Undertreatment Of Pain Research Articles

Prevalence and treatment of pain in non-institutionalized very old population: transversal study at national level.

In Europe, there is no conclusive data at national level about pain prevalence in non-institutionalized very old population. In USA, it has recently been reported a high prevalence (56%); however, this data can not be extrapolated to other regions because the known influence of geographical and ethnic differences. Furthermore there are few data on use of treatments for pain in this population. To explore prevalence and considered pharmacological treatments for pain in this population. Transversal study on 551 participants aged 80 or more living in Spain (non-institutionalized). Probabilistic multistage sampling was carried out, stratified by sex and place of residence. All Spanish regions were considered for recruitment process. Pain (last 4weeks), intensity (Face Pain Scale), localization and pharmacological treatments were evaluated by in-person interviews. Pain's prevalence was 52.5% (CI 95% 48.28-56.80) and 38.5% experienced pain of at least moderate intensity. The most frequently involved body regions were lower limbs (26.6%) and dorso-lumbar region (21.9%). Only 40% of participants with pain and 43.2% with moderate or severe pain used analgesics, and paracetamol was less frequently used than non-steroidal anti-inflammatory drugs at any pain intensity. Age was not associated with higher prevalence [odds ratios 0.97 (CI 95% 0.93-1.02) in females and 0.99 (CI 95% 0.92-1.06) in males]. The prevalence of pain in non-institutionalized very old people is high. Pain is probably being undertreated, even moderate or severe pain. Guideline's recommendations are probably not being considered to select the analgesic therapy.

The Michigan Opioid Safety Score (MOSS): A Patient Safety and Nurse Empowerment Tool.

Safely treating postsurgical pain continues to be a challenge, despite more than a decade of focus on its appropriate management. Overuse of opioids and undertreatment of pain continues, as does insufficient monitoring of patients at risk for opioid and pain-related complications. It is clear that relying only on numeric subjective pain scores is inadequate when treating pain. Appropriate bedside evaluation should also include measures of respiration and sedation. Furthermore, assessment of risk should be done with initial pain assessment and continued throughout the pain management course. The recently developed Michigan Opioid Safety Score integrates health risks and objective measures of respiratory rate and sedation, while encouraging the use of multimodal analgesia for all patients.

The complexity model: a novel approach to improve chronic pain care.

More than 25% of the US population experiences chronic pain; yet few physicians specialize in the field of pain medicine. This article will review a theoretical model of care that stratifies treatment and patients by level and type of complexity and promotes communication between specialist and primary care providers. The undertreatment of pain was recently brought to national attention to encourage both clinicians and patients to advocate for improved pain care. The specialty of pain medicine and models of care, challenges of managing pain in a primary care setting, and the reliance on an opioid-focused approach are reviewed. An evolved model of pain care based on the complexity of pain and emphasizing a dynamic collaboration between the primary care provider and the pain specialist is discussed. From the perspective of the busy clinician, the treatment of chronic pain can be overwhelming. The scarcity of trained pain practitioners and the burgeoning number of patients with chronic pain necessitate a new approach that values the complex nature of chronic pain and offers a practical blueprint to meet these challenges.

Emerging therapies for patients with symptoms of opioid-induced bowel dysfunction.

