Optimizing post-operative pain management in Latin America

Abstract

Post-operative pain management is a significant problem in clinical practice in Latin America. Insufficient or inappropriate pain management is in large part due to insufficient knowledge, attitudes and education, and poor communications at various levels. In addition, the lack of awareness of the availability and importance of clear policies and guidelines for recording pain intensity, the use of specific analgesics and the proper approach to patient education have led to the consistent under-treatment of pain management in the region. However, these problems are not insurmountable and can be addressed at both the provider and patient level. Robust policies and guidelines can help insure continuity of care and reduce unnecessary variations in practice. The objective of this paper is to call attention to the problems associated with Acute Post-Operative Pain (APOP) and to suggest recommendations for their solutions in Latin America. A group of experts on anesthesiology, surgery and pain developed recommendations that will lead to more efficient and effective pain management. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more efficient and effective system for the delivery of APOP services as recommended by the authors of this paper. The writing group believes that implementation of these recommendations should significantly enhance efficient and effective post-operative pain management in Latin America.

KEYWORDS
Acute post-operative pain; Pain management; Latin America; Chronic pain

Resumo

O controle da dor no período pós-operatório é um problema significativo na prática clínica na América Latina. O controle insuficiente ou inadequado da dor é devido, em grande parte, à insuficiência de conhecimento, atitudes e formação e à comunicação precária em vários níveis. Além disso, a falta de conscientização da disponibilidade e importância de políticas e diretrizes inequívocas para avaliar a intensidade da dor, o uso de analgésicos específicos e a abordagem adequada para instruir o paciente levaram ao subtratamento consistente da dor na região. Contudo, esses problemas não são insuperáveis e podem ser abordados no âmbito tanto do provedor quanto do paciente. Políticas e diretrizes substanciais podem ajudar a garantir a continuidade dos cuidados e reduzir as variações desnecessárias na prática. O objetivo deste artigo é chamar a atenção para os problemas associados à dor aguda no pós-operatório (DAPO) e sugerir recomendações para solucioná-los na América Latina. Um grupo de especialistas em anestesiologia, cirurgia e dor desenvolveu recomendações que levarão a um controle mais eficiente e eficaz da dor. Será preciso mudar o conhecimento e o comportamento dos profissionais de saúde e pacientes e obter um compromisso por parte de legisladores. O sucesso dependerá de uma atitude positiva e do compromisso de cada parte através do desenvolvimento de políticas e programas e da promoção de um sistema mais eficiente e eficaz para a prestação de serviços para a DAPO, como recomendado pelos autores deste trabalho. O grupo que as redigiu acredita que a aplicação dessas recomendações deve melhorar de modo significativo a eficiência e eficácia do controle da dor no período pós-operatório na América Latina.

PALAVRAS CHAVE
Dor aguda no pós-operatório; Controle da dor; América Latina; Dor crônica

Introduction

Post-operative pain affects millions of patients world-wide. Pain itself is a highly subjective experience with multiple dimensions. Basically, it is whatever the experiencing person says it is, existing whenever they say it does.^1,2 Despite this simple and straightforward definition there continues to be barriers to effective pain management. Moreover, it is well-known that poor post-operative pain management not only delays recovery and results in excess morbidity and mortality, but can lead to the development of a chronic pain state which further increases morbidity.³

Many health professionals unfortunately believe that pain is a natural, inevitable, acceptable and harmless consequence of surgery. Common reasons cited for poor pain management include inadequate staff training and knowledge, poor pain assessment, unfamiliarity with the benefits and adverse effects of pain medications and a misguided belief that since post-surgical pain is often temporary and all humans experience pain in life, everyone must "grin and bear it". Insufficient or inappropriate post-operative pain management is, therefore, a significant problem in clinical practice, but the problem is not at all insurmountable and can be rectified at both the provider and patient level.⁴

Methods

To aid policymakers and regulatory authorities in better understanding the challenges of effective Acute Post-Operative Pain (APOP) management, specifically in Latin America, the Americas Health Foundation convened a group of Latin American experts on anesthesiology, surgery and pain to develop recommendations that will lead to more efficient and effective pain management.

A comprehensive literature search was performed querying Pub Med, Embase and Scielo for articles related to post-operative pain management in general and post-operative pain management in Latin America. The objective of this paper is to call attention to the problems associated with APOP and to suggest recommendations for their resolution. The authors structured this paper as a response to a series of questions related to the topic. The entire research and writing process was completely independent of any input from the financial sponsor of the effort.

