Jnging the Face of Pain Management

Jnging the Face of Pain Management 12 Complementary and Alternative Medicine 19 Practical Aspects in Pelvic Pain Treatrr t You Eat: Managing Chronic Pain 14 Treating Post-deployment Chronic Pain 20 Talk on Analgesia Explores New ossification and Treatments: Master Class in Challenging Populations 18 Chronic Pain Problems Among the Medically Underserved 22 Appraoches to Pain Management Taking a Better Look at Drug Interad Ig the Concept of the Integrated linic Means Demonstrating Verifiable Icy rry approach to pain management produces the best outcomes for patients. Clinicians who this approach must avoid repeating the mistakes of the past and concentrate on providing service. Discrepant Goals in Pain int: Strategies for Balancing rsician, and Other r Needs" (SIS-19) ice' E. Schatman, PhD, CPE, DASPE y, September 8 1- 12:10pm al 4, Mont-Royal Ballroom rdisciplinary pain dinics are an endangered patient numbers keep dwindling, and their Ming, all because financial considerations of- elfare. ernment would compel hospitals to main- rce insurers to cover treatment, says Mi- 1, PhD, CPE, DASPE, Executive Director of r Ethics in Pain Care. Until such mandates Schatrnan. "This strategy works because interdisciplinary pain management really does help nearly all stakeholders. The trick is learning to demonstrate that: To ilustrate the challenges pain specialists face, Schatrnan will start by tracing the sad decline of interdisciplinary pain manage- ment and explaining why a nation that had more than 1,000 integrated drics in 1998 has fewer than 100 today. Integrated pain management clinics initially opened, both inside hospitals and independently, because researchers consis- tently found that coordinated teams of complementary pain spe- cialists—usually a physician, a psychologist, a physical therapist, a nurse practitioner, and possibly several others—provide the best care for serious chronic pain. Indeed, the research looked so good that insurers became (by their standards) positively enthusiastic about pain clinics, many of which responded to the easy money by adding services and padding bills. Worse, the flow of insurance money inspired under- qualified (and occasionally dodgy) practitioners to open their own clinics to make a quick buck. Costs rose. Outcomes worsened. Insurers began slashing reimbursement rates and dropping coverage altogether. Clin- rs to see things from the other rspective and show how he benefits or desired course of action. This works because interdisciplinary nagement really does help nearly holders. The trick is learning to rate that. RECAP Research into the Intl of Music and Neuroi tion May Unlock Nel Treatments New data is demonstrating the heali of music and suggesting new applica management everal presentations during PAINWeek S tny the ways in which the brain interacts 1 , pail. On Tuesday, Michael B. Elko. Daniel F. Cleary presented on the ways ii Ali can help to aleviate pero. On Wednesday, Reb spoke about how our brains can be positively pail differently. The trend contrwed Friday n tin by Maio J. Trans, MD, PhD, Director Insi Brain Science; Department of Neurology, Dc of Medicine at UCLA. Fis presentation, 'The Nesomodulation of Pain Responses," provided how the human brain processes sound.VVhileT adze in the management of pain, he has pa studies that have examined the correlation b that way it inpads our bodies. Tramo began by telling the audience tha: sic as a healing power dates bock thousand! mythology, Apollo was associated with both Asclepius, a Greek god of healing, was belie. help rid sick patients of their disease. While tl cal figures, the fact is that there have been anecdotal reports over the centuries about tio ameliorate pain and suffering across a wide eases, and clinical settings. Yes, it is important when dealing with any kind of anecdotal dc some of these recounted experiences have I- study of the correlation of music and healing There is also a growing body of evidence ized-controlled trials demonstrating music's of agement, said Tramo. He went on to discus ing the pathways by which the brain proces that, basically, our brains have an auditory N (con over, Schatman has some advice for cli- to revive the integrated pain program, ore today at PAINWeek 2012 during his ics began losing money. Then many of them shut their doors. Needlessly, according to Schatman. "Patients suffered because everyone got greedy," Schatman Experience the expanded Living Bey a "multimedia showcase that presen EFTA01114703 r rain management in America )ents touch on all aspects of the delivery of quality pain care—from the research laboratory to ambers across the nation. the exam room, from the courtroom ents in Law and Public ications for Pain Care 3" (SIS-20) mei C. Barnes, JD y, September 8 20pm ≥I 4, Mont-Royal Ballroom nth isn't the only thing that will change how ciafists treat patients in the upcoming year. •ange of recent legal, financial, and cultural an more to affect standards of care. nes, JD, managing partner of DCBA Law Igton, will outline the most relevant recent n what they could mean for pain clinicians in his presentation this evening, "Current d Public Policy: Implications for Pain Care legislators, regulators, and journalists have terested in pain management recently, and iuch in the past year to exercise their power is and their patients. are starting to worry about prescription drug abuse. He says that "Pain specialists may think they can't possibly hear any more about the dangers of opioid abuse, but they haven't heard anything yet. The issue has finally reached a tipping point in terms of mainstream media coverage, which means coverage will perpetuate itself, probably until the problem is 'solved" in the public mind. Barnes notes that in the past year or two, "nearly every major newspaper in America has published articles highlighting the fact that prescription opioid overdoses kill more people each year than car crashes in some states," along with other now-familiar factoids about the effects of pre- scription opioid abuse and misuse. In the wake of these news reports, celebrity overdoses continuing to make headlines, and sensational media accounts of "addicted babies: Barnes says that "we've already seen an uptick in opioid-related legislation, regulation, litigation, and prosecution. And more is coming. Probably a lot more: Another important trend is that pain advocacy groups are losing funding and power. Barnes says that concerns about the opioid abuse problem were already deterring donors, even before this year's public relations nightmare in which investiga- tions shined a spotlight on the close ties between some phar- maceutical companies and advocacy groups. Oddly, these in- vestigations come just as drug makers—worried that efforts to curtail opioid abuse will slash overall sales and profits—are cut- ting expenditures on pain advocacy. Pain advocacy groups are thus losing money from all sides at the very moment when their Pain specialists may think they can't possibly hear any more about the dangers of opioid abuse, but they haven't heard anything yet. The issue has finally reached a tipping point in terms of mainstream media coverage. potentially influential events is huge: hun- •ds each year, certainly: says Barnes. "The sense of them is to look for trends, and I've nes that people who treat pain really should inderstand: iccording to Barnes, is that more Americans message about the importance of treating pain is falling out of favor. As a consequence, Barnes warns that pain specialists and advocates could see their ability to influence legislatures, insurers, and the public decline. Addiction treatment may become a major component of pain care. Because their expertise would, in theory, allow them to spot opioid abuse (or even potential abu patients overcome any problems that develc selors strike many as a natural fit for pain ilia few insurers cover addiction treatment, whi a non-starter, until the Affordable Care Ac law mandates coverage for addiction treatn financially feasible opportunities for pain p to serve patients better (and, potentially, r ity), either by hiring their own counselors or I third-party treatment programs. "Most of the people in the audience prob to like hearing most of what I have to say," Bc is different. This is a real opportunity for care The greater legal risks faced by dinicians oids "too freely" is another trend that should attendees, says Barnes. Criminal prosecutions mills and "careless" practitioners are on the California stood trial for second-degree murd patients overdosed. The local DA argued that ment that there was nothing she could do tc from taking a month's worth of pills in one da ful omission, and thus justified the murder chc Civil suits are dso on the rise, both against dc companies. In one case, a family landed survh workers compensation policy after their relative opioids for an on-the-job story overdosed. Insu ginreig to increase restrictions on coverage of c According to Barnes, tamper-resistant op make-or-break moment. This is an issue becc studies suggest that new formulations do inc often quite dramatically—financial considerati from the market unless the government mand become tamper resistant. Today's tamper re are more expensive, branded products. Man pay for them, and most generic drug maker licensing fees to make their products tamper t Finally, Barnes says that clinicians who pn soon need extra training courses. A couple ready mandated new educational prograrr prescribes controlled substances. Many oche ering it, as is the US Congress. "The first trend — growing public concern drug abuse — underlies all the others," Barnes bly drive more changes to the industry than a ued from cover) 4 respond to or get excited by sound. Based terprets these sounds, our body gives a natural had the experience of going to the dentist and g 11 our teeth. How many of us have grabbed clenched our hands to try and decrease the rt we are having in our mouths? Any of us who evoking the gate theory for pain. We are alo- observe the effects in a controlled environment. Although it was a small-scale