PAINWeek 2013 Preview

7 | UNDERSTANDING 15 | CYTOCHROME AND TREATING NEUROPATHIC PAIN

22 | AVOIDING THE

25 | CHRONIC PAIN

P450: INTERPRETATIONS PITFALLS OF RUMOR- IN CHILDREN: & ACTIONS BASED MEDICINE ARE THEY AT RISK?

Neuropathic pain, a mixture of peripheral and central mechanisms, requires multidisciplinary treatment.

Guidelines on genetic testing and individualized opioid selection in pain management.

Misperceptions of government regulations can negatively impact pain management practices.

Assessing and understanding chronic pain in children to safely provide appropriate pain treatment

OVeRVieW LOCATION & VENUE

NATIONAL CONFERENCE

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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-ofthe-art convention and meeting space, it offers a multitude of benefits and features to PAINWeek attendees: ●

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Check in for the conference and the hotel all on the same level Many rooms offering private terraces and patios Rooms equipped with sophisticated entertainment system, plasma-screen television, and state-of-theart control panels 3 distinct pool experiences Full-service spa (extra cost) Many gourmet offerings from a wide variety of restaurants Quick and inexpensive transportation from McCarran International Airport

PLEASE NOTE: It is IMPORTANT that you book your accommodations during your registration process at www.painweek.org, not directly with the hotel or via third party.

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PAINWeek Conference Preview

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 practitioners, 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 master 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 information 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

PWE REGIONAL CONFERENCES

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he PAINWeekEnd Regional Conference Series brings certified 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.

n0. 1 q 2 2013

PWJ—PAINWEEK JOURNAL

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

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AINWeek 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 throughout 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 feature articles on the following topic areas:

Behavioral Pain Management Complementary and Alternative Medicine Diabetes and Chronic Pain Emergency Medicine Geriatric Pain Management Government & Public Policy Health Coaching Interventional Pain Management Medical/Legal Issues Music & Art Therapy Neurology

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Occupational Therapy Pain and Chemical Dependency Pain Clinical Trials Palliative Care Pediatric Pain Management Pharmacotherapy Physical Medicine & Rehabilitation Physical Therapy Regional Pain Syndromes Rheumatology 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) ●

PAINWeek Conference Preview

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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

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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

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

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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

PAINWeek Conference Preview

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PARTiCiPATiNG ORGANiZATiONS’ FULL DAY PROGRAMS

AMERICAN PAIN SOCIETY FRIDAY, 9 | 6 7:00–8:00AM ➤

Using Quantitative Sensory Testing for Mechanism-Based Pain Assessment 9:20–10:20AM

Brain Imaging as an Objective Biomarker for Pain

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 evidencebased, interdisciplinary approach to pain treatment.

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

11:10AM–12:10PM ➤

How to Assess and Manage Sleep Disturbances in Patients with Pain 4:40–5:40PM

Does Exercise Increase or Decrease Pain?

RELATED PROGRAMS OF INTEREST New Developments in Evidence-Based Pain Assessment and Treatment

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FEATURED PRESENTATION

Using Quantitative Sensory Testing for Mechanism-Based Pain Assessment Roger B. Fillingim, PhD

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ain treatment is typically based on signs and symptoms combined with medical tests that provide minimal information regarding the pathophysiological mechanisms underlying the patient’s pain. Tests that can reveal these mechanisms would enable therapy optimization by targeting specific pain mechanisms.

Quantitative sensory testing (QST) can identify pathophysiological mechanisms and sensory abnormalities that FEATURED PRESENTATION

How to Assess and Manage Sleep Disturbances in Chronic Pain Michael T. Smith, PhD, CBSM

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PAINWeek Conference Preview

leep and pain reciprocally interact, and as literature demonstrates sleep disturbance is a risk factor for

may contribute to patients’ pain. QST quantifies patients’ responses to carefully 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 development of pain risk and response to treatment. This session will discuss the clinical application of QST in evaluating and treating 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. developing chronic pain.

