Challenges In Pain Management Research Articles

Preoperative Optimization of Chronic Pain Patients Undergoing Surgery

Surgery presents unique challenges in pain management for patients with chronic pain. A perioperative optimization program, starting at decision to surgery, is likely to yield the best results for this population. Perioperative optimization focuses on psychological, medical, and physical optimization. Psychological optimization includes cognitive behavior therapy, relaxation, and music therapy. Medical optimization focuses on the multimodal approaches of pharmacological adjustment and physical optimization focuses on prehabilitation and nutrition optimization. The ideal care model incorporates these optimization strategies into clinical practice to prepare the patient appropriately for the best possible outcomes. Although preoperative optimization is key for sustained outcomes, intraoperative and inpatient protocols are equally important, as is postdischarge subacute support by pain specialists, as needed, for up to 90 days after surgery.

Challenges in anaesthesia and pain management for burn injuries.

Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.

The Role of Cannabidiol (CBD) in Chronic Pain Management: An Assessment of Current Evidence.

Given the growing challenges in chronic pain management coupled with the ongoing consequences of the opioid epidemic, pain management practitioners are looking into more effective, innovative, and safer alternatives to treat pain. Cannabis-based medicine had been described for hundreds of years but only recently have we seen the more scientific, evidence-based approach to its use, and ongoing investigations continue to explore its potential medical benefits. While historically more attention has been paid to the psychoactive component of the cannabis plant Δ9-tetrahydrocannabinol (THC), there have been fewer scientific studies on the medical use of the cannabidiol (CBD) - a non-psychoactive component of the cannabis plant. By examining recent literature, we investigated the use of CBD and its potential role in pain management. Since there are currently no approved pharmaceutical products that contain CBD alone for the management of pain, this review focused on nabiximols (which is a combined product of THC/CBD in a 1:1 ratio) as the only pharmaceutical product available that contains CBD and is being used for the management of pain. It is difficult to definitely attribute the therapeutic properties to CBD alone since it is always administered with THC. Based on the available literature, it is difficult to make a recommendation for the use of CBD in chronic pain management. It is also important to note that there are many CBD products currently availableas supplements, but these products are non-pharmaceuticals and lack the appropriate clinicalstudies to support their efficacy claims.

Audit of pain management following emergency laparotomies in cancer patients: A prospective observational study from an Indian tertiary care hospital.

Background:Emergency laparotomies present a challenge in pain management given sick patients, odd timings and poor outcomes. Current recommendations favour multimodal opioid-sparing analgesia following elective laparotomies. No recommendation exists for emergency surgeries.Methodology:After approval and registration of the trial, adult patients posted for emergency laparotomy in the hospital (tertiary centre for cancer care) starting August 2015, for 6 months, were included in this prospective study. Patients' details including indication for emergency surgery, preoperative haemodynamic parameters, baseline coagulation status were captured. Patients were followed for pain scores, satisfaction with pain management and outcome. The number of anaesthesiologists present and their experience concerning regional techniques were noted.Results:Intestinal obstruction was the commonest cause of emergency laparotomy. Most patients belonged to the ASA IE/IIE class (91%). Intraoperatively, opioids were the mainstay of pain management with an epidural catheter inserted in only 9% of cases even though most cases were conducted by anaesthesiologists confident/expert in thoracic epidural insertion. There was no correlation of choice of pain management technique with the time of surgery (P = 0.22), ASA grading (P = 0.28), predicted mortality by p-Possum scores (P = 0.24). Pain at movement was moderate-severe in more than 50% of patients within the first 24 h. The regional group had better satisfaction when compared to opioid and non-opioid based management. (P < 0.001).Conclusion:Regional techniques for pain management in emergency laparotomies are less preferred, therefore, opioids are the mainstay. Lack of experience is essentially not the primary reason for regional techniques not gaining popularity. Pain management in this group needs a thorough re-evaluation.

Pain Management Challenges in Acute and Critically Ill Patients.

Pain Management Challenges in Acute and Critically Ill Patients.

