The Pain Practitioner - Headache Management

american academy of pain management

Integrative No Life Limited Pain Management

by Pain for Optimal Patient Care

The Pain Practitioner Summer Winter 2015 2013

approaches to A​ LSO INSIDE Complications of Chronic Opioid Therapy Medication Overuse Headache Urine Drug Monitoring: Making the Right Decisions A Traditional Chinese Medicine Approach​ to Headache And More!

headache

management

American Academy of Pain Management www.aapainmanage.org

ACADEMY BOARD OF DIRECTORS President Robert A. Bonakdar, MD, FAAFP Vice President Joanna Katzman, MD, MSPH Past President Alfred V. Anderson, MD, DC Secretary Thomas N. Watson, DPT, MEd Treasurer Jackie S. Rowles, CRNA, MBA, FAAPM Directors-at-Large Kevin T. Galloway, BSN, MHA, Colonel, US Army (Retired) Christian D. González, MD Gerald Q. Greenfield, Jr., MD W. Clay Jackson, MD, DipTh Michael Kurisu, DO, ABIHM Arthur S. Roberts, DDS, MD

pain practitioner Volume 25, number 2

Table of contents Editor’s Corner

2 Our Vision: No Life Limited by Pain

By Bob Twillman, PhD, FAPM, Executive Director

Academy News

4 Newly Credentialed Members 8 You Should Know...

Executive Director Emeritus and Director of Board Development Lennie Duensing, MEd

ACADEMY STAFF AND CONSULTANTS Executive Director Robert Twillman, PhD, FAPM Director of Education and Credentialing Debra Nelson-Hogan Director of Sales, Marketing and Events Jillian Manley Director of the State Pain Policy Advocacy Network (SPPAN) Amy Goldstein, MSW Researcher and Policy Analyst Katie Duensing, JD Credentialing Account Manager MacKenzie Davis Website and Database Director Eric Blosch Account Managers Rosemary LeMay, Staci Criswell, and Sheila Miller Accounting Director Kristin Taylor Education Manager Cathleen Coneghen Office Manager Karen Hebert

THE PAIN PRACTItiONER STAFF AND CONSULTANTS Editor-in-Chief Debra Nelson-Hogan Advertising and Sales Jillian Manley, 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, Phone 209-533-9744, Fax 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 Nelson-Hogan at dhogan@aapainmanage. org. Contact Sheila Miller at 209-533-9744 regarding advertising opportunities, media kits, and prices.

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.

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Page 16

Page 34

Features

16 Complex Headaches Need a Complex Approach

By Robert A. Bonakdar, MD, FAAFP

19 Post-Traumatic Headache: Knowledge Update

By Nathan D. Zasler, MD, and Sara Etheredge, DPT

23 Medication Overuse Headache: Just Following Doctors’ Orders?

By Michael Ready, MD

28 A Patient with Headache: Project ECHO® Chronic Pain

and Headache Management TeleECHO™ Clinic Case Study Edited by Brian M. Shelley, MD, on behalf of the ECHO Pain Team

30 What is Your Headache Telling You?

A Traditional Chinese Medicine Approach Jennifer Johnston, PhD, DNM, NMD, MS

34 Complications of Chronic Opioid Therapy

By Jeffrey Gudin, MD, and Adam Laitman, MD

40 Urine Drug Monitoring: Making the Right Decisions

By Brooke Mueller, PharmD

46 Physician and Patient Beliefs and Behaviors

Relating to Pain Medications: Results of a Survey

By Partnership for Drug-Free Kids

Subscribe to The Pain Practitioner!

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

THE PAIN PRACTITIONE R

| VOLUME 25, NUMBER 2 |

1

EDITOR’S CORNER

Our Vision: No Life Limited by Pain

BY ROBERT T WILL M AN, PHD, FAPM, E XECU TI V E DIREC TOR

A

t the end of February, the Academy’s Board of Directors held its mid-year meeting. While the Board conducted the usual business, it also spent a day working with a talented facilitator to develop statements of our core purpose, core values, and vision.

Unlike many such efforts in which I’ve participated, this one was energizing and produced an inspirational set of statements that will carry the Academy forward for the foreseeable future. I’ve been thinking about how these statements relate to each other and represent the Academy, and the picture that emerges for me is something like the graphic accompanying this article—if the Academy is seen as an edifice, then these statements represent key components of that edifice, components that provide a solid structure for our organization.

supporting collaborative therapeutic communities; and promoting mindful caring. Among the major pain manage-

ment organizations, none embodies these values better than the Academy. Our inclusive approach enables us to build and enrich therapeutic communities that embrace the integrative approach, an approach whose excellence we seek to enhance in all of our programs. This is distinctly not for our own benefit, but for the benefit of the people with pain for whom we care. It is fostering a mindful approach to caring for these individuals, in the service of relieving their pain and suffering and improving their quality of life, that is our core value, as opposed to seeking to enhance our own status.

The Academy’s mission statement existed before the Board’s recent exercise, and remains unchanged: The mission of the American Academy of Pain Management is to improve the lives of people with pain by advancing a person-centered, integrative model of pain care through evidence-guided edu-

Our Vision

cation, credentialing, and advocacy. This statement outlines

No Life Limited by Pain

Our Mission

Promoting mindful caring

Inclusivitysupporting collaborative therapeutic communities

Our Core Values

Fostering excellence in integrative practice

To improve the lives of people with pain by advancing a person-centered, integrative model of pain care through evidence-guided education, credentialing, and advocacy.

Our Core Purpose To relieve pain and suffering and improve quality of life

At the base of that edifice, the most basic statement of the Academy’s purpose and raison d’être is our core purpose: To relieve pain and suffering and improve quality of life.

That statement reflects what the Academy is all about, and as long as we remain grounded on such a firm foundation, our efforts will be truly meaningful.

From the foundation, three columns rise, representing our core values. These values reflect our orientation to our work and guide how we carry it out. The three values are: Fostering excellence in integrative practice; inclusivity—

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the work we undertake to carry out our core purpose— it embodies the strategy and tactics that guide what we do.

Finally, atop the edifice is the ultimate goal to which we aspire—our vision statement: No life limited by pain. Vision statements are meant to be lofty, aspirational, and inspirational, and to reflect how things would be if we reached a sort of nirvana in the realm of our work, by successfully completing that work. You will begin seeing this statement in most, if not all, communications from the Academy, including, for the first time, on the cover of this issue of our magazine. It will be featured prominently at our Annual Clinical Meeting in September, and it will be obvious when you visit our website. You might even see it on T-shirts!

The building that we have constructed from these blocks (i.e., the Academy) is robust, welcoming and inviting, and secure, not because a group of people sat around a table and dreamed up these statements, but because these statements truly reflect who we are, what we do, and the ends to which we aspire. The mutual support of the Academy by its members, and of those members by the Academy, will ensure that the building remains standing long after others have crumbled into dust.

ACADEMY NE WS

Newly Credentialed Members Open to all pain practitioners, the Academy’s Credential demonstrates that a clinician is knowledgeable about interdisciplinary/integrative pain management; has practiced in the field of pain management for at least two years; remains in good standing with federal and state regulatory agencies; has passed a rigorous exam; and is committed to ongoing education in the field of pain. The Academy welcomes the following credentialed pain practitioners who have met the Academy’s requirements and demonstrated proficiency in the management of pain.

FELLOW Karen Ann Schwartz, MS, NP-BC, is a

nurse practitioner who has worked in pain management for the past three years. She received her bachelor’s of science degree from the Medical College of Georgia in 1995 and master’s degree from Georgia State University in 2000. She has extensive experience in gynecology and obstetrics and did an internship in pain management in 2012. She works for Eastside Spine and Wellness in Snellville, Georgia. She has a passion for health and wellness and believes in a holistic approach to pain management. She encourages her patients to be active participants in their health and pain management.

Robert Louis DeLillo, CRNA, APRN, is

the CEO of Metro Anesthesia Affiliates, a professional anesthesia corporation in the Dallas-Fort Worth area, and of Southwest Pain Management, Inc., a professional health care company based in Roswell, New Mexico, where he is currently developing a private pain practice. He is board certified in both nurse anesthesiology and non-surgical pain management and has specialized in these areas for 33 years. His experience includes, but is not limited to, all types of general, neurological, cardiothoracic, and obstetrical anesthesia as well as most techniques of regional and non-surgical pain management. During his career he has served as a clinical preceptor for nurse anesthetists at the master’s degree level and he has also served 4

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as an expert witness-consultant in medical/legal cases. His professional interests are in interventional pain management and bio-behavioral approaches to pain management. He is a member of the American Association of Nurse Anesthetists, Texas Association of Nurse Anesthetists, New Mexico Association of Nurse Anesthetists, and the International Anesthesia Research Society.

DIPLOMATE Rizwan Muhammad, MBBS, MRCGP, MRCS, has been

practicing medicine for 15 years. He received his basic surgical training from the Royal College of Surgeons Edinburgh and did his family medicine training at the Royal College of General Practitioners. He has always been interested in dealing with pain management as he got to work on an acute emergency team, which brought him into regular contact with patients suffering from a variety of pain-related problems. He is looking forward to further practicing and specializing in the vast specialty of pain management in order to better cater to people dealing with pain.

Karl A. Robinson, DC, FNP, is a health care

provider with multiple foci of specialization, emphasizing evidence-based health care in musculoskeletal medicine, functional neurology, pain management, clinical nutrition, and primary care.

Christopher S. Otka, DVM, Rph, CVA, DAAPM, is the owner of Noank-Mystic

Veterinary Hospital. He is a graduate of the Massachusetts College of Pharmacy and Mississippi State University College of Veterinary Medicine. He is well versed in both human and animal pain management. As a clinical pharmacist, Dr. Otka worked closely with Connecticut Hospice and Yale pediatric and adult oncology centers.

Dr. Otka is certified in veterinary acupuncture, stem cell therapy for the treatment of osteoarthritis, and PennHIP for the diagnosis of hip dysplasia in dogs. Dr. Otka plans to further his pain management expertise through the International Veterinary Academy of Pain Management as well as a board specialty in both canine and feline medicine and exotic animal medicine. Continued on page 6

ACADEMY NE WS

Continued from page 4

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Muhammad Jalaluddin, MD, FRCS, is a neurosurgeon. He is certified by AAPM in pain management. He provides a full range of interventional pain management at J Clinic, Bath, New York. His goal is to develop simple, economical, and efficient techniques for pain management.

Raouf Gharbo, DO, completed his specialty residency medical training in physical medicine and rehabilitation at The Ohio State University Medical Center in Columbus, Ohio. Prior to specialty residency training he learned a holistic approach to medicine at Ohio University Heritage College of Osteopathic Medicine in Athens, Ohio. Dr. Gharbo is board certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Neuromuscular and Electrodiagnostic Medicine. He is a long-standing Eastern Virginia Medical School clinical associate faculty member of the department of physical medicine and rehabilitation.

Dr. Gharbo has served extensively with Physicians for Peace as part of the medical operations committee and as a leader of medical missions.

Thank you to our Corporate Council Members!

®

American Academy of Pain Management Corporate CounCil MeMbership Contact sheila Miller (smiller@aapainmanage.org) or Jillian Manley (jmanley@aapainmanage.org) (209) 533-9744 to become a Corporate Council Member today!

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ACADEMY NE WS

You Should Know...

The State Pain Policy Advocacy Network (SPPAN)

Improving pain policy throughout the nation SPPAN, a project of the American Academy of Pain Management, focuses on promoting person-centered care for people affected by pain through advancing effective pain policy. One way we advocate is by writing letters to legislators—an act that we urge all of you to take part in as important issues arise. By early April 2015, the Academy had sent more than five dozen letters in response to important bills, and below are a few of those bills that have passed this year.

Improving Patient Safety Through Well-Designed Prescription Monitoring Programs (Pmps) With the full support of SPPAN, Wyoming recently passed WY SF 100, a bill that allows authorized delegates

•

to check the PMP on behalf of a prescriber or dispenser when the release of the information may be of assistance in preventing or avoiding inappropriate use of controlled

substances. This helps to improve patient health and public safety without impeding a health care practitioner’s ability to treat patients. Delegate authority to access the PMP will take effect in Wyoming January 1, 2016.

• At the time of this writing, New Hampshire is considering NH SB 31, which, in its original form, would define “dispenser” in such a way that it could result in a chilling effect, preventing some people from receiving appropriate medication for the treatment of acute pain. SPPAN submitted a letter to the Senate Health and Human Services Committee urging an amendment to the bill—and they listened!

The current amended version of SB 31, now with SPPAN’s full support, has passed from the Senate to the House.

Increasing Access To Life-Saving Overdose Prevention Medication In Colorado and South Dakota, SPPAN advocated

•

for the passage of bills that increase access to naloxone, an important safety tool that prevents tragic deaths from unintended opioid overdoses. We are pleased to announce that CO SB 53 and SD SB 14 have both been signed into law and will take effect during 2015.

SPPAN continues to actively support more than 20 similar bills across the country that still need your support!

To take action on improving pain policies important to your patients and your practice, be sure to regularly check SPPAN’s state pages at http://sppan.aapainmanage.org/ states for hot issues that need your expert opinion.

As always, you can contact SPPAN Director Amy Goldstein at agoldstein@aapainmanage.org to talk about getting involved with the Academy’s advocacy efforts.

PAIN NEWS–WEEKLY Check out our new web column, This Week in Pain.

www.aapainmanage.org/category/ this-week-in-pain/ 8

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ACADEMY NE WS

Academy Contributors

Preceptors observe ACPP candidates performing an OSCE as part of the ACPP program.

New Additions to the Advanced Credentialed Pain Practitioner Program In response to feedback from our members, we are planning to make changes that affect the Advanced Credentialed Pain Practitioner (ACPP) program. The most significant change is that we will be creating an additional exam geared for nurse practitioners and physician assistants. We have convened a committee to work on this program and expect to have it available sometime in 2016.

In addition, we will be offering a Curriculum Review session at the Academy’s Annual Clinical Meeting in Washington, in September. This review is intended to support those candidates who are studying for the ACPP exam; however, attending the course does not guarantee passing the test. Candidates must study the curriculum on their own, in addition to learning the information presented in the course.

Watch the website for further developments, and if you have any questions or comments please contact Debra Nelson-Hogan, Director of Education and Credentialing, at dhogan@aapainmanage.org.

PHOTO BY LENNIE DUENSING

Coming Soon!

The Academy’s All New Online Learning Center The Academy is preparing an online learning management center dedicated to providing education on caring for people in chronic pain.

This new section of our website will contain audiovisual presentations and written educational activities that will be accredited for continuing education. This on-demand system will provide members access to accredited education and allow users to print certificates and access their continuing education history at any time. We’re planning to add new programs every month.

Stay tuned for more information!

Donations to the American Academy of Pain Management (the Academy) support the vital work of the Academy’s policy and advocacy efforts—efforts aimed at ensuring that people with pain have access to the care they need and deserve.

