An examination of the prevalence of acute pain for hospitalised adult patients: a systematic review

Present and Future of Pharmacological Management for Acute Moderate-to-Severe Postoperative, Traumatic, or Musculoskeletal Pain in Europe: A Narrative Review

Acute moderate-to-severe pain is common after surgery, trauma, or musculoskeletal injury, but its management remains suboptimal. Current single-agent treatments are limited by safety concerns, narrow therapeutic windows, and abuse potential, leaving substantial unmet needs. Here, we aimed to review guidelines for the management of acute moderate-to-severe post-surgical, trauma-related, or musculoskeletal pain in adults and discuss existing and potential future analgesics in this setting. We searched PubMed to identify relevant guidelines and existing analgesics for acute pain. To identify compounds in development, we searched ClinicalTrials.gov and the European Union Clinical Trials Register. Guidelines universally recognize the limitations of single-agent analgesics (particularly those with a single mechanism of action [MoA]) and recommend a multimodal approach as an established standard for acute pain. The benefit-risk profiles of traditional treatments, including paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs, selective cyclooxygenase-2 inhibitors, and opioids, can be improved by combining agents targeting different pain pathways. In multimodal approaches, lower doses of constituent agents can be used to achieve the same or superior analgesic effects relative to the individual agents. In some cases, novel formulations and co-crystal technology offer enhanced physicochemical and pharmacokinetic properties over individual agents. Lastly, initiatives to increase patient awareness and education around pain management may improve treatment satisfaction and quality of life, and hasten recovery. In conclusion, management of acute moderate-to-severe pain remains inadequate. Multimodal analgesics may offer advantages over traditional single-agent treatments (that often have a single MoA) for acute moderate-to-severe post-surgical, trauma-related, or musculoskeletal pain in adults. Multimodal analgesics, combined with patient education initiatives and non-pharmacological measures, when necessary, offer promise in addressing unmet needs in this setting.

Nurses' Knowledge and Attitudes about Adult Post-Operative Pain Assessment and Management: Cross Sectional Study in Qatar

BACKGROUND

Pain is a complex and challenging phenomenon. People have different pain experiences, but everyone has the right to effective pain management. Pain assessment and management are integral components of a nurse's role.

AIM

To assess the knowledge and attitudes of nurses in Qatar about adult post-operative patients' pain assessment and management, and the factors that may be associated with such knowledge and attitudes.

METHODS

Post-operative registered nurses from all peri-operative areas at Hamad Medical Corporation participated in a cross-sectional online survey using a self-administered questionnaire. A knowledge and attitudes (K&A) score was calculated. Associations between K&A and potential explanatory variables were assessed using t-tests and one-way ANOVA.

RESULTS

A total of 151 post-operative nurses participated in the study. The mean knowledge and attitudes (K&A) score was 19.6 ± 4.5 out of 41 (48%), indicating a large deficit in nurses' knowledge and attitudes about adult post-operative pain. There were no statistically significant differences in the mean K&A scores of participants based on gender, nationality, education level, marital status, workplace facility, current job designation, or hours of pain education.

CONCLUSIONS

There is a significant deficit in post-operative nurses' knowledge and attitudes about pain across the nursing workforce in post-operative care. Implications for nursing education and policy: Evidence-based, innovative nursing education courses are needed to improve nurses' knowledge and attitudes about pain assessment and management. Health service policy is required to ensure that evidence-based in-service education on pain management is compulsory for all nurses. This study was not registered.

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Pain Prevalence and Treatment in Hospitalized Children and Adolescents at a US Tertiary Pediatric Hospital

Poorly controlled acute pain is associated with worsened patient outcomes. Prior studies suggest that acute pain is a common complaint among hospitalized pediatric patients, but recent studies with substantial numbers of patients from US hospitals are lacking. We retrospectively reviewed inpatients at a single academic children's hospital during twelve 24-hour periods in 2021. Outcomes were assessed for patients on non-intensive care unit (ICU) inpatient floors and in ICUs. The primary outcome was any presence of moderate to severe pain. Of 1355 patients on a non-ICU inpatient floor and 485 patients in the ICU, 23.5% and 58.6%, respectively, had ≥1 moderate to severe pain score during the 24-hour analysis period. While the mean pain score was low for the majority of patients, moderate to severe pain is frequent in hospitalized children. Future studies may focus on identification of variables associated with pediatric inpatients at risk of moderate to severe pain as well as improved pain prevention and reduction strategies.

A multidisciplinary approach on music induced-analgesia differentiated by socio-cultural background in healthy volunteers (MOSART): A cross-over randomized controlled trial protocol

Background

Integrating music into pain treatment demonstrates significant benefits, effectively reducing subjective pain levels and perioperative opioid requirements. Currently, the relationship between the impact of specific types of music and listeners' socio-cultural background is still unclear. This is especially relevant given that sociological research indicates that these factors can have a notable influence on music preference and perception. Current evidence suggests that individuals who choose their own music may experience greater benefits. However, additional research is needed to comprehensively grasp whether the effect of (preferred) music on pain endurance remains consistent across different socio-cultural backgrounds.

Methods

In this study, a collaborative effort between medical and sociological researchers aims to investigate music-induced analgesia differentiated by socio-cultural background in healthy volunteers. Participants (n = 84) will listen to self-, and researcher-chosen music and a podcast as a control condition in a cross-over study design. The primary outcome of this study is pain endurance measured by electric stimuli of increasing intensity. Detailed sociological validated questionnaires will be utilized. Considering the notable influence of educational level on music taste formation found in previous research and its crucial role as a source of socio-cultural differentiation, participants will be stratified based on their level of education.

Discussion

This experimental study represents one of the first efforts to gain a socio-culturally differentiated understanding of the therapeutic potential of music. Consequently, this could pave the way to purposefully and inclusively implement personalized music in healthcare settings.

Understanding the association between pain and delirium in older hospital inpatients: systematic review and meta-analysis

OBJECTIVE

Delirium and pain are common in older adults admitted to hospital. The relationship between these is unclear, but clinically important. We aimed to systematically review the association between pain (at rest, movement, pain severity) and delirium in this population.

METHODS

PubMed, EMBASE, CINAHL, PsycINFO, Cochrane and Web of Science were searched (January 1982-November 2022) for Medical Subject Heading terms and synonyms ('Pain', 'Analgesic', 'Delirium'). Study eligibility: (1) validated pain measure as exposure, (2) validated delirium tool as an outcome; participant eligibility: (1) medical or surgical (planned/unplanned) inpatients, (2) admission length ≥ 48 h and (3) median cohort age over 65 years. Study quality was assessed with the Newcastle Ottawa Scale. We collected/calculated odds ratios (ORs) for categorical data and standard mean differences (SMDs) for continuous data and conducted multi-level random-intercepts meta-regression models. This review was prospectively registered with PROSPERO [18/5/2020] (CRD42020181346).

RESULTS

Thirty studies were selected: 14 reported categorical data; 16 reported continuous data. Delirium prevalence ranged from 2.2 to 55%. In the multi-level analysis, pain at rest (OR 2.14; 95% confidence interval [CI] 1.39-3.30), movement (OR 1.30; 95% CI 0.66-2.56), pain categorised as 'severe' (OR 3.42; 95% CI 2.09-5.59) and increased pain severity when measured continuously (SMD 0.33; 95% CI 0.08-0.59) were associated with an increased delirium risk. There was substantial heterogeneity in both categorical (I2 = 0%-77%) and continuous analyses (I2 = 85%).

CONCLUSION

An increase in pain was associated with a higher risk of developing delirium. Adequate pain management with appropriate analgesia may reduce incidence and severity of delirium.

Co-crystal of Tramadol-Celecoxib Versus Tramadol or Placebo for Acute Moderate-to-Severe Pain After Oral Surgery: Randomized, Double-Blind, Phase 3 Trial (STARDOM1)

INTRODUCTION

Co-crystal of tramadol-celecoxib (CTC) is the first analgesic co-crystal for acute pain. This completed phase 3 multicenter, double-blind trial assessed the efficacy and safety/tolerability of CTC in comparison with that of tramadol in the setting of moderate-to-severe pain up to 72 h after elective third molar extraction requiring bone removal.

METHODS

Adults (n = 726) were assigned randomly to five groups (2:2:2:2:1): orally administered twice-daily CTC 100 mg (44 mg rac-tramadol hydrochloride/56 mg celecoxib; n = 164), 150 mg (66/84 mg; n = 160) or 200 mg (88/112 mg; n = 160); tramadol 100 mg four times daily (n = 159); or placebo four times daily (n = 83). Participants in CTC groups also received twice-daily placebo. The full analysis set included all participants who underwent randomization. The primary endpoint was the sum of pain intensity differences over 0 to 4 h (SPID0-4; visual analog scale). Key secondary endpoints included 4-h 50% responder and rescue medication use rates. Safety endpoints included adverse events (AEs), laboratory measures, and Opioid-Related Symptom Distress Scale (OR-SDS) score.

