Safety and efficacy of ketorolac continuous infusion for multimodal analgesia of vaso-occlusive crisis in patients with sickle cell disease

Pain is an hallmark of sickle-cell-related acute clinical manifestations as part of acute vaso-occlusive crisis (VOC). In SCD pain has different origins such as vascular or neuropathic pain, which requires multimodal analgesia. This is based on the administration of drugs with different pharmacological mechanisms of action, maximizing analgesia and minimizing their adverse events and the risk of drug-addition in patients experiencing acute-recurrent pain events as in SCD. Ketorolac is a potent non-narcotic analgesic, being relatively safe and effective during pain-management in children and adults. Up to now, there is a lack of safety information on continuous infusion ketorolac as used to control acute pain in patients with SCD, and the benefits/risks ratio needs to be investigated. Here, we report for the first time the safety profile of ketorolac in the special population of patients with SCD. We confirmed that ketorolac in combination with tramadol, an opioid like molecule, is effective in pain control of adult patients with SCD experiencing acute severe VOCs defined by pain visual analog scale. Our study shows that short term (72 h) continuous infusion of ketorolac plus tramadol is not associated with adverse events such as liver or kidney acute disfunction or abnormalities in coagulation parameters during patients' hospitalization and within 30 days after patients discharge. This is extremely important for patients with SCD, who should have access to multimodal therapy to control recurrent acute pain crisis in order to limit central sensitization a fearsome issue of undertreated recurrent acute pain and of chronic pain.

Testing a model for person-centred pain management: A systematic review and synthesis guided by the Fundamentals of Care framework

AIMS

To test a model for person-centred pain management using qualitative evidence in the literature and refine it based on the results.

DESIGN

A qualitative systematic review with thematic synthesis using the Fundamentals of Care framework.

METHODS AND DATA SOURCES

A literature search in February 2021 in six scientific databases: CINAHL, PsycInfo, Pubmed, Scopus, Social Science Premium Collection and Web of Science, reported using ENTREQ and PRISMA. Quality assessment was performed for the individual studies. Thematic analysis and the GRADE-CERQual approach were used in the synthesis including the assessment of confidence in the evidence.

RESULTS

The model was tested against the evidence in 15 studies appraised with moderate or high quality and found represented in the literature but needed to be expanded. A refined model with a moderate/high confidence level of evidence presents elements to be used in a holistic care process; The nurse is guided to establish a trusting relationship with the patient and enable communication to identify and meet pain management needs using pharmacological and non-pharmacological management. Nurse leaders are guided to support this process by providing the right contextual conditions.

CONCLUSIONS

The strengths of the confidence level in the refined model, and that it is represented from the nurse and patient perspectives in nursing research across countries and cultures, support our recommendation for empirical evaluation.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The model links the knowledge of pain management elements from individual studies together into actions to be performed in clinical practice. It also outlines the organizational support needed to make this happen. Nurses and nursing leaders are suggested to test the model to implement person-centred pain management in clinical practice.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT

What Problem Did the Study Address? There is a need to transfer available evidence of person-centred pain management into practice to relieve the patient from pain. What Were the Main Findings? Person-centred pain management is of high priority for patients and nurses around the world and can be performed in a holistic care process including patient-nurse trust and communication, supported by contextual conditions to deliver timely pharmacological and non-pharmacological pain management addressing the patient's physical, psychosocial and relational care needs. Where and on Whom will the Research Have an Impact? The model is to be tested and evaluated in clinical practice to guide the providers to relieve the patient from pain.

REPORTING METHOD

Relevant EQUATOR guidelines were used to report the study: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

Raising Awareness on the Clinical and Social Relevance of Adequate Chronic Pain Care

Appropriate pain care should be regarded as a right and effectively guaranteed to people with chronic pain (CP). Law 38, enacted in Italy in 2010, establishes the citizen's right not to suffer. Twelve years later, such right appears still disregarded in Italy and the current access to adequate pain care reveals significant shortcomings. In addition, a mismatch between CP-associated burden and the available healthcare resources in the framework of our national health system has been observed. This article gathers the perspectives of a Board of Italian anesthesiologists on the state of the art of CP management in Italy and aims at strengthening the scientific rationale and clinical relevance of pursuing the enforceability of the right not to suffer and at promoting widespread multidisciplinary care of patients with CP.

