Past Meeting Highlights

Highlights of the 2016 Pain Care for Primary Care (PCPC)



Thursday, July 28, 2016




The clinician mindset about pain management: Starting off on the right foot
Louis Kuritzky, MD, University of Florida, Gainesville; Robert McCarron, DO, University of California, Davis School of Medicine, Sacramento


Physicians may be pre–conditioned by their own negative experiences or those of colleagues to be prejudiced against pain management, according to Drs. Louis Kuritzky and Robert McCarron. The 2 outlined steps for building more positive feelings toward pain patients and their care. They also reviewed comprehensive pain and function assessments and described how to help patients set realistic expectations for outcomes.



Classification of pain and somatic symptom and related disorders
Robert McCarron, DO, University of California, Davis School of Medicine, Sacramento


It's not uncommon for primary care physicians to see patients with generalized, unexplained pain or life–disrupting somatic symptoms, said Dr. Robert McCarron. He went on to explain how to diagnose somatic symptom and related disorders. He also described how to approach these disorders from a pharmacologic and non–pharmacologic perspective.


AMPS: A quick, effective approach to the primary care chronic pain/psychiatric interview
Robert McCarron, DO, University of California, Davis School of Medicine, Sacramento


Using the acronym, AMPS (Anxiety disorders, Mood disorders, Psychotic disorders, Substance use disorders), Dr. Robert McCarron explained how to perform a fast, effective, and targeted psychiatric assessment in a busy primary care or pain medicine setting.


Overcoming barriers to effective pain treatment
David J. Tauben, MD, FACP, University of Washington, Seattle


Patient complaints of chronic pain have led to overreliance on opioid prescriptions, which, in turn, have led to revised guidelines and approaches to reduce opioid overdose and misuse. To better equip primary care physicians to manage patients' pain, Dr. David Tauben reviewed the multidimensional pain assessment tools that are most useful and effective in a busy primary care setting and explained how to maximize the use of other health care providers, such as nurse care coordinators, pharmacists, and therapists, in a collaborative pain care model.


Pharmacogenetics of pain
Forest Tennant, MD, DrPH, Veract Intractable Pain Clinic, West Covina, California


To answer the basic question, "Why do patients with the same condition have different pain needs?" Dr. Forest Tennant explored the role of genetics. He explained that current targets of genetic testing in pain care include cytochrome P450 enzyme activity, opioid receptor binding, and catecholamine metabolic enzyme activity. He also noted that current genetic testing technology actually far outstrips our current clinical ability to utilize the test results. Nevertheless, genetic abnormalities have a profound effect on pain care therapeutics. To that end, he reviewed the physiologic systems that are targeted by pharmacogenetic testing, how to identity candidates for pharmacogenetic testing, which genetic diseases are highly associated with chronic pain, and how to implement specific clinical decisions based on test results.


Best approach to treat migraines: First–line treatment for acute and chronic management
Wendy L. Wright, MS, RN, APRN, FNP, FAANP, Wright and Associates Family Healthcare, Bedford, New Hampshire


With over 28 million migraine sufferers in the United States alone, Wendy Wright shed new light on how to differentiate migraine from other types of headaches, such as tension and cluster headaches. She also described what the latest research tells us about the etiology, triggers, pathophysiology, and preventive strategies for this difficult neurologic phenomenon. In reviewing the efficacy of the various pharmacologic and nonpharmacologic treatment options, she emphasized that the optimal strategy is to treat early before central sensitization occurs.


Management of fibromyalgia: Applying multimodal therapy to a tough condition
Wendy L. Wright, MS, RN, APRN, FNP, FAANP, Wright and Associates Family Healthcare, Bedford, New Hampshire


There is emerging evidence of a genetic component to the widespread pain condition known as fibromyalgia, according to Wendy Wright, and some MRI evidence indicating that it may be a central pain processing disorder. Affecting 2% to 5% of the US population, mostly women, the condition results in high levels of health care utilization and lost productivity, yet it is often difficult to diagnose. Wright reviewed the most current diagnostic criteria for the condition, as well as the appropriate workup, and discussed the efficacy of various pharmacologic and nonpharmacologic treatment options.


Motivational interviewing and behavioral approaches to chronic pain
Robert McCarron, DO, University of California, Davis School of Medicine, Sacramento


Motivational interviewing is a directive, patient–centered counseling style for enhancing intrinsic motivation to change such behaviors as exercise, diet, smoking, and illicit drug use, by exploring and resolving ambivalence, said Dr. Robert McCarron. Founded on open–ended questions, affirmation, reflection, and summarization, Dr. McCarron explained how to incorporate the technique into a busy primary care setting and reviewed specific ways to engage patients who are depressed or particularly reticent.

 

Friday, July 29, 2016




Update on nonopioid analgesics and adjuvants
Louis Kuritzky, MD, University of Florida, Gainesville; Daniel S. Craig, PharmD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida


Dr. Louis Kuritzky explained that properly categorizing pain is the first step in identifying the most appropriate treatment. Then he reviewed the pain conditions for which each category of agent—from nonsteroidal anti–inflammatory drugs to serotonin–norepinephrine reuptake inhibitors—is effective. Appropriate dosing and safety were also discussed. Dr. Daniel Craig then described the pros and cons of using acetaminophen for acute and chronic pain conditions, the efficacy and limitations of antiepileptics for pain management, the utility and safety of anxiolytics, and new and emerging analgesic options.




Interventional approaches for pain: Traditional and emerging
Paul J. Christo, MD, MBA, The Johns Hopkins University School of Medicine, Baltimore, Maryland


Procedural interventions are important alternatives to opioids. About 60% of more than 40 controlled studies show short–term benefit from epidural steroid injections (ESIs), remarked Dr. Paul Christo. In fact, he said, there is good evidence for short– and long–term benefit from ESIs in a carefully selected patient population with clear–cut radicular pain. He continued that there is good evidence for short– and long–term relief with facet radiofrequency denervation, and fair evidence for cooled radiofrequency of the sacroiliac joint. In addition, spinal cord stimulation is effective in treating neuropathic pain.


Opioid prescribing: Safe practices, changing lives
David E. J. Bazzo, MD, University of California, San Diego School of Medicine


Dr. David Bazzo reviewed a risk evaluation and mitigation strategy (REMS) developed by the Collaborative for REMS Education (CO*RE) and approved by the US Food and Drug Administration for the use of extended–release (ER) and long–acting (LA) opioid medications. He noted that the strategy focuses on properly assessing the patient to determine the appropriateness of ER/LA opioid analgesics; applying proper methods to initiate therapy, modify dose, and discontinue use of ER/LA opioid analgesics; managing ongoing therapy (which includes assessing for adverse effects); and counseling patients and caregivers about the safe use, storage, and disposal of these agents.


Approaches to responding to positive urine tests and taper strategies–Case study
Edwin Salsitz, MD, Mount Sinai Beth Israel, New York, NY


The question of which patient's urine to test is eliminated by a uniform practice policy, began Dr. Edwin Salsitz. He emphasized the importance of urine drug testing when treating pain with opioids and other controlled substances. He explained that the rationale for urine drug testing is two–fold: to help identify drug misuse/addiction and to assist in assessing adherence to therapy. In addition, he emphasized that specimen validity testing is an essential component of urine drug testing. Dr. Salsitz also reviewed the various types of drug tests; appropriate frequency of testing; interpretation of results (including how to rule out poppy seed ingestion); how to approach patients with unexpected results; and successful opioid tapering strategies.


Managing opioid–induced constipation
David S. Craig, PharmD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida


Opioid–induced constipation (OIC) is an issue for 40% to 80% of patients taking opioids, said Dr. David Craig. He noted that while stimulants (eg, senna, Bisacodyl) are the laxatives of choice, they are effective only about half of the time. Dr. Craig then provided appropriate dosing information for the 3 agents approved by the Food and Drug Administration for the treatment of OIC—naloxegol, methylnaltrexone, and lubiprostone, and concluded by emphasizing that its best to work to prevent OIC before it occurs.


Common low back problems
David E.J. Bazzo, MD, University of California, San Diego School of Medicine


Acute low back pain (6 to 12 weeks of pain) usually occurs for the first time in people ages 20 to 40, reported Dr. David Bazzo. Up to one–third of patients will not fully recover in 6 months, and in as many as two–thirds of patients, the episodes will recur. As a result, the differential diagnosis is especially important, as are the physical exam and radiographic studies to rule out red flags (eg, a leaking abdominal aneurysm, Cauda equina syndrome, spinal infection, malignancy). Pharmacologic treatment usually begins with nonsteroidal anti–inflammatory drugs (NSAIDS), followed by non–benzodiazepine muscle relaxants. Diazepam may be used for up to 5 days, and epidural steroids are helpful for radicular symptoms after 2 to 6 weeks.

Chronic pain, on the other hand, lasts longer than 3 months and may occur in the presence of such conditions as osteoporosis, osteoarthritis, and cancer. The treatments with the most research behind them are analgesics (eg, acetaminophen, tramadol), NSAIDS, acupuncture, and multidisciplinary rehabilitation. Those with less evidence include herbal remedies, tricyclic antidepressants, exercise therapy, behavior therapy, massage, and spinal manipulation.


Debate: Should we be prescribing opioids for chronic pain management?
Moderator: David E. Bazzo, MD
Panelists:
1. Paul J. Christo, MD, MBA, The Johns Hopkins University School of Medicine, Baltimore, Maryland


When considering prescribing opioids, primary care physicians must balance the increased risks of addiction and death associated with prescription opioid use with undertreatment of chronic pain, explained Dr. Paul Christo. Given that overdose risk doubles between 50 and 99 morphine milligram equivalents (MME)/day, and is 9 times greater at 100 MME/day or higher, clinicians should try non–opioid therapies first whenever possible. Those agents include acetaminophen and nonsteroidal anti–inflammatory agents (NSAIDs) (for arthritis and low back pain), pregabalin and gabapentin (for diabetic peripheral neuropathy [DPN] and postherpetic neuralgia [PHN]), pregabalin (for fibromyalgia and spinal cord injury), tricyclic antidepressants and serotonin–norepinephrine reuptake inhibitors (for DPN, PHN, and fibromyalgia), and duloxetine (for DPN, fibromyalgia, and musculoskeletal pain).

2. Louis Kuritzky, MD, University of Florida, Gainesville

Until the latter part of the 1990s, use of long–term opioids for chronic non–cancer pain (lasting >3 months) was effectively prohibited in most states, began Dr. Kuritzsky. But lobbying of medical boards and legislatures turned things around in the absence of clear evidence that opioids could be safely and effectively used in this patient population.

In reviewing a number of studies, Dr. Kuritzky concluded that opioids are safe and effective for chronic, non–cancer pain for up to 16 weeks. And even though evidence for use beyond 16 weeks is lacking, a favorable risk/benefit ratio endures for some patients who do not have a compelling rational for discontinuation (eg, addiction, misuse, adverse effects) and who are appropriately monitored.

