Undertreatment Of Pain Research Articles

Pre-hospital pain assessment in paediatric patients.

The aim of this article is to review the literature on pre-hospital assessment of pain in paediatric patients. Many articles highlight the under-treatment of pain in paediatrics by pre-hospital clinicians, showing that this is an area falling short of best practice. This article evaluates the effectiveness of two established pain assessment tools authorised for the pain assessment of children in pre-hospital environments.

General Practitioners' Barriers and Facilitators to Opioid Prescription in Medellin, Colombia (S810)

1.Identify the attitudes and specific practices of general practitioners regarding opioid prescription.2.Recognize general practitioners' perceived barriers and facilitators of opioid prescription.3.Describe how general practitioners' knowledge of opioids influence opioid prescription. Understanding key attitudes, barriers and facilitators of opioid prescription can help overcome the current undertreatment of pain in Low and Middle-Income Countries (LMICs). Identify barriers and facilitators for opioid prescription by GPs in Medellin, Colombia. Descriptive-quantitative, cross-sectional study. A 53-item questionnaire was designed to assess: 1) attitudes (concerns and confidence when prescribing opioids), 2) practices related to opioid prescription, 3) perceived barriers and facilitators of opioid prescription; and 4) knowledge of opioids. We surveyed GPs who graduated from medical schools in Medellin, and GPs currently practicing in ten institutions in Medellin, Colombia. 179 participants completed the questionnaire. Descriptive and correlational analyses were conducted. The mean age was 33.3 years old (SD 10.43), 53.3% were female, 47.8% had been practicing for over 5 years, 51.66% did not receive training in pain management during medical school and only 2.8% received training after medical school. Regarding knowledge, 49.5% responded accurately. Common concerns were managing adverse effects and potential opioid abuse. Participants felt less confident to prescribe opioids to pediatric, pregnant patients, and those with history of substance abuse. Common barriers to opioid prescription were restriction to access, high costs, and insufficient training. Adequate opioid prescription practices were significantly and positively correlated with confidence when prescribing opioids (0.466; p<0.01), knowledge of opioids (0.422; p<0.01), age (0.233; p<0.01), and training in pain management (0.308; p<0.01); and significantly and negatively correlated with perceived barriers (-0.332; p<0.01). Adequate practices regarding opioid use are related to training, knowledge and confidence when prescribing opioids. However, GPs in our context have insufficient knowledge about pain control and opioid use.

Appropriateness of postoperative analgesic doses among pediatric surgical patients in a teaching hospital in Northwest Nigeria

The inappropriate and suboptimal use of analgesic drugs is a global problem, and is an area of concern with regard to the management of postoperative pain, particularly in children. Information relating to the management of postoperative pain in children is generally limited, particularly in low- and middle-income countries, and is unavailable in Northwest Nigeria. The aim of this study was to describe the types of analgesics used postoperatively in children, evaluate the appropriateness of their doses compared with best practice, and determine risk factors for underdosing of analgesics. We performed a retrospective chart review of patients administered analgesics after surgery between 1 January 2015 and 31 December 2017. The appropriateness of the analgesic doses was categorized as underdose, normal dose, or overdose. Simple descriptive and comparative statistical analyses were performed. Logistic regression was used to build an analgesic underdose risk-prediction model. Overall, 194 patients received a total of 281 prescriptions for seven different analgesics, with 112 (57.7%), 77 (39.7%), and 5 (2.6%) patients receiving one, two, and three analgesics, respectively. Of the 281 analgesic prescriptions, paracetamol accounted for 148 (52.7%) and pentazocine accounted for 77 (27.4%), and there were 64 cases of overdosing (22.8%) and 89 of underdosing (31.7%). There was a statistically significant association between analgesic type and category of dose appropriateness (p < 0.001). The risk of underdosing was not predicted by any of the patient demographic characteristics or by the number of analgesics used. Inappropriate use of analgesics (overdosing or underdosing) is common and is found across all analgesic types and all age groups. A substantial number of children were underdosed, suggesting undertreatment of pain.

Magnesium for the Management of Chronic Noncancer Pain in Adults: Protocol for a Systematic Review.