Challenges and current status of children pain management in Spain

Pain in children population is prevalent, but its proper diagnosis and management are frequently insufficient in pediatrics daily practice. Lack of knowledge of the professionals in charge is a recognized barrier to ensure an appropiate approach to pain in this population. Our present study reflects the current status of pain management and the challenges in diagnosis and treatment that pediatricians face in their daily work. This information is obtained from a survey made with a voluntary questionaire, desinged and distributed online by "Grupo Español para el Estudio del Dolor Pediátrico (GEEDP)" to pediatricians in Spain from october 2021 to march 2022. The final objective of the questionaire was to shed some light into the problem and find out which areas of pain management knowledge are in need of improvent.

Access to pain management from a legal and human rights perspective

Patients who experience pain require adequate pain management provided by healthcare professionals who have access to pain relief medicines and are trained in the assessment and treatment of pain. Patients also need their pain to be acknowledged, understood and believed. These patient needs in relation to pain management can be considered from a legal and human rights perspective. This article describes human rights legislation in the UK, how it affects healthcare practice and what it means for healthcare professionals. It discusses barriers to pain management, the concept of pain management as a human right, the obligation of healthcare organisations to provide pain management and the limits to patients' rights to pain management. Finally, it proposes strategies that nurses can use to uphold a patient's human rights in relation to pain management.

Quality of Life and Mental Distress in Patients with Chronic Low Back Pain: A Cross-Sectional Study

The aim of this study was to examine the levels of health-related quality of life (HRQoL), pain intensity, and mental distress in participants with chronic low back pain (CLBP), and to examine the differences in the HRQoL of participants with respect to mental distress and the correlations of the examined variables. Data were collected from 148 patients using the SF-36 Health Status Questionnaire (SF-36), the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) questionnaire, and the visual-analog pain scale (VAS). The results indicate poorer self-assessment of physical health (M_e = 28.1) compared to mental health (M_e = 39.4). Participants with higher levels of mental distress reported significant emotional limitations (p = 0.003), lower energy (p < 0.001), poorer psychological health (p < 0.001) and social functioning (p < 0.001), more pain (p = 0.007), and, ultimately, poorer general health (p < 0.001). The level of mental distress was related to the level of HRQoL, while a correlation with the level of pain of the participants was not found. The study results indicate a connection between the presence of mental distress and almost all aspects of HRQoL in participants with CLBP.

An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives

Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.

Student nurses' pain knowledge and attitudes towards pain management over the last 20 years: A systematic review

OBJECTIVE

To discover if nursing students have improved their level of pain knowledge and their attitudes towards pain management over the last 20 years.

DESIGN

Systematic review utilising the Kable, Pich, and Maslin-Prothero 12 step approach to document a search strategy.

DATA SOURCES

A search was conducted from 2000 to 2020 using CINAHL, PubMed, Embase and ProQuest.

REVIEW METHODS

Studies exploring the level of pain management knowledge and attitudes of nursing students were included. The Critical Review Form - Quantitative Studies provided the appraisal framework (Law et al., 1998). A narrative synthesis of eligible studies was undertaken.

RESULTS

Six studies with a total of 1454 participants were included. The studies demonstrated that nursing students have not improved their level of pain knowledge and attitudes towards pain management in the last 20 years. Whilst many nursing students thought they possessed adequate pain knowledge, the studies all demonstrated that their pain knowledge is lacking and that they do not have appropriate attitudes towards pain. Students did not recognise the patient who was not grimacing as being in pain despite the patient report of pain.

CONCLUSIONS

These findings support the notion that nursing education does not include sufficient focus on pain identification and management. Alignment of nursing pain education with the curriculum developed in 1993 by the International Association for the Study of Pain is needed to ensure nurses have appropriate knowledge so that patients can receive effective pain management.

