PAINWeek Podcasts: Recent Episodes
PAINWeek
PAINWeek is the preferred resource for frontline practitioners treating acute and chronic pain. For over a decade, we have demonstrated that “education is the best analgesic’’ by presenting over 12,000 hours of content across our national and regional conferences, conducting hundreds of Expert Opinion interviews, and publishing an array of faculty authored articles in our quarterly journal.
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The management of chronic noncancer pain with opioid medications is controversial. The negative consequences have been described as a public health emergency and the efficacy of chronic opioid therapy remains a subject of significant debate.
Despite recommendations that chronic opioid therapy not be utilized until other methods fail, there remains a large population of patients for whom no other therapy has been effective and a large cohort of people who have been treated for years with opioids.
Many new patients are still started and maintained on chronic opioid therapy. This course describes one system’s use of clinical pharmacists incorporated into the pain management team to reduce risks. Participants will learn how the pharmacists are utilized in this team-based model.
Topics covered will include the nuts and bolts about how to incorporate pharmacists into clinical management, outcomes of the model of care, DEA certification for pharmacists, billing for services, and lessons learned.
Buprenorphine was developed by UK based Reckitt & Colman Products and released in the United Kingdom in 1978. That same year, a clinical study determined that buprenorphine could be helpful in reducing cravings of pure opioids in patients with an opioid abuse disorder.
Then, a separate study published in 1982 demonstrated that buprenorphine offered excellent analgesia with a blunted abuse liability. Buprenorphine is a partial agonist at the mu-opioid receptors and an antagonist at the kappa receptors. Mu-opioid receptor activity produces the analgesic effects of buprenorphine, while a strong affinity for the kappa receptors render them inactive. While initially buprenorphine was used as an anesthetic, currently it has been prescribed for the induction and maintenance in patients with an opioid use disorder.
However, buprenorphine is a unique molecule with multiple applications. This presentation will provide an in-depth discussion of the history of buprenorphine and its application for pain control, opioid use disorders, and antisuicide properties in patients with chronic pain
The use of opioids to treat chronic pain has become quite contentious in recent years. Things get even more confusing when we consider adding an adjuvant analgesic in the mix.
Does this reduce or heighten risk? The audience can decide where to throw spitballs when 2 practitioners debate 2 separate topics. First, is the use of cannabis plus an opioid likely to provide an enhanced clinical effect (eg, allow for opioid dose reduction and by extension, harm), make no difference, or possibly cause more harm. The second debate will evaluate the use of gabapentin plus an opioid.
On one hand, we have data showing the gabapentinoids may be habituating and result in addiction. Combining gabapentin with an opioid may also increase the risk of mortality. On the other hand, rational polypharmacy, using an opioid and gabapentin, has been shown to result in superior clinical outcomes compared to either analgesic alone. So perplexing. What’s a practitioner to do? Listen to the debate and decide for yourself!
In previous presentations, Dr. Jay has discussed the pathophysiology, neuroanatomical, and other aspects of fibromyalgia.
In this activity, all of that will NOT be discussed, so the focus can be only on the diagnosis and treatment of fibromyalgia and restless leg syndrome. Treatment will be covered in depth, not the phenomenology that is the complex neuroanatomical and neuropathological backgrounds of these diatheses.
The goal is to provide clinicians with practical information to be utilized upon seeing patients following the conference.
The prevalence of back pain continues despite the many treatments available, without any single treatment being a panacea. In routine clinical practice there has been a tendency of clinical examinations to become more cursory, largely influenced by increasing demands of time and arguably an overreliance upon technology.
It has been suggested that the failure to adequately differentially diagnose the cause of back pain can account for clinical failures in treatment. The purpose of this discussion is to assist clinicians in the development of a more problem focused examination to enhance the differential diagnosis of specific pain generators, and therefore lead to more patient specific treatment.
Attention will be given to considering all aspects of the examination, including physical assessment as well as imaging studies, and the ability to rationalize when pathologies seen on imaging studies may or may not be clinically significant. The importance of considering how failed treatments influence the differential diagnosis will also be discussed.
Today’s providers are limited by time and must work with extreme efficiency. And yet for many, 100% of their time is used trying to treat 20% of their patients’ problems. This presentation will address the problem of chronic pain, provide simple tools to use during any office visit, and explain the power of positive and negative thoughts on the chronic pain experience.
Several recent studies have found intriguing links between gut microbes, rheumatoid arthritis, and other diseases. Additional studies have shown the interactions between the central nervous system, enteric nervous system, and the gastrointestinal tract, suggestive that gut microbiota appears to influence the development of emotional behavior, and stress- and pain-modulation systems.
In the age of modern medicine, it is easy to forget that we change our body chemistry every time we eat. The quality and composition of our food has the power to increase or decrease body wide inflammation and modulate pain. Our relationship to food and the way we eat is also cultural and influenced by stress and our environment. The research evidence is robust for dietary interventions and improved health.
The changes needed are simple, but not necessarily easy. This lecture will focus on the role that modulation of the microbiome plays in pain, and the ways to optimize the health of the individuals’ gut microbes for pain management and overall well-being.
Pain is common in the aging population. Findings from an NIH funded study looking at the impact on pain in the older adult found that over 50% of people surveyed had pain within the last month, often in more than one location.
Despite the high prevalence of pain, pain often remains undertreated, resulting in impaired cognition, decreased socialization, sleep disturbances, and a reduced quality of life. Our bodies react differently to medications due to medical comorbidities and metabolic changes due to the aging process itself. Understanding the correct choices of analgesic utilizing a multimodal approach to treatment is important in providing safe and effective pain therapies. Patients with dementia or in the late stages of disease may propose a unique pain control challenge due to difficulty in the ability to verbalize pain.
This session will explain the differences in response to analgesic medications due to the aging process and provide recommendations for individualized pain control based on specific patient characteristics.
This course will review the scientific evidence for/against opioid therapy, risk mitigation, and different methods of opioid tapering. Providers need guidance to determine which patients may or may not benefit from opioids.
While most pain patients on opioid therapy manage opioids safely, the risks are detrimental to some patients and society. Clinicians are faced with contradictory professional advice and legal mandates/scrutiny. Many patients are exposed to risk due to inappropriately executed opioid tapering. Suicide rates are rising, and illicit drug use including overdose deaths from synthetic opioids continue to rise. How do we maximize benefit over harm? T
his session will review the scientific evidence and legal requirements that contribute to optimized opioid therapy when clinically indicated and how to discontinue opioid therapy if appropriate.
Understanding the mechanisms that drive a persistent pain process is critical for effectively treating pain in any patient. While it is common to treat pain from a primary nociceptive perspective, this approach often fails in patients with central sensitization.
Pain mechanism based classifications can help clinicians make recommendations that may improve functional outcomes and enhance patient adherence by identifying primary pain mechanisms. This course will offer practical tips for evaluation of patients with mixed pain mechanism presentations and includes an interactive discussion of multimodal treatment options for each.
Course DescriptionWhen we practitioners approach complex medical problems (whether pain, depression, or even GERD) that have psychological and lifestyle components and we do so with minimally monitored drug-only therapies, we may bounce from one “wonder drug” to another and end up bewildered or worse.
These problems need complex approaches that address the component parts and we can’t just rely on finding the next wonder drug. Perhaps it’s part of the American mindset: wanting a pill to fix problems. Part of it is from the perverse incentives in a healthcare system that wants to find solutions to complex issues and then implement them on the cheap, running them through primary care on a conveyor belt. In pain we see history repeating itself around the medical cannabis issue.
All the same mistakes are being made again and with poor care coordination, risk management, and assessment it will end up doing harm.
Forced downward titration has been broadly implemented throughout the country as a direct result of the CDC Guideline for Prescribing Opioids for Chronic Pain.
Prescribing clinicians feel pressured to follow the CDC’s recommendations of dose limits to avoid regulatory sanctions, and pharmacists feel a corresponding obligation to intervene in accordance with the CDC guideline and corporate policies. In many instances, prescribers have refused to treat opioid-requiring pain patients, resulting in the patients’ discharge from the specialist’s practice or a consult refusal—the latter of which, by default, often leaves the most medically complex and challenging patients with only their primary care providers to manage their pain. Some patients have chosen to leave their existing providers because of mistrust, cynicism, disbelief, and abandonment, but they then find it difficult to secure any other provider willing to treat their pain.
This presentation will chronicle the events that have delivered an unreasonable burden on patients and providers.
Forced downward titration has been broadly implemented throughout the country as a direct result of the CDC Guideline for Prescribing Opioids for Chronic Pain.
Prescribing clinicians feel pressured to follow the CDC’s recommendations of dose limits to avoid regulatory sanctions, and pharmacists feel a corresponding obligation to intervene in accordance with the CDC guideline and corporate policies. In many instances, prescribers have refused to treat opioid-requiring pain patients, resulting in the patients’ discharge from the specialist’s practice or a consult refusal—the latter of which, by default, often leaves the most medically complex and challenging patients with only their primary care providers to manage their pain. Some patients have chosen to leave their existing providers because of mistrust, cynicism, disbelief, and abandonment, but they then find it difficult to secure any other provider willing to treat their pain.
This presentation will chronicle the events that have delivered an unreasonable burden on patients and providers.
This session is designed to familiarize learners with the principles of the neurobiology of the traumatized patient and illuminate the salient concepts that are germane to the presentations and treatment of patients with chronic pain.
At the conclusion of this activity, practitioners should be able to identify several key aspects of behavior and presentation in patients with chronic pain who have a history of trauma, as well as utilize these concepts when interacting and treating these patients to improve outcomes and pain scores.
There are various types of studies that are necessary to perform in order to determine their clinical relevance. The process extends from benchtop to bedside side and includes various special populations like pediatrics and geriatrics.
This course addresses various elements related to the study of analgesics. Novel improved preclinical animal models in analgesic studies are examined. The unique issues of unusually high placebo and nocebo effects in analgesic which can lead to confusing results are discussed. The role and responsibilities of acting as a Principal Investigator in an analgesic trial are discussed. The practical impact of new healthcare measures and the increased the importance of comparative effectiveness trials and health outcomes and pharmacoeconomic are reviewed.
The process of publishing data and determination of authorship At the conclusion of the program participants shall have a comprehensive understanding of the analgesic trials.
Chronic pain is much more than a physical sensation. It can be all-encompassing and often impacts an individual in a multitude of ways, spawning discouraging, painful, or unwanted psychological experiences such as thoughts, feelings, and memories as well as functional limitations.
The natural approach might be to dedicate time and expend energy and resources (emotional, psychological, financial, etc) to controlling or avoiding these uncomfortable experiences. However, increasing evidence suggests that, not only are attempts to control the frequency and form of these types of private experiences often unsuccessful, doing so may result in an increase in their occurrence and an increased sensitivity to their impact, thus, paradoxically exacerbating one’s situation. Additionally, especially with chronic pain, avoidance of discomfort (physical and emotional) often results in isolation and inactivity, thus robbing an individual of participation in valued activities. Acceptance and commitment therapy (ACT), a 3rd wave spinoff of cognitive behavioral therapy, is now considered an evidence-based therapeutic treatment for chronic pain that is set apart from other, more commonsense solutions.
ACT poses a useful alternative to control-based treatments and operates on a set of 6 core processes within a unified model called psychological flexibility—“the capacity to be directly, consciously, and fully in contact with the present moment without needless defense and to persist or change one’s behaviors in the service of one’s goals.”
Spirochetal infection symptoms include muscle pain, nausea, vomiting, abdominal pain, and many others. Lyme disease can cause joint pain and stiffness, fatigue, flu-like symptoms, and sleep problems, among others. Depending on the species of bacteria involved, symptoms may be quite painful and range from acute to chronic.
How are patients infected? What treatments work best? Although an “appropriate” treatment for the various stages of infection is not universally accepted, this course will suggest means for treatment while it reviews causes and types of infection and symptoms.
The healthcare community is at a crossroads as the opioid crisis rages in America – how to provide effective pain management while preventing opioid abuse and addiction.
This session will explore evidence-based opioid-sparing pain management techniques and how they are improving patient outcomes and quality of life while also reducing overall costs.
The Pain Management Best Practices Inter-Agency Task Force identified inconsistencies and fragmentation of pain care as gaps in US healthcare that limit best practices and patient outcomes.
The report encourages coordinated care and cites the collaborative stepped model of pain care, as adopted by the Department of Veterans Affairs and the Department of Defense health systems as a best practice.
The session will address the challenges and successes of VA’s pain care transformation towards patient-centered biopsychosocial pain care for Whole Health for Veterans. Attendees will learn how to anticipate challenges and minimize risks when implementing a comprehensive pain care transformation away from opioids based on lessons learned from the largest integrated healthcare system in the United States.
This presentation will focus on the development of a clinical decision tool to standardize opioid prescribing for patients with sickle cell disease.
Pain is the hallmark symptom of sickle cell disease, which is often managed by hematologists or primary care physicians. Currently, there is no clinical decision tool or any type of standardization regarding opioid prescribing among these patients.
The Management of Sickle Cell Disease guidelines, published in JAMA in 2014, states that there is little evidence related specifically to chronic pain is those with sickle cell disease and most of the recommendations were adapted from general pain guidelines.
Therefore, opioid prescribing is not consistent regarding management of chronic pain in this patient population, potentially due to a lack of standardized prescribing practices. In order to mitigate this absence, this pilot project aims to create an opioid prescribing protocol for use in patients with sickle cell disease who are prescribed or may be prescribed opioid therapy.
The research was funded and began in January 2019 to develop the clinical decision tool. The tool was implemented in April 2019 and evaluated. The goal is to continue implementation and potentially expand to other sites that treat sickle cell or other chronic pain patients.
Chronic pain and alcohol consumption are both very common in the general population, and alcohol is often used to numb both physical and emotional pain.
The epidemiology of co-occurring pain and alcohol use will be discussed in this presentation. In addition, we will review the latest evidence surrounding the interaction between alcohol consumption and pain. Moderate alcohol use has been associated with improved pain related outcomes for certain pain conditions.
However, both excessive binge drinking and alcohol use disorder are associated with worsened pain outcomes including increased pain intensity, and alcohol use is associated with specific pain conditions. Pain may also trigger alcohol consumption, and alcohol consumption represents a negative pain coping strategy.
The interaction of alcohol with pharmacologic treatments for pain will be reviewed, and behavioral strategies to treat co-occurring alcohol use disorder and chronic pain, and to reduce problem drinking, will be presented.
Virtually all healthcare professionals have some degree of altruism and a strong desire to help patients in need. As healthcare continues to evolve, the burdens on clinicians change as well. While most of us have been taught that providing a “medical home” to patients along with shared decision-making is the most ethical way to provide effective healthcare, many are finding that other stakeholders may potentially derail those worthy intentions.
While insurers are not often considered to be “regulatory agencies” by most, they indeed have become major players in determining the trajectory of everything from pain assessment to treatment planning and implementation to follow-up and monitoring. Many feel that insurance related paperwork and associated administrative burdens are contributing significantly to clinician burnout and ultimately having a negative impact on patient care.
Additionally, navigating these challenges is not part of the standard curriculum of most educational training programs. This session will focus on these topics and the concept of “institutional iatrogenesis” and identify the challenges they present to healthcare providers, as well as strategies to manage them and minimize interference with our primary mission: caring for patients with pain.
There are many potential underlying causes for neck and upper extremity pain. All too often, only the most common conditions such as a disk herniation or carpal tunnel syndrome are explored.
The purpose of this course is to review other common problems (such as radiculitis), and not so common (such as rib arthropathy pain syndromes) that can affect the neck and upper extremities.
Attention will be given to clinical pearls for recognizing when patients present with such problems, as well as treatments that may prove helpful for both differentially diagnosing and treating various neck and upper extremity pain syndromes, especially many of those that are often missed or overlooked and easily treatable to resolution when they are identified.
Psychosocial factors have become increasingly recognized as important moderators and determinants of the pain experience. One such factor that has garnered great empirical attention is pain catastrophizing. Pain catastrophizing has been described for more than half a century, yet many frontline practitioners continue to be unfamiliar with the construct. It is conceptualized as a negative cognitive affective response to anticipated or actual pain and has been associated with a number of important pain related outcomes.
There are several determinants for pain catastrophizing, including female sex, Asian/African race, age, certain genotypes, and hormonal/neurophysiological phenotypes.
There are two psychometrically sound self-report instruments (Coping Strategies Questionnaire and CSQ and the Pain Catastrophizing Scale) that can be readily and reliably used with a variety of pain populations. High levels of pain catastrophizing on these measures should be considered a risk marker for adverse pain related outcomes.
The primary treatment for pain catastrophizing is cognitive behavior therapy for chronic pain (CBT-CP). Education, relaxation, and acceptance and commitment therapy (ACT) skills have also shown promise.
Therapy of pain is a challenge and requires special approaches. This course, as part of the Pain Educators Forum (PEF), will build on information provided in other PEF sessions and focus on the prevalence and impact of unrelieved pain, pathogenesis, and treatments of pain.
Participants will learn about approaches and advances in therapy of common acute and chronic pain syndromes, and evidence based recommendations for pharmacotherapy of pain will be provided.
Pain Therapeutics examines current trends in pain relief, which can be implemented into practice as soon as attendees return to work.
This session is designed to familiarize learners with the principles of the neurobiology of the traumatized patient and illuminate the salient concepts that are germane to the presentations and treatment of patients with chronic pain.
At the conclusion of this activity, practitioners should be able to identify several key aspects of behavior and presentation in patients with chronic pain who have a history of trauma, as well as utilize these concepts when interacting and treating these patients to improve outcomes and pain scores.
The ancient Sumerians first cultivated the poppy plant for its opium in 3000 BC. The analgesic properties of opium were formalized into morphine and later commercialized by Merck Pharmaceuticals in 1827. To this date, morphine and its derivatives are effectively used for treating acute pain.
In recent years, however, the overuse of opioids to treat chronic nonmalignant pain has contributed to the prescription opioid epidemic. As society has recognized this problem and our government has stepped into opioid crisis efforts, we turn to technology in treating chronic pain as an alternative to opioid medications. This presentation is targeted for general practitioners and current pain management physicians.
We will explore the evolution of pain medicine leading up to the current and future opioid-sparing interventional pain treatment options. Specifically, we will focus on electroceuticals (spinal cord stimulation, peripheral nerve stimulation, vagus nerve stimulation), minimally invasive spinal decompression spacers, and percutaneous sacroiliac joint fusion.
The United States is struggling with how to deal with two competing problems: the undertreatment of pain and the abuse of opioids. At the same time, millions of people in third-world countries are dying without access to any opioids, even liquid morphine, due in large part to a variety of barriers relating to distance, regulation, and knowledge.
Could marijuana be the solution to both problems? Although marijuana continues to remain prohibited by federal law and treaty, several countries and US states have defied these prohibitions by passing their own laws and regulating marijuana for recreational or medical purposes.
This presentation examines the labyrinth of laws relating to marijuana in the United States, the extent of suffering in third-world countries, and how the global legalization of marijuana may become a viable solution—or a pipe dream?
Motivational interviewing (MI) is a counseling approach that was initially applied to address drinking behavior. At its core, it helps reduce patients’ ambivalence and move them toward action through use of their own intrinsic motivation.
Over the years, MI has been applied broadly across different health domains to help shape outcomes. The approach can be particularly beneficial when working with patients who are perceived to be stuck and not making satisfactory progress in treatment. This presentation will introduce the audience to MI, review the concepts underlying it, and discuss its specific application in pain settings.
Medication assisted therapy (MAT) for addiction has been available since 2000. Up until 2016, physicians have been the only healthcare providers able to prescribe buprenorphine for opioid addiction. On July 22, 2016, President Obama signed into law the Comprehensive Addiction and Recovery Act (CARA).
This is the first major federal addiction legislation in 40 years and the most comprehensive effort undertaken to address the opioid epidemic. CARA incorporated many needed resources to better manage patients with addiction, but one specific aspect of the legislation was focused at nurse practitioners and physician assistants: providing greater access to care by easing the restrictions on who could provide MAT after completion of continued education. Nurse practitioners and physician assistants caring for patients with chronic pain and addiction need continued education and empowerment to accept this level of responsibility.
This session will look at the history of addiction, past therapies, current therapies, and the future of addiction, specifically how it intersects with chronic pain management.
Individuals with chronic pain may lack awareness that they are feeling grief. People who suffer from chronic pain may experience losses in several areas: comfort, sexual function, career, income, self-efficacy, cognitive function, intimacy, pride, joy, self-esteem, self-control, independence, mental health, hope, dignity, and certainty. Providers may overlook these patients biggest loss: themselves. While everyone copes in their own way and experiences their chronic pain condition uniquely, there are common feelings that most of us share: denial, anger, bargaining, depression, and acceptance.
Elizabeth Kübler-Ross’s five stages of grief outlined in her 1969 book, On Death and Dying, may help patients better understand what they are going through. Frontline providers can help patients better cope with the grief that often has no resolution by understating the limitations of their illness, listening and trying to understand what they are going through, looking for signs and completing a thorough psychosocial assessment, and organizing psychoeducational support groups and other interventions. The goal is to transform their experience into something livable and bearable.
Myopain conditions including myofascial pain and fibromyalgia are among the most common disorders causing chronic pain and are a significant cause of suffering, addiction, disability, and healthcare utilization. More than half of the persons seeking care for these pain conditions at 1 month still have pain 5 years later despite treatment.
The good news is that successful treatment of these painful conditions is achievable, and this course aims to teach providers the 2 key factors that clinically make the biggest impact. The first is recognition of the contribution of the fascia to myofascial pain and fibromyalgia, and improving diagnostic skills promoting early recognition. Along with better recognition of myofascial pain, effective treatment will incorporate evidence-based manual therapies and myofascial self-care.
The second key to success is utilizing a transformative care approach that integrates comprehensive patient self-management training and coaching to empower patients to address the many risk factors that can lead to delayed recovery and chronic pain. This activity will describe the growing body of evidence for fascial dysfunction contributing to pain in fibromyalgia and myofascial pain, along with research supporting the effectiveness of manual therapies either performed by a therapist or as part of a myofascial self-treatment program.
Reimbursement for transformative care with telehealth coaching with online technology will also be covered by Drs. Fricton and Liptan.
Myopain conditions including myofascial pain and fibromyalgia¬ are among the most common disorders causing chronic pain and are a significant cause of suffering, addiction, disability, and healthcare utilization.
More than half of the persons seeking care for these pain conditions at 1 month still have pain 5 years later despite treatment. The good news is that successful treatment of these painful conditions is achievable, and this course aims to teach providers the 2 key factors that clinically make the biggest impact.
The first is recognition of the contribution of the fascia to myofascial pain and fibromyalgia, and improving diagnostic skills promoting early recognition. Along with better recognition of myofascial pain, effective treatment will incorporate evidence-based manual therapies and myofascial self-care.
The second key to success is utilizing a transformative care approach that integrates comprehensive patient self-management training and coaching to empower patients to address the many risk factors that can lead to delayed recovery and chronic pain.
2018 was not a good year to be on the wrong side of medical necessity when it came to drug testing and ongoing prescribing of controlled medication or substance abuse treatment programs.
2019 is likely to be an expensive year for those who do not proactively take steps to understand medical necessity for drug testing, prescribing controlled medication, and ongoing substance abuse treatment, as payers continue to carefully scrutinize these areas.
Using a series of case hypotheticals, attendees will learn how to identify the elements of medical necessity, efficiently and effectively document medical necessity for drug testing and use of drug test results in the ongoing care of the patient, and locate and use payer medical policies and coverage determinations. Attendees will be given 3 tools to reinforce learning objectives: a checklist for medical necessity documentation, sample summaries of payer medical policies, and templates for documenting use of drug test results and tailoring ongoing treatment decisions to the individual patient.
Multiple guidelines have recently emphasized nonpharmacologic interventions for chronic pain, with the role of nutrition strikingly absent.
Given pain’s potential coexistence with metabolic dysregulation, including obesity, metabolic syndrome, and nutrient deficiency, nutrition-based interventions hold promise as an approach for improving pain status in multiple patient populations.
Unfortunately, nutritional and dietary approaches can be complex and time consuming to implement and daunting for clinicians feeling inadequate preparation to provide guidance. Fortunately, nutrition pain management can often be provided in staged interventions based on patient status. This session will review why nutrition is often overlooked, as well as the foundational science of how it can both promote and relieve pain.
The session will discuss how to evaluate nutritional status and initiate foundational anti-inflammatory interventions. Also to be examined is the role of nutritional supplementation in individualized cases including vitamin D, omega-3s, magnesium, and other emerging nutrients.
