Narcotic Pain Medication Research Articles

Comparison of postoperative pain between laser‐assisted uvulopalatoplasty, uvulopalatopharyngoplasty, and radiofrequency volumetric tissue reduction of the palate

OBJECTIVESThis study compares the posttreatment discomfort between laser‐assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP), and radiofrequency volumetric tissue reduction (RFVTR) of the palate through the use of visual analog pain scales and a quantitative assessment of the analgesic medication taken.METHODSIn one group, LAUP (n = 10) or UPPP (n = 9) was used to treat patients' snoring or sleep‐disordered breathing (SDB), and the other group underwent RFVTR (n = 22).RESULTSThe mean numbers of days with pain after RFVTR, LAUP, and UPPP were 2.6, 13.8, and 14.3 days, respectively. Narcotic analgesics were required in the RFVTR, LAUP, and UPPP groups in 9%, 100%, and 100% of the subjects, respectively. The mean number of these days requiring narcotic pain medications for RFVTR, LAUP, and UPPP was 0.2, 11.8, and 12.4 days, whereas the total narcotic equivalent was 0.3, 7.4 and 29.6 days, respectively.CONCLUSIONRFVTR of the soft palate produced less posttreatment pain than LAUP or UPPP. LAUP and UPPP appeared to show little difference in the severity or duration of posttreatment discomfort.

Interval appendectomy in the laparoscopic era

In the acute setting, patients with periappendiceal masses generally improve with broad-spectrum antibiotics with or without percutaneous catheter drainage, but whether or not to perform an interval appendectomy remains controversial. We have analyzed our experience over the past decade, comparing results from interval laparoscopic appendectomy (ILA) and interval open appendectomy (IOA). Medical records were reviewed for 56 patients who initially presented with the diagnosis of periappendiceal mass or abscess and who subsequently underwent interval appendectomy. Data were accumulated for both the initial hospitalization and interval appendectomy. Comparisons were made between period 1 (1987 to 1993) and period 2 (1994 to 1997). Follow-up data were obtained via telephone conversations with the patients. patient characteristics with regard to age, sex, and comorbidities did not differ between the ILA and IOA groups. The number of patients undergoing CAT scan increased from 33% to 55%, whereas the initial hospital stay decreased from 7.42 to 4.61 days ( P <0.001). The percentage of interval appendectomies performed by the laparoscopic method increased from 30% to 85%. The total operating room time did not differ (95 vs. 103 minutes), but the hospital stay was much shorter in the ILA group (0.55 vs. 3.07 days, P <0.001). There were no instances of intra-abdominal or wound infections in either group. In the later time period the mean hospital stay decreased to 0.38 days, with 59% of the operations performed on an outpatient basis. Following ILA, narcotic pain medication was used for an average of 1.3 days and the reported “time to return to full activities” was 2.5 days. ILA is a simple and safe procedure that can usually be performed on an outpatient basis. Given the minimal morbidity of the procedure, we believe that ILA should be considered for most patients who initially present with periappendiceal masses.

Outpatient ACL reconstruction using intraoperative local analgesia and oral postoperative pain medication.

Thirty-five consecutive anterior cruciate ligament (ACL) reconstructions were performed in an ambulatory surgical unit using a bone-patellar tendon-bone autograft. Patients were evaluated postoperatively to determine the amount of pain medication used, the readmission rate, postoperative complications, and cost. Outpatient ACL reconstruction led to a savings of $4700 compared with the cost of performing the same procedure in a hospital operating room with an overnight admission. This study demonstrates that outpatient ACL reconstruction, using local analgesia intraoperatively and oral narcotic pain medication postoperatively, is a safe and cost-effective procedure with minimal to no morbidity.