Procedural Pain Management: Clinical Practice Recommendations American Society for Pain Management Nursing

Throughout the life span procedures are common within health care and have the potential to cause pain. Nurses have an ethical responsibility involving the care of people with pain. The American Society for Pain Management Nursing holds the position that all patients undergoing painful procedures have the right to safe and effective pain management throughout the phases of care and that the interprofessional health care team ensures such ethical obligation is fulfilled within a framework of patients or their designees' goals and preferences. It is recommended that nurses, other health care providers, and health care organizations offer the use of integrative intervention for managing pain during procedures.

Interventions to reduce arterial puncture-related pain: A systematic review and meta-analysis

BACKGROUND

Arterial puncture-related pain remains unaddressed across several clinical settings. Analgesic techniques are not routinely employed before arterial puncture despite the recommendation that local anesthesia be used, except in emergencies. A comprehensive review of interventions aimed at reducing arterial puncture-related pain and their potential effectiveness is lacking, and the benefit of some interventions is uncertain.

OBJECTIVE

To describe interventions aimed at reducing arterial puncture-related pain and provide an estimate of their effectiveness.

DESIGN

Systematic review and meta-analysis (PROSPERO no. CRD42020212299).

DATA SOURCE(S)

PubMed, CINAHL EBSCO, EMBASE, the Cochrane Database of Systematic Reviews, and Scopus were searched from their inception to 7 October 2020. No temporal or language limits were applied.

METHODS

Published, quantitative studies on interventions aimed at reducing arterial puncture-related pain among adults were included. Screening, quality appraisal, and data extraction were undertaken independently by two reviewers. Random effects meta-analyses were performed to assess the association between interventions aimed at reducing arterial puncture-related pain and patients' perceived pain using difference in means (MD) with 95% confidence intervals (CIs). A funnel plot and Egger test were used to assess publication bias.

RESULTS

The titles and abstracts of the 2446 identified articles were screened, and 43 and 31 studies were finally included in the systematic review and meta-analysis, respectively. Interventions to reduce arterial puncture-related pain included: topical anesthetics (n = 16), cryotherapy (n = 9), local anesthetic infiltration (n = 5), narrower needle gage (n = 5), ultrasound-guided procedure (n = 3), topical anesthetics combined with local anesthetic infiltration (n = 1), iontophoresis using anesthetics (n = 1), engineered blood gas syringe (n = 1), jet injector (n = 1), and local massage (n = 1). Topical anesthetics [MD -0.58, 95% CI -1.00, -0.15], cryotherapy [MD -1.13, 95% CI -1.72, -0.53], and local anesthetic infiltration [MD -1.13, 95% CI -1.72, -0.53] reduced arterial puncture-related pain. No benefit was found for narrower needle gage [MD -0.07, 95% CI -0.86, 0.71] or ultrasound-guided procedure [MD -1.74, 95% CI -3.51, 0.03]. No publication bias was detected.

CONCLUSIONS

Local anesthetic infiltration provided the greatest pain reduction and should be considered standard practice. Cryotherapy may be a safe, convenient alternative to local anesthetic infiltration. Topical anesthetics had limited benefit, and their lengthy time of onset makes them unsuitable for critical or emergency situations, though they may represent an option when comorbid conditions make cooling impossible. Caution must be used when interpreting these results, given the high risk of bias in the methods of included studies and the heterogeneity across the studies.

A survey evaluation comparing pain curriculum taught in Australian exercise physiology degrees to graduate perceptions of their preparedness and competency to treat people with chronic pain

BACKGROUND AND AIMS

This cross-sectional study evaluated the nature of pain curriculum being taught in accredited exercise physiology degrees across Australian universities and its perceived usefulness for preparing exercise physiologists to treat people with chronic pain. MATERIALS & METHODS: Universities and graduates were asked about the nature and sufficiency of pain curriculum taught, with particular emphasis on competencies for physical therapists as outlined by the International Association for the Study of Pain.

