[Opioids for chronic noncancer pain: recommendations based on clinical practice guidelines]. / Uso de opioides en el tratamiento del dolor crónico no oncológico. Recomendaciones basadas en las guías de práctica clínica.

OBJECTIVE: The need for major opioids in the treatment of chronic pain unrelated to cancer is increasing. We therefore appraised available clinical practice guidelines in order to identify recommendations for good practice in the use of these drugs. MATERIAL AND METHODS: By searching the main guideline repositories as well as resources provided by medical associations, we identified clinical practice guidelines on the use of major opioids published up to 2007. Fourteen of the 28 guidelines we found met the inclusion criteria. To appraise the guidelines we applied the criteria for scientific evidence of the AGREE collaboration (Appraisal of Guidelines Research and Evaluation). The AGREE instrument consists of 23 items organized in 6 areas for appraisal. RESULTS: Of the 14 guidelines appraised, 5 were judged to be of high quality. In each of the 5 selected guidelines, the relation between a recommendation and the evidence it was based on was stated explicitly; all 5 had overall quality scores over 60%. The recommendations drawn from these guidelines deal with 3 sequential moments in the use of opioids: start of treatment, maintenance therapy, and withdrawal of the drug. CONCLUSION: The use of opioids to treat chronic noncancer pain is controversial in terms of effectiveness, safety, and the possibility of addiction or abuse. The opioid should be indicated for the pain and prescribed with caution; each case should be assessed individually. Following the recommendations drawn from these guidelines will be important for achieving control of both pain and the accompanying symptoms. The use of major opioids to relieve chronic pain unrelated to cancer, and therefore to improve the quality of life of patients who experience this type of pain, is a legitimate treatment approach.

Calcitonin for metastatic bone pain.

BACKGROUND: Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone, calcitonin, has the potential to relieve pain, and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in The Cochrane Library (Issue 3, 2003) on this topic. OBJECTIVES: To assess the effectiveness of calcitonin in controlling metastatic bone pain and reducing bone complications (hypercalcemia, fractures and nerve compression) in patients with bone metastases. SEARCH STRATEGY: Electronic searches were performed in MEDLINE (1966 to 2005), EMBASE (1974 to 2005), the Cochrane Central Register of Controlled Trials (Issue 2, 2005), specialised registers of the Cochrane Cancer Network and of the Cochrane Pain, Palliative and Supportive Care Group. Registers of clinical trials in progress were also searched. SELECTION CRITERIA: Studies were included if they were randomised, double-blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. DATA COLLECTION AND ANALYSIS: Study selection and data extraction were performed by two independent review authors. Only two studies (90 patients) were eligible for inclusion in the review and therefore meta-analysis of the data was not possible. Intention-to-treat analysis was performed by imputing all missing values as adverse outcomes. MAIN RESULTS: Of the two small studies included in the review, one study showed a non-significant effect of calcitonin in the number of patients with total pain reduction (RR 2.50; CI 95%, 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; CI 95%, 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases; for improving quality of life; or patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.35, CI 95%, 0.72 to 15.66). AUTHORS' CONCLUSIONS: The limited evidence currently available does not support the use of calcitonin to control pain from bone metastases. Since the last version of this review, none of the new relevant studies have provided additional information on this treatment, in contrast to other therapeutic approaches that should be considered.

[Pain in the hospital: from prevalence to quality standards]. / El dolor en el hospital: de los estándares de prevalencia a los de calidad.

OBJECTIVES: Pain diminishes the quality of life of patients and a high prevalence of pain calls into question the quality of health care being delivered. The present study analyzes the prevalence of pain in one hospital, by departments and by therapeutic approach used. PATIENTS AND METHODS: This cross-sectional study was carried out in a representative sample of 309 patients admitted to a tertiary care hospital. Information was gathered by patient interviews and by reviewing hospital records for personal characteristics, clinical situation, pain characteristics and analgesic treatment. RESULTS: The prevalence of pain was 54.7% overall. The prevalence of pain eligible for treatment (intensity >2 on a visual analog scale) was 43.5%. The prevalence of pain that was moderate to intense (>3) was 34.7%. No analgesia was prescribed for 18.7% of the patients eligible, and analgesia was effective for 47.3%. Analgesia was provided on demand (63.2%) in most clinic protocols, usually with nonsteroidal antiinflammatory drugs, acetaminophen, opioids and special techniques, administered in combination to half the patients. The prevalence and intensity of pain and the prescription protocols varied from one hospital department to another. Analgesic treatment was adequate for 67.1% of the patients. CONCLUSIONS: The results suggest that the prevalence of pain in the hospital is high and that it is possible to improve quality of clinical approach, in agreement with studies that have been appearing since the 1980s. The persistence of the problem of pain in health care centers requires action on all levels of the health care system.

