Moving Beyond Pain as the Fifth Vital Sign and Patient Satisfaction Scores to Improve Pain Care in the 21st Century

Pain intensity scales: A cross-sectional study on the preferences and knowledge of physiotherapists and participants with musculoskeletal pain

BACKGROUND

Subjective pain intensity can be measured using instruments like the Faces Pain Scale-Revised (FPS-R), Verbal Rating Scale (VRS), Numerical Pain Rating Scale (NPRS), and Visual Analogue Scale (VAS). However, information on physiotherapists' and patients' knowledge and preference for these tools is scarce.

OBJECTIVE

We investigated the knowledge and preference of physiotherapists and participants with musculoskeletal pain (MP) regarding the pain intensity measurement scales.

METHODS

This cross-sectional study consisted of physiotherapists and participants with MP. Physiotherapists were recruited via social media for an online open survey, gathering sociodemographic, professional data, and their knowledge and preferences for pain intensity scales. Participants over 18 with MP, participated in interviews focusing on their familiarity and preferences for pain intensity scales. Data was analyzed descriptively, and Chi-squared test evaluated scale preferences.

RESULTS

We included 352 physiotherapists (mean experience = 10.5 years) and 94 participants with MP. Of the physiotherapists, 94.3% were familiar with pain scales, but 30.4% struggled to differentiate them. The NPRS was the most used (56.3%) and preferred scale (52.4%). Among participants with MP, unfamiliarity was noted with all scales. After instruction, 46% preferred FPS-R, with preference varying by income and education levels (p < 0.001).

CONCLUSION

We found a knowledge gap among physiotherapists in identifying pain intensity scales, with a preference for the NPRS among those familiar with the scales. Participants with MP had limited familiarity with these scales. After instructions, these participants preferred the FPS-R, particularly those with lower income and education levels.

The impact of opioid versus non-opioid analgesics on postoperative pain level, quality of life, and outcomes in ventral hernia repair

PURPOSE

Managing postoperative pain remains a significant challenge in hernia operations. With ventral hernia repair (VHR) being one of the most commonly performed procedures, this study aimed to compare the effectiveness of non-opioid analgesia to opioid-based regimens for postoperative pain management.

METHODS

The Abdominal Core Health Quality Collaborative was queried for elective VHR patients between 2019-2022. Subjects prescribed opioid or non-opioid analgesics at discharge were matched using a propensity score. Postoperative Hernia-Related Quality of Life Survey (HerQLes) summary scores, Patient-Reported Outcome Measurement Information System (PROMIS) 3a questionnaire, and clinical outcomes were compared between the two groups.

RESULTS

1,051 patients who underwent VHR met the study criteria. The 2:1 matched demographics were opioids (n = 188) and non-opioids (n = 94) (median age 63, 48% females, 91% white, and 6.5 cm hernia length). Long-term (1-year post-operation) patients' pain levels were similar between opioids vs non-opioids (median (IQR): 31(31-40) vs. 31(31-40), p = 0.46), and HerQLes summary scores were similar (92(78-100) vs. 90(59-95), p = 0.052). Clinical short-term (30-days post-operation) outcomes between opioid vs non-opioid patients had similar length-of-stay (1(0-5) vs 2(0-6), P = 0.089), readmissions (3% vs. 1%, P = 0.28), recurrences (0% vs. 0%, P = 1), reoperations (1% vs. 0%, P = 0.55), surgical site infections (3% vs. 7%, P = 0.11), surgical site occurrences (5% vs. 6%, P = 0.57), and surgical site occurrences requiring procedural intervention (3% vs. 6%, P = 0.13). Finally, long-term recurrence rates were similar (12% vs. 12%, P = 1).

CONCLUSION

Non-opioid postoperative regimens for analgesia are non-inferior to opioids in VHR patients with similar outcomes. Aggressive efforts should be undertaken to reduce opioid use in this population.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Trauma Patients and Acute Compartment Syndrome: Is There an Ariadne's Thread That Can Safely Guide the Anesthesiologist/Emergency Physician Out of the Labyrinth?

Trauma patients in the emergency department experience severe pain that is not always easy to manage. The risk of acute compartment syndrome further complicates the analgesic approach. The purpose of this review is to discuss relevant bibliography and highlight current guidelines and recommendations for the safe practice of peripheral nerve blocks in this special group of patients. According to the recent bibliography, peripheral nerve blocks are not contraindicated in patients at risk of acute compartment syndrome, as long as there is surveillance and certain recommendations are followed.

Music to relieve pain and anxiety in cardiac catheterization: A systematic review and meta-analysis

Objectiveto evaluate the effectiveness of using music to relieve pain, anxiety, and change in vital signs in adult and older adult patients undergoing cardiac catheterization.Methodsthis is a systematic review with meta-analysis carried out in October 2022, using 12 data sources, without time or language restrictions. The study followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The "Risk-of-bias tool" was used to assess the risk of bias, the "R CORE Team program: A language and environment for statistical computing" was used to perform the meta-analysis, and the "Grading of Recommendations Assessment, Development and Evaluation" was used to assess the quality of evidence in the studies.

Results

a total of nine studies were included, totaling 1456 participants. The most used tools for measuring anxiety were the State-Trait Anxiety Inventory and Numerical Rating Scale. This was also used to measure pain, in addition to the Visual Analogue Scale. The use of instrumental, classical and relaxing music prevailed, applied using headphones during the painful procedure, at a frequency of 60 to 100bpm and sound intensity of 60-70 dB. There was statistical significance in the use of music in reducing pain, anxiety and systolic blood pressure.

Conclusion

music interventions are effective in relieving pain, reducing systolic pressure and anxiety, but indifferent in terms of heart rate, respiratory rate and diastolic pressure. They provide humanization of care, can reduce hospital costs and length of hospital stay.

The burden of significant pain in the cirrhosis population: Risk factors, analgesic use, and impact on health care utilization and clinical outcomes

BACKGROUND

We aimed to characterize pain and analgesic use in a large contemporary cohort of patients with cirrhosis and to associate pain with unplanned health care utilization and clinical outcomes in this population.

METHODS

We included all patients with cirrhosis seen in UCSF hepatology clinics from 2013 to 2020. Pain severity and location were determined using documented pain scores at the initial visit; "significant pain" was defined as moderate or severe using established cutoffs. Demographic, clinical, and medication data were abstracted from electronic medical records. Associations between significant pain and our primary outcome of 1-year unplanned health care utilization (ie, emergency department visit or hospitalization) and our secondary outcomes of mortality and liver transplantation were explored in multivariable models.

RESULTS

Among 5333 patients with cirrhosis, 32% had a nonzero pain score at their initial visit and 25% had significant (ie moderate/severe) pain. Sixty percent of patients with significant pain used ≥1 analgesic; 34% used opioids. Patients with cirrhosis with significant pain had similar Model for End-Stage Liver Disease-Sodium scores (14 vs. 13), but higher rates of decompensation (65% vs. 55%). The most common pain location was the abdomen (44%). Patients with abdominal pain, compared to pain in other locations, were more likely to have decompensation (72% vs. 56%). Significant pain was independently associated with unplanned health care utilization (adjusted odds ratio: 1.3, 95% CI: 1.1-1.5) and mortality (adjusted hazard ratio: 1.4, 95% CI: 1.2-1.6).

