The Pain Practitioner - Drug Interactions by Academy of Integrative Pain Management

Integrative Pain Management for Optimal Patient Care

american academy of pain management

Integrative Pain Management for Optimal Patient Care

The Pain Practitioner May 2016

the good, the bad & the ugly of Drug Interactions Treating the Person, Not the Pain Mindfulness for Burnout Prevention Periosteal Acupuncture Electrical Stimulation for Postamputee Pain Reducing Prescription Misuse & Abuse

ONCE daily with EVENING MEAL

Bring 24-hour relief into their routine GRALISE is the only once-a-day gabapentinoid that offers Night to Day control of PHN pain1

ONCE daily with

EVENING MEAL

ONCE daily with

EVENING • Patients receiving GRALISE experienced significant pain reduction vs placebo beginning Week 1 and continuing MEAL 2,3 throughout the 10-week study (P<0.05)

•Average daily pain score reduction for GRALISE was -2.1 vs -1.6 with placebo (P=0.013)2 Study Design: Patients from 89 investigative sites participated in this randomized, double-blind, parallel design, placebo-controlled, multicenter clinical trial. The study period included a 1-week baseline period, followed by randomization and a 2-week titration to a once-daily dose of 1800 mg G-GR or matched placebo, followed by an 8-week maintenance-dose period, followed by a 1-week dose-tapering period. 452 patients were randomized, with 221 receiving 1800 mg of GRALISE and 231 receiving placebo.2 Primary endpoint: change in the baseline observation carried forward (BOCF) average daily pain score from the baseline week to Week 10 of the efficacy treatment period.2

Learn more today at www.Gralise.com INDICATIONS AND USAGE GRALISE is indicated for the management of postherpetic neuralgia (PHN). GRALISE is not interchangeable with other gabapentin products because of differing pharmacokinetic profiles that affect the frequency of administration. IMPORTANT SAFETY INFORMATION ADVERSE REACTIONS The most common side effects were dizziness (10.9%) and somnolence (4.5%). USE IN SPECIFIC POPULATIONS Reductions in GRALISE dose should be made in patients with age-related compromised renal function. WARNINGS AND PRECAUTIONS Suicidal Behavior and Ideation Antiepileptic drugs (AEDs) including gabapentin, the active ingredient in GRALISE, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.

For more information about GRALISE, please see Brief Summary on the following page. References: 1. GRALISE [prescribing information]. Newark, CA: Depomed Inc.; December 2012. 2. Sang CN, Sathyanarayana R, Sweeney M. Gastroretentive gabapentin (G-GR) formulation reduces intensity of pain associated with postherpetic neuralgia (PHN). Clin J Pain. 2013;29:281-288. 3. Argoff CE, Chen C, Cowles VE. Clinical development of a once-daily gastroretentive formulation of gabapentin for treatment of postherpetic neuralgia: an overview. Expert Opin Drug Deliv. 2012;9:1147-1160.

Relief Uninterrupted

GRALISE® (gabapentin) tablets Rx Only BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION This does not include all the information needed to use GRALISE safely and effectively. See full Prescribing Information for GRALISE. INDICATIONS AND USAGE • GRALISE is indicated for the management of postherpetic neuralgia. • GRALISE is not interchangeable with other gabapentin products because of differing pharmacokinetic profiles that affect the frequency of administration. DOSAGE AND ADMINISTRATION • GRALISE should be titrated to an 1800 mg dose taken orally, once-daily, with the evening meal. GRALISE tablets should be swallowed whole. Do not crush, split, or chew the tablets. For recommended titration schedule, see DOSAGE AND ADMINISTRATION in full Prescribing Information. • If GRALISE dose is reduced, discontinued, or substituted with an alternative medication, this should be done gradually over a minimum of 1 week or longer (at the discretion of the prescriber). • Renal impairment: Dose should be adjusted in patients with reduced renal function. GRALISE should not be used in patients with CrCl less than 30 mL/min or in patients on hemodialysis. CONTRAINDICATIONS GRALISE is contraindicated in patients with demonstrated hypersensitivity to the drug or its ingredients. WARNINGS AND PRECAUTIONS GRALISE is not interchangeable with other gabapentin products because of differing pharmacokinetic profiles that affect the frequency of administration. The safety and effectiveness of GRALISE in patients with epilepsy has not been studied. Suicidal Behavior and Ideation Antiepileptic drugs (AEDs), including gabapentin, the active ingredient in GRALISE, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior. The increased risk of suicidal thoughts or behavior with AEDs was observed as early as one week after starting drug treatment with AEDs and persisted for the duration of treatment assessed. Table 1: Risk by Indication for Antiepileptic Drugs (including gabapentin, the active ingredient in GRALISE) in the Pooled Analysis

Indication Epilepsy Psychiatric Other Total

Placebo Patients with Events Per 1000 Patients 1.0 5.7 1.0 2.4

Relative Risk: Risk Incidence of Difference: Events in Drug Additional Drug Patients Patients/Incidence Drug Patients with Events Per in Placebo with Events Per 1000 Patients Patients 1000 Patients 3.4 3.5 2.4 8.5 1.5 2.9 1.8 1.9 0.9 4.3 1.8 1.9

The relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications. Anyone considering prescribing GRALISE must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. Epilepsy and many other illnesses for which products containing active components that are AEDs (such as gabapentin, the active component in GRALISE) are prescribed, are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated. Patients, their caregivers, and families should be informed that GRALISE contains gabapentin, which is also used to treat epilepsy and that AEDs increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of the signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. Behaviors of concern should be reported immediately to healthcare providers. Withdrawal of Gabapentin Gabapentin should be withdrawn gradually. If GRALISE is discontinued, this should be done gradually over a minimum of 1 week or longer (at the discretion of the prescriber). Tumorigenic Potential In standard preclinical in vivo lifetime carcinogenicity studies, an unexpectedly high incidence of pancreatic acinar adenocarcinomas was identified in male, but not female, rats. The clinical significance of this finding is unknown. In clinical trials of gabapentin therapy in epilepsy comprising 2,085 patient-years of exposure in patients over 12 years of age, new tumors were reported in 10 patients, and pre-existing tumors worsened in 11 patients, during or within 2 years after discontinuing the drug. However, no similar patient population untreated with gabapentin was available to provide background tumor incidence and recurrence information for comparison. Therefore, the effect of gabapentin therapy on the incidence of new tumors in humans or on the worsening or recurrence of previously diagnosed tumors is unknown. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)/Multiorgan Hypersensitivity Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), also known as Multiorgan Hypersensitivity, has been reported in patients taking antiepileptic drugs, including GRALISE. Some of these events have been fatal or life-threatening. DRESS typically, although not exclusively, presents with fever, rash, and/or lymphadenopathy in association with other organ system involvement, such as hepatitis, nephritis, hematological abnormalities, myocarditis, or myositis sometimes resembling an acute viral infection. Eosinophilia is often present. Because this disorder is variable in its expression, other organ systems not noted here may be involved. It is important to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, may be present even though rash is not evident. If such signs or symptoms are present, the patient should be evaluated immediately. GRALISE should be discontinued if an alternative etiology for the signs or symptoms cannot be established. Laboratory Tests Clinical trial data do not indicate that routine monitoring of clinical laboratory procedures is necessary for the safe use of GRALISE. The value of monitoring gabapentin blood concentrations has not been established. ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In clinical trials in patients with postherpetic neuralgia, 9.7% of the 359 patients treated with GRALISE and 6.9% of 364 patients treated with placebo discontinued prematurely due to adverse reactions. In the GRALISE treatment group, the most common reason for discontinuation due to adverse reactions was dizziness.

Table 2: Treatment-Emergent Adverse Reaction Incidence in Controlled Trials in Neuropathic Pain Associated with Postherpetic Neuralgia (Events in at Least 1% of all GRALISE-Treated Patients and More Frequent Than in the Placebo Group) Body System – Preferred Term Ear and Labyrinth Disorders Vertigo Gastrointestinal Disorders Diarrhea Dry mouth Constipation Dyspepsia General Disorders Peripheral edema Pain Infections and Infestations Nasopharyngitis Urinary tract infection Investigations Weight increased Musculoskeletal and Connective Tissue Disorders Pain in extremity Back pain Nervous System Disorders Dizziness Somnolence Headache Lethargy

GRALISE N = 359 %

Placebo N = 364 %

1.4

0.5

3.3 2.8 1.4 1.4

2.7 1.4 0.3 0.8

3.9 1.1

0.3 0.5

2.5 1.7

2.2 0.5

1.9

0.5

1.9 1.7

0.5 1.1

10.9 4.5 4.2 1.1

2.2 2.7 4.1 0.3

The following adverse reactions with an uncertain relationship to GRALISE were reported during the clinical development for the treatment of postherpetic neuralgia. Events in more than 1% of patients but equally or more frequently in the GRALISE-treated patients than in the placebo group included blood pressure increase, confusional state, gastroenteritis, viral herpes zoster, hypertension, joint swelling, memory impairment, nausea, pneumonia, pyrexia, rash, seasonal allergy, and upper respiratory infection. Postmarketing and Other Experience with Other Formulations of Gabapentin In addition to the adverse experiences reported during clinical testing of gabapentin, the following adverse experiences have been reported in patients receiving other formulations of marketed gabapentin. These adverse experiences have not been listed above and data are insufficient to support an estimate of their incidence or to establish causation. The listing is alphabetized: angioedema, blood glucose fluctuation, breast enlargement, elevated creatine kinase, elevated liver function tests, erythema multiforme, fever, hyponatremia, jaundice, movement disorder, Stevens-Johnson syndrome. Adverse events following the abrupt discontinuation of gabapentin immediate release have also been reported. The most frequently reported events were anxiety, insomnia, nausea, pain, and sweating. DRUG INTERACTIONS In vitro studies were conducted to investigate the potential of gabapentin to inhibit the major cytochrome P450 enzymes (CYP1A2, CYP2A6, CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A4) that mediate drug and xenobiotic metabolism using isoform selective marker substrates and human liver microsomal preparations. Only at the highest concentration tested (171 mcg/mL; 1mM) was a slight degree of inhibition (14% to 30%) of isoform CYP2A6 observed. No inhibition of any of the other isoforms tested was observed at gabapentin concentrations up to 171 mcg/mL (approximately 15 times the Cmax at 3600 mg/day). Hydrocodone Coadministration of gabapentin immediate release (125 mg and 500 mg) and hydrocodone (10 mg) reduced hydrocodone Cmax by 3% and 21%, respectively, and AUC by 4% and 22%, respectively. The mechanism of this interaction is unknown. Gabapentin AUC values were increased by 14%; the magnitude of the interaction at other doses is not known. Antacid (containing aluminum hydroxide and magnesium hydroxide) An antacid containing aluminum hydroxide and magnesium hydroxide reduced the bioavailability of gabapentin immediate release by approximately 20%, but by only 5% when gabapentin immediate release was taken 2 hours after the antacid. It is recommended that GRALISE be taken at least 2 hours following the antacid (containing aluminum hydroxide and magnesium hydroxide) administration. Drug/Laboratory Test Interactions False positive readings were reported with the Ames-N-Multistix SG® dipstick test for urine protein when gabapentin was added to other antiepileptic drugs; therefore, the more specific sulfosalicylic acid precipitation procedure is recommended to determine the presence of urine protein. USE IN SPECIFIC POPULATIONS Pregnancy Category C: GRALISE should be used during pregnancy or in women who are nursing only if the benefits clearly outweigh the risks. See full Prescribing Information for more information about use of GRALISE in pregnancy. Pediatric Use The safety and effectiveness of GRALISE in the management of postherpetic neuralgia in patients less than 18 years of age has not been studied. Geriatric Use The total number of patients treated with GRALISE in controlled clinical trials in patients with postherpetic neuralgia was 359, of which 63% were 65 years of age or older. The types and incidence of adverse events were similar across age groups except for peripheral edema, which tended to increase in incidence with age. Renal Impairment GRALISE is known to be substantially excreted by the kidney. Dosage adjustment is necessary in patients with impaired renal function. GRALISE should not be administered in patients with CrCl between 15 and 30 or in patients undergoing hemodialysis. [see Dosage and Administration in full Prescribing Information]. DRUG ABUSE AND DEPENDENCE The abuse and dependence potential of GRALISE has not been evaluated in human studies. OVERDOSAGE Acute oral overdoses of gabapentin immediate release in humans up to 49 grams have been reported. In these cases, double vision, slurred speech, drowsiness, lethargy and diarrhea were observed. All patients recovered with supportive care. Gabapentin can be removed by hemodialysis. Although hemodialysis has not been performed in the few overdose cases reported, it may be indicated by the patient’s clinical state or in patients with significant renal impairment.

