- Email: [email protected]
Advances in pain and anxiety management
patients, even those having impacted third molars removed. Mandatory clinical follow-up takes time and may offer limited benefit to the patient and the practitioner.
Susaria SM, Black R, Dodson TB: After dentoalveolar surgery, most patients are satisfied with telephone follow-up. J Oral Maxillofac Surg 69:2099-2105, 2011 Reprints available from SM Susaria, Dept of Oral and Maxillofacial Surgery, Massachusetts General Hosp, WACC230, Boston, MA 02114; e-mail: [email protected]
Pain Management Advances in pain and anxiety management Background.—Advances have been made not only in the pharmacologic management of pain and anxiety but also in terms of pain management delivery systems and surgical modalities. These advances were outlined. New Pain Management Drugs.—Tapentadol is a centrally acting analgesic used for moderate to severe pain. It activates m-opioid receptors and inhibits norepinephrine reuptake, offering both opioid and nonopioid activity in a single compound. Nausea, dizziness, constipation, and central nervous system sedation, common to opioids, have been reported as side effects. Clinically, tapentadol has equianalgesic effect with fewer side effects compared with oxycodone and morphine. Tapentadol causes less nausea and dizziness than are seen with morphine. The abuse potential of this agent are as yet unknown, but it is a class II schedule drug, although it may have relatively limited potential for dependency compared with other strong opioids. Tramadol is a weak m-opioid receptor agonist that prompts the release of serotonin and inhibits norepinephrine reuptake. It is effective against moderate to severe pain and chronic pain such as trigeminal neuralgia. Among its side effects are nausea, vomiting, sweating, and constipation. No clinically significant respiratory depression, which is a common side effect with opioids, has been reported when tramadol is given in normal doses. However, when used with other serotonin reuptake inhibitors or monoamine oxidase inhibitors, the increased risk of serotonin toxicity can be fatal. Propofol is the intravenous (IV) agent of choice for inducing general anesthesia and providing sedation in outpatient or intensive care unit settings. It is a sedative hypnotic rather than an analgesic and is often used with fentanyl in polymodal sedation regimens for analgesia. Propofol offers rapid sedation (within 30 seconds), rapid rate of distribution half-life (2 to 4 minutes), and a short elimination halflife (30 to 60 minutes). However, its clinical effect is shorter.
192
Dental Abstracts
Its advantages also include a lack of accumulation and minimal effect on liver and renal function. Adverse effects with normal use or overdoses include cardiovascular depression that can lead to hypotension, bradycardia, and reduced intracranial pressure; hyperlipidemia; transient apnea with respiratory depression; and mild myoclonic movements and dystonia. In critical care settings, prolonged propofol use may induce propofol infusion syndrome, marked by rhabdomyolysis and cardiac and renal failure. Clinicians using propofol must be trained in advanced airway management. Remifentanil is a potent ultrashort-acting synthetic opioid derivative used adjunctively in general anesthesia and in outpatient office procedures. It is 100% stronger than fentanyl and 200 times more potent than morphine. Its rapid onset (initial distribution half-life 1 minute) and offset (biologic half-life 3 to 10 minutes) make it highly desirable compared with other opioids. Renal and hepatic impairments do not affect its metabolism. As a specific m-receptor agonist, it produces both analgesia and sedation. Side effects include reduced sympathetic tone, respiratory and cardiovascular depression, muscle rigidity, nausea, constipation, and urinary retention. Remifentanil can provide rapid postoperative recovery time in a polymodal sedation regimen. It is also useful as the rate-limiting drug in the initiation and termination of synergistic polymodal sedation. Careful monitoring can reduce its adverse effects on anesthesia, respiration, and cardiovascular function. Triazolam is a benzodiazepine derivative used for sedation to manage short-term anxiolysis or insomnia. Its properties include amnesic, sedative, anxiolytic, and anticonvulsant activity. Compared with other anxiolytic agents, it offers a more rapid onset and a shorter half-life (about 2 to 4 hours). Side effects include anterograde amnesia, addiction, rebound insomnia, rebound anxiety, amnesia, confusion, and disinhibition; these can last up to 24 hours, depending on the dose delivered. Several countries no longer permit its use for short anxiolysis because of its adverse
