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1.  Laparoscopic Adhesiolysis and Relief of Chronic Pelvic Pain 
Objective:
To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy.
Methods:
Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief.
Results:
We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50% or no pain relief. Some patients required between 1 and 3 subsequent laparoscopic adhesiolysis. A total of 3 enterotomies and 2 cystotomies occurred, all of which were repaired laparoscopically.
Conclusion:
We conclude that laparoscopic enterolysis may offer significant long-term relief of chronic pelvic pain in some patients.
PMCID: PMC3113188  PMID: 11051185
Laparoscopy; Adhesiolysis; Pain relief; Complications
2.  Treatments for Chronic Pain in Persons With Spinal Cord Injury: A Survey Study 
Background/Objective:
To determine the degree and duration of pain relief provided by specific pain treatments used by individuals with spinal cord injury (SCI) who have chronic pain.
Design:
Postal survey.
Setting:
Community.
Participants:
Participants were 117 individuals who had traumatic SCI, were 18 years of age or older, and reported a chronic pain problem.
Main Outcome Measures:
Questions assessing current or past use of 26 different pain treatments, the amount of relief each treatment provided, and the length of time that any pain relief usually lasts.
Results:
The medications tried most often were nonsteroidal anti-inflammatory drugs (tried by 71%) and acetaminophen (tried by 70%); these medications were still being used by more than one half of the patients who had tried them. Opioids produced the greatest degree of pain relief on average (mean, 6.27 ± 3.05 [SD] on a 0–10 scale, with 0 = no relief and 10 = complete relief) but were unlikely to be continued by those who tried them. Although 38% of respondents with pain had tried gabapentin, only 17% were still using it, and average pain relief was only moderate (mean, 3.32 ± 3.03 on the 0–10 relief scale). Seventy-three percent of the respondents had tried at least 1 of 7 alternative pain treatments, and the most frequently tried were massage, marijuana, and acupuncture. The most relief was provided by massage (mean, 6.05 ± 2.47] on the 0–10 relief scale) and marijuana (mean, 6.62 ± 2.54 on the 0–10 relief scale). The relief from the various treatments, including most medications, tended to last only minutes or hours; however, pain relief from alternative treatments such as massage, acupuncture, and hypnosis was reported to last for days in 25% to 33% of those who tried these treatments.
Conclusions:
Many patients are not finding adequate pain relief from commonly prescribed medications. Alternative therapies should be considered as additional treatment options in this population.
PMCID: PMC1864800  PMID: 16739554
Spinal cord injuries; Pain; Chronic; Neuropathic; Musculoskeletal; Analgesia; Gabapentin; Massage; Acupuncture; Alternative therapy
3.  Pain relief in labor: a survey of awareness, attitude, and practice of health care providers in Zaria, Nigeria 
Journal of Pain Research  2011;4:227-232.
Background:
The purpose of this study was to assess the attitudes of maternal health care providers to pain relief during labor in Zaria, Nigeria.
Methods:
This was a multicenter, collaborative, cross-sectional pilot study of provider perspectives concerning pain relief during labor. A structured, self-administered, questionnaire was completed by 95 consenting maternal health care providers at three high-volume facilities in Zaria, an ancient northern Nigerian city. Descriptive statistics was performed on the data.
Results:
Most respondents (94.8%) agreed that pain relief is needed during labor. Only 2.1% of respondents were undecided about the provision of pain relief during labor and 3.2% were of the opinion that pain relief was not necessary during labor. Most respondents (93.7%) had attended a woman in labor in the 4 weeks preceding the survey. Of these, 56.8% had counseled a parturient in labor. Most of the counseling (42.1%) took place during labor. Less than half of the respondents (48.4%) had administered pain relief in labor in the preceding 4 weeks and systemic opioids was the most commonly form of pain relief. Among the respondents who did not offer pain relief agents in labor, the majority (54.5%) had no reason for not offering it. Unavailability of methods, inability to afford the cost of pain relief, lack of knowledge and skills, as well as lack of essential equipment to provide the procedure were also given by respondents as reasons for not offering pain relief.
Conclusion:
Even though maternal health care providers in this environment have a positive attitude to pain relief in labor, most women go through labor without the benefit of analgesia. There exists a gap between provider attitudes to pain relief in labor and practice of the same, with many providers having no genuine reason(s) for not offering pain relief to their clients during labor. Providers need to align their practice to their attitudes, and need to be helped to do this through training as well as enhancing their ability to think critically about their practice.
doi:10.2147/JPR.S21085
PMCID: PMC3160836  PMID: 21887120
pain relief; providers; attitudes; practice; labor; conflict
4.  Single dose oral paracetamol (acetaminophen) with codeine for postoperative pain in adults 
Background
This is an updated version of the Cochrane review published in Issue 4, 1998. Combining drugs from different classes with different modes of action may offer opportunity to optimise efficacy and tolerability, using lower doses of each drug to achieve the same degree of pain relief. Previously we concluded that addition of codeine to paracetamol provided additional pain relief, but at expense of additional adverse events. New studies have been published since. This review sought to evaluate efficacy and safety of paracetamol plus codeine using current data, and compare findings with other analgesics evaluated similarly.
Objectives
Assess efficacy of single dose oral paracetamol plus codeine in acute postoperative pain, increase in efficacy due to the codeine component, and associated adverse events.
Search methods
We searched CENTRAL, MEDLINE, EMBASE, the Oxford Pain Relief Database in October 2008 for this update.
Selection criteria
Randomised, double-blind, placebo-controlled trials of paracetamol plus codeine, compared with placebo or the same dose of paracetamol alone, for relief of acute postoperative pain in adults.
Data collection and analysis
Two authors assessed trial quality and extracted data. The area under the “pain relief versus time” curve was used to derive proportion of participants with paracetamol plus codeine and placebo or paracetamol alone experiencing least 50% pain relief over four-to-six hours, using validated equations. Number-needed-to-treat-to-benefit (NNT) was calculated using 95% confidence intervals (CIs). Proportion of participants using rescue analgesia over a specified time period, and time to use of rescue analgesia, were sought as additional measures of efficacy. Information on adverse events and withdrawals were collected.
Main results
Twenty-six studies, with 2295 participants, were included comparing paracetamol plus codeine with placebo. Significant dose response was seen for the outcome of at least 50% pain relief over four-to-six hours, with NNTs of 2.2 (95% CI 1.8 to 2.9) for 800 to 1000 mg paracetamol plus 60 mg codeine, 3.9 (2.9 to 4.5) for 600 to 650 mg paracetamol plus 60 mg codeine, and 6.9 (4.8 to 12) for 300 mg paracetamol plus 30 mg codeine. Time to use of rescue medication was over four hours with paracetamol plus codeine and two hours with placebo. The NNT to prevent remedication was 5.6 (4.0 to 9.0) for 600 mg paracetamol plus 60 mg codeine over four to six hours. Adverse events increased of mainly mild to moderate severity with paracetamol plus codeine than placebo.
