Barriers to pain management: focus on opioid therapy

Incarcerated Men: Pain Experiences Shaped by Altered Independence and Loss of Autonomy

BACKGROUND

Individuals experiencing pain while incarcerated depend on nurses, security structures, processes, and regulations for relief.

PURPOSE

The intent of this research was to understand men's experience of pain during incarceration to inform correctional nursing practice.

METHOD

Interpretive description, co-positioned with relational ethics, guided this study. Twelve incarcerated men participated in a single 1-hour interview that was audio-recorded and transcribed. The resultant text was analyzed for themes.

FINDINGS

The two main themes were dependence on staff and institutional processes and dependence on oneself and others who were incarcerated. Participants reported a substantial loss in their ability to access pain-relieving medications, products, and services. Unresponsive or delayed pain-relieving interventions from nurses contributed to their sense of indignity, disrespect, and injustice. The participants employed whatever was available, mainly exercise equipment and social support, to manage their pain.

DISCUSSION

Nurses must engage with incarcerated patients meaningfully to understand and respond to contextual factors that influence their pain experiences. Participants identified loss of autonomy and dependence on nurses as barriers to their pain relief.

CONCLUSION

Nurse engagement and responsiveness are crucial to altering incarcerated men's perceptions of injustice or helplessness while improving their pain experiences. Nurses must also foster autonomous pain-management approaches that men can use without limitations within correctional settings.

The Impact of Palliative Care on Mitigating Pain and Its Associated Effects in Determining Quality of Life among Colon Cancer Outpatients

Pain continues to be a significant problem for cancer patients, and the impact of a population-based strategy on their experiences is not completely understood. Our study aimed to determine the impact of palliative care on mitigating pain and its associated effects in determining the quality of life (QoL) among colon cancer outpatients. Six collection databases were used to perform a structured systematic review of the available literature, considering all papers published between the year 2000 and February 2023. PRISMA guidelines were adopted in our study, and a total of 9792 papers were evaluated. However, only 126 articles met the inclusion criteria. A precise diagnosis of disruptive colorectal cancer (CRC) pain disorders among patients under palliative care is necessary to mitigate it and its associated effects, enhance health, promote life expectancy, increase therapeutic responsiveness, and decrease comorbidity complications. Physical activities, the use of validated pain assessment tools, remote outpatient education and monitoring, chemotherapeutic pain reduction strategies, music and massage therapies, and bridging social isolation gaps are essential in enhancing QoL. We recommend and place a strong emphasis on the adoption of online training/or coaching programs and the integration of formal and informal palliative care systems for maximum QoL benefits among CRC outpatients.

Trends in Prescription Chronic Pain Medication Use before and during the First Wave of the COVID-19 Pandemic in Québec, Canada: An Interrupted Time Series Analysis

BACKGROUND

In Canada, a state of health emergency was declared in May 2020 as a result of the COVID-19 pandemic. This study aimed to assess trends in the use of prescription medication for pain management by people living with chronic pain before and during the first wave of the pandemic.

METHODS

Participants (n = 177) were adults reporting chronic pain who had completed a web-based questionnaire in 2019 and for whom complete longitudinal private and public insurance prescription claims were available. The monthly prevalence of medication use for nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and prescribed cannabinoids was assessed. An interrupted time series analysis was then performed to evaluate if the COVID-19 pandemic had had an impact on trends in pain medication use.

RESULTS

The beginning of the first wave of the pandemic was associated with the onset of a downward trend in opioid use (p < 0.05); no such association was found regarding NSAIDs. However, point prevalence of opioid use at the beginning (Nov. 2019) and at the end (Mai 2020) of the study period remained somewhat stable (17.0% vs. 16.4%). Regarding prescribed cannabinoids, a gradual increase in use was observed over the entire study period independently from the impact of the first wave of the pandemic (15.3% vs. 22.6%, p < 0.05).

CONCLUSION

While the occurrence of the first wave did have an impact on opioid use among people living with chronic pain, access to and use of opioids appear to have returned to normal before the end of the first wave of COVID-19.

Barriers of Access to Opioid Medicines within the Context of Palliative Care in Latin America: The Perception of Health Professionals

Background: Different sets of barriers have been identified to explain the difficulties in the access and availability of opioid analgesics in palliative care, particularly in low- and middle-income countries, including Latin America. Objective: To validate a structured questionnaire for the access to opioid medicines and to investigate the perception of health professionals regarding access barriers to opioid analgesics in 17 countries of the Latin American Region. Design: Survey to identify the domains and barriers of access to opioid medicines according to health professionals, including physicians, nurses, and pharmacists affiliated to institutions that provide palliative care in Latin America between August 2019 and October 2020. Results: We analyzed responses from 426 health professionals. The median age was 44 years old (ranging from 23 to 73 years) with an average experience in palliative care of 10 years (range: 1-35), 71.8% were women, and 49.8% were affiliated to specialized health care facilities of urban areas (94.6%). The main barriers perceived to be extremely relevant by the respondents were "belief that patients can develop addiction" and "financial limitations of patients" for the patient's domain and the "appropriate education, instruction, and training of professionals" for health professional's domain. Conclusions: It is necessary to develop strategies to strengthen less-developed health systems of the region to review legal frameworks, ensure integrated palliative care systems, and deploy multidisciplinary strategies for sensitizing, training, and raising the awareness of patients, caregivers and, particularly, health professionals regarding appropriate prescription and rational use of opioid analgesics.

The Effect of Remote-Based Monitoring and Education Program on Cancer Pain Management in an Outpatient Pain Clinic

BACKGROUND

Pain is one of the most feared consequences of cancer for patients and their families. Many barriers may hinder optimal pain management.

AIM

Examine the effect of remote-based monitoring and education program on cancer pain management, patient-related barriers, and level of adherence to pain medication.

METHODS

A sample of 134 patients was assigned to two groups; 68 in the intervention group and 66 in the control. The intervention group received three educational sessions by telephone. Both groups completed questionnaires at baseline and one month after the initial visit.

RESULTS

Significant differences were found between the groups in the levels of pain right now (p = .030), pain at its least (p = .016), and in the percentage of achieved pain relief (p = .048). Moreover, the intervention group experienced lower levels of interference with their general activity (p = < .001), mood (p = .011), and normal work (p = .004) post-intervention. The Attitudinal Barriers differences were statistically significant in the total mean (p = < .001), and the subscales of physiological effects (p = < .001), fatalism (p = < .001), communication (p = < .001), harmful effects (p = < .001). Participants in the intervention group exhibited higher adherence levels (p = .001).

