REVISTA
BRASILEIRA DE
ANESTESIOLOGIA
Publicação Oficial da Sociedade Brasileira de Anestesiologiawww.sba.com.br
SPECIAL ARTICLE
Optimizing post-operative pain management
in Latin America
João
Batista
Santos
Garcia
a,∗,
Patricia
Bonilla
b,
Durval
Campos
Kraychete
c,
Fernando
Cantú
Flores
d,
Elizabeth
Diaz
Perez
de
Valtolina
e,
Carlos
Guerrero
faUniversidade Federal do Maranhão (UFMA), Departamento de Anestesiologia, Dor e Cuidados Paliativos, Sao Luis, MA, Brazil bInstituto Oncologico Luis Razetti, Departamento de Medicina Paliativa, Caracas, Venezuela
cUniversidade Federal da Bahia (UFBA), Departamento de Anestesiologia e Cirurgia, Bahia, BA, Brazil
dHospital Zambrano-Hellion TEC Salud, Departamento de Anestesia/Tratamento da Dor do Instituto de Dor, San Pedro Garza
García, Mexico
eInstituto Nacional de Doenc¸as Neoplásicas, Departamento de Medicina Paliativa e Servic¸o de Tratamento da Dor, Lima, Peru fHospital Universitario Fundacion Santa Fe, Departamento de Anestesia --- Clínica de Dor, Bogota, Colombia
Received 14 February 2016; accepted 26 April 2016 Available online 18 June 2016
KEYWORDS
Acute post-operative pain;
Pain management; Latin America; Chronic pain
Abstract Post-operative pain management is a significant problem in clinical practice in Latin
America. Insufficient or inappropriate pain management is in large part due to insufficient knowledge, attitudes and education, and poor communications at various levels. In addition, the lack of awareness of the availability and importance of clear policies and guidelines for recording pain intensity, the use of specific analgesics and the proper approach to patient edu-cation have led to the consistent under-treatment of pain management in the region. However, these problems are not insurmountable and can be addressed at both the provider and patient level. Robust policies and guidelines can help insure continuity of care and reduce unnecessary variations in practice. The objective of this paper is to call attention to the problems associated with Acute Post-Operative Pain (APOP) and to suggest recommendations for their solutions in Latin America. A group of experts on anesthesiology, surgery and pain developed recommen-dations that will lead to more efficient and effective pain management. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more effi-cient and effective system for the delivery of APOP services as recommended by the authors of this paper. The writing group believes that implementation of these recommendations should significantly enhance efficient and effective post-operative pain management in Latin America. © 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Corresponding author.
E-mail:[email protected](J.B. Garcia). http://dx.doi.org/10.1016/j.bjane.2016.04.003
PALAVRASCHAVE
Doragudano pós-operatório; Controledador; AméricaLatina; Dorcrônica
Aprimorarocontroledadornopós-operatórionaAméricaLatina
Resumo Ocontroledadornoperíodopós-operatórioéumproblemasignificativonaprática
clínicanaAméricaLatina.Ocontroleinsuficienteouinadequadodadorédevido,emgrande parte,àinsuficiênciadeconhecimento,atitudeseformac¸ãoeàcomunicac¸ãoprecáriaemvários níveis.Alémdisso,afaltadeconscientizac¸ãodadisponibilidadeeimportânciadepolíticase diretrizesinequívocasparaavaliaraintensidadedador,ousodeanalgésicosespecíficosea abordagemadequadapara instruiropaciente levaramaosubtratamentoconsistentedador naregião.Contudo,essesproblemasnãosãoinsuperáveisepodemserabordadosnoâmbito tantodoprovedorquantodopaciente.Políticasediretrizesrobustaspodemajudaragarantir acontinuidadedoscuidadosereduzirasvariac¸õesdesnecessáriasnaprática.Oobjetivodeste artigoéchamaraatenc¸ãoparaosproblemasassociadosàdoragudanopós-operatório(DAPO) esugerirrecomendac¸õesparasolucioná-losnaAméricaLatina.Umgrupodeespecialistasem anestesiologia,cirurgiaedordesenvolveurecomendac¸õesquelevarãoaumcontrolemais efi-cienteeeficazdador.Seráprecisomudaroconhecimentoeocomportamentodosprofissionais desaúdeepacienteseobterumcompromissoporpartedelegisladores.Osucessodependeráde umaatitudepositivaedocompromissodecadaparteatravésdodesenvolvimentodepolíticas eprogramasedapromoc¸ãodeumsistemamaiseficienteeeficazparaaprestac¸ãodeservic¸os paraaDAPO,comorecomendadopelosautoresdestetrabalho.Ogrupoqueasredigiu acred-itaqueaaplicac¸ãodessasrecomendac¸õesdevemelhorardemodosignificativoaeficiênciae eficáciadocontroledadornoperíodopós-operatórionaAméricaLatina.
