The medical necessity of adequate pain management

A Stress and Pain Self-management mHealth App for Adult Outpatients With Sickle Cell Disease: Protocol for a Randomized Controlled Study

BACKGROUND

This paper describes the research protocol for a randomized controlled trial of a self-management intervention for adults diagnosed with sickle cell disease (SCD). People living with SCD experience lifelong recurrent episodes of acute and chronic pain, which are exacerbated by stress.

OBJECTIVE

This study aims to decrease stress and improve SCD pain control with reduced opioid use through an intervention with self-management relaxation exercises, named You Cope, We Support (YCWS). Building on our previous findings from formative studies, this study is designed to test the efficacy of YCWS on stress intensity, pain intensity, and opioid use in adults with SCD.

METHODS

A randomized controlled trial of the short-term (8 weeks) and long-term (6 months) effects of YCWS on stress, pain, and opioid use will be conducted with 170 adults with SCD. Patients will be randomized based on 1:1 ratio (stratified on pain intensity [≤5 or >5]) to be either in the experimental (self-monitoring of outcomes, alerts or reminders, and use of YCWS [relaxation and distraction exercises and support]) or control (self-monitoring of outcomes and alerts or reminders) group. Patients will be asked to report outcomes daily. During weeks 1 to 8, patients in both groups will receive system-generated alerts or reminders via phone call, text, or email to facilitate data entry (both groups) and intervention use support (experimental). If the participant does not enter data after 24 hours, the study support staff will contact them for data entry troubleshooting (both groups) and YCWS use (experimental). We will time stamp and track patients' web-based activities to understand the study context and conduct exit interviews on the acceptability of system-generated and staff support. This study was approved by our institutional review board.

RESULTS

This study was funded by the National Institute of Nursing Research of the National Institutes of Health in 2020. The study began in March 2021 and will be completed in June 2025. As of April 2022, we have enrolled 45.9% (78/170) of patients. We will analyze the data using mixed effects regression models (short term and long term) to account for the repeated measurements over time and use machine learning to construct and evaluate prediction models. Owing to the COVID-19 pandemic, the study was modified to allow for mail-in consent process, internet-based consent process via email or Zoom videoconference, devices delivered by FedEx, and training via Zoom videoconference.

CONCLUSIONS

We expect the intervention group to report reductions in pain intensity (primary outcome; 0-10 scale) and in stress intensity (0-10 scale) and opioid use (Wisepill event medication monitoring system), which are secondary outcomes. Our study will contribute to advancing the use of nonopioid therapy such as guided relaxation and distraction techniques for managing SCD pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04484272; https://clinicaltrials.gov/ct2/show/NCT04484272.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/33818.

Estimates of sedation in patients undergoing endotracheal intubation in US EDs

BACKGROUND

Sedations after endotracheal intubation (ETI) reduce the risk of self-extubation, uncontrolled pain, and myocardial infarction. Although several small single-center studies demonstrate low rates of sedative drug administration after ETI in the emergency department (ED), little is known regarding post-ETI sedative drug practices nationally.

METHODS

We performed a retrospective cohort analysis of the ED portion of the National Hospital Ambulatory Medical Care Survey from 2006 to 2009. We identified all ED patient visits with ETI. Using the multiple probability sampling design of the National Hospital Ambulatory Medical Care Survey, we estimated the proportion of ETI patients receiving pharmacologic sedation, defined as benzodiazepines, opiates, or other sedative agents (propofol, ketamine, etc). We compared patients receiving sedative drugs with those who did not using descriptive statistics and univariable logistic regression.

RESULTS

During the 4-year study period, 1071000 patients (95% confidence interval [CI], 839000-1303000) underwent ETI in the ED. Of intubated patients, 46.4% (95% CI, 40.2%-52.7%) received sedative drugs, most commonly benzodiazepines (67.9%). Of patients who survived to hospital admission, 57.4% (95% CI, 48.7%-65.7%) received sedative drugs. Patients were less likely to receive sedation if they were diagnosed with circulatory or cardiac disease (odds ratio, 0.51; P = .026). Use of sedative drugs was not associated with patient age, sex, race, geographic location, or extended ED length of stay (>2 hours).

CONCLUSION

Less than one-half of patients undergoing ETI in the ED receive sedative drugs while in the ED. These findings are congruent with prior smaller studies from single academic centers.

The effects of preoperative extradural bupivacaine and morphine on the stress response in dogs undergoing femoro-tibial joint surgery

OBJECTIVE

To evaluate the efficacy of preoperative extradural bupivacaine and morphine in attenuating the stress response in dogs undergoing femoro-tibial joint surgery.