3. Edwin Salsitz, MD, Mount Sinai Beth Israel, New York, NY

Balancing the fact that 116 million Americans have pain that persists for weeks to years with the fact that rates of opioid overdose, sales, and treatment admissions steadily rose during 1999 to 2010 is the challenge, began Dr. Salsitz. While nonsteroidal anti–inflammatory drugs are an option, they have potential gastrointestinal, renal, and cardiovascular side effects. Dr. Salsitz emphasized that common mental health and drug disorders are associated with initiation and use of prescribed opioids. Thus, attention to possible psychiatric disorders in patients is important when considering opioid therapy. In addition, he explained that whether or not opioid dependence is called an addiction, complex persistent opioid dependence is a serious, and not easily reversed, consequence of long–term pain treatment that requires careful consideration when deciding whether to embark on long–term opioid therapy and during the course of therapy.


Reversing opioid overdose
Edwin A. Salsitz, MD, Mount Sinai Beth Israel, New York, NY


New drug use patterns, the ready availability of heroin, and changing prescribing patterns (higher prescribing of schedule II opioids and benzodiazepines) are driving the increase in overdose, began Dr. Edwin Salsitz. While numerous strategies and public health approaches exist to combat and reverse the opioid epidemic, the problem persists. After reviewing the risk factors for—and the signs and symptoms of–overdose, Dr. Salsitz reviewed the characteristics of the opioid antagonist naloxone, cautioning that although it will reverse acute–opioid induced respiratory depression, it can cause withdrawal symptoms and that is does not work for non–opioid substances. He said to consider co–prescribing naloxone for those who are: taking high doses of opioids (at least 50 mg/d or equivalent), receiving rotating opioid medication regimes (because these patients are at higher risk for incomplete cross tolerance), taking opioid preparations with increased overdose risk, or taking benzodiazepines concurrently. Dr. Salsitz said that patients should be encouraged to have an overdose plan; involve and train family, friends, partners, and caregivers; and frequently check the expiration date on the naloxone to ensure that a viable dose is always on hand.

 

Saturday, July 30, 2016




Case study: Bob’s journey–osteoarthritis of the knee: Perspectives from a primary care physician, physical therapist, and surgeon
1. Jose Amundaray, MD, Celebration Orthopaedic and Sports Medicine Institute, Florida

The most common error made by primary care physicians when managing patients with knee osteoarthritis is delaying evaluation by an orthopedic surgeon, began Dr. Jose Amundaray. Surgical options include arthroscopy (which treats mechanical symptoms, but not osteoarthritis), osteochondrial microfracture or grafting (reserved for small, localized lesions), femoral or tibial osteotomy (appropriate for younger [<40 years], more active patients), partial knee arthroplasty (less surgery, but shorter longevity than total knee arthroplasty), and total knee arthroplasty. Dr. Amundaray concluded by noting that the risks and outcomes vary significantly with the patient and the chosen procedure.

2. Louis Kuritzky, MD, University of Florida, Gainesville

Dr. Louis Kuritzky began his talk by noting that the osteoarthritis patient’s journey generally entails 3 phases: management in the primary care setting; co–management by primary care and physical therapy; and team management by orthopedics, physical therapy, and primary care. Dr. Kuritzky discussed the roles of the pharmacologic options, including acetaminophen, oral and topical nonsteroidal anti–inflammatory drugs (NSAIDS), tramadol, and intraarticular steroids, as well as the nonpharmacologic strategies of exercise, weight loss, physical therapy, and surgery. He also reviewed a study comparing the use of less potent and more potent opioids to NSAIDs, which concluded that there was no significant difference in pain reduction between the 3 (as measured by the Western Ontario and McMaster Universities Arthritis Index [WOMAC]).

3. Laura Frey Law, PhD, PT, University of Iowa Carver College of Medicine, Iowa City

Dr. Laura Law began her talk by explaining that physical therapy options include various types of exercise; manual therapy; modalities for temporary pain relief (transcutaneous electrical nerve stimulation, ice, heat, ultrasound); bracing, taping, shoe inserts, or other supports; and patient education. She also noted that treatment must be individualized and that success is defined in many ways, including improved function and/or quality of life, reduced pain, delayed surgical intervention, or an optimized presurgical status (to improve later outcomes).



Special populations: Aging patient; pregnant women; patients with addiction
Edwin Salsitz, MD, Mount Sinai Beth Israel, New York, NY


Pain differences exist between the sexes, began Dr. Edwin Salsitz, with research suggesting that women experience greater clinical pain and pain sensitivity during the premenstrual and menstrual phases, that exogenous estrogen replacement is associated with increased clinical pain and pain sensitivity, and that compared with men, women experience more chronic tension type (1.5:1) and migraine (3:1) headaches and more fibromyalgia (7:1). Some evidence suggests that opioids are more likely to be prescribed to women and at higher doses. This information, as well as pregnancy, Dr. Salsitz said, mandates careful consideration when prescribing medication for pain to female patients. In addition, Dr. Salsitz reviewed the current data on the prevalence of neonatal abstinence syndrome.

In deliberating about prescribing pain medication for elderly patients, Dr. Salsitz continued, physicians must consider whether patients have any medical problems that could increase the risk of opioid–related adverse effects. Respiratory depression is more likely in elderly, cachectic, and debilitated patients, and older adults are more likely to develop constipation.


A clinical conversation: Diagnosis and treatment of neuropathic pain
David E. J. Bazzo, MD, University of California, San Diego


Up to half of all pain clinic visits are due to neuropathic pain and much of it is under–diagnosed and undertreated, began Dr. David Bazzo. Cardinal signs and symptoms of neuropathic pain include allodynia, hyperalgesia, and hyperpathia. Pharmacologic treatment options include the serotonin–norepinephrine reuptake inhibitors duloxetine and venlafaxine, pregabalin and gabapentin, certain tricyclic antidepressants, opioids, and certain topical agents and transdermal delivery systems. Nonpharmacologic options include osteopathic and other manual medicine techniques, acupuncture, hot/cold packs, transcutaneous electrical nerve stimulation, motor cortex stimulation, and lifestyle modifications, such as stress reduction and exercise.


