REPORT
ESSENTIAL PAIN MANAGEMENT (EPM) WORKSHOPS
Chittagong, Bangladesh
18-20 March 2014
Executive Summary
Globally pain (of all types) is often an unrecognised and inadequately treated problem.
Fortunately many effective pain management strategies are “low tech” and cheap and can offer
significant improvements to an individual’s quality of life.
The Essential Pain Management (EPM) workshop has been developed:
•
•
•
To improve knowledge about pain
To provide a simple framework for treating pain
To address pain management barriers
We ran a series of EPM workshops at the Chittagong Medical College in Chittagong, Bangladesh
•
•
•
EPM Workshop on Tuesday 18 March
EPM Instructor Workshop on Wednesday 19 March
EPM Workshop on Thursday 20 March (taught by local and external instructors)
The objective of the visit was to introduce EPM to a regional centre in Bangladesh.
Recommendations Summary
1. Encourage the running of further EPM workshops at Chittagong Medical College with
ongoing training of instructors.
2. Encourage multidisciplinary participation in the workshops (particularly nursing staff).
3. Professor AKM Akhtaruzzaman would like to run an EPM program in another regional
centre in Bangladesh, Sylhet (north-east Bangladesh). This may require assistance from
external instructors. Depending on the logistics it may be sensible to recruit instructors
from the region.
4. Continue to support Professor AKM Akhtaruzzaman’s efforts in promoting EPM in
Bangladesh through ongoing multidisciplinary workshops in Dhaka.
5. The Bangladesh Society for the Study of Pain (BSSP) continues to work closely with
regulatory authorities as well as both medical and nursing schools to address local pain
management barriers such as access to opioids and education.
6. Dr Rush will continue to liaise with Professor AKM Akhtaruzzaman with regards to the
development of EPM in Bangladesh.
Background
Bangladesh has a population of approximately 160 million. It has a very low per capita GDP but in
recent years there has been strong economic growth. Dhaka, the capital has a population of
approximately 7 million (15-20 million in the greater Dhaka area). The city of Chittagong, which is in
the south of Bangladesh, 208 km from Dhaka, has a population of almost 4 million people (the
Chittagong Metropolitan Area has an estimated population of 6.5 million). Chittagong is the second
largest city and principal seaport of Bangladesh.
Chittagong Medical College is a government medical college which was established in 1957. It offers
a Doctor of Medicine (MD) in Anaesthesia. The Professor of Anaesthesiology is Professor AKM
Shamsul Alam.
The EPM Workshop was developed by Wayne Morris and Roger Gouke with the assistance of ANZCA
to improve pain knowledge, to provide a simple framework for managing pain and to address pain
barriers. Pilot courses were held in Papua New Guinea in April 2010 and workshops have since been
held in a number of countries in the Pacific, Asia, Central America, Africa and most recently Russia.
The management framework we use is RAT, standing for Recognise, Assess and Treat. This has been
used very successfully to discuss common and also difficult pain management scenarios.
Course coordination
Professor AKM Akhtaruzzaman was the main coordinator of the EPM workshops in Chittagong. He is
based in Dhaka at the Bamgabandhu Sheikh Mujib Medical University (BSMMU) as the Professor of
Anaesthesiology and co-ordinator of the MD (Anaesthesia) resident program. He was accompanied
by Dr Dilip Kumar and assisted by Professor AKM Shamsul Alam at Chittagong Medical College. Both
Professor AKM Akhtaruzzaman and Dr Kumar also acted as instructors in Chittagong.
External instructors
1. Professor AKM Akhtaruzzaman (PA)
Professor of Anaesthesiology, BSMMU, Dhaka, Bangladesh
2. Dr Dilip Kumar (DK)
Anaesthetist, BMSSU, Dhaka, Bangladesh
3. Dr Moira Rush (MR)
Anaesthetist, Victoria, Australia
4. Dr Liz Bashford (LB)
Anaesthetist, Victoria, Australia
5. Dr Rashmi Patel (RP)
Anaesthetist, Perth, Australia
Course Participants
See Appendix 1
19 doctors attended the first one day EPM Workshop in Chittagong on Tuesday 18th March. Most of
the doctors were training to be anaesthetists however we did have one doctor from obstetrics and
gynaecology and four from physical medicine.
We had 17 doctors attending the Instructor Workshop on Wednesday 19th March. Most of these
doctors were professors in their specialty area at Chittagong Medical College. They had not
participated in the workshop on the first day which meant some reworking of the timetable in order
to include as much of the course material as possible as well as the teaching component itself. Some
of the feedback reflects the slightly rushed program.
On the third day we had a new group of participants again. We had 18 doctors, most of them
training to be anaesthetists. A couple of the new instructors from day 2 were able to help us out
with this workshop.
Professor Akhtaruzzaman delivers a lecture on Day 1
Course Programs
The workshop programs are shown in Appendix 2 and 3. Due to significant time restrictions we ran
the courses from 830 – 1430 each day (to coincide with the participants’ normal working hours).
EPM Workshops
The standard EPM workshops were used on the 18th and 20th of March with some small
modifications in order to ensure that all the material was covered adequately. We had a short break
for morning tea after the interactive lectures and group discussion about the barriers to pain
management. A late lunch was provided at the end of the day following the small group discussions.
In these groups the participants discussed a number of cases using the RAT approach.
EPM Instructor Workshop
The instructor workshop was modified somewhat on this occasion due to the fact that the
participants had not heard the material presented in the EPM workshop on day 1. We presented
some of the lectures from the EPM workshop as well as some of the lectures on how to teach and
run group discussions. Some of the new instructors indicated that they would be able to help us run
the one day workshop the following day.
Drs Liz Bashford, Rashmi Patel and Dilip Kumar Bhowmick move participants into groups for the case
discussions.
Venue and Catering
The workshops were held in a class room in the Department of Anaesthesiology at Chittagong
Medical College.
Morning tea and lunch were provided by UniHealth. The food was excellent and we were very well
fed.
Teaching materials
All printed teaching materials (manuals, pre and post tests and feedback sheets) were printed in
Dhaka at BSMMU.
Assessment
The course participants completed a 25 question test at the beginning and at the end of the
workshop. The graph only shows data from participants who completed both the pre-and posttests. Pre-test scores were high however there was some improvement in the post-test sores.
Mean Pre- and Post - Test Scores
25
20
15
Pre-test
Post-test
10
5
0
EPM 1 (n=17)
EPM 2 (n=18)
Drs Rashmi Patel, Liz Bashford and Moira Rush with some of the participants from Day 3 after
presentation of the certificates.
Feedback
See Appendix 4.
Participants completed a feedback form at the end of each course. Overall the feedback was
positive. The RAT approach to pain management was well received and many participants indicated
that they would be able to use the knowledge gained to improve the way they assess and manage
pain. Many felt that they had gained some confidence in prescribing opioids. Overwhelmingly it was
thought that the program should be repeated and made accessible to other health care
professionals. The shorter days did provide some concern about the lack of time for more in depth
discussion.
The feedback from the instructors’ course largely reflects the fact that none of the participants had
heard the material on the first day. Mismatched expectations about the nature of the program likely
contributed. However a number of participants did feel that EPM was a program that they could
confidently introduce to their junior doctors. It would be important for future programs to
emphasise the need to adhere to the one/half/one day program with suitable candidates
(particularly on day 2) to ensure that the workshops could be continued.
Financial
The program would not have been possible without the financial support provided by Interplast
Australia and New Zealand. The funding provided by Interplast covered travel expenses from both
Australia and Dhaka, accommodation and meals in Chittagong and printing costs.
The catering was arranged locally and covered by UniHealth Pharma.
The class room was provided free of charge through the Chittagong Medical College.
We are incredibly grateful for this support.
Publicity
There was no specific publicity associated with this trip.
Dr Rush presented a talk on the ‘Role of Tramadol in Acute Pain Management’ at a dinner
organised by UniHealth Pharma which was well attended.
Success and Relevance of the Visit
This series of workshops provided some challenges. While we were able to run the EPM workshops
as planned we did have to compromise a little in order to accommodate the local requirements.
Professor AKM Akhtaruzzaman was responsible for organising the course in Chittagong from Dhaka
and once again he and his team did a fantastic job.
We were only able to run the workshops from 830-1430 each day which did mean that we rushed
through some parts of the course in order to ensure that we covered all the material. We had an
enthusiastic and incredibly knowledgeable group of participants on both days 1 and 3 and the
feedback that we received was overwhelmingly positive.
The instructors’ course on day 2 was slightly disappointing however I think that we made the best of
the situation. None of the participants had attended the workshop on Day 1 and a number were, I
think, anticipating a series of lectures on chronic pain management. We did emphasise the aims of
the course on a number of occasions and hopefully provided the participants with a program that
can be applied across a number of disciplines.
Professor AKM Akhtaruzzaman continues to be a champion of the EPM program in Bangladesh. I am
hopeful that some of the participants from the workshops in Chittagong will be able to support his
efforts.
Recommendations
1. Encourage the running of further EPM workshops at Chittagong Medical College with
ongoing training of instructors.
Hopefully Professor AKM Akhtaruzzaman will be able to liaise with Professor Alam to
encourage the running of more EPM workshops in Chittagong, possibly with the assistance
of instructors in Dhaka. Prof has some money left from our visit to Dhaka in 2013 which
could be put towards the printing of manuals and certificates. Sponsorship to cover catering
may be required.
2. Encourage multidisciplinary participation in the workshops (particularly nursing staff).
Prof continues to run EPM courses in Dhaka for both doctors and nurses however they are
usually done in separate groups. It may be useful to run multidisciplinary courses in the
future.
3. Professor AKM Akhtaruzzaman would like to run an EPM program in another regional
centre in Bangladesh, Sylhet (north-east Bangladesh).
This may require assistance from external instructors. Depending on the logistics it may be
sensible to recruit instructors from the region.
4. Continue to support Professor AKM Akhtaruzzaman’s efforts in promoting EPM in
Bangladesh through ongoing multidisciplinary workshops in Dhaka.
Dr Rush and Dr Morris continue to keep in regular contact with Prof and are very pleased to
support his ongoing efforts to promote EPM in Bangladesh.
5. The Bangladesh Society for the Study of Pain (BSSP) continues to work closely with
regulatory authorities as well as both medical and nursing schools to address local pain
management barriers such as access to opioids and education.
Prof has begun discussions with the government regulatory authorities in order to attempt
to increase access to opioids in Bangladesh for pain management. He is also trying to
introduce EPM into the nursing curriculum and develop pain management protocols for use
in the hospital. An audit of current practice and prescribing would be a useful measure of
the effectiveness of the EPM teaching. There continue to be significant pain management
barriers in Bangladesh.
6. Dr Rush will continue to liaise with Professor AKM Akhtaruzzaman with regards to the
development of EPM in Bangladesh.
Acknowledgements
This program would not have been possible without the incredible efforts of Professor AKM
Akhtaruzzaman and his team, particularly Dr. Dilip Kumar Bhowmick who accompanied Professor
Akhtaruzzaman to Chittagong from Dhaka.
Many thanks to Professor AKM Shamsul Alam and his team at Chittagong Medical College for their
generous hospitality.
My deepest gratitude goes to Dr Rashmi Patel and Dr Liz Bashford who accompanied me to
Chittagong from Australia. Their support proved to be invaluable.
Many thanks to the organisations who provided financial or logistical support – Chittagong Medical
College, the Bangladesh Society for the Study of Pain (BSSP), UniHealth, Interplast Australia and New
Zealand (in particular Julia Keating) and the Australian and New Zealand College of Anaesthetists
(namely Paul Cargill and Chrissy Theodoridis at FCM Travel).
I am also very grateful to Dr Wayne Morriss for his ongoing support.
Dr Moira Rush
4 May 2014
Debrief with Professor AKM Akhtaruzzaman regarding EPM in Bangladesh
Professor Akhtaruzzaman continues to champion EPM in Bangladesh. He and his team have run 7
EPM programs in Dhaka since our visit in February 2013, with the 8th planned for May, 2014. The
programs have included both nurses and doctors. Prof is keen to introduce EPM to another regional
centre in Bangladesh, Sylhet which is in the north east of the country. Given the recent experience in
Chittagong I think that it would be important to emphasise the need to adhere to the current
structure of the EPM course over the 3 days in order to maximise the benefit gained.
A number of barriers exist in Bangladesh which makes it difficult to translate the EPM principles into
practice. Prof is working with the government regulatory authorities in his role with the Bangladesh
Society for the Study of Pain (BSSP) to improve access to opioids in all forms. Oral opioids are
available in Dhaka however they are not available outside of the capital. This is a challenging
problem that Prof feels will take some time to address. The cost of prescribing opioids for pain
management outside the hospital system is often prohibitive for the patient and their family. There
continues to be significant reluctance to use morphine for post-operative analgesia and doctors
remain quite fearful of prescribing opioids in appropriate doses. I understand that some cultural
beliefs also impact on the willingness of both patients and doctors to accept analgesia in some
circumstances. Prof thinks that practices on the wards are slowly changing as a result of the EPM
teaching however to date there has been no formal audit to verify this. At the moment there are no
protocols to guide rational prescribing however Prof mentioned that he had sent some proposals to
Wayne Morris for comment.
Prof is also working to introduce EPM into the nursing curriculum in Bangladesh which would be a
significant achievement.
Prof is keen for the instructors that he has trained in Dhaka to get involved in teaching EPM in the
region. Local, enthusiastic champions disseminating the EPM knowledge base is a great way of
ensuring that the material remains relevant to a local audience.
Appendix 1: Course Participants
EPM 1 (18 March)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Name
Dr. Zannatul Nayeem Helaly
Dr. Emdadul Hoque
Dr. Nur E Jahan
Dr. Shahabuddin Siddiqui
Dr. Ashin Barua
Dr. Tanjim Reza
Dr. G A M Shalauddin
Dr. Mohammad Istiaq Mahmud Sawon
Dr. Kamruddin Bahadur Chowdhury
Dr. Ziaul Quader
Dr. K M Jobaydul Huda
Dr. Mohammad Iftekhar Shamim
Dr. Rasel Ahmed Chowdhury
Dr. Rowshan Ana Begum
Dr. Abdur Rahim
Dr. Selina Nazir
Dr. Imran Shahriar
Dr. Fahad Islam
Dr Farjana Basher
Designation
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
DA Student
Registrar
Consultant
Registrar
Astt. Registrar
HMO
Asst. Registrar
Department
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Gynae & Obs.
Psychiatrist
Physical Medicine
Physical Medicine
Physical Medicine
Physical Medicine
Designation
Assistant Professor
Associate Professor
Associate Professor
Assistant Professor
Assistant Professor
Assistant Professor
Assistant Professor
Assistant Professor
Assistant Professor
Assistant Professor
Assistant Professor
Associate Professor
Associate Professor
Professor
Professor
Associate Professor
Anaesthetist
Department
Cardiac Anaesthesia
Anaesthesia
Anaesthesia
Neurology
Physical Medicine
Neurology
Physical Medicine
Neurology
Anaesthesia
Anaesthesia
Anaesthesia
Physical Medicine
Neurology
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
EPM Instructor Workshop (19 March)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Name
Dr. Mamunur Rahman
Dr. MD Shahjahan
Dr. Ranjan Kumar Nath
Dr. Shiuly Majumar
Dr. Nitai Prasad Dutta
Dr. Pradip Kumar Kayastuager
Dr. MD Shamket Hossain
Dr. S A M Masihuzzaman
Dr. MD Haron-Or-Roshid
Dr. Kalyan Kumar Barua
Dr. MD Nizam Uddin
Dr MD Shaik Ahmed
Dr. MD Harauzzaman
Prof. AKM Shamsul Alam
Prof. Aminuddin A Kana
Dr. Ahmed Naser Chey
Dr. MD Abdus Samad
EPM 2 (20 March)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Name
Dr. Feroja Afrej Tali
Dr. Sanjida Hasan
Dr. Tahmina Islam
Dr. Murfeqin Rahman
Dr. Subir Barma
Dr. Minhazur Rahman Chowdhury
Dr. Mizan Uddin Emran
Dr. Sajib Talukder
Dr. MD Aktar Hossain
Dr. Mainul Islam Mazumder
Dr. Mustafa Musshed
Dr. Pravay Kumar Datta
Dr. Glazi Nowrose Farzana
Dr. Afroza Bilkis
Dr. MD Abdullah al Mamun
Dr. MD Foisal Wazed Chowdhury
Dr. Nurul Azim
Dr. MD Rubel
Designation
IMO
MD Student
DA Student
DA Student
Junior Consultant
Junior Consultant
DA Student
DA Student
DA Student
DA Student
HMO
Assistant Professor
Medical Officer
Medical Officer
DA Student
DA Student
DA Student
HMO
Department
Medicine
Anaesthesia
Anaesthesia
Anaesthesia
Cardiac Surgery
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Anaesthesia
Physical Medicine
Anaesthesia
Gynae. & Obs.
Gynae. & Obs.
Anaesthesia
Anaesthesia
Anaesthesia
Physical Medicine
Appendix 2: EPM Workshop Program
18-20 March, 2014
Time
Duration Lecture / Discussion
Instructor/s
(mins)
08:30-09.15
45
Welcome
Prof AKM Akhtaruzzaman
Local perspective
Prof AKM Shamsul Alam
Dr Moira Rush
Pre-test
Dr. Dilip Kumar Bhowmick
09:15-9:30
15
Introduction
MR
09:30-09:40
10
What is pain?
LB
09:40-09:50
10
Why should we treat pain?
MR
09:50-10:05
15
Classification of pain
LB
10:05-10:35
30
Physiology and pathology
RP
10:35-11:00
25
Tea Break
11:00-11:20
20
Pain treatment overview
Dr. Dilip Kumar Bhowmick
11:20-11:40
20
Pain drugs
MR
11:40-12:10
30
Barriers to pain management
Prof. AKM Akhtaruzzaman
12:10-12:40
30
Basic approach to pain management
LB
12:40-13:40
60
Case discussions
Dr. Dilip Kumar Bhowmick
13:40-14:10
30
Overcoming barriers
Prof AKM Akhtaruzzaman
14:10-14:40
30
Post-test –
Dr. Dilip Kumar Bhowmick
Feedback
Certificates
Group photo
14:40-15:00
Lunch
Appendix 3: EPM Instructor Workshop Program
Time
Duration
(mins)
Lecture / Discussion
Session 1: Introduction and Teaching Basics
Welcome
0930-0945
15
Introduction
0945-1000
15
Adult Learning
1000-1010
10
Teaching overview
1010-1020
10
Giving a lecture
1020-1030
10
Running a group discussion
1030-110
30
Morning tea
Session 2: Teaching Rotations
Divide into 2 groups:
•
Giving a lecture
•
Running a discussion group
110-1145
45
Teaching rotation 1
1145-1230
45
Teaching rotation 2
Session 3: How to Run an EPM Workshop
1230-1240
10
EPM Planning
1240-1305
25
Workshop preparation – venue,
lecturers, catering etc
1305-1330
25
Feedback
Certificates
Photo
Instructor/s
Appendix 4: Analysis of Participant Feedback
EPM 1 (19 responses)
1
Strongly
disagree
EPM will be useful in
my daily work
EPM has improved my
understanding of pain
I will now be able to
assess pain better
I will now be more
willing to prescribe or
give opioids
The training today was
effective
2
Disagree
2
3
Not sure
1
Comments
Most important things learned?
