Doses Of Opioid Analgesics Research Articles

Constipation after thoraco-lumbar fusion surgery

BackgroundThoraco-lumbar posterior fusion surgery is a frequent procedure used for patients with spinal instability due to tumor, trauma or degenerative disease. In the perioperative phase, many patients may experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus possibly due to immobilization and high doses of opioid analgesics and narcotics administered during and after surgery. MethodsRetrospective single-center study on patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability in 2012. Study groups were built according to presence/absence of postoperative constipation, with postoperative constipation being defined as no bowel movement on postoperative days 0–2. ResultsNinety-nine patients (39 males, 60 females) with a mean age of 57.1±17.3 years were analyzed, of which 44 patients with similar age, gender, BMI and ASA-grades showed constipation (44.4%). Occurrence of constipation was associated with longer mean operation times (247±62 vs. 214±71min; p=0.012), higher estimated blood loss (545±316 vs. 375±332ml; p<0.001), and higher mean morphine dosages in the postoperative days 0–7 (the difference being significant on postoperative days 1 (48mg vs. 30.9mg, p=0.041) and 2 (43.2mg vs. 29.1mg, p=0.028). The equivalence dose of morphine administered during surgery was similar (339±196 vs. 285±144mg; p=0.286). The use of laxatives in the postoperative days 0–7 was generally high in both study groups, while it was more frequent in patients experiencing constipation. One patient with constipation developed a sonographically confirmed paralytic ileus. Patients with constipation showed a tendency toward longer postoperative hospitalization (7.6 vs. 6.7 days, p=0.136). ConclusionsThe rate of constipation was high after thoraco-lumbar fusion surgery. Moreover, it was associated with longer surgery time, higher blood loss, and higher postoperative morphine doses. Further trials are needed to prove if the introduction of faster and less invasive surgery techniques may have a positive side effect on bowel movement after spine surgery as they may reduce operation times, blood loss and postoperative morphine use.

Gastrointestinal Morbidity after Lumbar Spondylodesis Surgery

Aim: Thoraco-lumbar fusion surgery is a frequent procedure used for patients with spinal instability due to trauma or degenerative disease. In the perioperative phase, many patients experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus possibly due to immobilization and high doses of opioid analgesics and narcotics administered during surgery.

Insurance company denial of payment and enforced changes in the type and dose of opioid analgesics for patients with cancer pain.

Opioids are the mainstay of treatment for moderate to severe cancer pain. The variations in average monthly cost can make it difficult for most patients to procure them without adequate insurance coverage. There are increasing numbers of denials of payment and statements made by insurance agents and other sources regarding inappropriate opioid use, resulting in severe pain and emotional distress for cancer patients and their families. This case series describes five events where the insurer was a major barrier to opioid access.

Liposome bupivacaine for postsurgical pain in an obese woman with chronic pain undergoing laparoscopic gastrectomy: a case report

IntroductionTo reduce incidence and severity of postsurgical pain and minimize the effect of its clinical and economic correlates, multimodal therapy for surgical patients is recommended. In this report, we discuss the use of liposome bupivacaine, a novel multivesicular formulation of bupivacaine indicated for single-dose infiltration into the surgical site to produce postsurgical analgesia, as part of a multimodal analgesic regimen in a patient with a history of chronic pain scheduled to undergo laparoscopic sleeve gastrectomy. To the best of our knowledge, this is the first published report of liposome bupivacaine in the setting of laparoscopic sleeve gastrectomy.Case presentationA 35-year-old white woman with morbid obesity was admitted for laparoscopic sleeve gastrectomy to lose weight prior to hip replacement surgery. Because of a complicated medical history that included rheumatoid arthritis, fibromyalgia, diabetes mellitus, hypertension, and chronic pain, for which she was receiving high doses of opioid analgesics, postsurgical pain management was a concern and she was considered a candidate for multimodal analgesia. At initiation of surgery, 50mL of lidocaine and epinephrine was infiltrated around the port sites. At the conclusion, 25mL of normal sterile saline was added to a 20mL vial of liposome bupivacaine (266mg) and injected around the port sites and at the site of liver retraction. Laparoscopic sleeve gastrectomy was successfully completed. Our patient was discharged to the postanesthesia care unit for approximately four hours before discharge to the surgical floor with a pain score of 5 (11-point scale; 0 = no pain, 10 = worst possible pain). Her postoperative course was uneventful; no adverse events were recorded during surgery or during the remainder of her hospital stay. Our patient was discharged on the same opioid regimen used previously for control of her preexisting chronic pain.ConclusionsLiposome bupivacaine use in this morbidly obese patient undergoing laparoscopic sleeve gastrectomy provided analgesic efficacy and limited postsurgical opioids to a level comparable with her baseline opioid regimen for chronic pain. Given her complex medical history and previous issues with acute and chronic pain, we consider these results highly successful and continue to use liposome bupivacaine as part of a multimodal analgesic regimen in an effort to optimize postsurgical pain management.