study (seven control babies, seven test babies), Tramo said it prodcued some interesting results. The music "created a lot of stabiTrty and lowered the blood pressure of those infants that it was played for: Although only two of the four babies who had not heard the music stopped crying following the heel stidc, all four infants who hod been able to hear the music stopped crying. Tramo told the audience to keep an eye on a relatively new journal EFTA01114704 UPIWeek: e to the fourth and final day of the conference. hedule today features the four sessions of this Complementary and Alternative Medicine presentation that focus on pain medicine nurs- resented by pain management experts from the *ion, the second half of the pharmacotherapy lule also includes a trio of sessions on regional cluing pelvic pain, arm and hand pain, and ("phantom tooth pain"). The Special Interest cover topics in pharmacy-based pain services, ferences in pain management, new develop- Kiblic policy, and the influence of various pain ',alders on the physician-patient relationship. it 7:00am with Hal S. Blatman, MD, present- thition aid pain that will explain the ways in s in our patients' diets actually stop their bod- nd get in the way of rehabilitation? Blatman ecific nutrients that will augment healing and/ luce pain? Debra J. Drew, MS, ACNS-BC, ie the challenges associated with pain assess- care setting, especially in special populations. sr, Phenyl!), BCPS, will give a talk on phar- pharmacokinetic pain and paVia- M. Fitzgerald, e epidemiology le chronic pelvic s in pathophysi- diagnosis, and s and treatment irome. ert A. Bonak- iew the preva- nd most con- 'pies as well as ne patient con- complementary spies in pain management. Helen N. Turner, 4S-BC, on the use of multimodal analgesia in She will also cover various nonpharmaceuticol to be effective additions to multimodal pain McPherson, Phenyl!), BCPS, will elucidate cokinetic and phormacodynamic properties of mysterious methadone," covering a range of propriate titration strategies as well as how to inverted from another drug to methadone? first of three satellite programs scheduled for 'atients and Your Practice: The Role of Drug pin and Risk Management," sponsored by Alere hire Jennifer E. Bolen, JD, and Jeffery A. issing practical approaches to incorporating comprehensive chronic pain and risk manage- theft A. Bonakdar, MD, continues the id Alternative Medicine track with "Overview Dietary Supplements," during which he will ace of supplement use in specific pain condi- medication facts." Roger B. Fillingim, PhD, will discuss sex and gender differences in pain management and explore possible answers to the question "Do we need pink and blue pills?" Cam-Ann Gibson, MD, and Ilene R. Robeck, MD, will exam- ine key topics and challenges in evaluating and treating chronic pain in veterans following deployment. Following the morning break, at 11:10am, Lora McGuire, MS, RN, will explore topics in the management of postoperative pain, induding preemptive analgesia, special methods of delivery of pain control, and nonopioid, opioid, and adjuvant analgesics. Srinivas Nalamachu, MD, will discuss the clinical characteris- tics, assessment diagnosis, and treatment of arm aid hand pain. Michael E. Schatrrtan, PhD, will talk about the evolving influence of non-patient and non-physician stakeholders in pain management (insurance, hospital, pharmaceutical, implantable device, and urine drug testing industries, etc) and explain why these various actors must coalesce into a "mutually cooperative system' if the suffering of pain patients is to be ameliorated. At 12:30pm, the schedule features the final two satellite events of PAINWeek 2012. The faculty of "Persistent and Breakthrough Pain: Responsible Opioid Prescribing for Multidimensional Disorders" will consolidate clinically relevant scientific studies and evidence-based guidelines into practical approaches to persistent pain and break- through pain assessment, responsible opioid prescrib- ing, and repeated re-eval- uation of patient outcomes. "Mission: Pain Management - The Efficient First Visit (An IDEAL® Clinical Encounter)" v/il discuss nociceptive, neu- ropathic, and centrally-me- diated chronic pain; the risks and benefits of nonpharma- cologic and pharmacologic treatments for chronic pain; barriers to the optimal use of opioid analgesics in chronic pain; and methods for screening and risk miti- gation in the initial and follow-up care of patients with chronic pain. At 2:10pm, Hal S. Blatman, MD, will present "a wide range of options for treatment, recovery, and body maintenance fa a healthy aid pain-free life" for women at midge. Bill Paquin, CEO of Vertical Health, will explore "the pivotal role that Web aid mobile applications wi ploy to both increase the efficiency of physician practices and improve patient outcomes" in pain management. Edward S. Lee, MD, and Tu A. Ngo, PhD, MPH, will offer a plenary session focus- ing on managing psychiatric comorbidties in chronic pain. Gary W. Jay, MD, will present a master class on the differential diagnosis and management of migrare and tension-type headache. Following the afternoon break, Carol P. Curtiss, MSN, RN-BC, will discuss key principles involved in balancing effective pain management and saeening for risk of substance misuse and addiction in persons with pain. Peter A. Foreman, DDS, will examine the difficult diagnostic and treatment challenges associated with orofacial neuropathies. Mary Lynn McPherson, PharmD, and Kathryn A. Walker, PharmD, will duke it out as Today's Schedule of Recommended Cou for First-time PAINVI Attendees 7:OOam-8:OOam Nutrition and Pain: Simple R for Pain-Free Health Hal S. Blatman, MD 7:OOam-8:OOam Pelvic Pain Colleen M. Fitzgerald, MD 8:10am-9:10am Analgesia: What are the Op Helen N. Turner, DNP, RN-BC, PCN 9:20am-10:20am Speed Dating with Pharmaci 50 Top Medication Tips at Er Mary Lynn McPherson, PharmD, BC Kathryn A. Walker, PharmD, BCPS 11:10am-12:10pm Pre- and Postop Pain Manag Lora McGuire, MS, RN 2:10pm-3:10pm Women on the Verge: Sleep, and Pain at Midlife Hal S. Blatman, MD 5:20pm-6:20pm VA Health Care: This is Not Your Father's VA Lucile Burgo-Black, MD, and Stephi MD, MPH EFTA01114705 rTeCT In leOTIenTS IGKIng Up10105 nor is Pain 'WV wescribe opioids should be aware of the symptoms of opioid-induced constipation of the pharmacologic options for managing this condition goid-kiduced Constipation: Considerations to 'propriate Early Targeted Therapy for Better Pa- ernes," a CME-accredited session yesterday at at focused on opioid-induced constipation, its and the pharmacologic options that are co- rrect this condition, presenters Bil McCarberg, O; and Michelle Rhiner, RN-BC, MSN, provided motion that clinicians can apply to daily practice. e session by talking about the scope of the induced constipation (OIC). Because prescrip- most commonly used medications in the pain alGative care settings, and because OIC is one ients with chronic experience OIC to gree. In fact, OIC ed in up to 90% its with cancer I 80% of patients mic nonmalignant :cause chronic pain of the most common adverse side effects associated with chronic opioid therapy,' Rhiner said that most patients with chronic pain will experience OIC to some degree. In fact, OIC is reported in up to 90% of patients with cancer pain and 80% of patients with chronic nonmalignant pain. She noted that because chronic pain patients rarely develop a tolerance to OIC, most of them will re- quire some form of pharmacologic therapy for constipation (up to 94% of patients with advanced illness who take opioids need laxatives, the most commonly used therapy for OIC). Untreated or undertreated OIC can compromise pain manage- ment in patients with cancer. Rhiner said that surveys have shown that O1C can cause patients to switch to switch to a different opioid, reduce their opioid dose (either in conjunction with their health care provider, or on their own without telling their provider), or even stop taking opioids altogether. Patients with OIC also use more health coy resources (they have more hospital admissions and doctor visits, use more home health services, etc). Rhiner said that OK also has a negative impact on quality of life and functionality in patients with chronic noncancer pain, leading to missed work, reduced productiv- ity, and compromised mental and physical health. Rhiner concluded her portion of the session by briefly review- ing normal colorectal functional processes. She said that bowel function is "governed by the enteric brain, an organ comprised of billions of neurons," and that any disruption in the neurotransmit- ter and mechanisms that regulate bowel function (such as those produce by opioids) can lead to constipation and bowel dysfunc- tion. She said that OK results when opioids bind with periphery sensors in the gut and in the enteric system.This affects not only the colon, but other components of the boweVgastrointestinal system, producing a spectrum of opioid-induced bowel dysfunction. This can indude cramping, bloating, decreased appetite, nausea and other symptoms in addition to constipation. She said that many of these symptoms are often missed by patients and providers and not attributed to the patient's opioid therapy. Assessing patients for OIC and selecting an appropriate management option During his portion of the presentation, McCarberg discussed the assessment and management of OK. He said that "there we no good diagnostic criteria for OIC." Although many patients and cli- nicians focus on stool frequency when discussing O1C, McCarberg said that this might not provide a complete picture because "there is wide variabMty in stool frequency" from patient to patient. Thus, when assessing patients for O1C, clinicians should also focus on other factors, such as those outlined in the Rome III criteria for functional constipation. McCarberg reminded the audience that these are not necessarily for O1C, just for functional constipation. There are no OIC-specific criteria: When assessing patients for O1C, taking a history is important to find out the patient's normal boweVdefecation routine in order to establish a baseline. "You have to ask the right questions" about the patient's previous and current bowel pattern and activity level, their amount of daly fiber and fluid intake, and laxative use prior PAINWeek Administ Redza Ibrahim Advertising, Sponsorships, Satellite Events Darryl Fossa Art Oiled on and Graphic Design Steve Porada Corporate Relations Debra Weiner Course Development Holly Caster Editorial Services Michael Shaffer Exhibit Sales', Management Wanda Tarnoff Finance Keith Dempster Mock Relations Benjamin R. Metzger, MD Meckal Direction Jeffrey Tamoff Operations and Technology Charles Brown Program Management Patrick Kelly Web and Print Production Pain Management Jack Lapping vke President, Sales Steve Porcelli Director of Sales Cowie Payson Notional Accounts Manager Megan O'Connell Soles & Marketing Coordinator Todd Kunkler Editor Silas Inman Web Editor Stephanie Ogozaly Assistant Web Ecitor John Salesi Art Director John Burke Group Director. Ciro,'otion & Production MJH & Associates Mike Hennessy Choir man /Chief Executive Officer/President Tighe Blazier Chief Operating Officer Neil Glasser, CPA/CFE EFTA01114706 I itoring gives you the IGHTof Rx Guardian CDs" you to compare your patient to a database nts clinically assessed for adherence. 