Potentiation of opioid analgesia can be achieved by the addition of midazolam intrathecally. At our institution, analgesia following open abdominal surgery is provided by continuous infusion of analgesic solutions either intravenously, intrathecally (incorporating midazolam) or epidurally. We report the results of a study comparing outcomes with these three analgesic regimens following major open abdominal surgery. This was an unblinded prospective audit of pain service intervention rates, pain scores and other outcomes after intravenous, intrathecal and epidural analgesia after open abdominal surgery in patients over 60 years of age. Both elective and emergency cases were included over a nine-month period. Patients ventilated for 24 hours or more were excluded. The analgesic regimens were as follows: 1. Intravenous: patient controlled analgesia with morphine+ketamine infusion 0.1 to 0.2 mg/kg/h. 2. Intrathecal: (morphine 10 g/ml+midazolam 100 g/ml+bupivacaine 0.05%) commenced at 2 ml/h. 3. Epidural: bupivacaine 0.125%+fentanyl 2 g/ml at 6 to 14 ml/h. Co-analgesic administration was as per our usual practice but was not standardised. The median number of calls per patient to the pain service differed between the intravenous (1), intrathecal (1) and epidural (3) groups. The number of unintentional analgesic regimen terminations differed between the intravenous (1), intrathecal (1) and epidural (5) groups. Pain scores differed significantly between groups and were lowest in the intrathecal group at all time points. The findings indicate that the intrathecal group had both a low requirement for postoperative interventions/ resources and excellent analgesia. It appears to be a suitable alternative to the other techniques.

It has been our observation that our chronic pain adult patients often fit the characteristic of ADHD. Inattention, Hyperactivity, and Impulsivity. Our evidence now demonstrates that the increased incidence of accidents found in chronic pain patients may be the result of undiagnosed and untreated ADHD.Roughly 4 million children may be diagnosed with ADHD, while only 2 million are being actively treated with d,l-methylphendidate or other psycho-stimulants. Examination of the statistics shows that the majority of children with ADHD are not recognized. One would then conclude that these children will also be inadequately treated as adults. Since the majority of children with ADHD carry these symptoms into adulthood there must then be a much greater total number of untreated adults between the ages of 16 to death.A retrospective review of 460 random patients during a 6-month period included new and existing chronic pain patients. Our results preliminarily identified a trend in patient's histories, characterized by anxiety problems and depressive symptoms, coupled with a family history of ADHD. Our methodological retrospective chart reviews are suggestive of an associated ADHD has revealed that undiagnosed ADHD may be a cause of the patient's accidents and that overall higher level functioning is appreciated in chronic pain patients when treatment with a long acting stimulant (d,l-methylphenidate hcl) is initiated. Thirteen percent of our study population of chronic pain patients represents approximately two to three times greater frequency of expected ADHD patients that would be in a general adult population. The preliminary data support the hypothesis that chronic pain patients have a greater incidence of ADHD than might be expected and more importantly. We do not believe there are any previously published reports suggesting a correlation of ADHD with chronic pain resulting from increase incidence of accidents.