The session will conclude with a discussion of how to combine nutritional interventions as a long-term strategy for improving both pain and metabolic status.
This course will provide the principals and practice of osteopathic medicine, showing anatomical unity, structure, and function, and pathways to innate healing. We will provide exam skills to incorporate kinetic chains of motion with movement restrictions. If time permits, there will be demonstrations of counterstrain techniques for the spine and extremities.
Pain represents a foremost feature of neurogenic thoracic outlet syndrome (NTOS). Symptoms include ipsilateral upper extremity pain, sensory loss, shoulder and neck discomfort, arm paresis or edema, headache, and even sympathetic nervous system impairment.
This presentation will cover an evidence-based review of the classification, etiology, clinical presentation, diagnostic measures, and surgical treatment of NTOS with a focus on nonoperative therapies such as physical modalities, pharmacological therapies, and the more contemporary, and minimally invasive, cervicothoracic intramuscular treatments with botulinum toxin.
Idiopathic intracranial hypertension (formerly called pseudotumor cerebri) is a cause of headache, along with optic nerve edema, and can lead to permanent visual loss. This course will address how to diagnose it, how best to treat it, and other topics including subgroups and issues of “outliers.” This is a frequently missed diagnosis, and important to include in a differential diagnosis.
Pelvic floor muscle dysfunction is associated with pelvic pain, physical disability, and sexual dysfunction. Prevalence estimates of musculoskeletal dysfunction in various pelvic pain conditions, including endometriosis, vulvodynia, and painful bladder syndrome, range from 21% to 80%.
In addition to being associated with other painful conditions, pain originating from pelvic floor muscles may refer to other body parts such as the lumbar spine, sacroiliac joints, hips, and abdomen. Adding to this complexity is an interplay between muscles and neurons including maladaptive neuronal plasticity associated with widespread muscle pain that may manifest beyond the pelvis. This presentation will provide an overview of key abdominopelvic musculature and their contributions to pelvic pain, screening for musculoskeletal dysfunction, and components of a musculoskeletal pelvic pain examination.
A focus will be placed on reviewing the pelvic anatomy and hormonal/life states related to sex specific musculoskeletal pain, such as pregnancy, endometriosis, and sexual pain.
Additionally, the presentation will discuss the role of different musculoskeletal specialists such as physiatrists and physical therapists in identifying and treating musculoskeletal pain conditions.
Despite being one of the more frequently noted triggers for migraine, estrogen and its role in the pathology of migraine is still unknown.
This talk discusses the current understanding of the role of estrogen in the headache experience. We will start by touching on the clinical experience the field has gathered and then dig into the fledging science on the role of estrogen in the brain, periphery, and blood vessels, and the hypothesis on how these pathways and interactions might trigger the migraine.
Opioid use and addiction have soared in the United States over the past 20 years, and drug overdoses have become the leading cause of injury death.
Persons with opioid use disorder (OUD), particularly those injecting opioids, frequently require hospitalization and encounter need of acute opioid analgesia for trauma, surgery, infection, and other medical conditions.
Treatment of acute pain in persons with OUD present challenges for acute pain management including altered nociception thresholds, physical dependence and withdrawal, tolerance, impaired immune response, and behavioral issues such as opioid seeking and poor coping skills.
Clear goals of care and use of engaging communication methods are essential to deliver optimal inpatient care and smooth plans for hospital discharge.
This session will cover key principles to working with this population including 1) improving patient safety and healthcare outcomes by treating underlying OUD; 2) optimizing pain relief for necessary surgical and medical treatment by providing multimodal analgesia; 3) facilitating access to medication treatment programs upon discharge; 4) empowering patients and providers by promoting clear, just, and equitable treatment of pain; and 5) protecting communities by promoting discharge opioid prescribing habits that minimize risk.
At the 2018 Department of Justice (DOJ) Opioid Summit, then-Attorney General Jeff Sessions remarked that opioid prescribing had reached its lowest point in 18 years. Still, the DOJ is committed to reducing opioid analgesic prescriptions an additional 30% to 33% within the next 3 years. More than ever, prescribers of controlled prescription medications are under intense scrutiny from lawmakers, regulators, and payers. At the same time, some 50 million adults in the US have persistent pain, nearly 20 million of whom experience pain that interferes with daily life or work activities.
As noted by the Pain Management Best Practices Inter-Agency Task Force (PMTF) in its December 2018 draft report, the trend of healthcare professionals opting out of treating pain has exacerbated the shortage of pain management specialists, leaving some patients without access to individualized care. In this session, a partner in a Washington, DC based health law firm will discuss recent legislative and regulatory activity at the federal level and trends in criminal enforcement. He will also discuss noteworthy developments at the state level and analyze the anticipated benefits, drawbacks, and unintended consequences of such actions on people with pain and those who treat them.
Topics will include the implications of recently passed comprehensive opioid legislation—the SUPPORT for Patients and Communities Act; a draft report on pain management best practices by PMTF and the pushback against it; and efforts to reform the federal approach to investigating controlled-medication prescribers.
Assessment, diagnosis, treatment plan formulation, implementation, and follow-up are processes familiar to clinicians and are the main drivers of safe and effective chronic pain treatment. However, many other things influence our clinical decision-making, including the continuing controversies about the role of opioid analgesics in the management of chronic pain, the “opioid epidemic” our nation faces today, and the fear of regulatory scrutiny just to name a few.
Additionally, when formulating decisions about pain treatment, the subjective nature of chronic pain and determining the context of how pain is affecting a person’s life may often be challenging. What we might not be aware of is how other more subtle forces can potentially influence us and have a negative impact on the care we provide for patients—the things that we “bring into the examination room.” This session will focus on how things like precognitive thinking, implicit biases, explicit biases, impressions about patient characteristics and even their demographics may potentially alter our judgment and create disparity.
Suggestions will be presented to help recognize and reflect about how we can make sure that the pain care we deliver is not compromised by these things we might not consider, even though they are there.
Marijuana and hemp are genetically distinct cousins of the genus Cannabis sativa L., yet they have been erroneously associated with each other for the past 80 years.
That all changed in December 2018 when Congress removed hemp from the federal Controlled Substances Act and legalized the plant and its derivatives such as cannabidiol (CBD), a substance which has received a great deal of attention for its potential to treat a variety of medical conditions. This change is historic and has enormous implications in medicine and the treatment of pain.
However, although the oversight of hemp has essentially been transferred from the DEA to the USDA and individual states, the FDA still retains its authority “to regulate products containing cannabis or cannabis-derived compounds” such as CBD.
Accordingly, in an effort to inform healthcare professionals about this rapidly changing field, this presentation will discuss the history of hemp, its legality, derivatives, and its potential future in pain treatment.
It’s your worst clinical nightmare: providing dosing recommendations for opioid and/or nonopioid pain medication treatment for a patient with renal or hepatic impairment.
Even scarier, a patient with end-stage renal or hepatic disease! Put your panic aside and learn about the INs and OUT of managing opioid and/or nonopioid pain medications, and why some medications might need adjustment and others may not.
From metabolism and metabolites to creatinine clearance and Child-Pugh score, you will leave this course feeling more confident in your ability to provide pain pharmacotherapy to patients with renal or hepatic impairment.
It is becoming increasingly common to hear a new analgesic drug molecule described as a “biased ligand,” being “peripherally restricted,” or as having been “engineered.” What do these terms mean? How are such drugs designed or discovered, and how do you even know that you have one when you have one?
For that matter, how are any modern analgesic drugs designed or discovered these days? It’s definitely not your father’s preclinical drug discovery lab any more. Modern drug discovery labs utilize a variety of approaches such as compound libraries, combinatorial chemistry, fragment based lead discovery, high-throughput screening, in silico modeling, in vitro human receptor assays, CRISPR and AI (artificial intelligence).
This session provides a painless introduction to what goes on in modern preclinical drug discovery and translational medicine. Three case studies will illustrate the concepts and the resultant clinical analgesic molecules.
In 2010, the Captain James A. Lovell Federal Healthcare Center became the first fully integrated facility caring for active duty, veterans, retirees, and dependents in the US. This presented healthcare professionals with unique challenges including how to address pain management in such a diverse population.
In 2017, a core team was tasked with the creation of a comprehensive pain management program to address their facility’s need for a cohesive and interdisciplinary approach to chronic pain management in light of the growing national opioid crisis.
The emphasis of this new program is to shift the facility’s focus away from a traditional biomedical curative pain management approach to one that emphasizes a more comprehensive biopsychosocial approach, which can empower patients to take on more responsibility for their pain management and overall functionality. Attendees will learn how this new comprehensive pain management approach has shifted the focus from “fix me” to “teach and empower me.” This journey of “moving mountains” will be illustrated by examining the pitfalls and specific challenges that were faced, as well as the pathways explored, to overcome and rise above these challenges.
The end result will reinforce the main goal of realigning the therapeutic relationship to being patient-centered vs provider-driven with the emphasis on improving overall quality of life and functionality. This focus will also speak on the paradigm shift not only for the patients but also for the providers/staff in order to create a common language that is shared facility wide in the realm of pain management.
Humans have been searching for the Fountain of Youth for millennia, from Herodotus to Ponce de León. Some people feel that regenerative medicine, a field that encompasses stem cells, growth factors, and other cell mediating proteins, is that magical fountain, while others, including some physicians, members of various regulatory committees, and some in the media, believe it is a fad.
As with many emerging topics, there is curiosity and confusion. While the regenerative medicine field is relatively new to most people, there is a wide variety of treatments and technologies available.
We will discuss the various stem cell and growth factors in regenerative medicine and conditions, such as neurological, degenerative changes, osteoarthritis, and tendinitis that have been treated with them.
Despite the widespread acceptance of medicinal and recreational cannabis use internationally and domestically, marijuana remains federally illegal in the United States.
For this reason, there are significant legal implications to clinical practice. Clinicians are unprepared to answer questions regarding legality or safety of cannabis use, and unprepared to counsel their patients on use or abstinence, particularly for pain management. This session will explore legal implications, discuss current science, and define the scope of the problem related to the need for education about risk and safety of counseling patients about cannabis use. Case examples representing real life will be presented.
Ah… drug math. Those 2 little words can make a strong healthcare provider want their mommy. But no fear. Armed with an understanding of conversion calculations, some semisolid facts about equivalencies, and a healthy sense of “Does that LOOK right?”—you’ll be just fine!
This lively session will review new and emerging data on opioid conversion calculations, and guidance for methadone dosing, both for chronic noncancer pain, and for patients with a serious, advanced illness. If you want to be able to dose opioids safety and effectively, you don’t want to miss this session!
This session is designed to familiarize learners with the principles of the neurobiology of the traumatized patient and illuminate the salient concepts that are germane to the presentations and treatment of patients with chronic pain.
At the conclusion of this activity, practitioners should be able to identify several key aspects of behavior and presentation in patients with chronic pain who have a history of trauma, as well as utilize these concepts when interacting and treating these patients to improve outcomes and pain scores.
Genitourinary syndrome of menopause (GSM) is a term used to describe what was formerly known as vaginal atrophy, atrophic vaginitis, or urogenital atrophy.
The older terminology was replaced by this more descriptive term with the goal of more accurately describing the constellation of symptoms experienced by GSM patients, including: vaginal pain, dryness, dyspareunia, urinary incontinence, urgency, frequency, hematuria, and sexual dysfunction.
Although GSM-like symptoms occur in 15% of premenopausal women and 40% to 54% of postmenopausal women, the condition is associated with social stigma and often remains ignored or underdiagnosed. This presentation will review the clinical manifestations, pathophysiology, etiology, evaluation, and management of this condition. Specific emphasis will be placed on differentiating GSM from other genital pain conditions such as vulvodynia and vulvar dermatoses.
Additionally, the presentation will review the impact of postmenopausal pain on quality of life, mental and physical health, and sexual function. Therapeutic recommendations will focus on multimodal therapies to address what is a complex but treatable syndrome.
The importance of early detection and patient education in avoiding long-term risks and complications that compromise quality of life will also be discussed.
Chronic pain, as one of the most common reasons adults seek medical care, requires foundational steps to set up treatment success. Patient education on diagnosis, treatment, and prognosis can have huge impacts on the outcomes of an individual seeking treatment.
Communication is often believed to be an important component of multidisciplinary care and patient experiences. This session will show how to effectively communicate with patients in chronic pain in order to maximize outcomes. We will discuss potential avenues to provide education and information in a way that focuses on appropriate management of a patient’s diagnosis and resolution of fears they may bring from previous medical advice or personal experience.
Understanding the benefits of placebo and nocebo effects, and taking these findings into consideration when providing procedural or intervention counseling and appropriate referral of patients, may have powerful impacts to current practice. Also to be discussed in this course will be patient expectation management—a challenging subject related to prognosis and developing tools on how to have those challenging conversations in a way that continues to promote activity engagement and reduce fear avoidance.
Acute pain is associated with negative outcomes, and efforts to prevent and control pain are necessary. Goals for acute postoperative pain management include reducing the incidence and severity of pain, particularly that which impacts patient function such as movement.
Also important is minimizing side effects from analgesics, preventing postoperative complications, enhancing recovery, and preventing chronic pain if possible. The purpose of this session will be to discuss common challenges including pain assessment, opioid safety, and individualizing multimodal analgesia.
Patient cases will be used to illustrate decision making when applying basic principles of multimodal treatment to perioperative treatment plans.
Chronic pain is quite common as well as challenging in geriatric patients. Common pain syndromes reported are back, neck, sciatica, joint, and headaches.
Any major surgery for back pain or joint replacement can be high risk secondary to comorbid conditions. Patients are quite sensitive to side effects from pain medications such as sedation, drowsiness, constipation, and respiratory depression. As the field of pain management is evolving, many minimally invasive alternatives are available to help the geriatric patient population with chronic pain.
Various treatment approaches will be discussed including radiofrequency ablation, percutaneous lumbar decompression, endoscopic discectomy, endoscopic foraminotomy, spinal cord and peripheral nerve stimulation.
Current and Future Opioid Abuse Risk Assessment and Mitigation Strategies
Both chronic pain and the harms associated with prescription opioid abuse, including serious adverse events and fatalities, are enormous public health problems. Opioid therapy has been a cornerstone of a multimodal approach to the management of chronic pain. However, the increased rate of opioid prescriptions has been paralleled by the abuse of prescription opioids in the US, escalating more than 113% between 2004 and 2013. Recent clinical guidelines and professional society position papers for opioid prescribing recommend that prior to initiating opioid therapy in selected candidates, providers should screen patients to identify those at risk for developing an opioid use disorder (OUD) and that patients maintained on opioids long term should be routinely monitored for the development of aberrant drug related behaviors suggestive of abuse. (Recorded at PAINWeek 2019)
Acute pain signaling has a key protective role and is highly evolutionarily conserved. Chronic pain, however, is maladaptive, occurring as a consequence of injury and disease, and is associated with sensitization of the somatosensory nervous system.
Primary sensory neurons are involved in both of these processes, and the recent advances in understanding sensory transduction and human genetics are the focus of this review. Voltage-gated sodium channels (VGSCs) are important determinants of sensory neuron excitability: they are essential for the initial transduction of sensory stimuli, the electrogenesis of the action potential, and neurotransmitter release from sensory neuron terminals. Nav1.1, Nav1.6, Nav1.7, Nav1.8, and Nav1.9 are all expressed by adult sensory neurons. The biophysical characteristics of these channels, as well as their unique expression patterns within subtypes of sensory neurons, define their functional role in pain signaling. Changes in the expression of VGSCs, as well as posttranslational modifications, contribute to the sensitization of sensory neurons in chronic pain states. .
The nitty-gritty of medication prescribing in a patient population that often feels voiceless or powerless in their quest for pain relief while also battling addiction.
Now more than ever, the opioid crisis and the overwhelming need to treat chronic pain are colliding. It used to just be we worried about opioid use in substance use disorder (SUD) patients, but now even some nonopioid pain medications have become drugs of abuse or have been found to potentially increase the risk for opioid overdose. In addition to providing naloxone education and counseling, learn how to balance the PROs and CONs, or risks vs benefits, of using opioids (when appropriate or indicated) as well as nonopioids for patients with active (or historical) SUD. (Recorded at PAINWeek 2019)
Three case studies will illustrate the concepts and the resultant clinical analgesic molecules.
It is becoming increasingly common to hear a new analgesic drug molecule described as a “biased ligand,” being “peripherally restricted,” or as having been “engineered.” What do these terms mean? How are such drugs designed or discovered, and how do you even know that you have one when you have one? For that matter, how are any modern analgesic drugs designed or discovered these days? It’s definitely not your father’s preclinical drug discovery lab any more. Modern drug discovery labs utilize a variety of approaches such as compound libraries, combinatorial chemistry, fragment based lead discovery, high-throughput screening, in silico modeling, in vitro human receptor assays, CRISPR and AI (artificial intelligence).
Pain Management Strategies for the Geriatric Population
This session will examine pain relief options for the elderly population, focusing mainly on the use of spinal orthoses as a way to reduce or eliminate the use of opioids in the elderly. Statistics have shown, in no uncertain terms, the aging of the American population. With this increase in the elderly population comes a substantial rise in the number of patients living in pain due to various spinal afflictions, from fractures to scoliosis to kyphosis, disc issues, and beyond. Due to the aging population plus the widespread opioid epidemic, practitioners need to explore viable alternative methods to assist elderly patients without the use of opioids. Spinal bracing is an effective alternative for relieving pain and providing a better quality of life for the elderly and may reduce the need for opioids. In this program, we will examine advances in spinal bracing as well as the the recent medical literature supporting its safety, efficacy, and pain relieving capabilities. In addition, we will look at the role that bracing can and should play in reducing the need for opioids in your practice. (Recorded at PAINWeek 2018)
Clinical Applications of Electronic Signal Treatment and the Combined Electrochemical Treatment: A New Method
Combined electrochemical treatment (CET) uses local anesthetics and with electronic signal treatment (EST) to mitigate/eliminate pain, allodynia, numbness, and other symptoms of neuropathic and chronic pain. Its physiological actions are understood using the principles of physics, not pharmacology. CET treats all causes of peripheral neuropathy and patients experience reduction of pain, dysesthesias, allodynia, numbness; an increase in strength; improvement in motor function, balance, and improved QoL. EST provides an alternative to steroids due to profound anti-inflammatory effects with evidence showing boosting of immune function. Central pain can be treated utilizing CET and EST. A case report of phantom limb pain illustrates the potential for sophisticated multiplexed electric energy signaling to treat central pain. Sports medicine care includes application of physical modalities to treat acute injuries so patients can remain active and competitive. This course will examine how EST provides risk free and cost effective treatments for the aches and pains of life by reducing muscle spasm, blocking pain, and allowing function to be restored more quickly than with many existing modalities. (Recorded at PAINWeek 2018)
Bridges to Babylon
Individuals who suffer from chronic pain often present with significant medical and psychiatric comorbidities that can exacerbate the pain experience and contribute to a further erosion of quality of life and disability. In this current climate of reducing the reliance on opioids or opioid sparing it is essential that clinicians effectively and efficiently identify and manage these comorbidities. This presentation will provide an overview of the prevalence of common comorbidities, assessment strategies, and pharmacologic and nonpharmacologic interventions in patients with chronic pain. (Recorded at PAINWeek 2018)
Benzodiazepines and "Z" Drugs for Pain Patients
Benzodiazepines and ‘Z’ drugs are frequently coprescribed to pain patients. They were developed for legitimate medical needs, but unbridled success and application has led to serious problems, some of which are known. The potential extreme duration of the withdrawal syndrome, however, is virtually unknown by providers and regulators. Patients suffer, not knowing the symptoms have a cause and not having medical professionals to turn to for help. They may become “difficult” patients, marginalized, or told that their symptoms are psychological. Paradoxically, the simplicity and success of GABA-A receptor knowledge has distracted from studying other pharmacology of these drugs. A glaring example is the almost universal lack of awareness of peripheral benzodiazepine receptors. Despite the higher risk, benzodiazepines have not been increased in scheduling per the DEA’s Controlled Substances Act. This course will address the unmet and largely unrecognized medical need of overprescription, dependence, and withdrawal, and discuss actionable change to improve the knowledge, attitudes, preemptions, and practices of stakeholders. (Recorded at PAINWeek 2018)
Despite the current opioid crisis, opioids remain the mainstay of analgesic therapy. They are associated with a multitude of side effects, including respiratory depression, pruritus, nausea, vomiting, urinary retention, ileus, and constipation. Beyond certain doses and duration of intake that vary from patient to patient, opioids can also induce a state of paradoxical hyperalgesia. Among these side effects, opioid induced ileus, urinary retention, and opioid induced hyperalgesia contribute to unnecessary prolongation of hospital length of stay. Naloxone is a well known antagonist used to reverse opioid induced respiratory depression. There is evidence supporting the use of low dose IV naloxone to prevent and reverse all of the above mentioned opioid induced side effects without reversing the analgesia. However, low dose IV naloxone appears to be underutilized. In addition to reviewing the literature, we will share our experience and clinical results from the implementation of low dose IV naloxone protocols at Cedars Sinai Medical Center in Los Angeles. (Recorded at PAINWeek 2018)
The content of this presentation will encourage audience participation. The “rights” section—drug, patient, time—will enable participants to reflect on medical malpractice cases where these rights were initiated in less than adequate outcomes and fell below the standard of care. Additionally, attendees will come to understand the pharmacokinetic challenges often reflected in the treatment of the geriatric patient, and there will be discussion of the various opioid metabolism routes of substrate, inducer, and inhibitor pathways. (Recorded at PAINWeek 2018)
Policies and Practicalities
The current opioid epidemic has resulted in numerous professional and society guidelines focused on safe opioid prescribing. In addition, policymakers have focused on state legislation to limit the duration of opioid prescribing for acute pain. As a result of the increased scrutiny, prescribers have shifted their focus to limiting opioid prescribing for patients with chronic noncancer pain. Now, more than ever, evidence based behavioral treatment modalities are essential for fostering pain coping skills and providing support as part of optimal interdisciplinary pain management. This course will begin with a brief review of the opioid epidemic. Current opioid prescribing guidelines will be discussed with a particular emphasis on indications for opioid tapering. Strategies for the medical management of opioid tapering will be presented, along with a detailed discussion of evidence based psychotherapeutic interventions known to result in improvements in physical and emotional functioning while promoting opioid tapering. (Recorded at PAINWeek 2018)
Counterfeit medicine and counterfeit medical services pose a clear and present danger to our society. While we have all heard of the opioid epidemic, many of us are not aware that a great deal of the morbidity and mortality within the opioid epidemic is caused by legal and illegal counterfeit medicine and counterfeit pain providers. According to the World Health Organization, global sales of counterfeit products in the pharmaceutical industry alone accounted for $431 billion in 2012. Counterfeit pharmaceuticals alone account for up to $200 billion in losses per year. Over the last few years, I have discussed this topic in detail and helped bring national attention to this “silent epidemic.” For the first time ever within an accredited CME conference, we will discuss solutions and technologies available TODAY that are aimed at fighting counterfeit medicine. (Recorded at PAINWeek 2018)
There are studies that must be performed in order to determine their clinical relevance. The process extends from bench top to bedside and incudes various special populations like pediatrics and geriatrics. This course addresses various elements related to the study of analgesics. Novel improved preclinical animal models in analgesic studies will be examined. The unique issues of unusually high placebo and nocebo effects in analgesic, which can lead to confusing results, will be discussed along with the role and responsibilities of acting as a principal investigator in an analgesic trial. This course will review the practical impact of new healthcare measures and the increased importance of comparative effectiveness trials, health and pharmacoeconomic outcomes, and the process of publishing data and determining authorship. At the conclusion of the program participants shall have a comprehensive understanding of analgesic trials. (Recorded at PAINWeek 2018)
Do As I Say!