Opioid-induced bowel dysfunction (OIBD) comprises gastrointestinal (GI) symptoms, including dry mouth, nausea, vomiting, gastric stasis, bloating, abdominal pain, and opioid-induced constipation, which significantly impair patients’ quality of life and may lead to undertreatment of pain. Traditional laxatives are often prescribed for OIBD symptoms, although they display limited efficacy and exert adverse effects. Other strategies include prokinetics and change of opioids or their administration route. However, these approaches do not address underlying causes of OIBD associated with opioid effects on mostly peripheral opioid receptors located in the GI tract. Targeted management of OIBD comprises purely peripherally acting opioid receptor antagonists and a combination of opioid receptor agonist and antagonist. Methylnaltrexone induces laxation in 50%–60% of patients with advanced diseases and OIBD who do not respond to traditional oral laxatives without inducing opioid withdrawal symptoms with similar response (45%–50%) after an oral administration of naloxegol. A combination of prolonged-release oxycodone with prolonged-release naloxone (OXN) in one tablet (a ratio of 2:1) provides analgesia with limited negative effect on the bowel function, as oxycodone displays high oral bioavailability and naloxone demonstrates local antagonist effect on opioid receptors in the GI tract and is totally inactivated in the liver. OXN in daily doses of up to 80 mg/40 mg provides equally effective analgesia with improved bowel function compared to oxycodone administered alone in patients with chronic non-malignant and cancer-related pain. OIBD is a common complication of long-term opioid therapy and may lead to quality of life deterioration and undertreatment of pain. Thus, a complex assessment and management that addresses underlying causes and patomechanisms of OIBD is recommended. Newer strategies comprise methylnaltrexone or OXN administration in the management of OIBD, and OXN may be also considered as a preventive measure of OIBD development in patients who require opioid administration.

Biopsychosocial contributions to sex differences in pain.

Women are at greater risk for pelvic and abdominal pain, compared with men, as discussed in the commentary by Curran. Indeed, women are at greater risk for most common forms of chronic pain, which has prompted abundant research to elucidate potential sex differences in pain processing. The optimal theoretical model for conceptualising sex differences in pain is the biopsychosocial model. This model posits that the experience of pain is sculpted by complex bidirectional interactions among biological, psychological and social factors, and sex differences in pain provide an excellent example of the biopsychosocial model in action. Specifically, biological processes, including sex hormones, endogenous opioid function, and genetic contributions influence pain in a sex-dependent manner (Fillingim et al. J Pain 2009;10:447–85). Also, recent studies suggest that sex differences in brain structure and function between females and males may contribute to differences in the experience of pain, including visceral pain (e.g. Hong et al. J Neurosci 2014;34:14252–9). In addition, psychological processes, including mood/affect and coping, as well as social influences such as gender stereotypes are also known to contribute to sex differences in pain. These three sets of factors interact to impact pain in ways that remain poorly understood. Thus, it is important to recognise that sex differences in pain are real and driven by a complex web of causation. Understanding the nature and mechanisms underlying sex differences in pain has important implications for pain prevention and treatment. An important yet often overlooked aspect of sex differences in pain is qualitative sex differences. That is, notwithstanding whether men and women have different amounts of pain, the mechanisms driving the pain can be fundamentally different between sexes. For example, a recent translational study demonstrated that vasopressin activates endogenous analgesic mechanisms, except when they have already been activated by stress, as in males with high functioning of the AVPR1A receptor (Mogil et al. Nat Neurosci 2011;14:1569–73). This genotype by sex by stress interaction is an example of a qualitative sex difference, as the vasopressin by stress interaction only emerged in males. These findings also typify the complexity of biopsychosocial influences on pain. Another important issue to consider regarding sex differences in pain relates to pain treatment. Curran notes the potential for bias in the provision of treatment, with women at greater risk for undertreatment of pain. Such findings do exist and providers do well to acknowledge their potential biases and misconceptions and mitigate their intrusion into clinical care. However, on balance the literature does not suggest widespread gender bias in pain treatment. Another treatment consideration is whether some therapies are more effective for women than for men (or vice versa). Opioids may be more effective for women than men, particularly in the acute pain setting (Niesters, Pain 2010;151:61–8), and sex differences in response to other kinds of treatment remain understudied. Nonetheless, it seems plausible that sex-specific treatments for certain types of pain could emerge in the future. For now, an understanding of the biopsychosocial underpinnings of sex differences in pain will allow providers to approach pain in women from a more informed perspective. I have no conflicts of interest related to this mini-commentary.