[Descriptive analysis of chronic pain clinics operating in Spain in 2001]. / Análisis descriptivo en el año 2001 de las Unidades de Tratamiento del Dolor Crónico en España.

OBJECTIVES: To describe the characteristics and care approaches to care of chronic pain clinics operating in Spain in 2001. DESIGN: Cross-sectional mail survey of pain clinics in Spain. SETTING: Chronic pain clinics in Spain. STATISTICAL ANALYSIS: Descriptive statistics of pain clinics responding to the questionnaire. RESULTS: Fifty-six of the 79 pain clinics (70.8%) responded; 57.1% were in public facilities, 55.4% were affiliated with medical schools, and 53.6% were interdisciplinary units. Both acute and chronic pain were treated by 72.4% of the respondents. Anesthesiology departments supervised 89.3% of the clinics. Only 57.1% had staff permanently assigned to the pain clinic. A mean 2194 (SD 2041) visits by patients were received annually. The most commonly applied treatments were drugs, blocks, spinal techniques, and transcutaneous electrical nerve stimulation. Implantable systems were more frequently used in chronic pain clinics than in mixed pain clinics, and in university-affiliated clinics than in non-teaching facilities (P=0.03 in both comparisons). A psychological approach was used more often in interdisciplinary clinics than in units operated by staff from a single specialty (P<0.01). CONCLUSIONS: Chronic pain clinics were not evenly distributed throughout Spain. The number of patients treated at pain clinics was high. The various characteristics of pain clinics--such as funding source, interdisciplinarity, university affiliation, and specialization in chronic pain--a were factors that affected the use of certain treatments.

[Management of transient radicular pain after receiving an epidural blood patch for headaches due to spontaneous intracranial hypotension]. / Radiculalgia transitoria tras administración de parche hemático epidural en la cefalea por hipotensión intracraneal espontánea, conducta a seguir.

Spontaneous intracranial hypotension headache is an uncommon disease that resolves spontaneously in most of the cases and in a short period of time. The initial treatment should be symptomatic. In some patients the symptomatology is extremely disabling, and in these cases both the diagnosis and treatment may be performed by an epidural blood patch. A 49-year-old Caucasian woman, with no previous record of epidural or intrathecal puncture, consulted in the Emergency Department complaining of a 9-day history of frontal headache and diplopia, along with nausea and vomiting. The patient was diagnosed with spontaneous intracranial hypotension headache. Considering the symptomatology and the uncontrolled pain, the Pain Unit of our hospital performed an epidural blood patch. In the first 24h the patient reported a remarkable relief of both headache and diplopia but developed a left lumbar radiculopathy that was treated successfully with supportive measures. Transient lumbar radiculopathy is a common and acceptable event secondary to the use of epidural blood patch as a treatment for spontaneous intracranial hypotension headache.

Prevalence of pain in the Spanish population: telephone survey in 5000 homes.

Pain has become the most common accompanying symptom in patients seeking medical advice, and it is one of the main issues in public health. In Spain, there are no reliable data about the impact of pain in general population. The aim of the study was to estimate the prevalence of acute and chronic pain in the Spanish general population. An epidemiological observational population-based cross-sectional study was carried out by means of a telephone survey. Multistep stratified quota-adjusted sampling was performed with people aged 18-95 years. A computer-assisted questionnaire was administered, covering physical pain symptoms, site, frequency, perceived cause, therapeutic measures and interference with daily life activities. There were 11,980 useful contacts, with 5000 effective interviews (42% of useful sample). Of the interviewees, 29.6% (95% confidence interval, 28.3-30.8%) reported having had pain the day before (women, 37.6%; men, 20.9%) and 43.2% the week before. Most common pain sites were lower extremities (22.7%) and back (cervical and lumbar levels) (21.5%), followed by head (20.5%). Frequency of pain increased with age, reaching 42.6% for people older than 65 years. Among people complaining of pain during the last day or week, duration of symptoms was higher than 3 months in 54% (chronic pain), representing 23.4% of the Spanish general population; most common causes of chronic pain were arthritis, rheumatism and migraine. Regarding treatment, 61.7% of people complaining of pain said they were taking drugs. Source of drug treatment advice was a physician or a nurse in 66.4% of cases and self-prescription in 29%. It is concluded that pain, particularly chronic pain, has a high prevalence in the Spanish general population and a significant impact on occupational and social relationships.