Fourteen studies, with 926 participants, were included in the comparison of paracetamol plus codeine with the same dose of paracetamol alone. Addition of codeine increased proportion of participants achieving at least 50% pain relief over four-to-six hours by 10 to 15%, increased time to use of rescue medication by about one hour, and reduced proportion of participants needing rescue medication by about 15% (NNT to prevent remedication 6.9 (4.2 to 19). Adverse events were mainly mild to moderate in severity and incidence did not differ between groups.
Authors’ conclusions
This update confirms previous findings that combining paracetamol with codeine provided clinically useful levels of pain relief in about 50% of patients with moderate to severe postoperative pain, compared with under 20% with placebo. New information for remedication shows that the combination extended the duration of analgesia by about one hour compared to treatment with the same dose of paracetamol alone. At higher doses, more participants experienced adequate pain relief, but the amount of information available for the 1000 mg paracetamol plus 60 mg codeine dose was small, and based on limited information.
doi:10.1002/14651858.CD001547.pub2
PMCID: PMC4171965  PMID: 19160199
Acetaminophen [*administration & dosage; adverse effects]; Administration, Oral; Analgesics, Non-Narcotic [*administration & dosage; adverse effects]; Analgesics, Opioid [*administration & dosage; adverse effects]; Codeine [*administration & dosage]; Drug Therapy, Combination; Pain, Postoperative [*drug therapy]; Adult; Humans
5.  Microcoagulation of Junctional Dorsal Root Entry Zone is Effective Treatment of Brachial Plexus Avulsion Pain: Long-term Follow-up Study 
Croatian medical journal  2006;47(2):271-278.
Aim
To analyze long-term clinical results of coagulation lesions of the dorsal root entry zone (DREZ) in patients with deafferentation pain due to brachial plexus avulsion and to correlate the pain relief after DREZ coagulation with pain duration before the DREZ coagulation.
Methods
Twenty-six patients with intractable deafferentation pain after brachial plexus avulsion lesion were treated for pain at the Department of Neurosurgery. Junctional coagulation lesion was made with bipolar forceps along the DREZ. The patients assessed post-operative analgesic effect using a visual analog scale at 1 week, 1 year, 3 years, and 5 years after the surgery.
Results
The greatest pain relief was reported immediately after the DREZ procedure. Over the 5-year follow-up period, the pain relief effect gradually and significantly decreased. There were no significant differences between the pain relief evaluated at 1 week and after 1 year and between the pain relief evaluated at 1 week and after 3 years. There was a correlation between the pain duration before the surgery and pain relief after the surgery, with best correlation found between pain duration before surgery and pain relief 5 years after DREZ procedure (r = 0.623, P = 0.007).
Conclusion
The long-term follow up showed that the pain relief gradually decreased over 5 years after surgery. However, the pain relief still did not significantly decrease after 3 years.
PMCID: PMC2080390  PMID: 16625692
6.  Prescription opioid use among addictions treatment patients : Nonmedical use for pain relief vs. other forms of nonmedical use 
Addictive behaviors  2012;38(3):1776-1781.
Background
Differences between those who engage in nonmedical prescription opioid use for reasons other than pain relief and those who engage in nonmedical use for reasons related to pain only are not well understood.
Methods
Adults in a residential treatment program participated in a cross-sectional self-report survey. Participants reported whether they used opioids for reasons other than pain relief (e.g., help sleep, improve mood, or relieve stress). Within those with past-month nonmedical opioid use (n=238), logistic regression tested differences between those who reported use for reasons other than pain relief and those who did not.
Results
Nonmedical use of opioids for reasons other than pain relief was more common (66%) than nonmedical use for pain relief only (34%), and those who used for reasons other than pain relief were more likely to report heavy use (43% vs. 11%). Nonmedical use for reasons other than pain relief was associated with having a prior overdose (Odds Ratio [OR]=2.54), 95% CI:1.36-4.74) and use of heroin (OR=4.08, 95% CI:1.89-8.79), barbiturates (OR=6.44, 95% CI:1.47, 28.11), and other sedatives (OR=5.80, 95% CI: 2.61, 12.87). Individuals who reported nonmedical use for reasons other than pain relief had greater depressive symptoms (13.1 vs. 10.5) and greater pain medication expectancies across all three domains (pleasure/social enhancement, pain reduction, negative experience reduction).
Conclusions
Among patients in addictions treatment, individuals who report nonmedical use of prescription opioids for reasons other than pain relief represent an important clinical sub-group with greater substance use severity and poorer mental health functioning.
doi:10.1016/j.addbeh.2012.11.005
PMCID: PMC4049343  PMID: 23254228
prescription opioids; nonmedical use; pain; addictions treatment
7.  Single dose dipyrone for acute postoperative pain 
Background
Dipyrone (metamizole) is a non-steroidal anti-inflammatory drug used in some countries to treat pain (postoperative, colic, cancer, and migraine); it is banned in others because of an association with life-threatening blood agranulocytosis. This review updates a 2001 Cochrane review, and no relevant new studies were identified, but additional outcomes were sought.
Objectives
To assess the efficacy and adverse events of single dose dipyrone in acute postoperative pain.
Search methods
The earlier review searched CENTRAL, MEDLINE, EMBASE, LILACS and the Oxford Pain Relief Database to December 1999. For the update we searched CENTRAL, MEDLINE,EMBASE and LILACS to February 2010.
Selection criteria
Single dose, randomised, double-blind, placebo or active controlled trials of dipyrone for relief of established moderate to severe postoperative pain in adults. We included oral, rectal, intramuscular or intravenous administration of study drugs.
Data collection and analysis
Studies were assessed for methodological quality and data extracted by two review authors independently. Summed total pain relief over six hours (TOTPAR) was used to calculate the number of participants achieving at least 50% pain relief. Derived results were used to calculate, with 95% confidence intervals, relative benefit compared to placebo, and the number needed to treat (NNT) for one participant to experience at least 50% pain relief over six hours. Use and time to use of rescue medication were additional measures of efficacy. Information on adverse events and withdrawals was collected.
Main results
Fifteen studies tested mainly 500 mg oral dipyrone (173 participants), 2.5 g intravenous dipyrone (101), 2.5 g intramuscular dipyrone (99); fewer than 60 participants received any other dose. All studies used active controls (ibuprofen, paracetamol, aspirin, flurbiprofen, ketoprofen, dexketoprofen, ketorolac, pethidine, tramadol, suprofen); eight used placebo controls.
Over 70% of participants experienced at least 50% pain relief over 4 to 6 hours with oral dipyrone 500 mg compared to 30% with placebo in five studies (288 participants; NNT 2.4 (1.9 to 3.2)). Fewer participants needed rescue medication with dipyrone (7%) than with placebo (34%; four studies, 248 participants). There was no difference in participants experiencing at least 50% pain relief with 2.5 g intravenous dipyrone and 100 mg intravenous tramadol (70% vs 65%; two studies, 200 participants). No serious adverse events were reported.
