[Physicians' knowledge and attitudes concerning the use of opioids in the treatment of chronic cancer and non-cancer pain]

Assessment of the Community Pharmacists' Knowledge and Attitudes Toward Pain and Pain Management in Saudi Arabia

Background

Pain is a global health issue that affects an individual's quality of life. Its alleviation and management will enhance patients' experience. Community pharmacists can help manage pain severity through their valuable roles in medical teams and by managing the consequences of pain.

Objective

This study aimed to evaluate community pharmacists' knowledge and attitudes toward pain and pain management in Saudi Arabia.

Methods

A cross-sectional study was performed to evaluate community pharmacists' knowledge and attitudes toward pain and pain management in Saudi Arabia. Pharmacists aged ≥ 21 years, with a degree in pharmacy were included in this study. Each respondent participated in an online survey covering cancer-oriented pain and assessment of pain; pharmacology; abuse of substances; and physical dependence. An independent t-test and One-way ANOVA, with least significant difference as a post-hoc test, were employed, in addition to the General Linear Regression Model using Main Effect as the model.

Results

This study revealed that the pain-related knowledge and attitude among community pharmacists in Saudi Arabia were inadequate. Age (p = 0.003), work experience (p = 0.036), nature of work (p = 0.001), and work location (p = 0.003) were determined as significant factors affecting their overall knowledge and attitude toward pain.

Conclusion

Overall, attempts to expand community pharmacists' knowledge and foster an appropriate attitude toward pain management among them in Saudi Arabia are highly recommended. Additional academic courses, studies, and tailored neuroscience courses will improve their awareness and knowledge of pain and pain management.

[Use of rapid-onset fentanyl preparations beyond indication : A random questionnaire survey among congress participants and pain physicians]

BACKGROUND

Despite publicised advice and warnings, there are only scant data on the non-indicated prescription of rapid-onset preparations of fentanyl (ROF) in non-cancer pain (NCP). Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation.

OBJECTIVE

Initiated by the Working Group Cancer Pain and supported by the German Pain Society, a random sample survey was conducted to assess the non-indicated use of ROF.

METHODS

The survey addressed attendees of pain conferences who were given the option to fill in the questionnaires outside the conference or online. Primary endpoints of the structured questionnaire were quantitative and qualitative items with regard to the prescription of ROF, while secondary endpoints were opioid-induced side effects.

RESULTS

Obtaining a response rate of 44% (132/300) and an additional 51 online questionnaires revealed that 165 (90%) respondents had knowledge of non-indicated prescriptions or were involved in these. Of these, 65% were clinicians and 17% worked in an outpatient capacity. In all, 22% were trained pain or palliative physicians. Approximately 1205 patients were assessed indirectly. The main causes for dispensing ROF included NCP entities such as back pain (44%), neuropathic pain (33%), head or facial pain (12%), and dyspnea (5%) in cancer pain or lack of break-through pain or basic medication (44%). Sedation (32%), nausea/vomiting (31%), constipation (16%) and insufficient analgesia (31%) were the mostly commonly reported adverse effects.

CONCLUSION

Despite the non-ambiguous indication for ROF, physicians often demonstrate inappropriate prescription behaviour. Iatrogenic misuse of ROF should be minimized. The rates of adverse effects of ROF seems to be in line with other opioids.

Pain knowledge and attitudes of final-year medical students at the University of Cape Town: A cross-sectional survey

Background

Pain is the most common presenting complaint in patients visiting a healthcare facility. Healthcare professionals need adequate knowledge of pain to be able to manage it effectively.

Aim

The aim of this study was to determine the pain knowledge and attitudes of the 2018 final-year medical students at the University of Cape Town (UCT).

Setting

This study was conducted by the Department of Anaesthesia and Perioperative Medicine in the Faculty of Health Sciences, UCT, South Africa, with final-year medical students.

