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Query: UMLS:C0344307 (analgesia)
 28,200 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

To assess the efficacy of nortriptyline, a tricyclic antidepressant, as an analgesic in chronic back pain without depression, we conducted a randomized, double-blind, placebo-controlled, 8-week trial in 78 men recruited from primary care and general orthopedic settings, who had chronic low back pain (pain at T-6 or below on a daily basis for 6 months or longer). Of these 57 completed the trial; of the 21 who did not complete, four were withdrawn because of adverse effects. The intervention consisted of inert placebo or nortriptyline titrated to within the therapeutic range for treating major depression (50-150 ng/ml). The main outcome endpoints were pain (Descriptor Differential Scale), disability (Sickness Impact Profile), health-related quality of life (Quality of Well-Being Scale), mood (Beck Depression Inventory, Spielberger State Anxiety Inventory, Hamilton Anxiety/Depression Rating Scales), and physician rated outcome (Clinical Global Impression). Reduction in pain intensity scores was significantly greater for participants randomized to nortriptyline (difference in mean change 1.68, 95%-0.001, CI -3.36, P = 0.050), with a reduction of pain by 22% compared to 9% on placebo. Reduction in disability marginally favored nortriptyline (P = 0.055), but health-related quality of life, mood, and physician ratings of overall outcome did not differ significantly between treatments. Subgroup analyses of study completers supported the intent-to-treat analysis. Also, completers with radicular pain on nortriptyline (n = 5) had significantly (P < 0.05) better analgesia and overall outcome than did those on placebo (n = 6). The results suggest noradrenergic mechanisms are relevant to analgesia in back pain. This modest reduction in pain intensity suggests that physicians should carefully weigh the risks and benefits of nortriptyline in chronic back pain without depression.
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PMID:A placebo-controlled randomized clinical trial of nortriptyline for chronic low back pain. 971 47

To understand the relative efficacy of noradrenergic and serotonergic antidepressants as analgesics in chronic back pain without depression, we conducted a randomized, double-blind, placebo-control head-to-head comparison of maprotiline (a norepinephrine reuptake blocker) and paroxetine (a serotonin reuptake blocker) in 103 patients with chronic low back pain. Of these 74 completed the trial; of the 29 who did not complete, 19 were withdrawn because of adverse effects. The intervention consisted of an 8-week course of maprotiline (up to 150 mg daily) or paroxetine (up to 30 mg daily) or an active placebo, diphenhydramine hydrochloride (up to 37.5 mg daily). Patients were excluded for current major depression. Reduction in pain intensity (Descriptor Differential Scale scores) was significantly greater for study completers randomized to maprotiline compared to placebo (P=0.023), and to paroxetine (P=0.013), with a reduction of pain by 45% compared to 27% on placebo and 26% on paroxetine. These results suggest that at standard dosages noradrenergic agents may provide more effective analgesia in back pain than do selective serotonergic reuptake inhibitors.
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PMID:Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity. 1120 64

Two separate trials compared controlled-release (CR) oral oxycodone (administered every 12 hours) with immediate-release (IR) oxycodone (4 times a day) to determine whether patients with chronic pain could be titrated to stable pain control as readily with the CR as with the IR formulation. In one study, 48 patients with cancer pain were randomized to open-label titration with either CR or IR oxycodone (maximum dose, 400 mg/day) for a period of up to 21 days. In a study of similar design, 57 patients with low back pain were titrated with either CR or IR oxycodone (maximum dose, 80 mg/day) for a period of up to 10 days. The majority of patients in both studies were converted to oxycodone from other opioid analgesics. Results of both studies showed no difference between CR and IR oxycodone with respect to both the percentage of patients achieving stable pain control, the time to achieve stable pain control, and the degree of pain control achieved. Among cancer patients, 85% achieved stable analgesia, 92% with the CR formulation and 79% with the IR formulation. Among noncancer patients, 91% achieved stable pain control, 87% with the CR formulation and 96% with the IR formulation. The most commonly reported adverse effects in both studies were similar for the two formulations and were those anticipated with opioids: nausea, vomiting, constipation, somnolence, dizziness, and pruritus. Nausea and vomiting were the most frequently cited reasons for treatment discontinuations. These studies suggest that dose titration can be accomplished as readily with oral CR oxycodone as with IR oxycodone in patients with chronic, moderate to severe pain.
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PMID:Can a controlled-release oral dose form of oxycodone be used as readily as an immediate-release form for the purpose of titrating to stable pain control? 1053 67

