Search Results

This chapter includes case studies which illustrate the necessary skills, attitudes, and knowledge required to manage end-stage renal disease (ESRD). It considers some questions such as: How frequent a problem is ESRD in the general population? What is the expected survival of the patient if she starts dialysis? What are the common causes of pain in patients with ESRD? How does ESRD interfere with the metabolism of analgesics? Would it influence the choice of analgesic? How common is depression in dialysis patients?

This chapter shows that spinal systems encode information that is sufficient to engender a pain state. Encoding occurs by multiple mechanisms manifesting a complex pharmacology. Importantly, these advances in the biology of pain have led to an implementation of several of these insights into clinical pain management. The focus on spinal drug delivery has achieved its goals by virtue of the distinct pharmacology of sensory encoding (e.g. light touch versus tissue injury). As such, it provides validation of the Cartesian assertion that pain at the spinal level has a specific encoding. The routine ability to deliver drugs acutely and chronically into the intrathecal space, along with the multiple targets and methods for intervening in the biology of specific neural nets and the importance of the spinal cord in pain processing, suggest that the continued development of agents for spinal delivery will yield important advances in the control of pain.

Supportive care aims to maintain or improve a patient's level of comfort and function. In attempting to achieve these goals, health-care professionals may be confronted with one of the most challenging tasks — mitigation and therapy of malignant pain. This chapter describes the basic pathophysiology of pain, highlights the importance of pain measurement and documentation, and illustrates the decision-making process in choosing the proper therapeutic approach from among a variety of analgesic methods. Finally, it emphasizes the interdisciplinary approach which is essential for a coordinated treatment plan in these patients outlining a clinical case. The importance of these tasks for urology patients is outlined by the following: 70% of prostate cancer patients suffer from pain; 60–80% of cancer patients experience significantly reduced quality of life due to pain; and adequate pharmacotherapy can provide satisfying pain control in 85–90% of patients.

This introductory chapter explains the coverage of this book, which is about palliative care and pain management in terminally ill patients. The book examines the issues of terminal pain, the use of analgesics, control of symptoms other than pain, components of total pain, and the use of adjuvant therapy in pain control. It also highlights the importance of community care and hospital-based geriatric services in easing the physical burden of care on relatives.

This chapter examines the use of analgesics for the control of terminal pain. Though there is no need to resort automatically to strong analgesics when a patient approaches the terminal stages of his illness, pain must be relieved as soon as it becomes a matter of complaint. The criteria for giving analgesia, particularly opioids, should be the presence of pain and not the expected length of life. The chapter provides recommended treatment for different levels of terminal pain.

This chapter examines the use of adjuvant therapy in the management of pain in terminally ill patients. It explains that analgesics are sometimes not enough to relieve the pain in some patients and that radiotherapy and nerve blocks are usually indicated for patients experiencing higher levels of pain. The chapter discusses the concept of palliative radiotherapy, anaesthetic techniques for pain control, and adjuvant analgesic drugs.

This chapter discusses pain and pain management in renal failure. Pain is defined in this chapter as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. The types and categories of pain in renal failure are discussed in this chapter, along with the evaluation of pain, using analgesics for pain relief, pain syndromes, and treatment strategies.

Cancer is often perceived as a life-threatening illness associated with severe and intractable pain. For most patients, pain is a powerful reminder of his or her disease, which in the latter stages will become more threatening and harder to bear if the symptoms become worse. Adding to the pain is the emotional and spiritual distress brought about by the disease. Pain can be managed; however, controlling pain requires proper administration of analgesics and adjuvant drugs, and therapeutic approaches that addressed the underlying cause of pain. This chapter offers an overview of the ways in which pain is caused by malignant diseases and their treatments. It discusses tumour-associated problems, with particular emphasis on pain. Discussions include the incidence of pain at the onset and at the latter stage of the disease, the mechanisms of pain, the pains caused by cancer treatment, and different forms of pain management.

In gastroenterology, chronic idiopathic constipation has been the subject of considerable investigation. The results form a large body of fundamental research into the physiological control of intestinal function, a range of techniques by which to investigate and describe the patterns of motility disorder associated with constipation, and a somewhat less extensive literature assessing the clinical effectiveness of existing or innovative treatments. In palliative care, research on constipation has attracted much less enthusiasm than investigations of symptoms such as pain and breathlessness. The etiology of constipation in palliative care has been little examined. Opioid analgesics are often blamed. Research into constipation is rarely easy and never glamorous, but it is important to tackle a persistent symptom that causes very many of the patients considerable distress.

Most of the patients suffering from cancer believe that pain is an inevitable consequence of their disease and diagnostics. Although pain is one of the most common symptoms particularly in patients with advanced cancer, it can be managed by implementing simple guidelines. However, some doctors fail to address the suffering of the patients even when effective analgesics exist. This chapter focuses on pain palliation. It begins with the principles of pain and the two broad types of cancer pain: nociceptive and neuropathic. The latter sections of the chapter focus on cancer pain management, with an emphasis on the principles of the analgesic ladder, including the application of these to the palliation of bone pain, visceral pain, and neuropathic pain. The chapter ends with the non-drug methods of analgesia and the necessary approach needed to be undertaken by the multidisciplinary team in providing the best pain palliation.

This chapter begins with the observation that ‘the use of the word terminal has tended to obscure the fact that it does not always refer to an irreversible state’. Terminal care is seen as a facet of oncology, being concerned with the control of symptoms of the disease process once that process has become uncontrollable. The chapter includes sections on the nature of terminal pain, its assessment and analysis, referral to other disciplines, the use of analgesics in pain prevention, absorption of oral narcotics, the last hours, the choice of opiate, and the Brompton Mixture. There are also sections on mental pain, social pain, spiritual pain, and staff pain. The paper establishes morphine as the preferred analgesic to diamorphine and also notes that following the research of Twycross, Melzack, and others, the use of mixtures containing alcohol and cocaine should be discontinued.

