• Safe and Effective Prescribing of Opioid Analgesics: A Hands-on, Case-based Clinical Curriculum in Primary Care

The Beacon Newsletter - Volume I, Issue 2

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A quarterly e-newsletter of Emerging Solutions in Pain

Volume I, Issue 2, November 2007

Welcome to the second edition of The Beacon, the quarterly e-newsletter dedicated to bringing you the latest updates on the science of pain management.

Rely on The Beacon to deliver the latest clinical news, CME programs, expert advice, reviewed articles, and much, much more. In this issue you'll find new information, new opinions, and new articles designed to provoke thought and discussion.

Visit www.EmergingSolutionsinPain.com

Supported by an independent educational grant from Cephalon, Inc.

The Beacon is just one of the many features you'll find at www.EmergingSolutionsinPain.com, the website that works with a distinguished panel of clinical experts and experts in legal and regulatory issues to develop practical, real-world resources that support appropriate risk assessment, patient monitoring, documentation and best practices. Visit our site today and find out about the developments that will be influencing tomorrow's pain management decisions.

In the News

Paracetamol and keeping active may be the best cure for back pain

November 9, 2007 — Australian researchers have suggested that taking paracetamol and keeping active are the best cures for back pain. According to The Lancet, the study of 240 back pain sufferers showed that though taking anti-inflammatory drugs and spinal manipulation are recommended in several guidelines, they did not make any difference in recovery time. In fact, the experts insisted that avoiding bed rest and taking paracetamol would work. For the study, researchers at the University of Sydney assigned patients to receive either an anti-inflammatory drug (diclofenac), placebo, spinal manipulation, or fake manipulation therapy.

The patients had already received simple treatment recommendation from their GP to keep active, avoid bed rest, and take paracetamol for the pain. The research team found that there was no difference in recovery times after 12 weeks in patients who also received diclofenac or spinal manipulation. According to Dr. Bart Koes, from the Department of General Practice at Erasmus University in the Netherlands, the results were probably applicable to other nonsteroidal anti-inflammatory drugs, such as ibuprofen. Nia Taylor, chief executive of BackCare said the key message for people was to keep moving.

Drugs Can Ease Juvenile Rheumatoid Arthritis—Three Trials Show Some Success in Helping Children

FRIDAY, Nov. 9 (HealthDay News) — Certain drugs may be effective in treating juvenile rheumatoid arthritis, according to studies presented this week at the American College of Rheumatology (ACR) meeting in Boston.

One study found that abatacept, used to treat adults with moderate-to-severe rheumatoid arthritis, may be a well-tolerated treatment for children and adolescents with severe, treatment-resistant juvenile rheumatoid arthritis, also known as juvenile idiopathic arthritis (JIA).

A second study that found that treatment with adalimumab (Humira®) reduced disease flare-ups and promoted improvement in patients with juvenile rheumatic arthritis (JRA). After 32 weeks, patients who received adalimumab had significantly fewer disease flare-ups and better ACR Pedi Responses than those who took a placebo.

A third study concluded that etanercept (Enbrel®) is safe in the long-term treatment of patients with JRA. In this study, 42 JRA patients took etanercept for four years, and 26 of them continued to take it for eight years The injectable drug blocks TNF-alpha, a protein that causes the pain and tenderness associated with rheumatic disease.

Botox® Offers Shot in Arm for Arthritis Sufferers

Nov. 8 — A preliminary study found that Botox? seems to relieve shoulder pain in arthritis sufferers. Dr. Jasvinder Singh, a staff physician at the Minneapolis VA Medical Center and author of the study, stated that more patients needed to be assessed before the treatment could be recommended. Dr. Singh presented his findings at the American College of Rheumatology annual meeting in Boston.

"We don't recommend people start using it until we have the definitive study," Dr. Singh stated. In the study, Dr. Singh and his colleagues randomly assigned 43 patients with moderate-to-severe osteoarthritis pain in their shoulders to one of two groups. One group received a single dose of the botulinum toxin type A and lidocaine, a local anesthetic. The other group got a dose of saline (salt water) plus the lidocaine. Neither group knew what they were receiving. Researchers compared the pain levels before the botulinum treatment to levels assessed 28 days later. They found that 38% of the botulinum group had a 30% or better reduction in their pain scores, compared to 9% of the saline group. Those who got botulinum also reported more improvement in shoulder function than the saline group. The toxin may work, Singh speculated, by reducing the release of certain proteins from nerves in the joint. And that, in turn, may decrease the pain sensation.

