PAINWeek Podcasts

The management of chronic noncancer pain with opioid medications is controversial. The negative consequences have been described as a public health emergency and the efficacy of chronic opioid therapy remains a subject of significant debate. Despite recommendations that chronic opioid therapy not be utilized until other methods fail, there remains a large population of patients for whom no other therapy has been effective and a large cohort of people who have been treated for years with opioids. Many new patients are still started and maintained on chronic opioid therapy. This course describes one system's use of clinical pharmacists incorporated into the pain management team to reduce risks. Participants will learn how the pharmacists are utilized in this team-based model. Topics covered will include the nuts and bolts about how to incorporate pharmacists into clinical management, outcomes of the model of care, DEA certification for pharmacists, billing for services, and lessons learned.

Buprenorphine was developed by UK based Reckitt & Colman Products and released in the United Kingdom in 1978. That same year, a clinical study determined that buprenorphine could be helpful in reducing cravings of pure opioids in patients with an opioid abuse disorder. Then, a separate study published in 1982 demonstrated that buprenorphine offered excellent analgesia with a blunted abuse liability. Buprenorphine is a partial agonist at the mu-opioid receptors and an antagonist at the kappa receptors. Mu-opioid receptor activity produces the analgesic effects of buprenorphine, while a strong affinity for the kappa receptors render them inactive. While initially buprenorphine was used as an anesthetic, currently it has been prescribed for the induction and maintenance in patients with an opioid use disorder. However, buprenorphine is a unique molecule with multiple applications. This presentation will provide an in-depth discussion of the history of buprenorphine and its application for pain control, opioid use disorders, and antisuicide properties in patients with chronic pain

The use of opioids to treat chronic pain has become quite contentious in recent years. Things get even more confusing when we consider adding an adjuvant analgesic in the mix. Does this reduce or heighten risk? The audience can decide where to throw spitballs when 2 practitioners debate 2 separate topics. First, is the use of cannabis plus an opioid likely to provide an enhanced clinical effect (eg, allow for opioid dose reduction and by extension, harm), make no difference, or possibly cause more harm. The second debate will evaluate the use of gabapentin plus an opioid. On one hand, we have data showing the gabapentinoids may be habituating and result in addiction. Combining gabapentin with an opioid may also increase the risk of mortality. On the other hand, rational polypharmacy, using an opioid and gabapentin, has been shown to result in superior clinical outcomes compared to either analgesic alone. So perplexing. What's a practitioner to do? Listen to the debate and decide for yourself!

In previous presentations, Dr. Jay has discussed the pathophysiology, neuroanatomical, and other aspects of fibromyalgia. In this activity, all of that will NOT be discussed, so the focus can be only on the diagnosis and treatment of fibromyalgia and restless leg syndrome. Treatment will be covered in depth, not the phenomenology that is the complex neuroanatomical and neuropathological backgrounds of these diatheses. The goal is to provide clinicians with practical information to be utilized upon seeing patients following the conference.

The prevalence of back pain continues despite the many treatments available, without any single treatment being a panacea. In routine clinical practice there has been a tendency of clinical 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 purpose of this discussion is to assist clinicians in the development of a more problem focused examination to enhance the differential diagnosis of specific pain generators, and therefore lead to more patient specific treatment. Attention will be given to considering all aspects of the examination, including physical assessment as well as 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.

Today's providers are limited by time and must work with extreme efficiency. And yet for many, 100% of their time is used trying to treat 20% of their patients' problems. This presentation will address the problem of chronic pain, provide simple tools to use during any office visit, and explain the power of positive and negative thoughts on the chronic pain experience.

Several recent studies have found intriguing links between gut microbes, rheumatoid arthritis, and other diseases. Additional studies have shown the interactions between the central nervous system, enteric nervous system, and the gastrointestinal tract, suggestive that gut microbiota appears to influence the development of emotional behavior, and stress- and pain-modulation systems. In the age of modern medicine, it is easy to forget that we change our body chemistry every time we eat. The quality and composition of our food has the power to increase or decrease body wide inflammation and modulate pain. Our relationship to food and the way we eat is also cultural and influenced by stress and our environment. The research evidence is robust for dietary interventions and improved health. The changes needed are simple, but not necessarily easy. This lecture will focus on the role that modulation of the microbiome plays in pain, and the ways to optimize the health of the individuals' gut microbes for pain management and overall well-being.