BackgroundChronic pain is a highly prevalent and complex health problem that is associated with a severe symptom burden, as well as substantial economic and social impact. Many patients with chronic pain still suffer from unrelieved or undertreated pain due to the incomplete efficacy and dose-limiting adverse effects of current therapies. Long-term and high-dose opioid use has considerably increased in the past 20 years despite limited evidence supporting its effectiveness in several chronic pain conditions, and serious concerns have emerged regarding adverse effects and potential misuse. Until recently, the steady increase in opioid prescribing rates has been associated with rising opioid-related mortality and other serious problems, emphasizing the need for better nonopioid therapies. Emerging evidence supports the safe use of magnesium in controlling chronic pain, but its overall efficacy and safety is still unclear.ObjectiveThis paper aims to assess the efficacy and safety of magnesium compared with a placebo for the treatment of chronic noncancer pain.MethodsWe will conduct a detailed search on Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from their inception until the date the searches are run to identify relevant randomized controlled trials. The reference lists of retrieved studies as well as Web-based trial registries will also be searched. We will include randomized double-blind trials comparing magnesium (at any dose, frequency, or route of administration) with placebo using participant-reported pain assessment. Two reviewers will independently evaluate studies for eligibility, extract data, and assess trial quality and potential bias. Risk of bias will be assessed using criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes for this review will include any validated measure of pain intensity or pain relief. Dichotomous data will be used to calculate the risk ratio and number needed to treat or harm. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.ResultsThis protocol is grant-funded and has undergone a peer-review process through the Queen’s University Department of Anesthesiology and Perioperative Medicine Vandewater Endowed Studentship. This project is also supported, in part, by the Chronic Pain Network of the Canadian Institutes of Health Research Strategy for Patient-Oriented Research. The electronic database search strategies are currently being developed and modified. The entire review is expected to be completed by January 1, 2019.ConclusionsThe completion of this review is expected to identify available high-quality evidence describing the efficacy and safety of magnesium for the treatment of chronic noncancer pain.International Registered Report Identifier (IRRID)PRR1-10.2196/11654

Paediatric pain education for health care professionals.

Paediatric pain education for health care professionals.

Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain.

Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain. This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes. Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups. In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.

Pediatric residents’ perceived barriers to opioid use in sickle cell disease pain management

Current guidelines recommend high-priority treatment of severe sickle cell disease (SCD) pain with opioids; however, patients with SCD have historically been undertreated. We used mixed methods to assess pediatric residents' perceptions toward opioid use in SCD pain management. We distributed a survey to 88 residents at an urban pediatric medical center in a cross-sectional study. Participants responded to questions about perceived barriers to acute SCD pain management and attitudes toward patients with SCD. Responses were examined using bivariate analyses. Five pediatric residents were interviewed, to provide more in-depth understanding of barriers to SCD pain management. Fifty-three residents (60%) completed the survey. Participants were divided into "more experienced" (had seen ≥ 21 patients with SCD; 45.3%) or "less experienced." Both groups reported potential for tolerance and dependence as major barriers to opioid use in SCD. Less experienced residents reported a greater need for additional training in SCD pain management (P<0.05), more concern about addiction, and greater empathy for patients with SCD (P<0.05). Both groups agreed that patients with SCD were "frustrating to care for." Thematic analysis revealed that increased patient and provider barriers led to distrust, ultimately leading to undertreatment of pain and inadequate care. Although more experienced residents reported feeling more comfortable treating acute SCD pain and were less concerned with addiction compared with less experienced residents, certain negative views of patients with SCD were prevalent among all residents. Findings suggest that residency training must address provider attitudes as well as knowledge about SCD.

Pain assessment in advanced dementia. Validity of the German PAINAD-a prospective double-blind randomised placebo-controlled trial.