CONCLUSIONS

Pain among patients with cirrhosis is often not well-controlled despite analgesic use, and significant pain is associated with unplanned health care utilization and mortality in this population. Effectively identifying and treating pain are essential in reducing costs and improving quality of life and outcomes among patients with cirrhosis.

The effect of local injection of bupivacaine with and without fentanyl at the operative site in mandibular open reduction on acute pain intensity and opioid requirement: a randomized clinical trial

PURPOSE

The aim of this study is to investigate the effects of bupivacaine local injection with and without fentanyl at the operative site in mandibular open reduction surgeries on the severity of acute pain and the need for opioids.

METHODS

This randomized clinical trial, age-sex-matched double-blind study included 44 patients with isolated mandibular fractures who would be candidates for open reduction. They were divided into two groups (intervention using fentanyl and control not using fentanyl). In both groups, the amount of opioid used, hemodynamic indices, oxygen saturation, and pain intensity were collected based on the Visual Analogue Scale (VAS) every 4 h for 24 h.

RESULTS

As for basic and demographic variables such as gender, age, ASA class, and duration of surgery (P > 0.05), there was neither a significant difference between the two groups nor was there any difference in nausea and vomiting and subsequent anti-nausea medication (P > 0.05). The need for a post-operative opioid in the bupivacaine + fentanyl group (13.6%) was significantly less than in those who received only bupivacaine (45.5%) (P < 0.05). Changes in pain scores over time were significantly different in the two groups, and bupivacaine + fentanyl reduced pain more than bupivacaine (P < 0.05). However, over time, there was no significant difference between the two groups in terms of changes in oxygen saturation, heart rate, systolic blood pressure, and diastolic blood pressure (P > 0.05).

CONCLUSION

The addition of fentanyl to bupivacaine for supraperiosteal injection in the open reduction surgery site reduces post-operative pain in the first 24 h and reduces the need for opioids without causing complications such as nausea and vomiting.

A Pharmacogenomics-Based In Silico Investigation of Opioid Prescribing in Post-operative Spine Pain Management and Personalized Therapy

Considering the variability in individual responses to opioids and the growing concerns about opioid addiction, prescribing opioids for postoperative pain management after spine surgery presents significant challenges. Therefore, this study undertook a novel pharmacogenomics-based in silico investigation of FDA-approved opioid medications. The DrugBank database was employed to identify all FDA-approved opioids. Subsequently, the PharmGKB database was utilized to filter through all variant annotations associated with the relevant genes. In addition, the dpSNP ( https://www.ncbi.nlm.nih.gov/snp/ ), a publicly accessible repository, was used. Additional analyses were conducted using STRING-MODEL (version 12), Cytoscape (version 3.10.1), miRTargetLink.2, and NetworkAnalyst (version 3). The study identified 125 target genes of FDA-approved opioids, encompassing 7019 variant annotations. Of these, 3088 annotations were significant and pertained to 78 genes. During variant annotation assessments (VAA), 672 variants remained after filtration. Further in-depth filtration based on variant functions yielded 302 final filtered variants across 56 genes. The Monoamine GPCRs pathway emerged as the most significant signaling pathway. Protein-protein interaction (PPI) analysis revealed a fully connected network comprising 55 genes. Gene-miRNA Interaction (GMI) analysis of these 55 candidate genes identified miR-16-5p as a pivotal miRNA in this network. Protein-Drug Interaction (PDI) assessment showed that multiple drugs, including Ibuprofen, Nicotine, Tramadol, Haloperidol, Ketamine, L-Glutamic Acid, Caffeine, Citalopram, and Naloxone, had more than one interaction. Furthermore, Protein-Chemical Interaction (PCI) analysis highlighted that ABCB1, BCL2, CYP1A2, KCNH2, PTGS2, and DRD2 were key targets of the proposed chemicals. Notably, 10 chemicals, including carbamylhydrazine, tetrahydropalmatine, Terazosin, beta-methylcholine, rubimaillin, and quinelorane, demonstrated dual interactions with the aforementioned target genes. This comprehensive review offers multiple strong, evidence-based in silico findings regarding opioid prescribing in spine pain management, introducing 55 potential genes. The insights from this report can be applied in exome analysis as a pharmacogenomics (PGx) panel for pain susceptibility, facilitating individualized opioid prescribing through genotyping of related variants. The article also points out that African Americans represent an important group that displays a high catabolism of opioids and suggest the need for a personalized therapeutic approach based on genetic information.

A multi-ancestry genetic study of pain intensity in 598,339 veterans

Chronic pain is a common problem, with more than one-fifth of adult Americans reporting pain daily or on most days. It adversely affects the quality of life and imposes substantial personal and economic costs. Efforts to treat chronic pain using opioids had a central role in precipitating the opioid crisis. Despite an estimated heritability of 25-50%, the genetic architecture of chronic pain is not well-characterized, in part because studies have largely been limited to samples of European ancestry. To help address this knowledge gap, we conducted a cross-ancestry meta-analysis of pain intensity in 598,339 participants in the Million Veteran Program, which identified 126 independent genetic loci, 69 of which are new. Pain intensity was genetically correlated with other pain phenotypes, level of substance use and substance use disorders, other psychiatric traits, education level and cognitive traits. Integration of the genome-wide association studies findings with functional genomics data shows enrichment for putatively causal genes (n = 142) and proteins (n = 14) expressed in brain tissues, specifically in GABAergic neurons. Drug repurposing analysis identified anticonvulsants, β-blockers and calcium-channel blockers, among other drug groups, as having potential analgesic effects. Our results provide insights into key molecular contributors to the experience of pain and highlight attractive drug targets.

Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients

BACKGROUND

Central to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering.

AIMS

The purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients.

DESIGN

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks.

SETTINGS

On a six-bed adult inpatient Palliative Care Unit (PCU).

PARTICIPANTS/SUBJECTS

Nonverbal palliative care patients.

METHODS

Evidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption.

RESULTS

Nurses' attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores.

CONCLUSIONS

MOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

Effects of comprehensive medication review on opioid overuse among medicare beneficiaries

Objectives

This study examined the effects of the comprehensive medication review of Medicare medication therapy management programs on opioid overuse among Medicare beneficiaries.

Methods

This retrospective study analyzed Medicare data from 2016 to 2017. The intervention group included Medicare beneficiaries who newly received comprehensive medication review in 2017; the control group referred to patients who met the general eligible criteria for the medication therapy management program but did not enroll in 2016 or 2017. Propensity score matching was performed to increase characteristic compatibility between the intervention and control groups. Three measures of opioid overuse were analyzed: use of opioids at a high dosage, use of opioids from multiple providers, and concurrent use of opioids and benzodiazepines. The effects of comprehensive medication review on opioid overuse were analyzed with a multivariate logistic regression with an interaction term between the receipt of comprehensive medication review and the year 2017.

Key Findings

The proportion of concurrent use of opioids and benzodiazepines declined at a greater rate among the recipients (2.21%) than non-recipients (1.55%) of the comprehensive medication review. In the adjusted analysis, the odds ratio of no concurrent use of opioids and benzodiazepines was 5% higher (1.05; 95% confidence interval = 1.02-1.09) among recipients than non-recipients. These significant findings were not found for the other two measures of opioid overuse.

