painweek 2013 preview

7 | UNDERSTANDING AND TREATING NEUROPATHIC PAINNeuropathic pain, a mixture of peripheral and central mechanisms, requires multidisciplinary treatment.

15 | CYTOCHROME P450: INTERPRETATIONS & ACTIONSGuidelines on genetic testing and individualized opioid selection in pain management.

22 | AVOIDING THE PITFALLS OF RUMOR- BASED MEDICINEMisperceptions of government regulations can negatively impact pain management practices.

25 | CHRONIC PAIN IN CHILDREN: ARE THEY AT RISK?Assessing and understanding chronic pain in children to safely provide appropriate pain treatment

OVeRVieW

2 PAINWeek Conference Preview

NATIONAL CONFERENCE

P AINWeek is the largest US pain conference for frontline clinicians with an interest in pain management. Going into its 7th year, PAINWeek has grown tremendously and will

welcome over 1,800 physicians, physician assistants, nurse prac-titioners, nurses, pharmacists, hospitalists, dentists, psychologists, and social workers this year.

Demographically, PAINWeek attendees are comprised of 56% physicians (MD/DO), and the remainder are allied healthcare practitioners. Of the physician segment, 70% are primary care and 30% are specialists. Recent attendee surveys have uncovered compelling information:

● 50% of attendees do not attend any other pain conference ● 30% of attendees do not attend any other medical conference

PAINWeek offers a diverse curriculum taught by a multidisciplinary faculty in the following course concentrations: behavioral and interventional pain management, diabetes and pain, health coaching, medical/legal, musculoskeletal pain syndromes, neurology, pain and chemical dependency, pharmacotherapy, and physical therapy. Full-day programs will be presented by the American Academy of Pain Medicine, American Pain Society, the American Society of Pain Educators, the National Association of Drug Diversion Investigators, and the Veterans Health Administration. There will be 100+ hours of continuing medical education (CME/CE) courses and mas-ter classes, special interest sessions, and satellite symposia.

Opioid Safety Day In response to increasing concern over misuse and abuse of prescription medications, particularly opioids, Friday, September 6, has been designated as “Opioid Safety Day” during PAINWeek 2013. The day will provide the latest informa-tion on prescribing safety for opioids, as well as on the increasingly stringent and complex regulatory environment surrounding them to better prepare frontline practitioners in the appropriate use of opioid analgesics as an element of multidisciplinary pain therapy.

PAINWeek 101 PAINWeek 101 is designed for first-timers and anyone else who would like more assistance with their course selection process and helps attendees to make the most of their PAINWeek experience. Selected faculty and staff will review session selections (and provide a recommended agenda), conference logistics, exhibits and special events, CME/CE credit request procedures, and more! This session will be presented on Tuesday evening before the start of the conference.

The conference is managed by Aventine Co., and sponsored by the Global Education Group.

*Faculty and schedule of sessions subject to change

LOCATION & VENUE

PAINWeek is convened annually the Wednesday to Saturday following Labor Day Weekend at The Cosmopolitan of Las Vegas.

The Cosmopolitan is a 2,995-room luxury resort located on the Las Vegas Strip next to Bellagio and City Center. With 150,000 square feet of state-of-the-art convention and meeting space, it offers a multitude of benefits and features to PAINWeek attendees:

● Check in for the con-ference and the hotel all on the same level

● Many rooms offering private terraces and patios

● Rooms equipped with sophisticated entertainment system, plasma-screen televi-sion, and state-of-the-art control panels

● 3 distinct pool experiences

● Full-service spa (extra cost)

● Many gourmet offer-ings from a wide vari-ety of restaurants

● Quick and inexpen-sive transportation from McCarran International Airport

PLEASE NOTE: It is IMPORTANT that you book your accommodations dur-ing your registration pro-cess at www.painweek.org, not directly with the hotel or via third party.

PWJ—PAINWEEK JOURNAL

PWE REGIONAL CONFERENCES

T he PAINWeekEnd Regional Conference Series brings cer-tified medical education to healthcare professionals in all disciplines with an interest in pain management. Created

by the producers of PAINWeek—the national conference on pain for frontline practitioners—PAINWeekEnd conferences are scheduled in convenient locations across the country. The 2014 conference series is currently scheduled for April–May in Atlanta, Chicago, Columbus, Denver, Greater New York City, Houston, Phoenix, and Seattle. Additional information will soon be available on www.painweekend.org.

PAINWeek has evolved into more than an annual national conference. It is now a significant and branded communications platform comprised of

national & regional conferences, a digital presence, and now print, with PWJ, our new quarterly journal.

PWJ, like our website, is meant to extend the energy and experience of the national conference through-out the entire year. Each issue presents articles developed by our PAINWeek faculty, adapted from their respective conference presentations. Along with rotating sections like Case & Commentary, Pundit Profile, and Expert Review, the journal presents fea-ture articles on the following topic areas:

● Behavioral Pain Management ● Occupational Therapy ● Complementary and Alternative Medicine ● Pain and Chemical Dependency ● Diabetes and Chronic Pain ● Pain Clinical Trials ● Emergency Medicine ● Palliative Care ● Geriatric Pain Management ● Pediatric Pain Management ● Government & Public Policy ● Pharmacotherapy ● Health Coaching ● Physical Medicine & Rehabilitation ● Interventional Pain Management ● Physical Therapy ● Medical/Legal Issues ● Regional Pain Syndromes ● Music & Art Therapy ● Rheumatology ● Neurology ● Sex and Gender Issues

PARTICIPATING ORGANIZATIONS

● American Academy of Pain Medicine (AAPM)

● American Chronic Pain Association (ACPA)

● American Headache Society (AHS)

● American Osteopathic Academy of Addiction Medicine (AOAAM)

● American Pain Society ● American Society of

Pain Educators (ASPE) ● American Society for

Pain Management Nursing ● Eastern Pain Association ● Foundation for Ethics in

Pain Care ● International Medical

& Dental Hypnotherapy Association (IMDHA)

● Interstitial Cystitis Association (ICA)

● National Association of Drug Diversion Investigators (NADDI)

● National Fibromyalgia & Chronic Pain Association

● National Stroke Association (NSA)

● National Vulvodynia Association (NVA)

● Nevada Psychiatric Association (NPA)

● Pain Society of Oregon (PSO)

● Power of Pain Foundation

● Rheumatology Nurses Society (RNS)

● TNA The Facial Pain Association

● US Pain Foundation ● Western Pain Society

(WPS)

n0. 1 q 2 2013

RISK ASSESSMENT 2.0/P.6 CENTRALIZED PAIN/P.11 STICK IT TO ME/P.18 MIGRAINES PART 1/P.28 GOVERNMENTAL

INTERVENTION IN PRESCRIBING/P.36

PAINWeek Conference Preview 3

PW13 7.75 x 10.50 6.11.indd 2 6/23/13 4:27 PM

PW13 7.75 x 10.50 6.11.indd 2 6/23/13 4:27 PM

FACULTY


● Jeremy A. Adler, MS, PA-C ● Charles E. Argoff, MD, CPE ➤ ● Marie Hoeger Bement, MPT, PhD ● Jennifer E. Bolen, JD ● Robert A. Bonakdar, MD, FAAFP ● Michael M. Bottros, MD ● Alfredo Bozzini, MD ● Fred Wells Brason II ● Lucile Burgo-Black, MD ● John J. Burke ● Daniel B. Carr, MD, FABPM ● Gregory T. Carter, MD, MS