Attendees will gain knowledge on the importance of assessing sleep disturbance 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.

AMERICAN ACADEMY OF PAIN MEDICINE FEATURED PRESENTATION

Understanding and Treating Neuropathic Pain Sean Mackey, MD, PhD, CPE

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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 mechanisms. The deleterious effects of neuropathic 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, musclegroup strengthening, transcutaneous electrical nerve stimulation), and procedural interventions (eg, trigger point injection, nerve blockade, and spinal drug delivery and stimulation).

SATURDAY, 9 | 7 8:10-9:10AM

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The Brain in Pain 9:10-10:10AM

Understanding and Treating Neuropathic Pain

This presentation will discuss the science of neuropathic pain and therapeutic approaches to managing it as well as provide clinical cases to illustrate appropriate treatment strategies for neuropathic pain.

I WENT TO PAINWEEK AND...

september 4–7, 2013

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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.

PAINWeek Conference Preview

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PARTiCiPATiNG ORGANiZATiONS’ FULL DAY PROGRAMS

AMERICAN ACADEMY OF PAIN MEDICINE FEATURED PRESENTATION

Cervical and Lumbosacral Spine: Assessment and Physical Exam

1:30-2:30PM ➤

Cervical and Lumbar Spine Pain: Assessment and Physical Exam

Steven P. Stanos, DO

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2:30-3:30PM ➤

Cancer Pain and Palliative Care

he physical exam must be individualized 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

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), paraspinals and gluteals (back), diaphragm (roof), and pelvic floor and hip muscles (bottom) will also be covered.

FEATURED PRESENTATION

metastases, plexopathies, and peripheral neuropathies), and pharmacologic and non-pharmacologic management.

Cancer Pain and Palliative Care Larry Driver, MD

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ain associated with cancer frequently is undertreated. Some 30%-45% of cancer patients experience moderate 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 discussion of the scope of the pain problem in cancer patients, pain assessment, cancer pain syndromes (such as bone metastases, epidural metastases, skull

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PAINWeek Conference Preview

as pain behavior, gait, motor strength, muscle stretch reflexes, and dural tension testing. Also presented will be an overview of the spinal anatomy, the differential diagnosis, and pain behaviors.

Reviewed will be how to assess pain intensity and character, psychosocial evaluation (e.g., the meaning of pain for the patient and patients’ typical coping response to pain), and physical, neurologic, and diagnostic examination. Discussion of pharmacologic management will include information ranging from the use of non-steroidal antiinflammatory agents to neuroleptic agents.

The non-pharmacologic management portion of the presentation will include information about such approaches as cutaneous stimulation, exercise, radiotherapy, and anesthetic techniques.

FACULTY FORUM

THIS IS ONE MEETING THAT TRULY UNDERSTANDS GOOD PAiN CARE STARTS iN PRiMARY CARE. ILENE ROBECK, MD

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SATURDAY, 9 | 7

AMERICAN SOCIETY OF PAIN EDUCATORS 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 mechanisms, 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.

WEDNESDAY, 9 | 4 7-8AM

Pain Terminology: Knowing the Difference Makes a Difference!

9:20-10:20AM

Pain Mechanisms 11:10aM-12:10PM ➤

Chronic Pain Assessment 1:30-2:30PM

Pain Therapeutics 2:40-3:40PM

When Acute Pain Becomes Chronic 4:40-5:40PM

FEATURED PRESENTATION

Chronic Pain Assessment Michael R. Clark, MD, MPH, MBA

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uccessful assessment and follow-up of patients with chronic non-cancer pain includes comprehensive, stepwise approaches and setting realistic, 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 management 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 riskbenefit ratio 5. Establishing treatment goals 6. Obtaining informed consent and agreement

Pain Diagnostic Methods

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 family 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.

THURSDAY, 9 | 5 7-8AM

Occupational and Physical Therapy: Complete Your Pain Management Team 8:10-10:10AM

Teaching the 5 Pain Coping Skills

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.

