Marko Jukić

Treatment of Chronic Musculoskeletal Back Pain in a Tertiary Care Pain Clinic

Objectives There are insufficient data about range and efficacy of treatments provided to patients with musculoskeletal back pain in tertiary pain clinics. We aimed to analyze the number of patients visiting a tertiary pain clinic due to chronic musculoskeletal back pain, the treatments prescribed to these patients in a pain clinic, and any reduction of pain intensity that patients report following the treatment. Methods Retrospective study of patients treated for chronic musculoskeletal back pain from 2006 to 2009 was conducted at a tertiary Pain Clinic of University Hospital Split in Croatia. We studied the number of patients, their medical documentation, prescribed therapy and their pain intensity determined by visual analog scale during the first visit and a follow-up visit. Results Patients with chronic musculoskeletal back pain represented 78 percent of all patients and 80 percent of all visits in the pain clinic. The majority of patients were women with a median age of 58 years. Patients were prescribed opioid and non-opioid drugs, transcutaneous electrical nerve stimulation, magnetic therapy, ultrasound and laser therapy, either as a single intervention , or in various combinations. Tramadol and combination of tramadol and paracetamol were the most commonly prescribed drugs. In all patients groups, the reduction of pain intensity on a control visit was about 30 percent; there was no significant difference between groups. Conclusions Chronic musculoskeletal back pain is the major reason why patients visit pain clinics. Efficacy of various pharmacological and non-pharmacological treatments offered at pain clinics was not significantly different. Introduction of a bio-psychosocial approach to treatment of chronic pain is recommended.

Futile Treatment—A Review

The main goal of intensive care medicine is helping patients survive acute threats to their lives, while preserving and restoring life quality. Because of medical advancements, it is now possible to sustain life to an extent that would previously have been difficult to imagine. However, the goals of medicine are not to preserve organ function or physiological activity but to treat and improve the health of a person as a whole. When dealing with medical futilities, physicians and other members of the care team should be aware of some ethical principles. Knowing these principles could make decision-making easier, especially in cases where legal guidelines are insufficient or lacking. Understanding of these principles can relieve the pressure that healthcare professionals feel when they have to deal with medical futility. Efforts should be made to promote an ethics of care, which means caring for patients even after further invasive treatment has been deemed to be futile. Treatments that improve patients’ comfort and minimize suffering of both patients and their families are equally as important as those aimed at saving patients’ lives.

Postoperative Pain in Complex Ophthalmic Surgical Procedures: Comparing Practice with Guidelines

OBJECTIVE To analyze the management of postoperative pain after complex ophthalmic surgery and to compare it to the guidelines. DESIGN A retrospective study. SETTING University Hospital Split, Croatia. SUBJECTS Patients (N = 447) who underwent complex ophthalmic surgical procedures from 2008 to 2012. METHODS The following data were extracted from patient medical records: age, gender, type and dosage of premedication, preoperative patients physical status, type of procedure, duration of procedure-surgical and anesthesia time, type and dosage of anesthesia, the type and dosage of postoperative analgesia for each postoperative day. RESULTS None of the patients had information about pain intensity in their records. There were 90% patients who did not receive any medication the night before surgery, 54% did not receive any premedication immediately before surgery, 19% did not receive any pain medication after the surgery in the operating room and 46% of patients did not receive any analgesics after being released to the ophthalmology department. Among those who received analgesia after surgery, 98% received only one dose of an analgesic, and 93% of patients received analgesia only on the day of the surgery. Furthermore, patients were returned to the department immediately after surgery, without intensive monitoring. During the analyzed five years there were no educational session organized by anesthesiologist to the ophthalmic surgeons. CONCLUSIONS Postoperative pain management and perioperative care of patients undergoing major ophthalmic surgery indicates lack of attention towards pain intensity and postoperative analgesia. Appropriate interventions should be employed to improve postoperative pain management, to facilitate patient recovery.

Legal and Ethical Aspects of Pain Management

In this manuscript we presented legal and ethical aspects of pain management. Pain is a global public health problem because the burden of acute and chronic pain is considerable and is continuously increasing. It has been postulated that pain management is a fundamental human right, and that health systems are obliged to ensure universal access to pain management services. The suggestion that pain management is a right was fuelled by ample evidence about inadequate treatment of pain. Undertreatment and underprescribing in the context of pain can potentially have serious legal consequences, including charges about negligence, elder abuse, manslaughter and euthanasia. Multiple international declarations by professional societies have outlined pain management as a core ethical duty in medicine. Therefore, healthcare professionals need to be aware of multiple facets of pain-related ethics, including appraisal of patients decision-making capacity. The worldwide opioid crisis also calls for careful consideration of specific ethical issues. Finally, healthcare workers need to be aware of the the risks associated with promoting pain management as a human right because patients and their caretakers can mistakenly perceive that they have right to total analgesia. CONCLUSION Patients do have the right to pain management, but patient rights have limits, which may interfere with other competing rights, and also rights of their physicians. Treatment of pain must be medically, ethically and economically justified. Healthcare workers have an obligation to continuously improve their knowledge about pain management, including medical, legal and ethical aspects of pain.