Prescription Of Analgesic Drugs Research Articles

Emergency Department Pain Management and Its Impact On Patients’ Short Term Outcome

Background: Although pain is the most common complaint in the Emergency Department (ED), there is still a lack of adequate pain treatment by Emergency Physicians. Aim of this study was to describe pain management in ED from triage to discharge and to verify the effect of pain treatment in ED on a short term follow-up after discharge in order to evaluate patient's outcome. Methods: A prospective multicentric study was conducted over two consecutive one week period in 4 ED teaching hospi- tals in Italy. All patients presenting with an acute, painful condition were eligible to participate in the study. The complete ED pain treatment was recorded, we enrolled 582 consecutive patients. One week after ED discharge a follow up evalua- tion through a phone call on patient's pain clinical condition was also obtained. Results: There was a statistical significant difference between nurse and Emergency Physicians pain judgement (p<0.001). During ED visit: 54.2% received non steroid anti inflammatory drug (NSAID), 12.2% received paracetamol and 9.9% tramadol while morphine was used only in 5.6%of patients. Overall patient's satisfaction at one-week follow-up was as follows: in 63% of patients pain was completely absent, but on the other hand, 37% of patients had no pain relief, despite analgesic therapy prescription. Conclusion: In our study we found differences between nurses and physicians judgments, they disagreed on the severity of pain. It was observed a low use of pain intensity scale with a formal measurement scales to assess pain. Our study demonstrates the importance of adequate ED and analgesic drug prescription for patients referring for pain in ED, and fol- low up assessment, many patients in follow up reported continued pain because of poor prescription of analgesic drug at discharge from ED. Improving analgesia in ED seems to be crucial for patients' quality of life and for preventing ED re- admission for relapse of pain.

WHO Ladder-Relevance in Today’s World

In an extensive review of 32 reports Bonica1 found that, pain is a major symptom in 70% of cancer patients. In 1986, the World Health Organisation (WHO) published a document titled Cancer Pain Relief, which set out the principles of cancer pain management based on the use of a ‘three-step analgesic ladder.This analgesic ladder was a conceptual framework to assist in the prescription of analgesic drugs.2

Analgesic Drug Use Associated with Statin Prescription – A Cross- Sectional Study in Primary Care Settings

To investigate whether features of muscular complaints (MC) differ between receivers of a statin prescription and non-receivers. To analyze the relationship between analgesics prescription, statin prescription and/or musculoskeletal disorders. Cross-sectional study. Consecutive patients in offices of family practitioners were interviewed using a standardized questionnaire. Target variables: Rates of features of MC in patients with or without a statin prescription and rates of analgesic drug prescription in patients with or without statin prescription and/or musculoskeletal disorders. Odds ratios (adjusted for age, sex, and socio-economic status) were calculated using logistic regression analysis. 1135 patients in 26 general practitioners' offices were asked to participate, and 1031 patients agreed. Features of MC did not differ between the two groups of patients. Analgesic prescription was found to be associated with statin prescription in patients without musculoskeletal disorders (OR 2.2, CI 1.1-4.7 without statin, OR 2.5, CI 0.9-6.9 with statin) and particularly in those with musculoskeletal disorders (OR 5.2, CI 2.9-9.3 without statin, OR 9.3, CI 4.5-19.1 with statin). Analgesic prescriptions are probably positively associated with statin prescription. Assuming that analgesics attenuate MC, an even stronger association between MC and statin use seems likely. The results generate the hypothesis that statin use contributes to analgesic use in primary care patients.

Socio‐economic burden of patients with a diagnosis related to chronic pain – Register data of 840,000Swedish patients