• Prescribing opioids in the postoperative period
• Safe use of opioids/dose calculation
• Choice of drugs in different types of pain
• Pain assessment and making a pain diagnosis
• Multimodal analgesia
• RAT
• Classification of pain
• Non drug treatments
• WHO analgesic ladder
• Management of cancer pain
Will EPM change how you work?
• Confidence in prescribing opioids
• Pain assessment and appropriate treatment
• Using the WHO analgesic ladder
How can the EPM Workshop be improved?
• Longer program schedule and greater detail
• Adding interventional pain management
• Should be multidisciplinary
• More practical
• Video/audio
Any other comments?
• Adding interventional pain management techniques
• Excellent
• More frequent programs
• Include more information about palliative care
• Thank you
4
Agree
8
5
Strongly
agree
11
8
11
5
14
11
5
4
15
EPM Instructor Workshop (16 responses)
The training today
was effective
I will be a better
teacher as a result
of this workshop
The workshop today
improved my
knowledge of EPM
1
Strongly
disagree
1
2
Disagree
3
Not sure
4
Agree
2
11
5
Strongly
agree
2
1
10
4
2
7
5
1
1
1
Comments
Most important thing learned?
• Methodical approach
• Barriers
• RAT
• Ways of teaching
• Pain classification
• Morphine use
• Treatment of pain at infrastructure level
• Pain pathology/classification
• Tips for running a workshop
• Pain management skills useful for all doctors
Will you be able to use your EPM Instructor training where you work? If yes, please give
examples.
• Mostly yes (10)
•
•
•
•
•
Train junior doctors to become instructors
Possible if financial support provided
Requires collaboration with authorities
Would add discussion about pain management procedures
Include doctors from other disciplines
•
•
No because little support from professors
Not effective training
How can the EPM Instructor Workshop be improved?
• Video/audio
• Encourage active participation/interaction
• Regular workshops
• More practical (pain management procedures)
• More clinically oriented
• Updated
•
•
•
•
•
More expert personnel should be present
Latest procedures and drugs available should be discussed
Allow people to read the manual before the lectures
Group discussions
A totally revised workshop plan should be in place
Do you have any other comments?
• Good basics of pain management
• Include in medical and nursing student curriculum
• Include new drugs
• Continued collaboration with overseas organisations
• Videos
• EPM workshops should be run in all hospitals
• Ongoing workshops
• ‘Pain drugs’ should be changed to ‘pain killers’
• Practical training should be included
• Barriers include financial constraints
EPM 2 (21 responses)
1
Strongly
disagree
EPM will be useful
in my daily work
EPM has improved
my understanding of
pain
I will now be able to
assess pain better
I will now be more
willing to prescribe
or give opioids
The training today
was effective
2
Disagree
1
3
Not sure
4
Agree
1
8
5
Strongly
agree
12
2
12
7
16
5
10
6
6
14
4
1
Comments
Most important things learned?
• Use of morphine
• Use of opioids
• Pethidine dose
• Classification of pain
• RAT
• Systematic management
• Prescription of appropriate analgesics
• Pain modulation
• Management approach
• Knowledge upgrade
• Exchange of views
Will EPM change how you work?
• Use opioids appropriately, in the correct doses and more confidently
• Use of morphine
• No
• Yes
• Treatment plan
• Better post-operative pain management
• Managing cancer and post-operative pain in obstetrics and gynaecology
How can the EPM Workshop be improved?
• Elaborate more
• Increase time for discussions
• Increase duration of workshop
• Video presentations
• Practical sessions/more clinical
• Discussion about other drugs
• Repeat workshops
• Better tea/coffee
• Small gift hamper/bags
• Guidelines for labour pain and postoperative pain
• Lectures in Bangla
• Discussion of web based resources for pain management
• Hands on training
Any other comments?
• Interventional pain management for anaesthetists
• Optimise information
• Give more workshops
• Thanks
• More clinically oriented
• A good concise workshop
• Include other doctors and health care workers