Pain is common in the aging population. Findings from an NIH funded study looking at the impact on pain in the older adult found that over 50% of people surveyed had pain within the last month, often in more than one location. Despite the high prevalence of pain, pain often remains undertreated, resulting in impaired cognition, decreased socialization, sleep disturbances, and a reduced quality of life. Our bodies react differently to medications due to medical comorbidities and metabolic changes due to the aging process itself. Understanding the correct choices of analgesic utilizing a multimodal approach to treatment is important in providing safe and effective pain therapies. Patients with dementia or in the late stages of disease may propose a unique pain control challenge due to difficulty in the ability to verbalize pain. This session will explain the differences in response to analgesic medications due to the aging process and provide recommendations for individualized pain control based on specific patient characteristics.

This course will review the scientific evidence for/against opioid therapy, risk mitigation, and different methods of opioid tapering. Providers need guidance to determine which patients may or may not benefit from opioids. While most pain patients on opioid therapy manage opioids safely, the risks are detrimental to some patients and society. Clinicians are faced with contradictory professional advice and legal mandates/scrutiny. Many patients are exposed to risk due to inappropriately executed opioid tapering. Suicide rates are rising, and illicit drug use including overdose deaths from synthetic opioids continue to rise. How do we maximize benefit over harm? T his session will review the scientific evidence and legal requirements that contribute to optimized opioid therapy when clinically indicated and how to discontinue opioid therapy if appropriate.

Understanding the mechanisms that drive a persistent pain process is critical for effectively treating pain in any patient. While it is common to treat pain from a primary nociceptive perspective, this approach often fails in patients with central sensitization. Pain mechanism based classifications can help clinicians make recommendations that may improve functional outcomes and enhance patient adherence by identifying primary pain mechanisms. This course will offer practical tips for evaluation of patients with mixed pain mechanism presentations and includes an interactive discussion of multimodal treatment options for each.

Course DescriptionWhen we practitioners approach complex medical problems (whether pain, depression, or even GERD) that have psychological and lifestyle components and we do so with minimally monitored drug-only therapies, we may bounce from one “wonder drug” to another and end up bewildered or worse. These problems need complex approaches that address the component parts and we can’t just rely on finding the next wonder drug. Perhaps it’s part of the American mindset: wanting a pill to fix problems. Part of it is from the perverse incentives in a healthcare system that wants to find solutions to complex issues and then implement them on the cheap, running them through primary care on a conveyor belt. In pain we see history repeating itself around the medical cannabis issue. All the same mistakes are being made again and with poor care coordination, risk management, and assessment it will end up doing harm.

Forced downward titration has been broadly implemented throughout the country as a direct result of the CDC Guideline for Prescribing Opioids for Chronic Pain. Prescribing clinicians feel pressured to follow the CDC’s recommendations of dose limits to avoid regulatory sanctions, and pharmacists feel a corresponding obligation to intervene in accordance with the CDC guideline and corporate policies. In many instances, prescribers have refused to treat opioid-requiring pain patients, resulting in the patients’ discharge from the specialist’s practice or a consult refusal—the latter of which, by default, often leaves the most medically complex and challenging patients with only their primary care providers to manage their pain. Some patients have chosen to leave their existing providers because of mistrust, cynicism, disbelief, and abandonment, but they then find it difficult to secure any other provider willing to treat their pain. This presentation will chronicle the events that have delivered an unreasonable burden on patients and providers.

Forced downward titration has been broadly implemented throughout the country as a direct result of the CDC Guideline for Prescribing Opioids for Chronic Pain. Prescribing clinicians feel pressured to follow the CDC’s recommendations of dose limits to avoid regulatory sanctions, and pharmacists feel a corresponding obligation to intervene in accordance with the CDC guideline and corporate policies. In many instances, prescribers have refused to treat opioid-requiring pain patients, resulting in the patients’ discharge from the specialist’s practice or a consult refusal—the latter of which, by default, often leaves the most medically complex and challenging patients with only their primary care providers to manage their pain. Some patients have chosen to leave their existing providers because of mistrust, cynicism, disbelief, and abandonment, but they then find it difficult to secure any other provider willing to treat their pain. This presentation will chronicle the events that have delivered an unreasonable burden on patients and providers.