Radioisotopes for metastatic bone pain.

BACKGROUND: Bone metastases manifest through pain, which can arise even before the injury is radiologically detected. Pain occurs as a result of bone destruction and, as more destruction ensues, more pain can be experienced. Radiculopathies, plexopathies and shrinkage of spinal nerves due to tumour growth and fractures are very frequent in these patients. Relief of pain from bone metastasis can be achieved by treating the cancer itself; radiotherapy; conventional analgesics; and specific drugs that work on the bone tumour-induced alteration: biphosphonates, calcitonin or radioactive agents. OBJECTIVES: To determine the efficacy of radioisotopes to control metastatic pain in patients with bone metastases and complications due to bone metastases (hypercalcaemia, bone fracture and spinal cord compression) as well as its efficacy in terms of patient survival and adverse effects. SEARCH STRATEGY: Randomised and controlled clinical trials related to this review were retrieved electronically using MEDLINE (1966-2003), EMBASE (1974-2003) and Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1 2003). general strategies to identify RCTs were combined with specific commands to identify trials of radioisotopes and metastatic bone pain. SELECTION CRITERIA: The inclusion criteria were: randomised trials of patients with metastatic bone pain that compared treatment with radioisotopes and placebo, and where the major outcome was either pain or complications of bone metastases (eg, hypercalcaemia, bone fracture, spinal cord compression) assessed at least four weeks after treatment. DATA COLLECTION AND ANALYSIS: The quality of included studies was assessed using the Jadad scale and the Oxford Pain Validity Score. Two independent reviewers extracted the data and completed a standard form designed for that purpose. An intention-to-treat analysis was performed, and global estimates of effect were calculated using a random effects model. MAIN RESULTS: Four trials (325 patients) provided data that suggest a small effect of radioisotopes on pain control both at short and medium term (one to six months). No evidence was available to assess long-term effects (12 months). Only one study provided data on analgesia use and concluded that patients given either radioisotopes or placebo showed similar levels of analgesic use when compared to baseline use. Leukocytopenia and thrombocytopenia are secondary effects associated with the administration of radioisotopes. The incidence of leukocytopenia is significantly greater in patients treated with radioisotopes (RR=4.56, 95% CI (1.22,17.08)). There were also a greater number of thrombocytopenia events in the treatment group, without reaching statistical significance. REVIEWER'S CONCLUSIONS: The efficacy of radioisotopes has been assessed in clinical trials with small sample sizes and short-term evaluations of the outcomes. There is some evidence indicating that radioisotopes may give complete reduction in pain over one to six months with no increase in analgesic use, but adverse effects, specifically leukocytopenia and thrombocytopenia, have also been experienced.

Calcitonin for metastatic bone pain.

BACKGROUND: Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastasis. The hormone, calcitonin, has the potential to relieve pain, and also retain bone density, thus reducing the risk of fractures. OBJECTIVES: To assess the effectiveness of calcitonin in controlling metastatic bone pain and reducing bone complications (hypercalcemia, fractures and nervous compression) in patients with bone metastases. SEARCH STRATEGY: Electronic searches were performed in MEDLINE (1966-2001), EMBASE (1974-2001), the Cochrane Central Register of Controlled Trials (Issue 2, 2001), specialised registers of the Cochrane Cancer Network and of the Cochrane Pain, Palliative and Supportive Care Group. Registers of clinical trials in progress were also searched. SELECTION CRITERIA: Studies were included if they were randomised, double-blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. DATA COLLECTION AND ANALYSIS: Study selection and data extraction were performed by two independent reviewers. Only two studies (90 patients) were eligible for inclusion in the review and therefore meta-analysis of the data was not possible. Intention-to-treat analysis was performed by imputing all missing values as adverse outcomes. MAIN RESULTS: Of the two small studies included in the review, one study showed a non-significant effect of calcitonin in the number of patients with total pain reduction (RR 2.50; CI 95%, 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; CI 95%, 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases; for improving quality of life; or patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.35, CI 95%, 0.72 to 15.66). REVIEWER'S CONCLUSIONS: The limited evidence currently available for systematic review does not support the use of calcitonin to control pain from bone metastases. Until new studies provide additional information on this treatment, other therapeutic approaches should be considered.

