterior mandible under local anesthesia. After the surgery, subjects completed a pain diary three times each day, rating pain intensity and unpleasantness on 100 mm visual analog scales (VAS). Once a day, they chose verbal descriptors from the McGill Pain Questionnaire (MPQ). Age of subjects, duration of surgery, the amount of local anesthetic used and the amount of pain medication taken were not statistically different for the two groups ( P≥0.32). Results showed that the senior surgeon produced significantly less pain than a 4th year resident ( P=0.04). Although there were no significant differences between sexes for mean daily ratings of intensity or unpleasantness over time ( P≥0.10), most women experienced the highest intensity of pain during the day, while most men had higher pain in the evening ( P=0.025). Also, the relative unpleasantness (unpleasantness/intensity ratio) increased significantly with time for males, but not for females ( P=0.016). Males and females did not differ in the total number of words chosen from the MPQ ( P=0.61), or in the averaged Pain Rating Index (PRI) ( P=0.53). However, women used significantly more evaluative words than men ( P=0.04), suggesting that woman found the overall intensity greater. These results indicate that women find post-surgical pain more intense than males, but that men are more disturbed than women by low levels of pain that last several days.

A Comparison of Pedicled and Free TRAM Flaps for Breast Reconstruction in a Single Institution

Several reports concluded that free tissue transfer of the transverse rectus abdominis muscle (TRAM) flap for breast reconstruction is superior to pedicled transfer of the flap. In an effort to compare the various parameters of both techniques, the authors took advantage of a unique experience at one hospital where one surgeon (D.L.L.) used only the pedicled method and the other (N.J.Y.) used only free tissue transfer. Additionally, the authors compared the findings of the study with the experiences of other surgeons by surveying active members of the American Association of Plastic Surgeons. The records of 119 patients who underwent TRAM flap reconstruction between January of 1988 and July of 1997 were reviewed. Of these, 33 patients received free TRAM flaps, and 86 received pedicled TRAM flaps. To provide an adequate number of patients for statistical analysis, only those with unilateral, single-muscle reconstructions were considered (immediate or delayed). This provided 61 patients in the pedicled flap group and 26 in the free tissue group. Parameters examined included length of operation and of hospitalization, amount of pain medication used, amount of blood lost and received, and complications. A small subset of the patients had hospital records available to compare hospital charges; the comparison of 17 pedicled and 12 free TRAM flaps showed a mean difference of $15,637 (p < 0.001) in favor of the pedicled flap. On the basis of the findings from this study, it seems that the pedicled TRAM flap has significant economic and clinical advantages over the free TRAM flap. There is less need for blood, a shorter operating time and hospital stay, and a need for less pain medication. However, both methods of transfer have indications and contraindications in certain clinical settings. It will always remain the responsibility of the surgeon to evaluate all issues and select a method that is economically responsible and within the abilities of the surgeon, while producing a satisfactory outcome that best serves the patient. The information provided in this report should aid in accomplishing this goal. (Plast. Reconstr. Surg. 104: 674, 1999.)

Evaluation of pediatric pain medications.

Pain management in burned children is complex and depends on the child's ability to express his pain as well as the attitude and knowledge of physicians and nurses in the administration of analgesics to children. A retrospective study of 85 records of children through age 12 was undertaken to compare the amount of medication ordered per kilogram of body weight per age group; the frequency with which medications were given per age group; the amount of pain medication per weight ordered with standard recommended dosages for children; and the drugs most frequently chosen per age group. The results showed that older children received more pain medication per weight than younger children (P

Transcutaneous Electrical Nerve Stimulation for Postlaparotomy Pain

This study was designed to evaluate the transcutaneous electrical nerve stimulation (TENS) postoperative program administered by a physical therapy department. A surgeon, a physical therapist, a recovery room nurse, and unit nurses participated in the program which included preoperative evaluation and patient education, application of sterile electrodes parallel to the incision in the operating room, TENS activation in the recovery room, follow-up visits, and data collection. Seventy-five patients who underwent laparotomy and received TENS at the most comfortable machine settings were compared by chart review to 75 patients who had undergone similar surgical procedures performed by the same surgeon before TENS postoperative pain management had been instituted. The TENS was applied for an average of five days; machine settings of intensity, frequency, and pulse width tended to be midrange. The TENS group took significantly less pain medication, but the length of hospital stay was not significantly different. Patients with TENS rated their pain on 10-point scales as more intense than uncomfortable. This study demonstrated that a well-structured interdisciplinary program of postoperative TENS management can reduce the amount of pain medication taken by patients after laparotomy.