This session is designed to familiarize learners with the principles of the neurobiology of the traumatized patient and illuminate the salient concepts that are germane to the presentations and treatment of patients with chronic pain. At the conclusion of this activity, practitioners should be able to identify several key aspects of behavior and presentation in patients with chronic pain who have a history of trauma, as well as utilize these concepts when interacting and treating these patients to improve outcomes and pain scores.

There are various types of studies that are necessary to perform in order to determine their clinical relevance. The process extends from benchtop to bedside side and includes various special populations like pediatrics and geriatrics. This course addresses various elements related to the study of analgesics. Novel improved preclinical animal models in analgesic studies are examined. The unique issues of unusually high placebo and nocebo effects in analgesic which can lead to confusing results are discussed. The role and responsibilities of acting as a Principal Investigator in an analgesic trial are discussed. The practical impact of new healthcare measures and the increased the importance of comparative effectiveness trials and health outcomes and pharmacoeconomic are reviewed. The process of publishing data and determination of authorship At the conclusion of the program participants shall have a comprehensive understanding of the analgesic trials.

Chronic pain is much more than a physical sensation. It can be all-encompassing and often impacts an individual in a multitude of ways, spawning discouraging, painful, or unwanted psychological experiences such as thoughts, feelings, and memories as well as functional limitations. The natural approach might be to dedicate time and expend energy and resources (emotional, psychological, financial, etc) to controlling or avoiding these uncomfortable experiences. However, increasing evidence suggests that, not only are attempts to control the frequency and form of these types of private experiences often unsuccessful, doing so may result in an increase in their occurrence and an increased sensitivity to their impact, thus, paradoxically exacerbating one’s situation. Additionally, especially with chronic pain, avoidance of discomfort (physical and emotional) often results in isolation and inactivity, thus robbing an individual of participation in valued activities. Acceptance and commitment therapy (ACT), a 3rd wave spinoff of cognitive behavioral therapy, is now considered an evidence-based therapeutic treatment for chronic pain that is set apart from other, more commonsense solutions. ACT poses a useful alternative to control-based treatments and operates on a set of 6 core processes within a unified model called psychological flexibility—“the capacity to be directly, consciously, and fully in contact with the present moment without needless defense and to persist or change one’s behaviors in the service of one’s goals.”

Spirochetal infection symptoms include muscle pain, nausea, vomiting, abdominal pain, and many others. Lyme disease can cause joint pain and stiffness, fatigue, flu-like symptoms, and sleep problems, among others. Depending on the species of bacteria involved, symptoms may be quite painful and range from acute to chronic. How are patients infected? What treatments work best? Although an “appropriate” treatment for the various stages of infection is not universally accepted, this course will suggest means for treatment while it reviews causes and types of infection and symptoms.

The healthcare community is at a crossroads as the opioid crisis rages in America – how to provide effective pain management while preventing opioid abuse and addiction. This session will explore evidence-based opioid-sparing pain management techniques and how they are improving patient outcomes and quality of life while also reducing overall costs.

The Pain Management Best Practices Inter-Agency Task Force identified inconsistencies and fragmentation of pain care as gaps in US healthcare that limit best practices and patient outcomes. The report encourages coordinated care and cites the collaborative stepped model of pain care, as adopted by the Department of Veterans Affairs and the Department of Defense health systems as a best practice. The session will address the challenges and successes of VA’s pain care transformation towards patient-centered biopsychosocial pain care for Whole Health for Veterans. Attendees will learn how to anticipate challenges and minimize risks when implementing a comprehensive pain care transformation away from opioids based on lessons learned from the largest integrated healthcare system in the United States.

This presentation will focus on the development of a clinical decision tool to standardize opioid prescribing for patients with sickle cell disease. Pain is the hallmark symptom of sickle cell disease, which is often managed by hematologists or primary care physicians. Currently, there is no clinical decision tool or any type of standardization regarding opioid prescribing among these patients. The Management of Sickle Cell Disease guidelines, published in JAMA in 2014, states that there is little evidence related specifically to chronic pain is those with sickle cell disease and most of the recommendations were adapted from general pain guidelines. Therefore, opioid prescribing is not consistent regarding management of chronic pain in this patient population, potentially due to a lack of standardized prescribing practices. In order to mitigate this absence, this pilot project aims to create an opioid prescribing protocol for use in patients with sickle cell disease who are prescribed or may be prescribed opioid therapy. The research was funded and began in January 2019 to develop the clinical decision tool. The tool was implemented in April 2019 and evaluated. The goal is to continue implementation and potentially expand to other sites that treat sickle cell or other chronic pain patients.

