PAINWeek Journal Vol 7, Q1

vol. 7 q 1 2019

mindfulness-based interventions for women experiencing postmastectomy pain syndrome p.14 the importance of documentation: avoiding pitfalls p.24 failed back surgery syndrome p.34 the science behind how dry needling “might” work p.42

PaiNWeeK 2019 Conference Preview P.66

The pendu

ulum swing

gs in both

directions

s.

Education moves forward. www.painweek.org

eXeCUTiVe eDiTOR KEViN L. ZACHAROFF md, facpe, facip, faap

eeK

PUBLiSHeR PAINW

ART DiReCTOR DARRYL FOSSA

eDiTORiAL DiReCTOR DeBRA WeiNeR eDiTOR HOLLY CASTeR

eDiTORiAL BOARD

Charles E. Argoff md, cpe Professor of Neurology Albany Medical College Department of Neurology Director Comprehensive Pain Center Albany Medical Center Department of Neurology Albany, ny Jennifer Bolen jd Founder Legal Side of Pain Knoxville, tn Martin D. Cheatle PhD Associate Professor Director, Pain and Chemical Dependency Program Perelman School of Medicine University of Pennsylvania Center for Study of Addiction Philadelphia, pa Paul J. Christo md, mba Associate Professor Johns Hopkins University School of Medicine Department of Anesthesiology and Critical Care Medicine Baltimore, md Michael R. Clark MD, MPH, MBA Associate Professor of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine Baltimore, md Chair of Psychiatry Inova Health System Falls Church, VA

David Cosio PhD, ABPP Psychologist Jesse Brown VA Medical Center University of Illinois at Chicago College of Medicine, Pain Medicine Northwestern Feinberg School of Medicine, Psychiatry and Behavioral Sciences Chicago, il

Srinivas Nalamachu md Clinical Assistant Professor Kansas University Medical Center Department of Rehabilitation Medicine Kansas City, ks President and Medical Director International Clinical Research Institute Overland Park, ks

David M. Glick DC, DAAPM, CPE, FASPE CEO & Medical Director HealthQ2 Richmond, va

Steven D. Passik phd Vice President Scientific Affairs, Education, and Policy Collegium Pharmaceuticals, Inc. Canton, ma

Douglas L. Gourlay MD, MSc, FRCPC, DFASAM Educational Consultant Former Director, Wasser Pain Centre Pain and Chemical Dependency Division Toronto, Ontario Gary W. Jay md, faapm Clinical Professor University of North Carolina Department of Neurology Chapel Hill, nc Jay Joshi MD, DABA, DABA-FM, FABA-FM CEO and Medical Director National Pain Centers Vernon Hills, il Theresa Mallick-Searle MS, NP-BC, ANP-BC Nurse Practitioner Stanford Health Care Division of Pain Medicine Stanford, ca

Joseph V. Pergolizzi md Chief Operating Officer nema Research Inc. Naples, fl Michael E. Schatman phd, cpe, daspe Editor-in-Chief Journal of Pain Research Adjunct Clinical Assistant Professor Tufts University School of Medicine Department of Health & Community Medicine Boston, ma Kathryn A. Schopmeyer PT, DPT, CPE Physical Therapy Program Coordinator Pain Management San Francisco va Healthcare System San Francisco, ca

Mary Lynn McPherson pharmd, ma, mde, bcps Professor and Vice Chair University of Maryland School of Pharmacy Department of Pharmacy Practice and Science Hospice Consultant Pharmacist Baltimore, md

Copyright © 2019, PAINWeek, a division of Tarsus Medical Group.

The opinions stated in the enclosed printed materials are those of the authors and do not necessarily represent the opinions of PAINWeek or its publication staff.

PAINWeek does not give guarantees or any other representation that the printed material contained herein is valid, reliable, or accurate. PAINWeek does not assume any responsibility for injury arising from any use or misuse of the printed materials contained herein. The printed materials contained herein are 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 PAINWeek to accept, reject, or modify any advertisement submitted for publication. It is the policy of PAINWeek to not endorse products.

Any advertising herein may not be construed as an endorsement, either expressed or implied, of a product or service.

vol. 7 q1 2019

14 24 34 42 50 57 58 59 60 62

behavioral

mindfulness-based interventions for women experiencing postmastectomy pain syndrome

by beth l. dinoff laura y. thompson

practice management

the importance of documentation: avoiding pitfalls

by darren mccoy

interventional

failed back surgery syndrome

by jay joshi

physical therapy

the science behind how dry needling “might” work

by jarod a. hall

op-ed

addressing the opioid crisis: we must get it right

by douglas l. gourlay howard a. heit gary w. jay

pw next generation

with mark garofoli

clinical pearls

by doug gourlay

pain by numbers one-minute clinician

with mario castellanos, peter pryzbylkowski, robert raffa, michael bottros, brett stacey, ravi prasad

pundit profile

with martin d. cheatle

PaiNWeeK 2019 Conference Preview P.66 8

PWJ | www.painweek.org

Q 1 | 2019

The national conference on pain for frontline practitioners.

2019

SePTeMBeR 3—7

Global Education Group (Global) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education to physicians. Global Education Group designates this live activity for a minimum of 39.0 AMA PRA Category 1 Credit(s)™. This activity will be approved for continuing pharmacy, psychology, nurse practitioner, nursing, and dentistry education. Applications for certification of social work NASW and family physician AAFP hours will be applied for. For more information and complete CME/CE accreditation details, visit our website at www.painweek.org.

TWO THiNGS

Next, Jarod A. Hall gives a physical therapist’s view of the utility of dry needling for likely come to mind when we think about the treatment of musculoskeletal pain, the Kevin L. Zacharoff the management of chronic pain: pharmamost common type of pain. Not usually concologic and physical treatments, ranging sidered to be an interventional treatment, from opioid and nonopioid analgesics to surgical, interventional, and com- the approach is based on the concept of attacking “trigger points,” which are plementary/alternative physical approaches. This issue of PWJ touches hyperirritable spots in the muscle tissue. Although the scientific evidence upon things we may not usually think about, things like mindfulness as for identification of trigger points has been variable, the author makes a part of a pain treatment plan; iatrogenic pain and what to do when we case that the risk/benefit ratio is so favorable it could be worthwhile to encounter it; failed treatments and who “picks up the pieces”; and the keep this technique in mind when other more risky treatments are being importance of documenting the patient narrative to improve outcomes. considered. While this is not something that requires a high level of expert It’s so refreshing to have material that doesn’t get caught up in the swirl training, it could prove to be very beneficial for certain patients. of controversy in today’s pain environment, and relates back to the traditional, artful, and ethical practice of medicine. I hope you enjoy this issue This issue’s Pundit Profile spotlights a staple of the pain community, Martin as much as I did.

D. Cheatle. For anyone who desires his legacy to be that, in some small way, his work and teachings positively impact patients with chronic pain is Drs. Beth L. Dinoff and Laura Y. Thompson provide important insight about A-OK in my book. Dr. Cheatle is widely known for his passion and integrity, a subject we may not often think about—iatrogenic pain, defined as a medi- and it’s great for us to have a look into what motivates him and what he cal condition resulting from examination or treatment. We may sometimes hopes to achieve. Throw in a large amount of humanitarian qualities and forget that what we do to help patients may result in residual, unexpected there you have our Pundit. I hope you enjoy getting to know him better. outcomes like surgically induced chronic pain. Postmastectomy pain syndrome is not as uncommon as people might think, and its potential may not Mark Garofoli is the focus of this issue’s Next Generation. As we continue be normally included in the informed consent process. Not only does this to recognize that the path to successful pain treatment outcomes involves article shed light on that, it points out the fact that we could find ourselves a truly multidisciplinary approach with an interprofessional team which helpless when treating pain resulting from treatment we give to patients. includes clinical pharmacists, it stands to reason that healthcare profesMindfulness techniques are illustrated to help us figure out ways to treat sionals like Dr. Garafoli are part of the “shape” of our future. I often worry the pain in patients who are likely already emotionally suffering. about who will become the next generation of leaders in the pain community, and people like him give me hope.

“If it isn’t documented in the medical record, it didn’t happen.” This is often taught early on in healthcare provider training. Now more than ever, doc- There is no question that the pain community and pain patients are in umentation lives in concert with other available information, including turbulent waters. My biggest issue with all of the controversy is that while prescription drug monitoring program (PDMP) data. In his article, Darren there is no shortage of information and recommendations about what not McCoy reminds us how the stigmas associated with chronic pain patients, to do, there seems to be very little about what to do. Maybe this means the subjectivity of the symptom profile, and the inherent emotionality of we need to use our heads a bit more readily than our prescription pad, that profile all likely contribute to the narrative of the patient’s pain, the and remember that everything we recommend to patients has potential narrative which we must document. Electronic medical records have done consequences. Most importantly in my opinion, it’s incumbent on us to much to improve the timeliness of documentation and uniformity but may consider the mission that our training has instilled in us: to make sure we be doing the opposite when it comes to capturing individual aspects of never lose sight of the fact that what defines us is our responsibility to the patient’s history. This article appropriately identifies the importance our patients and the care we provide to and for them. The fact is that we of patient context in documentation. have important societal responsibilities that should influence what we do, but never deter us from our mission.

Another article in this issue focuses on undesirable outcomes of surgical pain treatment. With back pain being as prevalent as it is around the world, it should come as no surprise that, as we age and degenerative changes Kevin L. Zacharoff MD, FACIP, FACPE, FAAP occur, its incidence increases, along with the number of back surgeries performed to treat it. Dr. Jay Joshi focuses on patients with back pain who have had surgery as part of the treatment plan. Surgery may result Kevin L. Zacharoff is Faculty and Clinical Instructor at suny Stony Brook School in temporary relief, no relief, increased pain and, in some cases, long-term of Medicine in New York, and is Ethics Committee Chair at St Catherine of Siena disability. “Failed back surgery syndrome” is an interesting name for a Medical Center in Smithtown, New York. medical condition, as it intimates that there has been failure on someone’s part. Is it the patient’s? The clinician’s? This article offers ponderables when possibly referring for surgery, not with the intention of preventing a necessary and potentially valuable surgical procedure, but to ensure that we consider what we might need to do if the outcomes aren’t the ones we expect and hope for.

10

PWJ | www.painweek.org

Q 1 | 2019

PaiNWeeKeNDâ„¢ ReGiONaL CONFeReNCe SeRieS

2019 visit www.painweekend.org for more information. aNaHeiM CA aTLaNTa GA aUSTiN TX BaLTiMORe MD BiRMiNGHaM AL BUFFaLO NY CHaRLeSTON SC CHaRLOTTe NC CHiCaGO IL

CLeVeLaND OH

MORRiSTOWN NJ

SaN DieGO CA

NeW ORLeaNS LA

SCOTTSDaLe AZ

DaLLaS TX

NaSHViLLe TN

HOUSTON TX

PHiLaDeLPHia PA

DeNVeR CO

iNDiaNaPOLiS IN JaCKSONViLLe FL LOS aNGeLeS CA

MiNNeaPOLiS MN

MORGaNTOWN WVA

PROViDeNCe RI

RaLeiGH-DURHaM NC RiCHMOND VA

SaCRaMeNTO CA SaN aNTONiO TX

SaNTa CLaRa CA SeaTTLe WA

SOUTHFieLD MI

ST. LOUiS MO

TaMPa FL

WeST PaLM BeaCH FL

Beth L. Dinoff phd

p.14

Beth Dinoff is a Pain Psychologist and Clinical Associate Professor at the Carver College of Medicine, Department of Anesthesia, at the University of Iowa Hospitals and Clinics in Iowa City. Dr. Dinoff’s writes a blog for the Psychology Today website. She coauthored her article with Laura Y. Thompson, PhD, of Laura Y. Thompson, LLC, who developed the Heartland Forgiveness Project (heartlandforgiveness.com) while a PhD student. It has been translated into 21 languages.

Jarod A. Hall PT, DPT, OCS, CSCS

p.42

Jarod Hall is a Physical Therapist and Clinic Director at Greater Therapy Centers in Fort Worth, Texas. His clinical focus is orthopedics with an emphasis in persistent pain. Jarod has shown clinical excellence in securing designation as a board certified Orthopedic Clinical Specialist (OCS) and Certified Strength and Conditioning Specialist (CSCS). He is a clinical lab instructor and guest lecturer at the UNTHSC DPT program. He is the author of Sticks and Stone: A Collection of Analogies and Stories to Better Understand Pain.

Jay Joshi MD, DABA, DABA-PM, FABA-PM

p.34

Jay Joshi is double board certified in anesthesiology and interventional spine and pain, and is the CEO/Medical Director of the National Pain Centers (nationalpain.com) in Illinois. He is a key opinion leader, presenter, innovator, and his primary research has focused on central sensitization. Other areas of interest include: descriptions of mechanisms of action of CRPS/PTSD/ hot flashes, stem cells/regenerative medicine, and ketamine infusions protocols and applications.

Darren McCoy FNP-BC, CPE

p.24

Darren McCoy is a Nurse Practitioner and Certified Pain Educator at Pain Consultants of East Tennessee and an adjunct instructor at the University of Tennessee College of Nursing.

12

PWJ | www.painweek.org

Q 1 | 2019

home with you—

Mindfulnessb

a

s

e

d

I n t e r v e n t i o n s F

o

W E

o

x

p

e

r

m r

i

e

e n

c

n i

n

g

P o s t m a s t e c t o m y

P S

a y

n

i d

r

n o

m

By Beth L. Dinoff PhD/Laura Y. Thompson PhD

e

!

behavioral

A b s t r a c t

16

Full disclosure, I (Dinoff) have postmastectomy pain. Given that I was already on my way to becoming a pain psychologist, nobody was more surprised than I to develop a chronic postsurgical pain syndrome. It all began in 2000 while I was on clinical internship to become a pain psychologist. My annual mammogram took 6 hours and the next day I was in surgery being diagnosed with ductal carcinoma in situ in the upper outer quadrant of my right breast.

My mother had died 3 years earlier after 19 years with breast cancer. I was a single mother to a 10-year-old daughter recently adopted from Russia. Against the strong recommendations of my oncology team, I elected to have bilateral mastectomies with immediate latissimus dorsi flap reconstruction. When I awakened from the 9 hour procedure I was in severe pain that continued, poorly controlled, for the duration of my hospitalization all the way to today.

PWJ | www.painweek.org

Q 1 | 2019

surgical oncologist and plastic surgeon were world-class, teaching at a top tier medical school, yet both said they had absolutely no idea why I was hurting. My search for information led me to only a handful of articles about pain after mastectomy in the medical literature at that time, with many early articles seeming to blame the patient for having preoperative anxiety or fear. I wondered why my surgical team didn’t seem to know that postmastectomy pain syndrome (PMPS)—a multifactorial pain condition often identified as being neuropathic in origin, including intercostobrachial neuralgia, phantom breast pain, and neuroma pain—could be a potential outcome. The earliest research already showed that about 50% of women studied experienced this set of symptoms. I learned that other women with PMPS have asked why the risk of severe life-long pain was not part of their informed consent process prior to undergoing the extensive procedure, and that these same women were told they “should just be grateful to be alive.” Over the years, I personally have heard the following from highly respected healthcare providers: “Your breasts can’t hurt because your implants look so pretty” and “I’m sure you’re not having pain, dear, because we cut all those nerves.”

Not much has changed since then but, instead of feeling permanently stuck in my own frustration with the medical system, I choose to remain hopeful that increased awareness and commitment to working openly with patients and healthcare providers will lead us toward a cultural transformation in the way women are treated during the mastectomy perioperative period so that PMPS can be prevented or treated successfully.

Importantly, clinical research continues to demonstrate that chronic PMPS is consistently associated with reduced quality of life and psychosocial distress.1-3 Across medical populations, mindfulness-based interventions (MBI) and other acceptance approaches have demonstrated consistent efficacy as pain management interventions. However, few reports have addressed the impact that MBIs could have on women experiencing mood changes, marital adjustment, reduced functioning, and increased disability in the context of PMPS. Briefly, this article will review what little is known about PMPS and highlight research supporting MBI techniques within qualified clinical practices to help women cope with this persistently painful condition.

