The Quality of Postoperative Pain Therapy in German Hospitals

Pain in Hospital: A Real-Word Data Analysis

AIM

The study aim was to describe the prevalence of pain, its assessment, and its associated characteristics in a university hospital in the French-speaking part of Switzerland.

BACKGROUND

Despite many advances in its management, pain is still a common and persistent symptom in hospitals. Nurses have a central role in its management. Pain assessment is essential for optimal management; it is nonetheless made insufficiently and randomly.

DESIGN

The design was a monocentric correlational descriptive study.

METHODS

This study was based on the secondary analysis of routine data from 22,987 computerised health records of the medical and surgical wards between 1 November 2017 and 31 March 2019.

RESULTS

The results showed that the prevalence of pain was high in medical and surgical wards. Almost one-fifth of the participants suffered from severe pain at least once during their hospital stay. There was no association between the presence of pain and hospital ward, but the likelihood of having severe pain increased if the participant was hospitalised in a medical ward. Close personalised pain monitoring should be promoted to prevent the onset of severe pain. No Patient or Public Contribution.

Pain After Outpatient Surgical Procedures

BACKGROUND

Approximately 8.1 million outpatient surgical procedures were performed in Germany in 2021. Little is known about the quality of postoperative pain treatment in the outpatient sector.

METHODS

The AQS1 project comprises a combined survey of patients and staff in the framework of quality control for ambulatory surgery. The primary endpoint of this study was the prevalence of relevant incisional pain (≥ 4/10 on the numerical rating scale) up to postoperative day 3. Secondary endpoints included prognostic variables for pain and pain-associated outcomes, based on the AQS1 patient questionnaire. Moreover, mixed regression models were used to analyze potential prognostic variables and associations of pain with other outcomes (study registration number DRKS00028052).

RESULTS

Data from 330 008 patients were evaluated (from 1 July 2001 to 31 December 2021). The overall prevalence of relevant incisional pain up to postoperative day 3 was 22.5%, with major differences between different types of procedure (3.2%-51.2%). Pain was most common after hemorrhoid surgery (51.2%) and the laparoscopic lysis of large and small bowel adhesions (45.4%). The main associations of relevant pain were with younger age (odds ratio [OR] 1.87, 95% confidence interval [1.82; 1.91]), early postoperative pain (1.34, [1.30; 1.39]), inadequate provision of analgesics (2.90, [2.71; 3.09]), and surgical wound infections (2.60, [2.43; 2.78]). Patients with pain reported lower overall satisfaction with the procedure and a longer inability to work.

CONCLUSION

These data have not been tested for representativeness. They can serve as a point of departure for the optimization of individualized perioperative pain therapy and for the planning of prospective studies.

[Dealing with "complex" pain patients in eye surgery : Perioperative management of patients with pre-existing chronic pain, opioid consumption and opioid use disorder]

The quality of postoperative pain management is still considered insufficient in many cases, also in surgical ophthalmology. Complex constellations and comorbidities, such as pre-existing chronic pain, opioid consumption and opioid use disorders represent a special challenge due to psychosocial influencing factors and sometimes psychological and psychiatric comorbidities but also due to pharmacological effects, such as the development of opioid tolerance, the opioid-induced hyperalgesia. This review article aims to impart knowledge on aspects of these comorbidities and the perioperative management to improve the treatment skills of ophthalmologists in the management of pain in these complex patients.

[Principles of acute pain therapy-An overview taking special features in the patient collective of ophthalmology into consideration]

For many years the quality of perioperative pain management in general has been repeatedly reported as inadequate and there is significant evidence to indicate that this is also true after surgical procedures in ophthalmology. The patient population in ophthalmology is quite challenging due to numerous comorbidities and a high average age resulting in numerous contraindications and organ dysfunctions and requiring special knowledge to ensure high quality acute pain management. The following overview covers basic knowledge of acute pain management, with a particular focus on analgesic approaches and the specifics of the patient population and the associated limitations in terms of analgesic and co-analgesic pharmacological options.

[Identifying patients with risk for severe pain after ophthalmological surgery]

Modern ophthalmology includes a wide range of surgical options and, accordingly, also requires appropriate pain management. There are established risk factors for severe postoperative pain that should be identified and considered in the perioperative management. The main risk factors and existing recommendations are presented in this article. Patients at risk should be identified before surgery. It is important that perioperative pain management is implemented in the treatment plan as part of an interdisciplinary cooperation to identify and address the risks as early as possible.

Status of inpatient pain therapy using the example of a general and abdominal surgery normal ward - a prospective questionnaire study to review a pain therapy algorithm ("real-world data")

Objectives

The mean pain intensity for inpatient consultations, for example in cancer patients, is known. However, the proportion of necessary consultations in the total volume of patients of a ward or a hospital, the general pain intensity in a surgical ward and the relationship between pain medication, length of stay and therapeutic success are unknown. The aim of the study was to examine surgical patients in a single normal ward subclassified into various groups (-/+ surgery, ICU stay, cancer, consultation for pain therapy etc.) during half a year with regard to their pain. For this purpose, the pain score (NAS) was recorded daily for each patient during the entire hospital stay and the change was assessed over the clinical course.