Fifty-six patients with low back pain and sciatica following radiological investigation were found to have abnormalities at multiple levels, more than one of which could be responsible for the clinical picture or at a single level, which correlated poorly with the clinical findings. Thirty-four patients had a diagnostic peri-neural root infiltration to clarify whether surgery would be appropriate. Evaluation of the technique was by reduction in analgesia. Eighteen patients have had surgery, 14 with a successful, two a moderate and two a poor outcome. Four patients have been denied and two are awaiting an operation. Ten patients referred for a diagnostic procedure deferred surgery in favour of a therapeutic course. Of 22 patients referred directly for a therapeutic course, 15 had a successful, three a moderate and four a poor result. CT-directed peri-radicular root infiltration is a useful adjunct in the management of low back pain and sciatica.
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PMID:A retrospective study to assess the results of CT-directed peri-neural root infiltration in a cohort of 56 patients with low back pain and sciatica. 1056 40

The study objective was to assess the efficacy and patient acceptance of ketorolac as an alternative to meperidine for the treatment of severe musculoskeletal low back pain (LBP). A double blinded prospective trial in a convenience sample of patients >18 years of age presenting to an urban university hospital emergency department (ED) was conducted over a 19-month period. Patients were included if the pain was musculoskeletal in origin and was severe enough to warrant parenteral analgesics. Patients were randomized to receive 1 mg/kg meperidine intramuscularly (IM) or 60 mg ketorolac IM. Pain intensity was measured preadministration and at 60 minutes via a 100 mm Visual Analog Scale (VAS). Outcomes measured at 60 minutes were pain intensity decrease (PID), patient satisfaction, rescue analgesia requirement, sedation level, and adverse effects. Clinically significant pain reduction was defined as a PID of at least 13 mm or a reduction in pain of least 30%. One hundred fifty-five patients were enrolled (meperidine = 75, ketorolac = 80) and 153 patients completed the study. At 60 minutes the mean PID was 7 mm less in the ketorolac group (95% confidence interval [CI] - 15 mm to 2.6 mm). Pain reduction of at least 30% occurred in 63% of the ketorolac group versus 67% of the meperidine group (95% CI, odds ratio [OR] .43 to 1.61). Rescue analgesia was required in 35% of the ketorolac group versus 37% of the meperidine group (95% CI, OR .47 to 1.74). Patient satisfaction was less in the ketorolac group (ketorolac 68% satisfied versus meperidine 74% satisfied) however this was not significant (95% CI, OR .66 to 2.72). Sedation level and adverse effects were significantly greater in the meperidine group. Ketorolac shows comparable single dose analgesic efficacy to a single moderate dose of meperidine with less sedation and adverse effects in an ED population with severe musculoskeletal LBP. The trend for greater pain reduction and patient satisfaction with meperidine needs further investigation.
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PMID:Ketorolac versus meperidine: ED treatment of severe musculoskeletal low back pain. 1091 28

