Healthcare-prescribed opioids are a known contributor to the opioid epidemic. Locally, there was an identified opportunity to improve opioid prescribing practices in cardiac surgical patients. The cardiac surgical team sought to standardise prescribing practices in postoperative patients and reduce opioid prescriptions at discharge. The improvement was undertaken at a large midwestern freestanding children’s hospital with over 400 beds and 120 cardiac surgeries annually. A multidisciplinary team was formed, using the model for Improvement to guide the improvement work. The key improvement interventions included standardised evidence-based prescribing guidelines based patient age and surgical approach, enhanced pain management with non-opioid medications, and integration of prescribing guidelines into the electronic health record. The primary outcome measure was rate of compliance with the prescribing guidelines and secondary measures included morphine equivalent dosing at discharge, opioid-free discharge, and length of stay. A balancing measure of opioid re-prescriptions was tracked. There were 289 patients included in the primary study period (January 2019 through December 2021). Sustainability of key outcomes was tracked though December 2022. The guideline compliance increased from 24% to 100%. The morphine equivalent dosing decreased to 22.5 in 2021 then 0 in 2022, from baseline of 36.25 in 2019. Opioid-free discharges decreased from 8% (2019) to 1.5% (2021) and 0% in 2022. Establishment and compliance with standardised guidelines for post-operative cardiac surgical pain management yielded a reduction in morphine equivalent dosing, an increase opioid-free discharges, and no increase in length of stay or opioid re-prescriptions.

Pain, a multifaceted condition associated with actual or potential tissue damage, transcends nociception and is characterised as a subjective, sensory, and emotional experience. Extensive literature describing the adverse effects of untreated post-surgical pain emphasises the necessity of a comprehensive pain management protocol, incorporating both pharmacological and non-pharmacological strategies to ensure successful patient outcomes. The present study aimed to determine whether a positive dog-owner interaction influences post-operative pain perception and stress (POPPS), as well as behavioural inactive rate variability in bitches that underwent elective surgery. Randomly selected bitches (n = 18) underwent ovariohysterectomy. Eight bitches experienced a 45-min visit post-surgery (VPS) characterised by positive dog-owner interaction, while the remaining ten did not (NVPS). Utilising the validated Short Form of the Glasgow Composite Measure Pain Scale (CMPS-SF) to assess acute pain in dogs via stress-related behaviours, a significant decrease in POPPS was evident in the VPS group after the 45-min dog-owner interaction at T3 (1 h after post-sedation recovery), in contrast to the NVPS group. CMPS-SF-associated descriptive items ‘Nervous/Anxious/Fearful’ and ‘Happy Content or Happy and Bouncy’ decreased and increased, respectively, with dog-owner positive interaction in the VPS group. The inactivity rate was significantly lower in VPS bitches after the post-surgery 45-min dog-owner interaction than in NVPS bitches. This preliminary study suggests that the owner’s presence reduces POPPS and may improve the dogs’ welfare while undergoing routine surgeries.

Stockpeoples’ ability to recognise pain in their livestock, and to respond appropriately, is of utmost importance for animal welfare. Assessment of pain is complex, and attitudes and empathy are thought to play a role in peoples’ responses to the sight of pain. In a separate paper we investigated the dimensionality of Norwegian dairy goat stockpeoples’ goat-oriented attitudes and empathy. This paper investigates how the stockpeople assess and manage pain and disease in goats. The interrelationships between pain perception and provision of veterinary attention were explored, as well as how these two measures are associated with demographics, attitudes and empathy. Pain assessment scores for individual conditions ranged across most of the picture-based pain assessment scale. Dystocia, gangrenous mastitis and the neurological form of caprine arthritis encephalitis were considered most painful. Linear regression showed that one attitude dimension was positively associated with mean pain assessment score (mPAS), while growing up on a goat farm, having farming as main income and having seen a large number of the conditions were negatively associated with mPAS. Cluster analysis on reported frequency of contacting veterinary surgeons for ten conditions revealed two distinct groups of stock-people. Logistic regression showed that females, older stockpeople and stockpeople who grew up in a rural district were significantly more likely to be in the group that more frequently contacted veterinary surgeons. We conclude that training of stockpeople needs to focus on evaluation and management of pain to ensure a high standard of animal welfare.