RESULTS

All CTC doses were superior to placebo (P < 0.001) for primary and key secondary endpoints. All were superior to tramadol for SPID0-4 (analysis of covariance least squares mean differences [95% confidence interval]: - 37.1 [- 56.5, - 17.6], - 40.2 [- 59.7, - 20.6], and - 41.7 [- 61.2, - 22.2] for 100, 150, and 200 mg CTC, respectively; P < 0.001) and 4-h 50% responder rate. Four-hour 50% responder rates were 32.9% (CTC 100 mg), 33.8% (CTC 150 mg), 40.6% (CTC 200 mg), 20.1% (tramadol), and 7.2% (placebo). Rescue medication use was lower in the 100-mg (P = 0.013) and 200-mg (P = 0.003) CTC groups versus tramadol group. AE incidence and OR-SDS scores were highest for tramadol alone.

CONCLUSIONS

CTC demonstrated superior pain relief compared with tramadol or placebo, as well as an improved benefit/risk profile versus tramadol.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02982161; EudraCT number, 2016-000592-24.

Chronic Pain, Hopelessness, and Suicide Risk Among Adult Medical Inpatients

BACKGROUND

Medically ill adults are at elevated risk for suicide. Chronic pain and hopelessness are associated with suicide; however, few studies have examined the interaction between chronic pain and hopelessness in predicting suicide risk among hospitalized adults.

OBJECTIVE

This study aimed to describe the association between chronic pain, hopelessness, and suicide risk, defined as recent suicidal ideation or lifetime suicidal behavior. In addition, we examined the interaction between chronic pain and hopelessness.

METHODS

This was a secondary analysis of a multisite study to validate the Ask Suicide-Screening Questions (ASQ) among adult medical inpatients. Participants reported if they experienced chronic pain that impacted daily life and if they felt hopeless about their medical condition and provided their current pain rating on a 1 to 10 scale, with 10 being the most severe pain. A t-test compared pain severity scores by ASQ outcome. A binary logistic regression model described the association between chronic pain, hopelessness, and suicide risk; parameter estimates are expressed as odds ratios (OR) for interpretation. The interaction between chronic pain and hopelessness was examined in both the transformed (logit) and natural (probability) scales of the generalized linear model.

RESULTS

The sample included 720 participants (53.2% male, 62.4% White, mean age: 50.1 [16.3] years, range = 18-93). On the ASQ, 15.7% (113/720) of patients screened positive. Half (360/720) of the sample self-reported chronic pain. Individuals who screened positive had higher pain rating scores than those who screened negative (t = -4.2, df = 147.6, P < 0.001). Among all patients, 27.2% (196/720) felt hopeless about their medical condition. In the logistic regression model, patients with chronic pain (adjusted OR: 2.29, 95% confidence interval [CI]: 1.21-4.43, P = 0.01) or hopelessness (adjusted OR: 5.69, 95% CI: 2.52-12.64, P < 0.001) had greater odds of screening positive on the ASQ. The interaction effect between pain and hopelessness was not significant in the transformed (B = -0.15, 95% CI: -1.11 to 0.82, P = 0.76) or natural (B = 0.08, 95% CI: -0.07 to 0.23, P = 0.28) scale.

CONCLUSIONS

There were significant independent associations between (1) chronic pain and suicide risk and between (2) hopelessness and suicide risk. Future research should examine the temporality and mechanisms underlying these relationships to inform prevention efforts for medically ill adults.

Boosting open-label placebo effects in acute induced pain in healthy adults (BOLPAP-study): study protocol of a randomized controlled trial

Introduction

Pain is a highly prevalent symptom in the hospital setting, but treatment options remain limited. Harnessing the placebo effect in an ethical manner could provide a new possibility to reduce pain in clinical practice. So called open-label placebos (OLP) have been shown to elicit significant effects in reducing acute pain. But, before implementation, more knowledge concerning the properties of OLPs is needed. This study aims to assess the duration of analgesic effects from OLP and to determine the possibility of boosting such effects.

Methods and analysis

This is the protocol of an ongoing (first patient enrolled in March 2023) single-site randomized trial investigating OLPs in two parts (i.e., substudies). In both parts, pain will be induced in healthy adults using an intradermal electrical stimulation model. Participants in Part 1 will have two study visits: An interventional visit with one OLP injection accompanied by an evidence-based treatment rationale and a control visit with no treatment. For Part 2, participants will be randomized into three groups: (1) A fixed-time "Booster" group including one single repetition of the OLP injection at a fixed time point, (2) an on-demand "Booster" group including one single repetition of the OLP injection on-demand, and (3) a control group who will receive just one OLP injection. Differences in pain ratings over time (using the Numeric Rating Scale) will be analyzed with several two-sample t-tests. The time point for a fixed-time "Booster" in Part 2 will be derived from Part 1 with additional statistical tools such as a broken-stick mixed-effect model.

Discussion

This study aims to further characterize the analgesic effects of OLPs. In doing so, it will provide valuable information needed for later implementation of OLPs in clinical practice, where they could play a role in multimodal analgesic concepts.

Ethics and dissemination

The "Ethikkommission Nordwest- und Zentralschweiz" (BASEC 2023-00296) approved the study protocol. Results of the analysis will be submitted for publication in a peer-reviewed journal.

Clinical Trial Registration

This study is registered at ClinicalTrials.gov (NCT05819476) and is listed in the Swiss National Registry at kofam.ch (SNCTP000005470).

Evaluating simulator sickness and acceptability of virtual reality prototype in pain management in hospitalized patients

Aim: Acute and chronic noncancer pain is a common healthcare problem locally and globally, and remains under treated and poorly controlled. We created a virtual reality (VR)-based prototype with customization of content to our local population. Materials & methods: This was an open-label, single center, single-arm study to examine the safety, acceptability and tolerability of the use of VR as an adjunctive tool for pain relief in hospitalized patients. The participants rated their baseline and post-VR pain and anxiety scores. Results & conclusion: All 50 patients completed the VR sessions with good tolerability and safety. Preliminary exploration of pain reduction indicated a positive effect (for pain and anxiety visual analog scale scores; p < 0.001). We believe VR is a potentially beneficial tool for use in pain management.

Patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS)

OBJECTIVE

This study aims to assess the patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS) as a patient-reported outcome measure (PROM) for pain assessment in a military population.

DESIGN

A critical evaluation of the DVPRS was conducted, considering its fit-for-purpose as a PROM and its patient-centeredness using the National Health Council's Rubric to Capture the Patient Voice.

SETTING

The study focused on the use of the DVPRS within the Department of Defense (DoD) and Veterans Health Administration (VA) healthcare settings.

SUBJECTS

The DVPRS was evaluated based on published studies and information provided by measure developers. The assessment included content validity, reliability, construct validity, and ability to detect change. Patient-centeredness and patient engagement were assessed across multiple domains.

METHODS

Two independent reviewers assessed the DVPRS using a tool/checklist/questionnaire, and any rating discrepancies were resolved through consensus. The assessment included an evaluation of psychometric properties and patient-centeredness based on established criteria.

RESULTS

The DVPRS lacked sufficient evidence of content validity, with no patient involvement in its development. Construct validity was not assessed adequately, and confirmatory factor analysis was not performed. Patient-centeredness and patient engagement were also limited, with only a few domains showing meaningful evidence of patient partnership.

CONCLUSIONS

The DVPRS as a PROM for pain assessment in the military population falls short in terms of content validity, construct validity, and patient-centeredness. It requires further development and validation, including meaningful patient engagement, to meet current standards and best practices for PROMs.

Pain assessment and management among adult patients in a gynecology ward: a best practice implementation project

OBJECTIVES

This project aimed to improve compliance with evidence-based practice in pain assessment and management in a gynecology ward.

INTRODUCTION

Effective pain control is important to prevent the negative consequences of pain that is poorly managed. However, it remains undervalued and inadequately treated. Applying evidence-based practices to correctly evaluate and manage pain is essential to improve pain relief.

METHODS

This project followed the JBI Evidence Implementation Framework. A baseline audit of 41 women admitted to the gynecology ward was conducted and measured against 5 best practice criteria, along with a patient satisfaction questionnaire. Targeted strategies were then implemented and a follow-up audit was conducted using the same criteria, methods, and sample size as the baseline audit.

RESULTS

The baseline audit revealed gaps between current and best practice. Barriers to implementation were identified and strategies to resolve the barriers were designed and implemented (nurse education, informative materials, electronic patient records system improvements). Comprehensive pain assessment, including dynamic and static pain assessment, use of a validated tool, and education provided to patients and carers, improved in the follow-up audit. There was no change in patient satisfaction levels; however, the discrepancy between pain measured by nurses and pain measured by patients was reduced.

CONCLUSIONS

The JBI methodology was useful in improving compliance with evidence-based practice criteria. It also facilitated adaptation to new barriers, such as the COVID-19 pandemic. Improving nurses' knowledge of pain assessment can lead to more accurate assessment. Inadequate records systems also made it difficult to record the care that was provided. Subsequent audits will assess sustainability and the project will be escalated to other wards.

Do we really know if they are in pain? A cross-sectional study in hospitalised adult patients in Spain

AIMS

To describe the prevalence and characteristics of pain in adult hospitalised patients, as well as to analyse the concordance between patient-reported and recorded pain and its impact on analgesic management.

DESIGN

A cross sectional study.

METHODS

The study was performed on a sample of 611 patients, from October to December 2017. Data were obtained from patient interviews, review of medical and nursing records and review of electronic prescribing.

RESULTS

The prevalence of pain at the time of the interview was 36.7%. The median VAS score was 4. 90% of the patients had their pain assessed within the last 24 h; however, concordance between patient-reported pain and recorded pain in the nursing record was slight.