● Jeffrey Fudin, BS, PharmD, FCCP ● Katherine E. Galuzzi, DO ● Jennifer Gansen, PT, DPT, CPE ● David M. Glick, DC, DAAPM, CPE, FASPE ● Douglas L. Gourlay, MD, MSc, FRCPC, FASAM ● Jeffrey A. Gudin, MD ● R. Norman Harden, MD ● Howard A. Heit, MD, FACP, FASAM ● Stephen C. Hunt, MD, MPH ● Gary W. Jay, MD, DAAPM, FAAPM ● Ted W. Jones, PhD, CPE ● Joanna Katzman, MD, MSPH ● Sandra Keavey, DFAAPA-C (AAPA)

● Srinivas Nalamachu, MD ● Kimberly S. New, BSN, JD ● Steven D. Passik, PhD ● David R. Patterson, PhD, ABPP ● John F. Peppin, DO, FACP ● Joseph V. Pergolizzi, MD ➤ ● Caroline Peterson, MA, ATR-BC, LPC ● James B. Ray, PharmD, BCPS, CPE ● Ilene R. Robeck, MD ● Victor W. Rosenfeld, MD ● Andrew R. Rossetti, MMT ● Michael E. Schatman, PhD, CPE, DASPE ● Erica Laura Sigman, DPT, OPT

● Martin D. Cheatle, PhD ● Charles F. Cichon ● Michael R. Clark, MD, MPH, MBA ● George D. Comerci, Jr., MD, FACP ● Rebecca L. Curtis, ACC ● Nabarun Dasgupta, MPH, PhD ● Geralyn Datz, PhD ● Larry Driver, MD ● James M. Elliott, PT, PhD ● Roger B. Fillingim, PhD ● Melanie Fiorella, MD ● Colleen M. Fitzgerald, MD, MS

● Ernest A. Kopecky, PhD, MBA ● Lee Ann Kral, PharmD, BCPS, RPh, CPE ● Michael Kurisu, MD ● Joanne V. Loewy, DA, LCAT, MT-BC ● Sean Mackey, MD, PhD, CPE ● Lisa McElhaney ● Susan K. McNulty, OTD, OTR/L ● Mary Lynn McPherson, PharmD, BCPS, CPE, FASPE

● John F. Mondanaro, MA, MT-BC, LCAT, CCLS

● Michael H. Moscowitz, MD ● Cynthia Knorr-Mulder, BCNP, NP-C

● Sanford Silverman, MD ● Kathleen A. Sluka, PT, PhD ● Michael T. Smith, PhD, CBSM ● Barbara St. Marie, PhD ANP-BC GNP-BC ACHPN (NPHF)

● Steven P. Stanos, DO ● Forest Tennant, MD, MPH, DrPH ● Allen Togut, MD ● Kathryn A. Walker, PharmD, BCPS, CPE ● Anthony A. Whitney, MS, LHMC, BCB ● Kevin L. Zacharoff, MD, FACPE, FACIP, FAAP

● Stephen J. Ziegler, PhD, JD

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AMERICAN PAIN SOCIETY

FEATURED PRESENTATION

How to Assess and Manage Sleep Disturbances in Chronic Pain

Michael T. Smith, PhD, CBSM

S leep and pain reciprocally inter-act, and as literature demonstrates sleep disturbance is a risk factor for

developing chronic pain.

Attendees will gain knowledge on the importance of assessing sleep distur-bance in patients with chronic pain. Additionally, this session will discuss key sleep assessment considerations, and review evidence-based behavioral approaches to treating insomnia in chronic pain.

PARTiCiPATiNG ORGANiZATiONS’ FULL DAY PROGRAMS


The American Pain Society (APS) is partnering with PAINWeek to present an educational track on new developments in pain assessment. This track offers APS the opportunity to showcase its commitment to an evidence-based, interdisciplinary approach to pain treatment.

Timely and important issues ranging from advancements made in evidence-based pain assessment, quantitative sensory testing, to assess-ment and management of pain-induced sleep disturbances will be pre-sented by a multidisciplinary panel of experts.


Using Quantitative Sensory Testing for Mechanism-Based Pain Assessment

Roger B. Fillingim, PhD

P ain treatment is typically based on signs and symptoms combined with medical tests that provide minimal

information regarding the pathophysiolog-ical mechanisms underlying the patient’s pain. Tests that can reveal these mecha-nisms would enable therapy optimization by targeting specific pain mechanisms. Quantitative sensory testing (QST) can identify pathophysiological mecha-nisms and sensory abnormalities that

may contribute to patients’ pain. QST quantifies patients’ responses to care-fully controlled, standardized sensory stimuli including pressure pain, heat and cold pain, two-point discrimination, and vibration detection. While QST has been commonly applied to neuropathic pain syndromes, its application to other pain conditions could also be informative.

Increasing evidence suggests QST may offer clinical benefit in predicting develop-ment of pain risk and response to treat-ment. This session will discuss the clinical application of QST in evaluating and treat-ing patients with chronic pain. Potential benefits as well as limitations of QST will be discussed, and some QST devices will be available for demonstration purposes.

7:00–8:00AM ➤ Using Quantitative Sensory Testing for Mechanism-Based Pain Assessment9:20–10:20AM Brain Imaging as an Objective Biomarker for Pain11:10AM–12:10PM ➤ How to Assess and Manage Sleep Disturbances in Patients with Pain4:40–5:40PM Does Exercise Increase or Decrease Pain?

FRIDAY, 9|6

● New Developments in Evidence-Based Pain Assessment and Treatment

RELATED PROGRAMS OF INTEREST



Understanding and Treating Neuropathic Pain

Sean Mackey, MD, PhD, CPE

N europathic pain is a large burden for society and the individual. It is defined as pain initiated or caused

by a primary lesion or dysfunction in the nervous system. The estimated prevalence of neuropathic pain, excluding back pain, is nearly 1.8 million cases. Painful diabetic neuropathy and postherpetic neuralgia are among the most common types of neuropathic pain, which is a complex mixture of peripheral and central mecha-nisms. The deleterious effects of neuro-pathic pain include poor sleep, negative

emotions, weight loss, and decreased quality of life. Multidisciplinary treatment approaches are the most effective way to manage it. These include medications (eg, antidepressants, opiates, anticonvulsants), psychological and physical/occupational therapy (eg, aerobic exercises, muscle-group strengthening, transcutaneous electrical nerve stimulation), and proce-dural interventions (eg, trigger point injec-tion, nerve blockade, and spinal drug delivery and stimulation).

This presentation will discuss the science of neuropathic pain and therapeutic approaches to managing it as well asprovide clinical cases to illustrate appro-priate treatment strategies for neuro-pathic pain.

AMERICAN ACADEMY OF PAIN MEDICINE

8:10-9:10AM The Brain in Pain 9:10-10:10AM Understanding and Treating Neuropathic Pain

SATURDAY, 9|7

At PAINWeek, we invite our registered attendees to record their own impressions of the conference experience, using “mini-canvases” that we post on “The PAINWeek Wall.” See how some of the previous attendees “left their mark” in entertaining and creative ways to share their thoughts on why PAINWeek is the best conference for pain and pain education. See more on page 15.

september 4–7, 2013

514

I WENT TO PAINWEEK AND...