Pain in combination with dementia is a common condition that makes pain recognition significantly more difficult. This results in undertreatment of pain in those suffering from dementia. The Pain Assessment in Advanced Dementia (PAINAD) scale currently represents one of the best approaches to pain detection in dementia. In a pilot study, strong inter-rater and retest reliability of the German version (PAINAD-G) was proven. However, the available data concerning the validity of this instrument were insufficient. The aim of the study was to validate the PAINAD-G scale by a double-blind randomised placebo-controlled trial in people with advanced dementia expected to be in pain. A second aim was to examine whether other observational tools (BISAD = Observation Instrument for Assessing Pain in the Elderly with Dementia) (German: Beobachtungsintrument für das Schmerzassessment bei alten Menschen mit Demenz, Checklist of Nonverbal Pain Indicators, Algoplus) were also able to demonstrate a significant difference between the study groups. Surprisingly, the study revealed no difference in "pain reduction" between those treated by oxycodone compared with those treated by placebo. Equally, none of the other 3 observational tools were able to demonstrate a significant difference between the study groups. However, correlations among the 4 observational tools were mostly moderate to high. A number of possible reasons for this observation, such as difficulties regarding sensitivity to change/responsiveness, consistence of the fundamental construct, influence of the early onset study, and efficacy of the analgesic in advanced dementia are discussed.

A Prospective, Interventional Study Evaluating the Use of a Prompt to Improve Compliance with Documentation of a Plan of Care for Pain in Patients with Bone Metastases Seen for Palliative Radiation Therapy

Management of cancer-related pain is an essential component of comprehensive oncologic care. Undertreated pain results in adverse clinical outcomes, undue suffering, and decreased quality of life. Furthermore, there are significant disparities in pain management, with racial/ethnic minorities and underserved populations at higher risk for undertreated cancer related pain. We studied whether the use of a simple electronic medical record (EMR) prompt could increase compliance with documentation of pain interventions in patients seen for palliative radiotherapy for bone metastases. A prospective, interventional study was approved by the Resident and Fellow Quality Improvement Incentive Program at our institution. Evaluable patients were seen in consultation for palliative radiation therapy for bone metastases. Resident physicians were asked to imbed a prompt in their consultation note, including pain scale (0/10) and plan of care for pain management. The primary endpoint was compliance rate of documenting a plan of care for >50% of audited patient encounters. The protocol aligned with Merit-based Incentive Payment System (MIPS) quality measures as defined by the Centers for Medicare Services. Quarterly EMR review was performed, with charts selected at random for auditing. Prior to initiation of the QI protocol, a pain intervention was documented in just 17.2% of patients. In the first 6 months following institution of the QI protocol, a plan of care for pain was documented in 65.5% of patients. The analgesic regimen was assessed or modified in 35% of consultations, urgent radiation therapy undertaken in 26%, communication with primary provider or oncologist in 10%, and referral to the Palliative Care service in just 4%. After institution of this protocol for patients being evaluated for palliative radiotherapy for bone metastases, substantially more patients had documentation of a plan of care for pain in accordance with MIPS quality guidelines. In addition to offering palliative radiation therapy, analgesics regimens were adjusted, referrals to palliative care were offered, and pain control was discussed with the referring provider. Ongoing efforts in our department are aimed at improving pain management and integrating radiation therapy with specialized palliative care providers.

Undertreated pain: Trends over time for older adults with and without cancer.

15 Background: Concerns about the adequacy of pain management among older adults are increasing. We examined calendar year (CY) trends in prescription medication (Rx) use by older adults with and without cancer who reported pain interference with normal activities. Methods: Using the 2007-2012 SEER-Medicare Health Outcomes Survey (MHOS) database with a unique linkage to Part D prescription claims data, we selected MHOS participants with Part D coverage who were within 5 years of cancer diagnosis or without cancer history. We used Rx claims to characterize use of opioids, non-opioid analgesics, local anesthetics and anti-epileptics during the 90 days post survey. Participant reported pain-related activity limitations within the past 30 days (pain interference) were summarized as severe, moderate, or none. We applied multivariable logistic regression to determine associations of Rx use with CY, cancer status, and pain interference, controlling for socio-demographics, chronic conditions, plan type and Part D Low Income Subsidy. Adjusted outcome levels were predicted based on the regression coefficients. Results: In the total sample (N = 15,624), pain Rx was used by 30%, with 20% receiving opioids. Severe or moderate pain interference with activities was reported by 23% and 46%, respectively. Among respondents with cancer (N = 9,105), 49% reporting severe (28% moderate) pain interference received any pain Rx; 37% &amp; 18% used opioids, respectively. For those without cancer, adjusted pain Rx use rates were significantly lower in all categories. Pain Rx increased over CY for cancer respondents with moderate pain (25% in 2008 to 31% in 2012; p = .017), but not for those reporting severe pain interference. In addition, pain Rx increased over CY for the cohort without cancer with no pain interference (11% in 2008 to 14% in 2012; p = .027). Conclusions: Despite increased focus on symptom management, the majority of older adults who experienced moderate or severe pain interference did not have Rx for pain management. Efforts to identify and target unmet supportive care needs for Medicare beneficiaries, with and without cancer, are necessary to further improve quality of life.