RESULTS

Ten universities and 101 graduates responded. Median (interquartile range) instruction time on pain curriculum was 12 (7.25-18.75) hours. Few universities (30%) were aware of the guidelines for physical therapy pain curricula, although most (70%) agreed their degrees contained adequate instruction on pain assessment and management. In contrast, 74% of graduates felt their degree did not adequately prepare them to treat people with chronic pain. Half the graduates (51%) were not aware of the guidelines for physical therapy pain curricula. DISCUSSION & CONCLUSION: There is a disconnect between perceptions of Australian universities and their graduates regarding the sufficiency of pain curriculum taught to student exercise physiologists. Benchmarking pain curriculum in Australian university programs against relevant international recommendations may enhance the suitability of pain curricula taught to exercise physiologists, thereby better preparing new graduates to treat people with pain.

Practical Advices for Treating Chronic Pain in the Time of COVID-19: A Narrative Review Focusing on Interventional Techniques

BACKGROUND

Since the management of chronic pain has become even more challenging secondary to the occurrence of SARS-CoV-2 outbreaks, we developed an exhaustive narrative review of the scientific literature, providing practical advices regarding the management of chronic pain in patients with suspected, presumed, or confirmed SARS-CoV-2 infection. We focused particularly on interventional procedures, where physicians are in closer contact with patients.

METHODS

Narrative Review of the most relevant articles published between June and December of 2020 that focused on the treatment of chronic pain in COVID-19 patients.

RESULTS

Careful triage of patients is mandatory in order to avoid overcrowding of hospital spaces. Telemedicine could represent a promising tool to replace in-person visits and as a screening tool prior to admitting patients to hospitals. Opioid medications can affect the immune response, and therefore, care should be taken prior to initiating new treatments and increasing dosages. Epidural steroids should be avoided or limited to the lowest effective dose. Non urgent interventional procedures such as spinal cord stimulation and intrathecal pumps should be postponed. The use of personal protective equipment and disinfectants represent an important component of the strategy to prevent viral spread to operators and cross-infection between patients due to the SARS-CoV-2 outbreaks.

Pain and Stress Detection Using Wearable Sensors and Devices-A Review

Pain is a subjective feeling; it is a sensation that every human being must have experienced all their life. Yet, its mechanism and the way to immune to it is still a question to be answered. This review presents the mechanism and correlation of pain and stress, their assessment and detection approach with medical devices and wearable sensors. Various physiological signals (i.e., heart activity, brain activity, muscle activity, electrodermal activity, respiratory, blood volume pulse, skin temperature) and behavioral signals are organized for wearables sensors detection. By reviewing the wearable sensors used in the healthcare domain, we hope to find a way for wearable healthcare-monitoring system to be applied on pain and stress detection. Since pain leads to multiple consequences or symptoms such as muscle tension and depression that are stress related, there is a chance to find a new approach for chronic pain detection using daily life sensors or devices. Then by integrating modern computing techniques, there is a chance to handle pain and stress management issue.

Palliative and end of life care for people with advanced dementia

Despite growing understanding in recent years of the biological, psychological, social, environmental and spiritual aspects of dementia, people with advanced dementia continue to experience inequalities in accessing healthcare capable of improving their lives. The complexities of advanced dementia challenge professional competence and demand the highest level of skilled, compassionate care. This article, the last in a series on living with advanced dementia, considers the status and direction of palliative care as it applies to people with dementia and explores contemporary issues regarding advanced dementia and end of life, with a focus on guidance for practitioners and support for best practice. It identifies that open communication, clear information and a person-centred approach adopted as early as possible in the syndrome can make this period less distressing. Crucially, people at the end of life should be offered care in line with best practice in palliative and end of life approaches.

Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol

Introduction

There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol.

Methods

This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017–December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients’ clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia.

Results

Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69–0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96–2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use non-opiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns.

Conclusion

The introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization.

Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Public Health Crises

BACKGROUND

It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for.

METHODS

To address these issues, an expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. Endorsement from stakeholder societies was sought upon completion of the document within a one-week period.

RESULTS

In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization.

CONCLUSIONS

The COVID-19 public health crisis has strained health care systems, creating a conundrum for patients, pain medicine practitioners, hospital leaders, and regulatory officials. Although this document provides a framework for pain management services, systems-wide and individual decisions must take into account clinical considerations, regional health conditions, government and hospital directives, resource availability, and the welfare of health care providers.