CONCLUSIONS

Patients suffering from cancer-related pain can benefit from remote-based monitoring and education programs to improve pain management outcomes, overcome barriers, and increase adherence. Further research is needed to investigate the different available educational methods and long-term effects.

The impact of a 12-hour educational program on nurses' knowledge and attitudes regarding pain management: a quasi-experimental study

Background

Proper pain assessment is fundamental to effective pain management. Training nursing staff is critical for improving pain assessment competence and patient clinical outcomes. However, there is a dearth of research examining interventions that can enhance nurses’ knowledge and attitudes toward pain management, especially in Saudi Arabia. Thus, this study aimed to evaluate the effectiveness of a structured education program on nurses’ knowledge and attitudes towards pain management.

Methods

A quasi-experimental design was used. The study sample included 124 registered nurses working in intensive care or inpatient units in Saudi Arabia. Data were collected between March and September 2021 using a knowledge and attitudes survey regarding pain, satisfaction with and self-confidence in learning, and the learning self-efficacy scale for clinical skills.

Results

Nurses showed moderate levels of knowledge and attitudes regarding pain before (M = 20.3, SD = 4.80) pain management education, which were significantly higher after the intervention (M = 22.2, SD = 5.09, t = 2.87, p < .01). Before the intervention, nurses with a baccalaureate degree had more knowledge and better attitudes regarding pain management than diploma nurses (t = 3.06, p < .01). However, there was no significant difference between the two groups after the intervention (p > .05), indicating that the education was effective in enhancing nurses’ knowledge and attitudes, regardless of nursing education level. Nurses in this study had high mean scores for self-confidence in learning (M = 35.6, SD = 4.68, range = 18–40), self-learning efficacy (M = 52.9, SD = 7.70, range = 25–60), and satisfaction with learning (M = 22.2, SD = 3.24, range: 10–25).

Conclusion

Regular pain education programs can improve nurses’ knowledge and attitudes. Increasing the breadth and depth of educational courses, alongside appropriate training, competency-based assessment, and pain education programs, is also recommended. Future research should consider the subjectivity and individualized nature of nursing by including patient satisfaction surveys to measure the improvement in nurses’ knowledge and attitudes from the patient perspective.

Disparities in Prehospital Non-Traumatic Pain Management

INTRODUCTION

While prior research has identified racial disparities in prehospital analgesia for traumatic pain, little is known about non-traumatic pain. Using a national prehospital dataset, we sought to evaluate for racial and ethnic disparities in analgesia given by EMS for non-traumatic pain.

METHODS

We analyzed the 2018 and 2019 data from the ESO Data Collaborative, a collection of de-identified prehospital electronic health records from nearly 1,300 participating EMS agencies in the US. We included all transported, adult, non-traumatic encounters with a primary or secondary impression of a pain complaint, and we stratified encounters based on race and ethnicity as recorded by the EMS clinicians. We performed a mixed model analysis, modeling EMS agency as a random intercept and adjusting for age, sex, pain location, level of service, location of incident, and highest pain score. With non-Hispanic White patients as the reference group, we then evaluated the association between race/ethnicity and receiving any pain medication (acetaminophen, non-steroidal anti-inflammatories, or opioids), receiving opioid pain medication, and receiving pain medication within 20 minutes of EMS arrival.

RESULTS

We included 1,035,486 patients; 67.5% non-Hispanic White, 26.8% Black, 4.9% Hispanic, 0.5% Asian, 0.1% Native Hawaiian or Other Pacific Islander, and 0.2% American Indian or Alaska Native patients. 4.7% of patients received pain medications. Compared to White patients (5.1%), Black patients were less likely to receive pain medication (3.3%, aOR 0.7; 95% CI 0.7-0.7) and Hispanics were more likely to receive pain medication (7.6%, aOR 1.5; 95% CI 1.4-1.6). Black patients were also less likely to receive opioids (1.8% for Black v 3.0% for White, aOR 0.7; 95% CI 0.6-0.7), while Hispanic patients were more likely to receive opioids (4.9%, aOR 1.4; 95% CI 1.3-1.5). The odds of receiving pain medication within 20 minutes was lower for Black patients (aOR 0.9; 95% CI 0.8-0.95) but no different for Hispanic patients (aOR 1.0; 95% CI 0.9-1.1), when compared to White patients.

CONCLUSION

Pain medication administration is uncommon for non-traumatic pain complaints. While Black patients were less likely than White patients to receive pain medications and receive pain medication within 20 minutes, Hispanics were more likely to receive pain medications.

What to Do and What Not to Do in the Management of Cancer Pain: A Physician Survey and Expert Recommendations

Background

Despite the prevalence of pain among patients with cancer and the availability of pertinent guidelines, the clinical management of oncological pain is decisively insufficient. To address this issue, we evaluated current trends in clinical practice and subsequently generated a list of ten corrective actions—five things to do and five things not to do—for the diagnosis, management, and monitoring of cancer pain.

Methods

The survey included 18 questions about clinical practice surrounding background pain and breakthrough cancer pain (BTcP). Survey questions were developed by a scientific board of 10 physician experts and communicated via email to an expanded panel of physicians in Italy. Responses were tabulated descriptively for analysis.

Results

Of 51 invited physicians, 32 (63%) provided complete survey responses. The responses revealed several incongruencies with current guideline recommendations: physicians did not always diagnose or monitor pain using diagnostically validated or disease-specific instruments; frequently based clinical decision-making on time availability or convenience; and pharmacological therapy was often inappropriate (eg, prescribing NSAIDs or corticosteroids for BTcP). The list of corrective actions generated by the scientific board favored a guideline-oriented approach that systematically characterizes oncological pain and implements treatment based on pain characteristics (eg, fast-acting transmucosal opioids for BTcP) and evidence-based recommendations.

Conclusion

Oncologists require better education and training about the diagnosis, treatment, and monitoring of oncological pain. Physicians should be aware of current guideline recommendations as well as available pharmacological tools for BTcP.

Patient and provider perspectives on patient-centered chronic pain management

BACKGROUND

Fifty million American adults have chronic pain, and nearly 20 million have high-impact, or disabling, chronic pain, with higher prevalence associated with advancing age. Patient-centered pain management has been cited as a national priority to ensure that patient values and preferences guide clinical decisions. However, explicit, and practical strategies for implementing patient-centered pain management have not been disseminated.

AIMS

The aim of this study was to elicit perceptions, beliefs, and experiences of patient-centered pain management among adults with chronic pain as well as among providers that could be used to develop recommendations for implementation and evaluation of patient-centered pain management.

DESIGN

A descriptive qualitative study.

SETTINGS/PARTICIPANTS

Fourteen adults with chronic pain were recruited from the communities. Besides, five providers caring for patients with chronic pain at an outpatient spine center affiliated to one academic hospital joined this study.