Q 1 | 2019

W h a t w n

o

e

w

K n o w Although no universally agreed upon definition of PMPS has been identified, most indicate that PMPS entails persistent pain for more than 3 months following any breast surgery, including mastectomy, lumpectomy, reconstruction, augmentation, reduction, sentinel note biopsy, and radiation therapy. The condition is believed to result from a complex pathophysiology involving perioperative factors including nerve damage and radiation therapy.4 Pains are often characterized by the “iron bra” sensations of extreme tightness, aching, burning, tingling, and soreness in the anterior chest, ipsilateral arm, and axilla www.painweek.org | PWJ

17

behavioral

…women with postmastectomy pain syndrome have asked why the risk of severe life-long pain was not part of their informed consent process prior to undergoing the extensive procedure, and…were told they ‘should just be grateful to be alive.’

that are exacerbated by most arm and torso movements, including breathing.

and depression tend to be more elevated in women with PMPS compared to women who did not develop PMPS.2

Epidemiological data are revealing. The American Cancer Society estimated in 2017 that 252,710 new cases of invasive breast cancer and 63,410 cases of carcinoma in situ would be diagnosed.5 Annually, approximately 41% of women diagnosed with breast cancer will undergo surgery as part of their treatment and one third of women treated for breast cancer will require mastectomy.6,7 The prevalence of PMPS in women who have undergone breast surgery for malignant neoplasms ranges from 20% to 60%.4 All types of surgery for breast cancer, including breast conserving procedures, lumpectomy, axillary lymph node dissection, single mastectomy, bilateral mastectomies, and reconstruction demonstrate significant risk for chronic pain. Potential causes for PMPS include3

Chronic PMPS can be highly debilitating, leading to substantial reductions in quality of life, limited range of motion, increased use of opioids, and a decreased ability to work. Furthermore, breast cancer survivors rate postmastectomy pain syndrome as their most distressing or troubling symptom after surgery.6 And studies have shown that PMPS significantly interferes with daily life.9 Even though major improvements have been made in breast cancer mortality, many women with breast cancer are living with significant morbidity related to PMPS. Treatments targeting the prevention of chronic pain and physical rehabilitation have been underutilized in persons with breast cancer.10

○○ Intraoperative damage (to the intercostobrachial nerve, axillary nerves, or chest wall) ○○ Incisional pain ○○ Musculoskeletal pain ○○ Neuromas or seromas ○○ Phantom breast pains Undergoing radiation and/or chemotherapy also increases the likelihood of development of PMPS. The more types of PMPS a woman reports correlates with greater degrees of distress and disability.8 Electing immediate breast reconstruction does not seem to lead to increased pain or reduction in quality of life.7 Women of younger age at diagnosis are at higher risk for developing PMPS, potentially due to having more aggressive treatment as well as increased perioperative anxiety.3 Psychosocial factors, including catastrophizing, somatization, anxiety,

18

PWJ | www.painweek.org

P r e v e n t i o n

a

n

d

Treatment

The Institute of Medicine’s report Relieving Pain in America highlights the need to prevent postsurgical pain by understanding factors that lead to chronic pain after surgery, increasing the ability to provide individualized treatment to each patient, and emphasizing the development of self-care coping strategies.11 Postmastectomy pain syndrome is known to be a complicated subset of postsurgical pain. Enhanced Recovery After Surgery (ERAS) pathways have improved perioperative care of patients, including less pain, reduced dependence upon opioids, improved patient satisfaction, and shorter hospital stays.

Q 1 | 2019

Adding psychological interventions to outstanding ERAS pre-, during-, and postoperative guidelines could increase opportunities for women to avoid a lifetime of debilitating chronic pain.

Another factor in preventing PMPS includes the mediating effect of psychological resilience. Resilience may be defined as the person’s ability to successfully cope with adversity, including trauma. Chronic pain has been identified as a possible predictor of trauma in persons with cancer.12 Factors related to positive, active coping and resilience may help to prevent the development of chronic PMPS. As of this writing, only one previous survey on provider’s recognition of PMPS has been reported in the literature. Kojima and colleagues surveyed 224 breast surgeons in Japan regarding postoperative chronic pain in women after breast cancer surgery.13 They found that more than 70% of the responding physicians recognized PMPS; however, less than 48% of these responders indicated that they provided any treatment for it.

Of the surgeons who did provide treatment, more than 78% recommended that women with PMPS use NSAIDS, which are generally known to be ineffective in relieving PMPS, and effective drugs were infrequently used. Only 25% of providers recommended rehabilitation for patients with PMPS. More than 48% of providers indicated that they believed the PMPS would resolve over time even though this belief is not supported by the clinical evidence. 65% of providers offered no treatment whatsoever to patients experiencing PMPS.13

include younger age, obesity, ethnicity, preoperative breast pain, pain in other areas, depression, anxiety, sleep disturbances, pain catastrophizing, intraoperative factors (ie, type of surgery, radiotherapy, type of lymph node biopsy/dissection), and use of adjuvant therapy (for an excellent review see Andersen & Kehlet4).

M F

C

B

a

n

o

c

I e

r

r

Surviv0rs

With Chronic Pain

Trends in the scientific literature indicate that cancer survivors are increasingly seeking complementary and alternative medical care, likely reflecting a desire for more comprehensive, multimodal treatment.17 Mindfulness-based interventions are one type of nonbiomedical multimodal treatment that can be used as adjunctive treatment or monotherapy for chronic pain and its sequelae. A growing body of evidence demonstrates that MBIs can reduce negative psychological states including pain as well as increasing positive psychological states and quality of life for both breast cancer survivors and people with chronic pain.18-21

As noted above, more than 315,000 women are diagnosed with breast cancer annually in the United States, and over 2.5 million women are currently living with breast cancer.5 Providing additional pain management education to healthcare providers and patients could decrease the possibility of women developM i n d f u l n e s s ing PMPS, enhance quality of life, reduce the need for depenAnd Wh at Are dence upon life-long opioids, and aid in restoring women to living a fully valued life in the context of breast cancer. Clearly, a relatively high prevalence of PMPS exists. Yet, even though B a s e d most surgeons now appear to recognize this syndrome, PMPS In terven tions? is often inadequately treated or completely untreated. Nervous system damage, such as would occur during breast cancer surgery, remains an incurable and debilitating symptom for many Although many people have heard the word mindfulness, women.14 To date, randomized controlled trials examining the they may not have a clear understanding of what it is in the treatment of PMPS have not been completed. Most of the clin- therapeutic context. The concept of mindfulness became ical trials on the management of chronic postoperative pain widely known in the healthcare field because of the work of have focused on the efficacy of pharmacological interventions. Jon Kabat-Zinn, who developed the Mindfulness-Based Stress Pharmacological treatments tend to reduce chronic noncancer Reduction (MBSR) program at the University of Massachusetts pain by up to 40% in fewer than half of people. And effect sizes Medical School in 1979. Kabat-Zinn has defined mindfulness as for biomedical treatments more broadly are, at best, modest.15,16 “moment-to-moment non-judgmental awareness.”22 Bishop et al The complete removal of chronic pain is not typically a realistic proposed a definition to be used by people researching mindgoal, and thus, multimodal care has been proposed15 to help fulness: “[W]e see mindfulness as a process of regulating attenpeople with chronic pain to improve both physical functioning tion in order to bring a quality of nonelaborative awareness to and quality of life while reducing pain.16 PMPS is multifactorial, a current experience and a quality of relating to one’s experience pain condition research often identifies as being neuropathic in within an orientation of curiosity, experiential openness, and origin, including intercostobrachial neuralgia, phantom breast acceptance.”23 Essentially, mindfulness is maintaining nonpain, and neuroma pain.8 Risk factors for development of PMPS judgmental moment-to-moment awareness of one’s bodily

Wh at

Is

Mindfulness-

Q 1 | 2019

www.painweek.org | PWJ

19

behavioral

Table Mindfulness-Based Stress Reduction (MBSR) ▸▸ Developed for: people with chronic pain, stress related conditions ▸▸ Focus: intensive mindfulness meditation training/practice ▸▸Typical class: 8 weeks, weekly 2.5 to 3 hour sessions; all-day session of practicing mindfulness usually held during 6th week ▸▸≤30 participants with wide range of conditions For more information:

Baer RA. Introduction to the core practices and exercises. In: Mindfulness-Based Treatment Approaches. 2nd ed.

Waltham, ME: Elsevier Academic Press; 2014:3–25.

Mindfulness-Based Cognitive Therapy (based on MBSR) ▸▸ Developed for: prevention of depressive relapse ▸▸Typical class: 8 weeks, weekly 2 hour sessions; all-day mindfulness session may be included, but is not part of original format ▸▸≤12 participants with history or ongoing symptoms of depression, bipolar disorder For more information:

Coffman SJ, Dimidjian S, Baer RA. Mindfulness-based cognitive therapy for recurrent depression. In: Baer RA. Mindfulness-Based Treatment Approaches. 2014:26–60.

Mindfulness-Based Cancer Recovery (based on MBSR) ▸▸ Developed for: people recovering from cancer ▸▸Typical class: 8 weeks, weekly 1.5 hour sessions; all-day mindfulness session included ▸▸≤12 participants recovering from cancer For more information:

Carlson LE, Speca M. Mindfulness-based cancer recovery: a step-by-step MBSR approach to help you cope with treatment and reclaim your life. Oakville, CA: New Harbinger; 2011.

Speca M, Carlson LE, Mackenzie MJ, et al. Mindfulness-Based Cancer Recovery: An Adaptation of Mindfulness-Based Stress Reduction (MBSR) for Cancer Patients. In: Baer RA. Mindfulness-Based Treatment Approaches. Waltham, ME: Elsevier Academic Press; 2014:293–316.

Mindful Awareness Practices ▸▸ Developed at: Mindful Awareness Research Center, UCLA (http://marc.ucla.edu) ▸▸Typical class: 6 weeks, weekly 2 hour sessions ▸▸≤40 participants For additional information:

Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4:33–47.

Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.

New York, NY: Delta. 1990.

Segal ZV, Williams JMG, Teasdale JD. Mindfulness-Based Cognitive Therapy for Depression: a New Approach to Preventing Relapse. New York, NY: Guilford. 2002 and 2013 editions.

sensations, thoughts, feelings, and external environment.

Originally derived from Buddhist meditation, the mindfulness currently taught in MBSR and other MBIs is nonreligious.

Most MBIs have a similar structure, usually including weekly group sessions that meet for 45 minutes to 2.5 hours for a total of 6 to 8 weeks. During MBI, participants learn a variety of

20 PWJ | www.painweek.org

mindfulness practices such as awareness of breath, mindful movement, and a body scan, as well as awareness of thoughts, emotions, and external surroundings. MBI classes also provide information about the theoretical underpinnings of mindfulness, and participants are asked to practice mindfulness in various ways for 10 to 45 minutes per day. See Table above for more information.19 Q 1 | 2019

A growing body of evidence demonstrates that MBIs can reduce negative psychological states including pain as well as increasing positive psychological states and quality of life for both breast cancer survivors and people with chronic pain.

Benefits o

M

B

f

I

For Chronic Pain

A N D Cancer Survivors

Hilton et al conducted a meta-analysis of 38 RCTs to evaluate the efficacy of mindfulness meditation for the treatment of chronic pain.21 Researchers concluded that, for people with chronic pain, “mindfulness meditation interventions showed significant improvements for chronic pain, depression, and quality of life.” They also found that MBIs may improve function, decrease disability, and decrease analgesic use. The findings related to function and disability were consistent and approached significance. Results regarding analgesic use were mixed.21 In a review of the current findings on the use of MBIs with breast cancer survivors, Haydon et al found that “research conducted within the past 5 years has demonstrated that MIs [mindfulness interventions] reduce negative psychological states, such as stress and depressive symptoms, and enhance positive psychological states, such as well-being and self-compassion. Further, MIs may influence biological processes that are highly relevant in cancer survivorship” such as inflammatory pathways implicated in both tumor growth and progression. MBIs were also shown to decrease fear of cancer recurrence.19 Two additional studies that were included among the RCTs reviewed by Hilton et al and Haydon et al are particularly relevant to patients with PMPS.19,21 First, Johannsen et al found that people who completed a course in mindfulness-based cognitive Q 1 | 2019

therapy experienced a significant decrease in the intensity of chronic pain following breast cancer treatment, including surgery, chemotherapy, and/or radiotherapy.24 Second, Esmer et al found that MBIs, used as adjunctive treatment or monotherapy can help reduce the intensity of chronic postoperative pain following surgery.25 Few side effects have been reported in the literature about MBIs for the treatment of chronic pain. For example, only 7 of 38 studies included in Hilton’s meta-analysis mentioned whether adverse events occurred. The side effects that were reported indicated that fewer than 5% of participants experienced temporary strong feelings of anger toward their pain, or increased anxiety. It is important to note that the research about MBIs and chronic pain is still being developed. Strong evidence indicates that MBIs decrease depressive symptoms and improve quality of life for people with chronic pain. Further research is needed, especially more rigorous large scale RCTs, to provide a robust evidence base for some of the other promising findings.19,21

Referring People

For

M B I s Healthcare providers treating people with PMPS may want to recommend MBIs, especially to those experiencing depressive symptoms and decreased quality of life related to their chronic pain, or who cannot or do not want to use pain medications or other biomedical treatments. Haydon et al reported that “qualitative research suggests breast cancer survivors find mindful www.painweek.org | PWJ

21

behavioral

interventions both enjoyable and beneficial.”19 Studies also indicate that MBIs may be most effective for cancer survivors who are distressed or who have pre-existing vulnerabilities such as a history of recurrent depression or childhood trauma.19 When being referred to an MBI, people often have questions.

Thus, here are links to information about mindfulness, MBIs, the benefits and risks for people with chronic pain and cancer survivors, and resources for accessing MBIs. Some of the resources can be used by providers who want more information about professional training to teach MBIs.

○○ Mindfulness-Based Cognitive Therapy mbct.com/index.html ○○ Access Mindfulness-Based Cognitive Therapy accessmbct.com/ ○○ The Centre for Mindfulness Studies www.mindfulnessstudies.com/# ○○ Oxford Mindfulness Centre oxfordmindfulness.org/ ○○ UMass Medical School Center for Mindfulness in Medicine, Heath Care, and Society www.umassmed.edu/cfm/ ○○ UC San Diego Health Center for Mindfulness health.ucsd.edu/specialties/mindfulness/Pages/ default.aspx ○○ New Harbinger Publications: Mindfulness-Based Cancer Recovery www.newharbinger.com/mindfulness-basedcancer-recovery

References 1. Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following breast cancer surgery: a prospective study. J Pain. 2006;7(9):626–634.

2. Schreiber KL, Martel MO, Shnol H, et al. Persistent pain in postmastectomy patients: comparison of psychophysical, medical, surgical, and psychosocial characteristics between patients with and without pain. Pain. 2013;54:660–668.

3. Wisotzky E, Hanrahan N, Lione TP, et al. Deconstructing postmastectomy pain syndrome: implications for physiatric management. Phys Med Rehabil Clinics N Am. 2017;28:153–169.

4. Andersen KG, Kehlet H. Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention. J Pain. 2011;12(7):725–746.

5. American Cancer Society. Breast cancer facts and figures, 2017–2018. Atlanta, GA; American Cancer Society, Inc: 2017.

6. Belfer I, Schreiber KL, Shaffer JR, et al. Persistent postmastectomy pain in breast cancer survivors: analysis of clinical, demographic, and psychosocial factors.

J Pain. 2013;14(10):1185–1195.

7. Heneghan HM, Prichard RS, Lyons R, et al. Quality of life after immediate breast reconstruction and skin-sparing mastectomy – a comparison with patients undergoing breast conserving surgery. Eur J Surg Oncol. 2011;37:937–943.

8. Kudel I, Edwards RR, Kozachik S, et al. Predictors and consequences of multiple persistent postmastectomy pains. J Pain Symp Manage. 2007;34(6):619–627.

9. Vilholm OJ, Cold S, Rasmussen L, et al. The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer.

Brit J Cancer. 2008;99:604–610.

10. Stubblefield MD. The underutilization of rehabilitation to treat physical impairments in breast cancer survivors. PMR. 2017;9(9S2):S317-S323.

11. Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press; 2011.

12. Dinoff BL, Jacobs ML. Pain may predict traumatic stress in persons with cancer.

Poster presented at the annual conference of the Academy of Integrative Pain Management, San Diego, CA. September 2017.

C u s

o s

n c l i o n

Unfortunately, postmastectomy pain syndrome is a very real complication stemming from the treatment of breast cancer, with up to 78% of women experiencing debilitating pain for the rest of their lives. Now that women are living long lives after being diagnosed with breast cancer, research priorities need to include identification of interventions that could prevent the development of postmastectomy pain syndrome. Ethically, women would also benefit from having the possibility of developing chronic pain included in the informed consent processes.

If this condition cannot be prevented, mindfulness-based interventions will certainly help by improving function, decreasing disability, and reducing analgesic use, including opioids. We hope that pain educators will invite women to participate in MBIs and prepare patients for the risk of postmastectomy pains while women are choosing treatments for breast cancer. Pain educators are ideally poised to help women with postmastectomy pain find quality mindfulness-based interventions and resources within their local communities.

22 PWJ | www.painweek.org

13. Kojima KY, Kitahara M, Matoba M, et al. Survey on recognition of postmastectomy pain syndrome by breast specialist physician and present status of treatment in Japan. Breast Cancer. 2014;21(2):191–197.

