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An analysis of the treatment of nonmalignant pain in the elderly at a long-term facility was conducted to allow development of a pain management program that complies with both JCAHO guidelines for pain management and with the Tennessee Medicaid (TennCare) reimbursement schedule, and to determine if tramadol can meet the standards of pain management under these new guidelines. Inclusion criteria were residence in our long-term care facility; a pain intensity score > 4 on a modified Wong Baker Pain Scale; the patient having prescription orders for one or more of the following drugs: propoxyphene, meperidine, or high dosages of acetaminophen (approaching 4 g/day); suspected neuropathic or mixed nociceptive/neuropathic pain; and/or a diagnosis of diabetes, osteoarthritis, or degenerative joint disease. Exclusion criteria were history of seizures, history of opioid or alcohol abuse, and demonstrated hypersensitivity to tramadol or opioids. Tramadol administration began at a dose of 25 mg/day titrated up to a maximum of 300 mg/day over a 16-day period. Data were collected from computer records, dispensing reports, medication administration reports (MARs), current federal minimum data set (MDS) data, and weekly care plan meetings. Data were tabulated at baseline and 4-6 weeks after a stable dose of tramadol had been established. Fourteen residents (mean age 85 years, 1 male, 13 female) met the criteria and received tramadol up to 300 mg/day (qid). Tramadol reduced the residents' pain scores from an average of 6 to 2 using the Modified Wong Baker Pain Scale, reduced the percentage of residents taking propoxyphene from 50% to 14%, and reduced those taking high doses of APAP or APAP products from 43% to 14%. Tramadol reduced the percentage of residents falling, losing weight, showing no change or decline in activities in daily living (ADLs), displaying inappropriate behavioral symptoms, suffering depression, and/or taking psychotropic medications. In the state of Tennessee, new reimbursement schedules by TennCare have allowed our hospital to comply with the JCAHO standards of "optimal achievable care" for the treatment of pain by allowing the hospital staff to treat patients with newer, safer, more effective analgesics such as tramadol. Early results from this ongoing study have shown that tramadol can provide a safe and effective treatment on non-malignant pain in a long-term care facility and improve adherence to JCAHO and TennCare standards for proper pain management.
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PMID:Pain management in a long-term care facility: compliance with JCAHO standards. 1464 89

Migraine is common during pregnancy, but fortunately this combination of conditions obviously exists for only a finite period. The greatest frequency of migraine attacks occurs during the first trimester. Accurate diagnosis is a sine qua non in this setting as in any headache patient. It is in the first trimester that the fetus is at greatest risk from abortifacient and teratogenic drugs, and when very early pregnancy may be undiagnosed. Ergot alkaloids (including methysergide) should be avoided during pregnancy because of their teratogenicity, and most other drug classes should be used only when unavoidable. The use of prophylactic agents during pregnancy should be the exception, not the rule, and preferably only during the second and third trimesters; propranolol is probably safest in this situation. De novo headache during pregnancy usually requires expert review of the patient. Treatment tactics for uncomplicated migraine in pregnancy depend on the concurrent clinical situation. Paracetamol (acetaminophen) is the mainstay for the patient whose typical attacks continue into the first trimester. If paracetamol is insufficient, then partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters (which is uncommon). 'Chronic migraine' in pregnancy, i.e. >or=15 headache days per month, is rare, and is the greatest therapeutic challenge. Co-morbidities such as depression or epilepsy require specialised approaches. The complexities associated with these tactics are discussed in this article, and it is emphasised that none has the specific approval of regulatory authorities. Heightened pharmacovigilance will better inform the future pregnant migraineur. However, this type of information is less likely to be available for novel classes of neuropharmacological agents than for existing ones.
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PMID:Migraine during pregnancy: options for therapy. 1596 98

The purpose of the present study was to describe associations between the use of common over-the-counter (OTC) and prescription medications with individual differences in salivary cortisol in infants and their mothers. Participants were 1020 mothers and 852 infants (52.5% boys; ages 5.03-13.44 months) from economically disadvantaged and ethnically diverse families (38.4% African American) who donated saliva samples before, 20 and 40 min after infants participated in a series of challenging tasks. Samples (N=5616) were later assayed for cortisol. Medication information was content analyzed separately for infants (e.g., teething gels, nonsteroidal anti-inflammatory drugs, acetaminophen, decongestants) and mothers (e.g., narcotics, antidepressants, antipsychotics, contraceptives, glucocorticoids). A large percentage of infants (44%) and the majority of mothers (57.5%) had used at least one medication (range 0-4) in the previous 48 h. Most frequent were acetaminophen (e.g., Tylenol) and cold medications (e.g., decongestants) for infants and contraceptives and acetaminophen for mothers. Compared to infants not taking any medications, cortisol reactivity to the challenge tasks was less pronounced for infants taking acetaminophen. Cortisol levels were higher for mothers taking oral or transdermal contraceptives and acetylsalicylic acid (e.g., Aspirin) but lower for mothers taking pure agonist opioids (e.g., Oxycontin) compared to mothers not taking any medications. These medication-related differences remained significant after controlling for sampling time, fever, maternal anxiety and depression, infant temperament, ethnicity, SES, and health status. Recommendations are provided to steer investigators clear of these potential sources of unsystematic error variance in salivary cortisol.
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PMID:Individual differences in salivary cortisol: associations with common over-the-counter and prescription medication status in infants and their mothers. 1668 32

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.
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PMID:Practical considerations for the treatment of elderly patients with migraine. 1687 31

Oxycodone and oxycodone-containing analgesics are often used for the relief of pain. In the presence of renal dysfunction, the half-life of oxycodone and metabolites can be prolonged. We describe the case of a 41-year-old chronic hemodialysis patient who received multiple doses of oxycodone/acetaminophen resulting in accumulation of the medication and consequent lethargy, hypotension and respiratory depression. These adverse effects were reversed with multiple bolus doses of naloxone, followed by a continuous infusion administered for 45 hours. Utilizing the Naranjo probability scale, the patient had a "probable" adverse drug reaction to the oxycodone. Oxycodone should be used with caution in patients with chronic renal failure.
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PMID:Oxycodone accumulation in a hemodialysis patient. 1733 Jun 96

Pain is a common occurrence for the hospitalized elderly, and may often be under recognized and inadequately managed. Insufficient pain management can lead to the sequelae of emotional distress and depression, delirium, anxiety, sleep disturbances, and physical disabilities, as well as increased health care costs. Effective pain management of the older adult begins with pain assessment using the proper tools. Morphine is the analgesic of choice for the older adult, and is appropriate for the postoperative period. It is important to maintain a therapeutic serum level of opioids to prevent inadequate management of the acute pain. Side effects of opioids include hypotension, nausea, mood disturbances, ileus, histamine production, and respiratory depression. The adage for pain treatment in the elderly is "start low and go slow". Paracetamol is commonly prescribed and may be the drug of choice for mild to moderate postoperative pain. Older adults may enjoy the benefits of Patient-Controlled Analgesia and Patient Controlled Epidural Analgesia in the postoperative period; however, thorough and ongoing teaching must occur to ensure understanding and compliance with the therapy. Treating post-procedure pain in the elderly patient requires an understanding of the normal changes associated with aging and the impact on medications, and multimodal analgesia can be the best approach.
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PMID:[Postoperative pain management in elderly patient]. 1759 59

For social, cultural and historical motives alcohol (ethanol or isopenthanol) is considered to be just a beverage rather than a liquor. However, from a pharmatherapeutic point of view alcohol is a depressor of the central nervous system. The effects of alcohol consumption can range from raised loquacity to drunkenness, loss of consciousness and death as a result of insufficient respiration. Probably the most frequent pharmacological interaction is the combination of alcohol with other depressors of the central nervous system which increases the depression even further. Some medicaments which more frequently produce an interaction are antihistamines, analgesics, antidepressants and medicaments for coughs, common cold and influenza. Paracetamol or acetaminophen is an analgesic medicament similar to acetylsalicylic acid lacking anticoagulatory properties and gastric irritation. However, its major drawback is hepatic toxicity as a result of a toxic metabolite produced in the liver by cytochrome P-450, principally cytochrome CYP2E1, which is detoxified under normal conditions by hepatic glutathione. Ethanol is also detoxified by CYP2E1, which is an inducer of ethanol such that chronic ingestion increases the level of this enzyme. When the ingestion of alcohol is stopped, CYP2E1 is greatly increased and only metabolises the paracetamol giving rise to high quantities of hepatotoxic metabolites so that the hepatic glutathione is unable to detoxify resulting in irreversible hepatic damage. Therefore for odontologists it is important that in chronic alcoholic patients the consumption of alcohol should not be suspended on prescribing paracetamol.
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PMID:Interaction of paracetamol in chronic alcoholic patients. Importance for odontologists. 1837 47

We reviewed commonly used analgesics and determined their safety and efficacy in surgical neonates in a retrospective study on surgical neonates who had analgesics at the University of Benin Teaching Hospital between January 1998 and December 2007. A total of 2590 pediatric operations were performed on 2563 children; 368 (14.2%) on neonates, 256 boys and 112 girls with male:female ratio 2.3:1, aged 12 hours to 28 days (mean, 8 +/- 5.1 days), and weighing 1.8 to 4.9 kg (mean, 2.7 +/- 0.5 kg). Paracetamol, pentazocine, pethidine, fentanyl, tramadol, and breast milk/glucose drinks were common analgesics and pacifiers used, and morphine, meperidine, alfentanil, and ketorolac were rarely used during the period. Opioids, especially pentazocine, produced satisfactory analgesia but were associated with life-threatening morbidities and mortalities, chiefly due to respiratory depression compounded by nonavailability of pediatric ventilator ( P < 0.0001). Excessive sedation, apnea, and mucous/vomiting were other complications. Nonsteroidal anti-inflammatory agents, particularly tramadol, had excellent analgesia with no significant complication. Overall, 18 (4.9%) deaths were recorded, 15 (83.3%) of them following pentazocine use. Many analgesics relieved pain but most were unsafe; cautious selection is important where there may be no adequate facilities.
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PMID:Safety profile and efficacy of commonly used analgesics in surgical neonates in Benin City, Nigeria. 1884 87