©2016SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Post-operativepainaffectsmillionsofpatientsworld-wide. Painitself is ahighly subjective experiencewithmultiple dimensions.Basically,it iswhatevertheexperiencing per-sonsaysitis,existingwhenevertheysayitdoes.1,2Despite
thissimple and straightforwarddefinitiontherecontinues tobebarrierstoeffectivepainmanagement.Moreover,it is well-known that poor post-operative painmanagement notonlydelaysrecoveryandresultsinexcessmorbidityand mortality,butcanleadtothedevelopmentofachronicpain statewhichfurtherincreasesmorbidity.3
Manyhealthprofessionalsunfortunatelybelievethatpain is a natural, inevitable, acceptable and harmless conse-quence of surgery. Common reasons cited for poor pain managementincludeinadequatestaff trainingand knowl-edge,poorpainassessment,unfamiliaritywiththebenefits andadverse effects of pain medications and a misguided beliefthatsincepost-surgicalpainis oftentemporaryand all humans experience pain in life, everyone must ‘‘grin and bear it’’. Insufficient or inappropriate post-operative painmanagementis,therefore,asignificantproblemin clin-icalpractice,buttheproblemisnotatallinsurmountable andcanberectifiedatboththeproviderandpatientlevel.4
Methods
To aid policymakers and regulatory authorities in better understanding the challenges of effective Acute Post-Operative Pain (APOP) management, specifically in Latin America,theAmericasHealthFoundationconvenedagroup of Latin American experts on anesthesiology,surgery and
pain to develop recommendations that will lead to more efficientandeffectivepainmanagement.
Acomprehensiveliteraturesearchwasperformed query-ing Pub Med, Embase and Scielo for articles related to post-operative pain management in general and post-operativepainmanagementinLatinAmerica.Theobjective ofthispaperistocallattentiontotheproblemsassociated withAPOP andtosuggest recommendations for their res-olution. The authors structured this paper as a response to a series of questions related to the topic. The entire researchand writingprocess wascompletelyindependent ofanyinputfromthefinancialsponsoroftheeffort.
Results
WhatisthecurrentstateofAcutePost-Operative Pain(APOP)managementinLatinAmericaand whataspectsshouldreceivepriorityattention?
Painthroughout historyhasbeenconsidered aproblemby all itsimplications. Although inancient times it was con-sidered an inevitable part of life,today, with the advent ofmanytherapeuticanalgesics,APOPshouldbeadequately alleviated.However,thisisnotthecaseinLatinAmerica.5
Despiterecentadvancesinourunderstandingofthe patho-physiologyof pain andmore widespreaduse of minimally invasivesurgicaltechniques,painaftersurgicalprocedures remainsachallengeformostphysicians.