The Academy’s commitment to this work is evidenced by the fact that it is the only pain management organization in the US with a dedicated in-house policy/advocacy team, which is guided by Bob Twillman, PhD—one of the nation’s most respected pain policy leaders. Dr. Twillman carries the Academy’s positions on key issues to policy makers on both the state and federal levels. The Academy’s growing state advocacy efforts are led by Amy Goldstein, MSW, State Pain Policy Advocacy Network (SPPAN) director.

We would like to thank the following contributors for their donations in support of the Academy’s policy and advocacy effort.

Albert C. Cura, MD Anita M. Ogle, DN Anthony F. Afong, MD Arthur E. Jordan, MD Bernard R. Wilcosky, MD Betty Amuzu, MD Carmelita Bamba-Dagani, MD Caroline P. Grierson, RN, BSN Christopher M. Justis, MD Daniel M. Merck, MD David A. Gentile, DO David James Smith, MD Demetrius P. Christoforatos, MD Donald H. Pritchard, MD Edward N. Carrol, PhD Edwin Lewis Kelsey, MD Elizabeth Lebrun, MD Eric Minassian, DC Esther Eke-Huber, PhD, MS, ANP-C Eugene S. Kulaga, DDS Gary B. Olson, DDS Gerald Boone, PA-C Gwinn Murray, MD Inge Decrosta, NP Janet McNiel, MD Jeffrey C. Vernon, DDS Jeffrey Paul Leppert, NP Jeffrey Scott Rogers, DO John Claude Krusz, PhD, MD Joseph B. Guerrini, MD Joseph Fred Stoner, MD Joseph T. Hayes, MD, MPH

In Memory

Julian M. Aviles, MD Kalapala Seshagiri Rao, MD Marios Michael, DC Mark A D’Andrea, MD Mark Anderson Ellis, MD Marlene L. Levy, PhD Michael C. Saltzburg, DO Michael E. Bearb, MD Michael E. Davis, PA Miriam Latorre, PsyD Patricia Jo Kearney, PT Penelope Porter, DVM Ralph M. Steele, MA, MFT Raymond M. Webster, DN Richard Kulwin, DDS Robert G. Salazar, MD Segundo Gabriel Roncal, MD Shairko Missouri, MD Sondra M. Adkinson, PharmD Stanley J. Sczecienski, DO Steven Rosenberg, PhD Steven R. Olmos, DDS Thelma Lynette Green-Mack, MD Vidya R Bethi, MD William R Bauer, MD, PhD, FAAN Yuhlin Lin, MD Donations may be tax deductible as an ordinary business expense. If you would like to donate in support of our policy and advocacy please contact the Academy at 209-533-9744 or aapainmanage.org.

In memory of our deceased members.

Ellen Shapiro, DPM Jack D. Smith, Adv Colon Therapist Thor David Swanson, MD

Ellen Shapiro, DPM Jack D. Smith, Adv Colon Therapist Thor David Swanson, MD

YOUR OPINION MATTERS! We want your beedback. Go to our website and take 5 minutes to complete the survey.

www.aapainmanage.org

THE PAIN PRACTITIONE R

| VOLUME 25, NUMBER 2 |

9

headache management

complex

headaches

Robert A . Bonak dar , MD, FAAFP

need a complex approach

The articles in this issue represent overviews of how to approach complex headaches. As I wrote in an article in 2010 for The Pain Practitioner titled “Integrative Approaches to Headache Management,” headaches often transform and take along on the ride the patient’s mood, energy, outlook, and musculoskeletal system (1).

You have then the typically chronic headache sufferers who also need support of their depression, myofascial pain, and reduced quality of life, just to name a few of the common co-travelers. It is at this point that the headaches are truly more than those simply relieved by taking two aspirin. In fact, Michael Ready, MD, in his article on medication overuse headache provides a practical and integrative approach to cases in which the medications that were initially an aid have become the culprit in promoting more severe and frequent headache episodes. It is often a struggle to find a patient-centered approach that provides a long-term solution. Dr. Ready is able to provide a host of pharmacological, behavioral, and self-management options that can make the transition to reduced headaches more successful.

Nathan D. Zasler, MD, and physical therapist Sara Etheredge discuss another challenging type of headache: post-traumatic headache. This is seen as one of the most refractory types of headache—often with long-term physical and psychological consequences that contribute and can be co-promoted with the headache. In this scenario, the authors articulate the importance of a detailed evaluation to identify promoters as well as create an individualized treatment approach to help patients and providers stay ahead of this formidable entity.

Jennifer Johnston, PhD, DNM, NMD, MS, provides insight into the complexities of headache diagnosis through perspectives including Traditional Chinese Medicine (TCM).

We often realize, and research points out, that headaches are typically not simply one subtype, such as migraine or muscle contraction. They are in many cases a combination of multiple diagnostic entities. Going beyond the diagnosis and viewing the patient multidimensionally, Dr. Johnston explores what diet, emotions, energetics, and personality patterns tell us about the headache. For all pain practitioners, this article points to the need to step back from the electronic medical record asking us 16

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COMPLE X HE ADACHES NEED A COMPLE X APPROACH

for a diagnosis and appreciate the often complex patient scenario to most successfully identify individualized solutions.

Headaches often transform and take along on the ride the patient’s mood, energy, and outlook.

Integrative Headache and Pain Management: When to Make the Leap?

Headaches often have a broader acceptance and incorporation of integrative therapies including mind-body therapies and dietary approaches. This comes from several sources including the well appreciated connection to areas such as stress (80% of migraine suffers claim it is a top trigger), inflammation, and mitochondrial dysfunction (2-4).

Unfortunately, this level of acceptance and incorporation of integrative approaches cannot be said for all pain conditions.

As a look back, almost exactly a decade ago in 2005, when I first wrote an article for The Pain Practitioner titled “Integrative Pain Management: A Look at a New Paradigm,” it was a relatively new concept (5). That article mentioned several key aspects of integrative pain management (IPM), namely: • An openness to new approaches and ideas • A desire to educate ourselves and others • An understanding of the synergy of treatments • An understanding that pain management is often about lifestyle management • A view of integrative pain management as a team exercise •A focus on the importance of a healing environment Since that article, some things have changed. However, the key steps in achieving meaningful integrative care for all in chronic pain are still not standard. I often see patients who have had chronic pain for several decades who have never had a meaningful discussion on the role of diet, activity, or behavioral health approaches. These encounters represent missed opportunities to advance pain care—one patient at a time. To make the leap so that all those with pain, not just those with headaches, can encounter and access integrative pain management, will take a triple effort in education, credentialing, and advocacy.

Education and Credentialing—The First Steps

Education is often the initial step in providing clinicians the knowledge and evidence for confidently incorporating integrative approaches. The Academy realizes this and will provide an expansive curriculum through its 26th Annual Clinical Meeting, September 17-20, 2015, in Washington, D.C. This year the assembly brings a number of acclaimed leaders in the effort THE PA IN PRACTITIONE R

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COMPLE X HE ADACHES NEED A COMPLE X APPROACH

to bring integrative medicine to the military. These speakers include Wayne Jonas MD, President and Chief Executive Officer of the Samueli Institute, and Eric B. Schoomaker, MD, PhD, Scholar-in-Residence, Uniformed Services University of the Health Sciences in Bethesda, Maryland.

As part of the meeting the Advanced Credentialed Pain Practitioner Program will again be offered. This examination and live assessment of skills for the evaluation and treatment of pain are a one-of-a-kind opportunity for clinicians who treat pain to signify their advanced training and commitment.

Another milestone education effort is the publication of the textbook of Integrative Pain Management as part of the Weil Integrative Medicine Library (6). As co-editor of this project, I am extremely proud of the completion of a several-year process that brought together more than 50 contributing experts in IPM. These contributors include many longtime Academy members and meeting faculty, including two of this issue’s contributors, Drs. Michael Ready and Brian Shelley. The book also provides historical and policy input from the Academy’s current and most recent Executive Directors Bob Twillman PhD, and Lennie Duensing, MEd. The ultimate goal of the textbook is to provide a solid foundation for the rationale and incorporation of IPM. Additionally, practical condition-based chapters and case examples are incorporated throughout to allow clinicians the resources for advancing their practice of IPM. This effort will culminate with the publication and inaugural release of the textbook at the 2015 annual meeting.

The Next Step for Pain Management—Advocacy

The last key step in the leap toward making integrative pain management a standard in pain care is advocacy. In this regard, the educational and credentialing steps are, in their own way, a type of advocacy in that they provide the resources, skills, and confidence to practice IPM. However on a larger level, we as Academy members and integrative providers need to take opportunities to point out the strides IPM has made while pushing forward toward the day that IPM is not a question but truly a standard. In this regard, the Academy has been a leader through efforts such as The State Pain Policy Advocacy Network (SPPAN) (7) and its effort to educate and support local and national initiatives to provide access to Integrative Pain Care. Additionally, the Academy and its leadership including Bob Twillman, PhD, have been involved with media outreach including being featured in the Discovery Channel documentary “Pain Matters” (8).

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A Leap to a Paradigm Shift

I am reminded of this distance we have come from a previous editorial written by headache specialist Dr. Frederick R. Taylor in the journal Headache titled, “When West meets East: is it time for headache medicine to complement ‘convention’ with alternative practices?”(9). The issue is noteworthy in that it features two articles that point to high rates of CAM/IM use for headache as well as a pilot study highlighting the potential benefit of an herbal (ginger/feverfew) treatment. The editorial is also noteworthy both in its title—a question—as well as this discussion of the transformation needed to answer the question.

As we often discuss the need for transformation in pain care, the editorial aptly points out, “Paradigm shifts … are scientific revolutions that happen non-linearly due to the inability to solve a problem sufficiently with current scientific concepts.” Headaches, especially those discussed in this issue, are problems where rates of recovery and patients’ satisfaction scores are poor (often < 50%) and truly require a paradigm shift. As Dr. Taylor points out, integrative medicine “…represents a paradigm shift in the practice of headache medicine which seems warranted today to improve the management of chronic daily headache...if not for all headache disorders.” The increasing paradigm shift of integrative headache management is refreshing and foreshadowing of the larger transformation needed to provide the same optimized care for all living with chronic pain.

References 1. Bonakdar RA, Jackson, K. Integrative approaches to headache management.

Pain Practitioner. 2010; 20(1):43-54.

2. Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia.

2007 May;27(5):394-402.

3. Ramsden CE, Faurot KR, Zamora D, et al. Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: a randomized trial. Pain.

2013 Nov;154(11):2441-51.

4. Yorns WR Jr, Hardison HH. Mitochondrial dysfunction in migraine. Semin Pediatr Neurol. 2013 Sep;20(3)-188-93.

5. Bonakdar RA: Integrative pain management: A look at a new paradigm. Pain Practitioner 2005;15(1):15-18.

6. Weil Integrative Medicine Library accessed at: https://global.oup.com/academic/ product/integrative-womens-health-9780195378818?lang=en&cc=us. Accessed at http://oup.com/us 7. The State Pain Policy Advocacy Network (SPPAN) accessed at http://sppan.aapainmanage.org 8. Pain Matters accessed at http://painmatters.com/ 9. Taylor FR. When West meets East: is it time for headache medicine to complement “convention” with alternative practices? Headache. 2011 Jul-Aug;51(7):1051-4.

Dr. Bonakdar MD, FAAFP, is the Director of Pain Management at the Scripps Center for Integrative Medicine and a member of the Scripps Green Hospital Physician Wellness Committees. He also serves as Assistant Clinical Professor at the University of California, San Diego, School of Medicine.

He is President of the American Academy of Pain Management.

The Clinicia nâ&#x20AC;&#x2122;s Perspec t i v e on REMS

headache management

Post-Traumatic Headache: Knowledge Update

By Nathan D. Z asler , MD, a nd Sara E t heredge, DP T

H

eadache and neck pain are the most common physical complaints following concussive brain injury and are experienced early after injury by up to 70% of patients (1-4). Headache also occurs after more severe brain injury; however, it tends to be less common in this group of patients (3,5,6). This may suggest that the traumatic brain injury (TBI) itself is probably not the primary cause of the headache because one would expect more headache problems with more severe TBI(4). Headache is also a common problem after cranial trauma, as well as after spinal acceleration/deceleration (i.e., whiplash) injuries (3,7,8). Headache is a hallmark co-morbidity associated with sports trauma and has been designated sports concussion headache (SCH) (4). Postconcussive headaches do not necessarily occur due to the concussion itself but often are the result of head impact injury and/or cervical whiplash-type injuries. The terms post-traumatic headache (PTHA) and SCH do not convey any real information of value regarding the specific headache etiology or underlying headache diagnosis, nor do they guide treatment of the headache disorder (3,9). Use of such general terms may, therefore, cause practitioners and others to misattribute the headache disorder to traumatic brain injury when in fact its cause may be extra-cerebral as

Headache is a hallmark co-morbidity associated with sports trauma and has been designated sports concussion headache.

in the case of impact injury pain, post-traumatic neuralgic or neuritic pain, and/or cervicogenic headache, temporomandibular joint dysfunction, among other possibilities, (2,4,10) or unknown as with tension headache.

The experienced clinician should be able to determine the underlying cause for the PTHA by taking the appropriate time to acquire an adequate pre-injury, injury, and post-injury history, as well as by conducting a careful physical evaluation (including all relevant head, jaw, neck, and upper thoracic structures) and ordering appropriate diagnostic testing (2,4,8). Treatment should be instituted in a holistic manner as early as possible as pain, particularly when chronic, can have numerous negative consequences including depression, anxiety, dyssomnia, and cognitive impairment. The clinician should strive to maximize the benefit/risk ratio of any particular intervention, prescribe treatment that can be optimally complied with, and educate the patient and family about the condition, its treatment, and its prognosis.

Late onset headaches (i.e., greater than six months post-trauma) should cue the treating clinician to think of less common injury-related conditions such as seizures or non-injury related causes such as a space-occupying lesion (i.e., brain tumor, colloid cyst) (3).

Although still debated, the most frequent cause of PTHA in our experience is cervicogenic headache, which may have several etiologies (11). Referred cervical myofascial pain as a consequence of cervical whiplash is a particularly common cause. Activated trigger points in the suboccipital musculature, sternocleidomastoid, and/ or upper trapezius muscles are common sources of THE PA IN PRACTITIONE R

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Figure 1.

Referred myofascial pain patterns from activated trigger points in the cervical and shoulder girdle musculature.

Reprinted and modified with permission from Zasler, ND, Katz, DI, Zafonte, RD (eds): Brain Injury Medicine: Principles and Practice, Second Edition, Demos Medical Publishing, 2013.

Sternocleidomastoid

Upper Trapzius

Multifidi

Table 1.

