Entries in Pain Management (3)


FDA Investigates Codeine Safety After Children’s Deaths

Jupiterimages/Thinkstock(WASHINGTON) -- The U.S. Food and Drug Administration announced Wednesday that it was investigating the safety of codeine for post-operative pain relief in children following reports of three deaths and one life-threatening emergency related to its use after tonsil surgery.

The children were between the ages of 2 and 5. All had received standard doses of codeine, but doctors believe each had a genetic trait that caused them to develop toxic levels of drug in their bodies.

“This will be news to the majority of [doctors] who are not well versed in opioid pharmacology, and it is very important,” says Dr. Elliot Krane, a professor of anesthesia and pediatrics at Lucile Packard Children’s Hospital.

The reason that codeine may be a special case is that it requires extra processing by the liver to work.

“Codeine doesn’t work in its natural form,” explained Dr. Joseph R. Tobin, professor and chairman of anesthesiology at Wake Forest University School of Medicine.  "It must be converted by enzymes in the body to its active form.”

This active form is morphine. For most patients, taking codeine leads to a relatively safe and therapeutic level of morphine in the body. In nearly a third of the patients who metabolize the codeine slowly, there may be minimal or no effect.

However, in the rare case of “ultra-rapid metabolizers,” the liver quickly converts the codeine into high levels of morphine in the blood -- a potentially deadly situation.

“If you are an ultra-rapid metabolizer, then the concentration of the active form of the drug can rise in the patient’s bloodstream quickly,” said Tobin. “When this is also associated with residual anesthetics, a child may be at risk to stop breathing or become completely obstructed.”

Unfortunately, few people are likely to know whether they are slow, regular, rapid or ultra-rapid metabolizers until they take codeine for the first time.  Also, because the mechanism controlling this drug’s metabolism is based on a person’s liver enzyme properties, there is no way to change how the drug is processed in any one person.

However, this does not necessarily mean that all people taking codeine are in danger. The children who died after they stopped breathing were also at higher risk because their underlying diseases -- having sleep apnea, followed by an operation on the tonsils -- also hindered their ability to breathe.

“Many of these patients have their surgery because they have existing airway obstruction,” said  Dr. Eugene Viscusi, director of acute pain management services at Jefferson Medical College and Hospital. “These children are already at risk of airway obstruction and respiratory events.”

Given these elevated risks with codeine, many pediatric physicians have already eliminated the drug from their post-operative management.

“Codeine is a poor choice for post-operative pain anyway,” says Dr. Laura Schanberg, co-chief of the division of pediatric rheumatology at Duke University Medical Center in Durham, N.C. “It is no longer considered standard of care for pain management.”

Fortunately, many good alternatives exist.

“There are several very good alternatives, principally hydrocodone (the active ingredient in Vicodin, Lortab, Lorcet and Norco), and oxycodone (the active ingredient in Percocet),” said Krane.

Other safe, though less powerful, options are the non-prescription pain medications such as acetaminophen (Tylenol) and ibuprofen (Motrin).

“There is no known benefit of acetaminophen with codeine over acetaminophen alone for post-tonsillectomy pain in kids,” said Dr. Alan Greene, clinical professor of pediatrics at Stanford University School of Medicine in Palo Alto, Calif.

“Pain relief should be a high priority after surgery for comfort and to speed healing,” he said, “but I can see no good reason to give codeine after tonsillectomy.”

Copyright 2012 ABC News Radio


Relieving Pain: The Institute of Medicine Calls for Action

Digital Vision/Thinkstock(WASHINGTON) -- The Institute of Medicine (IOM) is releasing a report identifying the shortfalls of pain management in the U.S. and outlining the necessary cultural, medical, educational, and research changes that need to take place in order to better prevent and treat pain of all types.
According to the IOM report, more than 115 million adult americans experience some type of pain.
And that physical hurt is being felt in our pockets, costing the U.S. anywhere from $560 billion to  $635 billion every year.
Some of it comes from direct medical expenses.  The rest from indirect costs such as disability, lost wages and productivity.
The report outlines changes needed to improve the prevention and treatment of pain.
Some of the suggestions include better data gathering by the federal government, more personalized pain management by primary care doctors working with pain specialists for patients with chronic pain, more pain management training for health professionals and the development of a National Pain Research Institute.
The IOM report says that some of its recommendations could be implemented as early as the end of next year, while others could be in place by 2015.

Copyright 2011 ABC News Radio


Is the Medical Community Not Providing Adequate Pain Management?

Thomas Northcut/Thinkstock(NEW YORK) -- A series of studies published in Lancet may provide proof that patients in pain may not be receive proper care for managing their aches and discomfort.

It is estimated that up to 75 percent of surgical patients in the U.S. may not receive adequate post-operative pain relief.  Research also shows that acute postoperative pain can become chronic in as many as 30-50 percent of patients who undergo procedures such as mastectomies, hernia repairs and coronary artery bypass procedures.  But improvements have been made over the past decade in providing pain relief, mostly through regional pain relief such as epidural analgesia or peripheral nerve catheters.  Study authors from Johns Hopkins University School of Medicine write that the use of multiple pain medications or techniques at once “may lead to substantial gains in the treatment of acute post-operative pain and potential reduction in the development of persistent pain states.”
The cost of chronic non-cancer pain, typically defined as pain lasting longer than three months or beyond the expected period of healing, is estimated to be over $210 billion per year here in the U.S.  The authors in a University of Washington study review some of the most commonly used interventions to treat chronic pain such as nerve blocks, surgeries, implantable drug-delivery systems, physical rehabilitation, psychological treatments, and even complementary and alternative treatments.  They find that “the best evidence for pain reduction averages roughly 30 percent in about half of treated patients.”  As with acute pain, these authors stress the need to research the effectiveness of combination treatments as “none of the most commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain and to have a major effect on physical and emotional function in most patients with chronic pain.”
Among patients with solid tumors, an estimated 15-75 percent experience significant chronic pain, but research suggests that an average of 43 percent of cancer patients receive inappropriate care for their pain.  The authors of a review from Beth Israel Medical Center in New York discuss the best ways of managing cancer-related pain, arguing that only addressing the physical symptoms is not sufficient.  Rather, a more individually tailored, holistic approach is necessary in order to reduce pain and improve the patients’ quality of life.  Although the term “palliative care” may be associated with end-of-life care, these researchers argue that such an approach to pain management should be initiated from the time of diagnosis and be applied “throughout the course of the illness…[including] interventions that are intended to maintain quality of life, mitigate suffering and improve coping and adaption by reducing the burden of illness and supporting communication, autonomy, and choice.”
Copyright 2011 ABC News Radio

ABC News Radio