Pain and the ethics of pain management.

KIE: After clarifying the concepts of "pain", "suffering", "pain of body", and "pain of soul", the author presents a humanistic ethic of pain management based on the premise that the patient has a strong "prima facie" right to freedom from unnecessary pain. This premise imposes two moral obligations upon medical professionals: (1) the duty not to inflict unnecessary pain and suffering upon the patient, and (2) the duty to do whatever is possible to alleviate pain and suffering. Both the questions of informed consent to treatment of pain and the right to refuse pain relief are addressed.

Spinal cord stimulation in failed back surgery syndrome.

We have reviewed our experience with spinal cord stimulation in treating patients with the failed back surgery syndrome and have assessed patient and patient-selection characteristics as predictors of the long-term outcome. Neuroradiological investigations eliminated the possibility of a surgically treatable lesion and electromyogram assessed the chronic radicular suffering in correlation with the complaints and the clinical examination of the patient. Excellent pain relief (75% or more) during 1 week of trial stimulation and no major psychiatric or psychological pathology were criteria of selection. Seventy-eight patients underwent trial stimulation. Fourteen (18%) failed to obtain excellent pain relief during 1 week of stimulation and their electrodes were removed. The remaining 64 underwent an internalization of the system and they were followed by a clinical observation every 3 months and this for a mean follow-up period of 4 years (range: 1-7 years). Thirty-five patients (55%) continued to experience at least 50% of pain relief at the latest follow-up. Fifty-eight patients (90%) were able to reduce their medication, 39 patients (61%) reported a change in lifestyle, in that their ability to perform daily activities had improved significantly. Fifty-three patients (83%) continued to use their device at the latest follow-up.

Postoperative titration of intravenous morphine in the elderly patient.

BACKGROUND: Intravenous morphine titration is used to obtain rapid and complete postoperative pain relief. Whether this titration can be safely administered in the elderly patients remains a matter for debate. METHODS: Intravenous morphine titration was administered as a bolus of 2 (body weight < or = 60 kg) or 3 (body weight > 60 kg) mg. The interval between each bolus was 5 min. There was no limitation in the number of boluses given until pain relief or severe adverse effect occurred. The visual analog scale threshold required to administer morphine was 30 mm, and pain relief was defined as a visual analog scale score of 30 mm or less. Patients were divided into two groups: young and elderly (age > or = 70 yr) patients. Data were expressed as mean +/- SD. RESULTS: Eight hundred seventy-five patients (83%) were young and 175 patients (17%) were elderly. At the end of morphine titration, the visual analog scale score and the number of patients with pain relief were not significantly different between groups. The total dose of morphine per kilograms of body weight administered was not significantly different between groups (0.15 +/- 0.10 vs. 0.14 +/- 0.09 mg/kg, not significant). No significant differences were observed in the incidence of morphine-related adverse effects (13 vs. 14%, not significant), the number of sedated patients (60 vs. 60%, not significant), and the number of patients whose titration had to be stopped (2 vs. 2%, not significant). CONCLUSION: Intravenous morphine titration can be safely administered to elderly patients. Because titration is adapted to individual pain, the same protocol can be applied to young and elderly patients.

Value of bone scan imaging in predicting pain relief from percutaneous vertebroplasty in osteoporotic vertebral fractures.

BACKGROUND AND PURPOSE: Patient selection for percutaneous vertebroplasty is often complicated by the presence of multiple fractures or non-localizing pain. Our purpose was to determine whether increased activity revealed by bone scan imaging is predictive of a positive clinical response to percutaneous vertebroplasty. METHODS: A retrospective chart review conducted at our institution yielded 28 vertebroplasty treatment sessions that had been performed after obtaining bone scan imaging for painful, osteoporotic compression fractures in 27 patients. Thirty-five compression fractures were treated during these 28 treatment sessions. In all cases, increased activity was revealed by bone scan imaging before treatment with vertebroplasty. Positive outcome was defined as subjective decrease in pain severity and/or increased level of patient mobility. RESULTS: Subjective pain relief was noted in 26 (93%) of 28 treatment sessions. In 14 (100%) of 14 cases with quantifiable pain levels, pain improved at least 3 points on a 10-point scale (range of improvement, 3-10 points; mean improvement, 7.4 points). Among the remaining 14 treatment sessions in which patients were unable or unwilling to quantify pain severity, the pain relief was described as complete or excellent pain relief in 11 (78%) of 14 cases. In 14 (100%) of 14 cases for which semiquantitative assessment of mobility was available, mobility improved at least one level (5-point graded scale; range of improvement, 1-4 points; mean improvement, 1.7 points). CONCLUSIONS: Increased activity revealed by bone scan imaging is highly predictive of positive clinical response to percutaneous vertebroplasty.