Chronic pain constitutes a substantial socio-economic challenge but little is known about its actual cost. To estimate the direct and indirect costs of patients with a diagnosis related to chronic pain (DRCP), to determine variation in these costs across different diagnosis groups, and to identify what resources constitute the most important components of costs. Patient level data from three administrative registries in Västra Götalandsregionen in Sweden including inpatient and outpatient care, prescriptions, long-term sick-leaves, and early retirement were extracted. Patients with a DRCP between January 2004 and November 2009 were selected. In total, 840,000 patients with a DRCP were identified. The mean total costs per patient and year were estimated at 6400 EUR but were higher for patients with cancer (10,400 EUR). Patients on analgesic drugs had more than twice as high costs as patients without analgesic drugs, on average. Indirect costs (sick-leaves and early retirement) constituted the largest cost component (59%) followed by outpatient (21%) and inpatient care (14%), whereas analgesic drug prescriptions constituted less than 1 percent of the total. The socio-economic burden of patients with a diagnosis related to chronic pain amounts to 32 billion EUR per year, when findings from Västra Götalandsregionen are extrapolated to the whole of Sweden. This compares to a fifth of the total Swedish tax burden in 2007 or about a tenth of Swedish GDP. This study does not provide evidence on what costs are caused by chronic pain per se. However, the higher costs of patients on analgesic drugs might indicate that the consequences of pain are of major importance.

Calidad del registro de la información acerca del consumo de antiinflamatorios y analgésicos en la Historia clínica del Centro de Salud

IntroductionTo examine medical records within a health centre to determine whether there are data in the information process on the secondary effects and interactions of analgesic and anti-inflammatory drugs, and to determine the patient profile as regards whether or not this information is recorded in their medical records. Material and methodsDescriptive, cross-sectional study based on electronic medical records in the Mariano Yago Primary Care Centre in Yecla (Murcia), Spain. A systematic random sample of 232 electronic medical records was reviewed. All the 232 patients, of legal age, gave their consent to review of their electronic medical records for the purposes of the study. ResultsThe percentage of doctors who recorded the fact that they had provided information regarding secondary effects and non-compatibilities of the prescription of analgesic and anti-inflammatory drugs was 21.6%. The factors involved in the non- recording of this information in the medical record were the type of prescription, the type of analgesic and anti-inflammatory drug prescribed, glomerular filtration, and adequate gastrointestinal protection. ConclusionsThe degree of compliance to patients rights to information about treatment with analgesic and anti-inflammatory drugs is low.

Recent Clinical Evidence for the Treatment of Osteoarthritis: What we have Learned

Osteoarthritis (OA) is a chronic arthritis affecting growing numbers of the ageing population. Patients diagnosed with OA place a large burden on access to healthcare services, including primary care, prescription of analgesic drugs, physiotherapy and joint replacement surgery. Not all patients diagnosed with OA will require joint replacement surgery, and therefore avenues for non-surgical treatment for such patients need to be explored in many cases. In this review we discuss current concepts underlying the pathophysiology of OA. These form a basis to understanding the rationale for new and existing therapies based on recent evidence available from clinical studies and trials in OA. In particular, we discuss the evidence for use of pharmacological treatments, including NSAIDs (non-steroidal anti-inflammatory drugs), chondroitin sulphate and glucosamine, hyaluronan, potential disease-modifying drugs and other interventions such as weight reduction and physiotherapy. Finally, we discuss new developments from clinical evidence for surgical options, including ACL repair surgery and joint replacement surgery.

Samtidig bruk av warfarin, analgetika og antiinflammatoriske midler

Concomitant use of warfarin and analgesics enhances the risk of bleeding. The frequency of such co-medication has not yet been investigated. The main aim of the present study was to determine the prevalence of concomitant use of warfarin and prescription analgesic drugs in Norway. All patients were included who were registered in the Norwegian Prescription Database as having received warfarin (Marevan) at Norwegian pharmacies from 2004 to 2006. Data were retrieved on prescription of warfarin and common analgesic drugs (paracetamol, weak opioids and NSAIDs). "Concomitant medication" was defined as the concurrent use of warfarin and analgesic drugs as prescribed by one or more different physicians at the same or different date, but within the time period for warfarin use. The number of warfarin users was approximately 80,000 in 2006 (60 % men), 93 % were older than 50 years and the majority were on long-term treatment. 25 % of warfarin patients used weak opioids in each of the following years: 2004, 2005 and 2006, while 16 - 23 % were on NSAIDs and 29 - 31 % on paracetamol. A higher number of Norwegians is treated with warfarin than previously presumed. Concomitant use of common analgesics was likely for at least one fourth of the warfarin users. As the investigated analgesics may interact with and increase the effect of warfarin (through different mechanisms), the frequent co-prescribing of these drugs may be associated with an increased risk of bleeding.