Physicians’ fear of criminal prosecution for prescribing opioid analgesics is a major reason why many chronic pain patients are having an increasingly difficult time obtaining medically appropriate pain relief. In Ruan v. United States, 142 S. Ct. 2370 (2022), the Supreme Court unanimously vacated two federal convictions under the Controlled Substances Act. The Court held that the government must prove that the defendant knowingly or intentionally acted in an unauthorized manner.

Chronic pain is a debilitating medical condition affecting a significant percentage of the population worldwide. Considerable evidence suggests that pain is an independent risk factor for suicide and inadequately managing pain has been identified as a risk for suicidal behaviour. Additionally, medications used to treat pain may also contribute to suicidal behaviour. Extensive research on pain highlights deficiencies in the clinical management on pain with more gaps in care when patients have pain in combination with mental illness and suicidal behaviour. Providing trainees additional knowledge and equipping them with relevant tools to screen and manage chronic pain efficiently is a potential strategy to mitigate suicide risk. Also, trainees need to be educated on how to screen for suicidality in individuals with pain and apply suicide prevention interventions. This paper will emphasise the necessity to improve education about pain, its close relationship with suicide and effective suicide screening as well as management strategies for medical providers. With additional research, it is the hope that novel treatment modalities will be developed to treat pain to improve the quality of life of individuals suffering from this condition and to decrease suicide risk in this patient population.

Deaths due to opioid overdose have reached unprecedented levels in Canada; over 12,800 opioid-related deaths occurred between January 2016 and March 2019, and overdose death rates increased by approximately 50% from 2016 to 2018.1 In 2016, Health Canada declared the opioid epidemic a national public health crisis,2 and life expectancy increases have halted in Canada for the first time in decades.3 Children are not exempt from this crisis, and the Chief Public Health Officer of Canada has recently prioritized the prevention of problematic substance use among Canadian youth.4

Introduction: Venipuncture is a frequent cause of pain and distress in the pediatric emergency department (ED). Distraction, which can improve patient experience, remains the most studied psychological intervention. Virtual reality (VR) is a method of immersive distraction that can contribute to the multi-modal management of procedural pain and distress. Methods: The main objectives of this study were to determine the feasibility and acceptability of Virtual Reality (VR) distraction for pain management associated with venipunctures and to examine its preliminary effects on pain and distress in the pediatric ED. Children 7-17 years requiring a venipuncture in the pediatric ED were recruited. Participants were randomized to either a control group (standard care) or intervention group (standard of care + VR). Principal clinical outcome was the mean level of procedural pain, measured by the verbal numerical rating scale (VNRS). Distress was also measured using the Child Fear Scale (CFS) and the Procedure Behavior Check List (PBCL) and memory of pain using the VNRS. Side effects were documented. Results: A total of 63 patients were recruited. Results showed feasibility and acceptability of VR in the PED and overall high satisfaction levels (79% recruitment rate of eligible families, 90% rate of VR game completion, and overall high mean satisfaction levels). There was a significantly higher level of satisfaction among healthcare providers in the intervention group, and 93% of those were willing to use this technology again for the same procedure. Regarding clinical outcomes, no significant difference was observed between groups on procedural pain. Distress evaluated by proxy (10/40 vs 13.2/40, p = 0.007) and memory of pain at 24 hours (2.4 vs 4.2, p = 0.027) were significantly lower in the VR group. Venipuncture was successful on first attempt in 23/31 patients (74%) in the VR group and 15/30 (50%) patients in the control group (p = 0.039). Five of the 31 patients (16%) in the VR group reported side effects Conclusion: The addition of VR to standard care is feasible and acceptable for pain and distress management during venipunctures in the pediatric ED. There was no difference in self-reported procedural pain between groups. Levels of procedural distress and memory of pain at 24 hours were lower in the VR group.

