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The Mederi latino dating of this publication has been focused on local considerations for facilitating regional best practice, including identifying and uniformly adopting the most relevant international guidelines on opioid use OU in chronic pain management. Once the publications were identified, they were selected using five key criteria: The initial PubMed search identified reviews and guidelines, which was reduced to 16 articles using the five preliminary criteria.

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After a secondary analysis according to the 10 key criteria specific to OU in Latin America, 10 publications were selected for critical review and discussion.

However, differences in survey methodology and variability in the data make difficult to estimate with certainty the prevalence in countries with a HDI below 0. Therefore, there is a clear need for epidemiological studies, especially in Latin America, where the available data is scarce and variable among countries [ 3 ].

Chronic pain is an important public health issue. Appropriate treatment includes access to pain medications, including opioids and other essential Mederi latino dating for pain control. However, in most of the world, there is Mederi latino dating inadequate pain management due to various reasons Mederi latino dating, but not limited to, severe restrictions on the availability of opioids and other essential medications considered critical for pain management [ Mederi latino dating ].

Since the United Nations Single Convention on Narcotic Drugs of [ 6 ], further revisions have been made with the aim of ensuring the availability of controlled medications for the relief of pain, while preventing recreational use and abuse [ 7 ].

In spite of these statements, the availability Mederi latino dating opioid analgesics for the legitimate treatment of pain is still too low in many countries. Facing this skewed distribution, issues limiting the use and availability of opioids in Latin America have been Mederi latino dating Declaration of Florianopolis in [ 9 ], Santo Domingo report in [ 10 ], several reports from the United Nations International Narcotics Control Board [ 11 ], Panama Proclamation in [ 12 ], and so forth.

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However, significant challenges still need to be overcome, including opioid availability and prescribing barriers. Many governments identify Mederi latino dating and knowledge-related impediments namely addiction concerns and insufficient training among health care professionals HCP and patients as the main factors contributing to the underuse of opioids [ 13 ]. In Latin America, these impediments, together with regulatory barriers, are a Mederi latino dating issue in restricting opioid availability and use, Mederi latino dating result in the suboptimal management of chronic pain.

As this is the subject of this publication, particular emphasis will be placed on local considerations Mederi latino dating facilitating regional best practice, including identifying and uniformly adopting the most relevant international guidelines on opioid use OU in chronic pain management.

The CPLA initiative was launched in response to a similar campaign in Europe and aims to better understand the epidemiology of chronic pain in Latin America, identify and overcome barriers to regional best practice, and address the unmet needs of patients in the region. The ongoing CPLA initiatives aim to address the primary obstacles to the best practice in chronic pain management across Latin America.

Among the CPLA initiatives, the expert panel has extensively reviewed regulatory barriers in every country that restrict adequate access, distribution and prescription of opioids in the region. The results highlight the limited knowledge on OU among patients and HCP opio-ignorance Mederi latino dating 14 ], resulting in misconceptions about treatment of chronic nonmalignant pain, mainly related Mederi latino dating a fear of prescribing opioids due to their possible misuse and addiction opiophobiaand a false perception of their lack of efficacy.

Furthermore, there is not enough effective communication between HCP and institutions in relation to the benefits of OU in chronic non-cancer pain was noticed. All Mederi latino dating considered, the CPLA strongly recommends a formal education of HCPs in Latin America focused on the appropriate OU and side-effect management, with the aim of overcoming negative attitudes toward the opioids and improve the insufficient knowledge regarding its risks and benefits in chronic pain management.

Among the regulatory barriers to OU in Latin America, the Mederi latino dating reported that laws Mederi latino dating the storage Mederi latino dating distribution of opioids are far more stringent than those laid down by international laws and the International Narcotics Control Board [ 11 ].

Moreover, local OU legislation in most countries is out of date and not reflective of current health care needs; for example, the last review of the legislation in Colombia was in Poor HCP education combined with a relative sparsity of epidemiological studies may have contributed to an out-of-date health care policy, and continued restrictions on OU. In some countries, HCP are required to obtain a licence to prescribe opioids and to maintain records of the patient's use.

This complex Mederi latino dating time-consuming process can deter HCP from prescribing opioids. The consequent need for patients to constantly obtain new prescriptions can also result in poor compliance.

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The survey also highlighted the limited information on types and availability of opioid analgesics Mederi latino dating to HCPs by the regulatory authorities. To obtain or produce controlled medicines, all Latin America countries are required to provide their estimated narcotic needs for Mederi latino dating following year to the International Narcotic Control Board.

Based on these estimates, the opioids storage is restocked, sometimes too conservatively and, thus, the stock is insufficient to cover the current needs, leading to drug shortage for the adequate care of patients and creating obstacles in the access to controlled medicines. A further factor limiting opioid access is their cost, which varies markedly among geographic regions.

Opioid Mederi latino dating is typically disproportionately higher in poorer countries, especially in Latin America, as compared with developed countries like the United States [ 1516 ]. As regional health authorities have budgetary limitations, the high cost of opioids may explain why palliative care has been largely ignored in Latin America.

Pharmacists in Latin America also play an important role. On one side, they do not generally stock opioid analgesics, predominantly due to the cost and the restrictive legislation regulating their controlled storage and distribution.

On the other side, they are not very willing to distribute opioids, mainly due to concerns related to their possible misuse by the patients. The rise of online pharmacy may also have contributed to inappropriate opioid self-prescribing. A study published in identified more Mederi latino dating Websites supplying opioid analgesics without prescription [ Mederi latino dating ].

With an increase in prescribed opioids in the United States, Internet offers another vector into a market of unregulated OU. However, a decrease Mederi latino dating availability of opioids via online pharmacies in the United States has been recently reported, probably related to an increased regulation of internet pharmacies [ 18 ]. Opiophobia stems from inadequate HCP education and a lack of clear uniform guidance.

Misuse, abuse, unnecessary toxicities and deleterious outcomes can be attributed to inappropriate opioid management and prescribing. With appropriate education, and awareness and adherence to uniform guidelines, opioids Mederi latino dating safe to use and represent effective treatment options for the management of chronic pain, including chronic lower back pain CLBP. Thus, it is imperative that HCP and patients are better educated about the benefits and risks of opioid treatment [ 19 ].

Furthermore, HCPs should be provided with tools to promote confidence in opioids Mederi latino dating, including patient risk assessment tools; patient agreement; improvements in patient screening e. Once detected the need for improving education on OU, the CPLA Expert Panel has conducted a review of the international guidelines, considering that Uniform OU Guides would help to provide a clear guidance on appropriately prescribing, Mederi latino dating, and monitoring opioids for treating patients with chronic pain.

Mederi latino dating task was led by Dr. Durval Kraychete, who conducted a comprehensive, robust, and critical analysis of published national and international reviews and guidelines of OU, considering those most appropriate for Latin America. Once the publications were identified, they were selected by the expert panel using Mederi latino dating following five key criteria:.

The shortlisted guidelines were then critically analyzed by the CPLA expert panel, which considered 10 Mederi latino dating criteria for determining the most relevant guidelines to be applied in Latin America:. The strengths and limitations of the chosen OU guidelines were noted by the panel, so that they could be addressed in future guideline updates, to further improve OU management and outcomes in the Latin American region.

The initial PubMed search identified reviews and guidelines, Mederi latino dating was reduced to 16 articles following analysis using the five preliminary criteria. Following discussion, the panel selected one of the 10 shortlisted OU guideline publications. The rest were considered unsuitable for the Latin American region due to different reasons:.

Moreover, the panel considered that they would not provide primary care physicians with sufficiently clear guidance on OU. The rejection of the guidelines from the American Pain Society [ 24 ] APS was based on the fact that they are mainly tailored for the United States health care system.

The panel acknowledged that the APS guidelines provide information and give strong recommendations on how to start Mederi latino dating titrate chronic opioid therapy, the need to obtain an informed consent, and which risk stratification tools are to be used.

However, these recommendations were only supported by low-quality evidence. Also the APS guidelines encourage the limitation of methadone use, based on United States opioid death Mederi latino dating, and contain information on opioid availability not suitable for Latin America.

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Mederi latino dating Despite a well-structured evidence-based treatment Mederi latino dating, the ASIPP guidelines over-emphasize the risk of opioid-associated death, which could discourage prescribers from considering opioids for chronic pain management. The ASIPP guidelines also highlight issues associated with obtaining risk stratification and informed consent informed decision-making and included risk assessment tools that had not been validated in Latin America.

The British Society for Rheumatology and the IASP [ 16 ] guidelines were rejected, as they were considered Mederi latino dating be out of date and focused predominantly on the management of rheumatoid disease.

The guidelines from the Institute for Clinical Mederi latino dating Improvement [ 27 ] ICSI were also rejected, as they provide a general overview of concepts and definitions relating to chronic pain, but were not focused on OU. The guidelines from the National Institute for Health and Mederi latino dating Excellence [ 29 ] NICE were rejected because they are tailored toward Mederi latino dating UK health care system and focused on palliative care, particularly for chronic diseases kidney, liver, and respiratory and neurodegenerative disorders.

The Inflexion Health Series [ 30 ] IHS guidelines were rejected because they were not based on a systemic review, with a lack of evidence-based recommendations. In addition, the format was considered akin to textbook, rather than concise reference guidance. However, the panel acknowledged that the IHS guidelines did provide the necessary educational instruction on OU, patient Mederi latino dating, and treatment of adverse effects for a primary care audience.

These guidelines were specifically tailored to the United States Army Veterans population and, therefore, could not be representative of the Latin American population. Also, the panel believed that the guidelines would not be easy to implement Mederi latino dating Latin America. The NOUGG guidelines were selected because they were considered to be valid, relevant, practical, evidence-based, clinically applicable, comprehensive, and unambiguous. The guidelines were considered valid because they highlighted opioids as useful tools in chronic pain treatment, outlining appropriate clinical outcomes.

The negative effects of opioids i. The guidelines were considered practical because they recommend pharmacologic therapeutic options available in Latin America, including opioid rotation and equianalgesic dosing. The guidelines are also easy to implement in Latin America; they consider individualized therapy; recommend adverse event management Mederi latino dating describe multidisciplinary approaches; are representative of current best practice; and are clinically applicable and flexible, plus comprehensive Figure 1 c.

The guidelines are evidence-based, as they are supported by a comprehensive revision of 87 first-level articles, and are based on clear inclusion and exclusion criteria, with graded evidence levels on a clear 0—5 Mederi latino dating, as determined using an instrument developed by Jadad et al.

The guidelines were considered clinically applicable particularly recommendations R1—R24 because they included a treatment algorithm that comprised three drugs available in Latin America, and provide advice on dosing and titration particularly on reducing benzodiazepine dosesand direction for the treatment of specific subpopulations Figure 2. They were also considered comprehensive, as they are divided into clearly defined sections, which address the majority of challenges faced by physicians when treating patients with chronic pain in Latin America Figure 3.

Furthermore, the NOUGG guidelines were considered unambiguous due to the inclusion of a glossary Mederi latino dating minimized the risk of misinterpretation by HCPs particularly primary care physicians.

The CPLA panel considered the NOUGG guidelines to be clinically applicable, providing clear advice on treatment decisions, opioid dosing, and titration recommendations, and caveats for prescribing opioids to specific subpopulations. When considering the consensus NOUGG guidelines [ 28 ] in Mederi latino dating context of daily clinical practice in Latin America, some caveats were noted by the panel.

The guidelines neither cover opiophobia nor provide guidance based on lessons that can be learned from opioid misuse in the United States. The CPLA panel noted that Latin Americans receiving Mederi latino dating may exhibit marked differences in the opioid side effect profiles and perceived efficacy compared Mederi latino dating other geographic regions. The panel perceived that Latin America does not have the high percentage of patients addicted to opioids, such as oxycodone, reported in North America.

However, despite the existence of this small subpopulation, HCP should Mederi latino dating be deterred from prescribing opioids for chronic pain management. Conversely, the document does not provide information about the use of buprenorphine metadone and hidrocodona, all of them widely used in our region.

Opioids availability in Latin America. Other possible formulations and doses not available in the Countries performing this study have not been included in this table. In addition, the panelists noted that in Brazil, there is limited training in urine testing, but great experience in the use Mederi latino dating methadone as an inexpensive treatment for chronic pain.

In Chile, urine testing is rarely used partly due to its difficult access. Consequently, Mederi latino dating pain management has remained as a low priority among health care policy-makers, resulting in poor access and distribution of opioids, and insufficient provision of trained pain management Mederi latino dating. The CPLA advisory panel considered these guidelines to be valid, relevant to Latin America, practical, evidence-based, concise, unambiguous, and sufficiently educational to provide clear instruction on OU and pain management in patients with chronic pain in particular for primary care practitioners.

However, the panel noted that the NOUGG guidelines did not include advice on dosages and use of buprenorphine, methadone, and hydrocodone; therefore, they have developed a table which includes all available opioids in Latin America which can be a Mederi latino dating source of reference for Mederi latino dating in this region.

The guidelines do not include a list of emerging therapies. Regional perspectives include a difficult access to urine testing in the region, the widespread use of methadone in Brazil for inexpensive chronic pain management, and a high proportion of poor opioid metabolizers in Mederi latino dating region. Opiophobia, opioid ignorance, and learning from opioid misuse in the United States have also been highlighted in this manuscript.

Ongoing CPLA initiatives are seeking to provide robust epidemiological information on the regional burden of chronic pain in Latin America, and improve the management of CLBP with or without a neuropathic component.

The authors wish to thank Iliana Argueta from Grunenthal for supporting the iniciative, Dr. The magazine's chief function is Mederi latino dating keep the Mederi latino dating profession up to date with the from Late Latin medicalis, from Latin medicus “doctor”, from mederi “to heal ”.

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