SOMATIC VERSUS SYMPATHETIC MEDIATED CHRONIC LIMB PAIN

It has been helpful in our practice to separate somatic from sympathetic-mediated peripheral nerve pain. We would recommend application of the new nomenclature of type I complex regional pain (sympathetic dystrophy) and type II complex regional pain (causalgia) (see Table 1). We believe it is essential that both of these conditions be separated into their early and late phases and that the treatment alternatives be customized for the individual patient and the peripheral nerve involved. If a cast, pin, or external fixation apparatus is associated with peripheral nerve pain, the offending apparatus must be removed immediately and other forms of treatment initiated for the underlying injury. For acute injury and postsurgical pain, narcotic pain medications should be used no longer than 72 hours and careful patient re-examination must be performed if pain persists. Prescription of narcotic pain medications on a continuing basis is often the primary reason for the development of chronic pain syndromes. Physical therapy for the patient with chronic peripheral limb pain must be performed in a pain-free environment. "No pain, no gain" does not apply in the treatment of chronic limb pain-rather the reverse: "Only gain with no pain." In differentiating between sympathetic pain and somatic pain, the use of the reflex sympathetic dystrophy (RSD) score can be helpful (Table 4). If the pain is somatic, treatment options include: Somatic Pain: Treatment Isolated nerve block Continuous nerve block TENS (external) Direct electrical nerve stimulation (internal) Nerve ablation If the pain is sympathetic in origin, treatments to be considered are: Sympathetic Nerve Pain: Treatment Protection of limb (garment or splint) Combine with active use Sympathetic blocks single continuous Sympathectomy In addition, the treatment of each of those conditions must be directed at the primary condition. Once the two conditions are separated, a careful program of pain management is required. In patients who present with late pain dysfunction, the more commonly observed phenomenon at our institution, the combination of physician, surgeon, and anesthesiologist is essential. The role of physical therapist in restoring function to the injured limb must be discussed and planned carefully. Initial pain management is organized through a qualified anesthesiologist dedicated to this field. Physical therapy follows but only in a pain-free environment. The surgeon's role is to assist and direct the pain management program. Surgeons can be involved in the placement of percutaneous catheters, as well as isolated peripheral nerve blocks. Surgical intervention is limited to the release of compressive neuropathies, nerve transfers, and revascularization of the peripheral nerve bed. The surgeon occasionally may be involved in the manipulation and pinning of contracted joints, as well as release of muscle or joint contractures, followed by a supervised program of early range of motion. Finally, it is important that both physician and surgeon serve as patient advocates when questions of workers' compensation intervene that could deter proper treatment programs or when the patient needs the encouragement and guidance to continue with treatments that don't always initially appear to have immediate results. Finally, requests to the surgeon to find an operative cure must be resisted while continued psychological encouragement is provided.

ELECTRICAL STIMULATION AND THE TREATMENT OF COMPLEX REGIONAL PAIN SYNDROMES OF THE UPPER EXTREMITY

Clinical, intractable pain in the upper extremity often results from neuroma, direct injury to a peripheral nerve, or repetitive operative insults to a peripheral nerve that has compressive neuropathy. Electrical stimulation applied directly to a single peripheral nerve can provide sufficient relief of pain, improve patient outlook, improve lasting sleep, release the individual from addictive narcotic pain medication, and restore a psychological sense of well-being.

INTENTIONAL REPLANTATION

A list of what was once advocated when performing a replantation versus what is done now follows: 1. It used to be advocated always to curettage the socket after removing the tooth. Now clinicians know not to touch the walls of the socket and only to aspirate gently the apical region if needed. 2. After removal, the tooth used to be held in gauze, desiccating viable PDL cells. Now the tooth is kept bathed in an emesis basin filled with HBSS, which maintains the viability of the PDL for 30 minutes. 3. All clinicians were able to do was visual inspection; now the microscope is used to illuminate and magnify the working area. 4. Splinting was done on every case; now clinicians rarely splint after replantation. 5. Narcotic pain medication was prescribed routinely; now clinicians premedicate with chlorhexidine rinse, anti-inflammatory medication, and sometimes antibiotics, rarely using narcotics. With increased understanding of the periodontium and improved techniques, replantation should no longer be viewed as a treatment of last resort, but rather a successful treatment alternative.