American Academy of Pain Management

The Pain Practitioner

www.aapainmanage.org May 2016

To access the virtual magazine, go to newsstand.aapainmanage.org

6 NOTES FROM THE FIELD A New Prescription for What Ails Us By Bob Twillman, PhD, FAPM, Executive Director PAGE 10

8 MEMBERSHIP Assessing Member Educational Needs and Interests By Debra Nelson-Hogan and Kathleen Strauser 10 MEMBERSHIP Treating The Person, Not The Pain: An Interview with Bruce F. Singer, PsyD By Debra Nelson-Hogan 11 EDUCATION Team Pain Care: Academy’s 27th Annual Meeting By Debra Nelson-Hogan 12 PROFESSIONAL DEVELOPMENT Expanded Reach for the Advanced Credentialed Pain Practitioner Program 14 ADVOCACY Reducing Prescription Medication Misuse, Abuse, and Diversion By Katie Duensing, JD 16 Promoting Rational Polypharmacy: The Good, the Bad, and the Ugly of Drug Interactions By Andrea Furlan, MD, PhD

PAGE 20

20 An Internet-based Mindfulness Program for Burnout Prevention in Pain Clinicians By Robert Alan Bonakdar MD, FAAFP, FACN 24 Periosteal Acupuncture Electrical Stimulation for Chronic Postamputation Pain By Saiyun Hou MD, PhD, and Jorge Garcia-Velasquez, MD 28 CALL FOR CASES Teamwork as a Matter of Life and Death By Tiffany J. Kirchner, MSN, RN, ACNS-BC, APNP, ACHPN 30 CALL FOR CASES Team-based Care at the Spine Institute Northwest By Abimbolu Makinde, MD

And More, on the Web... OVERVIEW About The National Pain Strategy

Everything you need to know about the federal government’s plan for reducing the burden of chronic pain. http://goo.gl/HL4e0W

▼

EXPERT INTERVIEW The Importance of a ‘High Touch, Low Tech’

Approach to Treating People in Pain Watch our interview with Charles E. Renner, OTR, CHT https://goo.gl/IPGufA

ON-DEMAND EDUCATION The Future of Pain Management:

The Role of Self-Care and Integrative Collaboration A new 1-hour CME activity in our Pain Care Learning Center. Free for Academy members! https://goo.gl/K6Mqbd SIGN UP Get More from The Pain Practitioner!

Access extra, interactive content with videos, slideshows, and more. http://goo.gl/aQXf7p

Subscribe to The Pain Practitioner!

If you are not a member, you can still get this bi-monthly publication for just $50/year. Send your check to the American Academy of Pain Management, 975 Morning Star Drive, Ste. A, Sonora, CA 95370

| T H E PA I N PR ACT IT ION ER | M AY 2 0 1 6

ACADEMY BOARD OF DIRECTORS President Joanna Katzman, MD, MSPH Past President Robert A. Bonakdar, MD, FAAFP Vice President W. Clay Jackson, MD, DipTh Secretary Paul Christo, MD, MBA Treasurer Kevin T. Galloway, BSN, MHA, Colonel, US Army (Retired) Directors-at-Large Alfred V. Anderson, MD, DC John Garzione, DPT Christian D. González, MD Gerald Q. Greenfield, Jr., MD Michael Kurisu, DO, ABIHM Arthur S. Roberts, DDS, MD Liaison to the Board Maggie Buckley

ACADEMY STAFF Executive Director Robert Twillman, PhD, FAPM Director of Education and Credentialing Debra Nelson-Hogan Director of the State Pain Policy Advocacy Network (SPPAN) Amy Goldstein, MSW Accounting Director Kristin Taylor Assistant Director of Education Cathleen Coneghen SPPAN Assistant Director for Legislative and Regulatory Affairs Katie Duensing, JD Account Managers Rosemary LeMay, Staci Criswell, MacKenzie Davis and Sheila Miller Office Manager Karen Hebert

THE PAIN PRACTItiONER STAFF AND CONSULTANTS Editor Debra Nelson-Hogan Advertising and Sales Sheila Miller Managing Editor Cathleen Coneghen Clinical Editor Christine Rhodes, MS Art Director Amy Bothwell Copy Editor Rosemary Hope The Pain Practitioner is published by the American Academy of Pain Management, 975 Morning Star Drive, Ste., A, Sonora, CA 95370, P: 209-533-9744, F: 209-533-9750, Email: aapm@aapainmanage.org, website: www. aapainmanage.org. Copyright 2007 American Academy of Pain Management. All rights reserved. Send correspondance to: Debra NelsonHogan at dhogan@aapainmanage.org. For advertising opportunities, media kits, and prices, contact: Sheila Miller at 209533-9744, or smiller@aapainmanage.org The Pain Practitioner is published by the American Academy of Pain Management solely for the purpose of education. All rights are reserved by the Academy to accept, reject, or modify any submission for publication. The opinions stated in the enclosed printed materials are those of the authors and do not necessarily represent the opinions of the Academy or individual members. The Academy does not give guarantees or any other representation that the printed material contained herein is valid, reliable, or accurate. The American Academy of Pain Management does not assume any responsibility for injury arising from any use or misuse of the printed material contained herein. The printed material contained herein is assumed to be from reliable sources, and there is no implication that they represent the only, or best, methodologies or procedures for the pain condition discussed. It is incumbent upon the reader to verify the accuracy of any diagnosis and drug dosage information contained herein, and to make modifications as new information arises. All rights are reserved by the Academy to accept, reject, or modify any advertisement submitted for publication. It is the policy of the Academy to not endorse products. Any advertising herein may not be construed as an endorsement, either expresed or implied, of a product or service.

Chronic Pain & Recovery Center A treatment program with proven results for patients with chronic pain and co-occurring mental illness or addiction. â&#x20AC;˘ 80% of patients who completed our program were either completely off opioids at discharge (63%) or on agonist therapy (17%) â&#x20AC;˘ Patients reported a 24% mean reduction in reported pain To get more information about our treatment outcomes, please call 866.542.4455.

www.silverhillhospital.org

THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

notes from the field

A New Prescription for What Ails Us

one of the best solutions to prescription opioid abuse lies in providing comprehensive, integrated pain care, because it’s more effective, less costly, less risky, and opioid-sparing.

President Barack Obama speaks during a National Governors Association dinner and reception in the State Dining Room of the White House in Washington, D.C.

In the last issue of The Pain Practitioner, our State Pain Policy Advocacy Network (SPPAN) team highlighted our work collecting state laws, regulations, and guidelines governing physicians’ treatment of pain, and pointed out the tremendous variability in what we found. It seems like some powerful people were listening, because at its late-February meeting, the National Governors Association (NGA) voted to develop a standardized opioid treatment guideline for all states to use. While having some interstate consistency would be nice, I was left with more than a little trepidation about who NGA will engage in this process, recalling the fiasco involving the Centers for Disease Control and Prevention opioid prescribing guideline. Interestingly, just the following day, President Obama addressed the assembled governors, and told them that, while he fully sympathized with their rush to address prescription opioid abuse, he really wasn’t sure that kind of policy was the best way to proceed. In particular, he was skeptical about imposing limits on the amount of opioid medication that can be prescribed, saying, “If we go to doctors right now and say ‘Don’t

| T H E PA I N PR ACT IT ION ER | M AY 2 0 1 6

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 ….” By “these communities,” the President meant rural communities where there is very limited access to pain treatments other than prescription medications—although I think it is no less true in suburban and urban settings. I was pleasantly surprised by that statement, as it represents the first time that I can recall a major force in the debate about prescription drug abuse saying that policymakers need to slow down and exercise some caution so that people with pain can still receive needed treatments. I also was struck by the response from patient advocacy organizations, which focused on the “don’t restrict access to opioids” aspect of the quote. While President Obama’s words certainly can be read in that manner, I think they also can be read in a far broader context, one that highlights the need for access to nonpharmaceutical treatments for pain. Might it not be the case that he was advocat-

ing for treatments like chiropractic, acupuncture, biofeedback, massage therapy, or yoga, as well as opioids? I’ve been saying, for some time now, that one of the best solutions to prescription opioid abuse lies in providing comprehensive, integrated pain care, because it’s more effective, less costly, less risky, and opioidsparing. Is the message starting to get through? We can only hope. The prescription for these two national ills, prescription opioid abuse and chronic pain, lies in implementing the kind of integrated pain care called for in the draft National Pain Strategy by the Interagency Pain Research Coordinating Committee of the National Institutes of Health (http:// iprcc.nih.gov/National_Pain_Strategy/ NPS_Main.htm). We are excited by that report’s formal release, because we think the Academy is “in the sweet spot” to take the lead in implementing it. It’s welcome news for those of us who’ve long been banging the drum for access to comprehensive, integrated pain care. In that light, I call your attention to the SPPAN team’s article in this edition of The Pain Practitioner. That article summarizes a letter we just sent to the US Senate Finance Committee, outlining steps that the Centers for Medicare & Medicaid Services can take to fill our new prescription referenced above. In it, we call for 11 steps that will bring us closer to realizing our vision of comprehensive, integrated pain care for everyone. Taking those 11 steps won’t enable us to reach our goal, but it would move us a long way down the road toward that goal, and give us some hard data to use in support of future steps. I urge you to read that column and to let us know what you think. Your support is critical, so please reach out to the SPPAN team and offer to help—they have lots of ways to use that help!

Pool photo by Pete Marovich/UPI

By Robert Twillman, PHD, FAPM, Executive Director

OUR 27TH ANNUAL MEETING The ONLY Clinical Meeting dedicated exclusively to Integrative Pain Management ! SAN ANTONIO, TEXAS

SEPTEMBER 22-25, 2016

JW MARRIOTT HILL COUNTRY

Join more than a thousand multidisciplinary professionals for the only clinical meeting designed specifically for all members of the integrative pain care team. The National Pain Strategy endorses integrative, multidisciplinary care as “best practice” in pain management. So our annual meeting is a must for clinicians who wants to improve their skills and learn more about leading or being a key member of Team Pain Care.

MAKE YOUR PLANS FOR 2016! Register early for reduced pricing.

6 KEY REASONS TO REGISTER NOW.... 1. Meeting registrants can earn up to 56 CME/ CEU credits (live + online). Every accredited, didactic session will be made available free of charge for one year to registered attendees on the Academy’s new Pain Care Learning Center. 2. If you register before 6/30, you pay just $499 (member rate) for the full meeting – the lowest price for the best integrative pain management education available. 3. 2016 Program Chairs, Robert A. Bonakdar, MD, FAAP, John E. Garzione, PT, DPT and Beth Darnall, PhD have assembled an impressive agenda of challenging topics and recruited a faculty of leading experts in integrative pain care. 4. We have captured the attention of the most influential names in US healthcare and pain management. Keynote addresses will be given by Linda Porter, PhD, Policy Advisor for Pain for NIH and co-chair of Oversight Panel of the National Pain Strategy, as well as the US Surgeon General Vice Admiral Vivek H. Murthy, MD, MBA (invited). 5. The academic program is complemented by 100+ multi-category exhibitors will showcase their latest pain management products, devices, and approaches in a hall designed to maximize professional networking opportunities. 6. The meeting is being held in a beautiful, serene resort environment that will allow you to relax and focus on your improving your professional self.

MEMBERSHIP

Assessing Academy Member Educational Needs and Interests By Debra Nelson-Hogan and Kathleen Strauser

Results of a membership survey show us where your interests lie.

Responder Profile The prototypical responder to this survey is or was an Academy member, a board-certified or credentialed physician with more than 20 years involved in direct patient care as either a pain specialist or another specialist with a secondary focus on pain management.

