Undertreatment Of Pain Research Articles

Do racial and ethnic disparities lead to the undertreatment of pain? Are there solutions?

The current review aims to empower anesthesiologists, specifically pain medicine specialists, to become leaders in ensuring equitable care. Disparities in both acute and chronic pain medicine lead to increased morbidity for patients of color. Gaps in care include misdiagnosis or under diagnosis of chronic pain disease states, undertreatment of sickle cell disease and other conditions that are common in minorities, under prescription of opioids, and lack of access to novel opioid sparing treatments. While the causes of these disparities are multifactorial, care team implicit bias and lack of representation are two of the major factors. Solutions are challenging, but the authors suggest an inside out solution. We believe that this practice will have far-reaching downstream effects, including improving diversity in our field and quality of care for our patients. The current article reviews disparities in both acute and chronic pain treatment for underrepresented racial and ethnic minorities in the United States. The authors examine whether implicit bias and lack of representation are a contributing factor for these disparities. Lastly, we will discuss potential solutions.

What is driving declines in oncology-prescribed opioids?

6583 Background: Patients with cancer have experienced sharp declines in opioid prescribing during the past decade, raising concerns about insufficient pain management in a population with high rates of undertreated pain. It is unclear whether these declines are driven by certain oncology subspecialties, payors, or clinical guidelines regarding opioid prescribing released in/after March 2016. Methods: We conducted time series analyses using 2006-2019 IQVIA Longitudinal Prescription Data, which represents up to 92% of all U.S. prescription fills. Using log-linear regression stratified by group, we estimated annual percent change in opioid receipt by: subspecialty (medical oncology MO, radiation oncology RO, and surgical oncology SO); payor (third-party; Medicare, including Medicare Part D; Medicaid; cash/out-of-pocket); and pre- versus post-March 2016. Opioid receipt outcomes included: monthly fills of any opioid; monthly fills of extended-release/long-acting (ER/LA) opioids; and monthly number of patients receiving long-term opioid therapy (LTOT). Outcomes were per 1,000 survivors to account for temporal changes in cancer prevalence. Results: Between 2006 and 2019, 14,301,900 opioid fills were prescribed by oncologists to 3,476,354 distinct patients. Across all outcomes, MO had the highest levels of dispensing, followed by RO, then SO; for example, in 2006 MO dispensed 6.2 fills per 1,000 survivors (compared to 1.9 fills among RO, and 0.5 among SO). We observed substantial declines in all opioid outcomes. Per 1,000 survivors, there was an annual decline of: 5.7% (95CI: 5.1-6.3; total unadjusted decline 2006-2019=70.2%) in the rate of all opioid fills; 4.9% (95CI: 4.1-5.6; total unadjusted decline=66.8%) in ER/LA fills; 3.2% (95CI: 1.5-5.0; total unadjusted decline=56.2%) in LTOT fills, and 1.9% in average daily dose (95CI: 1.9-2.0; total unadjusted decline=29.8%). The annual decline in opioid fills prescribed by MO (7.1%, 95CI: 6.6-7.7) was sharper than for RO (5.9%, 95CI: 5.4-6.4) and SO (5.2%, 95CI: 4.7-5.7). Annual declines were steepest among fills paid out-of-pocket (14.5%, 95CI: 13.9-15.0), followed by those paid by Medicaid (13.1%, 95CI: 12.5-13.6), third-party payors (9.3%, 95CI: 8.7-9.9), and Medicare (2.4%, 95CI: 1.8-3.1). Declines in every outcome accelerated following clinical guidelines released in/after 2016. Conclusions: Opioids prescribed by oncologists declined dramatically across groups and outcomes. Medical oncologists were responsible for a disproportionate share of opioid fills in 2006, and for the sharpest declines. Out-of-pocket fills declined more sharply than fills covered by insurance and clinical guidelines may have contributed to accelerating declines. While de-escalation of opioid therapy may reduce risk of opioid-related harms to cancer survivors, care is needed to ensure cancer-related pain is appropriately treated.

Pain and pain management in children and adolescents receiving hospital care: a cross-sectional study from Sweden.