This chapter aims to discuss current ideas about the mechanism of action of peripheral analgesics, and to provide a rational basis both for their therapeutic use and for the development of new drugs. The classical explanation for the mechanism of inflammatory hyperalgesia is that it results from excitatory actions of endogenous mediators that are released by inflamed or damaged tissues. This concept implies that there are many mediators present, in what might be called a ‘mediator soup’. If the concentration of one or several agonists in this ‘mediator soup’ is increased, as a result of further stimulation, activation of the nociceptor is achieved. The concept also implies that all types of nociceptive mediator are qualitatively similar — that is, that they are all equally capable of activating the nociceptors.

This chapter describes drugs that exert major actions on reward and punishment systems and are all drugs of dependence. Some have potent effects on pain systems and are of therapeutic importance (narcotic analgesics), but all are also used as recreational agents because of their rewarding properties. Antidepressant drugs and drugs which induce depression also affect reward and punishment systems.

This chapter focuses on the management of pain, particularly neuropathic pain. Pain is experienced approximately by 75 per cent of cancer patients with advanced-stage disease. The neuropathic mechanisms are generally involved in almost 40 per cent of cancer pain syndromes. These pains are either disease or treatment related. In patients with metastatic solid tumours, neuropathic pain is generally disease related, while in patients with haematological malignancies, overall pain is less; however, neuropathic pain is prevalent in these patients. Neuropathic pain is a challenging symptom to many healthcare professionals. Although it may respond to opioids, it is less responsive to such treatment compared to other pain caused by pathophysiologies. In patients with haematological malignancies, management of neuropathic pain is more difficult, as non-steroidal anti-inflammatory drugs and intra-spinal catheters are problematic in these populations. Drugs discussed in the chapter that may be an alternative to opiods and which may alleviate neuropathic pain that is unresponsive to opiods include: adjuvant analgesics, corticosteroids, anti-convulsants, anti-depressants, local anaesthetics, and N-methyl-D-aspartate (NMDA) receptor antagonists. Other alternatives included herein are: topical analgesics therapies, intra-spinal therapies, and neural blockade.

Chapter Three surveys narrative techniques for rejecting pain as a locus of meaning in martyrdom. A number of texts explicitly deny the experience of pain altogether by employing the language of analgesia or anesthesia in their descriptions of the martyrs’ experiences of torture; other texts employ typical terms for pain but negate them; some narratives differentiate the experiences of the martyrs’ bodies from those of their spirits. Often texts attribute Christian impassibility to the presence and support of the divine. Finally, many texts thwart the audience’s visual imagination by preparing listeners to envision a grotesque murder, but then unexpectedly describing, instead, a beautiful body unharmed by torture. In these stories, torture does not harm Christians but, rather, it heals them.

Psychoactive substances vary tremendously in their pharmacological properties, cultural symbolism, and reinforcing effects. Comparative risk assessments indicate that legal substances like tobacco and alcohol are at least as dangerous to health and social welfare as many illicit substances. Any consideration of the public health impact of psychoactive substances needs to take into account three important mechanisms of harm: the physical toxicity of the substance, the intoxicating effects it produces, and its potential for creating a syndrome of drug dependence. Policies on substance use should reflect the social and pharmacological complexities of psychoactive substances as well as the relative differences among them.

The growth of modern medicine, is paralleled by substantial growth in psychopharmaceutical medications designed to treat psychiatric disorders, pain, cognitive dysfunction, mental distress, and sleep disorders. These medications, many of which have high dependence potential, are primarily distributed through a prescription system. Diversion of psychopharmaceuticals from this system for non-medical use constitutes a substantial part of the illicit drug market in a growing number of countries. While there is considerable criminal or organized diversion from the prescription system, much of the leakage happens informally, often at the consumer/patient end of the distribution or availability chain. Modern technologies, including Internet-based market elements and new synthetic medications, are blurring the boundaries between medicines and illicit drugs, especially in affluent countries. The pathways of availability and distribution for non-medical use of ‘illicit drugs’ and of psychopharmaceuticals are thus increasingly converging and overlapping.

This chapter considers the collection of samples and storage methods for disease diagnosis in reptiles; and provides an overview of ethics and animal welfare considerations, the role of the Institutional Animal Care and Use Committees (IACUC), the subject of pain and, conversely, analgesia and anaesthesia, several of the most important diseases and pathogens for the major taxonomic groups of reptiles, and biosecurity. Viral, bacterial, fungal, and parasitic diseases have been identified in all major groups of reptiles, with more being studied in captive reptiles than their wild counterparts. Yet of all the factors relevant to the structure of wild populations of reptiles, the impacts of diseases have been poorly studied.

Among the 47 options reviewed in this book, most show some evidence of effectiveness in at least one country, but the evidence is less than definitive for many others, either because the interventions are ineffective, or the research is inadequate. Unfortunately, policies that have shown little or no evidence of effectiveness continue to be the preferred options of many countries and international organizations. The evidence reviewed in this book supports two overarching conclusions. First, an integrated and balanced approach to evidence-informed drug policy is more likely to benefit the public good than uncoordinated efforts to reduce drug supply and demand. Second, by shifting the emphasis toward a public health approach, it may be possible to reduce the extent of illicit drug use, prevent the escalation of new epidemics, and avoid the unintended consequences arising from the marginalization of drug users through severe criminal penalties.