27th Napa Pain Conference - Archives

Regular price: $419.95

Save $70 by purchasing the entire set of sessions from the 2020 Napa Pain Conference.

Contains: All 9 courses broadcast August 15, 2020 during the 27th Napa Pain Conference.

Completion of all sessions will earn 7.0 AMA PRA Category 1 Credits(tm)

Preventing Pandemics & Preparing Health Care

Expiration Date: Aug 14, 2023

COVID-19, Lung Insufficiencies, Fractal Geometry & Hyperactivity of the Inflammatory System

Outline

• Evolution of Pandemics
• 3 P´s for Pandemics
• Understanding the pandemic disease
• Some Health Care Challenges
• Conclusion

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Systems-Based Practice [ACGME/ABMS] as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosures of Financial Relationships

Neither the speaker, peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any relevant financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Additional Reading

• Lindahl, S. G. (2020). Using the prone position could help to combat the development of fast hypoxia in some patients with COVID‐19. Acta Paediatrica.
• de Groot, R. J., Baker, S. C., Baric, R. S., Brown, C. S., Drosten, C., Enjuanes, L., ... & Perlman, S. (2013). Commentary: Middle east respiratory syndrome coronavirus (mers-cov): announcement of the coronavirus study group. Journal of Virology, 87(14), 7790-7792.
• Woo, P. C., Lau, S. K., Lam, C. S., Lau, C. C., Tsang, A. K., Lau, J. H., ... & Zheng, B. J. (2012). Discovery of seven novel Mammalian and avian coronaviruses in the genus deltacoronavirus supports bat coronaviruses as the gene source of alphacoronavirus and betacoronavirus and avian coronaviruses as the gene source of gammacoronavirus and deltacoronavirus. Journal of Virology, 86(7), 3995-4008.
• Forni, D., Cagliani, R., Clerici, M., & Sironi, M. (2017). Molecular evolution of human coronavirus genomes. Trends in Microbiology, 25(1), 35-48.
• Ye, Z. W., Yuan, S., Yuen, K. S., Fung, S. Y., Chan, C. P., & Jin, D. Y. (2020). Zoonotic origins of human coronaviruses. International Journal of Biological Sciences, 16(10), 1686.
• Gussow, A. B., Auslander, N., Faure, G., Wolf, Y. I., Zhang, F., & Koonin, E. V. (2020). Genomic determinants of pathogenicity in SARS-CoV-2 and other human coronaviruses. Proceedings of the National Academy of Sciences.
• Wei, J., Alfajaro, M., Hanna, R., DeWeirdt, P., Strine, M., Lu-Culligan, W., ... & Mankowski, M. (2020). Genome-wide CRISPR screen reveals host genes that regulate SARS-CoV-2 infection. Biorxiv.
• Tracey, K. J. (2015). Approaching the next revolution? Evolutionary integration of neural and immune pathogen sensing and response. Cold Spring Harbor Perspectives in Biology, 7(2), a016360.
• Nicoli, F., Solis-Soto, M. T., Paudel, D., Marconi, P., Gavioli, R., Appay, V., & Caputo, A. (2020). Age-related decline of de novo T cell responsiveness as a cause of COVID-19 severity. GeroScience, 1-5.
• Grifoni, A., Weiskopf, D., Ramirez, S. I., Mateus, J., Dan, J. M., Moderbacher, C. R., ... & Marrama, D. (2020). Targets of T cell responses to SARS-CoV-2 coronavirus in humans with COVID-19 disease and unexposed individuals. Cell.
• Tracey, K. J. (2002). The inflammatory reflex. Nature, 420(6917), 853-859.
• Andersson, U., Yang, H., & Harris, H. (2018). Extracellular HMGB1 as a therapeutic target in inflammatory diseases. Expert opinion on therapeutic targets, 22(3), 263-277.
• Tracey, K. J. (2007). Physiology and immunology of the cholinergic antiinflammatory pathway. The Journal of Clinical Investigation, 117(2), 289-296.
• Douglas, W. W., Rehder, K., Beynen, F. M., Sessler, A. D., & Marsh, H. M. (1977). Improved oxygenation in patients with acute respiratory failure: the prone position. American Review of Respiratory Disease, 115(4), 559-566.
• Beck, K. C., & Rehder, K. (1986). Differences in regional vascular conductances in isolated dog lungs. Journal of Applied Physiology, 61(2), 530-538.

• Prof. Sten Lindahl, MD, PhD, FRCA, Chair Emeritus, Nobel Committee in Physiology or Medicine

Excitation & Inhibition - A Critical Balance

Expiration Date: Aug 14, 2023

8th Annual Lindahl Lecture: 

Excitation & Inhibition - A Critical Balance

Target Audience

This activity is designed for clinicians and researchers utilizing or developing therapies with application to the nervous system. 

This activity may benefit anyone with a lack of understanding of the role that excitation and inhibition play within the nervous system; how improper or maladaptive 'tuning' or 'balance' of these impulses contributes to disease formation or treatment.

Learning Objectives

The inhibitory systems within the CNS can be activated by brain stimulation, intracerebral microinjection of morphine, and peripheral nerve stimulation. 

Of Specific Relevance to the Study and Treatment of Pain

Excitation and inhibition are central to the development and treatment of pain. Pain information in the CNS is controlled by ascending and descending inhibitory systems and studies have shown that patients with painful neuropathy have an excitatory/inhibitory neurotransmitter imbalance in the brain. Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury.

Understanding pain mechanisms is key to the development of novel analgesics and to better use of existing agents.  Spinal inhibition may be impaired under conditions of neuropathy and inflammation, and the available evidence suggests that disinhibition in the spinal dorsal horn may lead to characteristic symptoms of neuropathic pain such as hyperalgesia, dynamic mechanical allodynia, and spontaneous paroxysmal pain. Centrally acting analgesic drugs activate these inhibitory control systems.

The concepts explored in detail here are supported and be expanded upon in other activities by Drs. Fillingim, Cheng and Guan.