CONCLUSION

Pain is still often documented inadequately. Despite the wide use of analgesics, half of the patients with moderate to severe pain do not have adequate pain management. A systematic assessment and recording of pain promotes appropriate analgesic prescription.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The findings of our study provide insight into the main gaps in the correct management of pain in hospitalised patients. A systematic assessment and recording of the pain suffered by the patient facilitates its control and allows a better management of the analgesic prescription by the physician. This information could help hospital managers to develop training programmes on pain assessment and on the importance of doctor-nurse collaboration to improve pain management, increasing the quality of care and reducing hospital costs.

REPORTING METHOD

The study has adhered to the relevant EQUATOR guidelines, according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Measuring person-centred pain management: Development of a questionnaire using the fundamentals of care framework

AIM

To develop and test a questionnaire using the Fundamentals of Care framework to measure person-centred pain management.

DESIGN

Cross-sectional exploratory descriptive design.

METHODS

Development in three phases: (a) literature search for questionnaires measuring person-centred pain management, (b) seven-step process developing items using thematic analysis, (c) initial feasibility and validity testing. Theoretical and empirical evidence was used, including the 'Strategic and Clinical Quality Indicators in Postoperative Pain management' questionnaire, the Fundamentals of Care framework and person-centredness principles. Theoretical experts (n = 2) reviewed the questionnaire, further evaluated by providers (n = 5) and patients (n = 5) using a think-aloud process, and by additional questions in the questionnaire answered by n = 100 patients. The questionnaire was tested February to March 2021, at four surgical wards in a university hospital.

RESULTS

The evaluation showed initial support for feasibility and validity, and the questionnaire was found to represent and be sensitive to capture the patients' experiences of person-centred pain management and being easy to answer. The 100 patients with acute abdominal pain who answered the questionnaire (aged 18-89 years, 46 women and 54 men), identified missing elements of fundamental care in their pain management, indicating that the questionnaire is sensitive to capture specific areas for improvement.

CONCLUSION

This first attempt at transforming the essential components of person-centred pain management into measurable items in a questionnaire was found promising. The questionnaire is suggested to be further tested for psychometric properties and patient benefit to provide clinical guidance in acute surgical care to meet the patient care need of pain management.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The developed questionnaire addresses the need of nurses and nursing leaders to evaluate the delivery of person-centred pain management in acute surgical care, to relieve the patient from pain.

PATIENT OR PUBLIC CONTRIBUTION

Patients and providers were involved in testing the questionnaire.

Tramadol for chronic pain in adults: protocol for a systematic review with meta-analysis and trial sequential analysis of randomised clinical trials

BACKGROUND

Chronic pain in adults is a frequent clinical symptom with a significant impact on patient well-being. Therefore, sufficient pain management is of utmost importance. While tramadol is a commonly used pain medication, the quality of evidence supporting its use has been questioned considering the observed adverse events. Our objective will be to assess the benefits and harms of tramadol compared with placebo or no intervention for chronic pain.

METHODS/DESIGN

We will conduct a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis to assess the beneficial and harmful effects of tramadol in any dose, formulation, or duration. We will accept placebo or no intervention as control interventions. We will include adult participants with any type of chronic pain, including cancer-related pain. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and BIOSIS for relevant literature. We will follow the recommendations by Cochrane and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The risk of systematic errors ('bias') and random errors ('play of chance') will be assessed. The certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

DISCUSSION

Although tramadol is often being used to manage chronic pain conditions, the beneficial and harmful effects of this intervention are unknown. The present review will systematically assess the current evidence on the benefits and harms of tramadol versus placebo or no intervention to inform clinical practice and future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019140334.

Pain Prevalence and Management in a General Hospital Through Repeated Cross-Sectional Surveys in 2011 and 2021

Background

There is great scope for improving the quality of pain management. Although pain prevalence has been investigated in several countries, few studies have comparatively assessed changes in pain prevalence and management over a span of multiple years.

Aim

This work was aimed at determining the pain prevalence and evaluating the condition of pain management in a Chinese general hospital in 2021 and comparing them with corresponding data from 10 years ago.

Methods

Repeated single-center cross-sectional studies were initiated on June 14th, 2011, and September 2nd, 2021, in the same tertiary grade A Chinese general hospital. The same structured questionnaire was used to collect inpatient data on pain intensity and classification and pain management outcomes. We performed statistical analyses to compare categorical variables to assess changes over time.

Results

The sample sizes for the investigations in 2011 and 2021 were 2323 and 4454, respectively. In 2021, 24.34% of patients experienced pain; this percentage was significantly lower than that in 2011. Meanwhile, the prevalence of moderate and severe pain decreased from 14.73% in 2011 to 4.98% in 2021. The other six indicators of pain management outcomes also improved significantly. The percentages of patients using painkillers, opioid analgesics, and multiple analgesics increased from 44.61 to 51.38%, 24.01% to 44.61%, and 6.82% to 14.11%, respectively. Furthermore, the percentages of patients who received pain information and who actively reported pain increased from 27.56% to 96.5% and from 85.54% to 98.71%, respectively. The percentage of patients qualified to accurately use the Numerical Rating Scale increased from 10.5% to 79.98%.

Conclusion

The quality and outcomes of pain management improved greatly after the establishment and implementation of the pain management system. Nonetheless, pain of different intensities is common after major surgeries, and it is recommended that hospitals popularize and implement perioperative multimodal analgesia strategies to reduce the incidence of postoperative pain.

Rescue Analgesia for Opioid-Dependent Individuals on Opioid Agonist Treatment during Hospitalization: Adherence to Guideline Treatment

INTRODUCTION

Opioid agonist treatment (OAT) is the first-line treatment for opioid use disorder (OUD). Simultaneously, opioids are essential medicines in acute pain management. The literature is scarce on acute pain management in individuals with OUD, and guidelines are controversial for patients on OAT. We aimed at analyzing rescue analgesia in opioid-dependent individuals on OAT during hospitalization in the University Hospital Basel, Switzerland.

METHODS

Patient hospital records were extracted from the database over 6 months (Jan-Jun) in 2015 and 2018. Of the 3,216 extracted patient records, we identified 255 cases on OAT with full datasets. Rescue analgesia was defined according to established principles of acute pain management, e.g., i) the analgesic agent is identical to the OAT medication, and ii) the opioid agent is dosed above 1/6th morphine equivalent dose of the OAT medication.

RESULTS

The patients were on average 51.3 ± 10.5 years old (range: 22-79 years), of which 64% were men. The most frequent OAT agents were methadone and morphine (34.9% and 34.5%). Rescue analgesia was not documented in 14 cases. Guideline-concordant rescue analgesia was observed in 186 cases (72.9%) and consisted mostly of NSAIDs, including paracetamol (80 cases), and identical agents such as the OAT opioid (70 cases). Guideline-divergent rescue analgesia was observed in 69 (27.1%) cases, predominantly due to an underdosed opioid agent (32 cases), another agent other than the OAT (18 cases), or contraindicated agents (10 cases).

DISCUSSION

Our analysis suggests that rescue analgesia in hospitalized OAT patients was predominantly concordant with guidelines, while divergent prescriptions seemed to follow common principles of pain medicine. Clear guidelines are needed to appropriately treat acute pain in hospitalized OAT patients.

Electroacupuncture for Pain Outcomes in a Trauma Center's Acute Pain Service: A Retrospective Observational Study

Background

Evidence for acupuncture to treat pain is growing. Electrostimulation of acupuncture needles (electroacupuncture) is common for pain and is thought to augment the therapeutic effect.

Objectives

To examine the association of pain outcomes after a single acupuncture session with electrostimulation included (EA) compared with no electrostimulation included (NEA).

Methods

A retrospective observational study was conducted using electronic health records of acupuncture sessions for adults with acute pain under the care of an acute pain service. Paired t-test and linear regression were used to report pain intensity changes after a single acupuncture session and by including EA. Ordered logistic regression was used to report categorical pain relief. Logistic regression was used to explore the odds of adding EA and the patient's age, gender, and pretreatment pain.

Results

From July 24, 2017, through November 9, 2020, 465 acupuncture sessions recorded EA (n = 194), or NEA (n = 271). Acupuncture, independent of EA status, reduced pain intensity by a mean 2.5 points. EA was associated with a mean 0.38-point reduction in pain intensity more than NEA (confidence interval [95% CI]: -0.75 to -0.01). Among sessions reporting categorical pain relief (n = 415), higher relief was more likely with EA (odds ratio = 2.16, 95% CI: 1.52-3.08). There was no association between EA and the patient's age, gender, and pretreatment pain intensity.

Conclusions

After a single acupuncture session, both EA and NEA reduced pain intensity. Higher categorical pain relief was reported with EA, though the clinical meaning is uncertain. Future research should focus on well-defined populations for electroacupuncture and factors for including electrostimulation.

Real-World Evidence on the Efficacy and Tolerability of Tramadol/Dexketoprofen (TRAM/DKP) Fixed-Dose Combination for the Management of Acute Non-surgical Pain in Asian Patients: A Multicentre Retrospective Case Series

INTRODUCTION

Multimodal analgesia is key in the effective management of acute pain. Previous clinical trials have demonstrated good results with the use of a fixed-dose combination (FDC) of tramadol 75 mg and dexketoprofen 25 mg (TRAM/DKP) in acute pain management. However, there is a dearth of real-world evidence on the efficacy and safety of this combination in the management of acute non-surgical pain, especially among Asian patients. The case series reported herein investigates the real-world experiences of physicians and Asian patients with the use of TRAM/DKP FDC in the management of acute non-surgical pain.