Laparoscopic Swenson pull-through: A comparison with the open procedure

This study was performed to compare the standard open Swenson pull-through (OSP) with the laparoscopic Swenson pull-through (LSP) for Hirschsprung's disease. The Swenson pull-through was performed on eight patients with a rectosigmoid transition zone, during a 14-month period, using one camera port and three working ports. The results were compared with those of 10 patients with a similar lesion treated by the open procedure during an overlapping 19-month period. One laparoscopic procedure was converted to the open version because of technical difficulties. Both methods had a hand-sewn anastomosis approximately 1 cm above the pectinate line. The preoperative variables of age, weight, incidence of colostomy, and incidence of Down's syndrome were similar for the two groups. The operating time for LSP was similar to that for OSP (4 hours 42 minutes v 4 hours 37 minutes, respectively; P =NS). Postoperatively, the laparoscopic group had a shorter hospital stay (5.25 v 8.8 days; P < .05) and had a shorter period until the start of oral intake (2.75 v 5 days; P < .05). The requirement for narcotic pain medication was similar (12.6 v 12.8 doses; P = NS). Early postoperative complications were more common in the open group (3 wound infections, 1 prolonged ileus, and 1 anastomotic leak). No complications occurred in the laparoscopic group. Late postoperative follow-up was too short to compare functional results. The authors conclude that the Swenson pull-through can be performed safely with the laparoscope, with reduced morbidity.

Postoperative delirium following radical gynecologic oncology surgery

The purpose of this study was to determine the incidence and possible predisposing factors for the development of postoperative delirum following radical gynecologic oncology surgery. A retrospective chart review was performed on 153 consecutive patients undergoing radical gynecologic oncology surgery. Preoperative variables assessed included: age, sepsis, decreased vision, decreased hearing, psychiatric history and abnormal mental status. Operative variables assess included: anesthesia time, estimated blood loss, hypotension, arrhythmia and transfusions. Preoperative medications, postoperative pain medication and abnormal perioperative laboratory values were also assessed. Sixteen of 150 patients (11%) developed postoperative delirium. Age was a significant predictor of postoperative delirium (median age 69 years vs 53 years, P = 0.006). Preoperative abnormal mental status examination was a significant predictor (P = 0.27). Use of chronic narcotic pain medication was significant (P = 0.008). All three patients who were septic at the time of emergency surgery developed postoperative delirum (P = 0.001). No other variables could be identified. When reviewing the date using any high risk factor as a positive test (advanced age, sepsis, abnormal mental status exam or chronic narcotic pain medication), sensitivity was 88%, specificity 76%, positive predictive value 35% and negative predictive value 77%. Delirium occurred most frequently on the second post-operative day (range 1–4 days) and lasted for a median of 2 days (range 1–5 days). Delirium resolved completely in all 16 patients. In conclusion, 11% of women undergoing radical gynecologic oncology surgery developed postoperative delirium. Advanced age, preoperative abnormal mental status, chronic narcotic pain medication and preoperative sepsis were all predisposing risk factors.

Pediatric nurses' knowledge and practice related to infant pain.

A convenience sample of 181 registered nurses completed questionnaires about their knowledge, attitudes, and clinical practice related to infant pain. The majority of respondents thought infants felt pain with the same intensity as adults and were comfortable administering narcotic and nonnarcotic pain medications. The most frequently identified infant pain cues were: crying, irritability, and inability to be consoled. There were associations between greater numbers of pain cues and higher pain severity ratings and between postlicensure education about pain and number of strategies proposed to relieve pain. There were no associations for noncritical versus critical care unit assignment or participation in postlicensure education about pain with number of assessment cues. There were no associations for pain severity or noncritical versus critical care unit assignment with pain management strategies. Until the research base about management of infant pain is expanded, nurses should continue to use and evaluate a variety of pain management interventions on a case-by-case basis.

Chronic peripheral nerve pain treated with direct electrical nerve stimulation

Chronic somatic peripheral nerve pain was treated prospectively in 24 nonrandomized patients by a program of direct electrical nerve stimulation. Patients qualified for the program if anesthetic (lidocaine) nerve block of the involved cutaneous zone of the peripheral nerve relieved symptoms and transcutaneous electrical nerve stimulation transiently improved and did not exacerbate somatic pain. Results were judged according to a pain score. Patients noted improved sleep and complete absence of the need for narcotic pain medication. On the basis of subjective and objective criteria, 18 patients had good or excellent results and 6 had implant failures. Of the six patients with failures, three failed the trial period and did not have implantation, and three had no significant pain relief and were judged as treatment failures. Three patients had late equipment failure after initial good results. Most patients had some relief of pain, which increased their quality of life and eliminated the need for narcotic analgesia. Direct electrical nerve stimulation should be considered for somatic peripheral nerve pain that has not been ameliorated with other methods. It will reduce, although not necessarily eliminate, pain and pain behavior in most patients.