A 5-year prospective review of postoperative pain management in Ahmadu Bello University Teaching Hospital Zaria: Challenges and way forward

Background: Perception of postoperative pain varies. It depends on the type of surgery and the individual involved, which is influenced by race. Postoperative pain, in general, is inadequately managed in developing countries. This study prospectively reviewed the challenges of postoperative pain management in our center, the incidences and other options available for effective postoperative pain management. Methods: Following hospital ethics approval and informed consent, a 5-year prospective review of postoperative pain management was carried out on 3623 patients operated in Ahmadu Bello University Teaching Hospital under subspecialty of general, maxillofacial, orthopedic, and obstetrics and gynecology surgeries, from January 2013 to December 2017. Following the enlightenment of patients about numeric pain score scale, pain scores of the patients that met the inclusion criteria were determined 24 h postoperatively through a predesigned questionnaire. Numeric pain scale was used to ascertain pain intensity and the level of satisfaction following postoperative pain management. The surgeons' and the anesthetic review, as well as the anesthetic chart of the 3623 patients managed, were studied. The incidence of the degree of pain scores was calculated for the different patient's populations. Techniques of anesthesia were also computed. Data were analyzed using Chi-square statistical package. Results: High rate of severe pain incidences was observed. Out of the overall 3623 patients managed within the study period, 42.1% (1525) of the patients reported severe pain. About 43.8% (1587) of patients had moderate pain and only 14.1% (511) of the patients recorded mild pain. Most of the patients [56.1% (2033)] had general anesthesia, while 41.5% (1503) had regional anesthesia. Around 2.4% (87) of the patients had both general and regional anesthesia. Conclusion: Postoperative pain is inadequately managed. There is need for the policymakers to provide intensive intervention on postoperative pain management by considering adequate supply of strong opioids regularly. More so, knowledge of the anesthetists and physicians involved in postoperative pain management need to be improved and updated, especially on the techniques for managing postoperative pain.

Practice Patterns and Treatment Challenges in Acute Postoperative Pain Management: A Survey of Practicing Physicians.

IntroductionThe management of acute postoperative pain remains a significant challenge for physicians. Poorly controlled postoperative pain is associated with poorer overall outcomes.MethodsBetween April and May 2017, physicians from an online database who regularly prescribe intravenous (IV) medications for acute postoperative pain completed a 47-question survey on topics such as patient demographics, IV analgesia preferences, factors that influence prescribing decisions, and the challenges and unmet needs for the treatment of acute postoperative pain.ResultsOf 501 surveyed physicians, 55% practiced in community hospitals, 60% had been in practice for > 10 years, and 60% were surgeons. The three categories of IV pain medications most likely to be prescribed to patients with moderate-to-severe pain immediately after surgery were morphine, hydromorphone, or fentanyl (95.8% of respondents); COX-2 inhibitors or nonsteroidal anti-inflammatory drugs (73.7%); and acetaminophen (60.5%). Past clinical experience (81.6%), surgery type (78.2%), and onset of analgesia (67.1%) were practice-related factors that most determined their medication choice. Key patient-related risk factors, such as avoidance of medication-related adverse events (AEs), each influenced prescription decisions in > 75.0% of physicians. Nausea and vomiting were among the most common challenges associated with postoperative pain management (76.2 and 60.3%, respectively), and avoidance of analgesic medication-related AEs was among the three most influential patient-related factors that determined prescribing decision (75%). Physicians reported the top unmet need for acute pain management in patients experiencing moderate-to-severe postoperative pain was more medications with fewer side effects (i.e., nausea, vomiting, and respiratory depression; 80.7%).ConclusionsOpioids remain an integral component of multimodal acute analgesic therapy for acute postoperative pain in hospitalized patients. The use of all IV analgesic medications is limited by concerns over AEs, particularly with opioids and in high-risk patients. There remains a key unmet need for effective analgesic medications that are associated with a lower risk of AEs.FundingTrevena, Inc.Electronic supplementary materialThe online version of this article (10.1007/s40122-018-0106-9) contains supplementary material, which is available to authorized users.