of each individual.6 Uncontrolled APOP can produce
seri-ousadverseconsequencessuchasincreasedmorbidityand mortality, prolonged hospital stay,a delay in healing and recovery, patient dissatisfaction, anxiety, and a reduced likelihoodofanearlyreturntotheactivitiesofdailylife.7,8
In addition, it is the main risk factor for chronic pain when intensepost-operative painhas notbeen addressed appropriately.9---11 Anotherseriousproblemofuncontrolled
APOPistheincreaseduseofhealthresourcesandhospital costs.11,12
AlthoughAPOPisknowntobeacommonoccurrence fol-lowingsurgery,becauseofthelimitednumberofpublished studies,thetrueextentoftheprobleminLatinAmericais unclear.Itislikely;however,thatinrecentdecadesthere hasbeennodiscernablechangeintheprevalenceof post-operativepain.Moderatetoseverepainispresentinthevast majorityofpost-operativepatients.13Painisalsoacommon
causeofpost-surgicalhospitalreadmission.11,12
There has been no epidemiological study onthe prob-lem of APOP for all of Latin America (LA). Recently, a smallsurveywasperformedatateachinghospitalinBrazil andpost-operativepainwaspresent in48%of thesurgical patients.14Likewise,across-sectionalstudydonein
Colom-bia showedthatpainwaspresent 4h aftersurgeryin51% of thecases.Overall, 30%of post-surgicalpatients stated thattheyexperiencedseverepain.15Threeotherstudiesin
Colombiashowed aprevalence of APOPbetween 22% and
69%.16---18InChile,astudyshowedthatupto59%ofpatients
hadatleastmoderatepainaftersurgery.19Astudyin
Mex-icofoundthatin97%ofrespondentsexperiencingacutepain aftersurgery,mostreportedmoderatetoseverepain;60% reported that the pain interfered withtheir work activi-ties;55% reportedthepain affectedtheir mood,and57% reportedthatitinterfered withsleep.20 All thesestudies,
albeitconductedinspecificlocales,suggestthatthe preva-lenceAPOPishighthroughoutLatinAmerica.Ofnote,these outcomesweresimilartoonefoundinanationalsurveydone intheUnitedStatesthatconcludedthatmoderatetosevere post-operativepainaffected40---60%ofpatients.21
Many factors are responsible for influencing the high prevalence ofAPOPin Latin America.These include inad-equate education of health professionals and patients on many aspectsof pain management.22,23 Also,the absence
of policies that make it difficult for some medications to beincorporated intoa formulary,or bereadilyavailable, andthecostoftechnologyusedtoprovidepaintreatment is sometimes problematic.24 Studies have also shown that
nurses and doctorstend tooverestimate the potentialof opioid addiction (or their side effects such as respiratory depression)sotheyprescribelowerdosesandlonger inter-valsbetweendoses,therebyresultinginsub-optimalcontrol ofAPOP.17,25
Therearenonationalhealthpoliciesorguidelinesforthe managementofAPOPinLatinAmerica.Nonexistentornot followedlocaltreatmentguidelines,alongwiththeabsence of indicators of effective pain managementare common. Thelatterhasresultedintheabsenceoftheabilityto eval-uate pain management programs andoutcomes.11,16,26 All
thesefactorscontributetotherelativelack ofacutepain managementservicesinhealthcaresettingsintheRegion. Evenwithinacountry,therearemajorvariationsinpain managementservices.Accesstohealthresourcesisclearly
differentbetween largecities and smalltowns. Economic resourcesareconcentratedinmajorcitiesthatalsohouse themajorityofthepopulation.Generally,onlylargecities havehealth institutionswiththeability toprovide ‘‘state oftheart’’APOP.Painmanagementservicesarefrequently verydifferentin publicversus privatehospitals; pain ser-vicesintheformerarefrequentlylessavailableand/orless comprehensive.
Specificrecommendations
1. Each countryintheRegionshouldconstitute a govern-ment sponsored Task Force to design and implement nationwideepidemiologicresearchontheprevalenceof post-operativepainandtheextentofunsatisfactorypain management.
2. The government of each country should establish an officeordepartmentofpainmanagementsoastocreate visibilityandlegitimacyforthesubject,establishclear andrealisticgoalsforthecountryandhaveadedicated budgettofundnation-wideactivities.
3. EveryhospitalintheRegionshouldconductperiodic sur-veysonthestateofpainmanagementintheirinstitution.
Howcanhealthprofessionalawareness,knowledge andattitudesbeimprovedsothatpost-operative painmanagementisamedicalpriority?
