Unrelieved Pain Research Articles

Survey: Nations failing to address cancer pain

Hundreds of millions of cancer patients are suffering needlessly because governments have failed to ensure access to pain-relieving drugs, according to an international survey released last fall during the 2012 European Society for Medical Oncology (ESMO) Congress held in Vienna, Austria. Unrelieved pain is causing worldwide suffering, not because physicians do not have the ability to treat it but because most patients do not have access to the medication, said the lead author of the report, Nathan Cherny, MD, of the Shaare Zedek Medical Center in Jerusalem, Israel and chair of the ESMO Palliative Care Working Group. ESMO initiated the International Collaborative Project to Evaluate the Availability and Accessibility of Opioids for the Management of Cancer Pain and coordinated with the European Association for Palliative Care, the Pain and Policy Study Group at the University of Wisconsin Carbone Cancer Center, the Union for International Cancer Control, and the World Health Organization. The data were gathered between December 2010 and July 2012 and included 156 reports submitted by experts in 76 countries and 19 Indian states. The survey found that very few countries provided all 7 of the opioid medications that are considered to be essential for the relief of cancer pain. In many countries, fewer than 3 of the 7 medications are available and, if they are available, they are either unsubsidized or weakly subsidized by many governments. In addition, availability is often limited. Researchers also learned that many countries have highly restrictive regulations, including those that limit patients' ability to receive prescriptions, limit prescriber privileges, impose limits on the duration of the prescription, restrict dispensing, and increase bureaucracy for the prescribing and dispensing process. The restrictions are particularly severe in Africa, Asia, the Middle East, and Latin and Central America, and researchers note that there is an urgent need to examine drug control policies that impede pain treatment. Studies have shown that pain can affect as many as 64% of patients with metastatic, advanced, or terminal disease and 59% of patients receiving anticancer treatment, says Carla Ripamonti, MD, head of supportive care in the cancer unit of the IRCCS Foundation National Cancer Institute in Milan, Italy. Dr. Cherny says the ESMO study has provided key information that will be useful in developing national efforts for treating cancer pain. Not only do researchers now know which countries have suboptimal formularies of medication to relieve pain, they also know how much patients pay out-ofpocket for such medications as well as which countries have excessive regulations that limit patients' ability to access vital medications. The presentation of the study at ESMO Congress is the beginning of an organized effort to tackle the challenge, says Dr. Cherny.

Postoperative opioids

Postoperative opioids

The impact of postoperative pain on early ambulation after hip fracture

Hip fractures are the most serious consequence of falling in older people with osteoporosis. Early ambulation is one of the main goals of inpatient rehabilitation aimed at reducing negative effects of immobilization, and promoting functional recovery. Recognizing the role of different factors that are associated with time to ambulation time after hip fracture surgery may help decrease morbidity and mortality rates. The aim of this study was to examine the impact of postoperative pain time to ambulation following hip fracture surgery. A total of 96 patients who consecutively presented at the Clinic for Orthopaedic Surgery and Traumatology, Clinical Center Serbia during a 6 month period were included in the study. Subjects were assessed regarding socioedemographic characteristics, prefracture functional status, cognitive status, general health status, fracture type, type of anaesthesia, and waiting time for surgery. The VAS scale (0-100) was used to measure pain intensity on the first postoperative day. Our results revealed that patients, whose time to ambulation was = 48 h postoperatively were of worse physical health, and had significantly higher VAS score on the first postoperative day. Unrelieved pain in geriatric hip fracture patients is associated with delayed ambulation. Future research should confirm the posi-tive effects of aggressive pain management programs on early functional outcome in elderly patients who sustain hip fractures.

Nurse'S Perceptions of Pain Assessment and Pain Managment for Patients with Myocardial Infarction in a Coronary Care Unit

Background: Pain is one of the most common medical problems that occur in hospitals; in spite of its incidence, there are many patients who suffer with untreated pain. Unrelieved pain can negativel ...

The ethics of Canadian entry-to-practice pain competencies: how are we doing?

