Although pain is not only a physical but also an emotional and cognitive distress, psychiatric management of pain has commonly been overlooked. In this article the author will review the psychiatric assessment and treatment of patients with chronic pain. Pain is not a simple sensory process but a complex perception involving higher levels of the central nervous system, emotional states, and highorder mental processes. Thus the psychosocial aspect should be underscored in patients with chronic pain, and a multidisciplinary approach is necessary in the treatment of chronic pain. Tricyclic antidepressants are most widely used and have proven effective in patients with chronic pain. Anticonvulsants/mood stabilizers, anxiolytics, antipsychotics, and opioid analgesics are beneficial in some cases. Non-Pharmacological and psychological therapy of chronic pain includes cognitive-behavioral therapy, relaxation techniques, biofeedback, hypnosis, psychotherapy, and family therapy. New psychotropic agents and various psychological therapies need to be developed and be proven to be effective and tolerable in patients with chronic pain through well-controlled and long-term follow-up studies. Psychiatric treatments, both pharmacological and non-pharmacological, are helpful in patents with chronic pain.
Analgesics, Opioid ; Anti-Anxiety Agents ; Antidepressive Agents, Tricyclic ; Antipsychotic Agents ; Biofeedback, Psychology ; Central Nervous System ; Chronic Pain* ; Family Therapy ; Humans ; Hypnosis ; Mental Processes ; Psychotherapy ; Relaxation Therapy

Neuropathic pain has recently been defined as "pain arising as a direct consequence of a lesion or disease affecting the somatosensory system". Neuropathic pain is a debilitating chronic condition that remains very difficult to treat and challenging to manage. Tricyclic antidepressants (amitryptiline, nortriptyline, imipramine), selective serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine), anticonvulsants (gabapentin, pregabalin), and 5% lidocaine patches have demonstrated efficacy in neuropathic pain and are recommended as first-line medications. In patients who fail to respond to these first-line medications alone and/or in combination, opioid analgesics or tramadol can be used as a second-line treatment alone or in combination with one of the first-line medications. Opioid analgesics and tramadol can also be considered for first-line use in selected clinical circumstances. Other pharmacological therapeutic options include selective serotonin reuptake inhibitors, antiepileptic drugs (levetiracetam, lacosamide, lamotrigine, valproic acid), cannabinoids, high concentration capsaicin patch, and botulinum toxin A. Medication selection should be individualized, with side effects taken into consideration as well as potential beneficial or deleterious effects on comorbidities, and whether or not prompt onset of pain relief is necessary.
Acetamides ; Analgesics, Opioid ; Anticonvulsants ; Antidepressive Agents, Tricyclic ; Botulinum Toxins ; Cannabinoids ; Capsaicin ; Comorbidity ; Humans ; Lidocaine ; Neuralgia ; Norepinephrine ; Nortriptyline ; Serotonin ; Serotonin Uptake Inhibitors ; Tramadol ; Triazines

STUDY DESIGN: A review of literature including definition, diagnosis and treatment of neuropathic pain. OBJECTIVES: To review and discuss the treatment guideline for neuropathic pain. SUMMARY OF LITERATURE REVIEW: Neuropathic pains are characterized by partial or complete somatosensory change caused by various disorders affecting central and peripheral nervous system, and are especially problematic because of their severity, chronicity and resistance to simple analgesics. MATERIALS AND METHODS: Review of literature. RESULTS: Tricyclic antidepressants and the anticonvulsants gabapentin and pregablin were recommended as first-line treatments for neuropathic pain. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications such as dual reuptake inhibitors of both serotonin and norepinephrine would be used in severe cases. More invasive interventions (e.g., spinal cord stimulation) may sometimes be helpful. CONCLUSIONS: Treatment must be individualized for each patient and aggressive, combinatory pharmacotherapy and multidisciplinary approach are recommended for the treatment of neuropathic pain.
Amines ; Analgesics, Opioid ; Anticonvulsants ; Antidepressive Agents, Tricyclic ; Cyclohexanecarboxylic Acids ; gamma-Aminobutyric Acid ; Humans ; Neuralgia ; Norepinephrine ; Peripheral Nervous System ; Serotonin ; Spinal Cord ; Tramadol