Non–pharmacological approaches: Focus on physical therapy
Laura Frey Law, PhD, PT, University of Iowa Carver College of Medicine, Iowa City


Patients with acute pain and most (if not all) of those with chronic pain are candidates for physical therapy, said Dr. Laura Law. She detailed the differences between peripheral (nociceptive), neuropathic, and central (nonnociceptive) pain and which physical therapy modalities best treat each type of pain. Emphasizing the importance of physical activity and exercise in helping to prevent chronic pain, she explained that patients with chronic pain are deconditioned and should start exercise slowly and progress slowly, stretching before and after activity. Medical marijuana: Clinical practice guidelines and emerging therapies Mark Ware, MD, MSC, McGill University, Quebec, Canada

Dr. Mark Ware reviewed the constituents and pharmacokinetics of cannabis, and then walked attendees through a number of studies that evaluated its use with chronic, non–cancer pain. Dr. Ware reported that while the evidence suggests that cannabinoids are safe, provide a modest analgesic effect, and are a reasonable option for the treatment of chronic non–cancer pain, knowledge gaps remain. Adverse effects are primarily non–serious and include somnolence, amnesia, cough, nausea, and dizziness.

 

Highlights of the 2015 Pain Care for Primary Care (PCPC)



Thursday, July 23, 2015




The Clinician Mindset About Pain Management
Louis Kuritzky, MD, University of Florida; Eric A. Dietrich, PharmD, BCPS, University of Florida


It's not uncommon for clinicians to become somewhat jaded in their approach to patients seeking treatment for pain. Drs. Kuritzky and Dietrich noted, however, that there are several steps one can take to make the patient's visit a more positive experience. These steps include clarifying the rules regarding things such as lost prescriptions and multiple providers and setting appropriate expectations for pain reduction and functional improvement.


Understanding Pain Mechanisms
Charles Argoff, MD, Albany Medical Center


The assessment and evaluation of a patient in pain should focus on establishing the mechanism(s) of the pain as clearly as possible so treatment can be as targeted as possible, according to Dr. Argoff. In patients with chronic pain, more than one mechanism of action is often involved. Dr. Argoff presented an overview of the classification of pain as nociceptive, inflammatory, neuropathic, and non–inflammatory/non–neuropathic.


Classification of Pain and How This Impacts Treatment
Charles Argoff, MD, Albany Medical Center


Building on his presentation on pain mechanisms, Dr. Argoff presented a series of case studies to illustrate how these mechanisms impact treatment strategies. The case studies involved patients with diabetic peripheral neuropathy, low back pain, fibromyalgia, osteoarthritis, and headache.


Diagnosis and Assessment: Performing a Comprehensive Workup
Louis Kuritzky, MD, University of Florida


In addition to using scales to document a patient's pain, Dr. Kuritzky recommended using tools that measure physical functional ability and screening instruments that measure the risk of opioid misuse. Dr. Kuritzky discussed the evidence that suggests a 128 Hz tuning fork is the best way to diagnose diabetic peripheral neuropathy, and described how to use this tool. Dr. Kuritzky also explained that most low back pain is mechanical, and while diagnostic accuracy is the goal, successful outcomes rarely depend on a precise pathoanatomic diagnosis. He also discussed hemochromatosis as a potential cause of osteoarthritis symptoms.


The Psychological Impact of Chronic Pain
Daniel Doleys, PhD, Doleys Pain Management Clinic


Chronic pain affects patients' psychological functioning, and psychological variables influence the patient's experience of pain, including whether the pain becomes chronic, noted Dr. Doleys. He discussed the link between pain and having experienced trauma, such as childhood physical or sexual abuse or emotional neglect. He explained that epigenetic factors (eg, histone acetylation and DNA methylation) influence the expression of nociceptive genes, thus affecting pain processing. Dr. Doleys also explored the link between pain and depression.


Cognitive and Behavioral Approaches
Daniel Doleys, PhD, Doleys Pain Management Clinic


A wide range of cognitive and behavioral treatments can effectively address pain. Self–regulatory techniques such as relaxation therapy, biofeedback, and hypnosis can help patients alter brain and nervous system activity related to pain, noted Dr. Doleys. He also touched on topics such as cognitive behavioral therapy, motivational interviewing, and multidisciplinary therapy as they pertain to the treatment of pain.


Interventional Approaches: Nerve Blocks, Implantations
Paul Christo, MD, The Johns Hopkins University School of Medicine 


Dr. Christo explained that many procedural interventions for treating pain have conflicting evidence, but likely provide short to intermediate benefits for well–selected patients. He noted that:


  • Ideal candidates for epidural steroid injection include younger patients and those with radiculopathy caused by a herniated disk.
  • Facet blocks are indicated for patients with deep, aching, diffuse pain in the neck, shoulder, base of skull, thorax, or low back.
  • Radiofrequency denervation is an effective treatment for pain, based on findings from well–conducted studies.
  • Sacroiliac joint injection is indicated for patients who have pain in the lumbar spine, buttock, groin, or back of thigh. Controlled studies have found these injections provide short–term relief.
  • Spinal cord stimulators, which deliver small doses of electricity directly to targeted nerve sites, are far more effective when used early in a patient's treatment than when they are used a decade or more after the patient first develops chronic pain.
  • Implantable drug delivery systems can be effective for certain patients, such as those with cancer pain.

CAM Approaches: Exercise, Acupuncture, Acupressure, Physical Therapy, Yoga
Daniel Doleys, PhD, Doleys Pain Management Clinic


Currently available evidence is not strong enough to allow definite conclusions about whether any complementary and alternative medicine (CAM) approach is effective for chronic pain, said Dr. Doleys. However, growing evidence suggests that several approaches, including spinal manipulation, acupuncture, massage, and yoga may help to manage certain painful conditions. Dr. Doleys reviewed some of this evidence.

