Pain remains as one of the most common reasons for visits to a doctor. The paper by Zalinawati et all published in this issue of the Journal confirmed this in two primary care settings, showing that a complaint of pain was recorded in almost a third of patients, similar to the prevalence reported in European studies.
The burden of pain in low- and middle income countries (LMICs) is high and expected to rise further with their ageing populations. Multidisciplinary pain management approaches based on the biopsychosocial model of pain have been shown to be effective in reducing pain-related distress and disability, but these approaches are still lacking in many LMICs due to various factors, including low levels of awareness about the role of multidisciplinary pain clinics, lack of prioritisation for pain services, and lack of healthcare professionals trained in pain management. The International Association for the Study of Pain (IASP) has several educational programs to promote multidisciplinary pain management in LMICs, in the form of education grants, pain fellowships, pain camps and, most recently, the development of a Multidisciplinary Pain Centre Toolkit. This article describes the various educational programs, focusing on Southeast Asia, that demonstrate how targeted educational programs which include skills training, follow-up and mentorship, can translate into the formation of new multidisciplinary pain management services in settings with limited resources.
The Malaysian Society of Anaesthesiologists published a document entitled "Recommendations for Standards of Monitoring during Anaesthesia and Recovery" in 1993. This paper examines the results of two surveys, carried out in 1995 and 1996 respectively; to determine compliance with published Monitoring Standards in Malaysian public and private hospitals. In the private sector, compliance with the recommended standards during anaesthesia varied greatly. Of the 28 government hospitals surveyed in 1996, compliance with monitoring standards during anaesthesia was almost 100%. Standards in recovery areas were less than ideal. The majority of anaesthesiologists thought that the current recommended standards were adequate.
In Study A, the incidence of arterial oxygen desaturation was studied using pulse oximetry (SaO2) in 100 sedated and 100 nonsedated patients breathing room air who underwent diagnostic upper gastrointestinal endoscopy. Hypoxia (SaO2 92% or less of at least 15 s duration) occurred in 17% and 6% of sedated patients and nonsedated patients, respectively (p < 0.03). Mild desaturation (SaO2 94% or less and less than 15 s duration) occurred in 47% of sedated patients compared with 12% of nonsedated patients (p < 0.001). In Study B, the effects of supplementary oxygen therapy and the effects of different pre-oxygenation times on arterial oxygen saturation (SaO2) in sedated patients were studied using pulse oximetry. One hundred and twenty patients who underwent diagnostic upper gastrointestinal endoscopy with intravenous sedation were studied. Patients were randomly allocated to one of four groups: Group A (n = 30) received no supplementary oxygen while Groups B-D received supplementary oxygen at 4 1 x min(-1) via nasal cannulae. The pre-oxygenation time in Group B (n = 30) was zero minutes, Group C (n = 30) was 2 min and Group D (n = 30) was 5 min before sedation and introduction of the endoscope. Hypoxia occurred in seven of the 30 patients in Group A and none in groups B, C and D (p < 0.001). We conclude that desaturation and hypoxia is common in patients undergoing upper gastrointestinal endoscopy with and without sedation. Sedation significantly increases the incidence of desaturation and hypoxia. Supplementary nasal oxygen at 4 1 x min(-1) in sedated patients abolishes desaturation and hypoxia. Pre-oxygenation confers no additional benefit.
Purpose: To examine the trends of analgesic prescribing at public tertiary hospital outpatient settings and explore the patterns of their utilization in nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol, and opioid patients.
Patients and methods: This cross-sectional study was conducted from 2010 to 2016 using the prescription databases of two tertiary hospitals in Malaysia. Prescriptions for nine NSAIDs (ketoprofen, diclofenac, celecoxib, etoricoxib, ibuprofen, indomethacin, meloxicam, mefenamic acid, and naproxen), tramadol, and five other opioids (morphine, fentanyl, oxycodone, dihydrocodeine, and buprenorphine) were included in this study. Annual number of patients and prescriptions were measured in repeat cross-sectional estimates. Descriptive statistics and linear trend analysis were performed using Stata version 13.
Results: A total of 192,747 analgesic prescriptions of the nine NSAIDs, tramadol, and five other opioids were given for 97,227 patients (51.8% NSAIDs patients, 46.6% tramadol patients, and 1.7% opioid patients) from 2010 to 2016. Tramadol (37.9%, n=72,999) was the most frequently prescribed analgesic, followed by ketoprofen (17.5%, n=33,793), diclofenac (16.2%, n=31,180), celecoxib (12.2%, n=23,487), and other NSAIDs (<4.5%). All the analgesics were increased over time except meloxicam, indomethacin, and mefenamic acid. Opioids, primarily morphine (2.2%, n=4,021) and oxycodone (0.5%, n=1,049), were prescribed the least, but the rate of increase was the highest.
Conclusion: Tramadol was the most frequently prescribed analgesic in hospital outpatient settings in Malaysia. Opioids were prescribed the least, but noted the highest increase in utilization.
Data source: Prescription databases of two public tertiary hospitals in Malaysia
Study site: two public tertiary hospitals in Malaysia
Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.