Comparison of chronic analgesic drugs prevalence in Parkinson’s disease, other chronic diseases and the general population

Patients with Parkinson’s disease (PD) frequently experienced pain. Nevertheless, there are no epidemiological data about frequency of pain in PD. We compare pain prevalence using analgesic prescription in PD patients, in the general population and in two samples of painful patients: diabetics and osteoarthritis patients in France. Data were obtained from the French System of Health Insurance for the year 2005. Medications (antiparkinsonian, antidiabetics drugs and osteoarthritis drugs) were used for identification of PD, diabetic and osteoarthritis patients. We estimated the prevalence of analgesic drugs prescription (at least one analgesic drug) and the prevalence of chronic analgesic drugs prescription (more than 90 DDD of analgesic drug). The study included 11,466 PD patients. PD patients significantly received more prescription of analgesics than the general population (82% versus 77%,) and fewer than patients with osteoarthritis (82% versus 90%). No significant difference was found between PD and diabetic patients. The chronic prescription of analgesic drugs was more prevalent in PD patients (33%) than in the general population (20%) and in diabetic patients (26%) and similar to that in osteoarthritis patients. PD patients were more exposed than the general population and diabetics to opiates, acetaminophen, and adjuvant analgesics chronic use.

Sedation and weaning from mechanical ventilation: effects of process optimization outside a clinical trial

Purpose We studied the effects of reorganization and changes in the care process, including use of protocols for sedation and weaning from mechanical ventilation, on the use of sedative and analgesic drugs and on length of respiratory support and stay in the intensive care unit (ICU). Materials and Methods Three cohorts of 100 mechanically ventilated ICU patients, admitted in 1999 (baseline), 2000 (implementation I, after a change in ICU organization and in diagnostic and therapeutic approaches), and 2001 (implementation II, after introduction of protocols for weaning from mechanical ventilation and sedation), were studied retrospectively. Results Simplified Acute Physiology Score II (SAPS II), diagnostic groups, and number of organ failures were similar in all groups. Data are reported as median (interquartile range).Time on mechanical ventilation decreased from 18 (7-41) (baseline) to 12 (7-27) hours (implementation II) ( P = .046), an effect which was entirely attributable to noninvasive ventilation, and length of ICU stay decreased in survivors from 37 (21-71) to 25 (19-63) hours ( P = .049). The amount of morphine ( P = .001) and midazolam ( P = .050) decreased, whereas the amount of propofol ( P = .052) and fentanyl increased ( P = .001). Total Therapeutic Intervention Scoring System-28 (TISS-28) per patient decreased from 137 (99-272) to 113 (87-256) points ( P = .009). Intensive care unit mortality was 19% (baseline), 8% (implementation I), and 7% (implementation II) ( P = .020). Conclusions Changes in organizational and care processes were associated with an altered pattern of sedative and analgesic drug prescription, a decrease in length of (noninvasive) respiratory support and length of stay in survivors, and decreases in resource use as measured by TISS-28 and mortality.

Female asylum seekers with musculoskeletal pain: the importance of diagnosis and treatment of hypovitaminosis D

BackgroundHypovitaminosis D is well known in different populations, but may be under diagnosed in certain populations. We aim to determine the first diagnosis considered, the duration and resolution of symptoms, and the predictors of response to treatment in female asylum seekers suffering from hypovitaminosis D.MethodsDesign: A pre- and post-intervention observational study.Setting: A network comprising an academic primary care centre and nurse practitioners.Participants: Consecutive records of 33 female asylum seekers with complaints compatible with osteomalacia and with hypovitaminosis D (serum 25-(OH) vitamin D <21 nmol/l).Treatment intervention: The patients received either two doses of 300,000 IU intramuscular cholecalciferol as well as 800 IU of cholecalciferol with 1000 mg of calcium orally, or the oral treatment only.Main outcome measures: We recorded the first diagnosis made by the physicians before the correct diagnosis of hypovitaminosis D, the duration of symptoms before diagnosis, the responders and non-responders to treatment, the duration of symptoms after treatment, and the number of medical visits and analgesic drugs prescribed 6 months before and 6 months after diagnosis.Tests: Two-sample t-tests, chi-squared tests, and logistic regression analyses were performed. Analyses were performed using SPSS 10.0.ResultsPrior to the discovery of hypovitaminosis D, diagnoses related to somatisation were evoked in 30 patients (90.9%). The mean duration of symptoms before diagnosis was 2.53 years (SD 3.20). Twenty-two patients (66.7%) responded completely to treatment; the remaining patients were considered to be non-responders. After treatment was initiated, the responders' symptoms disappeared completely after 2.84 months. The mean number of emergency medical visits fell from 0.88 (SD 1.08) six months before diagnosis to 0.39 (SD 0.83) after (P = 0.027). The mean number of analgesic drugs that were prescribed also decreased from 1.67 (SD 1.5) to 0.85 (SD 1) (P = 0.001).ConclusionHypovitaminosis D in female asylum seekers may remain undiagnosed, with a prolonged duration of chronic symptoms. The potential pitfall is a diagnosis of somatisation. Treatment leads to a rapid resolution of symptoms, a reduction in the use of medical services, and the prescription of analgesic drugs in this vulnerable population.

