[Prolonged mydriasis caused by Lamaline]

Atropine derivatives. The presence of atropine derivatives in numerous combined medicines is often ignored or reflected. A case report of prolonged bilateral non reactive mydriasis with "cycloplegia", linked with the utilisation of a therapeutic dose of Lameline suppositories raises the question of individual susceptibility, with particular ocular sensitivity. This urge one not to ignore the presence of these products and to respect the contraindications, even with minute doses.

[Remarks on some analgesics used in the pain clinic]

The mechanism of action of aspirin as an analgesic is an inhibition of biosynthesis of prostaglandins. Thus the site of action has been believed to be peripheral. However, when aspirin is injected intra- thecally, it produces an analgesic effect. Aspirin has a membrane-stabilizing effect and it is used locally for the treatment of post- herpetic neuralgia. Epidural opioids are frequently used for the management of post-operative pain or cancer pain. Pharmacokinetic studies have shown that delayed respiratory depression results from migration of morphine in the cerebrospinal fluid to the brain. Peak concentrations of morphine near the brain stem occur about 3 hours after lumbar epidural injection, whereas lipophilic opioids such as meperidine, peak concentration occur within 30 to 60 minutes. The clearance from cerebrospinal fluid of lipophilic opioids is more rapid than that of morphine. Besides opioids, alpha 2 receptor agonists such as clonidine also have analgesic action when administered into the epidural space. Somatostatin is one of many neuropeptides found in the spinal cord. It has dual action: a mediation of thermal nociception and a general antinociceptive action. When somatostatin is administered intrathecally or epidurally, it produces analgesic effect and its efficacy appears to be equal to that of morphine.

Intercostal blockade and pulmonary function after cholecystectomy

Sixty-six patients undergoing cholecystectomy were randomly allocated to receive either intercostal blockade with bupivacaine supplemented with papaveretum or papaveretum alone for postoperative analgesia. Both groups were similar regarding distribution of sex, age, and weight. These two groups were compared. Patients who did not have intercostal blockade required postoperative analgesia sooner. There was no significant difference, however, in the total consumption of papaveretum. Both groups experienced similar degrees of pain, and there were no differences in postoperative pulmonary function. We conclude that although single intercostal blockade is an effective analgesic, it does not improve pain relief and does not improve pulmonary function after cholecystectomy when compared with a regimen of on-demand, intramuscularly administered papaveretum.

A comparison of rectal diclofenac with intramuscular papaveretum or placebo for pain relief following tonsillectomy

A controlled investigation was conducted to compare the effectiveness of diclofenac and papaveretum in the prevention of pain and restlessness after tonsillectomy in children. Sixty children between 3 and 13 years of age were randomly allocated to receive rectal diclofenac 2 mg/kg, intramuscular papaveretum 0.2 mg/kg or no medication immediately after induction of anaesthesia. Pain and appearance were assessed 1, 3 and 6 hours postoperatively, and the following morning. The assessments were double-blind and performed by the same observer. No significant differences in postoperative pain were found between the groups at any time. The use of diclofenac was associated with a significantly more rapid return to calm wakefulness and had significantly less effect upon respiratory rate. Consumption of paracetamol on the day of operation was significantly less in the diclofenac group. Diclofenac may offer advantages compared to papaveretum with regard to safety and convenience for use in the treatment of pain after tonsillectomy in children.

Gastric emptying: a study to compare the effects of intrathecal morphine and i.m. papaveretum analgesia

Gastric emptying was studied in two groups of 10 patients who underwent elective cholecystectomy. The groups were comparable for age, weight and duration of operation. Gastric emptying was measured with a radioisotopic technique using Tc99m-DTPA (diethylene triamine pentaacetic acid) before, and 24 h after, surgery. Analgesia was provided by intrathecal morphine 0.8 mg alone (group A) or by i.m. papaveretum 10 mg, administered as required, plus one additional dose 1 h before the postoperative measurement (group B). Control gastric emptying rates were not significantly different in the two groups (mean +/- SD: A = 76.6 +/- 23.0 ml; B = 81.8 +/- 16.3 ml in 30 min). After surgery, gastric emptying was significantly greater in group A (42.9 +/- 35.6 ml) than in group B (11.0 +/- 27.9 ml) (P less than 0.05).