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] (about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care)
  
• Employ Evidenced-based Practice [IOM]   Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Utilize Informatics [IOM] Communicate, manage, knowledge, mitigate error, and support decision making using information technology

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.1: Explain the complex, multidimensional, and individual-specific nature of pain
  • 1.2: Present theories and science for understanding pain
  • 1.3: Define terminology for describing pain and associated conditions

• 3. Management of pain: How is pain relieved?
  • 3.5:  Monitor effects of pain management approaches to adjust the plan of care as needed
  • 3.7: Develop a treatment plan that takes into account the differences between acute pain, acute-on-chronic pain, chronic/persistent pain, and pain at the end of life

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships

Neither the speaker, peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any relevant financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Additional Reading

• Rosenberg, R. N., & Pascual, J. M. (Eds.). (2020). Rosenberg's Molecular and Genetic Basis of Neurological and Psychiatric Disease: Volume 1. Academic press.
• Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders?. BMC Musculoskeletal Disorders, 16(1), 25.
• Petrou, M., Pop-Busui, R., Foerster, B. R., Edden, R. A., Callaghan, B. C., Harte, S. E., ... & Feldman, E. L. (2012). Altered excitation-inhibition balance in the brain of patients with diabetic neuropathy. Academic Radiology, 19(5), 607-612.
• Abbott, L. F., & Nelson, S. B. (2000). Synaptic plasticity: taming the beast. Nature Neuroscience, 3(11), 1178-1183.
• Vogels, T. P., Rajan, K., & Abbott, L. F. (2005). Neural network dynamics. Annu. Rev. Neurosci., 28, 357-376.
• Goffer, Y., Xu, D., Eberle, S. E., D'amour, J., Lee, M., Tukey, D., ... & Wang, J. (2013). Calcium-permeable AMPA receptors in the nucleus accumbens regulate depression-like behaviors in the chronic neuropathic pain state. Journal of Neuroscience, 33(48), 19034-19044.
• Song, S., & Abbott, L. F. (2001). Cortical development and remapping through spike timing-dependent plasticity. Neuron, 32(2), 339-350.
• Song, S., Miller, K. D., & Abbott, L. F. (2000). Competitive Hebbian learning through spike-timing-dependent synaptic plasticity. Nature Neuroscience, 3(9), 919-926.
• Latremoliere, A., & Woolf, C. J. (2009). Central sensitization: a generator of pain hypersensitivity by central neural plasticity. The Journal of Pain, 10(9), 895-926.
• Mainen, Z. F., & Abbott, L. F. (1999). Functional plasticity at dendritic synapses. In Dendrites (pp. 310-338). Oxford University Press, Oxford.
• Sussillo, D., & Abbott, L. F. (2009). Generating coherent patterns of activity from chaotic neural networks. Neuron, 63(4), 544-557.
• Gold, M. S., & Gebhart, G. F. (2010). Nociceptor sensitization in pain pathogenesis. Nature Medicine, 16(11), 1248-1257.
• Potter, L. E., Paylor, J. W., Suh, J. S., Tenorio, G., Caliaperumal, J., Colbourne, F., ... & Kerr, B. J. (2016). Altered excitatory-inhibitory balance within somatosensory cortex is associated with enhanced plasticity and pain sensitivity in a mouse model of multiple sclerosis. Journal of Neuroinflammation, 13(1), 142.
• Staud, R. (2013). The important role of CNS facilitation and inhibition for chronic pain. International journal of Clinical Rheumatology, 8(6), 639.
• Sandkühler, J. (2009). The role of inhibition in the generation and amplification of pain. In Current Topics in Pain: 12th World Congress on Pain (pp. 53-71).
• Burke, N. N., Finn, D. P., McGuire, B. E., & Roche, M. (2017). Psychological stress in early life as a predisposing factor for the development of chronic pain: clinical and preclinical evidence and neurobiological mechanisms. Journal of neuroscience research, 95(6), 1257-1270.

• Larry F. Abbott, PhD, William Bloor Professor of Theoretical Neuroscience and Professor of Physiology and Cellular Biophysics (in Biological Sciences), Zuckerman Institute, Columbia University

Central Sensitization and Chronic Overlapping Pain Conditions: Neuroplasticity Gone Wrong

Expiration Date: Aug 14, 2023

Central Sensitization & Chronic Overlapping Pain Conditions: Neuroplasticity Gone Wrong

Outcomes

Learners completing this activity routinely report improved abilities in:

• Assessing 2 types central sensitization
• Identifying the cumulative effect of multiple pain generators
• Adopting a multifactorial approach to the patient with respect to integration of various causes for their pain
• Recognize failing pain treatments
• Conducting a comprehensive assessment
• Treating pain
• Communicating with patients

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Assess persons with chronic pain for multiple pain conditions and treat the patient as a whole
• Use the constellation of symptoms to address and treat the underlying mechanisms

Activity Outline

• Neuroplasticity and Central Sensitization
• Central Sensitization (CS)
• Chronic Overlapping Pain Conditions (COPCs)
• Evidence for CS in COPCs
• Clinical Implications of CS

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • Demonstrates knowledge of the theories and science for understanding the physiology of pain and pain transmission

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships

Neither the speaker, peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any relevant financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Additional Reading

1. Maixner, W., Fillingim, R. B., Williams, D. A., Smith, S. B., & Slade, G. D. (2016). Overlapping chronic pain conditions: implications for diagnosis and classification. The Journal of Pain, 17(9), T93-T107.
2. Levitt, A. E., Galor, A., Chowdhury, A. R., Felix, E. R., Sarantopoulos, C. D., Zhuang, G. Y., ... & Levitt, R. C. (2017). Evidence that dry eye represents a chronic overlapping pain condition. Molecular pain, 13, 1744806917729306.
3. Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders?. BMC Musculoskeletal Disorders, 16(1), 25.
4. Latremoliere, A., & Woolf, C. J. (2009). Central sensitization: a generator of pain hypersensitivity by central neural plasticity. The Journal of Pain, 10(9), 895-926.
5. Woolf, C. J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152(3), S2-S15.
6. Ohrbach, R., Fillingim, R. B., Mulkey, F., Gonzalez, Y., Gordon, S., Gremillion, H., ... & Maixner, W. (2011). Clinical findings and pain symptoms as potential risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study. The Journal of Pain, 12(11), T27-T45.
7. Ohrbach, R., & Dworkin, S. F. (2019). AAPT diagnostic criteria for chronic painful Temporomandibular disorders. The Journal of Pain, 20(11), 1276-1292.
   