Methods

In 2017, all consecutive new admissions to a normal ward of general surgery at a university hospital ("tertiary center") were monitored over half a year according to a standardized procedure. Pain severity (measured by the "Numeric rating scale" [NRS] respectively "Visual analogue scale" [VAS]) from admission to discharge was recorded, as well as the length of stay and the administered medication. Patient groups were sub-classified as surgery, intensive care unit, cancer and pain consultation. An algorithm in two parts (part 1, antipyretics and piritramide; part 2, WHO-scheme and psychotropic drugs), which was defined years before between surgeons and pain therapists, was pursued and consequently used as a basis for the evaluation of the therapeutic success.

Results

269 patients were included in the study. The mean pain intensity of all patients at admission was VAS 2.2. Most of the groups (non-cancer, intensive care unit [ICU], non-ICU, surgical intervention (=Operation [OP]), non-OP, pain intensity greater than VAS 3) were significantly reduced in pain at discharge. An exception in this context was patients with cancer-associated pain and, thus, initiated pain consultation.

Conclusions

Since three quarters of the consultation patients also reported cancer pain, it might be possible that the lack of treatment success in both the consultation and cancer groups is associated with cancer in these patients. However, it can be shown that the successfully treated groups (without ICU-based course) had a mean length of stay from 4.2 ± 3.9 up to 8.4 ± 8.1 days (d), while the two unsuccessfully treated groups experienced a longer stay (mean"cancer", 11.1 ± 9.4 d; mean"consulation", 14.2 ± 10.3 d). Twenty-one consultation patients, in whom it had been intended to improve pain intensity, could not be successfully treated despite adapted therapy - this can be considered a consequence of the low number of patients. Since the consultation patients were the only patient group treated with part 2 of the algorithm, it can be concluded that part 1 of the algorithm is sufficient for a mean length of stay up to 9 days. For all patients above this time point, a pain consultation with adaption of medical treatment should be considered.

[Resolution of the Federal Joint Committee on the mandatory introduction and implementation of acute pain management concepts-Importance and consequences for ophthalmology]

Patient-centered and adequate postoperative pain management is an important part of a modern treatment concept and should also be standard in ophthalmology. Due to the "Regulation on the mandatory introduction and implementation of acute pain management concepts for adequate postoperative pain therapy" prescribed by the Federal Joint Committee of the German statutory healthcare system (G-BA), hospitals and outpatient facilities have been required to have regulations on pain management in place since 9 December 2020. It is very likely that the need of pain management in ophthalmic surgery has been systematically underestimated so far and studies on postoperative pain hardly exist. In the opinion of the authors, the decision represents an opportunity to pay more attention to the topic and to develop standards for ophthalmology as well. This article explains the G‑BA decision and the resulting consequences for ophthalmic surgical institutions.

[The guidelines of the Federal Joint Committee on acute pain management : Background and consequences for the practice in hospitals]

The quality of postoperative pain therapy in Germany shows a heterogeneous treatment practice and large differences in quality between individual institutions, The patient representatives in the Federal Joint Committee (G-BA) have therefore decisively campaigned for many years that instruments of non-legislative standards are employed in order to noticeably improve the quality of perioperative pain therapy for patients in Germany. As a result of these efforts, in October 2020 a binding specification for internal quality management was included in the quality management guidelines (QM-RL) by the G‑BA. This describes in concrete terms the structural and procedural requirements for an internal quality management of acute pain for all institutions in which operations and comparable potentially painful interventions are carried out. This article describes the content of this regulation and the resulting consequences for the institutions, the medical and administrative management and especially the role of anesthesia.

Acute postoperative pain in 23 procedures of gynaecological surgery analysed in a prospective open registry study on risk factors and consequences for the patient