Guidance concerning chiropractic practice in response to COVID-19 in the U.S.: a summary of state regulators' web-based information

INTRODUCTION

The COVID-19 pandemic led to unprecedented changes, as many state and local governments enacted stay-at-home orders and non-essential businesses were closed. State chiropractic licensing boards play an important role in protecting the public via regulation of licensure and provision of guidance regarding standards of practice, especially during times of change or uncertainty.

OBJECTIVE

The purpose of this study was to summarize the guidance provided in each of the 50 United States, related to chiropractic practice during the COVID-19 pandemic.

METHODS

A review of the public facing websites of governors and state chiropractic licensing boards was conducted in the United States. Data were collected regarding the official guidance provided by each state's chiropractic licensing board as well as the issuance of stay-at-home orders and designations of essential personnel by state governors. Descriptive statistics were used to report the findings from this project.

RESULTS

Each of the 50 state governor's websites and individual state chiropractic licensing board's websites were surveyed. Stay-at-home or shelter-in-place orders were issued in 86% of all states. Chiropractors were classified as essential providers in 54% of states, non-essential in one state (2%), and no guidance was provided in the remaining 44% of all states. Fourteen states (28%) recommended restricting visits to only urgent cases and the remaining states (72%) provided no guidance. Twenty-seven states (54%) provided information regarding protecting against infectious disease and the remaining states (46%) provided no guidance. Twenty-two states (44%) provided recommendations regarding chiropractic telehealth and the remaining states (56%) provided no guidance. Seventeen states (34%) altered license renewal requirements and eight states (16%) issued warnings against advertising misleading or false information regarding spinal manipulation and protection from COVID-19.

CONCLUSION

State guidance during the COVID-19 pandemic was heterogenous, widely variability in accessibility, and often no guidance was provided by state chiropractic licensing boards. Some state chiropractic licensing boards chose to assemble guidance for licensees into a single location, which we identified as a best practice for future situations where changes in chiropractic practice must be quickly communicated.

Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Over-indebtedness and its association with pain and pain medication use

In developed countries, millions of households are over-indebted, and the number continues to rise. Studies have found an increased risk of adverse health effects among individuals that cannot cover payment obligations with available assets persistently. However, little is known about the role of over-indebtedness in pain. This study examined the association between over-indebtedness and pain and pain medication use. A cross-sectional study conducted among over-indebted individuals in 70 debt advisory centres in Germany (OID-survey; n = 699) was linked to the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). Descriptive statistics and logistic regression analyses were used to examine the association between over-indebtedness and pain and pain medication use among participants with valid data on both outcome variables (n = 7560). Pain was experienced by over-indebted individuals more frequently (71.3%) compared to the general population (59.6%) whereas the prevalence of pain medication use was similar in both samples (DEGS1 12.6% vs. OID-survey 13.1%). Over-indebtedness significantly increased the odds of pain (aOR 1.30; 95%-CI 1.07-1.59) after adjusting for socioeconomic, demographic and health factors. The over-indebted were significantly less likely to use pain medication compared to the general population after adjustment (aOR 0.76; 95%-CI 0.58-0.99). Taking over-indebtedness into account as risk factor for pain and restricted pain medication use in research and clinical practice will help to advance the understanding of pain disparities, develop suitable interventions for preventive action and promote accessible pain management among those at risk.

Pain curricula across healthcare professions undergraduate degrees: a cross-sectional study in Catalonia, Spain

BACKGROUND

Pain management is a challenge and effective treatment requires professionals to collaborate if they are to address the needs of patients with pain. Comprehensive education and training is key to helping skilled professionals provide the best pain care possible. The objective of this work was to study the content of the pain education provided to undergraduates in healthcare and veterinary programs in Spain.

METHODS

A survey was developed on the basis of previous surveys that had been used in the field. The final version included 31 questions about different issues on pain education, including, type of subject, number of pain mandatory/elective hours, and specific content covered. The survey was sent to all course leaders for all subjects on the undergraduate programs in Dentistry, Human Nutrition and Dietetics, Medicine, Nursing, Occupational Therapy, Pharmacy, Physiotherapy, Podiatry, Psychology, and Veterinary Science, in Catalonia, Spain. The survey was conducted from January to June, 2018. Students' t-test were used to study mean differences in responses.