Methods

Unruh’s Modified Pain Knowledge and Attitudes (MPKA) questionnaire was utilised to collect data in a cross-sectional survey using an Internet-based electronic format.

Results

A total of 104 students out of 232 students in the class (44.8%) participated in the study. The total median score on the MPKA questionnaire was 46 (interquartile range [IQR] 44–50.5) out of 57, or 80.7% (IQR 77.2–88.6%). The participants performed worst in the section on the pharmacological management of pain with median scores of 6 (IQR 4–8) (55%) correct out of 11 questions.

Conclusion

Pain knowledge, especially with regard to the pharmacological aspects of pain management, has some important deficiencies in these final-year medical students. It appears that the undergraduate curriculum and teaching thereof would benefit from a review of the pain curriculum.

Changes in Pain Medication Profile among Patients Admitted to Specialized Home Palliative Care in Relation to Referral Source: An Exploratory Study

Pain is a common symptom leading to referrals to specialized home palliative care (SHPC) services and is known to affect patients' quality of life. To date, little is known about the impact of referral source on its management. To assess changes to pain medication profile in the course of SHPC and to identify potential differences in relation to referral source. This exploratory study is a retrospective analysis of 501 electronic medical records of a SHPC team in Germany. This included the assessment of baseline pain medication profiles according to the WHO analgesic ladder and changes to analgesic treatment in the course of SHPC with respect to referral source. At the time of admission, 77.4% of patients referred by a hospital and 78.8% of patients referred by the outpatient sector received a fixed analgesic regimen. In all, 61.9% of the inpatient group versus 62.9% of the outpatient group were treated with opioids, and 79.0% received modifications to pain medication at one point in time following admission. Thereby, patients referred by the outpatient sector received significantly earlier modifications and more supplementations of pain medication. Our study suggests positive development in the prescription of opioid analgesics compared to earlier studies in Germany. On the one hand, it highlights the relevance of thorough assessment and responsive evaluation of pain in SHPC, and on the other hand it reveals possible training needs of referring physicians, particularly those working in the outpatient sector. Our results inspired further research examining more closely the links between referral source and pain management.

Pain therapy - Are there new options on the horizon?

This article reviews the role of analgesic drugs with a particular emphasis on opioids. Opioids are the oldest and most potent drugs for the treatment of severe pain, but they are burdened by detrimental side effects such as respiratory depression, addiction, sedation, nausea, and constipation. Their clinical application is undisputed in acute (e.g., perioperative) and cancer pain, but their long-term use in chronic pain has met increasing scrutiny and has contributed to the current opioid crisis. We discuss epidemiological data, pharmacological principles, clinical applications, and research strategies aiming at novel opioids with reduced side effects.

[The effects of setting a standard in the acute pain therapy on a ward : Parameters for patient and provider satisfaction and cost structure (STANDAKU)]

BACKGROUND

There is neither a "gold standard" nor commonly approved therapy goals in postoperative pain therapy. In a multi-center study, more than 80% of all patients treated stated that they suffered from postoperative pain. Moreover, patients evaluated the pain therapy as significantly worse than other medical or nursing practices. Therefore, there is a need for optimization in therapy for acute pain.

OBJECTIVES

The goal of our project was to figure out if the introduction of a "pain treatment standard" would increase the satisfaction of patients, physicians, and nurses, and reduce the costs of pain-related medicine.

MATERIALS AND METHODS

Overall, 2769 patients and 285 providers (202 nurses and 83 physicians) were polled. The medication costs in ten areas of the ward were evaluated and compared. The providers were offered a training course on the "pain standard" and it was officially introduced onto the wards. After some time, the satisfaction of patients and providers and the use of medicine were recorded again.

RESULTS AND DISCUSSION

The maximum pain values declared by the patients significantly decreased after the introduction of the "pain standard." The satisfaction with pain therapy significantly increased for the patients and for the providers. The reported minimum pain values of the patients did not change significantly. The costs of pain medicine slightly increased. In general, there was a positive effect of introducing a "pain standard" for patients and providers.