Psychological factors influencing post-operative pain and analgesic consumption

The personality factors, post-operative pain experience and analgesic requirements after minor oral surgery under general anaesthesia of 103 patients are presented. Psychiatric morbidity, neuroticism and anxiety were related to increased pain which tended to persist longer than normal. Trait anxiety also correlated with simple analgesic consumption, and neuroticism was weakly associated with Omnopon requirements. Thus, regular analgesics prescribed for at least 3 days will anticipate the needs of such patients. Despite higher levels of anxiety and neuroticism, women did not complain of more pain or require more analgesia than men in this study. There was also no overall correlation between post-operative pain experience and analgesic requirements. Therefore analgesic tablet consumption cannot be used as a measure of pain control.

Unusual opioid withdrawal syndrome. A case-report

In a patient with advanced cancer, neurosurgery relieved severe pain that had been uncontrolled by very high doses of opioids. On reduction of opioid dosage he had visual and auditory hallucinations and showed deterioration of consciousness progressing to coma. Naloxone worsened his mental state whereas morphine restored it to normal. This syndrome may be related to opioid withdrawal at receptors other than the mu receptors that have been linked to analgesia and drug abuse.

Human immunodeficiency virus infection in heterosexual intravenous drug users in San Francisco

To investigate the risk of infection with the human immunodeficiency virus (HIV) in San Francisco, the prevalence of antibodies to HIV was determined in 281 heterosexual intravenous drug users recruited from community-based settings. Ten per cent of subjects had ELISA and Western blot confirmed seropositivity for antibodies (95 per cent CI 6.8-14.2 per cent). Analysis of behavioral factors revealed an increased risk of seropositivity in addicts who reported regularly sharing needles when injecting, particularly those sharing with two or more persons (odds ratio = 5.43; 95 per cent CI 1.08-52.5). Blacks and Latinos also had a greater prevalence of seropositivity than Whites, and this finding persisted after adjustment for needle sharing (adjusted odds ratio = 2.8; 95 per cent CI .84-8.59). Seropositivity was not associated with age, sex, duration of drug use, or history of prostitution. These data indicate that a new epidemic of AIDS (acquired immunodeficiency syndrome) in intravenous drug users, similar to that which has occurred among homosexuals in San Francisco, is possible. The relatively low seroprevalence in 1985 provides health officials an important opportunity to intervene and attempt to prevent widespread infection of drug users with HIV.

Renal failure does not impair the metabolism of morphine

The pharmacokinetics of morphine were measured using gas chromatography-mass spectrometry (GCMS) with specific ion monitoring after the intramuscular administration of papaveretum to four patients with renal failure (one anephric) and three normals. The apparent t1/2 of absorption and t1/2 of elimination were significantly shorter in the patients with renal failure (P less than 0.05). Morphine glucuronides are eliminated slowly in these patients as expected. Renal failure does not impair the elimination of morphine.

Caudal analgesia for perianal surgery. A comparison between bupivacaine and diamorphine

Seventy-three patients undergoing elective perianal surgery were randomly divided into a control group, a group who received a caudal injection of 20 ml bupivacaine 0.5% plain and a group who received diamorphine 2.5 mg in 10 ml normal saline by caudal injection; a comparison was then made of postoperative analgesia requirements. The bupivacaine group had better analgesia than the control group for the first 8 hours, after which there was no difference. The diamorphine group had better analgesia than the control group for the first 24 hours postoperatively. Side effects were less in the diamorphine group than the control, or the bupivacaine group. In particular, 41% of the bupivacaine group complained of some degree of urinary retention and one patient required temporary catheterisation. It is concluded that caudal diamorphine gives good postoperative analgesia for perianal operations, particularly when motor blockade is not wanted by the surgeon.