Pain evaluation scales for elderly patients with dementia

BACKGROUND AND OBJECTIVES: Elderly people with dementia are impaired in the way they interpret and communicate pain, being important the use of specific tools for accurate diagnosis. This study aimed at summarizing literature data on tools for pain evaluation in hospitalized elderly patients with dementia. CONTENTS: This is a literature review of the following databases: LILACS, Pubmed/Medline, CINAHL, SCOPUS, Cochrane, Web of Science and Joanna-Briggs Institute. Eligibility criteria were established for studies selection. A specific tool was used for critical evaluation. From 383 studies found, 4 were included in this review. Studies have evaluated the performance of 8 observational or self-report scales. CONCLUSION: Our study results suggest that observational and self-report scales may be used to evaluate pain in hospitalized elderly patients with dementia, provided the level of cognitive impairment is observed to select the scale, thus avoiding inadequate evaluations and consequently the undertreatment of pain.

An evaluation of discharge opioid prescribing practices in a burn population.

Opioids are the cornerstone of pain treatment in burn patients. Undertreatment of pain has been associated with psychological sequela. However, prescription opioids have been increasingly associated with adverse drug effects. Safe opioid prescribing practices have been established in other populations. The purpose of this study was to explore postdischarge prescribing practices in a regional burn center. A retrospective review of hospital and discharge records of patients ≥18 years admitted to the burn center from December 2009 to June 2012 was performed. Charts were reviewed for demographic, burn, hospital treatment, and follow-up data. Pain scores and opioid needs were assessed 24 and 48 hours before discharge. Discharge opioid prescriptions and opioid refills were recorded. Pearson correlation and multiple linear regression was used to assess variables related to discharge opioid amounts. Jonckheere-Terpstra nonparametric test was used to identify the variables associated with the number of refills of opioid analgesia. Of the 140 patients, 120 (85.7%) were discharged on opioids. The median daily prescribed amount was 114 (interquartile range, 90-180) mg morphine equivalents (ME) for a median total duration of 6 (interquartile range: 4-10) days. Age (P < .0001), male sex (P = .024), and total mg ME before discharge (P < .0001) were independently associated with the amount of opioids prescribed at discharge. The number of refills was significantly associated with the average pain within 48 hours before discharge (P = .005) and with 24 hour predischarge mg ME (P = .006). By 14 days, 114 (84.3%) patients were still being seen in clinic and 127 (90.0%) were no longer taking opioids. The treatment of burn pain requires large amounts of opioids. Continued opioid therapy is necessary as the patients transition to the out-patient setting. This study identified several areas that could be modified to align with safer opioid prescribing practices, including lowering daily amount of prescribed opioids, prescribing only short-acting opioids, and providing patient opioid education. Future studies should focus on the adverse effects of opioid use in burn patients.

Denial of pain medication by health care providers predicts in-hospital illicit drug use among individuals who use illicit drugs.

Undertreated pain is common among people who use illicit drugs (PWUD), and can often reflect the reluctance of health care providers to provide pain medication to individuals with substance use disorders. To investigate the relationship between having ever been denied pain medication by a health care provider and having ever reported using illicit drugs in hospital. Data were derived from participants enrolled in two Canadian prospective cohort studies between December 2012 and May 2013. Using bivariable and multivariable logistic regression analyses, the relationship between having ever been denied pain medication by a health care provider and having ever reported using illicit drugs in hospital was examined. Among 1053 PWUD who had experienced ≥ 1 hospitalization, 452 (44%) reported having ever used illicit drugs while in hospital and 491(48%) reported having ever been denied pain medication. In a multivariable model adjusted for confounders, having been denied pain medication was positively associated with having used illicit drugs in hospital (adjusted OR 1.46 [95% CI 1.14 to 1.88]). The results of the present study suggest that the denial of pain medication is associated with the use of illicit drugs while hospitalized. These findings raise questions about how to appropriately manage addiction and pain among PWUD and indicate the potential role that harm reduction programs may play in hospital settings.

