Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non‐specialist opioid prescribers. There is much confusing and conflicting information available to non‐specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi‐faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non‐specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe. Significance This position paper provides expert recommendations for primary care physicians and other non‐ specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi‐faceted approach to pain management, in properly selected and supervised patients.

countries: Turkey (ranked 9 th), China (12 th), Brazil (15 th) and South Korea (18 th). The geographical analysis reveals: (a) continuous decline of North America's publication share from 46% in 1987 to 38% in 2007; (b) rising importance of the European share to over 46% in 2007, accompanied by an increasing prevalence of the European Union; (c) emergence of the Asian countries for a nearly 20% share of publications in 2007 largely from Japan, China, Taiwan and South Korea; (d) negligible presence of Africa (<2%) and (e) slow growth of South America from <1% in 1977 to <3% in 2007. Conclusion: The rapid evolution and explosion of pain research in the last 30+ years was accompanied by important changes in the landscape of the contributing countries and geographical regions.

Background ‘Pharmacists in the Emergency Department’ is a two-year implementation project carried out in collaboration between the pharmacy of Capital Region and the Emergency Department (ED) at Hillerød hospital. The task of the pharmacist is to draw up a current and valid medicines history and to make a medicines review before the physician sees the patient at the ED. During the first year of the project the interventions developed gradually while the professional skills and clinical experience of the pharmacists built up. Purpose To describe the evolution of the interventions recommended when Drug Related Problems (DRPs) are identified, as described in the pharmacist’s notes. Materials and Methods 5 samples of pharmacist’s notes were recorded. The samples represent the interventions made in the 2 first weeks of each quarter of 2011 and the first quarter of 2012. This showed the development in interventions made by pharmacists. The interventions were coded based on 8 categories of DRP introduced by Hepler and Strand. In total 383 pharmacist’s notes were analysed. ResultsIn all 549 DRPs were identified. 70–80% of the pharmacist’s notes contained one or more DRP. On average 1.4 DRPs were identified per note. During the first 15 months of the project the DRPs recorded evolved as follows: The number of comments tended to increase in the categories “inappropriate choice of drug”, “overdose”, “adverse drug events” and “medicine without reasonable indication”. The number of comments identified in the category “interactions” decreased. The categories “untreated indication”, “subtherapeutic dosing” and “inappropriate use by the patient” were stable throughout the study period. Conclusions When introducing a new pharmaceutical service one must expect a gradual evolution of the interventions as the pharmacist gradually develops hands-on-competencies and clinical experience on the particular ward. After 12 months, the findings in the pharmacist notes were stable. This must be taken into account when introducing new pharmaceutical services in the clinic. No conflict of interest.

Background Patients have medicines reviews conducted by different health care professionals in different settings. Introducing a clinical panel to drug related problems (DRPs) to evaluate their clinical significance is common practice. The clinical panel discuss the potential consequences and come to a mutual agreement on the level of clinical significance. However, to what degree does the panel agree? Purpose To compare the agreement between different health care professionals who have evaluated the clinical significance of DRPs. Materials and methods DRPs were identified in 30 comprehensive medicines reviews conducted by a clinical pharmacist. Two hospital pharmacists, a general practitioner and two specialists in pain management from hospital care (the Panel) evaluated each DRP considering the potential clinical outcome for the patient. The DRPs were rated either nil, low, minor, moderate or highly clinically significant. Agreement was analysed using Kappa statistics. A Kappa value of 0.8 to 1.0 indicated nearly perfect agreement between ratings of the Panel members. Results The Panel rated 45 percent of the total 162 DRPs as of moderate clinical significance. However, the overall kappa score was 0.12 showing nil agreement when comparing the ratings of clinical significance. The Panel disagreed on which DRPs were of minor or moderate clinical significance. Further analysis of the interrelationship of the five Panel members described fair agreement between one specialist and the two pharmacists. In two types of DRPs, sub-therapeutic dosing and side effects, the Panel agreed fairly well on moderate clinical significance. Conclusions Each profession rates the clinical significance of DRPs differently, especially in cases of intervention by pharmacist versus practitioner, and opinion also varies within each profession. Take into account the profession and setting when clinical relevance of DRPs is discussed in the literature and when choosing a method for evaluating the clinical significance of DRPs. Acknowledgement Many thanks to Grünenthalfonden and Actavisfonden, participants in the project ‘Drug Related Problems in the Frontier between Primary and Secondary Health Care’. No conflict of interest.

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