PTHA Headache Historical Points Timing of headache onset Pattern of progression of pain over time Treatments that have either helped headache pain or made it worse Frequency of pain Severity of pain, typically rated using some type of pain scale (e.g., pain faces)

referred pain into the head in patients post-whipash (2-4) (see Figure 1). Cervical ligamentous laxity and associated instability may be a cause of both neck pain and headache (12). Facet dysfunction, especially in the upper cervical spine, is another pain generator of cervicogenic headaches. The C2/3 segment refers into the occiput region and is more commonly involved following a whiplash injury (13,14). A recent treatise by Rana details management of cervicogenic headache (15).

Etiology

Genetic loading risk factors for PTHA/PCH such as migraine

Headache typically results from six major physiologic phenomena, including displacement of intracranial structures, inflammation, ischemia and/or metabolic changes, myodystonia, meningeal irritation, and increased or decreased intracranial pressure. Neuralgic and neuritic pain generators associated with surgical trauma, direct scalp contusional injury, and craniocervical acceleration/deceleration forces are often overlooked. Cervicogenic, tension, neuralgic and migraine headaches make up the majority of the causes of PTHA.

Corroboration of patient accounts of the accident, symptom evolution, and functional consequences

Examination of the patient with PTHA

â&#x20AC;&#x153;COLDERâ&#x20AC;? mnemonic: Character of pain, Onset, Location, Duration, Exacerbation, and Relief Effect of pain on ability to perform work and non-work related activities Headache of any kind pre-dating the injury and, if so, alteration in any way post-injury Potential pain generators based on the injury history including mechanics (if known)

Reprinted and modified with permission from Zasler ND: Sports concussion headache: A Review. Brain Injury. 2014. Oct 7:1-14.

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Splenius Capitis and Cervicis

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The examination should start with a thorough history of the patient relative to his or her PTHA complaint (see Table 1). The hands-on physical exam, which is often ignored in PTHA assessment, should take central and peripheral neuro-

Pos t-Traumatic He adache

logical clinical findings into consideration, as well as musculoskeletal findings (2-4). The neurological evaluation should include examination of all 12 cranial nerves, the ocular fundus to rule out papilledema, deep tendon reflexes including pathological reflexes, sensory system with confrontation visual field testing, motor systems, and cerebellar function, which should also encompass assessment of postural stability (4,16). Appropriate cognitive screening should be performed if brain impairment is suspected secondary to trauma.

Peripheral examination should include assessment of the face, temporomandibular joints, head, and craniocervical junction, mainly focused on assessment for neuralgic and/or neuritic headache pain generators (2-4).

The musculoskeletal evaluation of the patient with PTHA should emphasize function and involves inspection for body asymmetries (such as head tilt, shoulder droop, tilted pelvis, leg length discrepancy, torticollis, or asymmetric gait), postural irregularities including forward head posture, rounded shoulders, abnormal stance or pelvic alignment, as well as assessment for cervical and lumbar lordosis. Jaw range of motion and tracking, as well as spinal range of motion, particularly cervicothoracic, should be assessed in any patient with PTHA. Auscultation for bruits should be done as appropriate

The physical exam should take central and peripheral neurological clinical findings into consideration, as well as musculoskeletal findings. over the carotid arteries, closed eyes, temporal arteries, and mastoids. The temporomandibular joints should also be auscultated, as clinically indicated, for abnormal articular sounds. A palpatory exam of the face, head (including TMJ and masticatory muscles), shoulder girdles, and neck should be done in a controlled, layer-by-layer fashion to truly localize pathology with an eye to identifying focal tender points, positive Tinel’s signs over activated nerve fibers (i.e., supra-orbital or greater occipital nerves), activated trigger points and referred pain patterns (3,4,16) (see figure 1). The neck exam should also include, at a minimum, facet provocative maneuvers, assessment of vertebral somatic dysfunction, as well as testing for alar and transverse ligament integrity (2-4,12).

Treatment of PTHA

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post-traumatic headache in children or adults. Generally, pain medications not specific for the particular headache subtype should be avoided, particularly opioids and barbiturates. These agents may cause a variety of long-term adverse effects, including medication overuse headache, cognitive and endocrine side-effects, functional impairment, and addiction (3,17). Appropriate use of pharmacotherapy along with physical and psychological/behavioral interventions appears to provide optimal outcomes (2-4,16,17).

Conservative treatment options can be especially useful for managing post-traumatic headaches, particularly with those headaches that have a cervicogenic origin. Potential treatments include physical therapy, dry needling, trigger point injections, modalities such as ice, heat, and electrical stimulation, and manipulative therapy (3,16,18,19). Interventional pain management may be indicated in unresponsive facet mediated pain, neuritic and neuralgic pain, and in situations where there is clinically significant ligamentous laxity (2,3).

Based on available studies, headache tends to improve in the months following trauma, whether to the brain, head, or neck. PTHA is a prevalent symptom in the first year after traumatic brain injury regardless of injury severity (20,21).

When properly diagnosed and treated, most PTHA can be cured or substantively modulated (particularly when addressed earlier than later). Most PTHA will not likely be disabling over the long term and work disability due to PTHA is very uncommon in the hands of the sophisticated practitioner unless there are secondary gain incentives.

Conclusions

PTHA is ultimately a symptom and not a diagnosis. This complex disorder has multiple potential causes (22) and, as a result, there are multiple ways to address the pain associated with the underlying pain generators (2-4,17,23).

Assessing and treating PTHA requires adequate time commitment and knowledge by the treating clinician. The challenge is finding clinicians who understand the disorder and have experience in holistic assessment and treatment of post-trauma patients including those with TBI, cranial trauma, and whiplash injuries.

This article was shortened for publication purposes.

The full article will be available on the Academy’s online learning system for CME credit later this year.

References 1. Lucas S, Hoffman JM, Bell KR, Dikmen S. A prospective study of prevalence and characterization of headache following mild traumatic brain injury. Cephalalgia.

2014;34(2):93-102.

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2. Zasler ND, Martelli MF, Jordan B. Post-concussive headache. In: Textbook of Concussion and Traumatic Encephalopathy. Cambridge University Press; In Press.

3. Horn LJ, Siebert B, Patel N, Zasler ND. Post-traumatic headache. In: Zasler ND, Katz D, Zafonte RD, eds. Brain Injury Medicine : Principles and Practice. 2nd ed.

New York, NY: Demos Medical Publishing, LLC; 2013:932-953.

4. Zasler ND. Sports concussion headache. Brain Inj. 2015;29(2):207-220.

5. Dobscha SK, Clark ME, Morasco BJ, Freeman M, Campbell R, Helfand M. Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury. Pain Med. 2009;10(7):1200-1217.

6. Walker RL, Clark ME, Nampiaparampil DE, et al. The hazards of war: blast injury headache. J Pain. 2010;11(4):297-302.

7. Zasler ND. Confounding factors in PCD: the role of persistent pain, mood disorder, medication use and litigation in symptom persistence. In: Zollman FS, ed. Manual of Traumatic Brain Injury Management. 1st ed. New York, NY: Demos Medical Publishing; 2011.

8. Russo A, D’Onofrio F, Conte F, Petretta V, Tedeschi G, Tessitore A. Post-traumatic headaches: a clinical overview. Neurol Sci. 2014;35 Suppl 1:153-156.

9. Zasler ND: Post-traumatic headache, caveats and controversies. J Head Trauma Rehabil. 1999;14(1):1-8.

10. Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator.

Headache. 2010;50(4):699-705.

11. Packard RC. The relationship of neck injury and post-traumatic headache. Curr Pain Headache Rep. 2002;6(4):301-307.

12. Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthop J. 2014;8:326-345.

13. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine. 1995;20(1):20-25; discussion 26.

14. Aprill C, Mb ADB, Mb NBB. Cervical zygapophyseal joint pain patterns II: a clinical evaluation. Spine. 1990;15(6):458-461.

15. Rana MV. Managing and treating headache of cervicogenic origin. Med Clin North Am. 2013;97(2):267-280.

16. Zasler N, Martelli MF, Nicholson K, Horn LJ. Post-traumatic pain disorders: medical assessment and management. In: Zasler ND, Katz DI, Zafonte RD, eds. Brain Injury Medicine : Principles and Practice. 2nd ed. New York, NY: Demos Medical Publishing, LLC; 2013:954-973.

17. Zasler ND. Pharmacotherapy and post-traumatic cephalalgia. J Head Trauma Rehabil. 2011;26(5):397-399.

18. Racicki S, Gerwin S, Diclaudio S, Reinmann S, Donaldson M. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. J Man Manip Ther. 2013;21(2):113-124.

19. Liu L, Huang Q-M, Liu Q-G, et al. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015. doi:10.1016/j.apmr.2014.12.015.

20. Hoffman JM, Lucas S, Dikmen S, et al. Natural history of headache after traumatic brain injury. J Neurotrauma. 2011;28(9):1719-1725.

21. Packard RC, Ham LP. Posttraumatic headache: determining chronicity. Headache.

1993;33(3):133-134.

22. Riechers RG, Walker MF, Ruff RL. Post-traumatic headaches. Handb Clin Neurol.

2015; 128:567-578.

23. Watanabe TK, Bell KR, Walker WC, Schomer K. Systematic review of interventions for post-traumatic headache. PM&R. 2012;4:129-140.

Nathan Zasler, MD, FAAPM&R, FAADEP, DAAPM, is CEO and Medical Director for Con-

cussion Care Centre of Virginia, Ltd., and CEO and Medical Director for Tree of Life Services, Inc., Richmond, Virginia. He is an affiliate Professor at the Virginia Commonwealth University Department of Physical Medicine and Rehabilitation, Richmond, and an adjunct Associate Professor in the Department of Physical Medicine and Rehabilitation at the University of Virginia, Charlottesville.

Sara Etheredge, DPT, earned her doctor of

physical therapy degree from Virginia Commonwealth University. She is a Certified Kinesiotape Practitioner, a Certified Myofascial Trigger Point Therapist, and specializes in treating patients with post-traumatic headaches of all etiologies including cervicogenic.

headache management

Medication Overuse Headache: Just Following Doctors’ Orders?

By Michael Re ady, MD

M

igraine is a hypersensitive, hypervigilant nervous system that is poorly tolerant of change. Most individuals with migraine have infrequent disabling headaches; however, an important subset are those individuals who have disabling headaches more days than not. Their headaches have transformed to chronic migraine, a disabling condition that affects up to 3 million of the 37 million migraine sufferers in the United States.

Several risk factors have been associated with migraine progression, including frequency of headache attacks; the presence of mood disorders, obesity, and snoring; and the overuse of acute analgesic medications. Of these risk factors medication overuse is the most common (1) and potentially least understood. However, it is important to remember that medication overuse is only one risk factor. If other risk factors are not addressed a successful resolution of medication overuse may not lead to a return to baseline headache frequency.

Previously known as rebound headache, medication overuse headache (MOH) results from the frequent use of acute analgesic medications. Often patients are taking medications as needed—just as the doctor ordered. The use of “rebound” often confuses individuals as they usually associate rebound with the return of an acute headache instead of what is actually occurring, that is, increased frequency of subsequent headaches.

The International Classification of Headache Disorders (ICHD-3 beta) defines MOH as a new type of headache or a marked worsening of a patient’s pre-existing primary headache in someone who overuses medication. This classification now defines overuse by the medication used.

Previous criteria specified that the MOH headache must resolve after the offending medication is withdrawn. This is no longer a requirement. By ICHD criteria MOH may develop with just three months of overuse. However, clinical experience demonstrates that MOH frequently takes

Medication overuse headache is a new type of headache or a marked worsening of a pre-existing primary headache in someone who overuses medication.

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months or years to develop. If an individual’s baseline headache worsens over a three-month period and during this time they are overusing acute medications, it is imperative that secondary headache or the disease of addiction be ruled out.

Patients do not intuitively understand MOH. After all, they are only taking medication when they need it or, better yet, as the doctor ordered (2). Patients do not see their use as overuse but rather as essential to relieve suffering and improve function (3). The different perspective drives home the need for patient education on what “overuse” means. We may explain MOH as an unfortunate but predictable consequence in individuals who are seeking relief from a disabling headache all the while believing that they are doing the right thing.

Diagnosis

The differential diagnosis for MOH should include chronic migraine, new daily persistent headache, hemicrania continua, high- or low-pressure headache, and secondary headache.

Three factors are required for a diagnosis of MOH: a history of migraine, an elevated baseline frequency, and overuse of acute medication(s) (4). Clinical risk factors for the development of medication overuse include the number of headache days, the average days of monthly medication use, the number of years of medication use, the baseline headache frequency at the start of the year, the number of physicians consulted, and the number of different medications used. Patients may also be at risk because of the adverse events of the medications they are overusing. Medication overuse also blunts the effectiveness of headache prophylaxis with few interventions having demonstrable benefits in the presence of MOH (4).

The incidence of MOH in the primary care setting is estimated to be 21% (5). It is the most common secondary headache seen in clinical practice, representing almost 70% of the patients seen in a tertiary headache clinic (4). Similar to the disease of addiction, MOH may best be understood as a chronic, relapsing, remitting disorder with many distinct influences. MOH can also be seen in children, who may be at higher risk because of their age (6).

Pathophysiology

Central sensitization may be a pathway for the development of MOH, or it may represent a final common pathway where combined influences lead to migraine progression.

Frequent and undertreated pain also contributes to central sensitization (7,8). Over time, the continued pain state 24

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lowers the central nociceptive threshold for activation, thereby increasing sensory receptive fields and resulting in progression to chronic migraine. Central sensitization has been shown to change the structure and function of the trigeminal nucleus caudalis. These changes decrease platelet serotonin and increase 5-H2A excitatory receptors (9).

Medication overuse increases cerebral cortex and trigeminal neuronal excitability. This hyperexcitability makes the migraine brain more susceptible to cortical spreading depression, thereby facilitating central and peripheral sensitization through the trigeminal system (10). The repetitive activation of hypersensitive neurons of the trigeminovascular pathway produces changes in form and function in wide dynamic nociceptive neurons in the nucleus caudalis, resulting in a reduced firing threshold, expansion of receptive fields, and the clinical correlates of cutaneous allodynia (10).

Allodynia, or central sensitization, is a risk factor for migraine progression. It may be induced by opioids (11), triptans (12), or increased headache frequency (13). It impairs descending pain modulation from the brainstem rostral ventral medial medulla, limiting individuals’ ability to tolerate nociceptive input (14). It is believed that continuous trigeminovascular neuronal activation in turn activates descending modulating pain pathways, culminating in functional impairment by free radical-induced neuronal cell damage in the periaqueductal gray (PAG), and ultimately damaging the migraine generator. MRI imaging demonstrating iron deposition in the PAG is consistent with this hypothesis (15-17).

A Substance Abuse Disorder?

Addictive disorders are greatly underestimated by both clinicians and patients. As headaches progress, individuals view their increasing medication use as an appropriate response to the increasing headaches. They rarely appreciate that increasing pain is often a sign of analgesic withdrawal.

Clinicians should examine patients’ use of other habituating substances, as the likelihood of medication overuse is increased by prior occurrences of substance abuse. In my experience, a large percentage of MOH patients meet the DSM-IV substance abuse criteria.