Intramuscular midazolam premedication in small children. A comparison with papaveretum and hyoscine

Midazolam 0.2 mg/kg was compared as an intramuscular premedication in small children with papaveretum and hyoscine 0.4 and 0.008 mg/kg. Midazolam produced satisfactory sedation and anxiolysis and in the early postoperative period patients were significantly more awake (p less than 0.05).

When do patients given intrathecal morphine need postoperative systemic opiates?

A prospective, randomised study has compared the requirements for intramuscular papaveretum after cholecystectomy in patients given either 0.8 mg intrathecal morphine preoperatively or intravenous papaveretum peroperatively. Patients given intrathecal morphine required significantly less papaveretum during the first 48 hours after operation, but no significant difference in analgesic requirements was observed by 72 hours due to a continuing demand for papaveretum by these patients.

Sciatic nerve block for children. Sciatic nerve block by the anterior approach for postoperative pain relief

This study aimed to establish whether it was practical to perform sciatic nerve block by the anterior approach in a group of children of different ages and weights. A total of 82 blocks were performed of which 78 (95.2%) were judged to have been successful. The technique of the block differed slightly from that used in adult practice, in that great reliance was placed on the loss of resistance felt as the needle point passed through the thigh muscles into the sciatic neurovascular compartment. There were no immediate or late complications associated with this block in any of the patients. It is concluded that the block is easy to perform and can produce reliable postoperative analgesia for most common operations on the foot and ankle in paediatric practice.

The need for analgesic cover after ENT surgery--comparison of nefopam and papaveretum

Intra-operative intramuscular injections of either papaveretum 0.3 mg/kg or nefopam 0.4 mg/kg were given to alternate patients to promote smooth emergence from ENT anaesthesia in a consecutive series of 40 children. Observations over a period of 30 minutes following completion of surgery showed that emergence was satisfactory in 19 out of 20 children given papaveretum, and in 15 out of 20 children given nefopam. The study confirms that this indication for papaveretum is justifiably popular and that nefopam is a useful alternative mainly because it does not cause respiratory depression. There are no previous reports of the use of nefopam in children.

The pattern of postoperative analgesic administration in non-English speaking Asian women following caesarean section

A survey of postoperative analgesic administration to non-English speaking Asian women following Caesarean section has shown significant differences when compared to English speaking Caucasian women. The main differences demonstrated were that analgesia was utilised for a shorter period (mean of 16 hours) and that a smaller number of doses were given to the Asian group.

Neonatal methadone withdrawal. Effect of two treatment regimens

Thirty-one infants exposed to methadone in utero who required pharmacologic treatment for withdrawal symptoms were randomly assigned to a paregoric or phenobarbital treatment group. Seven infants had symptoms too mild to require treatment. Respiratory rate, blood pH, PCO2, systolic BP, and serum thyroxine concentrations were measured on the 4th, 7th, and 14th days of life. Platelet counts were performed on the seventh and 14th days of life, and urinary catecholamine excretion was measured on the sixth day of life. Rates of weight gain were recorded during the second and third weeks of life. With the exception of a slightly higher blood PCO2 level in the phenobarbital-treated infants on day 7, no significant intergroup differences were observed in the treated infants. Paregoric-treated infants required a significantly longer period of treatment than phenobarbital-treated infants (22 v 17 days). This may have been due, at least in part, to the prolonged half-life and relatively high blood levels of phenobarbital present after cessation of therapy.

Premedication for fibreoptic bronchoscopy

A randomised, double-blind trial of atropine, atropine plus papaveretum, and atropine plus diazepam given intramuscularly as premedication for fibreoptic bronchoscopy in 60 patients showed no difference between the three regimens as assessed by bronchoscopist or patient. Bronchoscopists frequently attributed a sedative action to atropine alone and their assessment of tolerance and sedation was more optimistic than that of the patients. In a second study comparing intravenous diazepam (10 mg) with saline, after prior intramuscular atropine (0.6 mg), both the bronchoscopists and the patients noted a significant sedative effect of diazepam, and coughing was reduced by diazepam.