Provision of Adequate Pain Management to a Young Adult Oncology Patient Presenting with Aberrant Opioid-Associated Behavior: A Case Study

Pain and emotional distress are relevant risk factors as clinicians assess for aberrant opioid-associated behavior and provide adequate and responsible pain relief to patients who engage in behaviors that may be interpreted as drug seeking in nature. The present case illustrates how undertreated pain and treatment-related anxiety affected the opioid use of a young adult with cancer. Because these risk factors were identified during the initial consult, the treatment team was able to implement a multimodal and multidisciplinary treatment approach that provided the patient with better analgesia and coping skills for anxiety.

Medical students' perspectives of their clinical comfort and curriculum for acute pain management.

ObjectivesAcute pain is a common presenting complaint in health care. Yet, undertreatment of pain remains a prevailing issue that often results in poor short- and long-term patient outcomes. To address this problem, initiatives to improve teaching on pain management need to begin in medical school. In this study, we aimed to describe medical students’ perspectives of their curriculum, comfort levels, and most effective pain teaching modalities.Materials and methodsA cross-sectional, online survey was distributed to medical students at the University of Alberta (Edmonton, Canada) from late May to early July 2015. Data were collected from pre-clerkship (year 1 and 2) and clerkship (year 3 and 4) medical students for demographic characteristics, knowledge, comfort, and attitudes regarding acute pain management.ResultsA total of 124/670 (19.6%) surveys were returned. Students recalled a median of 2 (interquartile range [IQR]=4), 5 (IQR=3.75), 4 (IQR=8), and 3 (IQR=3.75) hours of formal pain education from first to forth year, respectively. Clerkship students were more comfortable than pre-clerks with treating adult pain (52.1% of pre-clerks “uncomfortable” versus 22.9% of clerks, p<0.001), and overall, the majority of students were uncomfortable with managing pediatric pain (87.6% [64/73] pre-clerks and 75.0% [36/48] clerks were “uncomfortable”). For delivery of pain-related education, the majority of pre-clerks reported lectures as most effective (51.7%), whereas clerks chose bedside instruction (43.7%) and small group sessions (23.9%). Notably, 54.2%, 39.6%, and 56.2% of clerks reported incorrect doses of acetaminophen, ibuprofen, and morphine, respectively, for adults. For children, 54.2%, 54.2%, and 78.7% of clerks reported incorrect doses for these same medications.ConclusionMedical students recall few hours of training in pain management and report discomfort in treating and assessing both adult and (more so) pediatric pain. Strategies are needed to improve education for future physicians regarding pain management.

Pharmacological profile of TAN-452, a novel peripherally acting opioid receptor antagonist for the treatment of opioid-induced bowel syndromes