Analgesic opioid dose is an important indicator of postoperative ileus following radical cystectomy with ileal conduit: experience in the robotic surgery era.

PurposePostoperative ileus (POI) is common following bowel resection for radical cystectomy with ileal conduit (RCIC). We investigated perioperative factors associated with prolonged POI following RCIC, with specific focus on opioid-based analgesic dosage.Materials and MethodsFrom March 2007 to January 2013, 78 open RCICs and 26 robot-assisted RCICs performed for bladder carcinoma were identified with adjustment for age, gender, American Society of Anesthesiologists grade, and body mass index (BMI). Perioperative records including operative time, intraoperative fluid excess, estimated blood loss, lymph node yield, and opioid analgesic dose were obtained to assess their associations with time to passage of flatus, tolerable oral diet, and length of hospital stay (LOS). Prior to general anaesthesia, patients received epidural patient-controlled analgesia (PCA) consisted of fentanyl with its dose adjusted for BMI. Postoperatively, single intravenous injections of tramadol were applied according to patient desire.ResultsMultivariate analyses revealed cumulative dosages of both PCA fentanyl and tramadol injections as independent predictors of POI. According to surgical modality, linear regression analyses revealed cumulative dosages of PCA fentanyl and tramadol injections to be positively associated with time to first passage of flatus, tolerable diet, and LOS in the open RCIC group. In the robot-assisted RCIC group, only tramadol dose was associated with time to flatus and tolerable diet. Compared to open RCIC, robot-assisted RCIC yielded shorter days to diet and LOS; however, it failed to shorten days to first flatus.ConclusionReducing opioid-based analgesics shortens the duration of POI. The utilization of the robotic system may confer additional benefit.

A Randomized Clinical Trial of the Efficacy of a Self-care Intervention to Improve Cancer Pain Management

The undertreatment of cancer pain remains a significant clinical problem. The aim of this randomized controlled trial was to evaluate the efficacy of the PRO-SELF Pain Control Program that was modified for Norwegian cancer patients in decreasing pain and increasing opioid intake compared with control care. Oncology outpatients with pain from bone metastasis were randomized into the PRO-SELF (n = 87) or control (n = 92) groups. A nurse visited patients in the PRO-SELF group in their home at weeks 1, 3, and 6 and conducted telephone interviews at weeks 2, 4, and 5. Patients in both groups completed a daily diary of pain intensity ratings and analgesic intake. For both groups, significant decreases in pain intensity scores and in hours per day in pain (both, P < .001) were found over the 6 weeks of the study. However, no significant group × time interactions were found for any of the pain measures. In both groups, total dose of opioid taken increased over time. However, no significant group × time interactions were found for changes over time in the total dose, around-the-clock dose, or as-needed dose of opioid analgesics taken. Possible reasons for the lack of efficacy include an inadequate dose of the psychoeducational intervention, inadequate changes in analgesic prescriptions, and/or the impact of attention provided to the control group. Coaching, nursing support, and the use of a pain diary may be important interventions to reduce pain intensity.