2 5 The Rx Guardian (normalized drug with other clinica indicate that if yo pain patient falls: • Within -2.0 to higher likeliho • Outside -2.0 to a possibility of Your patient's sta are tracked over t identify patterns. ivardianC,D" with the new Rx Guardian INSIGHT Rel )vative tool to help assess adherence in your chronic pain patients. RECEDENTED SCIENCE 'X GUARDIAN CD'" • REVOLUTIONARY REPORTING WITH RX GUARDIAN INSIGHT REPORT lizes a proprietary, dynamic database of )re than one thousand chronic pain patients lically assessed for adherence advanced proprietary algorithm creates formalized value based on your patient's ysiological variables ur patient's normalized results are compared this proprietary database to help you assess ur patient's adherence ■ Standard scores are tracked over time to help: —Detect patterns of results that could indicate misuse, abuse, or diversion —Identify possible drug metabolism is! Identify illicit drug use Identify the absence of medications prescribed by you, as well as the presenc of medications you did not prescribe cally advanced urine drug monitoring system is brought to you by Ameritox, the leade ledication Monitoring". Together with your expertise, Rx Guardian CDS with the Rx GI Report can help you make clinical decisions to enhance the care of your chronic pain Booth #114, to learn more about Rx Guardii EFTA01114707 Kiln-fighting diet that calls for eliminating trans fats, artificial sweeteners, nutritionally deficient foods, digestive tract disruptors, and oth dients, patients may be able to effectively reduce the severity of their pain without the use of prescription medications. and Pain: Simple Rules for lealth" (CAM-Ol) S. Blatman, MD, DAAPM, ABIHM y, September 8 )0am '13, Castellano 1 e owes much of its success to a quality that's I among foodstuffs: an utter inability to sup- )st forms of life. ) eat it. Mold takes no root inside it. Even e it a miss. Industrial food makers, who have a mirade ingredient that can cut costs and )ave made it one of the most common ingre- humans ,ond all pds" that says Hal DAAPM, argarine yedients make us will ex- hINWeek wesenta- nd Pain: 'ain-Free actively Others I stop our what they are designed to do: heal them- prevent medications from working properly: ) runs the Blatman Pain Clinic in Cincinnati. rods and your patients will hurt less. They'll er to opioid medications—and develop less :an prescribe lower doses and stop worrying sing down your door." :nt the past couple of decades testing ingre- fighting diet he will outline during his talk. He very credible book and study he can find on le conducts tiny experiments, first on himself, I friends, and finally on patients. of testing have left him with a reasonably elines that seem to provide at least some every patient who sticks to them for any tman says that he cannot scientifically prove mess because he recommends it to every in maintaining control groups, but he be- hypothesize from what I've read about the mechanisms by which particular compounds increase pain. But case after case demonstrates a major impact. It's common for my patients with fibromyalgia to report that pain goes down by as much as half when they eliminate all artificial sweeteners," Blatman says. The insufficiently nutritious category includes many of the usual suspects: sugar, potatoes, fruit juices, and many other foods with high glycemic indexes. As for the digestive tract disruptors, the list there includes excessive red meat and all wheat products. "The gut plays an incredibly important role in good health," Blatman says. "The good flora that are inside of it break down your food so you can absorb nutrients properly. They also keep your immune sys- tem working right which is why patients with autoimmune dis- eases get particular relief when they start eating a gut-healthy diet." Blatman's dietary recommendations are simple. Sticking to them, however, can be tricky. Many diets advise patients to cut back on certain foods and ingredients. Blatman tells patients to avoid them completely, a maxim that requires not only iron self- discipline but also frequent detective work. Many of the forbid- den ingredients are found in a wide variety of foods, and often turn up in unexpected places. Blatman remembers one patient who "gave up" wheat but saw no health benefits--because she had no idea about the wheat in her favorite soy sauce. Patients must also be willing to wait long p start to see any benefits. Blatman cautions foods take weeks to work their way entirely Others take as long as four months, and a bite of the wrong thing can set the clock bac can see significant benefits just by cutting be ingredients I advise against, but in most case only come from total abstinence: Blatman sr Many patients, obviously, will sabotage th. ing here and there. Many end up simply at altogether. "Patients obviously have the right to cho but I make it clear to them that they are doir ing to be in pain. I also make it clear to the changes come before any unusually large Blatman says. "If they follow the diet religiously and the try what I can to fix that. But if the pain isn't e a patient to eat better, then it certainly isn't k to risk his or her health by increasing the op and again," Blatman says. "This diet isn't an e anything, but it produces very impressive res and it can do the same for yours." "Eliminate problem foods and ingredients and youi patients will hurt less. They'll also respond better tc medications—and develop less tolerance—so you cal prescribe lower doses and stop worrying about the kicking down your door." EFTA01114708 fective 24-hour pain control' nce-daily oral dosing with e evening meal' )w incidence of dizziness id somnolence' :ration to an 1800 mg dose 2 weeks' was a reported incidence of dizziness ) vs 2.2% placebo) and somnolence vs 2.7% placebo) at 1800 mg once daily? nore information, 3e visit Booth 316. ition and Usage ISE' is indicated for the management of Drpetic neuralgia (PHN). GRALISE is not )angeable with other gabapentin products Ise of differing pharmacokinetic profiles fect the frequency of administration. -tant Safety Information ISE is contraindicated in patients who have nstrated hypersensitivity to the drug or its ingredients. ileptic drugs (AEDs) including gabapentin, the active ingredient in GRALISE, increase suicidal thoughts or behavior in patients taking these drugs for any indication. Patient: with any AED for any indication should be monitored for the emergence or worsenir )ression, suicidal thoughts or behavior, and/or any unusual changes in mood or beha% lost common adverse reaction to GRALISE (5% and twice placebo) is dizziness. 3 all GRALISE clinical trials the other most common adverse reactions (2%) are Dlence, headache, peripheral edema, diarrhea, dry mouth, and nasopharyngitis. 'pes and incidence of adverse events were similar across age groups except for leral edema, which tended to increase in incidence with age. ;ee next page for Brief Summary of Prescribing Information, V. 14311-Hil+)+0 - • , Watch how GRALI: r rin technology works z Scan the barcode to view the video at /0-1 • EFTA01114709 antuntunata tiacnue natas t tat um %ea...maw at um picouniscin. Dose should be adjusted in patents with reduced renal function. GRALISE should not be h Gra less than 30 or in patents on hernodialysis. emetic neuralgia. GRALISE therapy should be initiated and nitrated as follows: ommended Titration Schedule Day 2 Days 3-6 Days 7-10 Days 11-14 Day 15 600 mg 900 mg 1200 mg 1500 mg 1800 mg S ated in patients with demonstrated hypersensitivity to the drug or its ingredients. age Based on Renal Function Once-daily dosing GRALISE dose (once daly with evening meal) 1800 mg 600 mg to 1800 mg GRALISE should not be administered 3digysis GRALISE should not be administered CAUTIONS engeable with other gabapentin products because of differing pharmacokinetic profiles that administration. The safety and effectiveness of GRALISE in patients with epilepsy has not been (prior and Ideation Antiepileptic drugs (AEDs). including gabapentn. the active Ogredient in risk of sticidal thoughts or behavior in patients taking these drugs for any indication. Patients ir any ideation should be monitored for the emergence or worsening of depression, suicidal nd/or any unusual changes in mood or behavior. ation for Antiepileptic Drugs (including gabapentin, the active ingredient Jed Analysis vents per 1000 patients its per 1000 patients of events in 3in placebo patients nal drug patients atients Epilepsy Psychiatric Other Total 1.0 5.7 1.0 2.4 3.4 8.5 1.8 4.3 3.5 1.5 1.9 1.8 2.4 2.9 0.9 1.9 *dal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials =dittos, but the absolute risk dif ferences were similar for the epilepsy and psychiatric isiderng prescribing GRALISE must balance the risk of suicidal thoughts or behavior with less. Epilepsy and many other illnesses