Misdiagnosis of acute appendicitis: Common features discovered in cases after litigation

To identify differences between correctly diagnosed appendicitis and misdiagnosed cases that resulted in litigation between 1982 and 1989 retrospective review of malpractice claims was conducted. A total of emergency department (ED) charts at the time of the initial ED visit were reviewed and compared with 66 concurrent controls. Missed cases appeared less acutely ill, had fewer complaints of right lower quadrant pain, received fewer rectal examinations, received intramuscular (IM) narcotic pain medication for undiagnosed abdominal pain or symptoms, and more often received an ED discharge diagnosis of gastroenteritis. Misdiagnosed patients had a 91% incidence of ruptured appendix, more extensive surgical procedures, and more postoperative complications. Data were analyzed using the Pearson's χ 2 Test, Mann-Whitney U test, and stepwise discriminant analysis. Significance was defined as P ≤ .05. Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions.

Harvesting bone marrow in an outpatient setting using newer anesthetic agents.

To evaluate the results of outpatient bone marrow harvest (BMH). Seventy-two adult patients with various malignancies had 79 BMH procedures performed for future autologous bone marrow transplantation (BMT) in our institution's outpatient surgical facility. All patients were evaluated and educated before the procedure. Newer anesthetic agents specifically developed to have shorter half-lives, more rapid recovery from general anesthesia, and fewer unpleasant side effects were chosen. Propofol was used for induction of anesthesia in 76 patients, the other three were induced with sodium pentothal. The blood volume removed was replaced by colloid (6% hydroxyethyl starch). Also, a new parenteral nonnarcotic pain medication, ketoroloc, was used during the last part of general anesthesia to help with expected postoperative pain in 76 patients. BMH took 111 +/- 24 minutes and patients were in postanesthesia care unit (PACU) for 220 +/- 72 minutes before being sent home with a companion and Tylenol with codeine (acetaminophen with codeine; McNeil Pharmaceutical, Spring House, PA). PACU complications were minor and included transient mild dizziness (7.6%), vomiting (3.8%), and fever (2.6%). No life-threatening complication was observed. Only one patient was hospitalized for observation (fever) and then sent home. Seventy-five patients (94.9%) were contacted at home by the hospital nursing staff the day following the procedure. Five (6.7%) complained of nausea or vomiting, and four (5.3%) developed fever at home (temperature, 37.2 to 38.3 degrees C). Only 36% of patients actually took oral narcotic pain medication at home. Autologous BMH (AuBMH) is a safe outpatient procedure with minimal side effects when newer anesthetic agents are used.

Attentional fatigue following breast cancer surgery.

Attentional fatigue usually follows intense use of mental effort and is manifested as a decreased capacity to concentrate, that is, to direct attention. The purpose of this study was to examine the capacity to direct attention in persons with cancer during the initial phase of illness. The sample consisted of 32 women without cognitive or affective disorders who underwent surgery for localized (Stage I or II) breast cancer. Subjects manifested attentional deficits of varying intensity on a battery of tests of directed attention on the day before discharge from the hospital, which was a mean of 3 days following mastectomy or breast conservation surgery. Unexpectedly, the two surgical groups did not differ significantly in attentional capacity and functioning. Attentional test scores were not significantly correlated with narcotic pain medication interval, mood state, or self-ratings of attentional functioning. However, as number of days postsurgery increased, attentional performance decreased. The theoretical basis for further examination of attentional fatigue in people with cancer or other life-threatening illnesses is discussed.