Challenges of pain management in neurologically injured patients: systematic review protocol of analgesia and sedation strategies for early recovery from neurointensive care

BackgroundA recent paradigm shift within the intensive care discipline has led to implementation of protocols to drive early recovery from the intensive care unit (ICU). These protocols belong to a large knowledge, translation and quality improvement initiative lead by the Society of Critical Care Medicine, aiming to “liberate” patients from the ICU. They “bundle” evidence-based elements shown to lower ICU stay and mortality and optimize pain management. The bundled elements focus on Assessing, preventing and managing pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; assessment, prevention, and management of Delirium; Early mobility and exercise; and Family engagement and empowerment (ABCDEF). It is evident that analgesia and sedation protocols either directly relate to or influence most of the bundle elements. A paucity of literature exists for neurologically injured patients, who create unique challenges to bundle implementation and often have limited external validity in existent studies. We will systematically search the literature, present the unique challenges of neurointensive care patients, conduct a stratified analysis of subgroups of interest, and disseminate the evidence of analgesia and sedation protocols in the neurointensive care unit (NICU). We hope the relevant stakeholders can adapt this information through knowledge translation—to make formal recommendations in clinical practice guidelines or a position statement.Methods/designThe authors will search MEDLINE (PubMed), EMBASE, Cochrane Library, Cochrane Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. The title, abstract, and full-text screening will be completed in duplicate, and a Cohen’s Kappa coefficient of agreement will be reported. Provided the data retrieved from studies is suitable, results will be combined statistically using meta-analysis. We aim to evaluate the impact of ABCDEF bundle components on multiple endpoints of NICU recovery. Our primary outcomes will be time to successful discontinuation of mechanical ventilation and time to early mobility. The authors will guide the methodological design of the study using the PRISMA-statement and the checklist compliance will be available.DiscussionUsing the evidence from this systematic review, we anticipate disseminating knowledge of analgesia and sedation protocols in the NICU. The results of this systematic review are imperative to close the knowledge gap in a patient population that is often excluded from studies, and to add to the body of literature aiming to enhance early recovery from the NICU and mitigate iatrogenic harm.Systematic review registrationPROSPERO CRD42017078909

Preparing Clinicians for Transitioning Patients Across Care Settings and Into the Home Through Simulation.

Assuring home care staff competencies through simulation has the potential to improve care transitions and clinical outcomes. Recreating a home environment can be used for orientation of home care staff and to meet other learning needs. Lessons learned from the use of simulation in a geriatric nursing course in a prelicensure program can be used to prepare clinicians for transitioning patients across care settings. With simulation, learners can identify challenges in patient safety, pain management, and management of patients' cognitive decline as well as learn how to communicate with patients, family members, and the healthcare team. Simulation, as an interactive pedagogy, provides opportunities for learners to practice assessment, monitoring, and patient care in a controlled, safe, risk-free environment. Following participation in a simulation, learners are given the opportunity to reflect on ways to improve patient care when transitioning from acute to home care settings. Simulations described in this article can be used for orientation of staff to a home healthcare agency because they allow clinicians to hone the skills necessary for patient care in the home. Staff educators can also use simulation to validate staff competencies in caring for patients at home.

Challenges in Pain Management in Palliative Care

Challenges in Pain Management in Palliative Care

Current Ketamine Practice: Results of the 2016 American Society of Pain Management Nursing Survey on Ketamine

Background: Ketamine is increasingly utilized for a variety of pain management challenges. Audience comments from a ketamine presentation at the 2015 American Society of Pain Management Nursing (ASPMN) Conference reflected wide variation in ketamine practices as well as barriers to use. Aim: The goal was to gain a greater understanding of ASPMN member practice patterns and barriers related to ketamine as adjunctive therapy for pain management. Design: A questionnaire survey design was used. Settings: Respondents represented 35 states and 2 countries. Participants: The participants were 146 respondents from ASPMN membership (1,485 members). Methods: The survey was distributed by ASPMN on SurveyMonkey. Practice setting and ketamine administration practices were assessed with areas for comments. Results were reviewed using frequencies to describe responses and formatted into tables. Comments were individually reviewed and grouped into common themes. Results: Administration of ketamine as an analgesic was reported by 63% of respondents. Continuous intravenous ketamine infusions were the most common route of administration (65%); however, wide variability in dosing and length of therapy was reported. A wide variety of practices and challenges related to ketamine utilization were noted. Conclusions: Numerous studies have indicated the analgesic benefits of ketamine in pain management. The lack of practice standardization has created challenges to its consistent use and outcome measurement. Additionally, the off-label use of ketamine for pain management creates its own unique challenges. However, given the current national climate with intense focus on pain management, interdisciplinary practitioners have an ideal opportunity to evaluate ketamine's use in a comprehensive approach to pain management.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Patient narratives in Yelp reviews offer insight into opioid experiences and the challenges of pain management.