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Cancer Pain and Palliative Care

Larry Driver, MD

P ain associated with cancer frequently is undertreated. Some 30%-45% of cancer patients experience moder-

ate to severe pain at the time of diagnosis and in the intermediate stages of disease. Seventy-five percent of patients with advanced cancer experience severe pain.

This presentation will include discus-sion of the scope of the pain problem in cancer patients, pain assessment, cancer pain syndromes (such as bone metastases, epidural metastases, skull

metastases, plexopathies, and periph-eral neuropathies), and pharmacologic and non-pharmacologic management.

Reviewed will be how to assess pain inten-sity and character, psychosocial evaluation (e.g., the meaning of pain for the patient and patients’ typical coping response to pain), and physical, neurologic, and diag-nostic examination. Discussion of pharmaco-logic management will include information ranging from the use of non-steroidal anti-inflammatory agents to neuroleptic agents. The non-pharmacologic management portion of the presentation will include infor-mation about such approaches as cutane-ous stimulation, exercise, radiotherapy, and anesthetic techniques.


Cervical and Lumbosacral Spine: Assessment and Physical Exam

Steven P. Stanos, DO

T he physical exam must be individu-alized and comprehensive, efficient, and comfortable for the patient

and clinician. This session will review key aspects of the physical exam in the work-up of patients with pain related to the cervical and lumbosacral spine, such

as pain behavior, gait, motor strength, muscle stretch reflexes, and dural tension testing. Also presented will be an over-view of the spinal anatomy, the differen-tial diagnosis, and pain behaviors.

Myofascial assessment and trigger points, gait, and motor strength testing, as well as a discussion of muscle pain and the “core” muscle groups: abdominals (front), paraspi-nals and gluteals (back), diaphragm (roof), and pelvic floor and hip muscles (bottom) will also be covered.

AMERICAN ACADEMY OF PAIN MEDICINE

1:30-2:30PM ➤Cervical and Lumbar Spine Pain: Assessment and Physical Exam2:30-3:30PM ➤Cancer Pain and Palliative Care

SATURDAY, 9|7

THIS IS ONE MEETING THAT TRULY UNDERSTANDS GOOD PAiN CARE STARTS iN PRiMARY CARE.

ILENE ROBECK, MD

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“FACULTY FORUM

AMERICAN SOCIETY OF PAIN EDUCATORS


Chronic Pain Assessment

Michael R. Clark, MD, MPH, MBA

S uccessful assessment and follow-up of patients with chronic non-cancer pain includes comprehensive,

stepwise approaches and setting real-istic, achievable pain reduction goals. Included in this presentation will be the basics of pain assessment, an overview and consequences of chronic pain, as well as an outline of support tools to assess and manage chronic pain. A 10-step approach to long-term manage-ment will be explored in detail:

1. Comprehensive initial evaluation 2. Establishing a diagnosis

3. Establishing medical necessity for the treatment of pain 4. Assessing a treatment risk- benefit ratio 5. Establishing treatment goals 6. Obtaining informed consent and agreement

7. Initiating the initial dose adjustment phase 8. Initiating the stable phase 9. Monitoring for adherence 10. Reviewing outcomes

The hierarchy of importance of measures of pain intensity will emphasize that a patient’s self-report using a pain scale is the gold standard, except when patients cannot report pain. Other measures include behaviors, reports from fam-ily members or friends, or physiologic measures, which are the least sensitive because acute pain may elicit a change in vital signs and, over time, response to pain may not be observed.

Several different pain rating scales will be compared, including the Numeric Pain Intensity Scale; the Visual Analog Scale; the Faces Rating Scale (which can be used in children as young as 3 years); the Face, Legs, Activity, Cry, Consolability (FLACC) Scale (for nonverbal children); and the CRIES Neonatal Postoperative PAIN Measurement Score, used in the NICU.


Pain educators are frontline practitioners charged with delivering better pain management outcomes. They impart evidence-based recommendations and develop, implement, and evaluate care plans. Taking place over two days, the American Society of Pain Educators (ASPE) forum will include sessions on pain terminology, pain mecha-nisms, chronic pain assessment, pain diagnostic methods, chronic pain syndromes, pain therapies, motivational interviewing, coping skills, the complementary roles of occupational and physical therapy, and development of peer and patient educational materials. These courses will aid in preparing pain educators to better serve as “go to” resources in their practices for alleviating pain by the safest and most effective means possible.

7-8AM Pain Terminology: Knowing the Difference Makes a Difference!9:20-10:20AM Pain Mechanisms11:10aM-12:10PM Chronic Pain Assessment1:30-2:30PM Pain Therapeutics2:40-3:40PM When Acute Pain Becomes Chronic4:40-5:40PM Pain Diagnostic Methods

7-8AM Occupational and Physical Therapy: Complete Your Pain Management Team8:10-10:10AM Teaching the 5 Pain Coping Skills

WEDNESDAY, 9|4

THURSDAY, 9|5

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THIS IS ONE MEETING THAT TRULY UNDERSTANDS GOOD PAiN CARE STARTS iN PRiMARY CARE.

ILENE ROBECK, MD

Chronic Pain Telementoring for the Remote Provider: Project ECHO

Joanna Katzman, MD, MSPH

I n 2009, Joanna Katzman, MD, MSPH, began the University of New Mexico Chronic Pain tele ECHO

clinic to address the limited availability of specialty pain consultations through-out the Southwest. This program, which received the 2011 American Pain Society Clinical Centers of Excellence Award, leverages technology and con-nects remote providers through video conferencing.

Attendees will learn more about the importance of learning loops, knowl-edge networks, and will be presented with a “Mock ECHO” case. In this course, Dr. Katzman and George



Comerci, MD, the medical directors for UNM ECHO Pain, will discuss the foun-dations of the Four Point ECHO Model and how the model can be adopted for a practice, whether it is a large group or a solo provider. This two-hour course during PAINWeek will provide primary care clinicians, and all members of the healthcare team, a thorough overview of Project ECHO’s weekly, interprofessional, chronic pain best practices telemonitor-ing clinics.

ECHO Pain consists of an interdisci-plinary pain team of specialists who offer case-based learning and formal didactics. Active learning and robust bi-directional discussion are the key ingre-dients to each clinic. This session will combine traditional presentations with case-based learning and short videos. Perhaps even a connection to the live ECHO clinic can be facilitated.

9:20-10:20AM ➤ break 11:10AM-12:10pM Chronic Pain Telemonitoring for the Remote Provider: Project ECHO

THURSDAY, 9|5

PAiNWEEK HAS BEEN A PHENOMENAL WAY OF iNTRODUCiNG THE PROBLEM OF PAiN AND THE SCOPE OF PAiN TO FRONTLiNE PRACTiTiONERS. iN THE MEDiCAL FiELD WE OFTEN THiNK OF PAiN AS BEiNG A SYMPTOM OF AN UNDERLYiNG DiSEASE PROCESS. BUT iT TURNS OUT THAT MORE AND MORE, WE’RE FiNDiNG THAT PAiN iS A DiSEASE iN AND OF iTSELF, AND WHEN iT BECOMES CHRONiC iT REALLY TAKES ON A LiFE OF iTS OWN. iT’S A FANTASTiC WAY OF BRiNGiNG THAT iNFORMATiON iN A REALLY GOOD DiGESTiBLE FORMAT.