BackgroundPain is a common symptom in children receiving hospital care. Adequate pain management in paediatric patients is of the utmost importance. Few studies have investigated children’s own experiences of pain during hospitalization.AimTo describe the prevalence of pain, self-reported pain intensity at rest and during movement, pain management and compliance with pain treatment guidelines in children and adolescents receiving hospital care. Furthermore, to examine self-reported statements about pain relief and how often staff asked about pain.MethodsA quantitative, cross-sectional study with descriptive statistics as the data analysis method was conducted at a county hospital in western Sweden. Sixty-nine children/adolescents aged 6–18 years who had experienced pain during their hospital stay were included. A structured, verbally administered questionnaire was used to obtain pain reports. The participants were also asked what they considered alleviated pain and how often they told staff about pain. Patient demographics, prescribed analgesics and documentation of pain rating were obtained from medical records.ResultsFifty children/adolescents (72%) experienced moderate to severe pain in the previous 24 hours. At the time of the interview 36% reported moderate to severe pain at rest and 58% during movement. Seven participants (10%) reported severe pain both at rest and during movement. About one-third were on a regular multimodal analgesic regimen and 28% had used a validated pain rating scale. Thirty children/adolescents (43%) reported that they had experienced procedural pain in addition to their underlying pain condition. Most of the children/adolescents (74%) reported that analgesics provided pain relief. Forty (58%) stated that various non-pharmacological methods were helpful.ConclusionsDespite evidence-based guidelines, half of the children/adolescents experienced moderate to severe pain, highlighting the need for improvement. Pain levels should be assessed both at rest and during movement. Response to treatment should be evaluated to prevent undertreatment of pain. Compliance with guidelines and professional communication are of the utmost importance for pain management in children/adolescents. Non-pharmacological methods are a valuable part of a pain management strategy. This study shows that it is important to evaluate and improve pain care also outside specialised tertiary clinics.

The use of virtual reality during medical procedures in a pediatric orthopedic setting: A mixed-methods pilot feasibility study.

Medical procedures cause pain and anxiety in children. Distraction techniques, including virtual reality (VR), may be used in healthcare settings to reduce rates of undertreated procedural pain and anxiety. A mixed-methods, concurrent triangulation design was piloted at a pediatric orthopedic hospital to assess the feasibility, clinical utility, tolerability, and initial clinical efficacy of VR distraction during medical procedures received by patients with complex musculoskeletal conditions. Questionnaire, scale, interview, observation, and focus group data were collected from patients, their parents, and healthcare professionals. Triangulation of key quantitative and qualitative findings produced final themes and meta-themes. A total of 44 patients and their parents undergoing intravenous insertions (n=30), pin removals (n=7), blood draws (n=3), Botox injections (n=2), dressing change (n=1), and urodynamic test (n=1) were recruited along with 11 healthcare professionals performing the medical procedures. The following themes resulted from triangulation of data sources: VR intervention was (a) feasible because VR was easily implemented into the clinical workflow, (b) clinically useful as VR was accepted by stakeholders and easy to use, (c) tolerable as VR caused minimal discomfort, and (d) showed initial clinical efficacy in managing procedural pain and anxiety. These findings will inform policies and procedures for VR use in practice and a sustainable implementation across the [name of hospital removed for peer review] network.

Pain Management for Older Adults Living with Dementia: Perspectives from African American Family Caregivers

African American older adults living with dementia are at increased risk for under-assessed and under-treated pain. This risk is even greater for those of lower socioeconomic status. The purpose of this study is to characterize family caregivers’ perspectives on pain assessment and management in the context of advance care planning for their loved one living with dementia. A convergent mixed methods approach will be used to gather descriptive, cross-sectional data within a community-based participatory design process with the impetus to develop targeted interventions.

Clinical Response of Nuberol Forte® for Pain Management With Musculoskeletal Conditions in Routine Pakistani Practice (NFORTE-EFFECT)

