Management Of Nonmalignant Pain Research Articles

Assessment of Knowledge on Palliative Care among the Community Health Officers in Rural Area of Purba Medinipur District, West Bengal, India.

Palliative care deals with patients who are facing problems of life-threatening diseases. Under the Ayushman Bharat programme, a new cadre of Community Health Officers (CHOs) is provisioned at Health and Wellness Centres (HWCs) who are nursing graduates. Being the team leader at the HWC level, having a low level of knowledge of palliative care would compromise their service. The study assessed the knowledge of CHOs about palliative care services in a rural district of Purba Medinipur, West Bengal, India. A descriptive study with a cross-sectional design was carried out among 314 CHOs posted in different HWCs of Purba Medinipur, West Bengal, during July-August' 2022. We used to collect data based on questionnaires of 'Palliative-Care-Knowledge Questionnaire-Basic' comprising items related to palliative care, the requirement of palliative care, pain management, communication, and dealing with psychosocial issues. A chi-square test was performed to check the association with educational- and experience-related variables and knowledge. Overall, adequate knowledge was present in 216 (68.8%) and inadequate knowledge in 98 (31.2%) of CHOs. Improper knowledge was present regarding the role of oxygen supplementation in dying patients, the need for palliative care in human immunodeficiency virus/acquired immunodeficiency syndrome, chronic non-malignant diseases, pain management, and communication about the prognosis of disease. The proportion of CHOs who had adequate knowledge who were highly educated (70%) and those who had previous job as CHO (73.3%). Almost similar knowledge scores were found among those who ever cared for or never cared for either terminally ill patients (P = 0.89) or cancer patients (P = 0.853). In-depth knowledge was lacking among the CHOs. Training and re-training of CHOs to develop technical and communication skills will help them deliver proper palliative care.

Arts Therapy and Its Implications in Chronic Pain Management: A Narrative Review.

Chronic nonmalignant pain is recognized as a complex, dynamic, phenomenological interplay between biological, psychological, and social factors that are individual to the person suffering from it. Therefore, its management and treatment ought to entail the individual's biopsychosocial aspects that are often addressed by collaborative, inter/multidisciplinary multimodal care, as there is no biologic treatment. In an effort to enhance inter/multidisciplinary multimodal care, a narrative review of arts therapy as a mind-body intervention and its efficacy in chronic pain populations has been conducted. Changes in emotional and physical symptoms, especially pain intensity, during arts therapy sessions have also been discussed in in the context of attention distraction strategy. Arts therapy (visual art, music, dance/movement therapy, etc.) have been investigated to summarize relevant findings and to highlight further potential benefits, limitations, and future directions in this area. We reviewed 16 studies of different design, and the majority reported beneficial effects of art therapy in patients' management of chronic pain and improvement in pain, mood, stress, and quality of life. However, the results are inconsistent and unclear. It was discovered that there is a limited amount of high-quality research available on the implications of arts therapy in chronic nonmalignant pain management. Due to the reported limitations, low effectiveness, and inconclusive findings of arts therapy in the studies conducted so far, further research with improved methodological standards is required.

Medical Cannabis for Chronic Nonmalignant Pain Management.

Cannabis has been used since ancient times for medical and recreational research. This review article will document the validity of how medical cannabis can be utilized for chronic nonmalignant pain management. Current cannabis research has shown that medical cannabis is indicated for symptom management for many conditions not limited to cancer, chronic pain, headaches, migraines, and psychological disorders (anxiety and post-traumatic stress disorder). Δ9-Tetrahydrocannabinol (THC) and cannabidiol (CBD) are active ingredients in cannabis that modulate a patient's symptoms. These compounds work to decrease nociception and symptom frequency via the endocannabinoid system. Research regarding pain management is limited within the USA as the Drug Enforcement Agency (DEA) classifies it as a schedule one drug. Few studies have found a limited relationship between chronic pain and medical cannabis use. A total of 77 articles were selected after a thorough screening process using PubMed and Google Scholar. This paper demonstrates that medical cannabis use provides adequate pain management. Patients suffering from chronic nonmalignant pain may benefit from medical cannabis due to its convenience and efficacy.