Effective perioperative pain management is essential for optimal patient recovery after surgery and reduces the risk of chronification. However, in clinical practice, perioperative analgesic treatment still needs to be improved and data availability for evidence-based procedure specific analgesic recommendations is insufficient. We aimed to identify procedures related with high pain scores, to evaluate the effect of higher pain intensity on patients and to define patient and intervention related risk factors for increased pain after standard gynaecological and obstetrical surgery. Therefore, we performed a prospective cross-sectional study based on the German registry for quality in postoperative pain (QUIPS). A cohort of 2508 patients receiving surgery between January 2011 and February 2016 in our tertiary referral centre (university departments of gynaecology and obstetrics, respectively) answered a validated pain questionnaire on the first postoperative day. Maximal pain intensity was measured by means of a 11-point numeric rating scale (NRS) and related to procedure, perioperative care as well as patient characteristics. The interventions with the highest reported pain scores were laparoscopic removal of ovarian cysts (NRS of 6.41 ± 2.12) and caesarean section (NRS of 6.98 ± 2.08). Factors associated with higher pain intensity were younger age (OR 1.75, 95% CI 1.65-1.99), chronic pain (OR 2.08, 95% CI 1.65-2.64) and surgery performed outside the regular day shift (OR 1.67, 95% CI 1.09-2.36). Shorter duration of surgery, peridural or local analgesic and preoperative sedation reduced postoperative pain. Patients reporting high pain scores (NRS ≥ 5) showed relevant impairment of daily activities and reduced satisfaction. Caesarean section and minimal invasive procedures were associated with the highest pain scores in the present ranking. Pain management of these procedures has to be reconsidered. Younger age, receiving surgery outside of the regular shifts, chronic pain and the surgical approach itself have a relevant influence on postoperative pain intensity. When reporting pain scores of 5 or more, patients were more likely to have perioperative complications like nausea or vomiting and to be impaired in mobilisation. Registry-based data are useful to identify patients, procedures and critical situations in daily clinical routine, which increase the risk for elevated post-intervention pain. Furthermore, it provides a database for evaluation of new pain management strategies.

[Applicability of QUIKS in conservatively treated tumor inpatients]

Hintergrund

„Qualitätsverbesserung im konservativen Schmerzmanagement“ (QUIKS), das Modul für nichtoperative Patienten welches an das „QUIPS“-Projekt angelehnt ist, wurde an einer Kohorte Tumorpatienten auf Anwendbarkeit getestet.

Material und Methoden

Prospektiv wurden stationär konservativ behandelte Patienten am Universitätsklinikum Würzburg (UKW) anhand des Ergebnisfragebogens QUIKS zur Qualität der Schmerztherapie befragt (AZ 129/17, Ethikkommission am UKW). Informationen zur Therapie und Demografie wurden dem klinikinternen Dokumentationssystem entnommen.

Ergebnisse

Im Erfassungszeitraum konnten 100 Tumorpatienten aus verschiedenen Kliniken eingeschlossen werden. 74 % der Patienten benötigten Unterstützung bei der Beantwortung des Fragebogens. Funktionelle Einschränkungen oder schmerztherapiebedingte Nebenwirkungen lagen bei 77 % der Patienten vor, im Durchschnitt lagen Schmerzen von 6 auf der numerischen Rating-Skala vor. Die am häufigsten benannten Schmerzentitäten waren Rücken- und Kopfschmerzen. 18 % der Patienten erhielten eine Schmerztherapie mit Opioiden, 26 % mit Nichtopioiden, eine Anpassung der Schmerztherapie erfolgte in 5 % mit Opioiden und in 44 % mit Nichtopioiden, ein Einbezug schmerzmedizinischer Spezialisten erfolgte in 9 %.

Fazit

Die Anwendung des Fragebogens wurde von den Patienten gut akzeptiert, war jedoch mit einem großen Maß an Unterstützung beim Ausfüllen verbunden. Es zeigte sich ein hohes Schmerzniveau während des Krankenhausaufenthalts. Eine Anpassung der Schmerztherapie oder ein Einbezug schmerzmedizinischer Spezialisten erfolgte selten. Die Interpretation bzgl. Aussagen zur Qualität des Schmerzmanagements könnte eingeschränkt sein, da andere (vorbestehende) Schmerzentitäten, wie nichttumorassoziierter Schmerz oder chronischer Tumorschmerz, nicht eindeutig abgrenzbar sind.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00482-021-00599-6) enthält die QUIKS-Prozessparameter und den QUIKS-Ergebnisfragebogen.

Association of Perioperative Regional Analgesia with Postoperative Patient-Reported Pain Outcomes and Opioid Requirements: Comparing 22 Different Surgical Groups in 23,911 Patients from the QUIPS Registry

(1) Background: In many surgical procedures, regional analgesia (RA) techniques are associated with improved postoperative analgesia compared to systemic pain treatment. As continuous RA requires time and experienced staff, it would be helpful to identify settings in which continuous RA has the largest benefit. (2) Methods: On the basis of 23,911 data sets from 179 German and Austrian hospitals, we analyzed the association of perioperative RA with patient-reported pain intensity, functional impairment of movement, nausea and opioid use for different surgeries. Regression analyses adjusted for age, sex and preoperative pain were performed for each surgery and the following groups: patients receiving continuous RA (surgery and ward; RA++), RA for surgery only (RA+−) and patients receiving no RA (RA−−). (3) Results: Lower pain scores in the RA++ compared to the RA−− group were observed in 13 out of 22 surgeries. There was no surgery where pain scores for RA++ were higher than for RA−−. If maximal pain, function and side effects were combined, the largest benefit of continuous RA (RA++) was observed in laparoscopic colon and sigmoid surgery, ankle joint arthrodesis, revision (but not primary) surgery of hip replacement, open nephrectomy and shoulder surgery. The benefit of RA+− was lower than that of RA++. (4) Discussion: The additional benefit of RA for the mentioned surgeries is larger than in many other surgeries in clinical routine. The decision to use RA in a given surgery should be based on the expected pain intensity without RA and its additional benefits.