Althoughit isunderstood that post-operativepaincontrol is essential to attain high-quality patientcare, failure to understand and appreciate the adverse consequences of painanditssequelae,hasledhealthcareproviderstolower effective analgesia to a secondary consideration.27 Even
professionalswithsome knowledgeofpainevaluationand management,oftenhaveunfoundedconcernsabouttheside effectsofanalgesicsorfearsofaddiction,andconsequently donotmake fulluse of pain medication.24,28,29 Also,
dur-ing the post-operative period, if the health care team is notattuned toactively accessingthelevelof pain experi-encedbythepatient,thenappropriatetreatmentmightbe delayed.
The cornerstone to resolve theseproblems throughout LatinAmericaiseducation.30Tostart,anexaminationofthe
curriculuminmajorLatinAmericanmedicalschoolsreveals thatthestudyofpainanditsmanagementisdeficient.Ina surveydone bytheInternationalAssociationfor theStudy ofPain(IASP),86%ofallhealthprofessionalrespondentsin LatinAmerica believed thatundergraduate educationand trainingin painmanagementisinadequate.31 Medical
stu-dentsareusuallyexposedtothisknowledgeinafragmented andunfocusedmanner,whichleadsstudentstounderstand painmerely as a symptom that should be approached as aninevitableanduncontrollableconsequenceofthe surgi-calprocedure.24Evenincountriesthatdoofferspecificand
directededucationonpainmanagement,theseareoffered asoptionalclasses(e.g.Chile),32orasextra-curricular
activ-ities(e.g.PainLeagues supportedbytheBrazilian Society for the Study of Pain).33 In Latin America, a more
struc-turedviewofpainmanagementistaughtinsomeresidency programsalbeitusuallyinanincompletefashion.
addressing pain as a ‘‘5th vital sign,’’ which was ini-tially promoted by the American Pain Society in order to bring attention to pain treatment among healthcare professionals.34 The notion thatpain shouldbe addressed
withthesamedegree ofvigilanceandtreatmentasblood pressure,heartrate,temperatureandrespiratoryrate,has beenthe subjectof afewstudies, albeitwith disappoint-ingresults.Onestudyshowedthatpainasthe5thvitalsign achievedlowaccuracywhenperformedbynursesonadaily basis.35 Asecondstudyshowedthatregardlessofthepain
scoresdocumented,nobenefitofpaincontrolwasachieved. Ofthepatientsthathadtheirpaindocumentedinthe medi-calrecord, 32%stillexperienced significantpain,andhalf ofthosepatientsdidnotreceiveanewprescriptionforpain alleviation.36 Itisclear thatitisnotenoughtosimplyask
patientsabout theirpainandthen record thefindingina chart.It is imperative thatthe next stepbetaken which iseffectivepainmanagement.Recently,thisapproachhas been emphasized.Thatis,caregivers should refocustheir effortsonpaincontrolratherthanconsiderdocumentation theonlyoutcomeofinterest.37
It should go without mention that the implementa-tion of protocols at the time of pre-surgical evaluation areimportant, includingdocumentation of the history of pain, the presence of predictors of pain, and analgesic requirements.Apainmanagementstrategyshouldbe devel-opedforall patientsundergoing surgery.Factors thatcan influence this strategy are the type of surgery, intensity of the expected post-operative pain, associated clinical conditions, the risk-benefit of available analgesic tech-niques,patientpreferencesandtheirpreviousexperiences with pain or analgesics. A plan of treatment should be established according to guidelines and protocols.26,38,39
Multidisciplinary teamwork is essential for such protocols andguidelinestobesuccessfulandalthoughthisapproach hasbeenadvocatedfordecades,itisstilluncommontoday inLatin America.25 Ideally, thisstrategy shouldbepartof
theinstitution’spatientcareplan.