MICHAEL M. BOTTROS, MD

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“FACULTY FORUM

AMERICAN SOCIETY OF PAIN EDUCATORS

NATIONAL ASSOCIATION OF DRUG DIVERSION INVESTIGATORS


Protecting Your Medical Practice: A Law Enforcement Perspective

John J. Burke

M ost prescribers estimate that 10% to 12% of the patient popula-tion engages in drug diversion,

or any criminal act involving prescription drugs. The proportion is likely higher in pain management practices, where opi-oid prescribing is much higher than at other types of practices. Individuals who want to utilize opioid medications to get high will use a number of ploys to obtain the drugs illegally from physicians’ offices, emergency departments, and pharma-cies, so physicians, nurses, pharmacists and other members of the healthcare team need to be vigilant.

Perhaps the most common ruse is going to multiple doctors in search of drugs,

so-called “doctor shopping.” Another con is to present with a difficult-to-diag-nose complaint, such as a kidney stone. Such drug seekers have been known to prick their finger to put a drop of blood into a urine specimen as supportive evi-dence of a kidney stone.

Healthcare providers should have a heightened suspicion of patients with frequent requests for early refills or trips to the emergency department. Medical staff should follow-up on anonymous phone calls providing tips as to what a patient is up to. Physicians can have patients sign a contract that spells out the terms under which care will be pro-vided—including conditions related to drug-seeking behavior—and what will happen if the terms are violated.

This presentation will provide practical advice on how to avoid being a victim of the various cons and deceptions asso-ciated with drug diversion.


Combating prescription drug abuse and diversion involves a joint effort between law enforcement and regulatory bodies, healthcare professionals, and pharmaceutical manufacturers. At this year’s PAINWeek, the National Association of Drug Diversion Investigators (NADDI) has assembled a panel of experts on law enforcement and regulatory issues to offer perspectives on the challenges faced when dealing with pharmaceutical diversion. This full day program will provide an overview of drug diversion in pain management, advice on how to protect a medical practice, and discuss federal and state regulations and laws. Attendees will gain insight into the bullying that occurs in medicine and learn if they play the role of victim or perpetra-tor in the events leading up to drug diversion.

7-8AM Protecting Your Medical Practice: A Law Enforcement Perspective 9:20-10:20AM Pill Mills & Pain Management: Legislation and Enforcement 11:10aM-12:10PM Drug Diversion vs. Pain Management-Finding a Balance 2:40-3:40PM Bullying in Medicine: Are You the Victim or the Perpetrator?

THURSDAY, 9|5

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Opioids Inside the Institutional Setting: Is it a Safe Haven?

Kevin L. Zacharoff, MD, FACPE, FACIP, FAAP

I s an institutional setting, such as a hospital, a “safe haven” with respect to opioid use?

The Joint Commission believes there is room for improvement: a Sentinel Event Alert, “Safe use of opioids in hospitals,” sent to all US hospitals on August 8, 2012, makes it clear there is a “need for the judicious and safe prescribing and administration of opioids, and the need for appropriate monitoring of patients.” In fact,

hospitals can take “a number of actions…to avoid the unintended consequences of opioid use among hospital inpatients.”

The Alert noted that of opioid-related adverse drug events reported from 2004-2011—including deaths—47% were medication errors, 29% improper patient monitoring, and 11% factors such as excessive dosing, medication interac-tions, and adverse drug reactions.

This session will focus on three topics to help avoid adverse events associated with opioid use in the hospital: coadministration of opioids, undertreatment of pain, and safe discharge of inpatients on opioids.

OPiOiD SAFETY DAY


7-8AM ➤ Opioids Inside the Institutional Setting: Is It a Safe Haven? 1:30-3:30PM A Clinical Debate on Long-Term Opioid Prescribing for Chronic Noncancer Pain

FRIDAY, 9|6Friday, September 6 has been designated as “Opioid Safety Day” during PAINWeek 2013. The day will feature multiple course offerings, symposia, and special sessions focusing on maximizing pain control while minimiz-ing toxicity, as well as practical strategies to reduce opioid misuse and abuse, and how to protect your medical practice from drug diversion. Commercially-supported activities, including a certified-for-credit sympo-sium on the FDA’s extended release/long acting opioid REMS (risk evalua-tion & mitigation strategy) will also be offered to PAINWeek attendees.

Among the featured courses will be:● Opioids Inside the ● Patient-Centered Urine Institutional Setting Drug Testing● Opioids A-Z ● Opioid Refugees: The ● Opioid Conversions New Diaspora?● Opioid-induced Hyperalgesia ● “Just Saying No to Opioids”:● Opioids: Update on Abuse- Not Necessarily Good Medicine Deterrent Formulations

A major highlight of the day will be a Special Interest Session, “A Clinical Debate on Long-Term Opioid Prescribing for Chronic Noncancer Pain.” This program will be presented as a formal debate with representatives from each side speaking to their clinical perspective on this controversial issue.


Opioid Conversions

Mary Lynn McPherson, PharmD, BCPS, CPE, FASPE

C linicians who practice in pain man-agement and/or palliative care must be knowledgeable about

how to safely and accurately perform opioid conversion calculations. Patients often require a switch because they are not achieving an optimal therapeutic response, they are experiencing an adverse effect, have an inability to use a given dosage formulation or route of administration, or personal or institutional opioid preference exists.

Using a case-based format, participants in this session will learn how to use a five-step process to assess a patient potentially requiring an opioid conversion. Case exam-ples will include switching between dosage formulations and routes of administration of the same opioid, such as going from oral to parenteral morphine or switching from short-acting to long-acting oxycodone.

More complex examples will illustrate how to switch between opioids, which may include alternate dosage formulations and routes of administration. Participants will learn when, and to what degree, the newly calculated dose should be increased or decreased, to maximize pain relief AND patient safety!

Opioid Refugees: The New Diaspora?

Steven D. Passik, PhD

I ncreasingly, patients with legitimate need for opioid medications to relieve pain are finding practitioners reluctant

to prescribe the medication they need. This has resulted in what could be called “opioid refugees,” patients who travel sometimes long distances in search of a clinician willing to prescribe the needed opioid medications. Several factors could explain the trend. One is physicians’ fear of consequences, such as losing their

license or prosecution, if they should be perceived as overprescribing opioid drugs. Clinicians also may not have the time and staffing to jump through all the legal hoops necessary to comply with opioid-prescribing laws.

This presentation by a well-known psy-chologist and addiction specialist will include discussion of how state laws pertaining to opioid prescribing, unin-tended consequences of prescribing laws, including arbitrary opioid dose limits and requirements for a psychology or pain medicine consult, may present challenges to physicians and patients.

PATiENTS WiTH LEGiTiMATE NEED FOR OPiOiD MEDiCATiONS TO RELiEVE PAiN ARE FiNDiNG PRACTiTiONERS RELUCTANT TO PRESCRiBE THE MEDiCATiON THEY NEED. THiS HAS RESULTED iN ‘OPiOiD REFUGEES’

STEVEN D. PASSIK, PhD

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7-8AM Opioids A-Z9:20-10:20AM Opioid Conversions

1:30-2:30PM Opioid Refugees: the New Diaspora?4:40-5:40PM Methadone

FRIDAY, 9|6

FRIDAY, 9|6

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OPiOiD SAFETY DAY


Opioids: Update on Abuse-Deterrent Technology


A s abuse and misuse of opioids continues to increase in the US, so does the attention focus on

abuse-deterrent formulations (ADFs) of opioids being a part of the solution.