14. Lee GH, Kim SS. Therapeutic strategies for neuropathic pain: potential application of pharmacosynthetics and optogenics. Mediators Inflamm. 2016; 2016:5808215:1–11.

15. Wylde V, Dennis J, Beswick AD, et al. Systematic review of management of chronic pain after surgery. Brit J Surg. 2017;104(10):1293–1306.

16. Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain.

Lancet. 2011;377(9784):2226–2235.

17. Boon HS, Olatunde F, Zick SM. Trends in complementary/alternative medicine use by breast cancer survivors: comparing survey data from 1998 and 2005. BMC Women’s Health. 2007;7:4.

18. Cramer H, Lauche R, Paul A, et al. Mindfulness-based stress reduction for breast cancer—a systematic review and meta-analysis. Curr Oncol. 2012;19(5):e343.

19. Haydon MD, Boyle CC, Bower JE. Mindfulness interventions in breast cancer survivors: current findings and future directions. Curr Breast Cancer Rep. 2018;10(1):7–13.

20. Bawa FLM, Mercer SW, Atherton RJ, et al. Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis. Br J Gen Pract.

2015;65(635):e387–400.

21. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Ann Behav Med. 20162017;51(2):199–213.

Q 1 | 2019

22. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York, NY: Bantam Books. 2013.

23. Bishop SR, Lau M, Shapiro S, et al. Mindfulness: a proposed operational definition. Clin Psychology Sci Practice. 2004;11(3):230–241.

24. Johannsen M, O’Connor M, O’Toole MS, et al. Efficacy of mindfulness-based cognitive therapy on late post-treatment pain in women treated for primary breast cancer: a randomized controlled trial. J Clin Oncol. 2016;34(28):3390–3399.

25. Esmer G, Blum J, Rulf J, et al. Mindfulness-based stress reduction for failed back surgery syndrome: a randomized controlled trial. J Am Osteopath Assoc. 2010;110(11):646-652.

Q 1 | 2019

www.painweek.org | PWJ

23

By Darren McCoy FNP-BC, CPE

practice management

Pain management providers frequently find themselves called upon to prescribe medications and other therapies that may be quite controversial.

It is, therefore, imperative for treatment decisions to be thoroughly documented. Documentation helps to ensure that patients have been given reasonable first-line therapies before being subjected to potentially more dangerous and/or costly treatments. Thorough documentation also helps to ease the transition to potentially complex care when patients must seek out new providers. This article presents suggestions to help providers make their decisions to treat easy-to-understand, and to avoid some of the hazards associated with modern documentation systems.

26 PWJ | www.painweek.org

Q 1 | 2019

it was not documented,

it was not done” is an adage taught to virtually all healthcare clinicians.

Q 1 | 2019

www.painweek.org | PWJ

27

practice management

The multiple problems encountered in certain healthcare settings are often straightforward to assess, diagnose, treat, and document. A trauma center patient who arrives with a compound fracture needs hemostasis, reduction of the fracture, skin closure, and mitigation of any risk of infection. The decision to treat is made without the clinicians making moral judgments about how the injured person conducts his or her life. The clinicians involved can document the supplies used, the time medications were administered, and even the time the patient first awoke following surgery. All the documentation can be done without the providers even knowing the patient’s name, or how the injury occurred. It is technical, impersonal, and rather noncontroversial.

In contrast, chronic pain management is fraught with controversy.

Who really needs an MRI, and who does not? Who needs 2 lumbar medial branch block procedures vs 1? When is it appropriate for a patient to be given an “off label” medication? Who, if anyone, should be given access to potentially addictive medications, in what quantities, by what delivery system, and for how long?

Answers to all of these questions are beyond the scope of this article. Instead, its purpose is to help clinicians identify and document elements of patient care to improve patient satisfaction, improve continuity of care, and avoid documentation pitfalls which have led to problems for previous clinicians.

“There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.”

formal names we assign to our best guesses, based on synthesis of all available data. The diagnosis recorded should be as specific as possible, while the documentation may help subsequent providers refine the diagnosis, over time.

For instance, if a patient complains of chronic neck pain and occipital headaches following a motor vehicle accident, the treating clinician may only be able to document “cervicalgia and headache” at the first visit. Depending on responses to physical therapy, anti-inflammatory medication, and/or interventional therapy, as well as information gleaned from diagnostic imaging, that clinician may later document “cervical spondylosis,” possibly even “occipital neuralgia.” While the patient may still complain of neck pain and headaches, the gradual refinement of the documented diagnosis serves to help that clinician, or subsequent clinicians, allay patient fears of a more ominous problem.

Additionally, if a clinician learns of a salient piece of psychosocial information, it may lead to changes in the documented treatment plan, such as referral to a mental health counselor for a person whose accident occurred while fleeing an abusive partner.

—William Osler, MD

Chronic pain documentation is made even more challenging by the presence of multiple dynamic processes, some of which The statement above, by one of the founders of Johns “feed” off one another. A patient with a work related injury to Hopkins Medical Center, is as true today as it was in an ankle may develop a need for a cane for safety and support. the early 20th century. Documentation of chronic pain Over time, use of the cane may lead to development of carpal requires the collection and synthesis of many subjective tunnel syndrome. While the work related injury was not to pieces of information, in addition to the objective information the hand, a clear line of documentation of the onset and proclinicians are able to collect through their senses and diagnostic gression of the hand pain may help the patient gain access to testing. Patients may be easily able to communicate what hurts, rational therapeutic treatments such as bracing, median nerve what it feels like, and how intense the pain is. However, the injection, possibly even surgery. onset and timing history may provide further information that is important to consider, more so than simply the “what” and Pain is a subjective experience. As such, the process of the pain “how much” characteristics of the pain. related patient interview can be aided by the use of systematic arrangement of subjective information. Salient details such as Symptoms are what patients report to clinicians—their data. onset, location, duration, character, aggravating factors, relievSigns are what we as clinicians observe, feel, hear, smell (or ing factors, and treatments (the OLD CART mnemonic) often proeven taste, as was done prior to the advent of the sweat chloride vide the skilled clinician with much of what is needed to narrow test for cystic fibrosis). Signs are our data. Diagnoses are the the differential diagnosis list.

stablishing the diagnosis

28 PWJ | www.painweek.org

Q 1 | 2019

Prior to prescribing opioid analgesic medications, clinicians should document which nonaddictive therapies a patient has tried, the responses to those treatments, and which others should be considered prior to committing to potentially addictive treatment.

Most clinicians are familiar with the SOAP arrangement of data (subjective, objective, assessment, plan) developed by Dr. Lawrence Weed in the late 1960s. The “SOAP note” format made it relatively simple for anyone—other clinicians, insurance carriers, attorneys, etc—reading the medical record to find the information they need, as well as to see places where information may have been missed.1 The more efficiently a clinician can record the information regarding a given visit, the more patients can receive the care they need in a given time period. Furthermore, improved efficiency may permit each provider to have more time available to pursue his or her personal activities.

etting goals

Chronic pain is also a highly emotional experience.2 Even if pain were to be completely eliminated in a given patient’s case, the patient may have already lost out on something meaningful in life to the point of being dejected, depressed, and despondent. Pain may have stopped that patient from being the productive employee, caring spouse, outgoing parent, or accomplished athlete that s/he had been Q 1 | 2019

at one point. Consequently, it is worth taking the time to ask patients which pleasurable activities have been impacted by their painful conditions. In doing so, the provider not only shows concern for patients as individuals, but also gains an understanding of what should be the patient-specific goals of rehabilitative efforts.

Those goals may need to be elicited and/or clarified with some suggestions by the clinician, or even in a group therapy setting with other patients.3 For instance, a patient with a 20-year history of phantom foot pain may list “being painfree” as a goal. Instead, if the clinician determines that the patient wakes frequently due to pain, a goal of “sleeping without waking due to pain” may be more attainable.

The theory of a “hierarchy of needs,” as developed by Abraham Maslow4 in the 1940s, remains useful in modern pain assessment and treatment. Every person has basic needs (food, water, rest, security) which must be attained before that person is able to effectively pursue more advanced needs (intimacy and family relationships), or even higher needs (self-esteem, self-actualization). By asking a patient what s/he has difficulty www.painweek.org | PWJ

29

practice management

accomplishing, the clinician is able to identify what the patient WANTS to accomplish. For instance, a patient who expresses frustration at not being able to vacuum a floor at home has made it clear that home cleanliness is important. If the patient is able to vacuum the floor following implementation of some therapy (nonmedicinal or otherwise), that “step up” on the hierarchy of needs serves as easily documentable evidence of improved function.

“One of the first duties of the physician is to educate the masses not to take medicine...”

—William Osler, MD

ocument nonaddictive treatments

Members of the public in the United States have been indoctrinated to expect some form of medical management for virtually every complaint, as evidenced by the nearly 4.5 billion prescriptions dispensed in 2016.5 Some medications used to treat chronic pain, such as nonsteroidal anti-inflammatory drugs (NSAIDS) and anticonvulsants, are fraught with adverse effects. They are by no means benign treatments, although they are not considered potentially addictive.

In contrast, much of the controversy in chronic pain management has to do with the prescribing of opioid analgesics. Prior to prescribing opioid analgesic medications, clinicians should document which nonaddictive therapies a patient has tried, the responses to those treatments, and which others should be considered prior to committing to potentially addictive treatment.

Multiple nonmedication treatment options exist for patients with chronic pain. Some actually reduce pain intensity, while others serve to maximize self-efficacy even without reducing pain intensity. Behavioral medicine treatment such as mindfulness-based stress reduction (MBSR) have proven to be useful for some patients to reduce the perceived intensity of pain.6 Skilled physical therapy serves to maximize strength and range of motion for an affected part of the body, while occupational therapy can help a patient learn different ways to perform tasks to minimize exacerbations of pain and risk of falling. Home based exercise regimens such as tai chi or yoga have helped millions of people worldwide maintain flexibility well into old age, and can be taught and incorporated into the lives of patients who have chronic pain disorders of almost any variety.7 The provider should document not only which therapies and medications have been tried and failed, but what led to the discontinuation of previous treatments. Was it lack of perceived efficacy? Was it a problem with side effects? Was it a cost issue?

Was it the presence of a family member in the home who was stealing medication? Is the previous limiting factor even still a limitation? A patient with neuropathic pain who reports having tried and “failed” pregabalin at 25 mg once daily may

30 PWJ | www.painweek.org

simply have had a failure of that dose. In contrast, that patient may experience significant relief with retrial and titration (≤150 mg BID over a period of a few weeks).

Some patients will have already received repeated prescriptions for opioid medication before ever being referred for more specialized evaluation and treatment. By the time the patient is evaluated by a rheumatologist, neurologist, physiatrist, orthopedist, neurosurgeon, or interventional pain specialist, the patient may have become dependent upon significant quantities of opioid analgesics. This situation makes the diagnostic process, as well as postoperative pain control and functional rehabilitation, all the more challenging. To that end, stringent regulations have been instituted in many states: regulations such as the limited quantity and potency of medications prescribed following acute injury or in the acute postoperative period.

By the time a patient sees a particular clinician for help, that patient may have already been to see a chiropractor or physical therapist for back pain or neck pain. He or she may have already consulted a nutritionist or bariatric surgeon for help with weight loss in hopes of relieving arthritic knee pain. The patient may have already even undergone interventional or surgical treatment to address nerve compression, only to have residual pain following the usual postop recovery period.

Documenting a medication history allows a provider to compare what medications the patient claims to have taken to what is shown on the prescription monitoring program (PMP) or records of previous drug tests. If the PMP indicates fentanyl patches had been prescribed and dispensed to a patient for several months, while the patient acknowledges only ever having taken hydrocodone or oxycodone, it could mean the patient is concealing information, has a cognitive disorder, or both. Likewise, if review of a drug test from another provider reveals the patient’s specimen tested positive for 6-monoacetylmorphine (a heroin metabolite), that documentation trumps the patient’s denial of any history of illicit substance use.

hen opioids are indicated for chronic pain

In this writer’s opinion, the reason many clinicians prefer to avoid prescribing opioid analgesics for chronic pain has little to do with fear of sanctions, nor about concerns about sequelae such as physical dependence, addiction, or neonatal abstinence syndrome. Rather, clinicians are simply not comfortable making moral judgments about the behavior of patients. Some clinicians may earn a comfortable living treating hypertension, hyperlipidemia, heart disease, diabetes, respiratory diseases, even cancer, without ever having to ask questions of a moral nature. Treating most diseases does not require the clinician to consider questions such as “Does this patient deserve a trial of this medication? Is this patient trustworthy to appropriately handle this medication? Is Q 1 | 2019

The provider should document not only which therapies and medications have been tried and failed, but what led to the discontinuation of previous treatments. Was it lack of perceived efficacy? Was it a problem with side effects?

Was it a cost issue?

this patient’s family environment stable enough for this medication to be in the home? Is this patient lying about the reason he is requesting this Brand X medication?”

Such is not the case in the world of pain management. Patients and their family members can, and often do, withhold and/or fabricate information in order to obtain controlled substances for nonmedical purposes. Those of us who are comfortable with prescribing opioids must continually assess and document information pertaining to disease processes, past and present patient behaviors, socioeconomic considerations, and myriad other bits of information. This collection of information, in conjunction with our train of thought about how they fit together, leads to changes in treatment plans.

When a clinician has established a diagnosis consistent with chronic pain, and when the patient has failed to achieve functional goals with nonaddictive treatments, and when there is no clear psychosocial contraindication, it is reasonable for a Q 1 | 2019

clinician to initiate a therapeutic trial of an opioid analgesic.

This is supported by the Federation of State Medical Boards guidelines, as adopted in 2017.8 Nurse practitioners and physician assistants, whose prescriptive privileges vary from state to state, should consult their respective boards for further guidelines pertaining to opioid prescribing since they may be more restrictive than the medical boards in their respective states.

Chronic pain management with opioid analgesics is far more complex than simply documenting an updated set of vital signs, a subjective pain score, and a urine drug test result. Documentation of patient activity, however seemingly anecdotal, indicates the clinician and patient are participating in meaningful therapeutic encounters. For instance, if a patient mentions going out to a restaurant with family to celebrate a birthday, that information is actually more valuable than any documented pain score. It shows the patient was not incapacitated by pain, and comfortable enough to pursue normal activities and maintain interpersonal relationships. As of the date of that visit, that www.painweek.org | PWJ

31

practice management

patient was higher on the Maslow hierarchy scale than if the pain were not being reasonably controlled.

State boards of medicine, nursing, pharmacy, and other such agencies recognize that guidelines are to be adhered to under normal circumstances, but expect there to be occasional deviations from those guidelines. Case reviewers in licensure matters may give the benefit of the doubt to a clinician in evaluating a clinical record, but want a clinician’s decision-making process to be well-documented whenever departures are made from a local standard of care.

Clinicians who work with chronic pain patients do so through repeated application of the scientific process. They assess pain complaints, diagnose the sources of pain, plan ways to alleviate the pain, implement the plans, and re-evaluate to determine the success of what amounts to small-scale clinical trials with an “n-of-1.”9 While a clinician may recognize the burden of pain on a patient’s life, and an ethical duty to do something about it, the same clinician may feel pressured by regulatory authorities and insurers to adhere to a strict set of guidelines.

Such pressure can, and already does, influence many clinicians to undertreat pain. If a particular state’s statute requires a query of a PMP for prescriptions of more than a 3-day supply of opioids, then many chronic pain patients in that particular state will only receive prescriptions for 3-day supplies, if at all. In other words, those patients only receive meaningful analgesia for 10% of a month, or less, despite describing activity limiting pain on a daily basis. In such a scenario, the risk of an overdose death from medication prescribed by those clinicians is miniscule. However, the undertreatment of pain may influence patients to obtain medication from potentially fatal counterfeit sources. This sort of problem has repeatedly occurred in the past few years as the pendulum has swung from liberal opioid prescribing policies to much more restrictive policies.

itfalls of electronic health records

Third party insurers pay for most of the healthcare activity in the United States,10 and can only be assured money is being well-spent when they can glean useful information from medical records created by various clinicians.

Furthermore, state licensing boards (as well as malpractice attorneys and defense attorneys) rely on medical records to determine who is, or is not, assessing and treating patients in a manner consistent with existing statutes and guidelines.

These agencies cannot assume that a provider thought about a diagnostic or therapeutic option for a patient if a statement to that effect is not easy to find in the clinical record. The reviewers whom these agencies employ cannot spend unlimited amounts of time looking for information. As a result, the responsibility falls to the clinician to make sure his or her thought processes have been well-documented.

32 PWJ | www.painweek.org

Electronic health records (EHRs) are the rule of the day, as any clinician who has entered practice within the past decade is well aware. The idea behind these record systems is fundamentally sound. By maintaining records in electronic format, the maintenance and accessibility of those records should be improved compared to their predecessors in pen-and-paper format. Additionally, old stereotypes regarding the illegibility of doctors’ handwriting led EHRs to be touted as a way of minimizing errors of transcription, thereby minimizing risks to patients.