BackgroundMusculoskeletal pain is the most common complaint presented to the health practitioner. It is well-known that untreated or under-treated pain can have a significant negative impact on an individual’s quality of life (QoL).ObjectivesThe current study aimed to assess the clinical response of Nuberol Forte® (paracetamol 650 mg + orphenadrine 50 mg) to musculoskeletal pain in routine Pakistani practice and its impact on improving the patient’s QoL.MethodsA prospective, observational multicenter study (NFORT-EFFECT: Safety & Efficacy of Nuberol Forte in Pain Management). Three hundred ninety-nine patients with known prescreened musculoskeletal pain were recruited from 10 major healthcare facilities across six (6) major cities of Pakistan, as per the inclusion/exclusion criteria. After the baseline visit (Visit 1), the patients were followed up one to two weeks (Visit 2) after the treatment as per the physician's discretion. Data were collected using the Case Report Form (CRF) designed for the study, and adverse events (AEs) were also monitored to assess drug safety. Pain intensity was assessed through a visual analog scale (VAS), and QoL was assessed using the Muscle and Joint Measure (MJM) scale.ResultsOut of 399 enrolled patients, 49.4% were males and 50.6% were females with a mean age of 47.24 ± 14.20 years. Most patients were presented with knee osteoarthritis (OA), i.e., 148 (38%), followed by backache 70 (18.2%). A significant reduction in the mean pain score was observed after treatment with the combination of paracetamol and orphenadrine (p<0.05). Furthermore, an overall improvement in the patient’s QoL was also observed. During the study, only 10 patients reported mild adverse events (AEs), namely, dryness of the mouth, dizziness, gastric irritation, tachycardia, restlessness, etc.ConclusionThe combination of paracetamol and orphenadrine (Nuberol Forte) exhibited effective pain management among patients with musculoskeletal conditions and improved their QoL.

Comparison of the Impacts of Under-Treated Pain and Opioid Pain Medication on Cognitive Impairment.

Purpose: To guide clinicians in balancing the risks and benefits of opioids when treating pain, we conducted two systematic reviews: 1) the impact of pain on cognitive function, and 2) the impact of opioids on cognitive function.Methods: Part one addressed the impact of pain on cognitive impairment; Part two considered the impact of opioids on cognitive impairment. PubMed was used to search for eligible articles. For part one, 1786 articles were identified, of which 23 met our eligibility criteria. For part two, among 584 articles, 18 were found eligible.Results: For part one, 16 studies concluded that patients with chronic pain showed impaired cognitive function; six studies found that chronic pain does not worsen cognitive function; one study concluded that the impact of pain on cognitive function differs based on the underlying cognitive status. For part two, 15 studies found that using opioids to control pain did not cause significant cognitive impairment, while three studies concluded the opposite. Studies evaluating older subjects did not observe different results from those in the whole population for both reviews.Conclusion: The published literature indicates that moderate to severe pain can impair cognitive function, and that careful use of opioid analgesics in such subjects does not necessarily worsen cognition. Although our results are insufficient to support clear guidance due to heterogeneity of cohorts and outcomes, this study may assist primary care providers by rendering explicitly the factors to be considered by providers caring for this population with pain when opioids are considered.

Is it Feasible? A Quality Improvement Project to Integrate Complementary Therapy Into a Pain Management Program on a Transitional Care Unit.

The cost of pain to society is high, not only in dollars but in physical and emotional suffering. Undertreated pain in the geriatric population can lead to functional impairments and diminished quality of life. A transitional care unit (TCU) described having higher levels of moderate to severe pain than state and national levels in like facilities. A team of university faculty and students, and staff members from the TCU developed a quality improvement project to examine the feasibility of integrating complementary therapies to treat pain into clinical practice. The team integrated three evidence-based complementary therapies into staff workflow. The nursing and therapy staff reported minimal to no interruption to their workflow when patients used the complementary therapies. Staff expressed satisfaction with an expanded menu of pain management options. Patients reported statistically significant lower (p = 0.002) pain levels after using the complementary therapies and benefits beyond pain relief, including relaxation, stress reduction, and improved sleep. Adding complementary therapies to the pain management program was feasible and the patients had less pain along with other benefits when using the therapies with standard care. Having additional methods for managing pain is beneficial and vital.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis.

Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.

Pain and the Alzheimer's Disease and Related Dementia Spectrum in Community-Dwelling Older Americans: A Nationally Representative Study