To characterize Yelp reviews about pain management and opioids. We manually coded and applied natural language processing to 836 Yelp reviews of US hospitals mentioning an opioid medication. Yelp reviews by patients and caregivers describing experiences with pain management and opioids had lower ratings compared with other reviews. Negative descriptions of pain management and opioid-related experiences were more commonly described than positive experiences, and the number of themes they reflected was more diverse. Yelp reviews offer insights into pain management and opioid use that are not assessed by traditional surveys. As a free, highly utilized source of unstructured narratives, Yelp may allow ongoing assessment of policies related to pain management and opioid use.

Chronic morphine exposure potentiates p-glycoprotein trafficking from nuclear reservoirs in cortical rat brain microvessels.

The rates of opioid prescription and use have continued to increase over the last few decades resulting in a greater number of opioid tolerant patients. Treatment of acute pain from surgery and injury is a clinical challenge for these patients. Several pain management strategies including prescribing increased opioids are used clinically with limited success; all currently available strategies have significant limitations. Many opioids are a substrate for p-glycoprotein (p-gp), an efflux transporter at the blood-brain barrier (BBB). Increased p-gp is associated with a decreased central nervous system uptake and analgesic efficacy of morphine. Our laboratory previously found that acute peripheral inflammatory pain (PIP) induces p-gp trafficking from the nucleus to the luminal surface of endothelial cells making up the BBB concomitant with increased p-gp activity and decreased morphine analgesic efficacy. In the current study, we tested whether PIP-induced p-gp trafficking could contribute to decreased opioid efficacy in morphine tolerant rats. A 6-day continuous dosing of morphine from osmotic minipumps was used to establish morphine tolerance in female rats. PIP induced p-gp trafficking away from nuclear stores showed a 2-fold increase in morphine tolerant rats. This observation suggests that p-gp trafficking contributes to the decreased morphine analgesic effects in morphine tolerant rats experiencing an acute pain stimulus. Attenuating p-gp trafficking during an acute pain stimulus could improve pain management by increasing the amount of opioid that could reach CNS analgesic targets and decrease the need for the dose escalation that is a serious challenge in pain management.

Communicating Caregivers' Challenges With Cancer Pain Management: An Analysis of Home Hospice Visits

ContextFamily caregivers (FCGs) of hospice cancer patients face significant challenges related to pain management. Addressing many of these challenges requires effective communication between FCGs and hospice nurses, yet little empirical evidence exists on the nature of communication about pain management between hospice nurses and FCGs. ObjectivesWe identified ways in which FCGs of hospice cancer patients communicated their pain management challenges to nurses during home visits and explored nurses' responses when pain management concerns were raised. MethodsUsing secondary data from audio recordings of hospice nurses' home visits, a deductive content analysis was conducted. We coded caregivers' pain management challenges and immediate nurses' responses to these challenges. ResultsFrom 63 hospice nurse visits, 101 statements describing caregivers' pain management challenges were identified. Thirty percent of these statements pertained to communication and teamwork issues. Twenty-seven percent concerned caregivers' medication skills and knowledge. In 52% of the cases, nurses responded to caregivers' pain management challenges with a validating statement. They provided information in 42% of the cases. Nurses did not address 14% of the statements made by caregivers reflecting pain management challenges. ConclusionTo optimize hospice patients' comfort and reduce caregivers' anxiety and burden related to pain management, hospice nurses need to assess and address caregivers' pain management challenges during home visits. Communication and educational tools designed to reduce caregivers' barriers to pain management would likely improve clinical practice and both patient- and caregiver-related outcomes.

The Challenge of Chronic Pain Management by PM&amp;R Specialist

According to the definition from international association for the study of pain (IASP), pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Besides, there are many term of unpleasant sensory that complaint by patient as a pain, such as allodynia, hyperalgesia, and hyperesthesia. The pain is one of the most cases that came to seeking a doctor. The data from Indonesian National Health Insurance (JKN) from 2014-2017 have revealed that pain cases were the most frequent in Rehabilitation Medicine Services, i.e. low back pain, knee pain, and shoulder pain. The prevalence of pain is increasing along with ageing, sedentary life style, obesity and chronic diseases.