Authors’ conclusions
Based on very limited information, single dose dipyrone 500 mg provides good pain relief to 70% of patients. For every five individuals given dipyrone 500 mg, two would experience this level of pain relief who would not have done with placebo, and fewer would need rescue medication, over 4 to 6 hours.
doi:10.1002/14651858.CD003227.pub2
PMCID: PMC4160844  PMID: 20824835
Acute Disease; Anti-Inflammatory Agents, Non-Steroidal [*administration & dosage; adverse effects]; Dipyrone [*administration & dosage; adverse effects]; Pain, Postoperative [*drug therapy]; Randomized Controlled Trials as Topic; Humans
8.  Between pain and pleasure: Pregnant women's knowledge and preferences for pain relief in labor, a pilot study from Zaria, Northern Nigeria 
Saudi Journal of Anaesthesia  2014;8(Suppl 1):S20-S24.
Background:
Pain relief in labor remains a hot topic and these debates get louder by the day as more women become aware of their rights to better quality of care in labor. This study was conceived in a background where the practice of pain relief in labor is evolving and where women are seeking to fulfill their need for pain-free labor.
Objective:
To investigate the knowledge, utilization and preferences of methods of pain relief in labor by expectant mothers in order to design a labor analgesia program.
Materials and Methods:
A questionnaire-based descriptive study involving 124 antenatal clients in a teaching hospital over a 1 week period. Descriptive statistics were carried out using SPSS for windows version 17.
Results:
The mean age of clients was 28.8 years (standard deviation = 5.17) with median parity of two and mean gestational age was 31.5 weeks. Majority of the respondents (47.9%) were of Hausa/Fulani ethnicity and 97.6% had primary school level education. Majority (87.3%) had heard about pain relief methods with the hospital being the source in 79% of cases. The most common method ever heard about was epidural analgesia (69.4%). Only 4% (n = 5) of respondents remembered ever using any form of pain relief agent in labor, of which three received parenteral opioids. In their current pregnancies, 45.2% consented to the use of pain relief in labor; of which, epidural analgesia was preferred by 92.9% (n = 52). Fear of adverse effects on self and infants were cited as reasons for non-consent by some respondents while others had no reason.
Conclusion:
The study reveals a high awareness of pain relief methods which is not matched by utilization and low knowledge about side-effects, although fear of side-effects is a factor for under-utilization. There is a need to educate adequately as well provide high quality pain relief services in labor in order to dispel with myths, misconceptions and fears associated with the use of methods of pain relief in labor.
doi:10.4103/1658-354X.144059
PMCID: PMC4268522  PMID: 25538515
Antenatal clients; epidural analgesia; knowledge; labor; Pain relief; preferences
9.  Remifentanil patient controlled analgesia versus epidural analgesia in labour. A multicentre randomized controlled trial 
Background
Pain relief during labour is a topic of major interest in the Netherlands. Epidural analgesia is considered to be the most effective method of pain relief and recommended as first choice. However its uptake by pregnant women is limited compared to other western countries, partly as a result of non-availability due to logistic problems. Remifentanil, a synthetic opioid, is very suitable for patient controlled analgesia. Recent studies show that epidural analgesia is superior to remifentanil patient controlled analgesia in terms of pain intensity score; however there was no difference in satisfaction with pain relief between both treatments.
Methods/design
The proposed study is a multicentre randomized controlled study that assesses the cost-effectiveness of remifentanil patient controlled analgesia compared to epidural analgesia. We hypothesize that remifentanil patient controlled analgesia is as effective in improving pain appreciation scores as epidural analgesia, with lower costs and easier achievement of 24 hours availability of pain relief for women in labour and efficient pain relief for those with a contraindication for epidural analgesia.
Eligible women will be informed about the study and randomized before active labour has started. Women will be randomly allocated to a strategy based on epidural analgesia or on remifentanil patient controlled analgesia when they request pain relief during labour. Primary outcome is the pain appreciation score, i.e. satisfaction with pain relief.
Secondary outcome parameters are costs, patient satisfaction, pain scores (pain-intensity), mode of delivery and maternal and neonatal side effects.
The economic analysis will be performed from a short-term healthcare perspective. For both strategies the cost of perinatal care for mother and child, starting at the onset of labour and ending ten days after delivery, will be registered and compared.
Discussion
This study, considering cost effectiveness of remifentanil as first choice analgesia versus epidural analgesia, could strongly improve the care for 180.000 women, giving birth in the Netherlands yearly by giving them access to pain relief during labour, 24 hours a day.
Trial registration number
Dutch Trial Register NTR2551, http://www.trialregister.nl
doi:10.1186/1471-2393-12-63
PMCID: PMC3464937  PMID: 22748068
Analgesia; Labour; Remifentanil; Patient controlled analgesia; Epidural
10.  Ibuprofen with or without an antiemetic for acute migraine headaches in adults 
Background
Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers do not seek professional help, relying instead on over-the-counter analgesics. Co-therapy with an antiemetic should help to reduce symptoms commonly associated with migraine headaches.
Objectives
To determine efficacy and tolerability of ibuprofen, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults.
Search methods
We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies through 22 April 2010.
Selection criteria
We included randomised, double-blind, placebo- or active-controlled studies using self-administered ibuprofen to treat a migraine headache episode, with at least 10 participants per treatment arm.
Data collection and analysis
Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and number needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment.
Main results
Nine studies (4373 participants, 5223 attacks) compared ibuprofen with placebo or other active comparators; none combined ibuprofen with a self-administered antiemetic. All studies treated attacks with single doses of medication. For ibuprofen 400 mg versus placebo, NNTs for 2-hour pain-free (26% versus 12% with placebo), 2-hour headache relief (57% versus 25%) and 24-hour sustained headache relief (45% versus 19%) were 7.2, 3.2 and 4.0, respectively. For ibuprofen 200 mg versus placebo, NNTs for 2-hour pain-free (20% versus 10%) and 2-hour headache relief (52% versus 37%) were 9.7 and 6.3, respectively. The higher dose was significantly better for 2-hour headache relief than the lower dose. Soluble formulations of ibuprofen 400 mg were better than standard tablets for 1-hour, but not 2-hour headache relief.
Associated symptoms of nausea, vomiting, photophobia and phonophobia and functional disability were reduced within 2 hours, and fewer participants used rescue medication with ibuprofen compared with placebo. Similar numbers of participants experienced adverse events, which were mostly mild and transient.
Ibuprofen 400 mg did not differ from rofecoxib 25 mg for 2-hour headache relief, 24-hour headache relief or use of rescue medication.