METHODS

Each focus group lasted about 1 hour, which was recorded and transcribed verbatim. Data were analyzed using Erlingsson and Brysiewicz's content analysis to identify themes and develop recommendations.

RESULTS

Four overarching themes emerged, including: (1) patient and (2) provider characteristics affecting patient-centered pain management; (3) processes and (4) outcomes of patient-centered pain management. We also visually depicted the determinants, processes, and outcomes of patient-centered pain management among providers and individuals with chronic pain.

CONCLUSIONS

Patients emphasized their desire for a provider that listens, genuinely cares, and sees them holistically to provide the best individual and tailored care for them. Providers focused on setting realistic expectations, vocalizing the significance of pain education at a young age, and balancing patient satisfaction and opioid prescriptions. While patients can be empowered to self-manage their chronic pain due to patient-centered pain care, provider mental exhaustion and mistrust of providers among patients resulted from suboptimal pain management.

Validity of Algorithms for Identification of Individuals Suffering from Chronic Noncancer Pain in Administrative Databases: A Systematic Review

BACKGROUND

Secondary analysis of health administrative databases is indispensable to enriching our understanding of health trajectories, health care utilization, and real-world risks and benefits of drugs among large populations.

OBJECTIVES

This systematic review aimed at assessing evidence about the validity of algorithms for the identification of individuals suffering from nonarthritic chronic noncancer pain (CNCP) in administrative databases.

METHODS

Studies reporting measures of diagnostic accuracy of such algorithms and published in English or French were searched in the Medline, Embase, CINAHL, AgeLine, PsycINFO, and Abstracts in Social Gerontology electronic databases without any dates of coverage restrictions up to March 1, 2018. Reference lists of included studies were also screened for additional publications.

RESULTS

Only six studies focused on commonly studied CNCP conditions and were included in the review. Some algorithms showed a ≥60% combination of sensitivity and specificity values (back pain disorders in general, fibromyalgia, low back pain, migraine, neck/back problems studied together). Only algorithms designed to identify fibromyalgia cases reached a ≥80% combination (without replication of findings in other studies/databases).

CONCLUSIONS

In summary, the present investigation informs us about the limited amount of literature available to guide and support the use of administrative databases as valid sources of data for research on CNCP. Considering the added value of such data sources, the important research gaps identified in this innovative review provide important directions for future research. The review protocol was registered with PROSPERO (CRD42018086402).

A survey of postoperative pain treatments and unmet needs

More than 300 million patients undergo surgery worldwide each year. Pain associated with these procedures is associated with short- and long-term negative sequelae for patients, healthcare providers, and healthcare systems. The following chapter is a review of the reality of postoperative pain management in everyday clinical routine based on survey- and registry-derived data with a focus on care in adults. Between 30% and up to 80% of patients report moderate to severe pain in the days after surgery. Structures, processes, and outcomes vary widely between hospitals and indicate gaps between evidence-based findings and practice. Pain assessment is not effectively implemented in many hospitals and should consider cultural differences. Few data exist on the situation of pain management in low- and middle-income countries, indicating lack of resources and available medication in many of these areas. Certain types of surgery as well as demographic and clinical factors are associated with increased risk of severe postoperative pain.

Discovery of Anticancer Clinical Candidate, Tosedostat, As an Analgesic Agent

Tosedostat is an inhibitor of aminopeptidases currently in phase II clinical trials for the treatment of blood-related cancers. In our laboratories, we have discovered that it possesses analgesic properties. Extensive in vivo pharmacological studies for the determination of antinociceptive effects of tosedostat are presented here. These studies have indicated that the observed analgesic effect of tosedostat stems from its action on the peripheral nervous system with minimal contribution from the central nervous system. Additionally, when given in combination with morphine, tosedostat exerts a synergistic analgesic effect resulting in a reduction of effective dosages required to achieve the same analgesic effect. With broad implications in addressing the opioid addiction crisis, these revelations attest to tosedostat being a highly valuable drug candidate with diverse pharmacological functions.

Framing of the opioid problem in cancer pain management in Canada

Two guidelines about opioid use in chronic pain management were published in 2017: the Canadian Guideline for Opioids for Chronic Non-Cancer Pain and the European Pain Federation position paper on appropriate opioid use in chronic pain management. Though the target populations for the guidelines are the same, their recommendations differ depending on their purpose. The intent of the Canadian guideline is to reduce the incidence of serious adverse effects. Its goal was therefore to set limits on the use of opioids. In contrast, the European Pain Federation position paper is meant to promote safe and appropriate opioid use for chronic pain. The content of the two guidelines could have unintentional consequences on other populations that receive opioid therapy for symptom management, such as patients with cancer. In this article, we present expert opinion about those chronic pain management guidelines and their impact on patients with cancer diagnoses, especially those with histories of substance use disorder and psychiatric conditions. Though some principles of chronic pain management can be extrapolated, we recommend that guidelines for cancer pain management should be developed using empirical data primarily from patients with cancer who are receiving opioid therapy.

Nurses' knowledge, perceived barriers, and practices regarding cancer pain management: a cross-sectional study from Palestine

BACKGROUND

Accurate knowledge and good pain evaluation and documentation practices should be present for efficient pain management. In this study, we aimed to assess the knowledge and practices of nurses relating to the management of cancer pain in Palestine, and to determine the barriers to efficient pain control in cancer patients.

METHODS

A cross-sectional survey took place at 8 hospitals across Northern West Bank. A convenience sample of 220 Nurses working in governmental and private hospitals in West Bank/Palestine was studied. For that purpose, a questionnaire was developed to assess knowledge, practices, perceived barriers, and delaying processes relating to cancer pain management (CPM).

RESULTS

In total, 220 questionnaires were completed with a response rate of 88%. Participants' mean age was 30.34 years. Overall, 69.5% worked in governmental hospitals, 26.8% worked in the private sector and the remainder worked in both governmental and private sectors. The correct response rate to questions that assess knowledge relating to cancer pain control was calculated and a mean knowledge score was found to be 5.1 with a standard deviation of 2.1. A relationship between the knowledge score and the sample characteristics was made and showed that males scored significantly higher (p = 0.001) than females with median scores of 6 [4-7] and 5 [3-6] for males and females, respectively. Inadequate pain assessment (76.8%), insufficient knowledge of pain control (70.5%) and strict regulation on opioid use (69.5%) were the most frequently perceived barriers. Nurses reported that they would assess pain on every round and check all items related to pain assessment. Contacting the physician for the prescription of opioids was cited as the main delaying process by 56.4% of participants.

