- Email: [email protected]
Elliot Krames responds
Vo!. 8 No. 7 Orlober 1993
-_
Lettms
453
tha! “if all you have is a h;rmmcr 1. Frames E. Fntrathecal Infusional intractable pain: patient management Pai;: Spptom Manage F993;8:36-46. 2. McQuay HJ. Opioids 1989;63:213-226.
in chronic
therapies for guidelines. J
pain. F3rJ Anaesth
3. Twycross RG, Lack S.4. Therapeutics in terminal cancer. Edinburgh: Churchill Livingstone, 1984:14. 4. Baines M. Pain re!ief in active patients with cancer: analgesic drugs are the foundaticn of management. BMJ 1989;298:3638. 5. Lipton S. Pain relief in active patients with cancer: the early use of nerve blocks improves the quality of life. Controversies in therapeutics. BMJ 1989;298: 36-38. 6. Parris WCV. Nerve block therapy. siol 1985;3:93-109.
Clin Anaesthe-
7. Cousins MJ, Plummer JL. Spinal opioitis in acute and chronic pain. Adv Pain Res Ther 1991;18:457479. 8. Portenoy FW Caxxer pain: genera! Adv Pain Res Ther 1991;18:W3-266. 9. Mather LE. Pharmacology 1986;144:424.
Tothe
design
of opioids.
MedJ
issues.
Aust
Editor: I am indebted to my good friend and colleague, Dr. Richard Patt, for his response to my article “Infusional Therapies for Intraclable Pain.” An author can receive no greater compliment than a “letter to the editor” that is thoughtful, addresses controversial issues, and expands on these issues. These letters keep authors honest. Although ti;e use of invasive procedures remains contrl~~versial, Dr. Patt suggests that my “oral opioid camp” only use of the ptrase serves to “enccurage divisiveness when efforts should instead relate to refining patient selection with contrcOlled studies and clinical observation.” In using phraseoiog-, :, iii ho i+ay, had intended to divide pain therapists into mutually exclusive cLmps. Unfor&unately, however, these camps do exist. Obeying the principle
everything
looks like a nail,” unnecessary procedures are performed by physicians who only do invasive procedures. Conversely, because of caregiver knowledge deficits or unavailability of invasive techniques, many patients who do not respond to pharmacologic tailoring do not receive the benefit of more invasive therapies such as infusional spinal techniques. It was my intention, in this article, to define a problem that already exists and to define a special niche for these procedures after failure of sequential drug trials using the World Health Organization guidelines for appropriate cancer pain management_ Dr. Patt also cautions the reader not to make conclusions regarding the use of intraspinal opioid therapies for nonmalignant pain based on the retrospective data from Fertinent studies that I reviewed. I concur with this conclusion. hut would suggest to Dr. Patt that prospective, well-controlled efficacy data regarding intraipinal opioids for cancer and non-canc:er-related pain just do not exist. The “science” hehind the clinical use of opioids intraspinally is based on animal data and not on prospective, well-controlled clinical studies. In fact. there are very few controlled studies regarding the chronic use of oral opioids for malignant or nonmalignant pain. Much of our “art” in opioid pain management is derived from retrospective efficacy studies or singledose acute studies in healthy volunteers. Lastly, Dr. Patt expresses concern for my usage of the term “infusional.” Although this word does not appear in the current Webster’s dictionary, it is ‘ised quite frequently in medical jargon when describing techniques for infusion of medications, either intravenously, subcutaneously, intraspinally, or intraventricularly. In fact, ajournal dedicated to this form of therapy, the Jouvnd of Infusional Thmafi, is widely distributed to caregivers interested in “infusional” therapies. In summary, I am quite pleased and honored by the fact that Dr. Patt would care to comment on my paper. His comments are well directed, thoughtful, and humbly accepted. EUkt S. Kranies, MD San Francisco Center for Comprehensive Pain Management San Francisco, California
-_
Lettms
453
tha! “if all you have is a h;rmmcr 1. Frames E. Fntrathecal Infusional intractable pain: patient management Pai;: Spptom Manage F993;8:36-46. 2. McQuay HJ. Opioids 1989;63:213-226.
in chronic
therapies for guidelines. J
pain. F3rJ Anaesth
3. Twycross RG, Lack S.4. Therapeutics in terminal cancer. Edinburgh: Churchill Livingstone, 1984:14. 4. Baines M. Pain re!ief in active patients with cancer: analgesic drugs are the foundaticn of management. BMJ 1989;298:3638. 5. Lipton S. Pain relief in active patients with cancer: the early use of nerve blocks improves the quality of life. Controversies in therapeutics. BMJ 1989;298: 36-38. 6. Parris WCV. Nerve block therapy. siol 1985;3:93-109.
Clin Anaesthe-
7. Cousins MJ, Plummer JL. Spinal opioitis in acute and chronic pain. Adv Pain Res Ther 1991;18:457479. 8. Portenoy FW Caxxer pain: genera! Adv Pain Res Ther 1991;18:W3-266. 9. Mather LE. Pharmacology 1986;144:424.
Tothe
design
of opioids.
MedJ
issues.
Aust
Editor: I am indebted to my good friend and colleague, Dr. Richard Patt, for his response to my article “Infusional Therapies for Intraclable Pain.” An author can receive no greater compliment than a “letter to the editor” that is thoughtful, addresses controversial issues, and expands on these issues. These letters keep authors honest. Although ti;e use of invasive procedures remains contrl~~versial, Dr. Patt suggests that my “oral opioid camp” only use of the ptrase serves to “enccurage divisiveness when efforts should instead relate to refining patient selection with contrcOlled studies and clinical observation.” In using phraseoiog-, :, iii ho i+ay, had intended to divide pain therapists into mutually exclusive cLmps. Unfor&unately, however, these camps do exist. Obeying the principle
everything
looks like a nail,” unnecessary procedures are performed by physicians who only do invasive procedures. Conversely, because of caregiver knowledge deficits or unavailability of invasive techniques, many patients who do not respond to pharmacologic tailoring do not receive the benefit of more invasive therapies such as infusional spinal techniques. It was my intention, in this article, to define a problem that already exists and to define a special niche for these procedures after failure of sequential drug trials using the World Health Organization guidelines for appropriate cancer pain management_ Dr. Patt also cautions the reader not to make conclusions regarding the use of intraspinal opioid therapies for nonmalignant pain based on the retrospective data from Fertinent studies that I reviewed. I concur with this conclusion. hut would suggest to Dr. Patt that prospective, well-controlled efficacy data regarding intraipinal opioids for cancer and non-canc:er-related pain just do not exist. The “science” hehind the clinical use of opioids intraspinally is based on animal data and not on prospective, well-controlled clinical studies. In fact. there are very few controlled studies regarding the chronic use of oral opioids for malignant or nonmalignant pain. Much of our “art” in opioid pain management is derived from retrospective efficacy studies or singledose acute studies in healthy volunteers. Lastly, Dr. Patt expresses concern for my usage of the term “infusional.” Although this word does not appear in the current Webster’s dictionary, it is ‘ised quite frequently in medical jargon when describing techniques for infusion of medications, either intravenously, subcutaneously, intraspinally, or intraventricularly. In fact, ajournal dedicated to this form of therapy, the Jouvnd of Infusional Thmafi, is widely distributed to caregivers interested in “infusional” therapies. In summary, I am quite pleased and honored by the fact that Dr. Patt would care to comment on my paper. His comments are well directed, thoughtful, and humbly accepted. EUkt S. Kranies, MD San Francisco Center for Comprehensive Pain Management San Francisco, California