Psychiatric comorbidities are more prevalent in MOH patients and generally precede MOH development. These include bipolar disorder, personality disorder, anxiety, depression, and obsessional drug taking-related behaviors (18). Individuals who overuse opioids and butalbital-containing medications are more likely to have comorbid psychopathology. However, individuals who overuse triptans appear to have fewer psychiatric

Medication Ov eruse He adache

and substance abuse disorders (19,20).

As medication overuse induces migraine progression, the clinical presentation of the headache and related comorbidities frequently changes. Sleep becomes non-restorative, and psychiatric comorbidities worsen. Often, neck pain increases and autonomic signs such as vasomotor instability occur. The headache may develop a circadian rhythm, often awakening individuals in the early morning as the medication wears off (21).

Patients’ perspectives about their headache and medication use will likely influence MOH progression. In one study, patients who viewed their medications as indispensable and believed that their lives would be unbearable without them focused more on their pain and less on the amount of medications used (22). They also had difficulty accepting a primary headache diagnosis and were skeptical of the use of daily prophylactic medications. They approached their daily acute medication with resignation, failing to see the irony in using daily acute analgesics while rejecting established prophylactic medication.

Treatment

Successful treatment of MOH employs the same modalities that are used for successful migraine management: a collabor-

Table 1. Educational Points to be Addressed in MOH • Overusing acute medication increases the amount of headaches in an individual and over time renders the acute medicine less effective for an acute migraine.

• Migraine can progress with infrequent use of acute medications.

• Headache frequency will often escalate before it improves.

• Improvement may take weeks to months. Terminating medication overuse does not mean the patient will have no migraines—the goal is a return to the baseline level of migraine frequency.

ative model of care that recognizes the presence of two headache experts (the provider and the patient), an understanding of the condition (migraine and MOH), and knowledge about how to use the various treatments.

Reasonable treatment goals include decreasing the frequency and intensity of the headaches and increasing the response to acute medications. This requires treating not only any medication overuse but addressing other significant factors that are contributing to the increased headache frequency, such as mood disorders, sleep disorders, and obesity. The basis of any successful migraine treatment strategy is education; this is especially true in treating medication overuse (see Table 1). An individual with transforming or

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chronic migraine will need to understand that the over utilization of acute medications (a passive coping skill) is part of the problem and not part of the solution. Without this knowledge individuals are not likely to endure pain when relief is perceived to be at arm’s length.

Failure to adequately educate a patient will often lead to disagreements regarding acute medication limits. Patients suffering from medication overuse headache may use acute medications, but they should not be given medications suspected of transforming the migraines or medications that may induce migraine progression at the prescribed frequency.

A reasonable prescribing limit would be enough medication to treat between 10 and 12 headache days a month. The physician and patient should agree on these limits. These limits may include allowances for interventional treatments or temporary suspension for exceptional cause. The interventions should be considered “rescue treatments” and could include nerve blocks or parenteral medications. Medication limits may be temporarily suspended if agreed upon by the provider and the patient if there is a compelling reason such as a family or work emergency. However patients should understand that if they are unable to control acute analgesic medication usage they are more likely to suffer.

Adequate education allows for the resolution of competing interests. The physician’s interest is most likely centered on winning the war—returning the migraine frequency to a baseline level, and the patient’s interest is most likely focused on winning the battle, or resolving the acute attack. In our migraine war there should be an agreed-upon

strategy that may need to be changed over time. A patient should be prepared so that the challenges encountered are not perceived as negative surprises.

Even if the headaches occur daily it is important to continue a headache diary. Initially, patients may notice a reduction in headache intensity rather than a reduction in the number of headache days. The patient may use the headache diary to record his or her level of functioning during that day, answering such questions as: What were you able to do? How much were you able to exercise? How well did you sleep? How much time did you spend out of bed?

Behavioral techniques directed at headache or pain management are essential for recovery, and their effectiveness increases with regular practice. Behavioral techniques have been shown to improve the effectiveness of both preventive and abortive medications, as well as increase resilience, improve sleep, reduce pain, address catastrophizing, and decrease mood disorders.

Stopping the Medication

If the overused medication is not stopped it is unlikely that the headache frequency will spontaneously improve.

Stopping the offending medication is associated with better outcomes, and prophylactic treatment should be prescribed prior to withdrawal (See Figure 1).

The decision to withdraw medication in an outpatient or inpatient setting depends on the motivation of the patient, the offending medication, and the available resources.

Outpatient withdrawal requires a motivated patient who is acutely aware of the goals of treatment.

Figure 1. Change in Headache Frequency Inpatient withdrawal may be appropriate if Following Medication Withdrawal the individual is on high doses of opioids or butalbital-containing medications. This will Overused Overused Overused added Overused ddrug rug ccontinued on5nued Overused ddrug rug ddiscontinued iscon5nued Overused ddrug rug ddiscontinued iscon5nued pplus lus nnew ew pprevention reven5on ddrug rug added allow for greater monitoring and treatment 18 of withdrawal symptoms. An outpatient 15 infusion center may often substitute for hospital admission.

12 Withdrawal may occur abruptly or as 9 a slow reduction over time. There is no set time frame suggested for a slow wean. If an 6 opioid is the offending medication, it may be transitioned to a long-acting formulation 3 and titrated down over time. If a rapid wean 0 from opioids is desired it is appropriate to -­‐1 0 1 2 3 4 5 6 7 8 9 10 11 12 Weeks discon4nuing overused medication medica4on Weeks aftera1er discontinuing overused treat the symptoms of opioid withdrawal. If Adapted from Mathew NT, Kurman R, Perez F. Drug-induced refractory headache— butalbital is the overused medication, abrupt clinical features and management. Headache. 1990;30:634-638. withdrawal should be approached cautiously Mean wweekly eekly headache index Mean headache index

Headache Frequency following Medica5on Withdrawal

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Medication Ov eruse He adache

References

Table 2. Bridge Therapies (Do not use the offending medication as a part of the bridge.)

Non-steroidal Bridge Therapy

Ergotamines Bridge Therapy

• Naproxen 500 mg twice daily for 7-10 days.

• Dihydroergotamine 1 mg sub Q twice daily for 7-10 days (likely to be most effective).

• Ketorolac 60 mg IM twice daily for 5 days (should use PPI or H2 blocker if using ketorolac).

Steroidal Bridge Therapy • Dexamethasone 4 mg twice daily X 7 days or 4 mg twice daily X 4 days, then 4 mg daily X 4 days, then stop. Dose packs typically are not effective.

• Prednisone taper 60 mg daily for 2 days, then 40 mg daily for 2 days, then 20 mg daily for 3 days, then stop.

• Not advisable to use NSAID in combination with steroids (increased risk of GI side effects). May use steroids first then follow with a bridge NSAID therapy.

Triptan Bridge Therapy • Short acting: sumatriptan 25 mg three times a day for 10 days or until the patient is pain free for 24 hours.

• Dihydroergotamine nasal spray twice to three times daily for 7-10 days (more available than injections but less effective).

• Methylergonovine 0.2 mg 1-2 pills three times a day for up to 14 days.

Bridge Polypharmacy/ Adjunctive Medications • Prochlorperazine 10 mg ± diphenhydramine 25-50 mg 3 times per day.

• Metoclopramide 10 mg ± diphen hydramine 25-50 mg 3 times per day (do not take with prochlorperazine).

• Olanzapine 10-20-mg PO every night at bedtime X 5-7 days. Start dosing with 10 mg, repeating the dose in 1 hour if not sleepy. A 20-mg dose is often needed if there is significant anxiety or insomnia.

• Long acting: naratriptan 2.5 mg twice daily for 1 week.

as seizures may result. Often these patients are transitioned to phenobarbital and then weaned over several days.

In order to address the expected worsening headaches that accompany withdrawal, it is reasonable to prescribe a “bridge therapy.” Bridge therapies include a steroid taper, long-acting triptans, nonsteroidal antiinflammatory medications, or methylergonovine (see Table 2). More aggressive outpatient bridge therapies include parenteral medications either self-administered or given at an infusion center. Occasionally it is appropriate to admit the patient to the hospital for withdrawal.

Finally, it is important to remember that not everyone with high-frequency, acute medication use will develop MOH. In these high-frequency users it is necessary to uncover and address additional perpetuating factors. It is also essential to assess whether or not the headaches have worsened while taking the medication, and it is absolutely important to determine whether or not the individuals are functioning better as a result of the high frequency acute analgesic medication use. Conversely, it shouldn’t be forgotten that many high-frequency users continue to take their medication in the face of worsening headache frequency and decreased function (23). These individuals see their frequent usage as a direct response to their worsening headaches ignoring the medication’s role in their condition. This reinforces the need for sound patient education.

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8. Staud R, Smitherman ML. Peripheral and central sensitization in fibromyalgia: pathogenetic role. Curr Pain Headache Rep. 2002; 6(4):259-266.

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2002;42(6):532-537.

10. Dodick DW, Freitag F. Evidence-based understanding of medication-overuse headache: clinical implications. Headache. 2006;46(suppl 4):S202-S211.

11. Jakubowski M, Levy D, Goor-Aryeh I, Collins B, Bajwa Z, Burstein R. Terminating migraine with allodynia and ongoing central sensitization using parenteral administration of COX1/ COX2 inhibitors. Headache. 2005;45(7):850-861.

12. Burstein R, Collins B, Jakubowski M. Defeating migraine pain with triptans: a race against the development of cutaneous allodynia. Ann Neurol. 2004;55(1):19-26.

13. Bigal ME, Ashina S, Burstein R, et al. Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology. 2008;70(17):1525-1533.

14. Welch KM, Nagesh V, Aurora SK, Gelman N. Periaqueductal gray matter dysfunction in migraine: cause of the burden of illness? Headache. 2001;41(7):629-637.

15. Burstein R, Cutrer MF, Yarnitsky D. The development of cutaneous allodynia during a migraine attack: clinical evidence for the sequential recruitment of spinal and supraspinal nociceptive neurons in migraine. Brain. 2000;123(pt 8):1703-1709.

16. Srikiathachorn A, Maneesri S, Govitrapong P, Kasantikul V. Derangement of serotonin system in migrainous patients with analgesic abuse headache: clues from platelets. Headache. 1998; 38(1):43-49.

17. Srikiatkhachorn A, Tarasbu N, Govitrapong P. Acetaminophen-induced antinociception via central 5-HT(2A) receptors. Neurochem Int. 1999;34(6):491-498.

18. Saper J, Hamel R, Lake AE 3rd. Medication overuse headache (MOH) is a biobehavioural disorder. Cephalalgia. 2005;25(7):545-546.

19. Lake AE 3rd. Placebo, chronic daily headache, and pain: ten points to ponder.

Curr Pain Headache Rep. 2006;10(1):4-6.

20. Pozo-Rosich P, Oshinsky M. Effects of dihydroergotamine (DHE) on central sensitization of neurons in the trigeminal nucleus caudalis. Program and abstracts of the American Academy of Neurology 57th Annual Meeting; April 9-16, 2005; Miami Beach, Florida. Abstract S19.003.

21. Tepper SJ, Tepper DE. Medication overuse headache in refractory migraine and its treatment. In: Schulman EA, Levin M, Lake AE III, Loder E, eds. Refractory Migraine: Mechanisms and Management. New York, NY: Oxford; 2010:136-159.

22. Fumal A, Laureys S, Di Clemente L, et al. Orbitofrontal cortex involvement in chronic analgesic overuse headache evolving from episodic migraine. Brain.

2006;129(Pt 2):543-550.

23. Saper JR, Lake AE 3rd. Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines. Headache. 2008;48(6):838-849.

Duren Michael Ready, MD, FAHS, ADAAPM, is a graduate of

the Texas Tech College of Medicine. He completed his family medicine residency at Brazos Family Medicine.

He is the director of the Headache Clinic at Baylor Scott & White in Temple, Texas. He is board certified in family medicine, certified in headache medicine by the United Council of Neurological Subspecialities, a fellow in the American Headache Society, and an Advanced Diplomate in the American Academy of Pain Management. Dr. Ready was also the recipient of the 2014 National Headache Foundation Lectureship Award.

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Case Study headache management

A Patient with Headache Project ECHO® Chronic Pain and Headache Management TeleECHO™ Clinic Case Study Edited by Brian M. Shelley, MD, on behalf of the ECHO Pain Team

Project ECHO (Extension for Community Healthcare Outcomes) was developed by the University of New Mexico Health Sciences Center (UNMHSC) to treat chronic and complex conditions in rural and underserved areas of New Mexico.

This case-based distance learning model teaches physicians and advanced practice providers, such as nurse practitioners and physician assistants, pharmacists, clinicians, and others about chronic pain issues. Throughout the state, providers in solo practice are working with very little access to specialty care referrals. Through Project ECHO’s Chronic Pain and Headache Management TeleECHO Clinic (ECHO Pain) providers learn how to care for patients in their own community, without the patient having to travel five or six hours for a consultation. This telementor and educational program also reduces the need of a patient needing a chronic pain consultation and having to wait three months to be seen. The physician, nurse practitioner, physician assistant, or other practitioners can join the teleECHO clinic every week to get a consultation.

Unlike a telemedicine program, the ECHO team does not see the patient on the other side of the video or the television. They see the providers, who earn continuing medical education credit for every hour they participate. Providers sign up with the program and they participate using either video or audio connection. The program includes a 30-minute didactic presentation by an invited faculty member and then a review of cases submitted by the participants to the ECHO Pain team (patients are de-identified for HIPAA compliance). Providers get their consultation from a virtual interdisciplinary team, which makes formal treatment recommendations. Thus, the pain clinic combines actual patient case studies with didactic learning on pain management topics.

The case presentation below, presented by Deb Newman, PA-C, exemplifies how the entire network—community clinicians and specialists—contribute to a case.

Deb Newman PA-C: Ms. H (name has been changed for confidentiality) is a 72-year-old woman with chronic headaches that started two-and-a-half years ago, six months before returning to work as an attorney. This was a stressful period in her life. The headaches are unilateral, left-sided, and appear every four to five days. There is no associated aura, photophobia, phonophobia, nausea, or vomiting. The pain comes with lying prone and other positional changes. The headaches extend from the left parietal area to the base of neck.

She had a fall in 1992 where she hit the back of her head but had no loss of consciousness. She had a similar episode in 2007. She has been seen by a neurologist and treated

28

with medications. She is not a candidate for topiramate because she does not want to feel “loopy.” Her eye exams have been normal.

Her current medications include levothyroxine 0.10 mg qd, losartan 25 mg qd, oxycodone (immediate release) 5 mg qd, duloxetine 60 mg qd, calcitonin, pantoprazole, acetaminophen as needed, and a topical analgesic compound. In the past she has tried using NSAIDs, steroids, and lamotrigine without success. She had also tried acupuncture, chiropractic, massage, physical therapy, and exercise without any lasting relief. Injections and mouth devices for TMJ were no help. She had left cervical facet injections but had a worse headache five days later, and an occipital nerve block provided no relief.