Chronic pain and alcohol consumption are both very common in the general population, and alcohol is often used to numb both physical and emotional pain. The epidemiology of co-occurring pain and alcohol use will be discussed in this presentation. In addition, we will review the latest evidence surrounding the interaction between alcohol consumption and pain. Moderate alcohol use has been associated with improved pain related outcomes for certain pain conditions. However, both excessive binge drinking and alcohol use disorder are associated with worsened pain outcomes including increased pain intensity, and alcohol use is associated with specific pain conditions. Pain may also trigger alcohol consumption, and alcohol consumption represents a negative pain coping strategy. The interaction of alcohol with pharmacologic treatments for pain will be reviewed, and behavioral strategies to treat co-occurring alcohol use disorder and chronic pain, and to reduce problem drinking, will be presented.

Virtually all healthcare professionals have some degree of altruism and a strong desire to help patients in need. As healthcare continues to evolve, the burdens on clinicians change as well. While most of us have been taught that providing a “medical home” to patients along with shared decision-making is the most ethical way to provide effective healthcare, many are finding that other stakeholders may potentially derail those worthy intentions. While insurers are not often considered to be “regulatory agencies” by most, they indeed have become major players in determining the trajectory of everything from pain assessment to treatment planning and implementation to follow-up and monitoring. Many feel that insurance related paperwork and associated administrative burdens are contributing significantly to clinician burnout and ultimately having a negative impact on patient care. Additionally, navigating these challenges is not part of the standard curriculum of most educational training programs. This session will focus on these topics and the concept of “institutional iatrogenesis” and identify the challenges they present to healthcare providers, as well as strategies to manage them and minimize interference with our primary mission: caring for patients with pain.

There are many potential underlying causes for neck and upper extremity pain. All too often, only the most common conditions such as a disk herniation or carpal tunnel syndrome are explored. The purpose of this course is to review other common problems (such as radiculitis), and not so common (such as rib arthropathy pain syndromes) that can affect the neck and upper extremities. Attention will be given to clinical pearls for recognizing when patients present with such problems, as well as treatments that may prove helpful for both differentially diagnosing and treating various neck and upper extremity pain syndromes, especially many of those that are often missed or overlooked and easily treatable to resolution when they are identified.

Psychosocial factors have become increasingly recognized as important moderators and determinants of the pain experience. One such factor that has garnered great empirical attention is pain catastrophizing. Pain catastrophizing has been described for more than half a century, yet many frontline practitioners continue to be unfamiliar with the construct. It is conceptualized as a negative cognitive affective response to anticipated or actual pain and has been associated with a number of important pain related outcomes. There are several determinants for pain catastrophizing, including female sex, Asian/African race, age, certain genotypes, and hormonal/neurophysiological phenotypes. There are two psychometrically sound self-report instruments (Coping Strategies Questionnaire and CSQ and the Pain Catastrophizing Scale) that can be readily and reliably used with a variety of pain populations. High levels of pain catastrophizing on these measures should be considered a risk marker for adverse pain related outcomes. The primary treatment for pain catastrophizing is cognitive behavior therapy for chronic pain (CBT-CP). Education, relaxation, and acceptance and commitment therapy (ACT) skills have also shown promise.

Therapy of pain is a challenge and requires special approaches. This course, as part of the Pain Educators Forum (PEF), will build on information provided in other PEF sessions and focus on the prevalence and impact of unrelieved pain, pathogenesis, and treatments of pain. Participants will learn about approaches and advances in therapy of common acute and chronic pain syndromes, and evidence based recommendations for pharmacotherapy of pain will be provided. Pain Therapeutics examines current trends in pain relief, which can be implemented into practice as soon as attendees return to work.

This session is designed to familiarize learners with the principles of the neurobiology of the traumatized patient and illuminate the salient concepts that are germane to the presentations and treatment of patients with chronic pain. At the conclusion of this activity, practitioners should be able to identify several key aspects of behavior and presentation in patients with chronic pain who have a history of trauma, as well as utilize these concepts when interacting and treating these patients to improve outcomes and pain scores.