Terapia del dolore: nuove norme e aspetti pratici per l’uso degli analgesici

Until recently, pain therapy in Italy was conducted with largely sub-optimal standards, as revealed by one of the lowest mean morphine consumption values, an important indicator of pain therapy quality according to the WHO, among industrialized countries. The recognition of such a negative situation has led to an important effort to improvement, carried out by the law-maker, institutions and health professionals. As suggested by the WHO, these efforts aimed at three main objectives: reducing the cultural barriers to appropriate opioid use through targeted education and information, easing of analgesic drug prescription and availability, and improvement of the integration among hospital-based and domiciliar pain management and care-giving. In this article, the new legal framework concerning the prescription and administration of analgesics - regulatory innovations started in February 2001 - is presented and its practical implications for health professionals are discussed. Alongside the new laws, some regulatory interventions recently adopted by the Italian Drug Agency (AIFA) are presented and discussed, as they share the proposition of simplifying pain therapy and permit the prescription of more analgesics paid for by the National Health Service. In the last years, the premises for a more rational and modern approach to pain therapy in Italy have been created, which will need to be followed by cultural, organizing and clinical practice adaptations in order to warrant effective and efficient management of algic patients.

Sublay Prosthetic Repair for Incisional Hernia of the Flank

A large hernia after flank incision for nephrectomy is a challenging problem in hernia surgery. In recent decades preperitoneal prosthetic herniorrhaphy became a widely accepted procedure for hernias of the abdominal wall. To evaluate the outcome of mesh hernia repair of the flank we reviewed our data on all patients who underwent preperitoneal mesh repair. We identified 4 patients who underwent prosthesis repair after incisional hernia of the flank within the last 6 years. The primary reason for surgery was nephrectomy in 2 cases, pyeloplasty in 1 and complicated kidney cyst resection in 1. Mean followup time was 33 months. In a mean operative time +/- SD of 208 +/- 55 minutes the patients underwent incisional hernia repair with prosthesis implantation in the sublay position. In 3 patients an expanded polytetrafluoroethylene patch was used and in 1 polypropylene mesh was implanted. Mean prosthesis size was 25 x 38 cm. (950 +/- 300 cm. ). There were no postoperative complications. Patients were discharged from the hospital after a mean of 15 +/- 2 days. Followup revealed that none of the 4 patients with flank incision had recurrent hernia. Pain persisted in 3 patients after flank incision. However, no regular analgesic drug prescription was necessary. Mesh repair for incisional flank hernia provides reinforcement of the hernia. However, the flank remains paralyzed with a muscle bulge and some patients have persistent discomfort.

Pilot epidemiological study of attitudes towards pain in horses.

This preliminary study investigated the attitudes, and evaluated the current practice of a sample of the veterinary profession in the UK in relation to the management of pain in horses. In June 2001, a questionnaire was posted to 260 veterinarians in specialised equine practice, and 140 veterinarians in general practice with a significant equine caseload. There was a 25 per cent response rate to the questionnaire, which recorded information about the availability and prescription of analgesic drugs, the factors influencing the selection of analgesics and their administration, and estimates of the severity of pain associated with selected clinical conditions. There were considerable variations in the practices applied to manage pain in horses, implying that there are similar attitudinal barriers to the optimal management of pain in horses as have been identified in other domestic spedes.