Authors’ conclusions
Ibuprofen is an effective treatment for acute migraine headaches, providing pain relief in about half of sufferers, but complete relief from pain and associated symptoms for only a minority. NNTs for all efficacy outcomes were better with 400 mg than 200 mg in comparisons with placebo, and soluble formulations provided more rapid relief. Adverse events were mostly mild and transient, occurring at the same rate as with placebo.
doi:10.1002/14651858.CD008039.pub2
PMCID: PMC4161114  PMID: 20927770
Administration, Oral; Analgesics, Non-Narcotic [* therapeutic use]; Antiemetics [* therapeutic use]; Drug Therapy, Combination [methods]; Ibuprofen [* therapeutic use]; Migraine Disorders [* drug therapy]; Randomized Controlled Trials as Topic; Adult; Humans
11.  Pain acceptance and personal control in pain relief in two maternity care models: a cross-national comparison of Belgium and the Netherlands 
Background
A cross-national comparison of Belgian and Dutch childbearing women allows us to gain insight into the relative importance of pain acceptance and personal control in pain relief in 2 maternity care models. Although Belgium and the Netherlands are neighbouring countries sharing the same language, political system and geography, they are characterised by a different organisation of health care, particularly in maternity care. In Belgium the medical risks of childbirth are emphasised but neutralised by a strong belief in the merits of the medical model. Labour pain is perceived as a needless inconvenience easily resolved by means of pain medication. In the Netherlands the midwifery model of care defines childbirth as a normal physiological process and family event. Labour pain is perceived as an ally in the birth process.
Methods
Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Two questionnaires were filled out by 611 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth either at home or in a hospital. However, only women having a hospital birth without obstetric intervention (N = 327) were included in this analysis. A logistic regression analysis has been performed.
Results
Labour pain acceptance and personal control in pain relief render pain medication use during labour less likely, especially if they occur together. Apart from this general result, we also find large country differences. Dutch women with a normal hospital birth are six times less likely to use pain medication during labour, compared to their Belgian counterparts. This country difference cannot be explained by labour pain acceptance, since - in contrast to our working hypothesis - Dutch and Belgian women giving birth in a hospital setting are characterised by a similar labour pain acceptance. Our findings suggest that personal control in pain relief can partially explain the country differences in coping with labour pain. For Dutch women we find that the use of pain medication is lowest if women experience control over the reception of pain medication and have a positive attitude towards labour pain. In Belgium however, not personal control over the use of pain relief predicts the use of pain medication, but negative attitudes towards labour.
Conclusions
Apart from individual level determinants, such as length of labour or pain acceptance, our findings suggest that the maternity care context is of major importance in the study of the management of labour pain. The pain medication use in Belgian hospital maternity care is high and is very sensitive to negative attitudes towards labour pain. In the Netherlands, on the contrary, pain medication use is already low. This can partially be explained by a low degree of personal control in pain relief, especially when co-occurring with positive pain attitudes.
doi:10.1186/1472-6963-10-268
PMCID: PMC2944275  PMID: 20831798
12.  Early migraine intervention with sumatriptan 100 mg in patients with a history of nonresponse to sumatriptan 50 mg: an open-label, prospective study of multiple attacks 
Background
Early treatment with sumatriptan tablets (50 and 100 mg) has been shown to be effective in retrospective and prospective study designs. Despite the efficacy of sumatriptan 50 mg and early intervention, however, some patients continue not to respond completely to this dose. New evidence with a scientific basis for early intervention suggests that some patients may need to treat early to prevent the establishment of central sensitization. Also, patients cite complete pain relief as the most important attribute of a migraine medication.
Objective
The primary objective of this study was to determine the 2-hour efficacy of sumatriptan 100 mg in achieving complete pain relief in patients with a history of nonresponse to sumatriptan 50 mg in an early-intervention treatment paradigm. Secondary end points included complete pain relief at 4 hours, consistency of complete relief in at least 2 of 3 attacks, sustained complete relief over 24 hours, satisfaction with the 100-mg dose, and relief of associated symptoms.
Methods
This open-label, prospective study was conducted at the Wesley Headache Clinic (Memphis, Tennessee). Male and female patients between the ages of 18 and 65 years who fulfilled International Headache Society classification criteria for migraine, and who had a documented history of nonresponse to sumatriptan 50 mg at 2 hours after dosing when treating in the early, mild-pain phase in at least 2 of 3 migraine attacks were eligible for the study. Patients were instructed to receive one 100-mg sumatriptan tablet at the earliest sign of pain, while still mild, in 3 subsequent migraine attacks. After each treated attack, patients were to record a detailed diary entry.
Results
Twenty patients (17 women, 3 men; mean age, 44 years) treated all 3 migraines during the early, mild-pain phase and completed the study. Of the 60 attacks treated, 48 (80%) were pain free at 2 hours, 56 (93%) were pain free at 4 hours, and 45 (75%) were pain free at 2 hours and continued to be pain free at 24 hours (sustained pain-free response). Sumatriptan 100 mg was well tolerated; none of the patients reported any adverse events.
Conclusions
In this study of migraineurs with a history of nonresponse to sumatriptan 50 mg at 2 hours after dosing in the early, mild-pain phase of migraine, increasing the dose of sumatriptan from 50 mg to 100 mg in the early-intervention paradigm, in most attacks complete pain relief was achieved for up to 24 hours. Because patients have indicated that becoming pain free was their therapeutic goal, based on the results of this study, physicians may want to consider increasing the dose of sumatriptan to 100 mg at the first sign of pain if the patient has consistently not responded to sumatriptan 50 mg in the early-intervention model.
doi:10.1016/j.curtheres.2004.06.003
PMCID: PMC3964575  PMID: 24672090
early intervention; nonresponders; migraine; sumatriptan
13.  Ethanol Sclerotherapy Reduces Pain in Symptomatic Musculoskeletal Hemangiomas 
Abstract
Hemangiomas, benign vascular lesions, require intervention if causing pain or functional limitations. Functional deficits are common after excision, favoring minimally invasive treatments. To determine whether ethanol sclerotherapy reduces pain and lesion size and to assess complications in symptomatic musculoskeletal hemangiomas, we retrospectively reviewed 19 patients (six males, 13 females; mean age, 34 years) meeting criteria of confirmed hemangioma, treatment with ethanol sclerotherapy, and minimum of 6 weeks of followup. Fourteen were primary lesions and five were recurrent; all were painful. Thirty-eight sclerotherapy procedures were performed, with each patient undergoing a maximum of three procedures. Mean followup was 24 months (range, 2–95 months). Four patients reported full pain relief, 11 had partial relief, and four had no relief. With recurrent lesions, one patient had full pain relief, one had partial relief, and three had no relief. For patients with lesions larger than 5 cm, two had full relief, six had partial relief, and three had no relief. Lesion shrinkage occurred in 12 patients. Temporary complications included paresthesiae (three), tendon contracture (one), skin breakdown (one), and deep vein thrombosis (one). Ethanol sclerotherapy afforded prompt pain relief in 15 of 19 patients with hemangioma, making it a reasonable option for initially avoiding surgical excision. However, the short followup of our patients requires additional long-term studies to assess the duration of the results.
Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-0919-2
PMCID: PMC2758985  PMID: 19536604
14.  The Efficacy of Repeated Radiofrequency Medial Branch Neurotomy for Lumbar Facet Syndrome 
Objective
Radiofrequency (RF) medial branch neurotomy is an effective management of lumbar facet syndrome. However, pain may recur after period of time. When pain recurs, it can be repeated, but the successful outcome and duration of relief from repeated procedures are not clearly known. The objective of this study was to determine the success rate and duration of pain relief from repeated radiofrequency medial branch neurotomy for lumbar facet syndrome.