Osteoarthritis is the "wear-and-tear" type of arthritis, and the risk for it increases with age, obesity and other factors. About 21 million Americans have this form of arthritis, according to estimates from the Arthritis Foundation.

Study Finds Over-the-Counter Pain Drugs May Reduce Risk of Parkinson's

Tuesday, November 6, 2007 — Regularly taking over-the-counter pain medications such as aspirin or Advil® could lower your chances of developing Parkinson's, a new study suggests. Parkinson's disease is a progressive neurodegenerative disease characterized by tremors, stiffness, poor balance, and muscle rigidity. Aspirin-NSAID use offered protection, predominantly to women, with female participants reducing their risk of developing the disease by 40%. In the study, 579 men and women were asked whether they had taken at least two pills of aspirin or non-aspirin NSAIDs a week for at least a month at some point. Those who were regular users of non-aspirin NSAIDs reduced their chances of developing Parkinson's by 60%. However, aspirin use offered protection predominantly to women. "Our findings suggest NSAIDs are protective against Parkinson's disease, with a particularly strong protective effect among regular users of non-aspirin NSAIDs, especially those who reported two or more years of use," said Angelika Wahner, the study's author and a researcher with the UCLA School of Public Health in Los Angeles, in a release. Researchers theorize that NSAIDs stave off the onset of the disease by reducing the destructive inflammatory enzymes that destroy the functioning of neurons in the brain.

For Your Information

This section of The Beacon contains information, expert opinion and opportunities to learn more about issues associated with pain and addiction.

Expert Commentaries
ESP's Expert Commentary Series is a monthly column featuring a rotating group of clinical expert thought leaders sharing their expert, and sometimes controversial, opinions on various topics in pain management.

Chemical Coping
Steven Passik, PhD

Do you have a patient that you've been prescribing opioids to for 3, 6, 9 months, who is still lying on the couch and floundering on a controversial therapy? If so, he or she may be a "chemical coper."

Chemical copers are patients who are on opioid therapy and not doing well. They're not moving ahead psychosocially. They're not meeting goals. They dabble. They don't engage in out-and-out substance abuse, but they dabble in misuse.

If a clinician could identify these patients up front, they might design treatment strategies that made the drugs and the medicines less central to the person. To this end, we've been in the process of designing and validating a measure that could be used in clinical trials and could even be used in the clinic. But since it might a while before this assessment tool is ready, how would I identify the chemical coper in my practice, react to it, and decide to make appropriate changes in management?

To finish reading Dr. Passik's commentary, or to view his video presentation of this commentary, please click here.

In the Know
Our In the Know column provides bi-monthly abstracts and reviews of the latest journal articles related to the management of chronic pain and addiction.

The Continued Battle Against Nicotine Dependence
In this review, Dr. Garwood and Dr. Potts provide an explanation of the addictive nature of nicotine as a prelude to reviewing the newest treatment options available to aid in smoking cessation. Despite increased public awareness of the detrimental effects of smoking on one's health, few smokers actually quit and attempts at quitting are four to six times more likely to be successful when an interventional technique is incorporated.

The authors go on to discuss common cessation techniques such as nicotine replacement therapy (NRT), bupropion, originally formulated as an antidepressant and accidentally found to reduce symptoms of nicotine withdrawal, and other emerging treatments for nicotine dependence.

To read the full summary of this journal article, please click here.

Ask the Experts
Clinicians with challenging questions in the fields of pain management or addiction medicine now have the opportunity to have those questions answered by clinical experts through the ESP Ask the Experts column! ESP members submit questions for review by the ESP faculty, and each month, answers to selected questions will be posted as audio or text files.