Rapid and safe withdrawal of intravenous papaveretum after prolonged continuous infusion

A case is reported in which papaveretum was administered to a patient by continuous intravenous infusion for 60 days. Complete and rapid withdrawal of the narcotic analgesic at the end of that period, despite a massive established daily requirement, was relatively simple and apparently safe. Aspects of narcotic analgesic dependence as they pertain to the case are discussed and the prolonged administration of intravenous opiates with greater confidence by clinicians involved in the intensive therapy of similar patients is suggested.

Variability in opium dosage: observations from Laos, 1965-75

Opiate addicts are generally believed to consume a fairly constant level of drug. These data indicate that, for most addicts over time, there is considerable variability in dosage. This variability occurs not only amongst addicts, but also in most individual addicts over time. Extreme constancy in dosage does prevail for some addicts over prolonged periods, but this is not the norm. Factors influencing dosage include age, gender, ethnicity, socioeconomic status, duration of addiction, drug cost and drug availability. Distributions in dosage patterns are presented in this report.

The use of meptazinol as a premedication for surgical patients

The acceptability of a mixture of meptazinol and hyoscine as a surgical premedication was compared with that of an Omnopon-hyoscine combination in a randomized, double-blind trial involving 101 surgical patients. Blood pressure and respiratory rate were significantly reduced to a similar extent by both premedicant combinations, and this may be interpreted as evidence of a satisfactory alleviation of anxiety by both test mixtures. The two mixtures produced a similar degree of sedation, and both were associated with a useful inhibition of salivary secretion. Side-effects were reported in 25% patients in the meptazinol group, and in 28% of those receiving Omnopon, although a number of these effects may be attributable to hyoscine. There was no difference in the pattern of post-operative analgesic requirements between the two groups, and no unfavourable interaction was noted with any of the anaesthetic agents used.

Continuous thoracic epidural fentanyl. A comparison of epidural fentanyl with intramuscular papaveretum for postoperative pain

A prospective open trial was conducted to compare the analgesic and side-effects of continuously infused fentanyl into the thoracic epidural space with those of intramuscular papaveretum given 4 hourly as required. It was demonstrated that during the first 24 hours after upper abdominal surgery thoracic epidural fentanyl produced better analgesia with less sedation than intramuscular papaveretum. However, the epidural group suffered more nausea. Likewise, postoperative respiratory function tests were statistically significantly better in those patients who received epidural fentanyl. Despite a significantly greater volume of nasogastric aspirate during the period of study, the epidural fentanyl group also had a significantly greater urine output than did the patients receiving papaveretum. Hypotension and respiratory depression were not problems, but pruritus occurred in two patients given fentanyl. It is concluded that epidural fentanyl delivered by continuous infusion offers significant advantages over a conventional intramuscular narcotic regime.

Continuous infusion of papaveretum for relief of postoperative pain

Postoperative analgesia, once established initially by the titration method, is sustained with a flexible regime of papaveretum, infused continuously with a portable syringe pump. The initial analgesic requirement (IAR) for titrating the pain threshold level, was between 4 and 10 mg of papaveretum and the maintenance dose between 1 and 1·66 mg/hr for the first 24 hr and between 0·83 and 1 mg/hr for the second 24 hr. There was no significant association between IAR and the maintenance dose (P<0·2) nor was there any correlation between the maintenance dose, body weight, age, sex or nature of operations. The results in 70 patients are encouraging.