Clinicians may access their records at any time, day or night, even from a distance, as long as they have access to suitable software. Unfortunately, in the event of a bad patient outcome, a clinician’s temptation to open the electronic record and look back at the last encounter may come up during investigation, since the EHRs maintain an irreversible log of who has accessed the note, and when. No clinician wants to hear words from an attorney to the effect of, “If you were so sure you had provided good care, why did you get into the note to look at it as soon as you heard something bad happened to the patient?”

EHRs hold the potential to improve intercommunication between providers, but only between those using the same program. Unfortunately, as insurers demanded records be submitted in an electronic format, they did so without requiring any standardization. Thus, various EHRs often have to be converted to other file formats, or even printed and faxed, in order to be shared with other clinicians using different record formats.

One prominent recent example involves the incompatibility between the electronic records of the Pentagon’s health system and those of the Veteran’s Administration. Attempts at “merging” those 2 EHRs is likely to take several more years, at a cost to taxpayers of many billions of dollars.

“The present letter is a very long one, simply because I had no leisure to make it shorter.” —Blaise Pascal

enefit of brevity

The absence of standardization in EHRs requires multiple people to “touch” the record, in terms of opening electronic files, gleaning information from the notes, editing that information, and recording changes from one visit to another. Unfortunately, consecutive entries in EHRs often result in “note bloat,” in which formerly pertinent information is retained within the body of subsequent note, even though it may no longer be applicable. For instance, a diagnosis of “osteoarthritis of the right knee” may be reasonable in a clinician’s note at one point, but should not still be included in the list of active diagnoses after that patient has undergone right knee replacement. The fact that such bloat occurs may be taken as a sign of inattention to detail by people who have been employed to review notes in case of unfortunate patient outcomes.

Q 1 | 2019

onclusions

Insurers all want to see something in writing to justify the billing for a given level of service. Since it is not uncommon for patients to see multiple clinicians over their lifespans, patients end up spending many hours filling out redundant medical history forms, undergoing repeat physical examinations, and even repeating costly diagnostic tests or enduring side effects from medication. Good documentation begins with observation, putting the salient details of that observation into the briefest terms possible, and removing unnecessary information whenever possible, while preserving the chain of events. A move toward brevity in documentation may help to facilitate continuity of care while reducing the burden of unnecessary and costly repeat testing. In doing so, good documentation holds the potential to save valuable hours in the lives of patients, as well as those of us who choose to spend our lives as clinicians.

References 1. Weed, LL. Medical records that guide and teach. N Eng J Med. 1968;278:593–600, 652–657.

2. Lumley MA, Cohen JL, Borszcz GS, et al. Pain and emotion: a biopsychosocial review of recent research. J Clin Psychol. 2011;67(9):942–968.

3. Bauer SM, McGguire AB, Kukla M, et al. Veterans’ pain management goals: changes during the course of a peer-led pain self-management program.

Patient Educ Couns. 2016;99(12):2080–2086.

4.

Maslow AH. A theory of human motivation. Psychol Rev. 1943;54(3):370–396.

5. Carr T. Too many meds? America’s love affair with prescription medication.

Consumer Reports, August 3, 2017. Available at: www.consumerreports.org/prescription-drugs/too-many-meds-americas-love-affair-with-prescription-medication/.

6. Zeidan F, Vago D. Mindfulness meditation-based pain relief: a mechanistic account. Ann N Y Acad Sci. 2016;1317(1):114–127.

7. Kong LJ, Lauche R, Klose P, et al. Tai chi for chronic pain conditions: a systematic review and meta-analysis of randomized controlled trials. Sci Rep. 2016;6:25325.

8. Federation of State Medical Boards. Guidelines for the chronic use of opioid analgesics. Available at: www.fsmb.org/globalassets/advocacy/policies/opioid_guidelines_as_adopted_april-2017_final.pdf.

9. Lillie E, Patay B, Diamant J, et al. The n-of-1 clinical trial: the ultimate strategy for individualizing medicine? Per Med. 2011;8(2):161–173.

10. Kaiser Family Foundation. State health facts: health insurance coverage of the total population, 2016. Available at: www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B”colId”:”Location”,”sort”:”asc”%7D.

Q 1 | 2019

www.painweek.org | PWJ

33

, daba -pm,

ay J oshi MD, daba

By J

faba -pm

  The incidence of failed back surgery syndrome after the first spinal surgery is between a whopping 20% to 40% ‌

interventional

. One of t he most d words. M readed any peop le are afr of surger aid y, and rig htfully so Complica . tions can intraope h a p p e n ratively, especiall surgical c y during ases nea r nerves the spina and l cord. Fo rtunately complica , the tion rate during th intraope rative po e rtion of s is relativ u r g e ry ely low, e specially the hand in s of a goo d surgeo Unfortun n. ately, the complica rates afte tion r surgery are frigh high. We teningly lcome to f a il ed back surgery s yndrome .

is a worldwide problem, with an estimated 9.4% global prevalence.1 It creates more disability than any other condition in the world.1 Not surprisingly, the prevalence of low back pain increases with age,2 and as a result, more lower back surgeries are being performed. During a 10 year span from 1998 and 2008, primary lumbar fusions increased by 170.9% from 77,682 to 210,407 and the rate of laminectomies increased by 11.3% from 92,390 to 107,790.3 Unfortunately, a significant percentage of patients will see temporary relief, no relief, or even increased pain and disability long-term after surgery. These scenarios fall under failed back surgery syndrome (FBSS).

Q 1 | 2019

www.painweek.org | PWJ

37

interventional

The International Association for the Study of Pain defines FBSS as “lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location.”4 The onset of FBSS occurs when surgery fails to treat the patient’s lumbar spinal pain. Minimization of the likelihood of FBSS is dependent on determining a clear etiology of the patient’s pain. After determining the cause of FBSS, a multidisciplinary approach is preferred.

Patients with FBSS have had ≥1 surgical interventions that have failed to treat the pain. The incidence of FBSS after the first spinal surgery is between a whopping 20% to 40% depending on the type of surgery and the population analyzed.5 The incidence of FBSS only rises on subsequent spinal surgeries. Invariably, scar tissue will form after surgery, thus causing FBSS even in the best surgical hands. However, sloppy technique, failure to correctly diagnose, and minimizing conservative and multimodal strategies are also major contributors to FBSS.

The etiology of FBSS is multifactorial. There are preoperative indicators that can help stratify risk ratios for developing FBSS prior to spinal surgery. It sounds simple, but verifying the accuracy of diagnoses is critical and is not always done.6 For example, misdiagnosis or incorrect assessment of central stenosis, lateral stenosis, nerve entrapment, and facet pain result in the majority of FBSS cases. We routinely see simple facetogenic pain secondary to facet arthropathy (arthritis in the joints in the spine) diagnosed as discogenic pain, leading to a plethora of unnecessary surgeries on nonpain generating areas causing lifelong FBSS. Interventional pain management, when performed correctly, can provide very accurate diagnoses as well as solid treatment results for many conditions with no chance of FBSS. Even more rarely performed are comprehensive assessments of patient’s behavioral, psychological, medical, and socioeconomic status.

Many lower back surgeries are performed for “lower back pain” with some types of MRI findings, many of them age related changes. This may be a result of fundamental system flaws.

Medical and pain management is not the surgeon’s job and in many cases was never properly taught to the surgeon. In addition, there are economic factors that play a role in the decision to perform surgery, both on the surgical side and the patient side. In cases involving litigation, such as Workers’ Compensation cases, patients respond poorly to spine surgeries compared with non-Workers’ Compensation patients in virtually all outcome criteria, including postoperative pain levels, opioid use, function, and emotional well-being.7,8 Understanding the patient’s behavior and habits can affect postoperative outcomes after spine surgery as well. For example, a study showed that patients who smoked and underwent spine

38 PWJ | www.painweek.org

surgery for spinal stenosis used more analgesics, had more trouble walking, and had a decreased quality of life 2 years after surgery compared with nonsmokers.9 It is commonly known that smoking inherently increases the risk for a multitude of other postoperative complications. Other behaviors and habits— such as diet, exercise, body habitus, and alcohol or other drug usage—should also be considered prior to surgery.

In addition to being aware of the patient’s behavior and habits, assessing the patient’s psychological status should be routine.

That assessment is mandatory by most insurance companies for dorsal column and peripheral stimulator trials and implants, which are reversible. Yet for permanent spinal surgery, many of which result in FBSS, psychological testing is virtually never performed or required. Patients should be assessed for central sensitization. Depression, a form of central sensitization, is one of the most common and strongest predictive indicators for a negative outcome after spinal surgery.10 Patients with central sensitization will involuntary perceive more pain due to the fundamental pathophysiology of central sensitization. The central nervous system will perceive the surgery as an ongoing injury and neuroplastic changes will cement in the injury as permanency. The same can be true with other procedures, even interventional pain management procedures. We have seen complex regional pain syndrome (CRPS) develop from surgeries and simple nerve blocks, even when proper technique was used.

Therefore, it is important to assess central sensitization, which includes depression, anxiety, posttraumatic stress disorder (PTSD), and CRPS, as well as other psychological and social factors prior to surgery. Psychological status is largely overlooked and not mandatory prior to life altering, irreversible surgery, and the majority of spinal surgeons do not require such an evaluation.11

After the preoperative screening and the intraoperative attention to detail that is required to maximize outcomes, there are multiple postoperative factors that can contribute to FBSS. Diligent postoperative assessment and follow up are imperative.

In addition to scar tissue formation—which is the basis of all healing of any tissue that’s been cut or altered—postoperative pain may be a result of the

○○ Preoperative source of pain that was not correctly addressed ○○ Additional degeneration to the spine at levels above and below the area of surgery ○○ Additional damage to the spine or surrounding tissue from the surgery ○○ Stress from the surgery to tissue or the central nervous system (central sensitization) All surgeries, including spinal surgery, result in different biomechanics, for better or worse. This may cause an increased Q 1 | 2019

…misdiagnosis

or incorrect assessment of central stenosis, lateral stenosis, nerve entrapment, and facet pain result in the majority of failed back surgery syndrome cases.

load on adjacent joints, muscles, and other structures, which could result in increased pain and decreased function. Eventually, those other areas will degenerate sooner then they might have without that surgical procedure.12 Two common areas of increased pain postspinal fusion are the facet joints and the sacroiliac joints (in lumbar fusion surgeries).13 Many of these cases are misdiagnosed, and additional spinal surgeries are recommended and performed, thus further worsening the patient’s pain and function and increasing their need for pain medications, including opioid medications.

Diagnosing FBSS, similar to any other disease or condition, always begins with a thorough history and physical examination. This includes, and is not limited to, assessment of central sensitization and outcomes from previous surgeries. Acute pain after surgery needs to be addressed urgently and wholeheartedly. It should not just be brushed off as normal or drug-seeking behavior. Longstanding pain after surgery also needs to be addressed with diligence and care. Chronic postoperative lower back pain is often difficult to assess because physical examination is not diagnostic and simply creates a large differential diagnosis. As a result, other diagnostic modalities, such as interventional pain management procedures, are useful in providing an accurate diagnosis.

Imaging is useful in screening for various disease processes and can be helpful in supporting certain diagnoses. X-ray imaging is typically chosen initially to show spinal architecture and deformities; however, they have many limitations. For example, Q 1 | 2019

X-rays do not show the spine in 3 dimensions and they cannot assess soft tissue. MRI imaging is the gold standard in evaluating the soft tissue in the lower back, especially after surgery, even though the imaging can be obscured due to hardware, if present. Contrast dye enhanced T1-weighted MRIs allow for soft tissue differentiation, such as scar tissue, disc herniation, and abscess.14 CT imaging is helpful in visualizing bony changes and facetogenic changes better than MRIs.15 CT myelography may be needed when hardware interferes with images.16 The radiation involved with CT imaging, however, must be taken into consideration and should only be ordered when there is a clear indication for the risks of additional radiation exposure to the patient. In certain cases, discography under fluoroscopic guidance may be needed to assess discogenic pain, even after fusion surgery. In many cases, disc material is left in the disc space after fusion surgery.

Once a diagnosis has been made, or at least a firm differential diagnosis is in place, management of FBSS is the next step. Management starts with conservative options that are followed by minimally invasive procedures, followed by surgical options, similar to the philosophy which should have been used prior to the first surgery. Conservative options include, but are not limited to, physical therapy, psychotherapy, stress reduction, cognitive behavioral therapy, acupuncture, diet, exercise, and medication management. Oral pharmacologic options for the treatment of FBSS are multimodal and controversial. They can include antiepileptics, nonsteroidal anti-inflammatories, oral steroids, antidepressants, muscle relaxants, and opioids. www.painweek.org | PWJ

39

interventional

Guided and specific procedures, such as those that are performed by interventional pain management physicians, can be both diagnostic and therapeutic. Some examples of diagnostic procedures17 include:

○○ Selective nerve root blocks or transforaminal epidural steroid injections, which can be more diagnostically predictive for pain than electromyograms ○○ Sacroiliac joint injections, which have variable outcomes due to operator technique, thus resulting in a high rate of false negatives ○○ Medial and lateral branch block for the sacroiliac joint, which has a lower rate of false negatives ○○ Facet intraarticular vs medial branch block (medial branch block is a superior approach, less traumatic, and more predictive for radiofrequency ablation) Management of FBSS with therapeutic interventional pain procedures include epidural steroid injections (ESI), which are more appropriately described and defined by their approach: transforaminal (TFESI), interlaminar (LESI), and caudal. ESIs are indicated for radiculopathy, which can sometimes be incomplete, resulting in mainly back pain and minimal-to-no extremity pain.

Radicular symptoms may be secondary to herniated disc, postoperative adhesions, ligamentum flavum hypertrophy, spondylolisthesis, and osteophyte formation.10 Properly performed TFESIs can be diagnostic and therapeutic. Up to one-half of patients can avoid spinal surgery with ESI, with even stronger percentages in patients who have not had prior surgery.18 Adhesiolysis has been used, most often via the caudal approach, for postoperative scar formation. Adhesions may cause back and leg pain. Adhesions may also contribute to pain in ≤36% of FBSS cases.19 Radiofrequency ablation has been used successfully for decades in the management of pain with various joint and peripheral neuralgias, especially with FBSS.

and cut costs associated with disability, imaging, medications, and hospitalizations.21 In some situations, repeat surgery is necessary. Revision surgeries are not associated with improved pain scores and have a higher rate of comorbidities and mortality.22 In other words, FBSS is higher on subsequent surgeries. As always, careful consideration of the type of therapy, risks, and benefits should be used. One study showed only a 35% success rate 15 months after an instrumented fusion for the treatment of FBSS.12 This data reemphasizes that spine surgery, especially hardware and fusion based spine surgery, should be considered last line therapy unless complications from the previous surgery, such as loss of bowel or bladder function, motor weakness, infection, and neurological impairments, persist.

Many healthcare providers still, unfortunately, refer patients to surgeons for evaluation and management of pain, leading to unnecessary surgeries. In fact, large employers are now forcing their employees to seek evaluation for their pain from specified hospitals and surgeons in an effort to “reduce costs” of surgery.

This approach may end up costing the employer more if those patients develop FBSS. Chronic pain is torture and it is understandable that patients want to resolve it. FBSS is real and it is imperative that, as providers, we try to minimize the additional trauma of FBSS whenever possible.

References 1. Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(6):968–974.

2. Smith M, Davis MA, Stano M, et al. Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Panel Survey data for years 2000 to 2007. J Manipulative Physiol Ther. 2013;36(1):2–11.

3. Rajaee SS, Bae HW, Kanim LE, et al. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine. 2012;37(1):67–76.

When conservative options and interventional injections have failed or provided success that has not lasted long enough, neuromodulation is considered an appropriate next step if there is no myelopathy. In fact, neurostimulation should be considered before even the first surgery to provide pain relief and avoid FBSS. Spinal cord stimulation (SCS) is split up into dorsal column stimulation and dorsal root ganglion stimulation. SCS and peripheral nerve stimulation are all forms of neurostimulation. SCS in some form has been around for over 50 years.20 Pain relief from SCS is theorized to be via a direct effect on the spinal cord, an indirect effect on the central nervous system, and an indirect effect on descending inhibitory pathways. This author theorizes that the indirect effects are best described by neuroplastic changes and reduction of central pain and central sensitization. SCS implantation would be cost-effective in 80% to 85% of patients when applying quality-adjusted life years.10 SCS may reduce loss of productivity and emergency room visits,

40 PWJ | www.painweek.org

4. Harvey AM. Classification of chronic pain – descriptions of chronic pain syndromes and definitions of pain terms. Clin J Pain. 1995;11(2):163.

