Felicity C. Veal

Pharmacological management of pain in Australian Aged Care Facilities

BACKGROUND up to 80% of residents in aged care facilities (ACFs) experience pain, and previous studies have found that older patients with pain are often undertreated. Few studies have been conducted in Australia evaluating the use of analgesic therapy in ACF residents. OBJECTIVE to explore the use of analgesics among ACF residents, including independent predictors of analgesic use, evaluate analgesic use against pain management guidelines and identify potential medication management issues. METHODS a retrospective analysis of 7,309 medicines reviews conducted on Australian ACF residents was undertaken. Medication use was compared with published guidelines relating to the management of pain in elderly patients or ACF residents. Multiple variable logistic regression was used to identify independent predictors of analgesic use. RESULTS nearly 91% of residents were prescribed analgesics. Of those, 2,057 residents were taking regular opioids (28.1%). Only 50% of those taking regular opioids received regular paracetamol at doses of 3-4 g/day. The concurrent use of sedatives was high, with 48.4% of those taking regular opioids also taking an anxiolytic/hypnotic. CONCLUSION there is a need to optimise the prescribing and administration of regular paracetamol as a first line and continuing therapy for pain management in ACF residents, to potentially improve pain management and reduce opioid requirements. Furthermore, with the risk of falls and fractures increased by concurrent use of opioids and sedatives, the widespread use of these drugs in a population already at high risk was concerning, indicating a need for better education of health professionals in this area.

Subacute Pain as a Predictor of Long-Term Pain Following Orthopedic Surgery: An Australian Prospective 12 Month Observational Cohort Study.

AbstractThe aim of this study was to document the level of pain and functionality in the 12 months following orthopedic surgery and identify if high pain levels following discharge were associated with pain persisting at 12 months.An observational prospective cohort study was undertaken, following 87 patients (mean age 62.4 years [18–92]; 47.1% male) who required orthopedic surgery at the Royal Hobart Hospital, Australia. Following an initial survey, patients were telephoned at 10 days, 6 weeks, 3 months, and 12 months after discharge.Postdischarge pain levels were high with 97.4% of patients suffering pain at 10 days, 81.2% at 6 weeks and 79.5% at 3 months. Pain affected the ability to undertake activities of daily living (ADLs) for 32.7% and 20.0% of patients at 10 days and 6 weeks, respectively. Twelve months after discharge, 65.5% of patients reported pain persisting at the surgical site, with 29.9% of all patients suffering moderate–severe incidental pain; and nearly one quarter of patients reported pain affected their sleep or ADLs. Average pain levels rated as moderate–severe at 10 days (P = 0.01) and 6 weeks (P = 0.02) and pain of neuropathic origin at 3 months (30.2% vs 10.3% P = 0.03) and 12 months (30.4% vs 4.9% P = 0.01) were associated with persistent pain at 12 months.Pain in the period following discharge from hospital is significant and undermanaged. Previous studies has shown that that acute pain, particularly in the first 48 hours following surgery is a predictor for long-term pain after surgery. This study adds to the current literature by showing that pain in the subacute period, following discharge from hospital is also associated with the pain persisting at 12 months. These findings have important implications for improving quality of life as well as potentially preventing persistent pain with increased follow-up and more intensive management of post-discharge pain.

Use of opioid analgesics in older Australians

OBJECTIVE To identify potential medication management issues associated with opioid use in older Australians. DESIGN Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012. SUBJECTS Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility. METHODS Patient characteristics in those taking regularly dosed opioids and not and those taking opioid doses >120 mg and ≤120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified. RESULTS Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations. CONCLUSIONS A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain.

Pain intensity and pain self-management strategies following discharge after surgery: An Australian prospective observational study

Up to 80% of patients experience acute pain following surgery. This study aimed to improve the current understanding about the strategies individuals use to self‐manage pain following discharge after surgery, stratified by pain intensity.

Persistent pain management in Australian general practice

Persistent pain is a common, albeit challenging, condition to treat in general practice. Analgesics, particularly opioids, are frequently employed, despite limited evidence to support longterm use and concerns regarding their safety (Chou et al. 2015). Our study aimed to identify the perceived barriers to optimal pain management in Tasmania, and potential ways in which these could be overcome. An electronic survey, administered throughLimeSurvey,was distributed to Tasmanian General Practitioners (GPs) through direct email to all general practices in the state and the inclusion of information about the study in the Local PrimaryHealth Network e-newsletter, which is distributed monthly to all practices in Tasmania. The survey involved tick-box answers based on previously identified barriers to pain management In addition, free text responses were available so that GPs could provide additional barriers and strategies used. An incentive of the chance to win one of five A

Pain and Functionality Following Sternotomy: A Prospective 12-Month Observational Study

