Improving Acute Pain Mgmt: Optimizing Patient Selection

Turk DC, Okifuji AP Bonica's Management of Pain. 3rd ed. Loeser JD, ed. New York: Lippincott, Williams & Wilkins; 2001:17.
Bonica JJ. Pain Management in Emergency Medicine. Paris PM, Stewart RD, eds. Norwalk, Conn: Appleton & Lange; 1998:xi.
Kehlet H. Acute pain control and accelerated post-operative surgical recovery. Surg Clin North Am. 1999;79:431-443. Abstract
Fortner BV, Okon TA, Portenoy RK. A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. J Pain. 2002;3:38-44. Abstract
Nicholson BD. J Am Acad Nurse Pract. 2003;15(suppl12):3-9.
Portenoy RK, Payne D, Jacobsen P. Pain. 1999;81:129-134. Abstract
MacIntyre PE, L Ready LB. Acute Pain Management a Practical Guide. Philadelphia, Pa: WB Saunders Co; 1996.
US Department of Health and Human Services. Acute Pain Management: Operative or Medical Procedures and Trauma, U.S. Department of Health and Human Services, Public Health Service Agency for Health Care Policy and Research. Washington, DC: US Department of Health and Human Services; 1992.
Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology. 1995;82:1071-1081. Abstract
Rosenquist RW, Rosenberg J. Postoperative pain guidelines. Reg Anesth Pain Med. 2003;28:279-288. Abstract
Backonja MM. Painful Neuropathies in Bonica's Management of Pain. 3rd ed. Loeser JD, ed. New York: Lippincott, Williams & Wilkins; 2001:371-387.
Dirks J, Fredensborg BB, Christensen D, Fomsgaard JS, Flyger H, Dahl JB. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mastectomy. Anesthesiology. 2002;97:560-564. Abstract
Turan A, Karamanlioglu B, Memis D, et al. Analgesic effects of gabapentin after spinal surgery. Anesthesiology. 2001;100:935-938.
Peterson KL, Maloney A, Hoke F, et al. A randomized study of the effect of oral lamotrigine and hydromorphone on pain and hyperalgesia following heat/capsaicin sensitization. J Pain. 2003;4:400-406. Abstract
Friedman R, Jallo J, Young F. Oral ketamine for opioid-resistant acute pain. J Pain. 2001;2:75-76. Abstract
Karmakar MK, Chui PT, Joynt GM, Ho AMH. Thoracic paravertebral block for management of pain associated with concomitant lumbar spinal trauma. Reg Anesth Pain Med. 2001;26:169-173. Abstract
Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. 2000;92:433-441. Abstract
Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home: controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. Anesthesiology. 2002;96:1290-1296. Abstract
Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized double-blinded, placebo-controlled study. Anesthesiology. 2002;96:1297-1304. Abstract
Fine PG. Advances in cancer pain management. In: Lake CL, Rice LJ, Sperry RJ, eds. Advances in Anesthesia. St. Louis, Mo: Mosby-Year Book, Inc; 1995:145.
Coluzzi PH, Schwartzberg L, Conroy JD, et al. Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR). Pain. 2001;91:123-130. Abstract
Farrar JT, Cleary J, Rauck R, et al. Oral transmucosal fentanyl citrate: randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in cancer patients. J Natl Cancer Inst. 1998;90:611-616. Abstract
Kotwal RS, O'Connor KC, Johnson TR, et al. Novel pain management strategy for combat casualty care. Ann Emerg Med. 2004;44:121-127. Abstract
Singer RS. Oral trans mucosal fentanyl citrate in the outpatient treatment of severe pain from migraine headache. Pain Clin. 2004;6:10-13.
Burns T, Shoemaker S, Bhependra JD, et al. Comparison of oral transmucosal fentanyl citrate and intravenous fentanyl citrate for perioperative sedation/analgesia for cataract surgery. Am J Anesthesiol. 2001;28:35-39.
Aronoff G. Oral transmucosal fentanyl citrate (OTFC): clinical evidence on dosing. Pain Med. 2004;5:111-112.
Ferrante FM, Ostheimer GW, Covino BG. Patient-Controlled Analgesia. Oxford, United Kingdom: Blackwell Scientific Publications; 1990:3-9.
Egan TD, Sharma A, Ashburn MA, Kievit J, Pace NL, Streisand JB. Multiple dose pharmacokinetics of oral transmucosal fentanyl citrate in healthy volunteers. Anesthesiology. 2000;92:665-673. Abstract
Streisand JB, Varvel JR, Stanski DR, et al. Absorption and bioavailability of oral transmucosal fentanyl citrate. Anesthesiology. 1991;75:223-229. Abstract
Viscusi ER, Reynolds L, Chung F, Atkinson LE, Khanna S. Patient-controlled transdermal fentanyl hydrochloride vs intravenous morphine pump for postoperative pain: a randomized controlled trial. JAMA. 2004;291:1333-1341. Abstract
Robert R, Brack A, Blakeney P, et al. A double-blind study of the analgesic efficacy of oral transmucosal fentanyl citrate and oral morphine in pediatric patients undergoing burn dressing change and tubbing. J Burn Care Rehabil. 2003;24: 351-355. Abstract
Klein EJ, Diekema DS, Paris CA, Quan L, Cohen M, Seidel KD. A randomized, clinical trial of oral midazolam plus placebo versus oral midazolam plus oral transmucosal fentanyl for sedation during laceration repair. Pediatrics. 2002;109:894-897. Abstract
Sharar SR, Carrougher GJ, Selzer K, O'Donnell F, Vavilala MS, Lee LA. A comparison of oral transmucosal fentanyl citrate and oral oxycodone for pediatric outpatient wound care. J Burn Care Rehabil. 2002;23:27-31. Abstract
Singer RS. Actiq (oral fentanyl citrate) in the outpatient treatment of acute ER-bound migraine patients. Headache. 2002;42:400.
Kuhlman JJ Jr, McCaulley R, Valouch TJ, Behonick GS. Fentanyl use, misuse, and abuse: a summary of 23 postmortem cases. J Anal Toxicol. 2003;27:499-504. Abstract