Although no one can argue the proven and potential benefits of ADFs, it would require a child-like faith to believe they represent a panacea for all patients.

This session will highlight the value proposition of ADFs, representing the past years of discussion, culminating in the US Food and Drug Administration’s (FDA) April 2013 decision to approve updated labeling for the reformulated version of oxycodone extended-release tablets on the basis of preliminary data showing it is indeed a difference in the right direction.

At the same time, the FDA decided not to accept or approve any generic forms of the original, non-ADF formulation “for reasons of safety or effectiveness,” according to Douglas C. Throckmorton, MD, FDA’s Deputy Director for Regulatory Programs in the Center for Drug Evaluation and Research.

This decision will no doubt affect future development of opioids, including generic formulations and consideration of whether or not they have abuse-deterrent properties. However, does this mean only nonabuse formulations should be developed moving forward? Will ADFs become the gold standard? What are the implications of the draft guidance the FDA issued for industry in January to guide development of abuse-deterrent opioids? What should frontline practitioners do, and how can they make educated decisions?

While ADF opioids are a good tool to have in the tool box, they are not the be-all, end-all tool to solve a patient’s potential misuse/abuse. Addressed will be the clinical, political, economic, and educational aspects of ADFs.

Questions posed to attendees will include a focus on whether risk stratification should be used for ADFs, including wheth-er primary care providers should refer patients who are candidates to specialists. Other questions raised include the level of responsibility of the prescriber—to the patient alone or his teenage children and their friends? How safe ultimately is safe? Are ADFs safer for everyone or should they be used only when necessary? Where do ADFs fit within the frontline practitioner’s repertoire? What about economic concerns for patients and the system?

WHiLE ABUSE-DETERRENT FORMULATiON (ADF) OPiOiDS ARE A GOOD TOOL TO HAVE iN THE TOOL BOX, THEY ARE NOT THE BE-ALL, END-ALL TOOLS TO SOLVE A PATiENT'S POTENTiAL MiSUSE/ABUSE.

KEVIN L. ZACHAROFF, MD, FACPE, FACIP, FAAP

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11:10aM-12:10PM Opioid-Induced Hyperalgesia1:30-3:30PM Patient-Centered Urine Drug Testing1:30-4:30PM CO*RE Opioid REMS2:40-3:40PM “Just Saying No“ to Opioids: Not Necessarily Good Medicine4:40-5:40PM ➤ Opioids: Update on Abuse-Deterrent Technology

FRIDAY, 9|6

Cytochrome P450: Interpretations and Actions

Forest Tennant, MD, MPH, DrPH

C ytochrome P450 testing has recently become readily avail-able. Pain practitioners must now

use cytochrome testing to individualize therapy and select the most effective treatment agents for that patient while avoiding adverse drug reactions, of which the most serious is overdose and death.

In order to utilize genetic testing, spe-cial training is necessary to

1. select appropriate patients for testing 2. order and interpret test results 3. know what clinical actions to take

after testing

Genetic testing to help guide therapy is now a permanent component of pain management. Guidelines will be provid-ed as to which tests should be ordered and which opioids should be selected based on test results.


3:50-4:50PM Glial Cells and Inflam- matory Products: How They Impact Pain, the Patient, and the Practitioner

11:10aM-12:10PM Rational Polypharmacy

9:20-10:20AM Topical and Transdermal Analgesics4:40-5:40PM Cytochrome P450: Interpretations and Actions

WEDNESDAY, 9|4

FRIDAY, 9|6

SATURDAY, 9|7

Topical and Transdermal Analgesics

James B. Ray, PharmD, CPE

T opical and transdermal analgesics are unique choices within the pain practitioner’s therapeutic tool box.

However, most clinicians are unaware or confused about these formulations and their role in therapy.

Participants in this session will learn about the efficacy and toxicity of topical analgesics, including com-mercially available products such as capsaicin, salicylates, counterirritants, nonsteroidal anti-inflammatory drugs, lidocaine, and compounded topical agents for pain. The appropriate use of transdermal buprenorphine and fentanyl will also be discussed.

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I WENT TO PAINWEEK AND...

PHARMACOTHERAPY

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FRONTLiNE PRACTiTiONER FOCUS


Physician Assistants in Pain Management

Jeremy Adler, MS, PA-C

I t has been said that no single person or profession holds all the resources nec-essary for the optimal management of

a person with chronic pain. Assembling a multidisciplinary team affords patients the greatest opportunity to achieve the highest quality of life possible.

More and more frequently, physician assis-tants (PAs) have entered into the specialty of pain management. PAs are well suited for this role by virtue of their training and scope of practice.

This session will focus on the educational background, national certification, scope of practice, and prescriptive authority of PAs. The presentation will spotlight the optimal utilization and implementation of PAs in the pain management practice.

The Role of Nurse Practitioners in Pain Management

Cynthia Knorr-Mulder, BCNP, NP-C

N urse practitioners (NPs) have become essential providers of primary care throughout the

healthcare delivery system and fulfill a critical role in pain management. In some states, NPs are permitted by regulation to practice independently for the provision of primary care, often in areas where access is limited. As the clinical role of the NP expands in an ever-changing healthcare paradigm, it is essential to incorporate effective pain management models into practice. Understanding how the NP role is per-ceived by other healthcare professionals in pain management creates stronger

interprofessional collaborative relation-ships within a model of care.

Nurse practitioners may be the best hope for dealing with the time constraints and increased reluctance of primary care providers to provide appropriate care for chronic pain patients. An NP model that reflects best practice involves the development of a therapeutic relationship and an empathetic provider to motivate patients to make behavioral changes that improve their quality of life.

As an innovative healthcare provider, Cynthia’s philosophy and style is human-istic and supportive. She believes at any given moment we are all teachers, learn-ers, and doers, with the ability to influ-ence the health and healing of patients with chronic pain.

1:30-2:30PM ➤ Physician Assistants in Pain Management

1:30-2:30PM ➤ The Role of Nurse Practitioners in Pain Management

WEDNESDAY, 9|4

THURSDAY, 9|5

iT IS NOW WELL ESTABLiSHED THAT THiS iS THE LARGEST NATiONAL CONFERENCE ON PAiN FOR FRONTLiNE PRACTiTiONERS. WE HAVE TAKEN OVER THiS SEGMENT OF PAiN AND PAiN EDUCATiON.

MICHAEL R. CLARK, MD, MPH, MBA

““FACULTY FORUM

Musculoskeletal Pain in Women

Colleen M. Fitzgerald, MD, MS

D evelopmentally, boys and girls are similar prepuberty. However, these similarities dissipate due to

the hormonal effects on female physiol-ogy during puberty, age 9 through 12 years, leading to differing musculoskel-etal influences on pain.

This session will describe predomi-nant musculoskeletal pain in women throughout the life stages of adoles-cence, pregnancy and childbearing, and mid-to-late life, including anatomi-cal reasons for the difference in pain presentations, such as pelvic pain. Attendees will gain an understanding of the diagnositc and rehabilitation treatment options for common musculo-skeletal conditions in women.