Dependence on Prescription Opioids

BACKGROUND

The incidence of initial prescriptions of opioids for chronic non-cancer pain rose by 37% in Germany from 2000 to 2010. Prescribing practice does not always conform with the recommendations of current guidelines. In the USA, 8-12% of patients with chronic non-cancer pain are opioid-dependent.

METHODS

This review is based on publications retrieved by a selective PubMed search and on the German S3 guideline on the long-term use of opioids in non-cancer pain.

RESULTS

Patients must be informed and counseled about the effects and risks of opioids before these drugs are prescribed. All opioid prescriptions for patients with chronic non-cancer pain should be regularly reviewed. The risk of abuse is high in young adults (odds ratio [OR] = 6.74) and in those with a history of substance abuse (OR = 2.34). Any unusual medication-related behavior, e.g., loss of prescriptions or increasing the dose without prior discussion with the physician, calls for further assessment by the physician in conversation with the patient. Urine testing for drugs and their metabolites is helpful as well. The goal of treatment of opioid abuse is opioid abstinence by gradual reduction of the dose. If this is not possible on an outpatient basis, hospitalization for drug withdrawal or substitution-based addiction therapy can be offered.

CONCLUSION

Physicians who know the indications and risks of opioid therapy and the typical behavior of drug-dependent patients will be better able to identify patients at risk and to prevent dependence. Studies on the prevalence of opioid abuse and dependence in German patients with chronic pain can help provide better estimates of the current extent and implications of this problem in Germany.

A description of clinical characteristics and treatment patterns observed within prescribed opioid users in Germany and the UK

SUMMARY 

Aims: To describe a cohort of new opioid users (adult noncancer patients) in terms of clinical characteristics and treatment patterns in the UK and Germany. Material & methods: Data used were extracted from electronic medical records databases (UK: Clinical Practice Research Database-Hospital Episode Statistics; Germany: IMS Disease Analyzer) covering the 2008–2012 period. Results: Most eligible patients were treated with opioids for less than 6 months (UK: 78.7% and Germany: 93.7%) and indexed on weak opioids (UK: 89.5% and Germany: 88.6%). Most prescribed opioids were codeine (UK) and tramadol (Germany). Most prevalent comorbidities were dorsalgia/depression. Constipation was observed in 16.8%/17.4% (UK/Germany) of chronic users (>6 months). Conclusion: While both populations were highly morbid populations largely initiated on weak opioids, chronic use was less common in Germany.

Ask The Experts: Critical issues in cancer pain management

Rainer Sabatowski qualified as anesthesiologist in 1995 and as pain specialist in 2003. He was head of a pain clinic at the University of Cologne, Germany, from 2002 to 2007. Since 2007 he has been head of the Comprehensive Pain Center at the University Hospital "Carl Gustav Carus" at the Technical University Dresden (Germany). This is an integrated center with a focus on cancer pain management in cooperation with the Comprehensive Cancer Center (UCC) and multimodal programs for the treatment of chronic noncancer pain patients. He performed several studies on the topic of the impact of opioids on cognitive and psychomotor function and worked as an external consultant of the European Driving under the Influence of Drugs, Alcohol and Medicines (DRUID) project. Currently his team works on - among other topics - spouses' impact on the chronification processes in noncancer pain patients and on the implementation and evaluation of multimodal pain management programs for different pain populations, as well as in different clinical settings. He has spoken at many national and international pain meetings and was scientific chair of the 8th Palliative Care Congress of the German Society of Palliative Care in Dresden in 2010. He has published over 100 papers and book chapters and is on the editorial board of several pain journals. He is also a member of the advisory board of the German IASP chapter and works in several focus groups of this pain society.