Observer Based Objective Pain Quantification in Sickle Mice Using Grimace Scoring and Body Parameters

Pain often starts in infancy and continues throughout life in sickle cell disease (SCD). Subjects typically quantify pain by themselves, which may lead to overtreatment or under-treatment of pain. Patient’s quantification of their own pain may also be influenced by external factors (mood, stress, sleep, etc.). Therefore, we examined the possibility of developing observer-based quantifiable measures of pain using facial features to obtain a mouse grimace scale (MGS) and body dimensions as measures of pain in HbSS-BERK (sickle) and control HbAA-BERK (control) mice.Methods: Mice aged 6-8 months, were placed in transparent cubicles on a Plexiglas surface at room temperature (RT) or on a cold plate (CP) at 4.5¡C. Mice were acclimated and digitally videotaped at RT for 5 min to capture action units (AU) and then videotaped on the cold plate for 5 min. Individual frames of clear, unobstructed headshots were ‘grabbed’. The experiment was repeated after 24h. Four AUs, (orbital tightening, nose bulge, cheek bulge, and ear position) were assessed for each mouse and condition using 4 randomized pictures of each by 3 blinded ‘coders’. For MGS, intensity of each AU was scored as follows: ‘0′ = absence; ‘1′= moderate and ‘2′ = severe. Average AU scores from the 3 coders were averaged for each AU. Cumulative pain calculations were made by averaging all AUs as described (Langford et al., 2010, Nature Methods). For length and body parameter measurements, one camera was placed with a top down view of the mouse with a Plexiglas graph template (1x1cm squares) in the background and another camera was placed in front of the mouse to capture the back curvature. Length was calculated using the graph template. To analyze spinal curvature, best-fit ellipses were constructed from points plotted on the arch of the spine of the mouse. Points were placed between the neck where the arch begins and at the end of the arch, near the tail. Two ellipses were generated for each mouse and difference between maximum and minimum axes were recorded. Smaller differences in max and min axes indicated more pain and a more circular shape and larger differences indicated less pain and a more elliptical shape. To validate facial AU data, sensitivity to 1.0 g Von Frey filament was used.Results: We observed significantly higher MGS in pain totals for control on CP vs. control at RT (P<0.01), sickle CP vs. sickle RT (P<0.05), and sickle CP vs. control CP (P<0.001), suggesting that both control and sickle mice exhibited a ‘pain face’ on the cold plate, but sickle mice showed increased intensity as compared to control on the cold plate. Curvature differences were significant in control on CP vs. control at RT (P<0.01), and sickle on CP vs. sickle at RT (P<0.01). Sickle mice showed an average 55% increase in curvature compared to 39% in control mice on a cold plate vs. RT for each (P<0.05), suggesting that sickle mice exhibit more pain in response to cold environment. Complementary to the curvature, sickle mice showed a significant decrease in length on a cold plate vs. RT (24%; P<0.01), but control mice did not show a significant difference in length. The Von Frey test demonstrated increased hyperalgesia in sickle mice as compared to control at RT (P<0.0001). Together, these data show that facial expressions and body dimensions provide quantifiable means to assess pain intensity in sickle mice. Thus facial characteristics, length and curvature can be adapted to assess pain in sickle patients particularly in children, who may not be able to express pain scores accurately in an unbiased way. DisclosuresNo relevant conflicts of interest to declare.

Underrecognition and Undertreatment of Pain and Behavioral Symptoms in End-Stage Dementia.

End-stage dementia, a terminal condition, is associated with a high prevalence of physical pain and behavioral symptoms. As these patients often have a decreased ability to express their symptoms, they are often underrecognized and undertreated. This article proposes opportunities to improve patient care. The article underscores the role of assessment scales to optimize behavioral management for patients with dementia and discusses the value of pain management to improve behavioral symptoms. Additionally, a collaborative interdisciplinary team, including palliative medicine, pharmacy services, and spiritual support can optimize patient care and develop a plan of care.