Results

What is the current state of Acute Post-Operative Pain (APOP) management in Latin America and what aspects should receive priority attention?

Pain throughout history has been considered a problem by all its implications. Although in ancient times it was considered an inevitable part of life, today, with the advent of many therapeutic analgesics, APOP should be adequately alleviated. However, this is not the case in Latin America.⁵ Despite recent advances in our understanding of the pathophysiology of pain and more widespread use of minimally invasive surgical techniques, pain after surgical procedures remains a challenge for most physicians.

Pain is very personal and multifactorial. It evokes unpleasant sensations and emotions and is influenced by multiple factors such as: cultural beliefs and values, previous experiences of pain, mood and the coping ability of each individual.⁶ Uncontrolled APOP can produce serious adverse consequences such as increased morbidity and mortality, prolonged hospital stay, a delay in healing and recovery, patient dissatisfaction, anxiety, and a reduced likelihood of an early return to the activities of daily life.^7,8 In addition, it is the main risk factor for chronic pain when intense post-operative pain has not been addressed appropriately.^9-11 Another serious problem of uncontrolled APOP is the increased use of health resources and hospital costs.^11,12

Although APOP is known to be a common occurrence following surgery, because of the limited number of published studies, the true extent of the problem in Latin America is unclear. It is likely; however, that in recent decades there has been no discernable change in the prevalence of post-operative pain. Moderate to severe pain is present in the vast majority of post-operative patients.¹³ Pain is also a common cause of post-surgical hospital readmission.^11,12

There has been no epidemiological study on the problem of APOP for all of Latin America (LA). Recently, a small survey was performed at a teaching hospital in Brazil and post-operative pain was present in 48% of the surgical patients.¹⁴ Likewise, a cross-sectional study done in Colombia showed that pain was present 4 h after surgery in 51% of the cases. Overall, 30% of post-surgical patients stated that they experienced severe pain.¹⁵ Three other studies in Colombia showed a prevalence of APOP between 22% and 69%.^16-18 In Chile, a study showed that up to 59% of patients had at least moderate pain after surgery.¹⁹ A study in Mexico found that in 97% of respondents experiencing acute pain after surgery, most reported moderate to severe pain; 60% reported that the pain interfered with their work activities; 55% reported the pain affected their mood, and 57% reported that it interfered with sleep.²⁰ All these studies, albeit conducted in specific locales, suggest that the prevalence APOP is high throughout Latin America. Of note, these outcomes were similar to one found in a national survey done in the United States that concluded that moderate to severe post-operative pain affected 40-60% of patients.²¹

Many factors are responsible for influencing the high prevalence of APOP in Latin America. These include inadequate education of health professionals and patients on many aspects of pain management.^22,23 Also, the absence of policies that make it difficult for some medications to be incorporated into a formulary, or be readily available, and the cost of technology used to provide pain treatment is sometimes problematic.²⁴ Studies have also shown that nurses and doctors tend to overestimate the potential of opioid addiction (or their side effects such as respiratory depression) so they prescribe lower doses and longer intervals between doses, thereby resulting in sub-optimal control of APOP.^17,25

There are no national health policies or guidelines for the management of APOP in Latin America. Nonexistent or not followed local treatment guidelines, along with the absence of indicators of effective pain management are common. The latter has resulted in the absence of the ability to evaluate pain management programs and outcomes.^11,16,26 All these factors contribute to the relative lack of acute pain management services in health care settings in the Region.

Even within a country, there are major variations in pain management services. Access to health resources is clearly different between large cities and small towns. Economic resources are concentrated in major cities that also house the majority of the population. Generally, only large cities have health institutions with the ability to provide "state of the art" APOP. Pain management services are frequently very different in public versus private hospitals; pain services in the former are frequently less available and/or less comprehensive.

Specific recommendations

1. Each country in the Region should constitute a government sponsored Task Force to design and implement nationwide epidemiologic research on the prevalence of post-operative pain and the extent of unsatisfactory pain management.

2. The government of each country should establish an office or department of pain management so as to create visibility and legitimacy for the subject, establish clear and realistic goals for the country and have a dedicated budget to fund nation-wide activities.

