Identification of patient, medical and nursing staff attitudes to postoperative opioid analgesia: stage 1 of a longitudinal study of postoperative analgesia.

Sixty-one successive patients undergoing routine cholecystectomy together with all the registered nursing staff and junior doctors working on the surgical wards in a major teaching hospital were studied by means of questionnaires. These were designed to identify beliefs and attitudes to postoperative analgesia in the hospital. The survey revealed that there is a continuing prevalence among medical and nursing staff of attitudes and practices likely to contribute to poor postoperative analgesia. Patients had low expectations of pain relief and displayed reluctance to request analgesia. Injections were generally effective when given, but dosing intervals were often too long for good analgesia. With this knowledge it has been possible to devise strategies to counteract those attitudes leading to poor analgesia and these have formed the basis of a new Acute Pain Service. It is intended to repeat this survey at 3 yearly intervals in order to monitor progress.

Out-patient cognitive-behavioural therapy with amitriptyline for chronic non-malignant pain: a comparative study with 6-month follow-up.

A study was carried out in a multidisciplinary pain clinic with the purpose of comparing the effectiveness of outpatient cognitive-behavioural therapy (CBT) with amitriptyline (AMI) to that of supportive therapy with AMI. The treatments were given weekly over 8 weeks. Global and continuous outcome measures were used. Analysis was by chi-square for global data and MANOVA with baseline scores as covariants for continuous variables. No significant differences could be demonstrated. The scores over a 6-month follow-up period suggested a delayed positive advantage for CBT but this only approached and did not achieve statistical significance. The findings are discussed.

Description of a mechanistic approach to pain management in advanced cancer. Preliminary report.

A mechanistic approach to advanced cancer pain management is proposed, based on the clinically perceived anatomical and pathophysiological mechanisms of pain generation. It is an extension of the World Health Organisation (WHO) analgesic ladder in which severity of pain is the principal determinant of analgesic choice. The mechanistic categories are: superficial somatic, deep somatic, visceral and neurogenic (mixed or pure, i.e., nociceptive component present or absent). Allocation of pain to the different categories is based on clinical history, physical findings and investigations to establish the site and extent of active primary or metastatic tumor deposits, and evidence of previous response to medication. Drug choice sequence is determined by the dominant pain mechanism judged to be present and not the severity of the pain. In order to describe this approach, mechanisms of pain, disease distribution and drug treatment have been analysed in the first 20 consecutive patients who consented to enter a longitudinal pain description and evaluation study on admission to an inpatient hospice unit. Despite a high exclusion rate from research standard monitoring due to severity of illness and related factors, the majority of eligible patients approached to enter the study did so, and the pain scoring was well tolerated. The implications of this for future research and clinical practice are discussed. In 6 patients only 1 pain mechanism was identified (visceral 4, deep somatic 2). Two mechanisms were present in 8 patients and 3 mechanisms in 6 patients. The deep somatic mechanism was identified in 15 patients, visceral mechanism in 13, neurogenic in 10 and superficial somatic in 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperalgesia in opioid-managed chronic pain and opioid-dependent patients.

UNLABELLED: This observational study aimed to determine whether pain sensitivity in patients with noncancer chronic pain, taking either methadone or morphine, is similar to patients maintained on methadone for dependence therapy, compared with a control group. Nociceptive thresholds were measured on a single occasion with von Frey hairs, electrical stimulation, and cold pressor tests. In all subjects receiving methadone or morphine, nociceptive testing occurred just before a scheduled dose. Cold pressor tolerance values in patients with noncancer, chronic pain, treated with morphine and methadone, were 18.1 +/- 2.6 seconds (mean +/- SEM) and 19.7 +/- 2.3 seconds, respectively; in methadone-maintained subjects it was 18.9 +/- 1.9 seconds, with all values being significantly (P < .05) lower than opioid-naïve subjects (30.7 +/- 3.9 seconds). These results indicate that patients with chronic pain managed with opioids and methadone-maintained subjects are hyperalgesic when assessed by the cold pressor test but not by the electrical stimulation test. None of the groups exhibited allodynia as measured using the von Frey hairs. These results add to the growing body of evidence that chronic opioid exposure increases sensitivity to some types of pain. They also demonstrate that in humans, this hyperalgesia is not associated with allodynia. PERSPECTIVE: This article presents an observational study whereby the pain sensitivity of patients with chronic pain managed with opioids and opioid-maintained patients were compared with opioid-naïve patients. The results suggest that opioid use may contribute to an increase in the sensitivity to certain pain experimental stimuli.