Surveys of healthcare providers indicate that one of the most distressing features of clinical practice is that of patient nonadherence. Its incidence in pain medicine is concerning: over 50% of patients with chronic noncancer pain are nonadherent with their prescribed exercise treatment and up to 62% of patients with chronic noncancer pain are nonadherent to psychopharmacological treatment. Nonadherence is a critical issue, not only because it undermines treatment effectiveness, but because it can waste limited resources and be dangerous, especially regarding medications. Although promoting adherence is an important component of clinical practice, unfortunately it’s rarely taught in medical, nursing, or dental school. This presentation will review the ethical considerations and current models and predictors of adherence in pain care and provide practical tools to improve adherence to medication management, exercise, nutrition, and weight loss. (Recorded at PAINWeek 2018)
Pain remains one of the most common reasons that people seek medical attention in the United States. When pain was designated as the fifth vital sign, people were given the right to have their pain assessed and effectively treated by their healthcare professionals. A number of ethical dilemmas have surfaced since, including the increased prescribing of opioid medications for patients with chronic pain, in the face of also increasing rates of abuse, misuse, and addiction related to these medications. The “opioid overdose epidemic/crisis” has led us to the challenge of balancing the safe, compassionate, and effective treatment of chronic pain against serious negative outcomes associated with the increased abuse and misuse of these medications. With overdose death rates increasing, tensions running high, a multitude of political and regulatory involvement, and knee-jerk reactiveness, it seems as if the only thing being forgotten is the needs of chronic pain patients and the core ethical principles intended to help clinicians maintain the highest standards of care. This session will describe these principles and clarify their role in determining reproducible courses of action that maximize safety, efficacy, and compassionate pain care, regardless of the direction the “opioid pendulum” is swinging. (Recorded at PAINWeek 2018)
Year of the Locusts
The CDC guidelines have caused controversy and spurred heated discussion. Produced with a paucity of evidence based medicine, they were never evaluated and iterated in the manner of more appropriate guidelines. In this course, we will examine the guidelines and their effect on practitioners—primary care physicians, pain specialists, etc—and chronic pain noncancer patients as well as some chronic cancer patients. Many functioning patients have had their opioid dosages diminished, either in concert with their physician or forcibly, without any say in the matter. This, along with a marked reduction in the amount of legal opioid medications that can be produced, has led to significant unintended consequences: practitioners are leaving the field; some refuse to even prescribe opioids, mostly due to fear of overregulation; once-functional patients are being abandoned by the medical field; patients are searching for something to return them to functionality, which can lead to overdose and death, particularly from heroin and illicit fentanyl. Indeed, the opioid crisis has now become the heroin and fentanyl crisis. During this presentation, solutions, and the changes necessary to bring them about, will be discussed. (Recorded at PAINWeek 2018)
The reality of chronic pain can be sobering and depressing. The term “empathy” in the context of medical care may sometimes be confusing and misunderstood. This often results in the conveyance of sympathy—the “I’m sorry approach”—to patients suffering from chronic pain, which does not achieve the same goals as providing a compassionate, meaningful, and empathic relationship. Empathy is often defined as the capacity to understand or feel what another person is experiencing from their frame of reference: to “put oneself in someone else’s shoes.” Empathic listening may not be easy to achieve, but often may result in a much more gratifying level of communication for patients and healthcare professionals. In a time where it seems as if we are being told more now than ever about documentation, regulatory scrutiny, and taking a detailed history, it can be quite difficult to take the patient’s narrative into account, and truly reflect and understand the life and context that people with chronic pain experience. This session will focus on these topics as well as strategies to implement in clinical practice to help identify the patient’s individualized needs and integrate them into the most targeted assessment and pain treatment plan possible. (Recorded at PAINWeek 2018)
Pain represents a foremost feature of neurogenic thoracic outlet syndrome (NTOS). Symptoms include ipsilateral upper extremity pain, sensory loss, shoulder and neck discomfort, arm paresis or edema, headache, and even sympathetic nervous system impairment. This presentation will cover an evidence based review of the classification, etiology, clinical presentation, diagnostic measures, and surgical treatment of NTOS with a focus on nonoperative therapies such as physical modalities, pharmacological therapies, and more contemporary minimally invasive, cervicothoracic intramuscular treatments with botulinum toxin. (Recorded at PAINWeek 2018)
Hello Darkness My Old Friend
A myriad of medical conditions are accompanied by depression. Somatic pain is frequent in major depression and is found in 50% to 90% of depressed patients. Assessing pain accurately and, most particularly, knowing the trauma history and acknowledging its impact on functionality, may provide key information on how to most effectively treat pain associated with depression. The criteria for major depression is inclusive of symptoms that can be directly impacted by music psychotherapy: pain, fatigue, agitation, feelings of worthlessness, impeded thinking/concentration. This presentation will address common diseases such as heart disease, cancer, neurologic dysfunction, and multiple sclerosis, in which depression is a frequent secondary/contingent diagnosis. We will provide research substantiated clinical interventions that support ways in which music psychotherapy can work on a neuro/physiological level to increase endorphins, oxytocin, immunoglobins, and T cells, while reducing cortisol and stress hormones, enhancing quality of life as a central part of the treatment trajectory. We will also explore the significance of the interactive pain-anxiety-depression connection in clinical applications for this fragile population. (Recorded at PAINWeek 2018)
Steadying Our Understanding with the Evidence
Low back pain is one of the most prevalent, costly, and complex issues we face in rehab and medicine as a whole. It has been proposed that a large portion of back pain cases are due to core weakness or, as it’s commonly referred to, instability. This idea originated from the work of Paul Hodges and Peter O’Sullivan in the early 1990s. The idea caught like wild fire, infiltrating university level classes, continuing professional education courses, and subsequently shaping societal beliefs about backs and back pain causes. Fitness, rehabilitation, and medical professionals frequently blame back pain on an unstable or weak core. Consequentially, patients believe that, if they experience back pain, they must be weak and unstable in their spines. Yet, what does the current best evidence tell us about this topic? Has this theory strengthened, or has it failed to keep up with more rigorous investigation? Finally, what implications could this clinical framework have on patient outcomes and resilience surrounding the most common musculoskeletal complaint in the world? (Recorded at PAINWeek 2018)
To Dream the Impossible Dream
With our current climate of opioid overuse and increasing opioid related deaths, alternatives to pure mu opioids are necessary. Buprenorphine, an important weapon in the arsenal for management of substance use disorder, is now rising in popularity as an opioid option for chronic pain. Evidence has demonstrated efficacy for various chronic pain conditions with less risk of adverse effects, such as the development of tolerance and respiratory depression. With increasing utilization, patients on chronic buprenorphine therapy are now more frequently being admitted to hospitals with severe acute pain due to surgery or trauma. A partial opioid agonist, buprenorphine has unique pharmacokinetic properties that differ from pure mu opioid agonists. Challenges with pain control can occur when acute pain treatment with a pure opioid is used in patients receiving buprenorphine due to its strong affinity to the mu receptor. This session will review the unique characteristics of buprenorphine and offer options for treatment of severe acute pain in patients receiving buprenorphine therapy. (Recorded at PAINWeek 2018)
Central Sensitization, Opioid Tapering, and Educational Support
Chronic pain involves a complex process, with an underlying pathophysiology that is now understood to involve a sensitized state. Understanding the etiology is essential to selecting appropriate treatment modalities. It is also essential to educate patients in a way that can be understood and incorporated into their lives and treatment plans. In this session, cases will be used to highlight clinical decision making and pain management options for patients experiencing chronic pain and central sensitization. We will focus on tapering opioids as part of this management plan, discuss how to taper and which supportive measures assist in developing an effective taper, including best practices around the use of nonopioid analgesics and withdrawal management, as well as effective patient education and programming. (Recorded at PAINWeek 2018)
The number of deaths from prescription opioids from 2014 to 2016 were essentially unchanged, but deaths from illicit fentanyl derivatives over the same time period increased by almost 650%. Between 2010 and 2015, we know that by county, prescribed morphine daily dose equivalents (MEDD) per capita decreased by about 50% and remained stable in about 30%. We also know that during the same time span, overall opioid prescribing rates by county decreased about 50% and remained stable at 34%. Additionally, between 2010 and 2015, the average daily MEDD per prescription dropped by 72%, remained the same in 26%, and increased only by 2% per county. Heroin related deaths have skyrocketed over the last 2 years and, in certain states, up to 70% of the presumed heroin related deaths in fact are attributable to heroin laced with illicit carfentanil or similar ultrahigh-potent derivatives. The CDC has often lumped aggregated data for opioids into various reports without consideration of combined prescription related opioids that were obtained illegally and used in combination with illicit opioids plus or minus other sedative hypnotics including alcohol. This data has unfortunately mushroomed into lay press (false) claims that prescription opioids are synonymous with the devil. This session will provide an overview of the data, separate fact from fiction, and provide a comprehensive overview of illicit fentanyl derivatives, relative potencies, and dangers. Participants will gather the necessary information to intelligently separate alternative facts from the real facts as they relate to opioid related deaths. (Recorded at PAINWeek 2018)
In professional practice, numerous medications are disguised as “muscle relaxants”; however, just how many actually are true relaxants of peripheral muscle? In this discussion on the overall classes of muscle relaxants, we will endeavor to evaluate these medications based on respective mechanisms of action and truly decipher just what type of medications the stereotypical “muscle relaxants” actually are. We will also aim to improve patient care by providing a strategic thought process into the appropriate selection of these medications for use in patients with muscle spasticity and/or muscle spasms. At the conclusion of our discussion, we will be able to declare that “The jig is up!” and reveal the true identity of these so-called muscle relaxants! (Recorded at PAINWeek 2018)
When treating acute and chronic pain conditions, there is a need for “balanced” analgesia or multimodal analgesia. These are cases in which opioids as monotherapy are rarely appropriate. The therapeutic role of adjuvant analgesics is to increase the therapeutic index of opioids by producing an opioid-sparing effect. The use of nonopioid analgesics, adjuvant agents, and, in some cases antidepressants, may provide additional pain relief by opioid-sparing effects. Many of these agents have additional benefits in treating other related comorbid conditions present in those who suffer from chronic pain. Newer regulatory guidelines, like the CDC Guideline for Prescribing Opioids for Chronic Pain, recommend that first-line treatment for acute and chronic pain should be nonopioid analgesics as an initial trial, emphasizing the need to optimize multimodal analgesia including nonpharmacologic interventions to improve outcomes. It is vital to have an appreciation and knowledge of alternative pain treatments in an era where mass opioid use has been the norm. During the so-called opioid epidemic, practitioners should provide patients with effective tools to help manage pain while minimizing the negative effects of opioid exposure. Adjuvant agents are not primarily identified as analgesic in nature but have been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when used with opioids. Adjuvants add a unique action in opioid-resistant pain and can play a role in reducing opioid side effects. Knowledge of this class of medications is critical for the prescriber to be able to document their thought process in treatment plan development in the event of regulatory review. The goal of this course is to provide you with the tools to successfully evaluate the appropriate role of these agents in your practice. (Recorded at PAINWeek 2018)
Throughout the course of history, mankind has experienced heightened effects from natural sources, and even delved into creating or modifying substances to the same accord. In our society we have a very “objective” classification of materials based on generally accepted medical use and propensity to become habit forming. However, as one can recall with ethyl alcohol (such as beer, wine, and hard liquor), a substance may never actually chemically change, yet can move across legal classifications. How does that happen? Well, join our discussion to learn how numerous illicit substances have similar, if not the same, mechpreanisms of action as legal prescription medications readily available today. One may even walk away with a few pointers from “street chemists” that are not easily available in any of our professional textbooks. (Recorded at PAINWeek 2018)
A perennial PAINWeek favorite returns! Many patients receiving opioids will need to be switched from one to another during therapy, or at least from one dosage formulation or route of administration to another. During this session, practitioners learn to recognize clinical situations in which opioid switching would be appropriate. Attendees will also work on a problem set designed to sharpen their skills in opioid conversion calculation. (Recorded at PAINWeek 2018)
It's a Bird! It's a Plane! No, it's a Case Manager!
Stanford Pain Management Clinic was one of the first programs of its kind to recognize that having complex care case managers could have a significant impact on care coordination for patients, resulting in more successful and positive patient outcomes. In the pain clinic, complex care case managers act as liaisons between patients, pain management providers, and other members of the multidisciplinary care team (both within a practice/hospital and in collaboration with community organizations) to ensure clear communication and coordination of care. This course will explore all the ingredients combining case managers and optimal pain management. (Recorded at PAINWeek 2018)
Clinical Pearls
Diagnostic testing is an integral component for the differential diagnosis. In routine clinical practice there has been a tendency for clinical examinations to become more cursory, largely influenced by increasing demands on a practitioner’s time and the patient’s expectations of technological advances. The end result may arguably lead to an overreliance on technology for basic clinical diagnosis. This session is meant to provide a review or, for some, an introduction to basic structural and functional studies used for the diagnosis of pain related problems. Attention will also be given to the limitations of such studies and the importance of establishing clinical relevance to their findings. Factors that adversely affect clinical management potentially resulting in failed treatment will be discussed, as well as best practices when utilizing such studies to help enhance clinical outcomes for treatment. (Recorded at PAINWeek 2018)
Pain therapy is a challenge and requires special approaches. This course, as part of the Pain Educators Forum (PEF), will build on information provided in other PEF sessions and focus on the prevalence and impact of unrelieved pain, pathogenesis, and treatments of pain. Participants will learn about approaches and advances in therapy of common acute and chronic pain syndromes, and evidence based recommendations for pharmacotherapy of pain will be provided. Pain Therapeutics examines current trends in pain relief, which can be implemented into practice as soon as attendees return to work. (Recorded at PAINWeek 2018)
Effective clinical interviewing and pain assessment are critical to the appropriate diagnosis and management of pain. In this presentation, attendees will learn how to apply principles of effective communication and also ascertain how to evaluate available assessment tools. (Recorded at PAINWeek 2018)
The Razor's Edge
Pelvic peripheral neuralgias may be a cause of pain in 6% of women with chronic pelvic pain. This type of pain is neuropathic and typically follows the distribution of specific peripheral nerves. Common causes of neuropathic pain include trauma and visceral pathology, and the diagnosis can be confirmed by performing selective peripheral nerve blocks. Treatment options include medication, nerve blocks, nerve ablation, and surgical resection or decompression. The objectives of this lecture are to enable providers to recognize peripheral neuropathic pelvic pain, identify the affected peripheral nerve based on the distribution of the pain, and develop strategies for conservative and surgical management. (Recorded at PAINWeek 2018)
Scars and Traumas
It is reported in the literature that physical scars have a systemic influence on chronic pain and are linked to chronic postsurgical, back, shoulder, and neuropathic pain, and are not only physical, but emotional. Scars initiate and maintain stress on the nervous system, “locking” the sympathetic nervous system into a prolonged fight/flight phase, adversely affecting muscle tone, fascia tension, chronic pain, and functional outcomes. This course introduces the concepts of scar release, exploring the integral relationship of scars, stress, and disease. Participants will see how scars/traumas influence nervous system regulation, fascia, and chronic pain, and identify the relationship between the physical location of scars and various chronic pains throughout the body. The presentation will include scientific analysis of scar release therapy applied to various pain patient samples and the widespread implications this may have in future pain management and functional rehabilitation. The session will conclude with scar release therapy demonstration so participants will be able to witness and learn how to integrate this therapy into their clinical practice. (Recorded at PAINWeek 2018)
When to Refer to a Specialist
The art of treating chronic pain requires one to address both the sensory and emotional aspects of pain. Pain medicine is a relatively new field conceived out of unmet needs to help those who suffer from chronic pain. With the recent development of formal pain medicine training programs, this new specialty has promoted the application of a multidisciplinary approach to treating chronic pain conditions. Over the last decade, our treatment paradigm for chronic pain has drastically shifted from opioid based medications to nonopioid based treatments and interventions. This presentation will review the various interventional pain management treatment options and discuss when to refer to a specialist for these interventions. All healthcare professionals in the field of pain medicine, with a special emphasis for those who practice primary care medicine and noninterventional pain management, will benefit from attending this course. (Recorded at PAINWeek 2018)
This presentation will highlight common procedures used for pain reduction, their evidence base, and a basic description of how each procedure is performed. We will primarily review epidural steroid injections, facet joint blocks and denervation, sacroiliac joint injections and denervation, myofascial pain, spinal cord stimulation, and intrathecal pumps. (Recorded at PAINWeek 2018)
West Virginia continues to lead the nation, and world, in drug overdoses, which makes one ponder as to what is being done at the “ground zero” of the opioid epidemic to save and improve lives. Where else but where it’s “worst” should some of the possible solutions come from? In 2016, an interprofessional panel of experts in pain management—ranging from medicine, osteopathy, nursing, pharmacy, dentistry; public health; the state PDMP; and representatives from insurance providers—was developed with aims of doing just that. The West Virginia Safe & Effective Management of Pain (SEMP) Guidelines were developed to facilitate the shift of the best practices in pain management becoming the new standard of care. SEMP Guidelines include 2 main components including the risk reduction strategy and the clinical treatment algorithms. Pain management algorithms are not available anywhere else in the entire world! So we would like to welcome you to “the West Virginia Way” and see just how the “Wild and Wonderful” state of West Virginia is approaching the opioid epidemic from a true ground zero. After all, if it works where it’s worst, how could it not help your state or your practice? (Recorded at PAINWeek 2018)
The Yin and the Yang of Pain Research
The clinical ideal is to match known, objectively identified mechanisms of disease with the known mechanisms of an intervention (drug or nondrug). Of course, we are far from this ideal as our knowledge of disease mechanisms is very elementary in some cases, especially in pain, and our knowledge of drug mechanisms is rudimentary, and our knowledge of how nondrug interventions actually work is almost nil. In this course we will discuss recent progress in regards to identifying clinically significant mechanisms/pathophysiology, especially by more objective testing and biomarkers, as juxtaposed with our spare knowledge of drug mechanisms (eg, pharmacodynamics, neuropharmacology), as well as discuss some of the hypothetical mechanisms of nondrug interventions. (Recorded at PAINWeek 2018)
Full-Metal Jacket
Ketamine is abused as a club drug due to its potent hallucinogenic properties. What we know of the drug’s adverse events/side effects/toxicity in high dose and frequent use come from this cohort of abusers, with most of the data coming from Japan. We will examine the neurocognitive effects (euphoria, visual, and auditory hallucinations) that are desired by abusers, but correspond to “adverse events” (dysphoria, frightening hallucinations) in the clinical context. We will also examine the cultural framework of abuse and qualitative sociological impact of the drug used in the context of a club drug. Finally, we will examine the toxicity of high dose chronic use as a caution to frequent infusion in certain clinical situations. (Recorded at PAINWeek 2018)
Mirror, Mirror on the Wall
Complex regional pain syndrome (CRPS) is a painful condition localized to a limb or body region, typically in response to trauma or surgery. Although several contributing mechanisms of CRPS have been described, the exact pathophysiology of the condition is not completely known. Graded motor imagery (GMI) is a comprehensive program aimed at sequentially activating motor cortical networks of the disordered limb to improve neural reorganization. GMI includes phases of progressive sensory-motor restructuring beginning with laterality training, guided imagery, and ultimately leading to mirror therapy. In this lecture, leading mechanisms for the development of CRPS will be discussed, along with the role of reorganization of the somatosensory cortex. In addition, treatment algorithms will be included along with medications, injections, and a thorough review of GMI and its outcomes. (Recorded at PAINWeek 2018)
The endocannabinoid system (ECS) is recognized as an important modulator of many physiological processes. Recently, an increasing body of evidence has been accumulated to suggest the antioxidant, anti-inflammatory, neuroprotective, and antinociceptive roles of the ECS. In 1997, the Office of National Drug Control Policy commissioned the Institute of Medicine (IOM) to conduct a comprehensive study of the medical efficacy of cannabis therapeutics. The IOM concluded that cannabis is a safe and effective medicine, patients should have access, and the government should expand avenues for research and drug development. This course will discuss cannabis as it relates to effective pain management. (Recorded at PAINWeek 2018)
An Unexpected Valentine
Skin conditions can be painful too. We are fortunate to have CBD and other cannabinoids as well as THC for many skin conditions including acne, itch, eczema, psoriasis, and wounds of all sorts. The cannabinoids help not only with the signs and symptoms of the dermatologic problem, but also help alleviate any concurrent pain. Cannabis can be an excellent alternative to opioids for pain, and may help to reduce the opioid crisis. First, we will examine the difference between hemp and cannabis, chemically, medicinally, and legally. Next, we will do a brief overview of just what the endocannabinoid system is, and how it is involved in the skin, and explore recent scientific studies behind cannabinoids and skin conditions. Other characteristically painful skin conditions that are not as frequently encountered include pyoderma gangrenosum, hidradenitis suppurativa, calciphylaxis, and vasculitis. Included in this course will be a summary of what skin care and topical pain products are already on the market, and what bright options the future holds. (Recorded at PAINWeek 2018)
The Psychology Toolbox
The opioid epidemic has caused many patients, clinicians, and payers to seek nonpharmacologic options to assist with managing pain. Psychology has a well-established role in the treatment of pain conditions but familiarity with the range of pain related interventions varies widely among clinicians. The Psychology Toolbox seeks to fill the knowledge gap by briefly explaining the role of psychology in pain treatment and reviewing a range of evidence based interventions to assist this burgeoning clinical population. Although cognitive behavioral therapy based interventions are the most frequently studied and applied paradigms, a number of other treatments also have demonstrated efficacy in pain care, but are lesser known. Thus, cognitive behavioral therapy for pain will be discussed, followed by an overview of several other pain treatment modalities: biofeedback training, mindfulness based stress reduction, and acceptance and commitment therapy. At the conclusion of the session, participants should possess a greater awareness of the vast array of evidence based treatments that can be used to help this group of individuals. (Recorded at PAINWeek 2018)
Depending on the condition, over 75% of individuals who experience chronic pain also experience disrupted sleep due to both direct factors (pain itself) and indirect factors (decreased activity, increased muscle tension, heightened stress). Conversely, up to 50% of individuals who seek help for sleep problems also have chronic pain. Research has shown that nonpharmacologic treatments are highly effective for chronic pain and insomnia. Cognitive behavioral therapy (CBT), an empirically validated intervention, is among the most successful and widely used of these treatments. This presentation will review recent research on the bidirectional relationship between sleep and pain, as well as effective interventions for treating insomnia and chronic pain that go beyond basic sleep hygiene or use of pharmaceutical sleep aids. It will introduce approaches for combining CBT protocols to treat concomitant chronic pain and insomnia, addressing the limitations of these combined approaches, and offering a brief overview of the literature regarding circadian rhythmicity of sleep and pain. (Recorded at PAINWeek 2018)
Unveiling the Mask
When tapering opioid therapy, frontline practitioners may at times be faced with chronic pain patients suffering from undiagnosed mental health disorders. In most cultures, the majority of mental health cases go unrecognized in primary care settings. About 60% of previously undetected cases could have been recognized if the patients had been evaluated for a mental health disorder. Research has shown that chronic pain is most often associated with depression, anxiety, and somatoform, personality, and substance use disorders, but less is known about the relationship with other conditions, such as schizophrenia spectrum/psychotic, sleep-wake, bipolar, neurocognitive, obsessive compulsive, and dissociative disorders. The purpose of this presentation is to help providers learn more about mental health disorders, how they are defined, and how the definitions have changed in the latest Diagnostic and Statistical Manual of Mental Disorders. The results of a pilot study looking at the prevalence rates of these new DSM disorders among patients who suffer from chronic pain will be delineated. (Recorded at PAINWeek 2018)
Exercise Your Demons
Nonpharmacological interventions are increasingly being prescribed for people with chronic musculoskeletal pain. Current evidence on the role of regular physical activity and exercise in the management of chronic musculoskeletal pain (eg, fibromyalgia, chronic low back pain, and osteoarthritis) will be discussed. We will review specific recommendations pertaining to therapeutic exercise including dose, progression, barriers to exercise adherence, and utilization of the biopsychosocial model of pain in the prescription of exercise. (Recorded at PAINWeek 2018)
Here a Pain There a Pain, Everywhere a Pain Pain
While we have increasing understanding of the mechanisms of musculoskeletal pain, this knowledge has translated into treatments that so far have left many patients and healthcare providers dissatisfied. This is particularly true for fibromyalgia syndrome (FM) and chronic widespread pain that afflicts up to 20% of the general population, mostly women. In this course, the epidemiology and clinical characteristics of FM, defined by widespread pain, tissue tenderness, and a host of somatic symptoms, will be briefly reviewed. In addition, new research over the last 10 years has identified a number of peripheral and central nervous system abnormalities. Some findings are consistent with central and peripheral sensitization; however, most of the available treatments have focused on central pain abnormalities. Much of the most recent evidence for abnormal pain mechansims comes from the functional magnetic brain and spinal cord imaging of FM patients. A brief overview of peripheral/central mechanisms and treatments for FM will be provided, along with findings regarding abnormal connectivity between sensory and affective brain areas. The session will conclude with a summary of findings and recommendations for a comprehensive approach to the assessment and treatment of FM focusing on pain but also integrating fatigue, sleep abnormalities, and mood. (Recorded at PAINWeek 2018)
Oh My Aching Back
Chronic low back pain (cLBP) is a pervasive problem, consistently among the top 5 most common reasons for primary care visits and among the most prominent painful conditions. Although some patients with cLBP have clear pathoanatomic causes of pain, for many there is no clear association between pain and identifiable pathology of the spine or associated tissues. This medically unexplained pain is often termed “nonspecific” and happens to be the most common form of cLBP. Observers tend to react with uncertainty and confusion when confronted with a patient whose pain is not clearly medically understood. Previous research has shown that laypersons and providers alike are less inclined to help, feel less sympathy, dislike patients more, suspect deception, and attribute lower pain severity to patients whose pain does not have an objective basis in tissue pathology. Because of these stigmatizing responses from others, patients with cLBP may feel that their pain is being devalued and discredited. In this presentation, research addressing experiences of stigma among patients with cLBP (and other chronic pain conditions) will be reviewed. Although thorough research to-date is lacking, preliminary evidence addressing the consequences of perceived stigma on the physical and psychological well-being of patients with cLBP will be discussed. Finally, therapeutic strategies that healthcare providers can utilize to help minimize potentially stigmatizing responses to their patients’ cLBP will also be addressed. (Recorded at PAINWeek 2018)
The Knee Bone’s Connected to the...