As the only pain organization to specialize in integrative pain management, and the largest pain organization of any kind in the US, understanding the different perspectives and preferences of multispecialty and multidisciplinary providers is essential. As is often seen with multidisciplinary and multispecialty associations, the American Academy of Pain Management (the Academy) is the primary professional affiliation for those who want to specialize in integrative pain management. Although the Academy is not the primary professional affiliation of clinicians with a secondary focus on pain management, these clinicians strongly associate with the Academy because their education, information, and clinical professional development needs are being met. Knowing what content members and professional audiences expect from an organization like the Academy is critical because it drives every article that is published, every session at the annual meeting, all training programs, and even which authors and speakers will be invited to contribute. While the Academy uses many methods and metrics to assess topic interest and educational need, last year, the first of a series of annual assessments conducted via Survey Monkey was undertaken and instantly become one of the most informative and interesting tools in the Academyâ&#x20AC;&#x2122;s history. The 2015 American Academy of Pain Management Information and Education Content Needs Survey was fielded in May to more than 90,000 members and highly affiliated non-members. Since the survey was to be taken online, only emails were used to solicit participation. Of the 4,500 Academy members who had selected email as their preferred communications method, 3,326, or 74%,

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Table 1. Survey Distribution and Completion Delivered

Opened Email

Clicked on Survey

Took Survey

Members

3,326

827 (24.86%)

146

131 (3.93%)

Non-Members

86,079

4,934 (5.73)

217

161 (0.19%)

Table 2. Content Priorities Ranked by Members Topics 1-25

Topics 26-50

Neuropathic Pain

Physical vs. Emotional Pain

Fibromyalgia

Breakthrough Pain

Myofascial Pain

Exercise

Emerging Pain Treatments

Geriatric Pain

Managing Pain in Patients with Substance Use Disorder

Psychosocial Dysfunction

Refractory or Unrelieved Pain

Supplements/Nutraceuticals

Integrative Pain Management Approaches

Clinical Research Updates

Headache

Electrical Stimulation (TENS, PENS, etc.)

Musculoskeletal Pain

Head/Neck Pain/TMJ (not headache)

Innovations in Pain Management

Mindfulness Based Stress Reduction

Assessment of Pain

Patient Education

Depression and Pain

Acute Pain

Long-term Opioid Treatment

Behavior Modification Therapies

Sleep and Pain

Diabetic Neuropathy

Complex Regional Pain Syndrome

Inter-professional Pain Management

Central Pain Syndromes

Cancer Pain

Neurobiology/Physiology/Biochemistry of Pain

Osteoarthritis

Pharmacology of Pain Medications

Psychiatric Comorbidities

Diagnosing Pain Conditions

Sciatica

Nutrition and Pain

Addiction

Lower Back Pain

Cognitive-Behavioral Therapy

Back Pain

Motivational Interviewing

Central Sensitization

Veterans/Military Patients

Hyperalgesia/Hypersensitivity Syndromes

Hands-on Manipulation

Interventional Therapies

Medication Efficacy

MEMBERSHIP

were asked to participate. The entire non-member file of more than 86,000 email addresses accumulated over the past 10 years was also solicited. Each group was given its own survey link, making comparisons between member and non-member responses easier. The survey solicitation was sent only one time and was left open for only a few weeks. An initial open rate of 25% is considered robust and representative in most circles, and, had the solicitation been repeated to any who did not open the invitation on the first promotion, the overall survey response rate would have gone much higher. Since the Academy is informed about needs and interests through many channels, the statistical power of this particular tool was less important than initiating the annual survey and testing the

questions, format, flow, and scope of information that would be captured in subsequent versions. That does not mean the results were not interesting or failed to provide insight. The research method selected for this survey is designed to capture the topics of greatest relevance to the clinicianâ&#x20AC;&#x2122;s day-to-day practice. Specifically, the survey responders are asked to answer the following question: If you could expand your current level of knowledge of 10 topics that would help you meet professional challenges and improve your personal practice relative to the effective management of pain, which would you study? Pick 10 topics. The questionnaire displayed four columns of 25 topics each. The array

of answers was randomized for each responder to improve confidence that the selected answers were chosen in response to the question rather than position on the page. The results were tabulated, ranked, and then grouped into four tiers. Within the Academy, content priorities are generally planned from the first two tiers (Table 2). Debra Nelson-Hogan is the director of education and credentialing at the American Academy of Pain Management. Kathleen Strauser is director of research, president, and managing partner at Highwater Partners, Inc., Morrisville, Pennsylvania.

We have relaunched this survey and would like to hear from you, Go to: surveymonkey.com/r/16needs and let us know your priorities.

Who Took the Survey

Years in Practice 65.48% > 20 years 10.66% < 5 years 10.15% 16-20 years 7.11% 11-15 years 6.60% 6-10 years

Discipline 41.2% MD, DO, PA 18.6% RN, MSN, NP, APNP, CRNA 40.2% Behavioral Health Professionals, Dentists, Pharmacists, Chiropractors, Physical Therapists, Acupuncturists, Nutritionists, Occupational Therapists, Others

Post-licensure Credentials 41.5% Board certified in another specialty/specialties 32.6% Credentialed by the Academy 31.6% Credentialed by another organization 14.5% Board certified in pain 14.5% No post-licensure certifications or credentials

Primary Work Focus 75.4% Direct Patient Care Provider 24.6% Research, Education, Administration

Work Setting 27.0% Solo Practice 25.0% Group Practice (2 or more providers) 48.0% Patient Care Facility, HMO, MCO, Hospital

Focus on Pain Management 39.7% Pain Management is the primary focus of my clinical practice 37.6% Pain Management is a secondary focus of my clinical practice 6.7% Pain Management is not currently a focus but I want to enhance my clinical abilities 5.7% Pain Management is not a focus of my clinical practice but I need to keep up with the latest information 10.3% Other

THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

MEMBERSHIP

Treating the Person, Not the Pain An Interview with Bruce F. Singer By Debra Nelson-Hogan, Director of Education and Credentialing

Bruce F. Singer, PsyD, currently sits on the Medical Advisory Board to the US Pain Foundation and the Education Committee of the AAPM. He is chief of psychology for Crossroads Centre, St. John’s, Antigua. He is authoring a book on mindfulness approaches to managing chronic pain titled, Find Your Black Ducks. His guided meditations and a new album of meditative music, “Heartful: Music for Julie,” may be found through his website, brucefsinger.com.

Bruce F. Singer, PsyD, an Academy member since 2008, is an addiction and pain psychologist who created and directed the Chronic Pain and Recovery Center (CPRC) at Silver Hill Hospital in New Canaan, Connecticut. He has presented at Academy Annual Meetings, and has written extensively on mindfulness and acceptance and commitment therapy approaches to pain management and addiction recovery. We spoke with him about integrated pain management. PP: How would you describe a good integrated pain management program? It would include biologic, psychologic, and social approaches, all on equal footing. For example, the CPRC has a core group of psychiatrists, psychologists, pain physicians, physical therapists, nurses, and residential counselors, assisted by adjunct staff that includes an art therapist, dietician, volunteer meditation leaders, and qigong instructors. Our program was designed to help individuals with complex chronic pain syndromes from a holistic perspective. By that, I mean we are less focused on treating symptoms than on facilitating active

coping skills for self-management. PP: As the program director how did you manage pain in a team setting? I tried to lead by example. It was important for me to convey a calming atmosphere of wellness in spite of pain. How we conduct ourselves as clinicians conveys a message that this is a place for healing. I would say that, for me, managing pain in an integrated team setting began with learning “how to listen.” There has to be a mutual respect and real-time communication between the disciplines. I learned to listen to doctors from other disciplines, to the nurses, to the residents or counselors, to the people we were treating. Out of this came a shared decision-making process that helped us achieve successful outcomes. Another challenge was maintaining the character of a small and unique program within the context of a larger hospital that often has requirements and needs in conflict with the program. For me, the hardest part of managing has been to accept compromise in this regard, and, in that compromise, learn how to maintain and improve on the high standards we set for the program. PP: What do you wish clinicians understood about an integrated model of care? I think that the world of pain management can benefit from greater education into the complex nature of chronic pain syndromes so that the focus of treatment is not on individual symptoms themselves, but on the whole person and how to help individuals transform pain and suffering into purposeful functioning. When a person goes to a clinician and says, “My back is killing me,” the tendency is to focus on the back, and we lose the underlying message: The person who has said my back is killing me, when he clearly is not dying, may be engaged in pain catastrophizing and might benefit from psychotherapy and physical therapy as much as from medication. If I’ve learned anything, it’s that we have to listen more deeply

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so as to focus less on “fixing” people and more on facilitating their abilities to live life with greater engagement and wellness in spite of pain. That is the acceptance and commitment therapy approach. PP: If the clinician is one of the most powerful tools in a treatment program, what do you bring to the table, in addition to your training? I bring my life experiences. Psychology is a second career for me. I had a long career as a writer in Hollywood before this so I’ve spent a lot of hours thinking about people’s characters and motivations. What I bring to the table is an understanding of people, an understanding of the metaphors that we use in telling stories to ourselves, and how powerful those narratives can be. Developing a mindfulness practice helped me to listen more deeply to the subtext of story so as not to get caught up with the surface content. Beyond that I think I have a sense of humor, empathy, and the ability to be “response-able” in treating individuals who are often reactive to difficult and complex problems. PP: What do you see as the biggest challenge in the pain management field? The biggest personal challenge has been to keep the teaching and therapy real with every person I encounter. I think for anyone who works in the pain world the challenge is helping people who are suffering to reclaim and maintain their sense of dignity as human beings. Too often they are perceived as “less than” by family members who become frustrated with their pain, as well as by a culture that may not see the “invisible” pain people are feeling inside. I think that we as providers are often guilty of categorizing individuals as complainers or medication seekers or unwilling to get better because of secondary gains. The difficulty of this work risks burning us out, and then the empathy that is essential to successful treatment is lost. The bottom line challenge is not to focus on what is wrong with people but on what is not wrong with them. You do that, the rest is easy.

EDUCATION

Team Pain Care

Academy’s 27th Annual Clinical Meeting By Debra Nelson-Hogan, Director of Education and Credentialing

The American Academy of Pain Management’s 27th Annual Clinical Meeting, which will be held in San Antonio, Texas, Sept. 22-25, 2016, once again will deliver three-and-a-half days of outstanding evidence-based and relevant education on treating people in pain. Keynotes, pre-conference sessions, and the general meeting sessions are aligned with the goals of the recently released National Pain Strategy. In fact, Linda Porter, PhD, Policy Advisor for Pain for the National Institutes of Health and co-chair of the Oversight Panel of the National Pain Strategy, will deliver the opening keynote on Thursday, September 22.

Program Chairs The Academy is the largest and only pain management organization that has traditionally embraced the integrated model of care that provides access to the full spectrum of care. To support this team approach, three program chairs will oversee the content in three key areas: primary care/ integrative pain management, physical medicine and rehabilitation, and behavioral medicine. Robert A. Bonakdar, MD, FAAFP, director of pain management

Education Advisory Committee

chief CRNA, Kish Health System Pain Clinics, DeKalb, Illinois.

For our planning purposes, we have relied on a team of clinicians representing several disciplines to assure the quality and balance of our live and online programming.

Roger Mignosa, DO, is a physical medicine and rehabilitation physician, clinical professor, and exercise physiologist in San Diego, California. He teaches pain management and exercise science at the University of Arizona, Arizona Center for Integrative Medicine.