Postoperative pain relief by continuous epidural infusion: a comparison of three solutions

The effect of three solutions on postoperative pain relief by continuous epidural infusion was studied. Seventy-five patients after upper or lower abdominal surgeries were assigned to one of three groups and the postoperative pain relief was evaluated for 48 hours. Group I: bolus injection of buprenorphine (Bn) 0.1 mg + saline (S) 8 ml and continuous infusion (2 ml.h-1) of Bn 0.8 mg + S 92 ml; Group II: bolus injection of Bn 0.1 mg + 0.5% bupivacaine (Bc) 4 ml + S 4 ml and continuous infusion of Bn 0.8 mg + S 92 ml; Group III: bolus injection of Bn 0.1 mg + 0.5% Bc 4 ml + S 4 ml and continuous infusion of Bn 0.8 mg + 0.5% Bc 40 ml + S 60 ml. The combination of buprenorphine with low-dose bupivacaine (Group III) offered the most effective postoperative analgesia in three groups without increasing the frequency of adverse effects induced by epidural administration of local anesthetics. However, even in Group III, the percentage of patients complaining of pain at bed rest was still high during early postoperative period (56% at 6 hours postoperatively). The results suggest that further consideration is necessary on agents selection and dosage adjustment for the postoperative epidural analgesia.

Family reports of cancer pain, pain relief, and prescription access.

PURPOSE: The authors 1) describe family caregiver reports of degree of pain, pain relief, and prescription access in persons with advanced cancer during the last 4 weeks of life and 2) test for differences according to geographic location and care setting. DESCRIPTION OF STUDY: A randomized, stratified sample of 375 caregivers was produced from a list of all state residents who died of cancer in 1994. Written informed consent was received from 170 family caregivers (46%) who were then interviewed by telephone. Caregiver responses regarding pain intensity, pain relief, prescription access, and care setting were analyzed. RESULTS: Eighty-six percent (n = 147) of caregivers reported that pain was a problem, and 61% (n = 103) recalled a great deal to quite a bit of pain compared with 25% (n = 44) who recalled some or little pain. The mean degree of pain was 2.23 (SD +/- 1.32) on a scale of 1 (a great deal) to 5 (no pain). Of 140 caregivers reporting pain relief data, 46% (n = 64) reported that interventions either stopped the pain or that pain became much better, whereas 54% (n = 76) reported that interventions made the pain a little better, had no effect, or made it worse. The overall mean of pain relief was 2.62 (SD +/-.87) on a scale of 1 (usually stopped the pain) to 5 (made it worse). Greater degrees of pain were associated with reports of less pain relief (r = -19; P =.02). No differences in pain or pain relief were found across county type or patient care setting. Caregivers in the institution-only group (n = 18) recalled lower degrees of pain and the home-only group (n = 61) reported the most pain relief. Many in this latter group were served by hospice and home health nurses, and only 4% of the entire sample were served by physicians alone. Notably, 12% (n = 21) of the sample reported problems filling prescriptions. Of these, half had difficulty obtaining medicine because it was "not available." A total of 48 problems with prescription access were found that were distributed evenly across county types and patient care settings. CLINICAL IMPLICATIONS: Findings suggest that caregiver reports about the degree of pain or the effectiveness of pain interventions do not vary by residence or care setting at the end of life. pain relief is moderate at best. Health professionals in all patient care settings should routinely address the issue of obtaining and paying for prescriptions, and local cancer pain task forces should be formed to advocate for better pain relief. An additional solution is to equip families with problem-solving skills specific to cancer pain.

Neurolytic block of the celiac plexus and splanchnic nerves with computed tomography. The experience in 150 cases and an optimization of the technic

INTRODUCTION: CT-guided celiac plexus and splanchnic nerve neurolytic blocks are procedures for pain relief in patients with upper abdominal malignancies. In the last 20 years, the technique has been modified by the introduction of CT guidance providing improved precision and safety. We report our personal experience and provide suggestions for technique optimization. MATERIALS AND METHODS: In 1991-1998 we performed 150 celiac plexus and/or splanchnic nerve neurolytic blocks with ethyl alcohol in 144 cancer patients; the procedure was repeated in 6 patients. In 69% of cases the patient had a pancreatic lesion. We prefer an anterior approach with very thin needles (22 Gauge). The sites of alcohol injection (celiac plexus, splanchnic nerves or both) are chosen after evaluation of anatomy by preliminary CT scans, or during the procedure, depending on alcohol (mixed with a contrast agent) spread. RESULTS: The mean duration of the procedure ranged 50 min (1991) to 22 min (1998). 48 hours after the block we obtained major pain relief in 79% of cases. After 15 days, 21% of patients had no pain (drugs: none), 29% had mild pain (therapy: non-steroid anti-inflammatory drugs), 32% had marked pain (therapy: non-steroid anti-inflammatory drugs and, occasionally, opioids), 18% had severe pain (only opioid therapy). pain relief was more frequent in splanchnic nerve blocks. DISCUSSION: Our experience confirms that neurolytic celiac plexus and/or splanchnic nerve block is a good choice in the treatment of upper abdominal cancer pain. We would also like to add that: 1) celiac plexus block with CT guidance (with the needle tip positioned anterior to aorta) and splanchnic nerve block (with the needle tip positioned posterior to diaphragmatic crura) are no longer two separated techniques, but they can be chosen and combined according to patients needs. 2) All procedures can be performed with anterior approach, in supine position, with a single thin needle, allowing to reach the target without any complication, even after puncturing stomach, liver, bowel, pancreas or aorta. 3) With CT guidance, even splanchnic nerve neurolysis is a low-risk technique, which should be adopted in all cases of insufficient alcohol spread in the celiac plexus. 4) When the operators are skilled and experienced enough, the time required for the block can be significantly decreased to nearly the time required for US-guided or fluoroscopic-guided procedures.