Although unrelieved pain continues to represent a significant problem, prelicensure educational programs tend to include little content related to pain. Standards for professional competence strongly influence curricula and have the potential to ensure that health science students have the knowledge and skill to manage pain in a way that also allows them to meet professional ethical standards. To perform a systematic, comprehensive examination to determine the entry-to-practice competencies related to pain required for Canadian health science and veterinary students, and to examine how the presence and absence of pain competencies relate to key competencies of an ethical nature. Entry-to-practice competency requirements related to pain knowledge, skill and judgment were surveyed from national, provincial and territorial documents for dentistry, medicine, nursing, pharmacy, occupational therapy, physiotherapy, psychology and veterinary medicine. Dentistry included two and nursing included nine specific pain competencies. No references to competencies related to pain were found in the remaining health science documents. In contrast, the national competency requirements for veterinary medicine, surveyed as a comparison, included nine pain competencies. All documents included competencies pertaining to ethics. The lack of competencies related to pain has implications for advancing skillful and ethical practice. The lack of attention to pain competencies limits the capacity of health care professionals to alleviate suffering, foster autonomy and use resources justly. Influencing professional bodies to increase the number of required entry-to-practice pain competencies may ultimately have the greatest impact on education and practice.

The Perianesthesia Nurse's Role in the Prevention of Opioid-Related Sentinel Events

EVERY DAY IN hospitals nationwide, patients undergo surgery and receive large amounts of opioids for unrelieved postoperative pain, subsequently experiencing life-threatening opioid-induced respiratory depression. Based on the Joint Commission 2004 to 2011 database of reported opioidrelated sentinel events, 47% of reported events were the result of a wrong dose, 29% from improper monitoring, and 11% due to other factors such as excessive dosing, medication interactions, and adverse effects. In its sentinel event alert, the Joint Commission underscored the need for hospital staff to focus on safe opioid administration and vigilant monitoring of the effects of opioids.

Paediatrics pain management

Pain is one of the most common symptoms experienced the world over. It has always received the needed attention and care in the adult but not until recently among children. Several erroneous beliefs contributed to the inadequate attention among children such as assumption that children did not experience pain to the extent that adults do, because of the immaturenervous system, or that children would not remember the pain. A paediatrician is expected to be knowledgeable about pediatric painmanagement principles, provide a calm environment for painful procedures, use appropriate assessment tools and techniques, anticipatepainful experiences, use a multimodal approach (pharmacologic, cognitive,behavioral, and physical) to pain management, use a multidisciplinaryapproach when possible and involve families in creating solutions for their child’s pain. Studies have shown that the most common reason for unrelieved pain is failure to routinely assess pain and provide pain relief. The theories, pathways, transmission, regulations, classifications, assessment scales and the treatment of paediatric pain and practical issues that arise from the use of pharmacologic analgesic in the children were also reviewed and highlighted.

Pain Management in Persons Who Are Terminally Ill in Rural Acute Care

The multifaceted burden of facing a terminal illness is compounded further by unrelieved pain. This descriptive qualitative study explores nurse perceptions of barriers to and facilitators for effective pain management for persons who are terminally ill and are in an acute care rural setting. Major

Inflammatory predictors of ongoing pain 2 years following knee replacement surgery

IntroductionThe prevalence of unrelieved pain following total knee arthroplasty (TKA) is substantial. ObjectiveWe asked if cytokine markers of inflammation in preoperative serum or knee synovial fluid (SF) would predict pain 2 years following TKA. MethodsDemographic data and functional outcomes were recorded at baseline and 2 years with the WOMAC index. Serum and SF tissue samples were collected at the time of surgery. Linear regression modeling was used to determine the relationship between SF/serum inflammatory markers and a lesser improvement in self reported pain at two years follow-up. ResultsOf our 28 patient cohort, significant correlations between serum and SF levels were found for IL-1β (p<0.002), MIP-1β (p<0.001), adiponectin (p<0.001) and leptin (p<0.001). Adjusted analysis showed that greater SF concentrations of TNF-α, MMP-13 and IL-6 were independent predictors of less pain improvement at two years follow-up (p<0.05). ConclusionsThose patients, having ongoing pain despite no clinical or radiological cause, may have an inflammatory profile characterizing a predisposition to ongoing pain after TKA. Level of EvidencePrognosis study, Level 2.