Successful management of pleuritic pain with thoracic paravertebral block.

BACKGROUND AND OBJECTIVES: Thoracic paravertebral block (TPVB) is a unilateral analgesic technique that has been advocated in both acute and chronic thoracic and abdominal pain. Other blocks such as interpleural and epidural can be effectively used in pleuritic pain. This report illustrates that TPVB could also be effective for this kind of pain. METHODS: A 45-year-old man with acute pancreatitis was referred to the critical care unit 11 days after emergency admission with severe left pleural effusion and acute respiratory failure. His medical history revealed hypertension and chronic obstructive pulmonary disease (COPD); in addition, he was a heavy drinker and smoker. A pleuritic pain that only slightly improved with nonopioid analgesics and opioids resulted in the patient's increasing inability to eliminate bronchial secretions. In an attempt to avoid endotracheal intubation, the pain unit recommended a continuous paravertebral block. The block was performed at T9 on the left side. An initial bolus of 15 mL bupivacaine 0.25% was administered and a continuous infusion, initially at 5 mL/h, was increased up to 10 mL/h to achieve the desired analgesic effect. RESULTS: After the block the verbal analogue scale decreased from 9 to 3, and this level of pain relief was maintained until the end of the treatment 48 hours after the block. The patient improved and was discharged to the ward without the need for endotracheal intubation. CONCLUSIONS: This case report supports the notion that, in practice, the paravertebral block could be an effective and safe alternative to relief of pleuritic pain.

[NSAID-induced hepatotoxicity: aceclofenac and diclofenac]. / Hepatotoxicidad por AINES: aceclofenaco y diclofenaco.

Diclofenac (Voltaren, Geigy) and aceclofenac (Falcol, Bayer) belong to a chemical subgroup of nonsteroidal antiinflammatory drugs (NSAID) that are arylalkanoic groups of phenylacetic acid. Hepatotoxicity has been reported with the majority of NSAID although its incidence is not known. We describe two patients who presented hepatic injury after diclofenac and aceclofenac therapy. Recognition of cholestasis associated with NSAID may prevent invasive investigations in jaundiced patients. Clinically liver injury associated with NSAID is not prevalent but we think it is interesting to report those patients for recognition of the role of certain risk factors and to suggest close monitoring.

[Analgesia of postoperative pain in ambulatory surgery]. / Analgesia del dolor postoperatorio en cirugía ambulatoria.

Although the role of outpatient surgery has become increasingly important in the campaign to reduce waiting lists and health care costs, careful control and treatment of postoperative pain too often receives slight attention. Pain control after surgery must produce high quality analgesia without lengthening the hospital stay or increasing the risk of complications. The risk of side effects must be low, the safety margin wide and administration simple. Anesthesiologists must therefore take preventive measures as well as apply techniques during and after surgery that diminish the intensity of pain and the incidence of nausea or vomiting. Drugs that act in the short term and have few side effects, regional anesthesia (depending on type of operation), non-opioid analgesics and balanced analgesia seem to give good quality control of pain after outpatient surgery.

[Thoracic paravertebral blockade: postoperative analgesic effectiveness and plasma concentrations of bupivacaine]. / Bloqueo paravertebral torácico: efectividad analgésica postoperatoria y concentraciones plasmáticas de bupivacaína.