Musculoskeletal (MSK) pain conditions are the leading cause of disability worldwide, and this year’s American Pain Society track will explore the latest evidence addressing measurement, mechanisms, and management of MSK pain conditions. Among the most prevalent MSK pain conditions is knee osteoarthritis (OA), which is the leading cause of pain and disability among older adults. A brief overview of peripheral mechanisms and treatments, along with the epidemiology and clinical characteristics of knee OA, will be discussed in this course. Knee OA has historically been viewed as a regional pain condition driven by peripheral input due to arthritis changes in the knee joint. Accordingly, treatments have primarily focused on targeting peripheral changes. However, burgeoning evidence suggests that central pain processing is substantively altered among knee OA sufferers, raising the possibility that peripherally focused treatments may be ineffective for some proportion of these patients. Findings from studies using quantitative sensory testing and neuroimaging to examine central mechanisms related to knee OA will be presented. Because knee OA appears to disproportionately affect specific population groups, with African Americans at increased risk for OA related pain and disability, findings regarding ethnic group differences in OA pain and associated contributing factors will be discussed. The session will conclude with a summary of findings and recommendations to adopt a biopsychosocial approach to assessment and treatment of knee OA. (Recorded at PAINWeek 2018)
Many healthcare professionals have experienced aberrant behaviors from patients when prescribing controlled substances. The formulation of a differential diagnosis of the behaviors and having a consistent plan of action is key. This presentation will draw upon real cases to highlight approaches that may be considered, as well as focus on some of the strengths and weaknesses of patient aberrant behavior monitoring tools. Through case studies and assessment tools, participants in this course will learn to recognize aberrant drug taking behaviors, and various approaches to patient interactions will be demonstrated. (Recorded at PAINWeek 2018)
Burnout, a phenomenon closely linked with depression and characterized by emotional exhaustion, depersonalization, and reduced self-efficacy, has increased at a disproportionate rate in physicians compared to the general US working population. While interventions have been developed to address factors that contribute to burnout among practicing physicians, there is a strong need to focus on prevention for all clinicians involved in the delivery of healthcare services. This presentation will provide information about burnout statistics, factors that contribute to it, and ways it can be prevented. Pathways to developing a work-life balance and promoting self-wellness will also be reviewed, as will a novel resident and fellow wellness program developed at Stanford University. (Recorded at PAINWeek 2018)
Reefer Madness Revisited
Medical and recreational marijuana are sources of great confusion to patients and clinicians alike. A culture of “neuromysticism” around medical marijuana has arisen, leaving patients and clinicians muddled regarding what constitutes “medical” marijuana. This is due in part to the poor quality of the available research on safety and efficacy, which is due, in turn, to the restrictive scheduling of the drug. This lecture will focus on what we know, and what we don’t know, about the efficacy and safety of medical cannabinoids. Specific recommendations regarding the safest and most effective use of medical marijuana as part of a pain management armamentarium will be provided. (Recorded at PAINWeek 2018)
In order to successfully clinically manage pain, it is essential to begin with an understanding of the underlying mechanisms responsible for its generation. A skillful approach based upon better knowledge concerning the anatomical structures, pathways, and events that result in pain is more likely to lead to effective clinical management of pain. This discussion will include an overview of medication classes typically considered for pain and the pathways they affect. (Recorded at PAINWeek 2018)
There are many reasons why healthcare providers choose not to manage pain, or unknowingly undertreat pain, including fear of addiction or overdose, litigation, and difficult personality types. Mostly practitioners undertreat because of a lack of knowledge, understanding, and confidence to manage such an elusive diagnosis. Have you ever asked yourself Which medication and why? Do I need an opioid agreement to prescribe hydrocodone? What about addiction? Which complementary treatment approaches are available to my patient and which ones does the evidence support? Is there anything else that I can try other than an opioid? What about behavioral management? How can my mental health colleagues help with pain management, and how do I suggest this to my patient? Improving the clinician’s knowledge and skills will help demystify and reduce the fear associated with managing such a subjective and otherwise challenging diagnosis. This timely lecture will focus on the importance of managing pain in the biopsychosocial model from a multidisciplinary perspective. In this case based learning presentation, we will be reviewing complex case studies on common, otherwise challenging-to-manage pain syndromes including chronic low back pain, postherpetic neuralgia, and diabetic peripheral neuropathy. Focus will be placed on educating the audience about pain physiology, pharmacology, interventional management, and complementary treatment modalities. Cases will be evaluated from a multidisciplinary perspective. (Recorded at PAINWeek 2018)
It is now recognized that the phenotypic features of centralized pain exist in many common pain conditions. The 2011 Survey Criteria for Fibromyalgia can be used as a surrogate of centralized pain to detect patients with fibromyalgia-like or centralized pain characteristics. Patients with higher fibromyalgia survey scores describe a more negative pain phenotype preoperatively, including more opioid use, higher pain scores, higher levels of anxiety and depression, and lower physical function. It is known that patients with fibromyalgia have decreased mu-opioid receptor binding availability and higher endogenous opioid levels. These data suggest that exogenous opioids may not be effective in patients with a fibromyalgia-like or centralized pain phenotype. As such, this could provide a mechanistic rationale for nonopioid, multimodal analgesia. The fibromyalgia measure was independently predictive of poorer long-term outcomes following total knee and hip arthroplasty (less change in knee/hip pain, overall body pain, and patient global impression of change). In fact, even among patients who were below the threshold for being termed “fibromyalgia-positive,” the measure was still predictive of outcomes. As a demonstration of the generalizability of the finding, the measure was also independently predictive of increased pain 6-months after hysterectomy. This course will discuss ongoing work focusing on brain imaging signatures and experimental pain testing responses of the fibromyalgia measure. Long-term goals to create a better measure of centralized pain that could be used in routine clinical care to tailor care to the individual will be presented. (Recorded at PAINWeek 2018)
Considering the significant risks of surgery, initiatives to improve safety and outcomes would have a broad impact on public health. The number of surgical procedures worldwide has grown to over 232 million annually. Studies report that Americans undergo an average of 9.2 surgical procedures per lifetime: 3.4 inpatient, 2.6 outpatient, and 3.2 nonoperating room invasive procedures. The per capita rate of surgery continues to increase through age 75, peaking at 0.16 operations per person per year. Acute pain is a consequence of most surgical interventions. Certain procedures result in higher pain trajectories that, if not adequately addressed, can lead to poorer outcomes and increased costs. Clinical pathways are being developed to address improving outcomes in the most cost-efficient manners. This program examines new options on the horizon for the management of moderate to severe in-hospital acute pain management; the impact of scheduled vs not scheduled analgesics related to the management of in-hospital acute postoperative pain management; health economic and outcomes measures related to in-hospital acute moderate to severe postoperative pain; and enhanced recovery after surgery. (Recorded at PAINWeek 2018)
Considering the significant risks of surgery, initiatives to improve safety and outcomes would have a broad impact on public health. The number of surgical procedures worldwide has grown to over 232 million annually. Studies report that Americans undergo an average of 9.2 surgical procedures per lifetime: 3.4 inpatient, 2.6 outpatient, and 3.2 nonoperating room invasive procedures. The per capita rate of surgery continues to increase through age 75, peaking at 0.16 operations per person per year. Acute pain is a consequence of most surgical interventions. Certain procedures result in higher pain trajectories that, if not adequately addressed, can lead to poorer outcomes and increased costs. Clinical pathways are being developed to address improving outcomes in the most cost-efficient manners. This program examines new options on the horizon for the management of moderate to severe in-hospital acute pain management; the impact of scheduled vs not scheduled analgesics related to the management of in-hospital acute postoperative pain management; health economic and outcomes measures related to in-hospital acute moderate to severe postoperative pain; and enhanced recovery after surgery. (Recorded at PAINWeek 2018)
Medicine and science builds and grows on the foundations of those who came before. Although pain management discoveries have been at a relative snail’s pace, there have been recent advances in existing medications and analgesic devices, as well as exciting new molecules and formulations on the horizon. With progressive changes in technology come advances in medicine. Inasmuch, this lecture will discuss newer formulations of older molecules (NSAIDs, local anesthetics, opioids, gabapentinoids), touch on developments in the abuse deterrent opioid space, and introduce some exciting animal based, preclinical, and early phase molecules in development. Come hear a discussion of the future of analgesics including topics such as NMDA, TRK-A, NOS, beta-arrestin, ORL-1, kappa, GABA, liposomes, and more! (Recorded at PAINWeek 2018)
The gabapentinoids are a popular class of medications among prescribers for use in chronic pain and various other neurological conditions. In fact, prescription rates for both gabapentin and pregabalin have increased in the United States and other countries in recent years. However, these medications have a street value to a newer niche of users, including patients taking them at mega doses to enhance the effects of other psychotropic drugs, and others taking them to manage or mitigate opioid withdrawal symptoms and possibly even opioid cravings. While pregabalin is already classified as a controlled substance, gabapentin does not yet carry this classification in most states. In response to rising abuse, various states and regulatory bodies are considering changes to enhance patient safety and protect the provider’s license. Learn what changes you should make to your practice, if any, in light of the growing abuse of gabapentinoids and how to identify patients who are potentially abusing these medications. (Recorded at PAINWeek 2018)
A CPE Approach to Engaging Patients in a Multimodal Care Plan
To quote a contemporary leader in pain care, “Treating pain is a team sport.” Although our healthcare system is still disjointed, causing many clinicians to operate in what may feel like a lonely silo, we can support each other and bolster our patients’ confidence in their prognosis by communicating all elements of a care plan to patients that we have in common. By using terminology that de-threatens confusing aspects of a plan, encourages behavior change, and reinforces colleagues in other disciplines, we can all make a difference. This course is taught by a Certified Pain Educator (CPE) and is intended for clinicians who may occasionally feel they operate on a deserted island of healthcare. (Recorded at PAINWeek 2018)
When sexual pain strikes, the impact goes beyond pain during intercourse. Painful sex is associated with significant cognitive, emotional, and physical consequences that affect women even outside the bedroom. This common condition, affecting nearly 45% of older women and 34% of younger women, is linked to local (ie, pelvic) and widespread pain sensitivity, in addition to other areas of bodily pain. Sexual pain is also associated with significant intercourse related distress, including fear and anxiety which may be present before, during, or after vaginal penetration. Unfortunately, this topic remains taboo among patients and providers—patients offen suffer in silence for years before receiving treatment from a provider with knowledge of sexual pain. This presentation will cover the proposed mechanisms of sexual pain and how this type of pain impacts sexual and physical function, partner dynamics, and health related quality of life. Participants will learn the key components of a musculoskeletal pelvic examination for sexual pain, how to screen for sexual pain, and how to engage other providers to provide the multidisciplinary care warranted for managing this condition. (Recorded at PAINWeek 2019)
Humans have been searching for the Fountain of Youth for millennia, from Ponce de León to Herodotus. Some people feel that regenerative medicine, a field that encompasses stem cells, growth factors, and other cell mediating proteins, is that magical fountain, while others, including some physicians, members of various regulatory committees, and some in the media, believe it is a fad. As with many emerging topics, there is curiosity and confusion. While the regenerative medicine field is relatively new to most people, there is a wide variety of treatments and technologies available. We will discuss the various stem cell and growth factors in regenerative medicine and some conditions, such as degenerative changes, osteoarthritis, tendinitis, and neurological conditions that have been treated with them. (Recorded at PAINWeek 2018)
Central poststroke pain (CPSP) is a neuropathic pain disorder frequently described as burning pain associated with allodynia and hyperalgesia over affected regions of the body. The underlying mechanisms are not well understood. It has been suggested that stroke associated loss of inhibitory neurons in the spinothalamic tract causes disinhibition of thalamic neurons, which generate ectopic nociceptive action potentials responsible for the pain experience. However, recent data suggests that pain is dependent on the peripheral afferent input and may be mediated by misinterpretation of sensory input. In this course, we review the pathophysiology, clinical presentation, and symptoms of CPSP. Recent findings may also shed light about future targets for treatment. (Recorded at (PAINWeek 2018)
In this session the science of the intersection between psychological factors, pain, and relief will be reviewed. Nocebo and pain catastrophizing will be highlighted as therapeutic targets for pain control, opioid analgesia, and enhanced treatment response. Attendees will learn about cutting edge research that is leading to patient centered pain treatment, and precision pain care via targeted interventions. (Recorded at PAINWeek 2018)
Developed by the American Headache Society®, the Chronic Migraine Education Program (CMEP) includes new advances and addresses acute and preventive treatment options. In addition, the CMEP highlights epidemiologic data on the scope and distribution of migraine with an emphasis on diagnosing chronic migraine. Recent insights into the mechanisms of the complaint will set the stage for improving treatment outcomes for this most disabling of headache disorders. Part 2 will cover Pathophysiology of Chronic Migraine and Episodic Migraine; Acute Treatment Strategies; and Preventative Treatment Strategies. (Recorded at PAINWeek 2018)
Developed by the American Headache Society®, the Chronic Migraine Education Program (CMEP) includes new advances and addresses acute and preventive treatment options. In addition, the CMEP highlights epidemiologic data on the scope and distribution of migraine with an emphasis on diagnosing chronic migraine. Recent insights into the mechanisms of the complaint will set the stage for improving treatment outcomes for this most disabling of headache disorders. Part 1 will cover Diagnosis of Chronic Migraine and Episodic Migraine; Transitions, Risk Factors, and Barriers to Care; and case studies and Q&A.
This course will review evidence based nonopioid medications and modalities for acute pain in the acute care and primary care setting. Among the tools to be discussed are intravenous lidocaine for renal colic, topical analgesics for muscular pain, trigger point injections for acute and chronic musculoskeletal pain, and sphenopalantine ganglion blocks for refractory migraine pain. Attendees will be presented the current evidence, indications, and contraindications for each medication and modality, and be provided with appropriate tips and tricks for billing and reimbursement of bedside procedures. In the midst of the nation’s opioid crisis, practitioners must equip themselves with any and all tools available in the management of acute pain in an attempt to minimize unnecessary opioid prescribing, as well as mitigate adverse events when also managing polypharmacy in an increasingly larger aging and sick population. Come and learn practical ways to elevate management of acute pain in daily practice and build a toolbox to better tailor your approach to individual pain management needs. (Recorded at PAINWeek 2018)
The Emperor's New Clothes
In the Emperor’s tale, 2 weavers promise an emperor a new suit of clothes that, they say, is invisible to those who are incompetent or unfit for their positions. When the emperor parades before his subjects nude, no one dares to say anything for fear that they will be seen as such. This is a similar sentiment many providers have towards our current healthcare system. The causes of chronic pain are many, and the remedies are complicated and oftentimes not available. Providers may also fail to explore other modalities because “access” is a barrier to care. This topic area of access to care focuses on 3 components: insurance coverage, health services, and timeliness of care. These are going to require outside-the-box solutions by medical systems, including using shared medical appointments, telehealth, investing in and expanding the workforce, and reducing administrative burden. However, there are things providers can do in their practice to address these access issues, including keeping track, being proactive, and prioritizing less invasive/intense treatments over the most invasive/intense treatments. This presentation will help practitioners figure out which resources are available to help their patients address chronic pain. Providers also need to reach out to specialists personally, so communication skills are key to ensure the best possible outcome. (Recorded at PAINWeek 2018)
The trigger point phenomena and dry needling as an approach to treat myofascial pain has gained much interest in recent years. However, the popularity of these topics has been rivaled by the controversy surrounding them within the medical and rehab community. Considering the rapid rise in continuing education courses marketed to clinicians, the media hype in the professional sports and chronic pain arenas, and the informed consumer seeking less invasive alternatives to surgery, having an in depth understanding of the current state of the literature on these topics is paramount. This course is designed to delve into the literature surrounding the reliability and validity of the trigger point hypothesis, the efficacy of dry needling and acupuncture, and how these may or may not fit into a biopsychosocial approach to treating pain. (Recorded at PAINWeek 2018)
Education is a powerful weapon in the management of pain. But an educational intervention must be carefully planned to be effective. The purpose of this presentation is to prepare clinicians to plan and develop education ranging from the curbside consult to an entire course. Participants will learn about the ABCDs of learning objectives, how to select learning activities to achieve the desired outcomes, and appropriate formative and summative assessments to demonstrate these achievements. Investing your time in this presentation will pay dividends for years to come! (Recorded at PAINWeek 2018)
During the past 10 years, small fiber neuropathy has become increasingly associated with a seemingly expanding number of medical conditions. This course will review the condition in general as well as the most recent advances in our understanding of its pathophysiology and how we can treat patients diagnosed with small fiber neuropathy. (Recorded at PAINWeek 2018)
This session will describe the impact and prevalence of pelvic girdle pain (PGP) in pregnancy and the postpartum period. Anatomic, biomechanical, and hormonal influences in the etiology of pain will be explored. The most common diagnoses in pain presentation will be highlighted, debunking the common notion that pain in pregnancy is normal, and the erroneous assumption that sciatica/sciatic neuropathy is usually the primary cause. Attendees will gain an understanding of the diagnostic and evidenced based practical treatment options for pregnancy related PGP. Overall, the course aims to describe the impact and prevalence of PGP in pregnancy and postpartum; present the musculoskeletal pelvic anatomy and anatomic changes during this life stage and the proposed mechanisms in the etiology of PGP; outline the differential diagnosis, physical examination, and diagnostic work-up of PGP; and highlight rehabilitation and other treatment approaches in the management of pregnancy related PGP. (Recorded at PAINWeek 2018)
By now, we should all be aware of the prevalence of chronic pain. Astonishingly though, few people are aware of the central pathophysiology of why people develop chronic pain. Central sensitization is one of the key processes in which chronic pain persists. In this presentation, we will explore central sensitization, what it is, what it means, and what can be done to reduce it. We will also discuss ketamine, which has emerged as one of the most useful compounds currently available to mitigate central sensitization. This staple lecture at PAINWeek is a must for anyone who wants to learn about central pain conditions. Dr. Joshi, the presenter of this lecture, helped create the current outpatient protocols and philosophies on outpatient ketamine infusions. Ketamine as a treatment is becoming more popular. This lecture will help you learn top level information from one of the leading experts with ketamine infusions and central sensitization in the country so you can help your patients and evaluate legitimate ketamine infusion centers. (Recorded at PAINWeek 2018)
There are many potential underlying causes for neck and upper extremity pain. All too often, only the most common conditions, such as a disk herniation centrally or carpal tunnel syndrome, are explored. The purpose of this course is to review other common problems such as radiculitis, and not so common such as rib arthropathy pain syndromes that can affect the neck and upper extremities. Attention will be given to clinical pearls for recognizing when patients present with such problems, as well as treatments that may prove helpful for both differentially diagnosing and treating various neck and upper extremity pain syndromes, especially many of those that are often missed or overlooked and easily treatable to resolution when they are identified. (Recorded at PAINWeek 2018)
The Carrot and the Stick
Current practice in the outpatient setting tends to utilize pain psychology and movement based interventions such as exercise, physical therapy, or yoga as adjuncts to care, and are often delivered separately to the patient. Healthcare providers are aware of the benefits of psychological therapies and physical therapies for patients with chronic pain; however, there is often a gap in understanding how to implement psychological therapies or movement interventions. In this session we describe empirically validated psychological flexibility interventions and functionally based exercise program outcomes. Outpatient programs that include psychological and movement interventions within the framework of improving quality of life and pain reduction are hard to implement when a person is solely seeking pain reduction. Furthermore, interdisciplinary care is often limited to inpatient programs or restricted to Workers Compensation. This course will explore the role of pain psychology and physical therapy in reducing disability in patients with chronic pain, the fundamental elements and delivery methods of acceptance and commitment therapy (ACT), pain biology education, exercise, and improved chronic pain acceptance. The speakers will cover a novel program developed at Stanford, the role of the pain psychologist and the physical therapist, and outcomes/data on pain, disability, chronic pain acceptance, and PROMIS measures from the 6 week ACT+PT program. (Recorded at PAINWeek 2018)
Increasingly widespread acceptance of the biopsychosocial model in chronic pain management, along with the relatively modest performance of monotherapies in clinical trials, has led to increased research into the effectiveness of multidisciplinary care. The greatest challenges to practicing multidisciplinary pain management in the community setting include cost, access, provider education, and patient acceptance. This presentation will explore the importance of multidisciplinary pain management, provide easy access to resources, and empower the community provider to practice comprehensive pain management for improved outcomes with some of their most challenging of patients. (Recorded at PAINWeek 2018)
Michigan OPEN—the Opioid Prescribing Engagement Network—was founded to develop a preventive approach to the opioid epidemic in the state through a focus on reducing acute care prescribing (surgery, dentistry, emergency medicine, and trauma). Addressing opioid prescribing during the acute care period among those patients not using opioids has the greatest potential to reduce the number of new chronic opioid users and minimize unintended distribution of prescription opioids into communities. Through a partnership with statewide, physician-led networks, Michigan OPEN is collecting data and identifying and disseminating best practices in acute care opioid prescribing to providers around the state. This session will describe the unique platform and approach of Michigan OPEN, launched under the leadership of 3 University of Michigan (UM) physicians with support from the Michigan Department of Health and Human Services, Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships, and the Institute for Healthcare Policy and Innovation at UM. The presenters will describe the program’s approach to understanding the impact of acute care prescribing in the opioid epidemic, as well as successes in changing prescribing practices in response to our data findings. (Recorded at PAINWeek 2018)
Objective Measures of Pain or a Journey Down the Rabbit Hole?