psychological effects, so its continued use in the United States remains controversial. Trigeminal neuralgia and other chronic neuropathies may be treated using low-dose anticonvulsants. Carbamazepine and phenytoin inhibit excessive release of glutamate, disrupting central sensitization and diminishing the incidence of hyperalgesia and allodynia. Gabapentin may also be used for chronic pain. Compared with other anticonvulsants, gabapentin rarely interacts with other drugs and has fewer side effects. Delivery Systems.—The transdermal application of fentanyl provides continuous opioid administration usually for patients with chronic pain or those who cannot take medications orally. This delivery system is not appropriate for acute postoperative pain because of the risk of respiratory depression. Transdermal opioids have a slow onset of action, making them difficult to titrate. Oral opioids must be used for at least 30 days before transdermal fentanyl is begun. Patient-controlled analgesia (PCA) allows the patient to select the amount of analgesia at programmed intervals with set lockout and baseline dosages. This method relieves postoperative pain at its onset and minimizes central sensitization. Recently, the fentanyl iontophoretic transdermal system has been added, which delivers set doses of fentanyl by iontophoresis via electronic transport. A low current moves the fentanyl stored in a hydrogel reservoir toward the skin, where the drug diffuses into the local circulation and is transported to the central nervous system. Transdermal patches are worn on the patient’s upper arm and permit PCA without IV access, bypassing pump failure and eliminating active metabolites found in morphine PCA. Fentanyl PCA transdermal systems have been found to produce equivalent results to IV PCA. Surgical Approaches.—Gamma knife radiosurgery was developed in the 1960s but poor imaging modalities limited its usefulness. This device focuses the intersection of 201 beams of gamma rays from a cobalt-60 energy source to perform radiosurgery. High-resolution computed tomography and magnetic resonance imaging scans combined with computer technology permit precise targeting so that gamma radiosurgery now achieves improved outcomes in trigeminal neuralgia treatment. Complications that may accompany gamma knife radiosurgery include facial numbness and pain relapse. However, this method avoids the
complications of infection, cerebrospinal fluid leak, hematoma formation, facial paralysis, and other nerve injury that may accompany traditional surgery. Anxiety Management.—Anxiety management continues to focus on developing holistic and behavioral treatments. Among the coping methods are strategies involving imagery, massage, breathing techniques, music interventions, and other relaxation techniques. The ADVANCE protocol is used preoperatively for children and focuses on family-centered preparation. Components include procedural information, training in coping mechanisms, and an exposure plan for both parents and children. The program has been credited with producing lower levels of preoperative anxiety, decreased incidence of emergency delirium, less need for analgesics, and shorter time to discharge. Music therapy for preoperative and postoperative anxiety has reduced levels of stress as indicated by measuring vital signs. Effects have been noted on cortisol levels in saliva as well. Imagery alleviates stress and anxiety by guiding patients through their imagination toward a relaxed, focused state. Patients use their senses to help create a mental picture of a safe or relaxing environment.
Clinical Significance.—Although more research is needed to obtain evidence of efficacy for some of the newer approaches to pain and anxiety management, many appear to offer promising results. Pain and anxiety are among the chief complaints of patients. Methods to provide relief in these areas will help to support a trusting relationship between patient and practitioner, which can improve patient compliance and permit timely care in support of oral health.
