The management of chronic noncancer pain with opioid medications is controversial. The negative consequences have been described as a public health emergency and the efficacy of chronic opioid therapy remains a subject of significant debate. 

Despite recommendations that chronic opioid therapy not be utilized until other methods fail, there remains a large population of patients for whom no other therapy has been effective and a large cohort of people who have been treated for years with opioids.

 Many new patients are still started and maintained on chronic opioid therapy. This course describes one system’s use of clinical pharmacists incorporated into the pain management team to reduce risks. Participants will learn how the pharmacists are utilized in this team-based model. 

Topics covered will include the nuts and bolts about how to incorporate pharmacists into clinical management, outcomes of the model of care, DEA certification for pharmacists, billing for services, and lessons learned.

Improving Safety of Chronic Opioid Prescribing by Incorporating Clinical Pharmacists on Teams

Buprenorphine was developed by UK based Reckitt & Colman Products and released in the United Kingdom in 1978. That same year, a clinical study determined that buprenorphine could be helpful in reducing cravings of pure opioids in patients with an opioid abuse disorder. 

Then, a separate study published in 1982 demonstrated that buprenorphine offered excellent analgesia with a blunted abuse liability. Buprenorphine is a partial agonist at the mu-opioid receptors and an antagonist at the kappa receptors. Mu-opioid receptor activity produces the analgesic effects of buprenorphine, while a strong affinity for the kappa receptors render them inactive. While initially buprenorphine was used as an anesthetic, currently it has been prescribed for the induction and maintenance in patients with an opioid use disorder. 

However, buprenorphine is a unique molecule with multiple applications. This presentation will provide an in-depth discussion of the history of buprenorphine and its application for pain control, opioid use disorders, and antisuicide properties in patients with chronic pain

Buprenorphine: A Molecule for All Seasons

The use of opioids to treat chronic pain has become quite contentious in recent years. Things get even more confusing when we consider adding an adjuvant analgesic in the mix. 

Does this reduce or heighten risk? The audience can decide where to throw spitballs when 2 practitioners debate 2 separate topics. First, is the use of cannabis plus an opioid likely to provide an enhanced clinical effect (eg, allow for opioid dose reduction and by extension, harm), make no difference, or possibly cause more harm. The second debate will evaluate the use of gabapentin plus an opioid. 

On one hand, we have data showing the gabapentinoids may be habituating and result in addiction. Combining gabapentin with an opioid may also increase the risk of mortality. On the other hand, rational polypharmacy, using an opioid and gabapentin, has been shown to result in superior clinical outcomes compared to either analgesic alone. So perplexing. What’s a practitioner to do? Listen to the debate and decide for yourself!

That’s Debatable! Does Cannabis Reduce Opioid Death, and Does Gabapentin Increase It?

In previous presentations, Dr. Jay has discussed the pathophysiology, neuroanatomical, and other aspects of fibromyalgia. 

In this activity, all of that will NOT be discussed, so the focus can be only on the diagnosis and treatment of fibromyalgia and restless leg syndrome. Treatment will be covered in depth, not the phenomenology that is the complex neuroanatomical and neuropathological backgrounds of these diatheses. 

The goal is to provide clinicians with practical information to be utilized upon seeing patients following the conference.

When Darkness Falls: Managing Pain in Fibromyalgia and Restless Leg Syndrome

The prevalence of back pain continues despite the many treatments available, without any single treatment being a panacea. In routine clinical practice there has been a tendency of clinical examinations to become more cursory, largely influenced by increasing demands of time and arguably an overreliance upon technology. 

It has been suggested that the failure to adequately differentially diagnose the cause of back pain can account for clinical failures in treatment. The purpose of this discussion is to assist clinicians in the development of a more problem focused examination to enhance the differential diagnosis of specific pain generators, and therefore lead to more patient specific treatment. 

Attention will be given to considering all aspects of the examination, including physical assessment as well as imaging studies, and the ability to rationalize when pathologies seen on imaging studies may or may not be clinically significant. The importance of considering how failed treatments influence the differential diagnosis will also be discussed.

Back Pain: It's All About the Diagnosis

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

Icebergs, Oceans, and the Experience of Pain

Several recent studies have found intriguing links between gut microbes, rheumatoid arthritis, and other diseases. Additional studies have shown the interactions between the central nervous system, enteric nervous system, and the gastrointestinal tract, suggestive that gut microbiota appears to influence the development of emotional behavior, and stress- and pain-modulation systems.

 In the age of modern medicine, it is easy to forget that we change our body chemistry every time we eat. The quality and composition of our food has the power to increase or decrease body wide inflammation and modulate pain. Our relationship to food and the way we eat is also cultural and influenced by stress and our environment. The research evidence is robust for dietary interventions and improved health. 