A doctor states he has had a busy family practice. Patients may see anyone in the practice for pain management but the majority would like to see the same physician. In this situation, the doctor asks the following questions:

1. What is the definition of aberrant behavior?
2. When should the doctor refer or triage the patient?

Since different doctors in the practice may see the same patient, you must have a uniform policy in which every doctor in the practice follows when he or she prescribes a Schedule II medication, especially for opioids. However, before I discuss aberrant behavior and triage, let me give some background information. It is possible that pain and addiction do exist as comorbid conditions. Pain and addiction could be a continuum, such as alcohol dependency with peripheral neuropathy. However, certain patients may present with a past history of prescription drug misuse or illicit opioid use on the street and in this case opioids used to treat the chronic pain patient may be identified as either the problem, the solution, a mixture of both depending upon the frame of reference used. Failure to identify early in the course of the treatment, either at the initial visit or subsequent visits, failure to identify these conditions when present, will undoubtedly lead to frustration and poor outcome in both domains.

To finish reading Dr. Heit's answer to this question, or to listen to his audio recording, please click here.

Knowledge Library
The Knowledge Library is ESP's video library that collects the most commonly asked pain management and/or addiction medicine questions, and presents them in easy-to-view, brief video vignettes. You can view 30 second to 2 minute videos in pharmacotherapy; assessment; abuse, misuse & addiction; best practices; and legal issues.

  • Is codeine an effective analgesic?
  • Have some of the new screening tools for aberrant behavior pointed to smoking as a risk factor?
  • Should an opioid be prescribed to every pain patient?
  • From a legal/regulatory perspective, what are some of the common misperceptions that licensing boards and law enforcement have about the use of controlled substances to treat pain?

To view the video answers to these questions, and to access the full ESP Multimedia Knowledge Library, please click here.

The ESP Scholarship Program
Residents, fellows, and nurses in the fields of pain management or addiction medicine are eligible to apply for an ESP Scholarship which will cover all costs associated with attending a national association meeting. Scholarship winners will create focused meeting summaries which will be posted online to share with the entire ESP community.

Read our latest winner's report and enter to represent ESP at the AAPM in February!

We're taking applications now to attend the 24th Annual Meeting of the American Academy of Pain Medicine (AAPM) in Orlando, Florida, February 12 to 16, 2008. Deadline for applying is December 7, 2007 and the winner will be notified by December 18, 2007.

Our latest winner, Angie Brucker, MSN, RN-C, CNP, represented Emerging Solutions in Pain at the American Academy of Physical Medicine and Rehabilitation Conference held in Boston, this past September 27-30. At the conference, Angie attended several lectures she felt would be of specific interest to all readers of The Beacon. These included Natural History of Pain Disorders, Plenary Session "Beyond the Medical Model of Disability," and Opioids: Clinical Pharmacology, Hyperalgesia and Compliance.

To read the Angie's full report and apply to be our special correspondent at the AAPM, click here.

State Your Case
Once each quarter, ESP members can submit an original and challenging case study in pain management or addiction medicine to the ESP State Your Case column. Selected cases receive comments and guidance from an ESP faculty member and clinical expert.

This case study involves a patient who presents as a healthy young man who underwent two spinal fusions at the age of 31 for low back pain. After the second back surgery, he had persistent back pain and new right hip pain. Several months later he was diagnosed with intraosseous hemangioma of the right acetabulum, a very rare location for this nonmalignant neoplasm. After the initial curettage and graft, he had a recurrence at the same location, requiring new surgery and allografting.

Since the time of first surgery, he has been prescribed multiple trials of oral opioids, which offered insignificant pain relief but a very broad spectrum of side effects. He had limited physical therapy because of interference with graft take and bone healing. Finally, he had an intrathecal delivery drug system (IDDS) implanted. One month later he still reports significant right hip and thigh pain, and inability to walk without assistance. He also takes a significant amount of short-acting (SA) opioid orally as needed.

What would be the best approach to rehabilitate this patient?

To find out how the ESP expert answers this challenging question, click here

CE Programs

This section of The Beacon contains brief descriptions of accredited programs available for self-study on the ESP website. Please click on the individual links to learn more about specific programs.

The Journal Club
The Journal Club is a popular feature that lets you earn CE credits by reading articles, downloading a transcript or listening to commentaries, and completing the appropriate CE form.