The Socioeconomic Costs of the Undertreatment of Pain.

The Socioeconomic Costs of the Undertreatment of Pain.

The therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations.

Context:Pain management in cirrhotic patients is a major clinical challenge for medical professionals. Unfortunately there are no concrete guidelines available regarding the administration of analgesics in patients with liver cirrhosis. In this review we aimed to summarize the available literature and suggest appropriate evidence-based recommendations regarding to administration of these drugs.Evidence Acquisition:An indexed MEDLINE search was conducted in July 2014, using keywords “analgesics”, “hepatic impairment”, “cirrhosis”, “acetaminophen or paracetamol”, “NSAIDs or nonsteroidal anti-inflammatory drugs”, “opioid” for the period of 2004 to 2014. All randomized clinical trials, case series, case report and meta-analysis studies with the above mentioned contents were included in review process. In addition, unpublished information from the Food and Drug Administration are included as well.Results:Paracetamol is safe in patients with chronic liver disease but a reduced dose of 2-3 g/d is recommended for long-term use. Non-steroidal anti-inflammatory drugs (NSAIDs) are best avoided because of risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage. Most opioids can have deleterious effects in patients with cirrhosis. They have an increased risk of toxicity and hepatic encephalopathy. They should be administrated with lower and less frequent dosing in these patients and be avoided in patients with a history of encephalopathy or addiction to any substance.Conclusions:No evidence-based guidelines exist on the use of analgesics in patients with liver disease and cirrhosis. As a result pain management in these patients generates considerable misconception among health care professionals, leading under-treatment of pain in this population. Providing concrete guidelines toward the administration of these agents will lead to more efficient and safer pain management in this setting.

Are We Undermedicating Patients With Neuromuscular Scoliosis After Posterior Spinal Fusion?

Study DesignRetrospective, matched study of patients with adolescent idiopathic scoliosis (AIS) and patients with cerebral palsy (CP) undergoing (PSF). ObjectivesTo compare pain management, through measurement of the amount of narcotic used and pain scores, for patients with neuromuscular (NM) scoliosis undergoing PSF to a cohort of patients with AIS. Summary of Background DataPosterior spinal fusion for children with severe NM scoliosis carries a high risk of complications. Appropriate assessment of pain is crucial; undertreatment of pain leads to anxiety whereas overtreatment can lead to respiratory depression and additional complications. MethodsA series of patients with NM scoliosis was matched for age, gender, and weight with a group of patients with AIS. Data collection included age, curve type and magnitude, and instrumentation type and levels fused. The total opioid used (TOU) was determined by summing all narcotics given during the hospital stay and converting them to morphine equivalent units. The data were then analyzed to determine differences in TOU. ResultsA total of 25 patients with NM scoliosis were included in the study. This group was matched with 25 patients with AIS scoliosis. The TOU for the NM group was 1.2 mg morphine/kg (range, 0.28–4.21 mg morphine/kg) whereas the TOU for the AIS group was 3.52 mg morphine/kg (range, 0.71–15.51 mg morphine/kg) (p < .0000001). ConclusionsIn this case-control analysis, patients with AIS undergoing PSF received more than twice the amount of narcotic compared with a matched group of patients with NM scoliosis. These data suggest that NM patients' pain may be undertreated compared with AIS patients. More study is indicated to investigate pain assessment and pain control in this vulnerable patient population to improve care.