The experience of anger (i.e. trait anger) and anger management style (i.e. anger-in, anger-out) are related to sensitivity to acute and chronic pain stimuli, although underlying mechanisms are unknown. This study tested whether anger variables are associated with impaired endogenous opioid antinociceptive activity, and whether these relationships differed between chronic pain patients and healthy normals. Forty-three chronic low back pain (LBP) sufferers and 45 pain-free normals received opioid blockade (8 mg naloxone i.v.) or placebo blockade (saline) in randomized, counterbalanced order in separate sessions. During each session, subjects participated in a 1-min finger pressure pain task followed by an ischemic forearm pain task (maximum duration 5 min), providing pain intensity ratings during and immediately following each task. As a measure of opioid antinociceptive function, drug effects were derived by subtracting placebo from blockade condition pain ratings. Multivariate general linear model analyses indicated that anger-out, but not anger-in, had significant main effects on both finger pressure drug effects (P < 0.05) and ischemic task drug effects (P < 0.05). As hypothesized, high anger-out scores were associated with an absence of opioid analgesia during the acute pain tasks; low anger-out scores were associated with effective opioid analgesia. A similar non-significant trend was noted for trait anger on finger pressure drug effects (P < 0.06). Anger-out x LBP/normal interactions were non-significant, suggesting that links between anger-out and drug effects were similar for patients and normals. Controlling for depression did not eliminate the significant relationship between anger-out and drug effects. Findings suggest that anger-in and anger-out affect pain sensitivity through different mechanisms: only the effects of anger-out may be mediated by endogenous opioid dysfunction.
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PMID:Anger and pain sensitivity in chronic low back pain patients and pain-free controls: the role of endogenous opioids. 1223

Since there have been side effects reported with the administration of corticosteroids epidurally, their application has been limited. Because some nonsteroidal antiinflammatory drugs have central and spinal antinociceptive actions, we have compared the effects of indomethacin (INM) given by the epidural route to methylprednisolone (MTP). This was a prospective, comparative study in an ambulatory pain care center. Two hundred six patients with recurrent low back pain (Visual Analog Scale >7) and radiculopathy after they had had 2 or more lumbar laminectomies with the diagnosis of "postlaminectomy syndrome" were randomly assigned to 1 of 3 groups. Group I (64 patients) was given 2 epidural injections of lyophilized INM 1 mg. Group II (60 patients) received 2 injections of 2 mg of INM at the same intervals. Group III (82 patients) was treated by 2 epidural injections of MTP 80 mg. In every case, the medication was diluted in 3 mL of 0.5% bupivacaine. Reductions of pain were assessed by changes in the Visual Analog Scale; physical activities, attitude, and medication intake were graded by the Pain Progress Score recorded before each treatment and 2 wk after the last. After each injection, all patients had pain relief to Visual Analog Scale <3. Increased analgesia (P < 0.05) was noted when a double dose of INM was used (Group II) or when 80 mg of MTP was given. The total average scores of the Pain Progress Score showed significant differences at the second injection in Groups II and III only. Physical activity, emotional attitudes, and medication intake were also improved but the changes were not statistically significant. In conclusion, in this group of patients, INM produced adequate analgesia in Groups I and II, with evidence suggesting that 2 mg of INM may produce a similar degree of pain relief as 80 mg of MTP after the second injection. Other nonsteroidal antiinflammatory drugs may be explored in the future for the same purpose.
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PMID:Epidural injections of indomethacin for postlaminectomy syndrome: a preliminary report. 1253 97

The role of the coxibs in the management of osteoarthritis and rheumatoid arthritis has been widely discussed, but there are other potential applications for the coxibs that have received less attention. Here we consider the use of the coxibs in acute pain syndromes such as primary dysmenorrhea and the pain associated with dental extraction, as well as considering their application in chronic low back pain and cancer pain. Another area where the coxibs may prove particularly beneficial is in the management of post-surgical pain. Traditional post-surgical analgesia has involved the use of non-selective NSAIDs and opioids, but these agents can be associated with side effects such as post-operative bleeding, gastrointestinal problems, nausea, and constipation. Because the coxibs do not inhibit COX-1 dependent platelet aggregation like traditional NSAIDs, the risk of post-surgical bleeding is reduced. The careful application of coxibs as part of a multi-modal approach to pain management in the perioperative period can reduce the requirement for opioid medications and thus reduce the risk of post-operative complications such as ileus. In the future, coxibs are likely to play an important role in multi-modal perioperative analgesic regimens with the aim of reducing post-operative periods of convalescence.
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PMID:Strategies in pain management: new and potential indications for COX-2 specific inhibitors. 1260 54