METHODS

Data were collected retrospectively on 11 Asian patients across multiple hospitals who had received a short course of TRAM/DKP FDC for acute non-surgical orthopaedic and non-orthopaedic pain. Data on baseline characteristics, medical history, treatment regimen, clinical outcomes, and patient satisfaction were compiled and shared at a peer-to-peer expert meeting in October 2022.

RESULTS

All patients experienced a reduction in pain intensity and were very satisfied with pain management, with a mean satisfaction score of 4.3/5. Five patients (range: 63-74 years) experienced mild adverse events, including nausea, vomiting, and dizziness, which resolved with no need for additional treatment in the majority of cases. No serious adverse events were recorded.

CONCLUSION

Asian patients with acute non-surgical orthopaedic and non-orthopaedic pain achieved good pain control with TRAM/DKP FDC. The regimen was well tolerated, and patients reported high levels of satisfaction with the outcomes, indicating that TRAM/DKP FDC is an effective choice for the control of acute non-surgical pain in Asian patients.

Pain prevalence and pain management in children and adolescents in an italian third level pediatric hospital: a cross-sectional study

BACKGROUND

In 2016, we performed a one-day investigation to analyze the prevalence of pain, pain intensity, and pain therapy in the Departments of Surgery and Onco-Hematology of the Ospedale Pediatrico Bambino Gesù. To improve the knowledge gap highlighted in the previous study, refresher courses and even personalized audits have been carried out during these years. The purpose of this study is to evaluate if, after 5 years, there have been improvements in the management of pain.

METHODS

The study was conducted on 25 January 2020. Pain assessment, pain therapies, pain prevalence and intensity in the preceding 24 h and during the recovery period were recorded. Pain outcomes were compared with previous audit results.

RESULTS

Out of the 63 children with at least one documented pain assessment (starting from 100 eligible), 35 (55.4%) experienced pain: 32 children (50.7%) experienced moderate /severe pain while 3 patients (4%) felt mild pain. In the preceding 24 h, 20 patients (31.7%) reported moderate/severe pain while 10 (16%) reported moderate or severe pain during the interview. The average value of the Pain Management Index (PMI) was - 1.3 ± 0.9 with a minimum of -3 and a maximum of 0. 28 patients (87%) undergoing analgesic therapy for moderate/severe pain had a PMI of less than 0 (undertreated pain), while 3 patients (13%) scored value of 0 or higher (adequate pain therapy), 4 patients (12.5%) received multimodal analgesia with opioids and 2 patients (6%) opioids alone. Time-based therapy was prescribed to 20 patients (62.5%), intermittent therapy was prescribed to 7 patients (22%) and 5 patients (15.5%) did not receive any therapy. The prevalence of pain was higher during hospitalization and 24 h before the interview, while at the time of the interview, the proportion was the same. In this audit, the daily prescription modality of the therapy had some improvements (time-based: 62.5% vs. 44%; intermittent: 22%vs 25%; no therapy: 15.5% vs. 31%).

CONCLUSION

Pain management in hospitalized children constantly requires special daily attention from health professionals aimed at mitigating the components of intractable pain and resolving those of treatable pain.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov, number (NCT04209764), registered 24 December 2019, https://clinicaltrials.gov/ct2/show/NCT04209764?term=NCT04209764&draw=2&rank=1 .

Frailty and pain in an acute private hospital: an observational point prevalence study

Frailty and pain in hospitalised patients are associated with adverse clinical outcomes. However, there is limited data on the associations between frailty and pain in this group of patients. Understanding the prevalence, distribution and interaction of frailty and pain in hospitals will help to determine the magnitude of this association and assist health care professionals to target interventions and develop resources to improve patient outcomes. This study reports the point prevalence concurrence of frailty and pain in adult patients in an acute hospital. A point prevalence, observational study of frailty and pain was conducted. All adult inpatients (excluding high dependency units) at an acute, private, 860-bed metropolitan hospital were eligible to participate. Frailty was assessed using the self-report modified Reported Edmonton Frail Scale. Current pain and worst pain in the last 24 h were self-reported using the standard 0-10 numeric rating scale. Pain scores were categorised by severity (none, mild, moderate, severe). Demographic and clinical information including admitting services (medical, mental health, rehabilitation, surgical) were collected. The STROBE checklist was followed. Data were collected from 251 participants (54.9% of eligible). The prevalence of frailty was 26.7%, prevalence of current pain was 68.1% and prevalence of pain in the last 24 h was 81.3%. After adjusting for age, sex, admitting service and pain severity, admitting services medical (AOR: 13.5 95% CI 5.7-32.8), mental health (AOR: 6.3, 95% CI 1. 9-20.9) and rehabilitation (AOR: 8.1, 95% CI 2.4-37.1) and moderate pain (AOR: 3.9, 95% CI 1. 6-9.8) were associated with increased frailty. The number of older patients identified in this study who were frail has implications for managing this group in a hospital setting. This indicates a need to focus on developing strategies including frailty assessment on admission, and the development of interventions to meet the care needs of these patients. The findings also highlight the need for increased pain assessment, particularly in those who are frail, for more effective pain management.Trial registration: The study was prospectively registered (ACTRN12620000904976; 14th September 2020).

Three-year hospital-wide pain management system implementation at a tertiary medical center: Pain prevalence analysis

We developed a pain management system over a 3-year period. In this project, "Towards a pain-free hospital", we combined evidence-based medicine and medical expertise to develop a series of policies. The intervention mainly included the development of standard procedures for inpatient pain management, the implementation of hospital-wide pain medicine education and training, the establishment of a dashboard system to track pain status, and regular audits and feedback. This study aimed to gain an understanding of the changes in the prevalence of pain in inpatients under the care of the pain management system. The subjects of the survey are inpatients over 20 years old, and who had been hospitalized in the general ward for at least 3 days. The patients would be excluded if they were unable to respond to the questions. We randomly selected eligible patients in the general ward. Our trained interviewers visited inpatients to complete the questionnaires designed by our pain care specialists. A total of 3,094 inpatients completed the survey from 2018 to 2020. During the three-year period, the prevalence of pain was 69.5% (2018) (reference), 63.3% (2019) (OR:0.768, p<0.01), and 60.1% (2020) (OR:0.662, p <0.001). The prevalence rates of pain in patients undergoing surgery during the 3-year period were 81.4% (2018), 74.3% (2019), and 68.8% (2020), respectively. As for care-related causes of pain, injection, change in position/chest percussion, and rehabilitation showed a decreasing trend over the 3-year period of study. Our pain management system provided immediate professional pain management, and achieved a good result in the management of acute moderate to severe pain, especially perioperative pain. Studies on pain prevalence and Pain-Free Hospitals are scarce in Asia. With the aid of the policies based on evidence-based medicine and the dashboard information system, from 2018 to 2020, the prevalence of pain has decreased year by year.

How Hospital Patients Experience Pain the Previous 24 Hours-A Prevalence Assessment of Pain in Five Hospitals in Sweden

BACKGROUND

Previous studies show that pain is common among hospital inpatients.

AIM

This study measures the prevalence of pain and the impact of pain on sleep in patients admitted to five hospitals in Sweden.

METHODS

The patients were admitted to a surgical or a medical ward. They answered on a self-reported questionnaire about their average pain intensity and how much their pain interfered with their sleep the previous 24 hours, on a 010 numerical rating scale (NRS).

RESULTS

Of the 500 patients, 308 experienced pain (62%), (NRS ≥ 3) and 111 (22%) rated their pain as NRS ≥ 7. We found no difference between surgical and medical specialty regarding pain prevalence. The results suggest that roughly the same proportion of patients with pain also experienced poor sleep due to pain265 patients (53%) reported pain interference on sleep, NRS ≥ 3.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This study shows that there is still an unacceptable high pain prevalence in inpatients and that patients experience pain as negatively impacting their sleep. Future pain care is likely to include a more comprehensive implementation strategy for the dissemination of knowledge, especially related to the complex context of today's healthcare system. That is, the possibility that anchoring new knowledge also benefits the patient is probably associated with optimization of the structural context. Future research should take this question further by examining how the organizational structure should be optimized for the dissemination of knowledge in healthcare professionals about pain and pain interference with sleep.

Effect of CYP2C9, PTGS-1 and PTGS-2 gene polymorphisms on the efficiency and safety of postoperative analgesia with ketoprofen

OBJECTIVES

Patients undergoing cardiac surgery develop post-sternotomy pain syndrome. The aim of this study was evaluation of the influence of CYP2C9, PTGS-1 and PTGS-2 genes polymorphisms on the efficacy and safety of postoperative analgesia with ketoprofen in patients with coronary artery disease after cardiac surgery.

METHODS

The study included 90 patients undergoing cardiac surgery. A real-time polymerase chain reaction was used for the detection of single nucleotide polymorphisms (SNP). Pain intensity was measured by the Numeric Rating Scale (NRS). Dyspeptic symptoms were evaluated using the Gastrointestinal Symptom Rating Scale (GSRS). Acute kidney injury (AKI) was determined by Kidney Disease Improving Global Outcomes criteria.