A comprehensive pain management strategy should include the following steps: (1) pre-anesthetic evalua-tion to identify factors for the inclusion or exclusion of a given technique or pharmaceutical; (2) selection of the analgesia; (3) patient informed consent; (4) patient education to avoid anxiety and unrealistic expectations regarding post-operative pain; (5) consultation with the anesthesiologist to adapt the analgesia technique to the intra-operative period; (6) post-operative follow-up, and (7)periodicevaluationofthesuccessofpainmanagement andthepossibilityof modificationsbasedonthepatient’s response.39---41
Anesthesiologists and other professionals involved in treating post-operative pain should use readily available evaluationanddocumentationinstrumentsfocusingonthe painatrestanduponmovement,treatmentresultsandside effectspotentiallycausedbypaintreatment.TheNumeric PainScale (0 nopainand10 the mostintense pain possi-ble)is easy tounderstand andapply,although it maynot accuratelyreflectthecomplexityofthesymptom.42Simpler
scalescanalsobeused,suchasthoseusinghumanfaces.For patientswithcognitive impairments, suchasdementia or learningdisabilities,behavioralmeasuresandphysiological responsestopaincanbeutilized.43
Thereis substantialevidenceindicating thatthe intro-ductionofanAcutePainService(APS),whichincludesthe developmentoftreatmentguidelines,leadstotheimproved treatment of pain.The conceptof a formalAPS wasfirst suggestedbyReadyin1988asananesthesiology-based post-operative pain management service.44 The APS assumes
responsibility for themanagementof post-operativepain, healthprofessionaltraining,thedevelopmentofguidelines andprocessesforthedocumentationofpain,patient edu-cationandinformationmaterials,andperformancecriteria for evaluation,aswellastheconductofaudits.45 APSare
designedtoprovideoptimalpainmanagementforevery sur-gical patient, including children and outpatients, as well astheregularreviewoftheinstitution’spainmanagement policiesandpractices.
The APS is led by anesthesiologists, with expertise in the pre-operative, intra-operative and post-operative phases of pain management. Anesthesiologists, who are considered perioperative specialists, are also optimally positioned throughout the hospitalization period to serve as liaisons with consulting medical and surgical services. For an APS to operate effectively and achieve its full potential, active collaboration is necessary between the departments of anesthesiology, surgery, medicine, acute pain management teams and the post-surgical nursing staff.46
Since 1995, the American Society of Anesthesiologists (ASA)47 has periodicallyconvened a groupof experts that
developandupdatepracticeguidelinesrelatedtopain man-agement. Theseguidelinescanserveasthebasisof APOP management in Latin America. Other initiatives that may beuseful have been conductedby thePROSPECT Working Group48---52 andtheAustralianandNew ZealandCollegeof
Anaesthetists,6amongothers.TheASAguidelinesandother
initiativesdonotincludemedicalliteraturewrittenin Span-ish or Portuguese, andmay not includemedications (e.g. dipyroneormetamizol)thathavebeenusedsafelyformany yearsin Latin Americaandarea fundamental partof the Regionalarmamentariumforthemanagementofacutepain. Thus,derivativedocumentsrelevanttoLatinAmericamay havetobewritten,inpart,toreflectthecharacteristicsof theRegion.
SpecificRecommendations
1. Comprehensive painmanagement education should be included in the curricula of all medical and nurs-ing schools and in the examination of undergraduate and postgraduatehealth care professionals.Pain man-agement should also be routinely incorporated into continuingeducationalprograms.24
2. AllhospitalsandclinicsintheRegionthatperforminand outpatientsurgerymusthaveanAPS.
3. Allhospitals andclinicsshoulddevelop andimplement procedure-specific, evidenced-based pain management guidelinesandprotocolsfortheperioperativeperiod.46
Howcanpatientknowledgebeimprovedsothat post-operativepainisminimized?
theythinkhastobeenduredasaninevitablepartoftheir surgery.24 Therefore,patientand familyeducationefforts
mustincludeconveyingtheadvantagesofusinganalgesia, an attempt tomitigatethe fearof takinganalgesics, and costconsiderations.Patientsshouldbeinformedabout all existingtherapeutic possibilitiestotreat surgical pain,as well as potential risks of the methods used. It is impor-tant to emphasize that aggressive pain treatment is key because the consequences of poorly managed acute pain are often greater than the risk of adverse side effects frompainmedicationitself.Patientsshouldbeencouraged toreportpainusingan appropriateinstrument.53 Patients
and their families should be allowed to actively partici-pate in all pain management decisions, which will likely result in better pain management and improved patient satisfaction.16,22,38Theinformationmustbeclearandgiven
verballyandwrittenanditisnecessarytorespectdifferent cultures,ethnicitiesaswellasthevaluesandbeliefsofeach patient.25
Patient education materials range from a simple booklet or manual to educational videos.54 A patient’s
expectations should be considered. If audiovisual and written materials are created in Spanish and Por-tuguese theycan beshared across countries and thereby become efficient tools to facilitate the education pro-cess, and also facilitate Regional standardization of pain management.
