To control or not? A motivational perspective on coping with pain

Pain relief is often the primordial treatment objective in pain patients. However, an exclusive focus upon pain relief may have costs. Evidence is accumulating that persistent attempts to gain control over pain may, paradoxically, hinder successful adaptation to pain and increase frustration and limitations due to pain. To better understand these apparently paradoxical findings, we propose to adopt a motivational perspective on coping with pain. Within this perspective, pain control is recast as an attempt to protect and restore valued life goals threatened by pain. This framework explains why some patients engage excessively in pain control strategies despite the costs associated with this, such as overuse of medication. A clinical implication is that cautiousness is warranted in promoting strategies exclusively aimed at pain relief. Beyond standard medical care, interventions should also be aimed at the improvement of functioning despite pain. Certainly those patients for whom there is no definite or sound cure to pain and who increasingly experience emotional and physical problems due to pain might benefit from paramedical help by psychologists and/or physiotherapists

The relevance of monitoring lamotrigine serum concentrations in chronic pain patients

Lamotrigine is a novel anticonvulsant initially used in epilepsy treatment. Because of its physiological properties it has subsequently been introduced in pain management and has become an interesting co-analgesic, because it inhibits release of excitatory neurotransmitters, influences different sodium, calcium en potassium channels and elevates the GABA levels. A linear relationship appears to exist between serum concentrations, drug activity and clinical outcome. However: measurement of lamotrigine serum concentrations is very useful for daily dose adjustments in order to prevent toxic reactions. In most studies describing the neuropathic pain-relieving effects of lamotrigine, a daily oral dose of 300 to 400 mg was administered. Some of our patients received 800 mg lamotrigine with better results than when 400 mg doses were used. The serum concentrations in these patients were higher but still below the so-called dangerous level of approximately 15 mg/L. Lamotrigine itself is metabolized by conjugation to form inactive metabolites. Lamotrigine serum concentrations can be influenced by the intake of other drugs metabolized by the cytrochrome P450. As good pain relief depends on adequate lamotrigine serum concentrations and dangerous side effects should be avoided, we recommend to monitor individual concentration levels in relation to lamotrigine dosage. However skin rash is an important adverse effect of lamotrigine and is independent from plasma concentration levels

Hyperalgesia induced by high-dose intrathecal sufentanil in neuropathic pain

The patient had lower lumbar arachnoiditis as part of a failed back surgery syndrome. Two years after discectomy, she still suffered from left lumbosciatic pain despite various invasive treatments. Psychologic impairment could be excluded, Finally intrathecal morphine was infused at the D12 level. Small amounts of morphine (500-750 mg daily) introduced intolerable vomiting, which could not be prevented by antiemetics, so intrathecal sufentanil was started. A daily dose of 25 mg of sufentanil diluted in 1.5 ml of saline evoked hyperalgesia in the lower part of the body, Increasing the dose to 50 mg, daily could only be supported for 3 h. Sufentanil was stopped and saline started, alter which the evoked hyperalgesia disappeared, It is concluded that relatively high doses of sufentanil may induce hyperalgesia in patients with arachnoiditis and neuropathic pain