Cochrane Review: Non‐pharmacological management of infant and young child procedural pain

AbstractBackgroundInfant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.ObjectivesTo assess the efficacy of non‐pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain‐related regulation).Search methodsWe searched CENTRAL inThe Cochrane Library(2011, Issue 1), MEDLINE (1966 to April 2011), EMBASE (1980 to April 2011), PsycINFO (1967 to April 2011), Cumulative Index to Nursing and Allied Health Literature (1982 to 2011), Dissertation Abstracts International (1980 to 2011) andwww.clinicaltrials.gov. We also searched reference lists and contacted researchers via electronic list‐serves.Selection criteriaParticipants included infants from birth to three years. Only randomized controlled trials (RCTs) or RCT cross‐overs that had a no‐treatment control comparison were eligible for inclusion in the analyses. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results.Data collection and analysisWe refined search strategies with three Cochrane‐affiliated librarians. At least two review authors extracted and rated 51 articles. Study quality ratings were based on a scale by Yates and colleagues. We analyzed the standardized mean difference (SMD) using the generic inverse variance method. We also provided qualitative descriptions of 20 relevant but excluded studies.Main resultsFifty‐one studies, with 3396 participants, were analyzed. The most commonly studied acute procedures were heel‐sticks (29 studies) and needles (n = 10 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non‐nutritive sucking‐related interventions (preterm: SMD ‐0.42; 95% CI ‐0.68 to ‐0.15; neonate: SMD ‐1.45, 95% CI ‐2.34 to ‐0.57), kangaroo care (preterm: SMD ‐1.12, 95% CI ‐2.04 to ‐0.21), and swaddling/facilitated tucking (preterm: SMD ‐0.97; 95% CI ‐1.63 to ‐0.31). For immediate pain‐related regulation, the largest SMDs were: non‐nutritive sucking‐related interventions (preterm: SMD ‐0.38; 95% CI ‐0.59 to ‐0.17; neonate: SMD ‐0.90, 95% CI ‐1.54 to ‐0.25), kangaroo care (SMD ‐0.77, 95% CI ‐1.50 to ‐0.03), swaddling/facilitated tucking (preterm: SMD ‐0.75; 95% CI ‐1.14 to ‐0.36), and rocking/holding (neonate: SMD ‐0.75; 95% CI ‐1.20 to ‐0.30).The presence of significant heterogeneity limited our confidence in the lack of findings for certain analyses.Authors' conclusionsThere is evidence that different non‐pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures.Plain Language SummaryNon‐pharmacological interventions for acute pain in infantsWe examined 13 different types of commonly investigated non‐pharmacological treatments (excluding breastmilk, sucrose, and music) to determine their efficacy for pain reactions after an acutely painful procedure (right after the needle ('pain reactivity') and less immediate pain reactions ('immediate pain‐related regulation').Fifty‐one randomized controlled trials were included involving 3396 participants. For preterm infants, there was sufficient evidence to recommend kangaroo care, sucking‐related interventions, and swaddling/facilitated tucking interventions for both pain reactivity and immediate pain‐related regulation. For neonates, there was sufficient evidence to recommend sucking‐related interventions as an effective treatment for pain reactivity and immediate pain‐related regulation.Rocking/holding was also found to be efficacious for neonatal immediate pain‐related regulation.For older infants, there were no treatments reviewed that demonstrated sufficient evidence. Due to significant differences in the magnitude of treatment effects among studies (heterogeneity), some analyses that found a lack of treatment effect need to be interpreted with caution.