Logic model for opioid safety in chronic non-malignant pain management, an in-depth qualitative study

BackgroundOpioids are commonly used for the management of chronic non-malignant pain in Pakistan; but there is a lack of literature around precursors or motivators in the use of opioids.AimThe study holistically explored factors contributing towards the unsafe use of opioids and identifies strategies to overcome them.MethodExploratory qualitative methods using interviews, focus groups and non-participant observational case studies were used. Interviews and focus groups were carried out face-to-face as well as virtually and observations were conducted in community pharmacies in Islamabad and Khyber Pukhtoon Khuwa province, Pakistan. Data were collected from 4 stakeholder groups; pharmacy policy makers (n = 11), people with chronic non-malignant pain (n = 14), doctors (n = 31) and community pharmacists (n = 36) by purposive critical case sampling method. Data were analysed inductively using reflexive thematic analysis and then deductively mapped to a social ecological framework. Non-participant observations were analysed using a cross case synthesis using explanation building technique. Data from all three methods were triangulated to develop a logic model.ResultsIdentified factors at macro (regulation), meso (social perceptions of pain and opioids) and micro levels (uncontrolled pain, self-medication, health literacy) and strategies are presented holistically and were used to develop a logic model for the prevention and mitigation of factors currently causing unsafe use of opioids.ConclusionThe study provides an in-depth view of factors contributing towards diversion of pharmaceutical opioids and can help guide national and international policy makers in their future initiatives to promote safe use of opioids in the management of chronic non-malignant pain in Pakistan.

Long-term safety and efficacy of sublingual ketamine troches/lozenges in chronic non-malignant pain management.

Chronic non-malignant pain is a disabling condition that results in a reduction in function and quality of life when inadequately managed. Sublingual ketamine has been shown to be efficacious for use in chronic pain. Despite its use for decades in chronic non-malignant pain, there is no published long-term data on safety, side-effects or adverse drug reactions. The aim of this case-series is to provide the initial evidence for safety and efficacy in this patient group. We present a retrospective review of 29 (n = 29) patients from a metropolitan tertiary pain service who have been receiving sublingual ketamine troches/lozenges between the period of 2012 and 2019. Patients were identified from the outpatient pain clinic, who had been admitted for inpatient subcutaneous ketamine infusions as part of opiate detoxification or management of central sensitisation due to a chronic neuropathic pain syndrome. An initial review was performed to check the patient started taking the ketamine troches. Each of these medical records was reviewed manually to extract information to a datasheet. There was a wide range of dosages used from 25 to 600 mg in divided doses. The duration of treatment ranged 2-89 months. There was no association with either the dosage or duration of treatment and frequency of side-effects. There was an overall reduction in the use of opioids, gabapentinoids or benzodiazepines in 59% of patients with 39% having a complete cessation of an analgesic agent. Side-effects were reported in 24%, but only 7% discontinued the treatment due to the side-effect (drowsiness). There were no reports of renal impairment, cystitis or hepatotoxicity. This retrospective case-series has demonstrated that sublingual ketamine is a safe and effective analgesic agent to use in chronic non-malignant pain management. It is indicated in a variety of chronic pain conditions and has an excellent safety profile, with no association between the frequency in side-effects and duration of therapy or total daily dosages. The study has also shown that the 'safe' dose may be higher than the previous consensus.

Goal-Directed Opioid Stewardship in Acute-on-Chronic Nonmalignant Pain Management

Prescription opioids were identified as being responsible for 14,000 deaths in 2019, with 9.3 million people admitting to misuse in 2020. This quality improvement project implemented the Institute for Clinical Systems Improvement (ICSI) guideline on pain management in acute care to decrease opioid prescriptions >90 morphine milliequivalents for acute-on-chronic pain. The change to current practice included completion of comprehensive functional assessments and opioid risk screening tools to guide a goal-directed shared decision-making discussion with patients. There was a statistically significant decrease in morphine milliequivalents per prescription (t43 = 2.579, P = .013).

Factors promoting self-medication and irrational use of opioids in chronic non-malignant pain management in Pakistan: A qualitative in-depth investigation

Abstract Introduction In many Lower and Middle-Income Countries (LMICs) people self-medicate, with non-prescription and prescription drugs both of which are easily available over the counter (1). One of the most common causes for self-medication is chronic pain (2). The role of community pharmacists becomes critical especially in LMICs where medicines are freely available and pharmacists are directly involved in supply of opioid medicines. Unresolved, prolonged chronic non-malignant pain (CNMP) may lead to self-medication with opioid analgesics and can cause irrational use of opioids. The complications of self-medication with opioids are vast in terms of both scarce resources and adverse clinical consequences such as adverse drug reactions, drug interactions and mortality associated with the diversion from intended use of opioid medicines. Self- medication with opioid analgesics in LMICs have not been explored before. Aim This study was designed to explore the factors that might contribute in promoting self-medication and irrational opioid medicine use in CNMP management and exploring potential roles of community pharmacists in stopping/avoiding self-medication with opioids in one LMIC, Pakistan. Method Qualitative interviews involving various stakeholders such as pharmacy policy makers (n=10) and people suffering from CNMP (n=12) were conducted. Additionally, focus groups were conducted with community pharmacists (n=38) and doctors (n=30). A semi-structured interview guide was drafted after an extensive literature review and was used for individual interviews and focus groups for each stakeholder respectively. The study duration was from December 2019 to July 2020. Critical case sampling, a type of purposive sampling, was done in order to promote applicability to other cases. Data was analysed using a CAQDAS software N-vivo 12, using thematic analysis. Ethical approval was obtained. Results Non-availability of community pharmacists in all pharmacies and lack of medication review services are amongst the major factors that are contributing towards self-medication of opioid medicines. Additionally, lack of awareness of people about opioid medicines and absence of strict laws regarding sale of opioid medicines under a valid prescription allows easy availability and promotes aberrant drug seeking behaviour. These factors contribute towards people not seeking professional health care services for the management of CNMP and continue self-medicating with opioid medicines. As a result, they do not get effective analgesic relief and waste limited financial resources. The major themes and sub-themes are presented in Table 1. Conclusion Self-medication with opioid medicines can cause irrational, inappropriate, and ineffective use of medicines and can additionally burden the limited financial resources available for health care needs. This in-depth exploratory study identifies many barriers that can promote self-medication with opioids and recognises a need for a multi-faceted intervention involving community pharmacists to promote rational opioid medicine use. However, major limitations of the proposed intervention identified from this study are the absence of integrated health systems and under-utilisation of community pharmacy workforce. The government needs to invest in infrastructure development, develop new health policies regarding medicine sale and build the role and capacity of pharmacy workforce to perform specialised roles in public safety especially in opioid medicines.

Pharmacology Update: Low-Dose Naltrexone as a Possible Nonopioid Modality for Some Chronic, Nonmalignant Pain Syndromes.

Pain can have a devastating effect on the quality of life of patients in palliative medicine. Thus far, majority of research has been centered on opioid-based pain management, with a limited empirical evidence for the use of nonopioid medications in palliative care. However, opioid and nonopioid medications such as nonsteroidal anti-inflammatory drugs have their limitations in the clinical use due to risk of adverse effects, therefore, there is a need for more research to be directed to finding an alternative approach to pain management in comfort care setting. The purpose of this article is to discuss a potential new drug that would adequately alleviate pain and enhance quality of life without significant risks of adverse effects that would limit its use. Naltrexone is a reversible competitive antagonist at μ-opioid and κ-opioid receptors, which when used at standard doses of 50 to 150 mg was initially intended for use in opioid and alcohol use disorders. However, it was discovered that its use in low doses follows alternate pharmacodynamic pathways with various effects. When used in doses of 1 to 5 mg it acts as a glial modulator with a neuroprotective effect via inhibition of microglial activation. It binds to Toll-like receptor 4 and acts as an antagonist, therefore inhibiting the downstream cellular signaling pathways that ultimately lead to pro-inflammatory cytokines, therefore reducing inflammatory response. Its other mode of action involves transient opioid receptor blockade ensuing from low-dose use which upregulates opioid signaling resulting in increased levels of endogenous opioid production, known as opioid rebound effect. Low dose naltrexone has gained popularity as an off-label treatment of several autoimmune diseases including multiple sclerosis and inflammatory bowel disease, as well as chronic pain disorders including fibromyalgia, complex regional pain syndrome, and diabetic neuropathy. Low-dose naltrexone (LDN) may also have utility in improving mood disorders and the potential to enhance the quality of life. This article will therefore propose the potential off-label use of LDN in management of nonmalignant pain in the palliative medicine setting.

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

This study was designed to address the current relative void of valid measures by developing evidence-based quality indicators for pain management of chronic nonmalignant pain. We performed a 10-year literature search to identify guidelines and review articles on chronic pain management to identify evidence-based recommendations for the different conditions associated to chronic pain. A complementary search of indicators and indicator-related articles was also performed. Then, we built new indicators or adapted existing ones to cover all the evidence-based recommendations we found. The resulting set was pilot tested for feasibility, reliability (kappa), and usefulness to identify quality problems, using the Lot Quality Acceptance method (α≤0.05 and β≤0.01) for 75% (40% threshold) and 95% (70% threshold) compliance standards, and estimates with binomial exact 95% confidence intervals. We reviewed clinical records from a primary care center, a medium-size hospital (250 beds), and a large hospital (500 beds). Forty-six indicators were developed (6 general and 40 condition specific). Thirty-three were feasible in primary care and/or hospitals. Feasible indicators were also reliable (most kappa >0.7). Regarding compliance, 4 quality indicators obtained compliance levels over 60%, addressing pharmacological treatment, multimodal approach, and appropriate use of neuro-image tests, while 16 obtained compliance scores under 15% (6 with 0% compliance). The created set has tested to be feasible, reliable, and useful, with the capacity to serve as the baseline for developing the necessary strategies to improve the management of chronic nonmalignant pain, by monitoring and evaluating quality of care.

Ideas and innovations: Inclusion of pharmacists in chronic pain management services in a primary care practice

Nonmalignant chronic pain management involves an ongoing process of complex evaluations including proper patient selection, proper prescribing, and careful monitoring. In the Pain Management Refill Clinic, patients are stabilized on an opioid regimen by either a pain specialist or a primary care physician (PCP). The PCP assumes long-term prescription of the regimen and proper follow-up. The inclusion of pharmacists in the management of patients suffering from chronic pain has allowed the physicians to improve opioid prescribing, documentation, and monitoring in accordance with chronic nonmalignant pain guidelines.

Abstract PR314

Background & Objectives: Chronic non-malignant neuropathic pain management is a major challenge for the clinicians despite a wide range of analgesics and pain treatment protocols. First, second, and third line drug treatments for neuropathic pain include the use of anticonvulsants, tricyclic antidepressants, mixed serotonin and norepinephrine reuptake inhibitors, opioids and other various treatment opportunities. However, the results of these treatment protocols for neuropathic pain management are heterogeneous and sometimes with short term outcomes. Although nerve blocks have been recognized as a major modality in chronic pain management, they are not included in guidelines for chronic non-malignant neuropathic pain management. The aim of our study was to investigate whether administration of peripheral nerve blocks with local anesthetic and corticosteroid significantly reduced pain in patients with chronic non-malignant neuropathic pain resistant to standard treatment, based on guidelines for chronic neuropathic pain management. Materials & Methods: 55 patients with chronic non-malignant neuropathic pain that was resistant to standard treatment based on guidelines for neuropathic pain were included in our study. The mixture of local anesthetic (0.125% levobupivacaine) and corticosteroid (betamethasone) was used to perform the blocks of peripheral nerves. Pain was assessed by the use of numeric pain rating scale (NPRS), with range 0-10 (0-no pain to 10-worst possible pain). Pain was evaluated before the application of peripheral nerve blocks and 3 weeks after. Differences between groups of patients were assessed by Wilcoxon signed rank test. All P-values were two-sided and statistical significance (p) was set at a value of 0.01. Results: A Wilcoxon signed rank test revealed a statistically significant reduction in pain, assessed on NPRS, following administration of peripheral nerve blocks, z= –6.47, p< 0.01, with a large effect size (r= 0.62). The median score on NPRS decreased from pre-peripheral nerve block administration (Median= 9; interquartile range (8-10)) to post-peripheral nerve block administration (Median= 3; interquartile range (2-5)). Conclusion: Our results suggest that peripheral nerve blocks improve pain management in patients with chronic non-malignant neuropathic pain and that these interventions could be used as therapeutic approach for patients with neuropathic pain resistant to other treatment alternatives.

Opioid Treatment Agreements: Helpful or Hurtful?

Opioid Treatment Agreements: Helpful or Hurtful?

An overview of treatment approaches for chronic pain management.

Pain which persists after healing is expected to have taken place, or which exists in the absence of tissue damage, is termed chronic pain. By definition chronic pain cannot be treated and cured in the conventional biomedical sense; rather, the patient who is suffering from the pain must be given the tools with which their long-term pain can be managed to an acceptable level. This article will provide an overview of treatment approaches available for the management of persistent non-malignant pain. As well as attempting to provide relief from the physical aspects of pain through the judicious use of analgesics, interventions, stimulations, and irritations, it is important to pay equal attention to the psychosocial complaints which almost always accompany long-term pain. The pain clinic offers a biopsychosocial approach to treatment with the multidisciplinary pain management programme; encouraging patients to take control of their pain problem and lead a fulfilling life in spite of the pain.

Desmoid Tumors: A Review of the Literature and Pharmacologic Management

ABSTRACTDesmoid tumors represent a nonmalignant proliferation of fibroblast-related cells. These rare tumors are difficult to treat and often persist as indolent, lifelong conditions. There are a number of treatments available for both anatomic and symptom regression. Some of these treatments, unfortunately, may not provide long-lasting results and may result in further complications. Pain is a distressing symptom that may be due to the tumor itself or the result of utilized treatments. Pharmacologic therapies represent a noninvasive alternative to surgical resection. Pain symptoms require therapeutic regimens that must be modified as the tumor evolves in expression. The individualized pain treatment program utilized may often reflect principles used in both nonmalignant and malignant pain management models. This review seeks to increase awareness of desmoid tumors through a review of the literature and discussion of its pharmacotherapeutic management.

General Practitioners and Chronic Non-Malignant Pain Management in Older Patients: A Qualitative Study.

Chronic non-malignant pain (CNMP) is commonly managed by General Practitioners (GPs) in primary care. Analgesics are the mainstay of CNMP management in this setting. Selection of medications by GPs may be influenced by micro factors which are relevant to the practice setting, meso factors which relate to the local or regional environment or macro factors such as those arising from national or international influences. The aim of this study is to explore influences on GP practises in relation to pain management for older adults with CNMP. Semi-structured interviews were conducted with 12 GPs. Transcripts were organised using the Framework Method of Data Management while an applied thematic analysis was used to identify the themes emerging from the data. Clinical considerations such as the efficacy of analgesics, adverse effects and co-morbidities strongly influence prescribing decisions. The GPs interviewed identified the lack of guidance on this subject in Ireland and described the impact of organisational and structural barriers of the Irish healthcare system on the management of CNMP. Changes in practice behaviours coupled with health system reforms are required to improve the quality and consistency of pharmacotherapeutic management of CNMP in primary care.

Academic family medicine physicians' confidence and comfort with opioid analgesic prescribing for patients with chronic nonmalignant pain.

To examine academic family medicine physicians' current practices, experiences, beliefs, level of concern about negative outcomes, and confidence and comfort when prescribing opioid analgesics for chronic nonmalignant pain management. Electronic cross-sectional survey. This study was part of the Council of Academic Family Medicine (CAFM) Educational Research Alliance omnibus survey of active academic US family physicians. Respondents completed survey items addressing their 1) sociodemographic and practice characteristics, 2) current opioid prescribing practices, 3) experiences and beliefs toward prescribing opioid analgesics for chronic nonmalignant pain management, 4) level of concern about negative opioid-related outcomes, and 5) confidence and comfort when prescribing opioid analgesics. The majority of the sample (n=491) were male (57.8 percent) with 84.1 percent identifying themselves as non-Hispanic white. Nearly all respondents (91.0 percent) reported currently prescribing opioids to patients with chronic nonmalignant pain. Most respondents reported being confident (88.4 percent) and comfortable (76.2 percent) in their prescribing for patients with chronic nonmalignant pain. Family physicians who were comfortable in their opioid prescribing skills were more likely to report satisfaction in prescribing opioids to patients with chronic pain (ρ=0.494, p<0.001), while those who were confident in their opioid prescribing skills were more likely to identify pain management as high priority (ρ=-0.287, p<0.001). Most academic family physicians currently prescribed opioid analgesics to patients with chronic nonmalignant pain. There was a strong inverse relationship between confidence regarding opioid prescription and concern about negative consequences. Similarly, comfort level was tied to increased satisfaction with the overall process of opioid prescription.

The challenges of pain management in primary care: a pan-European survey.

The OPENMinds Primary Care group is a group of European primary care physicians (PCPs) with an interest in pain management, formed to improve the understanding and management of chronic pain in primary care. A survey was conducted to assess the challenges of chronic nonmalignant pain (CNMP) management in primary care in Europe, focusing particularly on pain assessment, opioid therapy, and educational needs. A questionnaire was developed for online use by PCPs in 13 European countries (Belgium, Denmark, France, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Spain, Sweden, and the UK). A total of 1309 PCPs completed the questionnaire, approximately 100 from each country. Most PCPs (84%) perceived CNMP to be one of the most challenging conditions to treat, yet a low priority within healthcare systems. Only 48% of PCPs used pain assessment tools, and 81% considered chronic pain and its impact on quality of life to be underassessed in primary care. PCPs were less confident about prescribing strong opioids for CNMP than for use in cancer pain. Most PCPs (84%) considered their initial training on CNMP was not comprehensive, with 89% recognizing a need for more education on the topic. These findings reveal that PCPs in Europe find CNMP a challenge to treat. Areas to address with training include underuse of pain assessment tools and lack of confidence in use of opioid therapy. Guidelines on CNMP management in primary care would be welcomed. The insights gained should provide the basis for future initiatives to support primary care management of chronic pain.

A Feasibility Study of Transdermal Buprenorphine Versus Transdermal Fentanyl in the Long-Term Management of Persistent Non-Cancer Pain

Buprenorphine and fentanyl transdermal patches are used widely for the management of persistent malignant and nonmalignant pain. Buprenorphine and fentanyl transdermal patches, both potent opioids, are considered to be equally efficacious in managing persistent pain. Various retrospective studies comparing dosage changes of buprenorphine and fentanyl patches in persistent pain patients have been completed; however, no long-term prospective, randomized, clinical study has compared the effectiveness of these patches. The objective of the present study was to satisfy this need. This study aims to compare prospectively the long-term efficacy, acceptability, and side effects of both of these patches in patients with persistent pain. This study would examine the feasibility and lay the groundwork for a larger, multicenter study where such efficacy and safety outcomes of the two medications can be adequately assessed. The participants were 46 adults (range 22-80 years.) with nonmalignant persistent pain (mean = 11 years), predominantly with lower back pain. Data were obtained monthly for 12 months. Participants recruited were opioid-naïve patients, having pain for the greater part of the day and night, and appropriate for treatment with transdermal patches. After initial assessment, participants were randomly allocated to either buprenorphine or fentanyl patch treatment. Participants were then titrated to optimal doses of medication. Patients with adverse effects or unsatisfactory pain relief were treated alternatively and discontinued from the study. Nearly one-third of all patients, 41% (8 of 22) of the transdermal buprenorphine (TDB) group and 37.5% (8 of 24) of the transdermal fentanyl (TDF) group stopped treatment due to unacceptable side effects or inadequate pain relief. The remaining participants showed a similar trend in the improvement of pain intensity, physical activity, sleep, and mood throughout the study. Significant relief in the intensity of pain was achieved for the initial 6 months and the effects stabilized in the remainder of the study in both groups. There were no significant group differences over time. However, a higher equipotent dose of fentanyl was required for comparable pain relief. Compared with TDF group, the TDB group initially experienced relatively less side effects. However, a greater number of buprenorphine users suffered from local skin reactions. Buprenorphine users had significant improvement in mood. Thirty-one percent (5 of 16) of the buprenorphine group and 57% (8 of 14) of the fentanyl users needed additional pain relief medications by the end of 3 months. By the end of 12 months, a significant number 78% (7 of 9) of buprenorphine users but comparatively fewer 44% (4 of 9) of the fentanyl group used rescue medicines. Both had more doctor visits in the latter half of the study. Thirty percent of the total number of patients discontinued treatment because of side effects or unsatisfactory pain relief. For those continuing treatment, clinical improvements were seen in the initial 6 months in both groups. Fifty percent of the TDB and 43% of TDF groups had significant relief in 3 months, which persisted up to 6 months. Only 11% and 13% of patients, respectively, had sustained relief after 6 months. Twenty percent more patients in the TDB group benefited significantly in symptoms of depression from TDB compared with the TDF group. Interestingly, switching of patches seemed to increase acceptability by preventing adverse effects and tolerance. Confirmation of these effects should be studied in future with a multicenter study and larger sample.

Low-dose 7-day transdermal buprenorphine in daily clinical practice – perceptions of elderly patients with moderate non-malignant chronic pain

Objective:To assess patients’ perceptions regarding the low-dose 7-day buprenorphine transdermal patch for treatment of moderate non-malignant chronic pain.Methods:Patient-reported outcome data were collected in clinical practices in Germany in a prospective, multicenter, non-interventional observation using the German Pain Questionnaire/German Pain Diary. Questionnaires were completed by the patients without influence from the attending physician. Mean change in pain intensity (lowest, average, and highest pain intensity in the previous 24 h), changes in Hospital Anxiety and Depression Scale scores (HADS-A and HADS-D), in impairments of daily activities (modified pain disability index, mPDI), in quality of life (quality of life impairment by pain inventory, QLIP), and in overall burden of pain over a 12-week treatment period were evaluated.Results:Data of 891 patients were assessed (mean age 72.8 years). Buprenorphine starting doses were mainly 5 µg/h (67.1% of patients) and 10 µg/h (27.3%). At the end of week 12, the majority received either 5 µg/h (41%) or 10 µg/h (42.3%) buprenorphine. Mean average pain intensity was reduced by 5.1 points to 1.7 ± 1.3 from 6.8 ± 1.5 points at baseline (76% improvement). Amelioration was observed in HADS-A (59% from 7.8 ± 3.3 at baseline) and HADS-D (56% from 9.2 ± 3.1), in mPDI sum score (76%; from 31.1 ± 9.8), and in quality of life (165%; from 13.9 ± 10.1). Mean burden of pain continuously decreased.Limitations:All those inherent in open-label observations and pain studies using subjective and patient-reported outcome parameters (such as the lack of a control group).Conclusions:Our results indicate that the 7-day buprenorphine patch might be considered an effective treatment option for moderate non-malignant chronic pain management in daily clinical practice. The mostly elderly patient population of this patient survey experienced sustained pain relief and improvements in pain-related impairments of daily activities and quality of life, leading to a substantial reduction in overall burden of pain.

Opioid Agreements and Drug Screens: Adapting Tools From Chronic Nonmalignant Pain Management to the Palliative Care Clinic (515)

In recent years there have been several major legal and policy developments concerning palliative options of last resort. These developments have important implications for the standards of practice applicable to those health care institutions and professionals who provide hospice and palliative care. A primary example is the promulgation of guidelines and policies governing the provision of palliative sedation for intractable terminal suffering. Some of these guidelines are based upon the proposition that not only is suffering a diagnosis, but that such a diagnosis can be sufficiently fine-grained as to identify distinct types or categories of suffering, some of which are designated as ‘‘clinical’’ and others as ‘‘nonclinical.’’ These guidelines then delineate when palliative sedation may be offered for refractory ‘‘clinical’’ symptoms while at the same time proscribing palliative sedation for ‘‘nonclinical’’ terminal suffering, even when it is severe and refractory to other palliative measures. Strict adherence to such guidelines presents serious issues of law, ethics, and professionalism. This session will also focus on recent evidence of a major shift in public and professional opinion on the nature and legitimacy of lethal prescriptions for terminally ill patients with decisional capacity, who wish to assert greater control over the timing and manner of their death. An impressive array of health professional organizations have issued policies or position statements opposing the characterization of this practice as ‘‘physician-assisted suicide.’’ We will review the rationale offered for this emerging public policy stance, and consider the implications of it for the provision of hospice and palliative medicine in the growing number of jurisdictions where it is now legal or may be authorized in the near future. Special consideration will be given to the data that has emerged from Oregon and Washington, as well as the reasoning of the Supreme Court of Montana on this issue.