AimOpioid-induced bowel syndromes deteriorate patients' quality of life and may lead to nonadherence to opioid schedule and under-treatment of pain. The objective was to characterize the pharmacological profile of 17-cyclopropylmethyl-6,7-didehydro-4,5α-epoxy-6′-ethoxycarbonyl-3,14-dihydroxyindolo [2′,3′-6,7]morphinan (TAN-452), a novel peripherally acting opioid receptor antagonist. Main methodsThe in vitro binding affinity for the μ-, δ-, and κ-opioid receptors (MOR, DOR, and KOR) and the inhibition of [35S]GTPγS binding were examined using membrane preparations from recombinant human (h) MOR, DOR, or KOR expressing cell. In vivo assays were performed to determine the inhibitory effect of TAN-452 on morphine-induced emesis (anti-emetic activity) in ferrets, morphine-induced inhibition of small intestinal transit (anti-constipation activity) in rats, and morphine-induced antinociception (anti-analgesic activity) in rats. A pharmacokinetic study was also performed. Key findingsThe binding affinities of TAN-452 (Ki) were 36.56 ± 1.48 nM, 0.47 ± 0.09 nM, and 5.31 ± 1.80 nM for hMOR, hDOR, and hKOR, respectively. Its antagonistic activities (Kb) were 9.43 ± 0.58 nM, 0.21 ± 0.06 nM, and 7.18 ± 0.75 nM, respectively. The ED50 values (95% Confidence interval) were <1.0 mg/kg p.o. and <0.3 mg/kg s.c. for anti-emetic activity, 9.45 (4.09, 47.79) mg/kg p.o. and 0.52 (0.10, 1.08) mg/kg s.c. for anti-constipation activity, and >300 mg/kg p.o. and >30 mg/kg s.c. for anti-analgesic activity. The pharmacokinetic study demonstrated low brain penetrability of TAN-452. SignificanceTAN-452 is a peripherally acting opioid receptor antagonist with selectivity for DOR that attenuates morphine-induced side effects, such as nausea, vomiting, and constipation, without affecting pain control.

Contextual influences in decoding pain expressions: effects of patient age, informational priming, and observer characteristics

We aimed to examine the effects of contextual factors (ie, observers' training background and priming texts) on decoding facial pain expressions of younger and older adults. A total of 165 participants (82 nursing students and 83 nonhealth professionals) were randomly assigned to one of 3 priming conditions: (1) information about the possibility of secondary gain (misuse); (2) information about the frequency and undertreatment of pain in the older adult (undertreatment); or (3) neutral information (control). Subsequently, participants viewed 8 videos of older adults and 8 videos of younger adults undergoing a discomforting physical therapy examination. Participants rated their perception of each patient's pain intensity, unpleasantness, and condition severity. They also rated their willingness to help, sympathy level, patient deservingness of financial compensation, and how negatively/positively they feel towards the patient (ie, valence). Results demonstrated that observers ascribed greater levels of pain and other indicators (eg, sympathy and help) to older compared with younger patients. An interaction between observer type and patient age demonstrated that nursing students endorsed higher ratings of younger adults' pain compared with other students. In addition, observers in the undertreatment priming condition reported more positive valence towards older patients. By contrast, priming observers with the misuse text attenuated their valence ratings towards younger patients. Finally, the undertreatment prime influenced observers' pain estimates indirectly through observers' valence towards patients. In summary, results add specificity to the theoretical formulations of pain by demonstrating the influence of patient and observer characteristics, as well as informational primes, on decoding pain expressions.

Pain assessment in native and non-native language: difficulties in reporting the affective dimensions of pain.

Background and aims The language in assessing intensity or quality of pain has been studied but the results have been inconsistent. The physicians' language skills might affect the estimation of the severity of pain possibly leading to insufficient use of analgesics. Several interfering cultural factors have complicated studies aimed at exploring the language used to detect the quality of pain. We aimed to compare native and non-native language related qualitative aspects of pain chosen by Swedish speaking patients with diabetes. Methods In the study participated 10 Finnish and 51 Swedish speaking patients with diabetes. The Pain Detect-questionnaire was used for clarifying the patients' pain and the mechanism of their pain (neuropathic or not) and for assessing the intensity and quality of pain. In addition, the patients completed the short-form McGill Pain Questionnaire (sfMPQ) in Finnish (test I). After 30 min the subjects completed the sfMPQ a second time in their native language (test II). The Swedish speakers estimated their second language, Finnish, proficiency on a 5-graded scale. Results There were significantly more discrepancies between sfMPQ test I and test II among the Swedish speaking respondents who reported poor (hardly none) Finnish language proficiency compared with those with good Finnish proficiency. Discrepancies occurred especially between the affective qualities of pain. Conclusions Poor second language proficiency exposes Swedish speakers to pain communication difficulties related to the affective aspects of pain. Consequently, discordant language communication could cause underestimation of the severity of pain and pain undertreatment. Implications To ensure adequate pain treatment measuring the affective dimension of pain in the patient's native language is crucial.

Perioperative Management of Patients with Addiction to Opioid and Non-opioid Medications.