CONCLUSIONS

This study allowed us to recognise the knowledge deficit and the barriers to effective management. On the other hand, the analysis has shown good pain documentation practices among nurses. Those knowledge deficits demonstrate the need for more education about CPM. The improvement of coordination and communication between physicians and nurses seems to play a crucial role in CPM, as contacting physicians was cited as the most delaying process in CPM by nurses.

Postoperative Patients in Jordan: Pain Prevalence, Characteristics, Beliefs, and Satisfaction

BACKGROUND

Unrelieved postoperative pain contributes to soaring medical costs and poor quality of life. Whilst much has been written about postoperative pain prevalence in the literature, few empirical studies have explored pain care in Middle Eastern countries.

AIMS

This study aimed to determine pain prevalence, its characteristics, beliefs and satisfaction among postoperative patients in Jordan.

DESIGN

This is a descriptive survey design.

SETTINGS

This study was conducted in a 200-bed Jordanian public hospital located in the southern province of Jordan.

PARTICIPANTS

A convenient sample of 143 surgical patients was selected.

METHODS

Data were collected by the American Pain Society Patient Outcomes questionnaire, Brief Pain Inventory scale and beliefs towards pain scale. Data were analyzed using SPSS version 21.

RESULTS

Pain prevalence following surgery during the first 24 hours was 87%. The overall Mean of satisfaction of all participants was moderate (66.6%). The analysis found that the greatest interference of pain was with activity (Mean ± SD = 6.27 ± 3.30). The belief "people get addicted to pain medicine easily" was the most common misunderstanding (Mean ± SD = 3.48 ± 1.71). Male participants had worse average pain experience but were more satisfied with pain management than females (ps = .012, .017, respectively). Participants aged 30 or more had better pain management experience and satisfaction than those aged under 30 (p = .021).

CONCLUSIONS

The study revealed high pain prevalence among surgical patients that remains undertreated. If patients' postoperative environment is to be a "Pain Free Zone", nurses' training programs and the application of various screening tools in the postoperative context taking into account the role of gender and culture are urgently needed.

Healthcare professionals' perceptions on the use of opioid analgesics for the treatment of cancer-related pain in Cyprus: A mixed-method study

Objectives:

Pain is considered the most common and debilitating symptom reported by patients affected by cancer, and opioids are at the front line for its effective management. However, the appropriate use of opioids can be limited by healthcare professionals’ perceptions on opioids. Therefore, the aim of this study was to explore their perceptions on the use of opioids medication.

Methods:

This was a study of sequential mixed-method design conducted in Cyprus. As part of the quantitative phase of the study, the Barriers to Opioid Analgesic Availability Test questionnaire was completed by 73 physicians randomly selected. In the qualitative phase, 28 healthcare professionals working in primary and secondary healthcare centers participated in two focus groups. They were asked to express their perceptions on the use of opioid analgesics for the treatment of cancer-related pain. Data were analyzed according to Colaizzis’ seven-stage phenomenological analysis.

Results:

The quantitative analysis showed that 69.85% of physicians acknowledge opiophobia as a main barrier to appropriate pain relief but also explicitly for cancer pain which is not adequately managed (45.19%). In terms of opioids availability, physicians stated that moderate to severe problems in opioids availability were mainly caused by their reluctance to prescribe opioids (49.3%) followed by the laws/regulations in place (41.08%). The qualitative analysis yielded the following six main themes: inadequate training of healthcare professionals in the use of opioid analgesics, inadequate patient/caregivers’ awareness of opioid analgesics, opiophobia in healthcare professionals, opiophobia of patients/caregivers, poor management of opioid analgesics by healthcare professionals and patients/caregivers, and ineffective pain relief with opioids.

Conclusions:

The lack of appropriate education is a significant barrier to opioids use in Cyprus. This is compounded by the attitudes and phobias of both healthcare professionals and the general public. In addition, there are barriers to opioid availability and unsatisfactory cancer pain relief.

The importance of chronic pain education and awareness amongst occupational safety and health professionals

Purpose: Occupational safety and health (OSH) professionals are often the point of contact for health and safety policies derived in the workplace, and the handling of incidents in their aftermath. As chronic pain affects 20% of people, many pain-awareness campaigns and educational activities target healthcare professionals. However, initiatives directed toward OSH professionals are also important to aid in prevention and rehabilitation efforts. The objective of this study was to describe knowledge and attitudes of OSH students with regard to chronic pain. Methods: A web-based cross-sectional study was conducted amongst a convenience sample of 88 students enrolled in the distance learning OSH undergraduate certificate program at the Université du Québec en Abitibi-Témiscamingue (Quebec, Canada). Results: Although 30% of students were already employed within OSH or human resources and 40% reported intervening in cases involving chronic pain in their line of work, 56% of respondents had received no training on chronic pain and its treatment in the past five years. Only 14% chose to take the optional 45 hr course dedicated to pain within the program. OSH students also exhibited poorer knowledge and more negative attitudes toward people suffering from chronic pain when compared to other groups assessed in the province of Quebec, including healthcare professionals, chronic pain patients, and people not suffering from chronic pain (p≤0.0002). Half of the respondents (51.9%) were not aware that chronic pain affects 1 in 5 adults. Conclusion: Our study demonstrates a need for pain education within OSH training programs and through continuing education.

Knowledge, Beliefs, and Attitudes of Emergency Nurses Toward People With Chronic Pain

More and more people suffering from chronic pain (CP) utilize the emergency department (ED). However, their needs are not properly addressed. Stigmatization toward people with CP can partially explain this gap. Most studies in the ED have been focused on measuring nurses' pain management knowledge in general, not negative attitudes toward CP. Hence, understanding of the determinants of the stigma related to CP is needed. The objectives of this study were to (a) describe the knowledge, beliefs, and attitudes of ED nurses toward people suffering from CP and (b) identify nurses' characteristics associated with these perceptions. A cross-sectional web-based survey design was conducted using the KnowPain-12 questionnaire and the Chronic Pain Myth Scale. A total of 571 participants from 20 different states across the United States were recruited among whom 482 completed the entire survey. The sample included about one third of the ED nurses suffering from CP. Negative beliefs and attitudes toward people with CP were present in a considerable proportion of participants (up to 64%), even in nurses suffering from CP (up to 47.5%). Nevertheless, our results suggest that higher levels of education and suffering from CP were associated with better beliefs and attitudes toward people with CP. The ED presents an increased risk of stigmatization of people with CP as compared with the general population. Identifying determinants of the stigma associated with CP is crucial, as it will help tailoring awareness and educational campaigns. In addition, CP patients utilizing the ED often have complex needs which are difficult to address in this clinical environment. This situation can contribute to negative beliefs and attitudes. Given the scarcity of specialized care clinics for this population, health-care stakeholders should devise solutions to improve continuity of care in primary care settings and between the latter and ED.