8. Fillingim, R. B., Loeser, J. D., Baron, R., & Edwards, R. R. (2016). Assessment of chronic pain: Domains, methods, and mechanisms. The Journal of Pain, 17(9), T10-T20.
9. Slade, G. D., Rosen, J. D., Ohrbach, R., Greenspan, J. D., Fillingim, R. B., Parisien, M., ... & Bair, E. (2019). Anatomical selectivity in overlap of chronic facial and bodily pain. Pain Reports, 4(3).
10. King, C. D., Sibille, K. T., Goodin, B. R., Cruz-Almeida, Y., Glover, T. L., Bartley, E., ... & Fessler, B. J. (2013). Experimental pain sensitivity differs as a function of clinical pain severity in symptomatic knee osteoarthritis. Osteoarthritis and Cartilage, 21(9), 1243-1252.
11. Greenspan, J. D., Slade, G. D., Bair, E., Dubner, R., Fillingim, R. B., Ohrbach, R., ... & Maixner, W. (2013). Pain sensitivity and autonomic factors associated with development of TMD: the OPPERA prospective cohort study. The Journal of Pain, 14(12), T63-T74.
12. Slade, G. D., Sanders, A. E., Ohrbach, R., Fillingim, R. B., Dubner, R., Gracely, R. H., ... & Greenspan, J. D. (2014). Pressure pain thresholds fluctuate with, but do not usefully predict, the clinical course of painful temporomandibular disorder. Pain, 155(10), 2134-2143.
13. Carlesso, L. C., Segal, N. A., Frey‐Law, L., Zhang, Y., Na, L., Nevitt, M., ... & Neogi, T. (2019). Pain susceptibility phenotypes in those free of knee pain with or at risk of knee osteoarthritis: the multicenter osteoarthritis study. Arthritis & Rheumatology, 71(4), 542-549.
14. Alshuft, H. M., Condon, L. A., Dineen, R. A., & Auer, D. P. (2016). Cerebral cortical thickness in chronic pain due to knee osteoarthritis: the effect of pain duration and pain sensitization. PLoS One, 11(9), e0161687.
15. McCloy, K., & Peck, C. (2020). Common Factors in the Presentation and Management of Chronic Temporomandibular Disorders and Chronic Overlapping Pain Disorders. Journal of Oral Pathology & Medicine.
16. Lewis, G. N., Parker, R. S., Sharma, S., Rice, D. A., & McNair, P. J. (2018). Structural brain alterations before and after total knee arthroplasty: A longitudinal assessment. Pain Medicine, 19(11), 2166-2176.
17. Ahn, H., Woods, A. J., Kunik, M. E., Bhattacharjee, A., Chen, Z., Choi, E., & Fillingim, R. B. (2017). Efficacy of transcranial direct current stimulation over primary motor cortex (anode) and contralateral supraorbital area (cathode) on clinical pain severity and mobility performance in persons with knee osteoarthritis: An experimenter-and participant-blinded, randomized, sham-controlled pilot clinical study. Brain Stimulation, 10(5), 902-909.
18. Nascimento, S. S., Oliveira, L. R., & DeSantana, J. M. (2018). Correlations between brain changes and pain management after cognitive and meditative therapies: a systematic review of neuroimaging studies. Complementary Therapies in Medicine, 39, 137-145.
19. Seminowicz, D. A., Shpaner, M., Keaser, M. L., Krauthamer, G. M., Mantegna, J., Dumas, J. A., ... & Naylor, M. R. (2013). Cognitive-behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain. The Journal of Pain, 14(12), 1573-1584.
20. Cunningham, N. R., Kashikar-Zuck, S., & Coghill, R. C. (2019). Brain mechanisms impacted by psychological therapies for pain: identifying targets for optimization of treatment effects. Pain Reports, 4(4).

• Roger B. Fillingim, PhD, Distinguished Professor & Director, University of Florida, Pain Research and Intervention Center of Excellence

Regenerative Medicine Targeting of Neuro-immune Interactions & Neuroinflammation

Expiration Date: Aug 14, 2023

Regenerative Medicine Targeting of Neuro-immune Interactions & Neuroinflammation: 

Promoting Restorative Adaptations of Detrimental Responses

Outcomes

Learners completing this activity routinely report improved abilities in:

• Implementing a multi-modality approach to chronic pain management 
• Influencing disease processes through neuroimmune modulation
• Targeting pain and not undertreating
• Considering neuroimmune interactions in nociceptive sensitization
• Implementing regenerative therapies into their practice
• Understanding of pathophysiology for regenerative treatments
• Educating staff and patients about regenerative medicine

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Apply a greater understanding of neuroimmune interactions to address neuropathic pain
• Influence disease process through neuroimmune modulation

Abstract

Regenerative pain medicine is rapidly emerging as a field within pain medicine and orthopedics^1,2. It is increasingly appreciated that common analgesic mechanisms for these treatments depend on neuroimmune modulation. In this lecture, we briefly review the mechanisms of state-of-the-art pain therapies^3-5, discuss recent progress in mechanistic understanding of nociceptive sensitization in chronic pain with a focus on neuroimmune modulation, and describe the rationale of evidence-based regenerative medicine in pain management¹.

Outline

• Overview of the mechanisms of state-of-the-art pain therapies
• Describe new mechanistic understanding of nociceptive sensitization through neuroimmune interactions
• Describe the need for new and innovative therapies for pain and promising treatments on the horizon
• Describe the current understanding of the mechanisms of regenerative medicine and its preclinical and clinical evidence.

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS]  about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Patient Care [ACGME/ABMS]  Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.2: Present theories and science for understanding pain
  • 1.3: Define terminology for describing pain and associated conditions

• 3. Management of pain: How is pain relieved?
  • 3.2: Identify pain treatment options that can be accessed in a comprehensive pain management plan
  • 3.4: Develop a pain treatment plan based on benefits and risks of available treatments

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity includes discussions and explorations of new and evolving topics. Such inclusion includes adequate justifications of statements based upon current science, evidence and clinical reasoning.