Methods
A retrospective review of medical records was done on 60 consecutive patients, from March of 2006 to February of 2009, who had an initial successful RF neurotomy but subsequently underwent repeated procedures due to recurrence of pain. All procedures were done in carefully selected patients after at least two responsive medial branch nerve blocks. C-arm fluoroscopic guide, impedance, sensory and motor threshold monitoring tools were used for the precise placement of electrodes. Responses of repeated procedures were compared with initial radiofrequency neurotomy for success rates and duration of pain relief.
Results
There were 48 females and 12 males. Mean age was 52.4 years (range, 26-83). RF medial branch neurotomy was done on one side in 38 and both sides in 22 patients, each covering at least three segments. Average visual analog scale at last procedure was 6.8. Twelve patients had previous lumbar operations, including 4 patients with instrumentations. Fifty-five patients had two procedures and five patients had three procedures. Mean duration of successful pain relief (> 50% of previous pain for at least 3 months period) after initial radiofrequency neurotomy was 10.9 months (range, 3-28) in 51 (85%) patients. From repeated procedures, successful pain relief was seen in 50 (91%) patients with average duration of 10.2 months (range, 3-24). Five patients had third procedure, which was successful in 4 (80%) patients with mean duration of 9.8 months (range, 5-16). This was not statistically different from initial results. There were no permanent neurological complications from the procedures.
Conclusion
Results of this study indicate that the frequency of success and durations of relief from repeated RF medial branch neurotomy for lumbar facet syndrome are similar to initial results that provided relatively prolonged period of pain relief without major side effects. Each procedure seems to provide successful pain relief for about 10 months in more than 85% of carefully selected patients when properly done.
doi:10.3340/jkns.2010.48.3.240
PMCID: PMC2966726  PMID: 21082052
Facet syndrome; Zygapophyseal joint denervation; Radiofrequency neurotomy; Repeat operation; Outcome
15.  More in hope than expectation: a systematic review of women's expectations and experience of pain relief in labour 
BMC Medicine  2008;6:7.
Background
Childbirth is one of the most painful events that a woman is likely to experience, the multi-dimensional aspect and intensity of which far exceeds disease conditions. A woman's lack of knowledge about the risks and benefits of the various methods of pain relief can heighten anxiety. Women are increasingly expected, and are expecting, to participate in decisions about their healthcare. Involvement should allow women to make better-informed decisions; the National Institute for Clinical Excellence has stated that we need effective ways of supporting pregnant women in making informed decisions during labour. Our aim was to systematically review the empirical literature on women's expectations and experiences of pain and pain relief during labour, as well as their involvement in the decision-making process.
Methods
A systematic review was conducted using the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Bath Information and Database Service (BIDS), Excerpta Medica Database Guide (EMBASE), Midwives Information and Resource (MIDIRS), Sociological Abstracts and PsychINFO. Studies that examined experience and expectations of pain, and its relief in labour, were appraised and the findings were integrated into a systematic review.
Results
Appraisal revealed four key themes: the level and type of pain, pain relief, involvement in decision-making and control. Studies predominantly showed that women underestimated the pain they would experience. Women may hope for a labour free of pain relief, but many found that they needed or benefited from it. There is a distinction between women's desire for a drug-free labour and the expectation that they may need some sort of pain relief. Inaccurate or unrealistic expectations about pain may mean that women are not prepared appropriately for labour. Many women acknowledged that they wanted to participate in decision-making, but the degree of involvement varied. Women expected to take control in labour in a number of ways, but their degree of reported control was less than hoped for.
Conclusion
Women may have ideal hopes of what they would like to happen with respect to pain relief, control and engagement in decision-making, but experience is often very different from expectations. Antenatal educators need to ensure that pregnant women are appropriately prepared for what might actually happen to limit this expectation-experience gap and potentially support greater satisfaction with labour.
doi:10.1186/1741-7015-6-7
PMCID: PMC2358911  PMID: 18366632
16.  A Comparison of Change in the 0–10 Numeric Rating Scale to a Pain Relief Scale and Global Medication Performance Scale in a Short-term Clinical Trial of Breakthrough Pain Intensity 
Anesthesiology  2010;112(6):1464-1472.
Background
Pain intensity is commonly reported using a 0–10 numeric rating scale in breakthrough pain clinical trials. Analysis of the change on the Pain Intensity Numerical Rating Scale as a proportion as most consistently correlated with clinically important differences reported on the Patient Global Impression of Change. The analysis of data using a different global outcome measures and the pain relief scale will extend our understanding of these measures. Use of the pain relief scale is also explored in this study
Methods
Data came from the open titration phase of a multiple crossover, randomized, double-blind clinical trial comparing oral transmucosal fentanyl citrate to immediate-release oral morphine sulfate for treatment of cancer-related breakthrough pain. Raw and percent changes in the pain intensity scores on 1,307 from 134 oral transmucosal fentanyl citrate-naive patients were compared to the clinically relevant secondary outcomes of the pain relief verbal response scale and the global medication performance. The changes in raw and percent change were assessed over time and compared to the ordinal pain relief verbal response scale and global medication performance scales.
Results
The p-value of the interaction between the raw pain intensity difference was significant but not for the percent pain intensity difference score over 4 15 minute time periods (p = 0.034 and p = 0.26 respectively), in comparison with the ordinal pain relief verbal response scale (p = 0.0048 and p = 0.36 respectively), and global medication performance categories (p = 0.048 and p = 0.45 respectively).
Conclusion
The change in pain intensity in breakthrough pain was more consistent over time and when compared to both the pain relief verbal response scale and global medication performance scale when the percent change is used rather than raw pain intensity difference.
doi:10.1097/ALN.0b013e3181de0e6d
PMCID: PMC2884191  PMID: 20463579
17.  Cement volume is the most important modifiable predictor for pain relief in BKP: results from SWISSspine, a nationwide registry 
European Spine Journal  2013;22(10):2241-2248.
Purpose
The effectiveness of vertebral augmentation techniques is a currently highly debated issue. The biomechanical literature suggests that cement filling volumes may play an important role in the “dosage” of vertebral augmentation and its pain alleviating effect. Good clinical data about filling volumes are scarce and most patient series are small. Therefore, we investigated the predictors of pain alleviation after balloon kyphoplasty in the nationwide SWISSspine registry where cement volumes are also recorded.
Methods
All single-level vertebral fractures with no additional fracture stabilization and availability of at least one follow-up within 6 months after surgery were included. The following potential predictors were assessed in a multivariate logistic regression model with the group’s average pain alleviation of 41 points on VAS as the desired outcome: patient age, patient sex, diagnosis, preoperative pain, level of fracture, type of fracture, age of fracture, segmental kyphotic deformity, cement volume, vertebral body filling volume, and cement extrusions.