The changes needed are simple, but not necessarily easy. This lecture will focus on the role that modulation of the microbiome plays in pain, and the ways to optimize the health of the individuals’ gut microbes for pain management and overall well-being.

No Guts, No Glory: Mystery of the Microbiome

Pain is common in the aging population. Findings from an NIH funded study looking at the impact on pain in the older adult found that over 50% of people surveyed had pain within the last month, often in more than one location. 

Despite the high prevalence of pain, pain often remains undertreated, resulting in impaired cognition, decreased socialization, sleep disturbances, and a reduced quality of life. Our bodies react differently to medications due to medical comorbidities and metabolic changes due to the aging process itself. Understanding the correct choices of analgesic utilizing a multimodal approach to treatment is important in providing safe and effective pain therapies. Patients with dementia or in the late stages of disease may propose a unique pain control challenge due to difficulty in the ability to verbalize pain. 

This session will explain the differences in response to analgesic medications due to the aging process and provide recommendations for individualized pain control based on specific patient characteristics.

Better With Age? Pain Management of the Older Adult

This course will review the scientific evidence for/against opioid therapy, risk mitigation, and different methods of opioid tapering. Providers need guidance to determine which patients may or may not benefit from opioids. 

While most pain patients on opioid therapy manage opioids safely, the risks are detrimental to some patients and society. Clinicians are faced with contradictory professional advice and legal mandates/scrutiny. Many patients are exposed to risk due to inappropriately executed opioid tapering. Suicide rates are rising, and illicit drug use including overdose deaths from synthetic opioids continue to rise. How do we maximize benefit over harm? T

his session will review the scientific evidence and legal requirements that contribute to optimized opioid therapy when clinically indicated and how to discontinue opioid therapy if appropriate.

Opioid Therapy and Opioid Tapering: Guidance for Clinicians to Improve Outcomes.

Understanding the mechanisms that drive a persistent pain process is critical for effectively treating pain in any patient. While it is common to treat pain from a primary nociceptive perspective, this approach often fails in patients with central sensitization. 

Pain mechanism based classifications can help clinicians make recommendations that may improve functional outcomes and enhance patient adherence by identifying primary pain mechanisms. This course will offer practical tips for evaluation of patients with mixed pain mechanism presentations and includes an interactive discussion of multimodal treatment options for each.

Applying Mechanism-Based Classification to Clinical Reasoning for Complex Persistent Pain

Course DescriptionWhen we practitioners approach complex medical problems (whether pain, depression, or even GERD) that have psychological and lifestyle components and we do so with minimally monitored drug-only therapies, we may bounce from one “wonder drug” to another and end up bewildered or worse. 

These problems need complex approaches that address the component parts and we can’t just rely on finding the next wonder drug. Perhaps it’s part of the American mindset: wanting a pill to fix problems. Part of it is from the perverse incentives in a healthcare system that wants to find solutions to complex issues and then implement them on the cheap, running them through primary care on a conveyor belt. In pain we see history repeating itself around the medical cannabis issue. 

All the same mistakes are being made again and with poor care coordination, risk management, and assessment it will end up doing harm.

A Modest Proposal: Addressing the Components and Complexities of Coordinated Care

Forced downward titration has been broadly implemented throughout the country as a direct result of the CDC Guideline for Prescribing Opioids for Chronic Pain. 

Prescribing clinicians feel pressured to follow the CDC’s recommendations of dose limits to avoid regulatory sanctions, and pharmacists feel a corresponding obligation to intervene in accordance with the CDC guideline and corporate policies. In many instances, prescribers have refused to treat opioid-requiring pain patients, resulting in the patients’ discharge from the specialist’s practice or a consult refusal—the latter of which, by default, often leaves the most medically complex and challenging patients with only their primary care providers to manage their pain. Some patients have chosen to leave their existing providers because of mistrust, cynicism, disbelief, and abandonment, but they then find it difficult to secure any other provider willing to treat their pain. 

This presentation will chronicle the events that have delivered an unreasonable burden on patients and providers.

The Visible Few: An Imperfect Burden on Patients and Providers

This session is designed to familiarize learners with the principles of the neurobiology of the traumatized patient and illuminate the salient concepts that are germane to the presentations and treatment of patients with chronic pain. 

At the conclusion of this activity, practitioners should be able to identify several key aspects of behavior and presentation in patients with chronic pain who have a history of trauma, as well as utilize these concepts when interacting and treating these patients to improve outcomes and pain scores.

