Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

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This study determined the median effective concentration for epidural infusions of bupivacaine during labor analgesia. Coadministered epidural fentanyl infusions were more than three times more potent than IV fentanyl infusions, suggesting a predominantly spinal mechanism of opioid action under these study conditions.

This case report discusses the anesthetic management of two parturients with severe osteogenesis imperfecta who presented for cesarean delivery. Although the anesthetic management for milder forms of the disease has been previously reported, anesthetic options for cases of this severity have not.

Spinal anesthesia recently has gained popularity for elective cesarean section. Our anesthesia service changed from epidural to spinal anesthesia for elective cesarean section in 1991. To evaluate the significance of this change in terms of time management, costs, charges, and complication rates, we retrospectively reviewed the charts of patients who had received epidural (n = 47) or spinal (n = 47) anesthesia for nonemergent cesarean section. Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 +/- 20 vs 83 +/- 16 min, [mean +/- SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 +/- 11 vs 29 +/- 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (i.v.) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections.