Pain Management Training Research Articles

Narcotic Prescriptions following Knee and Shoulder Arthroscopy: A Survey of the Arthroscopy Association of Canada.

PurposeCanada has the second-highest opioid use in the world. Despite knee and shoulder arthroscopy being among the most commonly performed orthopaedic procedures, there exists little guidelines for pain management.MethodsA survey was developed and distributed to members of the Arthroscopy Association of Canada. The objectives were: to understand opioid prescribing patterns after knee and shoulder arthroscopy, to determine if surgeons believe opioid over-prescription is an issue and to identify other pain management strategies surgeons are regularly using.ResultsA total of 38 responses were included (38.3%). Eighty-two percent of surgeons felt opioid over-prescription was an issue in arthroscopic surgery. The average post-operative knee or shoulder arthroscopy prescription included a total of 156 +/- 84.4 (0-400) mg of oral morphine equivalents (OMEs). Less than one-third of respondents (29%) had received formal peri-operative pain management training. Fifty-five percent of respondents felt that non-opioid medications do not provide adequate pain relief after arthroscopic surgery. Nearly all respondents (95%) stated they would change their prescription practice if high-quality evidence were to suggest that they should do so.ConclusionsThe majority of respondents identified opioid over-prescription as a problem after arthroscopic surgery. Surgeons are prescribing five times the amount of OMEs to patients that previous literature suggests the median patient uses after arthroscopic knee surgery. Surgeons generally state they would reduce or eliminate opioid prescriptions to arthroscopy patients if high-level evidence were to emerge suggesting that adequate pain control could be achieved without the use of narcotics.

The Effect of Cardiopulmonary Resuscitation and Cardiac Chest Pain Management Training on Perceived Control, Depression, Stress and Anxiety in the Spouses of the Patients with Myocardial Infarction: A Randomized Controlled Trial.

ABSTRACTBackground: Sudden cardiac death is the most common cause of mortality worldwide. Most cases occur at home and the individuals most likely witnessed are family members. Spouses play a significant role in the recovery of such patients. We aimed to investigate the effect of Cardiopulmonary Resuscitation (CPR) and cardiac chest pain management trainings on the perceived control, depression, stress and anxiety in the spouses of the patients with Myocardial Infarction (MI).Methods: The present randomized controlled trial study was performed on 78 spouses of the patients admitted to Cardiac Care Unit of the hospitals affiliated to Shiraz University of Medical Sciences from August 2013 to April 2014. The subjects were randomly assigned into intervention (n=40) and control groups (n=38). The intervention group took part in educational workshop on CPR and cardiac chest pain management and followed-up for six weeks. Data were collected using Depression Anxiety Stress (DASS) Scale and Rotter’s internal-external locus of Control Scale. Statistical methods of data analysis included descriptive statistics, Chi-squared test, paired sample t-test, independent sample t-test, one way analysis of covariance, and multivariate analysis of covariance.Results: There were significant differences between intervention and control groups in perceived control and DASS subscales. After the intervention, perceived control scores reduced from 9.42±3.33 to 8.15±3.65 (P=0.001); depression from 28.85±11.99 to 21.65±8.64 (P=0.001); anxiety from 26.6±9.46 to 20.70±6.29 (P=0.02); and stress from 30.20±10.91 to 24.32±10.23 (P=0.01) in the intervention group.Conclusion: CPR and cardiac chest pain management trainings could effectively improve the perceived control, depression, anxiety, and stress in the spouses of the patients with MI. Trial Registration Number: IRCT201310128124N2.

Effect of Comprehensive Pain Management Training Program on Awareness and Attitude of ICU Nurses.

BackgroundPain is one of the main complaints of many patients in intensive care units. However, most nurses and physicians are unable to properly monitor and relieve pain in these patients. Factors such as patients' inability to describe their pain and insufficient knowledge of nurses and physicians have made pain management difficult. Given that the knowledge and attitude of nurses play an important role in the effective implementation of the pain management process, this study aimed to investigate the effect of comprehensive pain management training program on the awareness and attitude of intensive care unit nurses.MethodsThis quasi-experimental single-group study was conducted in two phases (pre and post-intervention) to investigate the awareness and attitude of all nurses employed in the intensive care unit of Tehran Modarres Hospital, based on the determined inclusion and exclusion criteria. In the pre-intervention phase, the awareness and attitudes of the nurses were assessed using a questionnaire. After conducting the pain management training course, an executive program and algorithm were implemented for pain management in ICUs. Then, the nurses’ awareness and attitude toward pain management were assessed again. Finally, changes in the scores of the nurses’ awareness and attitude were analyzed by SPSS V. 22 software in two phases before and after applying the interventions using the Wilcoxon test. The relationship between some demographic variables and the level of awareness and attitude of nurses was also investigated using the Kruskal-Wallis and Mann-Whitney tests.ResultsThe results of this study indicated that the mean score of the nurses’ awareness was significantly different in pre- and post-intervention phases (P < 0.05). Despite an increase in the post-intervention mean score of the nurses’ attitude (71.03), no statistically significant change was observed. Additionally, among the demographic variables, there was only a significant relationship between the nurses' job experience in ICUs and their attitudes.ConclusionsBased on the results of this study, teaching and implementing a comprehensive program for pain management can play an effective role in promoting the nurses’ awareness. Therefore, it is proposed to use pain management models to improve the nurses' knowledge and attitude toward pain management in ICU patients.

Understanding Clinicians' Decisions to Assume Prescriptions for Inherited Patients on Long-term Opioid Therapy: A Qualitative Study.

Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy. We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology. We identified three approaches to assuming a new patient's opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians "dumping" patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses. Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action.

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management. Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.

Nurses' experiences of providing nonpharmacological pain management in palliative care: A qualitative study.

To explore the experiences and views of nurses who provide nonpharmacological therapies for chronic pain management in palliative care. Nursing expertise in palliative care is essential in providing pain relief to patients with chronic diseases. Examinations of the use of nonpharmacological therapies for chronic pain management in palliative care have revealed what nonpharmacological therapies have been used, but there is insufficient knowledge regarding nurses' attitudes, views and experiences regarding pain therapies in this context. A qualitative descriptive design was chosen. Data were collected through individual interviews in a purposive sample with 15 nurses to ensure maximum variation. The data were analysed using qualitative content analysis. This study aligns with the consolidated criteria for reporting qualitative research (COREQ) checklist. The analysis yielded four categories, as follows: "building and sustaining favourable therapeutic relationships" involved the creation of trust and a solid relationship; in "recognising the diversity of patients' needs," person-centred care is expressed as being vital for individualised nonpharmacological pain management; "incorporating significant others" describes how nurses can help to ease the patient's pain by identifying positive encounters with family members or friends; and in "recognising the existence of barriers," nurses highlight vulnerable groups such as children, for whom nurses require special education to enable optimal nonpharmacological pain management. The unique knowledge that nurses gain about the patient through the nurse-patient relationship is central and crucial for successful nonpharmacological pain management. This study emphasises the need for nurses to get to know their patient and to be open and sensitive to patients' descriptions of their unique life situations, as this provides the necessary knowledge for optimal care and pain management. Nurses should be encouraged and given the opportunity to attend specialised training in palliative care and pain management.

Hypoalgesic Effects of Aerobic and Isometric Motor Imagery and Action Observation Exercises on Asymptomatic Participants: A Randomized Controlled Pilot Trial.

The objective was to explore whether action observation (AO) and motor imagery (MI) of aerobic and isometric exercise could induce hypoalgesic responses in asymptomatic individuals compared with placebo observation (PO). A randomized controlled pilot trial was designed. Twenty-four healthy participants (mean age = 21.9 ± 2.1 years) were randomized into three groups: AO+MI (N = 8), AO, (N = 8), and PO (N = 8). All participants performed an actual aerobic running exercise (three series of 90 seconds at 85% of their VO2max and 30 seconds at 65% of their VO2max) and an isometric exercise protocol (isometric squats). A day later, they all performed the mental intervention, observing or imagining exercise execution performed the day before, according to their allocated group. Pressure pain thresholds (PPTs) of the quadriceps and epicondyle regions were assessed at baseline, postintervention, and 15 minutes postintervention. Analysis of variance revealed statistically significant differences in the group*time interaction for PPT in the quadriceps. The AO group showed a statistically significant increase at postintervention and at 15 minutes postintervention. The AO+MI group obtained a statistically significant increase in the two PPT regions compared with the PO group at Δpre-post. The AO group obtained a greater increase in the PPT in the quadriceps femoris than the PO group at Δpre-post and Δpre-post 15 minutes. AO and MI induce hypoalgesic responses compared with PO. AO isolated training showed pain modulation responses in the PPTs of the quadriceps region in young physically active adults. These findings highlight the potential role of brain training in pain management.

Nurses' experiences of pain management in end-of-life dementia care: a literature review.

Nurses play an important role in assessing and managing pain. However, this is often poorly managed for people living with dementia. To explore nurses' experiences of pain management in end-of-life dementia care. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic narrative review of research papers published in English between 2008 and 2018 was conducted. Data sources were CINAHL, Medline, PsycINFO, ScienceDirect and SocIndex. Articles focused on nursing at the end of life and pain management in people with dementia. Eight articles were retrieved that met the search criteria. Four studies used qualitative methodology, two quantitative and two mixed methods. Studies from the UK dominated (n=5), the remainder were from Sweden, Norway and the US. Following thematic analysis, three themes were identified: training and education in pain management at the end of life for people with dementia, challenges in identifying pain and pain assessment tool use. The review revealed inadequate education for nurses concerning end-of-life care for people living with dementia, notably concerning pain recognition and use of assessment tools. It is recommended that specialist education is mandated for all nurses working with this client group to improve care delivery.

Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial.

PurposePain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016–2018).ParticipantsClusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included.InterventionIn addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses.MethodsBased on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10–30) using self-report instruments or observed (MMSE 0–9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD).ResultsOut of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10–30) and logistic regression (n=222 residents, MMSE 0–9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=−0.07, p<0.001), and was lower when dementia diagnoses were present (B=−1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05).ConclusionWhile no significant positive intervention effect was measured, findings suggest nurses’ raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

Prescribers’ experiences of, and attitudes to, use of morphine for palliative care at a tertiary hospital in Zambia

ABSTRACT Objective To explore medical doctors’ experiences of, and attitudes to, use of morphine for palliative care at a tertiary hospital in Zambia. Methods A qualitative, exploratory case study was undertaken. Semi-structured interviews were used to collect data from 14 medical doctors working in the fields of oncology, pediatrics, and internal medicine at a tertiary hospital in Lusaka, Zambia, regarding their experiences and attitudes to prescribing morphine for palliative care. Thematic analysis of interview transcripts was carried out to establish common themes in the data. The study was approved by BSMS and UNZA research ethics committees. Results All participants agreed that doctors were becoming more comfortable with the prescribing of morphine, although experiences were notably different for doctors working in oncology, compared to other departments. Themes of difficulty discussing end-of-life, poor recognition of pain, and fear of patient addiction, were more prominent in the responses of non-cancer doctors. Morphine use was generally restricted to cancer and sickle cell disease patients, with most non-cancer doctors stating that they rarely prescribe morphine for outpatient use. Training in pain management and the presence of a palliative care team were perceived to be facilitators to morphine prescribing. Conclusions Although there is an increased willingness to prescribe morphine, limited knowledge of pain management, especially for nonmalignant disease, underlies many of the findings in this study. Opportunity exists for professional development in pain management to further improve the acceptance and use of opioids in palliative care, especially for out-patients.

The effect of pain management training in workshop on the knowledge, attitude and self-efficacy of pediatric nurses.

Background and Aims:Pain is the fifth vital sign, and pediatric nurses plays a key role in the process of pediatric pain management. The present study aimed to determine the effect of pain management training on the knowledge, attitude and self-efficacy of pediatric nurses.Methods:This is a quasi-experimental study including two groups of test and control. The experimental group received a workshop method with a content including (ethical aspect, physiology, assessment tools, and pharmaceutical and non-pharmacological pain management) and was not given in the control group. The PNKAS self-efficacy questionnaires was completed by the participants before and one month after the beginning of the study. The data were analyzed using descriptive statistics and independent T-test, Fisher exact, and Chi-square tests using SPSS version 20 software.Results:The mean pre-test scores of knowledge and attitude in the control and experimental groups was 50.79-47.14, and after one month was 47.46-53.09, respectively, showed that, training was significantly effective in the knowledge and attitude of the experimental group (P value = 0.01). The mean pre-test score of self-efficacy in the control and experimental groups was (17.01-18.06), and one month later was 20.36-21.03 respectively. Although the self-efficacy score increased in both groups, training significantly increased the self-efficacy of pediatric nurses in the experimental group (P value <0.001).Conclusion:Pain management training is required due to the poor knowledge of pediatric nurses and the importance of pain management in improving the quality of nursing care and the satisfaction of patients with the In addition, feeling high self-efficacy without sufficient knowledge of pain management can disrupt pediatric pain management.