Huang D, Wun D, Stern A: Current treatments and advances in pain and anxiety management. Dent Clin N Am 55:609-618, 2011 Reprints available from D Huang, Dept of Dentistry/Oral Maxillofacial Surgery, The Brooklyn Hosp, 121 Dekalb Ave, Box 187, Brooklyn, NY 11201; e-mail: [email protected]
Volume 57
Issue 4
2012
193
Susaria SM, Black R, Dodson TB: After dentoalveolar surgery, most patients are satisfied with telephone follow-up. J Oral Maxillofac Surg 69:2099-2105, 2011 Reprints available from SM Susaria, Dept of Oral and Maxillofacial Surgery, Massachusetts General Hosp, WACC230, Boston, MA 02114; e-mail: [email protected]
Pain Management Advances in pain and anxiety management Background.—Advances have been made not only in the pharmacologic management of pain and anxiety but also in terms of pain management delivery systems and surgical modalities. These advances were outlined. New Pain Management Drugs.—Tapentadol is a centrally acting analgesic used for moderate to severe pain. It activates m-opioid receptors and inhibits norepinephrine reuptake, offering both opioid and nonopioid activity in a single compound. Nausea, dizziness, constipation, and central nervous system sedation, common to opioids, have been reported as side effects. Clinically, tapentadol has equianalgesic effect with fewer side effects compared with oxycodone and morphine. Tapentadol causes less nausea and dizziness than are seen with morphine. The abuse potential of this agent are as yet unknown, but it is a class II schedule drug, although it may have relatively limited potential for dependency compared with other strong opioids. Tramadol is a weak m-opioid receptor agonist that prompts the release of serotonin and inhibits norepinephrine reuptake. It is effective against moderate to severe pain and chronic pain such as trigeminal neuralgia. Among its side effects are nausea, vomiting, sweating, and constipation. No clinically significant respiratory depression, which is a common side effect with opioids, has been reported when tramadol is given in normal doses. However, when used with other serotonin reuptake inhibitors or monoamine oxidase inhibitors, the increased risk of serotonin toxicity can be fatal. Propofol is the intravenous (IV) agent of choice for inducing general anesthesia and providing sedation in outpatient or intensive care unit settings. It is a sedative hypnotic rather than an analgesic and is often used with fentanyl in polymodal sedation regimens for analgesia. Propofol offers rapid sedation (within 30 seconds), rapid rate of distribution half-life (2 to 4 minutes), and a short elimination halflife (30 to 60 minutes). However, its clinical effect is shorter.
192
Dental Abstracts
Its advantages also include a lack of accumulation and minimal effect on liver and renal function. Adverse effects with normal use or overdoses include cardiovascular depression that can lead to hypotension, bradycardia, and reduced intracranial pressure; hyperlipidemia; transient apnea with respiratory depression; and mild myoclonic movements and dystonia. In critical care settings, prolonged propofol use may induce propofol infusion syndrome, marked by rhabdomyolysis and cardiac and renal failure. Clinicians using propofol must be trained in advanced airway management. Remifentanil is a potent ultrashort-acting synthetic opioid derivative used adjunctively in general anesthesia and in outpatient office procedures. It is 100% stronger than fentanyl and 200 times more potent than morphine. Its rapid onset (initial distribution half-life 1 minute) and offset (biologic half-life 3 to 10 minutes) make it highly desirable compared with other opioids. Renal and hepatic impairments do not affect its metabolism. As a specific m-receptor agonist, it produces both analgesia and sedation. Side effects include reduced sympathetic tone, respiratory and cardiovascular depression, muscle rigidity, nausea, constipation, and urinary retention. Remifentanil can provide rapid postoperative recovery time in a polymodal sedation regimen. It is also useful as the rate-limiting drug in the initiation and termination of synergistic polymodal sedation. Careful monitoring can reduce its adverse effects on anesthesia, respiration, and cardiovascular function. Triazolam is a benzodiazepine derivative used for sedation to manage short-term anxiolysis or insomnia. Its properties include amnesic, sedative, anxiolytic, and anticonvulsant activity. Compared with other anxiolytic agents, it offers a more rapid onset and a shorter half-life (about 2 to 4 hours). Side effects include anterograde amnesia, addiction, rebound insomnia, rebound anxiety, amnesia, confusion, and disinhibition; these can last up to 24 hours, depending on the dose delivered. Several countries no longer permit its use for short anxiolysis because of its adverse