Caudal Blockade for Children Undergoing Infra-abdominal Surgery

The assessment and management of pain in children can be complicated by their inability to communicate effectively; therefore, it is important that every attempt be made to circumvent the undertreatment of pain. Caudal blockade is associated with excellent pain relief and minimal side effects, and it is an established technique used in conjunction with general anesthesia for children undergoing infra-abdominal surgery. Available local anesthetic agents have a relatively short analgesic duration period, so anesthesia professionals often combine their use with adjuvant medications (eg, epinephrine, clonidine, fentanyl, morphine, preservative-free ketamine, neostigmine). Additional consideration should be given to intraoperative care, postoperative observation (eg, measuring sedation, motor blockade, postoperative nausea and vomiting, pain), and discharge instructions for the patient’s caregiver.

Quality Assessment of Acute Inpatient Pain Management in an Academic Health Center.

The quality of acute inpatient pain management remains suboptimal and poorly understood. In this retrospective study, we analyze acute pain management practice in a large academic health center using several quality indicators. Not surprisingly, despite high rate of pain assessment, many patients still have frequent, prolonged, and unrelieved severe pain episodes. Upon examination of naloxone administration, we identify potential inappropriate opioid prescription practices such as the use of wrong opioids in hepatic and renal failure and simultaneous use of multiple short-acting opioids. Most importantly, we find that chronic opioid users appear to suffer the most in terms of undertreatment of pain as well as opioid overdose, highlighting the urgent need to target this underserved population of patients.

Pain management perceptions among prescription opioid dependent individuals

BackgroundNearly two-thirds of prescription opioid dependent individuals report chronic pain conditions as both an initial and current motivation for prescription opioid use. However, to date, limited information exists regarding perceptions of the adequacy of pain management and pain management behaviors among prescription opioid dependent individuals with a history of treatment for chronic pain. MethodsThe current study examined perceptions of the medical management of chronic pain among community-recruited individuals (N=39) who met DSM-IV-TR criteria for current prescription opioid dependence and reported a history of treatment for chronic pain. Prescription opioid dependence, symptoms of depression, and pain management perceptions were assessed using the Structured Clinical Interview for DSM disorders, Beck Depression Inventory, and the Pain Management Questionnaire, respectively. ResultsReports of insufficient pain management were common (46.2%), as was utilization of emergency room services for pain management (56.4%). Nearly half reported a physician as their initial source (46.2%) and pain management as their primary initial reason for prescription opioid use (53.8%), whereas 35.9% reported pain relief as their primary reason for current prescription opioid use. Symptoms of depression were common (51.3%), as was comorbid abuse of other substances and history of treatment for substance abuse. ConclusionsResults highlight the complicated clinical presentation and prevalent perception of the under-treatment of pain among this population. Findings underscore the importance of interdisciplinary approaches to managing the complex presentation of chronic pain patients with comorbid prescription opioid dependence. Implications for future research are discussed.

191: Pediatric Pain Management: the Emergency Medicine Residents' Perspectives

Pain is a component of up to 80% of all emergency department (ED) visits. Oligoanalgesia, the under-treatment of pain, is a recognized problem in the ED and can have numerous detrimental effects for the pediatric patient. Surveying emergency medicine residents, our primary objectives were to describe a) the extent and type of training received in pediatric acute pain management, b) their management approach to common painful pediatric presentations, c) their level of comfort in assessing and treating acute pain, d) their perceived facilitators and barriers to optimally managing pain, and e) their attitudes towards managing such pain in the ED. A descriptive, cross-sectional survey was administered to all Royal College Emergency Medicine (EM) and Pediatric Emergency Medicine (PEM) residents, the Canadian College of Family Physician's EM residents, Clinical Fellows and PEM Fellows at three Canadian universities. A novel survey tool was created and distributed from May to June 2013. Surveys were completed online, using a modified Dillman approach. Our response rate was 46% (56 of 122). Forty-five percent (25 of 55) of residents had not received any training for pediatric pain assessment. All years of residents were uncomfortable with the assessment of pain in 0- to 2-year-olds (P=0.07). For patients aged two to 12 years, level of comfort with pain assessment increased with years of training (P=0.02). When assessing pain in children with disabilities, 83% (45 of 54) of residents were ‘extremely’ or ‘somewhat’ uncomfortable; 65% (47 of 55) of residents had not received any training on how to assess pain for such patients. Sixty-nine percent (38 of 55) of residents had received training on how to treat pediatric pain. All residents were more comfortable using pain medication for a nine-year-old, as compared to a one-year-old (oral oxycodone P=0.00003, oral morphine P=0.00002, IV morphine P=0.004). Ninety-eight percent (54 of 55) of residents felt that it was ‘extremely’ or ‘somewhat’ important to receive education about pediatric pain management. Their preferred methods to learn children's pain management were through role modeling (61%) and lectures (57%). Top challenges to optimal pediatric pain management were non-verbal patients, patients with disabilities, and young infants. Pediatric pain management education is important to EM residents. Residents recall receiving sub-optimal training on this important topic. They are especially uneasy in the management of younger children and those with disabilities. This study's findings can be used to inform post-graduate curriculum planning, in order to optimize pediatric pain assessment and treatment education.