 

Friday, July 24, 2015



Non–Opioid Analgesics and Adjuvants
Louis Kuritzky, MD, University of Florida; Eric A. Dietrich, PharmD, BCPS, University of Florida


The question to answer when considering opioid vs non–opioid treatment of pain is, "When is the risk–benefit ratio of non–opioid Rx superior to the risk–benefit ratio of opioid Rx?" In their discussion of non–opioid options, Drs. Kuritsky and Dietrich explained that while acetaminophen may be less effective than nonsteroidal anti–inflammatory drugs (NSAIDs), when it works, it avoids the use of potentially more toxic agents. NSAIDs are efficacious, but prescribers need to remain vigilant for potential gastrointestinal, renal, and cardiovascular adverse effects. The efficacy of skeletal muscle relaxants may be limited because these agents are indicated for short–term use and may cause sedation. Drs. Kuritsky and Dietrich also discussed the evidence supporting adjunctive treatments, including antidepressants, gabapentinoids, and duloxetine, as well as topical analgesics and nontraditional treatments such as magnetic fields.


Medical Marijuana, Clinical Practice Guidelines and Emerging Therapies
Douglas L. Gourlay, MD, MSC, FRCPC, FASAM, Mount Sinai Hospital, Toronto


Cannabis is not a single drug, but a mixture of more than 400 compounds. The substances in cannabis that are of most interest are tetrahydrocannabinol (THC) and cannabidiol (CBD). Dr. Gourlay said that while these substances may have certain potentially therapeutic benefits, such as anti–inflammatory and antiemetic effects, the evidence supporting the use of cannabis as an analgesic is weak. Dr. Gourlay encouraged physicians to carefully consider any decision to prescribe cannabis. He also discussed responses to patient's views on marijuana, such as, "But it's the only thing that works for me" and "Can you help me taper my use of marijuana?"


Understanding Addiction from the Inside Out
Edwin A. Salsitz, MD, FASAM, Mount Sinai Beth Israel


The neurochemical output of the limbic system sets an individual's hedonic tone, which Dr. Salsitz explained is a sense of well–being, happiness, pleasure, and contentment that can be altered by psychoactive activities such as substance use. Vulnerability to addiction encompasses genetic, environmental, and cultural factors. Dr. Salsitz covered treatment options for tobacco, opioid, and alcohol addiction.


Rules of the Game: Latest Guidelines and Safe Practices in Prescribing Controlled Substances
Howard A. Heit, MD, Georgetown University


Dr. Heit described the scheduling system of controlled substances (CS). He noted that physicians must comply with both state and federal laws that govern prescribing CS, and when the 2 differ, the more stringent rule applies. Federal regulations have set requirements for how physicians can prescribe CS; for example, with some exceptions, prescriptions for Schedule II CS must be written. Dr. Heit also covered specifics regarding partially filling and refilling CS prescriptions, prescribing procedures for emergency situations, and disposing of unused CS.


The Treatment Agreement: You and Your Patient
Howard A. Heit, MD, Georgetown University; Melissa Weimer, DO, Oregon Health & Science University


A "universal precautions" approach should be used when treating all patients with chronic pain and has been endorsed as a standard of care by several professional organizations, including the American Pain Society and the American Academy of Pain Medicine. These precautions include conducting a comprehensive history and exam and an opioid misuse risk assessment, as well as establishing a specific pain diagnosis, scheduling regular office visits, and creating clear documentation. Dr. Weimer said to assess a patient's risk of opioid misuse, use a validated questionnaire, implement urine drug testing (UDT), review prior medical records, and check your state prescription drug monitoring program.

Dr. Heit explained that although UDT is an important tool, it does not replace clinical judgment. He described the differences between qualitative vs. quantitative UDT.

Dr. Weimer discussed strategies for tapering a patient off opioids in a primary care setting. She described several tapering timetables based on the individual's circumstances, and the use of adjuvant therapies, including clonidine and hydroxyzine.


What to Do with the Inherited Patient and When to Refer
Howard A. Heit, MD, Georgetown University


Dr. Heit suggested that physicians take a personal inventory of their knowledge of, and comfort with, treating a patient with a chronic pain syndrome and the disease of addiction, and consider referring the patient to another doctor if unsure or uncomfortable. He noted that treatment agreements are becoming more common, especially for patients for whom controlled substances are being considered. These agreements should be readable, reasonable, and flexible. When deciding to discontinue a certain class of medications, Dr. Heit said that it is important to emphasize to the patient that this does not mean treatment is being discontinued.


Special Populations: Aging Patients, Women, Patients with Addiction History
Howard A. Heit, MD, Georgetown University; Edwin A. Salsitz, MD, FASAM, Mount Sinai Beth Israel


Women tend to have elevated rates of persistent pain relative to men, Dr. Salsitz noted. They may have greater pain sensitivity during the premenstrual and menstrual phases of their menstrual cycle. Dr. Salsitz discussed special considerations when treating pain in pregnant women, and emphasized the importance of counseling women of childbearing potential about the risks and benefits of opioid therapy during pregnancy and after delivery. He went on to say that older patients might have medical problems that increase the risk of opioid–related adverse effects.

Dr. Heit discussed treating pain in patients with a history of addiction. According to federal regulations, physicians can prescribe methadone or any other opioid to a patient with addiction, but must document in the patient's chart that the primary reason for prescribing the opioid is to treat pain, and not to treat addiction. Dr. Heit discussed using buprenorphine to treat patients with pain and a history of addiction.

 

Saturday, July 25, 2015



Back Pain
David Bazzo, MD, University of California, San Diego


Acetaminophen and nonsteroidal anti–inflammatory drugs are first–line medications for treating chronic low back pain. Dr. Brazzo explained that imaging, such as lumbar spine radiography, should be delayed at least one to 2 months in patients with nonspecific low back pain without red flags for serious disease. Evaluation of psychosocial problems and "yellow flags" such as anxiety, depression, or a history of physical or sexual abuse is useful in identifying patients with chronic low back pain who have a poor prognosis.


Debate: Diabetic Peripheral Neuropathy—First Line of Treatment
Louis Kuritzky, MD, University of Florida; Wendy L. Wright, MS, RN, APRN, FNP, FAANP, Wright & Associates Family Healthcare


Both pregabalin and duloxetine are FDA–approved for treating diabetic peripheral neuropathic pain (DPNP). Ms. Wright reviewed the evidence supporting pregabalin for DPNP and said this medication should be considered first because it offers early (one week) pain reduction, a flexible dose range (150–600 mg/d), and beneficial effects on sleep, as well as pain. Dr. Kuritzky reviewed the evidence supporting duloxetine for DPNP and said this medication should be considered first because it can be dosed once daily as a single pill, and because it may help treat comorbidities such as depression, chronic musculoskeletal pain, and fibromyalgia.


Osteoarthritis
David Bazzo, MD, University of California, San Diego


Osteoarthritis (OA) is the most common form of arthritis in the United States and the most common cause of disability in adults. Dr. Bazzo described the characteristics of an effective OA evaluation and features that can be used to distinguish OA from other conditions, such as rheumatoid arthritis. He outlined treatment options for OA that can lead to improved function, including medications (eg, acetaminophen, nonsteroidal anti–inflammatory drugs, opioids), nonpharmacologic options (eg, exercise, physical/occupational therapy, weight loss), and surgical interventions.


Fibromyalgia
Wendy L. Wright, MS, RN, APRN, FNP, FAANP, Wright & Associates Family Healthcare


In addition to widespread pain, patients with fibromyalgia may present with a wide range of additional symptoms including tenderness, sleep disturbances, fatigue, morning stiffness, cognitive complaints, and mood disorders. Most patients with fibromyalgia will require multimodal treatment. Ms. Wright explained that nonpharmacologic therapeutic options with a strong level of evidence include patient education, aerobic exercise, and cognitive behavioral therapy. She discussed the evidence for a variety of pharmacologic options, including tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, analgesics, and anticonvulsants.


An Interactive Conversation: Best Approach to Treat Migraines
David Bazzo, MD, University of California, San Diego; Wendy L. Wright, MS, RN, APRN, FNP, FAANP, Wright & Associates Family Healthcare


Migraines affect approximately 13% of the population. Dr. Bazzo and Ms. Wright discussed new insights into the pathophysiology of migraines that suggest the condition is not solely a vascular disorder. A wide range of medications have level A or level B evidence supporting their effectiveness for preventing migraines, including divalproex sodium/valproate, metoprolol, topiramate, amitriptyline, and ibuprofen. Dr. Bazzo and Ms. Wright discussed the pros and cons of these medications, including which agents offer the best efficacy and the fewest adverse effects.



Highlights of the Inaugural (2014) Pain Care for Primary Care (PCPC)



Thursday, July 17, 2014



The Primary Care Clinician's Role in Pain Management
Louis Kuritzky, MD, University of Florida

Pain can't be proved or disproved with lab tests or radiography and clinicians may view those with chronic pain as "problem" patients. To improve outcomes for pain patients, Dr. Kuritzky recommended that clinicians validate the patient's pain, establish trust, and avoid suggestions of opioid abuse and dependency. Opioids may be appropriate for some pain patients if "universal precautions" are taken. These include making a diagnosis with an appropriate differential, assessing for addiction risk, obtaining a treatment agreement, assessing pain and function regularly, and documenting all aspects of treatment.

Understanding Pain Mechanisms, Classification of Pain, and How This Impacts Treatment
Charles Argoff, MD, Albany Medical College, Albany Medical Center

A given pain mechanism can be responsible for many different symptoms, and more than one mechanism can operate in a single patient (and change over time). Dr. Argoff described the "pain road map," consisting of peripheral and central nervous system landmarks, and discussed the different locations in the brain that may be involved in processing pain signals. He noted that the evaluation of a patient in pain should be directed to establishing, as clearly as possible, the pain mechanism(s) so that treatment can be as targeted as possible.

Diagnosis and Assessment of Pain: Performing a Comprehensive Work–up
Louis Kuritzky, MD, University of Florida

Assessing a patient's pain level using a validated pain scale establishes a baseline and helps document progress throughout treatment. It also aids in therapeutic decision–making. Dr. Kuritzky reviewed symptom scoring systems and tools for diagnosing diabetic peripheral neuropathic pain (DPNP), including a "back–to–basics" 128–Hz tuning fork that, according to one study, had better predictive value than other tools. If a patient does not perceive vibrations when a percussed tuning fork is placed against the wrist or great toe, a diagnosis of DPNP can be made.

Developing Treatment Plans for People Experiencing Chronic Pain: A Case–Based Approach
Charles Argoff, MD, Albany Medical College, Albany Medical Center

Physical activity, mind– and behavioral–based therapies, pharmacologic treatments, interventional approaches, and alternative modalities such as acupuncture should be considered when caring for a patient with chronic pain. Dr. Argoff reviewed the case of a 67–year–old woman with a 15–year history of poorly controlled diabetes and painful neuropathy. He suggested encouraging physical activity, assessing for anxiety and depression, and aggressively managing her diabetes to address the neuropathy. He advised that if there were no improvement, the clinician should initiate multimodal treatment.