Conclusions

Comprehensive medication review is associated with reduced concurrent use of opioids and benzodiazepines among Medicare beneficiaries. Such service should be incorporated into the current approaches for addressing the opioid epidemic.

Development, refinement, and validation of an equine musculoskeletal pain scale

Musculoskeletal disease is a common cause of chronic pain that is often overlooked and inadequately treated, impacting the quality of life of humans and horses alike. Lameness due to musculoskeletal pain is prevalent in horses, but the perception of pain by owners is low compared with veterinary diagnosis. Therefore, this study aims to establish and validate a pain scale for chronic equine orthopaedic pain that is user-friendly for horse owners and veterinarians to facilitate the identification and monitoring of pain in horses. The newly developed musculoskeletal pain scale (MPS) was applied to 154 horses (mean age 20 ± 6.4 years SD) housed at an equine sanctuary, of which 128 (83%) suffered from chronic orthopaedic disease. To complete the MPS, the horses were observed and videotaped from a distance while at rest in their box or enclosure. In addition, they received a complete clinical and orthopaedic exam. The need for veterinary intervention to address pain (assessed and executed by the sanctuary independent from this study) was used as a longitudinal health outcome to determine the MPS's predictive validity. To determine the interrater agreement, the MPS was scored for a randomly selected subset of 30 horses by six additional blinded raters, three equine veterinary practitioners, and three experienced equestrians. An iterative process was used to refine the tool based on improvements in the MPS's correlation with lameness evaluated at the walk and trot, predictive validity for longitudinal health outcomes, and interrater agreement. The intraclass correlation improved from 0.77 of the original MPS to 0.88 of the refined version (95% confidence interval: 0.8-0.94). The refined MPS correlated significantly with lameness at the walk (r = 0.44, p = 0.001) and trot (r = 0.5, p < 0.0001). The refined MPS significantly differed between horses that needed veterinary intervention (mean MPS = 8.6) and those that did not (mean MPS = 5.0, p = 0.0007). In summary, the MPS showed good interrater repeatability between expert and lay scorers, significant correlation with lameness at the walk and trot, and good predictive validity for longitudinal health outcomes, confirming its ability to identify horses with orthopaedic health problems.

Pills and the damage done: the opioid epidemic as man-made crisis

The prescription opioid epidemic has slowly evolved over the past quarter century with increasingly detrimental consequences for public health. Man-made crises are often unforeseen and characterized by a situation without natural causes where - because of human intent, error, negligence, or the failure of manmade systems - the level of needs in the population exceeds available resources to counter the problem. This paper presents the prescription opioid epidemic as a man-made crisis and explores the public health impact of opioid manufacturers and other industries producing commodities with addictive potential as a shared vulnerability among countries. We examine this concept within the framework of the commercial determinants of health. We address three key aspects of the commercial determinants of health: (1) Cross-industry mechanisms, (2) policy inertia, and (3) the role of industry in science. Within cross-industry mechanisms, we explore parallels between prescription opioid epidemic and unhealthy commodity industries in terms of marketing, corporate use of misinformation, and diversionary tactics. Next, we examine how policy inertia has dominated the slow response to this man-made crisis. Lastly, we discuss how results from clinical trials are used as a key marketing strategy for drugs. The origins of the prescription opioid epidemic may be traced to innovations in drug development with the promise of improved pain management. However, through multiple factors, including fraudulent marketing from pharmaceutical industry and policy inertia, the resulting crisis represents a multi-system failure of regulation exploited by corporate greed.

SOMAScience: A Novel Platform for Multidimensional, Longitudinal Pain Assessment

Chronic pain is one of the most significant health issues in the United States, affecting more than 20% of the population. Despite its contribution to the increasing health crisis, reliable predictors of disease development, progression, or treatment outcomes are lacking. Self-report remains the most effective way to assess pain, but measures are often acquired in sparse settings over short time windows, limiting their predictive ability. In this paper, we present a new mobile health platform called SOMAScience. SOMAScience serves as an easy-to-use research tool for scientists and clinicians, enabling the collection of large-scale pain datasets in single- and multicenter studies by facilitating the acquisition, transfer, and analysis of longitudinal, multidimensional, self-report pain data. Data acquisition for SOMAScience is done through a user-friendly smartphone app, SOMA, that uses experience sampling methodology to capture momentary and daily assessments of pain intensity, unpleasantness, interference, location, mood, activities, and predictions about the next day that provide personal insights into daily pain dynamics. The visualization of data and its trends over time is meant to empower individual users' self-management of their pain. This paper outlines the scientific, clinical, technological, and user considerations involved in the development of SOMAScience and how it can be used in clinical studies or for pain self-management purposes. Our goal is for SOMAScience to provide a much-needed platform for individual users to gain insight into the multidimensional features of their pain while lowering the barrier for researchers and clinicians to obtain the type of pain data that will ultimately lead to improved prevention, diagnosis, and treatment of chronic pain.

Trends of Opioid Usage in Surgical Patients in a Small Community Hospital: Analysis of Patient Data Between 2017 and 2021

Purpose: The purpose of our study was to quantify and analyze the annual opioid usage in surgical patients at Wood County Hospital (WCH) between 2017 and 2021. Methods: In this retrospective study, patient data between 2017 and 2021 was analyzed to determine the oral morphine milligram equivalent (MME) of opioids used in surgical patients at WCH. Annual MME prescribed per admission was compared each year using one-way ANOVA followed by Tukey post hoc test. Similarly, the annual use of intravenous (IV) acetaminophen for surgical patients per admission was also calculated and analyzed using the one-way ANOVA followed by Tukey post hoc test. Results: Compared to the year 2017 (42.0 ± 3.6), a statistically significant decrease in opioid usage per surgical admission (mean±SEM of MME) was observed during the years 2018 (32.6 ± 1.4; P = .04), 2019 (30.4 ± 1.2; P = .01), and 2021 (30.8 ± 1.9; P = .01). An analysis of individual opioid use revealed a trend toward lower fentanyl and hydromorphone usage each year since 2017. A significant decrease in the annual morphine usage (mean±SEM of MME) for surgical patients was observed during both 2020 (14.4 ± 0.9; P = .05) and 2021 (14.0 ± 0.7; P = .05) compared to the year 2017 (22.1 ± 2.4). Finally, compared to the year 2017, a statistically significant decrease (P < .05) in the annual use of oxycodone (MME) and IV acetaminophen (mg) for pain management in surgical patients was observed from 2018 to 2021. Conclusion: Our analysis reveals a significant decrease in opioid usage per surgical admission at WCH over 2017 to 2021 indicating a positive impact of the various opioid stewardship measures implemented at the hospital.

Evolving Trends in US Mortality from Opioid Overdose: Heroin and Beyond

OBJECTIVE

Our objective was to explore evolving trends in US drug overdose mortality, overall and by age, sex, race, urbanization, and geography from 1999-2020.

METHODS

This is a descriptive epidemiologic study. We used the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research and Multiple Cause of Death files from the National Center for Health Statistics. We used crude and age-adjusted cause of death and mortality rate ratios as measures of effects and 95% confidence limits to test for significance.

RESULTS

From 1999-2020, drug overdoses caused 1,013,852 deaths and 4.3-fold increase in mortality rate ratios. Subgroup findings were sex (4.5 men, 4.0 women), race (4.6 White, 3.9 Black or African American, 4.0 Asian or Pacific Islanders, 5.1 Native Americans or Alaskan Natives), age (highest 5.6 in 25-34 years, lowest 1.1 in 75-84, and 0.77 in 85+), geography (highest 6.0 in Midwest, lowest 2.6 in West), and urbanization (highest 6.2 in non-metro, lowest 3.7 in metro).