Results
There were 194 female and 82 males with an average age of 70.4 and 65.3 years, respectively. Female patients were about twice as likely for achieving the average pain relief compared to males (p = 0.04). The preoperative pain level was the strongest predictor in that the likelihood for achieving an at least 41-point pain relief increased by about 8 % with each additional point of preoperative pain (p < 0.001). A thoraco-lumbar fracture had a three times higher odds for the average pain relief compared with a lumbar fracture (p = 0.03). An A.3.1 fracture only had about a third of the probability for average pain relief compared with an A.1.1 fracture (p = 0.004). Cement volumes up to 4.5 ml only had an approximately 40 % chance for a minimum 41-point pain alleviation as compared with cement volumes of at least 4.5 ml (p = 0.007). In addition, the relationship between cement volume and pain alleviation followed a dose-dependent pattern.
Conclusions
Cement volume was revealed as a significant predictor for pain relief in BKP. Cement volume was the third most important influential covariate and the most important modifiable and operator dependent one. The clear dose-outcome relationship between cement filling volumes and pain relief additionally supports these findings. Cement volumes of >4.5 ml seem to be recommendable for achieving relevant pain alleviation. Patient sex and fracture type and location were further significant predictors and all these covariates should be recorded and reported in future studies about the pain alleviating effectiveness of vertebral augmentation procedures.
doi:10.1007/s00586-013-2869-3
PMCID: PMC3804705  PMID: 23775292
Kyphoplasty; Predictors; Pain relief; Cement volume; SWISSspine
18.  A randomized, placebo controlled, trial of preoperative sustained release Betamethasone plus non-controlled intraoperative Ketorolac or Fentanyl on pain after diagnostic laparoscopy or laparoscopic tubal ligation [ISRCTN52633712] 
BMC Anesthesiology  2003;3:3.
Background
Gynecological laparoscopic surgery procedures are often complicated by postoperative pain resulting in an unpleasant experience for the patient, delayed discharge, and increased cost. Glucocorticosteroids have been suggested to reduce the severity and incidence of postoperative pain.
Methods
This study examines the efficacy of a sustained release betamethasone preparation to reduce postoperative pain and the requirement for pain relief drugs after either diagnostic laparoscopy or tubal ligation. Patients were recruited, as presenting, after obtaining informed consent. Prior to surgery, patients were randomly selected by a computer generated table to receive either pharmacy-coded betamethasone (12 mg IM Celestone™) or an optically identical placebo injection of Intralipid™ and isotonic saline mixture. The effect of non-controlled prophylactic intraoperative treatment with either fentanyl or ketorolac per surgeon's orders was also noted in this study. Blood samples taken at recovery and at discharge times were extracted and analyzed for circulating betamethasone. Visual analog scale data on pain was gathered at six post-recovery time points in a triple blind fashion and statistically compared. The postoperative requirement for pain relief drugs was also examined.
Results
Although the injection achieved a sustained therapeutic concentration, no beneficial effect of IM betamethasone on postoperative pain or reduction in pain relief drugs was observed during the postoperative period. Indeed, the mean combined pain scores during the 2 hour postoperative period, adjusted for postoperative opioids as the major confounding factor, were higher approaching statistical significance (P = 0.056) in the treatment group. Higher pain scores were also observed for the tubal ligation patients relative to diagnostic laparoscopy. Intraoperative fentanyl treatment did not significantly lower the average pain score during the 2 hour postoperative period. Intraoperative ketorolac treatment significantly lowered (P = 0.027) pain scores and reduced the postoperative requirement for additional pain relief drugs.
Conclusions
There was a lack of efficacy of preoperative sustained release betamethasone in reducing postoperative pain despite maintaining a therapeutic concentration during the postoperative period. Intraoperative Ketorolac did afford some short-term pain relief in the postoperative period and reduced the need for additional pain relief drugs.
doi:10.1186/1471-2253-3-3
PMCID: PMC194702  PMID: 12932277
19.  Dutch women in midwife-led care at the onset of labour: which pain relief do they prefer and what do they use? 
Background
Pain experienced during labour is more extreme than many other types of physical pain. Many pregnant women are concerned about labour pain and about how they can deal with this pain effectively.
The aim of this study was to examine the associations among low risk pregnant women’s characteristics and their preferred use and actual use of pain medication during labour.
Methods
Our study is part of the DELIVER study: a dynamic prospective multi-centre cohort study. The data for this study were collected between September 2009 and March 2011, from women at 20 midwifery practices throughout the Netherlands. Inclusion criteria for women were: singleton pregnancies, in midwife–led care at the onset of labour and speaking Dutch, English, Turkish or Arabic. Our study sample consisted of 1511 women in primary care who completed both questionnaire two (from 34 weeks of pregnancy up to birth) and questionnaire three (around six week post partum). These questionnaires were presented either online or on paper.
Results
Fifteen hundred and eleven women participated. Prenatally, 15.9% of women preferred some method of medicinal pain relief. During labour 15.2% of the total sample used medicinal pain relief and 25.3% of the women who indicated a preference to use medicinal pain relief during pregnancy, used pain medication. Non-Dutch ethnic background and planned hospital birth were associated with indicating a preference for medicinal pain relief during pregnancy. Primiparous and planned hospital birth were associated with actual use of the preferred method of medicinal pain relief during labour. Furthermore, we found that 85.5% of women who indicated a preference not to use pain medication prenatally, did not use any medication.
Conclusions
Only a small minority of women had a preference for intrapartum pain medication prenatally. Most women did not receive medicinal pain relief during labour, even if they had indicated a preference for it.
Care providers should discuss the unpredictability of the labour process and the fact that actual use of pain medication often does not match with women’s preference prenatally.
doi:10.1186/1471-2393-13-230
PMCID: PMC4029565  PMID: 24325387
20.  Single dose oral fenoprofen for acute postoperative pain in adults 
Background
Fenoprofen is a non-steroidal anti-inflammatory drug (NSAID), available in several different countries, but not widely used.
Objectives
To assess the efficacy of single dose oral fenoprofen in acute postoperative pain, and associated adverse events.
Search methods
We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to December 2010.
Selection criteria
Single oral dose, randomised, double-blind, placebo-controlled trials of fenoprofen for relief of established moderate to severe postoperative pain in adults.
Data collection and analysis
Studies were assessed for methodological quality and data extracted by two review authors independently. Summed total pain relief (TOTPAR) or pain intensity difference (SPID) over 4 to 6 hours was used to calculate the number of participants achieving at least 50% pain relief. These derived results were used to calculate, with 95% confidence intervals, the relative benefit compared to placebo, and the number needed to treat (NNT) for one participant to experience at least 50% pain relief over 4 to 6 hours. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals was collected.
