High-dose Morphine for Intractable Phantom Limb Pain

Mishra, Seema; Bhatnagar, Sushma; Singhal, Amit

doi:10.1097/01.ajp.0000210944.88933.3d

Cited by 9 publications

(4 citation statements)

References 21 publications

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“…The following pharmacologic treatments have been tried for PLP: amitriptyline, 34 , 35 doxepin, 35 – 37 gabapentin, 38 pregabalin, 39 topiramate, 40 carbemazepam, 41 , 42 clonazepam, 43 calcitonin, 44 – 46 ketamine, 46 – 49 memantine, 50 dextromethorphan, 51 methadone, 52 lidocaine, 53 mexiletine, 54 ropivicaine, 55 bupivacaine, 56 , 57 morphine, 35 , 58 , 59 fentanyl, 60 propranolol, 61 – 63 fluoxetine, 64 duloxetine 39 and milnacipran. 65 The vast majority found that PLP intensity was reduced, but the low methodological quality and small sample sizes mean that no clinical decisions should be made based on these studies.…”

Section: Resultsmentioning

confidence: 99%

A review of the management of phantom limb pain: challenges and solutions

Richardson¹,

Kulkarni²

2017

JPR

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BackgroundPhantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment.ObjectivesTo comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain.MethodMEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using “Phantom limb” initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system.ResultsThirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use.ConclusionNo decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.

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Section: Resultsmentioning

confidence: 99%

A review of the management of phantom limb pain: challenges and solutions

Richardson¹,

Kulkarni²

2017

JPR

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“…The need of high-dose morphine for PLP has been earlier reported. [ 9 ] Our patient had an intermittent break through phantom pain needing progressive dose escalation. Trial of optimal dose of adjuvants for neuropathic pain and interventional pain management techniques such as epidural local anesthetics and chemical sympathectomy did not confer satisfactory and sustained pain relief.…”

Section: Discussionmentioning

confidence: 99%

Long-term high-dose oral morphine in phantom limb pain with no addiction risk

Kumar¹,

Garg²,

Bharati³

et al. 2015

Indian J Palliat Care

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Chronic phantom limb pain (PLP) is a type of neuropathic pain, which is located in the missing/amputated limb. Phantom pain is difficult to treat as the exact basis of pain mechanism is still unknown. Various methods of treatment for PLP have been described, including pharmacological (NSAIDs, opioids, antiepileptic, antidepressants) and non-pharmacological (TENS, sympathectomy, deep brain stimulation and motor cortex stimulation). Opioids are used for the treatment of neuropathic pain and dose of opioid is determined based on its effect and thus there is no defined ceiling dose for opioids. We report a case where a patient receiving high-dose oral morphine for chronic cancer pain did not demonstrate signs of addiction.

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Section: Pharmacological Therapiesmentioning

confidence: 99%

“…68 More recent work by Mishra et al suggested that high doses of morphine may be necessary to achieve effective reduction of PLP. 69 In addition, work by Wu et al found that while morphine may be effective in decreasing PLP, it was associated with significant side effects and did not improve selfreported function or pain-related interference in ADLs. 70 In summary, while opioids may have some utility in the treatment of PLP, the significant side effects associated with their use, as well as limited demonstrated functional improvement, suggest that the risks may outweigh the benefit.…”

Section: Opioidsmentioning

confidence: 99%

An Algorithm Approach to Phantom Limb Pain

Boomgaardt¹,

Dastan²,

Chan³

et al. 2022

JPR

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Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. First recognized and described in 1551 by Ambroise Pare, research into its underlying pathology and effective treatments remains a very active and growing field. To date, however, there is little consensus regarding the optimal management of phantom limb pain. With few large well-designed clinical trials of which to make treatment recommendations, as well as significant heterogeneity in clinical response to available treatments, the management of PLP remains challenging. Below we summarize the current state of knowledge in the field, as well as propose an algorithm for the approach to the treatment of PLP.

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High-dose Morphine for Intractable Phantom Limb Pain

Cited by 9 publications

References 21 publications

A review of the management of phantom limb pain: challenges and solutions

A review of the management of phantom limb pain: challenges and solutions

Long-term high-dose oral morphine in phantom limb pain with no addiction risk

An Algorithm Approach to Phantom Limb Pain

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