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Currently, Ms. H exercises regularly. She reports fatigue from disturbed sleep because of the pain, which is the most frustrating aspect for her. She does not use tobacco or other substances. Her past medical history includes hypertension, hypothyroidism, back pain, diverticulitis, temporomandibular joint pain, depression, osteoporosis, seasonal allergies, heart murmur, and a gastric ulcer.

She had a GI bleed from NSAIDs. Her past surgical history includes pancreatic abscess drainage, ventral hernia, total knee arthroplasty, dilatation and curettage, and an appendectomy.

On exam she has a lot of tenderness in her posterior neck muscles, the splenii, which are lateral to the paraspinals. Cervical spine range of motion was significantly reduced in all planes, especially in extension and lateral rotation. Reflexes, gait, sensation, and strength were all normal. She had no tenderness over the greater occipital nerve area.

Ms. H has had extensive imaging studies. Plain films of the neck showed multilevel degenerative changes at the discs and facets, with a 4 mm anterolisthesis of C6 on C7 resulting in some neural foraminal narrowing. This was stable with flexion and extension. An MRI of the brain showed a small meningioma, with no mass effect. MRI of the temporomandibular joint documented that the discs were in normal position with opening and closing of the jaw, mild synovitis, and mild condyle irregularities on the left.

Matthew Rafferty MD, pain physician in St. Cloud, Minnesota: Has she had an MRI of the cervical spine?

Ms. Newman: She had an MRI of the cervical spine, which showed multilevel facet arthropathy with a disc-osteophyte complex at just about every level, with moderate bilateral neural foraminal narrowing at C6-7, but no spinal stenosis and no nerve root impingement.

Edward Figueroa, MD, internist at UNM: Has she experienced any trismus, that is, spasm of masseter muscles?

Ms. Newman: I don’t know. But two different oral devices did not help her.

Mark Hunter, MSW, social worker at a pain clinic in Thunder Bay, Ontario: How much sleep is she getting?

Case Study

Through Project ECHO’s ... clinic, providers learn how to care for patients in their own community, without the patient having to travel five or six hours for a consultation.

Ms. Newman: She is not getting enough sleep, due to the pain. She uses the oxycodone at night as a preventive agent for pain, rather than as a hypnotic.

Lisa Quintero, PA-C, primary care provider in Farmington, New Mexico: Is she using any dietary supplements?

Ms. Newman: Not that I know of.

Christine Zampach, DPT, at the UNM Pain Center: What is her posture like?

Ms. Newman: She exercises regularly, and does Pilates. She is very aware of her posture. She thinks stress is more of a factor in her headaches. She was very anxious about restarting her law practice at age 70. She keeps her neck healthy and is very frustrated.

Amy Johnson, MD, psychiatrist in Santa Fe, New Mexico: Would she consider leaving her job?

Ms. Newman: No, she loves her job now.

Daniel Duhigg, MD, addiction psychiatry, affiliated faculty at ECHO Pain, session moderator: How is her mood? Is she depressed or anxious?

Ms. Newman: She has had depression in the past, but she denies current depressive symptoms.

Brian Shelley, MD, family medicine and myofascial pain expert, affiliated faculty at ECHO Pain: Has she had any blood work, especially ESR and CRP? Ms. Newman: I don’t know, but I am trying to get records from her primary care provider.

Dr. Duhigg: Thanks for all of the excellent clarifying questions. Let’s move into diagnosis. Deb, what is your working headache diagnosis?

Ms. Newman: My diagnosis is untreated TMJ contributing to headache. She also has neck problems, which may contribute. I am concerned about the possible role of the meningioma. But I am mostly concerned about her stress and have recommended mindfulness meditation to her. I have also recommended a gluten-free diet.

Dr. Duhigg: So the differential diagnosis includes temporo-

mandibular joint dysfunction, stress-related/tension headache, and/or cervicogenic headache.

However, it does not sound as if she has migraine or an ominous type of headache.

Let’s discuss some non-pharmacological approaches first. I would like to suggest she start keeping a headache diary to look for patterns.

George Comerci, MD, internal medicine, affiliated faculty at ECHO Pain: There is some literature on the use of alphastimulation, although many of those studies were proprietary. My understanding is that it is like a TENS unit for headaches. It is widely used in the Department of Defense.

Dwayne Luck, DC, chiropractor at Madigan Army Base Pain Center, Tacoma, Washington: Alpha-stim is usually 5-100 Hz applied to the earlobes, originally used for anxiety, depression, and sleep. A recent fMRI study showed decreased brain activity in pain centers, but those participants did not have chronic pain. At our center, we have used it with pain patients who also have anxiety and depression, or complex regional pain syndrome, and some have loved it. It helps them with sleep and it is relaxing, especially when paired with slow breathing and biofeedback. But we have not used it in patients with headache, and I have not seen research for it in headache patients.

Dr. Johnson: Swimming might be helpful. She should stop her job too, at least to see if she feels better when she does.

Dr. Shelley: There is a gifted mindfulness instructor in your town, and I will send you his information. I would also want to examine Ms. H’s sternocleidomastoid, masseter, and temporalis muscles. Her neck certainly has potential pain generators, but these are probably decades-old, so I agree that stress is probably the main problem here.

Dr. Duhigg: Let’s talk about pharmacological therapies now.

Has she used COX-II inhibitors, given her history of a GI bleed from NSAIDs? Ms. Newman: No, she is really afraid. She needed multiple transfusions and feels like she nearly died at that time. She would not try celecoxib.

Dr. Duhigg: It might be worth bringing up again, but her apprehension may be an obstacle. If her EKG

does not show heart block, then a tricyclic antidepressant like imipramine or amitriptyline may be helpful for her.

Ms. Newman: Would her duloxetine be a problem if combined with a TCA? Dr. Duhigg: Great question! Is that being used for pain or depression?

Ms. Newman: Probably both.

Dr. Duhigg: If it is just for pain, then lower doses of TCAs can be used. Let’s discuss interventions. It sounds like she has had several types of injections without relief.

Dr. Figueroa: Is there a role for Botox here?

Dr. Comerci: Another great question! I usually refer folks for Botox if they have a lot of myofascial pain.

Follow-up

Recently, Ms. Newman reported that Ms. H. had improved considerably. In the end, generic Midrin (acetaminophen, dichloralphenazone, and isometheptene) helped her the most. She also reported benefit with the supplement butterbur (Petasites species), which she obtained at a local natural supplement store that carries high-quality brands. She attempted stress reduction although she resisted the idea at first, since she reiterated that she loved her job. She did not enroll in a mindfulness course, although this is available in her town. She tried acupuncture and yoga and said she loved them. Her headaches are now “few and far between” after trying these modalities. She was very grateful to Ms. Newman for her efforts and suggestions.

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headache management

What is Your Headache Telling You? A Traditional Chinese Medicine Approach

By Jennifer Johns ton, PhD, DNM, NMD, MS

M

igraine and severe headaches often cause significant interference with the function and quality of daily life, despite current treatment options. Three-month headache prevalence rates from four major general health surveillance studies range from 16.6% to 22.7% (1). Moreover, individuals reporting migraine are associated with an increased risk for other physical and psychiatric comorbidities. These risks increase as the frequency of headache symptoms increases (1). Current treatment and therapy options for head pain include pharmacological treatment for cluster headache and migraine, occipital nerve stimulation for cluster headache, and botulinum toxin for chronic migraine (2).

In a patient-centered approach, the patientâ&#x20AC;&#x2122;s story is the key to discovering and developing a plan to address the underlying root cause of any type of headache. Where, who, when, why, and how are fundamental questions needed to determine the best approach to unlock a headache.

Dr. John Sarno, a pioneer in the field of rehabilitative medicine and mindbody disorders, described how pain symptoms usually appeared in tandem with other physical complaints, suggesting that they result from a common cause (3). The common root cause of pain is often related to psychological factors, such as stress, sadness, fear, and worry, and awareness that an emotion may be the origin of a headache is enough to reduce and, in some cases stop, the pain (4).

A study designed to investigate the effectiveness of Traditional Chinese Medicine (TCM) treatment for migraine and tension headaches found that TCM treatment produced lasting improvements in the majority of patients treated (5). Dr. Nan Lu, a master in the field of TCM and Wu Ming Qigong, uses the philosophies of TCM to help patients resolve contributing factors that lead to pain. TCM views headache symptoms as a message from the body revealing where imbalances reside in the organ system. The TCM perspective concludes that there are at least 720 underlying causes for headaches, and emotions are often at the root of physical symptoms, including pain (6). Dr. Lu uses patient-centered information to identify the root cause of

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pain symptoms. Important identifying factors include timing, location, frequency, severity, other related symptoms, and any events correlated with the pain (7).

Using patient-centered evaluation can make diagnosis and treatment more successful. Discovering the root cause of the headache can supplement the use of prescribed pain management protocols to provide a powerful formula for pain relief. The first step is to start with the questions where, who, when, why, and how?

Where is the headache located?

Location is a very important concept in TCM philosophy.

TCM uses the body as a map to identify both physical and emotional imbalances. The location of the headache can provide the first clue to successfully reducing headache-related pain. It tells us where there is a lack of flow or congested energy in the head. The area where pain is experienced is related to a specific organ, emotion, and time of day.

For example, pain located on one or both sides of the head is associated with the gallbladder. We often think of this type of headache as a tension headache. The gallbladder is associated with decision-making and the ability to pay attention. Emotions of stress, anger, and frustration are associated with the gallbladder. It is easy to see why these types of headache are so predominant. Long hours at work or at the computer can contribute to their development.

Headaches that originate at the forehead are related to the stomach. These headaches are commonly associated with digestive symptoms and excessive worry or overthinking. Eating on the run, skipping meals, and poor nutrition are factors commonly seen with this headache location.

Taking the time to sit down and enjoy a good meal may be of great help in taming these types of headaches.

The top of the head is related to the liver and kidney.

Headaches that start there need to be correlated with other symptoms or time of day when the headache begins to better evaluate the root cause. Generally, they are related to stress and anxiety. These types of headaches are strongly

WHAT IS YOUR HE ADACHE TELLING YOU?

correlated with high-pressure lifestyles and demanding schedules.

and bladder organs and meridians. Meridians are energy channels that run through the body. TCM identifies 12 major meridians running through the body that connect Who is associated with the headache? to organs and viscera and act as an energy network making An interesting cause of the modern headache is associated valuable energy connections. Lower back and joint pain, with the company we keep. Asking patients key questions insomnia, and tinnitus are often related symptoms. can provide important clues. For example, who is your pain TCM relies on an internal body clock that depicts where in the neck? Do you notice a tension headache when your energy flow changes every two hours (see figure). Different boss comes in the room? Does your frontal headache show times represent different organs. Symptoms beginning or up around the time your relatives are coming to visit? ending during a given time speak to whether the organ is How do we make sense of all the potential “who” causes functioning optimally. For example, a headache that begins so we can develop a treatment plan that will help the pain in the early afternoon may be associated with the heart or symptoms? We can ask patients to watch for signs. What small intestine. Such a headache may give the practitioner is happening when the headache begins or ends? Who is valuable information about cardiovascular and digestive around? Or, maybe more importantly, who are you thinkhealth. This information may aid in prevention or early ing about? detection of future health risks.

Even the time of the week or month that a headache When does the headache occur? starts gives us information. The 9-to-5 headache is a comThe time of day a headache begins and ends tells a lot about mon ailment that many individuals experience. This is the its root cause. Headaches that start in the morning are asso- headache that flows perfectly with the patient’s work schedciated with digestive function. Generally, patients will have ule, beginning on Monday morning and going away on other digestive complaints in addition to the headaches.

Friday afternoon. Many people report that Sunday evening, Mid-afternoon and late afternoon headaches are usually when work planning begins for the new week, is when they related to imbalances, deficiencies, or excesses in the kidney feel the 9-to-5 headache starting.

Many women experience headaches that correlate with their menstrual cycle. Menstrual Headache-Body headaches can appear during ovulation, or Clock Liver before, after, or during the menses and can proGallLung vide valuable information about gynecological bladder 1 AM 3 AM health and daily stress. These types of headaches can be indicators of hormone imbalances 11 PM 5 AM Large and overall gynecological health. In fact, the San Jiao Intestine burden of headache is highest in women ages 18-44 years, where the three-month prevalence 9 PM 7 AM of migraine or severe headache was found to be 26.1% and head pain was the third leading PeriStomach cardium cause of emergency department visits (1).

7 PM

TCM relies on an internal body clock that depicts where energy flow changes every two hours.

9 AM

Spleen

Kidney 5 PM

Bladder

11 AM 3 PM

Small Intestine

1 PM

Heart

Why is the headache occurring?

Symptoms can be valuable information on which areas of the body are not in balance.

Stress is a leading root disturbance in overall wellness. Almost all headaches can somehow be linked to stress. By closely watching the signs and symptoms of the body we can help our patients understand how stress can create imbalances in any body system.

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WHAT IS YOUR HE ADACHE TELLING YOU?

It may be helpful to have patients view their headaches as an opportunity to take a break, close their eyes, and remove themselves from stress, even if the break from stress is brief. All symptoms give valuable information and headaches are a great opportunity discover what your pain is telling you. Helping patients find balance in their daily schedule with plenty of breaks and adding some enjoyment can be of tremendous help in reducing head pain.

How can you prevent or reduce the frequency or intensity of a headache?

In addition to any pharmacological therapy you prescribe, counseling patients on lifestyle changes may go a long way toward ameliorating their headaches. Ask them to listen to what their bodies are communicating and look for messages that their bodies are showing you. These messages can be simple things to help you discover the root cause of a headache.

Putting additional stress on the body’s daily energy reserves can make patients more vulnerable to headache. The body has its daily allotment of energy that is derived from the foods we eat and the quality of our sleep.

Eating fresh seasonal foods is a great first step in reduc-

ing the incidence of headache. According to TCM, eating warm and cooked foods adds more bio-available energy to the system, making the body work less to metabolize and absorb the energy required to get through a long day of time demands.

A good night’s sleep goes a long way. Even if the patient has trouble sleeping it is important to be in a resting state at night. Yes, computer solitaire at 3 a.m. can contribute to the next day’s headache.

Finally, one of the very best ways to reduce headaches is through laughter. This is an easy one. So easy that many might find it difficult. Tell patients to just do something they enjoy or have always wanted to do. Advise them to have some fun, go on an adventure, and smile.

No matter the type of headache, it may be offering you and your patients a valuable message about potential health risks, clues to balancing your daily schedule, or even an aid in getting a break from daily stressors. In an abstract on common headache misdiagnoses the authors report that it is worthwhile for the physician to become the patient on occasion. When a physician takes the role of both doctor and patient proper diagnosis and appropriate treatment methods are more likely made (8).

