Electric energy have been in use for the treatment of various ailments, including pain, since the time of Pharaohs. The theoretical basis of electrotherapy of pain was provided by the Gate Control Theory of Melzak and Wall. In 1965, Shealey et al. first introduced electrical stimulation of spinal cord for treating pain. At present spinal cord stimulation (SCS) is a well established form of treatment for failed back surgery syndrome, complex regional pain syndrome and refractory pain due to ischemia. The indications for SCS is growing and the technology involved in this is rapidly advancing, however, high level of scientific evidence is still lacking to support this form of therapy due to difficulties in blinding and comparing with control groups. Future developments in SCS could include, combined SCS-drug delivery system, bio feedback and closed loop systems.

The total global production of opium for opioid manufacturing is enough to supply the growing global demands. However, licit opioids are only consumed by 20% of the world population. Most people throughout the world had no access to opioid analgesics for pain relief in case of need. Opioid misuse and abuse is not only a phenomena plague by the USA but globally across many countries. Many countries have a lack of availability of opioids, contributing factors being strict government regulations limiting access, lack of knowledge of the efficacy of opioid analgesics in treating acute and chronic pain and palliative care, and the stigma that opioids are highly addictive. For the countries in which opioids are readily available and prescribed heavily, diversion, misuse, abuse, and the resurgence of heroin have become problems leading to morbidity and mortality. It is pertinent to find a balance between having opioids accessible to patients in need, with ensuring that opioids are regulated along with other illicit drugs to decrease abuse potential.

Intrathecal drug delivery system (IDDS) is a targeted therapy system for treating pain and muscle spasm. IDDS is recommended for the treatment of chronic pain which does not respond to optimal medical management. The aim of this review article is to give an up to date and concise account of the use of IDDS. It will explore the main indications, pre-implantation trials and different implantation techniques, the licensing of drugs for intrathecal use and the adverse effects and benefits of this therapy. IDDS is an invasive technique, which can result in severe morbidity and mortality. The up to date knowledge gained from this article along with the recommendations for improving safety in patients receiving IDDS, makes it a valuable resource for healthcare practitioners. Continued research, including outcome studies of this therapy continues to be necessary.

Purpose of Review The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant. Recent Findings The latest research has found that the development of standardized mechanisms and protocols to optimize the diagnosis, assessment, and management of pain in the critically ill can provide the best outcomes. The numerical rating scale, critical care pain observation criteria, and behavior pain scale has shown higher reliability to accurately assess pain in the critically ill. Most importantly, preemptive analgesia and the emphasis on early pain control-in the perioperative setting, ICU, and post-discharge-are crucial in minimizing chronic post-discharge pain. Finally, the multimodal approach is still found to be the most effective. This includes pharmacological treatments, regional nerve block, and epidural techniques, as well as alternative methods that are cheap, safe, and easily available. All these together have shown to help control pain, provide psychological support, and prevent long-term co-morbidities in the critically ill. Summary Largely, pain in the critically ill patient is still a very complex issue that requires appropriate diagnosis, assessment, and management of the pain itself and treating all the underlying co-morbidities as well. Many different factors makes it challenging, especially the difficulty in communicating with an ICU patient. However, by looking at the patient as a whole, treating pain early with the multimodal approach, there seems to be some promising results in improving outcomes. It has shown that the improved outcomes in critically ill patients in the perioperative period seen with optimized pain management and ICU can shorten hospital stays, decreased inpatient costs, and limit the use of limited resources.

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