The ancient Sumerians first cultivated the poppy plant for its opium in 3000 BC. The analgesic properties of opium were formalized into morphine and later commercialized by Merck Pharmaceuticals in 1827. To this date, morphine and its derivatives are effectively used for treating acute pain. In recent years, however, the overuse of opioids to treat chronic nonmalignant pain has contributed to the prescription opioid epidemic. As society has recognized this problem and our government has stepped into opioid crisis efforts, we turn to technology in treating chronic pain as an alternative to opioid medications. This presentation is targeted for general practitioners and current pain management physicians. We will explore the evolution of pain medicine leading up to the current and future opioid-sparing interventional pain treatment options. Specifically, we will focus on electroceuticals (spinal cord stimulation, peripheral nerve stimulation, vagus nerve stimulation), minimally invasive spinal decompression spacers, and percutaneous sacroiliac joint fusion.

The United States is struggling with how to deal with two competing problems: the undertreatment of pain and the abuse of opioids. At the same time, millions of people in third-world countries are dying without access to any opioids, even liquid morphine, due in large part to a variety of barriers relating to distance, regulation, and knowledge. Could marijuana be the solution to both problems? Although marijuana continues to remain prohibited by federal law and treaty, several countries and US states have defied these prohibitions by passing their own laws and regulating marijuana for recreational or medical purposes. This presentation examines the labyrinth of laws relating to marijuana in the United States, the extent of suffering in third-world countries, and how the global legalization of marijuana may become a viable solution—or a pipe dream?

Motivational interviewing (MI) is a counseling approach that was initially applied to address drinking behavior. At its core, it helps reduce patients’ ambivalence and move them toward action through use of their own intrinsic motivation. Over the years, MI has been applied broadly across different health domains to help shape outcomes. The approach can be particularly beneficial when working with patients who are perceived to be stuck and not making satisfactory progress in treatment. This presentation will introduce the audience to MI, review the concepts underlying it, and discuss its specific application in pain settings.

Medication assisted therapy (MAT) for addiction has been available since 2000. Up until 2016, physicians have been the only healthcare providers able to prescribe buprenorphine for opioid addiction. On July 22, 2016, President Obama signed into law the Comprehensive Addiction and Recovery Act (CARA). This is the first major federal addiction legislation in 40 years and the most comprehensive effort undertaken to address the opioid epidemic. CARA incorporated many needed resources to better manage patients with addiction, but one specific aspect of the legislation was focused at nurse practitioners and physician assistants: providing greater access to care by easing the restrictions on who could provide MAT after completion of continued education. Nurse practitioners and physician assistants caring for patients with chronic pain and addiction need continued education and empowerment to accept this level of responsibility. This session will look at the history of addiction, past therapies, current therapies, and the future of addiction, specifically how it intersects with chronic pain management.

Individuals with chronic pain may lack awareness that they are feeling grief. People who suffer from chronic pain may experience losses in several areas: comfort, sexual function, career, income, self-efficacy, cognitive function, intimacy, pride, joy, self-esteem, self-control, independence, mental health, hope, dignity, and certainty. Providers may overlook these patients biggest loss: themselves. While everyone copes in their own way and experiences their chronic pain condition uniquely, there are common feelings that most of us share: denial, anger, bargaining, depression, and acceptance. Elizabeth Kübler-Ross’s five stages of grief outlined in her 1969 book, On Death and Dying, may help patients better understand what they are going through. Frontline providers can help patients better cope with the grief that often has no resolution by understating the limitations of their illness, listening and trying to understand what they are going through, looking for signs and completing a thorough psychosocial assessment, and organizing psychoeducational support groups and other interventions. The goal is to transform their experience into something livable and bearable.

Myopain conditions including myofascial pain and fibromyalgia are among the most common disorders causing chronic pain and are a significant cause of suffering, addiction, disability, and healthcare utilization. More than half of the persons seeking care for these pain conditions at 1 month still have pain 5 years later despite treatment. The good news is that successful treatment of these painful conditions is achievable, and this course aims to teach providers the 2 key factors that clinically make the biggest impact. The first is recognition of the contribution of the fascia to myofascial pain and fibromyalgia, and improving diagnostic skills promoting early recognition. Along with better recognition of myofascial pain, effective treatment will incorporate evidence-based manual therapies and myofascial self-care. The second key to success is utilizing a transformative care approach that integrates comprehensive patient self-management training and coaching to empower patients to address the many risk factors that can lead to delayed recovery and chronic pain. This activity will describe the growing body of evidence for fascial dysfunction contributing to pain in fibromyalgia and myofascial pain, along with research supporting the effectiveness of manual therapies either performed by a therapist or as part of a myofascial self-treatment program. Reimbursement for transformative care with telehealth coaching with online technology will also be covered by Drs. Fricton and Liptan.