RESULTS

A total of 550 course leaders from all healthcare undergraduate programs in Catalan universities took part. There were considerable differences in the number of pain-related hours among disciplines: Nursing reported the highest number of hours, and Psychology the lowest. The area least covered by all the disciplines was the "Management of pain", and particularly the content related to the most vulnerable members of society (i.e., youths, the elderly and special populations). No interprofessional educational program on pain was identified.

CONCLUSIONS

Pain is not such a large component of the undergraduate healthcare curriculum in Spain as could be expected given the extent of pain and its impact. Curricula need to be changed so that the problems all stakeholders have with pain care can be addressed.

Access to Opioids for Patients with Advanced Disease

Pain at the end of life is common in both malignant and non-malignant disease. It is feared by patients, their families and careers, and professionals. Effective pain control can be achieved for the majority of patients at the end of life using a multimodal approach. Pharmacological management relies predominantly on strong opioids. In spite of this, evidence suggests that under treatment of pain is common resulting in unnecessary suffering. Multiple barriers to use of opioids have been identified. Patient barriers include reluctance to report pain and to take analgesics. Professional barriers include inadequate pain assessment and lack of specialist knowledge and confidence in opioid therapy. Fear of side effects including respiratory depression affects patients and professionals alike. The impact of the "opioid epidemic", with increasing prescribed and illicit opioid use around the world, has also led to increasingly stringent regulation and concern about under prescribing in palliative care. System barriers to use of opioids at the end of life result from limited opioid availability in some countries and also inconsistent and limited access to palliative care. Multiple interventions have been developed to address these barriers, targeted at patients, professionals and systems. There is increasing evidence to suggest that complex interventions combining a number of different approaches are most effective in optimising pain outcomes for patients at the end of life.

Rising Trends of Prescription Opioid Sales in Contemporary Brazil, 2009-2015

OBJECTIVES

To present and discuss recent patterns of prescription opioid sales throughout Brazil.

METHODS

We graphed linear trends of opioid prescriptions sold from registered pharmacies across Brazil from 2009 to 2015. We then calculated the change in rate of prescriptions sold per 1000 persons in 2015 compared with 2009.

RESULTS

Opioid sales increased across Brazil from 1 601 043 prescriptions in 2009 to 9 045 945 prescriptions in 2015, corresponding to a 465% increase in 6 years. The largest absolute increase was for codeine products (rate ratio (RR) = 5.30; 95% confidence interval [CI] = 5.29, 5.31), accounting for more than 98% of prescriptions in both years. Oxycodone had the largest relative increase (RR = 11.39; 95% CI = 11.19, 11.59), and fentanyl products had the smallest absolute and relative increase (RR = 2.91; 95% CI = 2.78, 3.03).

CONCLUSIONS

Given rapid increases in opioid sales across Brazil, it is critical to introduce effective prescribing and monitoring methods that allow patients to access necessary medications without escalating risk of opioid misuse and related consequences. Careful surveillance of supply and subsequent outcomes are needed to prevent the development of another devastating opioid epidemic in the Americas.

Paediatric Palliative Care in Resource-Poor Countries

There is a great need for paediatric palliative care (PPC) services globally, but access to services is lacking in many parts of the world, particularly in resource-poor settings. Globally it is estimated that 21.6 million children need access to palliative care, with 8.2 needing specialist services. PC has been identified as important within the global health agenda e.g., within universal health coverage, and a recent Lancet commission report recognised the need for PPC. However, a variety of challenges have been identified to PPC development globally such as: access to treatment, access to medications such as oral morphine, opiophobia, a lack of trained health and social care professionals, a lack of PPC policies and a lack of awareness about PPC. These challenges can be overcome utilising a variety of strategies including advocacy and public awareness, education, access to medications, implementation and research. Examples will be discussed impacting on the provision of PPC in resource-poor settings. High-quality PPC service provision can be provided with resource-poor settings, and there is an urgent need to scale up affordable, accessible, and quality PPC services globally to ensure that all children needing palliative care can access it.