processing....

Neuropathic and Nociceptive Pain

If we start with the concept of pain as a disease, then treatment begins with a pain diagnosis. Pain pathophysiology comprises 2 categories: nociceptive and neuropathic pain. Nociceptive pain is further divided into visceral and somatic pain, and neuropathic pain is divided into peripheral and central neuropathic pain.

Nociceptive, or somatic, pain is the common discomfort we have all experienced as a result of injury -- a paper cut, a broken bone, or appendicitis, among other things. Somatic pain makes sense to us; we can understand the patient's pain.

Neuropathic pain is associated with injury to a nerve or the central nervous system. Such injuries can give rise to paresthesias, such as numbness, tingling, or electrical sensations. Neuropathic pain can also generate unusual symptoms, such as anesthesia dolorosa, in which the area producing the pain is numb to the touch. This symptom is often puzzling to patients, and some have questioned their own sanity because painful numbness makes no sense. They can pinch the area and not feel the pinch, yet the area is excruciatingly painful. In addition, with nerve, spinal cord, or brain injuries, syndromes (such as allodynia) can develop and ordinarily non-noxious stimuli (such as light pressure or stroking) cause pain.

An in-depth discussion of nociceptive and neuropathic pain is beyond the scope of this column, but the key concepts are straightforward: Nociceptive pain is typically responsive to anti-inflammatory agents and opiates, whereas, for unclear reasons, neuropathic pain is often poorly responsive to these agents. Recent studies suggest that in neuropathic pain, anatomic and physiological changes occur within the spinal cord and perhaps the brain. These consequences of central nervous system plasticity mean that some of the processes that generate neuropathic pain may, over a relatively short period of time, become hardwired into the nervous system.^[11]

Postoperative and posttraumatic pain are primarily nociceptive and not neuropathic in nature. A simple fracture produces somatic nociceptive pain and should respond to an anti-inflammatory or opiate. A stone in the ureter produces visceral somatic pain and often responds well to an anti-inflammatory or opiate. Despite the fact that most acute pain is nociceptive, there are relatively common acute situations in which nociceptive and neuropathic pain occur together. An example is the patient with an acute herniated disc who experiences somatic nociceptive pain from the disruption of the disc and neuropathic pain from compression and inflammation of the nerve root. Thus, in this case, treatment should be directed at both the somatic and neuropathic pain components.