Myopain conditions including myofascial pain and fibromyalgia¬ are among the most common disorders causing chronic pain and are a significant cause of suffering, addiction, disability, and healthcare utilization. More than half of the persons seeking care for these pain conditions at 1 month still have pain 5 years later despite treatment. The good news is that successful treatment of these painful conditions is achievable, and this course aims to teach providers the 2 key factors that clinically make the biggest impact. The first is recognition of the contribution of the fascia to myofascial pain and fibromyalgia, and improving diagnostic skills promoting early recognition. Along with better recognition of myofascial pain, effective treatment will incorporate evidence-based manual therapies and myofascial self-care. The second key to success is utilizing a transformative care approach that integrates comprehensive patient self-management training and coaching to empower patients to address the many risk factors that can lead to delayed recovery and chronic pain.

2018 was not a good year to be on the wrong side of medical necessity when it came to drug testing and ongoing prescribing of controlled medication or substance abuse treatment programs. 2019 is likely to be an expensive year for those who do not proactively take steps to understand medical necessity for drug testing, prescribing controlled medication, and ongoing substance abuse treatment, as payers continue to carefully scrutinize these areas. Using a series of case hypotheticals, attendees will learn how to identify the elements of medical necessity, efficiently and effectively document medical necessity for drug testing and use of drug test results in the ongoing care of the patient, and locate and use payer medical policies and coverage determinations. Attendees will be given 3 tools to reinforce learning objectives: a checklist for medical necessity documentation, sample summaries of payer medical policies, and templates for documenting use of drug test results and tailoring ongoing treatment decisions to the individual patient.

Multiple guidelines have recently emphasized nonpharmacologic interventions for chronic pain, with the role of nutrition strikingly absent. Given pain’s potential coexistence with metabolic dysregulation, including obesity, metabolic syndrome, and nutrient deficiency, nutrition-based interventions hold promise as an approach for improving pain status in multiple patient populations. Unfortunately, nutritional and dietary approaches can be complex and time consuming to implement and daunting for clinicians feeling inadequate preparation to provide guidance. Fortunately, nutrition pain management can often be provided in staged interventions based on patient status. This session will review why nutrition is often overlooked, as well as the foundational science of how it can both promote and relieve pain. The session will discuss how to evaluate nutritional status and initiate foundational anti-inflammatory interventions. Also to be examined is the role of nutritional supplementation in individualized cases including vitamin D, omega-3s, magnesium, and other emerging nutrients. The session will conclude with a discussion of how to combine nutritional interventions as a long-term strategy for improving both pain and metabolic status.

This course will provide the principals and practice of osteopathic medicine, showing anatomical unity, structure, and function, and pathways to innate healing. We will provide exam skills to incorporate kinetic chains of motion with movement restrictions. If time permits, there will be demonstrations of counterstrain techniques for the spine and extremities.

Pain represents a foremost feature of neurogenic thoracic outlet syndrome (NTOS). Symptoms include ipsilateral upper extremity pain, sensory loss, shoulder and neck discomfort, arm paresis or edema, headache, and even sympathetic nervous system impairment. This presentation will cover an evidence-based review of the classification, etiology, clinical presentation, diagnostic measures, and surgical treatment of NTOS with a focus on nonoperative therapies such as physical modalities, pharmacological therapies, and the more contemporary, and minimally invasive, cervicothoracic intramuscular treatments with botulinum toxin.

Idiopathic intracranial hypertension (formerly called pseudotumor cerebri) is a cause of headache, along with optic nerve edema, and can lead to permanent visual loss. This course will address how to diagnose it, how best to treat it, and other topics including subgroups and issues of “outliers.” This is a frequently missed diagnosis, and important to include in a differential diagnosis.