RESULTS

Pain intensity by the NRS score was significantly higher in patients with CYP2C9*3 АA genotype compared to АC genotype: 7 [1,10] and 6 [2,7] (p=0.003); 7 [1,10] and 6 [2,7] (p=0.04); 6 [0; 10] and 5 [2,6] (p=0.04); 5 [0; 8] and 3 [0; 8] (p=0.02), on days 1, 2, 3 and 5 in the postoperative period, respectively. GSRS score was higher in patients with CYP2C9*2 CT genotype compared to CС genotype: 19 [15; 42] and 18 [15,36] (p=0.04), respectively. There were no significant differences in the pain intensity, dyspepsia severity and AKI frequency in patients with homozygous and heterozygous genotypes for PTGS-1 rs10306135, PTGS-1 rs12353214, PTGS-2 rs20417.

CONCLUSIONS

CYP2C9*3 and CYP2C9*2 gene polymorphisms may affect efficacy and safety of postoperative analgesia with ketoprofen in patients with coronary artery disease after cardiac surgery.

Mechanisms of Action of the Peptide Toxins Targeting Human and Rodent Acid-Sensing Ion Channels and Relevance to Their In Vivo Analgesic Effects

Acid-sensing ion channels (ASICs) are voltage-independent H⁺-gated cation channels largely expressed in the nervous system of rodents and humans. At least six isoforms (ASIC1a, 1b, 2a, 2b, 3 and 4) associate into homotrimers or heterotrimers to form functional channels with highly pH-dependent gating properties. This review provides an update on the pharmacological profiles of animal peptide toxins targeting ASICs, including PcTx1 from tarantula and related spider toxins, APETx2 and APETx-like peptides from sea anemone, and mambalgin from snake, as well as the dimeric protein snake toxin MitTx that have all been instrumental to understanding the structure and the pH-dependent gating of rodent and human cloned ASICs and to study the physiological and pathological roles of native ASICs in vitro and in vivo. ASICs are expressed all along the pain pathways and the pharmacological data clearly support a role for these channels in pain. ASIC-targeting peptide toxins interfere with ASIC gating by complex and pH-dependent mechanisms sometimes leading to opposite effects. However, these dual pH-dependent effects of ASIC-inhibiting toxins (PcTx1, mambalgin and APETx2) are fully compatible with, and even support, their analgesic effects in vivo, both in the central and the peripheral nervous system, as well as potential effects in humans.

The Effects of Pain and Analgesic Medications on Blood Pressure

PURPOSE OF REVIEW

To review the blood pressure (BP) effects of pain and analgesic medications and to help interpret BP changes in people suffering from acute or chronic pain.

RECENT FINDINGS

Acute pain evokes a stress response which prompts a transient BP increase. Chronic pain is associated with impaired regulation of cardiovascular and analgesia systems, which may predispose to persistent BP elevation. Also analgesics may have BP effects, which vary according to the drug class considered. Data on paracetamol are controversial, while multiple studies indicate that non-steroidal anti-inflammatory drugs may increase BP, with celecoxib showing a lesser impact. Hypotension has been reported with opioid drugs. Among adjuvants, tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors could be pro-hypertensive due to potentiation of adrenergic transmission. Pain and analgesics may induce a clinically significant BP destabilization. The implications on hypertension incidence and BP control remain unclear and should be explored in future studies.

Uncontrolled pain in critically ill patients and acute kidney injury: a hypothesis-generating cohort study

Background

In critically ill patients, acute pain occurs frequently, causes sympathetic activation, release of inflammatory mediators, and potential organ dysfunction, with the kidneys potentially sensitive to inflammation-mediated injury. This study aimed to explore the association between acute pain in critically ill patients and the occurrence of acute kidney injury (AKI).

Methods

Data from a retrospective cohort of adult patients admitted between June 2013 and June 2016 to the Intensive Care Unit (ICU) of a tertiary hospital in São Paulo, Brazil, were analyzed. The main exclusion criteria were ICU length of stay < 48 h, coma, and prior kidney dysfunction. The outcome (AKI) was defined as an elevation in the baseline serum creatinine level of ≥ 0.3 mg/dl and/or > 50% at any time after the first 48 h in the ICU. Multivariable logistic regression and hierarchical cluster analysis were performed.

Results

The isolated incidence of pain was 23.6%, and the incidence of pain duration > 5 days was 10.6%. AKI occurred in 31.7% of the cohort. In multivariable logistic analysis, duration of pain > 5 days (OR 5.25 CI 2.19–12.57 p < 0.01) and mechanical ventilation (MV) ≥ 3 days (OR 5.5 CI 2.3–13.5 p < 0.01) were the variables with positive association with AKI. The hierarchical cluster analysis reinforced the relation between AKI, MV and duration of pain.

Conclusions

Pain is an especially important issue in critically ill patients and in this exploratory study it appears to be associated with AKI development. The search for more rigorous pain control in ICU is crucial and can influence organ dysfunction.

Graphical Abstract

Reimagining How We Treat Acute Pain: A Narrative Review

Acute pain may be influenced by biopsychosocial factors. Conditioned pain modulation, distraction, peripheral nerve stimulation, and cryoneurolysis may be helpful in its treatment. New developments in opioids, such as opioids with bifunctional targets and oliceridine, may be particularly suited for acute pain care. Allosteric modulators can enhance receptor subtype selectivity, offering analgesia with fewer and/or less severe side effects. Neuroinflammation in acute pain is caused by direct insult to the central nervous system and is distinct from neuroinflammation in degenerative disorders. Pharmacologic agents targeting the neuroinflammatory process are limited at this time. Postoperative pain is a prevalent form of acute pain and must be recognized as a global public health challenge. This type of pain may be severe, impede rehabilitation, and is often under-treated. A subset of surgical patients develops chronic postsurgical pain. Acute pain is not just temporally limited pain that often resolves on its own. It is an important subject for further research as acute pain may transition into more damaging and debilitating chronic pain. Reimagining how we treat acute pain will help us better address this urgent unmet medical need. 

The effect of slow deep breathing relaxation exercise on pain levels during and post chest tube removal post coronary artery bypass graft surgery

Objectives

This study aimed to evaluate the effectiveness of slow deep breathing relaxation exercise (SDBRE) in reducing patients’ pain levels during chest tube removal (CTR) post coronary artery bypass grafting (CABG) surgery.

Methods

In 2019, fifty post-CABG patients were conveniently selected from a cardiac intensive care unit in Jordan’s major referral heart institute. The patients were randomly assigned to either an intervention group or a control group. A total of 25 patients were assigned into the experimental group who received slow deep breathing relaxation Exercise (SDBRE) alongside the conventional care before CTR. The remaining 25 patients constituted the control group (50%) that had CTR following conventional care. The Visual Analogue Scale (VAS) was used to measure the participants’ pain levels during three phases: before CTR (Time 1), 5-min post CTR (Time 2), and 15-min post CTR (Time 2) to compare the intervention effect between the two groups.

Results

The data analysis findings for the control and intervention group of patients showed that there was a statistically significant decline in their pain level across time for both groups (H = 32.71, P < 0.01; H = 47.23, P < 0.01) respectively. The intervention group had significantly lower pain levels than the control group at Time 2 (3.50 [1.20, 5.30] vs. 7.90 [7.00, 9.00], P < 0.01) and Time 3 (0.00 [0.00, 1.30] vs. 3.60 [2.40, 4.10] P < 0.01).

Conclusions

Using SDBRE during CTR is an effective technique for reducing pain which can minimize the need for analgesics and their associated adverse effects.

CE: Assessing Movement-Evoked Pain

ABSTRACT

One of the most common and nuanced tasks that nurses perform is pain assessment, particularly in acute postoperative settings where frequent reassessments are needed. Most assessments are limited to obtaining a pain intensity score with little attention paid to the conditions necessitating the assessment or the factors contributing to the pain. Pain is frequently assessed during rest, but seldom during periods of movement or activity, which is a crucial omission given that acute postoperative movement-evoked pain (MEP) is intense and a common barrier to healing and restoration of function. In addition to physical limitations, MEP can impede cognitive, emotional, and social functioning in ways that can contribute to chronic pain, mood disorders, and disability. Professional and regulatory standards are moving away from a focus on pain intensity to an emphasis on its context, impact on function, and associated distress. Thus, there are many driving forces compelling nurses to integrate MEP assessments into practice to expedite the restoration of biopsychosocial functioning in postoperative patients. The authors discuss the clinical significance of a MEP assessment as well as protocols and tools for completing such assessments.

Evaluation of the Influence of CYP2C9* 2, CYP2C9*3 Gene Polymorphisms on the Efficacy and Safety of Postoperative Analgesia with Ketoprofen in Patients after Cardiac Surgery

Aim. The aim of the study was to evaluate the efficacy and safety of ketoprofen as an analgesic therapy in patients with CYP2C9*2 (430C>T) rs179985 and CYP2C9*3 (1075A>C) rs1057910 gene polymorphisms after cardiac surgery.

Material and methods. The study included 90 patients. Postoperative analgesia was perfomed by ketoprofen 100 mg intramuscularly twice daily. The evaluation of pain was determined daily by Numeric Rating Scale for 5 days after cardiac surgery. The safety of ketoprofen was determined by assessing the severity of gastroenterological symptoms using the Gastrointestinal Symptom Rating Scale questionnaire and determining the frequency of episodes of acute kidney injury. The material for DNA was venous blood. To determine the single nucleotide genetic polymorphisms CYP2C9*2 (430C>T) rs179985 and CYP2C9*3 (1075A>C) rs1057910, the real-time polymerase chain reaction was used.