Using functional magnetic resonance imaging (fMRI) techniques, we have been able to open windows to the brain, to noninvasively study its structure and function. Pain processing within the central nervous system (CNS), brain and spinal cord, and how it is disrupted in chronic pain has been increasingly characterized using neuroimaging. However, to date, fMRI has provided minimal direct clinical application for pain. We believe that will soon change. Furthermore, the use of more sophisticated analysis techniques is providing us with greater mechanistic understanding of the role of the brain in pain. The purpose of this course is to provide an overview of recent advances in the development of brain based biomarkers for pain that hold the potential for advancing the goal of precision pain management: finding the specific treatment for the specific person with the specific painful condition. We expect that brain based biomarkers will be used to help predict those who develop chronic pain or persistent opioid use after surgery, as well as for prognosis to identify who will respond to a particular treatment. The topic of brain based biomarkers has generated much controversy over the past several years in the media, legal community, and even in our own scientific community. We have recently published a consensus statement from the International Association for the Study of Pain that will be reviewed. We hope to engender good discussion and help attendees understand that no single region within the CNS is responsible for the brain representation of acute or chronic pain. Also to be discussed is how machine learning is a new and powerful technology allowing for a whole-brain identification of altered brain structure and function in chronic pain. It may ultimately help to develop brain based biomarkers of pain and advance the goal of precision pain management. (Recorded at PAINWeek 2018)
Clinicians have a responsibility to educate and reassure patients who live with pain so they can overcome barriers, such as fear of movement, and re-engage in healthy behaviors. Despite the progressive embrace of a biopsychosocial framework in pain care, most patients conceptualize their persisting pain symptoms as an isolated biomechanical/structural problem. Words such as degeneration, wear and tear, unstable, and impingement have an emotive impact, and can negatively affect a patient’s self-efficacy, which sabotages individual functional outcomes. Clinicians have a significant influence over the beliefs of their patients, and words used in clinical interactions can deeply shape health beliefs. This course will provide arguments in favor of using words that promote health, resilience, and adaptability rather than descriptors consistent with destruction and injury. Research to support an alternate approach when discussing pain with patients will be presented, and practical alternative narratives will be offered. (Recorded at PAINWeek 2018)
The shift away from opioid use in medication management for chronic pain has changed the dynamic of opioid prescribing in many ways. Now, more than ever, prescribers are under the microscope regarding selection of opioids and doses as well as clinical documentation and appropriate action based on findings during the patient visit. Risks of opioids outweighing the benefits due to lack of effect, adverse effects, or aberrant behavior are just some of the possible justifications when considering opioid tapering. There are other instances when there is outright dangerous or illegal behavior that justifies discontinuation of opioids. This lecture will review different patient situations and discuss when to taper or discontinue opioids and how to implement the change in opioid therapy. (Recorded at PAINWeek 2018)
The Pain Educators Forum presents this course because there are so many different levels of practitioner experience with pain management. Specifically, inspiration came from someone who, after attending one of our courses, had a burning question for our faculty: “What do sodium channels have to do with pain?” Yikes!!! After attending this humorous, informative course you will definitely know the difference between paresthesia and dysesthesia, allodynia and hyperalgesia, and how sodium channels confer excitability on neurons in nociceptive pathways. In sum, after this course, you’d be a fierce and worthy contestant on Jeopardy! (Recorded at PAINWeek 2018)
Musculoskeletal pain complaints are among the most common problems encountered by any clinician in an ambulatory care practice, yet many clinicians lack basic training and knowledge about the proper evaluation of these conditions. This course will discuss concepts of the evaluation, including the appropriate and directed history and exam findings that should be evaluated. A great deal of emphasis will be placed on the importance of the clinical evaluation as opposed to ancillary testing such as imaging tests. There will be special attention paid to the importance of knowing the limitations and pitfalls of imaging tests in the evaluation of spinal pain conditions, particularly in the setting of chronic spinal pain, and potential secondary gains/disability. The existing relevant literature regarding this correlation between spinal imaging and pain will be discussed in detail, using clinical scenarios and illustrative cases. Initial general primary management principles—illustrated through common injuries/complaints such as neck pain, low back pain, joint pain (shoulder, hip, knee), and common focal and generalized neuropathies—will be presented, along with clear indications and clinical pearls for specialist referral. (Recorded at PAINWeek 2018)
To provide high-quality care for individuals with pain, a healthcare practitioner should have current knowledge of clinical standards, analyze each patient’s medical needs, and create an individualized treatment plan. Providing such care to patients who often present with complex histories, unique needs, and comorbid conditions can be more of an art than a science, as practitioners must base decisions on their formal education and training, medical literature, and practical experience. Given the ever-changing regulatory environment and increasing scrutiny by public and private payers alike, practitioners must also be keenly aware of the laws, regulations, payer standards, and enforcement trends affecting pain management today. This presentation, led by an experienced healthcare attorney, will provide a timely update on criminal enforcement and payer recoupment actions, and highlight their impact on pain practitioners and clinical laboratories. Drawing from the law and his practical experience in advising pain care providers on compliance matters, the presenter will also recommend safeguards practitioners and laboratories can put in place to remain compliant in an era of increasing litigiousness when prescribing controlled medications, conducting urine drug testing, and structuring payment arrangements between ordering providers and laboratories. (Recorded at PAINWeek 2018)
When Stars Collide
This course will cover the pathophysiology and the diagnosis of minor traumatic brain injury, including the major factors which, together, make the diagnosis and treatment difficult and time dependent. We will also look at the concept of posttraumatic headache. After describing the phenotypic posttraumatic headache types, including the most common 3 headache types or phenotypes, we will explore treatments not including pain medication. Also to be discussed: the similarities and differences between posttraumatic headache in the US population vs that in our veteran population (where and how a headache exists), and who may have posttraumatic headache secondary to an explosive blast. (Recorded at PAINWeek 2018)
A Spy in the House of Love
Although endometriosis is the most common condition identified among women with dysmenorrhea and chronic pelvic pain, its evaluation and management presents many challenges to practicing clinicians. This lecture will provide participants with a practical and state-of-the art approach to the care of endometriosis patients that reviews the clinical evaluation, appropriate multidisciplinary diagnostic workup, and innovations in medical and surgical treatment options. We will emphasize diagnostic and treatment strategies for the primary care clinician, and when to refer to a gynecologic surgeon or other specialist. At the conclusion of this activity, the participant will be able to describe the epidemiology and common clinical presentation of endometriosis, describe the diagnosis and evaluation of women with suspected endometriosis, and review medical and surgical treatment options for endometriosis associated pelvic pain.
Since the Roman Empire, electricity has been used in the field of medicine for treating pain. In the era of modern medicine, the field of neuromodulation has entered its renaissance with the introduction of novel wave forms such as HF10, burst closed loop, and noninvasive vagal nerve stimulation. This ripple effect has provided chronic pain patients with additional treatment options and challenged our current understanding of neurostimulation. Simultaneously, our society is faced with a healthcare crisis—the prescription opioid epidemic. This presentation, for all healthcare professionals in the field of pain medicine, will review the current status of the electroceutical industry as it stands to offer nonopioid and opioid sparing chronic pain treatment options. (Recorded at PAINWeek 2018)
This presentation will discuss the basic concepts of the evaluation of patients with various degrees of sacroiliac joint dysfunction, including presenting symptoms and pain referral patterns. Basic exam findings and special tests and their respective predictive values will be demonstrated. The sensitivity and specificity of guided sacroiliac joint injections will also be discussed as part of zooming into the diagnosis of this musculoskeletal entity. Various therapeutic approaches will be illustrated, including specific physical therapy protocols, physical modalities, manipulation techniques, and interventional therapeutic procedures. The importance of guided injections will be reviewed, along with the literature for various approaches such as ultrasound, fluoroscopy, and contemporary radio frequency/denervation procedures, emphasizing neuroanatomical principles. Special attention will be paid to the importance of knowing the limitations and pitfalls of imaging tests in the evaluation of this condition. The existing relevant literature regarding the correlation between imaging and sacroiliac pain will be discussed in detail, using clinical scenarios and illustrative cases. (Recorded at PAINWeek 2019)
Many frontline practitioners often describe feeling like they are “held hostage” by their chronic pain patients. A lot can be learned from reviewing hostage negotiation techniques used in real-life crisis situations. These negotiation strategies typically yield a 95% success rate, which is a remarkable statistic for any form of intervention strategy. Hostage negotiation is all about psychology. These skills are critical for any “negotiator” faced with high-tension conflicts that occur during shared medical decision making. The goal of such negotiations is to work with people in crisis towards a peaceful resolution that previously seemed impossible. It entails influencing a behavioral change in someone in order to gain voluntary compliance. The unifying factor in crisis situations is that the person’s actions are being dictated by their emotions to the detriment of rational thinking. Therefore, an effective crisis negotiator seeks to reduce the negative emotions and bring back a more rational thinking process by employing a set of skills. Using the Behavioral Change Stairway Model developed by the FBI’s international hostage negotiation unit, 5 steps—including active-listening techniques, maintaining an open-minded approach, and building rapport—can be utilized to influence one’s counterpart. (Recorded at PAINWeek 2018)
The prevalence of back pain continues in spite of the many treatments available, without any single treatment being a panacea. In routine clinical practice there has been a tendency of clinical examinations to become more cursory, largely influenced by increasing demands of time and arguably an overreliance upon technology. It has been suggested that the failure to adequately differentially diagnose the cause of back pain can account for clinical failures in treatment. The purpose of this discussion is to assist clinicians in the development of a more specific problem focused examination to enhance the differential diagnosis of specific pain generators, and therefore lead to more patient specific treatment. Attention will be given to considering all aspects of the examination, including physical assessment as well as imaging studies, and the ability to rationalize when pathologies seen on imaging studies may or may not be clinically significant. The importance of considering how failed treatments influence the differential diagnosis will also be discussed. (Recorded at PAINWeek 2018)
Altered sensory acuity occurs at spinal and supraspinal levels via sensitization and chronicity. Cortical changes including imprecision of the somatosensory homunculus have been evidenced with fMRI and identified in a wide variety of musculoskeletal and neuropathic pain. However, these changes can occur in acute instances of pain as well. Literature is demonstrating that addressing these sensory disturbances can decrease pain and improve mobility. This course will provide an overview of how pain facilitates plastic changes at spinal and supraspinal levels, a literature review identifying pain conditions that demonstrate sensory acuity disturbances, and show how to incorporate multisensory discrimination treatment into clinical practice in 5 minutes or less. (Recorded at PAINWeek 2018)
Currently there are more than a dozen abuse deterrent formulations (ADF) on the market, and several formulations that have abuse deterrent properties but do not carry the official FDA designation. This session will highlight what constitutes an ADF, and the benefits, pitfalls, and drawbacks for prescribing ADF opioid products. The ADF product is novel, expensive, and unproven by category 4 status to have a real-world impact on curtailing opioid abuse. While abuse deterrent opioid formulations purportedly meet the FDA demand for safer opioid medications, the expense of these new medications is rarely supported by third-party insurance payers. Consequently, the practitioner is faced with the FDA stating that ADF opioid medications should be considered, yet the patient’s insurance often will not pay for new ADF medications, and there are no corresponding generic medications available. Drs. Schatman and Fudin will highlight data to support ADF use, discuss the lack of evidence to support their use, and the ethical dilemmas associated with prescribing or withholding ADFs from the standpoint of practitioners, patients, and third-party payers.
A Spy in the House of Love:
Although endometriosis is the most common condition identified among women with dysmenorrhea and chronic pelvic pain, its evaluation and management presents many challenges to practicing clinicians. This lecture will provide participants with a practical and state-of-the art approach to the care of endometriosis patients that reviews the clinical evaluation, appropriate multidisciplinary diagnostic workup, and innovations in medical and surgical treatment options. We will emphasize diagnostic and treatment strategies for the primary care clinician, and when to refer to a gynecologic surgeon or other specialist. At the conclusion of this activity, the participant will be able to describe the epidemiology and common clinical presentation of endometriosis, describe the diagnosis and evaluation of women with suspected endometriosis, and review medical and surgical treatment options for endometriosis associated pelvic pain. (Recorded at PAINWeek 2018)
Washington was one of the first states to legislate prescribing rules for the treatment of chronic pain, a unique model which relied on the use of a dosage trigger and the necessity to calculate morphine equivalency. Following Washington’s lead, other states and the Centers for Disease Control and Prevention (CDC) have created their own guidelines and rules that not only vary widely but are often in conflict with each other. This presentation will discuss the recent history of prescribing guidelines, their diffusion across the United States, and their potential impact on medical practice and the treatment of pain. (Recorded at PAINWeek 2017)
Pelvic pain is a global problem affecting people across the gender spectrum through a limitation of quality of life, a loss of pleasure, and often a loss of hope for recovery. This session will outline the interdisciplinary options for taking advantage of current pain science as a framework to identify persons with pelvic pain and design treatment programs to restore optimal function. Evidence for manual therapy, psychosocial interventions, and motivational interviewing are used to describe a treatment model that promotes self-efficacy and can be used in a variety of settings. (Recorded at PAINWeek 2017)
Pharmacogenetics provides an opportunity for individualized drug selection and dosing. The question remains whether or not the cost of testing and phenotype identification provides optimal outcomes for the patient and opportunities for providers to more precisely target therapy. Lab companies have spent considerable time and money marketing genetic testing and the relevant clinical utility. This session will highlight the controversial nature of pharmacogenetic testing through a healthy debate of PROs and CONs. The audience will learn about updates on current evidence and practice contrasted with practical limitations. The debate is sure to be entertaining and informative, leaving the audience with a true perspective of both sides.
(Recorded at PAINWeek 2017)
Pharmacogenetics is an emerging field and is defined as the variability in drug response due to genetics. Genetic differences can be divided into pharmacokinetic (what the body does to the drug) and pharmacodynamic (what the drug does to the body) biomarkers. Pharmacokinetic biomarkers include cytochrome P450 enzymes, drug transporters, and more. Examples of pharmacodynamic biomarkers important to pain therapeutics include opioid mu receptor 1 (OPRM 1), catechol-o-methyltransferase (COMT), and methylenetetrahydrofolate reductase (MTHFR). Ultimately, polymorphic variations in these biomarkers may lead to alterations in effectiveness, safety, and tolerability of medications. In this comprehensive interactive forum, led by Dr. Jeffrey Fudin, the next generation of clinical pharmacy specialists in pain management will focus on patient case based pharmacogenetic profiles used to discuss relevant biomarkers with genetic variations and the role these play to enlist actionable outcomes for optimizing medication regimens. These genetic variations may impact a person’s response to a medication including safety and effectiveness, potentially supporting supratherapeutic or presumed subtherapeutic opioid dosing (PAINWeek 2017)
Effective clinical interviewing and pain assessment are critical to the appropriate diagnosis and management of pain. In this presentation, the clinician attendee learns how to apply principles of effective communication and also ascertain how to evaluate available assessment tools. (Recorded at PAINWeek 2017)
Complex medication decisions are an integral part of treating patients with pain and palliative care. Pharmacists have a unique perspective on using these medications creatively and effectively. This session will flirt with tips and tricks on using medications appropriately for patients with chronic pain and those facing advanced diseases. Whether debriding a medication profile, aggressively treating symptoms, or strategizing a dosage formulation, it can be hard to commit to medication decisions. Two pharmacists will “speed date” their way through medication tips designed to impart highly important and little known medication facts that are important in pain management and palliative care practice. (Recorded at PAINWeek 2017)
To provide high quality care for individuals with pain, a healthcare practitioner should have current knowledge of clinical standards, analyze each patient’s medical needs, and create an individualized treatment plan. Similarly, to provide high quality legal counsel to pain care practitioners, an attorney should have current knowledge of the law, analyze each factual situation, and recommend a compliance plan specific to the circumstances. Healthcare and legal professionals alike practice more of an art than a science, making decisions based on their formal education and training, case studies, literature, and practical experience. In this presentation, 3 legal professionals will share their approaches to compliance in treating people with pain during an era of intense scrutiny and litigiousness. The presenters will discuss the principles they employ in advising practitioners on topics including prescribing opioids and other controlled medications, conducting urine drug testing, and discharging a patient for nonadherence to the treatment plan. The varying perspectives of the speakers will highlight the need for pain care professionals to ensure that their own attorney has experience in healthcare and, just as importantly, understands the unique challenges of pain care practice. (Recorded at PAINWeek 2017)
Pain represents a foremost feature of neurogenic thoracic outlet syndrome (NTOS). Symptoms include ipsilateral upper extremity pain, sensory loss, shoulder and neck discomfort, arm paresis or edema, headache, and even sympathetic nervous system impairment. The presentation will cover an evidence based review of the classification, etiology, clinical presentation, diagnostic measures, and surgical treatment of NTOS with a focus on nonoperative therapies such as physical modalities, pharmacological therapies, and more contemporary minimally invasive, cervicothoracic intramuscular treatments with botulinum toxin. (Recorded at PAINWeek 2017)
It is estimated that up to 21% of women worldwide experience significant pain during intercourse at some point in their lifetime. Research shows that most women suffer in silence for years before they obtain proper care. Pain during intercourse, or dyspareunia, can be classified into superficial dyspareunia (pain with entry affecting the vulvar vestibule or vaginal introitus) or deep dyspareunia (internal pain with vaginal penetration). Superficial dyspareunia can be associated with vaginal dermatosis, atrophic vaginitis, vulvovaginitis, and vulvodynia, whereas deep dyspareunia is commonly caused by endometriosis, adhesions, fibroids, and cervicitis. Dyspareunia can occur before, during, or following intercourse and can be found along with interstitial cystitis, irritable bowel syndrome, and/or sexual abuse. In spite of the negative impact it has on women’s lives, this condition often goes unrecognized, undiagnosed, and untreated. Many times patients have difficulty discussing this ‘private’ subject with their providers, and providers often do not know how to properly evaluate women for sexual pain. This lecture will discuss many of the myths associated with sexual pain and how sexual pain fits the biopsychosocial model of pain. Useful to all healthcare providers, a comprehensive guideline for the evaluation and management of this disorder will be formulated. (PAINWeek 2017)
Humans have been searching for the Fountain of Youth for millennia. Some people feel that regenerative medicine is that magical fountain while others believe it is a fad. As with many emerging topics, there is curiosity and confusion. While the regenerative medicine field is relatively new to most people, there is already a wide variety of treatments and technologies available including, but not limited to, stem cells. We will discuss the various options of regenerative medicine and conditions that have been treated with them. (Recorded at PAINWeek 2017)
New paradigms of patient care postsurgery (such as spinal surgery) utilizing both pre- and postoperative multimodal approaches to analgesia, nonopioid medications specifically, will be discussed. Included in the course will be presurgical and immediate postoperative medications, and both acute and chronic/persistent postoperative pain. And yes, we will mention opiates! We will cover preventative analgesia, concepts for perioperative pain control, regional or local anesthetics, the analgesic selection process, monitoring special populations, and discharge pain treatment plans. (Recorded at PAINWeek 2017)
Patients with chronic pain are less active than average, exposing them to increasing risks of comorbid conditions, resulting in decreasing functional status for ADLs and low activity ability. This cycle results in low tolerance for physical activities; decreased participation in school, workforce, or in job retraining programs; increased care costs; and a poorer prognosis for recovery and return to a healthy and independent lifestyle. Clinicians of all backgrounds can profit from understanding the benefits of exercise as a treatment and prevention approach for their patients, as well as learning practical strategies for implementing exercise therapy in the clinic and improving patient compliance. This presentation will review the recommendations on physical activity for healthy adults, discuss the problem of low exercise compliance in the chronic pain patient, and provide practical strategies for clinicians to prescribe exercise in the clinic. We’ll review consensus scientific guidelines and published clinical trials and discuss implementation of patient coaching techniques to bridge the gap between evidence and practice to help patients attain better function and a healthier lifestyle. (Recorded at PAINWeek 2017)
Motivational interviewing is a patient centered, collaborative style of communication that represents one tool to help clinicians overcome the challenges of conversations surrounding opioid tapers. MI can help strengthen motivation and interest in health behavior change. With regard to initiating an opioid taper, MI may elicit reasons for committing to an opioid taper, confirm beliefs in the ability to successfully complete a taper, and increase commitment to a treatment plan. Additionally, MI may increase provider comfort and skill in guiding conversations that have potential to cause conflict and undermine patient-provider rapport. Although training and education about the use of MI has proliferated in medical education, providers often report that incorporating MI into their daily practices is challenging due to the abstract nature of its concepts and pressure to maintain brief appointment times. This course will: review the spirit of MI and barriers to using it in practice; define/list challenges specific to using MI in the long-term opioid therapy population; provide concrete examples of clinical situations in which an opioid taper is clinically indicated; and discuss MI-consistent phrases that can be incorporated into common scenarios regarding long-term opioid therapy. (Recorded at PAINWeek 2017)
This is a MUST session for all practitioners who wish to remain cutting edge and prepared for questions from patients and other practitioners concerning new medications. Up to 100 new drugs and dosage formulations are approved every year by the Food and Drug Administration. Some of these are new molecular entities, while others are new formulations, new indications, generic drug approvals, or labeling revisions. Participants in this fast paced session will learn about new medications approved in 2015/2016 and their usefulness in treating pain and symptoms associated with advanced illness. Specifically, participants will learn the indication, any off-label uses, adverse effects, major drug interactions, dosing, clinical pearls, and financial implications if the medication is a controlled substance. (Recorded at PAINWeek 2017)
This course will discuss the background and prevalence of occipital neuralgia, its etiology, clinical features, diagnosis, and treatment options. Additionally discussed will be treatment techniques and differential diagnosis of occipital neuralgia vs other headache/head pain disorders.
