The journal of pain : official journal of the American Pain Society
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Multicenter Study Comparative Study
Does the Neonatal Facial Coding System differentiate between infants experiencing pain-related and non-pain-related distress?
The Neonatal Facial Coding System (NFCS) is widely accepted as a measure of infant pain-related distress in known pain-specific contexts. It has clearly shown the ability to distinguish between facial reactivity in no-pain and pain-related situations. The primary purpose of this study was to explore whether NFCS differentiates between pain-related and non-pain-related distress. Two groups of 35 infants (1 group was distressed before injection whereas the other group was not distressed before injection) were coded using NFCS before and after an immunization procedure. Within-group analyses of infants who were distressed before immunization suggested that NFCS was not able to discriminate between pain-related and non-pain-related distress. However, between-group analyses showed NFCS discriminated between potential gradations of distress in infants after immunization. Results suggest that NFCS has the ability to discriminate between intensities of distress but not between pain-related and non-pain-related distress. ⋯ Adding to the NFCS validity literature, this study suggests that while able to distinguish between no-distress and pain-related distress, facial actions of NFCS may not distinguish between pain-related and non-pain-related distress expressions. However, NFCS was able to discern infants presumed to have higher pain-related distress due to experiencing pre-needle distress.
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This investigation determined the psychometric properties and acceptability of an animated face scale presented on a hand-held computer as a means to measure pediatric pain and mood. In study 1, 79 hospitalized, pediatric patients indicated their levels of pain by adjusting the expression of an animated cartoon face. The first objective was to determine feasibility, concurrent validity, and acceptability of the method. All patients were tested both with the Computer Face Scale and the poster format of the Wong-Baker Faces Scale. A second objective was to evaluate test-retest reliability of the method. In study 2, 50 hospitalized, pediatric patients were tested on 2 occasions, but in this case the patients used the Computer Face Scale to indicate both their pain (how much they hurt) and their mood (how they felt). Children in study 1 were able to use the Computer Face Scale to express relative amounts of pain/hurt; the method showed concurrent validity with the Wong-Baker Face Scale; and most children expressed a preference for the Computer Face Scale. The method also showed adequate test-retest reliability. In study 2, adequate test-retest reliability was demonstrated for ratings of both pain and mood. ⋯ The Computer Face Scale allows the health provider to obtain reliable and valid measures of pediatric pain and mood. The method can be understood and used by children as young as 3 years and is appropriate for use with adults.
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Iatrogenic errors producing serious and often preventable injury occur frequently in hospitalized patients, particularly in children. Little is known about the epidemiology of analgesic medication errors in patients being discharged from the hospital. The goal of this study was to describe the epidemiology of controlled substance prescription errors by physicians-in-training for children being discharged from the hospital. We conducted a prospective, observational study of the analgesic prescriptions and discharge forms of 241 pediatric patients discharged from a Children's Center of a major urban teaching hospital from November 2003 to April 2004. All patients who were actively followed by the Pediatric Pain Service at the time of their discharge and were discharged with an analgesic prescription were included in the study. Primary outcome variables were the percentage of prescriptions that contained at least 1 medication error or potential adverse drug event. Errors were defined using the Institute for Safe Medication Practices' (ISMP) List of Error-Prone Abbreviations, Symbols, and Dose Designations, literature review, expert panel consensus, and the Johns Hopkins Department of Pharmacy hospital formulary. Two hundred forty-one patients who received 314 prescriptions were included in this study. Prescription errors were common; 257 of 314 (82%) of the prescriptions examined contained 1 or more errors. The most common errors were missing or wrong patient weight (n = 127, 77%), incomplete dispensing information (n = 167, 53%), and no or wrong date on prescription (n = 19, 6%). Nine prescriptions (2.9%) had the potential for significant medical injury and were considered potential adverse drug events. Discharge prescription errors for children requiring potent, opioid analgesic drugs in the management of pain are common, and nearly 3% could cause significant harm. The high rate of prescribing errors highlights the importance of developing, testing and implementing effective error-prevention strategies, especially in high-risk medications such as narcotics. ⋯ Narcotic prescriptions written by trainees at discharge from a pediatric hospital are error prone and nearly 3% have the potential to cause significant harm. With a low therapeutic profile, the hospital may consider a review/verification process to reduce the risk of patient harm.
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Multicenter Study Clinical Trial
A single-blind, placebo run-in study of duloxetine for activity-limiting osteoarthritis pain.
Osteoarthritis pain is a significant problem for our aging population. Antidepressants that are serotonin-norepinephrine reuptake inhibitors are effective for other forms of chronic pain and may provide a new treatment option for osteoarthritis pain. We performed a single-blind, placebo run-in trial of 60 to 90 mg of duloxetine in 25 subjects with activity-limiting osteoarthritis pain. Each subject received 2 weeks of placebo followed by 10 weeks of duloxetine. The primary outcome was reduction in average pain intensity between 2 and 12 weeks for subjects completing the trial. Average pain on the Brief Pain Inventory (BPI) was 5.7 at baseline, 4.8 after the 2-week placebo run-in, and 3.5 at 12 weeks for the 17 patients completing the trial (28% decrease between 2 and 12 weeks, P = .122). Eight of 15 study completers who had nonmissing BPI results (53%) reported at least 30% pain reduction between weeks 2 and 12. The Western Ontario McMaster Osteoarthritis Index (WOMAC) pain score at baseline was 2.3, 1.8 after 2 weeks, and 1.3 after 12 weeks (30% decrease between 2 and 12 weeks, P = .018). Ten of 17 patients (59%) reported at least 30% pain relief between weeks 2 and 12 on the WOMAC. Significant improvements in self-reported physical and role function were reported but observed physical function did not improve. ⋯ Duloxetine did not significantly reduce pain intensity on the BPI but did improve pain intensity and self-reported function on the WOMAC. Duloxetine warrants further investigation as a novel treatment for osteoarthritis pain.
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Practice Guideline
Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies. ⋯ Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.