PAINWeek Conference Preview

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PARTiCiPATiNG ORGANiZATiONS’ FULL DAY PROGRAMS

AMERICAN SOCIETY OF PAIN EDUCATORS Chronic Pain Telementoring for the Remote Provider: Project ECHO

9:20-10:20AM ➤

break

Joanna Katzman, MD, MSPH

Chronic Pain Telemonitoring for the Remote Provider: Project ECHO

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11:10AM-12:10pM

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 throughout the Southwest. This program, which received the 2011 American Pain Society Clinical Centers of Excellence Award, leverages technology and connects remote providers through video conferencing.

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

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ECHO Pain consists of an interdisciplinary pain team of specialists who offer case-based learning and formal didactics. Active learning and robust bidirectional discussion are the key ingredients 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.

FACULTY FORUM

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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Comerci, MD, the medical directors for UNM ECHO Pain, will discuss the foundations 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 telemonitoring clinics.

PAINWeek Conference Preview

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THURSDAY, 9 | 5

NATIONAL ASSOCIATION OF DRUG DIVERSION INVESTIGATORS 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 perpetrator in the events leading up to drug diversion.

THURSDAY, 9 | 5 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

FEATURED PRESENTATION

Protecting Your Medical Practice: A Law Enforcement Perspective John J. Burke

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ost prescribers estimate that 10% to 12% of the patient population engages in drug diversion, or any criminal act involving prescription drugs. The proportion is likely higher in pain management practices, where opioid 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 pharmacies, 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-diagnose 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 evidence of a kidney stone.

Bullying in Medicine: Are You the Victim or the Perpetrator?

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 provided—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 associated with drug diversion.

PAINWeek Conference Preview

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OPiOiD SAFETY DAY

FRIDAY, 9 | 6 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, 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 minimizing 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 symposium on the FDA’s extended release/long acting opioid REMS (risk evaluation & mitigation strategy) will also be offered to PAINWeek attendees.

Among the featured courses will be: ● Opioids Inside the ● Institutional Setting ● Opioids A-Z ● ● Opioid Conversions ● Opioid-induced Hyperalgesia ● ● Opioids: Update on AbuseDeterrent Formulations

Patient-Centered Urine Drug Testing Opioid Refugees: The New Diaspora?

“Just Saying No to Opioids”: Not Necessarily Good Medicine

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.

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

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

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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,

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PAINWeek Conference Preview

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 interactions, 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.

Mary Lynn McPherson, PharmD, BCPS, CPE, FASPE

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linicians who practice in pain management 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.

Opioid Refugees: The New Diaspora?

Steven D. Passik, PhD

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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

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Using a case-based format, participants in this session will learn how to use a fivestep process to assess a patient potentially requiring an opioid conversion. Case examples 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.

FRIDAY, 9 | 6 7-8AM

Opioids A-Z 9:20-10:20AM ➤

Opioid Conversions

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!

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 psychologist and addiction specialist will include discussion of how state laws pertaining to opioid prescribing, unintended 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.

FRIDAY, 9 | 6 1:30-2:30PM ➤

Opioid Refugees: the New Diaspora?

4:40-5:40PM

Methadone

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Opioid Conversions

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

PAINWeek Conference Preview

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OPiOiD SAFETY DAY Opioids: Update on Abuse-Deterrent Technology

11:10aM-12:10PM

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

Opioid-Induced Hyperalgesia 1:30-3:30PM

Patient-Centered Urine Drug Testing 1:30-4:30PM

CO*RE Opioid REMS 2:40-3:40PM

“Just Saying No“ to Opioids: Not Necessarily Good Medicine 4:40-5:40PM ➤

Opioids: Update on Abuse-Deterrent Technology

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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.