ContextPain is a significant concern among older adults with Alzheimer's disease and related dementias (ADRD). ObjectivesExamine the association between cognitive impairment across the ADRD spectrum and pain assessment and treatment in community-dwelling older Americans. MethodsThis cross-sectional, population-based study included 16,836 community-dwelling participants ≥ 50 years in the 2018 Health and Retirement Study. ADRD, assessed by validated cognitive measures, was categorized into “dementia,” “cognitive impairment, no dementia (CIND)” and “intact cognition.” Pain assessment included pain presence (often being troubled with pain), pain severity (degree of pain most of the time [mild/moderate/severe]), and pain interference (pain making it difficult to do usual activities). Pain treatment included recent use of over-the-counter pain medications and opioids (past 3 months), and regular intake of prescriptions for pain. ResultsDementia were associated with lower likelihood of reporting pain presence (Odds Ratio [OR]= 0.61, P = 0.01), pain interference (OR = 0.46, P < 0.001), reporting lower pain severity (e.g., moderate vs. no: Relative Risk Ratio = 0.38, P < 0.001), and lower likelihood of receiving pain treatment, that is, recent use of over-the-counter pain medications (OR = 0.60, P = 0.02) and opioids (OR = 0.33, P < 0.001), and regular intake of prescriptions for pain (OR = 0.461, P = 0.002). CIND was associated with reporting lower pain severity (e.g., moderate vs. no: Relative Risk Ratio = 0.75, P = 0.021), lower likelihood of reporting pain interference (OR = 0.79, P = 0.045) and recent over-the-counter pain medication use (OR = 0.74, P = 0.026). ConclusionCIND and dementia increased the risk of under-report and under-treatment of pain. Systematic efforts are needed to improve pain recognition and treatment among older adults with cognitive impairment, regardless of dementia diagnosis.

Living systematic review to assess the analgesic undertreatment in cancer patients.

This living and systematic review aimed to provide an updated summary of the available evidence on pain undertreatment prevalence in patients with cancer; correlations with some potential determinants and confounders were also carried out. We updated a systematic review published on 2014, including observational and experimental studies reporting the use of the pain management index (PMI) in adults with cancer and pain, from 2014 to 2020. We conducted searches in PubMed/MEDLINE, Embase, and Google Scholar. We performed univariate and multivariable regression analyses to describe the relationship between PMI and a list of potential explanatory variables. Twenty new papers were identified, yielding a total sample size of 66 studies. The proportion of patients classified as undertreated according to the year of study publication shows a higher decrease from 1994 to 2013 (-13% as relative change) than the most recent years 2014-2020 (-11%). The quality of the included studies has increased over the years (from 80% to 93%). At the multivariable analysis, a statistically significant relationship was confirmed between undertreatment and the year of the publication of the study and with a low-medium economic level of the countries, where the studies were conducted. Despite the improvement when compared to the period 1994-2000, still about 40% of the cases identified received an analgesic treatment inadequate to the intensity of pain, according to the PMI. Despite its intrinsic limitations, PMI continues to be widely used, and it could allow a continuous monitoring of pain management across a different mix of studies and patients.

Pain in neurodegenerative diseases with atypical parkinsonism: a systematic review on prevalence, clinical presentation, and findings from experimental studies.

Parkinson's disease-related pain has increasingly been investigated in research studies. Still, only a few studies have addressed the prevalence and clinical characteristics of pain in neurodegenerative disorders with atypical parkinsonism. The existing evidence, although scarce, suggests that, similarly as in Parkinson's disease, individuals with neurodegenerative diseases with atypical parkinsonism might be predisposed to the development of persistent pain. Today, as the global population is aging and we face an epidemic of neurodegenerative disorders, under-treated pain is taking a great toll on an ever-rising number of people. Here, we provide an up-to-date review of the current knowledge on the prevalence of pain, its clinical features, and findings from experimental studies that might signpost altered pain processing in the most prevalent neurodegenerative disorders with atypical parkinsonism: multiple system atrophy, progressive supranuclear palsy, corticobasal syndrome, frontotemporal dementia, and dementia with Lewy bodies. Finally, we point out the current gaps and unmet needs that future research studies should focus on. Large-scale, high-quality clinical trials, coupled with pre-clinical research, are urgently needed to reveal the exact pathophysiological mechanisms underpinning heightened pain and pave the path for mechanistically-driven analgesic interventions to be developed, ultimately leading to an improvement in the quality of life of individuals with neurodegenerative disorders.

2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats.