for wtich products containng active components gabapenfin. the active component n GRALISE) are prescribed are themselves associated tarry and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and I treatment. the prescriber needs to consider whether the emergence of these symptoms y be related to the illness being treated. Patients, their caregivers. and families should be contains gabapentin %Mich is also used to treat epilepsy and that AEDs increase the risk of ehavior and should be advised of the need to be alert for the emergence or worsening of the depression. any unusual changes in mood or behavior, or the emergence of suicidal thoughts. bout self-harm. Behaviors of concern should be reported immediately( to healthcare providers. actin Gabapentin should be withdrawn gradualy. If GRALISE is discontinued. this should a minimum of 1 week or longer (at the discretion of the prescriber). Tumorigenic Potential vivo lif etime carcinogenicity studies, an unexpectedly high incidence of pancreatic acinar identified in male. but not female. rats. The cinical significance of this finding is triknoym. pentin therapy in epilepsy comprising 2,085 patient-years of exposure in patients over imam were reported in 10 patients, and preexisting tumors worsened in 11 patients, during fiscontinung the drug. However, no similar patient population untreated with gabapentin was :kground tumor incidence and recurrence nformaton for comparison. Therefore. the effect in the incidence of new tumors in humans or on the worsenng or recurrence of previously Morn. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)! °silkily Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), also known nsitivity. has been reported in patients taking antiepileptic drugs, including GRALISE. Some een fatal or life-threatening. DRESS typically, although not exclusively. presents with fever, !nopathy in association with other organ system involvement. such as hepatitis. nephritis, elites. myocardits, or myositis. sometimes resembling an acute viral infection. Eosinophilia ise this disorder is variable in its expression, other organ systems not noted here may be t to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, lough rash is not evident. If such signs or symptoms are present, the patient should be . GRALISE should be discontinued it an alternative etiology for the signs or symptoms Laboratory Tests Clinical trial data do not indicate that routine monitoring of clinical s necessary fa the sate use of GRALISE. The value of monitoring gabapentin blood been established. S ence Because clinical trials are conducted under widely varying conditions, adverse reaction itical trials of a drug cannot be directly compared to rates in the cinical trials of another :t the rates observed in practice. A total of 359 patients with neuropathic pain associated ilgia have received GRALISE at doses up to 1800 mg daily during placebo-controlled cfrical . in patients with postherpetic neuralgia, 9.7% of the 359 patients treated with GRALISE its treated with placebo discontinued prematurely due to adverse reactians. In the GRALISE ost common reason for discontinuation due to adverse reactions was dizziness. Of GRALISE- :perienced adverse reactions in clinical studies, the majority of those adverse reactions were ate'. Table 4 lists all adverse reactions, regardless of causally, occurring n at least 1% of It pain associated with postherpetic netralgia in the GRALISE group for which the incidence placet:0 group nergent Adverse Reaction Incidence in Controlled Trials in Neuropathic Pain therpetic Neuralgia (Events in at Least 1% of all GRALISE-Treated Patients and in the Placehn Gronnl Dizziness 10.9 2.2 Somnolence 4.5 2.7 Headache 4.2 4.1 Lethargy 1.1 0.3 In addition to the adverse reactions reported in Table 4 above, the followng adverse reactionswith relationship to GRALISE were reported during the clinical development for the treatment of posthr Events in we than 1% of patients but equally or more frequently in the GRALISE-treated patient the placebo group included blood pressure increase, confusional state, gastroenteritis viral. herp hypertension, joint swelling, memory impairment. nausea, pneumonia, pyrexia, rash, seasonal all respiratory infection. Postmarlceting and Other Experience with other Formulations of Ga addition to the adverse experiences reported during clinical testing of gabapentin, the following ad have been reported n patients receiving other formulator's of marketed gabapentin. These adverse not been fisted above and data are insufficient to support an estimate of their incidence or to establ fistng is alphabetized: angioedema, blood glucose fluctuation, breast hypertrophy, erythema multi( liver function tests, fever. hyponatrernia. jaundice. movement disorder, Stevens-Jdrison syndrome. followng the abrupt discontinuation of gabapentin immediate release have also been reported. The reported events were anxiety, insomnia, nausea, pain and sweating. DRUG INTERACTIONS An increase in gabapentin AUC values has been reported when admiristmed with hydrocodone with morphine. An antacid containing aluminum hydroxide and magnesium hydroxide reduced lt of gabapentin immediate release by about approximately 20%, but by only 5% when gabapentir 2 hours after antacids. It is recommended that GRALISE be taken at least 2 hours following antaci There are no pharmacokinetic interactions between gabapentin and the folowing antiepileptic drui carbamazepine. valproic add, phenobarbital. and naproxen. Cimefidne decreased the apparent or gabapentin by 14% and creatinine clearance by 10%. The effect of gabapentin immediate release was not evaluated. This decrease is not expected to be clinically significant. Gabapentb immediate three times daily ) had no effect on the pharmacokinetics of nmethindrone (2.5 mg) or ethiwl esti administered as a single tablet, except that the Cin, of norethindrone was increased by 13%. This considered to be clinically significant. Gabapentil immediate release pharmacokinetic parameters with and without probenecid, indicating that gabapentin does not undergo renal tubular secretion t that is blocked by probenecid. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C: Gabapentin has been shown to be fetotoxic in rodents, causi ossification of several bales in the skull, vertebrae, forelimbs. and hindlimbs. There are no adequati controlled studies in pregnant women. This drug should be used dung pregnancy only if the potent justifies the potential risk to the fetus. To provide information regarding the effects of in Om expos' physicians are advised to recommend that pregnant patients taking GRALISE ergot in the North i Antiepileptic Drug (NAAED) Pregnancy Registry. This can be done by calling the toll free number 1-I and must be done by patients themselves. Information on the registry can also be found at the webs aedpregnancyregistry.org/. Nursing Mothers Gabapentin is secreted into human milk folowiig A nursed infant could be exposed to a maximum dose of approximately 1 mg/kg/day of gabapentin. effect an the nursing infant is unknown. GRALISE should be used in women who are nursing only it clearly outweigh the risks. Pediatric Use The safety and effectiveness of GRALISE in the manag postherpetic neuralgia in patients less than 18 years of age has not been studied. Geriatric Use of patients treated with GRALISE n controlled clinical trials n patients with postherpetic neuralgia which 63% were 65 years of age or older. The types and incidence of adverse events were simile groups except for peripheral edema, which tended to increase in incidence with age. GRALISE is substantially excreted by the kidney. Reductions in GRALISE dose should be made in patients wit compromised renal function. (see Dosage and Administration]. Hepatic Impairment Because g metabolized, studies have not been conducted in patients with hepatic impairment. Renal Impai is known to be substantially excreted by the kidney. Dosage adjustment is necessary in patients will function. GRALISE should not be administered in patients with CrCL between 15 and 30 or in patier hemodmtysis [see Dosage and Admitistrafion]. DRUG ABUSE AND DEPENDENCE The abuse and dependence potential of GRALISE has not been evaluated n human studies. OVERDOSAGE A lethal dose of gabapentin was not identified in mice and rats receivng single oral doses as high as • Signs of acute toxicity in animals included ataxia. labored breathing. Mosis, sedation, hypoactivity, c Acute oral overdoses of gabapentin immediate release in humans up to 49 grams have been reports cases, double vision, slurred speech, drowsiness, lethargy and diarrhea were observed. Al patients supportive care. Gabapentin can be removed by hemocfmtysis. Although hemodialysis has not been the few overdose cases reported, it may be ndicated by the patient's cinical state or in patients wit renal inpairment. CLINICAL PHARMACOLOGY Pharmacokinetics AbsomPtion and Sioavalability Gabapentin is absorbed from the proximal small saturable L-amino transport system. Gabapentin bioavaiabifity is not dose proportional: as the dose bioavailability decreases. When GRALISE (1800 mg once daily) and gabapentin immediate release times a day) were administered with high fat meals (50% of calories from fat), GRALISE has a bight AUC at steady state compared to gabapentii immediate release. Toe to reach maximum plasma a for GRALISE is 8 hcsirs.whth is about 4.6 hours longer compared to gabapentin immediate Meas. NONCLINICAL TOXICOLOGY Ca rcinogenesis, Mutagenesis, Impairment of Fertility Gabapentin was given in the diet to rr 600. and 2000 mg/kg/day and to rats at 250. 