Management of Chronic Pain

Arthur M. Gershkoff, MD; Mitchell Freedman, DO; John R. McGowan, PhD
JAMA. 1989;261(3):381. doi:10.1001/jama.1989.03420030055022.
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To the Editor. —  While nalbuphine may be worthy of consideration as an appropriate analgesic for certain patients, Dr Defalque's1 discussion of the use of that drug in injectable form for chronic, intractable nonmalignant pain in the QUESTIONS AND ANSWERS section was inadequate. Presuming that the patient indeed has tissue damage and can respond to the agent pharmacologically is not enough. Dr Leveque must be asked whether other medical, psychological, social, and behavioral factors exist that serve to perpetuate this patient's pain.Behavioral factors are particularly important given the perceived lack of alternatives to injectable medication and the dosing interval of nalbuphine. While nalbuphine may have low potential for abuse, the patient may be psychologically dependent on the injections themselves. Injections cause a rapid increase in blood levels of medication and resultant analgesia. If they are not spaced closely enough together so as to maintain near-constant blood levels of


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