Disclosure of Financial Relationships

Neither the speaker, peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any relevant financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Additional Reading

1. Buchheit T, Huh Y, Maixner W, Cheng J, Ji RR: Neuroimmune modulation of pain and regenerative pain medicine. J Clin Invest 2020; 130: 2164-2176
2. Li F, Liu L, Cheng K, Chen Z, Cheng J: The Use of Stem Cell Therapy to Reverse Opioid Tolerance. Clin Pharmacol Ther 2018; 103: 971-974
3. Hua Z, Liu L, Shen J, Cheng K, Liu A, Yang J, Wang L, Qu T, Yang H, Li Y, Wu H, Narouze J, Yin Y, Cheng J: Mesenchymal Stem Cells Reversed Morphine Tolerance and Opioid-induced Hyperalgesia. Sci Rep 2016; 6: 32096
4. Liu LP, Hua Z, Shen J, Yin Y, Yang J, Cheng K, Liu AJ, Wang LN, Cheng JG: Comparative Efficacy of Multiple Variables of Mesenchymal Stem Cell Transplantation for the Treatment of Neuropathic Pain in Rats. Military Medicine 2017; 182: 175-184
5. Cheng J: State of the Art, Challenges, and Opportunities for Pain Medicine. Pain Med 2018; 19: 1109-1111

• Dr. Jianguo Cheng, MD, PhD, FIPP, Professor of Anesthesiology, Cleveland Clinic, Learner Research Institute & Case Western Reserve University

Neuronal & Non-neuronal Modulations by Spinal Cord Stimulation (SCS) in Pain Control

Expiration Date: Aug 14, 2023

An exploration of the neuronal and non-neuronal modulatory effects of SCS.

Abstract

Chronic pain is difficult to treat. Spinal Cord Stimulation (SCS) has been used for over 50 years for pain treatment. Although it is useful, conventional SCS is associated with suboptimal clinical efficacy and short-lived pain relief. Mechanistic study for better understanding the biological actions of SCS will help to improve clinical efficacy of SCS.

This presentation reviews spinal neuronal mechanisms for pain inhibition from SCS, including new evidence suggesting mode of action beyond traditional gate control theory of pain. Despite the ability of glial cells to modulate neuronal excitability and pain processing, glial mechanisms often have been overlooked in the study of SCS.

We will discuss recent findings which suggest non-neuronal modulation by SCS, and the potential of targeting neuron-glial interaction and neuro-immune responses for improving pain control by SCS.

Outcomes

Learners completing this activity routinely report improved abilities in:

• Utilize mechanistic understanding of the effects of spinal cord stimulation (SCS)
• Explaining to patients non neuron-glial interaction and neuro-immune mechanisms of action of SCS besides neuronal stimulation
• Identifying patients who may benefit from SCS therapies
• Selecting the right neurostimulation therapy for each patient
• Making informed referrals

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Integrate the concept of non-neuronal activation via spinal cord stimulation into the process of identifying patients for whom bioelectronic therapies may or may not be advisable 
• Utilize a mechanistic understanding of the effects of SCS to select the right neurostimulation therapies for a variety of patients

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.2: Present theories and science for understanding pain
  • 1.3: Define terminology for describing pain and associated conditions

• 3. Management of pain: How is pain relieved?
  • 3.2: Identify pain treatment options that can be accessed in a comprehensive pain management plan
  • 3.4: Develop a pain treatment plan based on benefits and risks of available treatments

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships & Measures to Resolve Conflicts of Interest

[Speaker] Yun Guan discloses the following financial relationships: Grants/Research Support: Medtronic, TissueTech, Inc. Consulting: Medtronic

Neither the peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity (planners) has, or has had within the past 12 months, any financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Materials were peer-reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Chen, Z., Wang, T., Fang, Y., Luo, D., Anderson, M., Huang, Q., ... & Xie, Y. (2019). Adjacent intact nociceptive neurons drive the acute outburst of pain following peripheral axotomy. Scientific Reports, 9(1), 1-12.
• Beauchene, C., Sacré, P., Yang, F., Guan, Y., & Sarma, S. V. (2019, July). Modeling Responses to Peripheral Nerve Stimulation in the Dorsal Horn. In 2019 41st Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) (pp. 2324-2327). IEEE.
• Sivanesan, E., Stephens, K. E., Huang, Q., Chen, Z., Ford, N. C., Duan, W., ... & Guan, Y. (2019). Spinal cord stimulation prevents paclitaxel-induced mechanical and cold hypersensitivity and modulates spinal gene expression in rats. Pain Reports, 4(5).
• Sdrulla, A. D., Guan, Y., & Raja, S. N. (2018). Spinal cord stimulation: clinical efficacy and potential mechanisms. Pain Practice, 18(8), 1048-1067.
• Miller, J. P., Eldabe, S., Buchser, E., Johanek, L. M., Guan, Y., & Linderoth, B. (2016). Parameters of spinal cord stimulation and their role in electrical charge delivery: a review. Neuromodulation: Technology at the Neural Interface, 19(4), 373-384.
• Sivanesan, E., Maher, D. P., Raja, S. N., Linderoth, B., & Guan, Y. (2019). Supraspinal Mechanisms of Spinal Cord Stimulation for Modulation of PainFive Decades of Research and Prospects for the Future. Anesthesiology: The Journal of the American Society of Anesthesiologists, 130(4), 651-665.
• Guan, Yun. "Spinal cord stimulation: neurophysiological and neurochemical mechanisms of action." Current Pain and Headache Reports 16.3 (2012): 217-225.

• Dr. Yun Guan, MD, PhD, Professor of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine

Caring for Pain During the COVID-19 Pandemic: Consensus Recommendations from an International Expert Panel

Expiration Date: Aug 14, 2023

Outcomes

Learners completing this activity report improved abilities in:

• Mitigating the risks of exposure to SARS-CoV-2 for patients, providers, and staff
• Assessing patient function and wellbeing during a pandemic
• Modifying treatment plans

Overview

This presentation will provide insight into solutions to mitigate the clinical challenges induced by COVID-19.

Abstract

The global COVID-19 pandemic has resulted in significant clinical and economic consequences for medical practices of all specialties across the nation. Of primary relevance to this audience, outpatient pain practices have had to significantly change their clinical care pathways, including the incorporation of telemedicine. Elective medical and interventional care has been postponed.

With regards to the treatment of persons with chronic pain, there are important considerations that need to be recognized, including: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritizing necessary procedural visits. 