CONCLUSIONS

Drug overdoses in the United States from 1999-2020 increased 4.3-fold, with the highest increase in White and Native American or Alaskan Native populations, and Midwest and non-metro areas. The data create preventive and therapeutic challenges, including restrictions on pharmaceutical industries and enhanced efforts by health care providers in safer prescribing. Addiction care should be integrated into all clinical practices, regardless of specialty, and into undergraduate, graduate, and continuing medical education. Targeted interventions are needed to adequately assess patients and provide care. Analytic studies designed a priori are necessary to test hypotheses formulated from these data.

Comparing Post-operative Opioid Consumption before and after a Patient-Controlled Analgesia Shortage: A Re-evaluation of Safety and Effectiveness

This retrospective cohort study aimed to compare post-surgical opioid consumption before and after a PCA (patient-controlled analgesia) shortage. The study evaluated patients who received PCA vs. nurse-administered opioid analgesia (non-PCA). Two hundred and twenty-four patients ≥18 years who were initiated on analgesia within 24 h of surgery were included. The primary outcome was opioid consumption in average daily oral morphine milliequivalents (MME). The results showed that patients in the PCA group had increased MME consumption (162 ± 100.4 vs. 70.7 ± 52.8, p < 0.01), increased length of hospital stay (4.2 vs. 3.2 days, p < 0.01), and increased frequency of nausea (33 vs. 17.9%, p < 0.01). After controlling for confounding factors, the PCA group utilized significantly more opioids (84.6 MME/day, p < 0.01) than the non-PCA group. There was no difference in pain AUC/T (0.19 ± 0.07 vs. 0.21 ± 0.08, p = 0.07) and average opioid prescribing upon discharge (150 [77.5-360] vs. 90 [77.5-400], p = 0.64) between the PCA group and non-PCA group, respectively. These results question the routine use of PCA in post-operative patients due to the increased risk of opioid consumption, longer length of hospital stay, and higher incidence of nausea.

Prospective study of pain and patient outcomes in the emergency department: a tale of two pain assessment methods

BACKGROUND

Accurate pain assessment is essential in the emergency department (ED) triage process. Overestimation of pain intensity, however, can lead to unnecessary overtriage. The study aimed to investigate the influence of pain on patient outcomes and how pain intensity modulates the triage's predictive capabilities on these outcomes.

METHODS

A prospective observational cohort study was conducted at a tertiary care hospital, enrolling adult patients in the triage station. The entire triage process was captured on video. Two pain assessment methods were employed: (1) Self-reported pain score in the Taiwan Triage and Acuity Scale, referred to as the system-based method; (2) Five physicians independently assigned triage levels and assessed pain scores from video footage, termed the physician-based method. The primary outcome was hospitalization, and secondary outcomes included ED length of stay (EDLOS) and ED charges.

RESULTS

Of the 656 patients evaluated, the median self-reported pain score was 4 (interquartile range, 0-7), while the median physician-rated pain score was 1.5 (interquartile range, 0-3). Increased self-reported pain severity was not associated with prolonged EDLOS and increased ED charges, but a positive association was identified with physician-rated pain scores. Using the system-based method, the predictive efficacy of triage scales was lower in the pain groups than in the pain-free group (area under the receiver operating curve, [AUROC]: 0.615 vs. 0.637). However, with the physician-based method, triage scales were more effective in predicting hospitalization among patients with pain than those without (AUROC: 0.650 vs. 0.636).

CONCLUSIONS

Self-reported pain seemed to diminish the predictive accuracy of triage for hospitalization. In contrast, physician-rated pain scores were positively associated with longer EDLOS, increased ED charges, and enhanced triage predictive capability for hospitalization. Pain, therefore, appears to modulate the relationship between triage and patient outcomes, highlighting the need for careful pain evaluation in the ED.

Evolution of Perioperative Pain Management in Shoulder Arthroplasty

Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.

Taking It to the States: Adapting Information Blocking Legislation to Oncology

Oncologists have successfully pushed for new state laws on how we release life-changing test results

Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation: A Proposal for Standardization in Fellowship and Training Programs

The need to be competent in neuromodulation is and should be a prerequisite prior to completing a fellowship in interventional pain medicine. Unfortunately, many programs lack acceptable candidates for these advanced therapies, and fellows may not receive adequate exposure to neuromodulation procedures. The American Society of Pain and Neuroscience (ASPN) desires to create a consensus of experts to set a minimum standard of competence for neurostimulation procedures, including spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), and peripheral nerve stimulation (PNS). The executive board of ASPN accepted nominations for colleagues with excellence in the subject matter of neuromodulation and physician education. This diverse group used peer-reviewed literature and, based on grading of evidence and expert opinion, developed critical consensus guides for training that all accredited fellowship programs should adopt. For each consensus point, transparency and recusal were used to eliminate bias, and an author was nominated for evidence grading oversight and bias control. Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation sets a standard for neuromodulation training in pain fellowship training programs. The consensus panel has determined several recommendations to improve care in the United States for patients undergoing neuromodulation. As neuromodulation training in the United States has evolved dramatically, these therapies have become ubiquitous in pain medicine. Unfortunately, fellowship programs and the Accreditation Council for Graduate Medical Education (ACGME) pain program requirements have not progressed training to match the demands of modern advancements. PEAK sets a new standard for fellowship training and presents thirteen practice areas vital for physician competence in neuromodulation.

Pain-management protocol aimed at reducing opioids following total knee arthroplasty does not negatively impact patient satisfaction

BACKGROUND

Prior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores.

METHOD

This study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen.

RESULTS

Of the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in "top box" percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775).

CONCLUSIONS

Protocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOE: III.

CLINICAL RELEVANCE

This study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Pain Assessment Disparities by Race, Ethnicity, and Language in Adult Hospitalized Patients

AIM

Nurses assess patients' pain using several validated tools. It is not known what disparities exist in pain assessment for medicine inpatients. Our purpose was to measure differences in pain assessment across patient characteristics, including race, ethnicity, and language status.

METHODS

Retrospective cohort study of adult general medicine inpatients from 2013 to 2021. The primary exposures were race/ethnicity and limited English proficiency (LEP) status. The primary outcomes were 1) the type and odds of which pain assessment tool nursing used and 2) the relationship between pain assessments and daily opioid administration.

RESULTS

Of 51,602 patient hospitalizations, 46.1% were white, 17.4% Black, 16.5% Asian, and 13.2% Latino. 13.2% of patients had LEP. The most common pain assessment tool was the Numeric Rating Scale (68.1%), followed by the Verbal Descriptor Scale (23.7%). Asian patients and patients with LEP were less likely to have their pain documented numerically. In multivariable logistic regression, patients with LEP (OR 0.61, 95% CI 0.58-0.65) and Asian patients (OR 0.74, 95% CI 0.70-0.78) had the lowest odds of numeric ratings. Latino, Multi-Racial, and patients classified as Other also had lower odds than white patients of numeric ratings. Asian patients and patients with LEP received the fewest daily opioids across all pain assessment categories.