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This decision will no doubt affect future development of opioids, including generic formulations and consideration of whether or not they have abusedeterrent 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 abusedeterrent 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 whether 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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FRIDAY, 9 | 6

PHARMACOTHERAPY Topical and Transdermal Analgesics

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 commercially 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.

Cytochrome P450: Interpretations and Actions

In order to utilize genetic testing, special training is necessary to

James B. Ray, PharmD, CPE

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Forest Tennant, MD, MPH, DrPH

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ytochrome P450 testing has recently become readily available. 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.

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 provided as to which tests should be ordered and which opioids should be selected based on test results.

WEDNESDAY, 9 | 4 3:50-4:50PM

Glial Cells and Inflammatory Products: How They Impact Pain, the Patient, and the Practitioner

FRIDAY, 9 | 6 11:10aM-12:10PM

Rational Polypharmacy

SATURDAY, 9 | 7 9:20-10:20AM ➤

Topical and Transdermal Analgesics 4:40-5:40PM ➤

Cytochrome P450: Interpretations and Actions

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FRONTLiNE PRACTiTiONER FOCUS Physician Assistants in Pain Management

1:30-2:30PM ➤

Jeremy Adler, MS, PA-C

Physician Assistants in Pain Management

THURSDAY, 9 | 5 1:30-2:30PM ➤

The Role of Nurse Practitioners in Pain Management

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t has been said that no single person or profession holds all the resources necessary 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.

The Role of Nurse Practitioners in Pain Management Cynthia Knorr-Mulder, BCNP, NP-C

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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 perceived by other healthcare professionals in pain management creates stronger

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More and more frequently, physician assistants (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.

interprofessional collaborative relationships 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 humanistic and supportive. She believes at any given moment we are all teachers, learners, and doers, with the ability to influence the health and healing of patients with chronic pain.

FACULTY FORUM

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

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WEDNESDAY, 9 | 4

MUSCULOSKELETAL TRACK HiGHLiGHTS

Musculoskeletal Pain in Women Colleen M. Fitzgerald, MD, MS

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evelopmentally, boys and girls are similar prepuberty. However, these similarities dissipate due to the hormonal effects on female physiology during puberty, age 9 through 12 years, leading to differing musculoskeletal influences on pain.

This session will describe predominant musculoskeletal pain in women throughout the life stages of adolescence, pregnancy and childbearing, and mid-to-late life, including anatomical 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 musculoskeletal conditions in women.

Pelvic and lower extremity structural differences predispose young women to certain injuries; specifically knee injuries 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 incontinence in young girls highlights that

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, osteoporosisrelated 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.

WEDNESDAY, 9 | 4 7-8AM

Myofascial Pain Syndrome 9:20-10:20AM

Osteoarthritis

11:10aM-12:10PM ➤

Musculoskeletal Pain in Women 4:40-5:40PM

Whiplash

RELATED PROGRAMS OF INTEREST 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 ●

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

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NEUROLOGY TRACK HiGHLiGHTS

WEDNESDAY, 9 | 4

Diagnosis and Management of Central Pain

11:10aM-12:10PM

Forest Tennant, MD, MPH, Dr PH

Recognition, Diagnosis, and Management of Postherpetic Neuralgia

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entral or “centralized” pain may result from a brain injury such as stroke or head trauma, rise de novo such as fibromyalgia, or develop following a peripheral nerve injury. The latter results from glial cell activation, which produces neuroinflammation, neuroplasticity, and implanting of the memory of pain. Centralized pain may be concomitantly associated with peripheral pain. Profound hormone and autoimmune 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

2:40-3:40PM

Neuropathic Itch

FRIDAY, 9 | 6 9:20-10:20aM ➤

Diagnosis and Management of Central Pain 2:40-3:40PM

Restless Leg Syndrome

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.