1000. and 2000 mg/kg/day for 2 years. A statistic increase in the incidence of pancreatic acinar cell adenoma and carcinomas was found in male rat high dose; the no-effect dose for the occurrence of carcinomas was 1000 mg/kg/day. Peak plasm of gabapentn in rats receiving the high dose of 2000 mg/kg/day were more than 10 times higher concentrations in humans receiving 1800 mg per day and in rats receiving 1000 mg/kg/day peal concentrations were more than 6.5 times higher than n humans receiving 1800 mg/day. The pant carcinomas did not affect survival, did not metastasize and were not locally invasive. The relevana to carcinogenic risk in humans is unclear. Studies designed to investigate the mechanism of gabag pancreatic carcinogenesis in rats indicate that gabapentin stimulates DNA synthesis n rat pancrea in vitro and, thus. may be acting as a tumor promoter by enhancing mitogenic activity. It is not knot gabapentin has the ability to increase cell proliferation in other cell types or in other species, ncbc Gabapentn did not demonstrate mutagenic or genotoxic potential in 3 in vitro and 4 in vivo assays. hunch/ rr .nn,, cenn wan nhenniarl in rate al .here urn In ,nnn ennArn lennmvirnehal EFTA01114710 'the uassitications and treatments sis and treatment requires an understanding of the signs, symptoms, and clinical presentation of the multiple forms of tension-type headache rand Tension-Type Differential Diagnosis and ant" (MAS-06) y W. Jay, MD, FAAPM, DAAPM y, September 8 10pm ≥l 4, Nolita 3 ;sfully address ' needs and to lining treatment- idverse outcomes, Is need to be able nine the type of e their patient is T ee way headache specialists think about the relationship between tension-type and migraine headaches has shift- d considerably over the last several decades. At one point, not that far back, people thought of headaches as a spectrum; a straight line with tension-type headaches (BHA) at one end and migraines at the other end. Everything in be- tween were gradations," says Gary W. Jay, MD, FAAPM. He says that the question nowadays is whether they are essentially one headache with two different clinical pictures. To bring attendees of PAINWeek 2012 up to speed on the latest trends in headache medicine, Jay will present a two-hour master class, "Migraine and Tension-Type Headache: NOT Two Ends of a Spectrum!: on Saturday afternoon. During this com- prehensive session, he will review the pathophysiologies and varieties of migraine headaches and TTHAs, as well appropri- ate treatment options. According to Jay, a major challenge faced by health care providers who treat patients with headache is recognizing the multiple forms of TTHAs and migraines. "I will review what we know about what happens in the brain, particularly different forms of migraine headaches: says Jay. When many people think about migraines, they still think of the classical migraine headache—typically, a woman with a one-sided throbbing headache who has pain that is triggered by sound or light. Jay says that there are "multiple types of mi- graine and they can occur with or without aura." He also notes that the nature of aura varies widely, Aura is visual in 80 to 85 percent of patients; patients can have neurological aura that may elicit speech difficulty or even hemiplegia." To successfully address patients' needs and to avoid induc- ing treatment-related adverse outcomes, physicians need to be able to determine the type of headache their patient is experi- encing. As an example, triptans and ergot alkaloids are typical abortive treatments for migraines. "Both of these are vasocon- strictors and you never want to offer them to a patient that may have significant aura secondary to vasoconstriction," says Jay. "This can cause further vasoconstriction and neurological deficit and very possibly lead to long-term or permanent damage. It can induce infarction: The ability to differentiate between symptoms and possible causes can have a profound impact on outcomes and quality of life. if a patient calls you in the middle of night and tells you something is happening, you need to be able to make a decision on whether to meet them at the emergency room as soon as possible: Jay says. In some visual auras, patients may develop transient monocular vision loss. This presents simi- larly to amaurosis fugax, a transient ischemic attack involving a retinal artery. During his session, Jay will discuss strategies for confidently and accurately assessing these types of episodes and others. Earlier this year, the American Academy of Neurology and the American Headache Society jointly published updated evidence-based guidelines on preventive pharmacologic treat- ment for episodic migraine headaches. The guideline authors used stringent evaluation criteria to review existing evidence. ops," he says. "So what starts as possibly becomes centralized." In addition to reviewing TTHA pathophys ments, Jay will talk about diagnostic criteria mon TTHAs. Certain types of headaches a reproducible patterns of pericranial muscle tc ger point activation. "Pericranial muscle ten multiple etiologies, but arises most commont myofascial pain syndrome: says Jay. Myofa along the masseter muscle refer pain to the Trigger points may also elicit autonomic dysf, in the sternodeidomastoid muscle where tri<. sociated with lacrimation and redness, in ad "An example of what often happens i≤ comes in with temporomandibular joint (TMJ multiple surgeries for it, and the real problen the TMJ is being referred by a muscle: says In cases like this, "It is the job of the physi what the patient needs: Physicians need to origin of the pain. Jay hopes to convey the m the right questions is an important part of tre headaches. "Patients don't know what to tell them what you need to know: he says. Gary W. Jay is a neurological consultai in pain and disorders of the central nery president-elect of the Eastern Pain Associati. tion of the American Pain Society. He is a f the American Academy of Pain Manageme Academy of Pain Medicine. He was one of I the American Academy of Pain Medicine in EFTA01114711 pain assessment means going beyond matching a patient's pain to a number on a scale; it requires dinicians to consider ors and approaches. anent in Acute Care" (NRS-01) Ira Drew, MS, ACNS-BC, RN-BC y, September 8 OOam ≥l 3, Gracia 7 ,ent is gaining traction as an important faun- :ment of pain management. In August 2012, ommission issued a Sentinel Event Alert re- m of opioids in the hospital setting. This pub- he need to assess and monitor pain as part management program. specialists on this topic, Debra Drew, MS, will present "Pain Assessment in Acute Care" ek 2012. The presentation will provide an ossessment, including tools and approaches cial populations relevant to acute care set- eed to understand the complexities of the KI all its facets before they can design a plan omfortable," says Drew. nize the importance of viewing pain assess- that involves much more than administering iestionnaire to assign a score to the patient's ion of good pain management begins with assessment," says Drew. "Is the 0-10 pain in- J think of when you think of pain assessment? lot is 'yes,' you may be missing the boat: entation, Drew will review the latest findings pain assessment and discuss some of the ted with pain assessment in special popula- children and the elderly), as well as patients >us, ventilated, or developmentally delayed. )atients who can't verbalize their pain, who Is what they are feeling or can't speak," says cuss how to optimally assess pain when you lenging population: pain of patients in the intensive care unit ologic measures like blood pressure or pulse are often used to measure patient pain—represents one exam- ple of a challenging pain assessment scenario. Because blood pressure and pulse are not reliable pain indicators, providers are often left feeling helpless when trying to manage pain in this setting. "There are some observational tools that can be introduced in the ICU that provide a better way to assess whether or not a patient has pain, rather than relying on unreli- able variables," she says. "Pain assessment and management become complex when a patient cannot tell you what they are feeling. The fad that pain is a totally subjective and complex experience amplifies the difficulties: For some challenging populations, nurses and physicians may believe that pain assessment is not possible. But, Drew asserts that there is no such thing as a patient who cannot be assessed. "I would like to debunk that notion: she says. "There ting. During her presentation, Drew will provi for using the DIRE scale. "Primary care phys very helpful because they are trying to make guess on how to help their patients after thi of the hospital," she says. Drew cautions that comprehensive pain a time to do properly. "But a good pain asses time in the end because it will get a patient without adverse events in the beginning," sF try to take shortcuts because we are busy c assessment up front it can lead to a lot of redundancy later on and a lot of adverse at. tient: She compares assessment with obtair cal history and conducting a thorough ph) "These take time, too; yet if you miss some I think as a pain community we are realizing how li those simple, unimodal pain measures are, especic patients with chronic pain. I think there is going to evolution where we will be focusing more and mor pain and functional status. is always something you can consider for each patient; some patients are more complex than others, but they can all be assessed: Drew will recommend approaches to consider for a variety of special populations. Drew's presentation will also offer attendees a summary of assessment tools with which many providers are not comfortable or familiar. Along with general background information on these tools, she will provide a framework for how and when to use them in practice. She will also offer clinical examples throughout the presentation to supplement the information provided. She will also relate assessment to patient selection for chron- ic opioid analgesia. The Diagnosis, Intractability, Risk, Efficacy (DIRE) scale is an example of a tool that can be used to help practitioners decide whether their patient is a good candidate for long-term opioid therapy. It takes into account factors like substance abuse history and characteristics of the home set- badly for the patient: Drew also plans on talking about the emi of functional status as it relates to pain. In ment focused on pain intensity. "I think as a r are realizing how limited those simple, unimc are, especially for patients with chronic pain,' there is going to be an