One of the fundamental bases for all pain control ini-tiativesthroughout theworldhas beenthe Declarationof Montreal(DM).55 Thisdocumentresultedfromacombined
effortofawiderangeofhealthprofessionals,humanrights organizations andothers. It resulted frominitial input by IASPChaptersin130 countries,followingan in-depth pro-cessculminatinginanInternationalPainSummit,whichalso harnessedawiderangeofinput.TheDMsupportstheright ofallpeopletohaveaccesstopainmanagementwithout dis-crimination,therightofpeopleinpaintoacknowledgetheir painandtobeinformedabouthowitcanbeassessedand managed,andtherightofallpeoplewithpaintohaveaccess to appropriate assessment and treatment by adequately trainedhealthprofessionals.Failuretooffersuchpain man-agementisabreachofthepatient’shumanrights.55
Oncehealthcaregiversembracetheideathatallpatients have a right to be treated for pain, a secondary bene-fit is that these professionals will have a better overall appreciation of pain management. And then, through medical education, health professionals will be able to acquire the necessary knowledge to provide appropriate treatment.
SpecificRecommendations
1. All hospitals should develop policies and procedures wherebyallpatientsundergoingsurgerywillbeassured oflearningaboutpainmanagementintheentire periop-erativeperiod.
2. All hospitals should distribute written materials to patientspriortosurgerythataddressthevalueofpain managementandother relevantissues.The topicmust alsobediscussedverballywiththepatientbyamember oftheAPS.
WhatistheroleofgovernmentandNGOsto supporttheimprovementofthedeliveryof effectivepainmanagement?
Afewyearsago,theEconomicCommissionforLatinAmerica andtheCaribbean(ECLAC)foundmanydeficienciesinthe provisionofhealth careservices,including:lack ofequity andefficiencyofhealthsystems,limitedaccesstoservices, poorqualityandinefficiencyofservices,insufficient man-agementcapacity,anddeficienciesinmonitoringandcontrol processes.56Someofthesedeficienciescouldcontributeto
thepoormanagementofAPOPinLatinAmerica.Moreover, constrained national healthcare budgets limit the alloca-tionofhuman,technologicalandinstitutionalinfrastructure resourcestoessentialhealth services.The lackofpolicies prioritizing pain control within national health plans hin-derstheimplementationofcomprehensivenation-widepain controlprograms.24
Oneofthemajorissuesrelatedtotheincomplete provi-sionofoptimalAPOPmanagementisthemannerbywhich countriesmakeavailableopioidsforthetreatmentofpain. Despitetheirrecognizedeffectiveness,oftentimes,opioids arenotfreelyavailableduetothesometimeshighcostof opioidtherapyandrestrictivelawsbasedonfearofmisuse andabuse. Forinstance, in 2011 theUnited States alone accounted for 55% of global opioid consumption and the combination of North America and Europe accounted for 89%.Incontrast,LatinAmericaaccountedforaround1%of theworld’sopioidconsumption,indicatinginadequate avail-abilityofopioidanalgesicsintheRegion.57---60Thismakesthe
implementationofeffectivetreatmentguidelinesdifficultin countrieswithouteasilyaccessibleopioids.61
In order to reduce the gap in developing, or resource limited, countries between the increasingly sophisticated knowledgeofpainanditstreatmentandtheeffective appli-cation of that knowledge, many initiatives have begun. In 2000, the WHO published a guideline manual entitled ‘‘Achieving Balancein National Opioids Control Policy’’.62
The IASP formed the Developing Countries Task Force in 2007thatlaterdevelopedthe‘‘GuidetoPainManagement inLow-Resource Settings’’in 2009.5 In addition,IASPhas
formed a special interest group on acute pain. The DM63
reviewstheresponsibilityof governmentsandhealth care providers.Finally,theASAdeveloped‘‘PracticeGuidelines forAcutePainManagementinthePerioperativeSetting.’’47
Inallthesedocuments,governments,withinthelegallimits oftheirauthorityandtakingintoaccountavailablehealth careresources,havebeenaskedtoestablishlaws,policies, andsystems that will help promote the access of people inpaintofullyadequatepainmanagement.31 Forallthese
actionsto be fullyrealized, government authorities must beeducatedontheconsequencesofthelackofAPOP man-agement,which ultimately translatesintomore extended hospitalstays,higherhealthcarecostsandgreater morbid-ityandmortality.