Multivariate analysis of countries’ government and health-care system influences on opioid availability for cancer pain relief and palliative care: More than a function of human development

Background: Many international governmental and nongovernmental organizations regard unrelieved cancer pain as a significant global public health problem. Although opioids such as morphine are considered essential medicines in the provision of palliative care and for treating cancer pain, especially when the pain is severe, low- and middle-income countries often lack such medications. Aim: The primary aim of this study was to examine countries’ government and health-care system influences on opioid availability for cancer pain and palliative care, as a means to identify implications for improving appropriate access to prescription opioids. Design: A multivariate regression of 177 countries’ consumption of opioids (in milligrams/death from cancer and AIDS) contained country-level predictor variables related to public health, including Human Development Index, palliative care infrastructure, and health system resources and expenditures. Results: Results were highly explanatory (adjusted R2 = 82%) and Human Development Index was the most predictive variable when controlling for all other factors in the statistical model (B = 11.875, confidence interval = 10.216, 13.534, p < 0.0001). Conclusions: Study findings demonstrate that a limited number of predictor variables characterizing a country’s government and health-care system infrastructure can explain its opioid consumption level, with the greatest influence being very high Human Development Index. However, Human Development Index is not the most policy-relevant factor, and this finding should be reconciled against the reality that many countries with low or medium Human Development Index have succeeded in creating and sustaining a health-care system to strengthen cancer pain care and palliative care, including through the appropriate use of essential prescription opioids.

Management of cancer pain: ESMO Clinical Practice Guidelines

Management of cancer pain: ESMO Clinical Practice Guidelines

Entscheidungswege von onkologischen Patienten im Umgang mit Schmerzmedikamenten im häuslichen Umfeld: eine qualitative Sekundäranalyse

Unrelieved pain affects up to 75 % of cancer patients. Possible reasons for the undertreatment of pain are, amongst others, patient-related barriers towards cancer pain management. However the way patients decide on the use of analgesics remains unclear. The purpose of this qualitative study was to explore decision-making processes of four women and four men with diverse cancers concerning their pain medications. Audiotaped protocols of the 10-week-intervention and interviews of the PEINCA-pilot study provided data for a secondary analysis. This pilot study was conducted at a comprehensive cancer centre in Germany to test the German version of a cancer pain self-management intervention to enhance oncology patients' pain self-management for the first time. The data of purposively selected patients were analysed using content analysis. The results showed that these patients were very ambivalent about their analgesic use. The need to relieve severe pain conflicted with the desire to avoid opioids at any price. Decisions were reconsidered and overturned even after good experiences with analgesics. This study seems to provide a first look into decision-making processes over 10 weeks during a self-management education. Individually tailored counselling by a professional within the education programme helped the patients adopt new attitudes towards analgesics and gradually reduce their pain levels. Previous experiences of the patients and their possible ambivalence towards analgesics should be considered in a pain therapy, and patients should be coached by professionals.

Pain management

Despite published guidelines and educational programs on the assessment and treatment of cancer-related pain, in any stage of oncological disease, unrelieved pain continues to be a substantial worldwide public health concern either in patients with solid and haematological malignancies. The proper and regular self-reporting assessment of pain is the first step for an effective and individualized treatment. Opioids are the mainstay of analgesic therapy and can be associated with non-opioids drugs such as paracetamol or non-steroidal anti-inflammatory drugs and to adjuvant drugs (for neuropathic pain and symptom control). The role and the utility of weak opioids (i.e. codeine, dihydrocodeine, tramadol) are a controversy point. Morphine has been placed by World Health Organization on its Essential Drug List. In the comparative study with other strong opioids (hydromorphone, oxycodone), there is no evidence to show superiority or inferiority with morphine as the first choice opioid. Oral methadone is a useful and safe alternative to morphine. Methadone presents the potential to control pain difficult to manage with other opioids. although the oral route of opioid administration is considered the one of choice, intravenous, subcutaneous, rectal, transdermal, sublingual, intranasal, and spinal routes must be used in particular situation. Transdermal opioids such as fentanyl and buprenorphine are best reserved for patients whose opioid requirements are stable. Switching from one opioid to another can improve analgesia and tolerability.

Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial.

Unrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making. The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents. The study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger's Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility. The final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. LIMITATIONS/LESSONS: The investigators encountered several methodological challenges that were inherent to both the design and implementation of the study. The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment. It was difficult to identify valid, reliable, and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report. Another challenge was the inability to incorporate advances in implementation science into the ongoing study Methodological challenges are inevitable in the conduct of an RCT. The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study.

Patient-related predictors of poor-quality pain care in advanced lung cancer patients.

6062 Background: Unrelieved pain remains a major problem for all patients, including those with cancer, despite national standards for pain management. Screening and addressing pain is an integral part of oncology visits and an ASCO QOPI indicator of quality oncology care. The goal of this study was to assess associations between patient-related factors, particularly patient distress, and meeting ASCO quality metrics for appropriate management of pain in patients with advanced lung cancers. Identification of patient related factors could lead to targeted quality improvement efforts. Methods: From 8/07 to 9/10, we recruited consecutive new patients in a multidisciplinary thoracic oncology clinic to participate in a research database for which patients completed self-report instruments for distress, depression (PHQ-9) and anxiety (GAD-7), at their first oncology visit. We then performed a QOPI chart audit for patients with advanced lung cancer who received care at our institution. A composite measure of appropriate pain management was calculated. Components of the composite measure included 1) documentation of pain assessment, and 2) for patients with moderate-severe pain (≥4 on 10 point scale) plan of care documentation. Results: 253 patients completed baseline assessments and had follow up. Pain was assessed in 252 (99%) patients. Over a third (88/253) of newly diagnosed advanced lung cancer patients had at least moderate pain on their first visit to the medical oncologist. Almost half of patients with moderate-severe pain were depressed (40/88). Of the patients with moderate-severe pain, 54/88 (63%) had a plan of care related to pain documented in the oncologist’s note. In total, 219 (87%) patients received appropriate pain assessment and care. In a multivariate model including age, sex, histology, ECOG PS, provider, depression, and anxiety, only depression independently predicted inadequate pain care. Depressed patients were 3 times more likely to receive poor quality pain care (OR 2.75, 95% CI 1.04-7.25, p=0.04). Conclusions: At initial oncology visit, pain is present in over a third of patients with advanced lung cancer. Depression is highly co-morbid with pain and appears to be a risk factor for inadequate pain care.

Unrelieved pain: a major health care priority

Unrelieved pain: a major health care priority

Time to Take Stock: A Meta-Analysis and Systematic Review of Analgesic Treatment Disparities for Pain in the United States

The recent Institute of Medicine Report assessing the state of pain care in the United States acknowledged the lack of consistent data to describe the nature and magnitude of unrelieved pain and identify subpopulations with disproportionate burdens. We synthesized 20 years of cumulative evidence on racial/ethnic disparities in analgesic treatment for pain in the United States. Evidence was examined for the 1) magnitude of association between race/ethnicity and analgesic treatment; 2) subgroups at an increased risk; and 3) the effect of moderators (pain type, setting, study quality, and data collection period) on this association. United States studies with at least one explicit aim or analysis comparing analgesic treatment for pain between Whites and a minority group were included (SciVerse Scopus database, 1989-2011). Blacks/African Americans experienced both a higher number and magnitude of disparities than any other group in the analyses. Opioid treatment disparities were ameliorated for Hispanics/Latinos for "traumatic/surgical" pain (P = 0.293) but remained for "non-traumatic/nonsurgical" pain (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.64-0.77, P = 0.000). For Blacks/African Americans, opioid prescription disparities were present for both types of pain and were starker for "non-traumatic/nonsurgical" pain (OR = 0.66, 95% CI = 0.59-0.75, P = 0.000). In subanalyses, opioid treatment disparities for Blacks/African Americans remained consistent across pain types, settings, study quality, and data collection periods. Our study quantifies the magnitude of analgesic treatment disparities in subgroups of minorities. The size of the difference was sufficiently large to raise not only normative but quality and safety concerns. The treatment gap does not appear to be closing with time or existing policy initiatives. A concerted strategy is needed to reduce pain care disparities within the larger quality of care initiatives.