With the rise of the opioid epidemic, anesthesiologists will find themselves faced with opioid-addicted patients more frequently. Addiction to opioids may also occur concurrently with abuse of other non-opioid medications. Our review article seeks to outline an armamentarium of pain management strategies in the perioperative period for these patients with addiction to opioid and non-opioid medications. Statistics from the CDC demonstrate a shocking increase in opioid prescription rates and opioid-related deaths. Furthermore, opioid-addicted patients have notoriously undertreated pain in the perioperative period. A multitude of strategies are available in the perioperative period to treat pain in these patients. Formulating treatment plans for opioid and non-opioid-addicted patients undergoing surgery should include considerations in the pre-, intra-, and post-operative period. Our review article outlines several non-opioid modalities which may be employed to treat pain in these patients; however, particularly in the opioid-addicted population, the practitioner must be aware that non-opioids alone may not suffice to treat post-surgical pain. Consultation with pain management may be warranted to optimize opioid and non-opioid treatment for these patients.

Undertreatment of pain and low use of opioids in Latin America.

Pain is highly prevalent among the adult Latin American population. However, many patients with moderate to severe pain do not have access to effective pain management with opioids due to limited access to healthcare, overuse of nonopioid analgesics, regulatory barriers and lack of appropriate information about opioids. There is scarce training on use of opioids among physicians and other healthcare providers, which leads to misconceptions, mainly related to a fear of prescribing opioids. Although opioids are safe and effective drugs for the treatment of moderate to severe chronic pain, the use of opioids in Latin American nations is clearly below standards compared with developed countries.

LO22: Improving the pain experience for children with limb injury: a city-wide quality improvement collaborative

Introduction: Undertreated pain is known to cause short and long-term harm in children. Limb injuries are a common painful condition in emergency department (ED) patients, accounting for 12% of ED visits by children. Our city has one pediatric ED in a freestanding children’s hospital and 3 general ED’s that treat both adults and children. 68% of pediatric limb injuries in our city are treated in the pediatric ED and 32% are treated in a general ED. A quality improvement (QI) initiative was developed at the children’s hospital ED in April 2015 focusing on “Commitment to Comfort.” After achieving aims at the childrens hospital, a QI collaborative was formed among the pediatric ED and the 3 general ED’s to 1) improve the proportion of children citywide receiving analgesia for limb injuries from 27% to 40% and 2) reduce the median time to analgesia from 37 minutes to 15 minutes, during the time period of April-September, 2016. Methods: Data were obtained from computerized order entry records for children 0-17.99 years visiting any participating ED with a chief complaint of limb injury. Project teams from each site met monthly to discuss aims, develop key driver diagrams, plan tests of change, and share learnings. Implementation strategies were based on the Model for Improvement with PDSA cycles. Patient and family consultation was obtained. Process measures included the proportion of children treated with analgesic medication and time to analgesia; balancing measures were duration of triage and length of stay for limb injury and all patients. Site-specific run charts were used to detect special cause variation. Data from all sites were combined at study end to measure city-wide impact using 2 and interrupted time series analysis. Results: During the 3.5-year time period studied (April 1, 2014-September 30, 2017), there were 45,567 visits to the participating ED’s by children 0-17.99 years with limb injury. All visits were included in analysis. Special cause was detected in run charts of all process measures. Interrupted time series analysis comparing the year prior to implementation at the childrens hospital in April 2015 to the year following completion of implementation at the 3 general hospitals in October 2016 demonstrated that the proportion of patients with limb injury receiving analgesia increased from 27% to 40% (p&lt;0.01), and the median time from arrival to analgesia decreased from 37 to 11 minutes (p&lt;0.01). Balancing measure analysis is in progress. Conclusion: This multisite initiative emphasizing “Commitment to Comfort” was successful in improving pain outcomes for all children with limb injuries seen in city-wide ED’s, and was sustained for one year following implementation. A QI collaborative can be an effective method for spreading improvement. The project team is now spreading the Commitment to Comfort initiative to over 30 rural and regional EDs throughout the province through establishment of a provincial QI collaborative.