A Pharmacist-Led Program to Taper Opioid Use at Kaiser Permanente Northwest: Rationale, Design, and Evaluation.

Primary care practitioners (PCPs) are concerned about adverse effects and poor outcomes of opioid use but may find opioid tapering difficult because of a lack of pain management training or time constraints limiting patient counseling. In 2010, Kaiser Permanente Northwest implemented a pharmacist-led opioid tapering program-Support Team Onsite Resource for Management of Pain (STORM)-to address high rates of opioid use, alleviate PCPs' workload demands, and improve patient outcomes. To describe the rationale, structure, and delivery of this unique pharmacist-led program, which partners with PCPs and provides individualized care to help patients reduce opioid use, and the Facilitating Lower Opioid Amounts through Tapering study, which examines the program's effectiveness, cost-effectiveness, and implementation. The STORM program includes a pain medicine physician, a social worker or nurse, and pharmacists who have received specialized clinical and communications training. The program has a 2-fold role: 1) to provide PCP education about pain management and opioid use and 2) to offer clinician and patient support with opioid tapering and pain management. After program training, PCPs are equipped to discuss the need for tapering with a patient and to refer to the program. Program pharmacists provide a range of services, including opioid taper plans, nonopioid pain management recommendations, and taper-support outreach to patients. The STORM program provides individualized care to assist patients with opioid tapering while reducing the burden on PCPs. The STORM program may be a valuable addition to health care systems and settings seeking options to address their patients' opioid tapering needs.

Discharge narcotic prescribing and management practices at pediatric trauma centers in the United States

IntroductionTrauma is the leading cause of mortality among children in the US. Injured children often receive narcotic pain medication throughout their hospital stays and upon discharge from pediatric trauma centers. While effective, narcotics carry significant risks. There is a dearth of knowledge regarding narcotic education, prescribing practices, and pain management training at pediatric trauma centers. We hypothesize that there is a lack of standardization in these practices among pediatric trauma centers nationally. MethodsA national survey was sent to medical directors at ACS-verified and state designated level 1 and 2 pediatric trauma centers. Data were collected over 6 months on discharge narcotic education and prescribing practices. ResultsOf 97 surveys sent, 92 were returned (94.8% response). Responses show that narcotics are most commonly prescribed by residents (79.1%). Electronic Medical Record (EMR) prescribing is common (89.2%); however, only 1.75% of EMRs give recommendation to prescribe naloxone. Only 9.7% report a standardized format of narcotic education. Most healthcare staff providing narcotic education receive no training in nonpharmacological pain management (68.8%). Most centers report no formal process to reduce the quantity of discharge narcotics prescribed (71.0%). Respondents report many barriers to providing discharge narcotic education to patients and families, including staff training on how to provide discharge narcotic education, staff availability, patient/ parent literacy, and format of available educational resources. ConclusionThe study results show that there is lack of standardization in discharge narcotic education and prescription practices among pediatric trauma facilities nationally and highlight the need for a standardized narcotic prescribing and management protocol. Despite the growing national concern of opiate misuse, particularly among children, respondents report inability to deliver adequate narcotic education owing to various communication and systems barriers. Type of studyCross-sectional survey. Level of evidenceLevel IV.