MORE FACES YOU’LL SEE AT PAINWEEK

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1. Michael M. Bottros, MD 2. John J. Burke 3. Daniel B. Carr, MD, FABPM 4. Michael R. Clark, MD, MPH, MBA 5. Roger B. Fillingim, PhD 6. Lisa McElhaney 7. Mary Lynn McPherson, PharmD, BCPS, CPE, FASPE 8. Michael E. Schatman, PhD, CPE, DASPE 9. Forest Tennant, MD, MPH, DrPH

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DiABETES AND PAIN TRACK HiGHLiGHTS

Diabetes and GI Pain Michael M. Bottros, MD

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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 complications. One of the more persistent problems is gastrointestinal (GI) pain. While being persistent, it is also transient, which makes for a more difficult diagnosis. Symptoms may include nausea, bloating, and abdominal pain, much of which relates to delayed gastric emptying. These symptoms correlate

Diabetes, Pain, and Sleep

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 symptoms 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 conditions such as hepatitis, pancreatitis, and abdominal aortic aneurysm. Dr. Bottros also will talk about use of different diagnostic tools, such as gastric emptying scintigraphy, manometry, transabdominal ultrasonography, and magnetic resonance imaging.

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, particularly sleep apnea, can have profound effects on metabolism. Studies show that sleep disorders are intricately linked with a number of medical conditions, including diabetes, stroke, heart attack, atrial fibrillation, hypertension, glaucoma, reflux, headaches, and seizures.

Sleep is divided into three phases: light sleep, deep (or delta wave) sleep, and REM (rapid eye movement) sleep.

Individuals cycle among the three phases 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.

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.

Any intervention that eases diabetes will help the overall long-term prognosis, especially with regard to pain.

Evaluating diabetic patients for good sleep, including sleep apnea, is among one of the most important things clinicians can do to help a patient with diabetes.

Victor W. Rosenfeld, MD

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SATURDAY, 9 | 7 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

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MASTER CLASSES

FRIDAY, 9 | 6

Differential Diagnosis of Back Pain

7-9AM

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

Pain and Hormones 1:30-3:30PM ➤

Differential Diagnosis of Back Pain 1:30-3:30PM ➤

Patient-Centered Urine Drug Testing

RELATED PROGRAMS OF INTEREST Urogenital Pain: Interstitial Cystitis, Endometriosis, Vulvodynia, and Dispaurenia ● Obesity-Related Pain ● Chronic Pain, PTSD, Substance Abuse Disorder and TBI ● Analgesic Effects of Virtual Reality

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he prevalence of back pain continues in spite of the many treatments available, without any single treatment 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.

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Patient-Centered Urine Drug Testing Howard A. Heit, MD, FACP, FASAM, DAAPM, FAAPM

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he goal of this 2-hour lecture is to define a practical approach to management 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 facilitate 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.

FACULTY FORUM

MARY LYNN MCPHERSON, PHARMD, BCPS, CPE, FASPE

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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.

MASTER CLASSES | CLiNiCAL CONUNDRUMS

Geralyn Datz, PhD

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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 comorbid mood or anxiety disorders; some precede their pain and others develop these reactions over time as a response to pain.

Mood and anxiety problems were once characterized as simply emotional overreactions to pain or organic disturbances

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

Gary W. Jay, MD, DAAPM, FAAPM

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ne of the common mistakes physicians make when diagnosing patients is looking at signs and symptoms and other clinical findings solely from the monocular perspective of their

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that were untreatable or refractory to treatment. There is now a greater understanding of the complex neurochemical changes involved in depression and anxiety, 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 manage 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 formulations 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 supported, evidence-based treatments for pain-related depression and anxiety.

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 experience to illustrate the kinds of mistakes physicians can make in handling certain cases.