Patient-centered evaluation can offer greater success in understanding the underlying cause of a patient’s headaches. Using current treatment protocols in conjunction with patient-centered evaluation can be a powerful formula for pain relief. The first step is simple, we start with a question. What is your headache telling you?

References

Find your state’s Policy Page on SPPAN’s new website sppan.aapainmanage.org

1. Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache. 2013;53(3):427-436.

2. Nater B, Dozier C. Drug-resistant headache: is it the end? Rev Med Suisse.

2012;8(339):937-938, 940-941.

3. Sarno J. The Mindbody Prescription – Healing the Body, Healing the Pain. New York, NY; Warner Books Inc. 1998:111-13.

4. Sarno J. The Divided Mind – The Epidemic of Mindbody Disorders. New York, NY; HarperCollins Publishers; 2006: 25-26, 164-65.

5. Melchart D, Hager S, Hager U, Liao J, Weidenhammer W, Linde K. Treatment of patients with chronic headaches in a hospital for traditional Chinese medicine in Germany. A randomised, waiting list controlled trial. Complement Ther Med. 2004;12(2-3):71-78.

6. Nan L, Schaplowsky E. Traditional Chinese Medicine: A women’s guide to a hormone-free menopause. New York, NY; TCM World Foundation; 2010: 178-79.

7. Nan L, Schaplowsky E. A Women’s Guide to Healing from Breast Cancer. New York, NY; TCM World Foundation; 1999: 24, 102-3, 151-52.

8. Ryan RE Jr, Pearlman SH. Common headache misdiagnoses. Prim Care. 2004;31(2):395-405, viii.

Jennifer Johnston, PhD, DNM, NMD, MS,

is a board certified practitioner at Holistic Health Solutions, Inc. with more than 13 years’ experience in naturopathic and Traditional Chinese medicines.

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Who attends?

80%

20%

Prescribers

Other

....................................................................................................................................................

26th Annual Clinical Meeting

....................................................................

2014 Meeting Demographics

55%

MDs and DOs

18% Nurses

7%

Psychologists

6%

Other Disciplines

3%

Pharmacists

3%

Physician Assistants

2%

Chiropractors

2%

Naturopathic Physicians

2%

Acupuncturists

2%

Physical Therapists

Event Location/Dates

#NoLifeLimitedByPain

2015 Facts

1,000

46

Practitioners

Expert Speakers

10

100+

2

Keynotes

Accredited Disciplines

Receptions

3

Experiential Sessions (meditation and movement)

4

Pre-Meeting Sessions

Exhibitors

5

30

Breakout Sessions Industry Supported Symposia Meeting App

....................................................................

Keynote Sessions and Speakers The Future of Pain Management: The Role of Self-Care and Integrative Collaboration with Wayne B. Jonas, MD Comprehensive Pain Management: The Military Medicine Experience with Eric B. Schoomaker, MD, PhD From Contracts to Consent: The Evolution of Opioid Ethics with Cynthia Geppert, MD, MA, MPH, PhD Migraine and Obesity: Epidemiological Lessons and new Directions with B. Lee Peterlin, DO Can Pharmacogenetic Testing Improve the Treatment of Pain? with Anita Gupta, DO, PharmD

September 17-20, 2015 Gaylord National Resort & Convention Center, 201 Waterfront St., National Harbor, MD 20745

For the full agenda and to register, visit www.aapainmanage.org THE PA IN PRACTITIONE R | V O L U M E 2 5 , N U M B E R 2

|

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safe use of opioids

Complications of Chronic Opioid Therapy

By Jeffre y Gudin, MD, and Ada m L aitm an, MD

W

hile much of the focus in the lay press and medical literature has been on abuse, addiction, and accidental deaths with opioids—and justifiably so (see sidebar on opioid-induced respiratory depression)—there are other complications of opioids that should be considered before starting or continuing chronic opioid therapy. When determining whether a patient is a good candidate for long-term opioid therapy, clinicians should prospectively review the potential side effects of opioids with the patient or caregiver, preparing them to preempt, treat, or deal with them effectively. Some of the more common adverse effects of opioids that will be discussed below are constipation, nausea, and vomiting, and endocrine dysfunction, such as hypogonadism/hypotestosteronism.

Opioid-Induced Bowel Dysfunction (OIBD)

Although we speak mostly of constipation, the use of opioids for chronic pain can lead to more generalized, opioid-induced bowel dysfunction (OIBD) characterized by a constellation

Clinicians should prospectively review the potential side effects of opioids with the patient or caregiver.

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of symptoms including hard dry stools, straining, incomplete evacuation, bloating, abdominal distension, and increased gastroesophageal reflux (1). Constipation is one of the most common and bothersome adverse effects of opioids, affecting at least 80% of patients taking them (2). In as many as 30% of patients taking opioids, opioid-induced constipation (OIC) and its accompanying GI symptoms significantly impair patients’ quality of life and may lead to under treatment of pain as patients limit the dose or discontinue opioids altogether (3).

Patients treated with opioids for non-cancer pain commonly endure constipation symptoms that limit their work productivity and overall health-related quality of life while adhering to treatments that provide little relief (4). Research using the Work, Productivity, and Activity Impairment (WPAI) health tool has found higher levels of absenteeism and lower levels of presenteeism, diminished overall work productivity, and impairment in activities for patients with OIC as compared with healthy controls (5).

The gastrointestinal tract is innervated by the enteric nervous system, which comprises the myenteric plexus, involved mostly in motor activity, and the submucosal plexus, involved with secretion and absorption. In the gut, opioid analgesics exert a number of characteristic physiological actions on the enteric nervous system, causing inhibition of peristalsis and secretory activity, increased water absorption from the bowel, and constriction of intestinal sphincters—all contributing to opioidrelated constipation. In contrast to other opioid adverse effects, which are mediated through central opioid receptors and lessen over time, OIC usually persists throughout treatment despite a regimen of stool softeners and laxative agents.

Treatment

Treatment of OIC includes implementation of lifestyle measures such as adequate fluid intake, regular physi-

Complic ations of Chronic Opioid T her ap y

cal activity, and proper toileting hygiene, including making time to defecate when the body senses the urge. High-fiber diets may help primary constipation, but often are avoided with OIC for their potential to worsen fecal impaction. The addition of bulk laxatives, stimulants, osmotic laxatives, and emollients have been the primary rescue modality for patients suffering with OIC, but unfortunately, laxatives do not address underlying mechanisms of OIC and are often partially or not all effective.

A new class of agents known as PAMORAs (peripheral acting mu opioid receptor antagonists) has been approved for the treatment of OIC. These work by preferentially blocking binding at the opioid receptors in the gut, but not in the CNS, thereby decreasing the constipating effects of opioids without affecting opioid-mediated analgesic effects or precipitating withdrawal symptoms. This strategy allows clinicians to block intestinal opioid receptors while allowing central receptors to function as normal.

Methylnaltrexone, the first of these agents, was approved in the United States in 2008 for the treatment of OIC in patients with advanced illness receiving palliative care, when the response to laxative therapy has not been sufficient. It is available as a subcutaneous injection. In 2014 it gained approval for the treatment of OIC for adult patients with chronic non-cancer pain. In 2014 the FDA also approved naloxegol as the first once-daily oral PAMORA for the treatment of OIC in adult patients with chronic, non-cancer pain.

There are a number of related PAMORAs in development. In addition, other classes of laxatives have been approved for use in OIC. Many of these agents are ion channel modulators that promote flow of ions into the bowel lumen, with water and secretions following to facilitate bowel movements. One example is lubiprostone, a chloride channel activator approved in 2013, which increases ion and fluid secretion in the gut lumen, leading to increased peristalsis and quicker passage of stool. Other strategies have focused on the use of low dose antagonists formulated in combination with opioids. One example is the recently approved prolongedrelease formulation of oxycodone and naloxone.

Opioid-Induced Nausea and Vomiting

Nausea from opioids is a rather distressing symptom and occurs both with and without vomiting. It can act as a deterrent to medication compliance, thus impacting opioid efficacy and quality of life. The precise mechanisms of opioidinduced nausea and vomiting are not entirely certain; it is believed that they are the result of a multitude of complex mechanisms including enhanced vestibular sensitivity, direct impact on the chemoreceptor trigger zone resulting in vomiting, and delayed gastric emptying resulting in early satiety and bloating and worsening post-prandial pain. As many

as one-third of non-cancer patients placed on morphine or other oral opioid analgesics experience nausea (6, 7).

Because there are numerous patient-specific responses to, and drug-specific variations in opioids, a selective trial and error approach (e.g., trying different opioid analgesics, opioid rotation) may reveal a particular beneficial opioid that provides for maximal analgesia with minimal nausea/vomiting for an individual patient, whereas a different opioid analgesic may be similarly optimal for another patient (8). Opioidinduced nausea can be mitigated or preempted by a variety of treatments. Multiple receptors may play a role in modulating nausea/vomiting, and clinicians make use of various antiemetics that act on these receptors (Table 1) (8).

Table 1.

Receptors Involved in Opioid-induced Nausea and Vomiting and Their Antagonists Emetogenic receptor

Antiemetic that antagonizes receptor

Dopamine-2 (D2)

Haloperidol (antipsychotic)

Histamine-1 (H1)

Promethazine (antihistamine)

Mu and delta opioid (DOR)

Naloxone (opioid antagonist)

5-Hydroxytryptamine (serotonin; 5-HT3)

Ondansetron, tropisetron, dolasetron, granisetron (serotonin antagonists)

Acetylcholine (ACh)

Scopolamine (anticholinergic)

Neurokinin-1 (NK-1)

Aprepitant (substance P antagonist)

Cannabinoid receptor-1 (CB1)

Dronabinol (cannabinoid)

When an antiemetic is indicated, the initial choice will depend on patient characteristics including concomitant disease states and likelihood of adverse reactions or drug interactions. Agents such as antipsychotics, prokinetic agents, serotonin antagonists, antihistamines, and corticosteroids are used alone or in combination, and as with opioids, patients will often tolerate one antiemetic over another.

There has been interest in development of combination drugs that would address or preempt the nausea related to opioids (9). Currently in Phase 3 clinical development, CL-108 is a novel, fixed-dose, bi-layered tablet containing 12.5 mg of immediate-release promethazine with a modified release formulation of 7.5 mg of hydrocodone and 325 mg of acetaminophen. CL-108 will be indicated as treatment for patients who suffer from moderate to severe acute pain with the potential to significantly reduce or eliminate opioidinduced nausea and vomiting (OINV).

Endocrine Dysfunction

Recent research has shed new light on the negative endocrine effects of long-term opioid use, either for chronic pain syndromes or in illicit drug use. Several studies in humans and in animal subjects have found evidence that opioids induce THE PA IN PRACTITIONE R

| VOLUME 25, NUMBER 2 |

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Complic ations of Chronic Opioid T her ap y

hypogonadism by suppressing the hypothalamic-pituitarygonadal axis (10). Long-term opioid use results in endocrine changes including reduced sexual function, decreased libido, infertility, mood disorders, osteoporosis, and osteopenia.

Both endogenous and exogenous opioids modulate gonadal function primarily by acting on opioid receptors in the hypothalamus (10). The resulting effect of this modulation is a decreased release or a disruption to the normal pulsatility of gonadotropin releasing hormone secretion, causing a reduction of the release of luteinizing hormone and follicle stimulating hormone from the pituitary gland, and of testosterone or estradiol from the gonads. Additionally, other mechanisms have also been hypothesized such as increased sex hormonebinding globulin production, which decreases available free testosterone, resulting in what is referred to as opioid-induced androgen deficiency (OPIAD) (11). Another effect of chronic opioid use that results in testosterone reduction and secretion is an increase in prolactin levels, which results in an inhibition of gonadotropin-releasing hormone secretion.

While there is a progressive decline in testosterone levels through normal aging, chronic opioid use can reduce testosterone levels, particularly in males, regardless of their age.

Symptoms of reduced androgen hormones for men include, but are not limited to, declines in libido, sexual function, spontaneous erections, facial and body hair, sperm count, and bone mineral density. Other effects of reduced androgen levels include breast discomfort, hot flashes, and sweats. A decline

in androgen levels also results in reduced energy, motivation, self-confidence, and sleep.

Although less drastic than in men, women are also at an increased risk of androgen deficiency. With prolonged opioid use, female patients can experience low estrogen and testosterone levels as well. Their side effects include dysmenorrhea, amenorrhea, and depression, as well as the aforementioned decline in bone density, particularly in post-menopausal women.

In addition to a decline in quality of life, these symptoms have been associated with other chronic diseases such as sleep apnea, metabolic syndrome, and osteoporosis. Unfortunately, tests to monitor bone density in patients who are not predetermined to be at risk for osteoporosis are generally not ordered.

While the data of various studies has been small, the prevalence of hypogonadism appears to be high among opioid users, with 75 to 100% of opioid consumers studied with symptoms and/or chemical evidence of hypogonadism (12). Hypogonadism occurs with decreased LH/FSH levels in both males and females as early as one week after starting opioid therapy, with LH levels more affected in males. In fact, testosterone concentrations drop approximately more than 50% within a few hours of taking an opioid, and return to baseline within 24 to 72 hours after withdrawal, depending on the dose used.

Treatment

Clinicians should routinely ask patients about symptoms related to mood, energy, lean muscle mass, and libido and per-

Opioid Emergencies and Take-Home Naloxone

By Eric S . Edwards, MD, PhD Chief Medical Officer and Vice President of Research and Development, Kaleo, Inc. Opioid overdose is somewhat of a misnomer as the term “overdose” implies a patient has taken too much of their opioid. In reality, it is not just an overdose that can lead to morbidity or mortality, but also anything that can change the therapeutic window and underlying toxicity potential of an opioid. Life-threatening opioid-induced respiratory and central nervous system (CNS) depression may occur despite a patient using medications as prescribed due to co-morbid medical conditions (chronic respiratory diseases, hepatic/renal disease [1]) and/or concomitant medications (benzodiazepines [2], macrolide antibiotics [3], etc.), which are often prescribed by other practitioners caring for the patient (4).

In patients who are taking opioids, opioidinduced respiratory depression (OIRD) should be discussed in the context of medication risk, not just in relation to the patient’s behavior or associated potential for abuse. Life-threatening OIRD in chronic pain can be compared to the risk of severe hypoglycemia in diabetes. This portrayal describes naloxone as a “rescue” medication (5), like glucagon is for severe hypoglycemia (6). Since life-threatening OIRD is preceded by decreased consciousness, caregiver administra-

36

tion of naloxone will be required, and, ideally, any conversation on naloxone use as emergency treatment for OIRD should involve a patient’s caregiver(s) and/or family members.

Injectable naloxone remains the standard of care for the emergency treatment of suspected opioid overdose/life-threatening OIRD (7).