(Recorded at PAINWeek 2017)
Overdose—a small word that packs a major punch, and a big reason for many recent legal regulatory changes in controlled substance prescribing and pain management. Too many physicians and allied healthcare practitioners are caught unawares by the legal issues surrounding overdose events, fatal and nonfatal. Often, prescribers are the last to learn about an overdose event and, worse yet, fail to take action once notified. Through a series of case examples, attendees will learn how to develop and implement overdose event policies and protocols. Attendees will receive copies of sample policies and protocols and learn how to tailor them to their respective practices and state licensing board framework. Professional licensing board and criminal cases involving overdose events do not usually end well for the prescriber, but there is much the prescriber can do proactively to signal his/her intent to get things right. While prescribers cannot control what their patients do once they leave the medical office, they are responsible for establishing a safe framework for opioid prescribing, including a proper response when something goes wrong. (Recorded at PAINWeek 2017)
The prevalence of back pain continues in spite of the many treatments available, without any single treatment being a panacea. In routine clinical practice there has been a tendency of clinical examinations to become more cursory, largely influenced by increasing demands of time and arguably an overreliance upon technology. It has been suggested that the failure to adequately differentially diagnose the cause of back pain can account for clinical failures in treatment. The purpose of this discussion is to assist clinicians in the development of a more specific problem focused examination to enhance the differential diagnosis of specific pain generators, and therefore lead to more patient specific treatment. Attention will be given to considering all aspects of the examination, including physical assessment as well as imaging studies, and the ability to rationalize when pathologies seen on imaging studies may or may not be clinically significant. The importance of considering how failed treatments influence the differential diagnosis will also be discussed. (Recorded at PAINWeek 2017)
When pelvic pain strikes, the impact is catastrophic. In this talk, we will uncover how the musculoskeletal system contributes to this debilitating condition. Pelvic floor muscle dysfunction is associated with pelvic pain, and prevalence estimates in various pelvic pain conditions, including endometriosis, vulvodynia, and painful bladder syndrome, range from 21% to a whopping 80%. Musculoskeletal pelvic pain negatively affects sexual and physical function, activities of daily living, and health related quality of life. To complicate the issue, pain coming from the pelvic floor muscles may refer to other body parts such as the lumbar spine, sacroiliac joints, hips, and abdomen. When pelvic pain becomes chronic, women may also show signs of maladaptive neuronal plasticity associated with widespread muscle pain beyond just the proximal pelvic region. Despite the high prevalence of musculoskeletal pelvic pain, medical and rehabilitative providers do not routinely screen for musculoskeletal dysfunction, leaving patients with limited access to providers skilled in managing musculoskeletal pelvic pain. This talk will provide an overview of key abdominopelvic musculature and its contributions to pelvic pain, screening for musculoskeletal dysfunction, and components of a musculoskeletal pelvic pain examination. (Recorded at PAINWeek 2017)
Lower back pain is the most common reason to see a physician for pain and the number one cause of disability. Some patients with lower back pain eventually require spinal surgery. Unfortunately, 20% to 40% of these patients will develop failed back surgery syndrome (FBSS or FBS) after the first surgery. FBSS, also known as postlaminectomy syndrome, is defined as “lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location.” During this presentation, we will learn more about FBSS, its pathology, causes, diagnosis, management, and treatment options. (Recorded at PAINWeek 2017)
Behavioral and psychological interventions for pain management have often been included in patient care as a last resort, a place to turn to when biomedical interventions fail to yield sustained amelioration in pain symptoms. Such an approach disregards research which has long suggested that patient outcomes are improved when incorporating psychosocial variables in the conceptualization and treatment of chronic pain from the onset of care. The opioid epidemic in the US may have an unintended consequence of changing the perception of behavioral and psychological interventions as a last line of defense as clinicians look for treatments to fill the space vacated by narcotic medications. Successful implementation of biopsychosocial treatment pathways will require clinicians to have a solid understanding of the fundamentals of this approach to care. This presentation will provide a broad perspective on the role of psychology in the etiology, maintenance, and exacerbation of pain. Psychological variables associated with the chronification of pain will be discussed, including their associations with disability. An overview of cognitive behavioral interventions for pain, stress, and mood management will be presented along with literature supporting their use. Strategies for including psychological approaches in regular medical appointments will be shared to facilitate incorporation of such tools in localities with limited access to mental health. (Recorded at PAINWeek 2017)
This presentation will focus on mindfulness meditation as an approach to building resilience and will highlight the speaker’s findings regarding the neural mechanisms whereby mindfulness might improve pain by building brain resilience. (Recorded at PAINWeek 2017)
Despite high prevalence and seemingly continuous attention, the clinical challenges associated with assessing, treating, and managing patients with chronic pain continue to persist. Many different forces are at play and responsible for this frequently frustrating situation and, as is often the case, the person with the most at risk is the patient with chronic pain. There is no deficit of opinions for possible solutions to this problem. In fact, the number of potential solutions seems to increase each year, all with the intent of helping pain care be more safe and effective, and most trying to stem the negative consequences of abuse, misuse, and diversion of prescription pain medications. Clinicians have had to juggle these good intentions along with the fear of regulatory scrutiny. This course will present and detail the variety of current regulatory forces that need to be considered in clinical practice; how they can potentially impact clinical decisions regarding chronic pain; and how they can be negotiated. A number of regulatory agencies are now “sitting at the pain management table” for the foreseeable future and it is critical to navigate the waters without sacrificing that most important stakeholder: the patient. (Recorded at PAINWeek 2017)
Traditional medical and rehabilitation training programs teach clinicians to frame an explanation of body pain in terms of anatomy and biomechanics. As intuitive as this may be, what we say is often not what patients hear. Research has demonstrated that use of common terms such as “degeneration,” “wear and tear,” or even “chronic” is associated with worse prognosis in the long term. This course will provide a research review of the nocebo effect of language, and offer alternative, descriptive terms and phrases for clinicians to use during brief or extended interactions. When patients have a greater sense of hope and control over their pain conditions, outcomes improve. This course is designed for any professional who educates patients about pain, directly treats pain conditions, or collaborates with other disciplines in multimodal pain care. (Recorded at PAINWeek 2017)
Understanding pain can be challenging, and using models or theories can simplify the complex. When treating people who have persistent pain, having a framework to reference is imperative, informative, and supports clinical reasoning. What is the gate control theory? Who introduced the neuromatrix? And what does Bayesian statistical modeling have to do with pain? This Pop-Up course will take a historic view of pain mechanism theories from the 1960s forward and briefly discuss the underpinnings of chronic pain in terms of theoretical models. (Recorded at PAINWeek 2017)
Many patients receiving opioids will need to be switched from one to another during therapy or at least from one dosage formulation or route of administration to another. During this session, practitioners learn to recognize clinical situations in which opioid switching would be appropriate. Attendees will also work on a problem set designed to sharpen their skills in opioid conversion calculation. (Recorded at PAINWeek 2017)
In order to successfully clinically manage pain, it is essential to begin with an understanding of the underlying mechanisms responsible for its generation. A skillful approach based upon better knowledge concerning the anatomical structures, pathways, and events that result in pain is more likely to lead to effective clinical management of pain. This discussion will include an overview of medication classes typically considered for pain and the pathways they affect. (Recorded at PAINWeek 2017)
This session will explore some of the challenges resulting from the recent “Decade of Pain.” Clearly, the overuse of opioids and, to some extent, the solutions proposed to curtail the misuse of prescription drugs has led to a shift in how we diagnose and how we treat substance use disorders in this often challenging patient population. (Recorded at PAINWeek 2017)
There are many changes in the body composition of the older adult that can lead to altered effects of drug therapies. Symptom management in the older adult can be complicated as many of the drugs which we use are amongst those recommended to be avoided in this population. It is critical to understand the metabolic changes that occur as we age and apply pharmacokinetic and pharmacodynamic properties to agent selection for symptom control. This session addresses these metabolic changes as well as outlines optimal pharmacologic choices for symptom management in the older adult. (Recorded at PAINWeek 2017)
Multiple medical conditions are associated with myelopathies (spinal cord disorder). This course will provide an overview of the multiple causes of myelopathy, as well as approaches to their diagnosis and treatment. (Recorded at PAINWeek 2017)
2016 was not a good year to be on the wrong side of medical necessity when it came to drug testing and ongoing prescribing of controlled medication or substance abuse treatment programs. 2017 is likely to be an expensive year for those who do not proactively take steps to understand medical necessity for drug testing, prescribing controlled medication, and ongoing substance abuse treatment, as payers continue to carefully scrutinize these areas. Using a series of case hypotheticals, attendees will learn how to identify the elements of medical necessity, efficiently and effectively document medical necessity for drug testing and use of drug test results in the ongoing care of the patient, and locate and use payer medical policies and coverage determinations. Attendees will be given 3 tools to reinforce learning objectives: a checklist for medical necessity documentation, sample summaries of payer medical policies, and templates for documenting use of drug test results and tailoring ongoing treatment decisions to the individual patient. (Recorded at PAINWeek 2017)
Multiple clinical treatment guidelines have been published regarding headache and pain management. However, many have questioned the benefit of such clinical guidelines for the treatment of individual patients. This course will review key published treatment guidelines for migraine, interventional pain management, chronic opioid use, neuropathic pain, and chronic low back pain. The faculty will review the relevant guidelines and discuss their strengths and critical weaknesses when using such guidelines to actually treat people. (Recorded at PAINWeek 2017)
Dysmenorrhea is the most common pain disorder among women, estimated to affect 40% to 90% of women in their reproductive years. Up to 20% of women report menstrual pain severe enough to interfere with usual activities. As such, it is a leading cause of school and work absenteeism in young women. Despite its high prevalence and negative impact on quality of life, dysmenorrhea remains undertreated and often disregarded by clinicians, researchers, and even women themselves, who may consider it a normal manifestation of the menstrual cycle. However, emerging data suggests that while untreated dysmenorrhea is often a precursor to chronic pelvic pain and other centralized pain conditions, some women with dysmenorrhea already display evidence of centralized pain. Therefore, early and prompt treatment of dysmenorrhea may be an important target for prevention of central sensitization, as well as the progression to various chronic pain conditions. This lecture will provide an overview of the impact of dysmenorrhea on daily function, mood, and quality of life. We will present emerging evidence that dysmenorrhea is not just a localized pelvic disorder, but is associated with central nervous system changes in pain processing. This lecture will then review a systematic approach to the evaluation and management of dysmenorrhea, including the differential diagnosis and treatment strategies of both primary and secondary dysmenorrhea. Primary dysmenorrhea is defined as pain associated with menstruation in the absence of organic pathology, whereas secondary dysmenorrhea is associated with identifiable pathology, such as endometriosis. We will emphasize diagnostic and treatment strategies for the primary care clinician, and when to refer to a gynecologic surgeon or other specialist. (Recorded at PAINWeek 2017)
This presentation will highlight common procedures used for pain reduction, their evidence base, and a basic description of how each procedure is performed. We will primarily review epidural steroid injections, facet joint blocks and denervation, sacroiliac joint injections and denervation, myofascial pain, spinal cord stimulation, and intrathecal pumps. (Recorded at PAINWeek 2017)
Erythromelagia is a rare and potentially devastating syndrome associated with severe heat and burning pain, and redness involving the skin of the hands or feet or both. The study of this disorder has led to the discovery of new insights into pain pathophysiology as well as new treatments. This course will describe not only the syndrome but how we may be able to apply the insights learned from studying this disorder to the treatment of pain. (Recorded at PAINWeek 2017)
Per the department of Health and Human Services, opioid related overdose deaths have increased almost 400% over the last 18 years. This shift has yielded heightened scrutiny of prescribing practices, and opioids have subsequently fallen out of favor as a first-line treatment for chronic pain. In this changing landscape of pain care, it is more important than ever for clinicians to identify treatment pathways that will maximize patient outcomes while minimizing medication load. This presentation will review current literature related to use of opioids and medical challenges associated with weaning individuals off this class of drug. The role of evidence based behavioral treatment modalities known to result in improvement in physical and emotional functioning will be discussed in detail, including their use in the context of opioid weaning. The terms dependence, abuse, tolerance, and addiction are often used interchangeably when discussing opioid medication; however, use of nomenclature in this fashion is erroneous. The differences between these words will be explained and the implications for treatment discussed. Clinical pathways that often lead to medication escalation will be identified. The role of behavioral interventions for pain treatment and the literature supporting their use will be reviewed, including data from an interdisciplinary clinical program which provides patients such education while concurrently reducing opioid medication. (Recorded at PAINWeek 2017)
Although opioids remain an important tool in aiding the management of pain in the United States, the balance between the potential benefits and harms must be considered. Some specific harms are manifested in the abuse of opioids for nonmedical purposes. The primary access to prescribable opioids for abuse is through illegal diversion. Those abusing opioids may do so through a variety of mechanisms, including taking excessive doses, altering formulations, and changing the route of delivery. For example, an oral formulation may be modified and abused through nasal snorting or intravenous injection. The FDA has developed guidelines for a clinical study design for “abuse deterrent opioids” and has labeled a number of opioids with language that they are “abuse deterrent.” This session will review the FDA’s publication “Abuse Deterrent Opioids–Evaluation and Labeling: Guidance for Industry” as well as discuss many of the novel technologies developed and labeled specifically to minimize the likelihood of abuse, while retaining the potential benefits of opioids in the management of pain. (Recorded at PAINWeek 2017)
Management of acute pain following surgery or trauma requiring opioid treatment can be particularly challenging in patients with substance use disorders. This session will explore ways to optimize analgesic care, keep patients safe, and promote behavioral consequences that are just and equitable in patients with active heroin use during hospitalization.
This presentation will review the consequences of not adequately addressing postoperative acute pain, strategies for balancing analgesia against opioid related adverse events in this setting, and new approaches on the horizon. Postoperative acute pain continues to be undertreated in a large number of cases. This may be due to a wide variety of factors, notably drug related adverse events. Conventional opioids, for example, are widely employed for the management of moderate to severe acute pain. They function by binding to μ receptors and nonselectively activating 2 downstream pathways: the G protein pathway, associated with analgesia, and the β-arrestin pathway, associated with opioid related adverse events (ORAEs) and inhibition of G proteinmediated analgesia. ORAEs, including respiratory depression, are serious, pose a risk to patient safety, and limit dosing required for optimal analgesia. Consequences of suboptimal acute pain management are numerous and include prolonged opioid use, potential development of chronic pain, and increased morbidity, length of stay, time to discharge, and time before ambulation. Greater spotlight is needed on this unmet need, particularly in patient groups--the opioid tolerant, obese, respiratory compromised, elderly, and those with sleep apnea--at greater risk for undertreatment of acute postoperative pain, where prevalence and impact of adverse events is heightened. New therapeutic approaches have been developed in the past decade to address some of these issues, including use of multimodal therapy, reformulations in analgesics, innovations in drug delivery, and μ-GPS modulators, which are novel μ receptor modulators that differentially activate G protein while causing low β-arrestin recruitment to the μ receptor.
EDs are searching for new ways to treat pain that are rapid, safe, and effective. The search for new options is being driven by the national outcry to decrease opioid prescribing, pressure to see patients faster, decrease ED length of stay, and prevent readmissions while still treating pain and suffering and obtaining positive patient satisfaction scores. This course will focus on new uses of old drugs, different routes of delivery, multimodal treatment, ED nerve blocks, nonopioids, and patient discharge education regarding nonpharmacologic pain management.
Acute pain is associated with negative outcomes; therefore, efforts to prevent and control pain are necessary. Goals for acute postoperative pain management include reducing the incidence and severity of pain, particularly that which impacts patient function such as movement; minimizing side effects from analgesics; preventing postoperative complications; enhancing recovery; and preventing chronic pain if possible. The purpose of this session will be to discuss common challenges including pain assessment, opioid safety, and individualizing multimodal analgesia.
Chronic pain affects 100 million US adults. It is the #1 reason people are out of work. It is the leading reason that people seek medical attention, costing the nation upwards of $635 billion annually--more than heart disease, cancer, and diabetes combined. Given the burden of unmanaged pain in terms of human suffering, societal burden, and healthcare dollars spent, relieving pain has become a national priority. This case based lecture will define the pathophysiology of various pain generators, and provide a comprehensive overview of multimodal management of chronic/persistent and acute pain. The use of pharmacotherapy, nerve blocks, and behavioral management strategies will be emphasized. This lecture will examine the decision making involved in developing a treatment strategy for patients with complex pain diagnosis. Special emphasis will be placed on cancer pain, the patient with an addiction history, central pain, and neuropathic pain.
Chart documentation is important in any practice, but even more so when working with chronic pain patients. The treatment of chronic pain management comes with increased potential for litigation. There are important steps that prescribers must take with their documentation to lessen that risk. As a case reviewer and expert witness, I will highlight important areas that should be documented, as well as what safe guards to use when using electronic medical records. What is being looked at? What is vital to every chronic pain chart? What must be included in your charts if they are ever called into question?
Opioid emergencies have risen with the increase in prescribing of opioids. It is imperative that prescribers of opioids know when to coprescribe naloxone therapy to their patients. It goes beyond the patient suspected of misuse and abuse. This presentation will focus on the patients you might not consider at risk for an opioid overdose.
Although opioids remain an important tool in aiding the management of pain in the United States, the balance between the potential benefits and harms must be considered. Some specific harms are manifested in the abuse of opioids for nonmedical purposes. The primary access to prescribable opioids for abuse is through illegal diversion. Those abusing opioids may do so through a variety of mechanisms, including taking excessive doses, altering formulations, and changing the route of delivery. For example, an oral formulation may be modified and abused through nasal snorting or intravenous injection. The FDA has developed guidelines for a clinical study design for "abuse deterrent opioids" and has labeled a number of opioids with language that they are "abuse deterrent." This session will review the FDA's publication "Abuse Deterrent Opioids-Evaluation and Labeling: Guidance for Industry" as well as discuss many of the novel technologies developed and labeled specifically to minimize the likelihood of abuse, while retaining the potential benefits of opioids in the management of pain.
Millions of patients each year suffer from acute pain as a result of trauma, illness, or surgery. Pain is the most common reason for admission to the emergency department (ED), comprising more than 40% of the over 100 million ED visits annually. The prevalence of intense acute pain is similarly high among patients undergoing surgery: in the United States, over 73 million surgical procedures are performed annually, and most patients report experiencing a high degree of pain postoperatively. Studies indicate that treatment of acute pain remains suboptimal due to attitudes and educational barriers on the part of clinicians and patients, as well as the intrinsic limitations of available therapies. Inadequate management of acute pain negatively impacts numerous aspects of patient health and may increase the risk of developing chronic pain. This presentation will review the differences between acute and chronic or persistent pain, while providing attendees with a multimodal treatment approach for the acute care setting. Emphasis will be placed on the role of the advanced practice provider.
This session will explore an interdisciplinary team approach for the treatment of pain and autonomic dysfunction and will look closely at chronic pain as a biopsychosocial disease. A pharmacotherapy guide for CRPS will be reviewed, along with a comparison of FM and MPS and treatments for diabetic neuropathy.
This session will explore research frontiers in pain medicine and the profound effect food has on inflammation, the immune system, and mood. Nutrient deficiencies associated with pain, holistic pain relief, and foods and vitamins as therapeutic agents will also be discussed.
This session will help clinicians understand the role of interdisciplinary care in pain management by identifying the components of the biopsychosocial model. Cases will be discussed, and a review of literature findings supporting multidisciplinary treatment approaches and the chronification of pain will be explored, as well as empirically validated treatments, addressing pain in outpatient settings, and more.
Manual therapy has long been used to treat spinal pain. Spinal manipulative therapy, in particular, has received special emphasis as many providers use it as a featured part of their practice. It has a favorable side effect profile, but there continues to be healthy debate on whether it is an effective option for pain relief compared to other treatment options. This presentation will review key aspects of the debate by differentiating between spinal manipulative therapy's ability to modulate nociception (largely through mechanistic studies) and having an impact on outcomes for those with acute or chronic spine pain (largely through clinical trials). A primary goal is to provide attendees with a better understanding of key components perpetuating this debate. The second half of the presentation will highlight future practice and research priorities that if implemented may lead to better defined information on how spinal manipulative therapy could be used to effectively provide pain relief.
Acupuncture has been used for centuries to treat pain; however, multiple recent randomized controlled trials of acupuncture in chronic pain disorders have largely shown mixed findings. In most of these studies acupuncture is no better than sham/placebo. Moreover, many basic as well as clinical studies have indicated that analgesia following acupuncture treatment involves the body's own endogenous opioid system, which is also known to be a key factor in placebo analgesia. This raises the question: Is acupuncture simply a sham/placebo? During this presentation we will examine evidence from the animal basic science literature indicating that there may be some specific effects of acupuncture needling that differ from placebo analgesia. Also we will explore how translational approaches using quantitative sensory testing as well as functional and neurochemical imaging in humans have been used to suggest that acupuncture may specifically work by upregulating receptor activity and neurotransmitter release, both hallmarks of synaptic plasticity. These results indicate a disconnect between acupuncture clinical trials and basic/translational research. New approaches are clearly needed to bridge this gap. We will end by stepping back and entertaining the question of how relevant this information is for the treatment of chronic pain patients.
Accumulating evidence suggests that widespread pain syndromes such as fibromyalgia display a generalized disturbance in central nervous system pain processing. Multiple lines of research have identified that the locus for many functional chronic pain disorders, including fibromyalgia, pelvic pain, and irritable bowel syndrome, is within the central nervous system, and the brain more specifically. Brain neuroimaging techniques have heralded a revolution in our understanding of chronic pain, as they have allowed researchers to noninvasively evaluate brain structure and function. In addition, growing interest has turned to proton magnetic resonance spectroscopy (1H-MRS), a noninvasive magnetic resonance imaging technique that can quantify the concentration of glutamate and GABA, the brain's main excitatory and inhibitory neurotransmitters, respectively, within the living human brain. During this presentation, we will explore the ability and utility of 1H-MRS to identify brain neurotransmitter concentrations in chronic pain patients. Moreover, we will examine how 1H-MRS may provide insight into the mechanism(s) of action of pharmacologic as well as nonpharmacologic therapies. A key question: Are alterations in neurotransmitter levels along the causal pathway for the development/ maintenance of chronic pain, or are they simply a response to sustained peripheral input?
Recent advances in neuromodulation approaches have resulted in several promising applications for the treatment of various chronic pain disorders. This course will review several of the more popular applications, including transcranial direct current stimulation (tDCS), transcutaneous vagus nerve stimulation (tVNS), and transcranial magnetic stimulation (TMS). The neural mechanisms by which these neuromodulatory therapies access pain associated brain circuitries will also be reviewed, and neuroimaging evidence will demonstrate how these therapies might impact brain physiology. For instance, recent functional MRI (fMRI) research for applications of tVNS in migraine has demonstrated targeting of specific medullary nuclei and modulation of pontine raphe response to processing along the spinal trigeminal pathway in these patients. Finally, the side effect profile for different neuromodulatory approaches should be considered with respect to pharmacological approaches to chronic pain management.
Historically, pain has been viewed as a symptom of perturbations in the tissues of the body, such that effective treatments would address the damage to the affected body region and pain relief would ensue. However, both clinical experience and the scientific literature are replete with examples of such body based treatments failing to relieve pain. In recent years, accumulating evidence implicates changes in the structure and function of the brain as important contributors to the pathophysiology of chronic pain, with some thought leaders concluding that chronic pain is often a brain disease in its own right. This raises the question whether the brain or the body represents the best target for pain treatment. This course will present a conceptual model of chronic pain based on a continuum of peripheral vs central contributions. Examples of pain conditions and their location on the continuum will be provided, and assessment methods that can be used to determine where a given patient falls on the spectrum will be discussed. Then, an overview of treatment approaches whose mechanisms cover the spectrum from peripheral to central pain mechanisms will be provided, including pharmacological, behavioral/psychological, and neuromodulatory therapies. The session will conclude with a discussion of how to decide whether treatment for a given patient should target the brain or the body and how best to tailor treatment to the mechanisms underlying that patient's pain condition.
There is strong evidence supporting the use of biobehavioral therapies for chronic pain conditions including fibromyalgia, migraine, and other forms of severe headache. Evidence based behavioral medicine treatments include cognitive behavioral therapy (CBT) and biobehavioral training. These techniques have demonstrated efficacy when learned and practiced correctly and may be used individually or in conjunction with pharmacological and other interventions. Migraine will be used as an example in this presentation; however, these techniques all have evidence for their use with chronic pain conditions and will also be applicable to chronic pain management. This workshop will review the well established approaches including include cognitive behavioral therapy, biofeedback, relaxation training, and stress management, as well as emerging therapies including acceptance and commitment therapy (ACT) and mindfulness based cognitive therapy (MBCT). The science supporting these therapies will be reviewed along with case examples and experiential learning where the audience will participate in diaphragmatic breathing and a guided visual imagery exercise so that they can either make referrals or teach these approaches themselves. Suggestions and resources for making successful referrals, finding and communicating with allied providers, and resources such as websites, apps, and books will also be reviewed.
Burnout has reached epidemic proportions among healthcare professionals and is especially high among those who care for patients with chronic pain and chronic painful conditions such as migraine and fibromyalgia. This course will review the definition and prevalence of burnout, review the risk factors for healthcare professionals, have participants take the Maslach Burnout Inventory, and review what the results may imply both professionally and personally. Then the course will review strategies for reducing stress, enhancing resilience, and improving quality of life. As well as improving satisfaction for healthcare professionals, these resilience enhancing strategies and healthy lifestyle practices also have benefits for patients.
Effective pain management has been deemed a human right, but some chronic pain patients perceive that to mean they are entitled to opioid analgesics for prolonged pain control. In response to these expectations, providers may feel pressured to say "Yes" and continue prescribing opioids, thereby reinforcing the patient's beliefs and reliance on medication. This has contributed to a dramatic rise in opioid analgesic misuse and deaths from prescription drug overdose. In fact, the CDC has identified opioid misuse as a "public health epidemic" and released new guidelines in March 2016. While a collaborative relationship is optimal for pain management, there may be times when a practitioner saying "No" is the best treatment. Many providers feel uncomfortable setting boundaries; however, boundary setting is important work because rights as a provider are also important. When reasonable limits are placed on a patient and the patient continues to step beyond those limits, it is imperative that providers maintain boundaries and be consistent in their message. Participants will learn about the gentle art of saying "No" and how to use a decision tree when making pain management decisions. Sample cases will be presented along with recommended treatment strategies.
The field of pain management has undergone a circuitous adventure, much like a rabbit hole. As the economic, mental health, and medical consequences of prescribing opioid medications have mounted, the prevailing logic regarding the usefulness of prescribing opioids for chronic pain has shifted. The widespread dissemination of opiates and the lax safety measures placed on their storage has also led to an increase in nonmedical use. Given the high level of comorbidity between opioid use disorders and chronic pain, providers' decisions about how to address treatment with patients who may have or who have been diagnosed with substance use disorders are often complex. The new CDC guidelines will require providers to assess for risk of overdose or development of a substance use disorder, and to be keenly aware of their patients' pain levels and pain management strategies when working as part of a system where opioid medications may be prescribed. Participants will learn how patient and provider education programs and communication interventions may improve outcomes in pain management. Participants will also learn how to select candidates for opioid trials, assess for risk, and initiate opioid therapy, but only after exploring nonopioid and nonpharmacological strategies.
There are a number of common neuropathic pain syndromes, such as complex regional pain syndrome, postherpetic neuralgia, and diabetic neuropathy, that have established diagnostic and treatment paradigms. There also are a number of neuropathic pain disorders that are as common but less understood and can be more challenging to the treating clinician. For example postthoracotomy pain syndrome is relatively common and is seen in approximately 50% of patients after thoracotomy. It is a chronic condition, and about 30% of patients still experience pain 4 to 5 years after surgery. Between 20% to 60% of women who undergo mastectomy for breast cancer develop postmastectomy pain syndrome. This multidisciplinary panel will review the prevalence, characteristics, and pathophysiology of these odd neuropathic pain disorders and discuss models for evaluation and treatment that include both pharmacologic and nonpharmacologic approaches.
Several studies from both pain clinics and primary care have found that regional myofascial pain is the most common presenting pain condition. Yet the lack of awareness of it is surprising. Everyone, at some point in their lives, has experienced acute muscle pain associated with overuse or repetitive strain. However, when acute pain becomes chronic, patients and their healthcare providers can become confused and overlook myofascial pain to focus on comorbid pain conditions such as orthopedic and neuropathic pain. This lack of recognition and understanding often leads to mistreatment and progression of a simpler acute problem into a more complex chronic pain condition. Identifying and managing myofascial pain is relatively straight-forward, by integrating patient training on exercises and reducing repetitive strain with evidence based treatments such as physical medicine treatments. This course presents the basic principles of etiology, diagnosis, and management of myofascial pain for all healthcare professionals.