Main results
Five studies (696 participants) met the inclusion criteria; 24 participants were treated with fenoprofen 12.5 mg, 23 with fenoprofen 25 mg, 79 with fenoprofen 50 mg, 78 with fenoprofen 100 mg, 146 with fenoprofen 200 mg, 55 with fenoprofen 300 mg, 43 with zomepirac 100 mg, 30 with morphine 8 mg, 77 with codeine 60 mg, and 141 with placebo. Participants had pain following third molar extraction, laparoscopy, minor day surgery and episiotomy. The NNT for at least 50% pain relief over 4 to 6 hours with a single dose of fenoprofen 200 mg compared to placebo was 2.3 (1.9 to 3.0). There were insufficient data to analyse other doses or active comparators, time to use of rescue medication, or numbers of participants needing rescue medication. There was no difference in numbers of participants experiencing any adverse events between fenoprofen 200 mg and placebo. No serious adverse events or adverse event withdrawals were reported in these studies.
Authors’ conclusions
Oral fenoprofen 200 mg is effective at treating moderate to severe acute postoperative pain, based on limited data for at least 50% pain relief over 4 to 6 hours. Efficacy of other doses, other efficacy outcomes, and safety and tolerability could not be assessed.
doi:10.1002/14651858.CD007556.pub2
PMCID: PMC4171001  PMID: 21328296
Acute Disease; Administration, Oral; Analgesics, Opioid [administration & dosage]; Anti-Inflammatory Agents, Non-Steroidal [*administration & dosage]; Codeine [administration & dosage]; Fenoprofen [*administration & dosage]; Morphine [administration & dosage]; Pain, Postoperative [*drug therapy]; Tolmetin [administration & dosage; analogs & derivatives]; Adult; Humans
21.  Comparison of the effects of lornoxicam versus diclofenac in pain management after cardiac surgery: A single-blind, randomized, active-controlled study 
Background:
Inadequate pain management after cardiac surgery may result 10 in increased morbidity and length of hospital stay. Although opioids are the mainstay of postoperative analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs) may be used instead to avoid the adverse effects (AEs) associated with opioids. Lornoxicam is a newly developed NSAID, the use of which is increasing. However, lornoxicam has not been studied for use in pain management after cardiac surgery.
Objective:
The objective of this study was to compare the efficacy and tolerability 10 of lornoxicam and diclofenac sodium, an NSAID well established for use in pain management after major surgery, in pain management after coronary artery bypass grafting (CABG).
Methods:
This single-blind, randomized, active-controlled study was conducted 10 at the Gaziantep University Hospital, Gaziantep, Turkey. Adult patients scheduled to undergo valve or CABG surgery for the first time were included. Patients were premedicated with diazepam 10 mg PO at 10 PM on the evening before surgery. General anesthesia was induced using fentanyl, midazolam, and propofol, and maintained using fentanyl and isoflurane in pure oxygen. After extubation and when they stated that they felt pain, patients were randomly assigned to 1 of 2 treatment groups: lornoxicam 8 mg IM q8h or diclofenac 75 mg IM q12h, for 48 hours. Meperidine 1 mg/kg IM was given for additional analgesia when needed (rescue medication). Pain relief was assessed using an I1-point visual analog scale (0 = no pain to 10 = worst pain imaginable) immediately before the first injection (baseline), and at 15 and 30 minutes and 1, 2, 3, 4, 6, 12, 18, 24, and 48 hours after the first injection. Sedation was assessed using a 5-point scale (0 = awake and alert to 4 = deep sedation) at the same time points. Tolerability was assessed by monitoring of AEs using patient interview and laboratory analyses.
Results:
Forty patients were enrolled in the study (30 men, 10 women; 10 mean [SD] age, 54.4 [11.1 ] years; 20 patients per treatment group). The demographic and clinical characteristics and mean baseline pain relief scores were statistically similar between the 2 treatment groups. The mean pain relief scores at 15 and 30 minutes were statistically similar to baseline values in the 2 treatment groups. However, the mean pain relief scores at ≥1 hour after the first injection were significantly lower compared with baseline values (both groups, P < 0.05 at time points ≥1 hour). No significant between-group differences in mean pain relief scores were found at any time point. The overall mean pain relief scores were statistically similar between the 2 treatment groups. The mean sedation scores were significantly higher at 30 minutes, 1 hour, and 2 hours after the first injection in the diclofenac group compared with the lornoxicam group (all, P < 0.05). No AEs were observed. The need for rescue medication was statistically similar between the 2 treatment groups (lornoxicam, 2 patients; diclofenac, 3 patients).
Conclusions:
In this study of adult patients who underwent CABG, the efficacy 10 of lornoxicam and diclofenac were similar in postoperative pain management. Both study drugs were well tolerated.
doi:10.1016/j.curtheres.2005.04.001
PMCID: PMC3964581  PMID: 24672117
postoperative analgesia; cardiac surgery; diclofenac; lornoxicam
22.  Single dose oral naproxen and naproxen sodium for acute postoperative pain (Review) 
Background
Postoperative pain is often poorly managed. Treatment options include a range of drug therapies such as non-steroidal anti-inflammatory drugs (NSAIDs) of which naproxen is one. Naproxen is used to treat a variety of painful conditions including acute postoperative pain, and is often combined with sodium to improve its solubility for oral administration. Naproxen sodium 550 mg (equivalent to 500 mg of naproxen) is considered to be an effective dose for treating postoperative pain but to date no systematic review of the effectiveness of naproxen/naproxen sodium at different doses has been published.
Objectives
To assess the efficacy, safety and duration of action of a single oral dose of naproxen or naproxen sodium for acute postoperative pain in adults.
Search strategy
We searched The Cochrane Library, MEDLINE, EMBASE and the Oxford Pain Relief Database for relevant studies. Additional studies were identified from the reference list of retrieved reports. The most recent search was undertaken in July 2004.
Selection criteria
Included studies were randomised, double blind, placebo-controlled trials of a single dose of orally administered naproxen or naproxen sodium in adults with moderate to severe acute postoperative pain.
Data collection and analysis
Pain relief or pain intensity data were extracted and converted into dichotomous information to give the number of patients with at least 50% pain relief over four to six hours. Relative risk estimates (RR) and the number-needed-to-treat (NNT) for at least 50% pain relief were then calculated. Information was sought on the percentage of patients experiencing any adverse event, and the number-needed-to-harm was derived. Time to remedication was also estimated.
Main results
Ten trials (996 patients) met the inclusion criteria: nine assessed naproxen sodium; one combined the results from two small trials of naproxen alone. Included studies scored well for methodological quality. Meta-analysis of six trials (500 patients) that compared naproxen sodium 550 mg with placebo gave a RR for at least 50% pain relief over 4 to 6 hours of 4.2 (95% confidence interval (CI) 2.9 to 6.0) and an NNT of 2.6 (95% CI 2.2 to 3.2). Three trials (334 patients) assessed naproxen 400 mg and naproxen sodium 440 mg, giving a RR of 4.8 (95% CI 2.75 to 8.38). Two small studies indicated that naproxen 200 mg and naproxen sodium 220 mg may provide effective postoperative pain relief. There was no significant difference between the number of patients experiencing any adverse event on treatment compared with placebo. Weighted mean time to remedication for naproxen sodium 550 mg was 7.6 hours compared with 2.6 hours for placebo.