[Pain management in departments of internal medicine : Results of a national survey on structures and processes of care]

Hintergrund und Ziel der Arbeit

Seit Jahren werden Defizite der Qualität der Schmerztherapie im Krankenhaus beschrieben. Ziel der vorliegenden Untersuchung war es, Strukturen und Prozesse des Schmerzmanagements in internistischen Abteilungen darzustellen.

Material und Methoden

Die Datenerfassung erfolgte mittels eines standardisierten Telefoninterviews (nichtuniversitäre Abteilungen); bei universitären Abteilungen separat mittels eines Onlinefragebogens (SurveyMonkey®).

Ergebnisse

Daten von 139 nichtuniversitären Abteilungen (Rücklauf: 21 %) und 33 universitären Abteilungen (davon 21 vollständig beantwortete Fragebögen, Rücklauf 17 % bzw. 11 %) wurden erhoben. 441 von 619 kontaktierten nichtuniversitären Abteilungen lehnten die Teilnahme ausdrücklich ab, am häufigsten mit der Begründung, es bestünde kein Interesse am Thema Schmerzmanagement. In den 172 teilnehmenden Einrichtungen wurde Schmerz als eigenständiger Parameter in 89 % der nichtuniversitären Abteilungen (96 % universitär) regelmäßig während der Visite erfasst; schriftliche Behandlungsstandards zur Schmerztherapie lagen in 57 % der nichtuniversitären Abteilungen vor (54 % universitär). In 76 % der nichtuniversitären Krankenhäuser (100 % universitär) stand auch für die internistischen Patienten ein Akutschmerzdienst zur Mitbehandlung zur Verfügung, schriftliche Vereinbarungen zur Zusammenarbeit lagen bei 35 % vor (18 % universitär).

Diskussion

Die berichtete Umsetzung des Schmerzmanagements war in den teilnehmenden Abteilungen gut. Gleichwohl sind die Ergebnisse bei niedriger Teilnahme und häufiger Ablehnung mit der Begründung einer fehlenden Relevanz nur eingeschränkt aussagekräftig. Die erfassten Daten reflektieren daher vermutlich eine erhebliche positive Selektion und sind nicht als repräsentativ für das Schmerzmanagement in der inneren Medizin zu werten.

Confirmatory factor analysis of the International Pain Outcome questionnaire in surgery

Supplemental Digital Content is Available in the Text.

The reliability and validity of International Pain Outcome questionnaire Spanish adaptation is confirmed in a large heterogeneous sample. Factor scores can be used as a global outcome analysis tool.

Background:

Choosing perioperative suitable treatments requires reliable and valid outcome measurements. The International Pain Outcome (IPO) questionnaire has been widely used for quality improvement and research purposes within the PAIN-OUT network that has collected more than 550,000 data sets of postoperative patients in 200 hospitals worldwide. Our aim is to confirm psychometric properties of the Spanish version of the IPO questionnaire and its invariance by pain predictors.

Method:

Sample included 4014 participants within a large age range, who underwent different surgical procedures. Confirmatory factor analysis (CFA) assessed internal structure, considering invariance by sex, age, procedure, smoking, obesity, affective disorder, and chronic pain. Incremental predictive validity of factor scores on question would have liked more pain treatment and opioid requirement was also estimated with logistic binary regression.

Results:

Confirmatory factor analysis verified original structure in 3 factors measuring pain intensity and interference (F1), adverse effects (F2), and perceptions of care (F3), with good internal consistency. Multigroup CFA analysis confirmed invariance by assessed pain predictors. Good incremental predictive capacity to identify would have liked more pain treatment was achieved.

Conclusion:

Our study confirms the factor structure, supports reliability, and adds some evidence of convergent validity of the Spanish adaptation of the IPO questionnaire. The sum of scores in its main factors serves a global outcome analysis tool. Low scores in F1 and F2 with high scores in F3 would indicate optimal quality of care.

Towards Better Perioperative Pain Management in Mexico: A Study in a Network of Hospitals Using Quality Improvement Methods from PAIN OUT

Objective

This was a pre–post study in a network of hospitals in Mexico-City, Mexico. Participants developed and implemented Quality Improvement (QI) interventions addressing perioperative pain management.

Methods

PAIN OUT, an international QI and research network, provided tools for web-based auditing and feedback of pain management and patient-reported outcomes (PROs) in the clinical routine. Ward- and patient-level factors were evaluated with multi-level models. Change in proportion of patients reporting worst pain ≥6/10 between project phases was the primary outcome.