100 vouchers was used to enhance recruitment. Approximately 700 GPs work in Tasmania (Tasmania Medicare Local Limited 2015), of which 41 completed the survey. Although, we acknowledge this low response, several important barriers to optimal pain management were identified. Participants were asked ‘Which of the following do you think are the major barriers to the management of persistent pain in general practice?’ Responses included: patients’ expectations (63.4%); access to pain clinics (53.7%); poor physiotherapy funding (43.9%); risk ofmedication side effects (36.6%),misuse, abuse or diversion of drugs (31.7%) and poor access to psychologists (31.7%). As noted, patients’ expectations were identified as a barrier to pain management. Although almost three-quarters (73.2%) of the GPs reported undertaking discussions with patients about expectations and nearly half (48.8%) indicated that they discuss trialling opioids, there is still room for improvement. Without such discussions, patients may assume that freedom from pain is achievable and that once an analgesic is started for persistent pain it will be automatically continued, making any subsequent discussions regarding de-prescribing more challenging. Although several initiatives exist that focus on improving patients’ expectation and knowledge, and public awareness of pain and its management (Pain Australia 2014), improved implementation of these would appear appropriate. Whereas specialist pain clinics make good use of physiotherapy and psychology services, there is only one publically funded multidisciplinary pain clinic in Tasmania, creating a significant barrier to treatment. To assist in overcoming this, different approaches must be considered. As nurseand pharmacist-run pain clinics have been found to reduce pain and improve physical functioning (Hadi et al. 2016), one potential approach is to expand the role of pharmacists and nurses already working with GP practices. These professionals could discuss treatment trials and expectations, and provide education about analgesics and pain management while potentially freeing up the time of the GP to deal with the often complicated clinical aspects of the patient’s care. While noting the GPs’ concerns about access to allied health professionals and pain clinics, improved teamwork within primary care may enhance the management of persistent pain, and help support GPs in this challenging area.

Author’s Reply to Zekry and Inderjeeth: “Pain in the Frail or Elderly Patient: Does Tapentadol Have a Role?”

OBJECTIVE To document pain levels, functionality, and analgesic use in the 12 months following a sternotomy to identify factors associated with the development of persistent post-sternotomy pain. DESIGN Prospective observational study. SETTINGS Royal Hobart Hospital, Australia. SUBJECTS Patients undergoing a sternotomy between January and November 2013. METHODS One hundred and ten patients were recruited and followed for 12 months, with telephone calls at 10 days, 6 weeks, 3 months, and 12 months. An initial survey was completed at the point of recruitment including patient history, depression and anxiety scales, self-rated health, and pain catastrophizing scale. RESULTS The mean age of participants was 69.6 years, with the majority of participants being male (84.5%). The proportion of patients reporting pain in the early post-discharge period was high, with 30% of patients experiencing on average moderate-severe pain in the 10 days following discharge and 11% experiencing on average moderate-severe pain at 6 weeks. At 12 months, 15.5% of participants reported on average mild pain and 0.9% an average of moderate-severe pain in the preceding week at their sternotomy site. Pain of neuropathic origin was reported by 41.2% of those with on average daily pain at 12 months. CONCLUSION This study highlights the need for further research to investigate whether more intensive pain management in the post-discharge period following sternotomy as well as the early identification of patients with neuropathic pain symptoms can reduce the incidence of persistent post-operative pain at 12 months.

Paracetamol should remain the first line option for persistent pain

We consider and respond to the comments by Zekry and Inderjeeth [1]. The suggestion that we have been unfair in applying a different set of rules and standards to a newer agent represents an interesting interpretation. We have clearly discussed the deficiencies in the literature pertaining to all opioids, particularly with regard to the paucity of data on their long-term efficacy and safety, and use in the elderly. Our concluding statement (‘‘better the devil you know than the devil you don’t’’) reflects concern over the lack of ideal analgesics, new or old, for use in the frail elderly [2]. A new drug can only be judged using the contemporary and recognized scientific approach prevailing at the time of its introduction. For instance, should the new antiplatelet drugs be judged according to the (lack of) safety and efficacy standards applicable at the time of introduction of aspirin? Tapentadol, being a new agent, must be judged using the current evidence-based criteria. We believe that our assessment of the drug against those standards is accurate and fair. As we also noted, we are not alone in that assessment of the published data relating to the drug. The correspondents state that older, frailer patients require agents that are more effective with fewer side effects. More precisely, what is required are agents that are safer and cost effective, as determined through sound scientific evidence and analyses. If tapentadol really is at least as effective, with fewer side effects and drug interactions than other opioids, this should be relatively easy to demonstrate in well-designed and adequately powered clinical trials. Once proven, the use of a high-cost medication, relative to older agents from the same pharmacological group, might then be justifiable.

Pain in the frail or elderly patient: does tapentadol have a role?

Persistent pain in older people is a serious problem that is often undermanaged.1 Osteoarthritis disproportionately affects older people, yet they are often under-represented in trials. Furthermore, their response to analgesics may differ from that of younger patients owing to altered pharmacokinetics and pharmacodynamics.2 The fundamental question raised by this meta-analysis is, if we dismiss paracetamol from our armamentarium, …