(1) Fibromyalgia is characterised by a range of symptoms that include muscle pain, fatigue and sleep disorders. Anxiety and depression are often also present. The cause is unknown. More women than men are affected; (2) The following review focuses on differential diagnoses and available treatments for fibromyalgia, based on a review of the literature using the standard Prescrire methodology; (3) Fibromyalgia is mainly diagnosed by excluding other possibilities. The principal differential diagnoses are rheumatic involvement of the spine, systemic inflammatory disorders, and hypothyroidism. Unlike these other conditions, fibromyalgia is not associated with radiological or laboratory abnormalities; (4) Paracetamol has not been compared with other treatments in fibromyalgia. Nonsteroidal antiinflammatory drugs have no specific effect; (5) The only two trials assessing tramadol showed little effect; in one study the average pain score was 53 mm in the tramadol group versus 65 mm in the placebo group, on a scale ranging from 0 to 100 mm. The adverse effects of tramadol are those of opiates in general, mainly nausea and dependence. Tramadol interacts with numerous other drugs; (6) The efficacy of tricyclic antidepressants is also difficult to quantify. Their limited superiority over placebo lasts no more than a few months. The efficacy of selective serotonin reuptake inhibitor antidepressants (fluoxetine, paroxetine and citalopram), serotonin and nonadrenaline reuptake inhibitors (duloxetine and milnacipran) is even less well established. Duloxetine has been tested in four placebo-controlled trials with unconvincing results; (7) Pregabalin and gabapentin, two antiepileptic drugs, appear to be more effective than placebo but have only been tested in short-term trials. In one trial 44% of patients in the pregabalin group said they felt better after 13 weeks versus 35% of patients in the placebo group. However, adverse effects are frequent and sometimes troublesome (drowsiness, dizziness, nausea, weight gain). In clinical trials, 19% to 33% of patients stopped treatment due to adverse effects after 13 weeks, depending on the dose of pregabalin; (8) Assessments of non-drug treatments in this setting are generally mediocre. The best-assessed alternative therapies (acupuncture and physical exercise) only have a limited effect; (9) In practice, when a patient presents with symptoms compatible with fibromyalgia, the first step is to rule out a treatable condition. Quality of life may be improved by first acknowledging that the pain is real, and possibly by providing psychological, medical, social and occupational support. The limited efficacy of available drugs, and their potential adverse effects, should be discussed with the patient.
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PMID:Fibromyalgia: poorly understood; treatments are disappointing. 1974 61

Paracetamol (acetaminophen) hepatotoxicity, whether due to intentional overdose or therapeutic misadventure, is an indication for liver transplantation in selected cases. However, there is a concern that long-term outcomes may be compromised by associated psychopathology that may predispose patients to further episodes of self-harm or poor treatment adherence. We therefore undertook a retrospective analysis of patients transplanted for paracetamol-induced fulminant hepatic failure (FHF) to determine their long-term outcomes, psychiatric problems, and compliance and whether these issues could be predicted from pretransplant information. Records from patients undergoing liver transplantation for paracetamol-associated liver failure in this unit and 2 comparison groups (patients undergoing liver replacement for FHF from other causes and for chronic liver diseases) were examined. Of 60 patients transplanted for paracetamol-induced FHF between 1989 and 2007, 44 (73%) survived to discharge. Currently, 35 patients (58%) are surviving at an average of 9 years post-transplantation. The incidence of psychiatric disease (principally depression) and 30-day mortality were greatest in the paracetamol group, but for those who survived 30 days, there was no difference in long-term survival rates between the groups. Adherence to follow-up appointments and compliance with immunosuppression were lowest in the paracetamol overdose group. Poor adherence was not predicted by any identifiable premorbid psychiatric conditions. Two patients grafted for paracetamol FHF died from self-harm (1 from suicide and 1 from alcoholic liver disease after 5 years). This study suggests that, notwithstanding the shortage of donor liver grafts, transplantation is an appropriate therapy in selected patients, although close follow-up is indicated.
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PMID:Outcomes of liver transplantation for paracetamol (acetaminophen)-induced hepatic failure. 1979 Jan 65


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