Affective Inter–Relationships: Epidemiology of Pain, Depression, and Suicidality
Jennifer Haythornthwaite, PhD, Johns Hopkins University
Persistent pain can undermine personal goals, alter an individual's daily function and self–identity, and increase the risk of developing depression and/or anxiety. In some cases, it can even lead to suicide.

Risk factors for suicide include family history of suicide, suicidal ideation, a previous suicide attempt, comorbid depression or insomnia, and high levels of pain–related catastrophizing. When inquiring into a patient's current suicidal thoughts, behaviors, plans, and intent, Dr. Haythornthwaite recommended starting with a general question about whether the patient feels hopeless or has thoughts of death. Ask whether the patient has explicit thoughts of suicide, a specific plan and the means to carry it out, and the intention to do so.

Any patient with a history of a suicide attempt or hospitalization for suicidal ideation should be seen by a psychiatrist.

Special Populations: Seniors, Women, and Patients with Addiction History
M. Cary Reid, MD, PhD, Weill Cornell Medical College

Older adults may believe that pain is a normal part of the aging process and fear experiencing harm with treatment. Their pain may be underassessed and undertreated. Treatment options include acetaminophen, oral and topical nonsteroidal anti–inflammatory drugs (NSAIDs), antidepressants, anticonvulsants, and opioids. A multimodal approach that includes both pharmacologic and nonpharmacologic therapy is the standard of care. Educating older patients about the value of nonpharmacologic approaches, such as tai chi and walking clubs, can be key.

Women have greater rates of pain–related disability and are more likely to receive long–term opioid therapy and to use complementary and alternative medicine treatments compared with men. Evidence has not demonstrated whether women are more likely to develop pain disorders because of inherent biologic differences or experience differential pain sensitivities. Frequent psychological monitoring and screening for opioid misuse and abuse is critical.

The prevalence of substance use disorders is increased in patients with chronic pain. For patients with both conditions, multimodal therapy directed toward treating both the pain and the substance use disorder is essential. Ongoing monitoring during treatment is also essential.

Friday, July 18, 2014



Pharmacological Approaches: Nonopioid Analgesics and Adjuvants
Kayode Williams, MD, MBA, The Johns Hopkins University School of Medicine

Many nonopioid analgesics and adjuvant therapies–acetaminophen, nonsteroidal anti–inflammatory drugs (NSAIDs), antidepressants, membrane stabilizers, nonopioid µ–receptor agonists, topical agents–are useful for managing chronic pain. Dr. Williams explained that the nature of pain may be nociceptive (somatic, visceral) or neuropathic (central, peripheral) and that these factors should be kept in mind when selecting an analgesic or adjuvant.

Psychological Treatments for Chronic Pain
Jennifer Haythornthwaite, PhD, Johns Hopkins University

Relaxation therapy, biofeedback, hypnosis, and cognitive–behavioral therapy are effective strategies for managing pain. Behavioral and psychological therapies should be offered early in the course of treatment, as anxiety and depression, psychiatric comorbidities, pain–related catastrophizing, and sleep disturbances play a role in the trajectory of acute to chronic pain.

Dr. Haythornthwaite noted that psychological treatments help to modulate muscle tension, reduce pain–related disability and pain behaviors, and improve active coping. She also recommended useful self–help resources for patients, including the workbook Managing Pain Before It Manages You and a source for online cognitive therapy for depression.

Integrative Medicine Approaches to Pain Management
Robert Bonakdar, MD, Scripps Center for Integrative Medicine

Primary care physicians should tailor pain care to each patient's experience and promote self–management of pain. Since none of the most commonly prescribed treatment regimens sufficiently reduce pain, a more realistic approach is to combine pharmacologic, physical, and psychological components.

Dr. Bonakdar reviewed the evidence on numerous integrative medicine therapies, including slow breathing, mindfulness meditation, yoga, tai chi, biofeedback, hypnotherapy, acupuncture, exercise, and diet. Many studies of these modalities have shown good strength of evidence for their efficacy. For example, one trial of yoga for low back pain in minority communities found that the yoga participants reported less analgesic use and opioid use, as well as greater overall improvement compared with patients who received usual care.

Managing Acute and Chronic Headaches
Wendy L. Wright, MS, RN, APRN, FNP, FAANP, Wright & Associates Family Healthcare

Ms. Wright discussed the pathophysiology of acute and chronic headaches, including the activation of nerves and blood vessels. Migraine–specific therapies include triptans, nonsteroidal anti–inflammatories, ondansetron for nausea, and nonpharmacologic adjuncts. Starting treatment early, before central sensitization occurs, is optimal. Headaches caused by medication overuse are common, but widely unrecognized. Using any product more than 3 times per week will result in rebound headaches until excessive use of immediate–relief medication is eliminated.

Migraine prevention guidelines recommend the following as level A effective treatments: divalproex/sodium valproate, metoprolol, petasites (butterbur), propranolol, timolol, and topiramate.

Common Low Back Problems
David Bazzo, MD, University of California San Diego Health System

Most people experience acute (6 to 12 weeks' duration) low back pain at least once in their life, and many cases self–resolve. Up to 31% of individuals, however, won't fully recover in 6 months. General treatment guidelines call for patients to stay as active as possible.

Dr. Bazzo noted that chronic low back pain (lasting longer than 3 months) can be categorized into 4 types: nonspecific low back pain, back pain associated with radiculopathy or spinal stenosis, back pain referred from a nonspinal source, and back pain associated with another specific spinal cause. Management goals should include improving pain, function, and self–care with analgesics, epidural steroids, nonpharmacologic approaches (acupuncture, herbal supplements, massage, multidisciplinary rehabilitation), and surgery.