In this issue, Bill McCarberg, MD, from San Diego, California discusses Systematic Review of Low Back Pain Prevalence, Opioid Efficacy and Substance Abuse Disorders Studies: Does the Conclusion Fit?

To find out more about The Journal Club and apply to receive Continuing Education credit, please click here.

Knowledge Series
Knowledge Series is your chance to earn CE credits while exploring the complexities surrounding the management of chronic pain through interviews, data, and case studies. In this edition, you'll be able to look at four monographs that tackle the topic of chronic pain management from a range of unique perspectives.

Module One
Determining the Risk of Opioid Abuse

Lynn R. Webster, MD

Certain risk factors supported by the scientific literature increase a patient's likelihood of abusing the opioids prescribed for chronic pain. Some of the most strongly supported factors include a personal or family history of substance abuse, youthful age, a history of preadolescent sexual abuse and certain mental diseases. Advance knowledge as to whether a patient possesses these risk factors can give a clinician the edge in monitoring the progress of treatment. Furthermore, it is desirable to assess each patient prior to beginning chronic opioid therapy to determine his or her level of risk for abuse.

To finish reading Dr. Webster's monograph and earn Continuing Education credit, please click here.

Module Two
The Connection Between Cigarette Smoking and Aberrant Drug-Taking Behavior in Opioid Therapy for Chronic Pain

Lara Dhingra, PhD and Steven Passik, PhD

Cigarette smoking is highly prevalent among individuals with chronic pain. In fact, significantly more individuals with pain disorders report smoking than adults in the general population. Certain risk factors associated with smoking also increase a patient's likelihood of abusing opioids prescribed for chronic pain and may increase the patient's risk of developing aberrant behaviors. In this monograph, you will review the latest theories and research findings in an area associated with chronic pain management in patients who may present with an increased risk of opioid abuse and aberrant behaviors.

To finish reading Dr. Dhingra and Dr. Passik's monograph and earn Continuing Education credit, please click here.

Module Three
VIGIL: A Five-Step Process Approach to Opioid Prescribing and Dispensing

An interview with David B. Brushwood, RPh, JD

VIGIL is a five-step process designed to help clinicians navigate the murky regulatory waters of controlled substance prescribing and dispensing. The purpose of VIGIL is to distill the most critical components of the Code of Federal Regulations (CFR) into easily understood process steps, which can then be incorporated into most practices. In doing so, it may increase open communications between patient, prescriber, dispenser, and other patient caretakers through the steps of Verification, Identification, Generalization, Interpretation, and Legalization. In short, VIGIL offers a preventive process option designed to minimize legal scrutiny and prosecution associated with controlled substance pharmacotherapy due to regulatory breach or patient infraction.

To finish reading Professor Brushwood's monograph and earn Continuing Education credit, please click here.

Module Four
Relating Central Sensitization and Hyperalgesia to Opioid Pain Management and Preemptive Analgesia

Jeffrey A. Gudin, MD

Despite significant advances in our understanding of the physiology of nociception, there are few new classes of drugs to treat pain. Opioids are one of the few analgesic classes proven effective for severe pain, and frequently replace or are added on to failed therapies. Today, opioid analgesics have become a mainstay of pharmacologic pain management. Unfortunately, the normal linear treatment model of increased dose for increased pain often fails to improve analgesia in these nonmalignant pain syndromes, and may actually diminish overall patient function.

To finish reading Dr. Gudin's monograph and earn Continuing Education credit, please click here.

Please note:

If you have previously participated and received credit for completion of any or all of the previously accredited content, published in the Practical Pain Management journal and also available on the Emerging Solutions in Pain site, you are ineligible for additional credit and may not resubmit for credits previously awarded.

Pain and Addiction 101
Pain & Addiction 101 is a video-based CE course that helps you maintain your credentials with on-demand testing that fits your schedule. Adapted from footage of a live symposium held in conjunction with the American Academy of Pain Management, the educational material relates specifically to issues associated with both pain and addiction management.

Module Three
Rational Pharmacotherapy of Pain

Presented by Dr. Brian Ginsberg

All medical therapies possess inherent risk, and the right balance between efficacious treatment and safe treatment is not always obvious. Selection of analgesics also carries a risk that must be weighed against the benefit for each individual patient.