The impact of a pain assessment intervention on pain score and analgesic use in older nursing home residents with severe dementia: A cluster randomised controlled trial

BackgroundPain is highly prevalent in older adults, especially those in institutional settings such as nursing homes. The presence of dementia may increase the risk of underdiagnosed and undertreated pain. Pain assessment tools are not regularly used in clinical practice, however, there are indications that the regular use of pain assessments tools may influence the recognition of pain by nursing staff and thereby affect pain management. ObjectivesTo assess whether regular pain assessment using a pain assessment tool is associated with changes in i) pain scores and ii) analgesic use in nursing home residents with severe dementia. DesignCluster-randomised controlled trial. SettingThe study was conducted in 16 nursing homes in four counties in Norway. ParticipantsA total of 112 nursing home residents aged 65 years and older with dementia who lacked the capacity for self-reporting pain or were non-verbal. MethodsThe experimental group were regularly assessed pain with a standardised pain scale (the Doloplus-2) twice a week for a 12-week intervention period. The control group received usual care. The primary outcome was pain score measured with the Doloplus-2, and the secondary outcome was analgesic use (oral morphine equivalents and milligram/day paracetamol). Data on the outcomes were collected at baseline and at the end of week 12. The nursing staff in both the experimental and the control groups received training to collect the data. Linear mixed models were used to assess possible between-group difference over time. ResultsNo overall effect of regular pain assessment was found on pain score or analgesic use. The mean score of Doloplus-2 and analgesic use remained unchanged and above the established cut-off in both groups. ConclusionThe current intervention did not change analgesic use or pain score compared with the control condition. However, there is not sufficient evidence to conclude that regular pain assessment using a pain assessment tool is not clinically relevant. Furthermore, our results indicated that pain continued to be inadequately treated in nursing home residents with severe dementia. Therefore, further research on how standardised pain assessment can be used to support effective pain management in this population is needed.

391 First Reported Use of Methylnaltrexone to Treat Opioid-Induced Constipation in a Pediatric Burn Patient

Pain in critically ill pediatric burn patients is a complex and challenging issue whose adequate control is further complicated by anticipative fear and anxiety. Undertreated pain increases risk for post-burn PTSD and other psychosocial impairments, so it is aggressively managed with regimens often including high-dose opiates. This often results in Opioid-Induced Constipation (OIC) and first line laxative treatments have high recurrence rates due to the continuous, direct gastrointestinal effects of μ-opioid antagonism. Methylnaltrexone (MLTX), an FDA-approved injectable µ-opioid receptor antagonist, selectively acts on the myenteric plexus to reverse OIC without crossing the blood-brain-barrier to impair systemic analgesia. MLTX is safe and highly efficacious at treating OIC in adult and pediatric oncologic patients with recent data showing great effect in adult burn patients. Here we report the first case of the safe and efficacious reversal of OIC in a critically ill pediatric burn patient who failed standard laxative therapies. A retrospective case review was performed on a pediatric burn patient who was treated with MLTX for OIC in the setting of high-dose intravenous opiates. In our unit, MLTX is reserved for patients who remain without a bowel movement for 3 or more consecutive days on escalating regimens of traditional laxatives, particularly if they have worsening abdominal pain, distension, bladder pressures, or intolerance to enteral feeding. Following approval by a pediatric gastroenterologist and pharmacist, subcutaneous MLTX was administered at a dose of 0.15 mg/kg. Any complications related to drug administration (e.g. new abdominal pain, nausea, or bowel perforation) were tracked for risk analysis. Patient was an 11-year-old female with 18% TBSA partial and full thickness burns to face, trunk, and all four extremities with inhalation injury from a house fire. She was intubated prior to arrival, averaged 114 mg morphine equivalents per day, and stopped responding to first line laxation therapy after 12 days, subsequently going 4 days without laxation. She was given 8 mg MLTX with laxation 19 hours after administration. There were no adverse events associated with MLTX administration. MLTX administered as a single dose of 0.15 mg/kg subcutaneously was safely used to induce laxation in a critically ill pediatric burn patient with no observed adverse effects. To our knowledge, this is the first reported case of treating OIC with MLTX in a pediatric burn patient. Larger studies are indicated to further elucidate the safety and efficacy profile of MLTX in pediatric burn patients. MLTX may be a safe and efficacious treatment for OIC in pediatric burn patients requiring high-dose opiates.