Several government organizations, including the Substance Abuse and Mental Health Services Administration (SAMHSA), have recommended considering the co-prescription of naloxone with a patient’s initial opioid prescription. In 2014, SAMHSA updated their Opioid Overdose Prevention Toolkit to recommend considering co-prescribing naloxone (8) for patients taking opioids chronically, including patients on extended-release/long acting preparations. The Toolkit also includes a naloxone auto-injector, which was approved in 2014 and is the only naloxone product that is specifically FDA-approved for use in non-healthcare settings (e.g., the home) by caregivers, family, or friends (9). In pre- and post-approval studies, the auto-injector was successfully used by more than 90% of individuals even without training during a simulated opioid overdose emergency.

| T H E PA I N PR AC TITION ER | S U M M E R 2 0 1 5

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):13151321.

Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med J. 2013;125(4):115-130.

Rollason V, Samer C, Piguet V, Dayer P, Desmeules J. Pharmacogenetics of analgesics: toward the individualization of prescription. Pharmacogenomics.

2008;9(7):905-933.

Nowak L, Nader JA, Stettin G. A Nation in Pain. Express Scripts. December 2014.

Buck ML. Naloxone for the reversal of opioid adverse effects. Pediatr Pharm. 2002;8(8):4-8.

Glucagon PI. http://dailymed.nlm.nih.gov/dailymed/ drugInfo.cfm ?setid=f143db10-e889-41c3-84ed603a0ab02f61. Accessed March 21, 2015.

Dahan A, Aarts L, Smith TW. Incidence, reversal, and prevention of opioid-induced respiratory depression.

Anesthesiology. 2010;112(January):226-238.

Substance Abuse and Mental Health Services Administration, SAMHSA Opioid Overdose Prevention Toolkit.

HHS Publication No. (SMA) 14-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

EVZIO Prescribing Information. kaléo. 2014. http://dailymed.nlm. nih.gov/dailymed/drugInfo. cfm?setid=df501ed0-c0f4-11e3-8a33-0800200c9a66.

Accessed March 21, 2015.

Complic ations of Chronic Opioid T her ap y

Table 2. Hormone Reference Ranges

3. Cherny N, Ripamonti C, Pereira J, et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. J Clin Oncol. 2001;19(9):2542-2554.

Hormone

Adult Men

Adult Women

Testosterone, total, serum (ng/dL)

249-836 (2049 y) 8-48 (20-49 y)

193-740 (>49 y) 3-41 (>49 y)

4. Coyne KS, LoCasale RJ, Datto CJ, Sexton CC, Yeomans K, Tack J. Opioid-induced constipation in patients with chronic noncancer pain in the USA, Canada, Germany, and the UK: descriptive analysis of baseline patient-reported outcomes and retrospective chart review. Clinicoecon Outcomes Res. 2014 May 23;6:269-281.

Estradiol, sensitive, serum (pg/mL)

3-70

9-175 (follicular phase) 107-281 (ovulation phase) 44-196 (luteal phase) 0-91 (with oral contraceptives) 42-289 (postmenopausal, treated) 0-19 (postmenopausal, untreated)

Follicle-stimulating hormone, serum (mIU/mL)

1.5-12.4

Luteinizing hormone, serum (mIU/mL)

1.7-8.6

3.5-12.5 (follicular phase) 4.7-21.5 (ovulation phase) 1.7-7.7 (luteal phase) 25.8-134.8 (postmenopausal) 2.4-12.6 (follicular phase) 14.0-95.6 (ovulation phase) 1.0-11.4 (luteal phase) 7.7-58.5 (postmenopausal)

Laboratory Corporation of America. Test Menu.

form appropriate laboratory analysis in an attempt to uncover potential endocrine dysfunction. Table 2 provides reference ranges for hormones affected by long-term opioid use.

Management options for opioid endocrinopathy include discontinuing opioid therapy, reducing the opioid dose, switching to a different opioid, and testosterone replacement therapy. Formulations include oral (traditional, buccal), topical (transdermal patches, gels), implants, and depot injections.

Preferred formulations are most often selected by patient preference, insurability, or both.

Conclusion

Opioid analgesics represent one of the few classes of medications that appear effective for moderate to severe pain. Used in the proper clinical setting, for the appropriate patient with ongoing monitoring and a “universal precautions” approach to risk, these agents improve the quality of life and overall function for pain patients. As with all medication classes, opioids have a characteristic adverse effect and risk profile. In this article, we discussed briefly some of the most common risks along with treatment recommendations. Guidelines or consensus statements for evaluation and treatment of opioid related side effects are lacking and would be of benefit to the pain management community. Ideally, effective treatment for chronic pain should provide significant pain relief that is sustainable and improves sleep, mood, and function in the majority of cases. Opioid analgesics are not for all pain patients, especially those that develop persistent, intolerable or untreatable adverse effects.

References 1. Brock C, Olesen SS, Olesen AE, Frokjaer JB, Andresen T, Drewes AM. Opioid-induced bowel dysfunction: pathophysiology and management. Drugs.

2012;72(14):1847-1865.

2. Bell TJ, Panchal SJ, Miaskowski C, Bolge SC, Milanova T, Williamson R. The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1). Pain Med. 2009;10(1):35-342.

5. Bell T, Annunziata K, Leslie JB. Opioid-induced constipation negatively impacts pain management, productivity, and health-related quality of life: findings from the National Health and Wellness Survey. J Opioid Manag. 2009 MayJun;5(3):137-144.

6. Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic noncancer pain: systematic review of efficacy and safety. Pain. 2004;112:372-380.

7. Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain: systematic review of randomised trials of oral opioids.

Arthritis Res Ther. 2005;7:R1046-R1051.

8. Smith HS, Smith JM, Seidner P. Opioid-induced nausea and vomiting. Ann Palliat Med. 2012 Jul;1(2):121-129.

9. Charleston Labs. R&D Pipeline. http://charlestonlabs.com/productspipeline/cl-108.

Accessed May 13, 2015.

10. Vuong C, Van Uum SH, O’Dell LE, Lutfy K, Friedman TC. The effects of opioids and opioid analogs on animal and human endocrine systems. Endocr Rev. 2010 Feb;31(1):98-132.

11. Smith HS, Elliott JA. Opioid-induced androgen deficiency (OPIAD). Pain Physician.

2012 Jul;15(3 Suppl):ES145-ES156.

12. Elliott JA, Opper SE, Agarwal S, Fibuch EE. Non-analgesic effects of opioids: opioids and the endocrine system. Curr Pharm Des. 2012;18(37):6070–6078.

Jeffrey A. Gudin, MD, has been the director of pain management and

palliative care at Englewood Hospital and Medical Center, a Mount Sinai University School of Medicine teaching affiliate in New Jersey, for the past 16 years.

Adam Laitman, MD, is a research associate in pain and palliative care at Englewood Hospital and Medical Center in New Jersey, an affiliate of the Icahn School of Medicine at Mount Sinai.

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THE PA IN PRACTITIONE R

| VOLUME 25, NUMBER 2 |

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safe use of opioids

Urine Drug Monitoring: Making the Right Decisions

By Brook e Mueller , PharmD

T

he nuances of ordering, interpreting, and acting on the results of urine drug testing can leave practitioners in a conundrum. By making the right decisions about using urine drug testing as a tool to monitor compliance, providers will be better equipped to take appropriate action for unexpected results.

Since the use of clinical judgment and reliance on risk factors to predict opioid misuse and illicit substance abuse may not capture all non-compliant patients, a good rule of thumb is to make it a policy to monitor all patients on chronic opioid therapy with urine drug testing. The practice of making urine drug monitoring (UDM) a standard of care removes the stigma of drug testing and does not damage the providerpatient relationship (1,2).

Regardless of the frequency deemed appropriate for the individual patient, testing should be performed on a random basis, as a scheduled or routine test may give the patient the opportunity to “prepare” for the test (5).

Ordering the Right Test

There are several things to consider when ordering a test to ensure adequate and accurate results.

Test Technology There are two main types of UDM testing—the screening test and the confirmatory test (Table 1). The screening test is an immunoassay qualitative test designed to separate negative samples from samples that are “presumptively” positive (2-4,6). The screening test can be performed in the provider’s Testing at the Right Time office at the time of specimen collection (point-of-care) or at In general, patients deemed to be at low risk should be tested the lab. While point-of-care (POC) screening tests can proapproximately once yearly. If the patient is deemed medium vide rapid results on multiple drug classes allowing providers or moderate risk, testing should be done twice a year, while to make initial therapeutic decisions during the patient’s office high-risk patients should be tested four times per year or more. visit, POC devices are quite limited in the drug classes for The patient’s risk should be reassessed at least yearly as it can which they can test. Many POC screening tests cannot test change, and patients with results revealing use of an illicit subfor synthetic opioids (e.g., fentanyl, tapentadol) or adjuvants stance should be placed in the “high risk” category (3,4). (e.g., muscle relaxants, non-benzodiazepine sedative hypnotics). Furthermore, immunoassay tests in general are quite susceptible to cross-react with other drugs and produce false-positive TABLE 1. A Comparison of Drug Screens and Drug Tests results. In addition, results falling below cutScreening Test Confirmatory Test (Immunoassay) (GC-MS or LC-MS/MS) off levels will produce false-negative results Point-of-Care (dipstick, reader cup) Lab-based (3,4,6,7).

In-office immunoassay There is debate regarding when to send Lab-based immunoassay screening test results for confirmation. ImLess specific and less sensitive Highly specific and highly sensitive munoassay test results have been reported to Quick results (minutes) Slower results (hours to days) return up to 50% false results, depending on Detects potential presence of drug classes, Measures concentrations of several medicathe drug class (8). Therefore, experts advise some specific medications, illicit substances tions, illicit substances, and metabolites submitting unexpected screening results, False positive results are common False positive results are rare positive or negative, to the lab for confirma(cross-reactivity) (more specific) tion (2-4,6,7).

More false negative False negative results are rare (higher cutoff levels) (more sensitive) The confirmatory test is a quantitative test designed for identification and quanGC-MS = gas chromatography-mass spectrometry LC-MS/MS = liquid chromatography-tandem mass spectrometry tification of specific drug substances. It is 40

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URINE DRUG MONITORING

Figure 1.

Opioid METABOLISM 6-MonoAcetyl Morphine (6-MAM) 100% *not CYP mediated

Codeine

Morphine

5 - 13% CYP2D6

**If codeine:morphine ratio <6, codeine likely NOT sole source

Minor *not CYP mediated **If codeine:hydrocodone ratio <10, codeine is NOT sole source

100% *not CYP mediated

Heroin

Minor ~0.8% (range 0.2-2.2%) * not CYP mediated

*Note: Codeine is a common contaminant of heroin

Hydrododone Primary CYP3A4

Minor (~5%) CYP2D6

Norhydrocodone

Methadone

Fentanyl

Tramadol

Oxycodone

Hydromorphone

CYP3A4, 2B6, 2C19 (minor 2C9, 2D6) CYP3A4

CYP3A4, 2B6

CYP2D6

Primary CYP3A4

Minor CYP2D6

Noroxycodone

Oxymorphone

EDDP

Norfentanyl

Buprenorphine

N-­d esmethyltramadol

Meperidine

O-desmethyltramadol

used to confirm the presence of a given drug, and/or identify drugs that cannot be isolated by screening tests. The confirmatory test is a distinctly different analytical technique that is more specific and more sensitive than the screening test. It is typically performed at the lab utilizing high-performance liquid chromatography, gas chromatography-mass spectrometry (GC-MS), or liquid chromatography-tandem mass spectrometry (LC-MS/MS) (2-4,6,7).

Drug Panels The prescriber must also select the most appropriate drug panels to include for confirmation. Testing for currently prescribed medications determines if the patient is compliant with prescribed therapy. However, it is also imperative to test for non-prescribed drugs and illicit substances to identify the patient’s potential risk of drug interactions, duplication of therapy, and signs of misuse, abuse, or

CYP3A4

Norbuprenorphine

Normeperidine CYP P450; exact enzyme unknown

other aberrant behaviors that could hinder patient care. A thorough panel will cover not only the patient’s prescribed opioids, but will also incorporate any other prescription medications with potential for abuse (e.g., opioids, benzodiazepines, carisoprodol), as well as illicit drugs of abuse, such as cocaine, heroin, and marijuana (9). Recommended panels include alcohol, amphetamines, barbiturates, benzodiazepines, the cocaine metabolite (benzoylecgonine), cannabinoids, opiates (e.g., morphine, codeine and 6-MAM), opioids (e.g., oxycodone, oxymorphone), and synthetic opioids (e.g., fentanyl, methadone, tapentadol, and tramadol) (3,4).

If the patient is also utilizing adjuvant medications to treat pain and/or comorbid conditions, the prescriber may want to include panels to test for compliance with these medications at least once per year. These panels may include benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), THE PA IN PRACTITIONE R

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URINE DRUG MONITORING

serotonin-norepinephrine reuptake inhibitors (SNRIs), non-benzodiazepine sedative hypnotics, muscle relaxants (e.g., carisoprodol), and anticonvulsants (e.g., gabapentin, pregabalin) (10).

Since trends of drug abuse may differ significantly depending on the region where a practice is located and/or the patient’s age, additional panels to test for other illicit drugs may be warranted (e.g., synthetic cannabinoids such as Spice) (3,11-13). In addition, patients that abuse a benzodiazepine may utilize gabapentin in an effort to minimize the withdrawal effects of abstaining from the benzodiazepine prior to a urine drug test (14). However, gabapentin can only be detected in the urine if a gabapentin panel is ordered.

Sample Adulteration Urine sample adulteration is a well-known problem in UDM. Adulteration is the tampering of a urine specimen with the intention of altering the test results. Observing urine collection is not necessarily warranted in the clinical setting; however, there are multiple recommendations to reduce the risk of tampering, including turning off the flow of the sink, adding a bluing agent to the commode, and requiring the patient to empty pockets and/or remove outer garments (3).

However, one of the best ways to test for adulteration or dilution is to determine certain urinary characteristics such as creatinine, pH, and specific gravity, and to detect the presence of oxidants in the urine through specimen validity testing (10).

test produces an unexpected result, the prescriber needs to consider all possible reasons for this outcome, and should consult with the laboratory’s toxicologist and/or clinical pharmacist to clarify results when necessary.

The prescriber should also be aware of the limitations of UDM. As mentioned previously, urine drug screen immunoassays are not as sensitive or specific as confirmatory tests; therefore, immunoassay results alone should not lead to a change in therapy or termination of care (3). It should also be noted that a positive result for a prescribed medication cannot distinguish whether the patient has been taking the drug as directed or used only a portion of the prescribed medication. Moreover, UDM cannot determine the source of the drug (1,3). For instance, if oxymorphone is present, this does not necessarily confirm the patient has been taking their prescribed Opana® and the oxymorphone is not a result of oxycodone metabolism.