Nurses' Knowledge, Attitudes, and Barriers Toward Pain Management Among Postoperative Patients in Jordan

PURPOSE

The purpose of this study was to measure nurses' knowledge, attitudes, and barriers regarding pain management (PM) of postoperative patients in Jordan.

DESIGN

A descriptive survey research design was used.

METHODS

This descriptive study adopted a modified version of the "Knowledge and Attitudes Survey Regarding Pain" tool, administered to 120 nurses working in surgical wards.

FINDINGS

Nurses had inadequate knowledge of PM, with a mean knowledge score of 63.9%. Knowledge of PM and attitudes toward PM were associated positively with the age of the participant (P = .001), years of experience in the surgical area (P = .026), and academic degree of participants (P = .026).

CONCLUSIONS

Surgical nurses in this study had low knowledge levels and poor attitudes regarding PM in postoperative patients. Unless identified barriers to PM are seriously addressed, this vital aspect of holistic care will continue to be marginalized.

Review of chronic non-cancer pain research among Aboriginal people in Canada

Purpose

Aboriginal people in Canada are disproportionately affected by chronic illnesses, compared to non-Aboriginal Canadians. The purpose of this review was to determine whether differences exist between the two groups with respect to chronic non-cancer pain (CNCP) in order to better inform clinical practice and to identify research gaps.

Data sources

Four electronic databases were searched for the period of 1990-2015.

Study selection

Only English and French language original studies that examined CNCP prevalence, assessment tools and beliefs among Aboriginal people in Canada were considered.

Data extraction

Data extracted included Aboriginal group, geographic location, study setting and pain definition (for prevalence studies only).

Results of data synthesis

A total of 11 studies matched the selection criteria: 10 reported estimates of chronic pain prevalence among Aboriginal people in Canada, 1 was about a culturally adapted pain assessment tool, and no study was found about CNCP beliefs within Aboriginal people.

Conclusion

CNCP among Aboriginal people is still a largely unexplored research field. The limited evidence available so far does not allow us to conclude that CNCP affects a higher proportion of Aboriginal than non-Aboriginal people in Canada. However, arthritis, a specific condition associated with chronic pain, is more prevalent in Aboriginal than non-Aboriginal people. Additional research is needed on other CNCP types and conditions. Furthermore, pain assessment tools are not culturally adapted and clinicians should inquire more about the beliefs of Aboriginal patients to make them feel safer and to better target interventions.

Development and Pilot Test of a New Set of Good Practice Indicators for Chronic Nonmalignant Pain Management

OBJECTIVES

This study was designed to address the current relative void of valid measures by developing evidence-based quality indicators for pain management of chronic nonmalignant pain.

METHODS

We performed a 10-year literature search to identify guidelines and review articles on chronic pain management to identify evidence-based recommendations for the different conditions associated to chronic pain. A complementary search of indicators and indicator-related articles was also performed. Then, we built new indicators or adapted existing ones to cover all the evidence-based recommendations we found. The resulting set was pilot tested for feasibility, reliability (kappa), and usefulness to identify quality problems, using the Lot Quality Acceptance method (α ≤ 0.05 and β ≤ 0.01) for 75% (40% threshold) and 95% (70% threshold) compliance standards, and estimates with binomial exact 95% confidence intervals. We reviewed clinical records from a primary care center, a medium-size hospital (250 beds), and a large hospital (500 beds).

RESULTS

Forty-six indicators were developed (6 general and 40 condition specific). Thirty-three were feasible in primary care and/or hospitals. Feasible indicators were also reliable (most kappa > 0.7). Regarding compliance, 4 quality indicators obtained compliance levels over 60%, addressing pharmacological treatment, multimodal approach, and appropriate use of neuro-image tests, while 16 obtained compliance scores under 15% (6 with 0% compliance).

CONCLUSIONS

The created set has tested to be feasible, reliable, and useful, with the capacity to serve as the baseline for developing the necessary strategies to improve the management of chronic nonmalignant pain, by monitoring and evaluating quality of care.

The Potential Role for Smartphones Among Older Adults with Chronic Noncancer Pain: A Qualitative Study

Objective

To determine the role that smartphones may play in supporting older adults with chronic noncancer pain (CNCP) in order to improve pain management in this expanding population.

Design

Qualitative study.

Setting

One academically affiliated primary care practice serving older adults with CNCP in New York City.

Subjects

Thirteen older adults (age 65-85 years) with CNCP on chronic opioid therapy, that is, continuous use of opioids for at least six months.

Methods

One researcher conducted one-on-one telephone interviews with participants, and two researchers analyzed the transcribed data using descriptive analysis. A nurse and a physician researcher iteratively critiqued and approved the results.

Results

Participants provided opinions as to the effects that smartphones may have on medication management and communications with their providers. Smartphones can benefit older adults by supporting interactions with the health care system such as more effective scheduling and coordinating prescribing practices with local pharmacies. Participants expressed difficulties with isolation due to CNCP and posited that smartphones could provide a means for social support. Specifically, smartphones should support older adult needs to effectively communicate pain experiences with personal contacts and caregivers, as well as health care providers. Based on these results, we provide suggestions that can inform future smartphone interventions for older adults with CNCP.

Conclusion

Smartphones that focus on supporting medication management, enhancing communication with providers, and facilitating connectedness within social networks to reduce feelings of isolation may help to improve CNCP outcomes in older adults.

Knowledge, beliefs, and attitudes of the Quebec population toward chronic pain: Where are we now?

Background: Many chronic pain (CP) awareness and educational initiatives have been achieved, but it is time to take stock of where we are today.

Aims: The aim of this study was to describe and identify determinants of knowledge, beliefs, and attitudes of different subgroups of the Quebec population regarding CP and especially toward people suffering from this condition.

Methods: A web-based, cross-sectional study was conducted between May and June 2014.

Results: A total of 1958 participants responded, among whom 70.9% reported suffering from CP and 14.4% reported being a health care professional (HCP). Almost half of the participants were not aware that the risk of developing CP is increased after undergoing surgery or that CP affects approximately one in five adults. A minority (10.30%) agreed that HCP are well trained in CP treatment. The two most frequent negative beliefs were that people suffering from CP become dependent on their medications as do drug addicts (16.7%) and that consulting a psychologist is useless unless the person with CP is depressed (16.9%). Multiple regression analysis showed that being a woman, being born in Canada, being unemployed, suffering from CP, and being an HCP were predictors of better knowledge and more positive attitudes toward people suffering from CP (all P values < 0.05). Older age and residing in a remote region were associated with poorer knowledge and more negative attitudes.