5. Thomson S. Failed back surgery syndrome – definition, epidemiology and demographics. Br J Pain. 2013;7(1):56–59.

6. Burton CV, Kirkaldy-Willis WH, Yong-Hing K, et al. Causes of failure of surgery on the lumbar spine. Clin Orthop Relat Res. 1981;157:191–199.

7. Gum JL, Glassman SD, Carreon LY. Is type of compensation a predictor of outcome after lumbar fusion? Spine. 2013;38(5):443–448.

8. Nguyen TH, Randolph DC, Talmage J, et al. Long-term outcomes of lumbar fusion among workers’ compensation subjects: a historical cohort study. Spine.

2011;36(4):320–331.

9. Sandén B, Försth P, Michaëlsson K. Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish spine register. Spine. 2011;36(13):1059–1064.

10. Baber J, Erdek M. Failed back surgery syndrome: current perspectives. J Pain Res. 2016;9: 979–987.

Q 1 | 2019

11. Young AK, Young BK, Riley LH, 3rd, et al. Assessment of presurgical psychological screening in patients undergoing spine surgery: use and clinical impact.

J Spinal Disord Tech. 2014;27(2):76–79.

12. Arts MP, Kols NI, Onderwater SM, et al. Clinical outcome of instrumented fusion for the treatment of failed back surgery syndrome: a case series of 100 patients.

Acta Neurochir. 2012;154(7):1213–1217.

13. Unoki E, Abe E, Murai H, et al. Fusion of multiple segments can increase the incidence of sacroiliac joint pain after lumbar or lumbosacral fusion. Spine.

2016;41(12):999–1005.

14. Babar S, Saifuddin A. MRI of the post-discectomy lumbar spine. Clin Radiol.

2002;57(11):969–981.

15. Eun SS, Lee HY, Lee SH, et al. MRI versus CT for the diagnosis of lumbar spinal stenosis. J Neuroradiol. 2012;39(2):104–109.

16. Hussain A, Erdek M. Interventional pain management for failed back surgery syndrome. Pain Practice. 2014;14(1):64–78.

17. Datta S, Manchikanti L, Falco FJ, et al. Diagnostic utility of selective nerve root blocks in the diagnosis of lumbosacral radicular pain: systematic review and update of current evidence. Pain Physician. 2013;16(2 suppl):SE97-S124.

18. Bicket MC, Horowitz JM, Benzon HT, et al. Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. Spine J. 2015;15(2):348–362.

19. Chan CW, Peng P. Failed back surgery syndrome. Pain Med. 2011;12(4):577–606.

20. Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. Anesth Analg. 1967;46(4):489–491.

21. Zucco F, Ciampichini R, Lavano A, et al. Cost-effectiveness and cost-utility analysis of spinal cord stimulation in patients with failed back surgery syndrome: results from the PRECISE study. Neuromodulation. 2015;18(4):266–276.

22. Diebo BG, Passias PG, Marascalchi BJ, et al. Primary versus revision surgery in the setting of adult spinal deformity: a nationwide study on 10,912 patients. Spine.

2015;40(21):1674-1680.

Q 1 | 2019

www.painweek.org | PWJ

41

By Jarod A. Hall PT, DPT

‌the bulk of the scientific literature does not appear to support the usage of dry needling or acupuncture‌ for the treatment of musculoskeletal pain.

Yet, in daily clinical practice a large group of highly educated, talented, and caring clinicians anecdotally find positive results with the usage of these interventions.

physical therapy

In the past several decades, the utilization of a treatment for musculoskeletal pain called dry needling has progressively exploded in popularity. Dry needling is an intervention that involves the insertion of thin monofilament needles into tender points in the body without the injection of any substance. Since its development, dry needling has become a commonly used intervention by physical therapists, chiropractors, and osteopathic physicians to treat a variety of painful musculoskeletal disorders. As present day dry needling is most often applied through the use of acupuncture needles, many acupuncture boards have pursued litigation against those practicing dry needling with accusations of practicing acupuncture without a license.

However, advocates propose that dry needling is a vastly different intervention from that of acupuncture due to the westernized biomedical diagnostic and treatment model that most often involves the concept of myofascial trigger points.1 For the purposes of this article, we will examine the literature surrounding dry needling and acupuncture weighted together as a single intervention using thin monofilament needles to penetrate the skin in order to reach a specific target perceived to be a cause of musculoskeletal pain. In addition, we will explore the literature examining shortcomings of the trigger point hypothesis, the limitations of trigger point palpatory reliability, the efficacy of needling for various musculoskeletal conditions, and explanations for why clinicians have experienced anecdotal success with needling interventions.

44 PWJ | www.painweek.org

Q 1 | 2019

Janet Travell, who first published her landmark paper on myofascial trigger points in 1942, is the name most closely associated with the development and popularization of dry needling and the proposed phenomenon of myofascial trigger points.2 Travell and Simons have since suggested a definition stating that myofascial trigger points (MTrP) are hyperirritable spots in skeletal muscle that are associated with a hypersensitive palpable nodule in a taut band. The spot is tender when pressed and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena.3 However, as evidence has continued to emerge, the definition and understanding of trigger points, as well as once accepted diagnostic criteria, has become more ambiguous and less definitive. Tough et al reported in 2007 that “An extensive review identified at least 19 different sets of diagnostic criteria used for the MPS/TrP [myofascial pain syndrome/trigger point] syndrome, and concluded there was a lack of consistency and consensus on case definition. Until reliable diagnostic criteria has been established, there is a need for greater transparency in research papers on how a case of MTrP pain syndrome is defined, and claims for effective interventions in treating the condition should be viewed with caution.”4 Furthermore, international panels of trigger point experts have not been able to confidently or consistently agree on a strict working definition or consensus on diagnostic criteria when investigated through Delphi study designs. These experts proposed a cluster of 3 diagnostic criteria as essential for the TrP diagnosis: 1 ) a taut band, 2 ) a hypersensitive spot, and 3 ) referred pain. If any 2 of the 3 proposed criteria were met, the diagnosis of a trigger point could be made. Remarkably, a finding of local tenderness was not considered necessary for the diagnosis of a trigger point.

Furthermore, these criteria failed to lend credence to the already underwhelming evidence on reliability of trigger point palpation.5

How can we effectively treat something on which we cannot consistently agree or define?

What is the reliability of palpating trigger points?

As stated above, many approaches to dry needling are underpinned by the theory of myofascial trigger points. However, upon closer examination of available evidence, the reliability and validity of medical providers’ abilities to diagnose trigger points Q 1 | 2019

through the use of manual palpation is overwhelmingly weak and raises cause for concern.6-11 The weight of these findings raises several questions of significance as medical diagnoses such as myofascial pain syndrome rest upon the palpation and diagnosis of MTrP as a key feature of the condition. To paraphrase Quintner et al, the construct of myofascial pain syndrome caused by myofascial trigger points remains conjecture, and sufficient research exists to discard MTrP theories. The scientific literature shows that the diagnosis of the pathognomonic feature of myofascial trigger points is unreliable and that all working hypotheses derived from this conjecture have been refuted.10 www.painweek.org | PWJ

45

physical therapy

A Test or Examination Cannot Be Valid Unless it is First Reliable

has biological plausibility and is in several studies dating as far back as 1938.14 Through close examination of the evidence, it appears that trigger points, at least in the traditionally understood rhetoric, may not exist as we have been taught to believe. Yet, we have many treatments, including but not limited to dry needling designed to treat them.

The evidence for needling

How can you manually treat something you can’t reliably find/palpate?

Soft tissue sore spots of unknown origin Despite lack of consistent diagnostic criteria or evidence supporting reliable manual palpation of myofascial trigger points, many people do often have tenderness to palpation in various musculoskeletal soft tissues. These areas have been referred to

by Meakins as “soft tissue sore spots of unknown origin” in a 2015 clinical commentary in the British Journal of Sports Medicine.12 Most clinicians who use manual techniques for assessment or treatment have likely felt areas of tissue that patients report to be painful. These “sore spots”:

○○ Elicit pain when manual pressure is applied ○○ Often flare in intensity and number when an individual is stressed ○○ Often flare in intensity and number when a person is either physically or cognitively overworked ○○ Often refer pain to other places ○○ Seem to feel better after being treated with manual therapies The question remains: what exactly are these sore spots?

There are alternate hypotheses to explain soft tissue sore spots, and several have more deeply considerable biological plausibility. Among these, 2 hypotheses have gained the most attention.

These soft tissue sore spots of unknown origin may in fact be peripheral neural inflammation at the level of the nervi nervorum or simply referred/secondary hyperalgesia from remote sites. Quintner and Teixeira have both proposed that nervi nervorum structural and functional abnormalities may contribute to the onset, maintenance, and worsening of neuropathic pain and “dermodulatory” painful syndromes.10,13 Quintner has additionally proposed the hypothesis of referred/secondary hyperalgesia, a phenomenon in which elicited nociception in deep or remote tissues can prompt the occurrence of pain and tenderness to palpation that is subsequently experienced in a remote location to that of the nociceptive origin. This theory

46 PWJ | www.painweek.org

Despite lackluster literature to support the existence of trigger points and a clinician’s ability to locate said soft tissue sore spots, we must endeavor to explore the literature on the effectiveness of dry needling/acupuncture, the treatment in question. When examining the literature15-21 on the efficacy of dry needling/acupuncture, we see that

○○ A 2009 systematic review on dry needling and acupuncture by Tough et al concluded “needling was not found to be significantly superior to placebo.”15 ○○ In 2005 placebo controlled RCTs by Melchart et al and Linde et al concluded acupuncture intervention was more effective than no treatment but not significantly more effective than minimal acupuncture or other known interventions for the treatment of tension-type headaches and migraine type headaches.16,19 ○○ A 2010 RCT by Perez et al concluded the effectiveness of dry needling is comparable to that of percutaneous electric nerve stimulation for treatment of low back pain.17 ○○ Double-blind RCTs by Linde in 2005 and Dıraçoğlu in 2012 concluded that there were no differences between placebo and intervention groups in the treatment of temporomandibular joint dysfunction or migraine headaches.19,20 ○○ A Cochrane Database systematic review by Manheimer in 2018 concluded that acupuncture has little or no effect in reducing pain or improving function relative to sham acupuncture in people with hip osteoarthritis.21 ○○ A 2009 RCT by Cherkin concluded needle penetration through the skin appeared to be an unimportant feature for success in eliciting therapeutic benefits from acupuncture.22

You can’t define it, you can’t reliably find it, and treatments do not appear to be better than sham Explanations for clinical observations In well designed, placebo controlled, and appropriately blinded studies, the bulk of the scientific literature does not appear to Q 1 | 2019

“The current body of literature suggests that while there may not be a reliable diagnostic criteria or clinical examination protocol for the myofascial trigger point phenomenon, there are certainly patients with complaints of soft tissue sore sports of unknown origin searching for quick, easy, and low risk treatments.”

support the usage of dry needling or acupuncture as an evidence based method for the treatment of musculoskeletal pain.

Yet, in daily clinical practice a large group of highly educated, talented, and caring clinicians anecdotally find positive results with the usage of these interventions. What explanation can be used to account for the discordance between these clinical success stories and the findings of well controlled scientific investigation? In this scenario we may be reminded of the wise words of famed physicist Richard Feynman of the Manhattan Project: “The first principle of science is that you must not fool yourself—and you are the easiest person to fool.” There are Q 1 | 2019

in fact many explanations as to how well-meaning clinicians may see results in day to day practice that do not reflect the findings in controlled studies. These findings include but are not limited to the following:

○○ Counterirritation/diffuse noxious inhibitory control/ conditioned pain modulation: ● Diffuse noxious inhibitory control refers to an endogenous pain modulatory pathway that has often been described as “pain inhibits pain.” It is known to function through the mechanism by which dorsal www.painweek.org | PWJ

47

physical therapy

horn wide dynamic range neurons responsive to stimulation from one location of the body may be inhibited by noxious stimuli (heat, high pressure, electric stimulation, etc) applied to another, remote location in the body.23 ○○ Regression to the mean: ● Regression to the mean is a statistical phenomenon that is a technical way of saying things tend to even out over time. For example, a medical treatment that achieves stunning results on the first trial will probably not be as efficacious on the second. Regression to the mean can result in wrongly concluding that an effect is due to treatment when it is actually due to chance.

Ignorance of the problem will lead to errors in decision making.24 ○○ Natural history of the condition: ● Natural history is the process that will occur in the absence of treatment. Applying treatment while a disease process naturally resolves allows for one to easily fall prey to the posthoc fallacy and conclude that resolution of the condition must have been due to the applied treatment.25 ○○ Placebo effect/meaning response: ● Extensive research demonstrates that placebo effects are genuine psychobiological phenomenon attributable to the overall therapeutic context, and that placebo effects can be robust in both laboratory and clinical settings.26 ○○ Nonspecific contextual effects: ● A patient’s faith in their physician’s ability to heal may have an important role in the process of recovery and should probably not be underestimated. Manipulation of the therapeutic ritual and theatrics of treatment application have been well demonstrated to alter the perceived benefit of treatments and reduce subjective reports of pain experience.27

Conclusion The current body of literature suggests that while there may not be a reliable diagnostic criteria or clinical examination protocol for the myofascial trigger point phenomenon, there are certainly patients with complaints of soft tissue sore sports of unknown origin searching for quick, easy, and low risk treatments. Furthermore, there continues to be a long line of healthcare providers standing at the ready to address these sore spots with their filiform needles despite mounting evidence of insufficient treatment efficacy. Until current best evidence is fully integrated into clinical practice and professional entry level training, and while increasing numbers of people suffering with persistent pain seek our help, we will continue to struggle with dogmatism, claims of anecdotal success that supersede strong evidence, and cognitive backfire effects which present themselves when biases are challenged. However, in this age of “the

48 PWJ | www.painweek.org

opioid epidemic,” it must be stated that there are ever “bigger fish to fry.” Dry needling/acupuncture are treatments that lack strong scientific support, but their risks are much lower than that of over reliance on opioid usage, questionable surgical procedures, and even the overuse of common over-the-counter NSAIDs.28,29 It is imperative we not miss the forest for all the small trees in our way.

References 1. Dommerholt J. Dry needling - peripheral and central considerations. J Man Manip Ther. 2011;19:223–227.

2. Travell JG, Rinzler SH, Herman M. Pain and disability of the shoulder and arm. Treatment by intramuscular infiltration with procaine hydrochloride. JAMA. 1942;120:417–422.

3. Simons DG, Travell JG, Simons LS. Upper half of body. Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. 2nd ed. Baltimore, Maryland: Williams & Wilkins; 1999.

4. Tough EA, White AR, Richards S, et al. Variability of criteria used to diagnose myofascial trigger point pain syndrome—evidence from a review of the literature.

Clin J Pain. 2007;23:278–286.

5. Fernández-de-las-Peñas C, Dommerholt J. International consensus on diagnostic criteria and clinical considerations of myofascial trigger points: a Delphi study. Pain Med. 2018;19(1):142–150.

6. Wolfe F, Simons DG, Fricton J, et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol.

1992;19:944–951.

7. Lew PC, Lewis J, Story I. Inter-therapist reliability in locating latent myofascial trigger points using palpation. Man Ther. 1997;2:87–90.

8. Hsieh CY, Hong CZ, Adams AH, et al. Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Arch Phys Med Rehabil.

2000;81:258–264.

9. Lucas N, Macaskill P, Irwig L, et al. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain.

2009;25(1):80–89.

10. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015;54(3):392–399.

11. Rathbone AT, Grosman-Rimon L, Kumbhare DA. Interrater agreement of manual palpation for identification of myofascial trigger points: a systematic review and meta-analysis. Clin J Pain. 2017;33(8):715–729.

12. Meakins A. Soft tissue sore spots of an unknown origin. Br J Sports Med. 2015;49(6):348.

13. Teixeira MJ, Almeida DB, Yeng LT. Concept of acute neuropathic pain. The role of nervi nervorum in the distinction between acute nociceptive and neuropathic pain. Revista Dor. 2016;17(suppl 1).

14. Kellgren JH. On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin Sci. 1938;4:3546.

15. Tough EA, White AR, Cummings TM, et al. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain. 2009;13(1):3–10 16. Melchart D, Streng A, Hoppe A, et al. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ. 2005;331(7513):376–382.

17. Perez S, Oliván-Blázquez B, Magallón-Botaya R, et al. Percutaneous electrical nerve stimulation versus dry needling: effectiveness in the treatment of chronic low back pain. J Musculoskel Pain. 2010;18: 23–30.

Q 1 | 2019

18. Huguenin L, Brukner PD, McCrory P, et al. Effect of dry needling of gluteal muscles on straight leg raise: a randomised, placebo controlled, double blind trial.

Br J Sports Med. 2005;39(2):84–90.

19. Linde K, Streng A, Jürgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005;293(17):2118–2125.

20. Dıraçoğlu D, Vural M, et al. Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study. J Back Musculoskelet Rehabil. 2012;25(4):285–290.

21. Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for hip osteoarthritis.

Cochrane Database Syst Rev. 2018;5:CD013010.

22. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.

Arch Intern Med 2009;169:858–866.

23. Le Bars D, Dickenson AH, Besson JM. Diffuse noxious inhibitory controls (DNIC).

I. Effects on dorsal horn convergent neurones in the rat. Pain. 1979;6(3):283–304.

24. Morton V, Torgerson DJ. Effect of regression to the mean on decision making in health care. BMJ. 2003;326(7398):1083–1084.

25. Bhopal RS. Interrelated concepts in the epidemiology of disease: natural history, spectrum, iceberg, population patterns, and screening. In: Concepts of Epidemiology: Integrating the Ideas, Theories, Principles, and Methods of Epidemiology. 2nd ed.

Oxford: Oxford University Press; 2008.

26. Finniss DG, Kaptchuk TJ, Miller F, et al. Biological, clinical, and ethical advances of placebo effects. Lancet. 2010;375(9715):686–695.

27. Czerniak E, Biegon A, Ziv A, et al. Manipulating the placebo response in experimental pain by altering doctor’s performance style. Front Psychol. 2016;7:874.

28. Fine M. Quantifying the impact of NSAID-associated adverse events.

Am J Manag Care. 2013;19(14 suppl):s267–272.

29. Els C, Jackson TD, Kunyk D, et al. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;10:CD012509.

Q 1 | 2019

www.painweek.org | PWJ

49

By Douglas L. Gourlay MD, MSc, FRCP(C), DFASAM ● Howard A. Heit MD, FACP, FASAM ● Gary W. Jay MD, FAAPM

op-ed

For the last 25 years,

the medical community and government regulatory bodies have had an unhealthy preoccupation with the opioid class of drugs in the treatment of chronic pain. Because we initially focused on the apparent positives, while virtually ignoring the obvious risks associated with the widespread use of this class of medications, we now find ourselves in the unenviable position of being the single largest per capita consumers of opioids in the world.1,2 Without a doubt, the Veterans Administration naming pain as the fifth vital sign3,4 and the US Congress defining the years 2000 to 2010 as the “decade of pain management and research” played a significant role in our current problematic use of the opioid class of medications.5 Pain is a multidimensional problem; a unidimensional solution is unlikely to be sufficient to solve it.6

Unfortunately, we are no longer at the point where simply reducing the medical availability of these drugs will address this problem. In fact, simple supply reduction may be contributing to unintended, negative consequences that may make things worse. When the medical supply of opioids is curtailed, we know that the illicit drug supply chain will step in to the breach and fill the need.3,4 Sadly, this has become a reality with tremendous cost of life and human suffering.

The problem of prescription drug abuse in America is a complex one. Recently, a major pharmacy chain in America chose to limit new patients’ opioid prescriptions to 1 week at a time.5 Certainly, we can expect to see some effects to the system as a result, but will they be positive? What are we likely to see?

First, there is an assumption that the prescription drug problem will benefit from this approach—that fewer pills per prescription is better. Unfortunately, this may have a negative impact on the many patients who are more than capable of responsibly controlling more than a 7 days’ supply of the drug. It will also add to the cost of each prescription. Plus, the added time of healthcare professionals and patients to adjust to these changes may significantly increase costs of appropriate and responsible chronic pain management. An even bigger question is “Will it positively impact the problem we have at hand?” If not, do we have any mechanism in place to assess and, if necessary, tweak the process to improve outcomes? At this point, the answer is “No.” Once a guideline is put into place, it tends to remain there indefinitely, even if it was based on poor evidence. The

Pain is a multidimensional problem; a unidimensional solution is unlikely to be sufficient to solve it.

likelihood that our best efforts at regulatory and guideline development will get it right on the first attempt is exceedingly low. Therefore, all credible guidelines that serve to underpin evidence based medicine should follow an iterative process.6 Each guideline should have a limited period over which it is in force.7 At the end of this period, the guideline committee should examine the available data to assess both intended as well as unintended consequences, modifying the guideline as necessary to improve outcomes. Unfortunately, guidelines are being elevated by some states to quasi standards of care virtually eliminating the clinicians’ ability to exercise clinical judgement on a case-by-case basis.8 But more importantly, we are missing the fact that the nature of the prescription drug problem in America has changed. The medical supply side of the equation is being controlled by well-intended but often arbitrary guidelines and regulations. The net result is that many capable and conscientious prescribers are simply electing to address “the problem” by not prescribing opioids, even when appropriate. Obviously, reducing the availability of prescribed opioids will reduce the direct harm caused by these drugs—but what of the unintended consequences?

There has been a significant increase in the use of street drugs, including heroin and illicit medications, often laced with ultrapotent and illicitly sourced drugs such as fentanyl and carfentanyl.9 These “additions,” designed to make the drugs more potent, also make them much deadlier. The result is a society reeling with more than 115 drug related deaths per day,10 with victims coming from virtually every corner of society.

It’s tempting to think that the people dying from street opioids are only those struggling with their own personal substance use disorder, and that no rational person would turn to a nonmedical supplier for the medications they previously had been obtaining from their own doctors. The risks would seem to be too high. Unfortunately, acute withdrawal, especially forced withdrawal from licit, prescribed drugs, can be debilitating, leading many people to do desperate things, including buying drugs on the street.

In some cases, their first use of these drugs is their last.

It is time for regulators to realize that we’ve moved beyond simple supply reduction as a workable solution to the current opioid crisis. We now must address demand reduction through both credible pain management as

op-ed

well as accessible substance use disorder treatment. By simply cutting off or reducing chronic pain patients from the opioids they have become physically dependent upon, we shouldn’t be surprised that some otherwise functional patients turn to illicit suppliers to meet their needs. But by introducing defensible, rational, and compassionate tapering and discontinuation strategies to this group, we can reduce their discomfort and so rationalize their need for the opioid class of drug.11 Clearly, some patients will do better off rather than on the opioid class of drugs.

Similarly, some patients’ lives are genuinely improved because of this class of medication. The challenge is to know which group is which. For those individuals who are burdened with true substance use disorders, their unmet need for affordable treatment must be addressed.

Otherwise, the body count will continue to rise.

Even the best intended guidelines and regulations will require sober second thoughts at some point in the

future to assess both intended as well as unintended consequences and, where necessary, they need to be adjusted accordingly.

To this end, the clinicians listed below have affixed their names, hoping that this will lead to a meaningful dialogue to more accurately define the current problem and to modify some of the well-intended but less than totally effective solutions that have been put in place.

Douglas L. Gourlay md, msc, frcp(c), dfasam, is an Educational Consultant and the Former Director of the Wasser Pain Centre, Pain and Chemical Dependency Division, in Toronto, Ontario.

Howard A. Heit, MD, FACP, FASAM, is in private practice.

Gary W. Jay, MD, FAAPM, is a Clinical Professor at the University of North Carolina, Department of Neurology, in Chapel Hill, North Carolina.

Daniel P. Alford md, mph

Paul Christo md, mba

Sidney Schnoll md, phd

Professor of Medicine

Associate Professor

VP, Pharmaceutical Risk Management

Director, Clinical Addiction Research and

Division of Pain Medicine

Pinney Associates, Inc.

Education (CARE) Unit

Department of Anesthesiology &

Director, Safe and Competent Opioid

Critical Care Medicine

B. Todd Sitzman md, mph

Prescribing Education (SCOPE of Pain) Program

Johns Hopkins Medicine

President, North American

Boston University School of Medicine Boston Medical Center

Robert L. Barkin mba, pharmd, fcp, dacfe, daipm, dacfm Professor

Peggy Compton rn, phd

Neuromodulation Society Past-President, American Academy of

Associate Professor

Pain Medicine

School of Nursing

Director, Advanced Pain Therapy, PLLC

University of Pennsylvania

Stephen J. Ziegler phd, jd

Rush Medical College

Ted Jones phd

Anesthesiology, Family Medicine,

Clinical Psychologist

Purdue University Fort Wayne

Pharmacology

BMI@PCET

Mayday Pain & Society Fellow

Clinical Pharmacologist

www.painconsultants.com

Department of Anesthesiology, Critical Care, Pain Management

George Kolodner MD, DLFAPA, FASAM

Pain Centers of Evanston Hospital

Co-Founder and Chief Clinical Officer

and Skokie Hospital

Kolmac Outpatient Recovery Centers

NorthShore University Health System Illinois

Marco Pappagallo md

Martin D. Cheatle phd

Director

Associate Professor of Psychiatry

Comprehensive Pain Management in

Perelman School of Medicine,

Patients with Rare and Neglected Diseases

University of Pennsylvania

New York Adjunct Clinical Professor Department of Anesthesiology Albert Einstein College of Medicine Bronx, NY

Professor Emeritus

References 1. Mandell BF. The fifth vital sign: a complex story of politics and patient care. Cleve Clin J Med. 2016;83(6):400–401.

2. Mularski RA, White-Chu F, Overbay D, et al.

Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006;21(6):607–612.

3.

Nachtwey J. The opioid diaries. TIME. March 5, 2018.

4. Anson P. DEA cutting opioid supply in 2017.

Pain News Network. Oct. 4, 2016. Available at: www.painnewsnetwork.org/stories/2016/10/4/ dea-cutting-opioid-supply-in-2017.

5. CVS Health fighting national opioid abuse epidemic with enterprise initiatives. 2017. Available at: cvshealth. com/newsroom/press-releases/cvs-health-fighting-national-opioid-abuse-epidemic-with-enterprise-initiatives.

6. Nuckols TK, Anderson L, Popescu I, et al.

Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014;160(1):38–47.

7. WHO Handbook for Guideline Development. 2010.

Available at: www.who.int/hiv/topics/mtct/grc_handbook_mar2010_1.pdf.

8. National Conference of State Legislatures.

Prescribing policies: states confront opioid overdose epidemic. 10/31/2018. Available at: www.ncsl.org/ research/health/prescribing-policies-states-confrontopioid-overdose-epidemic.aspx.

9. Misailidi N, Papoutsis I, Nikolaou P, et al. Fentanyls continue to replace heroin in the drug arena: the cases of ocfentanil and carfentanil. Forensic Toxicol.

2018;36(1):12–32.

10. Volkow ND, McLellan AT. Opioid abuse in chronic pain--misconceptions and mitigation strategies.

N Engl J Med. 2016;374(13):1253–1263.

11. Gourlay DL, Heit HA. Pain and addiction: managing risk through comprehensive care. J Addict Dis. 2008;27(3):23-30.

“Meetings come to an end, but learning never stops.

PWJ keeps you going all year long.”

— Michael R. Clark Md, Mph, Mba

short cuts

Mark Garofoli pharmd, MBA, BCGP, CPE Assistant Clinical Professor West Virginia University School of Pharmacy

My father taught me that having two jobs was basically slacking, while three jobs was just about right.

mark GaROFOLi GPS Morgantown, West Virginia Typical Day Wake up, espresso, workout, cup of joe, head to the University, mold the

minds of future healthcare professionals, head to our pain center, safely maximize patients’ pain management treatments within an interprofessional team, field an interview or present a CE program, family dinner, playtime, bedtime routine, watch a show and chat with my wife, work on presentations/consults, bed. Persona My father taught me that having two jobs was basically slacking, while three jobs was just about right. My in-laws (ironically also pharmacists) built upon that to invigorate me to find and follow my true passions. My beautiful and intelligent wife, Dr. Gretchen Garofoli, and my son Luke are my life, my rock. I’ve been on-deck my whole life, now it’s the bottom of the ninth, bases loaded, and I’m ready to be at the plate. Social Media Habits I post nothing to Facebook but enjoy updates on the lives of friends/family. I’ve tweeted the Pope, that’s about it. He seems to be a rather busy gentleman, so I understood his lack of reply. Instagram and Snapchat are for my young nieces. I do however frequently post on LinkedIn and enjoy the professional interactions amongst colleagues across the globe. Contribution Coordinating my state’s pain management guidelines (sempguidelines.org), personally developing a 21-hour pharmacist pain management CE certificate with www.freece.com, and being given a PAINWeek microphone have all been wonderful, but nothing beats the kind words of a patient or an audience member after a presentation. No one cares how much you know until they know how much you care. People It truly takes a village. Whether advice from a parent, support from my wife, cookies from an aunt, a beverage with a buddy, or a recommendation from a colleague, all have made me who I am. Words My daily reads are dominated by The Very Hungry Caterpillar, Llama Llama, and The Pout-Pout Fish intermixed with pain articles and general best-sellers revolving around the “war on drugs.” Popcorn Rocky IV, hands down. If PAINWeek were a boxing match (hey, it is Vegas!), I’d listen to the motivational Rocky IV soundtrack before getting on stage. P NWeek PAINWeek is the prime cut of healthcare conferences. Every detail is top notch, whether the scanning of badges in lieu of treating professionals like 4-year-olds with mundane CE codes, or the fact that presentations are depicted in posters created by a truly gifted artist. The faculty are not only experts, but actually know how to educate as well, which does not often intertwine. I have yet to even find a better lip balm than the conference marketing product used a few years ago. Every detail, every time. And did I mention Vegas?

ai

Q 1 | 2019

www.painweek.org | PWJ

57

short cuts

By Doug Gourlay md, msc, frcpc, fasam

In the absence of knowing what to do, knowing what NOT to do is a close second!

When faced with a proposed change in therapy, some patients will reluctantly go along assuming that, if the change doesn’t work, they can always go back to the original therapy.

Unfortunately, for some, the success or failure of a new treatment plan is connected to a belief that they can always return to the status quo.

In these cases, support, education, and empathy from the practitioner will go a long way to achieving success, but it must be made clear that the status quo is not acceptable.

Just because you can’t offer a guarantee of the new treatment doesn’t magically make the previous ‘bad choice’ now acceptable.

58 PWJ | www.painweek.org

Q1 | 2019

short cuts

Chemotherapy induced peripheral neuropathy (CIPN) is a significant problem affecting anywhere from

of chemotherapy recipients.

The mechanisms that provoke CIPN are poorly understood, and treatments for prevention or control of the condition do not presently exist.

In 2017, scientists reported that a protein, APE1/REF1, could alter the function of sensory neurons and that targeted molecule APX3330 was effective in limiting the ability of APE1 to promote tumor growth and spread.1

A pectoralis nerve plane (PECS) block administered before a mastectomy may result in better pain relief/reduced opioid consumption.

who underwent bi- or unilateral mastectomy were categorized to receive PECS block before general anesthesia (98 subjects) or general anesthesia alone (54 subjects).

Researchers noted statistically significant reduction in opioid consumption among the block recipients both during surgery and 1 day postprocedure.3

Researchers examined data from

with rheumatoid arthritis.

140 received a tapered biologic disease modifying antirheumatic drugs (bDMARDs) schedule, and 192 received a full dose.

Although only 3 clinics were participants in 2015 at the outset, the Buffalo area now has 27 clinics able to absorb 64 opioid use disorder patients per week within 48 hours of discharge from the ED.2

The study followed

who underwent gynecologic or abdominal surgery and then received a new ultrarestrictive opioid prescription protocol (UROPP) for management of postsurgical pain: an average of 12 opioid tablets after major surgery, 1 after minimally invasive surgery, and 0 after outpatient or ambulatory surgery.

Standard protocol at US cancer centers is 44, 38, and 14 tablets following the respective procedures. Pain scores, postop complications, and patient requests for additional opioids were not impaired by the new protocol, which reduced the amount of opioid medications in circulation by ≥16,000 pills.5

In a study of patient education about postsurgical pain management,

Buffalo Medication Assisted Treatment & Emergency Referrals (MATTERS), which delivers medication assisted treatment for patients with opioid use disorder, has been awarded

from BlueCross BlueShield of Western New York to fund expansion into 8 counties in the region.

A 2 year study by cancer specialists/surgeons concluded that opioids are seldom required for postsurgical pain management.

Statistically significant differences were noted in health assessment questionnaire scores, rheumatoid factors, disease duration, and the concomitant use of methotrexate.

Conclusion: in daily clinical practice, successful tapering of bDMARDs may be undertaken in patients with low RA disease activity or remission.4

who underwent joint or spine surgery in 2016 were evaluated. Postprocedure, the research team surveyed the study subjects at 2 days, 2 weeks, 1 month, and 6 months to assess their pain management approaches.

At 2 days after surgery, only 5% of patients were using multiple nonopioid medications in conjunction with opioids.