Alfred Anderson, MD, DC, past president of the Academy Board of Directors, is the Medical Director of Medical Pain Management in Minneapolis, Minnesota. Paul Christo, MD, is an associate professor, division of pain medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. Kevin T. Galloway, BSN, MHA, Colonel, US Army (Retired), treasurer of the Academy Board of Directors, is a senior project manager at the Defense and Veterans Center for Integrative Pain Management (DVCIPM) in Rockville, Maryland. Alice Inman, PsyD, MSCP, is clinical health psychologist, hematology/oncology clinic; director, clinical health psychology fellowship, Brooke Army Medical Center; and adjunct professor, Department of Psychiatry, Department of Medicine, University of Texas Health Science Center, San Antonio. W. Clay Jackson, MD, DipTh, is a clinical assistant professor of family medicine and psychiatry, University of Tennessee College of Medicine; in private practice in family and palliative medicine, Memphis, Tennessee; and is vice-president of the Academy Board of Directors. Joanna G. Katzman, MD, MSPH, is president of the American Academy of Pain Management, director of the University of New Mexico Pain Center, and co-director of the University of New Mexico Project ECHO Chronic Pain Program. Jeremiah Loch, CRNA, DOMTP, PhD, is

Catherine O’Connell, PhD, is a psychologist in private practice in Phoenix, Arizona. Shauna Pittman, PharmD, is a clinical pharmacist, sole provider committee coordinator, at Walter Reed National Military Medical Center, National Capital Region Pain Initiative, Bethesda, Maryland. Arthur S. Roberts, DDS, MD, Academy director at large, has been in private practice for nearly four decades, Indianapolis, Indiana. Bruce F. Singer, PsyD, is chief of psychology, Crossroads Centre Antigua, and on the Medical Advisory Board of the US Pain Foundation. Brett B. Snodgrass APRN, FNP-C, is director of clinical operations at the LifeLinc Pain Center, Cordova, Tennessee; owner of BBS Consultants, Bartlett, Tennessee, specializing in chronic pain education; and Tennessee state representative to the American Association of Nurse Practitioners. Thomas N. Watson, DPT, MEd, DAAPM, is a chronic pain specialist at Rebound Physical Therapy, in Bend, Oregon. Lucy Whyte Ferguson, DC, is a volunteer faculty member, department of neurosurgery, University of New Mexico; and consulting doctor at the Pain Consultation and Treatment Center, University of New Mexico. She has treated chronic and acute pain conditions for more than 30 years with a focus on treating myofascial pain syndrome.

at the Scripps Center for Integrative Medicine, La Jolla, California, a member of the Scripps Green Hospital Pain Management Committee, and immediate past president of the Academy, will be responsible for content related to the primary care audience. Dr. Bonakdar is one of the country’s primary thought leaders on integrative pain management. He will also chair a pre-conference session on “Nutrition, Supplements, and Lifestyle Choices.” Dr. Bonakdar also recently co-edited the book Integrative Pain Management published by Oxford University Press. John E. Garzione, PT, DPT, is a founding member and past president of the Pain Management Special Interest Group of the Orthopaedic Section of the American Physical Therapy Association. He has served on the advisory board of Orthopaedic Physical Therapy Practice, Ithaca College Physical Therapy Department, and is a consultant in electrotherapy for DJO Global, Vista, California. Dr. Garzione has more than 40 years’ experience as a physical therapist and is the owner of Chenango Therapeutics in Norwich, New York. He will oversee the content related to physical medicine and rehabilitation.

Keynotes, pre-conference sessions, and the general meeting sessions are aligned with the goals of the recently released National Pain Strategy

The Education Department is looking for volunteers to review meeting presentations. If you are interested, please e-mail your CV to Cathleen Coneghen, assistant director of education, at cconeghen@ aapainmanage.org.

Beth D. Darnall, PhD, is a clinical associate professor of anesthesiology at Stanford University as well as an attending psychologist at the Stanford Outpatient Pain Management Center. She is an NIH-funded principal investigator for pain psychology research that is examining the mechanisms of pain catastrophizing treatment, including a novel single-session pain catastrophizing class she developed (funded by the NIH National Center for Complementary and Integrative Health). She will be responsible for the behavioral medicine content of the meeting.

THE PAIN PRACTITIONE R

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Professional Development

Expanded Reach for the Advanced Credentialed Pain Practitioner Program

we have made changes to the credentialing program, which opens the door for new programs disigned for all of our members.

In an attempt to better organize our educational and credentialing activities, we have created a new department called Professional Development. This not only includes management of the Academy’s existing credentialing programs, but opens the door for new programs designed for all of our members. As a first step, we have made some significant changes.

The Advanced Credential is Now Open to NPs, PAs, and CRNAs The Academy Board of Directors approved expanding the Advanced Credentialed Pain Practitioner (ACPP) program to include nurse practitioners (NPs), physician assistants (PAs), and certified registered nurse anesthetists (CRNAs). The ACPP was launched in September 2014 and until now has been limited to MDs and DOs. Recently, the Academy leadership evaluated the exam and the Curriculum and determined that they were appropriate for NPs, PAs, and CRNAs. The 200item exam is based on the Curriculum that was created by the Academy and three expert faculty from the University of New Mexico: George D. Comerci, Jr, MD, Daniel Duhigg, DO, and Brian M. Shelley, MD. Leading experts in pain contributed content to the Curriculum as well.

The ACPP Exam The exam, which was also written by Drs. Comerci, Duhigg, and Shelley, consists of 200 questions, 180 of which are scored. Candidates are given the choice to complete the exam at a computer-based testing center, or by paper and pencil exam at the Academy’s Annual Clinical Meeting. They will have four hours to complete the exam. Also, beginning in 2016, the Academy will no longer require participants to participate in the skills assessment educational program in order to earn the Credential. The Curriculum and exam are broken down into 13 key-content areas that are further divided into subtopics.

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The number of questions in each section reflects that category’s relative importance: Percentage of Test Questions by Catagory 19%—Pharmacotherapy 14%—Pain Assessment 12%—Pain Conditions 11%—Unique Populations with Pain 09%—Regulatory Issues Related to Pain Treatment 07%—Interventions for Pain 06%—Psychology of Pain 05%—Pain Basics 05%—Integrative Treatment of Pain 05%—The Interdisciplinary Pain Team 04%—Bioethics and Pain 02%—Surgical Approaches to Pain 01%—Patient and Clinician Self-Care

The Curriculum Review Course (CRC) In order to support candidates who are interested in taking the exam, or to educate clinicians who simply want an outstanding foundation in pain management, the Curriculum authors have developed a 15-hour review course. Although the course is not intended to replace rigorous selfstudy in preparation for the exam, it is a comprehensive overview of best practices in pain management. The CRC is available as a two-day live program that will take place September 21 and 22 immediately preceding the Academy Annual Clinical Meeting in San Antonio. The program costs $1,000 for Academy members and $1,250 for non-members. The program will be accredited for CME, CEs for nurses, and CE for family physicians. The CRC is also available via our online Pain Care Learning Center. For more information or to register for the course, please call MacKenzie Davis at 209-288-2205 or send her an email at mdavis@aapainmanage.org.

Academy to Discontinue the General Credential Exam Academy leadership stopped accepting applications for the General Credentialed Pain Practitioner exam as of March 31, 2016. A committee is being convened to survey our mem-

bers and other clinicians to determine a program that best meets their needs. If you are interested in serving on the Professional Development Committee, please contact Debra Nelson-Hogan at (208) 288-2211. Currently credentialed Academy members will retain their status as long as they meet the recredentialing criteria. If you have any questions, please contact MacKenzie Davis at (209) 288-2205 or send her an email at mdavis@aapainmanage.org.

Newly Credentialed Members

Advanced Diplomate

Patricia Lopez-Po, MD, interventional pain management specialist, El Paso Pain Management Center, Orthopaedic Surgery Group, El Paso, Texas; board certified in family medicine.

Advanced Diplomate

Joanne Hojsak, MD, associate professor of pediatrics and medical education, Icahn School of Medicine at Mount Sinai, New York, New York; medical director, Pediatric Intensive Care Unit, division chief, pediatric critical care medicine and director of the Pediatric Pain Team, Mount Sinai Kravis Children’s Hospital, New York, New York.

General Diplomate

James M. Porcelli, MD, internal medicine/ chronic pain management, The Living Young Institute, Port Charlotte, Florida.

Fellow

Kasey E. Talon, APRN, family nurse practitioner—pain management, Pain Care Centers, Somersworth, New Hampshire.

Fellow

Hua Shi Davis, NP, adult care nurse practitioner, Delaware Chronic Pain Management & Detox Center, Wilmington, Delaware.

Clinical Associate

Elizabeth A Yoxthimer, PT, physical therapist, St Peter’s Health Partners, Albany, New York.

FROM NEUROGENX

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PROVEN BUSINESS SOLUTION Over $100,000 CASH in the first 30 days! “Between the resources provided by the Neurogenx marketing support team and their in-office training, I was able to have a brand-new medical center up and running in about 30 days and have the center profitable within its first month. The most rewarding part is that our patients have been able to enjoy results that have been literally life-changing.” - Dr. Michael Begley, President and Executive Director, NeurogenxNerveCenter of Brentwood, TN

Over $75,000 CASH in 4 days! “I am absolutely ecstatic with Neurogenx: the program and support are amazing! My new patient volume far exceeds my expectations - during my first four days of operation I grossed over $75,000 and at the end of 7 days! I was honestly a little nervous about launching a new business, but all I had to do was trust them and everything fell into place. I couldn’t be happier with the Neurogenx team and our new NerveCenter.” - Dr. Swangim, President, NeurogenxNerveCenter of LaPorte, IN

PROVEN CLINICAL SOLUTION “I’m 61 years old and my diabetic neuropathy made my toes feel as if the skin had been sanded off with 80-grit sandpaper. During my 3rd Neurogenx treatment the muscles in my legs started tensing, flexing and moving - they came back to life! For the first time in years I could actually feel the rug under my feet!” (Todd W.) “Before I came to Neurogenx, my feet were swollen badly and I was in lots of pain. I had been suffering with neuropathy since the 1990s. It had gotten so bad that I couldn’t walk. Now the pain and swelling is all gone.” ( H. Lann) “I’ve had neuropathy for 25 years, and after the first treatment I was able to move my feet and roll my toes in ways that I couldn’t since I was 40 years old. I’m grateful for this!” ( W. Owen)

• We help you learn step-by-step with our Proven TURNKEY Clinical and Business Solutions Program! • Jump Start Boot Camp where our team closes & collects $40-50K in 4 to 5 days for you! • Quick Start Program coaches you to close and collect $100K in 30 Days and $1 Million in 12 months!

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ADVOCACY

Reducing Prescription Medication Misuse, Abuse, and Diversion while Improving Pain Care By Katie Duensing, JD, SPPAN Assistant Director for Legislative and Regulatory Affairs

Supporting Organizations Chronic Pain Research Alliance Foundation for Peripheral Neuropathy Global Healthy Living Foundation International Pain Foundation Interstitial Cystitis Association PAINS Project Reflex Sympathetic Dystrophy Syndrome Association The Pain Connection TMJ Association US Pain Foundation

There is currently a startling and unfortunate lack of attention to our nation’s inadequate treatment for pain. The country’s current state of pain care, research, education, and prevention is woefully inadequate, as highlighted by the 2011 Institute of Medicine study, Relieving Pain in America. The study found that more than 100 million American adults suffer from chronic pain, at a cost of approximately $600 billion annually in direct medical expenses and lost productivity. Yet, our federal agencies continue to invest poorly in chronic pain research, which averaged just 4 cents per patient in 2015. There is, however, no shortage of state and federal attention in regard to prescription drug abuse in recent months—legislatures and agencies all over the nation are scrambling to reduce opioid overdose deaths, generally through a strategy of reducing the number and dosage of prescriptions dispensed for opioid analgesic medications. To date, policy solutions to the opioid crisis have focused on opioid misuse, addressing prescription practices and treatments for people after they have become addicted to opioids. These issues are important and deserve attention; however, a long-term solution to the opioid epidemic will fall short unless policies are broadened to address the underlying public health crisis of chronic pain. To better understand the issue, the Senate Finance Committee in February held a hearing entitled, “Examining the Opioid Epidemic: Challenges and Opportunities.” In response, the American Academy of Pain Management, with the support of 10 other organizations, issued a series of recommendations to the committee that would provide a balanced response to both epidemics: chronic pain and prescription medication abuse. Service Delivery

1. The Centers for Medicare & Medicaid Services (CMS) should allow a greater number of physical and occupational therapy sessions annually, and should allow patients to access physical and occupational therapy

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without first requiring a referral or prior authorization. 2. CMS should provide total reimbursement—and collect long-term efficacy and cost data—for at least the following five nonpharmacologic treatments recognized by the Department of Defense and the Veterans Health Administration as effective treatments for chronic pain: chiropractic and osteopathic manipulation, acupuncture, massage therapy, biofeedback, and yoga. 3. CMS should provide reimbursement to providers of behavioral health services for the prevention, treatment, or management of physical health problems utilizing the behavior assessment and intervention reimbursement codes 96150 to 96154. Research

4. In order to provide methods and measures to guide progress toward achieving improved prevention and management of pain in the United States, CMS should fund research that evaluates longitudinal pain outcomes among Medicare, Medicaid, and other beneficiaries. 5. The Center for Medicare & Medicaid Innovation (CMMI) should be required to set aside certain funds to establish demonstration projects related to interdisciplinary and integrated pain care. 6. CMS should research post-operative pain and opioid use in order to identify how many pills are actually being used and are needed by this population. Education

7. Medical residencies funded by Medicare and Medicaid should include adequate content on pain management and substance abuse. 8. To improve education for providers already in practice, CMS should require completion of the three-hour Risk Evaluation and Mitigation Strategy (REMS) program related to extended release and long-acting opioid analgesic medications as a condition of participation in Medicare. Prescribing and Dispensing

9. Medicare should contact known prescribers and dispensers in the

event that a patient overdoses on any controlled substance. 10. When a prescriber writes a prescription for a controlled substance for a Medicare or Medicaid patient, they should be required to check the prescription monitoring program (PMP) prior to writing the initial prescription and regularly thereafter, at least annually. 11. Medicare Part D should consider implementing a policy similar to that proposed in New York Assembly Bill 8601 (2016), which provides that the initial prescription or dispensing of a controlled substance for acute pain shall be limited to a small supply (seven days, for example), but then goes on to prohibit the imposition of an additional health insurance copayment if a subsequent prescription is issued for an aggregate of not more than a 30-day supply of such controlled substance. In the coming months, we will work alongside our partner organizations in an attempt to work these recommendations into pending federal legislation. The Academy, with the full support of the organizations listed to the left, views these suggestions as vital components of a comprehensive approach to addressing the intertwined public health crises of undertreated pain and prescription medication abuse. To view the full letter that was submitted to the Senate Finance Committee, along with more details for each of these recommendations, visit bit.ly/1poXtR1. Visit sppan.aapainmanage.org regularly for updates on policy issues that matter to you and to find more specific details about opportunities for action in your state and federally. Katie Duensing, JD, is a member of the American Academy of Pain Management’s policy and advocacy department, which includes the Academy’s State Pain Policy Advocacy Network. She monitors, analyzes, and works to improve pain-related policies from every jurisdiction across the nation, actively engaging with policymakers to help shape optimal, person-centered pain policies.