Sedative and analgesic practice in the intensive care unit: the results of a European survey.

Sedation and analgesia are important aspects of patient care on the intensive care unit (ICU), yet relatively little information is available on common sedative and analgesic practice. We sought to assess international differences in the prescription of sedative and analgesic drugs in western European ICUs by means of a short, self-administered questionnaire. Six hundred and forty-seven intensive care physicians from 16 western European countries replied to the questionnaire. Midazolam was used as a sedative often or always by 63% of respondents and propofol by 35%. There were considerable international variations, with midazolam being preferred over propofol in France, Germany, the Netherlands, Norway and Austria. For analgesia, the drugs most commonly used were morphine (33%), fentanyl (33%) and sufentanil (24%). Morphine was preferred over fentanyl and sufentanil in Norway, UK and Ireland, Sweden, Switzerland, the Netherlands, and Spain and Portugal. Fentanyl was preferred in France, Germany and Italy. Sufentanil was preferred in Belgium and Luxemburg and in Austria. Multivariate analysis showed that the combination of midazolam with fentanyl was most often used in France; propofol with morphine in Sweden, the UK and Ireland, and Switzerland; midazolam with morphine in Norway; and propofol with sufentanil in Belgium and Luxemburg, Germany and Italy. The use of a sedation scale varied from 72% in the UK and Ireland to 18% in Austria. When used, the most common sedation scale was the Ramsay scale. This study demonstrates substantial international differences in sedative and analgesic practices in western European ICUs.

Multi-Media CD-ROM Review One-Visit Endodontic Treatment

The advent of digital radiography, apex locators, NiTi rotary preparation and rapid thermoplastic obturation have made it possible to complete many endodontic cases with a single visit. But such an approach is not without problems. Practitioners must first be philosophically convinced that single-visit treatment is reliable and scientifically based, and must then become fully conversant with the time-saving technology and its use before turning to patients. One-Visit Endodontic Treatment follows closely on the heals of ‘Cleaning and Shaping’ (reviewed IEJ 33 : 79), and aims to provide a rationale and technique guide for the predictable management of endodontic infection at a single clinical visit. The quality of production is again impressive, exploiting well the potential of multimedia, and incorporating photographs and detailed illustrations with video and animation to describe a broad range of contemporary issues and procedures. This package covers a lot of ground, but it is rightly emphasized that no amount of viewing can circumvent the need for practical, hands-on training and caution. During a total of approximately one and a half h, the software guides the viewer through an easily navigated series of five self-contained modules covering: rationale, access opening, cleaning and shaping, obturation and post-treatment care. The illustrative material is of stunning quality, and is readily understood and assimilated. Each section contains core material, supplemented by helpful additional notes, problem-solving tips and a bibliography of key references. It is assumed that future upgrades will allow a dynamic bibliography and technique guide. The scope of the clinical sections is ambitious and promises much, but can be little more than an introductory taste of the many fruits on offer. Some sections are already in need of updating, with little coverage of well-established Profile .06 protocols, little discussion of root canal sealers, and no mention of the Lightspeed Simplifil obturation technique. It would also be helpful to see the important issue of coronal seal covered more carefully, with clear guidance on cutting back root-fillings deep and effective temporization. Most controversial is the section on post-treatment patient care, where the routine prescription of analgesic and antibiotic drugs is commended. Analgesic prescribing is rationally based in Hargreaves’ flexible prescribing protocol, but blanket prescription of ibuprofen and acetaminophen for 72 h does not seem to be in the spirit of a responsive protocol tailored to individual analgesic needs. Greater caution should also be noted in the routine prescription of antimicrobial drugs given the growing worldwide concerns about antibiotic misuse and the emergence of drug resistance. Whilst routine medication may represent expedient, defensive practice, such an approach does seem anomalous in the light of the rationale section, which indicates that few post-operative complications are to be expected following the one-visit approach. The final section of self-assessment tests is disappointingly scant, with few explanatory notes. This section could usefully be expanded to provide a much more effective educational resource, and to reinforce the many messages contained in this substantial work. One-Visit Endodontics is an impressively produced piece of work which has been well received by our students and general dentists as an updating resource, and by established endodontists as a catalyst for debate. In short, this has proved to be an attractive and useful package, and one we will continue to use in all of our teaching areas. But this reviewer is still to be convinced by the single-visit approach to infected cases. One-Visit Endodontic Treatment is designed and presented by Dr Stephen Cohen, coauthor and editor of Pathways of the Pulp. It is available from NewMentor Group, 360 Post Street, Suite 402, San Francisco, CA 94108, USA (Website: http://www.newmentor.com), and in Europe from PJ Le Berre, 12 Ch. de la Dole, CH 1260 Nyon (E-mail: pinicega@bluewin.ch). Minimum system requirements Processor: Pentium 160 Operating System: Windows 95, 98, NT 4.X CD-ROM: 8x CD-ROM Ram: 32MB RAM (20MB free on hard drive) Sound: 16bit sound card Display: 640 × 480 display in thousands of colours Mouse required.