Results

Participants created locally adapted resources for teaching and pain management, available to providers in the form of a website and a special issue of a national anesthesia journal. They offered teaching to anesthesiologists, surgeons, including residents, and nurses. Information was offered to patients and families. A total of 2658 patients were audited in 9 hospitals, between July 2016 and December 2018. Participants reported that the project made them aware of the importance of: training in pain management; auditing one’s own patients to learn about PROs and that QI requires collaboration between multi-disciplinary teams. Participants reported being unaware that their patients experienced severe pain and lacked information about pain treatment options. Worst pain decreased significantly between the two project phases, as did PROs related to pain interfering with movement, taking a deep breath/coughing or sleep. The opportunity of patients receiving information about their pain treatment options increased from 44% to 77%.

Conclusions

Patients benefited from improved care and pain-related PROs. Clinicians appreciated gaining increased expertise in perioperative pain management and methods of QI.

[Quality improvement in conservative pain management (QUIKS) : A module of the QUIPS project for benchmarking of pain treatment in patients with nonoperative care]

BACKGROUND

National and international surveys have shown that the quality of pain therapy in hospitals shows deficits, especially in the nonoperative disciplines.

OBJECTIVE

The objective was to develop and clinically validate a module for the outcome and process parameters for pain management in patients in the context of a conservative/nonoperative hospital treatment analogous to the QUIPS questionnaire (quality improvement in postoperative pain therapy), which focuses on postoperative pain management.

MATERIAL AND METHODS

In a 4-step procedure the QUIPS outcome questionnaire and the process assessment sheet of the QUIPS module were adapted to the conditions of conservative/nonoperative treatment. Patients from internal medicine, neurology and dermatology took part in the systematic testing and the clinical validation.

RESULTS

A total of 973 patients were enrolled (inclusion rate 74%, n = 403 internal medicine, n = 401 neurology, n = 169 dermatology). The majority completed the questionnaire independently while 33% of the patients needed support, which was given in the form of an interview. Apart from a few deficits, most questions about pain intensity and function were fully recorded. The evaluation of the outcome was difficult as regardless of the pain therapy, a relevant proportion of the patients reported no pain. Due to the lack of conclusive diagnoses at the time of the assessment, organ-related disease groups were developed using word diagnoses instead of the OPS coding used in QUIPS.

CONCLUSION

In addition to the perioperative modules of QUIPS, QUIKS (quality improvement in conservative pain management), an instrument for quality assurance of pain treatment in patients in nonoperative disciplines, is now available.

[Pain inhibition by opioids-new concepts]

BACKGROUND

Opioids are the oldest and most potent drugs for the treatment of severe pain but they are burdened by detrimental side effects, such as respiratory depression, addiction potential, sedation, nausea and constipation. Their clinical application is undisputed in the treatment of acute (e.g. perioperative) and cancer pain but their long-term use in chronic pain has met increasing criticism and has contributed to the current "opioid crisis".

OBJECTIVES

This article reviews the pharmacological principles and new research strategies aiming at novel opioids with reduced side effects. The basic mechanisms underlying pain and opioid analgesia and other effects of opioids are outlined. To illustrate the clinical situation and medical problems, the plasticity of opioid receptors, intracellular signaling pathways, endogenous and exogenous opioid receptor ligands, central and peripheral sites of analgesic and side effects are discussed.

CONCLUSION

The epidemic of opioid misuse has shown that there is a lack of fundamental knowledge about the characteristics and management of chronic pain, that conflicts of interest and validity of models must be more intensively considered in the context of drug development and that novel analgesics with less addictive potential are urgently needed. Currently, the most promising perspectives appear to be augmenting endogenous opioid actions and the selective activation of peripheral opioid receptors.

Quality of postoperative pain management in Ethiopia: A prospective longitudinal study

Background

The annual number of surgical operations performed is increasing throughout the world. With this rise in the number of surgeries performed, so too, the challenge of effectively managing postoperative pain. In Africa, there are scanty data available that make use of multi-center data to characterize the quality of postoperative pain management. In this study using a longitudinal data, we have attempted to characterize the quality of postoperative pain management; among patients scheduled for major elective orthopedic, gynecologic and general surgery.

Methods

This prospective longitudinal study evaluated the quality of postoperative pain management in patients undergoing elective general, gynecologic, and orthopedic surgery. We quantified the prevalence of moderate to severe postoperative pain with the International Pain Outcome Questionnaire and the corresponding adequacy of treatment with the pain management index. At four time points after surgery, we estimated pain severity, its physical and emotional interference, and patient satisfaction.