Integrative Pain Management for Optimal Patient Care

american academy of pain management

Integrative Pain Management for Optimal Patient Care

The Pain Practitioner

Be a Part of The Pain Practitioner Editorial Team! Submit your articles, case studies and scientific research abstracts for publication in our magazine. We invite you—our experts—to contribute evidence-based articles that support integrated, multidisciplinary, and multimodal models of care to be published in The Pain Practitioner magazine. We value our members’ insight and information about caring for people in pain, and are seeking content from you on everything from initial assessment and diagnosis, to care planning and self-management. While you can submit proposals for content on any topic you feel strongly about, we are in particular need for content about:

• Sleep and pain

• Back pain

• Practice management, especially reimbursement issues for integrative pain management • Tips for clinicians, ethical issues and the challenges you face and how you resolve them • Go to page 8 for a list of topics of interest to our readers

To submit article ideas and review our author guidelines, go to aapainmanage.org/about/publications/ For more information, contact Cathleen Coneghen, Managing Editor, at cconeghen@aapainmanage.org

PROMOTING RATIONAL POLYPHARMACY

THE GOOD, THE BAD & THE UGLY of Drug Interactions

She brought a large bag containing 12 different medications for pain, somnolence, and agitation. BY ANDREA FURL AN, MD, PHD

used to run my chronic pain clinic by myself in Toronto, but found it to be very stressful, so I started bringing together a team, which has increased my well-being as well as that of my patients. The first person that I brought to the team was a nurse, who is able to take the time to talk to patients, provide education, and find resources. The second person that I brought in was a social worker, who can help fill out insurance forms, file workers’ compensation claims, and find financial resources for my patients who’ve lost everything, as well as provide psychological support. The third person that I brought to my team was the pharmacist. I wasn’t sure exactly why, but now I find I cannot run my clinic without a pharmacist. She runs a pain medication management clinic in the office beside me, and we discuss cases, such as the one described below. Case Study

Mr. G, a 91-year-old man, was referred by his family physi16

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cian for treatment of chronic low back pain and because he has had two serious falls in the last several weeks, possibly due to his medication. His son reports that Mr. G complains of pain all the time. He has some cognitive impairment but not dementia. He has cataracts, some hearing loss, and pain in his neck and low back that persisted despite numerous physical maneuvers which, ironically, Mr. G used to teach as an expert on dance and ergonomics. His wife came with him, and reported that he seemed to be hoarding and hiding some of his medications. Mr. G’s appearance and physical exam revealed thoracic kyphosis. His straight-leg raise test was negative, his range of motion was preserved and his joints were flexible. He had no neurological abnormalities, but his sensory examination showed some hyperesthesia to pin prick, especially in his face, lumbar spine, and legs. Numerous tender points on palpation suggested myofascial trigger points. During the consultation Mr. G was oversedated to the

the good, the bad & the ugly of Drug Inter actions

point of falling asleep. He had two recent, very serious falls. During the night he woke up frequently and was agitated. I took a history and performed a physical examination and asked Mrs. G to bring all his medications to the next appointment. She brought a large bag containing 12 different medications for pain, somnolence, and agitation, some of which were expired. Mr. G was not sure how he was supposed to be taking all of these, and there were several potential interactions. Polypharmacy is common, despite the limited evidence for its effectiveness (1). We know, for example, that 45% of patients with neuropathic pain are taking two or more medications. In Mr. G’s case acetaminophen was indicated for his osteoarthritis of the neck and cervical and lumbar spine, but the dose was low at 500 mg daily and, at the same time, he was taking multiple opioids. He was also taking baclofen, quetiapine, and tricyclic antidepressants, all of which have numerous side effects. He was taking multiple NSAIDs and combining opioids with benzodiazepines, which are known to be very sedating and most likely the cause of his falls. He was taking multiple sedating drugs and he still had insomnia at night. Mr. G had mild dementia and exhibited very-high risk behaviors. He was hiding and hoarding his medications, which he was obtaining from multiple prescribers who were not checking the state’s prescription monitoring program database.

synergistic effects possible by combining drugs with different mechanisms of action, the prolonged analgesic efficacy by combining short-acting and long-acting drugs, the opioidsparing effect, and the minimization of adverse events of individual drugs. Unfortunately, combining multiple medications is also associated with numerous risks. How do you classify what is good, what is bad, and what is ugly in polypharmacy? In general, a good multidrug combination is one with evidence to show it is more effective with fewer side effects than the drugs given individually, especially in a patient with pain that responds to multiple agents (see Table 1). However, it is important to check with your pharmacist about potential drug interactions and review the patient’s history carefully for predisposing conditions, such as kidney problems with duloxetine or a prior cardiac event with NSAIDs. In addition, prescribing multiple medications that increase serotonin in the brain increases the risk for serotonin syndrome, and prescribing multiple antiinflammatory agents is excessive, especially when adding steroids. Multiple central nervous system depressants may cause oversedation, putting the patient at very high risk of falling. Opioids and benzodiazepines, and opioids and methadone are very dangerous and frequent combinations. Unfortunately, the evidence for combination therapies is small and not convincing, mostly because of the difficulties in performing adequate trials. A Cochrane review of various combination therapies for neuropathic pain showed that, Polypharmacy in general, two-drug combinations had superior efficacy, Polypharmacy, also known as multidrug therapy, combibut also had more side effects, including sedation and nation drug therapy, or multimodal treatment, involves cognitive dysfunction (2,3). Anecdotal reports of combicombining multiple medications with distinct drug actions to nations of opioids with cannabinoids demonstrated their simultaneously combat multiple underlying disease mechaopioid-sparing effects (4). In a study comparing combinanisms (1). The advantages of polypharmacy include the tion polypharmacy with an opioid and a cannabinoid with opioid treatment alone, the combination Table 1. The Good, the Bad, and the Ugly of Polypharmacy was shown to have an additive effect on pain relief (5). Ultimately, the multimodal Good (rational) Bad Ugly approach recommended for older adults Evidence-based multimodal Multiple opioids Multiple antiinflammatories with osteoarthritis involves a combination therapy (steroids, NSAIDs) of pharmacologic, nonpharmacologic, and Multiple CNS depressants Type of pain ➔ selection of Add-on drugs to manage rehabilitative approaches in addition to adverse effects: laxatives, appropriate agent androgens, methylphenidate a strong therapeutic alliance between the for drowsiness, or diphenypatient and physician (6). drinate for itching. Opioid sparing Fewer adverse effects

Drugs contra-indicated: e.g., duloxetine and kidney failure; NSAIDs and previous MI

Opioids and benzos

Additive side effects: e.g., SNRI + SSRI + TCA ➔ serotonin syndrome

Opioids and methadone

How Drugs Interact

Simply put, pharmacodynamics is the effect of the drug on the body, and pharmacokinetics is the effect of the body on THE PAIN PRACTITIONE R

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the good, the bad & the ugly of Drug Inter actions

Before the trial

During the trial

End of the trial

Pain diagnosis

Opioid selection

Optimal dose

drug interactions (8). Working with a pharmacist can help identify the combinations that are potentially unsafe and help prevent fatal interactions.

Discuss goals with patient

Initial dose and titration

Overdose risk

Watchful dose

IMPORTANT:

The N-of-1 Trial

Risk of aberrant behaviors

What to monitor

Explain benefits, adverse effects and risks

Tell the patient not to drive during trial of opioid

Give information sheet

Deadline

Exit strategy if trial is not successful 1- Switch to another opioid and re-start trial 2 – Taper and stop

Table 2. An N-of-1 Trial for an Opioid

Signed treatment agreement Urine drug screening

the drug. Opioids combined with benzodiazepines, alcohol, cannabinoids, or gabapentinoids cause sedation, respiratory depression, confusion, drowsiness, weakness, and even ataxia because of their central nervous system depression, a pharmacodynamic interaction that increases patients’ risk of overdose and death. Another important, although rare, pharmacodynamic interaction results in serotonin syndrome, which can be fatal if it is not identified and treated. Serotonin syndrome can occur when combining SSRIs, SNRIs, tricyclic antidepressants, MAO inhibitors, tramadol, methadone, trazodone, and triptans. The characteristic signs of serotonin syndrome are fever, hyperreflexia, and mental status changes. Pharmacists can flag these interactions if they are aware of the patient’s entire regimen, but unfortunately they may only see the prescription at the time that it is being dispensed. Pharmacokinetic effects are experienced as a change in how the drug acts. Most drugs are metabolized in the liver by the cytochrome P450 enzymes. Medications metabolized by the CYP 2D6, for example, such as venlafaxine, duloxetine, tricyclic antidepressants, or methadone will be metabolized faster causing a loss in efficacy if an activator such as codeine or tramadol is added. On the other hand, adding an enzyme inhibitor such as fluoxetine or paroxetine will cause these medications to accumulate in the body because they are not being metabolized as quickly (7). Buprenorphine and methadone also interact with numerous drugs and place patients who take either of these agents at risk for potentially toxic

Tapering and stopping opioids is much more difficult than starting opioids. Having an exit strategy is very important.

| T H E PA I N P RACT ITION ER | M AY 2 0 1 6

When starting a patient on any drug regimen that includes an opioid, especially if it is a combination of drugs, an N-of-1 trial should be performed (see Table 2). It is important to take the time needed to document the pain diagnosis, discuss the treatment goals with the patient, assess whether the patient is at risk of overdose, explain the medication benefits and risks, complications, and side effects and provide patient information before signing a treatment agreement. Urine drug screening should be done to make sure the patient is not taking methadone or benzodiazepines. These preliminary steps can be performed over several visits, but the success of the trial depends on taking the time to properly assess the patient. Occasionally, patients may even decide not to proceed with the trial once they fully understand the risks of taking the drug. Selection of the opioid is based on whether a short-acting or long-acting agent is needed and what is available in your formulary. There is no one opioid that is less dangerous than the others so don’t select an opioid based on its abuse potential unless the patient tells you he or she had a very strong physical dependence to a specific formulation. During the trial, start with a low initial dose and titrate slowly. Have a dose ceiling in mind and watch and monitor the patient’s behavior while you increase the dose over several weeks. There is some evidence that during opioid titration, patients can be cognitively impaired and should not be allowed to drive (9). Have a deadline by which time you will know if the trial has been successful. If the trial has not been successful, try rotating to another opioid, or the trial should be stopped. Tapering and stopping opioids is much more difficult than starting opioids. Having an exit strategy is very important.