[Prescription of high-potency opioids in 2011]

BACKGROUND

The aim of this study was to analyze the prescription of high-potency (WHO step III) opioids with respect to regional differences and to assess the proportion of opioid-naïve new users of transdermal fentanyl.

METHODS

Prescription claims data of the largest single German health fund (BARMER GEK) with 9.1 million insured persons from the year 2011 were used. For new users of transdermal fentanyl who had had no prescription in the preceding 6 months it was studied whether they had received other high-potency or low-potency opioids before.

RESULTS

A total of 18.9 million defined daily doses (DDD) of high-potency opioids were included corresponding to a mean of 208.6 DDD per 100 persons. Significant regional differences were found with lower values in the south, ranging from 145.9 DDD in Baden-Württemberg to 259.5 DDD per 100 persons in Lower Saxony. Fentanyl was the most frequently used step III opioid (40.8% of DDDs) which is nearly only given transdermally. Of the 11,184 patients with new use of transdermal fentanyl 80.7% had received no other high-potency opioid before and 52.9% had received neither low-potency nor high-potency opioids before. The first prescription exceeded the smallest available dose of 12.5 μg/h for over half of the patients starting treatment.

CONCLUSIONS

Although oral morphine, oxycodone and hydromorphone are recommended as first-line step III opioids, transdermal fentanyl seems to be prescribed too often as the first choice and might not be appropriate.

[Interprofessional education in pain management: development strategies for an interprofessional core curriculum for health professionals in German-speaking countries]

The care of patients, suffering from acute, chronic, or malignant pain, requires systematic and interprofessional collaboration between all team members to ensure a holistic approach to pain management. In doing so, the different professions are often in a competitive, tense, or dependent relationship resulting from a lack of precise definitions and concepts regarding their responsibilities in the wide field of pain management. Considering pain management as a whole, we can define numerous interfaces concerning competencies and tasks which may open up some new perspectives on concepts of interprofessional education (IPE). Internationally, there have been many attempts to establish concepts of interprofessional education, and it is considered a great challenge to improve continuing medical education. However, interdisciplinary subjects like pain management may benefit from it. Apart from enhancing specialized knowledge, interprofessional education aims to consider the different roles, skills, and responsibilities as well as interprofessional strategies of decision-making. In Germany, only a few efforts have been made with regard to interprofessional pain education. In the following paper, different challenges, tasks, and roles within the field of pain management are discussed in the sense of potential areas of collaboration in the context of interprofessional education. Against this background, the Regensburg model for interprofessional pain management education is described as one national program to enhance the effectiveness of pain management.

Increase in opiate prescription in Germany between 2000 and 2010: a study based on insurance data

BACKGROUND

Insufficient data have been available to date on the prevalence of opioid treatment in Germany, physicians' prescribing habits, and the percentages of cancer patients and non-cancer patients among those receiving opioids for an evaluation of the quality of care and an assessment of possible underuse or misuse.

METHODS

The data analyzed in this study were derived from the statutory health insurance sample of the AOK health insurance company in the German state of Hesse / ASHIP Hesse for the years 2000-2010. For the purpose of this study, prevalence was defined as the percentage of insurees who received at least one outpatient prescription of an opioid (ATC N02A, excluding codeine, levomethadone and methadone). In order to control for population aging, the prevalence was standardized to the German population on December 31(st) of the preceding year and to the age-structure of the population as it was in 1999. Opioid prescribing for cancer was assumed when a cancer diagnosis was documented in the same year in which the opioid prescription was issued.

RESULTS

The percentage of insurees receiving at least one opioid prescription rose over the period of the study from 3.31% in 2000 to 4.53% in 2010, a relative gain of 37%. Opioids were mostly prescribed to patients with non-cancer pain (2010: about 77% of opioid recipients). The percentage of non-cancer patients receiving long-term opioid treatment has also increased over the period of the study.

