THE RELIEF OF CHRONIC PAIN

Brit. J. Anaesth. (1955), 27, 101. ANNOTATION THE RELIEF OF CHRONIC PAIN sedative or analgesic drugs which administered to 18 patients with satisfactory depress respiration with antidotes to their respira- results, although in a few cases it was followed tory depressant action is by no means a new idea by nausea and vomiting and all patients experito anaesthetists. Soon after the introduction of enced a desire to sleep. Although their series is thiopentone, Lundy (1935) described a method small the principle of miving a potent analgesic of minimizing respiratory depression by adding with an effective antidote to its respiratory effects 25 mg. nikethamide to each 100 ing. thiopentone. opens up great possibilities in the treatment of The synthesis of nalorphine in 1941 opened up chronic pain. In regard to the above combination it should be a new field in the problem of producing relief of pain without respiratory depression. It was pointed out that there is some difference between claimed that this drug would antagonize the the drug called " Dromoran " as referred to in central effects of opiates and the synthetic anal- American and British literature. In both countries gesics such as pethidine, amidone and levorphan. the laevo form is now used, its generic designation Eckenhoff, Hoffman and Dripps (1952) cast some being levorphan tartrate (1-methorphinan). The doubts on its ability to antagonize the central racemic form was originally used by American action of analgesics, while Payne (1954) has shown workers and is known as racemorphan hydrothat nalorphine potentiates the narcotic action of bromide (d-1-methorphinan). This latter has only morphine. All workers are agreed that it one-half the analgesic potency of levorphan. antagonizes morphine-induced respiratory depres- Glazebrook (1952) found 1.5-2 mg. levorphan sion, although this effect may be transient and produced satisfactory analgesia in the majority of patients, but occasionally the dose had to be inside effects, such as vomiting, are troublesome. A recent addition to this field is levallorphan creased to 4 mg. It has the advantage of being tartrate (1-3-hydroxy-N-allylmorphinan tartrate), longer lasting than morphine and is usually which bears the same relationship to levorphan effective when taken by mouth. as nalorphine does to morphine. Reports suggest Another new approach to the relief of chronic that it has many advantages over nalorphine. pain is the combination of analgesics with chlorHamilton and Cullen (1953) found it to be an promazine. The latter has a leucotomy-like effect effective antagonist to the respiratory depression in large doses and also potentiates analgesic and produced by morphine, pethidine and levorphan. hypnotic drugs. Satisfactory reports on this Their findings suggested that, although respira- method have come frorri Sadove (1954), Howell, tory depression was abolished, some action of the Harth and Dietrich (1954), and Dundee (1954). analgesics persisted which enabled them to be The latter claimed good results from a combinaused as effective supplements to nitrous oxide- tion of 25 mg. chlorpromazine and 1.5 mg. levoxygen anaesthesia. orphan given three to four times daily. Cullen and Santos (1954) have recently REFERENCES reported on the use of a combination of levorphan and levallorphan for the relief of chronic pain. Cullen, S. C , and Santos, C. C. (1954). Arch. Surg., 69, 410. When combined in a 4 : 1 ratio there was a loss Dundee, J. W. (1954). Brit. J. Anaesth., 25, 357. of analgesia and many patients complained of Eckenhoff, J. E., Hoffman, G. L., and Dripps, R. D. symptoms similar to the acute abstinence syn(1952). Anesthesiology, 13, 242. drome. They found that a mixture of 8 to 10 Glazebrook, A. J. (1952). Brit. med. /., 2, 1328. W. K., and Cullen, S. C. (1953). Anesparts levorphan with 1 part levallorphan resulted Hamilton, thesiology, 14, 550. in no loss of the analgesic properties of the former Howell, T. H., Harth, J. A. P., and Dietrich, M. (1954). Practitioner, 173, 172. and there was a significant increase in the minute J. S. (1953). Proc. Mayo. Clinic, 10, 791. volume of respiration as compared with the use Lundy, Payne, J. P. (1954). Brit. J. Anaesth., 26, 22. of levorphan alone. This combination was Sadove, M. S. (1954). J. Amer. med. Ass., 155, 626. 101 COMBINING

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