Anaesthesiology and Reanimation Education in Turkey: Residents’ Views

This study aimed to determine opinions of medical residents undergoing anaesthesia and reanimation training about equipment, programmes, applications, study conditions and shift systems at training institutions in Turkey. A web-based survey was sent by e-mail to residents in anaesthesiology and reanimation training programmes. The survey comprised 73 questions about demographic characteristics, satisfaction, basic specialisation knowledge, anxiety and motivation. The study included 270 individuals. Of the residents, 82.2% willingly chose their field, whereas 66.7% stated that specialisation was necessary because of incorrect application of first-stage and GP medical services. The mean of the weekly working hours was 91.69±36.69 hours; the mean number of monthly on-call shifts was 7.49±1.99. Of the participants, 61.9% found the predicted five-year training duration long. The intensive care training duration was sufficient for 71.1% and only 26.3% found the pain management training duration sufficient. According to the results, the number of residents is insufficient, workload is heavy, working hours are long and large numbers of shifts are worked without leave afterwards. In spite of negatives and high dissatisfaction, most residents willingly chose their departments and would choose the same branches again. Participants stated that their institutions emphasised service rather than education and research, and educators were less accessible to residents due to increasing service loads.

Interventional pain management for chronic pain: a survey of physicians in Canada.

The use of interventional pain management (IPM) modalities to alleviate chronic pain is increasing despite the lack of high-quality evidence. We undertook this survey to explore patterns, training, and attributes of IPM practice. We administered a 32-item survey via seven Canadian physician member organizations, whose members were engaged in the management of chronic pain. Of 777 physicians contacted, 256 (33%) responded: 45 (6%) declined to participate and 211 (27%) agreed to participate; the number of participants answering any given question varied. One hundred and sixty-nine of 194 (87%) practiced IPM and 103 of 194 (53%) managed only non-cancer pain. Pain management training of ≥ six months was associated with higher odds of IPM training (odds ratio [OR], 2.98; 95% confidence interval [CI], 1.32 to 6.7), but not necessarily ongoing IPM practice (OR, 1.97; 95% CI, 0.74 to 5.3). A substantial percentage of physicians (108 of 168 [64%]) practiced IPM based only on training received during either their base residency program or courses. Only 48 of 186 (26%) felt that there were adequate opportunities for IPM training, and 69 of 186 (37%) believed that their colleagues practiced IPM in accordance with the best current evidence. Our survey indicates that IPM practice and training were not uniform, and that interventional therapies for chronic pain may not be performed in accordance with the best available evidence. Our survey highlights a lack of IPM training opportunities, which may result in substandard training. Concerted efforts involving physician organizations and regulators are needed to standardize IPM training and develop clinical guidelines to optimize evidence-based practice.

Pain assessment of nursing home's residents by certified nursing assistants: a real-world study

In French care facilities for dependent aged people (NHDAP), prevalence of pain among residents with dementia is high, and source of behavior disturbances and quality of life impairment. However, in spite of many international expert statements, pain remains under-assessed and under-managed in these patients. Certified nursing assistants (CNA) are on the front-line in NHDAP to detect the presence of pain in residents with communication difficulties, while they received little training for pain management and directives for specific care. Moreover, no studies were presently devoted to the impact of demographic and socio-professional determinants of CNA on pain assessment. In our study, we assessed the presence and intensity of pain in cognitively impaired residents in NHDAP, by CNA performing as a pair for the morning care. 42 pairs were recruited and independently completed a standardized behavioral assessment for pain (Doloplus scale) as well as a numeric rating scale. CNA personal characteristics were investigated to analyse the determinants of potential assessment discrepancies between each of the pairs. Presence of pain was detected in 51.1 to 91.1% of the patients depending on the tool and analysis criteria. In 28.9% important discrepancies were observed in the pain assessment between the CNA pairs, which could be related to professional status and prior use of the observational assessment. These inter-rater discrepancies should be reduced providing clear pain assessment guidelines for CNA in NHDAP, and further studies should be completed to figure out the role of CNA personal determinants in the patients' pain assessment.