Respiratory effects of analgesia after cholecystectomy: comparison of continuous and intermittent papaveretum

Two methods of administering papaveretum for relieving postoperative pain were compared in two groups of patients who had undergone cholecystectomy. In one group a loading dose of papaveretum was administered by continuous intravenous infusion (1 mg/min) until the patient could breathe deeply without undue pain. Eight times this loading dose was given as a continuous intravenous infusion over the subsequent 48 hours. This regimen was compared with a conventional intermittent intramuscular dose (0.25 mg/kg at four hourly intervals as necessary) in a second group of patients. The intravenous regimen relieved pain better than the intramuscular regimen, which may have reflected the larger dose of papaveretum given to the intravenous group, but it was accompanied by a greater degree of respiratory depression and potentially life-threatening changes in respiratory pattern. These findings suggest that the fear which often accounts for inadequate postoperative pain relief-that larger dose of analgesics will cause respiratory complications-is well founded.

Postoperative analgesia using continuous infusion of papaveretum

A technique of postoperative analgesia using continuous intravenous papaveretum with a dosage derived from previous intravenous titration is described. Hourly pain scores, pulse and respiration rates, and blood pressure readings were recorded. The patients were followed up until discharge from hospital. The nature and incidence of various complications were noted.

Accidental intra-arterial injection of papaveretum during anaesthesia

The circulatory depressant action of papaveretum was demonstrated when the drug was injected accidentally into the radial artery during neuroanaesthesia in the upright (sitting) position. The signs of air embolism were mimicked. The condition reponded promptly to a vasopressor given intravenously. There were no harmful sequelae to the patient's hand.

Ingested mutagens from opium and tobacco pyrolysis products and cancer of the oesophagus

Substances which are commonly sucked or chewed in two areas where the incidence of oesophageal cancer is high, the Transkei and north-east Iran, were tested in bacterial mutagenicity assays. Pyrolysed substances, opium dross in north-east Iran and tobacco pipe residues in the Transkei, displayed mutagenic activity in Salmonella typhimurium strains TA98 and TA100 in the presence of rat liver microsomes.

Aminopyrine breath test in alcoholic liver disease and in patients on enzyme-inducing drugs

The 14C-aminopyrine breath test was used to measure liver function in 14 normal subjects, 16 patients with alcoholic cirrhosis, 14 alcoholics without cirrhosis, and 29 patients taking a variety of drugs. The normal value for the breath test was 8.6 +/- 1.5%, whereas it was significantly lower (5.1 +/- 3.8%) in patients with alcoholic cirrhosis. Higher than normal values were found in some alcoholic patients without cirrhosis and in patients receiving enzyme-inducing drugs, such as phenobarbitone. There was a significant correlation between serum gamma-glutamyltransferase and breath test in these groups. Some patients with alcoholic cirrhosis may also be capable of enzyme induction.

Oral premedication with oxypertine

The preoperative effects of oral oxypertine have been compared with those of papaveretum and atropine in 185 patients in a double-blind between-patient study. Oxypertine 20 mg given orally as a nocturnal sedative and again on the morning of operation produced relief of anxiety comparable to that of papaveretum 10 mg and atropine 0.6 mg. It is concluded that oxypertine may be of value in medication before anaesthesia.

Papaveretum for anaesthesia and its comparison with morphine. Anaesthetic time/dose curves VIII

Intravenous papaveretum was used for the induction and supplementation of nitrous oxide-relaxant anaesthesia in 32 subjects undergoing major surgical operations. An anaesthetic time/dose curve was constructed from the size and timing of successive narcotic increments received by each patient and from these the loading and maintenance requirements of the group were determined. Compared with a similar series in which plain morphine was employed in the same fashion, the morphine content of papaveretum accounted for only 82 per cent of the observed anaesthetic activity. Since the remaining 18 per cent was provided by more readily inactivated alkaloids, papaveretum's therapeutic half-life was only 58 per cent (3.61 hr) of morphine (6.18 hr). All the statements outlined above proved to be statistically significant to various degrees. The advantages of a shorter acting morphine-like compound in anaesthesia are discussed.