Results. In patients with the AA genotype of CYP2C9*3 polymorphism, the intensity of pain on the numeric rating scale scale (points) was significantly higher than in patients with the AC genotype: 7 [6; 8] vs 6 [5; 6] (р=0,003), 7 [6; 8] vs 6 [5; 6] (р=0,04), 6 [5; 7] vs 5 [4; 5] (р=0,04), 5 [3; 6] vs 3 [3; 4] points (р=0,02) on days 1, 2, 3 and 5 of the postoperative period, respectively. The severity of gastroenterological symptoms was higher in patients with a heterozygous CT genotype for the allelic variant CYP2C9*2 than in patients with a wild CС genotype and amounted to 19 [19; 22] vs 18 [16; 20] points, respectively, (p=0,04). The distribution of genotypes for CYP2C9*2 polymorphisms and CYP2C9*3 polymorphisms between the groups of acute renal injury did not differ significantly.

Conclusion. Associations of polymorphisms CYP2C9*3 with a lower intensity of pain syndrome and CYP2C9*2 with a greater severity of gastroenterological symptoms were revealed.

Association between malnutrition risk and pain in older hospital patients

OBJECTIVE

To describe the prevalence of malnutrition risk and pain in older hospital patients and characterise the association between these two problems.

RESEARCH METHODS AND PROCEDURES

The study includes a secondary data analysis of data collected in two cross-sectional studies. Data collection was performed in 2017 and 2018 using a standardised and tested questionnaire. The study protocol was approved by an ethical committee.

RESULTS

Data from 3406 patients were analysed. Among the participants, 24.6% of the patients were at risk of malnutrition, and 59.6% of the patients reported feeling pain. A significantly higher number of patients with pain (26.4%) were at risk of malnutrition than patients without pain (22.1%). The multivariate logistic regression analysis showed that patients with severe/very severe or unbearable pain were 1.439 times more likely to develop a risk of malnutrition than patients without pain. Patients with cancer or diseases of the digestive system were twice as likely to develop malnutrition than those without these diseases.

CONCLUSIONS

The results of this study show that older patients with severe pain are at higher risk of developing a risk of malnutrition than those without pain, although the study design (cross-sectional) does not imply causality. Therefore, special efforts should be made to assess pain in these patients to reduce the negative consequences of this pain, such as malnutrition.

Efficiency and safety of pharmacotherapy for postoperative pain in cardiac surgery

Intraoperative injury with the formation of a sternotomy wound is inevitably accompanied by postoperative pain, which has a negative effect on the postoperative period and prognosis of patients. Today, moderate and severe pain affects at least half of patients in the early postoperative period after cardiac surgery. Inadequate pain relief in the early postoperative period can lead to chronic pain, which significantly reduces the quality of life of patients. The concept of multimodal analgesia with different painkillers is a priority, effective and safe technique both after cardiac surgery and in other areas of surgery. The current review article is devoted to the analysis of efficacy and safety of various drug groups for postoperative pain relief in cardiac surgery.

Pain Assessment Tool With Electrodermal Activity for Postoperative Patients: Method Validation Study

BACKGROUND

Accurate, objective pain assessment is required in the health care domain and clinical settings for appropriate pain management. Automated, objective pain detection from physiological data in patients provides valuable information to hospital staff and caregivers to better manage pain, particularly for patients who are unable to self-report. Galvanic skin response (GSR) is one of the physiologic signals that refers to the changes in sweat gland activity, which can identify features of emotional states and anxiety induced by varying pain levels. This study used different statistical features extracted from GSR data collected from postoperative patients to detect their pain intensity. To the best of our knowledge, this is the first work building pain models using postoperative adult patients instead of healthy subjects.

OBJECTIVE

The goal of this study was to present an automatic pain assessment tool using GSR signals to predict different pain intensities in noncommunicative, postoperative patients.

METHODS

The study was designed to collect biomedical data from postoperative patients reporting moderate to high pain levels. We recruited 25 participants aged 23-89 years. First, a transcutaneous electrical nerve stimulation (TENS) unit was employed to obtain patients' baseline data. In the second part, the Empatica E4 wristband was worn by patients while they were performing low-intensity activities. Patient self-report based on the numeric rating scale (NRS) was used to record pain intensities that were correlated with objectively measured data. The labels were down-sampled from 11 pain levels to 5 different pain intensities, including the baseline. We used 2 different machine learning algorithms to construct the models. The mean decrease impurity method was used to find the top important features for pain prediction and improve the accuracy. We compared our results with a previously published research study to estimate the true performance of our models.

RESULTS

Four different binary classification models were constructed using each machine learning algorithm to classify the baseline and other pain intensities (Baseline [BL] vs Pain Level [PL] 1, BL vs PL2, BL vs PL3, and BL vs PL4). Our models achieved higher accuracy for the first 3 pain models than the BioVid paper approach despite the challenges in analyzing real patient data. For BL vs PL1, BL vs PL2, and BL vs PL4, the highest prediction accuracies were achieved when using a random forest classifier (86.0, 70.0, and 61.5, respectively). For BL vs PL3, we achieved an accuracy of 72.1 using a k-nearest-neighbor classifier.

CONCLUSIONS

We are the first to propose and validate a pain assessment tool to predict different pain levels in real postoperative adult patients using GSR signals. We also exploited feature selection algorithms to find the top important features related to different pain intensities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/17783.

Efficacy of a Self-Hypnotic Relaxation App on Pain and Anxiety in a Randomized Clinical Trial: Results and Considerations on the Design of Active and Control Apps

Despite an explosion of mobile app offerings for management of pain and anxiety, the evidence for effectiveness is scarce. Placebo-controlled trials are the most desirable but designing inactive placebo apps can be challenging. For a prospective randomized clinical trial with 72 patients in a craniofacial pain center, we created an app with self-hypnotic relaxation (SHR) for use with iOS and Android systems. A placebo background audio (BA) app was built with the same look and functionality. Both iOS and Android SHR apps alone and in comparison to the BA group significantly reduced pain and anxiety during the waiting-room time. The Android BA app significantly reduced anxiety but not pain. The iOS BA app affected neither pain nor anxiety, functioning as an ideal placebo. Usage analysis revealed that different default approaches of the iOS and Android devices accounted for the difference in results.

Prevalence of frailty and pain in hospitalised adult patients in an acute hospital: a protocol for a point prevalence observational study

INTRODUCTION

Frailty and pain are associated with adverse patient clinical outcomes and healthcare system costs. Frailty and pain can interact, such that symptoms of frailty can make pain assessment difficult and pain can exacerbate the progression of frailty. The prevalence of frailty and pain and their concurrence in hospital settings are not well understood, and patients with cognitive impairment are often excluded from pain prevalence studies due to difficulties assessing their pain. The aim of this study is to determine the prevalence of frailty and pain in adult inpatients, including those with cognitive impairment, in an acute care private metropolitan hospital in Western Australia.

METHODS AND ANALYSIS

A prospective, observational, single-day point prevalence, cross-sectional study of frailty and pain intensity of all inpatients (excluding day surgery and critical care units) will be undertaken. Frailty will be assessed using the modified Reported Edmonton Frail Scale. Current pain intensity will be assessed using the PainChek smart-device application enabling pain assessment in people unable to report pain due to cognitive impairment. Participants will also provide a numerical rating of the intensity of current pain and the worst pain experienced in the previous 24 hours. Demographic and clinical information will be collected from patient files. The overall response rate of the survey will be reported, as well as the percentage prevalence of frailty and of pain in the sample (separately for PainChek scores and numerical ratings). Additional statistical modelling will be conducted comparing frailty scores with pain scores, adjusting for covariates including age, gender, ward type and reason for admission.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Ramsay Health Care Human Research Ethics Committee WA/SA (reference: 2038) and Edith Cowan University Human Research Ethics Committee (reference: 2020-02008-SAUNDERS). Findings will be widely disseminated through conference presentations, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

ACTRN12620000904976.

Predictors of Mental Health Status among Older United States Adults with Pain

Poor mental health is common among older adults with pain, resulting in high economic burden and impaired quality of life. This retrospective, cross-sectional database study aimed to identify characteristics associated with good mental health status among United States (US) adults aged ≥50 years with self-reported pain in the last four weeks using a weighted sample of 2017 Medical Expenditure Panel Survey data. Hierarchical multivariable logistic regression models were used to identify statistically significant predictors of good (versus poor) perceived mental health status. From a weighted population of 57,074,842 individuals, 85.5% (95% confidence interval (CI) = 84.4%, 86.7%) had good perceived mental health. Good mental health was associated most strongly with physical health status (adjusted odds ratio (AOR) = 9.216, 95% CI = 7.044, 12.058). Employed individuals were 1.7 times more likely to report good mental health versus unemployed (AOR = 1.715, 95% CI = 1.199, 2.452). Individuals who had completed less than high school education (AOR = 0.750, 95% CI = 0.569, 0.987) or who reported having a limitation (AOR = 0.513, 95% CI = 0.384, 0.684) were less likely to report good mental health. These key characteristics can be utilized to predict mental health status, which may be investigated to better manage concurrent pain and poor mental health.

Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement

BACKGROUND

A literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients.

DESIGN

This was a systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies.

REVIEW METHODS

The systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis.

RESULTS

In total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, -0.22; 95% confidence interval [CI], -0.42 to -0.02), and educational interventions were especially effective (effect size, -0.36; 95% CI, -0.69 to -0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis.

CONCLUSION

Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management.

IMPLICATIONS FOR NURSING

Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.

The Effectiveness of Virtual Reality in Managing Acute Pain and Anxiety for Medical Inpatients: Systematic Review

Background

Virtual reality is increasingly being utilized by clinicians to facilitate analgesia and anxiolysis within an inpatient setting. There is however, a lack of a clinically relevant review to guide its use for this purpose.

Objective

To systematically review the current evidence for the efficacy of virtual reality as an analgesic in the management of acute pain and anxiolysis in an inpatient setting.

Methods

A comprehensive search was conducted up to and including January 2019 on PubMed, Ovid Medline, EMBASE, and Cochrane Database of Systematic reviews according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search terms included virtual reality, vr, and pain. Primary articles with a focus on acute pain in the clinical setting were considered for the review. Primary outcome measures included degree of analgesia afforded by virtual reality therapy, degree of anxiolysis afforded by virtual reality therapy, effect of virtual reality on physiological parameters, side effects precipitated by virtual reality, virtual reality content type, and type of equipment utilized.

Results

Eighteen studies were deemed eligible for inclusion in this systematic review; 67% (12/18) of studies demonstrated significant reductions in pain with the utilization of virtual reality; 44% (8/18) of studies assessed the effects of virtual reality on procedural anxiety, with 50% (4/8) of these demonstrating significant reductions; 28% (5/18) of studies screened for side effects with incidence rates of 0.5% to 8%; 39% (7/18) of studies evaluated the effects of virtual reality on autonomic arousal as a biomarker of pain, with 29% (2/7) demonstrating significant changes; 100% (18/18) of studies utilized a head mounted display to deliver virtual reality therapy, with 50% being in active form (participants interacting with the environment) and 50% being in passive form (participants observing the content only).

Conclusions

Available evidence suggests that virtual reality therapy can be applied to facilitate analgesia for acute pain in a variety of inpatient settings. Its effects, however, are likely to vary by patient population and indication. This highlights the need for individualized pilot testing of virtual reality therapy’s effects for each specific clinical use case rather than generalizing its use for the broad indication of facilitating analgesia. In addition, virtual reality therapy has the added potential of concurrently providing procedural anxiolysis, thereby improving patient experience and cooperation, while being associated with a low incidence of side effects (nausea, vomiting, eye strain, and dizziness). Furthermore, findings indicated a head mounted display should be utilized to deliver virtual reality therapy in a clinical setting with a slight preference for active over passive virtual reality for analgesia. There, however, appears to be insufficient evidence to substantiate the effect of virtual reality on autonomic arousal, and this should be considered at best to be for investigational uses, at present.

Prospective Study Evaluating a Pain Assessment Tool in a Postoperative Environment: Protocol for Algorithm Testing and Enhancement

Background

Assessment of pain is critical to its optimal treatment. There is a high demand for accurate objective pain assessment for effectively optimizing pain management interventions. However, pain is a multivalent, dynamic, and ambiguous phenomenon that is difficult to quantify, particularly when the patient’s ability to communicate is limited. The criterion standard of pain intensity assessment is self-reporting. However, this unidimensional model is disparaged for its oversimplification and limited applicability in several vulnerable patient populations. Researchers have attempted to develop objective pain assessment tools through analysis of physiological pain indicators, such as electrocardiography, electromyography, photoplethysmography, and electrodermal activity. However, pain assessment by using only these signals can be unreliable, as various other factors alter these vital signs and the adaptation of vital signs to pain stimulation varies from person to person. Objective pain assessment using behavioral signs such as facial expressions has recently gained attention.

Objective

Our objective is to further the development and research of a pain assessment tool for use with patients who are likely experiencing mild to moderate pain. We will collect observational data through wearable technologies, measuring facial electromyography, electrocardiography, photoplethysmography, and electrodermal activity.

Methods

This protocol focuses on the second phase of a larger study of multimodal signal acquisition through facial muscle electrical activity, cardiac electrical activity, and electrodermal activity as indicators of pain and for building predictive models. We used state-of-the-art standard sensors to measure bioelectrical electromyographic signals and changes in heart rate, respiratory rate, and oxygen saturation. Based on the results, we further developed the pain assessment tool and reconstituted it with modern wearable sensors, devices, and algorithms. In this second phase, we will test the smart pain assessment tool in communicative patients after elective surgery in the recovery room.

Results

Our human research protections application for institutional review board review was approved for this part of the study. We expect to have the pain assessment tool developed and available for further research in early 2021. Preliminary results will be ready for publication during fall 2020.

Conclusions

This study will help to further the development of and research on an objective pain assessment tool for monitoring patients likely experiencing mild to moderate pain.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17783

E-Learning course for nurses on pain assessment in patients unable to self-report

Public hospitals in Catalonia, Spain, have recommended assessing pain in non-communicative inpatients by means of the Spanish version of the Pain Assessment in Advanced Dementia scale (PAINAD-Sp) since 2010; a modification for patients with neurologic disorders and cancer, PAINAD-Sp_Hosp, has also been validated. However, nurses are not routinely trained in the use of the scales. The aim of this study was to assess knowledge on pain assessment in nurses following an online training course. We surveyed participants prior to the course to determine baseline knowledge of pain and pain assessment. Course material included conceptual content on pain and practical videos demonstrating the scoring system for the PAINAD-Sp_Hosp scale. After completing the course, participants took a multiple choice quiz to test understanding of course content and a satisfaction survey to determine acceptability. Of the 836 nurses invited, 401 participated in the training course; 37.7% reported having no previous specific training on pain, and just 32.2% used the PAINAD-Sp scale regularly. Following the course, virtually all (99%) of the participants passed the quiz. Overall satisfaction among nurses with regard to the training received was 8.6/10. Thus, the e-learning course was effective and acceptable for training nurses on pain assessment using validated tools.

Psychometric Evaluation of the Nursing Outcome Knowledge: Pain Management in People with Chronic Pain

Pain has a major impact on health and quality of life. Since the level of knowledge of painful conditions can influence how these are addressed and managed, assessing this knowledge in patients becomes crucial. As a result, it is necessary to have culturally adapted and validated instruments that specifically measure patients' knowledge of chronic pain management. The objective of this study was to carry out the Spanish cultural adaptation and the validation of the outcome Knowledge: Pain Management of the Nursing Outcomes Classification (NOC) in patients with chronic pain, defined as extent of understanding conveyed about causes, symptoms, and treatment of pain. A three-stage study was designed: 1) translation and cultural adaptation through an expert panel, 2) content validation, 3) clinical validation. This study provides nurses with a Spanish version of this scale adapted to their context, as well as a set of structured indicators to measure patients' knowledge about chronic pain. The results indicated that the culturally adapted Spanish version of the outcome Knowledge: Pain Management had a high level of content validity (CVI = 0.92), with 27 indicators being distributed between two factors. This version has been shown to be reliable in terms of inter-observer agreement (κ = 0.79) and internal consistency (α = 0.95). In conclusion, Knowledge: Pain Management has been shown to be reliable and valid to measure knowledge of chronic pain.

A Brief Mindfulness Intervention for Medically Hospitalized Patients with Acute Pain: A Pilot Randomized Clinical Trial

OBJECTIVE

Mindfulness interventions may be beneficial for patients with chronic pain; however, the effects for acute pain are not understood. The purpose of this study was to pilot test a brief mindfulness intervention for acute pain and stress for patients in an inpatient medical setting.

DESIGN

Pilot randomized clinical trial.

SETTING

An inpatient Acute Care Surgery service at an urban hospital.

SUBJECTS

Sixty patients with acute pain were randomly selected and agreed to participate.

METHODS

Interested patients consented to the study and were randomized to the 10-minute intervention (i.e., mindfulness strategy) or comparison group (i.e., education on the Gate Control Theory of Pain). Participants completed pre- and post-assessment measures on pain severity and stress.

RESULTS

Preliminary results showed that within the intervention and comparison groups, participants experienced decreases in pain from pre- to post-intervention (P = 0.002 and 0.005, respectively). Within the intervention group, there was a significant decrease in stress from pre- to post-intervention (P = 0.001). There were no significant changes for stress within the comparison group (P = 0.32). There were no significant differences between the intervention and comparison groups for pain (P = 0.44) or stress (P = 0.07) at post-intervention, although Cohen's d effect sizes were small to medium for pain and stress, respectively.

CONCLUSIONS

A brief mindfulness intervention for medically hospitalized patients with acute pain may decrease pain and stress. Future research should examine this intervention with a fully powered, larger sample to examine efficacy.

Cannabinoids versus placebo or no intervention for pain: protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Pain is a frequent clinical symptom with significant impact on the patient's well-being. Therefore, adequate pain management is of utmost importance. While cannabinoids have become a more popular alternative to traditional types of pain medication among patients, the quality of evidence supporting the use of cannabinoids has been questioned. The beneficial and harmful effects of cannabinoids in patients with pain is unknown. Accordingly, we aim to assess the efficacy, tolerability and safety of cannabinoids (herbal, plant-derived extracts and synthetic) compared with placebo or no intervention for any type of pain.