This course presents the basic principles of etiology, diagnosis, and management of orofacial pain using transformative care. Because orofacial structures have close association with eating, communication, sight, and hearing as well as forming the basis for appearance, self-esteem, and personal expression, persistent pain in this region can deeply affect an individual and significantly interfere with quality of life and ability to function. We will review diagnosis and management of the more common orofacial pain conditions and highlight advances in education, research, and patient care from risk assessment and prevention to early successful treatment of acute pain and interdisciplinary individualized transformative care. Explored will be the evidence behind treatment strategies for personalized transformative care ranging from self-management and pharmacology to physical medicine, splints, surgery, and interdisciplinary team management. It is hoped that this review will provide the clinician with broad perspective on the evolution of this field to the current scientific approach for prevention and management that helps the patient achieve a truly transformative experience.
The Institute of Medicine stated in 2011 that one of the health professional's primary roles for chronic pain should be guiding, coaching, and assisting patients with day-to-day self-management of their pain condition and, along with National Institutes of Health, have established research involving self-management as one of the highest priority topics. A transformative care model integrates self-management training with evidence based treatments. The use of web based cognitive behavioral patient training programs with a telehealth coach therapist is an innovative strategy to improve the long-term outcomes of pain care. This approach can help patients make necessary changes in their life to reduce risk factors and promote protective factors while making the implementation affordable, rapidly deployed, scalable, and transferable to all settings and conditions. This presentation will provide the rationale, implementation, and outcomes associated with employing transformative care for chronic pain.
Pain is a very common complaint in the emergency department (ED) yet it presents in various ways. The hectic nature of the ED is not always conducive to obtaining the "real story." ED practitioners can be misled by prehospital reports, triage notes, vital signs, past history, and personal biases. This course will present acute and chronic pain case scenarios that will highlight "near miss" patient safety features and lessons learned in patients of all ages.
Pain is a component of up to 78% of ED presenting complaints yet most ED physicians have had minimal training related to pain recognition, assessment, and management. Adequate pain assessment is complex and requires time to determine the patient's past pain and medication history, current pain history, and pain intensity. ED providers are under pressure to recognize and treat pain while also dealing with overcrowding, a vast array of patient complaints, and course descriptions concerns over opioid addiction and overprescribing. This course will review critical components of a rapid ED pain assessment, the current status of pain scales in the ED, electronic medical record documentation of pain, and current literature.
This course will discuss the use of ketamine in emergency departments (EDs) for the management of pain and procedural sedation in adults, children, and high risk populations. Ketamine has been used for years in pediatric procedural sedation and has now become the "go-to" drug for adult subdissociative analgesia in ED, trauma, and prehospital settings and in patients with chronic opioid use or those at high risk for addiction.
Pain is a common presenting complaint to emergency departments and EMS, and painful procedures are often necessary. Most EDs do not have child life specialists, psychologists, or other resources to assist patients in pain or during procedures. The majority of emergency care providers (physicians, nurses, and paramedics) are not trained in nonpharmacologic means of managing pain and anxiety. This course will discuss nonpharmacologic methods of relieving and managing pain in ED and prehospital/EMS settings. Although mainly used in children, many of these techniques and tools are helpful in adult patients.
Perhaps the single most failure producing aspect of chronic pain is its inherent isolation. Add the medical hopelessness faced by many patients, and a perfect storm is created for chronic pain patients to fall permanently out of the workforce and fail to thrive. Pain management coaching provides the bridge between medical care and the patient's innate will to survive. Pain management coaching pioneer Becky Curtis will share how the latest research on the brain and pain relate to relearning and pain management. Attendees will gain understanding of the role pain management coaching plays in reshaping the learned phenomenon of chronic pain, and how coached clients acquire knowledge and implement effective pain management strategies with the guidance of a coach.
Pain management coaching is a systematized application of techniques, including motivational interviewing, that enable your patients to work through ambivalence and take action to change their lives. One of the primary components is education. Coaches teach skills to enable the patient to regain a sense of control and direction. Working with patients to implement the providers' recommendations, coaches give support and tools to help the patient reframe their perspective hopelessness and safely navigate through the treacherous jungle of complicated pain.
The Centers for Disease Control and Prevention's new prescription guidelines strongly urge physicians to reduce their use of opioid analgesics in the treatment of chronic pain. Specifically, the guidelines outline a multidisciplinary approach that includes interventional pain management and limited use of immediate-release opioids instead of extended-release or long-acting opioids. This presentation will address the practical aspects of these recommendations and how frontline practitioners can contextualize this information to better manage their patients to restore functionality and quality of life.
Pain management in the elderly can be quite complex. The most common method of pain control in this population is pharmacotherapy. However, this patient population is becoming subject to the complex interactions and risks associated with polypharmacy. Hence, interventional strategies are increasingly being recognized as an important part of their multimodal pain management. In this session, we will explore unique and emerging interventional strategies for some of the most common pain complaints in the elderly.
Interventional spine and pain procedures continue to play an important role in the management of chronic pain for many patients. Pain procedures can result in improved function and better quality of life for patients, as well as pain medication sparing effects. With the aging American population and increasing polypharmacy, it is vital that clinicians working in an interventional pain procedure environment have an understanding of the complexity associated with antiplatelet and anticoagulant therapies, namely, which medications need to be held prior to a pain procedure and for how long? If anticoagulation is held, is bridging required? When should the patient resume therapy? All of these questions and more will be addressed in this presentation with a detailed review of the 2015 ASRA (American Society of Regional Anesthesia and Pain Medicine) guideline recommendations for anticoagulation and antiplatelet therapy in this unique patient population.
Central pain conditions are difficult to treat. What is worse, many central pain conditions are misdiagnosed or mistreated. Conditions such as depression, anxiety, trigeminal neuralgia, complex regional pain syndrome (CRPS), various neuropathies, phantom limb pain, postherpetic neuralgia, fibromyalgia, PTSD, and others can be very responsive to ketamine infusions. There have been many infusion protocols out there with variable results. We will discuss various conditions, the infusion, and the results we have seen.
Fibromyalgia has frequently been referred to as the most common chronic widespread pain disorder. Many investigators have viewed fibromyalgia as a central nervous system disorder of sensory amplification resulting in many symptoms including chronic pain. Recently, however, others have reported conditions affecting the peripheral nervous system in which chronic widespread pain sensory amplification has been reported. This session will focus on how various mechanisms underlying sensory amplification may be associated with various clinical phenotypes.
Neurogenic thoracic outlet syndrome (NTOS) is a chronic neuropathic illness that involves all or part of the brachial plexus. It is predominately a sensory disorder of pain and paresthesias, although it often includes motor dysfunction. Previous trauma(s) create the initial sensory injury of course descriptions A-delta and C-fibers. More recent trauma(s) aggravate the previous injury and impact the central nervous system. Not only is motor function impacted, but the traumas may cause radiation of sensory symptoms beyond the original dermatomes and central sensitization (complex regional pain syndrome II). The pain is unrelenting and grinds on the psyche, particularly if the patient hears or even senses "It's all in your head." The patient may lose his/her identity as a wage earner, parent, or spouse. Happiness and self-image are seriously affected. The effective physician needs to know how the illness has impacted the individual's life and how the individual copes. Recommended therapies must be based on a thorough psychosocial assessment as well as a clinical examination. A biopsychosocial approach is crucial in assessing and treating the patient with NTOS. This presentation will concentrate on 5 areas: 1) anatomy and etiology, 2) symptoms, 3) physical and neurological examination, 4) psychosocial, and 5) laboratory testing and management.
Pain and depression. Depression and pain. Are they the same or do they just "look" the same? Is one the chicken and one the egg? Both terms reflect more than just a single concept. They represent complex constructs that relate to and interact with one another. In order to appreciate all the angles, the practitioner must evaluate the patient from different perspectives. This course will review the formulation of both pain and depression in patients who present suffering from either one or both. The different natures of pain and/or depression as diseases of the body, vulnerabilities of capacities, reinforcements of choices, and outcomes of interpretation will be described. The underlying logics of these natures of suffering will be contrasted with an emphasis on prescribing comprehensive and tailored therapy regimens to promote a patient centered plan for rehabilitation and life satisfaction.
During this 2-hour Master Class, participants will learn the pathoetiology of central pain syndromes (CPS). Six specific CPS will be described and clinical aspects will be discussed: multiple sclerosis, Parkinson's disease, phantom limb pain, spinal cord injury, poststroke pain syndrome, and traumatic brain injury. Treatment of an individual CPS as well as the general problem of CPS will be discussed.
The prescribers of opioid medications for pain and addiction are under heavy scrutiny from state regulators, law enforcement, and plaintiffs' attorneys. With benzodiazepine related overdose deaths quadrupling between 2001 and 2013, and sedative induced impairment garnering increasing attention in communities, courts, and the media, scrutiny of the prescribing of all classes of controlled prescription medications is rapidly increasing. This session--led by an attorney whose practice focuses heavily on managing the risks of prescribing controlled prescription medications-- will set forth best practices to protect patients from harm and providers from criminal and civil liability. The speaker will discuss methods to determine medical necessity, comply with the standard of care, implement safety precautions, and provide adequate documentation in the medical record.
In February 2016, President Obama expressed his compassion for people with pain loud and clear, saying, "If we go to doctors right now and say 'Don't overprescribe' without providing some mechanisms for people in these communities to deal with the pain that they have or the issues that they have, then we're not going to solve the problem, because the pain is real." Nevertheless, governors, members of Congress, and regulators are calling for aggressive government action that poses grave consequences for people with pain and their healthcare providers. The presentation will address the pressing policy issues affecting pain management. Also discussed will be recent federal action, including the CDC's opioid prescribing guidelines, and we'll look ahead to noteworthy federal and state level proposals. This course will examine the likely impact of legislation and regulations, looking at the current status, and predicted benefits, drawbacks, and unintended consequences of such efforts on the clinical management of pain.
Every day something new happens in pain management. One day it might be a change in a licensing board practice standards and the next day might bring new legislation on opioid overdose prevention. Whatever the case, pain management practitioners need a system to help keep themselves and their staff current on new prescribing regulations, patient education efforts, and reimbursement challenges. This course will examine critical pain management practice issues and offer practical guidance on staying current, compliant, and focused on providing quality pain relief.
Arachnoiditis is officially listed as a rare disease, but its estimated incidence has increased over about 400% in the past decade. Almost every pain practice has now encountered a case. Technically, the name implies an inflammatory disease of the arachnoid layer of the thecal sac or meninges. In most cases the underlying pathologic cause is neuroinflammation of the nerve roots of the cauda equina. Pain practitioners need to know the inciting causes, symptoms, physical signs, and MRI findings of arachnoiditis. A clinical protocol for treatment of this "most painful" of pain states has been developed and will be presented.
Approximately 40 million people in the United States suffer from peripheral neuropathy and a growing subset of those appear to suffer from small fiber neuropathy. This presentation will review the causes and symptoms of small fiber neuropathy, a grossly underappreciated painful disorder that frequently is manifested by chronic widespread pain. Symptoms--burning and shooting pain, allodynia, and hyperesthesia--may result from myriad diseases, including diabetes, thyroid dysfunction, sarcoidosis, vitamin B12 deficiency, HIV, and neurotoxic medications, among others; however, often no specific cause is determined. Data about treatment specifically for small fiber neuropathy remain sparse. Recent guidelines propose using antidepressants, anticonvulsants, opioids, topical therapies, and nonpharmacologic treatments. History and physical examination are primarily used to diagnose this condition. Functional neurophysiologic testing and intraepidermal nerve fiber density evaluation using skin biopsy should also be used to confirm the diagnosis, as many patients are misdiagnosed as having fibromyalgia and continue to experience pain. For up to 50% of patients, the diagnosis may, however, remain "idiopathic." In this course, emphasis will be placed on determining the underlying etiology so that treatment can be tailored as much as possible, including management of associated neuropathic pain
During this session, we will discuss migraine, specifically migraine with aura. Types of migrainous auras will be shown, and we will "deep dive" into the Alice in Wonderland Syndrome, a very specific and rare migrainous aura. Also to be discussed: evidence based medicine treatments to abort migraines and prevent them; how migraine with aura affects the output of creative individuals such as painters; and celebrities who experience(d) migraine.
Chronic pain may centralize in the spinal cord and brain leaving the patient with constant, neuropathic pain. The mechanism of this development is microglial activation and neuroinflammation. Successful treatment usually requires a special pharmacologic regimen that includes analgesics, neuropathic agents, and agents which reduce neuroinflammation.
In clinical practice today, more often than not patients receive care from an interprofessional team. How can we best prepare students and practitioners to optimize working in an interprofessional environment? This presentation will review the definition of interprofessional education, what is meant and NOT meant by this definition, what evidence supports IPE practice and education, and proposed competencies. Strategies useful for developing and implementing an interprofessional education program will be reviewed, using a hands-on, interprofessional approach!
Diagnostic testing is an integral component for the differential diagnosis. In routine clinical practice there has been a tendency for clinical examinations to become more cursory, largely influenced by increasing demands of time and patient expectations of technological advances. The end result may arguably lead to an overreliance on technology for basic clinical diagnosis. The purpose of this session is 2-fold. It is meant to provide a review and, for some, an introduction to basic structural and functional studies used for the diagnosis of pain related problems. Attention will also be given to the limitations of such studies and the importance of establishing clinical relevance to their findings. Factors that adversely affect clinical management potentially resulting in failed treatment will be discussed as well as best practices when utilizing such studies to help enhance clinical outcomes for treatment.
In order to successfully clinically manage pain, it is essential to begin with an understanding of the underlying mechanisms responsible for its generation. A skillful approach based upon better knowledge concerning the anatomical structures, pathways, and events that result in pain is more likely to lead to effective clinical management of pain. The discussion will include an overview of medication classes typically considered for pain and the pathways they affect.
The Pain Educators Forum presents this course because there are so many different levels of practitioner experience with pain management. Specifically, inspiration came from someone who, after attending one of our courses, had a burning question for our faculty: "What do sodium channels have to do with pain?" Yikes!!! After attending this humorous, informative course you will definitely know the difference between paresthesia and dysesthesia, allodynia and hyperalgesia, and how sodium channels confer excitability on neurons in nociceptive pathways. In sum, you will be a fierce and worthy contestant on Jeopardy
Therapy of pain is a challenge and requires special approaches. This course, as part of the Pain Educators Forum, will build on information provided in other sessions and focus on the prevalence and impact of unrelieved pain, pathogenesis, and treatments of pain. Participants will learn about approaches and advances in therapy of common acute and chronic pain syndromes. Evidence based recommendations for pharmacotherapy of pain will be provided. Pain therapeutics will examine current trends in pain relief that can be implemented into practice.
Pain science education has gained international praise as an underutilized clinical intervention for treating pain. Research supports teaching patients about pain using a neurophysiology framework, rather than explaining pain in biomedical or biomechanical terms. To "explain pain, not anatomy" is easier said than done. This course provides arguments for utilizing this type of education in the clinic and simplifies talking points to help busy clinicians feel more confident when teaching patients about pain.
Practitioners routinely wrestle with the issue of medication aberrant behavior (MAB)—What should I do about this? Should I discharge the patient? Will I get in trouble if I don't discharge this patient? Often there is no one right answer, and practitioners struggle with what to do in the face of a failed drug screen or some other evidence of MAB. This session will help prescribers decrease and prevent MAB in their practice as well as be more comfortable making clinical decisions when faced with MAB. The session will address such issues as universal precautions, assessing risk of MAB, clinical decision-making with regards to MAB, and deciding when to discontinue opioids. The session is designed to move practitioners from a simple "I'll discharge anyone who does anything wrong" to a more balanced and clinically sound decision-making practice.
Effective clinical interviewing and pain assessment are critical to the appropriate diagnosis and management of pain. In this presentation, the clinician learns how to apply principles of effective communication and also ascertain how to evaluate available assessment tools.
This session will teach participants the 5 core pain coping skills that all pain patients need: understanding, believing, calming, balancing, and coping. By knowing these skills providers will have a better idea of how they can plan treatment and intervene with patients more effectively. Participants will also learn how they can teach these skills to patients in individual sessions or in a group setting. By learning these core skills and simple ways to teach them to patients, providers can add to their treatment armamentarium in helping patients deal with their pain.
Despite the increase in prescriptions of pain medication and interventional procedures to treat pain, there is scant evidence from population based research that these treatments have been successful in reducing pain associated functional impairment. This is because successful treatment of chronic pain requires a comprehensive approach that should include self-care, psychological, psychosocial, functional restorative, and alternative integrative approaches to complement medical treatments.
The prescription drug problem in America has led to many guidelines and, in some cases, regulations aimed at stemming the tide of prescription drug abuse. Some are evidence based, but most are driven by fear and an overwhelming need to do "something." Unfortunately, while these guidelines have offered suggestions of how to apply this information in a clinical context going forward, they provide little information as to the management of those patients who already exceed these current guidelines. This is where the concept of the "inherited patient" comes into play. Some of these patients are doing well while some are doing quite poorly. The undeniable fact is that as these guidelines are being exceeded, risk of a bad outcome increases while likelihood of achieving therapeutic goals decreases. This workshop will, through the use of representative cases, help participants to recognize irrational pharmacotherapy and, when necessary, address it through a combination of pharmacological as well as biopsychosocial frameworks.
The science of drug testing in chronic pain has advanced rapidly over the past few years. Yet there is still confusion around optimal test choices, frequencies, and what test results actually provide. Today's definitive drug testing technology can help to identify more than the simple "presence or absence" of drugs, such as possible drug-drug interactions, variations in individual metabolism that could impact medication efficacy or side effects, potential genetic variations in metabolism, and more. This case based session will focus on patient centered, guideline driven drug testing, and medical necessity documentation to support definitive drug testing. Attendees will participate and help to complete case studies with practical clinical resources that can be immediately incorporated into their practice setting.
Complex medication decisions are an integral part of treating patients with pain and palliative care. Pharmacists have a unique perspective on using these medications creatively and effectively. This session will flirt with tips and tricks on using medications appropriately for patients with chronic pain and those facing advanced diseases. Whether debriding a medication profile, aggressively treating symptoms, or strategizing a dosage formulation, it can be hard to commit to medication decisions. Two pharmacists will "speed date" their way through medication tips designed to impart highly important and little known medication facts that are important in pain management and palliative care practice.
Opioids are the most powerful tool we have in our arsenal for the management of moderate to severe pain, yet great care and attention to detail in dosing is necessary to prevent patient suffering and death. This presentation is a "boots on the ground" approach to selecting, dosing, titrating, and converting bolus doses and basal infusions of opioids. Inappropriate determining and titrating basal infusion doses of opioids, especially for patients with an advanced illness, is a leading cause of opioid induced death. Practitioners often write inappropriate orders such as "titrate to comfort" with no regard for the pharmacokinetic parameters of specific opioids, which can result in "dose stacking" and often fatality. This presentation will cover how to calculate an appropriate starting infusion dose of an opioid, how to titrate the basal dose, including how quickly you can titrate, and the magnitude of the increase, and how to write the order correctly. Participants will also learn about the importance of a clinician bolus, including what it is, when it should be administered, how to determine the dose, the pharmacokinetic explanation of the clinician bolus, and how to use administration data to further guide dosing. The final portion of this amazing program will include guidance on switching from a parenteral basal/bolus opioid regimen to an alternate regimen including different opioids and different routes of administration. Every palliative care prescriber should attend this presentation!
Step right up and receive all the updates on alternative routes of administration to the oral and intravenous route. In this lively session the pharmacology of rectal, sublingual, topical, and subcutaneous routes of opioid therapy in the setting of palliative care will be discussed. For each alternative route, the burden-to-benefit ratio and the role of the palliative care pharmacist will be discussed.
The United States is in the midst of a prescription drug crisis. Each year, over 100 million surgical procedures are performed in the US and routinely opioid use is prescribed for postoperative pain. While the recent CDC guidelines are geared towards outpatient chronic pain management, few concerns have been directed toward the postoperative setting as a potential source of this problem. In this lecture, we will examine the current opioid problem and the evidence suggesting that we should rethink how to care for these patients postoperatively.
Methadone is a very useful opioid that indisputably requires careful attention to dosing and monitoring. In this fast paced presentation, participants will learn about the American Pain Society guidelines for the safe and effective use of methadone and how those guidelines should be applied for patients with an advanced illness. Using a case based approach, participants will explore methadone dosing in opioid naïve and opioid tolerant patients, how to adjust a calculated dose based on patient related variables (eg, comorbid conditions, concurrent drug therapy), and how to use methadone in an adjunctive role. As if that weren't controversial enough, participants will also learn about medical cannabis, including its proposed indications, mechanism of action, adverse effects, and role in management of patients with chronic noncancer pain or an advanced illness. Methadone and marijuana--all you need now is potato chips!
Although long regarded as an appropriate standard of care for treating acute and cancer pain, the use of prescription opioids to treat chronic benign pain conditions has been highly controversial. The lack of empirical support in conjunction with the increased prevalence of prescription opioid abuse has subsequently led professional and regulatory boards, as well as the general public, to become more critical of physician prescribing practices. As a result, patients who were once prescribed high doses of opioid medication are now being told that they need to reduce or eliminate their reliance on this form of treatment. How can individuals successfully eliminate use of a substance that they have relied on for an extended period of time? A pain physician will review current literature related to the use of opioids and will discuss the medical challenges associated with weaning individuals off of this class of drug. A psychologist will then speak about the role of interdisciplinary treatment programs in facilitating opioid cessation while concurrently improving patients' functional outcomes. Emphasis will be placed on the critical role that psychological and behavioral interventions play in this process, and the evidence which supports their inclusion.
Nonopioid analgesics are oftentimes considered first-line therapy for most chronic pain syndromes. A strong understanding of these agents' mechanism of action, pharmacokinetics, and toxicity profiles is paramount for today's pain practitioner. This course will provide an in-depth look at each of the agents within these drug classes, their potential role in pain management, and available data supporting their use. Additionally, clinically relevant monitoring pearls will be discussed.
Designer drugs are structurally related to illegal psychoactive drugs and include cathinones (bath salts and flakka), synthetic cannabinoids (K2), piperazines (Molly), salvia, kratom, and desomorphine (krokodil). Often designer drugs are readily available on the Internet or in head shops and skirt regulation through the development of novel analogs and labeling the products "not for human consumption." These novel psychoactive substances are consumed typically by younger males via various routes and modes for their desirable effects; however, undesirable and even life-threatening reactions or death may occur. Additionally, designer drugs are often coingested with other psychoactive substances and may be metabolized through cytochrome P450 pathways leading to drug-drug interactions furthering the potential for harm. Management is normally with supportive measures and symptomatic care. Unfortunately, most of these agents are challenging to detect as they are not readily identified by immunoassay urine drug testing, though some may lead to false positives. More advanced testing with liquid or gas chromatography/mass spectroscopy is able to detect designer drugs but is limited due to its availability, cost, delay in results, and the ever-changing designer drug structures.
Many patients receiving opioids will need to be switched from one opioid to another during therapy or at least from one dosage formulation or route of administration to another. During this session, practitioners learn to recognize clinical situations in which opioid switching would be appropriate. Attendees will also work on a problem set designed to sharpen their skills in opioid conversion calculation.
Opioid therapy fairly predictably causes constipation, which can be a great source of distress for patients. Defined as a reduction in bowel movement frequency and increased straining, this adverse effect is so common that good practice dictates preventive therapies, not waiting to see if it develops. We will cover the pathogenesis of opioid induced constipation, mechanisms of action of common and newer laxatives, including the PAMORAs (peripherally acting mu opioid antagonists). This presentation promises to be a "moving" experience!
Social media presents many opportunities for pain practitioners to keep up with the pulse of what is happening in pain practice and pain policy. Thought leaders share valuable information via social media, and social media is one way patients obtain and share information about pain. This session looks at the use of social media in pain practice, discusses various vehicles of social media and how each can be used in pain practice, examines the benefits of social media for pain practitioners along with the potential pitfalls that social media may present. In short, this course will provide a road map to help navigate the benefits, burdens, and policies of social media for pain practitioners.
Social media presents many opportunities for pain practitioners to keep up with the pulse of what is happening in pain practice and pain policy. Thought leaders share valuable information via social media, and social media is one way patients obtain and share information about pain. This session looks at the use of social media in pain practice, discusses various vehicles of social media and how each can be used in pain practice, examines the benefits of social media for pain practitioners along with the potential pitfalls that social media may present. In short, this course will provide a road map to help navigate the benefits, burdens, and policies of social media for pain practitioners.
We will discuss the difficulties in diagnosing and treating a patient with a significant neurological entity who develops a "Catch-22." This Catch-22 may prevent appropriate testing and therefore impede finding the correct diagnosis and treatment.