Results

Moderate to severe postoperative pain was present in 88.2% of patients, and pain was inadequately treated in 58.4% of these patients. Chronic pain (β = 0.346, 95% CI: 0.212, 0.480) predicted patients’ worst pain intensity. Gender was not associated with the worst pain intensity or percentage of time spent in severe pain. Patient’s pain intensity did not predicted the level of satisfaction.

Conclusions

The prevalence of moderate to severe postoperative pain and its functional interference is high in Ethiopian patients. The treatment provided to patients is inadequate and not in line with international recommendations and standards.

Improving perioperative pain management: a preintervention and postintervention study in 7 developing countries

Supplemental Digital Content is Available in the Text.

Introduction:

The burden of untreated postoperative pain is high.

Objective:

This study assessed feasibility of using quality improvement (QI) tools to improve management of perioperative pain in hospitals in multiple developing countries.

Methods:

The International Pain Registry and Developing Countries working groups, from the International Association for the Study of Pain (IASP), sponsored the project and PAIN OUT, a QI and research network, coordinated it, and provided the research tools. The IASP published a call about the project on its website. Principal investigators (PIs) were responsible for implementing a preintervention and postintervention study in 1 to 2 surgical wards in their hospitals, and they were free to choose the QI intervention. Trained surveyors used standardized and validated web-based tools for collecting findings about perioperative pain management and patient reported outcomes (PROs). Four processes and PROs, independent of surgery type, assessed effectiveness of the interventions.

Results:

Forty-three providers responded to the call; 13 applications were selected; and PIs from 8 hospitals, in 14 wards, in 7 countries, completed the study. Interventions focused on teaching providers about pain management. Processes improved in 35% and PROs in 37.5% of wards.

Conclusions:

The project proved useful on multiple levels. It offered PIs a framework and tools to perform QI work and findings to present to colleagues and administration. Management practices and PROs improved on some wards. Interpretation of change proved complex, site-dependent, and related to multiple factors. PAIN OUT gained experience coordinating a multicentre, international QI project. The IASP promoted research, education, and QI work.

[Pain inhibition by opioids-new concepts]

BACKGROUND

Opioids are the oldest and most potent drugs for the treatment of severe pain but they are burdened by detrimental side effects, such as respiratory depression, addiction potential, sedation, nausea and constipation. Their clinical application is undisputed in the treatment of acute (e.g. perioperative) and cancer pain but their long-term use in chronic pain has met increasing criticism and has contributed to the current "opioid crisis".

OBJECTIVES

This article reviews the pharmacological principles and new research strategies aiming at novel opioids with reduced side effects. The basic mechanisms underlying pain and opioid analgesia and other effects of opioids are outlined. To illustrate the clinical situation and medical problems, the plasticity of opioid receptors, intracellular signaling pathways, endogenous and exogenous opioid receptor ligands, central and peripheral sites of analgesic and side effects are discussed.

CONCLUSION

The epidemic of opioid misuse has shown that there is a lack of fundamental knowledge about the characteristics and management of chronic pain, that conflicts of interest and validity of models must be more intensively considered in the context of drug development and that novel analgesics with less addictive potential are urgently needed. Currently, the most promising perspectives appear to be augmenting endogenous opioid actions and the selective activation of peripheral opioid receptors.

[Oxycodone, piritramide and tramadol for the management of postoperative pain : A registry study on use and effectiveness in clinical routine]

BACKGROUND

In the context of improving perioperative pain management and shortening hospital stays, potent oral analgesics, such as slow release opioids, are gaining increasingly in importance.

OBJECTIVE

The aim of this study was to compare the use and effectiveness of different opioids in postoperative pain treatment in Germany.

MATERIALS AND METHODS

Using data from the QUIPS database, the records of 5249 patients were evaluated. The total study population was divided into four groups: group 1 (10 mg oxycodone with or without naloxone 5 mg), group 2 (20 mg oxycodone with or without naloxone 10 mg), group 3 (piritramide) and group 4 (tramadol). Maximum pain intensity, pain-related interference with sleep and respiration, vomiting, postoperative fatigue, desire for more pain treatment and satisfaction with pain management were evaluated.

RESULTS AND DISCUSSION

The differences in pain intensity were statistically significant between groups. Patients with piritramide reported more pain, more interference with sleep and respiration and more fatigue compared to those from the other groups. In the group with 10 mg oxycodone, the desire for additional pain medication was the lowest. Postoperative vomiting and satisfaction with pain management differed significantly between the four groups. Procedure-specific analysis has shown that differences between sub-groups were also significant following cholecystectomy and total knee arthroplasty.

CONCLUSIONS

In summary, our findings suggest that postoperative pain treatment with slow release oral oxycodone does not show disadvantages compared to tramadol or piritramide with regard to pain-related impairments and opioid-induced side effects. This hypothesis needs to be further analyzed in controlled studies.