Interventional Approaches to Pain
Paul J. Christo, MD, MBA, Johns Hopkins University School of Medicine

Epidural steroid injections, sacroiliac joint injections, spinal cord stimulation, and implantable drug delivery systems provide short– to intermediate–term pain reduction in well–selected patients with back and neck pain. Dr. Christo reviewed the clinical profiles of patients who might benefit from these interventional approaches. He noted that patients with chronic, severe low back pain who have not responded to conservative therapies, for example, may be candidates for spinal cord stimulation or implantable drug delivery systems.

A Clinical Conversation: Diagnosis and Treatment of Neuropathic Pain
David Bazzo, MD, University of California San Diego Health System

Chronic neuropathic pain is a disease process resulting from injury to, or dysfunction of, peripheral and central nervous system neurons. It has a complex pathophysiology, is underassessed and undertreated, and accounts for 25% to 50% of all pain clinic visits, said Dr. Bazzo.

Cardinal signs of neuropathic pain include allodynia, hyperalgesia, and hyperpathia. Dr. Bazzo pointed out that combined analgesic therapy for neuropathic pain makes sense because several physiologic mechanisms are likely involved. Drug therapies include tricyclic antidepressants, serotonin–norepinephrine reuptake inhibitors, opioids, and topical analgesics. He noted that osteopathic and other manual medicine techniques, acupuncture, stress reduction, and exercise are useful nonpharmacologic adjuncts.

Management of Fibromyalgia: Applying Multimodal Therapy to a Tough Condition
Wendy L. Wright, MS, RN, APRN, FNP, FAANP, Wright & Associates Family Healthcare

Fibromyalgia is a common widespread pain condition that is characterized by hyperalgesia and allodynia. Patients may present with a wide range of symptoms, such as widespread pain, tenderness, sleep disturbances, fatigue, morning stiffness, cognitive complaints, and mood disorders.

Most fibromyalgia patients require multimodal therapies. Aerobic exercise, cognitive–behavioral therapy, patient education, strength training, acupuncture, biofeedback, and hypnotherapy are part of a multidisciplinary treatment approach shown to improve patient outcomes. Ms. Wright noted that the evidence supports treatment with antidepressants, analgesics, and anticonvulsants.

Saturday, July 19, 2014



Opioids in Pain Management
Seddon Savage, MD, Dartmouth Medical School

While opioids play a critical role in the treatment of acute pain and cancer pain, their role in chronic (nonterminal) pain continues to evolve. The potential for tolerance, abuse, addiction, and diversion, as well as regulatory pressures, must be considered when prescribing opioids. Dr. Savage explained that while opioid withdrawal is distressing, it is rarely life threatening. Tapering the opioid dosage can help avoid acute withdrawal. Withdrawal symptoms can be managed with clonidine, antispasmodic medication, nonsteroidal anti–inflammatory drugs, and benzodiazepines.

Policy and Clinical Practice to Reduce Opioid–Related Harm

Seddon Savage, MD, Dartmouth Medical School

Treating pain with opioids necessitates special practice strategies and oversight, including obtaining informed consent and having the patient sign an opioid treatment agreement, a document that outlines treatment risks, benefits, and goals and establishes a basis for continuing or changing the care plan. Opioid misuse screening tools and urine drug screens, which help identify behaviors of concern, should be part of the clinical management and reassessment plan. Opioid dosage adjustment, opioid tapering, and opioid rotation may help improve pain control and reduce adverse effects. Dr. Savage noted that patients at higher risk of opioid misuse or those with complex pain or comorbidities might do best in a specialty care setting. Having an "exit strategy" that outlines clinical reasons for opioid cessation (eg, no progress toward goals, risks outweigh benefits) is essential.

Referral to a Pain Center/Specialist: Timing, Rationale, and Route
Kayode Williams, MD, MBA, The Johns Hopkins University School of Medicine

Dr. Williams discussed the common pain conditions seen in primary care settings that often require referral to specialists. He noted, for example, that patients with complex regional pain syndrome (CRPS) and failed back surgery syndrome are the populations most frequently referred for spinal cord stimulation interventions. Dr. Williams used case vignettes of patients with low back pain, hip pain (osteoarthritis), neuropathic pain, and CRPS to illustrate key diagnostic features, red flags, initial treatment approaches, and timing for referral for interventional treatment options.


An Integrated Approach to Osteoarthritis Pain
Suraj Achar, MD, University of California San Diego School of Medicine

Dr. Achar noted that osteoarthritis is a response to trauma, mechanical forces, genetic factors, and inflammation—not the aging of joints. Exercise and topical analgesic therapies are first–line treatments. Dr. Achar explained that intra–articular corticosteroid injections have no detrimental effects on cartilage and can be used with or without ultrasound guidance to improve pain and function and to delay surgery. Platelet–rich plasma injections may augment tissue healing and lead to greater symptomatic improvement than viscosupplementation.

Current Context and Future Directions: Medical Marijuana, Clinical Practice Guidelines, and Emerging Therapies
Suraj Achar, MD, University of California San Diego School of Medicine

In Dr. Achar’s comprehensive presentation, he noted that commercial cannabinoid–type drugs (eg, delta–9–tetrahydrocannabinol [dronabinol]) may be useful as multipurpose analgesics, but are not currently FDA approved for the treatment of pain. Evidence from randomized controlled trials on cannabinoids' efficacy, safety, and tolerability is limited as studies have been short and included only small populations; few studies have been conducted in cancer patients.

Dr. Achar went on to discuss controlled drugs, in general, and emphasized how important it is to keep meticulous records. He advised that physicians document discussions about treatment risks and benefits, and consider drafting a pain contract. He recommended that at least 2 physicians be involved in the care of patients treated long term with controlled substances. Periodic follow–up should include documenting achievement of treatment goals.