CONCLUSION

As opioids are frequently prescribed for non-cancer pain, it cannot be inferred from the observed increase in opioid prescribing that cancer patients are now receiving better opioid treatment than they were before. Further issues of concern are the observed increases in the prescribing of potent immediate release opioids and in the long-term opioid treatment for non-cancer patients, the benefit of which is currently debated.

The international CHANGE PAIN physician survey: does specialism influence the perception of pain and its treatment?

OBJECTIVES

This survey explores how physicians perceive chronic non-cancer pain, and examines their opinions on current treatment options.

METHODOLOGY

The computer-based survey comprises a questionnaire that is completed by physicians, mostly at professional conferences and congresses, but also online. The focus is on pain specialists, primary care physicians and other specialists (such as neurologists and rheumatologists), to discover any differences in their approach to treating chronic non-cancer pain.

RESULTS

No common understanding existed of where severe pain starts on an 11-point Numeric Rating Scale. Overall, two-thirds of respondents aim for treatment to reduce pain intensity to an NRS score of 2-4, with primary care physicians tending to aim for lower scores. All three groups considered reduction of pain to be the most important treatment goal, followed by quality of life. Asked to rank the most important factors when choosing an analgesic agent to treat severe, chronic non-cancer pain, respondents ranked efficacy first, tolerability second, and quality of life third. In each rank, more primary care physicians chose these options than in the specialist groups. More pain specialists used classical strong opioids often or very often - and for longer - than did physicians in the other two groups. Nausea/vomiting, bowel dysfunction and somnolence were ranked the first, second and third main reasons, respectively, for treatment failure with these agents. Over 90% of respondents used combination treatment rather than monotherapy to treat severe, chronic pain, but no fewer than 176 different combinations were cited.

CONCLUSIONS

Pain reduction and improvement in quality of life are the most important treatment goals. Wide variation in treatment indicates that no single drug is particularly good for managing chronic pain, and suggests that current treatment is not evidence-based. Differences between the groups imply that first-line treatment is more cautious and conventional. The key limitations of this survey include its small sample size, informal implementation and lack of detail regarding the respondents surveyed.

[Physicians' knowledge on cancer pain therapy : Comparison of palliative care and prehospital emergency physicians in training]

BACKGROUND

Palliative care needs a high level of expertise. In particular, there are some potential difficulties in the treatment of patients with the symptom cancer pain (for example lack of education). In Germany, various physicians are involved in cancer pain treatment but in general palliative care patients are treated by a physician who is educated in palliative medicine. In special circumstances prehospital emergency physicians and other physicians are involved in therapy decisions in palliative care patients as well. The authors surveyed different groups of physicians in Germany about their specific knowledge of cancer pain management.

MATERIAL AND METHODS

A self-designed, standardized questionnaire (50 items) was given to palliative physicians in training (PP). The survey asked prospectively for knowledge on the World Health Organization (WHO) step ladder of cancer pain therapy. The results were retrolectively compared with an earlier investigation with the same background (emergency physicians in training EP).

RESULTS

There was a 99.5% response rate with a total of 654 respondents (PP 185, EP 469) and 461 (70.5%) of the respondents had knowledge of the WHO step ladder for the treatment of cancer pain [PP 164/185 (88.6%), EP 297/469 (63.3%), PP versus EP p < 0.001)]. The correct numbers of therapeutic levels were known by 361/461 participants [PP 151/164 (92.1%), EP 210/297 (70.7%), p < 0.001].The EPs with a professional experience less than 5 years answered statistically significantly more questions correctly (p = 0.004). Concerning the defined parameters knowledge and professional experience, there was no statistically significant difference in the group of PP.

CONCLUSIONS

The results of this study verified that the highest knowledge scores were achieved by PPs and overall, the knowledge scores showed an improvement in comparison to previous investigations. In recent years there seems to have been an improvement in education on pain treatment,for example during medical school. Whether this also leads to an improvement of patient care and the relevance of these data for the clinical practice needs to be investigated in further studies.