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SPINAL 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 ~. " 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
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