Behavioral Pain Assessment Tool for Critically Ill Adults Unable to Self-Report Pain

Critically ill adults often cannot self-report pain. To determine the effect of the Critical-Care Pain Observation Tool on frequency of documentation of pain assessment and administration of analgesics and sedatives in critically ill patients unable to self-report pain. Data on patients in 2 intensive care units of a university-affiliated hospital were collected before and after implementation of the tool. Patients were prospectively screened for eligibility; data were extracted retrospectively. Data were recorded for a maximum of 72 hours before and after implementation of the tool in the cardiovascular intensive care unit (130 patients before and 132 after) and in the medical/surgical/trauma unit (59 patients before and 52 after). Proportion of pain assessment intervals with pain assessment documented increased from 15% to 64% (P < .001) in the cardiovascular unit and from 22% to 80% (P < .001) in the other unit. Median total dose of opioid analgesics decreased from 5 mg to 4 mg in the cardiovascular unit (P = .02) and increased from 27 mg to 75 mg (P = .002) in the other unit. Median total dose of benzodiazepines decreased from 12 mg to 2 mg (P < .001) in the cardiovascular unit and remained unchanged in the other unit. Increased documentation of pain assessment was associated with increased age in the cardiovascular unit and with decreased maximum scores on the Sequential Organ Failure Assessment in the other unit. Implementation of the tool increased frequency of pain assessment and appeared to influence administration of analgesics in both units.

Mandatory Palliative Care Education for Surgical Residents: Initial Focus on Teaching Pain Management

BackgroundKnowledge concerning palliative care and the associated skills, including effective pain control, is essential for surgeons who treat cancer patients in daily practice. This study focuses on a palliative care training course that has been mandatorily conducted for all surgical residents of our hospital since 2009.MethodsWe evaluated the effectiveness of our mandatory palliative care training course by conducting a retrospective study of the patients' medical records and participants' questionnaire results and discussed the importance of palliative care education for surgical residents.ResultsAll 12 surgical residents who participated in the course in 2009 had graduated 4–9 years back. They were assigned to look after a total of 92 cases (average, 7.66 cases per resident) during the course. The purpose of care in most cases (92.3%) was to mitigate pain. Introducing analgesic adjuvants such as gabapentin or amitriptyline accounted for the largest part of initial interventions (23.9%) aimed at controlling cancer pain, followed by changes in route of administration or doses of prior opioid analgesics (21.7%). Interventions with opioid analgesics were conducted most frequently (47.7%). The overall pain improvement rate was 89.1%. We used a questionnaire after the course to evaluate its effectiveness.ConclusionsThe surgical residents stated that it was a meaningful course through which they gained practical knowledge on palliative care and that the experience would change their approach to home care.

The Role of Pre-induction Ketamine in the Management of Postoperative Pain in Patients Undergoing Elective Gynaecological Surgery at the University Hospital of the West Indies

To determine if a single preoperative dose of ketamine hydrochloride reduces the narcotic analgesic requirements and/or pain scores reported by patients in the first 24 hours postoperatively. A single-centred, prospective, case-control study was conducted on 84 patients aged 18-65 years, American Society of Anaesthesiologists (ASA) I and II, undergoing elective gynaecological procedures at the University Hospital of the West Indies (UHWI). Patients were randomly assigned to one of two treatment groups: (a) ketamine group, where patients received intravenous ketamine 0.15 mg/kg pre-induction of anaesthesia; and (b) placebo group, patients received normal saline. The anaesthetic technique was standardized. Postoperatively, patients were interviewed at 15-minute intervals for the first hour then at 2, 4, 6, and 24 hours to determine their pain scores and any side effects. Timing and dose of opioid analgesics were also recorded. The mean cumulative morphine dose over the first 24 hours postoperatively was 29.6 +/- 10.8 mg for the ketamine group and 31.9 +/- 11.2 mg for the placebo group (p = 0.324). There was also no significant difference in pain intensity measured by the visual analogue scale (VAS) between the groups. Patient age and the type of surgery performed were not found to influence pain intensity. The most common adverse effects were nausea and vomiting (32.5%), dizziness (42.2%), drowsiness and sedation (45.8%) with no significant difference between groups. Both groups had an average in-hospital stay of three days postoperatively, however, the patients in the ketamine group reported higher satisfaction scores than those in the placebo group (p = 0.039). Despite no significant reduction in postoperative narcotic requirements or pain intensity, more patients who received ketamine reported higher levels of satisfaction with their pain management.