CONCLUSIONS

Asian patients and patients with LEP were less likely than other patient groups to have a numeric pain assessment and received the fewest opioids. These inequities may serve as the basis for the development of equitable pain assessment protocols.

Physicians' Knowledge, Attitudes, and Perception Toward Pediatric Palliative Care in Saudi Arabia: A National Exploratory Survey

Background

Pediatric palliative care (PPC) helps maintain the quality of life for both children and their families. It has been identified as an important goal within the global health agenda. In Saudi Arabia, the discipline remains in its infancy, as illustrated by the absence of PPC programs in academic and health care institutions.

Aim

The aim was to conduct a pilot study assessing physicians' knowledge, attitudes, and perceptions toward PPC.

Method

Data were gathered through a self-administered questionnaire sent to physicians working in Saudi Arabia.

Results

One hundred twelve completed the survey (male 54.2%, n = 50). A total of 40.8% (n = 42) had 20 years or more of experience, 42.9% (n = 48) were from the hematology-oncology specialty, and 68.5% (n = 74) received no training in PPC. Half suggested that children should be informed of their condition but mostly when reaching 12 or 15 years of age. Various physicians reported that the most appropriate time to discuss a transition to palliative care goals is when diagnosing an incurable condition or when despite all efforts, a condition continues to progress and death is expected.

Conclusion

Multiple gaps were identified. PPC basic concepts should be included in the formal medical curriculum (e.g., pain management, communication, and ethical considerations at the end of life). There is also a significant need to develop further both primary and specialized palliative care.

The Effects of Virtual Reality Glasses on Vital Signs and Anxiety in Patients Undergoing Colonoscopy: A Randomized Controlled Trial

Colonoscopy is a painful procedure that causes anxiety and changes in vital signs. Pain and anxiety may cause patients to avoid colonoscopy, which is a preventive and curative healthcare service. The aim of this study was to examine the effects of virtual reality glasses on the vital signs (blood pressure, pulse, respiration, oxygen saturation, and pain) and anxiety in patients undergoing colonoscopy. The population of the study consisted of 82 patients who underwent colonoscopy without sedation between January 2, 2020, and September 28, 2020. Post-power analysis was performed with 44 patients who agreed to participate in the study, met the inclusion criteria, and were followed up for pre- and post-tests. The experimental group participants (n = 22) watched a 360° virtual reality video through virtual reality glasses whereas the control group participants (n = 22) underwent a standard procedure. Data were collected using a demographic characteristics questionnaire, the Visual Analog Scale-Anxiety, Visual Analog Scale-Pain, Satisfaction Evaluation Form, and monitoring of vital signs. The experimental group participants had significantly lower levels of pain, anxiety, systolic blood pressure, and respiratory rate and significantly higher peripheral oxygen saturation during colonoscopy than the control group participants. The majority of the experimental group participants were satisfied with the application. Virtual reality glasses have a positive effect on vital signs and anxiety during colonoscopy.

Validation of the tablet-based Turkish-PAINReportIt® for lung cancer patients after thoracotomy in Turkey

BACKGROUND

Digital pain assessment is advantageous and timely for healthcare priorities in Turkey. However, a multi-dimensional, tablet-based pain assessment tool is not available in the Turkish language.

PURPOSE

To validate the Turkish-PAINReportIt® as a multi-dimensional measure of post-thoracotomy pain.

METHODS

In the first of a two-phased study, 32 Turkish patients (mean age 47.8 ± 15.6 years, 72 % male) participated in individual cognitive interviews as they completed the tablet-based Turkish-PAINReportIt® once during the first four days post-thoracotomy, and 8 clinicians participated in a focus group discussion of implementation barriers. In the second phase, 80 Turkish patients (mean age 59.0 ± 12.7 years, 80 % male) completed the Turkish-PAINReportIt® preoperatively, on postoperative days 1-4, and at the two-week post-operative follow-up visit.

RESULTS

Patients generally interpreted accurately the Turkish-PAINReportIt® instructions and items. We eliminated some items unnecessary for daily assessment based on focus-group suggestions. In the second study phase, pain scores (intensity, quality, pattern) were low pre-thoracotomy for lung cancer and high postoperatively high on day 1, decreasing on days 2, 3 and 4, and back down to pre-surgical levels at 2-weeks. Over time, pain intensity decreased from post-operative day 1 to post-operative day 4 (p < .001) and from post-operative day 1 to post-operative week 2 (p < .001).

CONCLUSIONS

The formative research supported proof of concept and informed the longitudinal study. Findings showed strong validity of the Turkish-PAINReportIt® to detect reduced pain over time as healing occurs after thoracotomy.

"I Prefer to Stay Away": A Qualitative Study of Patients in an Opioid-Sparing Pain Management Protocol

OBJECTIVE

The aim of this study was to explore beliefs and behaviors of opioid pain medications among patients undergoing elective surgery.

BACKGROUND

Opioid dependence after surgery is a major contributor to the ongoing opioid epidemic. Recent efforts by surgeons and health systems have sought to improve the education patients receive regarding safe opioid use after surgery; however, little is known about patients' pre-existing beliefs surrounding opioids.

METHODS

Semistructured interviews were conducted with patients who underwent 1 of 4 common elective surgical procedures at 1 institution. Patients were specifically asked about their knowledge and beliefs about opioids before surgery and their opinions of opioid-sparing recovery after surgery. Coding was conducted through iterative steps, beginning with an initial cycle of rapid analysis, followed by focused coding, and thematic analysis.

RESULTS

Twenty-one patients were interviewed. Three major themes emerged regarding patient opinions about using opioids after surgery. First, there was widespread awareness among patients about opioid medications, and preoperatively, patients had specific intentions about using opioids, often informed by this awareness. Second, patients described a spectrum of opioid related behavior which both aligned and conflicted with preoperative intentions. Third, there was tension among patients about opioid-free postoperative recovery, with patients expressing support, opposition, and emphasis on tailoring recovery to patient needs.

CONCLUSIONS

Patients undergoing common surgical procedures often arrive at their surgical encounter with strong, pre-formed opinions about opioids. Eliciting these preexisting opinions may help surgeons better counsel patients about safe opioid use after surgery.

A Novel Movement-Evoked Pain Provocation Test for Older Adults With Persistent Low Back Pain: Safety, Feasibility, and Associations With Self-reported Physical Function and Usual Gait Speed

OBJECTIVES

Low back pain (LBP) is highly prevalent and disabling for older adults. Movement-evoked pain is an emerging measure that may help to predict disability; but is not currently a part of geriatric LBP clinical care. This study tested the safety and feasibility of a new Movement-Evoked Provocation Test for Low Back Pain in Older Adults (MEPLO). We also compared associations between movement-evoked pain via 2 different scoring methods and disability-associated outcomes.

MATERIALS AND METHODS

Thirty-nine older adults with persistent LBP provided baseline recalled and resting pain ratings, self-reported physical function, and usual gait speed. Participants then completed MEPLO, involving 4 tasks essential for functional independence: chair rises, trunk rotation, reaching, and walking. Movement-evoked pain was then quantified using the traditional change score (delta) method of pain premovement to postmovement; and also, a new aggregate method that combines pain ratings after the 4 tasks.