In an instant, a rollover car accident left me partially paralyzed from the neck down and in constant burning nerve pain. I began a fateful journey into the personal realities and facts of chronic pain. In my quest for a cure I discovered that the best solutions for chronic pain are not surgeries, pills, or other passive therapies. What I learned by accident is that pain is an experience of the brain. And chronic pain is an experience that has been memorized and continually repeated to such an extent that it has overtaken the lives of over 116 million people in the United States alone. Presenting evidence based modalities I used to retrain my brain and decrease my chronic pain, I will show how brain research provides wisdom for communicating with patients. Words spoken inspire thoughts, thoughts impact emotions, and emotions define the pain experience. Learn how words either emphasize the negative aspects of a condition or focus on positive options and attitudes. Hear through the ears of a pain patient as I describe the power words have had in my own experience and in the recovery of people I coach every day.
All types of healthcare professionals may encounter challenges and obstacles to patient outcomes despite providing optimized treatment plans and state-of-the-art care. These obstacles may come from a variety of barriers including the existence of secondary gains, low patient motivation, misalignment of goals, and miscommunication. This course will discuss secondary gains and define and provide examples of empirically supported clinical pearls to improving outcomes. We will discuss the use of motivational interviewing techniques to match treatment to patient readiness to change; a research review of medical communication and pearls to improve communication; the use of strategies to improve patient adherence and self-efficacy; and the encouragement of an internal locus of control. In addition to improving outcomes, these strategies are proven to reduce negative provider outcomes including burn-out, negative feedback, and legal issues such as malpractice. The strategies reviewed will lead to improved satisfaction for patients and providers alike.
There are over 16,000 deaths per year associated with opioid induced respiratory depression and overdose. These occur in the substance abuse population and also in chronic pain patients who are legitimately receiving opioids. This interactive lecture will review unexpected and unanticipated risks of opioid therapy, including drug interactions that are not generally included in pharmacy software programs. Opportunities for collaboration between healthcare providers will be discussed, including current comparative state policies for naloxone standing orders, standardized procedures, and clinical documentation. Available software to assess risk and the validated RIOSORD tool--risk index for overdose or serious opioid induced respiratory depression--will be introduced to participants with an explanation of how they can be implemented by all clinicians to qualify patients for in-home naloxone. Attendees will leave with a foundation on how to best counsel patients and caregivers to mitigate against opioid induced risks in terms of preparedness for naloxone reversal in the home.
Leonard Kish called patient engagement the wonder drug of the 21st century. The Affordable Care Act requires it, and the evidence shows that people engaged in their own care, including those with chronic pain, experience improved health outcomes, lower costs, improved patient care, and decreased medical errors. Engaged individuals with chronic conditions are also more likely to adhere to treatment regimens. This session looks at the evidence that supports the benefits of patient engagement and the barriers pain patients often face. It provides specific strategies for pain practitioners to meet the need for increased patient engagement among pain patients. This session provides practical information about shared decision-making and tools for implementation. It provides suggested vehicles to encourage the provider and the pain patient to move forward together.
This presentation will examine the uses and benefits of adopting mindfulness therapies within the scope of a comprehensive treatment plan. For people with persistent pain, practicing mindfulness meditation can be helpful, with moderate effects seen in reducing pain intensity. Compared to normal medical care for pain, meditation also seems to improve other important aspects of life, such as depression, coping ability, quality of life and sleep, acceptance, and physical functioning. Compared to people who do not meditate, people with acute or short term pain who have had meditation training report less distress and more pain tolerance in the research laboratory. This presentation will define mindfulness and meditation, offer a guided practice addressing pain symptoms, and provide an overview of multimodal management of mindfulness therapy. Only secular, nonreligious forms of mindfulness will be discussed.
A common practice for treating chronic back pain includes core stabilization. There is strongly held belief in health care and fitness that back pain is related to the strength of core muscles. Where did this belief originate? Why is it so popular? What is the evidence supporting widespread use of this approach? This short course will explore the history of core stabilization and the current evidence that may change your opinion of this popular treatment approach.
Virtual reality (VR) has been used as a pain treatment technique in some settings for decades. However, the cost of the technology has traditionally been out of reach for almost all practitioners. This has changed in the last year as the hardware has become affordable and the possibility of using VR in the treatment of pain in additional settings is now a possibility. This session will review the existing literature on the use of VR for pain. Then we will present the results of a recent clinical trial in the use of VR for chronic pain conditions. Finally, we will review some of the hardware and software options now available, and discuss the emerging options for frontline practitioners to help patients deal with pain without opioids.
Using "the right language" to trigger positive physiological responses in patients is a wellestablished practice based on robust placebo research. The nocebo effect is less studied but should be considered in pain care. Healthcare providers and educators try to help patients understand their painful conditions by describing anatomy or diagnosing common ailments like arthritis, impingement syndrome, or bulging discs. This approach can result in an unintended nocebo effect of increasing anxiety and fear-avoidance behavior. This pop-up course will highlight clinically relevant research focused on language commonly used in the clinic to explain pain from a biomechanical perspective and will outline the pitfalls of this approach. Learners will be presented with alternative word choices to create a therapeutic context.
Chronic pain can lead to inactivity, functional impairments, and prolonged disability. Some of the potential secondary consequences of pain related avoidance of typical daily activities include unemployment, a loss of independence, and an increased risk of other chronic diseases including cardiovascular disease, diabetes, and obesity. The need to improve physical fitness and function with daily activities should be considered an essential component of addressing chronic pain as a public health epidemic. Helping pain patients become both more globally active and functional with symptomatic body parts can be difficult. Practitioners are often not trained in focusing on chronic pain and rehabilitation and may struggle in achieving long-term success. Understanding the complex central nervous system changes that take place in chronic pain syndromes and how exercise can positively counteract these changes is an important first step. Fear avoidance is often a significant barrier to progress, and learning specific steps to work past it can be critical. While each patient's own set of physical limitations and challenges are unique, there are certain core concepts of chronic pain rehabilitation that practitioners can employ to improve measurable outcomes.
The emerging role of botulinum toxins as chemical neuromodulators, specifically in the management of chronic intractable painful syndromes, will be presented. There is compelling evidence showing that toxins modulate chronic neurogenic inflammation, commonly expressed as peripheral sensitization leading to central sensitization with allodynia and hyperalgesia. Existing medical literature will be discussed. Several cases successfully managed with type A botulinum toxins will be discussed, including chronic intractable headaches of several etiologies (migraine, posttraumatic, postintracranial bleed, etc), occipital neuralgia, intractable facial pain, temporomandibular joint pain syndromes, postradiation fibrosis, and other focal painful syndromes (ie, distal limb ischemic pain seen in Raynaud's phenomenon, temporal arteritis, and (others).
On September 16, 2015, the Centers for Disease Control and Prevention (CDC) hosted a public webinar where they revealed a draft of their 12 prescribing guidelines for chronic pain. Due to technical difficulties, the entire process was repeated the following day. Concerns over the way the guidelines were introduced was raised by the pain community and, following a congressional inquiry, the CDC decided to offer an extended open comment period that resulted in over 4000 written responses. It is anticipated that the CDC guidelines will be finalized by the time PAINWeek convenes. Panelists will discuss the history of the guidelines as well as their concerns, both procedurally and substantively.
Fierce debates rage on about chronic pain. These include the utility of chronic opioid therapy, the value proposition of multidisciplinary approaches, reimbursement related issues, risk of aberrant drug related behaviors, along with many other questions related to assessment and treatment. Additionally, and unfortunately, education about chronic pain, one of the most prevalent medical conditions, remains poor or nonexistent for most clinicians in the majority of medical training programs, including the training of most if not all clinical disciplines. While many existing and familiar clinical strategies for managing other medical conditions can often be applied to chronic pain, educational deficits may often result in the lack of application of commonly accepted clinical tools and approaches, of which none are more important than dialogue and communication. This presentation will focus on the significant role of communication as an often forgotten yet supremely important component of assessment, treatment plan formulation, and management. It seems logical that if pain is one of the few medical conditions where the patient has a say in whether or not a treatment plan is successful, communication should be a consistent and omnipresent component of the healthcare provider and patient relationship.
In this dynamic and interactive session, Drs. Darnall and Mackey will tag team content that will lead attendees through the recent and relevant political developments including the CDC opioid prescribing guidelines and recommendations from the National Pain Strategy (developed by a committee of 80 individuals chaired by Dr. Mackey). The underlying imperative is to treat pain differently, but how do we do that?
Pain and restrictions on movement are often inextricably linked. The pain of movement and the tendency to hold oneself still in order to avoid further pain can have a residually negative impact in a disease trajectory. Compelling research in music and medicine illuminates the therapeutic benefits of 'coupling' and movement in groove to heighten feelings of pleasure, build resilience, and extend one's capacity to cope with pain and its ensuing anxiety and stress. The convergence of advancement in personal technology fosters heightened self-awareness of individuals to be active players in their own modulation of pain, and has substantiated that accessing the 'groove' in music is a tangible and enjoyable means of self-treatment. Music as an active resource, and most particularly groove's hooks, can therapeutically impact those living with pain. We will explicate and 'sample' this idea through new research as evidenced and practiced by music therapists in the Louis Armstrong Center for Music and Medicine. In this eye- and ear-opening presentation, we will discuss: the applicability of groove-based music toward resilience and wellness in everyday life; entrainment and groove in the treatment of acute pain; and rhythmicity's means to increasing fluidity in those living with the trauma of pain.
Low pressure headaches (LPH) are caused by low cerebral spinal fluid (CSF) pressure or volume and may be spontaneous or provoked. Although the suspected incidence of spontaneous intracranial hypotension (SIH) is rare, improved imaging and greater awareness have led to increased identification. Undiagnosed LPH can lead to years of painful, expensive, and unyielding diagnostics. Patients endure years of suffering as a result of inappropriate treatment and the stigma of chronic or even a suspicion of psychogenic pain. Practitioners struggle with the inability to diagnose or manage the patient's symptoms because of inadequate education. This presentation will review the clinical features of a low intracranial pressure headache, explore the unique patient history and imaging characteristics, and identify the proper treatment options available.
Pain management is prevalent in the workers' compensation industry as employees are treated for a workplace injury or illness. In managing an injured worker's pain, there are many things to consider, from appropriate utilization of opioid analgesics to the potential impact of underlying comorbid conditions. This presentation will discuss the pain management issues to look for in a workers' compensation claim, methods to help injured workers improve function, and the importance of collaboration in facilitating a successful return to work.
In the age of modern medical miracles, it is easy to forget that we change our body chemistry every time we eat. The quality and composition of our food has the power to increase or decrease body-wide inflammation. Yet most medical schools have only a few hours of learning time devoted to a topic that has the potential to help every patient seen. The research evidence is robust for dietary interventions and improved health. The changes needed are simple, but not necessarily easy. Topics covered in this sessions will include the evidence, suggested interventions, and how to overcome barriers to change.
Many common chronic pain conditions including headache, various types of musculoskeletal pain, and certain neuropathic pain conditions can be successfully treated with office based procedures. In this session, common office based procedures that can be performed to treat chronic pain will be discussed and demonstrated, with emphasis on the rationale for performing, as well as the methods to assess their efficacy. In addition, their role as part of a multimodal treatment program for an individual person with chronic pain will be discussed.
Prolonged exposure to opioids hypothetically activates a pro-nociceptive mechanism resulting in opioid induced hyperalgesia (OIH). Opioid hysteria doctors are causing payors and governing bodies to rush to bring the OIH concept into law and protocol, but are finding a lack of any scientific evidence for this process, at least in humans. The FDA is now requiring pharma to run extensive and expensive trials to demonstrate OIH associated with opioid therapy, but the construct is vaguely defined, the mechanisms are poorly understood, and the outcomes and methods for studying OIH are very poorly developed. In this session we will examine the state of the science surrounding OIH including terminology, technology/methodology, and existing evidence. I will also present a preliminary data set executed to determine practical, workable methods to study the phenomena, and its results. Our pilot study showed no trend toward development of OIH (by our quantitative definitions) beyond the hyperalgesia and allodynia that all pain patients develop as pain becomes chronic (AKA sensitization/augmentation), which was seen equally in our control group of subjects with the same diagnosis not taking opioids. Importantly, I will try to outline practical methods for future study.
The significance of investigational drugs can be identified by performing a variety of clinical studies. These studies can range from bench top to bedside and include various populations like pediatrics and geriatrics. This course will address the elements related to the clinical study of analgesics. Discussed with be new analgesic drugs; their mechanism of action; how to design a study around these characteristics; why trial design for these types of analgesics (and others) do not always mimic clinical practice; and pitfalls of analgesic trials. Issues surrounding some of the new regulatory requirements of analgesics, especially controlled substances, and the impact of these requirements on trial design will be presented. In addition, dissemination of data from analgesic clinical studies into the public domain will be covered. At the conclusion of the program, participants will have a comprehensive understanding of analgesic trial design and reporting.
In this time during which the use of opioids for analgesia is being attacked by well-organized zealots, society is desperately seeking ways to make utilization of these medications safer and more effective. In a growing number of developed nations, genetic testing is being routinely utilized to determine which opioid is likely to provide the best choice for each patient. There have been excellent results reported in terms of prescription of the lowest possible dosage of an opioid with ideal analgesia--for individualized pain medicine. Unfortunately, the United States is lagging behind in pain pharmacogenomics, thereby perpetuating our 2 opioid crises: "abuse, overdose, and death" and "the swing of the pendulum to frank opiophobia and olioanalgesia." In the first part of this comprehensive symposium, a PharmD will discuss the science behind course descriptions pharmacogenomics. This will be followed by a neurologist who will discuss practice issues associated with this scientific approach to opioid prescribing. Finally, a policy and bioethics specialist will discuss the conundrum of gaining insurance coverage for this cost-efficient yet currently expensive paradigmatic revision, along with some of the myriad ethical issues associated with pharmacogenomic testing in practice as well as research.
Most states have passed legislation to honor a type of advanced directive, commonly known as a POLST, for Physician Orders for Life Sustaining Treatment. It is basically a more detailed and specific DNR (do not resuscitate). Patients consistently report preferences to die peacefully at home but all too often end up dying in hospitals, with advanced medical interventions and an uncomfortable end. Most clinicians are not adequately prepared to address this issue. End-oflife care is about listening to patients and their families and engaging them in honest dialogue about options and outcomes--easy to say, but excruciatingly hard to do. This presentation will explore the economic and societal issues of end-of-life care for an aging society and encourage the use of an enduring set of medical orders guided by clinicians but chosen by patients and their families. This session will discuss POLST and ongoing research in the state of Oregon, which has proven that the POLST program more accurately conveys end-of-life preferences that are more likely followed by medical professionals. The POLST program has been a key vehicle in Oregon's successful efforts to increase the effectiveness of advance care planning and decrease unwanted hospitalizations at the end-of-life.
The course will overview current believed mechanisms of actions surrounding platelet rich plasma (PRP) and how it is acquired from patients. It will describe current indications for use and possible side effects of its use. The literature as it stands will be reviewed in depth with specific time spent discussing the role PRP may play in interventional pain therapies.
Controversies continue to exist regarding safe and appropriate management of people with chronic pain. The "pendulum has swung in the other direction" with respect to the utility, safety, and efficacy of the use of opioids as a key component of chronic pain treatment. It seems to be unclear to many what can rationally be offered to patients whose lives have been derailed by often debilitating chronic pain. This is further complicated by the "opioid epidemic" that has resulted in a dramatic increase in unintended deaths related to opioids, heroin, and now fentanyl. This presentation will detail many of the hurdles that exist in clinical practice trying to compassionately help and support patients while navigating the challenges and pressures of state and national guidelines, educational deficits, ethical dilemmas, and regulatory scrutiny. This discussion will include the fact that in many cases, clinicians have questioned whether or not it is worth the effort to try to conform to all of the constraints involved, especially in the face of decreased available resources and funding. Intended and unintended consequences of this exodus will be addressed, along with possible strategies for preventing it.
For decades, the concept of morphine equivalent daily dosage (MEDD) or some variant thereof has been routinely utilized clinically (eg, for opioid rotation) as well as in research as a dependent variable. However, recently, the concept has been demonstrated to be a scientifically invalid course descriptions one. Irrespective, MEDD continues to be utilized, with many of the individuals dedicated to the eradication of opioid analgesia fully aware of their fraudulent behavior. In this symposium, the scientific basis of the MEDD myth will be explored, as well as its implications for clinical practice. Additionally, there will be a discussion of the need to discontinue the practice of conveniently yet invalidly "lumping together" opioid dosages in empirical investigation if the research that should be informing clinical practice is to be legitimate and valid. Finally, we will explore perhaps the most egregious use of MEDD, ie, as the basis of recently released opiophobic prescribing guidelines that are causing unnecessary distress to prescribers and patients suffering from pain alike.
Managing risk is an essential part of medical practice, particularly in light of the reported increase in morbidity and mortality associated with the use of opioids. Recent anecdotal data indicate that as a result of the "opioid crisis," patients are being told by their prescribers that they can no longer manage pain with opioids and must therefore find another healthcare provider. Consequently, healthcare professionals are now faced with the increased likelihood of inheriting patients. The moderated panel will discuss the many clinical, legal, and ethical challenges that are associated with terminating/discharging patients, inheriting a patient, and managing risk.
Counterfeiting is big business. In 2012, counterfeit auto parts accounted for $4 billion in the US and $12 billion globally; electrical parts were $15 billion; personal care $4 billion; aerospace & defense accounted for 520,000 counterfeit parts in the US, and >5% of wine sold on the secondary market is counterfeit. Those numbers pale in comparison to the pharmaceutical industry. >8% of the medical devices in circulation are counterfeit. Global sales of counterfeit products in the pharmaceutical industry alone accounted for $431 billion in 2012 according to the World Health Organization. Counterfeit pharmaceuticals account for up to $200 billion in losses per year alone. Counterfeit medications are a cause for decreased wellness, increased morbidity, and even deaths. According to the Business Action to Stop Counterfeiting and Piracy group (BASCAP), the global value of the counterfeit industry will grow to $1.7 trillion in 2015 without any real solution in sight. The Drug Supply Chain Security Act (DSCSA) passed in 2013 mandated verification of the legitimacy of the drug product identifier down to the package level and enhanced detection and notification of illegitimate products in the drug supply chain. This session will discuss counterfeiting and what can be done.
Although many providers have experience in advising their patients to use topical analgesics for treatment of various types of acute and chronic pain conditions, there are new insights into just how important the skin is in evaluating and treating people with chronic pain. In this translational session, basic science data will be presented in a clinically relevant manner, describing how keratinocytes and other skin structures play an active role in the development of pain as well as potentially in identifying best treatments for patients. The results of several recently completed trials will be presented, and application of such knowledge to practice will be addressed.
As we acknowledge the recent increases in deaths and other negative outcomes associated with chronic opioid use, abuse, and overdose, we as clinicians are faced with very important questions: Can opioids be rationally prescribed for chronic pain? For whom? How? For how long? Recent CDC guidelines have been published regarding the use of chronic opioid therapy for noncancer pain FOR THE PRIMARY CARE PROVIDER. This course will not only describe the CDC guidelines but will also illustrate how these might be utilized in clinical practice. The weaknesses of the guidelines and their limitations will also be discussed. Faculty will also describe application of current guidelines to their own patients. This promises to be a lively interactive session.
Osteoarthritis (OA) is the fastest growing major health condition with symptomatic disease affecting approximately 46 million people in the US. Hyaluronic acid gives synovial fluid the viscous quality that helps to lubricate and absorb shock. Joints affected by OA have poorer quality and less hyaluronic acid in the joint fluid. Viscosupplementation--the injection of a synthetic version of hyaluronic acid into joints such as knees, shoulders, and hips--is thought to improve the viscosity of synovial fluid, resulting in smoother movement and reduced pain. FDA and non-FDA approved indications for various viscosupplements in the management of pain related to OA will be discussed. We will also present existing medical literature and pragmatic recommendations for the use of viscosupplementation for the management of symptomatic OA in large synovial joints.
Patients suffering from chronic pain commonly experience comorbid problems that can further impair quality of life. These include psychological and medical comorbidities and fatigue and sleep disorders. Greater than 50% of patients with pain disorders experience sleep disturbance, with estimates as high as 70% to 80%. Experimental studies of healthy subjects and crosssectional research in clinical populations have demonstrated that there is a strong relationship between sleep disturbance and pain, and that this relationship is reciprocal--pain disturbing sleep continuity/quality and poor sleep exacerbating pain. Chronic pain and sleep disorders independently have been demonstrated to contribute to psychiatric and medical morbidities, disability, and a significantly reduced quality of life. In spite of the persuasive literature on the deleterious effect of sleep on pain and pain on sleep, clinicians may not adequately assess and effectively treat sleep disorders in the pain population. This symposium will review the prevailing theories of this interrelationship, outline efficient and sensitive methods to assess sleep disorders, and discuss both pharmacologic and nonpharmacologic interventions to improve sleep quality in patients with chronic pain.
There is a group of intractable pain patients who have extensively accessed the pain treatment system only to be unable to find satisfactory pain relief. These patients have sought treatment at multiple academic centers and attempted numerous nonmedical, pharmacologic, and invasive interventions including surgery, implants, and intrathecal drugs. Our experience in a special unit for these patients will be presented. Only a few underlying painful conditions are found in this subgroup and patients tend to have profound genetic, metabolic defects and hormonal alterations. Special treatment regimens based on their unique clinical abnormalities have to be developed for these individuals.
Functional pain syndromes (irritable bowel syndrome, fibromyalgia, interstitial cystitis, vulvodynia, etc) are commonly seen in primary care and by pain medicine practitioners. For example, fibromyalgia affects 5 million people and interstitial cystitis 8 million women per year, and the etiologies of these syndromes remain unknown. These syndromes are challenging, both diagnostically and in developing efficacious treatments. Patients who present with functional pain syndromes tend to have significant psychiatric comorbidities that further reduce their quality of life. It is critical that practitioners are versed in the assessment and management of these complex cases to avoid iatrogenic complications such as unneeded surgery and medication dependency and to improve clinical and functional outcomes. This multidisciplinary panel will review common functional pain syndromes, underlining theoretical pathophysiologies, diagnostic strategies, and effective interventions, including pharmacologic and nonpharmacologic approaches.
Ketamine, known on the street as "special K," is a dissociative anesthetic with hallucinogenic properties and is classified as a controlled substance. Its unique mechanism as an N-methyl-Daspartate (NMDA) receptor antagonist is thought to be responsible for many of the drug's most promising properties. Stimulation of the NMDA receptor results in central sensitization (wind up phenomenon), hyperalgesia, reduced sensitivity to opioids, and the development of opioid tolerance. This can result in allodynia, hyperalgesia, and prolonged pain response. Ketamine partially reverses the previously mentioned complications that can restore the effectiveness of opioids in various settings and often allows for reduced opioid doses and improved pain control. With the appropriate clinical knowledge and patient monitoring, ketamine at subanesthetic doses can play a role in the treatment of complex regional pain syndrome (CRPS), cancer pain, and even neuropathic or chronic pain refractory to typical treatment options. Depending on the clinical setting, ketamine can be administered via either intravenous or oral routes. Clinical monitoring is required to ensure that side effects, such as dysphoria, do not adversely impact the patient.
This presentation will outline 3 sustainable stepwise approaches for providing chronic pain care within the patient centered medical home (PMH). Treatment of chronic pain is going through a systemic transformation (see 2016 National Pain Strategy from HHS and the 2009 VHA Stepped Care Model).
This interactive course will instruct participants in how to begin implementation of an outpatient functional restoration program for chronic pain, ie, intensive integrated coaching for self-care for wellness. The model will be the Atlanta VA Health System's Empower Veterans Program (EVP).
The prevalence of chronic pelvic pain in women aged 18 to 50 is around 15%. However, only one-third of these women seek medical care. Also, the average time from presentation to a primary care provider and appropriate specialty referral and diagnosis ranges from 3 to 7 years.
Painful menstruation, or dysmenorrhea, is the most common gynecological pain condition, affecting 45% to 95% of menstruating women. In spite of its prevalence, it is often ignored and poorly treated because many healthcare providers and patients may consider pain a normal part of the menstrual cycle.
Chronic vulvar pain, or vulvodynia, is a prevalent pain disorder that affects nearly 14 million women in the US. Unfortunately a poor understanding of disease pathophysiology leads to less than 2% of women actually being properly diagnosed and treated.