Pelvic floor muscle dysfunction is associated with pelvic pain, physical disability, and sexual dysfunction. Prevalence estimates of musculoskeletal dysfunction in various pelvic pain conditions, including endometriosis, vulvodynia, and painful bladder syndrome, range from 21% to 80%. In addition to being associated with other painful conditions, pain originating from pelvic floor muscles may refer to other body parts such as the lumbar spine, sacroiliac joints, hips, and abdomen. Adding to this complexity is an interplay between muscles and neurons including maladaptive neuronal plasticity associated with widespread muscle pain that may manifest beyond the pelvis. This presentation will provide an overview of key abdominopelvic musculature and their contributions to pelvic pain, screening for musculoskeletal dysfunction, and components of a musculoskeletal pelvic pain examination. A focus will be placed on reviewing the pelvic anatomy and hormonal/life states related to sex specific musculoskeletal pain, such as pregnancy, endometriosis, and sexual pain. Additionally, the presentation will discuss the role of different musculoskeletal specialists such as physiatrists and physical therapists in identifying and treating musculoskeletal pain conditions.

Despite being one of the more frequently noted triggers for migraine, estrogen and its role in the pathology of migraine is still unknown. This talk discusses the current understanding of the role of estrogen in the headache experience. We will start by touching on the clinical experience the field has gathered and then dig into the fledging science on the role of estrogen in the brain, periphery, and blood vessels, and the hypothesis on how these pathways and interactions might trigger the migraine.

Opioid use and addiction have soared in the United States over the past 20 years, and drug overdoses have become the leading cause of injury death. Persons with opioid use disorder (OUD), particularly those injecting opioids, frequently require hospitalization and encounter need of acute opioid analgesia for trauma, surgery, infection, and other medical conditions. Treatment of acute pain in persons with OUD present challenges for acute pain management including altered nociception thresholds, physical dependence and withdrawal, tolerance, impaired immune response, and behavioral issues such as opioid seeking and poor coping skills. Clear goals of care and use of engaging communication methods are essential to deliver optimal inpatient care and smooth plans for hospital discharge. This session will cover key principles to working with this population including 1) improving patient safety and healthcare outcomes by treating underlying OUD; 2) optimizing pain relief for necessary surgical and medical treatment by providing multimodal analgesia; 3) facilitating access to medication treatment programs upon discharge; 4) empowering patients and providers by promoting clear, just, and equitable treatment of pain; and 5) protecting communities by promoting discharge opioid prescribing habits that minimize risk.

At the 2018 Department of Justice (DOJ) Opioid Summit, then-Attorney General Jeff Sessions remarked that opioid prescribing had reached its lowest point in 18 years. Still, the DOJ is committed to reducing opioid analgesic prescriptions an additional 30% to 33% within the next 3 years. More than ever, prescribers of controlled prescription medications are under intense scrutiny from lawmakers, regulators, and payers. At the same time, some 50 million adults in the US have persistent pain, nearly 20 million of whom experience pain that interferes with daily life or work activities. As noted by the Pain Management Best Practices Inter-Agency Task Force (PMTF) in its December 2018 draft report, the trend of healthcare professionals opting out of treating pain has exacerbated the shortage of pain management specialists, leaving some patients without access to individualized care. In this session, a partner in a Washington, DC based health law firm will discuss recent legislative and regulatory activity at the federal level and trends in criminal enforcement. He will also discuss noteworthy developments at the state level and analyze the anticipated benefits, drawbacks, and unintended consequences of such actions on people with pain and those who treat them. Topics will include the implications of recently passed comprehensive opioid legislation—the SUPPORT for Patients and Communities Act; a draft report on pain management best practices by PMTF and the pushback against it; and efforts to reform the federal approach to investigating controlled-medication prescribers.

Assessment, diagnosis, treatment plan formulation, implementation, and follow-up are processes familiar to clinicians and are the main drivers of safe and effective chronic pain treatment. However, many other things influence our clinical decision-making, including the continuing controversies about the role of opioid analgesics in the management of chronic pain, the “opioid epidemic” our nation faces today, and the fear of regulatory scrutiny just to name a few. Additionally, when formulating decisions about pain treatment, the subjective nature of chronic pain and determining the context of how pain is affecting a person’s life may often be challenging. What we might not be aware of is how other more subtle forces can potentially influence us and have a negative impact on the care we provide for patients—the things that we “bring into the examination room.” This session will focus on how things like precognitive thinking, implicit biases, explicit biases, impressions about patient characteristics and even their demographics may potentially alter our judgment and create disparity. Suggestions will be presented to help recognize and reflect about how we can make sure that the pain care we deliver is not compromised by these things we might not consider, even though they are there.