RESULTS

No safety or feasibility issues were identified. Compared with the delta score, the aggregate score was more strongly associated with self-reported physical function (beta: -0.495 vs. -0.090) and usual gait speed (beta: -0.450 vs. -0.053). Similarly, the aggregate score was more strongly associated with self-reported physical function than recalled and resting pain (beta: -0.470, -0.283, and 0.136, respectively).

DISCUSSION

This study shows the safety and feasibility of testing movement-evoked pain in older adults with persistent LBP, and its potential superiority to traditional pain measures. Future studies must validate these findings and test the extent to which MEPLO is implementable to change with geriatric LBP standard of care.

The genetic architecture of pain intensity in a sample of 598,339 U.S. veterans

Chronic pain is a common problem, with more than one-fifth of adult Americans reporting pain daily or on most days. It adversely affects quality of life and imposes substantial personal and economic costs. Efforts to treat chronic pain using opioids played a central role in precipitating the opioid crisis. Despite an estimated heritability of 25-50%, the genetic architecture of chronic pain is not well characterized, in part because studies have largely been limited to samples of European ancestry. To help address this knowledge gap, we conducted a cross-ancestry meta-analysis of pain intensity in 598,339 participants in the Million Veteran Program, which identified 125 independent genetic loci, 82 of which are novel. Pain intensity was genetically correlated with other pain phenotypes, level of substance use and substance use disorders, other psychiatric traits, education level, and cognitive traits. Integration of the GWAS findings with functional genomics data shows enrichment for putatively causal genes (n = 142) and proteins (n = 14) expressed in brain tissues, specifically in GABAergic neurons. Drug repurposing analysis identified anticonvulsants, beta-blockers, and calcium-channel blockers, among other drug groups, as having potential analgesic effects. Our results provide insights into key molecular contributors to the experience of pain and highlight attractive drug targets.

Evaluation of pain in the paediatric patient admitted to sub-intensive care: a scoping review protocol

BACKGROUND AND AIM

pain is considered as the 5th vital sign thus it's paramount that healthcare professionals are equipped with validated tools for his correct assessment. There are different paediatric pain assessment scales that take into account patients' age. Actually, the "Face, Legs, Activity, Cry, Consolability" (FLACC), Wong-Baker and NRS scales are regarded as the gold standard in low intensity clinical areas, while the COMFORT-Behavior (COMFORT-B) and Behavioral Pain Scale (BPS) ones are used for high intensity clinical areas where paediatric patients are sedated/intubated. It's unclear which pain assessment scale should be used in sub-intensive areas such as Sub-Paediatric Intensive Care Unit (Sub-PICU) e Sub-Neonatal Intensive Care Unit (Sub-NICU). The aim of this protocol is to map the literature in order to identify what evidences are available regarding the assessment of pain in the paediatric sub-intensive clinical areas.

RESEARCH QUESTION

"What is the literature available on pain assessment in paediatric patients in sub-intensive clinical areas such as Sub-PICU and sub-NICU?".

SOURCE OF EVIDENCE

literature search will be performed through the following databases: PubMed, Scopus, CINAHL, Cochrane Library, Open Dissertations (EBSCO) and DOAJ. Furthermore, Cochrane CENTRAL and ClinicalTrials.gov will also be included.

METHODS

this scoping review will be conducted in accordance to the Joanna Briggs Institute guidelines and the results presented through a PRISMA flowchart.

REVIEW REGISTRATION

Open Science Framework https://doi.org/10.17605/OSF.IO/8KBRQ.

Integrative Surgery: Embedding Complementary and Nonpharmacologic Therapies into Surgical Pain Management Strategies

There has been a growing interest in the use of complementary and alternative medicine in modern pain management strategies on behalf of both patients and clinicians. Nonpharmacologic modalities such as cryotherapy, acupuncture, music, and mind-body therapies have been shown to aid in symptom control and improve quality of life in patients suffering from acute and chronic pain, and there is a growing body of literature demonstrating their feasibility, acceptability, and efficacy in the perioperative period. Here, we provide a brief review of the current evidence supporting the use of complementary therapies within existing perioperative pain management strategies and highlight evidence-based protocols to facilitate implementation into modern surgical practice.

Enhanced Recovery After Surgery Patients Are Prescribed Fewer Opioids at Discharge: A Propensity-score Matched Analysis

OBJECTIVE

We aimed to compare discharge opioid prescriptions pre- and post-ERAS implementation.

SUMMARY OF BACKGROUND DATA

ERAS programs decrease inpatient opioid use, but their relationship with postdischarge opioids remains unclear.

METHODS

All patients undergoing hysterectomy between October 2016 and November 2020 and pancreatectomy or hepatectomy between April 2017 and November 2020 at 1 tertiary care center were included. For each procedure, ERAS was implemented during the study period. PSM was performed to compare pre - versus post-ERAS patients on discharge opioids (number of pills and oral morphine equivalents). Patients were matched on age, sex, race, payor, American Society of Anesthesiologists score, prior opioid use, and procedure. Sensitivity analyses in open versus minimally invasive surgery cohorts were performed.

RESULTS

A total of 3983 patients were included (1929 pre-ERAS; 2054 post-ERAS). Post-ERAS patients were younger (56.0 vs 58.4 years; P < 0.001), more often female (95.8% vs 78.1%; P < 0.001), less often white (77.2% vs 82.0%; P < 0.001), less often had prior opioid use (20.1% vs 28.1%; P < 0.001), and more often underwent hysterectomy (91.1% vs 55.7%; P < 0.001). After PSM, there were no significant differences between cohorts in baseline characteristics. Matched post-ERAS patients were prescribed fewer opioid pills (17.4 pills vs 22.0 pills; P < 0.001) and lower oral morphine equivalents (129.4 mg vs 167.6 mg; P < 0.001) than pre-ERAS patients. Sensitivity analyses confirmed these findings [open (18.8 pills vs 25.4 pills; P < 0.001 \ 138.9 mg vs 198.7 mg; P < 0.001); minimally invasive surgery (17.2 pills vs 21.1 pills; P < 0.001 \ 127.1 mg vs 160.1 mg; P < 0.001).

CONCLUSIONS

Post-ERAS patients were prescribed significantly fewer opioids at discharge compared to matched pre-ERAS patients.

Cirrhosis Inpatients Receive More Opioids and Fewer Nonopioid Analgesics Than Patients Without Cirrhosis

GOALS/BACKGROUND

Pain is common among cirrhosis patients, particularly those hospitalized with acute illness. Managing pain in this population is challenging due to concern for adverse events and lack of guidelines for analgesic use. We sought to characterize analgesic use among inpatients with cirrhosis compared with matched noncirrhosis controls, as well as hospital-level variation in prescribing patterns.

METHODS

We utilized the Vizient Clinical Database, which includes clinical and billing data from hospitalizations at >500 US academic medical centers. We identified cirrhosis patients hospitalized in 2017-2018, and a matched cohort of noncirrhosis patients. Types of analgesic given-acetaminophen (APAP), nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjuvants (eg, gabapentinoids, antidepressants) were defined from inpatient prescription records. Conditional logistic regression was used to associate cirrhosis diagnosis with analgesic use.

RESULTS

Of 116,363 cirrhosis inpatients, 83% received at least 1 dose of an analgesic and 58% had regular inpatient analgesic use, rates that were clinically similar to noncirrhosis controls. Cirrhosis inpatients were half as likely to receive APAP (26% vs. 42%, P <0.01) or NSAIDs (3% vs. 7%, P <0.01), but were more likely to receive opioids (59% vs. 54%, P <0.01), particularly decompensated patients (60%). There was notable variation in analgesic prescribing patterns between hospitals, especially among cirrhosis patients.