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Implement or modify risk mitigation strategies to protect patients and/or staff during the COVID-19 pandemic
• Modify their clinical care to account for factors of the COVID-19 pandemic and/or the SARS-CoV-2 virus

Outline

1. Clinical Care During the Pandemic & Upon Reopening
   1. Telehealth
   2. Safety precautions within the office
   3. Impact on healthcare workers
2. Effect of COVID-19 on Pain Management
   1. Analgesia vs. Immunosuppression 
   2. Steroids & Viruses
   3. Opioid treatment
   4. Ibuprofen & COVID-19
   5. Implantable pain therapies
   6. Effectiveness of eHealth-guided physical therapy
   7. Telehealth
   8. Biopsychosocial management

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Provide Patient-centered Care [IOM] Identify, respect, and care about patients’ differences, values, preferences and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health
• Interpersonal and Communication Skills [ACGME/ABMS] Effective information exchange and teaming with patients, their families, and other health professionals
  
• Professionalism [ACGME/ABMS] As manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
• Apply Quality Improvement [IOM}  Identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; and design and test interventions to change processes and systems of care, with the objective of improving quality
• Systems-Based Practice [ACGME/ABMS]  as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value)

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • Present theories and science for understanding pain
  • Define terminology for describing pain and associated conditions

• 3. Treatment: How is pain safely and effectively treated?
  • Demonstrate knowledge of risk stratification, patient selection, and ongoing monitoring for pharmacological pain treatment
  • Identify pain treatment options that can be accessed in a comprehensive pain management plan
  • Develop a pain treatment plan based on benefits and risks of available treatments

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Speaker] David Provenzano discloses the following financial relationships: Research Support: Abbott, Avanos, Medtronic, Nevro, Stimgenics Consulting: Avanos, Boston Scientific, Medtronic, Nevro, Heron, Esteve

Neither the peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Materials were peer-reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

1. Shanthanna, H., Strand, N. H., Provenzano, D. A., Lobo, C. A., Eldabe, S., Bhatia, A., ... & Narouze, S. (2020). Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel. Anaesthesia.
2. Provenzano, D. A., Sitzman, B. T., Florentino, S. A., & Buterbaugh, G. A. (2020). Clinical and economic strategies in outpatient medical care during the COVID-19 pandemic. Regional Anesthesia & Pain Medicine.
3. Silva, M. J., & Kelly, Z. (2020). The Escalation of the Opioid Epidemic Due to COVID-19 and Resulting Lessons About Treatment Alternatives. American Journal of Managed Care, 26(7), 202-204.
4. Meier, C. A., Fitzgerald, M. C., & Smith, J. M. (2013). eHealth: extending, enhancing, and evolving health care. Annual review of biomedical engineering, 15, 359-382.
5. Schäfer, A. G. M., Zalpour, C., von Piekartz, H., Hall, T. M., & Paelke, V. (2018). The Efficacy of Electronic Health–Supported Home Exercise Interventions for Patients With Osteoarthritis of the Knee: Systematic Review. Journal of medical Internet research, 20(4), e152.
6. Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network — United States, March–June 2020. MMWR Morb Mortal Wkly Rep 2020;69:993-998. DOI: http://dx.doi.org/10.15585/mmw...
7. Chew, N. W., Lee, G. K., Tan, B. Y., Jing, M., Goh, Y., Ngiam, N. J., ... & Sharma, A. K. (2020). A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain, Behavior, and Immunity.
8. Ripp, J., Peccoralo, L., & Charney, D. (2020). Attending to the emotional well-being of the health care workforce in a New York City health system during the COVID-19 pandemic. Academic Medicine.
9. Douglas, M., Katikireddi, S. V., Taulbut, M., McKee, M., & McCartney, G. (2020). Mitigating the wider health effects of COVID-19 pandemic response. BMJ, 369.
10. Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, L. T. C., Chen, Y., Hooten, W. M., ... & King, L. T. C. (2020). Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine.
11. Moore, N., Carleton, B., Blin, P., Bosco-Levy, P., & Droz, C. (2020). Does Ibuprofen Worsen COVID-19? Drug Safety.
12. Ranganathan, P., Chen, H., Adelman, M. K., & Schluter, S. F. (2009). Autoantibodies to the δ-opioid receptor function as opioid agonists and display immunomodulatory activity. Journal of Neuroimmunology, 217(1-2), 65-73.
13. Friedman, H., Newton, C., & Klein, T. W. (2003). Microbial infections, immunomodulation, and drugs of abuse. Clinical Microbiology Reviews, 16(2), 209-219.
14. Wang, J., Barke, R. A., Charboneau, R., & Roy, S. (2005). Morphine impairs host innate immune response and increases susceptibility to Streptococcus pneumoniae lung infection. The Journal of Immunology, 174(1), 426-434.
15. Daniell, H. W. (2008). Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. The Journal of Pain, 9(1), 28-36.
16. Deyo, R. A., Smith, D. H., Johnson, E. S., Donovan, M., Tillotson, C. J., Yang, X., ... & Dobscha, S. K. (2011). Opioids for back pain patients: primary care prescribing patterns and use of services. The Journal of the American Board of Family Medicine, 24(6), 717-727.
17. Nelson, A. M., Battersby, A. S., Baghdoyan, H. A., & Lydic, R. (2009). Opioid-induced decreases in rat brain adenosine levels are reversed by inhibiting adenosine deaminase. Anesthesiology: The Journal of the American Society of Anesthesiologists, 111(6), 1327-1333.
18. Moore, J. T., & Kelz, M. B. (2009). Opiates, Sleep, and Pain: The Adenosinergic Link. Anesthesiology: The Journal of the American Society of Anesthesiologists, 111(6), 1175-1176.
19. Wenk, M., Pöpping, D. M., Chapman, G., Grenda, H., & Ledowski, T. (2013). Long-term quality of sleep after remifentanil-based anaesthesia: a randomized controlled trial. British Journal of Anaesthesia, 110(2), 250-257.
20. Coutinho, A. E., & Chapman, K. E. (2011). The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments and mechanistic insights. Molecular and Cellular Endocrinology, 335(1), 2-13.
21. Abdul, A. J., Ghai, B., Bansal, D., Sachdeva, N., Bhansali, A., & Dhatt, S. S. (2017). Hypothalamic pituitary adrenocortical axis suppression following a single epidural injection of methylprednisolone acetate. Pain Physician, 20(7), E991-1001.
22. Sytsma, T. T., Greenlund, L. K., & Greenlund, L. S. (2018). Joint corticosteroid injection associated with increased influenza risk. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(2), 194-198.
23. Popma, J. W., Snel, F. W., Haagsma, C. J., Brummelhuis-Visser, P., Oldenhof, H. G., van der Palen, J., & van de Laar, M. A. (2015). Comparison of 2 dosages of intraarticular triamcinolone for the treatment of knee arthritis: results of a 12-week randomized controlled clinical trial. The Journal of Rheumatology, 42(10), 1865-1868.
24. Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, L. T. C., Chen, Y., Hooten, W. M., ... & King, L. T. C. (2020). Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine.
25. Baranidharan, G., Bretherton, B., Eldabe, S., Mehta, V., Thomson, S., Sharma, M. L., ... & Hall, S. (2020). The impact of the COVID-19 pandemic on patients awaiting spinal cord stimulation surgery in the United Kingdom: a multi-centre patient survey. British Journal of Pain.