Assessment of initial differences between inpatient and outpatient patients receiving pain therapy in Germany: the KEDOQ-Pain quality assurance system

KEDOQ-Pain is a quality assurance system for documentation and quality management of pain therapy under different treatment settings initiated by the German Pain Society. We used KEDOQ-Pain data to describe initial differences in sociodemographic, pain-related and psychological factors between pain patients receiving pain therapy in inpatient or outpatient treatment settings. Our data, collected by the German Pain Questionnaire (DSF), comprised information on pain patients receiving out- and inpatient therapy (n=4,705). Statistical analysis was carried out by descriptive and comparative data analysis using uni- and multivariate statistical methods. Patients receiving inpatient pain therapy were significantly older, more often female and had more often multiple pain localizations. They reported greater pain intensity, had a higher stage of pain chronification and higher pain-related disabilities. They showed higher levels of anxiety, depression and stress and had a lower quality of life. Significant group differences, however, had only small effect sizes. Even though multivariate analysis revealed most predictors of treatment in an inpatient setting to be significant, taken as a whole they explained less than 5% of the observed variance. Criteria underlying the current practice of allocation of patients to inpatient or outpatient pain therapy remain unclear. Our analysis suggests that highly chronified pain will increasingly be the challenge of future pain management, requiring professional competence from a multidisciplinary specialist team.

Harlequin Baby: the Challenge of Pain Management in the Neonatal Period

This case is about a 35-week neonate diagnosed with harlequin ichthyosis. The neonate was managed by a multidisciplinary team composed of specialists from neonatology, genetics, dermatology, plastic surgery, ophthalmology, rehabilitation medicine, and anesthesiology. Harlequin ichthyosis is characterized by defective keratinization and desquamation of the epidermis which is very painful. Pain management in the neonate entails a proper balance between pain relief and avoidance of serious adverse effects which is a major challenge for caregivers.

Regional nerve blockade for early analgesic management of elderly patients with hip fracture - a narrative review.

Elderly patients with hip fracture experience high morbidity and mortality, and are often undertreated for pain. Acute pain management in the elderly is challenging, with physiological frailty, medical comorbidities and cognitive impairment commonly compounding pain assessment and treatment. Guidelines outlining current best practice for acute pain management in the elderly now exist, but evidence suggests that practice remains variable and there continues to be scope for improvement. We conducted a narrative review of the literature to examine the challenges of acute pain management in the elderly, and to evaluate evidence for the role of regional nerve blocks for acute pain associated with hip fracture in the elderly. There is consistent evidence that regional nerve blocks can effectively reduce pain associated with hip fracture, providing rapid-onset, site-specific analgesia that is more effective than standard systemic analgesia alone. There is also moderate evidence that nerve blocks may contribute to reduced rates of delirium, and some suggestion of reduced length of inpatient stay, morbidity and mortality, although limited evidence is available. Fascia iliaca blocks are emerging as a block of choice, with evidence they can be safely and rapidly administered under ultrasound guidance in the acute setting, by both trained medical and nursing staff, with good effect. Ideally, comprehensive pain protocols for elderly hip fracture patients are required, that integrate evidence-based fascia iliaca block use, timely and repeated pain assessment, and multidisciplinary orthogeriatric patient care.

Parent Perspectives on Pain Management in Preschool-Age Children With Sickle Cell Disease.

Pain episodes occur for many preschoolers with sickle cell disease (SCD), but little is known about parent perceptions of managing pain episodes in young children. We surveyed parents of young children with SCD who had managed pain episodes in the past year to assess their management and satisfaction with their strategies, challenges of pain management, and interest in additional education. Parents were recruited from health maintenance visits at a SCD specialty clinic. Forty-two of 51 parents (82%) of 2- to-6-year-olds reported managing pain over the past year. Parents who had managed pain primarily reported using medications. These parents reported at least moderate satisfaction with current management strategies and resources. At least one-third of parents found each facet of pain management queried as at least somewhat challenging. Identifying when their child was in pain, encouraging functional activities, and managing irritable behavior were reported as most challenging. Parents of young children with SCD reported interest in additional pain management education, which could promote better parent and child coping skills.