A CRITICAL REVIEW OF PAIN MANAGEMENT TRAINING PROGRAMS FOR FAMILY CAREGIVERS

Many American family caregivers (FCs) manage hospice and palliative patients’ pain at home. However, FCs encounter many barriers to pain management due to inadequate training. Although some studies have designed pain management training programs for caregivers, the content and durations vary greatly. Thus, there is a lack of consistent recommendation on how to educate caregivers on pain management. The purpose of this study is to critically evaluate existing training programs to inform clinical practice and future program design. A literature review was conducted to search available articles published before June 2018 in databases including PubMed, CINAHL, PsycINFO, and Scopus. Search strategies used index and keyword methods. The inclusion criteria were peer-reviewed, research studies published in English that evaluated a pain management education or training for family caregivers. Twenty-seven studied were included. All studies improved either patients’ outcomes (e.g. pain intensity, hospital visits) or caregivers’ outcomes (e.g. knowledge, quality of life). Most studies (85%) had research teams provide caregivers with pain management education via multiple face-to-face training sessions and written booklet, while some studies (15%) had practicing nurses used videophones, web-based platforms, and telehealth to enhance the collaboration of care and pain management with caregivers. Providing adequate pain management training can improve patients’ and caregivers’ outcomes. However, in-person training programs are not practical for busy and overwhelmed caregivers. Researcher-delivered training sessions are not clinically adoptable. Future studies should develop pain management interventions that allow nurses to coach caregivers during routine visits and enhance their communication and collaboration with caregivers.

Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography

BackgroundUp to 80% of cancer patients in Kenya suffer from untreated moderate to severe pain. AimThis study explored barriers to cancer pain management among nurses caring for oncology patients in Kenya. This was part of a larger study whose primary objective was to understand the role of nursing subculture on cancer pain management. DesignA focused ethnographic was used in this study. SettingsAn oncology private unit in large referral hospital in Kenya. ParticipantsTwenty-five (n = 25) nurses participated in this study. MethodsSemi- structured interviews and observations were used to collect data. Nurses were recruited through purposive, snowball sampling strategy. Content analysis led to identification of key barriers to optimal cancer pain management. ResultsOrganizational, cognitive, professional and patient/family related barriers to cancer pain management were noted. Specifically, barriers such as lack of accessibility to pain management guidelines and training, professional collaboration, restrictive dispensing guidelines, and opioid related fears were identified. ConclusionsInterventions should streamline palliative care training and implementation of pain management guidelines in both units. Interventions should consider the influence of different subcultures while implementing pain management policies and training.

Epidemiology of the U.S. opioid crisis: the importance of the vector.

The roots of the remarkably lethal U.S. opioid crisis are complex and inextricably entangled with healthcare, especially in its treatment of another serious health problem: pain. Failures of the healthcare system-including lack of both training in pain management and caution in using an addictive class of medications-precipitated the rise in opioid misuse and addiction over the past two decades, but a wider range of social and economic forces has helped perpetuate the crisis and altered its character. The classic epidemiologic host-agent-environment triad can be augmented for the purpose of elucidating the current opioid crisis by addition of the "vector" to emphasize the importance of purveyors of opioids (licit and illicit), leading to our proposing an expanded host-agent-vector-environment model. Interventions addressing multiple components are needed, including solutions that account for behaviors of all vectors associated with the crisis. For prescription opioids, the vectors include clinicians and pharmaceutical-related companies involved in marketing, prescribing, distributing, and dispensing opioid medications; for illicit opioids, they include drug manufacturing and distribution networks. Attending to the vectors of opioids, while simultaneously implementing a full range of public health, clinical, law enforcement, and other approaches to ending the opioid crisis, may help to improve public health outcomes.

Characteristics of physicians who prescribe opioids for chronic pain: a meta-narrative systematic review.

Background: The primary objective of this systematic review was to identify the characteristics of physicians who prescribe opioids to adults with chronic pain. This review was limited to studies examining fully-trained physicians, as relevant characteristics of resident physicians and non-physician clinicians may differ.Methods: A comprehensive search of databases from January 1, 1980 to December 5, 2017 was conducted. Eligible study designs included (1) randomized trials; (2) nonrandomized prospective and retrospective studies; and (3) cross-sectional observational studies. The risk of bias in the included studies was assessed using an adapted version of the Newcastle-Ottawa Scale for cross-sectional studies. A total of 2508 records were screened and 22 studies met inclusion criteria. The majority of studies were cross-sectional (n=20) and the total number of participants was 8433.Results: The risk of bias was high overall. The majority of physicians were confident managing and prescribing opioids for chronic pain but had high levels of dissatisfaction. Physicians reported high awareness of the potential for opioid misuse and were concerned about inadequate prior training in pain management. The majority of physicians were less likely to prescribe for patients with a history of substance abuse and reported major concerns about regulatory scrutiny.Conclusion: This systematic review provides the foundation for the development of prospective studies aimed at further elucidating the constellation of mechanisms that influence physicians who manage pain and prescribe opioids.