Preliminary analysis of state prescription monitoring programs

Prescription Monitoring Programs (PMPs) that are operational in 38 states create state-run electronic databases to track the dispensing of controlled substances. The White House Office of National Drug Control Policy and the Centers for Disease Control have viewed PMPs as important mechanisms for helping clinicians identify high-risk patients. PMPs can provide clinicians critical information about a patient's controlled substance prescription history and alert them to “doctor shoppers” or to persons who take high daily doses of opioid analgesics or are using multiple drugs that have the potential to be abused. Unfortunately, there are no published studies that document the effectiveness of these programs. Here we report preliminary results from a project whose overall objective is to improve the effectiveness of PMPs. We first identified the elements that we believe are essential for a program to be balanced and effective. We then conducted a systematic analysis of state laws and regulations compiled by the National Alliance for Model State Drug Laws to determine if those elements were present in state PMPs or in the legislation that authorizes the creation of PMPs in other states. Our analysis provides empirical evidence of the need for modifications to enhance the effectiveness of existing programs. Only 28% recognize the principle of balance. Very few states provide prescribers or pharmacists real time access (within 24 hours) to information in the data base about current or prospective patients. PMP data are accessible to 74% of health care regulatory boards, but to only 42% of medical assistance programs. We thank Sherry Green, Executive Director of the National Alliance for Model State Drug Laws for her advice and technical support with this work. Funded in part by Purdue Pharma LP and King Pharmaceuticals.

The 7th American Urological Association and the Japanese Urological Association International Affiliate Society Meeting

The 7th American Urological Association and the Japanese Urological Association International Affiliate Society Meeting

Opioid therapy for treating rheumatoid arthritis pain

Despite improvements in the management of rheumatoid arthritis (RA), pain control is often inadequate even when inflammation is well controlled. To assess the efficacy and safety of opioid analgesics for treating pain in patients with RA. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE for studies to May 2010. We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of articles. Studies were included if they were randomized or quasi-randomized controlled trials (RCTs or CCTs) which compared opioid therapy to another therapy (active or placebo) for pain in patients with RA. Outcomes of interest were pain, adverse effects, function and quality of life. Two review authors independently selected the studies for inclusion, extracted the data, and performed a risk of bias assessment. Eleven studies (672 participants) were included in the review. Four studies assessed the efficacy of single doses of various opioid and non-opioid analgesics; a pooled analysis of these studies was not performed but in each study opioids reduced pain more than placebo. There were no differences between analgesic drugs in these studies.Seven studies were between one and six weeks in duration and assessed six different oral opioids (dextropropoxyphene, codeine, tramadol, tilidine, pentazocine, morphine), either alone or combined with non-opioid analgesics. The only strong opioid investigated was controlled-release morphine sulphate, in a single study with 20 participants. Six studies compared an opioid to placebo. Opioids were superior to placebo in patient-reported global impression of change (3 studies, 324 participants: relative risk (RR) 1.44, 95% CI 1.03 to 2.03) but not for the number of withdrawals due to inadequate analgesia (4 studies, 345 participants: RR 0.82, 95% CI 0.34 to 2.0). Adverse events (most commonly nausea, vomiting, dizziness and constipation) were more frequent in patients receiving opioids compared to placebo (4 studies, 371 participants: odds ratio 3.90, 95% CI 2.31 to 6.56); the pooled risk ratio for withdrawal due to adverse events was 2.67 (3 studies, 331 participants: 95% CI 0.52 to 13.75). One study compared an opioid (codeine with paracetamol) to an NSAID (diclofenac) and found no difference in efficacy or safety between interventions. There is limited evidence that weak oral opioids may be effective analgesics for some patients with RA, but adverse effects are common and may offset the benefits of this class of medications. There is insufficient evidence to draw conclusions regarding the use of weak opioids for longer than six weeks, or the role of strong opioids.