Conclusions: Our results underline the importance of continuing the efforts and the need for more education programs, awareness campaigns, and stigma reduction activities about CP for HCP, patients, and the general public.

Decreasing Opioid Utilization in Rehabilitation Patients Using a Clinical Nurse Specialist Pain Consultant Program

OBJECTIVE

To investigate whether access to a clinical nurse specialist (CNS) with expertise in pain management will result in more rapid decline in opioid use across the rehabilitation hospitalization.

DESIGN

Retrospective chart review of patients discharged during 6 months prior to and 6 months after introduction of the CNS role.

SETTING

Not-for-profit 98-bed community inpatient rehabilitation hospital.

PARTICIPANTS

Two population-based samples of adult, inpatient rehabilitation patients (N=72) with daily opioid use ≥30mg morphine equivalent dose (MED) per day on admission and length of stay ≥24 days.

INTERVENTIONS

Implementation of a CNS pain consult program.

MAIN OUTCOME MEASURES

Change in average daily opioid use (milligrams of MED per day), measured at admission, week 1, week 2, and week 3.

RESULTS

Linear mixed modeling was used to estimate individual and group average opioid trajectories, including individual patient intercepts (opioid use at admission) and slopes (change in opioid use over time). There was a significant interaction between group and time (b=5.75, t=2.52, P<.01), indicating faster change in opioid use for the CNS group (quadratic slope, -5.91) compared with the no CNS group (quadratic slope, -.16). Quadratic change in the CNS group reflected an initial increase in opioid use from admission to week 1, followed by a steady decline. Conversely, there was virtually no change in the no CNS group. Random effects revealed considerable variability in opioid trajectories across patients.

CONCLUSIONS

Addition of a CNS pain consultant program to an inpatient rehabilitation hospital supported a distinct pattern of opioid tapering that promoted more rapid titration of daily opioid use across the rehabilitation hospitalization.

Chronic Non-Cancer Pain Management Capacity in Karachi

Chronic non-cancer pain (CNCP) affects people everywhere in the world, but people in developing countries have far less access to therapies that provide relief. There are often missed opportunities to implement these therapies. Karachi shares many characteristics with megacities of the global south and represents Pakistan in the global city league. This review informs readers about the availability of health management and pain services for CNCP in Karachi, and their comparability to those found in other global cities. The literature about CNCP and its management in Karachi and Pakistan is scarce. Nevertheless, some conclusions can be made. In order to inform readers based in other global cities, a brief review of the current health system and pain services in Karachi and Pakistan are discussed together with barriers that impede pain service outputs. The present review employs vignettes to illustrate typical experiences of CNCP patients seeking pain management services in three sectors: public, charitable, and private institutions.

[Optimizing post-operative pain management in Latin America]

Post-operative pain management is a significant problem in clinical practice in Latin America. Insufficient or inappropriate pain management is in large part due to insufficient knowledge, attitudes and education, and poor communications at various levels. In addition, the lack of awareness of the availability and importance of clear policies and guidelines for recording pain intensity, the use of specific analgesics and the proper approach to patient education have led to the consistent under-treatment of pain management in the region. However, these problems are not insurmountable and can be addressed at both the provider and patient level. Robust policies and guidelines can help insure continuity of care and reduce unnecessary variations in practice. The objective of this paper is to call attention to the problems associated with Acute Post-Operative Pain (APOP) and to suggest recommendations for their solutions in Latin America. A group of experts on anesthesiology, surgery and pain developed recommendations that will lead to more efficient and effective pain management. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more efficient and effective system for the delivery of APOP services as recommended by the authors of this paper. The writing group believes that implementation of these recommendations should significantly enhance efficient and effective post-operative pain management in Latin America.

Emergency Department Patient Perspectives on the Risk of Addiction to Prescription Opioids

OBJECTIVE

To characterize emergency department (ED) patients' knowledge and beliefs about the addictive potential of opioids.

DESIGN

Mixed methods analysis of data from a randomized controlled trial.

SETTING

Urban academic ED (>88,000 visits).

SUBJECTS

One hundred and seventy four discharged ED patients prescribed hydrocodone-acetaminophen for acute pain.

METHODS

The study analyzed data collected from a randomized controlled trial investigating patients' knowledge of opioids. ED patients discharged with hydrocodone-acetaminophen completed an audio-recorded phone interview 4–7 days later. This analysis focuses on responses about addiction. Responses were categorized using content analysis; thematic analysis identified broad themes common across different categories.

RESULTS

Participants' mean age was 45.5 years (SD, 14.8), 58.6% female, 50.6% white, and the majority had an orthopedic diagnosis (24.1% back pain, 52.3% other injuries). Responses were categorized first based on whether the patient believed that opioids could be addictive (categorized as: yes, 58.7%; no, 19.5%; depends, 17.2%; or do not know, 4.6%), and second based on whether or not the patient discussed his/her own experience with the medication (categorized as: personalized, 35.6%; or not personalized, 64.4%). Cohen's Kappa was 0.84 for all categories. Three themes emerged in the thematic analysis: theme 1) patients expect to “feel” addicted if they are addicted, theme 2) patients fear addiction, and theme 3) side effects affected patient views of addiction.

CONCLUSION

In this sample, patients had misconceptions about opioid addiction. Some patients did not know opioids could be addictive, others underestimated their personal risk of addiction, and others overtly feared addiction and, therefore, risked inadequate pain management. Despite limited data, we recommend providers discuss opioid addiction with their patients.

The Chronic Pain Myth Scale: Development and Validation of a French-Canadian Instrument Measuring Knowledge, Beliefs, and Attitudes of People in the Community towards Chronic Pain

Background. In order to better design awareness programs on chronic pain (CP), measurement of knowledge, beliefs, and attitudes of people in the community towards this condition is most useful. Objectives. To develop and validate a French-Canadian scale that could be used for this purpose. Methods. Items of the Chronic Pain Myth Scale (CPMS) were developed based on different information sources, reviewed by pain experts, and pretested. The CPMS was administered to 1555 participants among the general Quebec population. Results. The final CPMS contained 26 items allowing the calculation of three subscales scores (knowledge, beliefs, and attitudes towards people suffering from CP, biopsychosocial impacts of CP, and treatment of CP) which showed adequate internal consistency (α = 0.72-0.82). There were statistically significant differences in subscales scores between participants who reported suffering versus not suffering from CP, reported knowing versus not knowing someone who suffers from CP, and reported being versus not being a healthcare professional, which supports the construct validity of the scale. Conclusions. Our results provide preliminary evidence supporting the psychometric qualities of the use of the CPMS for the measurement of knowledge, beliefs, and attitudes towards CP among French-speaking individuals of the Quebec general population.

The impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery

BACKGROUND

Relevant discharge information about the use of analgesic medication and other strategies may help patients to manage their pain more effectively and prevent postoperative persistent pain.

AIMS

To examine patients' pain characteristics, analgesic intake and the impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery. Concerns about pain and pain medication prior to surgery will also be described.

METHODS

From March 2012 to September 2013, 416 participants (23% women) were consecutively enrolled in a randomized controlled trial. The intervention group received usual care plus an educational booklet at discharge with supportive telephone follow-up on postoperative day 10, and the control group received only usual care. The primary outcome was worst pain intensity (The Brief Pain Inventory - Short Form). Data about pain characteristics and analgesic use were collected at 2 weeks and at 1, 3, 6 and 12 months post-surgery. General linear mixed models were used to determine between-group differences over time.

RESULTS

Twenty-nine percent of participants reported surgically related pain at rest and 9% reported moderate to severe pain at 12 months post-surgery. Many participants had concerns about pain and pain medication, and analgesic intake was insufficient post-discharge. No statistically significant differences between the groups were observed in terms of the outcome measures following surgery.

CONCLUSION

Postoperative pain and inadequate analgesic use were problems for many participants regardless of group allocation, and the current intervention did not reduce worst pain intensity compared with control. Further examination of supportive follow-up monitoring and/or self-management strategies post-discharge is required.

Perception of barriers to postoperative pain management in elderly patients in Polish hospitals - a multicentre study

AIM

The purpose of the paper was to compare the prevalence of barriers to optimum postoperative pain management in elderly patients, observed by nurses in a clinical, provincial and municipal hospital in Poland.

BACKGROUND

It is currently estimated that the lack of adequate pain management affects 80% of the global population and the phenomenon poses a serious problem in more than 150 countries.

METHODS

A questionnaire-based study of 1602 nurses working at clinical, provincial and municipal hospitals.

RESULTS

In the clinical hospitals barriers more often related to a poorly organised systems of care and obstacles in discussing pain management within the team. In provincial and municipal hospitals lack of uninform pain measurement was more evident.

CONCLUSIONS

Despite the availability of effective pain treatments in hospitals difficulties continue with communication, poorly organised care and limited access to clinical guidelines.

IMPLICATIONS FOR NURSING MANAGEMENT

Although there are possibilities of pain relief after surgery, they are still used insufficiently. Postoperative pain management in Poland needs considerable improvement. This study can contribute to the improvement of pain management quality by supporting and developing practical guidelines or management algorithms for nurses, facilitating the effective implementation of new pain management practices.

Fibromyalgia-related costs and loss of productivity: a substantial societal burden

BACKGROUND

This study aimed at describing pain-related health care resource use, direct costs, and productivity loss among patients suffering from fibromyalgia syndrome (FMS).

METHODS

A cost-of-illness study with a sample of 57 adults having a diagnosis of FMS was conducted in the province of Quebec (Canada). Data regarding FMS-related direct costs and productivity loss from paid and unpaid work over a three-month period were collected using a standardized structured telephone interview protocol. Direct costs were valued in 2009 Canadian dollars using a societal perspective.

RESULTS

Results showed that average direct costs over a three-month period added up to $951 per patient (SD: $710), which could be translated in a mean annual cost of $3804. The purchase of prescribed medications led to the highest costs (mean: $329, SD: $321), followed by consultations to health care professionals other than physicians (mean: $129, SD: $222) and physicians consultations (mean: $98, SD: $116). Results further showed a high economic burden for patients themselves, aside from costs covered by public or private insurers. Among the subsample of participants who had a paid job (45.6%), an average of 5.6 days (SD: 13.2) were lost due to pain during the past three months. Among those who were not employed (54.4%), an average of 25.1 days in household productivity (SD: 24.8) were lost.

CONCLUSIONS

FMS is associated with a substantial socioeconomic burden. Further research is clearly needed to improve the management of this type of disorder and make better decisions regarding resource allocation.

Health Services for Management of Chronic Non-Cancer Pain in Kuwait: A Case Study Review

The experience of chronic pain is universal, yet pain management services delivered by health professionals vary substantially, depending on the context and patient. This review is a part of a series that has examined the issue of chronic non-cancer pain services and management in different global cities. The review is structured as a case study of the availability of management services for people living with chronic non-cancer pain within the context of the Kuwaiti health systems, and the cases are built from evidence in the published literature identified through a comprehensive review process. The evolution of the organizational structure of the public and private health systems in Kuwait is described. These are discussed in terms of their impact on the delivery of comprehensive chronic pain management service by health professionals in Kuwait. This review also includes a description of chronic pain patient personas to highlight expected barriers as well as compliance issues with services likely to be encountered in Kuwait. The case study analysis and persona descriptions illustrate a need to move beyond pain symptom management towards considering the entire person and his/her individual experience of pain such that health care success is judged by enhancement of patient well-being rather than access to services. A road map for improving integrative chronic pain management in Kuwait is discussed.

Critical appraisal of extended-release hydrocodone for chronic pain: patient considerations

Opioid analgesics are currently the most effective pharmacologic option for the management of both acute and chronic forms of moderate-to-severe pain. Although the "as-needed" use of immediate-release formulations is considered optimum for treating acute, painful episodes of limited duration, the scheduled dosing of extended-release formulations with immediate-release supplementation for breakthrough pain is regarded to be most effective for managing chronic conditions requiring around-the-clock treatment. The recent introduction of extended-release formulations of the opioid analgesic hydrocodone potentially broadened the possibility of providing pain relief for individuals for whom current formulations are either ineffective or not tolerated. However, reaction to the approval of the new formulations has fueled controversy over the general safety and need for opioid medications, in light of their potential for misuse, abuse, diversion, and addiction. Here, we discuss how the approval of extended-release formulations of hydrocodone and the emotionally charged controversy over their release may affect physician prescribing and the care available to patients in need of chronic opioid therapy for the management of pain.

Pain in systemic inflammatory rheumatic diseases

The sometimes intense, persistent and disabling pain associated with rheumatoid arthritis (RA) and spondyloarthritis frequently has a multifactorial, simultaneously central and peripheral origin, and it may be due to currently active inflammation or joint damage and tissue destruction caused by a previous inflammatory condition. The symptoms of inflammatory pain symptoms can be partially relieved by non-steroidal anti-inflammatory drugs, but many patients continue to experience moderate pain due to alterations in central pain regulation mechanisms, as in the case of the chronic widespread pain (CWP) characterising fibromyalgia. The importance of distinguishing CWP from inflammatory pain is underlined by the fact that drugs such as tumour necrosis factor inhibitors are expensive, and direct costs are higher in patients with concomitant CWP than in those without. The management of pain requires a combination approach that includes pharmacological analgesia, and biological and non-biological treatments because, although joint replacement surgery can significantly improve RA-related pain, it may only be available to patients with the most severe advanced disease.

