Background: There are marked differences in the numbers of pain clinicians to population and medical doctors among 47 prefectures. However, there was no significant difference among 11 district Societies of the Japan Society of Pain Clinicians (JSPC). In the present study, we investigated the regional distribution of the numbers of pain clinicians and pain clinic institutions.
Methods: We compared the numbers of medical doctors, regular members of the JSPC, Board members of the JSPC, and certified training hospitals of the JSPC to the numbers of general hospitals and hospital beds in the 47 prefectures and the 11 district Societies of the JSPC.
Results: There were significant correlations in all combinations between population, the numbers of medical doctors, general hospitals, hospital beds, regular members, Board members, and certified training hospitals of the JSPC in the 47 prefectures. The average number of regular members of the JSPC per one general hospital was 0.44. It was largest (0.94) in the Tokyo District Society, and smallest (0.27) in the Shikoku District Society. The average number of Board members of the JSPC per one general hospital was 0.14. It was largest (0.30) in the Tokyo District Society, and smallest (0.07) in the Kyushu District Society. The percentage of certified training hospitals of the JSPC per all general hospital was 2.9%. It was highest (5.5%) in the Tokyo District Society, and lowest (1.4%) in the Kyushu District Society. However, there was no significant regional difference in the percentage of certified training hospitals of the JSPC. The average number of regular members of the JSPC per 1, 000 hospital beds was 2.5. It was largest (4.9) in the Tokyo District Society, and smallest (1.8) in the Kyushu District Society. The average number of Board members of the JSPC per 1, 000 hospital beds was 0.8. It was largest (1.6) in the Tokyo District Society, and smallest (0.5) in the Kyushu District Society.
Conclusion: These results suggest that there are regional differences in the numbers of pain clinicians and pain clinic institutions to general hospitals and per hospital beds in Japan. Tokyo has the largest number of pain clinicians and Kyusyu and Shikoku have the fewest numbers.

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We report a 40-year-old female patient with medication-overuse headache (MOH) following triptan abuse. She was diagnosed as having migraine without aura at the age of 16. At the age of 39, she started taking sumatriptan orally in addition to a calcium antagonist to treat her headache. Initially, the sumatriptan was effective against her migraine attacks. However, the frequency of sumatriptan intake gradually increased because she may have had tension-type headache as well. From the time she started taking 100mg of sumatriptan daily, and headache was persistent, but different from her previous headache. Thus, she started taking 300mg of sumatriptan daily based on her own judgment. We diagnosed her MOH following sumatriptan overuse. We immediately discontinued the sumatriptan, replacing it with long-acting NSAIDs and drugs against tension-type headache. Although severe withdrawal headache appeared after sumatriptan discontinuation, there was remission of her headache within a week. The experience obtained by treating this patient suggests the following. First, we should suspect MOH when treating a patient with a history of triptan overuse if the characteristics of the headache have changed. Second, MOH treatment is difficult because the patient must be aware that in the initial few days there will be a deterioration of the headache. Finally, it is important to control the pain and associated symptoms during the withdrawal headache and to establish a prophylactic treatment. Moreover, we must educate patients.

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There have been no reports of families with juvenile periodic arthralgia. The inheritance pattern of this family was a positive autosomal dominant disorder closely correlated with their blood type, which suggests that the mutation might exist on the long arm of the 9^th chromosome and that the disease is unique among all the other genotypes of familial arthropathies in children so far reported.

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We describe iliopsoas muscle abscess contralateral to the superior hypogastric plexus block. A 70-year-old man developed intractable lower abdominal and anal and perineum pain due to recurrence of rectal cancer. Superior hypogastric plexus block with alcohol was performed on the right. Fever developed three days after the block. Leukocytosis and elevation of CRP occurred. Left-sided lumbar pain occurred 14 days after the block. CT and MRI studies suggested a left-sided iliopsoas abscess. He received aggressive treatment with antibiotics. The pain gradually subsided. He was discharged 52 days after the block.

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A 64-year-old male suffering hiccups for 14 years appeared in the clinic. His intractable hiccups led him to alcoholism, because hiccups drew vomiturition of solid foods. Oral medication of carbamazepine, baclofen, valproic acid, chlorpromazine or harbal medicine “Shakuyaku-kanzo-to” were not effective for ceasing his hiccups. Cervical epidural block and phrenic nerve block were also not effective, and stellate ganglion block worsened his hiccups. Although oral diazepam or clonazepam were slightly effective, the patient was not tolerate to effective doses of these drugs. Finally, I found that the hiccups of this patient had decreased efficaciously with oral amitriptyline, propranolol, low dose of clonazepam and temporary vagus nerve block. Considering that GABA receptors have some role in decreasing hiccups, the nil effect of baclofen and the others seemed to suggest that intractable hiccups may not be treated by only one medication. So beta antagonist and vagus nerve block, even though there are a few reports, should be considered for this kind of patients. It would be notable that the cure of hiccups treated his alcoholism by decrease of vomiturition.

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Since 1988, we have administered morphine, based on the “WHO method of cancer pain relief”, to patients suffering from severe chronic non-cancer pain. The greater part of the patients completed the therapy with satisfactory results within a few months. In fourteen patients the treatment was continued effectively up to over one year. In the case of a 55 year-old female (SLE), severe spinal and multiple joint pain were relieved with morphine and daily activity was restored for 13 years. In another case, a 48 year-old female (Scleroderma), with severe pain due to ulcers on the fingers and toes was treated well with morphine for 7 years. As the pain-relieving dose of morphine was varied according to the severity of pain, it decreased promptly with no trouble after pain was reduced in all patients. It is an essential part of our treatment strategy to advise patients on the proper use of morphine when taking analgesics (morphine) as their own decision and maintaining a pain-free state at all times. When “patient-controlled pain-relief” with oral morphine is carried out well, it becomes a reliable and safe method for the treatment of severe chronic pain.

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We describe two patients who developed profound sedation and unconsciousness during continuous administration of morphine through an epidural catheter. Both patients underwent abdominal surgery under combined epidural and general anesthesia. There were no symptoms or signs suggestive of subarachnoid migration of the epidural catheter during surgery. Clear fluid, which contained sugar, was aspirated through the epidural catheter, when profound sedation was noted. Their SpO₂ did not decrease to abnormal levels while breathing oxygen-enriched air. Continuous intravenous administration of naloxone improved profound sedation and respiratory depression. Subarachnoid migration of an epidural catheter should be considered as a differential diagnosis of unusual profound sedation during epidural administration of opioids.

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