evolution where more and more on pain and functional sta some of these earlier tools: The focus will st patients with activities of their daily lives. Debra Drew, MS, ACNS-BC, RN-BC is a cialist for pain management at the Univei Medical Center, Fairview. In addition to he bilities, she is involved in patient and staff e. and institutional committees on pain and pa tinued from cover) I serve the patients who very much need us, the stakeholders what's changed and what an care can do for them: very starts with verifiable efficiency. will never roll again, so Schatman notes that to provide integrated pain care must learn to hey confine their efforts to clinically-validated ted at reasonable costs. clinicians can responsibly offer payers far bet- ers compensation policy, and the insurer's primary goal will be returning the patient to productive employment. In such cases, pain clinicians should bombard the insurer with studies that show how interdisciplinary pain treatment restores patient function better than any alternative. If, on the other hand, a patient is injured at home, the medi- cal bills will fall to a regular health insurer that will focus pri- marily on minimizing long-term costs. In such cases, caregiv- ers should bombard the insurer with studies that show cost costs a fortune because he keeps seeking new for years on end: Hospitals, likewise, have their own spec cerns, which caregivers need to consider bef open (or, in many cases, reopen) pain clini no plausible way to argue that hospital p< become directly profitable again, but he d pain clinics could generate indirect profits able hospital employees from their existing EFTA01114712 ation in this area of pharmacology is necessary for improving outcomes and maximizing treatment options. T he conference room where Thomas 8. Gregory, PharmD, BCPS, DASPE, CPE, gave his presentation "opioids A to r was so jam-packed on Friday morning that Gregory joked that "You guys are such hardcore pain guys that you bypassed the breakfast spread just to be in here early this morning." (Luckily there were still leftover urns of coffee and trays of croissants for those who waited for the session to end to grab breakfast.) If there is one thing that serves as a common denominator for all PAINWeek 2012 attendees—which includes physicians, phar- macists, nurse practitioners, physician assistants, and even social workers—it is a unified interest in the dosing strategies, side effects, and patient and medication variables associated with opioids. That is exactly what Gregory spoke about during his engaging presentation. Beginning with the patient and medication variables, Gregory started by discussing the importance of knowing the distinction between opioids that are pure agonists, which have no ceiling ef- fect and are not problematic in terms of increasing dosage (until side effects become intolerable) and those that are partial ago- nists, which can have a ceiling effect (ie, once a plateau dose is achieved, there will be no further analgesic activity). Gregory also touched on many different aspects of patient vari- ables in opioid therapy. He said that clinicians who are prescribing or administering opioids must consider a patient's age, particu- tive formulation technology ing intended drug action its of INTAC° outstanding crush resistance urdles against prescription drug abuse riendly formulation requires no aversive additives ade release properties to match reference or clinical needs ed at commercial manufacturing scale in FDA-approved products lady because metabolic enzymes in our bodies Muscle mass must also be considered due to patterns. Comorbidities must be taken into co renal dysfunction, for instance, can cause seric patients on chronic opioid therapy. The cost of be a factor, and not just in terms of the pat about whether the medication allows the patir mal daily routine," said Gregory. As far as medication pharmocokinetics is r sorption rate of opioids must be considered istered transdermally via a patch, Gregory s will vary depending on age. During this part one of the audience members asked Gregor to be the best method for disposing of opioic said that although there is no one correct a rules and regulations governing disposal vary he thinks that patches should be absorbed and that the diffused drug should then be drain. He added that attendees should mak• out what their states' rules and regulations they were abiding by the law. The discussion segued into various opioid cic (contin, EFTA01114713 )nge in patient condition, or even health care iregory reminded the audience that when they nge a patient's dosage formulation or route of necessary to review opioid equianalgesic dos- : said should "serve as a guide and not a gos- s cross tolerance is not universal in nature. He of specific scenarios, such as what health care )e aware of when switching patients from one dtiondly bioequivalence between routes of administration must be considered before beginning the 5-step opioid conversion process: 1. Gbbally assess pain complaint. 2. Determine total daily dose of current °plaid. 3. Decide which opioid analgesic will be used for the new agent and consult established conversion tables to determine new dose. Gregory conveyed a significant amount of Lion about opioids during his session, and le• number of excellent instructions, resources, an motion on dosing, conversion charts, and man ementary and Alternative Medicine: Putting Evidence It nplementary and alternative medicine (CAM) use among chronic pain patients range from 30 to ing to try CAM approaches, including for pain management. entary and Alternative 3verview and Effective n Pain" (CAM-02) ert Bonakdar, MD ry, September 8 10am al 3, Castellana 1 :ult to define because it consists of diverse ns and it is constantly changing. Many oaches have gained attention as safe and les or adjuncts to pharmacologic interven- agement of chronic pain. With increasing of CAM and integrative medicine is men- sed in evidence-based guidelines. Despite ations, many practitioners remain hesitant into their own practice or to discuss CAM ; MD, will present "Complementary and Alter- eerview and Effective Therapies in Pain"on Sat- Meek 2012. His presentation will review exist- imendations for CAM use and offer guidance nt these recommendations in practice. "The key engage patients and discuss CAM approaches most out of them in conjunction with everything lending: says Bonakdar. ration of CAM as part of mainstream treat- ,v+ paradigm for many physicians. in many are learning these approaches on the fly, flts we may not have learned about in sidency, or fellowship: says Bonakdar. This ncies and fellowships are starting to incor- iodologies into their training programs. In ts Bonakdar, "Physicians need to get more :AM, especially if the evidence is saying we In fact, Bonakdar says that discussions about CAM happen so infrequently that the National Institutes of Health has de- veloped a packet to guide doctors and patients on how to approach the topic of CAM. He will review this and other re- sources to guide CAM usage during his talk. He plans to address many of the factors that contribute to providers lack of motivation to use CAM. The presentation will include useful information about a variety of CAM interven- tions that are backed by strong evidence. "I will go into a host of treatments and help providers know what to consider, and more importantly, how to coordinate care," says Bonakdar. He will pro- vide guidance on accessing and obtaining products and services, dosing, side effects, and potentially dangerous interactions. The inclusion of CAM in practice guidelines represents ad- vancement in the fields of CAM and pain management.At the same time, this development has actually posed some barri- ers to implementation because not all of the guidelines are in agreement. "Part of my talk will be about how to arrive at a bottom line you are comfortable suggesting to your patient: says Bonakdar. "Along with practical advice for how to use the guidelines, I will talk about who is a good candidate for CAM: Providers also need to be updated and aware of impor- tant safety issues related to CAM usage. When using CAM approaches that are backed by trial evidence, for example, Bonakdar recommends using the standardized version used in the trial. He will review this and other safety considerations that must be kept in mind during patient selection and follow up. Financial considerations may play a role in whether patients and providers pursue CAM therapies. if you ask most physicians who have not considered bing through their office whether any of these interventions would be covered, they would think no," says Bonakdar. "My clink tries to put everything through insurance and we have found reasonable reimbursement." He wil discuss reim- bursement and other financial factors that may be posing a barrier to integrating CAM recommendations into finical practice. In terms of cost-effectiveness of CAM, not many analyses have been performed. Bonakdar says, "There can be cost sav- ings, but the care needs to be coordinated: Cost savings will not be achieved if a patient goes to a CAM provider three times a week indefinitely. "If a patient is self-choosing a CAM therapy, it may not be cost-effective because there is no over- In many cases, physi are learning about C approaches on the fl especially treatment may not have learns about in medical sch residency, or fellows Physicians need to gi comfortable with CA EFTA01114714 Cir EVENTS nts and Your Practice: The Role of Chronic Pain and Risk Management eptember 8, 8:25-9:55an era Ballroom I: NO 3 (breakfast) squired: NO re Toxicology otion, Jennifer E. Bolen, JD, and Jeffery A. Gudin, MD, will discuss practical approaches to incorporating drug screening into comprehensive chronic pain and risk management plans. They will also address key topics in legal and regulatory considerations for drug testing frequency, docu- mentation, and the interpretation of results. and BTP, and multidisciplinary approaches tha range of biopsychosocial causes and sympton persistent pain and BTP. Mission: Pain Management —The First Visit (An IDEAL® Clinical En Time: Saturday, September 8, 12:30-2:00p Room: Level 4, Gracia 1-4 CE/CME certified: YES Meal served: YES (lunch) Preregistration required: N/A Supported by educational grants provided by and Mallinckrodt, the pharmaceuticals bui The faculty will discuss the underlying pothopl transmission mechanisms associated with noci pothic, and centrally-mediated chronic pain; c five risks and benefits of nonphormocologic ai treatment options for chronic pain; explain hog barriers to the optimal use of opioid analgesic chronic pain; and assess methods for screenin lion in the initial and follow-up care of patient Persistent and Breakthrough Pain: Responsible Opioid Prescribing for Multidimensional Disorders Time: Saturday, September 8, 12:30-2:00pm Room: Level 4, Gracia I CE/CME certified: YES Meal served: YES (lunch) Preregistration required: N/A Supported by an educational grant from Teva Pharmaceutical Industries Ltd. This activity was designed to "consolidate clinically relevant scientific studies and evidence-based guidelines into practical approaches to persisten pain and BTP assessment, responsible opioid prescribing, and repeated re-evaluation of patient outcomes.