Pain in patients with cancer.

Pain is an important concern in patients with cancer who are receiving active treatment and in long-term cancer survivors. It is one of the most feared aspects of cancer, and it can have a major adverse impact on quality of life. It has long been recognized that untreated or undertreated pain is common in patients with cancer, with little evidence of recent improvement. 1,2 Given the many advances in knowledge regarding cancer pain and its management over the past decade, this Special Series issue was assembled to provide readers with an update on the current understanding of the biology of cancer pain, the biology and mechanisms of action of the opioids used to treat cancer pain, challenges in the management of cancer pain, and evidence-based multidisciplinary approaches to management of cancer pain. We hope that the articles in this Special Series issue will enhance clinician understanding of cancer pain and its treatment and provide practical approaches to managing pain in patients with cancer. Hui and Bruera 3 outline “A Personalized Approach to Assessing and Managing Pain in Patients With Cancer.” They provide a practical yet evidence-based approach to personalized pain assessment and management in the clinic. They also discuss a paradigm shift in pain management, outlining a multistep approach that includes systematic screening, comprehensive pain assessment, characterization of pain, identification of personal modulators of pain expression, documentation of personalized pain goals, and implementation of a multidisciplinary treatment plan with subsequent customized longitudinal monitoring. Their article summarizes an expert clinician’s approach to pain management and provides practical tables and figures that will be helpful to the clinician who manages cancer pain. Falk and Dickenson 4 discuss the biology of pain in patients with cancer, with a special focus on bone pain, in their article entitled “Pain and Nociception: Mechanisms of Cancer-Induced Bone Pain.” The authors review mechanisms of cancer pain, stating that it is a “complex pain state involving components of both inflammatory and neuropathic pain, but also displaying elements that appear to be unique to cancer pain.” They discuss cancer pain as unpredictable, with highly variable intensity, which makes it difficult to manage. They also review mechanisms of acute pain, neuropathic pain, inflammatory pain, and complex cancer pain, providing informative figures that will help clinicians understand the biology of pain and may help guide the selection of management approaches. Gavril Pasternak 5 reviews “Opiate Pharmacology and Relief of Pain,” a complex area that is presented in a clear fashion. Pasternak states that opioids “selectively impact the hurt of nociceptive stimuli”; they act through activation of a pain modulating system consisting of endogenous opioid peptides and their receptors. He discusses three classes of opioid/receptors—mu, delta, and kappa—and suggests that individual responses to specific opioids may reflect differences in the biology of these receptors. Pasternak discusses important issues such as opioid cross tolerance, benefits, and risks of opioid rotation and the growing understanding of mu receptor subtypes, introducing the

The damage done by the war on opioids: the pendulum has swung too far.