METHODS AND ANALYSES

We will conduct a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis to assess the beneficial and harmful effects of cannabinoids in any dose, formulation and duration. We will accept placebo or no treatment as control interventions. We will include participants with any type of pain (acute and chronic pain, cancer-related pain, headache, neuropathic pain or any other types of pain). We will systematically search The Cochrane Library, MEDLINE, Embase, Science Citation Index and BIOSIS for relevant literature. We will follow the recommendations by Cochrane and the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The risk of systematic errors (bias) and random errors (play of chance) will be assessed. The overall certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethical approval is not a requirement since no primary data will be collected. The findings of this systematic review will be submitted for peer-reviewed publication and disseminated in national and international conferences.

DISCUSSION

Although cannabinoids are now being used to manage different pain conditions, the evidence for the clinical effects are unclear. The present review will systematically assess the current evidence for the benefits and harms of cannabinoids to inform practice and future research.

The clinical efficacy of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain: a protocol for a meta-analysis of randomised controlled trials (RCTs)

INTRODUCTION

The aim of this systematic review with meta-analysis is to evaluate the clinical efficacy of transcutaneous electrical nerve stimulation (TENS) for any type of acute and chronic pain in adults.

METHODS AND ANALYSIS

We intend to search electronic databases (Cochrane Library, MEDLINE, Embase, CINAHL, PsycINFO, LILACS, PEDRO, Web of Science, AMED and SPORTDiscus) from inception to the present day to identify all randomised controlled trials (RCT) on the use of TENS in adults for any type of pain including acute pain, chronic pain and cancer-related pain. We will screen the RCTs against eligibility criteria for inclusion in our review. Two reviewers will independently undertake RCT selection, data extraction and risk of bias assessment. Primary outcomes will be: (i) participant-reported pain relief of ≥30% expressed as frequency (dichotomous) data; and (ii) participant-reported pain intensity expressed as mean (continuous) data. We will conduct meta-analyses to determine risk ratio for dichotomous data, and mean difference (MD) or standardised MD for continuous data for TENS versus placebo TENS, no treatment or waiting list control, standard of care, and other treatments. Subgroup analyses will include different pain conditions (eg, acute vs chronic), TENS intensity, during versus after TENS, TENS as a sole treatment versus TENS in combination with other treatments and TENS administered as a single dose versus repetitive dose.

ETHICS AND DISSEMINATION

This systematic review will not use data from individual participants, and the results will be disseminated in a peer-reviewed publication and presented at a conference.

PROSPERO REGISTRATION NUMBER

CRD42019125054.

Co-crystals as a new approach to multimodal analgesia and the treatment of pain

Pain is highly prevalent, but frequently untreated or under-treated, and health care professionals are faced with a range of treatment challenges. Multimodal therapy is recommended and can be achieved using open combinations (ie, concomitant administration) of individual agents, fixed-dose combinations (FDCs), or multimodal agents (ie, single agents with multiple mechanisms of action). Co-crystallization of active pharmaceutical ingredients (APIs) offers another approach, with the potential to provide drugs with unique properties and advantages for therapeutic applications compared to combinations. API–API co-crystals are single-entity forms that offer a unique possibility of improving the physicochemical properties of both constituent APIs, as well as permitting their synchronous release. Consequently, this may positively impact on their pharmacokinetic (PK) properties and profiles, providing a potential advantage over FDCs and translating into improved clinical efficacy and safety profiles. We report here a revision of the literature concerning API–API co-crystals for the treatment of pain. It becomes apparent that identifying APIs with complementary mechanisms of action that can be adequately co-crystallized in an appropriate molecular ratio applicable for therapeutic use is challenging. In addition, API–API co-crystals normally result in a mere increased exposure of an API without defined clinical benefits (since, to maintain the benefit-risk, the dose needs to be proportionally reduced to adjust for the increased exposure). An exception to this is the co-crystal of tramadol-celecoxib (CTC), that represents a unique concept in co-crystal technology. In CTC neither of its three active components that have complementary mechanisms of action (ie, the two enantiomers of tramadol and celecoxib) show increased exposure levels versus commercially available single-entity reference products, but rather show a change in their PK profile with potential clinical advantages. CTC is in Phase III clinical development for the treatment of pain.

Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review

CONTEXT

Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment.

OBJECTIVES

The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium.

METHODS

A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed.

RESULTS

A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications.

CONCLUSION

The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.

Mobile applications for pain management: an app analysis for clinical usage

BACKGROUND

Pain is the most common and distressing symptom for patients in all clinical settings. The dearth of health informatics tools to support acute and chronic pain management may be contributing to the chronic pain and opioid abuse crises. The purpose of this study is to qualitatively evaluate the content and functionality of mobile pain management apps.

METHODS

The Apple App Store and the Google Play Store were searched to identify pain management apps. The inclusion criteria were as follows: (1) that apps include a pain diary function allowing users to record pain episodes, (2) are available in either Apple App Store or Google Play Store, and (3) are available in the English language. We excluded apps if they were limited to only specific forms of pain or specific diseases.

RESULTS

A total of 36 apps met the inclusion criteria. Most of the apps served as pain diary tools to record the key characteristics of pain. The pain diary features of the apps were grouped into nine categories: the recordings of pain intensity, pain location, pain quality, pain's impacts on daily life, other features of pain, other related symptoms, medication, patients' habits and basic information, and other miscellaneous functions. The apps displayed various problems in use. The problem of not involving healthcare professionals in app development has not been resolved. Approximately 31% of apps including a pain diary function engaged clinicians in app development. Only 19% involved end-users in development and then only in an ad-hoc way. Only one third of the apps supported the cross-platforms, none of the apps supported clinician access to graphical pain data visualization, none secured HIPAA compliance, and none endorsed the PEG tool for primary care physicians' chronic pain management.

CONCLUSIONS

Most of the 36 pain management apps demonstrated various problems including user interface and security. Many apps lacked clinician and end-user involvement in app development impacting the clinical utility of these apps. We could not find any pain apps suitable for clinical usage despite high demand from clinicians due to the US opioid crisis.

Knowledge and Attitudes about Pain Management among Canadian Nursing Students

BACKGROUND

Poorly managed pain is a problem that affects individuals, entire health care systems, and societies worldwide. Nurses are involved in pain management, yet little is known about the knowledge and attitudes of nursing students.

AIMS

The aim of this study was to examine preregistration nursing students' knowledge and attitudes about the assessment and management of pain.

DESIGN

This was a cross-sectional, descriptive survey.

SETTINGS

Four education sites from two post-secondary institutions in Ontario, Canada.

PARTICIPANTS/SUBJECTS

A convenience sample of 336 final year Bachelor of Science in Nursing and practical nursing students.

METHODS

Participants were recruited in the classroom setting to complete the Knowledge and Attitudes Survey Regarding Pain. A score of eighty percent is considered a pass.

RESULTS

Ninety percent of students who were in class on the day of the survey agreed to participate (n = 336/373). Fifteen (4.5%) participants passed the Knowledge and Attitudes Survey Regarding Pain, and the mean score was 66.7% (standard deviation 9.1). English as primary language, institution attended, and prior experience caring for someone with pain were independently associated with higher scores (p < .05). Students were found to have major gaps in knowledge and attitudes related to understanding the risk of respiratory depression after opioid therapy, calculating medication dosages, administrating medication, and understanding pharmacology.

CONCLUSIONS

The majority of nursing students in this sample did not have adequate knowledge and positive attitudes about pain assessment and management.

Impact of a Training Intervention on the Pain Assessment in Advanced Dementia (PAINAD) Scale in Noncommunicative Inpatients

BACKGROUND

Public hospitals in Catalonia (Spain) recommend using the Spanish version of the Pain Assessment in Advanced Dementia (PAINAD-Sp) scale for assessing pain in adult patients unable to self-report. However, since its inclusion in Catalonian nursing care plans in 2010, there have been no training programs for nurses, contributing to its current underuse.

AIMS

The aim of this study was to assess the impact of a nurse training intervention on the PAINAD-Sp scale in noncommunicative inpatients unable to self-report.

DESIGN

Before-after study.

SETTINGS

Two public hospitals in Catalonia (Spain).

PARTICIPANTS/SUBJECTS

Four hundred and one nurses participated in the training course and 219 patients received PAINAD-Sp assessments.

METHODS

We used a before-after study design, evaluating the use of the PAINAD-Sp scale over two 6-month periods before and after an online training intervention for nurses in February 2017, in two public hospitals. Data were collected from patient records in each center. The primary outcome was the number of patients receiving PAINAD-Sp assessments during admission. Secondary outcomes were the number of assessments undertaken per patient during admission, the total (0-10) and item-specific (0-2) PAINAD-Sp score, and pharmacologic treatment administered.

RESULTS

There were 401 nurses who took part in the training program. Over the study period, 219 patients received PAINAD-Sp assessments: 29 in the preintervention period and 190 in the postintervention period (p < .001). Administration of analgesics and antipyretics decreased (p < .001) after the intervention, whereas use of hypnotic drugs and sedatives increased.

CONCLUSIONS

Theoretical and practical training may be an effective way to improve nurses' approach to identifying, assessing, and managing pain in patients unable to self-report.