Meanwhile, at 1 month postsurgery, 91% reported unsafe opioid storage and 96% failed to safely dispose of their unused opioids as outlined in FDA guidelines.6

1. https://bit.ly/2SAUsMA 2. https://bit.ly/2saq0gP 3. https://bit.ly/2SHogHy 4. https://bit.ly/2Rubf6G 5. https://bit.ly/2GUPWHf 6. https://bit.ly/2F7KzCa

Q 1 | 2019

www.painweek.org | PWJ

59

short cuts

1

Pelvic Pain: “Never Just One Cause” Mario Castellanos MD

There are a lot of different causes of pelvic pain, and there’s never just one cause of pelvic pain. Many times there is more than one or two, three, or four causes in someone who presents with pelvic pain. And it spans all organ systems. It goes from vascular, urological, gynecological, musculoskeletal, neurological, and dermatological. So it becomes really difficult to assess someone with chronic pelvic pain because there could be so many different causes. My practice is dedicated in evaluating and treating women with chronic pelvic pain. Most of my referrals come from primary care or gynecologists who have seen those patients and are unable to identify what may be causing their pain, or why they’re having trouble with controlling their pain. It’s estimated about 15% of all women have experienced chronic pelvic pain; some statistics say about 35% of patients who go to a primary care office will have chronic pelvic pain.

The first step? A comprehensive evaluation and a very thorough history. A lot of these patients have had pain for many years, so I always like to ask, “How did all this begin? What were your first types of symptoms?” That takes maybe 30 minutes. From there on it’s a comprehensive examination, trying to identify pain sources or pain triggers on examination. We also work with physical therapists and PM&R physicians who evaluate the patients for musculoskeletal conditions. I think what’s important when we continue our studies of women or men who have chronic pelvic pain is to focus more on identifying sources of pain, to identifying phenotypes of the patients. Because everybody is different in their experience of pain and not everybody is going to respond to certain treatments. I think if we focus our studies in identifying subtypes of patients who have chronic pelvic pain we can then begin to actually formulate better treatment options and studies and medications for them.

2

Urine Toxicology in the Pain Practice

Peter Pryzbylkowski MD

Urine toxicology is actually a big business in many fields of medicine, not just pain management. A lot of healthcare facilities, critical care units, and emergency departments utilize tox screening as well. As of 2015, it was close to a $5,000,000,000 business. A lot

60 PWJ | www.painweek.org

of new companies are offering tox screening services across multiple states, and some have gotten into trouble in terms of having contracts with physicians who were doing more tox screening than was probably medically necessary. There are different definitions in the tox screening world. One of the newer ones is presumptive vs definitive urine drug screen testing. Presumptive testing, also known as point of care testing, just kind of gives us feedback on what drug classes are in a patient’s system, things like morphine metabolites, oxycodone, fentanyl, without actually telling you what metabolite is in the screen. Whereas definitive testing usually gets sent out to a lab to specifically quantify what drugs are in a patient’s urine. There are various guidelines available to the practitioner. The American Society of Interventional Pain Physicians has guidelines, as does the American Society of Anesthesiologists, and the VA. Some states have guidelines. The basic thing for primary care to take home about urine tox screening practice is you want to show what’s medically necessary for the patient. If a patient is a high risk patient, you want to have that seen in your electronic medical record so when you do high risk tox screening or definitive studies you’re reimbursed for those studies. A concluding thought regarding tox screening is to document, document, document. If you’re seeing someone who you think is at high risk for aberrant behavior, document it in your notes so that when you send the screen out for definitive studies, it is clear why you did, and what you’re interested in looking at in that sample.

3

Sleep and Pain in Older Adults — Looking for a Better Way to Treat Robert Raffa PhD

Chronic pain patients tend to be a little older and that in and of itself leads to a decrease in quality of sleep. Loss of quality sleep makes the pain seem a little worse and more difficult to deal with.

So how can we treat both pain and sleep issues to break that cycle?

And to make matters even more complicated, some of the drugs used to treat chronic pain, such as opioids, have a deleterious effect on quality of sleep. Benzodiazepines are good for anxiety. They don’t decrease the nerve’s physiology, but what they do is make that nerve less likely to overreact. They also calm a person, allowing them to sleep a little better. Unfortunately, they have their own downsides when they’re used in combination with other CNS depressants, like opioids. The FDA has now come down pretty strongly against the concomitant use of benzodiazepines plus opioids. There are some newer nonbenzodiazepine chemical drugs, sometimes called the Z drugs or the Z plus C drugs, but pharmacologically they work the exact same way the benzodiazepines do. They’re a little safer, but still not the answer. Some other approaches involve the melatonin mechanism, our natural way of falling asleep and getting good rest.

We’re looking for how does the body normally have restful sleep? So, you tend to look for the neurotransmitters that might be involved.

A lot of times you don’t want to take traditional antihistamines because they make you a little drowsy. But if they’re used properly in the right patients and at the right time of day, it could actually be pretty beneficial and could be a way to get away from the benzodiazepines. Clinicians should hear what FDA is saying about benzodiazepines, but also should not forget that their patients with pain need help with what is almost certainly going to be some adverse effect on their quality of sleep.

Q 1 | 2019

4

What Causes Poststroke Pain?

Michael Bottros MD

It has been suggested that stroke associated loss of inhibitory neurons in the spinothalamic tract causes disinhibition of thalamic neurons, which generate ectopic nociceptive action potentials responsible for the pain experience. However, recent data suggests that pain is dependent on the peripheral afferent input and may be mediated by misinterpretation of sensory input. Pain after a stroke is a very difficult thing to categorize. There’s a lot of prevailing theories, and we talk about five or so distinct possibilities. It all has to do with deafferentation of the pathways from the periphery into the brain after a stroke. Essentially what happens is an imbalance between the signaling that occurs and, because of this, the floodgate opens and people have this unopposed perception of pain that can occur in the area of the stroke. Typically, it’s thalamic but there are oftentimes what we call extrathalamic strokes that can cause pain as well. Central poststroke pain is a phenomenon that occurs in 8% to 10% of patients who have a stroke. It can occur in a variable time course: anywhere from immediately after a stroke to as far out as a year after a stroke. Oftentimes it occurs in the distribution of the sensory areas where the person had their stroke. It’s obviously a central phenomenon in the sense that it occurred in the brain. That way, those floodgates open and there’s an unopposed sensation of the spinothalamic tract to the thalamus and whatnot that causes a very difficult pain syndrome to control.

5

Beyond Opioids: Plan B for Pain A Brett Stacey MD

If I ask patients how satisfied they are with their pain treatment, there’s an inverse correlation with whether they’re on opioids or not—the higher the dose of opioids, the less satisfied they are. In general, I don’t think that they’re a great treatment. I think they’re reserved for a small subset and there’s a small subset that work well.

The things that work the best are the things I was taught when I was in training as a pain provider: ask the patient about how their life is different because of their pain, find out the things they can’t do, work on things you can correct, help them get their sleep back in order, help

Q 1 | 2019

find strategies to work on their mood, help them think about and reconceptualize the pain differently and decrease their fear of injury, find some way to get them to use their body. In general, when we give people pharmaceuticals as treatment, we’re taking away their role as an active participant in their healthcare. It’s better to find some way to get them to be more active in their healthcare and to view medications as an adjuvant to other treatments. When you get in better shape, you have less pain. When you sleep better, your pain tolerance is increased. When your mood is improved, your pain tolerance is improved and your pain experience is different. So what I would say is, look broadly at your patient; look at their overall quality of life, their overall functioning, their overall mental health and think of ways to improve each of those things and turn the discussion from a patient saying “I want to be pain free and escape and have no responsibility” to a practitioner saying “Hey what can we do to partner together to get you to be able to do these things that are important to you” because that’s how people make changes and feel better.

6

A Look at Patient Barriers to Pain Management and Acceptance Ravi Prasad

There are patients who say “I don’t want to live with pain. The pain has taken a lot out of my life and I don’t want to learn to live with it. I just want it gone.” That’s a significant barrier to acceptance, but it’s understandable, and the way that we approach dealing with that is helping a patient work toward a model of acceptance. “Acceptance” doesn’t mean that they give up the fight, but try to accept the reality of the chronicity of their pain and learn how they can still have very good quality of life despite the presence of pain. For a lot of patients it’s hard to conceptualize that, because their experience of pain is just what it is at that time. When you tell them “You have to learn to live with pain” they think it’s learning to live with pain at that level of intensity and with that degree of interference. But managed pain is completely different. The discomfort of course will still be there, but if a person is able to be engaged in more productive activities, things that are more meaningful, then the pain becomes more of a nuisance variable. When we conceptualize that to patients, or help them start to see what that can look like, it goes a long way, and we’re able to help shift their conceptualization of learning to live with pain and they become more open to it.

www.painweek.org | PWJ

61

short cuts

with

martin d.

cheatle

phd

62 PWJ | www.painweek.org

Q1 | 2019

“I began to gravitate to individuals who suffered from chronic pain and found my niche and passion, which I have pursued for my entire career.”

Q What inspired you to become a healthcare professional?

a

I was completing my PhD when I had the opportunity to spend time with a visiting professor in psychology, Dr. Ed Kremer. Dr. Kremer developed one of the first behavioral medicine treatment programs at Dartmouth. We had many discussions regarding the mind/body approach to health and illness, and I became intrigued with the mind/body/ spirit interaction and its potential to transform lives. Upon finishing my PhD, I completed my internship in clinical psychology with an emphasis in behavioral medicine at the University of Pennsylvania School of Medicine. This deepened my appreciation for the role of promoting behavior change in improving an individual’s quality of life.

Q

a

Why did you focus on pain management?

During my postdoctoral training in behavioral medicine, I was exposed to the management of a number of conditions including bariatrics, smoking, cancer, and noted that there was a real paucity of emphasis on pain management. One of my first positions after completing my training and joining the faculty of the School of Medicine at PENN was to provide inpatient consultation services at one of the University hospitals. I began to gravitate to individuals who suffered from chronic pain and found my niche and passion, which I have pursued for my entire career.

Q 1 | 2019

Q

Who were your mentors?

a

One is Dr. Charles O’Brien, Professor of Psychiatry at penn, a world-renowned expert in addiction medicine, who taught me the importance of both patience and persistence and always encouraged me to strive to achieve higher personal and professional goals. I established the first inpatient pain management program in the Commonwealth of Pennsylvania at PENN and was fortunate to have a medical partner, Dr. John Esterhai, as my codirector. He is one of the most compassionate and caring professionals and individuals that I have ever had the fortune to call a friend and mentor. Dr. Esterhai helped me deepen my passion in caring for the unrepresented and undertreated individuals who suffer from chronic pain. Lastly, I would say that the thousands of patients that I have had the blessing to interact with and care for have taught me innumerable lessons and driven me to be a better healthcare provider, each and every day.

Q If you weren’t a healthcare provider, what would you be?

a

In my current life I have diverse interests, including providing clinical care to patients with chronic pain, managing NIH-funded research projects on the intersection of pain and substance use disorders, publishing both evidence based and review articles in the area of pain medicine, and I’m

www.painweek.org | PWJ

63

short cuts

I believe when you are caring for individuals who suffer greatly, connecting and communicating emotionally can engender an incredible therapeutic bond.

a mentor to nursing and medical students, postdoctoral fellows and pain fellows. If I was not providing direct healthcare services, I would focus more on my science and in teaching, as I believe the future in improving pain care is to produce evidence based research not just opinion pieces and to better train the new generation of healthcare providers.

Q

What is your most marked characteristic?

a

I have always admired the passion and commitment that my colleagues and mentors consistently display in their pursuit of improving pain care and disseminating novel research. I would hope that both my patients and my peers would see me as a passionate, caring individual, who places the needs of others before my own. Lastly, I would say my humor and open nature are characteristics that help to foster a positive therapeutic relationship with my patients and their families.

Q What do you consider your greatest achievement?

a

To overcome certain insecurities and, in fact, to use my insecurities to fuel my persistence in achieving my goals in life.

Q

What is your favorite language?

Well, as the joke goes, I speak two languages: English and bad English. I would say my favorite language is that of emotions that can be transmitted between individuals without a spoken word. I believe when you are caring for individuals

64 PWJ | www.painweek.org

who suffer greatly, connecting and communicating emotionally can engender an incredible therapeutic bond.

Q If you had to choose one book, one film, and one piece of music to take into space for an undetermined amount of time, what would they be?

a

Book: Man’s Search for Meaning

by Viktor Frankl Film: Good Will Hunting Song: Swept Away by Christopher Cross

Q

What would you like your legacy to be?

a

That in some small way, through my writings, research, teaching, and clinical care, I helped transform the way we deliver pain care to the countless numbers of individuals who suffer each day, and destigmatize pain, and to see pain as a true disease that should garner the same respect and resources as other major diseases. Lastly, that I approach my work and life with passion and integrity.

Q

What is your motto?

a

“Learn from the past, plan for the future, and live in the moment,” being fully engaged in work and life, not tethered by past mistakes or future obligations.

Martin D. Cheatle, PhD, Associate Professor, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania.

Q 1 | 2019

Let’s take a look…

66

September 3—7 2019

The Cosmopolitan of Las Vegas

September 3—7

elebrating our 13th year, PAINWeek remains the largest US pain conference and the favorite destination for frontline practitioners to enhance their competence in pain management.

5 Days, 120+ Hours, and 90+ Faculty In 2019, you can look forward to a week of Special Interest Sessions, Master Classes, Multidisciplinary Course Concentrations, Satellite Events, and Exhibits.

To learn more and register for PAINWeek 2019, visit www.painweek.org and follow us on Twitter® at twitter.com/painweek.

N W ew

orkshops!

Innovations in Pain Medicine Ultrasonography:

Image Guidance, Diagnosis, and Emerging Applications Jennifer Hah MD, MS Einar Ottestad MD Presented Tuesday, September 3 1:40p – 5:40p Registration Fee: $350 The field of pain medicine ultrasonography is continually evolving with utility in image guidance, diagnosis or pointof-care assessment, and treatment. Around the world, pain medicine specialists favor the use of ultrasound guidance for its accuracy, portability, direct visualization of vasculature, and decreased radiation exposure. In addition, emerging applications continue to evolve for pain medicine sonography with new developments in peripheral nerve stimulation and regenerative medicine. This hands-on session will cover the latest evidence-based rationale for ultrasound image guidance for interventions vs other modalities including fluoroscopy and CT-guidance. An introduction to diagnostic ultrasonography will be presented covering common pain conditions. Emerging applications for pain medicine ultrasonography particularly relating to peripheral nerve stimulation, regenerative medicine, cryotherapy, and radiofrequency will be discussed.

Hitting the Bull’s Eye in Pain Management:

Rationalizing Excessive Opioid Prescribing With Buprenorphine:

Initiation, Stabilization, Maintenance, and Exit Strategies Douglas L. Gourlay MD, MSC, FRCPC, FASAM Presented Wednesday, September 4 1:40p – 4:40p Registration Fee: $165

Buprenorphine is a partial mu agonist that has been clinically available for many years. It was recently made available for the treatment of opioid dependency in the office-based setting. Even more recently, it is enjoying a renewed popularity as an opioid analgesic for the treatment of chronic pain. In this workshop, attendees will explore problematic and sometimes excessively high opioid prescription levels in the context of a treatable clinical condition; case-based examples will be provided.

The basics of buprenorphine pharmacology, clinical utility, and the regulatory status of a variety of currently available preparations will be examined through the prism of current as well as past peer reviewed literature.

F

eatured

S

essions

Inside the Trojan Horse:

Using All the Arrows in Your Quiver Alexandra L. McPherson pharmd, MPH Mary Lynn McPherson pharmd, MA, MDE, BCPS Presented Wednesday, September 4 9:30a – 12:30p Registration Fee: $165

Addressing Current Legal Actions Against Healthcare Practitioners Jennifer Bolen JD Douglas L. Gourlay MD, MSC, FRCPC, FASAM Bill McCarberg MD

Rarely is one medication or pharmacologic class of drugs the answer to a medical conundrum, including pain management. While opioids are indisputably valuable in treating acute pain and some forms of chronic pain, they are just one therapeutic option. Participants in this fast paced, case-based session will learn about the appropriate use of different medications in lieu of, or in combination with, opioid therapy. Along the way we will explore contemporary issues in pain management such as the positive and negative implications of gabapentinoid plus opioid therapy, specific evidence that supports the use of cannabinoids in the management of chronic pain (and does it reduce opioid burden), and other controversial issues.

Participants will learn how to deal with difficult pain syndromes including wound pain, complicated neuropathic pain, and functional pain syndromes. Last, we will wrestle with cases that illustrate the need to deploy interventional pain management strategies instead of, or in addition, to opioid therapy. Bring your seat belt: this is going to be a crazy ride!

Using case examples, this course will address the insider’s view to illustrate the connection between carrying out licensing board directives on using opioids to treat pain, reasonably prudent medical decision-making, and documentation. The content presented is designed to engage participants who will work through several short case examples with faculty, all of whom are experienced as medical and legal experts. These case examples will cover patient history and risk evaluation; treatment plans including treatment goals and exit strategies; true informed consent and treatment agreements; follow-up encounters and risk monitoring, including the use of prescription drug monitoring databases, drug testing, and adjustments to the treatment plan; and use of consultations and referrals. Attendees will learn about current trends in medical expert assessment of prescribing decisions and how to improve documentation of medical decision-making and opioid prescribing decisions. This session is a must-attend for Main Street Practitioners!