°The faculty of Michael J. Brennan, MD; Jeffrey A. Gudin, MD; Douglas C. Schottenstein, MD; and David M. Simpson, MD, MAN, will discuss the diagnostic criteria for BTP pain and clinical characteristics of its subtypes, strategies for indMdual- izing opioid therapy for persistent pain Vaillulballialifies•••••••••••••••• •41•••••••••••••••• ••• •••••••••• .•••••• •••••• 4*•••••••• OM 1 ra • • imi..1•1 aso I be•••••• •••••••••••••••adabad.aiefte lt••••••••Mie....0.. bliai wave creshe •••••••••••%•••• an ••••••••••••••••••••••••., •1•Isa I adelli•••••••••••••••••••••••••••••••••••11amn• tot mo, list it favorite pharmacy journal, reimagined for the iP Fxnlore multimedia resources. exclusive articles. and CF lessons at your fingertins. EFTA01114715 c rain and comorbidities istration hospitals have a unique and extensive expertise when it comes to treating post-deployment chronic pain and its associated a ≥nary session, PAINWeek attendees will learn more about what the VA has to offer and how clinicians in the private sector can improv its by liaising with the VA. lyment Chronic Pain ies" (VHA-02A) Ti-Ann Gibson, MD, and Ilene R. y September 8 :20am 4, Nolita 1 s in Iraq and Afghanistan have had a tre- s impact on US troops and their loved ones. :terans are returning home with physical in- motional difficulties, such as post-traumatic ;D). !012, two specialists in caring for returning M. Gibson, MD, DAAPM, Chief of Spe- ion, Mental Health and Behavioral Sciences mes A. Haley Veterans' Hospital in Tampa, beck MD, Co-Chair of the National Primary rce in St. Petersburg, FL will be presenting Chronic Pain Comorbidities" in a Plenary n will review the prevalence of PTSD and heoretical models that explain the mainte- xlitions, and the challenges faced by pro- s who care for these patients. In addition, k will present Department of Veterans Affairs (VA)/Department of Defense (DOD) VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress, with spe- cial attention to chronic pain. limited scientific evidence supports specific care and treat- ment of PTSD and chronic pain, and this challenges providers to investigate and research potential treatment options. This pre- sentation will focus on the techniques and strategies to address not only PTSD and chronic pain, but other conditions, induding substance dependence and depression," Gibson says. All veterans who have honorably served our country have earned and truly deserve the most comprehensive, individualized, and holistic treatment approaches that can be made available to address their physical and emotional conditions. "We have many patients coming back fr Iraq and Afghanistan with chronic pain probl "Many people assume that all of these patier by the VA; however only 50% of returning foot into a VA. The rest are cared for by outsi many of the patients who do get seen by VA seek care by outside providers, so outside understand the dynamics of what happens • and their comorbidities, even if they are beinc way by the VA." Importantly, 100% of the family member erans are seen by outside providers, and al the VA. Unfortunately, many of the problems veterans also impact their families, Robeck n, important for non-VA providers to understc what is involved in terms of chronic pain in and their families: It can be challenging to treat post-deplo) with comorbidities, and this makes it imperati viders to learn what the VA has learned at returning veterans, Robeck says. "The important thing to keep in mind is t patients are young and resilient and when ately, they respond to treatment. This fad fu importance of learning about their problen what the VA has learned about treating t what resources are available for co-manage she says. Outside providers should know that it i! patients to get care at both the VA and thei dinics. They should also know that if they we tients established at the VA, this does not me will get all of their care at the VA. What it do is that the non-VA provider can then work wi the VA and be able to access the VA service access, Robeck says. "The VA welcomes the partnership or tf outside provider. We understand that some remain with their own family doctor and tF but their own family doctor may end up feel equipped to do everything, so I think there she says. "That family doctor knows the family or that patient for years. We don't want to los. But we also want to make sure that the full available to these patients is understood, an, misconceptions about how to access care a to make sure that our desire to be able to a with the outside provider is well understood, All veterans who have honorably served earned and truly deserve the most compreher and holistic treatment approaches that can be address their physicd and emotional condition EFTA01114716 An early-bird registration fee of $249 is being offered until September 30, 2012. Register NOW at www.painweek.org using code 2013. PAINWEE < EFTA01114717 ms do to manage OK? McCarberg slid that nith OK requires a "professional and sensitive ize any potential embarrassment for patients: patients, especialy older patients, ore uncom- >ut defecation. Many will attempt to self-treat and other medications. ms ore "the current stcn- revernon and trwhnent >erg. Although there are guideines for the use of IcCarberg said that the is to initiate Inzuliteent of stool softeners and recommended that &II- 4 bulk-forming agents in fails to produce a satis- cians can treat with PEG approach doesn't work, try an opioid receptor nettiyhaltrexone. Doses r all forms of treatment. OK, but you have to loses of bowel stimulants rberg said. >f laxative use ridude pain, flatulence, nausea, perianal soreness. Mother important consider- mediations is onset of action. McCarberg said >refer laxative agents that have a shorter onset owel predictability is very important for patients, the faster acting litutilient: Saline laxatives ours to take effect, bowel stimulants take 6-12 Jute and osmotic laxatives can take 1-3 days. ie and other agents for opioid-induced ed issues in the management of OIC during ssion, offering information about the clinical side effects of oral nalxone, methylnaltrexone, iprostone, and other agents. produce symptoms of opioid withdrawaft. Several short-term trials us- ing a range of doses and frequency of administration of oral naloxone in patients with OIC have produced mixed results, wih some producng signifiord increases n stool frequency and improvement in symptoms. Some reversal and analgesia and/or opioid withdrawal symptoms were observed in most of the trials. Methybotirexcne is approved for the annulment of OIC n patients with advanced ilness who are receiving paktive care and have demonstrated nsufficient response to laxative therapy. It is currently available for subcutaneous administration. Peppin said that iuetliylnaltrexone "does not stinulate the bowel, it just returns it to normal," which is why it is important to take the patient's history to know what the patient's normal bowel process and routines are. In one study, nearly half of patients with OC treated with inelnInaltiexone plus laxative therapy achieved rescue-free Icaation after three doses (0.15 mg/kg) ad- ministered over five days. In another study, patients with advanced Less (riducting patients with cancer, ordovascular dis- ease, COPD, and Alzheimer's disease or dementia) who were receiving opioid therapy and who also had OIC were treated with repeated dos- ing of either placebo plus laxatives or inutliyInaltiexone plus laxatives. Nearly half (48%) of patients treated with methybotirexcne demon- strated taxation response within four hours of receiving their first dose. More than half (52%) of patients treated with nr thylnaltrexone dem- onstrated bxation response within four hours after two or more of their first four doses of the medication Peppin noted that the data indcates that "you may have to by up to four doses before seeing a response: In another trial invoking patients with chronic noncancer pain 6n- clucing back pain, cervicaVneck pain, fbromyalgia, hip pain, and osteoarthrilis) who were receiving opioid therapy and who also had OK were treated with either placebo or methylnaltrexone (12 mg QD or QOD). More than one-third (34%) of patients achieved rescue-free bowel movement within four hours after receiving the:- The most common adverse effects associi altrexone use reported by patients in contr abdominal pain (28.5% of patients), flatulent sea (11%). Other adverse effects reported diarrhea, and hyperhidrosis. Another option for OIC, alvimopan, does n brain barrier and demonstrates higher bindinc. ceptors than methylnaltrexone. It is approved I time to upper and lower GI recovery followi surgery: Peppin said that alvimopan is "a hos states (e, only surguuns can write for it). The chloride-channel activator lubiprostor proved for use in chronic idiopathic constip< women. In one 12-week trial of lubiprostone in k noncancer pain and OIC, 26% of patients bowel function. The