3. Every hospital in the Region should conduct periodic surveys on the state of pain management in their institution.

How can health professional awareness, knowledge and attitudes be improved so that post-operative pain management is a medical priority?

Although it is understood that post-operative pain control is essential to attain high-quality patient care, failure to understand and appreciate the adverse consequences of pain and its sequelae, has led healthcare providers to lower effective analgesia to a secondary consideration.²⁷ Even professionals with some knowledge of pain evaluation and management, often have unfounded concerns about the side effects of analgesics or fears of addiction, and consequently do not make full use of pain medication.^24,28,29 Also, during the post-operative period, if the health care team is not attuned to actively accessing the level of pain experienced by the patient, then appropriate treatment might be delayed.

The cornerstone to resolve these problems throughout Latin America is education.³⁰ To start, an examination of the curriculum in major Latin American medical schools reveals that the study of pain and its management is deficient. In a survey done by the International Association for the Study of Pain (IASP), 86% of all health professional respondents in Latin America believed that undergraduate education and training in pain management is inadequate.³¹ Medical students are usually exposed to this knowledge in a fragmented and unfocused manner, which leads students to understand pain merely as a symptom that should be approached as an inevitable and uncontrollable consequence of the surgical procedure.²⁴ Even in countries that do offer specific and directed education on pain management, these are offered as optional classes (e.g. Chile),³² or as extra-curricular activities (e.g. Pain Leagues supported by the Brazilian Society for the Study of Pain).³³ In Latin America, a more structured view of pain management is taught in some residency programs albeit usually in an incomplete fashion.

Another approach to bringing greater awareness of the need and value of pain management is the concept of addressing pain as a "5th vital sign," which was initially promoted by the American Pain Society in order to bring attention to pain treatment among healthcare professionals.³⁴ The notion that pain should be addressed with the same degree of vigilance and treatment as blood pressure, heart rate, temperature and respiratory rate, has been the subject of a few studies, albeit with disappointing results. One study showed that pain as the 5th vital sign achieved low accuracy when performed by nurses on a daily basis.³⁵ A second study showed that regardless of the pain scores documented, no benefit of pain control was achieved. Of the patients that had their pain documented in the medical record, 32% still experienced significant pain, and half of those patients did not receive a new prescription for pain alleviation.³⁶ It is clear that it is not enough to simply ask patients about their pain and then record the finding in a chart. It is imperative that the next step be taken which is effective pain management. Recently, this approach has been emphasized. That is, caregivers should refocus their efforts on pain control rather than consider documentation the only outcome of interest.³⁷

It should go without mention that the implementation of protocols at the time of pre-surgical evaluation are important, including documentation of the history of pain, the presence of predictors of pain, and analgesic requirements. A pain management strategy should be developed for all patients undergoing surgery. Factors that can influence this strategy are the type of surgery, intensity of the expected post-operative pain, associated clinical conditions, the risk-benefit of available analgesic techniques, patient preferences and their previous experiences with pain or analgesics. A plan of treatment should be established according to guidelines and protocols.^26,38,39 Multidisciplinary teamwork is essential for such protocols and guidelines to be successful and although this approach has been advocated for decades, it is still uncommon today in Latin America.²⁵ Ideally, this strategy should be part of the institution's patient care plan.

A comprehensive pain management strategy should include the following steps: (1) pre-anesthetic evaluation to identify factors for the inclusion or exclusion of a given technique or pharmaceutical; (2) selection of the analgesia; (3) patient informed consent; (4) patient education to avoid anxiety and unrealistic expectations regarding post-operative pain; (5) consultation with the anesthesiologist to adapt the analgesia technique to the intra-operative period; (6) post-operative follow-up, and (7) periodic evaluation of the success of pain management and the possibility of modifications based on the patient's response.^39-41

Anesthesiologists and other professionals involved in treating post-operative pain should use readily available evaluation and documentation instruments focusing on the pain at rest and upon movement, treatment results and side effects potentially caused by pain treatment. The Numeric Pain Scale (0 no pain and 10 the most intense pain possible) is easy to understand and apply, although it may not accurately reflect the complexity of the symptom.⁴² Simpler scales can also be used, such as those using human faces. For patients with cognitive impairments, such as dementia or learning disabilities, behavioral measures and physiological responses to pain can be utilized.⁴³

There is substantial evidence indicating that the introduction of an Acute Pain Service (APS), which includes the development of treatment guidelines, leads to the improved treatment of pain. The concept of a formal APS was first suggested by Ready in 1988 as an anesthesiology-based post-operative pain management service.⁴⁴ The APS assumes responsibility for the management of post-operative pain, health professional training, the development of guidelines and processes for the documentation of pain, patient education and information materials, and performance criteria for evaluation, as well as the conduct of audits.⁴⁵ APS are designed to provide optimal pain management for every surgical patient, including children and outpatients, as well as the regular review of the institution's pain management policies and practices.

