Preliminary survey of the attitudes of Brazilian scientists towards pain management and assessment in animals used in science.

OBJECTIVE: To investigate the current scenario in Brazil regarding pain assessment and control in experimental animals. STUDY DESIGN: Prospective survey. METHODS: A confidential questionnaire was available online and sent by e-mail to Brazilian scientists working with animal experimentation in Brazil. Data collection was conducted from October 2016 to October 2017. The exclusion criteria included blank questionnaires or with <80% completed responses, researchers not performing experiments involving animals and foreign scientists. RESULTS: A total of 96 questionnaires from 104 respondents were analyzed. The Fisher's exact test showed a disparity between the proportions of scientists who recognized the importance of analgesia and their application of analgesic techniques in painful procedures (p < 0.0003), and also for the researchers who assumed that experiments inflicted pain and their classification of the degree of invasiveness (p < 0.0001), indicating their insufficient knowledge of these topics. Overall, 77% of institutions did not offer specific training to assess pain in experimental animals, and 24% of respondents had no training to work with animal experimentation. In total, 62% of the studies inflicted pain, 48% of respondents used pain scales, and the drugs administered most frequently for pain management were morphine (44%), meloxicam (43%) and tramadol (37%); 15% of respondents did not include analgesics even though their studies inflicted pain. Commonly used animals were rats (33%), mice (29%) and rabbits (8%). CONCLUSIONS AND CLINICAL RELEVANCE: The results of this preliminary survey indicated that in Brazil there is a gap in the knowledge and training on pain assessment and management of experimental animals. Therefore, there is a necessity for an educational program to prepare and train scientists to assess and manage pain in laboratory or experimental animals. Further studies using a psychometrically validated survey instrument are warranted.

Why Would the Pope Have A Private Audience with Anesthesiologists? The Origin of the "Doctrine of Double Effect" and Its Application to Pain Control.

Sunday February 24, 1957 was a pivotal day in the history of anesthesiology and pain medicine. The leader of the Roman Catholic Church, Pope Pius XII met with anesthesiologists attending an international symposium sponsored by the Italian Society of Anesthesiologists entitled, "Anesthesia and the Human Personality". The purpose of this audience was to seek clarification about the use of opioids at the end of life to reduce suffering. Three questions had been formulated from the previous year's Italian Congress of Anesthesiologists and sent to the Holy See on this specific issue. The Pope responded during this audience remarking that there was no moral obligation to withhold pain medication that could elevate suffering. He further remarked that the suppression of consciousness that can occur with opioids was consistent with the spirit of the Christian gospels. Finally, he also stated that it was not morally objectionable to administer opioids even if it might shorten life. The moral philosophy behind these answers is the doctrine of double effect. In essence, administering medications to relieve pain, the primary effect, may also hasten death, the unintended secondary effect. In seeking answers to these questions, the Italian anesthesiologists were at the forefront of a larger and ongoing debate. As new therapies are developed that may have unintended consequences, when it is morally permissible to use them?

Ethical and IACUC Considerations Regarding Analgesia and Pain Management in Laboratory Rodents.

Scientists have ethical and regulatory commitments to minimize pain and distress during their use of sentient laboratory animals. Here I discuss pain as a special form of distress and the long history of ethical and regulatory standards calling on scientists to prevent, minimize, treat or terminate animal pain. Scientists, veterinarians, and IACUC face 2 challenges: knowledge of effective analgesic doses and regimens for all sexes, ages and genotypes of rodent is incomplete, and concerns regarding the effects of analgesic drugs on research outcomes push scientists to request approval to withhold analgesics and leave animal pain unalleviated. IACUC thus conduct what I call an 'ethics of uncertainty,' in which they factor in the limits of available ethically relevant information on the amount of expected animal suffering, the usefulness of analgesics to mitigate this suffering, and the eventual benefits that come from the research. IACUC must factor in current limitations in severity assessments of various experimental manipulations in various strains, inaccurate pain diagnosis, in known effective analgesic and other refinements, and on effects of pain medications and untreated pain on data outcomes, when deciding to allow potentially painful experiments and animal care practices. This article focuses on 3 areas of concern: the limits of veterinary "professional judgment" when the animal model's degree of pain and the efficacy of pain medications are not yet known; the review of proposals with known, unalleviated significant pain and distress (that is, Category E experiments); and the attempt to review the balance between animal welfare harms and scientific objectives. I propose no new regulations, standards, or ethical norms herein but rather explore some of the implications when existing ethical principles are applied to evolving scientific knowledge (and vice versa). I conclude that applying current animal pain management knowledge to prevailing ethical principles will shift IACUC toward greater caution in allowing potentially painful animal experiments, with heightened caution regarding the ability of analgesics to mitigate the animals' pain.

Top 10 cuestiones bioéticas en dolor / Top 10 bioethical issues in pain

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Ethical considerations in the management of analgesia in terminally ill pediatric patients.