psychological effects, so its continued use in the United States remains controversial. Trigeminal neuralgia and other chronic neuropathies may be treated using low-dose anticonvulsants. Carbamazepine and phenytoin inhibit excessive release of glutamate, disrupting central sensitization and diminishing the incidence of hyperalgesia and allodynia. Gabapentin may also be used for chronic pain. Compared with other anticonvulsants, gabapentin rarely interacts with other drugs and has fewer side effects. Delivery Systems.—The transdermal application of fentanyl provides continuous opioid administration usually for patients with chronic pain or those who cannot take medications orally. This delivery system is not appropriate for acute postoperative pain because of the risk of respiratory depression. Transdermal opioids have a slow onset of action, making them difficult to titrate. Oral opioids must be used for at least 30 days before transdermal fentanyl is begun. Patient-controlled analgesia (PCA) allows the patient to select the amount of analgesia at programmed intervals with set lockout and baseline dosages. This method relieves postoperative pain at its onset and minimizes central sensitization. Recently, the fentanyl iontophoretic transdermal system has been added, which delivers set doses of fentanyl by iontophoresis via electronic transport. A low current moves the fentanyl stored in a hydrogel reservoir toward the skin, where the drug diffuses into the local circulation and is transported to the central nervous system. Transdermal patches are worn on the patient’s upper arm and permit PCA without IV access, bypassing pump failure and eliminating active metabolites found in morphine PCA. Fentanyl PCA transdermal systems have been found to produce equivalent results to IV PCA. Surgical Approaches.—Gamma knife radiosurgery was developed in the 1960s but poor imaging modalities limited its usefulness. This device focuses the intersection of 201 beams of gamma rays from a cobalt-60 energy source to perform radiosurgery. High-resolution computed tomography and magnetic resonance imaging scans combined with computer technology permit precise targeting so that gamma radiosurgery now achieves improved outcomes in trigeminal neuralgia treatment. Complications that may accompany gamma knife radiosurgery include facial numbness and pain relapse. However, this method avoids the
complications of infection, cerebrospinal fluid leak, hematoma formation, facial paralysis, and other nerve injury that may accompany traditional surgery. Anxiety Management.—Anxiety management continues to focus on developing holistic and behavioral treatments. Among the coping methods are strategies involving imagery, massage, breathing techniques, music interventions, and other relaxation techniques. The ADVANCE protocol is used preoperatively for children and focuses on family-centered preparation. Components include procedural information, training in coping mechanisms, and an exposure plan for both parents and children. The program has been credited with producing lower levels of preoperative anxiety, decreased incidence of emergency delirium, less need for analgesics, and shorter time to discharge. Music therapy for preoperative and postoperative anxiety has reduced levels of stress as indicated by measuring vital signs. Effects have been noted on cortisol levels in saliva as well. Imagery alleviates stress and anxiety by guiding patients through their imagination toward a relaxed, focused state. Patients use their senses to help create a mental picture of a safe or relaxing environment.
Clinical Significance.—Although more research is needed to obtain evidence of efficacy for some of the newer approaches to pain and anxiety management, many appear to offer promising results. Pain and anxiety are among the chief complaints of patients. Methods to provide relief in these areas will help to support a trusting relationship between patient and practitioner, which can improve patient compliance and permit timely care in support of oral health.
Huang D, Wun D, Stern A: Current treatments and advances in pain and anxiety management. Dent Clin N Am 55:609-618, 2011 Reprints available from D Huang, Dept of Dentistry/Oral Maxillofacial Surgery, The Brooklyn Hosp, 121 Dekalb Ave, Box 187, Brooklyn, NY 11201; e-mail: [email protected]
Volume 57
Issue 4
2012
193