Table Of ContentSPINAL NARCOTICS
CURRENT MANAGEMENT OF PAIN
P. PRITHVI RAJ. SERIES EDITOR
The series, Current Management of Pain, is intended by the series editor and
the publishers to provide up-to-date information on advances in the clinical
management of acute and chronic pain and related research as quickly as
possible. Both the series editor and the publishers felt that, although compre
hensive texts are now available, they do not always cover the rapid advances
in this field. Another format was needed to publish advances in basic sciences
and clinical modalities and to bring them rapidly to the practitioners in the
community. A questionnaire was sent to selected clinicians and, based on
their responses, topics were chosen by the series editor. Editors of each
volume were chosen for their expertise in the field and their ability to
encourage other active pain specialists to contribute their knowledge:
Ghia, J. N., ed.: The Multidisciplinary Pain Center: Organization and Per
sonnel Functions for Pain Management, 1988. ISBN 0-89838-359-5.
Lynch, N.T., Vasudevan, S.V., eds.: Persistent Pain: Psychosocial Assess-
ment and Intervention, 1988. ISBN 0-89838-363-3.
Abram, S.E., ed.: Cancer Pain, 1988. ISBN 0-89838-389-7.
Racz, G.B., ed.: Technique's of Neurolysis, 1989. ISBN 0-89838-397-8.
Stanton-Hicks, M., ed.: Pain and the Sympathetic Nervous System, 1989.
ISBN 0-7923-0304-0
Rawal, N., Coombs, D.W., eds.: Spinal Narcotics, 1990. ISBN 0-7923-0374-1.
SPINAL NARCOTICS
Edited by
NARINDER RAWAL AND DENNIS W. COOMBS
~.
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KLUWER ACADEMIC PUBLISHERS
BOSTON DORDRECHT LONDON
Distributors
for North America: Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell,
Massachusetts 02061 USA
for all other countries:, Kluwer Academic Publishers Group, Distribution Centre, Post Office Box
322,3300 AH Dordrecht, The Netherlands
Library of Congress Cataloging-in-Publication Data
Spinal Narcotics / edited by Narinder Rawal, Dennis W. Coombs.
p. cm. - (Current management of pain; 6)
Includes index.
ISBN-13: 978-1-4612-8890-9 e-ISBN-13: 978-1-4613-1609-1
DOl: 10.1007/978-1-4613-1609-1
1. Spinal anesthesia. 2. Endorphins - Receptors. 3. Narcotics.
I. Rawal, Narinder. II. Coombs, Dennis W. III. Series.
[DNLM: 1. Anesthesia, Spinal. 2. Narcotics - pharmacology.
3. Narcotics - therapeutic use. 4. Pain - drug therapy.
5. Receptors, Endorphin. WO 305 S757]
RD85. S7S63 1989
617.9'64-dc20
DNLMIDLC
for Library of Congress 89-15480
CIP
Copyright
© 1990 by Kluwer Academic Publishers
Softcover reprint of the hardcover 1st edition 1990
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or
transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the publisher, Kluwer Academic Publishers, 101 Philip
Drive, Assinippi Park, Norwell, Massachusetts 02061.
CONTENTS
CONTENTS
Contributing authors Vll
Series editor foreword IX
Preface Xl
1. Opioid receptors: Types, distribution, and pharmacological profiles
THOMAS HEDNER, GUNNAR NORDBERG
2. Systemic and local distribution of opioids after spinal administration:
Implications for their clinical use 33
LARS L. GUSTAFSSON
3. Indications for the use of intraspinal opioids 43
NARINDER RAW AL
4. Perioperative stress reduction with intraspinal opioids 63
MARK YEAGER
5. Adverse effects of spinal opioids in acute pain and their management 77
NARINDER RAW AL
6. The role of intraspinal opioids in obstetrics 89
SAMUEL C. HUGHES
7. Delivery systems for chronic spinal analgesia 115
DENNIS W. COOMBS
8. Spinal opioid analgesia: Present status and future developments 129
PERRY G. FINE, THEODORE H. STANLEY
Index 145
CONTRIBUTING AUTHORS
Dennis W. Coombs, M.D., Editor
Assistant Professor of Anesthesiology
Dartmouth Medical School
Dartmouth-Hitchcock Medical Center
Hanover, NH 03756, U.S.A.