Pelvic and lower extremity structural differences predispose young women to certain injuries; specifically knee inju-ries such as patella femoral syndrome and lower extremity injuries, including anterior cruciate ligament injury. Bone health, stress fractures, and the high prevalence of urinary stress inconti-nence in young girls highlights that


continence mechanisms is a musculo-skeletal issue, even in women who have not yet had children.

Women in their childbearing years have biomechanical, hormonal, and anatomical changes that occur during this time of their lives, with pregnancy, labor, and delivery all inherently disrupting the core musculature and causing different pain presentations, such as pelvic girdle pain. In middle age and later life, women are more likely to have osteoarthritis, osteoporosis- related fractures, and tendonitis/ bursitis, and have various causes of low back pain.

Finally, within each time period, we’ll discuss realistic treatment options for women with the variant musculoskeletal conditions that predominate in each phase of the female lifespan.

We will also explore the female athlete triad, defined as the combination of disordered eating, amenorrhea, and osteoporosis.

The Musculoskeletal track will also include sessions on Myofascial Pain Syndrome, Osteoarthritis, and Repetitive Stress Injury.

WOMEN iN THEiR CHiLDBEARiNG YEARS HAVE BiOMECHANiCAL, HORMONAL, AND ANATOMiCAL CHANGES THAT OCCUR DURiNG THiS TiME OF THEiR LiVES, DiSRUPTiNG THE CORE MUSCULATURE AND CAUSiNG DiFFERENT PAiN PRESENTATiONS.

COLLEEN M. FITZGERALD, MD, MS

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7-8AM Myofascial Pain Syndrome 9:20-10:20AM Osteoarthritis 11:10aM-12:10PM Musculoskeletal Pain in Women 4:40-5:40PM Whiplash

WEDNESDAY, 9|4

● The Big 3: Biofeedback, Muscle Tension and Myofascial Pain

● Stiff and Stuck: Using Joint Mobilization to Restore Movement and Relieve Pain

● Stretch, Strengthen, Support: Exercise Rx for Chronic Pain


MUSCULOSKELETAL TRACK HiGHLiGHTS

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9:20-10:20aM ➤ Diagnosis and Management of Central Pain 2:40-3:40PM Restless Leg Syndrome

FRIDAY, 9|6

NEUROLOGY TRACK HiGHLiGHTS


Diagnosis and Management of Central Pain

Forest Tennant, MD, MPH, Dr PH

C entral or “centralized” pain may result from a brain injury such as stroke or head trauma, rise de novo

such as fibromyalgia, or develop follow-ing a peripheral nerve injury. The latter results from glial cell activation, which produces neuroinflammation, neuro-plasticity, and implanting of the memory of pain. Centralized pain may be con-comitantly associated with peripheral pain. Profound hormone and autoim-mune disorders may result. A clinical diagnosis of centralized pain is made if pain is constant, causes insomnia and episodic flares, and demonstrates excess sympathetic discharge. Treatment

is with agents that directly affect the central nervous system and include pharmacologic agents, hormones, and electromagnetic measures. Guidelines to assist in a clinical diagnosis of central pain and protocols for therapy will be presented.

11:10aM-12:10PM Recognition, Diagnosis, and Management of Postherpetic Neuralgia 2:40-3:40PM Neuropathic Itch

WEDNESDAY, 9|4

MORE FACES YOU’LL SEE AT

PAINWEEK1. Michael M. Bottros, MD2. John J. Burke3. Daniel B. Carr, MD, FABPM4. Michael R. Clark, MD, MPH, MBA 5. Roger B. Fillingim, PhD6. Lisa McElhaney7. Mary Lynn McPherson, PharmD, BCPS, CPE, FASPE8. Michael E. Schatman, PhD, CPE, DASPE9. Forest Tennant, MD, MPH, DrPH1

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Diabetes, Pain, and Sleep

Victor W. Rosenfeld, MD

S leep disorders are pervasive in the US According to a 2005 survey, about 75% of Americans suffer from

a sleep problem, such as snoring and sleep apnea. Sleep disorders, particu-larly sleep apnea, can have profound effects on metabolism. Studies show that sleep disorders are intricately linked with a number of medical conditions, includ-ing diabetes, stroke, heart attack, atrial fibrillation, hypertension, glaucoma, reflux, headaches, and seizures.

Sleep disorders can have a significant impact on diabetes. For example, sleep apnea can result in elevated blood sugar and insulin resistance. The International Diabetes Foundation has recommended screening all patients with diabetes for sleep apnea and to inquire about other sleep issues, such as snoring.

Sleep is divided into three phases: light sleep, deep (or delta wave) sleep, and REM (rapid eye movement) sleep. Individuals cycle among the three phas-es during the night. Patients who are in chronic pain have disturbed deep sleep. It is well known that deep sleep is critical for physiologic functioning in general. In a recent phase 3 trial involving patients with fibromyalgia, sodium oxybate, a sodium salt of gamma hydroxybutyrate (GHB) that induces deep sleep, was associated with a significant reduction in pain level in a large proportion of patients.

Any intervention that eases diabetes will help the overall long-term prog-nosis, especially with regard to pain. Evaluating diabetic patients for good sleep, including sleep apnea, is among one of the most important things clini-cians can do to help a patient with diabetes.


Diabetes and GI Pain

Michael M. Bottros, MD

T he prevalence of diabetes is increasing worldwide. The World Health Organization predicts that

about 366 million people worldwide will be diagnosed with the disease by 2030. With the increasing prevalence, clinicians can expect to see more of the associated symptoms and complica-tions. One of the more persistent prob-lems is gastrointestinal (GI) pain. While being persistent, it is also transient, which makes for a more difficult diag-nosis. Symptoms may include nausea, bloating, and abdominal pain, much of which relates to delayed gastric emptying. These symptoms correlate

with glycemic control. Diabetes causes anatomical changes in the enteric nervous system and other systems that affect GI function and gut motility. An important challenge with patients with diabetes who present with GI symp-toms is that presenting findings often are nonspecific or vague and patients are not sure what makes their symptoms better or worse. The presentation will walk attendees through the differential diagnosis in detail, with a discussion on ruling out more worrisome condi-tions such as hepatitis, pancreatitis, and abdominal aortic aneurysm. Dr. Bottros also will talk about use of dif-ferent diagnostic tools, such as gastric emptying scintigraphy, manometry, transabdominal ultrasonography, and magnetic resonance imaging.

11:10aM-12:10PM Diabetes and Peripheral Artery Disease (PAD) 1:30-2:30PM Diabetes and GI Pain 4:40-5:40PM Diabetes, Pain, and Sleep

SATURDAY, 9|7

DiABETES AND PAIN TRACK HiGHLiGHTS

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MASTER CLASSES


7-9AM Pain and Hormones 1:30-3:30PM ➤ Differential Diagnosis of Back Pain 1:30-3:30PM ➤ Patient-Centered Urine Drug Testing

FRIDAY, 9|6

Patient-Centered Urine Drug Testing

Howard A. Heit, MD, FACP, FASAM, DAAPM, FAAPM

The goal of this 2-hour lecture is to define a practical approach to man-agement of patients with chronic

pain using patient-centered urine drug testing (UDT). UDT represents a tool in the tool box for appropriate care of this

population by assisting in the diagnosis of drug abuse and/or misuse to facili-tate appropriate changes in a patient’s treatment plan. This lecture will discuss the strengths and limitations of UDT; its purpose in why, who, when to test; and, most importantly, how to interpret the results. Included will be an explanation of basic opioid metabolism—mandatory for interpreting UDT results. Case studies will be presented to illustrate the lecture’s teaching points.

