Summary: This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri‐operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid‐related harm, including persistent postoperative opioid use; opioid‐induced ventilatory impairment; non‐medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre‐operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long‐acting (modified‐release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid‐related harm in adults.

Summary: Background: Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri‐operative pathway by healthcare professionals, institutions and patients. Methods: We conducted a directed literature review followed by a four‐round modified Delphi process to formulate recommendations for organisations and individuals. Results: We make recommendations for the entire peri‐operative period, covering pre‐admission; admission; intra‐operative; post‐anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post‐discharge phases of care. We also provide generic principles of peri‐operative pain management that clinicians should consider throughout the peri‐operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non‐pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain. Conclusions: We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.

Background: Pain is the leading cause of disability and reduced quality of life worldwide. Despite the increasing burden for patients and healthcare systems, pain research remains underfunded and under focused. Having stakeholders identify and prioritize areas that need urgent attention in the field will help focus funding topics, reduce ‘research waste’, improve the effectiveness of pain research and therapy and promote the uptake of research evidence. In this study, the European Pain Federation (EFIC) developed a Pain Research Strategy for Europe.Methods: The study used multiple methods, including literature searches, multidisciplinary expert debate, a survey and a final consensus meeting. The cross‐sectional survey was conducted among 628 European pain researchers, clinicians, educators and industry professionals to obtain the rating and hierarchy of pain research priorities.The final consensus meeting involved a multidisciplinary expert panel including people with lived experience from 23 countries. The survey results guided discussions where top priorities were agreed.Results: Content analysis identified nine survey themes, of which five emerged as top priorities: (i) understand the pathophysiology of pain; (ii) understand and address comorbidities; (iii) critically assess current therapies; (iv) develop new treatments; and (v) explore the biopsychosocial impacts of pain. Physical, psychological and social approaches were prioritized at the same level as pharmacological treatments. The top priorities were endorsed by a multidisciplinary expert panel. The panel emphasized the importance of also clearly communicating the concepts of prediction, prevention self‐management and personalized pain management in the final strategy.Conclusions: The content of the final top research priorities' list reflects a holistic approach to pain management. The equal importance given to physical, psychological and social aspects alongside pharmacological treatments highlights the importance of a comprehensive biopsychosocial‐orientated research strategy. The expert panel's endorsement of five top priorities, coupled with an emphasis on communicating the concepts of prediction, prevention, self‐management and personalized pain management, provides a clear direction for future basic, translational and clinical research.Significance: EFIC has developed a Pain Research Strategy for Europe that identifies pain research areas deserving the most focus and financial support. Implementation and wide dissemination of this Strategy is vital to increase the conduct of urgent pain projects, pain research funding and the implementation of research findings into practice, to ultimately decrease the personal, societal and financial burden of pain.

A cost-effectiveness analysis is one form of full economic evaluation where drug acquisition costs and the costs that are incurred as a result of using a particular treatment are assessed together with clinical efficacy. This paper reviews two such studies. One of the studies was a prospective randomised cost-effectiveness study which compared ondansetron (8 mg i.v. 0, 4 and 8 h following chemotherapy) with metoclopramide (3 mg/kg i.v. followed by an infusion of 0.5 mg/kg/h for 8 h) over the first 24 h following chemotherapy in hospitalised patients receiving highly emetogenic chemotherapy. This study showed that the cost per successfully treated patient (defined in this study as having < 1 emetic episode and no adverse events) for these 2 treatments were approximately equal: ondansetron E95 and metoclopramide E92. The second study was an economic evaluation based on data collected over a 5-day period following cyclophosphamide-based chemotherapy given on an outpatient basis for the treatment of breast cancer. Patients received an intravenous dose of 16 mg dexamethasone with either 8 mg ondansetron or 60 mg metoclopramide intravenously before chemotherapy followed by oral dosing with 8 mg ondansetron or 20 mg metoclopramide 3 times daily for 5 days. The costs per successfully treated patient (defined in this study as no vomiting or retching episodes and no anti-emetic-related adverse events during the 5-day period) were comparable: ondansetron E184 and metoclopramide E160. A recent study has established that ondansetron (8 mg) given orally twice daily is as effective as the same dose given 3 times a day. A sensitivity analysis using the cost of an ondansetron twice daily regimen showed that ondansetron is more cost-effective than metoclopramide (E133 vs. E 160). These cost effectiveness studies have shown that ondansetron is at least as cost-effective as metoclopramide and simplified ondansetron dosing schedules render ondansetron more cost-effective. These full economic evaluations illustrate that drug acquisition costs can be a misleading guide to the economic impact of antiemetics.

This article, the first in a series written by pain nurse specialists, provides an overview of the nature, causes and structured management of acute, chronic and neuropathic pain. The differences between nociceptive and neuropathic pain, and treatment options are identified. The pain management service's roles are described in the context that a person's experience of pain is the result of biological, psychological and social factors. Future articles will explore the physiology and pharmacology of pain, how patients express pain and interventions for acute and chronic pain. They will also provide guidance on managing pain in challenging circumstances.