STUDY DESIGN

Prospective clinical study. Animal population Twelve client-owned dogs undergoing surgery for either repair of cruciate ligament rupture (ten) or correction of luxating patella (two). Body masses ranged from 12 to 45 kg (mean: 28.58 +/- 18.38). Age ranged from 19 to 121 months (mean: 66.5 +/- 49.5).

MATERIALS AND METHODS

Six of the dogs received extradural bupivacaine (up to 1.5 mg kg(-1)) combined with morphine (0.1 mg kg(-1); ED) while the other six received no extradural analgesia (C). The levels of cortisol, acute phase proteins (APPs), and red and white blood cell variables were measured in both groups of dogs before, and at various times after surgery. Pain was also assessed at various times after surgery. The number of postoperative morphine doses required, and their time of administration, was recorded for each animal. Method of statistical analysis Data were analysed using anova for repeated measures with p-values of <0.05 considered significant.

RESULTS

Cortisol levels in the ED group were significantly (p < 0.05) lower than those of the control group at the end of surgery. No statistically significant differences were found in APPs or red and white cell variables between dogs receiving, and those not receiving extradural bupivacaine and morphine. Four dogs in the control group and one in the ED group required postoperative morphine.

CONCLUSIONS AND CLINICAL RELEVANCE

Pre-emptive extradural bupivacaine and morphine was effective in lowering the neuroendocrine stress response (cortisol) in the ED group but had no effect on the inflammatory response (acute phase response).

Inhibition of cell invasion by indomethacin on glioma cell lines: in vitro study

Malignant glioma invasion into the surrounding brain tissue is still a major problem for any therapeutical methods. Matrix metalloproteinases (MMPs) have been implicated as important factors in this pathological process. In this study, one of the non-steroidal anti-inflammatory drugs (NSAIDs) indomethacin was employed to investigate the effect of inhibition of cell invasion mediated by MMP-2 and MMP-9 in human malignant glioma cell lines, A172, U87MG, U251MG, and U373MG in vitro. MTT assay was firstly examined to determine non-cytotoxic dose range, then gelatin zymography, matrigel invasion assay, migration assay and MMP-2 activity assay for 24 h exposure in indomethacin were employed to assess the inhibitory effect of indomethacin. MTT assay revealed that dose with 0, 50, and 500 microM/ml were non-cytotoxic. Zymography demonstrated: (a) expression of MMP-2 and MMP-9 activity was downregulated along with elevated dose of indomethacin. (b) MMP-2 activity that changed from pro-MMP-2 to active form of MMP-2 in supernatants of cell lines could not be inhibited by indomethacin. Invasion assay disclosed that the number of invading cells through the matrigel were significantly decreased in a dose dependent manner. Migration assay indicated indomethacin did not affect cells migration. MMP-2 activity assay showed the total and active MMP-2 secretion was suppressed by 500 microM/ml of indomethacin. Our present study is the first report on inhibitive effect of indomethacin mediated by MMP-2 and MMP-9 in invasion assay of glioma cell lines. The current study suggested that non-cytotoxic level of indomethacin was able to reduce the cell invasion of malignant gliomas mediated by MMP-2 and MMP-9, but it did not affected on cell motility. It also lowered down the activity of MMP-2 and MMP-9, and could reduce of MMP-2 secretion of cell lines. Thus, high concentration of indomethacin within non-cytotoxic dose might offer a new therapeutic strategy to impair cell invasion of gliomas.

Indomethacin attenuates the immunosuppressive and tumor-promoting effects of surgery

We have previously shown in rats that both intrathecal and systemic analgesia regimens attenuate surgery-induced increases in tumor susceptibility. The current study used indomethacin to assess the role of prostaglandins and inflammation-associated pain in mediating the deleterious effects of surgery on immunity and tumor susceptibility. Male and female Fischer 344 rats were anesthetized with halothane and were either subjected or not to experimental laparotomy, followed by the administration of indomethacin or vehicle. Tumor susceptibility was assessed by the lung retention assay using the syngeneic MADB106 mammary adenocarcinoma cell line, a natural killer (NK)-sensitive tumor that colonizes only in the lungs. Surgery resulted in a 2- to 3.5-fold increase in lung tumor retention, and indomethacin administration significantly reduced this effect in both sexes without affecting unoperated animals. Indomethacin also attenuated the reductions in rearing behavior evident after surgery, suggesting that it relieved abdominal discomfort. Surgery increased interleukin-6 levels and suppressed NK activity per milliliter blood. Indomethacin restored NK activity in both male and female rats but attenuated surgery-induced interleukin-6 increases only in the male rats. These findings further support our previous work implicating pain in mediating the tumor-enhancing effects of surgery and implicate prostaglandins in mediating this effect. If similar relationships occur in humans, controlling postoperative pain and inflammation must become a priority in the management of cancer patients undergoing surgery.