[High pain expectation and impairment from pre-existing pain are risk factors for severe postoperative pain : Results of a study using the Lübeck Pain Risk Questionnaire]

BACKGROUND

The intensity of postoperative pain is characterized by large interindividual variability. Furthermore, strong postoperative pain is known to influence physical recovery after surgery. High (preoperative) pain expectation and pre-existing pain, which are associated with pain-related disability (impairing pain) are risk factors for strong postoperative pain. They can be determined with the Lübeck Pain Risk Questionnaire used for the first time in this study. The aim of this study was to explore the hypothesis that patients with a combination of the characteristics (1) preoperative impairing pain and (2) high pain expectation are more likely to have strong postoperative pain. Patients with these characteristics represent a unique group of patients and are more likely to develop distinct postoperative pain and can therefore be characterized as a risk group.

MATERIAL AND METHODS

A total of 501 patients at the departments of general surgery, plastic surgery, trauma surgery and orthopedic surgery of the UKSH Campus Lübeck were included in this study. All underwent elective surgery. Study patients were 18 years and older. Those needing postoperative treatment in an intensive care unit were excluded from this study (n = 18). The characteristics "preoperative pain" and "pain expectation" were measured with the Lübeck Pain Risk Questionnaire the day before surgery. The primary outcome variable was the average postoperative pain intensity, which was measured with a numeric rating scale (NRS 0-10) and scores > 4 were defined as severe pain.

RESULTS

The NRS range for "preoperative pain" was subdivided as follows: "no pain" (NRS = 0), "functional pain" (NRS = 1-3), and "impairing pain" (NRS = 4-10); that for "pain expectation" as: "low expectation" (NRS = 0-4) and "high expectation" (NRS = 5-10). To determine these cut-off points, they were varied from > 1 to > 8 and those with highest effect size for strong postoperative pain were chosen. Patients with a high pain expectation had significantly stronger postoperative pain (p < 0.001) and significantly more often higher pain intensity than patients with a low expectation (53.3% vs. 20.6%, respectively, p < 0.001). Patients with pre-existing impairing pain had significantly stronger and more frequently higher postoperative pain than patients with pre-existing functional pain (43.4% vs. 18.4%, p < 0.05). Patients with a combination of the factors "preoperative impairing pain" and "high pain expectation" showed distinct postoperative pain with NRS > 4 significantly more often (59.4%, p < 0.001). These findings could be demonstrated for the departments general surgery, plastic surgery and trauma surgery.

CONCLUSION

The combination of both risk factors results in a unique risk group for the appearance of strong postoperative pain. This group can be economically determined in the daily clinical routine using the Lübeck Pain Risk Questionnaire. Further studies must be carried out to show if additional perioperative procedures can be profitable for the risk group identified with the Lübeck Pain Risk Questionnaire; however, patients falling outside the risk group must not be neglected because they too can develop severe postoperative pain.

Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study

OBJECTIVE

To describe trends in the rate and daily dose of opioids used among commercial and Medicare Advantage beneficiaries from 2007 to 2016.

DESIGN

Retrospective cohort study of administrative claims data.

SETTING

National database of medical and pharmacy claims for commercially insured and Medicare Advantage beneficiaries in the United States.

PARTICIPANTS

48 million individuals with any period of insurance coverage between 1 January 2007 and 31 December 2016, including commercial beneficiaries, Medicare Advantage beneficiaries aged 65 years and over, and Medicare Advantage beneficiaries under age 65 years (eligible owing to permanent disability).

MAIN ENDPOINTS

Proportion of beneficiaries with any opioid prescription per quarter, average daily dose in milligram morphine equivalents (MME), and proportion of opioid use episodes that represented long term use.

RESULTS

Across all years of the study, annual opioid use prevalence was 14% for commercial beneficiaries, 26% for aged Medicare beneficiaries, and 52% for disabled Medicare beneficiaries. In the commercial beneficiary group, quarterly prevalence of opioid use changed little, starting and ending the study period at 6%; the average daily dose of 17 MME remained unchanged since 2011. For aged Medicare beneficiaries, quarterly use prevalence was also relatively stable, ranging from 11% at the beginning of the study period to 14% at the end. Disabled Medicare beneficiaries had the highest rates of opioid use, the highest rate of long term use, and the largest average daily doses. In this group, both quarterly use rates (39%) and average daily dose (56 MME) were higher at the end of 2016 than the low points observed in 2007 for each endpoint (26% prevalence and 53 MME).

CONCLUSIONS

Opioid use rates were high during the study period of 2007-16, with the highest rates in disabled Medicare beneficiaries versus aged Medicare beneficiaries and commercial beneficiaries. Opioid use and average daily dose have not substantially declined from their peaks, despite increased attention to opioid abuse and awareness of their risks.