The World According to Cannabinoids Theresa Mallick-Searle ms, np-bc, anp-bc Ethan B. Russo MD

Despite the widespread acceptance of medicinal and recreational cannabis use internationally and domestically, marijuana remains federally illegal in the United States. For this reason, there are significant legal implications to clinical practice. Clinicians are unprepared to answer questions regarding legality or safety of cannabis use, and unprepared to counsel their patients on use or abstinence, particularly for pain management. This session will explore legal implications, discuss current science, and define the scope of the problem related to the need for education about risk and safety of counseling patients about cannabis use. Case examples will be presented.

The Static Pendulum: Pain, Drugs, and Ethics Kevin L. Zacharoff MD, FACIP, FACPE, FAAP

Pain remains one of the most common reasons that people seek medical attention in the United States. When pain was designated as the fifth vital sign, people were given the right to have their pain assessed and effectively treated by their healthcare professionals. A number of ethical dilemmas have surfaced since, including the increased prescribing of opioid medications for patients with chronic pain, in the face of also increasing rates of abuse, misuse, and addiction related to these medications. The “opioid overdose epidemic/crisis” has led us to the challenge of balancing the safe, compassionate, and effective treatment of chronic pain against serious negative outcomes associated with the increased abuse and misuse of these medications. With overdose death rates increasing, tensions running high, a multitude of political and regulatory involvement, and “knee-jerk” reactiveness, it seems as if the only thing being forgotten is the needs of chronic pain patients and the core ethical principles intended to help clinicians maintain the highest standards of care. This session will describe these principles and clarify their role in determining reproducible courses of action that maximize safety, efficacy, and compassionate pain care, regardless of the direction the “opioid pendulum” is swinging.

Lost in the Weeds:

The Past, Present, and Future of Hemp in Pain Treatment Stephen J. Ziegler phd, JD Marijuana and hemp are genetically distinct cousins of the genus Cannabis sativa L., yet they have been erroneously associated with each other for the past 80 years. That all changed in December 2018 when Congress removed hemp from the federal Controlled Substances Act (CSA) and legalized the plant and its derivatives such as cannabidiol (CBD), a substance which has received a great deal of attention for its potential to treat a variety of medical conditions. This change is historic and has enormous

implications in medicine and the treatment of pain. However, although the oversight of hemp has essentially been transferred from the DEA to the USDA and individual states, the FDA still retains its authority “to regulate products containing cannabis or cannabis-derived compounds” such as CBD. Accordingly, in an effort to inform healthcare professionals about this rapidly changing field, this presentation will discuss the history of hemp, its legality, derivatives, and its potential future in pain treatment.

Everybody’s Greasing Up, But Should You Rub It In?

A Review of Topical Analgesics and Available Evidence in Clinical Trials Timothy Atkinson pharmd, BCPS, CPE

Topical analgesics are often recommended in clinical practice but differences between formulations and routes of administration lead to confusion. In addition to commercially prepared topical analgesics, compounded topical analgesics are highly promoted and widely utilized from compounding pharmacies with individualized recipes of multiple combined medications at substantial cost. To assist providers with tough decisions in this area, the available clinical trials supporting use will be reviewed along with formulations, locations, and doses where their use has been shown to the be most effective. This session will review the role of various topical analgesics as well as explore the rationale for “topical polypharmacy” with compounded drugs.

The Golden Girls Dilemma:

gsm Pain Georgine Lamvu MD, MPH

Genitourinary syndrome of menopause (GSM) is a term used to describe what was formerly known as vaginal atrophy, atrophic vaginitis, or urogenital atrophy. The older terminology was replaced by this descriptive term with the goal of more accurately describing the constellation of symptoms experienced by GSM patients, including: vaginal pain, dryness, dyspareunia, urinary incontinence, urgency, frequency, hematuria, and sexual dysfunction. Although GSM-like symptoms occur in 15% of premenopausal women and 40% to 54% of postmenopausal women, the condition is associated with a lot of social stigma and often remains ignored or underdiagnosed. This presentation will review the clinical manifestations, pathophysiology, etiology, evaluation, and management of this condition. Specific emphasis will be placed on differentiating GSM from other genital pain conditions such as vulvodynia and vulvar dermatoses. Additionally, the presentation will review the impact of postmenopausal pain on quality of life, mental and physical health, and sexual function. Treatment recommendations will focus on multimodal therapies to address what is a complex but treatable syndrome. The importance of early detection and patient education in avoiding long-term risks and complications that compromise quality of life will also be discussed.

Agenda

For planning purposes, please note that the first certified-for-credit course begins on Tuesday, September 3, at approximately 7:00a. The last certified-for-credit course concludes on Saturday, September 7, at 4:30p.

Monday

■

Presented from 6:00p – 7:00p

PAINWeek 101*

9.2

●● Making the Most of Your PAINWeek Experience!

AINWeek 101 is a noncertified primer for first P time attendees—or anyone seeking a refresher on the conference agenda, faculty, onsite technology, and venue logistics. Moderated by PAINWeek staff and faculty with Global Education Group, all questions as they pertain to course selection and CME protocol will be answered. With so much packed into the 5-day conference, PAINWeek 101 will make sure that you’re fully briefed and oriented to navigate, plan, select, and make the most of your PAINWeek experience!

Interventional Pain Management ●● Dorsal Root Ganglion:

Neuromodulation as an Alternative to Opioids

●● Injections, Nerve Blocks, Pumps, and Spinal Cord Stimulation ●● Spinal Stenosis:

Epidemiology, Pathophysiology, and Treatment

●● Neuromodulation for Advanced Practice Providers ●● Stem Cells and Regenerative Medicine for Chronic Pain ●● Interventional Pain Management: Opioid Sparing Technologies

Not certified for credit.

Visit www.painweek.org for more information.

Master Class ●● Blinded by the Light:

The Danger of Idiopathic Intracranial Hypertension

Tuesday

■

Sessions presented from 7:00a – 6:30p

Behavioral Pain Management

9.3

●● Moving Beyond the Obvious:

The Pivotal Role of Psychology in Pain Management

●● Icebergs, Oceans, and the Experience of Pain ●● The Death of Caesar:

Psychological Stages of Grief and Chronic Pain

●● Lip Service:

Using Words as the Foundation for Effective Pain Management

Special Interest Sessions ●● Status Traumaticus:

A Trauma Informed Approach to Chronic Pain Management

●● The World According to Cannabinoids: linical and Research Updates C ●● Salt of the Earth: T he Importance of Sodium Channels in Pain Management

●● Geriatric Pain Management: Minimally Invasive Interventions

●● Malpractice for Dummies:

Getting Sued and Surviving to Talk About It

●● Pain Catastrophizing:

●● Eyes Without a Face:

Chronic Pain Syndromes

●● Pain Management Coaching

Making a Mountain Out of a Mole Hill

●● Not Tonight:

Headache & Sex Hormones

●● Hanging by a Thread: Facial & Orofacial Pain

●● Neck and Upper Extremity Pain Syndromes ●● Neurogenic Thoracic Outlet Syndrome

Pain Management for Those Living With Alzheimer’s Disease

●● Alchohol As Analgesia:

Does it Really Numb the Pain

NeW Workshop ●● Innovations in Pain Medicine Ultrasonography: I mage Guidance, Diagnosis, and Emerging Applications

Wednesday 9.4

■

Sessions presented from 7:00a – 6:30p

Acute Pain Management

NeW Workshops

●● Acute Pain in Patients With Active Substance Use Disorder

●● Hitting the Bull’s Eye in Pain Management: sing All the Arrows in Your Quiver U

●● The Dynamics of Managing Acute Postoperative Pain in the Current Opioid Sparing Environment

●● Rationalizing Excessive Opioid Prescribing With Buprenorphine: Initiation, Stabilization,

●● Case-Based Challenges in Acute Pain Management ●● Enhancing Recovery After Surgery: How Certified Nurse Anesthetists Are Improving Outcomes

International Pelvic Pain Society (IPPS)

Maintenance, and Exit Strategies

Keynote ●● Are the Monsters Coming to Main Street?

Welcome Reception/Exhibit Hall Opening* *Not certified for credit.

●● The BIG BANG of Pain:

Chronic Overlapping Pain Conditions in Women

●● The Force is With You:

Jedi Mind Tricks for Chronic Pain Patients

●● Let’s Get Physical!

Musculoskeletal Pelvic Pain

●● The Golden Girls Dilemma: gsm Pain

Medical /Legal ●● Inside the Trojan Horse:

Addressing Current Legal Actions Against Healthcare Practitioners

Pain Educators Forum ●● Pain Terminology:

Knowing the Difference Makes a Difference!

●● Pain Pathways Made Simple ●● Chronic Pain Assessment ●● Clinical Pearls:

Unraveling the Secrets of Imaging Studies

●● Pain Therapeutics

Special Interest Sessions ●● Casualytics: You’re in Pain and It’s All Your Fault ●● How Healing Works, and What it Means for Chronic Pain Management ●● Preventing a Benzodiazepine Crisis and Understanding Protracted Withdrawal Syndrome ●● Psych Twister: sing Metaphors, Mindfulness, and Values to Promote U Behavioral Change

●● Maleficient Morphine Milligram Equivalents & Dosing Dilemma Disasters

“PAINWeek

is by far the best and most diverse educational and networking opportunity in the field.”

— R. N

or

ma

nH

ard

en

m

d

T

9.5

■ hursday

Sessions presented from 7:00a – 6:30p

Advanced Practice Providers

Pain Educators Forum

●● Medication Assisted Therapy:

●● Life Hacks to Teach Chronic Pain Patients

●● No Guts, No Glory:

●● Navigating the OTC Analgesic Aisle: hat a Pain in the Aspirin!

W

New Opportunities in Treatment Mystery of the Microbiome

●● The Curbside Consult in Management

●● Achieving Change from Within: se of Motivational Interviewing U ●● Through the Eyes of an Expert Witness: he Importance of Chart Documentation T ●● Starting an Acute Pain Service

American Headache Society (AHS) Chronic Migraine Education Program (CMEP) ●● Diagnosis of Chronic Migraine and Episodic Migraine ●● Transitions, Risk Factors, and Barriers to Care ●● Pathophysiology of Chronic Migraine and Episodic Migraine ●● Acute and PreventiveTreatment Strategies

Medical/Legal

●● Red Rover, Red Rover, Send Pain Patients Right Over: Patient Engagement in Multimodal Care Plans ●● Spilled Beans and Hard Stops:

How Legislation, Guidelines, and Reimbursement Policies Impact Patient Care

Pharmacotherapy ●● Which Came First…

Pain or Substance Abuse Disorder?

●● Kratom or Bait ’em? nderstanding the Pharmacology of Kratom U ●● Mirror, Mirror on the Wall… ho’s the FDA’s Fairest ADF of All? W ●● Putting the “FUN” in Dysfunctional: ain Management Options in Renal and P Hepatic Dysfunction

●● A New Leaf:

A Legal and Medical Perspective on Marijuana Use When Prescribing Controlled Substances

Special Interest Sessions ●● Insight into Preclinical Drug Discovery and Translational Medicine ●● Buprenorphine: Molecule for All Seasons A ●● The Static Pendulum: ain, Drugs, and Ethics P

“PAINWeek

is what every pain conference wants to be… what every pain conference — should be!”

M ich

ae

lS

ch

at m

an

●● The Gang that Couldn’t Shoot Straight: evisiting the CDC Guidelines R ●● Understanding Analgesic Trials ●● Back to the Future: urrent and Future Opioid Abuse Risk Assessment C

ph

d, cpe

,d aspe

and Mitigation Strategies

●● The Elephant in the Room: elping Patients to Navigate the “O” Impasse H ●● Central Sensitization and Ketamine ●● Deuces Wild: udin & Gudin Argue the New Rules of the Game F

Scientific Poster Session and Reception* *Not certified for credit.

F

■ riday

Sessions presented from 7:00a – 6:30p

9.6

Cannabinoids and Medical Marijuana

Special Interest Sessions

●● Lost in the Weeds: he Past, Present, and Future of Hemp in T

●● Medical Stasi: he Standardization Proclamation and T

●● Reefer Madness Revisited

●● The Visible Few: n Imperfect Burden on Patients and Providers A

Pain Treatment

●● Medical Marijuana: sychiatric and Medical Conditions With Specific P Attention to Chronic Pain

●● The Global Legalization of Marijuana: Reasonable Solution to Treat Pain…or a Pipe Dream?

A ●● Cannabis and Opioids Together: yn or Synergistic?

S

Master Classes ●● Complex Regional Pain Syndrome: pdate on Research, Diagnosis, and Treatment U ●● Back Pain:

It's All About the Diagnosis

Its Consequences

●● Managing Opioid Withdrawal and Overdose With Alternative Treatment Options ●● The Glass Bead Game ●● Applying Mechanism-Based Classification to Clinical Reasoning for Complex Persistent Pain ●● Analgesics of the Future ●● Opioid Moderatism: eeking Middle Ground S

Exhibit Hall Closing Reception* *Not certified for credit.

Medical /Legal ●● I’m Not a Doctor, But I Play One in DC

Neurology ●● An Elusive Villain: ain Associated With Lyme Disease and Other P Spirochetal Infections

●● When Darkness Falls: anaging Pain in Fibromyalgia and Restless M Leg Syndrome

●● The Spider’s Strategem: Arachnoiditis

●● Not Glad All Over: hronic Widespread Pain C

Pharmacotherapy ●● Everybody’s Greasing Up, But Should You Rub It In? A Review of Topical Analgesics and Available Evidence in Clinical Trials

●● Opioid Math Calculations: itrations and Breakthroughs T ●● He SAID, She SAID. hat’s the Deal with NSAIDs? W ●● Thug Drugs: J ust Say Know

“PAINWeek

is the premier interdisciplinary pain management conference for frontline practitioners and the leading edge of science in pain medicine.”

— Je

nn

ife

rH

ah

m

d, ms

Saturday

■

Sessions presented from 7:00a – 4:30p

Encore Presentations

9.7

●● Pain Pathways Made Simple ●● Clinical Pearls:

Unraveling the Secrets of Imaging Studies

Integrative Pain Management ●● Acupuncture for Opioid Use Disorder ●● An Integrative Pain Management Program: What Does a Multimodal Program for Chronic Pain Look Like?

●● Toolkit for Implementing Multimodal Care & Treating Chronic Pain

Medical/Legal ●● Embrace Changes and Prevent Overdose: Basic Blueprint for Legal Risk Mitigation A and Response

●● Get Your Specimens in Order: imely Use of Test Results T

Palliative Care ●● That’s Debatable! Does Cannabis Reduce Opioid Death, and Does Gabapentin Increase It? ●● Addressing the Pain While Dressing the Wound ●● You’re Using WHAT for Pain Management?

Psilocybin, Ecstasy, and Ketamine

●● Doing Business or Risky Business? enzodiazepines and Opioids in Palliative Care B

Special Interest Sessions ●● Let’s Get on the Same Prescribing Page: tandardizing Opioid Prescribing Practices Among S Sickle Cell Disease Patients

●● Improving Safety of Chronic Opioid Prescribing by Incorporating Clinical Pharmacists on Teams ●● The Cracked Mirror: xploring Opioid Abuse Deterrent Methods from E Lab to End User

●● It’s Not You, It’s Me: he Prescriber’s Role in Creating and Solving T the Opioid Crisis

Veterans Health Administration (VHA) ●● Moving Mountains: hifting the Pain Management Paradigm S ●● VA’s Stepped Care Model for Pain Management and Whole Health: Patient Centered Biopsychosocial Pain Care ●● Opioid Therapy and Opioid Tapering— Guidance for Clinicians to Improve Outcomes: A Case-Based Pro/Con Discussion Format

●● Opioids and Mental Health: uicide Prevention as Highest Priority S Please note: faculty and courses are subject to change.

Pharmacotherapy ●● Better With Age? ain Management of the Older Adult P ●● Testing the Waters: rine Drug Screening for the Perplexed Among Us U ●● Frankie says RELAX: he INs and OUTs of Skeletal Muscle Relaxants T

Accreditation Over 120 hours of content will be presented! This activity is provided by Global Education Group. Global Education Group is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Global Education Group designates this live activity for a maximum of 39.0 AMA PRA Category 1 Credits™.

This activity will be approved for continuing pharmacy, psychology, nurse practitioner, and nursing education.

Applications for certification of social work nasw and family physician aafp hours have been applied for and are pending decision. For more information and complete cme/ce accreditation details, please visit our website at www.painweek.org.

Be there or be

Register Now September 3—7 2019 www.painweek.org

The Cosmopolitan of Las Vegas