Relief of persistent postamputation stump and phantom limb pain with intrathecal fentanyl.

Two patients with postamputation stump and phantom limb pain respectively responded favorably to intrathecal fentanyl which temporarily abolished the pain, normalized sensations and produced euphoria without supraspinal effects. One of the patients subsequently received intrathecal, extradural and intravenous fentanyl as well as intrathecal lidocaine. The neuraxial (intrathecal and epidural) fentanyl temporarily abolished the pain. Intravenous fentanyl and intrathecal lidocine were unable to reproduce this effect. Neuraxial fentanyl apparently produced its effects by a segmental spinal action. Spinal modulation of postamputation pain was important in these patients.

Physicians' attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain.

Prescribing long-term opioids for patients with chronic pain is controversial. The primary purpose of this study was to examine physicians' beliefs about and prescribing of the long-term use of opioids in the treatment of chronic pain patients. Concerns about regulatory pressure and appropriateness of education regarding opioids were also examined. The design was a stratified random sample. In the United States, 6962 physicians were randomly selected from two states in each of five regions of the country (Northeast, Midwest, Southeast, Southwest, and Pacific). Physicians from seven medical specialties (Family Practice, Internal Medicine, Physical Medicine and Rehabilitation, Rheumatology, Orthopedic Surgery, Neurosurgery, and Neurology) were surveyed and 1912 (27.46%) responded. A survey consisting of questions regarding years of practice, number of chronic pain patients treated, frequency of prescribing long-term opioids, concerns about opioids, goals of treatment, beliefs about education regarding opioids, and concerns about regulatory pressures was used. Based on the physicians who responded, it appears that prescription of long-term opioids is relatively wide-spread. Differences were noted by region, specialty, and the requirement for the use of multiple prescriptions for schedule II drugs. Physicians in the Midwestern United States were the least likely to prescribe the long-term use of opioids. Rheumatologists and general practitioners were significantly more likely to prescribe long-term opioids than were surgeons, neurologists, or physiatrists and were more likely to emphasize the importance of symptom improvement as an appropriate goal even in the absence of functional improvements.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of the effects of intrathecal fentanyl and lidocaine on established postamputation stump pain.

Eight patients with established lower limb postamputation stump pain were given lumbar intrathecal fentanyl 25 micrograms and lidocaine 70 mg 2 weeks apart in an attempt to better understand the role of peripheral and central mechanisms in this condition. Baseline pain was recorded and then analgetic and side effects and their duration were assessed. Three self-administered questionnaires with appropriate psychometric proprieties were given to the patients. Intrathecal fentanyl always abolished the pain. Its onset was rapid being heralded within 1-2.5 min by a pleasant sensation of warmth involving the lower trunk and legs. Analgesia was complete by 5-10 min and had a median duration of 8 h. The patients had a sense of well being and were unable to elicit discomfort by pain aggravating maneuvers. Normal motor and sensory functions were retained. Pruritus was the only adverse effect unique to intrathecal fentanyl. Intrathecal lidocaine usually relieved the discomfort but was unable to abolish it in 3 of 8 patients despite adequate neural blockade. Its onset of action was slower and duration of effect shorter than fentanyl. Intrathecal fentanyl provided profound analgesia associated with normalization of stump sensations and euphoria, probably due to a segmental spinal action. The effects of lidocaine were inferior to fentanyl due to the associated motor and sensory paralyses as well as the absence of euphoria. This study suggests that, while peripheral mechanisms played a role, central mechanisms involving the spinal cord were more important in the modulation of established stump pain in the 8 subjects evaluated.

Intrathecal methadone: a dose-response study and comparison with intrathecal morphine 0.5 mg.

The analgesic and adverse effects of intrathecal methadone 5 mg, 10 mg and 20 mg were assessed and compared with intrathecal morphine 0.5 mg. The study was conducted on 38 patients who underwent total knee or hip replacement surgery. The intrathecal opioid was administered at the end of surgery and assessments began 1 h thereafter and continued for 24 h. Pain measurements, supplementary analgesia requirements, and adverse effects were recorded. Intrathecal morphine 0.5 mg provided effective and prolonged analgesia. Intrathecal methadone 5 mg, 10 mg, and 20 mg produced good analgesia of 4 h duration. Thereafter the median pain scores with intrathecal methadone were consistently higher (worse) than those with intrathecal morphine (P less than 0.05). The time to the onset of discomfort severe enough to require supplemental morphine was longer after intrathecal morphine than following methadone (15 h with morphine 0.5 mg; 6.25 h, 6.5 h and 6 h with methadone 5 mg, 10 mg, and 20 mg respectively: P less than 0.05). Central nervous system depression manifesting as respiratory depression, hypotension, and excessive drowsiness occurred in 3 of 8 patients injected with methadone 20 mg intrathecally. Generalized pruritus, nausea, vomiting, and urinary retention were common and equally distributed among the treatment groups. We conclude that both intrathecal morphine 0.5 mg and methadone 5, 10, and 20 mg provide excellent analgesia but that morphine has a more prolonged effect. Methadone 20 mg produced unacceptable side effects. Clinical evidence for rostral spread of methadone within the CSF, as indicated by facial itching and excessive drowsiness, was less apparent with 5 mg than with 10 and 20 mg. Various explanations for the observed differences between the drugs are discussed.

Quantification of biomedical findings of chronic pain patients: development of an index of pathology.

Difficulties in assessing and quantifying the biomedical signs and symptoms that may be related to patients' reports of pain are well recognized. Although there appears to be some consensus among physicians as to the potential utility of examination and diagnostic tests frequently used to evaluate chronic pain patients, little attention has been paid to the reliability of interpreting the results of these procedures. Moreover, the integration of biomedical findings to form a general index of pathology associated with chronic pain has been a difficult problem to solve because not all biomedical procedures used to evaluate pain patients are necessarily relevant or indicated for a specific patient. Two studies are presented that were designed to evaluate the reliability of 23 biomedical procedures commonly used to evaluate chronic pain patients and to determine if findings on these procedures can effectively be combined to form a reliable index of physical pathology. The results of study 1 suggest that 17 of the 23 procedures can be applied in clinical setting with acceptable levels of reliability. Study 2 provides evidence that an innovative weighted scoring approach, based on current medical consensus, can be used to produce a reliable, general index of pathology that is independent of the number of procedures used to evaluate patients. The utility of this quantification approach to biomedical findings for clinical and research purposes is discussed.