Human variability affects the individual's therapeutic response to analgesic medications and to the patient's risk of developing unforeseen adverse side effects. Hepatic and renal functions, as well as the patient's cardiovascular profile are also considerations when prescribing analgesia. Screening can unveil certain elements of risk, but other pharmacotherapeutic risks are not so clearly observed, such as genetic implications related to opioid receptors.

This program highlights studies that underscore human variability in relationship to pharmacologic therapy with discussion designed to improve analgesic selection for pain management.

To view Dr. Ginsberg's full video or read a transcript and apply for Continuing Education credit, please click here.

Module Four
On the Road to Enlightenment: Taking a Rational Approach to Pain Management

Presented by Howard A. Heit, MD, FACP, FASAM

This program provides practical strategies on how to treat chronic pain patients with addictive disorders in a safe and effective manner. Focusing on the need for open and honest communication between patient and clinician, practical strategies are presented on how to identify, treat, and monitor the at-risk or addicted pain patient.

The presentation also explores how these strategies work within the confines of federal and state regulations regarding prescribing of controlled substances. The most positive therapeutic outcomes will be achieved by incorporating careful patient assessment and monitoring in an environment of mutual respect while adhering to federal and state prescribing regulations.

To view Dr. Heit's full video or read a transcript and apply for Continuing Education credit, please click here.

Module Five
Boundary Applications for the Management of Pain and Addiction

Presented by Douglas Gourlay, MD

Although opioids are generally safe and effective, the potential for addiction or abuse must be considered, especially in high risk patients. The Universal Precautions in Pain Medicine, a best-practice initiative, was developed to provide improved patient management and risk containment guidance and tools for clinician use in areas of

  • Pain and risk assessment
  • Treatment consensus via informed consent
  • Boundary-setting via opioid treatment agreement
  • Monitoring efforts for identification of aberrant behaviors

Adopting universal precautions in the clinical management of all chronic pain patients reduces stigma, improves care and contains risk, raising the routine standard of care. In the course of assessment and monitoring, urine drug testing is a clinical tool that may be employed to detect, and subsequently address aberrant behaviors and encourage compliance.

To view Dr. Heit's full video or read a transcript and apply for Continuing Education credit, please click here.

To view all of the modules in the Pain and Addiction 101 series, please click here.

The Emerging Solutions in Pain Accredited Monograph Series
The ESP Accredited Monograph Series lets you select a program, download the monographs, then earn CE credits in Pharmacotherapy, Assessment, Monitoring, or Best Practices. On-demand testing fits even the most demanding schedule.

A series of accredited print monographs, originally printed in Practical Pain Management Journal.

Patient and Clinician: Mutual Shareholders in the Treatment of Chronic Pain
August 1, 2007
By April Vallerand, PhD, RN, FANN

Optimal management of chronic pain requires the use of clear communication skills on the part of both patient and clinician. The standard or traditional model of health care communications was disease centered, with the clinician as primary decision maker. Emerging research has demonstrated that management of chronic pain can be improved through integration of a patient-centered, self-management model of communications and care. This places the patient, not the disease or clinician, at center of communications, care, decision making, and treatment.

Pain is a subjective experience, influenced by a host of factors including age, gender, race, culture, environment, and genetics. These factors are important in understanding pain, treatment options, and patient response to therapy. However, they are often beyond the control of clinician and patient. Additionally, multiple barriers exist in regard to effective pain treatment, and include the following categories: health care systems, regulatory and legal environment, clinician, and patient.

In addition to these challenges, the traditional role of medical care is evolving from a disease-centered model to one that is patient centered. The Patient-Centered Model of Care has been described as one in which "the clinician tries to enter the patient's world, to see the illness through the patient's eyes." Unfortunately, although many clinicians indicate that they embrace the Patient-Centered Model of Care, it has been observed that most practicing clinicians, residents, and medical students use a dominant mode of inquiry when talking with their patients. Researchers at the University of Colorado Medical School have found an expeditious and effective method to train and encourage interview style, open-ended questioning meant to support patient-centric care. The method consists of three techniques: inviting, listening, and summarizing.

To read Dr. Vallerand's full monograph and apply for Continuing Education credit, please click here.

See you in February!

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