Causes of Unexpected Results Since the laboratories base their analysis off the list of current medications submitted as part of the urine sample package, if a medication was inadvertently left off the list by the prescriber, the presence of that medication’s analyte(s) would be deemed inconsistent by the laboratory when it is actually consistent with the patient’s prescription profile (Table 2). However, it may also be due to more dangerous reasons, such as the use of someone else’s medication or the use of leftover medication the patient was instructed to Interpreting Results discontinue. It may also be due to the presence of a minor Once test results are obtained, it is imperative that they be metabolite that the clinician did not realize was a result of interpreted properly and within the entire clinical conthe metabolism of the prescribed parent drug. In addition, text for that patient, including other methods of assessbecause clinical UDM has lower cutoffs than workplace or ing compliance (e.g., pill counts, family and/or caregiver pre-employment testing, a positive result might be secondary interviews, and prescription monitoring data) (3,5). Proper to dietary choices, such as poppy seeds or certain teas (8,10interpretation requires an understanding of opioid (Figure 16). Finally, there are small amounts of some medications 1, page 41) and benzodiazepine drug metabolism, pharma- found as impurities in others and, as a result, a low level of a cokinetics, as well as the limitations of UDM (5). When a non-prescribed medication might be detected in a patient’s urine specimen (6,7). For instance, if a patient is prescribed oxycodone, small amounts of hydrocoTABLE 2. Possible Explanations for Unexpected Results done may be detected in the patient’s urine.

Unexpected Positive Unexpected Negative An unexpected negative result may occur when Parent medication left off list Below cut-off level the substance is actually present, but in amounts Use of medication belonging to others Timing and frequency of dosing that fall below the cutoff level. This can be secondUse of “leftover” medication Ran out early ary to intentional or unintentional dilution of the Metabolite not recognized by provider Individual metabolism urine or the time between the ingestion of the last Dietary Drug-Drug interactions dose and urine collection, or it could be that the Impurity Diversion chosen test was not sensitive enough to detect that 42

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URINE DRUG MONITORING

particular agent (6,7,10). Additionally, if a parent medication is taken as needed, and it has been a few days since the last dose, it may not be detectable in the urine above cutoff since most windows of detection for opioids are one to three days (16). There are also cases in which the patient uses all of the medication very early on after the prescription is dispensed, either due to binging or self-escalation of the dose; thus, they were unable to take any medication in the days leading up to urine collection.

As the field of pharmacogenetics has grown, it is wellknown that individuals metabolize medications differently. In ultrarapid metabolizers, the parent drug may not be found in the urine because it has already been eliminated, while the metabolite may be undetectable in a poor metabolizer. It is also recognized that pharmacokinetic drug-drug interactions can also alter the way medications are metabolized—either causing much quicker metabolism or inhibiting it altogether (2,7).

Yet with every unexpected result, the possibility that the patient diverted the medication by selling, trading, or giving it away to others cannot be overlooked.The patient may have substituted or adulterated the sample in some way in an attempt to hide the presence of an unexpected substance such as a drug of abuse. By hiding the presence of the unexpected substance, they may also have inadvertently hidden the presence of their prescribed medication. One way patients try to ensure a positive result for their prescribed medication is by scraping a small amount of the prescribed medication directly into the urine sample. While this will produce a positive result for the parent medication, the quantity found is usually extremely high and, because the drug has not been metabolized, there are no metabolites present (7).

Conclusion

Taking the Right Action

12. Lum G, Mushlin B. Urine drug testing: approaches to screening and confirmation testing. Lab Med. 2004;6(35):368-373.

Every urine drug test is an opportunity to create dialogue between the patient and prescriber and impact clinical decisions.

When the prescribed medication is missing and the conversation with the patient confirms inappropriate use, tapering the medication or changing the prescription to more closely meet the patient’s needs (e.g., decreasing the frequency or quantity dispensed) should be considered (3,16,17). When a non-prescribed medication, drug of abuse, alcohol, or other “red flag” result is confirmed, the prescriber should consider a controlled taper or stopping prescribed opioids immediately with referral to an addiction specialist or drug treatment program, if necessary (3,4). Test results, the outcome of the patient conversation, and the action plan to address unexpected results should be documented in the medical file (3,10,16).

Urine drug monitoring can be a very useful tool to assess patient compliance by confirming the presence of prescribed medications and detecting the presence of unauthorized substances. However, to optimize the value of testing, providers should ensure appropriate testing is completed, results are accurately interpreted, and action is taken on the results. Follow through on testing can lead to better outcomes for patients and help ensure that clinical decisions are made for the right reasons at the right time.

References 1. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2 – guidance. Pain Physician. 2012;15(3 Suppl):S67-S116.

2. Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain.

Pain Physicians. 2011; 14(2):123-143.

3. Official Disability Guidelines (ODG). Treatment in Workers’ Comp 2013 on the Web. Work Loss Data Institute. www.odg-twc.com Updated April 6, 2015.

Accessed April 8, 2015.

4. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy (2010).

Agency Medical Directors’ Group website. http://www.agencymeddirectors. wa.gov/Files/OpioidGdline.pdf. Updated 2010. Accessed March 12, 2015.

5. Chou R, Fancuillo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.

6.

Pesce A, West C, Egan-City K, Clarke W. Diagnostic accuracy and interpretation of urine drug testing for pain patients: an evidence-based approach.

In: Acree W, ed. Toxicity and Drug Testing. INTECH; 2012:25-43.

7. Pesce A, West C, Egan City K, et al. Interpretation of urine drug testing in pain patients. Pain Med. 2012;13(7):868-885.

8. Manchikanti L, Mall Y, Wargo BW, Fellows B. Comparative evaluation of the accuracy of immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing (UDT) opioids and illicit drugs in chronic pain patients. Pain Physician. 2011;14(2):175-187.

9. Hegmann KT, Weiss MS, Bowden K, et al. ACOEM practice guidelines: opioids for treatment of acute, subacute, chronic, and postoperative pain. J Occup Environ Med. 2014;56(12):e143-159.

10. Webster LR. The role of urine drug testing in chronic pain management: 2013 update. Pain Med News. 2013; Dec:45-50.

11. Joranson DE, Ryan KM, Gilson AM, et al. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283(13):1710-1714.

13. Melanson SEF, Ptolemy AS, Wason AD, et al. Optimizing urine drug testing for monitoring medication compliance in pain management. Pain Med. 2013;14(12):1813-1820.

14. O’Neil MG. Trends in prescription drug abuse: ‘bridging medications’. Medscape. http://www.medscape.com/viewarticle/804740. Updated May 28, 2013.

Accessed April 1, 2015.

15. Gourlay D, Heit H, Caplan Y. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. 5th ed Monograph. PharmaCom Groups, Inc. 2012.

16. Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. Pain Physician.

2012;15(3 Suppl):ES119-ES133.

17. Bronstein K, Passik S, Muitz L, Leider H. Predicting abnormal urine drug testing in patients on chronic opioid therapy. Poster abstract presented at: PainWeek; September 8-11, 2010. Las Vegas, NV.

Brooke Mueller, PharmD, is a senior clinical pharmacist at Helios in Tampa, Florida.

Figure credit: Emily Dutton, PharmD, of Helios, assisted with the creation of the opioid metabolism figure.

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safe use of opioids

Results of a Survey

Physician and Patient Beliefs and Behaviors Relating to Pain Medications

By THE Part ner ship for Drug - Free K ids

T

he Partnership for Drug-Free Kids, in collaboration with the American Cancer Society, the American Academy of Pain Management, and Mallinckrodt Pharmaceuticals, conducted research to better understand current beliefs and behaviors relating to the prescriber-patient interaction when prescribing pain medication. These research findings have implications for both prescriber and patient education—particularly in the areas of communication of dependence and addiction risk, appropriate use, and home storage and disposal of pain medications.

conversations should happen more often, especially since most patients indicate that they continue to feel concerned about taking prescription opiates.

However, these conversations should also include the proper use and storage of prescription medications, but often do not. National data show that nearly two-thirds of teens who have misused or abused a prescription pain reliever within the past year had received the prescription medicine from a friend or family member (1).

Addiction and Dependence

Methodology

Two 15-minute online surveys were distributed to 360 physicians who prescribed opiates in the past 30 days and 705 adults who filled an opiate prescription in the past 60 days. In addition, 21 in-office dialogues between opiateprescribing physicians and their patients were recorded.

Physicians included primary care physicians, pain management specialists, surgeons, and oncologists.

Summary of Findings

The findings suggest that many prescribers are uncertain of their ability to spot at-risk or drug-seeking patients, and often fail to discuss the risks of prescription misuse, abuse, and diversion.

Patients are concerned with the addiction potential of powerful pain relievers and have an interest in alternative treatments that often goes unfulfilled because of a lack of insurance coverage.

Many prescribers have not received proper training in assessing risk potential and often feel uncomfortable prescribing opiates and contributing to opiate addiction or dependence, especially since they believe patients often do not comply with their instructions.

Most chronic pain patients investigate alternative treatments before resorting to prescription opiates, and prescribers are increasingly promoting these treatments. Unfortunately, both patients and prescribers are facing difficulties working around insurance restrictions to access these alternative treatments.

On a positive note, most prescribers and patients are discussing the potential for addiction and dependence, yet these 46

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In this survey, misuse and abuse of prescription pain relievers are clearly a problem, with roughly 7% of chronic pain patients and 13% of acute pain patients reporting misuse of their own opiate prescription medicines. More than 13% of chronic pain patients and 15% of acute pain patients say they have taken someone else’s opiate prescription. But despite the concerns of many patients, prescribers do not always communicate the risk that misuse and abuse may lead to addiction, or that opiate use as prescribed may lead to dependence.

The majority of prescribers say they discuss the potential of dependence or addiction with their pain patients: 65% of primary care physicians and 51% of pain management specialists say they “always” give information regarding the potential for addiction and dependency. Yet when asked who, if anyone, had explained to them the potential for becoming dependent on or addicted to prescribed painkillers, 19% of chronic and 40% of acute pain patients said “no one.” Nevertheless, more than 77% of prescribers said they felt they are primarily responsible for providing information on the potential to become addicted to or dependent on opiates.

Improper Use of Prescribed Opiates

The majority of prescribers are worried about patients not properly using their prescribed opiates in accordance with their instructions. Concerns about noncompliance include not taking prescriptions within the allotted time, not taking the prescribed amount during each dose, and taking the prescription for non-pain related reasons.

RESULTS OF A SURV EY

However, more than eight in 10 pain patients say they always follow the instructions from their physicians when taking their opiate prescriptions. These statements are contradicted by the findings that only 59% of chronic pain patients and 35% of acute pain patients have taken their opiates as directed within the allotted time.

Proper Storage and Disposal of Prescription Medications

According to this survey, patients are not concerned with the proper use and storage of medications—only 11% of chronic and 13% of acute pain patients say they are concerned with someone else in their household accessing their medications; and only 20% of both chronic and acute pain patients say they store their medication somewhere their children cannot reach.

This inattention to proper storage may be influenced by physicians, who are not communicating the importance of proper storage and disposal: Only one in five prescribers said they “always” give their patients information on how to store and dispose of their medications.

Patients corroborate these statements. Most patients report that they did not receive information on where to store medication, what to do with unused medication, or what to do with expired medication.

Risk Assessment

Approximately one in five physicians reported that they don’t feel comfortable prescribing opiates or identifying opiate abuse among their patients. Two-thirds of primary care physicians (66%) and three-quarters (73%) of pain management specialists are concerned with causing addiction; 78% of primary care physicians and 80% of pain management specialists are concerned with prescribing opiates to someone who already abuses substances. Yet in order to assess risk potential among their patients, some prescribers rely predominantly on personal experience and marked behaviors, such as patients asking for specific brands, rather than utilizing more standardized tools and resources.

Alternative Treatments

Ninety percent of chronic pain patients have tried using a non-opiate based treatment before relying on opiates. The most common alternatives were physical therapy (84%), pain relieving injections (69%), and massage (52%).

Prescribers are also offering these alternatives more often than they once did. In general, prescribers say they provide about three different options, including prescription opi-

ates, to treat their patients’ pain. The most common alternatives mirror those reported by patients.

However, potential barriers exist in accessing alternative medications, notably insurance restrictions, and some patients have to resort to opiates as their only viable option. About one in 10 pain patients said they did not seek out alternative treatment because it was not covered by their insurance. And roughly half of the prescribers surveyed said they have had trouble prescribing alternative treatments because of insurance restrictions.

Implications

Many prescribers have not received formal education in identifying opiate misusers and abusers, and therefore they may not be trained in the use of tools to objectively assess risk and drugseeking behavior. Prescriber education, tools such as Prescription Drug Monitoring Programs (PDMPs), evidence-based screeners, and risk evaluation and mitigation strategies (REMS) education should be more widely implemented to address these knowledge gaps, while both addiction science and pain management should be more routinely included in medical education.

Prescribers should feel that these objective tools are recommended as a means of improving quality of treatment. Additional discussion guides and checklists, such as those developed by the C.A.R.E.S. Alliance, can also be used in discussing potential misuse and abuse behaviors (2).

Prescribers and patients should also be made more aware of the dangers of improper storage and disposal of pain medications. Campaigns such as “Mind Your Meds” by the Medicine Abuse Project, have been created to help inform parents and the general population of the risks of diversion, especially when adolescents have access to prescriptions (3). Prescribers and their staff must more consistently take on the responsibility of informing patients of the importance of properly storing and disposing of opiate medications.

Lastly, barriers to more widespread use of alternative treatments for pain should be lowered. Insurance companies should adopt standards of care that incorporate scientifically proven sources of alternative therapies, particularly in the treatment of chronic pain.

References 1. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs2013/NSDUHDetTabs2013.htm#tab6.47b 2. C.A.R.E.S. Alliance. http://www.caresalliance.org/index.aspx. Accessed April 20, 2015.

3. The Medicine Abuse Project. http://medicineabuseproject.org/. Accessed April 20, 2015.

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DEPARTMENT

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Do you ache for a new opportunity?

Aurora Health Care currently has TWO Pain Management positions available in two great locations Oshkosh, WI: This is a fantastic opportunity to build and grow a Comprehensive Pain Management program. The candidate selected will be board certified with fellowship training in pain medicine and will fill the role of Director. You’ll provide leadership to the team and see patients with acute and chronic pain conditions. Your role includes medication management and interventional and non-interventional treatments.

Kenosha, WI: We are seeking a BC/BE physician (physiatry, psychiatry, family medicine, or internal medicine trained) to work as a critical component of our Comprehensive Pain Management program. You will provide all of the on-going day-to-day medication management of our chronic pain patients.

A background in addictionology and/or suboxone certification would be a benefit although not required.

About Aurora Health Care Aurora Health Care is the largest health care system in Wisconsin. With service areas extending to Northeastern Illinois, Aurora is anchored by two top tier tertiary/quaternary care centers. Our integrated delivery model allows Aurora physicians and advanced practice professionals to support their patients, connect with colleagues and offer state-of-the-art, top tier quality care.

We offer a competitive compensation and benefits package that includes paid medical liability insurance and relocation assistance.

To learn more contact: Alison Burki (414) 389-2543 or alison.burki@aurora.org You can also visit our website www.aurora.org/doctor for more information.

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