BACKGROUND: The adductor canal block (ACB) is an effective intervention for postoperative analgesia following total knee arthroplasty (TKA). However, the ideal ACB regimen has not yet been established. We compared the analgesic effects between a continuous ACB group and fentanyl-based intravenous patient-controlled analgesia (IV-PCA) with a single-shot ACB group. METHODS: Patients who underwent TKA were randomly allocated to either a continuous ACB group (Group CACB) or IV-PCA with a single-shot ACB group (Group IVACB). Before the surgery, ultrasound guided ACB with 0.5% ropivacaine 20 cc was provided to all patients. Before skin incision, the infusion system (0.2% ropivacaine through an adductor canal catheter in group CACB vs. intravenous fentanyl in group IVACB) was connected. The postoperative pain severity; the side effects of local anesthetics and opioids; administration of rescue analgesics and anti-emetics; and sensorimotor deficits were measured. RESULTS: Postoperative pain severity was significantly higher in the IVACB group at 30 min, 4 h, 24 h, and 48 h after surgery. The averages and standard deviations (SD) of the NRS score of postoperative pain were 0.14 ± 0.37, 4.57 ± 2.37, 6.00 ± 1.63, and 4.28 ± 1.49, respectively in the IVACB group. Rescue analgesic requirements and quadriceps muscle strength were not statistically different between the groups throughout the postoperative period. Moreover, rescue antiemetic requirements were higher in group IVACB than group CACB. CONCLUSIONS: In this study, the continuous ACB provided superior analgesia and fewer side effects without any significant motor deficit than the IV-PCA with a single-shot ACB.
Analgesia ; Analgesia, Patient-Controlled ; Analgesics ; Analgesics, Opioid ; Anesthetics, Local ; Antiemetics ; Arthroplasty, Replacement, Knee ; Catheters ; Fentanyl ; Humans ; Nausea ; Pain Management ; Pain, Postoperative ; Postoperative Period ; Quadriceps Muscle ; Skin ; Ultrasonography ; Vomiting

Long QT syndrome is a cardiac repolarization disorder and is associated with an increased risk of torsades de pointes. The acquired form is most often attributable to administration of specific medications and/or electrolyte imbalance. This review provides insights into the risk for QT prolongation associated with drugs frequently used in the treatment of chronic pain. In the field of pain medicine all the major drug classes (i.e. NSAIDs, opioids, anticonvulsive and antidepressant drugs, cannabinoids, muscle relaxants) contain agents that increase the risk of QT prolongation. Other substances, not used in the treatment of pain, such as proton pump inhibitors, antiemetics, and diuretics are also associated with long QT syndrome. When the possible benefits of therapy outweigh the associated risks, slow dose titration and electrocardiography monitoring are recommended.
Analgesics ; Analgesics, Opioid ; Anti-Inflammatory Agents, Non-Steroidal ; Anticonvulsants ; Antidepressive Agents ; Antiemetics ; Cannabinoids ; Chronic Pain ; Diuretics ; Electrocardiography ; Long QT Syndrome ; Muscle Relaxants, Central ; Narcotics ; Proton Pump Inhibitors ; Torsades de Pointes

PURPOSE: The purpose of this study was to evaluate the usefulness of intravenous lipid emulsion as well as adverse events in acute poisoning patients. METHODS: Literature was accessed through PubMed, EMBASE, Cochrane library, Web of science, and KoreaMed. All forms of literatures relevant to human use of intravenous lipid emulsion for acute poisoning were included. Cases reports or letters without description of clinical outcomes for each case were excluded. The literature search was conducted by two investigators in March, 2015, with publication language restricted to English and Korean. The effect, onset time, and adverse event of lipid emulsion and final outcome of each case were analyzed. RESULTS: Eighty-one published articles were included, excluding articles whose title and abstract were not relevant to this study. No articles were classified as high level of evidence. Sixty-eight case reports were identified, consisting of 25 local anesthetics and 43 other drugs, such as tricyclic antidepressants and calcium channel blockers. Although most cases described significant clinical improvements, some of them showed no beneficial effect or worsening of clinical course. Several adverse events including hyperamylasemia and laboratory interference were reported. CONCLUSION: Although there were many case reports illustrating successful use of lipid for various drug poisonings, the effect cannot be estimated due to significant possibility of publication bias. Therefore, lipids might be considered in severe hemodynamic instability resulting from lipophilic drug poisoning, however further studies should follow to establish the use of lipid as the standard of care.
Anesthetics, Local ; Antidepressive Agents, Tricyclic ; Calcium Channel Blockers ; Drug Overdose ; Fat Emulsions, Intravenous ; Hemodynamics ; Humans ; Hyperamylasemia ; Lipid A ; Poisoning* ; Publication Bias ; Publications ; Research Personnel ; Standard of Care

Intrathecal drug delivery is an effective and safe option for the treatment of chronic pathology refractory to conventional pain therapies. Typical intrathecal administered drugs are opioids, baclofen, local anesthetics and adjuvant medications. Although knowledge about mechanisms of action of intrathecal drugs are every day more clear many doubt remain respect the correct location of intrathecal catheter in order to achieve the best therapeutic result. We analyze the factors that can affect drug distribution within the cerebrospinal fluid. Three categories of variables were identified: drug features, cerebrospinal fluid (CSF) dynamics and patients features. First category includes physicochemical properties and pharmacological features of intrathecal administered drugs with special attention to drug lipophilicity. In the second category, the variables in CSF flow, are considered that can modify the drug distribution within the CSF with special attention to the new theories of liquoral circulation. Last category try to explain inter-individual difference in baclofen response with difference that are specific for each patients such as the anatomical area to treat, patient posture or reaction to inflammatory stimulus. We conclude that a comprehensive evaluation of the patients, including imaging techniques to study the anatomy and physiology of intrathecal environment and CSF dynamics, could become essential in the future to the purpose of optimize the clinical outcome of intrathecal therapy.
Analgesics, Opioid ; Anesthetics, Local ; Baclofen ; Catheters ; Chronic Pain ; Humans ; Posture