• Dr. David Provenzano, MD, President, Pain Diagnostics and Interventional Care

Preview Available

Oral and Intrathecal Opioids: Rational Approaches and Realistic Expectations

Outcomes

Learners completing this activity report improved abilities in:

• Communicating with, and educating their patients
• Weigh risk vs. benefit for patients when choosing opioid analgesic regimen
• Implementing proper evaluation and risk assessment practices for long-term opioid therapy
• Tapering opioids when appropriate

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Integrate opioid analgesics into a pain treatment plan individualized to the needs of the patient
• Manage patient expectations and interactions with regards to opioid prescribing and tapering
• Assess the success of opioid therapy for each patient
• Mitigate iatrogenic opioid dependence or abuse

Activity Description 

Best practices for chronic pain management agree on specific recommendations for mitigating opioid-related risk through risk assessment, including screening for risks (e.g., depression, active or prior history of SUDs, family history of SUD, childhood trauma) prior to initiating opioids; medication dosing thresholds; consideration of drug-drug interactions, with specific medications and drug-disease interactions; risk assessment and mitigation (e.g., patient-provider treatment agreements); drug screening/testing; prescription drug monitoring programs; and access to nonpharmacologic
treatments.

Because there are opioid receptors on the spinal cord and at specific areas of the brain, significantly smaller doses of opioids in the spinal fluid can provide significant analgesia at much lower doses than oral opioids. Implanted intrathecal pumps with catheters in the spinal fluid can supply medication continuously, and they have been used for both cancer and noncancer pain. The largest trial ever performed in cancer patients demonstrated improved pain control with fewer side effects and a trend toward improved life expectancy with implantable pumps. However, there are significant side effects, including delayed respiratory depression, granuloma formation, and opioid-induced hypogonadism.

It is vital to consider a risk-benefit analysis to provide the best possible patient-centered outcome while mitigating unnecessary opioid exposure. Reevaluation of patients is critical in this setting because the use of medications to control acute pain should be for the shortest time necessary while also ensuring that the patient is able to mobilize and restore function.

Outline

1. Examine changes in attitudes, beliefs, laws and prescribing practices for opioids in recent years
2. Identify key pharmacological aspects of oral and intrathecal opioids
3. Explore the role of opioids in the overall treatment of chronic pain
4. Evaluate the definitions of success and failure for chronic opioid therapy
5. Propose next steps when opioid therapy is a failure

Overview

• Changing attitudes, beliefs and prescribing practices in recent years
• Pharmacology of opioids – oral, transdermal and intrathecal
• Is there a scientific approach to dosing?
• The role of pharmacogenomics
• Intrathecal panel based recommended dosing
• Role of opioids in the larger scheme of pain treatment
• Definitions of success and failure
• Calling out failure and proposing subsequent actions
• Importance of physician/patient relationships

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS]  about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Patient Care [ACGME/ABMS]  Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Provide Patient-centered Care [IOM]  Identify, respect, and care about patients’ differences, values, preferences and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health
• Interpersonal and Communication Skills [ACGME/ABMS]  Effective information exchange and teaming with patients, their families, and other health professionals
  
• Professionalism [ACGME/ABMS]  As manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.5: Explain how cultural, institutional, societal, and regulatory influences affect assessment and management of pain

• 2. Pain assessment and measurement: How is pain recognized?
  • 2.1: Use valid and reliable tools for measuring pain and associated symptoms to assess and reassess related outcomes as appropriate for the clinical context and population
  • 2.2: Describe patient, provider, and system factors that can facilitate or interfere with effective pain assessment and management
  • 2.3. Assess patient preferences and values to determine pain-related goals and priorities
  • 2.4: Demonstrate empathic and compassionate communication during pain assessment

• 3. Management of pain: How is pain relieved?
  • 3.1: Demonstrate the inclusion of patient and others, as appropriate, in the education and shared decision-making process for pain care
  • 3.2: Identify pain treatment options that can be accessed in a comprehensive pain management plan
  • 3.4: Develop a pain treatment plan based on benefits and risks of available treatments
  • 3.5: Monitor effects of pain management approaches to adjust the plan of care as needed
  • 3.6: Differentiate physical dependence, substance use disorder, misuse, tolerance, addiction, and nonadherence

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Speaker] Richard Rosenquist discloses the following financial relationships: Consulting: Mainstay Medical

Neither the peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

All relevant financial relationships have been mitigated. Materials were peer-reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Strickler, G. K., Kreiner, P. W., Halpin, J. F., Doyle, E., & Paulozzi, L. J. (2020). Opioid Prescribing Behaviors—Prescription Behavior Surveillance System, 11 States, 2010–2016. MMWR Surveillance Summaries, 69(1), 1.
  