Circadian distribution of oral opioid consumption in cancer patients.

Diurnal variations are reported in pain perception, potency of placebo and in the pharmacokinetics of morphine. It is not established if such diurnal variation should be reflected in the routine prescription of analgesic drugs to cancer patients. One approach for investigating this question is to study the circadian rhythm of patients' requests for analgesics. We included 40 patients with malignant disease and intolerable pain despite treatment with weak opioids. Weak opioids were stopped and the patients' pain treatment was restricted for the next 2 days to strong oral opioids (ketobemidone) given on an as-needed basis. The number and times of all ketobemidone administrations were recorded. No significant diurnal variation in use of ketobemidone was observed. A descriptive curve that interpolates between successive observations displayed only slight circadian fluctuations of opioid consumption. Thus, the data reported in this paper does not support the necessity of considering chronopharmacological factors in the routine prescription of oral opioids.

Management of postoperative pain in abdominal surgery in Spain. A multicentre drug utilization study.

Postoperative pain is common in hospital-admitted patients. Its management is determined by different therapeutic traditions and by the attitudes of health professionals in each hospital. The aim of this study was to describe the patterns of prescription and administration of analgesic drugs used for postoperative pain after abdominal surgery in Spanish hospitals, to know the prevalence and the severity of postoperative pain, and to determine the extent of variability in the management of postoperative pain among the participating centres. The study was a multicentre descriptive cross-sectional drug utilization study in 12 Spanish hospitals. The subjects were an unselected sample of consecutive patients undergoing abdominal surgery, admitted between October 1994 and January 1995. For each patient, information about the surgical procedure and the use of analgesics was prospectively collected. The severity of postoperative pain was assessed during the first day after surgery by means of a six-category (none, mild, moderate, severe, very severe, and unbearable) rating scale and a visual analogue scale (VAS). Nine hundred and ninety-three patients (547 men) were included. The most common surgical procedures were inguinal hernia repair (315, 32%), cholecystectomy (268, 27%), appendectomy (140, 14%), bowel resection (137, 14%), and gastric surgery (58, 6%). Fifty-nine percent of patients (587) received nonopioid analgesics only, 9% (89) received opioid analgesics only, and 27% (263) received both opioid and nonopioid analgesics. The most frequently administered drugs were metamizole (667 patients) and pethidine (213 patients). Although in the majority of medical orders the administration of analgesics was scheduled at regular time intervals, the majority of actual doses were given 'as-needed'. The average administered daily doses of all analgesics were lower than those prescribed. Thirty-eight percent (371/967) of patients rated their maximum pain on the first day as severe to unbearable. Wide interhospital variability was recorded in the surgical procedures which had been performed, in the analgesics used, and also in the pain scores referred by patients. The percentage of patients in each centre who suffered severe to unbearable pain varied from 22 to 67%. In Spain many patients still suffer severe pain after abdominal surgery, and this seems to be due to an inadequate use of analgesics. Wide interhospital variability in the management of postoperative pain and in its prevalence was also recorded.

Analgesic drug prescription and use in cognitively impaired nursing home residents.