AIMS: To compare the analgesic efficacy of thoracic paravertebral blockade with that of endovenous morphine to measure the plasma levels of bupivacaine and to study the complications derived from both techniques in patients undergoing thoracic or abdominal surgery with unilateral incision. METHODS: Twenty ASA I-II patients allocated to two groups (A and B) of ten patients each were studied. Group A (5 cholecystectomies and 5 thoracotomies) received morphine 0.075 mg/kg i.v. every 3 hours after operation. Group B (5 cholecystectomies and 5 thoracotomies) received thoracic paravertebral blockade 15 ml of 0.37-5% bupivacaine with 1:200.000 adrenaline following tracheal extubation. Analgesia was evaluated according to the visual analogic scale (VAS) with laterality and extension of the blockade being assessed. The plasma levels of bupivacaine were measured by liquid chromatography in 5 patients. Blood pressure, heart rate and respiratory frequency were assessed in both groups. In group B the appearance of pneumothorax or other local complications were noted. The results were statistically analyzed using to the Student's test. RESULTS: The patients in group A presented significantly more pain than those of group B. In these patients analgesia was unilateral. Plasma levels ranged between 0.56 mg/l at 5 minutes of administration and 0.17 mg/l at 240 minutes with a peak of 0.70 mg/l at 10 minutes with all these values being considerably lower those a determined as toxic (2-4 mg/l). No significant differences were found between the values of blood pressure, and cardiac and respiratory frequency of both groups. There were no complications derived from the technique. CONCLUSIONS: Thoracic paravertebral blockade is a very effective postoperative analgesic technique and is superior to that of i.v. morphine in patients undergoing thoracic or unilateral abdominal surgery. Peak plasma levels were much lower than those considered as toxic complications of interest were observed. Therefore, this technique may be considered as an alternative to other blockades such as extradural, interpleural or intercostal.

An implantable drug delivery system (IDDS) for refractory cancer pain provides sustained pain control, less drug-related toxicity, and possibly better survival compared with comprehensive medical management (CMM).

BACKGROUND: The randomized clinical trial of implantable drug delivery systems (IDDS) plus comprehensive medical management (CMM) versus CMM alone showed better clinical success at 4 weeks for IDDS patients. This 'as treated' analysis assessed if improvements in pain control, drug toxicity and survival were maintained over time. PATIENTS AND METHODS: We compared those who received IDDS with those who did not receive IDDS (non-IDDS). All patients had Visual Analogue Scores (VAS) for pain > or =5/10 on at least 200 mg morphine or equivalent daily. RESULTS: At 4 weeks, 46 of 52 (88.5%) IDDS patients achieved clinical success compared with 65 of 91 (71.4%; P=0.02) non-IDDS patients, and more often achieved > or =20% reduction in both pain VAS and toxicity [35 of 52 (67.3%) versus 33 of 91 patients (36.3%); P=0.0003]. By 12 weeks, 47 of 57 (82.5%) IDDS patients had clinical success compared with 35 of 45 (77.8%; P=0.55) non-IDDS patients, and more often had a > or =20% reduction in both pain VAS and toxicity [33 of 57 (57.9%) versus 15 of 45 patients (33.3%); P=0.01]. At 12 weeks the IDDS VAS pain scores decreased from 7.81 to 3.89 (47% reduction) compared with 7.21 to 4.53 for non-IDDS patients (42% reduction; P=0.23). The 12 week drug toxicity scores for IDDS patients decreased from 6.68 to 2.30 (66% reduction), and for non-IDDS patients from 6.73 to 4.13 (37% reduction; P=0.01). All individual drug toxicities improved with IDDS at both 4 and 12 weeks. At 6 months, only 32% of the group randomized to CMM and who did not cross over to IDDS were alive, compared with 52%-59% for patients in those groups who received IDDS. CONCLUSIONS: IDDS improved clinical success, reduced pain scores, relieved most toxicity of pain control drugs, and was associated with increased survival for the duration of this 6 month trial.

Percutaneous neurolysis of the celiac plexus via the anterior approach with sonographic guidance.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of sonographically guided percutaneous neurolysis of the celiac plexus in patients with abdominal tumors or chronic pancreatitis in whom systemic analgesics were ineffective. SUBJECTS AND METHODS: Neurolysis of the celiac plexus was performed in 38 patients, 34 with neoplastic disease and four with chronic pancreatitis. Under sonographic guidance, a 22-gauge needle was advanced by the anterior route to the area above the celiac plexus, and 30-40 ml of 50% alcohol was injected. Pain relief was assessed 1 week, 6 months, and 1 year after the procedure. Patients subjectively rated the pain after treatment as totally relieved, partially relieved, or unchanged. RESULTS: At 1 week and at 6 months after treatment, pain was totally relieved in 61% of patients, partially relieved in 31%, and unchanged in 8%. After 1 year, pain was totally relieved in 39%, partially relieved in 52%, and unchanged in 9%. The complications observed were five cases of mild diarrhea and one case of retroperitoneal pain, which subsided with conservative treatment. CONCLUSION: The anterior, sonographically guided approach appears to be as successful as other percutaneous techniques for neurolysis of the celiac plexus.