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

Introduction: Needle-related procedures are considered the most important source of pain and distress in children in hospital settings. Time constraints, heavy workload, busy and noisy environment represent barriers to the use of available interventions for pain management during needle-related procedures. Therefore, the use of a rapid, easy-to-use intervention could improve procedural pain management practices. The objective was to determine if a device combining cold and vibration (Buzzy) is non-inferior (no worse) to a topical anesthetic (Maxilene) for pain management in children undergoing needle-related procedures in the Emergency Department (ED). Methods: This study was a randomized, controlled, non-inferiority trial. We enrolled children aged between 4-17 years presenting to the ED and requiring a needle-related procedure. Participants were randomly assigned to the Buzzy or Maxilene group. The primary outcome was the mean difference in pain intensity during the procedure, as measured with the CAS (0-10). Secondary outcomes were procedural distress, success of the procedure at first-attempt and satisfaction of parents. Results: A total of 352 participants were enrolled and 346 were randomized (Buzzy = 172; Maxilene = 174). Mean difference in procedural pain scores between groups was 0.64 (95%CI -0.1 to 1.3), showing that the Buzzy device was not non-inferior to Maxilene according to a non-inferiority margin of 0.70. No significant differences were observed for procedural distress (p = .370) and success of the procedure at first attempt (p = .602). Parents of both groups were very satisfied with both interventions (Buzzy = 7.8 ±2.66; Maxilene = 8.1 ±2.4), but there was no significant difference between groups (p = .236). Conclusion: Non-inferiority of the Buzzy device over a topical anesthetic was not demonstrated for pain management of children during a needle-related procedure in the ED. However, considering that topical anesthetics are underused in the ED setting and require time, the Buzzy device seems to be a promising alternative as it is a rapid, low-cost, easy-to-use and reusable intervention.

Background: Greater than 80% of patient visits to emergency departments (EDs) are for a pain-related concerns. Approximately 38,000 patients per year have such complaints in our academic hospital ED. 3,300 (8.6%) of those visits are for musculoskeletal (MSK) pain (i.e. back or extremity injury/pain), which are typically triaged as low-acuity presentations, leading to longer times to clinician assessment. Delays to adequate analgesia result in unnecessary suffering, worse patient care and satisfaction, and increased patient complaints. Aim Statement: We aimed to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 minutes) in 9 months’ time (May 2018). Measures & Design: Our outcome measures were TTA (in minutes) and ED length of stay (LOS; in minutes). Process measures included nurses’ use of medical directive and rate of analgesia administration. Balancing measures included patient adverse events and time spent triaging for nurses. We utilized weekly data capture for the Statistical Process Control (SPC) chart, and we used Mann-Whitney U test for our before-and-after evaluation. Utilizing the Model for Improvement, we performed wide stakeholder engagement and root cause analyses, and we created a Pareto chart. This led to our Plan-Do-Study-Act (PDSA) cycles: 1) nurse-initiated analgesia (NIA) at triage; 2) new triage documentation aid for medication administration; 3) quick reference medical directive badge tag for nurses; 4) weekly targeted feedback of the project's progress at clinical team huddle. Evaluation/Results: TTA decrease from 129 minutes (n = 153) to 100 minutes (22.5%; n = 87, p < 0.05). ED LOS decreased from 580 minutes (n = 361) to 519 minutes (10.5%; n = 187; p = 0.77). Special cause variation was identified on the ED LOS SPC chart with eight consecutive points below the midline, after PDSA 1. The number of patients who received any analgesia increased from 42% (n = 361) to 47% (n = 187; p = 0.13). The number of patients who received medications via medical directives increased from 22% (n = 150) to 44% (n = 87; p < 0.001). Balancing measures were unchanged. Discussion/Impact: The significant reduction in the TTA and increase in the use of medical directives in the before-and-after analyses were likely due to our front-line focused improvements and deliberate nursing engagement. With continued success and sustainable processes, we are planning to spread our project to other EDs and broaden our initiative to all pain-related concerns.

Introduction: Pain management is a cornerstone of emergency department (ED) practice, yet ongoing pain after ED discharge and return visits for inadequate analgesia are common. Over-the-counter (OTC) acetaminophen and nonsteroidal anti-inflammatory drugs are widely accepted first line agents for mild to moderate pain. Previous research has not investigated how patients actually consume such agents after discharge, and if they consume them synergistically and at sufficient doses for optimal analgesia. We sought to determine the proportion of patients in ongoing pain post-discharge that were utilizing analgesics as well as the type and dose of agent(s) used. Methods: Adults presenting to our ED with an acutely painful musculoskeletal complaint during research assistant hours were eligible for enrollment. After excluding non-English speakers as well as admitted, pregnant/breastfeeding, and chronic pain patients, consenting subjects completed in-person questionnaires during their ED stay and a follow-up telephone interview 2-3 days later. Results: 158 individuals were approached during the study period, of which 99 enrolled. 78 completed follow-up. At follow-up, 71 (91%) individuals experienced ongoing pain with a median score of 5 (interquartile range (IQR) 3-6) on an 11-point scale. 48 (67%) of patients still in pain consumed analgesics in the preceding 24 hours. The most commonly used agents were acetaminophen by 18 individuals (38% of analgesic users), ibuprofen by 16 (33%), and naproxen by 9 (19%). 29 respondents (60% of analgesic users) were using solely oral OTC analgesics. Only 15 (31% of analgesic users) used multiple agents concurrently, and 11 (23%) used prescription opioids. Acetaminophen was used at a median daily dose of 1500mg (IQR 1000-2000mg), much lower than that recommended for maximal analgesia (4000mg). Ibuprofen daily doses (1200mg, IQR 800-1300mg) were slightly lower than typical recommended doses (1600mg, 400mg every 6 hours). Conclusion: Only two-thirds of patients with ongoing pain at 2-3 days post-ED discharge were consuming analgesics, most commonly acetaminophen and ibuprofen. Of patients using analgesics, less than one-third used multiple agents. OTC medications are not used by most patients at doses for maximal analgesia. It may be possible to reduce pain burden and repeat-visits in discharged ED patients by optimizing the use of OTC analgesics.