Status Traumaticus: A Trauma Informed Approach to Chronic Pain Management

There are various types of studies that are necessary to perform in order to determine their clinical relevance. The process extends from benchtop to bedside side and includes various special populations like pediatrics and geriatrics.  

This course addresses various elements related to the study of analgesics. Novel improved preclinical animal models in analgesic studies are examined.  The unique issues of unusually high placebo and nocebo effects in analgesic which can lead to confusing results are discussed. The role and responsibilities of acting as a Principal Investigator in an analgesic trial are discussed. The practical impact of new healthcare measures and the increased the importance of comparative effectiveness trials and health outcomes and pharmacoeconomic are reviewed. 

The process of publishing data and determination of authorship At the conclusion of the program participants shall have a comprehensive understanding of the analgesic trials.

Understanding Analgesic Trials

Chronic pain is much more than a physical sensation. It can be all-encompassing and often impacts an individual in a multitude of ways, spawning discouraging, painful, or unwanted psychological experiences such as thoughts, feelings, and memories as well as functional limitations.

 The natural approach might be to dedicate time and expend energy and resources (emotional, psychological, financial, etc) to controlling or avoiding these uncomfortable experiences. However, increasing evidence suggests that, not only are attempts to control the frequency and form of these types of private experiences often unsuccessful, doing so may result in an increase in their occurrence and an increased sensitivity to their impact, thus, paradoxically exacerbating one’s situation. Additionally, especially with chronic pain, avoidance of discomfort (physical and emotional) often results in isolation and inactivity, thus robbing an individual of participation in valued activities. Acceptance and commitment therapy (ACT), a 3rd wave spinoff of cognitive behavioral therapy, is now considered an evidence-based therapeutic treatment for chronic pain that is set apart from other, more commonsense solutions. 

ACT poses a useful alternative to control-based treatments and operates on a set of 6 core processes within a unified model called psychological flexibility—“the capacity to be directly, consciously, and fully in contact with the present moment without needless defense and to persist or change one’s behaviors in the service of one’s goals.”

Psych Twister: Using Metaphors, Mindfulness, and Values to Promote Behavioral Change

Spirochetal infection symptoms include muscle pain, nausea, vomiting, abdominal pain, and many others. Lyme disease can cause joint pain and stiffness, fatigue, flu-like symptoms, and sleep problems, among others. Depending on the species of bacteria involved, symptoms may be quite painful and range from acute to chronic. 

How are patients infected? What treatments work best? Although an “appropriate” treatment for the various stages of infection is not universally accepted, this course will suggest means for treatment while it reviews causes and types of infection and symptoms.

An Elusive Villain: Pain Associated With Lyme Disease and Other Spirochetal Infections

The healthcare community is at a crossroads as the opioid crisis rages in America – how to provide effective pain management while preventing opioid abuse and addiction. 

This session will explore evidence-based opioid-sparing pain management techniques and how they are improving patient outcomes and quality of life while also reducing overall costs.

Enhancing Recovery After Surgery: How Certified Nurse Anesthetists Are Improving Outcomes

The Pain Management Best Practices Inter-Agency Task Force identified inconsistencies and fragmentation of pain care as gaps in US healthcare that limit best practices and patient outcomes. 

The report encourages coordinated care and cites the collaborative stepped model of pain care, as adopted by the Department of Veterans Affairs and the Department of Defense health systems as a best practice. 

The session will address the challenges and successes of VA’s pain care transformation towards patient-centered biopsychosocial pain care for Whole Health for Veterans. Attendees will learn how to anticipate challenges and minimize risks when implementing a comprehensive pain care transformation away from opioids based on lessons learned from the largest integrated healthcare system in the United States.

VA's Stepped Care Model for Pain Management and Whole Health

This presentation will focus on the development of a clinical decision tool to standardize opioid prescribing for patients with sickle cell disease. 

Pain is the hallmark symptom of sickle cell disease, which is often managed by hematologists or primary care physicians. Currently, there is no clinical decision tool or any type of standardization regarding opioid prescribing among these patients. 

The Management of Sickle Cell Disease guidelines, published in JAMA in 2014, states that there is little evidence related specifically to chronic pain is those with sickle cell disease and most of the recommendations were adapted from general pain guidelines. 

Therefore, opioid prescribing is not consistent regarding management of chronic pain in this patient population, potentially due to a lack of standardized prescribing practices. In order to mitigate this absence, this pilot project aims to create an opioid prescribing protocol for use in patients with sickle cell disease who are prescribed or may be prescribed opioid therapy. 

The research was funded and began in January 2019 to develop the clinical decision tool. The tool was implemented in April 2019 and evaluated. The goal is to continue implementation and potentially expand to other sites that treat sickle cell or other chronic pain patients.

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