Prior research has documented the high prevalence of pain in elderly adults and the difficulties associated with properly assessing and treating pain in elders with cognitive impairment. To investigate the prescription and administration of analgesic medications to treat pain in cognitively impaired nursing home residents. The current sample consisted of 339 nursing home residents (295 women and 44 men) with a mean age of 87 years (range 66-104). Forty-six percent of the sample had diagnosed cognitive impairment, and 55% had at least one diagnosed painful condition. Data for this correlational study were drawn from four nursing homes in Western Pennsylvania. The Multidimensional Observation Scale for Elderly Subjects was used to assess behavioral indicators of cognitive impairment, and chart review was used to obtain demographic, medication, and diagnostic data. The results indicated that cognitively impaired nursing home residents are prescribed and administered significantly less analgesic medication, both in number and in dosage of pain drugs than their more cognitively intact peers. In multiple regression analyses holding the presence of painful conditions constant, more disoriented and withdrawn residents were prescribed significantly less analgesia by physicians; more disoriented, withdrawn, and functionally impaired residents were administered significantly less analgesia by nursing staff. The findings highlight the difficulties of assessing pain in cognitively impaired elders and the lack of knowledge among health care providers about effective pain management.

Compliance in administration of prescribed analgesics.

In this noninterventional study, the implementation of 'modern' pain management in clinical practice was investigated by recording the regular prescription, administration and efficacy of analgesic drugs. This resulted in a reproducible and superficial quality control design for hospitals. One hundred and fifty surgical patients were followed during 5 days postoperatively. For every patient, pain, mood and sedation were measured using visual analogue and verbal descriptive scores; the prescription of analgesics at set times and administered doses of analgesics were also recorded. Only paracodeine and naproxen were administered regularly as prescribed, unlike paracetamol and morphine. The prescribed daily dose of morphine was only received by 4.2% of all patients. Although the postoperative pain treatment pathway was considered to be improved after better education and communication, in fact the opposite was found. This is probably caused by traditional thinking, lack of control and time pressure on the hospital staff and the subservient attitude of the patient.

Pain and its relief

Reiief of pain, Pharmacologic management, Surgical management, Implanted electrodes. The physician who attends patients with malignant disease must draw a practical distinction between the management of pain as a symptom requiring analysis and treatment of underlying causes and pain as suffering requiring considerate treatment of the symptom per se. Unremitting pain associated with cancer is a late manifestation. A sympathetic physician whose analytical powers are burdened by feelings of hopelessness and helplessness in the face of a patient’s advancing malignancy may pursue symptomatic pain relief through prescription of narcotic agents without maintainance of adjuvant clinical reflection. The outcome can be most devestating to the patient. Symptomatic treatment of constant midline back pain in a patient known to have metastatic cancer without detailed investigation of the clinical syndrome may obscure the reality of malignancy-related early spinal cord compression. The development of new complaints such as difficulty in urination and obstipation which readily might raise the possibility of spinal cord compression under other diagnostic circumstances may be attributed to the side effects of the prescribed narcotic drugs. Insight into the underlying pathophysiological process may come too late to prevent paraplegia. Other similar examples will undoubtedly come to mind readily. The first precept in the management of pain associated with malignancy must be the maintainance of analytical clinical initiatives. INTRACTABLE PAIN: PHARMACOLOGIC MANAGEMENT Pain associated with carcinomatous invasion of brachial or lumbar plexus, intercostal nerves, parietal pleura, peritoneum and periosteum which persists despite specific treatment directed at altering the course of the malignant process requires symptomatic treatment which alters the patient’s perception of or reaction to pain. Pain at this stage of the disease is usually constant with exacerbations. Often. we physicians institute the use of analgesic drugs to treat the exacerbations but not the pervasive background of pain. Hence, analgesic medication is ordered to be taken p.r.n. Following this dosage plan, resultant analgesia is partial at best. The practical aim of symptomatic treatment is the provision of total pain relief with preservation of physical, intellectual and emotional strengths. Therefore, the prescription of analgesic drugs ought to be directed toward this end. Scheduled, rather than episodic use of analgesic agents will be effective in this regard. Saunders” has pointed out that “pain itself is the strongest antagonist to successful analgesia and if it is ever allowed to become severe the patient will then increase it with his own tension and fear”. The secret in the use of medication for the management of intractable pain lies as much in proper dosage scheduling as in drug selection.