Attitudes and Beliefs of Working and Work-Disabled People with Chronic Pain Prescribed Long-Term Opioids

OBJECTIVE

This study was designed to gain insight into the apparent contradiction between the perspectives of researchers and policy makers, who have questioned the efficacy and safety of chronic opioid therapy for non-cancer pain patients, and the patients themselves, who often indicate that the therapy has value.

SUBJECTS

A convenience sample of 54 patients on chronic opioid therapy was studied.

METHODS

Participants completed a questionnaire specifically designed for the study, and also several standard instruments that addressed functional interference, emotional functioning, and possible misuse of opioids. Their treating physicians rated the participants on the severity of their disability and the success of their opioid therapy.

RESULTS

Although participants reported significant ongoing pain, they gave positive global ratings to their opioid therapy, and reported little concern about addiction or side effects of opioids. They strongly endorsed the beliefs that opioids helped them control their pain and allowed them to participate in important activities such as work. They expressed the belief that their pain would be severe if they did not have access to opioids, and reported negative experiences with tapering or discontinuing opioids in the past. Work-disabled participants reported higher levels of affective distress, catastrophizing, and functional interference than working participants, and were judged by their physicians to be relatively less successful in managing their pain.

CONCLUSION

The results of this study suggest several tentative hypotheses about why patients on chronic opioid therapy value opioids, and identified several areas for systematic investigation in the future.

Prevalence and determinants of cannabinoid prescription for the management of chronic noncancer pain: a postal survey of physicians in the Abitibi-Témiscamingue region of Quebec

BACKGROUND

Few studies have been conducted to explore physicians' prescription practices and attitudes toward the use of cannabinoids in Canada.We measured the prevalence and identified determinants of cannabinoid prescription for the management of chronic noncancer pain among physicians in southwestern Quebec.

METHODS

In February 2013, we conducted a postal survey using a modified Dillman method that involved physicians practising in the Abitibi-Témiscamingue region of Quebec. We used multivariate logistic regression models to identify determinants of cannabinoid prescription.

RESULTS

A total of 166 physicians of 318 practising in the region participated in the survey (response rate 52.2%). The prevalence of cannabinoid prescription was 27.3% (45/165) for any indication and 23.0% (38/165) for the management of chronic noncancer pain; 91.1% (41/45) of the physicians prescribed cannabinoids to 5 or fewer patients. Of the 38 physicians who prescribed cannabinoids for chronic noncancer pain, 35 (92.1%) prescribed nabilone, 7 (18.4%) medical marijuana and 2 (5.3%) nabiximols. The principal determinant of cannabinoid prescription was the physician's level of comfort with prescribing cannabinoids (adjusted odds ratio 1.25, 95% confidence interval 1.01-1.55, per 1-point increase in comfort level measured on 10-point scale). Respondents reported that continuing medical education (CME) activities could increase their comfort level. They also indicated a need for guidelines or algorithms that included cannabinoid use as well as more studies about the efficacy and safety of cannabinoids for the management of chronic noncancer pain.

INTERPRETATION

We found that cannabinoids were not often prescribed for the management of chronic noncancer pain and that survey respondents were not comfortable with prescribing this drug class. This degree of discomfort could be addressed by CME activities, more effective dissemination of guidelines and more evidence regarding cannabinoid use for the management of chronic noncancer pain.

Traditional Uses of Medicinal Plants from the Canadian Boreal Forest for the Management of Chronic Pain Syndromes

OBJECTIVE

Chronic pain is more prevalent in indigenous populations who often prefer traditional remedies over allopathic drugs. Our objective was to investigate the traditional uses of medicinal plants from the Canadian boreal forest for the management of chronic pain syndromes.

METHODS

We reviewed the most extensive database on medicinal plants used by aboriginal people of the Canadian boreal forest to investigate the plants used in the management of 3 of the most common chronic pain syndromes: arthritis/rheumatism; back pain; and headache/migraine. We also reviewed the pharmacology and phytochemistry literature to investigate concordance with indigenous knowledge.

RESULTS

A total of 114 medicinal plant species were reported, of which 27 (23.5%) were used to treat more than 1 chronic pain syndrome. Pharmacological or phytochemical evidence to explain plant function as chronic pain remedy was available in the literature for only 38 species (33%), with several species reported to have anti-inflammatory and analgesic properties effective in treating chronic pain syndromes.

CONCLUSIONS

Our study showed the potential of boreal plants as alternative and complementary medicines for the treatment of chronic pain syndromes that could be enhanced by further research on efficacy and safety issues.

Overcoming barriers in cancer pain management

Pain is a devastating symptom of cancer that affects the quality of life of patients, families, and caregivers. It is a multidimensional symptom that includes physical, psychosocial, emotional, and spiritual components. Despite the development of novel analgesics and updated pain guidelines, cancer pain remains undermanaged, and some patients with moderate to severe pain do not receive adequate pain treatment. Inadequate pain management can be attributed to barriers related to health care professionals, patients, and the health care system. Common professional-related barriers include poor pain assessment, lack of knowledge and skill, and the reluctance of physicians to prescribe opioids. Patient-related barriers include cognitive factors, affective factors, and adherence to analgesic regimens. System-related barriers such as limits on access to opioids and the availability of pain and palliative care specialists present additional challenges, particularly in resource-poor regions. Given the multidimensional nature of cancer pain and the multifaceted barriers involved, effective pain control mandates multidisciplinary interventions from interprofessional teams. Educational interventions for patients and health care professionals may improve the success of pain management.

Acute pain management in the opioid-tolerant patient

SUMMARY Opioid use is increasing worldwide leading to an increasing number of opioid-tolerant patients requiring acute pain management after surgery, trauma and acute diseases. Provision of analgesia in opioid-tolerant patients is complex due to the pharmacological effects of long-term opioid exposure, but also due to pre-existing pain states, comorbidities and psychosocial issues. Acute pain management in these patients is governed by the principles of provision of good analgesia, avoidance of withdrawal and organized discharge. Pain relief needs to be achieved by the use of multimodal analgesia, including regional anesthetic techniques and, if needed, opioids in increased doses. Withdrawal is best prevented by ongoing opioid substitution at previously established doses. Discharge planning requires multidisciplinary input and good communication with all healthcare providers involved.