Naloxone pro-drug rescues morphine induced respiratory depression in Sprague-Dawley rats

Respiratory depression is the main obstacle for the safe administration of morphine for acute pain after injury. Due to this complication, new delivery methods are needed to insure that safe and effective doses of opioid analgesics are administered during emergencies. A depot formulation containing a naloxone pro-drug was designed to release the antidote when morphine causes dangerous hypoxic conditions in the blood. The aim of this work was to test the naloxone release in vivo in response to a severe overdose of morphine in the Sprague-Dawley rat model. Non-invasive two-chamber plethysmography was used to monitor and record respiration and to test the capability of the naloxone pro-drug to respond to and rescue morphine-induced respiratory depression in the animal. We show that the pro-drug formulation can both prevent and reverse severe morphine induced respiratory depression. The animal model demonstrates that co-administration of the naloxone pro-drug reliably antagonizes profound respiratory depressive effects of morphine.

Improvements in objective and subjective functioning following completion of an interdisciplinary pain rehabilitation program

The benefits of interdisciplinary pain programs are well documented; however, coverage is denied by many payer systems. Further data are warranted to expand the evidence for such positive treatment outcomes. The present study examined outcome data for 75 patients who completed a four-week residential pain rehabilitation program. The program consists of appropriate medication adjustment (not necessarily opioid withdrawal), education, relaxation training, counseling, biofeedback, and physical therapy. Average age was 43.28 years (SD=9.25) with an average duration of 57.46 months from injury to program entry. The sample was 57.3% female and 86.3% Caucasian. Pre- to post-treatment outcomes were analyzed with repeated measures design. Results revealed significant reductions in psychological distress (e.g., Pain Anxiety Symptoms Scale; p<0.001, and Beck Depression Inventory; p<0.001, among others) and increase in pain acceptance (Chronic Pain Acceptance Questionnaire; p<0.001). Self-reported pain intensity significantly decreased (Numerical Rating Scale; p<0.001) and perceived functional impairment decreased (Oswestry Activity Rating Scale; p<0.001). Improvements in functional measures were also noted, including trunk range of motion (e.g., forward flexion, extension, etc.; all p<0.001) and timed 100 yard walk (p<0.001). Exercise tolerance increased by an average of 13.28% (SD=14.10). The majority of these effects were of moderate size (mean partial η2 = .47). Patients reported significant satisfaction at discharge, including improvements in mood (M=46.79%, SD=33.31), activity level (M=51.89%, SD=31.38), social interactions (M=37.29%, SD=34.47), coping self-efficacy (M=50.08%, SD=33.61), and pain intensity (M=25.32%, SD=27.79). It is interesting to note that significant psychological, pain, and functional improvements were observed, despite starting treatment on average almost 5 years post-injury and despite relatively stable medication dosing (i.e., there was a trend toward decreased morphine equivalent doses of opioid analgesics, p=0.06). This analysis provides further evidence that an interdisciplinary rehabilitation program can result in significant improvements in both subjective and objective functioning, independent of medication use and time since injury. The benefits of interdisciplinary pain programs are well documented; however, coverage is denied by many payer systems. Further data are warranted to expand the evidence for such positive treatment outcomes. The present study examined outcome data for 75 patients who completed a four-week residential pain rehabilitation program. The program consists of appropriate medication adjustment (not necessarily opioid withdrawal), education, relaxation training, counseling, biofeedback, and physical therapy. Average age was 43.28 years (SD=9.25) with an average duration of 57.46 months from injury to program entry. The sample was 57.3% female and 86.3% Caucasian. Pre- to post-treatment outcomes were analyzed with repeated measures design. Results revealed significant reductions in psychological distress (e.g., Pain Anxiety Symptoms Scale; p<0.001, and Beck Depression Inventory; p<0.001, among others) and increase in pain acceptance (Chronic Pain Acceptance Questionnaire; p<0.001). Self-reported pain intensity significantly decreased (Numerical Rating Scale; p<0.001) and perceived functional impairment decreased (Oswestry Activity Rating Scale; p<0.001). Improvements in functional measures were also noted, including trunk range of motion (e.g., forward flexion, extension, etc.; all p<0.001) and timed 100 yard walk (p<0.001). Exercise tolerance increased by an average of 13.28% (SD=14.10). The majority of these effects were of moderate size (mean partial η2 = .47). Patients reported significant satisfaction at discharge, including improvements in mood (M=46.79%, SD=33.31), activity level (M=51.89%, SD=31.38), social interactions (M=37.29%, SD=34.47), coping self-efficacy (M=50.08%, SD=33.61), and pain intensity (M=25.32%, SD=27.79). It is interesting to note that significant psychological, pain, and functional improvements were observed, despite starting treatment on average almost 5 years post-injury and despite relatively stable medication dosing (i.e., there was a trend toward decreased morphine equivalent doses of opioid analgesics, p=0.06). This analysis provides further evidence that an interdisciplinary rehabilitation program can result in significant improvements in both subjective and objective functioning, independent of medication use and time since injury.