Comorbid Addiction At the End of Life: A Theoretical Approach (782)

1.Describe unmet palliative needs unique to those with comorbid addiction at the end of life.2.Explain risks of failed symptom management and hastened mortality in those with cormorbid addiction at the end of life.3.Apply theoretical approaches to enhance the unity and efficacy of interdisciplinary care planning, implementation and outcomes. Advanced, life limiting illness and comorbid addiction/history of substance abuse combine to present unique clinical challenges for professionals working in palliative care. A review of the literature identifies that substance abuse history combined with advanced disease often results in inadequate symptom management, especially unrelieved pain. This combination complicates symptom assessment and treatment; increasing the risk of treatment failure, or hastening morbidity and mortality. Integrated assessment and treatment can reduce suffering and improve quality of life. The purpose is to develop strategies to improve palliative care for those with comorbid addiction at the end of life. Primary Aims include improved assessment of problems and needs with enhancement of interdisciplinary care and outcomes for those with comorbid addiction at the end of life. A review of literature was conducted seeking a theoretical model to provide structure for addressing addiction/substance abuse history and concomitant advanced disease at end-of-life. Problem recognition and biopsychosocial need comprehension for dual diagnoses can evolve care towards healing and recovery. Adapting biopsychosocial theories offers a framework for integrated and progressive interdisciplinary care of symptoms, and transformation and transcendence despite illness. Care implementation consistent with these models can increase overall treatment adherence and efficacy, reduce suffering and improve quality of life.

Application of Clinical Microsystems Improves the Speed of the Initial Pain Relief in Sickle Cell Disease (SCD) Patients Admitted with Acute Vaso-Occlusive Crisis (VOC)

Abstract 4740 Background-The management of acute vaso-occlusive crisis continues to be a challenge in patients with sickle cell anemia. Long Island Jewish Medical Center is a 500 adult bed, tertiary care facility, with more than 500 reported admissions for acute vaso-occlusive crisis in 2009. Suboptimal pain management in the Emergency Department (ED) frequently resulted in unrelieved pain, recurrent admissions, prolonged hospitalization, and increased patient dissatisfaction. Methods-An interdisciplinary team which included a patient with SCD was assembled to meet weekly to address the above issues. The team was educated in Clinical Microsystem methods as described by Nelson et.al (1) over 6 months. Preliminary data was collected to assess performance with respect to pain management in adult SCD patients presenting to the ED through pain diaries. The admission process was analyzed and significant delays were noted from time of presentation to the time that sufficient sustained analgesia was achieved. The PDSA (Plan Do Study Act) cycle method to test and study change was utilized. The specific aim was to achieve a sustained 2 point reduction in subjective pain score within 2 hours of inpatient admission. Four interventions were simultaneously tested. First, given the high frequency of admission from our ED for this patient population, we tested proactive bed designation initiated when the patient presented to the ED. Second, we educated the housestaff on providing appropriately dosed narcotic administration upon admission after pharmacy verification of previous patient specific dose requirements. Third, we arranged expedited transfer to the medical floors for these patients. Lastly, we arranged for storage of PCA pumps on the medical unit designated for SCD patients, facilitating immediate initiation of pain medication via this modality. Timing of analgesic response was assessed based on patient interviews and the above mentioned diaries. Results-During the pre-intervention stage it took an average of 55 hours and 20 minutes to achieve a sustained reduction in pain by two points. Post intervention, the team achieved a sustained 2 point reduction in subjective pain score by an average of 9 hours and 58 minutes (see figure). Conclusion-The Clinical Microsystems Methodology is an effective means of engaging an interdisciplinary team in improving the initial analgesic response to treatment in sickle cell patients admitted with acute vaso-occlusive crisis. Disclosures:No relevant conflicts of interest to declare.