• Silva, M. J., & Kelly, Z. (2020). The Escalation of the Opioid Epidemic Due to COVID-19 and Resulting Lessons About Treatment Alternatives. American Journal of Managed Care, 26(7), 202-204.
• Kral, L. A., Jackson, K., & Uritsky, T. J. (2015). A practical guide to tapering opioids. Mental Health Clinician, 5(3), 102-108.
• AMA Opioid Task Force (2020) Progress Report: Physicians' progress toward ending the nation's drug overdose and death epidemic. https://www.ama-assn.org/syste...
• Mackey, S. (2014). National pain strategy task force: the strategic plan for the IOM pain report. Pain Medicine, 15(7), 1070-1071.
• IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.
• Krebs, E. E., Gravely, A., Nugent, S., Jensen, A. C., DeRonne, B., Goldsmith, E. S., ... & Noorbaloochi, S. (2018). Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA, 319(9), 872-882.
• Brummett, C. M., Waljee, J. F., Goesling, J., Moser, S., Lin, P., Englesbe, M. J., ... & Nallamothu, B. K. (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA surgery, 152(6), e170504-e170504.
• Klueh, M. P., Hu, H. M., Howard, R. A., Vu, J. V., Harbaugh, C. M., Lagisetty, P. A., ... & Lee, J. S. (2018). Transitions of care for postoperative opioid prescribing in previously opioid-naive patients in the USA: a retrospective review. Journal of General Internal Medicine, 33(10), 1685-1691.
• Lu, L. (2015). The impact of genetic variation on sensitivity to opioid analgesics in patients with postoperative pain: a systematic review and meta-analysis. Pain Physician, 18, 131-152.
• Ruano, G., & Kost, J. A. (2018). Fundamental considerations for genetically-guided pain management with opioids based on CYP2D6 and OPRM1 polymorphisms. Pain Physician, 21(6), E611-E621.
• Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., ... & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal Medicine, 162(4), 276-286.
• Wang, J. K., Nauss, L. A., & Thomas, J. E. (1979). Pain relief by intrathecally applied morphine in man. Anesthesiology: The Journal of the American Society of Anesthesiologists, 50(2), 149-151.
• Deer, T. R., Pope, J. E., Hayek, S. M., Bux, A., Buchser, E., Eldabe, S., ... & Doleys, D. M. (2017). The Polyanalgesic Consensus Conference (PACC): recommendations on intrathecal drug infusion systems best practices and guidelines. Neuromodulation: Technology at the Neural Interface, 20(2), 96-132.
• Deer, T. R., Pope, J. E., Hanes, M. C., & McDowell, G. C. (2019). Intrathecal therapy for chronic pain: a review of morphine and ziconotide as firstline options. Pain Medicine, 20(4), 784-798.
• Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Medicine, 6(6), 432-442.
• Butler, S. F., Fernandez, K., Benoit, C., Budman, S. H., & Jamison, R. N. (2008). Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). The Journal of Pain, 9(4), 360-372.
• MacPherson EL. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. Bethesda, MD: American Society of Health System Pharmacists; 2010.
• HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose [news release]. HHS Press Office; December 19, 2018
• Henry, S. G., Paterniti, D. A., Feng, B., Iosif, A. M., Kravitz, R. L., Weinberg, G., ... & Verba, S. (2019). Patients’ experience with opioid tapering: A conceptual model with recommendations for clinicians. The Journal of Pain, 20(2), 181-191.

• Dr. Richard W. Rosenquist, MD, Chairman, Department of Pain Management, Cleveland Clinic

Improving Patient Engagement with Their Health Care Provider

Expiration Date: Aug 14, 2023

Improving Patient Interactions: Managing Expectations With Tools, Resources and Documentation

Outcomes

Learners who completed this activity routinely report improvements in:

• Assessing function and quality of life
• Counseling and educating patients
• Patient intake procedures
• Addressing implicit biases that affect clinical care
• Developing patient care plans, tailored to the needs of the individual

Learning Objectives

As a result of participating in this activity, learners will be better able to:  

1. Empathize with the impact that pain has on the person with pain and their lifestyle 
2. Discuss how the impact of treatment plays a role in the treatment outcomes  
3. Enhance communication with patients to uncover patient needs and improve adherence to treatment plans
4. Empower persons with chronic pain to become active agents in their care and treatment

Critical Questions

1. What are the expectations of the individual person with pain?  
2. What happens between appointments with their health care plan and lifestyle changes? 
3. How do you really know if they are following through with necessary activities?  
4. What do we need to change in order to improve care?  
5. Are the goals of treatment realistic for the person with pain?

Desirable Physician Attributes

• Patient Care [ACGME/ABMS]  Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Provide Patient-centered Care [IOM]  Identify, respect, and care about patients’ differences, values, preferences and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health
• Interpersonal and Communication Skills [ACGME/ABMS]  Effective information exchange and teaming with patients, their families, and other health professionals
• Professionalism [ACGME/ABMS]   As manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • Describe the impact of pain on society
    
  • Explain how cultural, institutional, societal, and regulatory influences affect assessment and management of pain

• 2. Pain assessment and measurement: How is pain recognized?
  • Assess patient preferences and values to determine pain-related goals and priorities
  • Uses and models language that destigmatizes pain, reflects a whole-person perspective, builds a therapeutic alliance, and promotes behavior change
  • Demonstrates empathic, compassionate, and professional communication during pain assessment

• 3. Treatment: How is pain safely and effectively treated? 
  • Empowers patients to recognize and apply health promotion and self-management strategies

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Claiming Credit: Watch the entire presentation and complete the Improvement Plan/Evaluation

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships

Neither the speaker, peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any relevant financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Additional Reading

• Payne, R., Anderson, E., Arnold, R., Duensing, L., Gilson, A., Green, C., ... & Shuler, N. (2010). A rose by any other name: pain contracts/agreements. The American Journal of Bioethics, 10(11), 5-12.
• Dworkin, R. H., Turk, D. C., Farrar, J. T., Haythornthwaite, J. A., Jensen, M. P., Katz, N. P., ... & Carr, D. B. (2005). Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain, 113(1), 9-19.
• Dworkin, R. H., Turk, D. C., Revicki, D. A., Harding, G., Coyne, K. S., Peirce-Sandner, S., ... & Farrar, J. T. (2009). Development and initial validation of an expanded and revised version of the Short-form McGill Pain Questionnaire (SF-MPQ-2). Pain, 144(1-2), 35-42.
• Mackey, S. (2014). National pain strategy task force: the strategic plan for the IOM pain report. Pain Medicine, 15(7), 1070-1071
• IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.
  