Latin American chapters of the IASPcan also promote paineducationwithseminars,workshops,andconferences intheirrespectivecountries.7 The IASPsupportstheview
Table1 Thedesirablecharacteristicsofanationalpostoperativepainstrategy(modifiedfromTableonNationalPainStrategies developedbyIASP,2011).
Characteristics Examples Responsibleparties
Paineducation
Undergraduate Atanearlystageintrainingtoequiphealth professionaltraineeswithboththe knowledgeandskillstoaddressAPOP.
Centersoflearning,regulatorybodies
Postgraduate Cliniciansinvolvedinpainmanagement shouldreceiveongoingeducationinthe reliefofAPOP.Morecliniciansshouldbe trainedaspainspecialists.
Centersoflearning,regulatorybodies
Patientandfamilyeducation Tounderstandpainanditsmanagement, patientsandfamiliesshouldbeeducatedon allaspectsofAPOPmanagement.
Providersofhealthcare,painmanagement specialists,patientorganizations,and healtheducators
Patientaccessandcarecoordination
Careindifferingsettings AllhospitalsshouldhaveAPS.Allpatients shouldbeevaluatedforpain,andif present,shouldbetreatedappropriatelyor referredtoapainmanagementspecialist.
Healthcarepolicymakers,health professionalsandcommissionersofhealth care
Medicines TheWorldHealthOrganization’slistof essentialmedicinesshouldbeavailableand accessibleinpreparationssuitableforall ages.Supportfromthepharmaceutical industrywillbeneededtoachievethisgoal.
Governmentregulatoryagencies,drug enforcementagencies,andkeyclinicalstaff
Informedchoice Coordinationofthesystemsothataccess totherighthelpisavailableasearlyas possiblewithafullyinformedchoiceon options.
APSTeam
Carepathways Establishedguidelinesandpoliciesrelated toAPOP.
APSTeamandcommissionersofhealthcare.
Interdisciplinaryapproach Amultidisciplinaryteamofhealthcare professionalsworkingcloselywithina non-hierarchicalframework.
Providersofhealthcare
Familyandcaregiverinvolvement Familiesandcaregiversshouldbeactively includedinthemanagementofAPOP.
APSTeamandpatientadvocacygroups
Specialpopulations Specialpopulationsincludetheveryyoung andveryold,thosewithlearning
difficulties,thosewithmentalhealthand addictiondisorders,ethnicminorities,and impairedpersons.Theirneedsshouldbe recognizedandprovidedfor.
Healthprofessionalsandcommissionersof healthcare
Monitoring-qualityimprovement
Timetocare Reductionsinwaitingtimeforpainrelief. APSTeamandanalgesicproviders Qualityofservice Improvementsinpatientsatisfaction. APSTeam
Economicburden Reducedlengthofhospitalizationand pain-relatedreadmissionsthrougheffective APOPmanagement.
APSTeam
Outcomes OutcomesfromeffectiveAPOP
managementroutinelymeasured.
APSTeam
Painresearch
Epidemiologic Anationalhealthsurveytodeterminethe statusandneedsforAPOPmanagement withineachcountryintheRegion.