Thoracoscopic Splanchnicectomy for Chronic, Severe Pancreatic Pain.

Fourteen patients with pancreatic cancer, 2 with cancer of the papilla of Vater, and 14 with chronic pancreatitis were operated on with bilateral thoracoscopic splanchnicectomy caused by severe chronic pain. The median follow-up time was 13 months. Twenty patients were followed up for 3 months and 14 for at least 6 months. The surgical results were evaluated prospectively, both with visual analogue scale (VAS) and with documentation of the consumption of analgesics at elective follow-up after 1 week and 1, 3, 6, and 12 months postoperatively. All 30 patients stated that the characteristics of their pain had changed at recovery from anaesthesia, but only 6 of them reported immediate complete pain relief. All but 1 of the 14 patients with chronic pancreatitis had clearly reduced pain as evaluated by VAS 1 month after the operation, and this beneficial effect remained for the whole study period. Furthermore, the need for analgesics decreased. Also, in the 16 patients with cancer, there was on average a marked relief of pain from 1 week and onwards. The 6 cancer patients with survival more than 3 months had reduced pain for the remaining period of their lives. It seems that the final pain relief is persistent as is the reduced consumption of analgesics. There was no correlation between the number of cut nerves and pain relief as evaluated by VAS. Three patients were reoperated on for intrathoracic bleeding the evening after the operation, and one had transient pain located to one of the port sites. Otherwise, there were no postoperative complications. The operation time was short and the length of hospital stay in most patients was 24 hours or less. It was concluded that thoracoscopic splanchnicectomy appears to be a promising and relatively simple treatment for severe chronic pancreatic pain. Further studies are needed to establish its role in the management of intractable pancreatic pain.

NSAID use and efficacy in the emergency department: single doses of oral Ibuprofen ( Motrin ) versus intramuscular ketorolac.

OBJECTIVE: To compare the clinical efficacy of single doses of intramuscular ketorolac and oral Ibuprofen ( Motrin ) in the emergency department (ED) treatment of acute pain. DESIGN: A retrospective analysis of data collected during a prospective survey of pain management efficacy. The design was noninterventional, and therapy was selected by the treating physician independent of the trial. SETTING: Urban teaching hospital adult patient emergency department. PARTICIPANTS: A convenience sample of ED patients in acute pain. INTERVENTIONS: Patients received Ibuprofen ( Motrin ) 800 mg po (n = 95), or ketorolac 60 mg im (n = 30) as a single dose. Therapy was selected by the treating physician and was not influenced by the study. RESULTS: Data collected were a 100-mm visual analog pain scale at patient arrival and discharge, verbal description of pain relief, patient demographics, pain management data, and discharge diagnosis. Baseline pain intensity was higher in patients receiving ketorolac (77 mm median) than in those receiving Ibuprofen ( Motrin ) (65 mm, p = 0.02). pain relief was similar (p = 0.29) with either treatment when assessed by visual analog scale or patient definition of pain relief. CONCLUSIONS: A single dose of either nonsteroidal antiinflammatory drug produced similar pain relief in the general ED population during clinical treatment of pain. Ketorolac should not necessarily be considered a more effective analgesic than Ibuprofen ( Motrin ) in these commonly used doses.

Treatment of deafferentation pain by chronic stimulation of the motor cortex: report of a series of 20 cases.

Twenty patients with deafferentation pain were treated by chronic stimulation of the motor cortex. The central fissure was localized using stereotactic MRI and the motor cortex was mapped using intra-operative somatosensory evoked potentials. Seven patients with trigeminal neuropathic pain experienced definite pain relief varying between 40 and 100%. Ten patients had central pain secondary to central nervous system lesions. A satisfactory long-lasting pain control (pain relief > 40%) was obtained in five of them (50% of cases). One patient with pain from peripheral nerve injury obtained more than 80% pain relief. Two patients had pain from spinal cord lesions. One did not respond but the other obtained an excellent long-term result. The location of the effective stimulation plots was in agreement with the somatotopic maps of the primary motor cortex. One patient developed a small extradural haematoma which resolved spontaneously. None of the patients developed seizure activity. This study confirms the potential value of motor cortex stimulation in the treatment of certain forms of intractable pain, especially in cases with trigeminal neuropathic pain.