Use of Hypnosis before and during Angioplasty

In this study, 16 patients matched with 16 controls were hypnotized prior to angioplasty. The hypnotized patients had a 25% increase in the time the cardiologist was able to keep the balloon inflated compared to the controls. Of the hypnotized patients, 13% required additional narcotic pain medication during the procedure as compared to 44% for the controls. Although we found no differences in rhythm, ischemia, blood pressure, or pulse between the two groups, the results of arterial catecholamine levels drawn at the start and at the end of the procedure were unexpected and seemed paradoxical. Norepinephrine levels were significantly higher in the hypnotized group (432 pg/ml, SE 51) than in the control group (281 pg/ml, SE 23) at the start of the procedure and fell more during the procedure than in control patients. Because catecholamines reportedly act as a barometer of neuroanxiety, further studies defining their role are needed.

Equity in medical care: are the deserving poor eligible?

EQUITY IN MEDICAL CARE: ARE THE DESERVING POOR EUGIBLE? JANE M. ORIENT* Doolittle: What am I, Governors both? . . . I'm one ofthe undeserving poor: that's what I am. . . . But my needs is as great as the most deserving widow's that evergot money out ofsixdifferentcharities in one weekfor the death ofthe same husband. I don't need less than a deserving man: I need more. I don't eat less hearty than him; and I drink a lot more. . . . I'm playing straight with you. I ain't pretending to be deserving. I'm undeserving; and I mean to go on being undeserving. ... [1] Unless infinite resources become available, any system ofmedical care, including or especially universal national health insurance, will be required to base some decisions on economics. Who should pay die taxes and who should receive benefits first when the budget is tight promise to remain topics of Uvely controversy. That the rich should pay more, and the poor receive more, has become axiomatic. The implication in the tide that some of the poor might be undeserving is certain to offend Uberai humanists, who assume that all poverty results from unequal opportunities , strokes of misfortune, and other external circumstances. However, Uberai humanists are underrepresented in pubUc emergency rooms, where the staff does not respond to all patients widi equal sympatiiy. From the descriptions of patients diat follow, die reader may guess die reaction of the doctor on duty: A hobojust offdie freight train, dirty and sweating but sober, politely requests treatment that might ease the pain ofa second-degree burn acquired many miles back. A thirty-year-old veteran does not remember how he might have been exposed to Agent Orange, but he has been unable to hold a steady job, feels nervous all die time, and is going bald. He wants a complete checkup and compensation for the effects of toxic herbicides. ?Adjunct assistant professor, Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona. Address: 1601 North Tucson Boulevard, Suite 9, Tucson, Arizona 85716.© 1983 by The University of Chicago. All rights reserved. 0031-5982/83/2603-0347$01.00 Perspectives in Biology andMediane, 26, 3 · Spring 1983 | 411 A World War I veteran can no longer afford treatment for his deforming arthritis. Unfortunately, he was too busy working to apply for a serviceconnected disability, and his old records were destroyed in a fire. A patient with chronic lung disease, packs of cigarettes stuffed in his socks, demands immediate service. The last time he was hospitalized he melted his oxygen mask, unable to refrain from smoking even when near respiratory failure. A disorderly youth is brought in restraints after attempting to assault two police officers who caught him sniffing glue in a field. A disgruntled veteran who has been inadequately compensated for his diagnosis of antisocial personality held an administrator and a nurse practitioner hostage widi a .45. Several months later he requests admission to the open psychiatric ward because he is temporarily short of money to pay his rent. A patient has the sniffles and a mild sore throat. He needs an excuse for his employer so that he can get paid for taking several days off work. A young diabetic who refuses to take her insulin is in ketoacidosis for the third time in a month. She breaks her intravenous bottle on the bathroom sink and threatens the staff with the fragments. The Fire Department paramedics respond to an emergency call at 3 a.m. from a distraught modier whose infant has diaper rash. They advise her to change die baby's diaper several times a day but, since uiis is not New York City, refuse to transport her to the hospital. A dramatic scene occurs in the receiving area as a screaming young woman arrives by ambulance. Separated from her family, and placed in an examining room, she is unable to diink up a medical complaint. Late in the evening, a patient comes to request a refill on his (narcotic) pain medications, saying diat his niece emptied the bottle into the toilet. Fortunately his bronchodilators were rescued just in time. His record shows diat he always visits late at night, and similar...