The effect of opioid analgesia on tests of muscular function in chronic low back pain (CLBP) is unknown. Twenty-eight subjects with CLBP of at least moderate intensity performed the Sorensen isokinetic exercise test once after receiving 1 microg/kg fentanyl intravenously and once after placebo in a randomized-order double-blind crossover design. Naloxone 3 microg/kg was administered after the fentanyl phase. Fentanyl reduced mean+/-SD pain from 4.0+/-2.1 to 3.1+/-2.2 on a 0-10 verbal rating scale (P<0.05). Mean+/-SD Sorensen test performance was 77+/-49 s in the fentanyl arm and 60+/-42 s in the placebo arm. This represents an increased performance with fentanyl of 28% (P<0.001). We conclude that in addition to relieving pain in CLBP, the administration of 1 microg/kg fentanyl is associated with an improvement in lumbar exercise test performance. We presume that the pain relief resulted in increased test performance. Our result is at odds with those of randomized trials which have failed to demonstrate increased function following the treatment of pain with opioid analgesics. This highlights the complexity of the interaction between pain, analgesia and changes in function.
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PMID:The effect of opioid analgesia on exercise test performance in chronic low back pain. 1458 Nov 18

Rofecoxib was the first specific inhibitor of cyclooxygenase-2 (COX-2) approved for the treatment of acute pain. It has been shown to provide analgesia that is significantly better than placebo and has an onset of action and efficacy similar to that of traditional nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen. In addition, the analgesic efficacy of rofecoxib has been demonstrated to be superior to that of the opioid combination of codeine 60 mg/acetaminophen 600 mg in an acute dental pain model. For the treatment of acute pain, the efficacy of rofecoxib was further demonstrated in a study of patients who had undergone orthopedic surgery. Rofecoxib has been found to be as effective as naproxen sodium and more effective than placebo in studies evaluating its use for the treatment of primary dysmenorrhea. In patients with osteoarthritis (OA) of the knee or hip, rofecoxib is superior to placebo and similar to diclofenac and ibuprofen in relieving OA pain and improving physical function. Rofecoxib has also been shown to be superior to acetaminophen and celecoxib after 6 weeks of treatment for OA. The efficacy of rofecoxib has also been demonstrated in patients with rheumatoid arthritis and low back pain. The advantages of using COX-2-specific NSAIDs include convenient once-daily dosing schedule and improved safety compared with traditional NSAIDs. Two large outcomes studies, VIGOR and CLASS, have shown that gastric mucosal ulceration occurs significantly less often in patients taking COX-2-specific inhibitors than in those treated with ibuprofen, diclofenac, or naproxen and occurs with a similar incidence to that of placebo. Absence of any effect on platelet aggregation and bleeding time further distinguishes these agents from traditional NSAIDs. Because COX-2-specific inhibitors do not have an antiplatelet effect, they cannot be used as a substitute for low-dose aspirin for cardiovascular prophylaxis. Rofecoxib is a safe and highly effective alternative to previously available NSAIDs and should be considered for the treatment of acute pain conditions in adult patients, especially those at risk for developing gastrointestinal complications. It is preferred in the perioperative setting because of its analgesic efficacy and lack of platelet effects. Because of its more favorable gastrointestinal toxicity profile compared with nonselective NSAIDs, rofecoxib is safer in patients, especially older patients, for whom chronic anti-inflammatory or analgesic therapy is indicated.
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PMID:The role of rofecoxib, a cyclooxygenase-2-specific inhibitor, for the treatment of non-cancer pain: a review. 1462 51


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