The APS is led by anesthesiologists, with expertise in the pre-operative, intra-operative and post-operative phases of pain management. Anesthesiologists, who are considered perioperative specialists, are also optimally positioned throughout the hospitalization period to serve as liaisons with consulting medical and surgical services. For an APS to operate effectively and achieve its full potential, active collaboration is necessary between the departments of anesthesiology, surgery, medicine, acute pain management teams and the post-surgical nursing staff.⁴⁶

Since 1995, the American Society of Anesthesiologists (ASA)⁴⁷ has periodically convened a group of experts that develop and update practice guidelines related to pain management. These guidelines can serve as the basis of APOP management in Latin America. Other initiatives that may be useful have been conducted by the PROSPECT Working Group^48-52 and the Australian and New Zealand College of Anaesthetists,⁶ among others. The ASA guidelines and other initiatives do not include medical literature written in Spanish or Portuguese, and may not include medications (e.g. dipyrone or metamizol) that have been used safely for many years in Latin America and are a fundamental part of the Regional armamentarium for the management of acute pain. Thus, derivative documents relevant to Latin America may have to be written, in part, to reflect the characteristics of the Region.

Specific Recommendations

1. Comprehensive pain management education should be included in the curricula of all medical and nursing schools and in the examination of undergraduate and postgraduate health care professionals. Pain management should also be routinely incorporated into continuing educational programs.²⁴

2. All hospitals and clinics in the Region that perform in and out patient surgery must have an APS.

3. All hospitals and clinics should develop and implement procedure-specific, evidenced-based pain management guidelines and protocols for the perioperative period.⁴⁶

How can patient knowledge be improved so that post-operative pain is minimized?

Patients may have a poor understanding of their medical condition and may expect to have post-surgical pain, which they think has to be endured as an inevitable part of their surgery.²⁴ Therefore, patient and family education efforts must include conveying the advantages of using analgesia, an attempt to mitigate the fear of taking analgesics, and cost considerations. Patients should be informed about all existing therapeutic possibilities to treat surgical pain, as well as potential risks of the methods used. It is important to emphasize that aggressive pain treatment is key because the consequences of poorly managed acute pain are often greater than the risk of adverse side effects from pain medication itself. Patients should be encouraged to report pain using an appropriate instrument.⁵³ Patients and their families should be allowed to actively participate in all pain management decisions, which will likely result in better pain management and improved patient satisfaction.^16,22,38 The information must be clear and given verbally and written and it is necessary to respect different cultures, ethnicities as well as the values and beliefs of each patient.²⁵

Patient education materials range from a simple booklet or manual to educational videos.⁵⁴ A patient's expectations should be considered. If audiovisual and written materials are created in Spanish and Portuguese they can be shared across countries and thereby become efficient tools to facilitate the education process, and also facilitate Regional standardization of pain management.

One of the fundamental bases for all pain control initiatives throughout the world has been the Declaration of Montreal (DM).⁵⁵ This document resulted from a combined effort of a wide range of health professionals, human rights organizations and others. It resulted from initial input by IASP Chapters in 130 countries, following an in-depth process culminating in an International Pain Summit, which also harnessed a wide range of input. The DM supports the right of all people to have access to pain management without discrimination, the right of people in pain to acknowledge their pain and to be informed about how it can be assessed and managed, and the right of all people with pain to have access to appropriate assessment and treatment by adequately trained health professionals. Failure to offer such pain management is a breach of the patient's human rights.⁵⁵

Once health caregivers embrace the idea that all patients have a right to be treated for pain, a secondary benefit is that these professionals will have a better overall appreciation of pain management. And then, through medical education, health professionals will be able to acquire the necessary knowledge to provide appropriate treatment.

Specific Recommendations

1. All hospitals should develop policies and procedures whereby all patients undergoing surgery will be assured of learning about pain management in the entire perioperative period.

2. All hospitals should distribute written materials to patients prior to surgery that address the value of pain management and other relevant issues. The topic must also be discussed verbally with the patient by a member of the APS.

What is the role of government and NGOs to support the improvement of the delivery of effective pain management?

A few years ago, the Economic Commission for Latin America and the Caribbean (ECLAC) found many deficiencies in the provision of health care services, including: lack of equity and efficiency of health systems, limited access to services, poor quality and inefficiency of services, insufficient management capacity, and deficiencies in monitoring and control processes.⁵⁶ Some of these deficiencies could contribute to the poor management of APOP in Latin America. Moreover, constrained national healthcare budgets limit the allocation of human, technological and institutional infrastructure resources to essential health services. The lack of policies prioritizing pain control within national health plans hinders the implementation of comprehensive nation-wide pain control programs.²⁴

One of the major issues related to the incomplete provision of optimal APOP management is the manner by which countries make available opioids for the treatment of pain. Despite their recognized effectiveness, oftentimes, opioids are not freely available due to the sometimes high cost of opioid therapy and restrictive laws based on fear of misuse and abuse. For instance, in 2011 the United States alone accounted for 55% of global opioid consumption and the combination of North America and Europe accounted for 89%. In contrast, Latin America accounted for around 1% of the world's opioid consumption, indicating inadequate availability of opioid analgesics in the Region.^57-60 This makes the implementation of effective treatment guidelines difficult in countries without easily accessible opioids.⁶¹

In order to reduce the gap in developing, or resource limited, countries between the increasingly sophisticated knowledge of pain and its treatment and the effective application of that knowledge, many initiatives have begun. In 2000, the WHO published a guideline manual entitled "Achieving Balance in National Opioids Control Policy".⁶² The IASP formed the Developing Countries Task Force in 2007 that later developed the "Guide to Pain Management in Low-Resource Settings" in 2009.⁵ In addition, IASP has formed a special interest group on acute pain. The DM⁶³ reviews the responsibility of governments and health care providers. Finally, the ASA developed "Practice Guidelines for Acute Pain Management in the Perioperative Setting."⁴⁷ In all these documents, governments, within the legal limits of their authority and taking into account available health care resources, have been asked to establish laws, policies, and systems that will help promote the access of people in pain to fully adequate pain management.³¹ For all these actions to be fully realized, government authorities must be educated on the consequences of the lack of APOP management, which ultimately translates into more extended hospital stays, higher health care costs and greater morbidity and mortality.

Latin American chapters of the IASP can also promote pain education with seminars, workshops, and conferences in their respective countries.⁷ The IASP supports the view that every nation should have policies on the management of pain that describe the burden of pain, its impact, and what should be done in terms of policy interventions to reduce these problems. The IASP has also developed recommendations for the core elements of any national pain strategy.⁶⁴ Recommendations by the IASP include obtaining evidence on countries’ burden of pain through health surveys targeted toward pain, pain management and its adverse consequences. The data collected can serve as a useful baseline from which to measure the impact of any interventions introduced and to inform new national pain management strategies.⁶⁵ The IASP also recommends gathering information on access to care, forming a broad coalition of stakeholders, and developing government policies on pain services that establish goals for improvement and a clear plan with timelines to achieve strategic actions. Although the IASP paper is oriented to chronic pain, it can be modified to address the treatment of APOP. The desirable characteristics of a national APOP strategy are shown in Table 1, that the authors adapted from IASP recommendations related to pain management.⁶⁴

Table 1
The desirable characteristics of a national postoperative pain strategy (modified from Table on National Pain Strategies developed by IASP, 2011).

Characteristics	Examples	Responsible parties
Pain education
Undergraduate	At an early stage in training to equip health professional trainees with both the knowledge and skills to address APOP.	Centers of learning, regulatory bodies
Postgraduate	Clinicians involved in pain management should receive ongoing education in the relief of APOP. More clinicians should be trained as pain specialists.	Centers of learning, regulatory bodies
Patient and family education	To understand pain and its management, patients and families should be educated on all aspects of APOP management.	Providers of health care, pain management specialists, patient organizations, and health educators
Patient access and care coordination
Care in differing settings	All hospitals should have APS. All patients should be evaluated for pain, and if present, should be treated appropriately or referred to a pain management specialist.	Health care policy makers, health professionals and commissioners of health care
Medicines	The World Health Organization's list of essential medicines should be available and accessible in preparations suitable for all ages. Support from the pharmaceutical industry will be needed to achieve this goal.	Government regulatory agencies, drug enforcement agencies, and key clinical staff
Informed choice	Coordination of the system so that access to the right help is available as early as possible with a fully informed choice on options.	APS Team
Care pathways	Established guidelines and policies related to APOP.	APS Team and commissioners of health care.
Interdisciplinary approach	A multidisciplinary team of health care professionals working closely within a non-hierarchical framework.	Providers of health care
Family and caregiver involvement	Families and caregivers should be actively included in the management of APOP.	APS Team and patient advocacy groups
Special populations	Special populations include the very young and very old, those with learning difficulties, those with mental health and addiction disorders, ethnic minorities, and impaired persons. Their needs should be recognized and provided for.	Health professionals and commissioners of health care
Monitoring-quality improvement
Time to care	Reductions in waiting time for pain relief.	APS Team and analgesic providers
Quality of service	Improvements in patient satisfaction.	APS Team
Economic burden	Reduced length of hospitalization and pain-related readmissions through effective APOP management.	APS Team
Outcomes	Outcomes from effective APOP management routinely measured.	APS Team
Pain research
Epidemiologic	A national health survey to determine the status and needs for APOP management within each country in the Region.	Public health services, health economists
Science	Prioritization of APOP management for funding opportunities that target gaps in treatment, implementation of science, knowledge transfer, education, and policy development.	Government research funding bodies and universities

Given the special characteristics of the Latin American Region, government strategies must be accessible to the entire population. Accessible health services are those that are physically available, affordable (economic accessibility), appropriate and acceptable. Health services can be inaccessible if providers do not acknowledge and respect cultural factors, physical and economic barriers, or if the community is not aware of available services.⁶⁶ Cross-cultural miscommunication between patients and health professionals may exist and should be documented to develop the necessary range of strategies to overcome these issues.

Specific Recommendations

1. All countries in the region should develop a national, post-operative pain strategy.

2. Hospitals and clinics that perform surgery should develop and make accessible relevant materials, become aware of new developments in the field of pain management, and have a source of expert advice and guidance in APOP.

3. All governments should re-examine their laws, policies and regulations related to the availability of opioids. These therapeutics must be readily accessible to health professionals for pain management.

Can pain management be standardized throughout the Region? If so, what might be the initial steps?

Although the problems of the Region are sometimes addressed as if Latin America were a single country, a major characteristic of this part of the world is the heterogeneity of the countries. Latin America is composed of many countries whose cultural, economic and political features differ greatly from one another and, perhaps more importantly, do not share a common health system and have highly variable or non-existent APOP policies. The emphasis of health care in the Region has mainly focused on public health, particularly malnutrition, control of infectious diseases, childhood immunization and the provision of clean water. Thus, pain management - whether acute or chronic - has been given a low priority.⁷

All that said, any Regional effort must take into account the differences between countries. A better understanding of the obstacles within each country and how pain management has been taught throughout Latin America may be a path to building Region-wide consensus. In addition, an effort to develop guidelines and policies on APOP management within a country may be the gateway toward Regional standardization. Finally, patient education principles and policies could perhaps be standardized across the Region and the desired outcomes (indicators) of successful APOP management may also be easily standardized.

Specific Recommendations

1. An organization with an interest in pain management should constitute a region wide task force that begins work to standardize all aspects of APOP management in the Region. Funding for the work of the task force can come from a modest contribution from governments and/or the pharmaceutical industry. If the latter, there should be no work of the task force related to the use of any specific, branded therapeutic agent.

Conclusion

Effective post-operative pain management in Latin America requires a proactive approach. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more efficient and effective system for the delivery of APOP services. Proper pain management is a fundamental human right, not just an indicator of good clinical practice and quality health care.⁶⁷

• ERRATUM

  In the article "Optimizing post-operative pain management in Latin America" [Rev Bras Anestesiol. 2017;67(4):395-403], where it reads Durval Campos Kraychette, it should read Durval Campos Kraychete. The online version of the article has already been corrected.

Acknowledgements

The authors wish to thank the Americas Health Foundation (Washington, D.C., United States) for its generous support in developing the conference.

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Publication Dates

• Publication in this collection
  Jul-Aug 2017

History

• Received
  14 Feb 2016
• Accepted
  26 Apr 2016