Introduction: Acute pain represents one of the most common reasons for emergency department (ED) visits. In the opioid epidemic that North America faces, there is a significant demand for novel pain control modalities that are both safe and effective. Regional anesthesia techniques have revolutionized perioperative pain management, and they are currently thought to be indicated for acute pain relief in the ED. The erector spinae plane block (ESPB) is a novel regional block that has the ability to block multidermatomal sensation, including cervical, thoracic and lumbar regions, depending on the vertebral level at which the anesthetic is injected along the erector spinae muscle. Under ultrasound guidance, the landmarks involved are easy to identify, and there are no vital structures in the immediate vicinity of the site of injection. By reviewing the literature on ESPB, this review aims to summarize all its indications and efficacy for acute pain management in the ED. Methods: In April 2019, PUBMED, EMBASE, MEDLINE as well as CINAHL databases were systematically searched for articles discussing the use of ESPB in the ED. In compliance with the PRISMA guidelines, the search results were selected against inclusion and exclusion criteria. Due to the novelty of the block, all types of articles were included. Results: Ten studies on 7 different indications have been published on the use of ESPB in the ED. It is currently most commonly used for rib and spine fractures. Other indications include, mechanical back pain, burn injuries, herpes zoster, renal colic, and acute pancreatitis. ESPB was administered at the vertebral level of region of most pain, unilaterally or bilaterally for complete dermatomal block. It was injected as a single or continuous block - in the seated, lateral, or prone position. All of the studies demonstrate a significant reduction in pain. Furthermore, it has been reported to improve respiratory function, and it has not been associated with any complications following administration. Conclusion: This review shows initial data on the promising effect of ESPB in acute pain management in the ED. Current evidence shows its effectiveness and safety for the most common presenting cases of pain, such as rib and spine fracture, mechanical back pain, burn injuries, herpes zoster, renal colic, as well as acute pancreatitis. ESPB is flexible in administration and relatively easy to perform under ultrasound guidance.

Introduction: Traumatic rib fractures (RF) are a common occurrence with 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and reducing morbidity and mortality. There is evidence of intravenous (IV) lidocaine's effectiveness and safety in the post-operative thoracic and abdominal surgical patient and we hypothesize that it may be ideal in trauma patients with RF. We evaluated IV lidocaine's analgesic efficacy in this population. Methods: A single-centre, double-blind, randomized control trial comparing a 72-96 hour IV lidocaine infusion plus standard analgesics to placebo infusion plus standard analgesics. Participants were adult trauma patients diagnosed with two or more RFs requiring hospital admission. A total of 36 patients were enrolled over 5 months in 2019. The study was powered to detect a 20% reduction in pain scores, which is determined to be clinically significant. Results: The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). There were consistent trends toward reduced VAS pain scores at rest and with movement in the lidocaine group as compared to placebo group with mean scores of 3.49 [SD 2.02 95% CI] and 7.08 [SD 1.71 95% CI] in the lidocaine group and 3.83 [SD 1.93 95% CI] and 8.03 [SD 1.44 95% CI] in the placebo group, at rest (p value 0.624) and with movement (p value 0.110), respectively . Secondary outcomes were patient satisfaction as measured on the VAS which demonstrated a score of 7.79 [SD 1.82 95% CI] in the lidocaine group and 6.63 [SD 1.77 95% CI] (p = 112) in the placebo group, and total morphine equivalents (ME) used (including breakthrough doses) that demonstrated a trend towards a reduction in the lidocaine group with 210.9 mg [SD 180.0 95% CI] compared to the placebo with total ME used of 309.9 mg [SD 221.8 95% CI]. Other secondary outcomes were protocol adherence, incidence of respiratory failure, hospital and ICU length of stay, mortality, incidence of lidocaine toxicity, and treatment regimens (non-opioid analgesics). Conclusion: These results demonstrate a trend towards lidocaine's analgesic benefit during rest and the critical times of patient movement and mobility, which has been demonstrated to be paramount in the reduction of respiratory complications from rib fractures. The results also tend towards a reduction in morphine equivalents, although the trial was not powered to demonstrate this