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 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.

It’s your worst clinical nightmare: providing dosing recommendations for opioid and/or nonopioid pain medication treatment for a patient with renal or hepatic impairment. Even scarier, a patient with end-stage renal or hepatic disease! Put your panic aside and learn about the INs and OUT of managing opioid and/or nonopioid pain medications, and why some medications might need adjustment and others may not. From metabolism and metabolites to creatinine clearance and Child-Pugh score, you will leave this course feeling more confident in your ability to provide pain pharmacotherapy to patients with renal or hepatic impairment.

It is becoming increasingly common to hear a new analgesic drug molecule described as a “biased ligand,” being “peripherally restricted,” or as having been “engineered.” What do these terms mean? How are such drugs designed or discovered, and how do you even know that you have one when you have one? For that matter, how are any modern analgesic drugs designed or discovered these days? It’s definitely not your father’s preclinical drug discovery lab any more. Modern drug discovery labs utilize a variety of approaches such as compound libraries, combinatorial chemistry, fragment based lead discovery, high-throughput screening, in silico modeling, in vitro human receptor assays, CRISPR and AI (artificial intelligence). This session provides a painless introduction to what goes on in modern preclinical drug discovery and translational medicine. Three case studies will illustrate the concepts and the resultant clinical analgesic molecules.

In 2010, the Captain James A. Lovell Federal Healthcare Center became the first fully integrated facility caring for active duty, veterans, retirees, and dependents in the US. This presented healthcare professionals with unique challenges including how to address pain management in such a diverse population. In 2017, a core team was tasked with the creation of a comprehensive pain management program to address their facility’s need for a cohesive and interdisciplinary approach to chronic pain management in light of the growing national opioid crisis. The emphasis of this new program is to shift the facility’s focus away from a traditional biomedical curative pain management approach to one that emphasizes a more comprehensive biopsychosocial approach, which can empower patients to take on more responsibility for their pain management and overall functionality. Attendees will learn how this new comprehensive pain management approach has shifted the focus from “fix me” to “teach and empower me.” This journey of “moving mountains” will be illustrated by examining the pitfalls and specific challenges that were faced, as well as the pathways explored, to overcome and rise above these challenges. The end result will reinforce the main goal of realigning the therapeutic relationship to being patient-centered vs provider-driven with the emphasis on improving overall quality of life and functionality. This focus will also speak on the paradigm shift not only for the patients but also for the providers/staff in order to create a common language that is shared facility wide in the realm of pain management.

Humans have been searching for the Fountain of Youth for millennia, from Herodotus to Ponce de León. Some people feel that regenerative medicine, a field that encompasses stem cells, growth factors, and other cell mediating proteins, is that magical fountain, while others, including some physicians, members of various regulatory committees, and some in the media, believe it is a fad. As with many emerging topics, there is curiosity and confusion. While the regenerative medicine field is relatively new to most people, there is a wide variety of treatments and technologies available. We will discuss the various stem cell and growth factors in regenerative medicine and conditions, such as neurological, degenerative changes, osteoarthritis, and tendinitis that have been treated with them.

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 representing real life will be presented.

Ah… drug math. Those 2 little words can make a strong healthcare provider want their mommy. But no fear. Armed with an understanding of conversion calculations, some semisolid facts about equivalencies, and a healthy sense of “Does that LOOK right?”—you’ll be just fine! This lively session will review new and emerging data on opioid conversion calculations, and guidance for methadone dosing, both for chronic noncancer pain, and for patients with a serious, advanced illness. If you want to be able to dose opioids safety and effectively, you don’t want to miss this session!

This session is designed to familiarize learners with the principles of the neurobiology of the traumatized patient and illuminate the salient concepts that are germane to the presentations and treatment of patients with chronic pain. At the conclusion of this activity, practitioners should be able to identify several key aspects of behavior and presentation in patients with chronic pain who have a history of trauma, as well as utilize these concepts when interacting and treating these patients to improve outcomes and pain scores.