BACKGROUND: Opioids are increasingly being administered intrathecally as adjuncts to local anesthetics. They enhance spinal anesthesia without prolonging motor recovery. We evaluated the effect of 10 microgram of fentanyl to bupivacaine on sensory, motor block and side effects. METHODS: Thirty six patients undergoing urologic surgery were randomized into two groups. Control group received bupivacaine 10 mg combined with normal saline 0.2 ml, and Fentanyl group received bupivacaine 10 mg with fentanyl 10 microgram (0.2 ml). RESULTS: There were no significant differences between two groups in the peak level of sensory block, onset of peak level, duration of motor block, and side effects. However, the time of regression from peak level to T10 in Fentanyl group was longer significantly than that of Control group. CONCLUSIONS: Intrathecal small dose fentanyl (10 microgram) on bupivacaine spinal blockade prolonged duration of sensory block and did not augment side effects and provide reliable anesthesia for urologic surgery.
Analgesics, Opioid ; Anesthesia ; Anesthesia, Spinal ; Anesthetics, Local ; Bupivacaine* ; Fentanyl* ; Humans

Physostigmine has been used to counteract somnolence or coma induced by different types of pharmacological agent, such as anticholinergics, opioids, ketamine, tricyclic antidepressants and inhalational anesthetics. In this study, we have assessed the effect of physostigmine on arousal and respiration after 50% N2O-50% O2-enflurane general anesthesia under controlled condition such as no premedication, no neuromuscular blockade, same operative procedure and duration. Fifty healthy gynecologic patients scheduled for dilatation & curettage and cervical cone biopsy were divided randomly into two groups such as control group and physostigmine group. In physostigmine group, 0.02 mg/kg of physostigmine was administered intravenously at the end of operation. We evaluated the recovery time of pain response, eye opening on verbal command and orientation after the end of operation. We also checked the end-tidal enflurane concentration with SARACAP spectrometry. Blood pressure, pulse rate, respiration rate and tidal volume were checked at the end of operation and at the time of each recovery parameters returned. The results were as follows; first, pain response time was 5.1+/-2.4 min in control group compared with 3.5+/-2.1 min in physostigmine group. Second, on simple order to patients, eye opening time was 8.5+/-2.3 min in control group compared with 6.5+/-2.1 min in physostigmine group. Third, recovery of orientation to time, place and person was 9.7+/-2.8 min in control group compared with 7.5+/-2.1 min in physostigmine group. Fourth, there was no significant difference in respiratory parameters between the two groups. But there was no significant difference in end-tidal enflurane concentration between the two groups inspite of rapid recovery time in physostigmine group. In conclusion, 0.02mg/kg of physostigmine has the effect of early arousal after enflurane anesthesia without specific problems.
Analgesics, Opioid ; Anesthesia ; Anesthesia, General* ; Anesthetics ; Antidepressive Agents, Tricyclic ; Arousal* ; Biopsy ; Blood Pressure ; Cholinergic Antagonists ; Coma ; Dilatation and Curettage ; Enflurane* ; Female ; Heart Rate ; Humans ; Ketamine ; Neuromuscular Blockade ; Physostigmine* ; Premedication ; Reaction Time ; Respiration* ; Respiratory Rate ; Spectrum Analysis ; Surgical Procedures, Operative ; Tidal Volume

Dexmedetomidine is a selective α-2 adrenoceptor agonist with anxiolytic, sedative, and analgesic properties that prolongs analgesia and decreases opioid-related side effects when used in neuraxial and perineural areas as a local anesthetics adjuvant. The current study was designed to evaluate the effects of a single perineural administration of dexmedetomidine without local anesthetics on narcotic consumption and pain intensity in patients with femoral shaft fractures undergoing surgery. This prospective randomized single-blind clinical trial was conducted in patients undergoing femoral fracture shaft surgery. Based on block permuted randomization, the patients were randomly divided into intervention and control groups. The intervention group received 100µg dexmedetomidine, for a femoral nerve block without any local anesthetics. Total intraoperative opioid consumption, postoperative opioid consumption, visual analogue score (VAS) for pain, and hemodynamic parameters were recorded and compared. Finally the data from 60 patients with a mean age of 30.4±12.3 were analyzed (90% male). There were no significant differences between the baseline characteristics of the two groups (p>0.05). The mean total consumption of narcotics was reduced during induction and maintenance of anesthesia in the intervention group (p<0.05). The amount of postoperative narcotics required showed a significant difference in the intervention group compared with the control group (p<0.05). It is likely that perineural administration of dexmedetomidine significantly not only reduced intra and postoperative narcotic requirement but also decreased postoperative pain intensity in patients undergoing femoral shaft surgery. Femoral blockade by dexmedetomidine can provide excellent analgesia while minimizing the side-effects of opioids.
Analgesia ; Analgesics, Opioid ; Anesthesia ; Anesthetics, Local ; Dexmedetomidine ; Femoral Fractures ; Femoral Nerve ; Hemodynamics ; Humans ; Narcotics ; Nerve Block ; Pain Management ; Pain, Postoperative ; Propofol ; Prospective Studies ; Random Allocation