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

THURSDAY, 9 | 5 1:30-3:30PM

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

RELATED PROGRAMS OF INTEREST The Madwoman in the Attic: Pain and Personality Disorders

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THURSDAY, 9 | 5 11:10-12:10PM ➤

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

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

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

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

Jennifer E. Bolen, JD

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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 decisions may result in cases of overdose

THURSDAY, 9 | 5

Avoiding the Pitfalls of Rumor-Based Medicine

1:30-3:30PM

Stephen J. Ziegler, PhD, JD

Critical Documentation Skills (Encore)

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any physicians who prescribe opiates and other tightly controlled 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 unintentional 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

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Attendees will learn the importance of lab test reports as faculty provide examples 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. or sued. This can lead to the faulty perception 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 challenges faced by regulators at the local, state, and federal level. He also will discuss the civil litigation process involved in malpractice 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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and subsequent lawsuits or termination. 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.

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WEDNESDAY, 9 | 4

SPECiAL iNTEREST SESSiONS The Complexity Model: A Novel Approach to Collaborative Pain Management John F. Peppin, DO, FACP Marty D. Cheatle, PhD

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reater than 25% of the US population experiences chronic pain, yet there is a paucity of physicians specializing in pain medicine. The undertreatment of pain was brought to national attention to encourage both clinicians and patients to advocate for improved pain care.

Chronic pain is complex, and effective treatment requires a multimodal approach. This approach is supported

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

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

WEDNESDAY, 9 | 4 7:00-8:00AM ➤

The Complexity Model: A Novel Approach to Collaborative Pain Management

From the perspective of the busy clinician, 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 stratifies treatment and patients by level and type of complexity and promotes communication between specialist and primary care providers will be reviewed.

FRIDAY, 9 | 6 4:40-5:40PM ➤

Persistent Postsurgical Pain: the Proverbial Pandora’s Box

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

Studies have identified risk factors for persistent postsurgical pain, which can be divided into preoperative, intraoperative, and post-operative risks.

Pre-operative risk factors include psychosocial issues (such as anxiety and depression), sleep disorders, and obesity. Intra-operative risk factors include nerve injury and tissue ischemia resulting from the surgical procedure, as well as anesthetic technique. Postoperative risk

Research has focused largely on preventing 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 neuropathic. 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 postsurgical pain.

Michael M. Bottros, MD

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 surgical pain that lasts for at least three months, a definition widely used in clinical practice.

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SPECiAL iNTEREST SESSiONS Chronic Pain in Children: Are They a Population at Risk?

3:50-4:50PM ➤

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

Chronic Pain in Children: Are They a Population at Risk?

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he good news: more children are surviving cancer. The bad news: the pain associated with either the cancer or its treatment remains, becoming chronic pain that may go untreated.

This example illustrates that children with chronic pain are indeed an underrepresented population at risk. Many may not receive appropriate treatment, either because clinicians lack an understanding 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 misuse 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 independence, 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 adolescent’s inexperience with prescription 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 opioids 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 available pain assessment tools to ensure their pain is being addressed and they are treated similarly to your other patients.

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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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THURSDAY, 9 | 5

Medical Cannabinoids: Science, Practice, Policy, and Ethics Gregory T. Carter, MD, MS

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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, history. 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 endocannabinoid system has greatly increased the understanding of the actions of exogenous cannabis. Endocannabinoids appear to control pain, muscle tone, mood state, and appetite, among other effects. Cannabis contains over 60 different types of cannabinoids, which have the capacity for analgesia through neuromodulation, neuroprotection, and anti-inflammatory mechanisms.

FRIDAY, 9 | 6 8:10-10:10AM ➤

Medical Cannabinoids: Science, Practice, Policy, and Ethics

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 cannabinoids. Newer cannabinoid-based drugs are coming to market, but are produced in other countries. A new strain of cannabis plant developed in Israel has no THC but does contain other therapeutic, nonpsychoactive 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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Despite the fact that many states have now re-legalized cannabis for medicinal purposes, the DEA still classifies it as Schedule I. Although hampered by legal restrictions, less research money, (compared to pharmaceutical industry-sponsored trials) and the fact that trials in the US must use low quality (3% tetrahydrocannabinol [THC]) federally grown cannabis, the peerreviewed 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 treated with cannabis alone or in combination with lower doses of opioids.

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