Differential Diagnosis of Back Pain

David M. Glick, DC, DAAPM, CPE, FASPE

T he prevalence of back pain contin-ues in spite of the many treatments available, without any single treat-

ment being a panacea. In routine clinical practice there has been a tendency of examinations to become more cursory, largely influenced by increasing demands of time and arguably an overreliance upon technology. It has been suggested that the failure to adequately differentially diagnose the cause of back pain can account for clinical failures in treatment.

The focus of this session is to assist clinicians in the development of a more specific problem-focused examination that can enhance the differential diagnosis of specific pain generators, and therefore lead to more individualized treatment. Emphasis will be given to considering all aspects of the examination, including physical assessment, imaging studies, and the ability to rationalize when pathologies seen on imaging studies may or may not be clinically significant. The importance of considering how failed treatments influence the differential diagnosis will also be discussed.

● Urogenital Pain: Interstitial Cystitis, Endometriosis, Vulvodynia, and Dispaurenia

● Obesity-Related Pain ● Chronic Pain, PTSD,

Substance Abuse Disorder and TBI● Analgesic Effects of Virtual Reality


FACULTY FORUM

PAiNWEEK iS A BONANZA OF PAiN EDUCATiON AND PAiN MANAGEMENT. AND iF YOU EVEN FLiRT WiTH PURSUiNG A PRACTiCE iN PAiN MANAGEMENT, YOU NEED TO BE HERE. THiS iS WHERE iT’S HAPPENiNG.

MARY LYNN MCPHERSON, PHARMD, BCPS, CPE, FASPE

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1:30-3:30PM The Dark Side of the Moon: How Affective Disorders Influence Chronic Pain & Recovery

THURSDAY, 9|5


The Dark Side of the Moon: How Affective Disorders Influence Chronic Pain & Recovery

Geralyn Datz, PhD

“W hy isn’t my patient getting better?!” Lack of progress or delayed recovery in pain

treatment can be due to uncontrolled mood or anxiety disorders in patients with pain. These patients may have difficulty managing stress, be in a constant search to be “fixed,” and be emotionally reactive. The majority of pain patients have comor-bid mood or anxiety disorders; some pre-cede their pain and others develop these reactions over time as a response to pain.

Mood and anxiety problems were once characterized as simply emotional over-reactions to pain or organic disturbances

that were untreatable or refractory to treatment. There is now a greater under-standing of the complex neurochemical changes involved in depression and anxi-ety, and how they reciprocally influence chronic pain via the sensitization of the central nervous system. It is vital to know how to properly identify, treat, and man-age these comorbidities in pain treatment settings. Providers must also be able to appreciate sex differences in mood and anxiety disorders.

Faculty will present case-based formu-lations of recovery to emphasize and educate on the ways practitioners can maximize recovery from psychiatric comorbidities through early screening and skilled intervention. Attendees will be presented with cognitive behavioral treatment methods that are strongly sup-ported, evidence-based treatments for pain-related depression and anxiety.

PHYSiCiANS NEED TO PULL DiSPARATE PiECES OF CLiNiCAL iNFORMATiON TOGETHER AND MAKE CONNECTiONS TO ARRiVE AT A CORRECT DiAGNOSiS.

GARY W. JAY, MD, DAAPM, FAAPM

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If 13 Clinicians Don’t Know What’s Wrong With You— You’ve Got a Problem!

Gary W. Jay, MD, DAAPM, FAAPM

One of the common mistakes physi-cians make when diagnosing patients is looking at signs and

symptoms and other clinical findings solely from the monocular perspective of their

specialty. Sometimes, physicians need to pull disparate pieces of clinical information together and make connections to arrive at a correct diagnosis. Without making such connections, patients with an unusual ailment could find themselves going from doctor to doctor in search of relief. Gary Jay, MD, encountered such a patient, and, in this presentation, he will use the experi-ence to illustrate the kinds of mistakes phy-sicians can make in handling certain cases.

11:10-12:10PM If 13 Clinicians Don’t Know What’s Wrong With You —You’ve Got a Problem!

THURSDAY, 9|5

● The Madwoman in the Attic: Pain and Personality Disorders


MASTER CLASSES | CLiNiCAL CONUNDRUMS

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Avoiding the Pitfalls of Rumor-Based Medicine

Stephen J. Ziegler, PhD, JD

M any physicians who prescribe opiates and other tightly con-trolled pain medications worry

about being targeted for investigation by government regulators, such as the DEA and state medical boards, or being sued for wrongful prescribing or negative treatment outcomes, such as an uninten-tional overdose. Some of this concern stems from the limited information given out during investigations and even after physicians have been prosecuted and sanctioned or their cases dismissed.

Physicians often never learn the specifics of why one of their own was arrested

MEDiCAL | LEGAL


or sued. This can lead to the faulty per-ception that the likelihood of an arrest, investigation, or a lawsuit is greater than it really is. The result is fear based on rumor that may prompt doctors to opt out of pain management or decrease their prescribing of narcotics. In his presentation, Stephen J. Ziegler, PhD, JD, and his panel members will inform attendees about regulatory protocols, investigational procedures, and challeng-es faced by regulators at the local, state, and federal level. He also will discuss the civil litigation process involved in malprac-tice cases and provide guidance on how to avoid, but not eliminate, the likelihood of getting sued. The goal is to educate physicians so they are less intimidated by rumor and press reports and can base decisions on their good medical judgment.

PHYSiCiANS OFTEN NEVER LEARN THE SPECiFiCS OF WHY ONE OF THEiR OWN WAS ARRESTED OR SUED. THiS RESULTS iN FEAR BASED ON RUMOR THAT MAY PROMPT DOCTORS TO OPT-OUT OF PAiN MANAGEMENT.

STEPHEN J. ZIEGLER, PhD, JD

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9:20-10:20AM ➤ Avoiding the Pitfalls of Rumor-based Medicine 11:10AM-12:10pM ➤ The Importance of Laboratory Test Reports to Medical Records: Legal and Clinical Perspective 1:30-3:30PM Critical Documentation Skills

1:30-3:30PM Critical Documentation Skills (Encore)

WEDNESDAY, 9|4

THURSDAY, 9|5

The Importance of Laboratory Test Reports to Medical Records: Legal and Clinical Perspective

Jennifer E. Bolen, JD

L aboratory tests play an integral role in the treatment of pain and drug testing is considered to be part of

the standard of care in chronic pain management. A prescriber’s failure to review lab test reports and use them actively in ongoing treatment deci-sions may result in cases of overdose

and subsequent lawsuits or termina-tion. Criminal prosecutors often use lab test reports with medical experts to determine whether a provider acted “outside the usual course of professional practice” when prescribing controlled medications.

Attendees will learn the importance of lab test reports as faculty provide exam-ples from reported cases and medical expert testimony and review examples of proper and improper handling of lab test reports in the care of patients with pain.

Persistent Post-Surgical Pain: The Proverbial Pandora’s Box

Michael M. Bottros, MD

P ersistent postsurgical pain has only recently been recognized as a clinical entity. The first paper on

the topic was published in 1998. While researchers have not settled on how to define it, the International Association for the Study of Pain defines it as sur-gical pain that lasts for at least three months, a definition widely used in clini-cal practice.