Case Study Continued

So, what happened to Mr. G, our 91 year-old-patient? My pharmacist called Mr. G’s community pharmacist who faxed us the list of medications dispensed in the last two months, which were ordered by multiple prescribers, such as the family doctor, the walk-in clinics, the dentist, and the pain specialists. We performed point-of-care urine drug screening

THE GOOD, THE BAD & THE UGLY OF DRUG INTER ACTIONS

to determine what he was taking. His test was positive only for tricyclic antidepressants and negative for opiates, benzodiazepines, and THC. We ordered a creatinine level to check his kidney function. We left him with acetaminophen 500 milligrams, which was well below his maximum daily dose. We told him to get rid of everything else, including another bag that the wife found in their house. We started pregabalin at a dose of 25 mg, for his low back pain, which we thought was neuropathic, because of the severe arthritis in his spine, and demonstrated by hyperalgesia in his face, lumbar spine, and legs. Based on his liver function results, the maximum pregabalin dose that Mr. G could take was 100 to 150 mg daily; however, at 25 mg twice daily, he was sleeping through the night and had no more falls. His wife told us that he was less agitated. But he told me, â&#x20AC;&#x153;Doctor, I still have pain. Can you help me with my pain?â&#x20AC;? We prescribed some home exercise and massage. We are still working with him and may increase the pregabalin and add other nonpharmacologic modalities such as acupuncture. There are no changes in his pain level and his posture has not improved, but his quality of life has improved because he is sleeping better and he has remained on the good side and avoided the bad and the ugly

sides of polypharmacy for chronic pain management. References 1.

Argoff CE, Albrecht P, Irving G, Rice F. Multimodal analgesia for chronic pain: rationale and future directions. Pain Med. 2009;10(S2):S53-S66. 2. Chaparro LE, Wiffen PJ, Moore RA, Gilron I. Combination pharmacotherapy for the treatment of neuropathic pain in adults. Cochrane Database Syst Rev. 2012 Jul 11;7:CD008943. 3. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162-173. 4. Ware MA, Doyle CR, Woods R, Lynch ME, Clark AJ. Cannabis use for chronic non-cancer pain: results of a prospective survey. Pain. 2003;102(1-2):211-216. 5. Narang S, Gibson D, Wasan AD, et al. Efficacy of dronabinol as an adjuvant treatment for chronic pain patients on opioid therapy. J Pain. 2008;9(3):254-264. 6. Makris UE, Abrams RC, Gurland B, Reid MC. Management of persistent pain in the older patient: a clinical review. JAMA. 2014;312(8):325-336. 7. Verdu B, Decosterd I, Buclin T, Stiefel F, Berney A. Antidepressants for the treatment of chronic pain. Drugs. 2008;68(18):2611-2632. 8. McCance-Katz EF, Sullivan LE, Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review. Am J Addict. 2010;19(1):4-16. 9. Mailis-Gagnon A, Lakha SF, Furlan A, Nicholson K, Yegneswaran B, Sabatowski R. Systematic review of the quality and generalizability of studies on the effects of opioids on driving and cognitive/psychomotor performance. Clin J Pain. 2012 Jul;28(6):542-555.

Andrea Furlan, MD, PhD, is an associate professor in the department of medicine at the University of Toronto and staff physician and scientist at the Toronto Rehabilitation Institute. She is also an associate scientist at the Institute for Work & Health in Toronto.

THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

A PILOT STUDY

An Internet-based Mindfulness Program for Burnout Prevention in Pain Clinicians BY ROBERT AL AN BONAKDAR MD, FA AFP, FACN

Funding for this study was provided by a grant from the AAPM Board of Directors in support of the AAPM Clinician Wellness Initiative. Abstract

Background: More than half of all physicians report burnout, with prevalence rates rising over the last decade. While mindfulness interventions have demonstrated benefit in this population, access and opportunity to attend are potential barriers. Online stress management programs that incorporate mindfulness and coaching might be a potential solution. Purpose: This study attempted to determine the feasibility of a six-week internet-based stress management program (ISM) incorporating mindfulness and coaching in reducing stress and burnout in a group of pain management clinicians.

More than half of all physicians report burnout, with prevalence rates rising over the last decade.

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Methods: Participants were active members of the American Academy of Pain Management. Members were sent an email invitation inviting their voluntary participation in the ISM. Participants were asked to answer baseline demographic questions and complete baseline and follow-up questionnaires including the Perceived Stress Scale (PSS), the SF-36, and the Maslach Burnout Inventory. Participants received daily email messages and reminders to complete four mindfulness practices per week, consisting of 10- to 20-minute audio meditations. In addition, clinicians were asked to call in to a phone session at several points during the intervention for instruction and support. Results: Twenty participants completed the program. They represented a diverse group of clinicians whose areas of care in pain management include primary care, trauma, rehabilitation, and orthopedics. Participants were able to improve their PSS scores from an average of 18.5 to 12.4 (P < .001); their SF-36 Emotional Well Being scores from 65.2 to 74.2 (P < .001); their SF-36 Vitality scores from 43.8 to 58.8 (P < .001); and their Maslach burnout exhaustion component scores from 14.6 to 10.7 (P < .001). The reduction in perceived stress was related to the number of mindfulness sessions per week with 1-2, 3-4, or 5+ session providing 22%, 32% and 51% reduction, respectively. Conclusions: A six-week internet-based stress management program based on mindfulness training was both feasible and successful in improving perceived stress, emotional well-being, vitality, and burnout in pain clinicians. These findings are similar to more traditional mindfulness programs while overcoming potential obstacles related to time commitment and availability. Interestingly, baseline experience with relaxation techniques

Burnou t Pre v en tion in Pain Clinicians

did not significantly predict level of stress reduction, but level of active participation during the intervention did. Based on the increasing prevalence and impact of clinician burnout it is imperative to identify practical evidence-based interventions that clinicians may access on demand to reduce burnout.

Figure 1. Mindfulness and stress management techniques provided by phone application

Introduction

The prevalence of clinician burnout, as defined by increasing emotional exhaustion, depersonalization, and low personal accomplishment, has been steadily increasing. A 2009 summary noted that “numerous global studies involving nearly every medical and surgical specialty indicate that one in every three physicians is experiencing burnout at any given time” (1,2). Unfortunately, even with improved recognition, there has been no reduction in this trend. A recent survey found that 54.4% of physicians reported at least one symptom of burnout in 2014 compared with 45.5% in 2011, which parallels a decline in satisfaction with work-life balance reported by physicians during the same time period. Importantly, the same survey found minimal changes in burnout or satisfaction with work-life balance during the same period among non-physician working US adults (3). This trend appears to be similar, if not worse, among other health professionals (4). The consequences of burnout are significant in all aspects of health care. The clinician experiencing burnout is more prone to leave medicine early as well as face higher rates of depression, substance abuse, and suicide. When encountering patients, physicians suffering from burnout receive lower satisfaction rates and appear to have higher rates of medical errors (5). A Canadian study found that the total cost of burnout for all physicians in that country is estimated to be greater than $210 million per year (6). Interventions aimed at reducing stress and burnout have yielded limited benefit; a recent review noted low-quality evidence that cognitive behavioral therapy and mental and physical relaxation in general can reduce stress and concluded that higher quality studies are needed (7). One intervention that has received recent attention is mindfulness, which is “a form of mental training that enables one to attend to aspects of experience in a nonjudgmental, nonreactive way. This in turn helps cultivate clear thinking, equanimity, compassion, and open-heartedness” (8). Mindfulness has traditionally been introduced in eight-week courses (known as Mindfulness Based Stress Reduction (MBSR) that require a 30-plus hour on-site time commitment. In addition, more abbreviated versions have been shown to improve burnout, stress, anxiety, and depression while improving mental

well-being and empathy in physicians and other health care providers (9-11). Not everyone has the ability to commit to a live course, and the Stress Free Now (SFN) program, an internet-based mindfulness intervention, was developed by the Cleveland Clinic to overcome the limitations of participants’ time and availability. The program uses an internet-based approach including daily emails, lessons, on-demand mindfulness-based guided meditations (Figure 1), and coaching support. Studies using this model in diverse populations, including health care employees, have noted benefit in improving stress and psychological well-being (12). The American Academy of Pain Management (AAPM) Clinician Wellness Initiative was established in 2012 to improve understanding of stress levels in members as well as provide resources to prevent burnout. The SFN program was chosen for a pilot study among the AAPM membership based on its preliminary benefit in a health care setting and its ability to provide mobile on-demand resources to diverse populations. Methods

Participants were active members of the American Academy of Pain Management (AAPM). Between June and August 2014, members were sent an email invitation requesting their voluntary participation in a six-week ISM. Participants were THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

BURNOU T PRE V EN TION IN PAIN CLINICIANS

Table 1. Results of the AAPM Stress Free Now Pilot (N = 20)

Figure 2. Improvement in Perceived Stress Scale (PSS) Based on number of mindfulness practice sessions per week.

Measures

Pre

Post Change

P Value

Change

PSS

18.5

12.4

6.2

P < .001

33%

SF-36 Emotional Well Being

65.2

74.2

P < .001

14%

SF-36 VITALITY

43.8

58.8

P < .001

34%

-20%

Maslach Burnout (Exhaustion)

14.6

10.7

-3.9

P < .001

28%

-30%

PSS = Percieived Stress Scale

1-2

3-4

0% -10% -22%

-40% -50% -60%

-32% -51%

51% improvement in those who practiced mindfulness five or more times per week. asked to answer baseline demographic questions as well as complete baseline and follow-up questionnaires including the Perceived Stress Scale (PSS), the SF-36, and the Maslach Burnout Inventory. In addition, they were asked to participate in several group teleconferences during the intervention for instruction and support. The participants were provided the program and resources free of charge but did not receive any other type of compensation or continuing education credit. Once initiated, participants received daily email messages and reminders to complete the recommended four mindfulness practices per week. Mindfulness practices included 10-20 minute audio meditations that could be accessed on-demand though a mobile application (Figure 1) or on a computer. Results

Once introduced to AAPM members, 163 members expressed interest, 123 were offered the program, 73 logged in and completed the pre-assessment, and 20 completed the full program and post-assessment. The 20 participants (12 female, eight male) who completed the entire intervention represented a diverse group of pain providers including physicians and specialists in behavioral health, physical therapy, and nursing. Areas of care in pain management included primary care, trauma, rehabilitation, and orthopedics. Use of the program varied by participant and the scheduled teleconference sessions were not attended by a significant number of participants. Baseline and follow-up measures on the survey are noted in Table 1. At baseline, participants scored on average in 22

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the high or moderate-high range across all measures related to stress and burnout. They were able to improve their PSS scores from an average of 18.5 (above average) to 12.4 (population norm) (P < .001), representing a 33% decrease in mean perceived stress. Their SF-36 Emotional Well Being scores increased from 65.2 to 74.2 (P < .001), representing a mean 14% increase in emotional well-being. In addition their SF-36 Vitality scores rose from 43.8 to 58.8 (P <.001), indicating a 34% increase in vitality. Participantsâ&#x20AC;&#x2122; Maslach burnout exhaustion scores decreased from 14.6 to 10.7 (P < .001), demonstrating a 28% mean decrease in personal burnout. The reduction in perceived stress (PSS) was related to the number of mindfulness sessions completed each week with 1-2, 3-4, or 5+ sessions providing 22%, 32%, and 51% reductions, respectively (Figure 2). Reductions in perceived stress were similar for those who did or did not currently practice a relaxation technique (-36% vs. -28%) at baseline, as well as those who felt least or most confident that the stress management program could help stress coping (-31% vs. -32%). Discussion

A six-week internet-based stress management program based on mindfulness and coaching was both feasible and successful in improving clinician stress, emotional well-being, vitality, and burnout in a pilot intervention. Use of the program resulted in findings similar to the results obtained using more traditional mindfulness programs while overcoming potential obstacles related to participantsâ&#x20AC;&#x2122; time commitment and availability. Interestingly, participantsâ&#x20AC;&#x2122; baseline experience with

Burnou t Pre v en tion in Pain Clinicians

relaxation techniques did not significantly predict their level of stress reduction, but their level of active participation during the intervention did. Several important limitations should be pointed out. First, the results are for a pilot group of non-randomized volunteer clinicians. Follow-up studies should evaluate the response against control interventions in larger groups of pain clinicians to determine the magnitude of benefit and whether the benefit and compliance with the program persist over time. Second, the study enrolled a diverse group of pain clinicians with various levels of experience with stress management techniques. It would be important to evaluate the benefit in specific subgroups of providers, particularly as it relates to baseline experience with these techniques. Third, participation and compliance varied from initial introduction to completion of the program, including utilization of the telephone support. Several factors are important to note regarding compliance. First, higher dropout rates in general have been noted with internet-based interventions (13). In addition, aspects of the program such as non-clinician-specific content, time-specific teleconferences, lack of continuing medical education credits, and colleague participation may have led some clinicians not to participate. Based on feedback from this and other ongoing SFN interventions, a number of modifications were implemented to the program including clinician-specific content, availability of CME credit, utilization in unified health systems, and modification of group teleconferences to on-demand coaching and support. These modifications are the basis for the Stress Free Now for Healers version now being offered to clinical populations (14). These modifications appear to be improving compliance rates with the Healers version of the program which provides eCoaching support and CME credits having an 80%+ completion rates. Conclusions