• Todd, K. H., Cowan, P., Kelly, N., & Homel, P. (2010). Chronic or recurrent pain in the emergency department: national telephone survey of patient experience. Western Journal of Emergency Medicine, 11(5), 408.
• Henry, S. G., Paterniti, D. A., Feng, B., Iosif, A. M., Kravitz, R. L., Weinberg, G., ... & Verba, S. (2019). Patients’ experience with opioid tapering: A conceptual model with recommendations for clinicians. The Journal of Pain, 20(2), 181-191.
• Elder, C. R., DeBar, L. L., Ritenbaugh, C., Rumptz, M. H., Patterson, C., Bonifay, A., ... & Deyo, R. A. (2017). Health care systems support to enhance patient-centered care: lessons from a primary care-based chronic pain management initiative. The Permanente Journal, 21.
• Cowan, P. (2013). Support groups for chronic pain. In Handbook of Pain and Palliative Care (pp. 639-648). Springer, New York, NY.
• IOM (Institute of Medicine). 2011. Patients charting the course: Citizen engagement and the learning health system: Workshop summary. Washington, DC: The National Academies Press

• Penney Cowan, Founder & CEO, American Chronic Pain Association (ACPA)

Ensuring Access to High Quality, Multidisciplinary Pain Care for Everyone: Tackling Barriers of Policy, Bias & Inequality

Expiration Date: Aug 14, 2023

It's time for a cultural transformation in the treatment of pain. 

The American Academy of Pain Medicine (AAPM) and World Health Organization (WHO) have declared pain relief a human right.

Most people with pain receive initial care in a primary care setting. Compared with physicians who have completed extensive specialization (eg, fellowships) in pain management, primary care physicians receive much less formal training in managing chronic pain.

It has been demonstrated that for pain management prior to specialty pain care, blacks and women had less adequate pain care at referral. These results suggest the need for interventions and education in the primary care arena to improve pain care.

Outcomes

Learners completing this activity report improved abilities in:

• Addressing unconscious and implicit biases
• Truthful and honest pain assessment of both gender and race in pain management
• Ensuring equitable access to care for all persons

Learning Objectives

As a result of participating in this activity, learners will be able/better able to:

• List the demographic trends changing the patient population in the United States
• Account for these trends when formulating long-term practice, policy or organizational decisions 
• Deconstruct ways in which clinical decision making is subject to biases of gender, race, and ethnicity
• Categorize the ways in which the phenotypes of gender, age, race, and ethnicity influence healthcare disparities
• Modify clinical care to account for implicit bias

Desirable Physician Attributes

• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Provide Patient-centered Care [IOM] Identify, respect, and care about patients’ differences, values, preferences and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health
• Professionalism [ACGME/ABMS] As manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
• Systems-Based Practice [ACGME/ABMS]  as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.4: Describe the impact of pain on society
    
  • 1.5: Explain how cultural, institutional, societal, and regulatory influences affect assessment and management of pain

• 2. Pain assessment and measurement: How is pain recognized?
  • 2.3: Assess patient preferences and values to determine pain-related goals and priorities
  • 2.4: Demonstrate empathic and compassionate communication during pain assessment

• 4. Clinical conditions: How does context influence pain management?
  • 4.1: Describe the unique pain assessment and management needs of special populations
  • 4.4: Implement an individualized pain management plan that integrates the perspectives of patients, their social support systems, and health care providers in the context of available resources
  • 4.5: Describe the role of the clinician as an advocate in assisting patients to meet treatment goals

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships

Neither the speaker, peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any relevant financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Additional Reading

• Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003. EXECUTIVE SUMMARY. Available from: https://www.ncbi.nlm.nih.gov/b...
• Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., ... & Todd, K. H. (2003). The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Medicine, 4(3), 277-294.
• Poleshuck, E. L., & Green, C. R. (2008). Socioeconomic disadvantage and pain. Pain, 136(3), 235.
• Green, C. R., Wheeler, J. R., Marchant, B., LaPorte, F., & Guerrero, E. (2001). Analysis of the physician variable in pain management. Pain Medicine, 2(4), 317-327.
• LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States.
• Green, C. R., Baker, T. A., Sato, Y., Washington, T. L., & Smith, E. M. (2003). Race and chronic pain: A comparative study of young black and white Americans presenting for management. The Journal of Pain, 4(4), 176-183.
• Schulman, K. A., Berlin, J. A., Harless, W., Kerner, J. F., Sistrunk, S., Gersh, B. J., ... & Eisenberg, J. M. (1999). The effect of race and sex on physicians' recommendations for cardiac catheterization. New England Journal of Medicine, 340(8), 618-626.
• Green, C., Todd, K. H., Lebovits, A., & Francis, M. (2006). Disparities in pain: Ethical issues. Pain Medicine, 7(6), 530-533.
• Green, Carmen R., John RC Wheeler, Frankie LaPorte, Beverly Marchant, and Eloisa Guerrero. "How well is chronic pain managed? Who does it well?." Pain Medicine 3, no. 1 (2002): 56-65.
• Sewell, J. L., & Velayos, F. S. (2012). Systematic review: the role of race and socioeconomic factors on IBD healthcare delivery and effectiveness. Inflammatory Bowel Diseases.
• Fuentes, M., Hart-Johnson, T., & Green, C. R. (2007). The association among neighborhood socioeconomic status, race and chronic pain in black and white older adults. Journal of the National Medical Association, 99(10), 1160.
• Elder, C. R., DeBar, L. L., Ritenbaugh, C., Rumptz, M. H., Patterson, C., Bonifay, A., ... & Deyo, R. A. (2017). Health care systems support to enhance patient-centered care: lessons from a primary care-based chronic pain management initiative. The Permanente Journal, 21.
• Baker, T. A., & Green, C. R. (2005). Intrarace differences among black and white Americans presenting for chronic pain management: The influence of age, physical health, and psychosocial factors. Pain Medicine, 6(1), 29-38.
• Kaplan, G. A. (2004). What’s wrong with social epidemiology, and how can we make it better?. Epidemiologic Reviews, 26(1), 124-135.
• Green, C. R., & Hart-Johnson, T. (2010). The adequacy of chronic pain management prior to presenting at a tertiary care pain center: the role of patient socio-demographic characteristics. The Journal of Pain, 11(8), 746-754.
• IOM (Institute of Medicine). 2011. Patients charting the course: Citizen engagement and the learning health system: Workshop summary. Washington, DC: The National Academies Press

• Dr. Carmen R. Green, MD, Dean of the CUNY School of Medicine (CSOM), The City College of New York