Pain during pharmacologically induced termination of pregnancy

In this issue of the Scandinavian Journal of Pain, Suhonen et al.[1] publish a study where they analyse pain during induced med-ical abortion and how pain may affect the perceived ability tostay at home during the treatment. They also studied how wellthesewomenrememberedtheintensityandunpleasantnessoftheabortion pain 3–6 weeks after the termination of pregnancy. Med-ical abortion was induced by the combination of the two drugsmifepristone and misoprostol. The uterine contractions followingmisoprostol will regularly cause pain in the lower abdomen. Thereportedpainintensitymayvary,andinaCanadianstudythemeanmaximumintensitywas6.2(NRSpain0–10)and23%ofthewomenreported NRS 9 or 10 despite analgesic therapy [2]. Medical abor-tion has replaced surgical abortion as the routine method in someclinics [3]. The easiness of this low tech treatment are welcomedby many but some politicians have even raised critical questionson ethical grounds and have questioned if it is too easy to haveabortion.Therearesurprisinglyfewcontrolledanalgesictrialsinthispop-ulation [4] and it seems like the meagre evidence may have led toinsufficienttreatmentandgreatvariationbetweenabortionclinics[5]. The combination of adequate doses of paracetamol and a non-steroid analgesic drug (NSAID) for acute pain is well documented[6,7], but is probably still not implemented in standard analgesictreatment. The British guidelines for medical abortion publishedby The Royal College of Obstetricans and Gynaecologists even con-clude, in a separate paragraph about pain, that “Requirements foranalgesia vary and there is no benefit in routine administration ofprophylactic analgesics” [8]. Some recent, well designed random-ized controlled trials of pain relief during medical abortion havedocumented the efficacy of paracetamol or ibuprofen, the latterbeing the most efficacious [9].Surgical termination of pregnancy will also cause pain, but theduration is shorter, and analgesic treatment will be provided bypersonnel in the post-anaesthesia care unit. Hopefully, most ofthese women will have adequate doses of both opioid and non-opioid analgesics during their stay. A recent publication in Paindocumented that pain after surgical abortion can be effectivelyrelievedbytranscutaneouselectricalnervestimulation(TENS)and

Psychological Distress as a Negative Survival Factor for Patients with Hematologic Malignancies Who Underwent Allogeneic Hematopoietic Stem Cell Transplantation

To evaluate the influence of distress on overall survival of patients with hematologic malignancies who underwent allogeneic stem cell transplantation (allo-SCT) and to analyze the possible risk factors for death. Retrospective cohort study. Large tertiary care teaching hospital. Seventy-seven patients (aged ≥ 15 yrs) with hematologic malignancies who underwent allo-SCT between January 2000 and August 2007; 20 patients with distress history were matched in a 1:3 ratio with 57 patients without distress history. The primary outcome was overall survival, defined as the time from allo-SCT to disease-related death or last date of follow-up. Secondary outcomes were time to hematologic recovery (absolute neutrophil count ≥ 500 cells/mm³) from day of allo-SCT, length of hospital stay, and opioid usage. Sociodemographic information and clinical characteristics were analyzed for possible risk factors. Patient history of psychological distress resulted in a significantly higher mortality rate in the first year after allo-SCT (hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.48-6.28, p=0.001) and led to a shorter overall survival rate (HR 1.63, 95% CI 0.86-3.10, p=0.133). However, psychological distress had no effect on hospital length of stay, hematologic recovery time, opioid usage status, or dose of opioid analgesics used. Factors associated with death after allo-SCT in the univariate analysis (p<0.05) were high-relapse risk disease, umbilical cord blood SCT, total-body irradiation-containing conditioning regimen, and higher educational background. In the multivariate analysis, high relapse risk (HR 3.85, 95% CI 1.81-8.20, p<0.001) and total-body irradiation-containing conditioning regimen (HR 3.50, 95% CI 1.29-9.51, p=0.01) were identified as risk factors for death. A history of psychological distress before allo-SCT, after adjusting for other patient- and disease-related prognostic factors, had a significant influence on early death in the first year after transplantation.