Increases in cat ownership worldwide mean more cats are requiring veterinary care. Illness, trauma and surgery can result in acute pain, and effective management of pain is required for optimal feline welfare (ie, physical health and mental wellbeing). Validated pain assessment tools are available and pain management plans for the individual patient should incorporate pharmacological and non-pharmacological therapy. Preventive and multimodal analgesia, including local anaesthesia, are important principles of pain management, and the choice of analgesic drugs should take into account the type, severity and duration of pain, presence of comorbidities and avoidance of adverse effects. Nursing care, environmental modifications and cat friendly handling are likewise pivotal to the pain management plan, as is a team approach, involving the cat carer. Pain has traditionally been under-recognised in cats. Pain assessment tools are not widely implemented, and signs of pain in this species may be subtle. The unique challenges of feline metabolism and comorbidities may lead to undertreatment of pain and the development of peripheral and central sensitisation. Lack of availability or experience with various analgesic drugs may compromise effective pain management. These Guidelines have been created by a panel of experts and the International Society of Feline Medicine (ISFM) based on the available literature and the authors' experience. They are aimed at general practitioners to assist in the assessment, prevention and management of acute pain in feline patients, and to provide a practical guide to selection and dosing of effective analgesic agents.

Self-Efficacy Survey Study of Pain Self-Management in Patients with Cancer

Background: Cancer pain prevalence remains high, and variance in self-efficacy for managing pain may explain why some patients experience greater pain severity.Aim: This study explored perceptions of self-efficacy in relation to cancer pain severity and treatment related characteristics.Method: A descriptive cross-sectional survey was administered to 50 cancer outpatients. Data analysis involved descriptive and correlational statistical analyses.Results: Self-efficacy to manage pain was significantly associated with time since diagnosis and ability to deal with frustration, and inversely associated with pain severity level. A large proportion of patients reported low satisfaction self-managing their pain. Most patients reported independently self-managing their cancer pain; however, satisfaction with pain management was low for a large proportion of patients. Time since cancer diagnosis and ability to deal with frustration due to cancer pain were positively associated with cancer pain self-efficacy, whereas pain self-efficacy had a significant inverse correlation with cancer pain severity.Conclusions: Enhancing self-efficacy to self-manage under-treated cancer pain is important with implications for improving pain outcomes and quality of life. Further investigation on unmet needs and preferences for cancer pain self-management support is warranted.

Pain as the fifth vital sign-A comparison between public and private healthcare systems.

BackgroundThe assessment of pain as the fifth vital sign (P5VS) is of paramount importance since it leads to the management of undertreated pain, consequently reducing suffering, readmissions and emergency department visits after hospital discharge.ObjectiveTo evaluate the implementation of P5VS in public and private hospitals.MethodsData analysis on validated questionnaires was sent to all 171 Portuguese hospitals via an official letter.ResultsWhen compared to private hospitals, public hospitals presented a higher adherence to the process related to the P5VS. It has demonstrated superiority in the charts properly placed to record P5VS, in the number of emergency departments recording P5VS, in the regularity of audits, and in the existence of guidelines and staff training on pain assessment and management.ConclusionThe standardization of both evaluation and recording of pain intensity constitutes a measure of good clinical practice. Public hospitals demonstrated better commitment to these procedures that should be properly carried out in all health care institutions.

Impact of Cannabis Use on Least Pain Scores Among African American and White Patients with Cancer Pain: A Moderation Analysis.

IntroductionBased on many published reports, African American patients with cancer experience higher pain severity scores and lower pain relief than White patients. This disparity results from undertreatment of pain and is compounded by low adherence to prescribed non-opioid and opioid analgesics among African American patients with cancer. While nearly one in four patients use cannabis to manage cancer-related symptoms, less is known about how cannabis use influences pain relief in this patient population.MethodsThis study is based on preliminary data from an ongoing study of longitudinal outcomes of opioid therapy among African American and White patients with cancer. Linear mixed-effects models were utilized to assess the interaction of race and cannabis use on pain relief using “least pain” item scores from the Brief Pain Inventory (BPI) averaged across three time points. Models were adjusted for sociodemographic and clinical variables.ResultsThis analysis included 136 patients (49 African American, 87 White). Overall, 30.1% of the sample reported cannabis use for cancer pain. The mean “least pain” score on BPI was 3.3 (SD=2.42) on a scale of 0–10. African American patients had a mean “least pain” score 1.32±0.48 units higher (indicating lower pain relief) than White patients (p=0.006). Cannabis use did not have a significant main effect (p=0.28). However, cannabis use was a significant moderator of the relationship between race and “least pain” (p=0.03). In the absence of cannabis use, African Americans reported higher “least pain” scores compared to Whites (mean difference=1.631±0.5, p=0.001). However, this disparity was no longer observed in African American patients reporting cannabis use (mean “least pain” difference=0.587±0.59, p=0.32).ConclusionThese findings point to the possible role of cannabis in cancer pain management and its potential to reduce racial disparities. These findings are preliminary and further research into the role of cannabis in cancer pain outcomes is needed.