As expected, pain clinicians participating in this intervention scored above population norms in baseline measures of stress, burnout, and lack of emotional well-being. The six-week ISM intervention provided statistically significant improvement in a number of areas including perceived stress, burnout, and measures of vitality and emotional well-being. The results demonstrated a dose-response. Clinicians who performed a greater number of mindful practice sessions per week had a greater reduction in stress. Feedback from this pilot study can inform future clini-

cian-specific interventions, which should be evaluated in larger cohorts that are monitored for long-term adherence. Based on the increasing prevalence and impact of clinician burnout it is imperative to identify practical, on-demand interventions that have the potential of reducing burnout and improving clinician wellness. Ultimately, such programs should be evaluated on their ability to impact potential improvements in parameters of patient care. References 1. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav. 1981;2(2):99-113. 2. Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302(12):1338-1340. 3. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600-1613. 4. Harris interactive poll for CareerBuilder. CareerBuilder April 30, 2013: More Than One Third of Employed Health Care Workers Plan to Look for a New Job This Year. Accessed February 18, 2016 at http://www.careerbuilder.com/share/aboutus/pressreleasesdetail.aspx?sd=4/30/2013&id=pr754&ed=12/31/2013 5. Shanafelt TD, Balch CM, Bechamps G, etal. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. 6. Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res. 2014;14:254. doi:10.1186/1472-6963-14-254. 7. Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2015;4. CD002892. doi: 10.1002/14651858.CD002892.pub5. 8. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300(11):13501352. 9. Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med. 2012;43(2):119-128. 10. Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med. 2013 Sep 1;11(5):412-420. 11. Lamothe M, Rondeau É, Malboeuf-Hurtubise C, Duval M, Sultan S. Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complement Ther Med. 2016 Feb;24:19-28. 12. Morledge TJ, Allexandre D, Fox E, et al. Feasibility of an online mindfulness program for stress management—a randomized, controlled trial. Ann Behav Med. 2013 Oct 1;46(2):137-148. 13. Melville KM, Casey LM, Kavanagh DJ. Dropout from Internet-based treatment for psychological disorders. Br J Clin Psychol. 2010;49(Pt 4):455-471. 14. Stress Free now for Healers. Cleveland Clinic Wellness. http://www.clevelandclinicwellness.com/EmployerPrograms/BonSecours/Pages/SFNDemo.asp. Accessed March 21, 2016.

Robert A. Bonakdar, MD, is the director of

pain management at the Scripps Center for Integrative Medicine, La Jolla, California. He is on the Board of Directors of the American Academy of Pain Management and was the president of the Board from 2012 to 2015. Dr. Bonakdar began the AAPM Clinician Wellness Initiative in 2012 as part of the Presidential Initiative. Dr. Bonakdar served as the liaison between and AAPM Cleveland Clinic Wellness Enterprise Team in setting up the pilot wellness program.

Thank you to the Cleveland Clinic Wellness Enterprise Team who were responsible for implementation and management of the program as well as data acquisition and reporting. We would like to especially acknowledge Jennifer Hunter, LISW-S, director of wellness, Tiffany Baker, systems analyst, and Nicole Jelovic, MSSA, LSW, program coordinator of the Cleveland Clinic Wellness Enterprise.

THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

A CASE REPORT

Periosteal Acupuncture Electrical Stimulation (PAES) for Chronic Postamputation Pain BY SAIYUN HOU MD, PHD, AND JORGE GARCIA-VEL ASQUEZ, MD

ostamputation pain (PAP), including phantom limb pain (PLP) and residual limb pain (RLP), is highly prevalent in amputees, challenging to treat, and often severely debilitating (1). Amputation is increasingly common in the United States with an annual incidence of about 185,000 and a projected increase in prevalence from 1.6 million in 2005 to 3.6 million by 2050 (2). In general, untreated PAP causes many issues such as continuous disability, deteriorating quality of life, and potential addiction to opioid medications. Many treatment strategies have been developed; unfortunately, there is a paucity of high quality clinical trials to support most of these treatments. Studies have shown periosteal acupuncture electrical stimulation (PAES) has modestly reduced

pain in advanced knee osteoarthritis, but there is a lack of documentation investigating the use of PAES for chronic postamputation pain (3,4). The following case describes a patient who suffered from unilateral phantom limb and residual limb pain refractory to conservative management. Three weeks after PAES treatment, he experienced complete relief of postamputation pain, and remained pain free for the following nine months to the point at which he was able to engage in athletic activities. Case Report

George S., a 65-year-old male veteran, presented with left lower extremity residual limb and phantom pain since below-knee amputation during military training in 1970; he received flap coverage surgery that same year. George described the pain as burning, shooting down his perceived “leg” to his “foot.” His residual limb pain was worse than the phantom limb pain. The pain was intermittent and only both-

Three weeks after only one treatment, George experienced complete resolution of pain, and a decrease in VAS score to 0. ered him while walking; he reported pain ranking 9 out of 10 on a visual analog scale (VAS). George is able to run without pain and he is currently training for the Houston Marathon. Prior to presentation, he had been treated with optimized doses of NSAIDs, strength training, stretching, rolling exercises, ice, and heat therapy, none of which provided 24

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PAES for Chronic Pos ta mpu tat ion Pain

any benefit. Physical examination demonstrated hyperalgia on an anterior well-healed surgical scar on the stump. Procedure

George was placed in a supine position and the insertion site was cleansed using aseptic technique. Four fine 30-gauge acupuncture needles were inserted as far as the periosteum at SP 9, GB 33, GB 34, and LR8 points as negative leads, and into soft tissue at ST34, SP10, and eyes of the knee (ST 35 and EX-LE-4) points as positive leads. (See Figure 1[5]). Electrical stimulation was delivered using a Pantheon electroacupuncture unit (model ITO(r) ES-130) at 60 Hertz for 45 minutes. The waveform delivered by this unit is an asymmetrical biphasic square wave. The pulse width is 0.1 milliseconds with a stimulus intensity range of 0 to 10 V. Stimulus intensity was adjusted so that it was clearly uncomfortable but tolerable. The input was adjusted so that the intensity remained uncomfortable but tolerable for the entire 45 minutes. Results

Three weeks after only one treatment, George experienced complete resolution of pain and a decrease in VAS score to 0. He had significant improvement in his quality of life, as measured by a score of 84% on the Q-LES-Q-SF (Quality of life enjoyment and satisfaction questionnaire-short form) from 63%. He was able to walk one to two miles every day without pain. He also remained pain free at a nine-month follow-up visit. There were no adverse events. Discussion

This report presents a successful treatment outcome after PAES in a patient with PAP. Treatment of PAP is very challenging because the underlying mechanisms are multifactorial in nature (6). The pathophysiology underlying phantom phenomena can be broadly categorized in terms of supraspinal, spinal, and peripheral mechanisms. Supraspinal mechanisms involve somatosensory cortical reorganization of the area representing the deafferentated limb and are predominant in phantom limb pain and phantom sensations. Spinal reorganization in the dorsal horn occurs after deafferentation from a peripheral nerve injury. The evidence for peripheral mechanisms playing a role in PAP includes the demonstration of spontaneous neuronal activity in the proximal end of cut nerves, the presence of stump pathology in some patients with PAP and the strong correlation between RLP and PLP, and the relief of phantom pain after the injection of local anesthetic into the painful stump.

Figure 1. A schematic representation of stimulation sites for periosteal acupuncture electrical stimulation (PAES). Courtesy: Carlos Vargas. Medical Acupuncture for Physicians. 2004 (5).

Axonal nerve damage during an amputation initiates inflammation and regenerative sprouting, which results in the development of “ectopic” activity, mechanical sensitivity, and chemosensitivity to catecholamines (7). The sympathetic nervous system may play a role in potentiating PAP. Despite the paucity of studies examining the effects of sympathetic blockade on the spectrum of PAP, numerous reviews have postulated that sympathetic dysfunction is likely to contribute to PLP and RLP (8,9). The evidence supporting a role for sympathetic maintenance of PAP consists mainly of anecdotal reports of increased PLP and RLP following injection of epinephrine into residual limbs, and relief of PAP following sympathetic blockade (10-12). Millions of Americans have used acupuncture, often for chronic pain. PAES is a technique that delivers high-frequency electrical stimulation to the periosteum using acupuncture needles. It has been hypothesized that PAES exerts its effect primarily by stimulating sympathetic fibers in and around the periosteum, which in turn stimulates a local increase in blood flow to the area that then modifies sympathetic and segmental nerve responses (13). Electrical stimulation of acupuncture needles is associated with release of endogenous opioids that may have analgesic effects on peripheral receptors (14,15). The gate control theory as proposed by Melzack and Wall (16,17) may explain how activation of large myelinated nerve fibers by PAES can inhibit transmission of pain signals (and “close the gate”) from the spinal cord to higher centers in the central nervous system to decrease the perception of pain. Evidence shows that numerous nociceptive nerve endings are found in the periosteum including C fibers and A delta fibers (18). Placing the needles into the periosteum proximal THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

PAES for Chronic Pos ta mpu tation Pain

PAES is an easily manipulated, cost-effective, less invasive, and safe procedure, compared to other methods of peripheral nerve stimulation.

to the stump area can directly stimulate nerve fibers and achieve pain relief by inhibiting activity in central pain pathways, such as the spinothalamic tract (19). Several reports have been published on the use of peripheral electrical nerve stimulation (PENS) in the treatment of postamputation pain. Soin, et al., (20) performed high frequency (10 kHz) electrical nerve block in seven patients with postamputation pain, and the average pain reduction was 75% at the three-month primary end point. The treatment efficacy was sustained up to 12 months. Rauck, et al., (21) reported insertion of an electrode to the femoral nerve under ultrasound guidance in a patient with chronic severe residual limb pain 33 years after a below-knee amputation. This patient achieved satisfactory pain relief at two weeks’ follow-up. The method of PAES used in George is distinct from

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peripheral nerve field stimulation or transcutaneous electrical nerve stimulation (TENS), in which the needle is placed near a pain area (22-25). It also differs from electrical acupuncture stimulation, in which the location of the needle is based on specific theories regarding energy flow throughout the human body (26,27). TENS and electrical acupuncture stimulation have indirect interaction with the nervous system and provide pain relief to the local surrounding area, although some studies still use the term “peripheral nerve stimulation” (26). PAES is an easily manipulated, cost-effective, less invasive, and safe procedure, compared to other methods of peripheral nerve stimulation. It can produce efficacious and durable pain reduction for chronic postamputation pain. Further prospective, double-blinded, randomized studies are required to thoroughly document the utility of the procedure. References 1. Hsu E, Cohen SP. Postamputation pain: epidemiology, mechanisms, and treatment. J Pain Res. 2013;6:121–136. 2. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422–429. 3. Weiner DK, Rudy TE, Morone N, Glick R, Kwoh CK. Efficacy of periosteal stimulation therapy for the treatment of osteoarthritis-associated chronic knee pain: an initial controlled clinical trial. J Am Geriatr Soc. 2007 Oct;55(10):1541-7.

ACCREDITED EDUCATION. ANYTIME YOU WANT. WHENEVER YOU WANT. The Academy’s new online learning management center provides on-going education for those caring for people with chronic pain. All programs are accredited for continuing education and include: • Audiovisual presentations from leading experts in the field of pain management. • Written educational activities that are theoretical and practical. • New programs added every month. • The ability to print your accreditation certiﬁcate and access your continuing education history at any time.