The damage done by the war on opioids: the pendulum has swung too far Timothy J Atkinson,1 Michael E Schatman,2 Jeffrey Fudin1,3–51PGY2 Pain and Palliative Care Pharmacy Residency, Stratton VA Medical Center, Albany, NY, 2Foundation for Ethics in Pain Care, Bellevue, WA, 3School of Pharmacy, University of Connecticut, Storrs, CT, 4Western New England University College of Pharmacy, Springfield, MA, 5Buffalo College of Pharmacy, State University of New York, Buffalo, NY, USAIn the United States, patterns of opioid use for the management of pain have drastically changed over the past 30 years. In the 1980s, the American pain medicine landscape was characterized by opiophobia, the fear to prescribe opioids. Around the turn of the millennium, however, we witnessed a fairly rapid shift to opiophilia, or the "overprescribing" of opioids. The ubiquitous undertreatment of pain was the catalyst for clinicians and pain societies to successfully lobby for increased use of opioids for all pain types, including non-cancer pain. The approval of new standards for pain management incorporating pain as the "fifth vital sign" by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)1 seemingly fueled this increase in opioid prescription. From 1991–2009, prescriptions for opioid analgesics tripled, with emergency department visits related to non-medical use of prescription opioid overdoses doubling from 2005–2009.2 In 2010, accidental overdose deaths associated with opioids increased for the eleventh consecutive year, highlighting the drastic shift in opioid use.3 The figurative pendulum began to swing toward opiophobia following the publication of data that demonstrated that the risk of addiction associated with chronic opioid use was likely underestimated.4 Guidelines for the use of controlled substances released by the Federation of State Medical Boards of the US in 1998 reflected this change in attitude.5 At present, there is a general consensus that opioids are over-prescribed and education among health care providers is sorely lacking, with considerable debate on how to appropriately address the issue not yet resulting in a balance between treating legitimate pain patients, and mitigating abuse, overdoses, and related deaths. In this environment, physicians and non-physician prescribers, health systems, regulatory agencies, and insurers are seeking tangible targets for intervention.

One size does not fit all: opioid dose range orders.

WITH THE INTRODUCTION of The Joint Commission (TJC) pain assessment standards 14 years ago, hospitals nationwide implemented initiatives to improve pain management. 1 Phillips D.M. JCAHO pain management standards are unveiled. JAMA. 2000; 284: 428-429 Crossref PubMed Scopus (454) Google Scholar The ongoing evaluation of pain management practices by TJC and Centers for Medicare and Medicaid (CMS) surveyors during hospital accreditation visits not only continues to fuel attempts to improve the way pain is managed in hospitals, but also has introduced unexpected and concerning consequences. The combination of a focus on reducing undertreated pain, obtaining pain intensity ratings as the primary (and sometimes only) method of pain assessment, and the prevalence of opioid-only pain treatment plans has resulted in an increase in life-threatening opioid-related adverse events. 2 Institute for Safe Medication Practices (ISMP) Pain Scales Don't Weigh Every Risk. Institute for Safe Medication Practices, 2002https://www.ismp.org/newsletters/acutecare/articles/20020724.asp Google Scholar , 3 Lucas C.E. Vlahos A.L. Ledgerwood A.M. Kindness kills: The negative impact of pain as the fifth vital sign. J Am Coll Surg. 2007; 205: 101-107 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar , 4 Pasero C. The perianesthesia nurse's role in the prevention of opioid-induced sentinel events. J Perianesth Nurs. 2013; 28: 31-37 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar , 5 Vila Jr., H. Smith R.A. Augustyniak M.J. et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: Is patient safety compromised by treatment based solely on numerical pain ratings. Anesth Analg. 2005; 101: 474-480 Crossref PubMed Scopus (202) Google Scholar , 6 White P.F. Kehlet H. Improving pain management: Are we jumping from the frying pan into the fire?. Anesth Analg. 2007; 105: 10-12 Crossref PubMed Scopus (58) Google Scholar Chris Pasero, MS, RN-BC, FAAN, Pain Management Educator and Clinical Consultant in El Dorado Hills, CA