CONCLUSIONS

Analgesic use was common among inpatients, with similar rates among patients with and without cirrhosis. Cirrhosis patients-particularly decompensated patients-were less likely to receive APAP and NSAIDs and more likely to receive opioid analgesics. Because of lack of evidence-based guidance for management of cirrhosis patients with pain, providers may avoid nonopioid analgesics due to perceived risks and consequently may overutilize opioids in this high-risk population.

Sex Differences in Pain and Its Treatment

Pain is a highly personal experience. Pain is often considered to be a purely neurologic phenomenon, but in actuality, it is a combination of both sensory and emotional experiences. This has sometimes been translated clinically toward a more mechanistic approach to the assessment and treatment of pain instead of one that does not discount pain mechanisms, but also is more inclusive of the need for humanism - considering the individual. In today's medical environment, more than ever before there is a significant amount of attention being paid to educating clinicians to better understand that several physiological, neurophysiological, and psychosocial factors can significantly impact responses to pain. The composition of these factors will be unique to that individual's life narrative, context, sex, and prior life experiences. Thus, the concept that a templated approach to pain assessment and pharmacotherapeutic treatment planning should not be expected to provide optimal patient satisfaction and treatment outcomes in the majority. The hypotheses that there may be sex-based differences in the pain experience in a variety of ways including pain sensitivity, tolerance to pain, threshold at which something becomes painful, and the effectiveness of endogenous pain modulation systems are not new and have been well represented in the literature. This chapter reviews important key findings in the scientific literature with respect to sex-based differences in pain and pain responses to experimentally induced painful stimuli, pain experienced in commonly occurring painful medical conditions, and variations in responses to pain treatments. Possible explanations to account for observed differences or similarities will also be discussed.

Prevalence and Factors Associated with Pain in Nursing Home Residents: A Systematic Review of the Literature

OBJECTIVES

To describe the pain prevalence in nursing home (NH) residents and the factors associated with the experience of pain.

DESIGN

Systematic review of descriptive studies.

SETTING AND PARTICIPANTS

Three electronic databases were searched from 2010 to September 2020 in English. Descriptive studies that examined pain in NH residents, reported pain prevalence, and/or associated factors were included. Studies that focused exclusively on a specific disease or type of care such as cancer or hospice were excluded.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias from included studies; narrative synthesis was performed. The review was guided by the Biopsychosocial Model of Chronic Pain for Older Adults.

RESULTS

Twenty-six studies met our inclusion criteria. Overall, the prevalence of current pain ranged from 22.2% to 85.0%, the prevalence of persistent pain ranged from 19.5% to 58.5%, and the prevalence of chronic pain ranged from 55.9% to 58.1%. A variety of pain scales were used reporting higher pain prevalence for those using self-report measures (31.8% to 78.8%) or proxy measures (29.5% to 85.0%) compared with using chart review (22.2% to 29.3%) as the source of pain information. The studies reviewed provide support that certain diseases and clinical conditions are associated with pain. Impairment in activities of daily living (ADL) (12 studies), cognition (9 studies), depression (9 studies), and arthritis (9 studies) are the most widely studied factors, whereas depression, ADL impairment, arthritis, dementia, and cognitive impairment present the strongest association with pain.

CONCLUSION AND IMPLICATIONS

This review highlights the complexities of pain in NH residents and has implications for both clinical practice and future research. Understanding the factors that underlie the experience of pain, such as depression, is useful for clinicians evaluating pain and tailoring management therapies. In addition, the gaps in knowledge uncovered in this review are important areas for future research.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database

BACKGROUND

It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use.

METHODS

Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression.

RESULTS

A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively.

CONCLUSIONS

Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

The Patient Care Experience as Perceived by Hispanic Patients With Chronic Illness Undergoing Transplant: A Grounded Theory

Hispanics are one of the largest-growing minorities, yet little is understood of the patient experience from their perspective. Patient experience is the current federally mandated hospital quality indicator that is measured via the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Minority representation in the HCAHPS survey development however was not robust. This study used a constructivist grounded theory method to explore how English- and Spanish-speaking Hispanic patients seeking kidney and liver transplant care at a safety-net hospital perceive and interpret the care experience. A grounded theory process model emerged finding comfort, communication, connection, and care to be interdependent factors crucial for a positive hospital admission. Furthermore, "cultural context" was found to influence perception of each of these concepts. This research provides key insights into how Hispanics may perceive their needs when seeking care. A Supplemental Digital Content video abstract is available at http://links.lww.com/ANS/A50 .

Pain Is Associated With Depressive Symptoms, Inflammation, and Poorer Physical Function in Older Adults With HIV

OBJECTIVE

People living with HIV (PLWH) frequently experience pain, which often co-occurs with psychological symptoms and may impact functional outcomes. We investigated cross-sectional associations between pain, depressive symptoms, and inflammation, and then explored whether pain was related to poorer physical function among older PLWH.

METHODS

We examined data from PLWH aged 54 to 78 years ( n = 162) recruited from a single outpatient program for a larger study on HIV and aging. Participants reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) and then attended a biomedical visit in which they reported past-month pain (Medical Outcomes Study-HIV pain subscale), completed physical function assessments, and provided blood samples (assayed for interleukin 6, interferon-γ, tumor necrosis factor α, and C-reactive protein). Links between pain, depressive symptoms, inflammation, and physical function were tested using linear regression models.

RESULTS

PLWH with greater depressive symptoms experienced more pain than did those with fewer depressive symptoms ( B = 1.31, SE = 0.28, p < .001), adjusting for age, sex, race, body mass index, smoking, disease burden, time since HIV diagnosis, and medication use. Higher composite cytokine levels were associated with worse pain ( B = 5.70, SE = 2.54, p = .027 in adjusted model). Poorer physical function indicators, including slower gait speed, weaker grip strength, recent falls, and prefrail or frail status, were observed among those with worse pain. Exploratory mediation analyses suggested that pain may partially explain links between depressive symptoms and several physical function outcomes.

CONCLUSIONS

Pain is a potential pathway linking depressive symptoms and inflammation to age-related health vulnerabilities among older PLWH; longitudinal investigation of this pattern is warranted. PLWH presenting with pain may benefit from multidisciplinary resources, including behavioral health and geriatric medicine approaches.

Unpacking the impact of chronic pain as measured by the impact stratification score

Background

In 2014, the National Institute of Health Pain Consortium’s research task force on research standards for chronic low back pain (CLBP) proposed a measure that could be used to stratify patients by the impact CLBP has on their lives, namely the Impact Stratification Score (ISS). This study examines the dimensionality of the ISS and support for its single total score, and evaluates its overall psychometric properties.

Methods

The sample included 1677 chiropractic patients being treated for CLBP and chronic neck pain, had an average age of 49, 71% female, and 90% White. Study participants completed the PROMIS-29 v2.1 profile survey that contains the 9 ISS items. The ISS was evaluated using item-total correlations, Cronbach’s alpha, factor analysis (i.e., correlated factors and bifactor models), and item response theory (IRT). Reliability indices and item properties were evaluated from bifactor and IRT models, respectively.