Ethical perspectives: opioid treatment of chronic pain in the context of addiction

The authors apply eight ethical domains of analysis to the question of treatment of chronic pain with opioids in patients with histories of substance use disorders: autonomy, nonmaleficence, beneficence, justice, medical condition, patient preference, quality of life, and consideration of specific individual or sociocultural issues. These eight domains are drawn from principle-based and case-based ethical perspectives. The domains are developed by review of available literature and through application to a specific presented case. Factors that interfere with rational, ethical decision-making regarding opioid pain management are identified. Chronic pain and substance use disorders share a history of stigmatization, underdiagnosis, and undertreatment. Using the presented case as a point of departure, the authors discuss principles for prescription of opioids for treatment of chronic noncancer pain in the setting of history of substance use disorders.

Increased burn-induced immunosuppression in lipopolysaccharide-resistant mice

Severe burns induce a state of immunosuppression, and the inflammatory response after burn injury may play a role in this phenomenon. This study examined the effect of the inflammatory response to endotoxin on burn-induced immunosuppression and oxidative stress. An endotoxin-resistant mouse strain (C3H/HeJ) and a normally responding mouse strain (C3H/HeN) were compared. The mice were separated into three groups of five animals for each experimental day: (1) saline, (2) buprenorphine, and (3) buprenorphine and 20% total body surface area burn. All animals were fed ad libitum. The inflammatory response was studied at 1, 4, 7, 10, and 14 days postburn. Proliferation of activated splenocytes in burn mice was significantly lower on days 7, 10, and 14 for the C3H/HeJ strain and on days 4 and 10 for the C3H/HeN strain. Globally, C3H/HeJ presented stronger immune suppression than C3H/HeN. Oxidative stress parameters (liver malonaldehyde, spleen metabolic activity, and thiol concentrations) were higher in endotoxin-resistant mice than in the control strain. Impairment of the inflammatory response was more pronounced and oxidative stress was greater in endotoxin-resistant burn mice than in normal burn controls. Buprenorphine administration was not related to depression of these immune parameters. The inflammatory response following burn injury may be beneficial to the immune system.

The new JCAHO pain standards: implications for pain management nurses

The newly approved Joint Commission on Accreditation of Healthcare Organizations (JCAHO) pain management standards present an important opportunity for widespread and sustainable improvement in pain assessment and management. Unrelieved pain is a major, yet avoidable, public health problem. Despite 20 years of work by educators, clinicians, and professional organizations and the publication of clinical practice guidelines, there have been, at best, modest improvements in pain management practices. Multiple barriers found in the health care system, and among health care professionals, patients, and families, continue to impede progress. In August 1997 a collaborative project was initiated to integrate pain assessment and management into the standards, intent statements, and examples of implementation of JCAHO--a rare opportunity to improve pain management in health care facilities throughout the country. After review by multiple JCAHO committees and advisory groups and critique by an expert panel, the JCAHO Board of Commissioners approved the revisions in May 1999. The revisions are published in the 2000-2001 standards manuals and will be effective January 1, 2001, for all patient care organizations accredited by JCAHO--ambulatory care, behavioral health, health care networks, home care, hospitals, long-term care, and long-term care pharmacies. An evaluation of the impact of the revisions is currently being completed, and education of the JCAHO surveyors and health care professionals is underway. Nurses, especially those with expertise in pain management, are valuable resources as health care organizations change their pain assessment and management processes to meet the new standards.

When there is no benchmark: designing a primary care-based chronic pain management program from the scientific basis up

Managed care has been accused of ignoring the patient with pain. The challenge for a health maintenance organization (HMO) was not just how to deliver state-of-the-art care, but how to deliver it to the 40,000 members who experience chronic pain at a reasonable cost and with enduring outcomes. This article describes how one managed care organization set about improving the care of patients with chronic pain. The article includes the design process, the model implemented, and some suggestions for transfer of this technology to others who might want to explore developing a similar model.

Primary care and pain medicine. A community solution to the public health problem of chronic pain

The author emphasizes that pain is an important public health problem that demands attention. He discusses ineffective management and its causes, administrative and socioeconomic problems perpetuating poor care, problems in technology transfer, organizational models, specialists and subspecialists, and other topics.

Pain management issues: the cost of medications in rural settings

Cost of analgesic and adjuvant medications used by rural patients with cancer cared for by 29 nurses participating in an in-depth education program were evaluated before and after the program. Across all time periods, the median daily cost was $5.16 across all medications. Average daily cost and maximum and median cost of all medications were $5.36, $74.38 and $3.58, respectively. Average daily cost did not change over time. Average pain intensity did not change over time and was not related to prescribing patterns or daily costs. While professional education was demonstrated to produce change in prescribing practices, further research is needed to evaluate patterns of medication administration and effectiveness patterns using reliable outcome measures other than self report of pain intensity.