Research has demonstrated the significant symptom burden present at the end of life of terminally ill children. Medicine has always viewed the relief of pain and suffering as a fundamental human right and a moral and ethical obligation. At the end of life, pain and dyspnea are symptoms commonly experienced by both adults and children. Opioids are the mainstay in treating the suffering associated with pain and dyspnea; however, there exist several barriers to the use of opioids. We describe a case in which parents prevent a young patient from receiving adequate pain management during the course of a terminal illness. We discuss the importance of recognizing the barriers to opioid use and the ethical ramifications of failing to find common ground with the family. We highlight parental responsibilities and limitations of parental authority in decision making for their child.

Airtraq como dispositivo de primera elección para un lactante con vía aérea difícil conocida / AIRTRAQ as the device of choice for infants with known difficult airway

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Ethics of treating postoperative pain.

You received a call advising that Mr S. H. Irk was in the emergency room having considerable wound pain following an above-knee amputation you performed 6 months ago. You discharged him from your clinic 6 weeks postoperatively to his primary care physician, still complaining of more pain than usual. Your examination, clinical lab tests, and X-rays do not reveal any serious problems, but he is writhing in pain and begging for relief. Mr Irk has been to a number of different physicians in the interlude including a chiropractor, a pain specialist, several primary care physicians, and a psychiatrist without relief. He has braced up with increasing amounts of analgesics, the latest of which was oral Dilaudid. His last source of pain meds on the street has dried up. You admit him with orders for analgesics. What should your treatment plan be?

A physician-driven solution--the Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain medicine.

The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.

Four themes in recent Swedish bioethics debates.

A wide variety of bioethical themes have recently been debated and researched in Sweden, including genetic screening, HPV vaccination strategies, end-of-life care, injustices and priority setting in healthcare, dual-use research, and the never-ending story of scientific fraud. Also, there are some new events related to Swedish biobanking that might be of general interest. Here we will concentrate on four themes: end-of-life care, dual-use research, scientific fraud, and biobanking.

A perfect storm in interventional pain management: regulated, but unbalanced.

Interventional pain management now stands at the crossroads at what is described as "the perfect storm." The confluence of several factors has led to devastating results for interventional pain management. This article seeks to provide a perspective to various issues producing conditions conducive to creating a "perfect storm" such as use and abuse of interventional pain management techniques, and in the same context, use and abuse of various non-interventional techniques. The rapid increase in opioid drug prescribing, costs to health care, large increases in death rates, and random and rampant drug testing, can also lead to increases in health care utilization. Other important aspects that are seldom discussed include medico-legal and ethical perspectives of individual and professional societal opinions and the interpretation of diagnostic accuracy of controlled diagnostic blocks. The aim of this article is to discuss the impact of several factors on interventional pain management and overuse, abuse, waste, and fraud; inappropriate application without evidence-based literature support (sometimes leading to selective use or non-use of randomized or observational studies for proving biased viewpoints - post priori rather than a priori), and issues related to multiple professional societies having their own agendas to push rather than promulgating the science of interventional pain management. This perspective is based on a review of articles published in this issue of Pain Physician, information in the public domain, and other relevant articles. Based on the results of this review, various issues of relevance to modern interventional pain management are discussed and the viewpoints of several experts debated. In conclusion, supporters of interventional pain management disagree on multiple aspects for various reasons while detractors claim that interventional pain management should not exist as a speciality. Issues to be addressed include appropriate use of evidence-based medicine (EBM), overuse, overutilization, and abuse.

Undertreating pain violates ethical principles.

Disabling pain or symptoms can occur at any age from many different causes. Pain and palliative specialists are able to relieve most pain and symptoms, although repeated adjustments to modalities, medications and doses may be needed. Because pain and palliative specialists comprise only a small percentage of physicians, many patients find it difficult to access them or obtain pain relief. Globally, there are too few such specialists to meet existing needs. Most are affiliated with hospice and palliative units, so their accessibility to patients without terminal conditions is negligible. Doctors outside pain and palliative specialties are often unfamiliar with pain guidelines and sceptical about patient reports of unrelieved pain. They are therefore likely to undertreat it. Undertreating pain, however, violates respect for persons and beneficence. This paper reviews literature supporting these claims and offers a narrative description of the author's attempts to find relief from shingles and postherpetic neuralgia. It argues that physicians in most specialties are not, but should be, familiar with palliative evidence and guidelines so that they are equipped to relieve pain and symptoms quickly and effectively. Such information should be routinely introduced in medical curricula to encourage the mastery of knowledge, attitudes and skills necessary to upholding ethical principles and to ensure that more doctors in any discipline are willing to believe and be compassionate to patients whose pain is unresponsive to initial treatments. Routinely exposing students to such information would better prepare them to fulfil their professional duties to patients and society.