Studies have identified risk factors for persistent postsurgical pain, which can be divided into preoperative, intra-operative, and post-operative risks. Pre-operative risk factors include psy-chosocial issues (such as anxiety and depression), sleep disorders, and obe-sity. Intra-operative risk factors include nerve injury and tissue ischemia resulting from the surgical procedure, as well as anesthetic technique. Postoperative risk


factors include severe untreated pain right after surgery—among the most important clinical variables to control when trying to prevent persistent post-surgical pain. Patients who undergo che-motherapy or radiotherapy after surgery also are at elevated risk. Moreover, the risk of persistent post-surgical pain varies by type of surgery.

Research has focused largely on pre-venting persistent postoperative pain because once it occurs, it is difficult to control, in part because of the absence of disease-modifying drugs. Surgical pain typically has three components: nociceptive, inflammatory, and neuro-pathic. In persistent postsurgical pain, neuropathic pain tends to predominate. Although narcotics are used to manage the pain, other medications are used concomitantly to address the underlying causes. This session will review the various therapies that can be used to treat the neuropathic, inflammatory, and nociceptive components of post-surgical pain.

4:40-5:40PM Persistent Postsurgical Pain: the Proverbial Pandora’s Box

7:00-8:00AM The Complexity Model: A Novel Approach to Collaborative Pain Management

FRIDAY, 9|6

WEDNESDAY, 9|4The Complexity Model: A Novel Approach to Collaborative Pain Management

John F. Peppin, DO, FACPMarty D. Cheatle, PhD

G reater than 25% of the US population experiences chronic pain, yet there is a paucity of

physicians specializing in pain medi-cine. The undertreatment of pain was brought to national attention to encour-age both clinicians and patients to advocate for improved pain care. Chronic pain is complex, and effec-tive treatment requires a multimodal approach. This approach is supported

by research that demonstrates the lack of efficacy of many unimodal interventions, both pharmacologic and non-pharmacologic.

From the perspective of the busy clini-cian, treatment of chronic pain can be viewed as an overwhelming losing battle. Given the scarcity of trained pain practitioners and the burgeoning number of patients with chronic pain, a new approach that values the complex nature of chronic pain is needed. A model of collaborative care that strati-fies treatment and patients by level and type of complexity and promotes com-munication between specialist and pri-mary care providers will be reviewed.

SPECiAL iNTEREST SESSiONS

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SPECiAL iNTEREST SESSiONS


3:50-4:50PM ➤ Chronic Pain in Children: Are They a Population at Risk?

THURSDAY, 9|5Chronic Pain in Children: Are They a Population at Risk?


T he good news: more children are surviving cancer. The bad news: the pain associated with either the can-

cer or its treatment remains, becoming chronic pain that may go untreated.

This example illustrates that children with chronic pain are indeed an underrep-resented population at risk. Many may not receive appropriate treatment, either because clinicians lack an understand-ing of how to treat such pain safely and effectively or believe that children are resilient and will “bounce back.”

To address these concerns, this Special Interest Session will review the state of chronic pain in children, defined as those up to 18 years of age, including available assessments and treatments.

Increasingly, the issue of abuse and mis-use of prescribed medications among children is something that needs to be on a clinician’s radar screen. Treatment of children is receiving more attention due to opioid use, misuse, and abuse, especially in the adolescent patient population.

Adolescents are on the bridge of inde-pendence, with the ability to manage

their own medications. However, when an adolescent is prescribed an opioid, who is responsible for its safe use, the patient or parent/caregiver? An ado-lescent’s inexperience with prescrip-tion drug use, combined with a higher desire to experiment and “get high” underscores the need—now, more than ever—that this once disparate patient population requires more attention so that their chronic pain can be managed safely and appropriately with whatever is available.

Other questions to be addressed will include:

● What if the teenager has friends—or even parents or caregivers—who might be at risk behaviorally with respect to opioid misuse/abuse?

● How many opioid pills do you have in your home right now and when is the last time you counted them?

● Should the most thought about the potential for misuse/abuse of opi-oids be given by those who write the prescription?

Finally, even though younger children may not be able to express chronic pain, it is important to ask them using avail-able pain assessment tools to ensure their pain is being addressed and they are treated similarly to your other patients.

PAiNWEEK iS TO PAiN TREATMENT AND EDUCATiON LiKE U2 iS TO THE MUSiC iNDUSTRY. BOTH REMAiN ON THE CUTTiNG EDGE.

STEPHEN J. ZIEGLER, PhD, JD

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“FACULTY FORUM

Medical Cannabinoids: Science, Practice, Policy, and Ethics

Gregory T. Carter, MD, MS

C annabis (marijuana) has been used for medicinal purposes for thousands of years. It was first

noted in the Chinese pharmacopoeia in 2800 BC. Medicinal cannabis arrived in the US much later, burdened with a remarkably checkered, yet colorful, his-tory. Despite early robust use, medicinal cannabis use faded after the advent of opioids and aspirin. Cannabis was criminalized in the US in 1937, against the advice of the American Medical Society (now the American Medical Association). The past few decades have seen renewed interest in medicinal cannabis, with the National Institutes of Health, the Institute of Medicine, and the American College of Physicians all issuing statements of support.

The recently discovered endocannabi-noid system has greatly increased the understanding of the actions of exog-enous cannabis. Endocannabinoids appear to control pain, muscle tone, mood state, and appetite, among other effects. Cannabis contains over 60 dif-ferent types of cannabinoids, which have the capacity for analgesia through neuromodulation, neuroprotection, and anti-inflammatory mechanisms.

Despite the fact that many states have now re-legalized cannabis for medici-nal purposes, the DEA still classifies it as Schedule I. Although hampered by legal restrictions, less research money, (compared to pharmaceutical industry-sponsored tri-als) and the fact that trials in the US must use low quality (3% tetrahydrocannabinol [THC]) federally grown cannabis, the peer-reviewed published research continues to show that cannabis is safe and effective for many conditions, including chronic pain, muscle spasticity, inflammation, cachexia, dysphoria, and other debilitating problems associated with chronic pain. In fact, the current medical literature indicates that many chronic pain patients could be treat-ed with cannabis alone or in combination with lower doses of opioids.

Dronabinol is 100% THC, the most potent psychoactive ingredient in cannabis. Dronabinol is considered safe by the DEA and is available by prescription as a Schedule III drug. Dronabinol is not a viable substitute for natural cannabis, which is rarely more than 20% THC, yet contains many other therapeutic cannabi-noids. Newer cannabinoid-based drugs are coming to market, but are produced in other countries. A new strain of canna-bis plant developed in Israel has no THC but does contain other therapeutic, non-psychoactive cannabinoids, indicating an area that may be ripe for an explosion of safe, effective drugs for chronic pain.

THE PAST FEW DECADES HAVE SEEN RENEWED iNTEREST iN MEDiCiNAL CANNABiS, WiTH THE NATiONAL iNSTiTUTES OF HEALTH, THE iNSTiTUTE OF MEDiCINE, AND THE AMERiCAN COLLEGE OF PHYSiCiANS ALL iSSUiNG STATEMENTS OF SUPPORT.

GREGORY T. CARTER, MD, MS

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8:10-10:10AM Medical Cannabinoids: Science, Practice, Policy, and Ethics

FRIDAY, 9|6

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