Authors’ conclusions
Naproxen sodium 550 mg, naproxen 400 mg and naproxen sodium 440 mg administered orally are effective analgesics for the treatment of acute postoperative pain in adults. A low incidence of adverse events was found but reporting was not consistent.
doi:10.1002/14651858.CD004234.pub2
PMCID: PMC4164452  PMID: 15495091
Acute Disease; Administration, Oral; Anti-Inflammatory Agents, Non-Steroidal [*therapeutic use]; Naproxen [analogs & derivatives; *therapeutic use]; Pain, Postoperative [*drug therapy]; Randomized Controlled Trials as Topic; Humans
23.  Single dose oral mefenamic acid for acute postoperative pain in adults 
Background
Mefenamic acid is a non-steroidal anti-inflammatory drug (NSAID). It is most often used for treating pain of dysmenorrhoea in the short term (seven days or less), as well as mild to moderate pain including headache, dental pain, postoperative and postpartum pain. It is widely available in many countries worldwide.
Objectives
To assess the efficacy of single dose oral mefenamic acid in acute postoperative pain, and any associated adverse events.
Search methods
We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to December 2010.
Selection criteria
Single oral dose, randomised, double-blind, placebo-controlled trials of mefenamic acid for relief of established moderate to severe postoperative pain in adults.
Data collection and analysis
Studies were assessed for methodological quality and the data extracted by two review authors independently. Summed total pain relief (TOTPAR) or pain intensity difference (SPID) over 4 to 6 hours was used to calculate the number of participants achieving at least 50% pain relief. These derived results were used to calculate, with 95% confidence intervals, the relative benefit compared to placebo, and the number needed to treat (NNT) for one participant to experience at least 50% pain relief over 4 to 6 hours. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals was collected.
Main results
Four studies with 842 participants met the inclusion criteria; 126 participants were treated with mefenamic acid 500 mg, 67 with mefenamic acid 250 mg, 197 with placebo, and 452 with lignocaine, aspirin, zomepirac or nimesulide. Participants had pain following third molar extraction, episiotomy and orthopaedic surgery. The NNT for at least 50% pain relief over 6 hours with a single dose of mefenamic acid 500 mg compared to placebo was 4.0 (2.7 to 7.1), and the NNT to prevent use of rescue medication over 6 hours was 6.5 (3.6 to 29). There were insufficient data to analyse other doses or active comparators, or numbers of participants experiencing any adverse events. No serious adverse events or adverse event withdrawals were reported in these studies.
Authors’ conclusions
Oral mefenamic acid 500 mg was effective at treating moderate to severe acute postoperative pain, based on limited data. Efficacy of other doses, and safety and tolerability could not be assessed.
doi:10.1002/14651858.CD007553.pub2
PMCID: PMC4170999  PMID: 21412904
Acute Disease; Administration, Oral; Anti-Inflammatory Agents, Non-Steroidal [*administration & dosage; therapeutic use]; Aspirin [administration & dosage; therapeutic use]; Mefenamic Acid [*administration & dosage; therapeutic use]; Pain, Postoperative [*drug therapy]; Randomized Controlled Trials as Topic; Sulfonamides [administration & dosage; therapeutic use]; Tolmetin [administration & dosage; analogs & derivatives; therapeutic use]; Adult; Humans
24.  Tramadol and acetaminophen tablets for dental pain. 
Anesthesia Progress  2001;48(3):79-81.
The purpose of this work was to compare the efficacy and time to analgesia of a new tramadol/acetaminophen combination tablet to those of tramadol or acetaminophen (APAP) alone. A meta-analysis was performed of 3 separate single-dose, double-blind, parallel-group trials in patients with moderate or severe pain following extraction of 2 or more third molars. Patients in each study were evenly randomized to a single dose of tramadol/APAP (75 mg/650 mg), tramadol 75 mg, APAP 650 mg, ibuprofen 400 mg, or placebo. Active control with ibuprofen was used to determine model sensitivity. Pain relief (scale, 0-4) and pain intensity (scale, 0-3) were reported at 30 minutes after the dose and then hourly for 8 hours. Total pain relief over 8 hours (TOTPAR8) and the sum of pain intensity differences (SPID8) were calculated from the hourly scores. Time to onset of pain relief was determined by the double-stopwatch technique, and patients were advised to wait at least 2 hours before taking supplemental analgesia. Patients assessed overall efficacy (scale, 1-5) upon completion. In all, 1197 patients (age range, 16-46 years) were evaluable for efficacy; treatment groups in each study were similar at baseline. Pain relief was superior to placebo (P < or = .0001) for all treatments. Pain relief provided by tramadol/ APAP was superior to that of tramadol or APAP alone, as shown by mean TOT-PAR8 (12.1 vs 6.7 and 8.6, respectively, P < or = .0001) and SPID8 (4.7 vs 0.9 and 2.7, respectively, P < or = .0001). Estimated onset of pain relief was 17 minutes (95% CI, 15-20 minutes) for tramadol/APAP compared with 51 minutes (95% CI, 40-70 minutes) for tramadol, 18 minutes (95% CI, 16-21 minutes) for APAP, and 34 minutes (95% CI, 28-44 minutes) for ibuprofen. Median time to supplemental analgesia and mean overall assessment of efficacy were greater (P < .05) for the tramadol/APAP group (302 minutes and 3.0, respectively) than for the tramadol (122 minutes and 2.0) or APAP (183 minutes and 2.7) monotherapy groups. A new combination analgesic, tramadol/APAP, is superior to tramadol or APAP alone with respect to pain relief and duration of action. It is also superior to tramadol alone with respect to time to onset.
PMCID: PMC2007376  PMID: 11724223
25.  Cancer pain management in ambulatory care: can we link assessment and action to outcomes? 
Purpose
Good cancer pain control requires appropriate assessment and treatment. The purpose of this study was to examine the relationships among physician, nurse practitioner, and nurse knowledge, documentation of assessment, treatment, and pain reduction in cancer patients seen in ambulatory settings.
Method
The study method included an assessment of pain knowledge of providers (physicians, nurse practitioners, and nurses) who worked in cancer clinics and a retrospective review of patients' records treated for cancer-related pain in their clinics. Fifty-eight providers from eight cancer clinics completed the knowledge questionnaire; 56 patient records were reviewed for assessment, treatment, and outcome data. Pain relief, the outcome, was obtained from documentation at the next clinic visit.
Results
Of the 54 patient records that documented pain relief at the next clinic visit, 61.9% reported no relief. Chi square analysis revealed clinics with a higher level of pain knowledge documented a greater number of elements of an ideal pain assessment (p=0.03) but was unrelated to treatment and pain relief reported. Assessment and treatment were unrelated to reported pain relief at the next clinic visit.
Conclusion
These data suggest that providers' pain knowledge is related to pain assessment but not treatment or outcome. In addition, these data showed no relationship between assessment, treatment prescribed, and pain relief in these ambulatory settings.
doi:10.1007/s00520-010-1030-7
PMCID: PMC3103757  PMID: 21052733
Cancer pain management; Healthcare provider pain knowledge; Ambulatory settings; Cancer pain guideline

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