Perry G. Fine, M.D.
Assistant Professor
Department of Anesthesiology
University of Utah Medical Center
Salt Lake City, UT 84132, U.S.A.
Lars L. Gustafsson, M.D., Ph.D.
Senior Clinical Associate
Department of Clinical Pharmacology
Huddinge University Hospital
Karolinska Institute
Stockholm, Sweden
Thomas Hedner, M.D., Ph.D.
Associate Professor
Department of Clinical Pharmacology
Sahlgrenska University Hospital
Gothenburg, Sweden
viii Contributing authors
Samuel C. Hughes, M.D.
Assistant Clinical Professor
Department of Anesthesia
San Francisco General Hospital
San Francisco, CA 94143-0410, U.S.A.
Gunnar Nordberg, M.D., Ph.D.
Senior Consultant Anesthetist
Department of Anesthesiology
Sahlgrenska University Hospital
Gothenburg, Sweden
Narinder Rawal, M.D., Ph.D., Editor
Senior Consultant Anesthetist
Department of Anesthesiology and Intensive Care
Orebro Medical Center Hospital
Orebro, Sweden
and
Visiting Professor
Department of Anesthesiology
University of Texas Medical School at Houston
Houston, TX 77030, U.S.A.
Theodore H. Stanley, M.D.
Professor of Anesthesiology
Department of Anesthesiology
School of Medicine
University at Utah Medical Center
Salt Lake City, UT 84132, U.S.A.
Mark Yeager, M.D.
Assistant Professor
Department of Anesthesiology
Dartmouth Medical School
Dartmouth-Hitchcock Medical Center
Hanover, NH 03756, U.S.A.
SERIES EDITOR FOREWORD
One of the most exciting developments in medicine in this century has been the
discovery of opioid receptors and their pharmacology. The breadth of know1 -
edge derived from such discovery has truly changed the practice of medicine
today. The acceptance by the clinicians of the research data obtained by the
basic scientist on spinal opioids is truly amazing. The clinical sequelae of the
discovery of opioid receptors has been the development of the technique of
intraspinal administration of opioids. In the last decade much has been written
about indications, effects, and side effects of intraspinal opioids. The technique
has become commonplace for cancer and postoperative pain. However, no
standards of care and management of patients with spinally administered
opioids have been developed. We need these standards to be developed and
universally followed.
The monograph was conceived to update clinicians on the applied pharma
cology of spinal opioids. We were fortunate to have Drs. N. Rawal and D.
Coombs agree to edit this monograph. They have been able to assemble
world-renowned experts as contributing authors. It is our hope that the con
tents of this book will be stimulating, informative, and useful to the reader.
PREFACE
Much has been written about the subject of spinal opioid analgesia, includ
ing several notable reviews. We were stimulated to assemble this particular
volume in this important series on pain management initiated by Dr. Raj for
a number of reasons. Our first intention was simply to update the anesthesio
logists working in pain management. However, this series clearly is intended
for other specialists working in the same area. Our hope is that the balance of
basic and clinical science is such that the clinician I scientist other than the
anesthesiologist may also benefit from the collected subjects.
We have attempted to cover certain "new" areas, such as spinal opioid
infusions and modulation of surgical and postoperative stress responses, and
to update both basic and clinical aspects of spinal opioid analgesia. The chapter
by Fine and Stanley reflects an interesting perspective on the general direction
that we may be taking in the 1990s.
Stylistic differences and some overlap are inevitable in a multi-authored
monograph of this nature, and for this we apologize. Throughout this volume,
the term opioid is used to denote both endogenous and exogenous agents and
agonists exerting effects upon opioid (opiate) receptors regardless of their site
or action. The term intraspinal has been employed as a generic equivalent to
both epidural and intrathecal. Similarly, epidural has been utilized throughout
for extradural or peridural and intrathecal; subarachnoid and spinal are favored
over intradural.
We gratefully acknowledge the efforts of the individual authors for their
timely contributions, the editorial assistance of Marilyn Schwiers, our secre
taries, Betty Cunha and Katherine Dow, and finally, our series editor, P. Raj,
for his many thoughtful suggestions and avuncular attitude.
SPINAL NARCOTICS