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| T H E PA I N P RACT ITION ER | M AY 2 0 1 6

PAES for Chronic Pos ta mpu tat ion Pain

4. Weiner DK, Moore CG, Morone NE, Lee ES, Kent Kwoh C. Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial. Clin Ther. 2013 Nov;35(11):1703-20. 5. Vargas CA. Medical acupuncture for physicians: a pocket clinical reference guide. Berkeley: Medical Acupuncture Publishers; 2004:37. 6. Knotkova H, Cruciani RA, Tronnier VM, Rasche D. Current and future options for the management of phantom-limb pain. J Pain Res. 2012;5:39-49. 7. Flor H, Nikolajsen L, Staehelin Jensen T. Phantom limb pain. A case of maladaptive CNS plasticity. Nat Rev Neurosci. 2006;7(11):873–881. 8. Smith HS, Lalani I, Argoff CE. Phantom pain. In: Fishman SM, Ballantyne JC, Rathmell JP (Eds.), Bonica’s Management of Pain. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:331-338. 9. Flor H. Phantom-limb pain: Characteristics, causes, and treatment. Lancet Neurol. 2002;1(3):182-189. 10. Chaturvedi A,Dash HH. Sympathetic blockade for the relief of chronic pain. J Indian Med Assoc. 2001;99:698-703. 11. Torebjork E, Wahren L, Wallin G, Koltzenburg M. Noradrenaline-evoked pain in neuralgia. Pain. 1995;63:11-20. 12. Cohen SP, Gambel JM, Raja SN, Galvagno S. The contribution of sympathetic mechanisms to postamputation phantom and residual limb pain: a pilot study. J Pain. 2011 Aug;12(8):859-867. 13. Joseph MH. Acupuncture energetics: a clinical approach for physicians. Berkeley: Medical Acupuncture Publishers; 1995:505. American Academy of Pain Management 14. COUNCIL Chen XH, Han JS. Analgesia induced by electroacupuncture of different frequenCORPORATE MEMBERSHIP cies is mediated by different types of opioid receptors: another cross tolerance Behav Brain Res. 1992;47:143-149.or Contact Sheilastudy. Miller (smiller@aapainmanage.org) Jillian Manley (jmanley@aapainmanage.org) (209) 533-9744 15. Peets JM, Pomeranz B. CXBK mice deficient in opiate receptors show poor electroacupuncture Nature. 1978;273:675-676. to become a Corporate Council analgesia. Member today! 16. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971-979. 17. Wall PD, Sweet WH. Temporary abolition of pain in man. Science. 1967;155(3758):108-109. 18. Witt KL, Vilensky JA. The anatomy of osteoarthritic joint pain. Clin Anat. 2014

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Apr;27(3):451-454. 19. Keller T, Krames E. “On the Shoulders of Giants”: a history of the understandings of pain, leading to the understandings of neuromodulation. Neuromodulation. 2009;12:77-84. 20. Soin A, Shah NS, Fang ZP. High-frequency electrical nerve block for postamputation pain: a pilot study. Neuromodulation. 2015 Apr;18(3):197-205. 21. Rauck RL, Kapural L, Cohen SP, et al. Peripheral nerve stimulation for the treatment of postamputation pain—a case report. Pain Pract. 2012 Nov;12(8):649655. 22. Goroszeniuk T, Kothari S, Hamann W. Subcutaneous neuromodulating implant targeted at the site of pain. Reg Anesth Pain Med. 2006;31(2):168-171. 23. Paicius RM, Bernstein CA, Lempert-Cohen C. Peripheral nerve field stimulation in chronic abdominal pain. Pain Physician. 2006;9(3):261-266. 24. Goroszeniuk T, Kothari S. Subcutaneous targeted stimulation. In: Krames E, Peckham P, Rezai A eds. Neuromodulation. Boston: Elsevier; 2009: 417-427. 25. Johnson MI, Mulvey MR, Bagnall AM. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Syst Rev. 2015 Aug 18;8: CD007264. 26. Slotty PJ, Vesper J, Pohlmeier K, Wille C. Predicting outcome in peripheral nerve stimulation for chronic neuropathic pain. Neuromodulation. 2013 SepOct;16(5):483-488. 27. Liu GP, Xue FS, Sun C, Li RP. Electroacupuncture for pain treatment after total knee arthroplasty. Acupunct Med. 2015 Oct;33(5):433.

Saiyun Hou MD, PhD, (left) is a resident

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Jorge Garcia-Velasquez, MD, is an assistant professor in the department of physical medicine and rehabilitation, Baylor College of Medicine/ Michael E. DeBakey VA Medical Center, Houston, Texas.

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THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

CALL FOR CASES

Teamwork as a Matter of Life and Death By Tiffany J. Kirchner, MSN, RN, ACNS-BC, APNP, ACHPN

Susan,* a 39-year-old woman with metastatic ovarian cancer, recently consulted our team for pain control. She had developed bony metastatic disease and was too ill for more chemotherapy. She presented to the hospital from home with uncontrolled pain. Our team was consulted to help with controlling her pain, but I realized that she needed much more than just help with pain—she needed help with her emotional and spiritual distress as well, as she and her husband Paul,* were coming to the realization that she was dying. I worked closely with Susan’s oncology team and discussed both ideas that had worked well and those that were unsuccessful to control her pain in the past. Working with pharmacy, her

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primary hospitalist, and the oncology team, I explored if there were other adjuvant medications to opioids that we could give Susan to achieve appropriate pain relief. The team determined a patient-controlled analgesia pump (PCA) as well as steroids for her bone metastases and anxiolytics for her anxiety, which was only worsening her pain, would be our best option. I worked with nursing staff to assure that the recommendations implemented were achieving adequate relief—often checking back hourly to assess Susan’s progress. After achieving appropriate analgesia, I involved our team social worker and our team chaplain to address Susan and Paul’s emotional and spiritual distress. Our team social worker sat down with the couple (often difficult to do in a chaotic, acute inpatient hospital setting) to address Susan’s primary concerns. Susan and Paul agreed that her goal was to not die in the hospital and she did not want to die in their home, as Susan was worried that the memory would be too painful for Paul. Susan’s second important goal was to be able to see her dogs one more time, as they were like “children” to her. Her final goal was to be comfortable and peaceful, surrounded by family members while she died, and she was very concerned about continued pain issues. Our social worker reviewed hospice services with Susan and Paul, and decided that transitioning to a residential hospice facility would best achieve those goals. She could see her dogs (who are often allowed at residential hospice facilities), have her pain well controlled, and not die at home or in the hospital. Our social worker identified a hospice facility and gave the couple the information they needed in order to accept her care. Our social worker and the case management staff in the hospital worked to assure that Susan didn’t spend a minute longer in the hospital than she had to. Our team chaplain worked closely with Susan and her family (who were growing in number during the day for visits) to assure peace and a calming presence during this difficult transition. He worked with her to assure her wishes would be met when it came to

planning her funeral with her husband. He developed such a close relationship with Susan and her family that he was asked a couple of weeks later to perform the funeral itself. After adjusting her medications and accurately titrating her pain medications to assure her physical pain was relieved, the communication between the oncologist, palliative care team, primary hospitalist, and case management became much more frequent in an effort to honor Susan’s last wishes. The same day our palliative care team was consulted, we had worked with all of the other consultants and team members involved in Susan’s care to improve her pain control, alleviate some of her anxiety, provide spiritual and emotional support to both her and her husband, and work to get her discharged to a local residential hospice facility. This challenging, complex, and emotional case could not have happened without the collaboration, communication, and a true sense of teamwork. Although the pain crisis was the primary reason the palliative care team became involved in her care, we were able to provide integrated, team-based solutions that focused on preserving Susan’s dignity and quality of life. Palliative care teams are an integrated team of experts. However, if you don’t have access to a palliative care team, the simple principles of communication, empathic listening, and collaboration between all disciplines involved in a patient’s care can be applied to every patient who is suffering from pain. A few days after discharge from the hospital, Susan died comfortably and peacefully at the residential hospice, surrounded by friends and family. And yes, her dogs were able to visit her as well. *The names have been changed. Tiffany Kirchner, MSN, RN, ACNS-BC, APNP, ACHPN, is board-certified clinical nurse specialist in palliative and hospice medicine. She is currently working for Wheaton Franciscan Healthcare in Milwaukee, Wisconsin, and is completing her doctor in nursing practice (DNP) degree this spring. Her areas of interest include symptom management and care transitions in patients with serious illness, as well as compassion fatigue and compassion satisfaction among nurses practicing in the acute care hospital setting.

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I REALIZED THAT SHE NEEDED MUCH MORE THAN JUST HELP WITH PAIN— SHE NEEDED HELP WITH HER EMOTIONAL AND SPIRITUAL DISTRESS.

Having worked on a palliative care team for years, I am no stranger to understanding the power and value of working with an interdisciplinary team to help and treat complex patients with serious illness. Working on a newly formed palliative care team within a small community hospital, our team has had to prove our value and worth to many referring providers, as most of them believe our role is to solely help patients sign onto hospice or discuss goals of care. However, another one of our often overlooked areas of expertise is pain management in the setting of serious illness.

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THE PAIN PRACTITIONE R

| VOLUME 26, NUMBER 2 |

CALL FOR CASES

Team-based Approach to Care Spine Institute Northwest By Abimbolu Makinde, MD

Processes that would normally take weeks were streamlined and expedited.

cian, a nurse practitioner, a sports medicine physician, a podiatrist, spine surgeons, and pain physicians in clinic in some combination at any given time. This has led to the fostering of an environment of collaboration and teamwork among the physicians that has led to improved care delivery for our patients. One example of this is the case of JS, a 57-year-old female originally seen in our office by our primary care/MSK physician. She initially presented with a complaint of intermittent lumbar back pain with radiation to her groin bilaterally after a work injury. Prior to entering our practice she had received chiropractic care that included adjustments, and medication therapy with opioid and muscle relaxant prescriptions. She had obtained magnetic resonance

| T H E PA I N P RACT ITION ER | M AY 2 0 1 6

imaging (MRI) outside of our office that showed degenerative changes and facet arthritis, as well as an electromyogram (EMG) of her low back and lower extremities that showed no evidence of lumbosacral radiculopathy or lumbosacral plexus lesion. Her past medical history was remarkable for hypertension and irritable bowel syndrome. Her surgical history included a partial hysterectomy in the 1980s and breast biopsies in 1996, 2011, and 2012. She was a light smoker and social drinker. Her initial exam was benign and she was advised to continue chiropractic care and begin a regimen of nonsteroidal antiinflammatory medication and hot/cold therapy as needed along with daily range of motion and therapeutic exercise. After three months of this course, she displayed some symptomatic improvement but was unable to return to her job as a custodian at a local school district. At that time an alternative opioid was added to her regimen and she was referred to a work conditioning program in attempt to get her fit for her job. During her work conditioning program she also underwent lumbar facet corticosteroid injections at an outside facility which provided her with additional symptom relief. At the completion of her work conditioning program, her lumbar pain had improved to the point that her main complaint was now leftsided hip pain. An MRI of her hip was obtained and the patient underwent an independent medical exam (IME). The conclusions of the independent medical exam were that the patient had suffered a lumbosacral strain injury at work and that the straining injury had reached a fixed and stable state requiring no further treatment and that her degenerative disease in the lumbar spine preceded her work injury. However, there were no conclusions made regarding her hip MRI, which showed an acetabular labral tear. During her follow-up visit to review the IME report, her case was discussed between our primary MSK physician and our sports medicine physician. It was determined that she would need a diagnostic injection of

her hip in order to determine if her hip or her back was the main pain generator keeping her from returning to work. During that same visit an authorization request for referral to our sports medicine physician for a diagnostic hip injection was initiated. She was able to undergo the procedure within 48 hours and responded with complete elimination of her pain. She was then scheduled for a therapeutic injection the following week. Her follow-up visits were coordinated by our office so that she saw both our primary care/MSK physician and the sports medicine physician on the same days. She was able to return to work with continued physical therapy for her hip after the therapeutic injection. This case is an example of some of the benefits of working within a team-based approach to patient care. Processes that would normally take weeks were streamlined and expedited secondary to the physicians involved being able to communicate in real time with the patient present, the office staff being familiar with the patient and her history, and being able to immediately send the appropriate documentation to the appropriate office in order to get requests approved. The influence of team-based approaches to the success of organizations and industries has been well documented in industries like defense and aviation, among others. Within health care, the typical successful team-based approach has historically been seen in the inpatient setting (rapid response, trauma, and high-risk newborn delivery). Our experience with JS and many other patients has taught us that many of the obstacles faced in the day-to-day management of patient care in an outpatient setting can be overcome by utilizing and practicing a team-based approach. Abimbolu Makinde, MD, is a fellowship-trained sports medicine physician at the Spine Institute Northwest in Bothell and Tacoma, Washington. He has an interest in diagnostic and interventional ultrasound for musculoskeletal conditions.

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Among the many changes occurring within and around health care delivery in the United States, one of the most profound has been the transition from physicians working in isolationâ&#x20AC;&#x201D; moving from one room to the next and only interacting with colleagues via referral forms, faxes, and chart notesâ&#x20AC;&#x201D; to a team-based delivery of care that utilizes multiple providers within an office, institution, or care organization to improve patient satisfaction, outcomes, and reduce cost. At the Spine Institute, on any given clinic day, we may have a primary care/musculoskeletal (MSK) physi-

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