Survey of postoperative pain control in different types of hospitals: a multicenter observational study

Background

Current pain assessment and treatment does not address every patient’s requirements. Although the Polish national guidelines for post-operative pain management have been published, many patients experience severe pain in the postoperative period. The main goal of our study was to assess pain severity among patients from different types of hospitals (primary, secondary, and tertiary centers) after similar types of surgeries. We also aimed to determine if there were any differences in pain severity associated with anesthesia technique, type of surgery, and the patient’s age and sex.

Methods

This was a prospective, observational study. A questionnaire form was used to collect demographic data, type of hospital, surgery, anesthesia, and patient satisfaction of pain control in the postoperative period. The visual analogue scale (VAS) was used to measure pain severity at four time points after surgery (4, 8, 12, and 24 h).

Results

The study was conducted from November 2015 to June 2016 in seven hospitals in Eastern Poland, and 269 women and 293 men participated. At the 4-h measurement, 39.32% of patients assessed the pain as moderate and 19.75% as severe. A difference was found in pain intensity between patients treated in primary and secondary hospitals. Vascular surgery patients had the lowest pain intensity (19 (13–26)), especially in comparison to those undergoing thoracic surgery (30 (27–33)). A sudden elevation in pain severity among patients anesthetized with single-shot spinal technique was observed. Only 4.9% of participants received strong opioids during the first 24 h after surgery.

Conclusions

Postoperative pain control seems to be unexpectedly poor after single-shot subarachnoid anesthesia. Despite concerns, the use of analgesics may be insufficient in some groups of patients. Our study indicates new variables that influence the severity of pain, such as operated region, anesthetic technique, and type of surgical department. The results obtained in our study are in discrepancy with recommendations presented by the national guidelines for post-operative pain management.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0551-3) contains supplementary material, which is available to authorized users.

Pain after orthopaedic surgery: differences in patient reported outcomes in the United States vs internationally. An observational study from the PAIN OUT dataset

BACKGROUND

A previous PAIN OUT study found that American orthopaedic-surgical patients rated 'worst pain' higher than did similar European patients. This study aims to confirm these findings in a larger, international patient sample, explore whether risk factors for greater postoperative pain exist disproportionately in the American population, and confirm the findings for one procedure.

METHODS

Surveyors collected patient reported outcomes (PROs) and perioperative pain management practices using PAIN OUT methodology. Most PROs used 11-point numerical rating scales (0=null, 10=worst possible). Risk factors included: female gender, younger age, high BMI, chronic pain, and opioid use before surgery. Initial analysis used a mixed patient cohort. A secondary analysis used only patients undergoing total knee replacement (TKR). Inference was based primarily on effect size using Cohen's d.

RESULTS

13,770 patients in 13 European and non-European countries (international ) and 564 patients from the United States (US) contributed data on the 1st postoperative day. Three of 11 PROs differed between the cohorts: 'worst pain' {US 7.5 (2.5) vs international 5.6 (2.8); d=0.66 [confidence interval (CI) 0.58-0.75]}; proportion 'receiving information about treatment options' [US 0.86 vs international 0.66; d=0.53 (CI 0.39-0.66)]; reporting adverse effects and their severity [US 0.87 vs international 0.73; d=0.52 (CI 0.38-0.66)]. Risk factors did not differ between the two cohorts. PROs and management patterns in TKR patients were similar to the mixed cohort.

CONCLUSIONS

Three PROs differed between international and US patients, with higher 'worst pain' for US patients. Neither risk factors, nor patient mix accounted for the observed differences for 'worst pain'.

CLINICAL TRIAL REGISTRATION

NCT 02083835.

[Nursing pain experts in German hospitals : A compilation of activity profiles and tasks]

BACKGROUND

In recent years nurses have come to play a professional role in pain management. In Germany, the publication of the national expert standards on pain management in nursing resulted in nurses being educated to be pain resource nurses; however, since education has started the continuance and commitments of specialized pain nurses in clinical practice is basically unclear. The goal of this evaluation was to identify how pain resource nurses are involved in pain management and organizational aspects in German hospitals.

METHOD

Online survey of 374 directors of nursing services of different types of hospitals on the assignment of nursing pain experts.

RESULTS

Pain resource nurses are involved in pain management in 70.6% of the hospitals responding to the questionnaire. Their task profile depends on the hospital size and 42.2% of the hospitals have documented task profiles. Pain resource nurses are primarily involved in invasive pain management processes (37.1%) and in the management of pain in patients with complex pain problems after surgery (33.2%). Educative tasks are training of colleagues and implementation and conversion of the national expert standards. Of the hospitals 36.1% implemented the national expert standards for acute pain and 57% of the medium-sized hospitals have at least also implemented the national expert standards for chronic pain.

DISCUSSION

The study shows a first insight into the task profiles of pain resource nurses. The implementation of this special qualification is meaningful and seems to be well-recognized in the hospitals. The tasks of patient care are orientated to the spectrum of patients treated in the hospital. The tasks of education also show the importance for the education of colleagues.