The Medical Consumption of Opioids in Colombia, 1997–2007

ABSTRACTThe World Health Organization classifies opioid analgesics as essential medicines in the treatment of severe pain and recommends their increased availability. The combination of availability, training of professionals, and a legal framework granting access to these medicines has led to a sharp increase in the consumption of morphine and other opioids in developed countries. However, in Colombia, consumption of opioid analgesics appears to fail to meet patient needs. To analyze the current trends in medical consumption of opioids in Colombia, the numbers of defined daily doses of opioid analgesics for total inhabitants and the population that died of cancer between 1997 and 2007 were calculated and compared. The import of raw materials and medicines varied greatly every year. However, from 2003, a trend toward the increased consumption of morphine, hydromorphone, and methadone was observed. Availability was inconsistent and opioid consumption showed an increase when calculated for total inhabitants and for cancer deaths. The unreliable availability of opioid analgesics may be responsible for their limited consumption. Chronic underuse and a trend toward increased consumption have been confirmed. Monitoring of consumption to promote rational use is recommended.

Multimodal analgesia in children

Acute and chronic pain management in children is increasingly characterized by either a multimodal or a preventive analgesia approach, in which smaller doses of opioid and nonopioid analgesics, such as nonsteroidal anti-inflammatory drugs, local anaesthetics, N-methyl-D-aspartate antagonists, alpha(2)-adrenergic agonists, and voltage-gated calcium channel alpha-2 delta-proteins, are combined alone and in combination with opioids to maximize pain control and minimize drug-induced adverse side effects. A multimodal approach uses nonpharmacological complementary and alternative medicine therapies too. These include distraction, guided imagery, hypnosis, relaxation techniques, biofeedback, transcutaneous electrical nerve stimulation, and acupuncture. Using the neurophysiology of pain as a blueprint, the molecular targets and strategies used in multimodal pain management are described. Finally, weight-based dosage guidelines for commonly used opioid and nonopioid analgesics are provided to facilitate therapy.

OPIOID‐INDUCED HYPERALGESIA IN A PATIENT WITH DEMENTIA

OPIOID‐INDUCED HYPERALGESIA IN A PATIENT WITH DEMENTIA

The Obesity-Hypoventilation Syndrome and Respiratory Failure in the Acute Trauma Patient

The Emergency Department experience, for many patients, involves procedures and therapies that can compromise ventilation. In the acute trauma patient, these include spinal immobilization, supine positioning, and the administration of sedative and analgesic medications. Patients with the obesity-hypoventilation syndrome have a syndrome distinct from mere obesity, and are more sensitive to these insults. To describe a case of respiratory failure in a patient with the obesity-hypoventilation syndrome resulting from injuries and therapies that in any other patient would not be expected to cause respiratory failure. A 59-year-old woman suffered a mechanical fall, fractured her T6 vertebral body and right proximal humerus, and, after spinal immobilization and the administration of routine doses of opioid analgesics, suffered significant hypoxemia and respiratory acidosis. Reversal agents were ineffective, but non-invasive mechanical ventilation restored adequate respiration. Although obesity-hypoventilation syndrome occurs in only a minority of morbidly obese patients, it is important because the consequences of respiratory failure can be severe if not recognized and anticipated. Such patients will not be able to adequately increase ventilation in response to mounting hypercapnia. The condition is easily addressed through non-invasive ventilation.