Results

Item-total correlations were high (0.64–0.84) with a Cronbach’s alpha of 0.93. Eigenvalues suggested the possibility of two factors corresponding to physical function and pain interference/intensity. Bifactor model results indicated that data were essentially unidimensional, primarily reflecting one general construct (i.e., impact) and that after accounting for ‘impact’ very little reliable variance remained in the two group factors. General impact scores were reliable (omegaH = .73). IRT models showed that items were strong indicators of impact and provided information across a wide range of the impact continuum and offer the possibility of a shorter 8-item ISS. Finally, it appears that different aspects of pain interference occur prior to losses in physical function.

Conclusions

This study presents evidence that the ISS is sufficiently unidimensional, covers a range of chronic pain impact and is a reliable measure. Insights are obtained into the sequence of chronic pain impacts on patients’ lives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05834-4.

A Comprehensive Assessment of The Eight Vital Signs

The term “vital sign” has been assigned to various phenomena with the presumptive intent to emphasize their importance in health care resulting in the emergence of eight vital signs with multiple designations and overlapping terms. This review developed a case definition for vital signs and identified and described the fifth through eighth vital signs. PubMed/Medline, Google and biographical databases were searched using the individual Medical Subject Headings (MeSH) terms, vital sign and fifth, vital sign and sixth, vital sign and seventh, and vital sign eighth. The search was limited to human clinical studies written in English literature from 1957 up until November 30, 2021. Excluded were articles containing the term vital sign if used alone without the qualifier fifth, sixth, seventh, or eighth or about temperature, blood pressure, pulse, and respiratory rate. One hundred ninety-six articles (122 for the fifth vital sign, 71 for the sixth vital sign, two for the seventh vital sign, and one for the eighth vital sign) constituted the final dataset. The vital signs consisted of 35 terms, classified into 17 categories compromising 186 unique papers for each primary authored article with redundant numbered vital signs for glucose, weight, body mass index, and medication compliance. Eleven terms have been named the fifth vital sign, 25 the sixth vital sign, three the seventh, and one as the eighth vital sign. There are four time-honored vital signs based on the case definition, and they represent an objective bedside measurement obtained noninvasively that is essential for life. Based on this case definition, pulse oximetry qualifies as the fifth while end-tidal CO2 and cardiac output as the sixth. Thus, these terms have been misappropriated 31 times. Although important to emphasize in patient care, the remainder are not vital signs and should not be construed in this manner.

Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures

BACKGROUND

Development and prioritization of quality measures typically relies on experts in clinical medicine, but patients and their caregivers may have different perspectives on quality measurement priorities.

OBJECTIVE

To inform priorities for health system implementation of palliative cancer and end-of-life care quality measures by eliciting perspectives of patients and caregivers.

DESIGN

Using modified RAND-UCLA Appropriateness Panel methods and materials tailored for knowledgeable lay participants, we convened a panel to rate cancer palliative care process quality measure concepts before and after a 1-day, in-person meeting.

PARTICIPANTS

Nine patients and caregivers with experience living with or caring for patients with cancer.

MAIN MEASURES

Panelists rated each concept on importance for providing patient- and family-centered care on a nine-point scale and each panelist nominated five highest priority measure concepts ("top 5").

KEY RESULTS

Cancer patient and caregiver panelists rated all measure concepts presented as highly important to patient- and family- centered care (median rating ≥ 7) in pre-panel (mean rating range, 6.9-8.8) and post-panel ratings (mean rating range, 7.2-8.9). Forced choice nominations of the "top 5" helped distinguish similarly rated measure concepts. Measure concepts nominated into the "top 5" by three or more panelists included two measure concepts of communication (goals of care discussions and discussion of prognosis), one measure concept on providing comprehensive assessments of patients, and three on symptoms including pain management plans, improvement in pain, and depression management plans. Patients and caregivers nominated one additional measure concept (pain screening) back into consideration, bringing the total number of measure concepts under consideration to 21.

CONCLUSIONS

Input from cancer patients and caregivers helped identify quality measurement priorities for health system implementation. Forced choice nominations were useful to discriminate concepts with the highest perceived importance. Our approach serves as a model for incorporating patient and caregiver priorities in quality measure development and implementation.

Opioid Prescribing Practices Among Plastic Surgeons: Results of the 2019 American Society of Plastic Surgeons Opioid Survey

BACKGROUND

Health care providers play an important role in the national opioid crisis with 40% of opioid-related deaths being attributed to prescription medications (Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. 2018) and as many as half of the opioid pills prescribed after outpatient plastic surgery may go unused (Plast Reconstr Surg 2019;143:929-938). The purpose of this study was to provide broad foundational data regarding postoperative analgesic prescribing patterns among members of the American Society of Plastic Surgeons (ASPS) to facilitate inclusion of opioid data fields in the ASPS Tracking Operations and Outcomes for Plastic Surgeons database for longitudinal evaluation.

METHODS

A survey regarding opioid prescribing practices was electronically distributed to a representative cohort of 2555 ASPS members. Two hundred seventy-nine responses (11% response rate) were received.

RESULTS

The majority of respondents reported prescribing opioids following 1 or more types of cosmetic and reconstructive procedures (90.2% and 81.7%, respectively; p = 0.0057), most commonly oxycodone and hydrocodone. Most (61.9%) reported less than 5% of patients request an opioid refill. Nonopioid medications, most commonly acetaminophen and ibuprofen/naproxen, were also prescribed but less commonly so for cosmetic (80.7-85.8%) than reconstructive (86.3-91.5%) procedures. Local anesthetic was less commonly used for mastopexy (83.7%) than augmentation (91.8%, p = 0.02).

CONCLUSIONS

Based on survey responses, potential areas of improvement to reduce opioid prescribing and use include provider education on the use of multimodal pain regimens including nonopioid medication and "as needed" rather than scheduled dosing, use of local anesthetic blocks, as well as patient education on opioid safety and proper disposal of unused medication.

Which Pain Treatment Goals Are Important to Community-Dwelling Older Adults?

OBJECTIVE

In this cross-sectional study of 237 older adults, we ascertained the importance of 7 pain treatment goals and identified factors associated with their perceived importance.

METHODS

Participants (mean age = 72 years) ranked each goal (e.g., pain reduction; finding a cure) on a 1 (not at all important) to 10 (extremely important) scale. We used general linear models to identify sociodemographic and pain factors independently associated with the perceived importance of each goal and repeated measures mixed models to examine their relative importance.

RESULTS

The goal with the lowest adjusted score was "minimize harmful side effects from pain medications" with a mean (SE) of 6.75 (0.239), while the highest ranked goals, "finding a cure," and "reducing my pain" had mean scores of 8.06 (0.237) and 7.89 (0.235), respectively. Pain reduction did not differ significantly from the average of the other 6 goals (p = 0.072) but was significantly different when compared with the goals of minimizing side effects (p < 0.0001) and finding a cause for the pain (p = 0.047), and different from the average of the 5 other goals excluding finding a cure (p = 0.021). We did not identify differences in the importance of the 7 goals by gender or race/ethnicity. Age was inversely associated with the goals of minimizing harmful side effects and decreasing pain's effects on everyday activities. Pain reduction was rated more important than all other goals but finding a cure.

CONCLUSIONS

Future research is needed to establish the benefits of eliciting treatment goals when delivering pain care to older adults.