Serious Mental Illness in Post-Acute and Long-Term Care:Building Knowledge, Sharing Care

Serious Mental Illness in Post-Acute and Long-Term Care:Building Knowledge, Sharing Care

The Practice of Pain Assessment and Management in a Tertiary Oncology Center.

BackgroundPain is one of the common and devastating symptoms that affects millions of cancer patients globally. Despite published guidelines and education on the assessment and management of cancer-related pain, underestimated or undertreated pain continues to be a considerable worldwide public health concern among cancer patients. In this study, we aimed to assess physicians’ adherence to the World Health Organization (WHO) guidelines in the management and assessment of pain in oncology patients based on the available score of pain in the Princess Noorah Oncology Center (PNOC) at the King Abdulaziz Medical City in Jeddah.MethodologyThis cross-sectional, retrospective chart review study studied 451 patients (selected through computerized random sampling) who were admitted to the PNOC during the study period.ResultsThe pain was assessed using the Brief Pain Inventory in almost all patients (n = 450, 99.8%). The pain was categorized as mild in 386 (85.6%) patients, moderate in 46 (10.2%) patients, and severe in 19 (4.2%) patients. Opioid prescriptions were significantly higher among patients with moderate (76.1%) and severe pain (89.5%) compared to those with mild pain (39.1%; p < 0.0001).ConclusionsThe practice of pain documentation for cancer patients was adequate as indicated by reporting the pain scores of 99.8% of inpatients. Patients with moderate and severe pain were more likely to receive opioids and a combination of opioids plus non-opioid analgesics, whereas the prescription of analgesics was predicted by experiencing moderate cancer pain.

Perioperative pain, analgesics and cancer-related outcomes: where do we stand?

Cancer-related pain is one of the most common and debilitating symptoms among cancer patients. Undertreated cancer-related pain interferes with daily activities and increases morbidity and mortality. While opioids continue to play an essential role in treating moderate to severe cancer-related pain, they are associated with many adverse effects including misuse. While preclinical and retrospective studies have shown a negative association between opioid use and cancer outcomes, randomized control trials demonstrate that opioid use does not influence cancer recurrence. Additionally, analgesics and adjuvants used for perioperatively or chronic pain control are unlikely to improve oncological outcomes. This article focuses on the pharmacological management of cancer-related pain and offers an overview regarding the use of these medications perioperatively and the cancer outcomes.

Expert review and recommendations for the management of acute, chronic, and neuropathic pain in Qatar.

Pain management is an evolving area of expertise in Qatar. Gaps in knowledge, inadequate training for physicians and nurses, and the absence of policies/guidelines are the main barriers to effective pain management in Qatar. In addition, the use of certain pain medication, especially opioids, is highly regulated, limiting their availability in outpatient pain management. These factors are responsible for the undertreatment of pain in Qatar. This study aimed to standardize evidence-based local recommendations for pharmacological treatment of pain in Qatar. An expert panel of physicians from different disciplines, with experience in diagnosis and treatment of the three pain types (i.e., acute, chronic, and neuropathic), was convened for two face-to-face meetings in Doha, Qatar, on November 29, 2019, and on February 22, 2020, with subsequent virtual meetings. A literature search was performed on Medline and Google Scholar databases from inception till December 2019, and all relevant articles were selected. Based on these articles and repeated feedback from the authors, the final pain treatment protocols were developed. Recommendations for the treatment of acute pain, based on pain severity, followed three approaches: acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) for mild pain and moderate pain and referral to a pain specialist for severe pain. Acetaminophen/paracetamol or NSAIDs is recommended for chronic pain, and the use of opioids was strongly discouraged because of its long-term side effects. For neuropathic pain, tricyclic antidepressants or gabapentin or pregabalin or serotonin-norepinephrine reuptake inhibitors were recommended first-line agents. Non-responders must be referred to neurologists or a pain specialist. The expert panel provides recommendations for the management of acute, chronic, and neuropathic pain based on international guidelines adapted to local practice and treatment availability in Qatar. More importantly, the panel has recommended taking extreme caution in the use of opioids for long-term management of chronic pain and to refer the patient to a pain specialist clinician as required.