Publichealthservices,healtheconomists
Science PrioritizationofAPOPmanagementfor fundingopportunitiesthattargetgapsin treatment,implementationofscience, knowledgetransfer,education,andpolicy development.
reduce these problems. The IASPhas alsodeveloped rec-ommendationsfor the core elementsof anynational pain strategy.64 RecommendationsbytheIASPincludeobtaining
evidenceoncountries’burdenofpainthroughhealth sur-veystargetedtowardpain,painmanagementanditsadverse consequences.Thedatacollectedcanserveasauseful base-linefromwhichtomeasuretheimpactofanyinterventions introduced and to informnew national pain management strategies.65 The IASP also recommends gathering
infor-mation on access to care, forming a broad coalition of stakeholders,and developing governmentpoliciesonpain servicesthat establish goals for improvement and aclear planwithtimelinestoachieve strategicactions.Although theIASPpaperisorientedtochronicpain,itcanbemodified toaddressthetreatmentofAPOP.Thedesirable character-isticsofanationalAPOPstrategyareshowninTable1,that theauthorsadaptedfromIASPrecommendationsrelatedto painmanagement.64
Given thespecialcharacteristics oftheLatin American Region, government strategies must be accessible to the entirepopulation.Accessiblehealthservicesarethosethat are physically available, affordable (economic accessibil-ity), appropriate and acceptable. Health services can be inaccessible if providers do not acknowledge and respect culturalfactors, physical andeconomic barriers,or if the community is not aware of available services.66
Cross-cultural miscommunication between patients and health professionals may exist and should be documented to developthenecessaryrangeofstrategiestoovercomethese issues.
SpecificRecommendations
1. All countries in the region should develop a national, post-operativepainstrategy.
2. Hospitalsandclinicsthatperformsurgeryshoulddevelop andmakeaccessiblerelevantmaterials,becomeaware ofnewdevelopmentsin thefieldofpainmanagement, andhaveasourceofexpertadviceandguidanceinAPOP. 3. Allgovernments shouldre-examinetheir laws, policies and regulations related to the availability of opioids. Thesetherapeuticsmustbereadilyaccessibletohealth professionalsforpainmanagement.
Canpainmanagementbestandardizedthroughout theRegion?Ifso,whatmightbetheinitialsteps?
Although the problems of the Region are sometimes addressedasifLatinAmericawereasinglecountry,amajor characteristicof thispartof theworldis the heterogene-ity of the countries. Latin America is composed of many countries whose cultural,economic andpolitical features differgreatlyfromoneanotherand,perhaps more impor-tantly, do not share a common health system and have highlyvariableornon-existentAPOPpolicies.Theemphasis ofhealth care inthe Regionhasmainlyfocused onpublic health,particularlymalnutrition,controlofinfectious dis-eases,childhood immunizationand theprovision of clean water.Thus,painmanagement---whetheracuteorchronic ---hasbeengivenalowpriority.7
Allthatsaid,anyRegionaleffortmusttakeintoaccount thedifferencesbetweencountries.Abetterunderstanding
of the obstacles within each country and how pain man-agementhasbeentaughtthroughoutLatinAmericamaybe apath to buildingRegion-wide consensus. Inaddition, an efforttodevelopguidelinesandpoliciesonAPOP manage-mentwithinacountrymaybethegatewaytowardRegional standardization. Finally, patient education principles and policies couldperhaps be standardized across the Region andthe desired outcomes (indicators) of successfulAPOP managementmayalsobeeasilystandardized.
SpecificRecommendations
1. An organization with an interest in pain management should constitute a regionwide taskforce that begins work to standardize all aspects of APOP management in the Region.Funding for the work of the task force cancomefromamodestcontributionfromgovernments and/orthepharmaceuticalindustry.Ifthelatter,there shouldbenoworkofthetaskforcerelatedtotheuseof anyspecific,brandedtherapeuticagent.
Conclusion
Effective post-operativepain managementin Latin Amer-icarequires aproactive approach. It willbenecessary to changetheknowledgeandbehaviorofhealthprofessionals andpatients,andtoobtainacommitmentofpolicymakers. Successwilldependonapositiveattitudeandthe commit-ment of each party throughthe developmentof policies, programsandthepromotionofamoreefficientand effec-tivesystemfor thedeliveryof APOPservices.Properpain managementisafundamentalhumanright,notjustan indi-catorofgoodclinicalpracticeandqualityhealthcare.67
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
TheauthorswishtothanktheAmericasHealthFoundation (Washington,D.C.,UnitedStates)for itsgeneroussupport indevelopingtheconference.
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