most common adverse eff nausea, and abdominal pain. According to Peppin, there are currently sets therapies in trials for OIC, induding prucalopr which is an oral PEGylated naloxol conjuga promising results in a short-term trial of park ducing increased frequency of spontaneous b patients during the first week of therapy. Peppin concluded the presentation by reminding • OIC is a significant and ncreasingly commi bents with chronic pain • OIC can compromise a patient's quality of effectiveness of pain management • Laxatives we the main therapy for preventioi of OIC, but their usefulness may be limited b adverse effects • There is not much data on treatment for OK • Peripheral mu-opioid receptor antagonists in reversing analgesia, producing "rapid laxat advanced illness without inducing opioid with central analgesic effects" • There are a number of phcrmacologic agent strafed benefit for the treatment of OIC 'sing, Assessing and Treating Diabetic Gastroparesis f diabetes is increasing worldwide, according to the International Diabetes Federation. In 2007 alone, the United States spent $218 bill ?s, with more than 500/0 of spending related to hospitalization for diabetes-related complications. >ugh, when it comes to diabetes and GI symptoms, "we tend to think of them as 4 symptoms: Michael Bottros, MD, said during his PAINWeek 2012 presentation, and GI Pain." Hs tak focused on the prevalence of GI symptoms associated with sed treatment options as well as possible future research areas to prevent or treat with diabetes. the session was of particular use and interest because of the effect this particular s having in health care as they have repeated hospital admissions. "These patients hospital and they describe upper GI pain," Bottros said. "They have nausea, they so we tend to think that most of the problems... occur n the upper GI tract. That's I the neuronal degeneration and changes that affect the gastrointestinal tract ptiros said that, in this patient population, the prevalence of upper and lower GI ; and there is a considerable amount of turnover in symptoms. Over time, as a pain. So, when you talk about GI pain in relation to diabetes, you're essentially tal gastroperesis: Bottros stressed the importance of performing a thorough differential diagno It will enable the physician to be sure that they have not missed any major prob with these patients, as it will be a diagnosis of exclusion. To make a diagnosis, phy a physical examination and imaging studies to rule out other causes. Scintigrar objectively measure gastric emptying. Although advances have been made in understanding the cellular changes t condition, there are few treatments for diabetic gastroparesis. Pharmacologic tn the condition include antiemetic agents, tricyclic antidepressants, and anticonvuk that opioids should be used sparingly with these patients. "Management of dic needs to focus on assessing the severity of the disorder, correcting nutritional dysft ing symptoms," he said. EFTA01114718 analgesic development can be arduous. Clinicians need to be aware of the necessary guidelines and regulations to tollow so that the c Drehensive, ethical, and offer societal benefit. k 2012 presentation, "Analgesic Development: From Bench to Bedside and Back: :e, MD, highlighted the process of clinical trial design. During the session, Wallace A trial phases, discussed the purpose and role of institutional review boards, and Its of informed patient consent. I clinical trials related to the development of analgesics, Wallace said physicians pf institutional review board guideines and federal regulations as well as ethical arch with human subjects. "One of the biggest hurdles with trial design is the issue Wallace said. hat the history behind institutional review board regulations dates back to Nazi development of the Nuremberg Code. "Individuals should be treated as autono- is a group," Wallace told attendees. "So we do these clinical trials, and we tend ngs in the population, and you forget the individual. You have to look at each 'kat trial: ated that some patient populations are entitled to certain protections that sic clinical trial design and development more difficult. Children, people titles, and prisoners require special consideration.. seeing more and more the pediatric population: Wallace said. -There is actually a movement of should be. We need better analgesics for children. We shouldn't be excluding urdle for clinicians designing clinical trials in pain management is folding partici- part to doing finical trials is patient recruiting,"Wallace told the audience. it's just Physicians should remember that any procedure done solely to determine eligi a part of the research and requires patient consent before the procedure. Wallace also highlighted the guiding principles of the Belmont Report on the e for the protection of participants in clinical trials, which include: • Beneficence: Clinical trials should do no harm, maximize possible benefits anc should be applied at an individual level for participating patients as well as at • Justice: Clinical trials should have fair distribution of the benefits and burdens the participant selection should involve groups that will benefit from the resea nient' populations. Wallace emphasized to attendees that if the risks outweigh the benefits, the trial be approved by the institutional review board. He also stressed the importance c The general accepted principle is that, if it is practicable to get consent, consen and documented. Some of the elements of informed consent indude on explanation of the purpc a description of the procedures, the risks and benefits, the expected duration of j reminder that pcnicipation is voluntary. Wallace's presentation examined the difficulties of designing clinical trials while tance of maintaining participant autonomy and maximizing societal benefit. By £0 Artillit %COY fart* PC'.1111 aa(II 11.1.POS • caltit soisas'Et Bearende On pan Mr 'rename practitioners. -•• claimant Onel Wen 'Ilergnigen casino he loan amides .6 - a 11m 0704.••• ••••••••••••••• 0000 scromi paskor Oran dr net sylltaileiaiin n ~MI •••••••••••••••• adairchinica, empty len••••41 rrt •••••••••••• sernisa snap. or owl mt pierarn, mead pis ores reosSligh (Sr voided ISSIO =NS etaArint afe rani log Mts.. .ad wise =wow S ccrealallen keel_ wave GAO Sp li• •••=11. OAS "SD Si. en •••••••••••••PPOSIONSINELS PIIII~L•••••••••••••• • •• ••••••••••••••• pm% CME/CE Credit Instructions for PAINWeek To obtain your CME/CE certificates, you will be required to complete evaluations for each cour≤ as well as an overall PAINWeek evaluation. These evaluations must be completed online (eg, or smartphone, or in the Cyber Café). When entering a session, please scan the square bar code on your name badge, which will reci attendance for ease of completing evaluations. Each evening of the conference (starting with W you will receive an e-mail notification indicating you have evaluations to complete. Please click the link in the e-mail, and you will be taken to a listing of evaluations for courses in y, have participated. In the event courses are missing or additional courses have been recorded, y the ability to edit the courses you wish to evaluate. To ensure accuracy and streamline issuing of credit for the various disciplines at PAW certificates will be issued electronically after the evaluation system closes. The evaluation system will be available until OCTOBER 31, 2012. You will only be el receive credit for sessions if the respective evaluations are completed by this date. Regrettably we will be unable to grant any extensions or make any exceptions to th SPECIAL NOTE TO PHARMACISTS: Please note: pharmacy learners will not be eligible to receive partial credit. Individual courses in attended in their entirety in order to be eligible to receive credit for those 1.0 or 2.0 credit hour s If you still need to create an NABP e-Profile and obtain an ID number, please visit http://www.n https://store.nabp.net/OA HTML/xxnabpibeGblLogin.jsp. EFTA01114719 ipecialist and I do not want to be. I am a fam- try to care for my patients in as comprehen- 35 possible. While I certainly value and make believe that in many cases a patient's medical fectively satisfied within the boundaries of a dical home. Furthermore, my patients are un- nsured. I am fortunate to have the support of ilitates my patients access to medical supplies its access is limited. Finally, by education and lining, I am as much a humanist as a scientist. pg on specific diseases or injuries, my job is to ny patients medical reality within the context .omote their well-being. iers recently observed that I have a particu- management. It is true that I have made an ?. myself with orthopedic and rheumatologic that I perform a fair number of injections— nd some of my partners' patients—and that I -e comfortable and willing to prescribe pain her narcotic, non-narcotic, disease-modify- Ian some other physicians. My interest in the stems from my belief that I am obligated to t of my ability those processes that threaten eing. To deny these obligations would be no ring their heart disease or diabetes. nomic and demographic factors lead to an .e of endocrine and cardiovascular disease s, these same patients suffer from a high in- Prthermore, my patients have a great deal of c, and addictive comorbidity. Even when my ss to an orthopedist, rheumatologist or pain >nsultants are limited in what interventions d are sometimes hesitant to do so for eco- ico-legal and logistical reasons. My practice eat I treat medical disease to a level at which patients elsewhere would have been referred to specialists. While I believe that my partners and I usually rise to the occa- sion and meet this demand, I fear that this is not often enough the case when it comes to chronic pain. This is detrimental to our patients health and well-being. I, like most of my peers, learned little about the manage- ment of chronic pain in medical school or residency training. I have been actively trying to increase my knowledge in this area through face to face, online, and print resources, as well as interacting with specialists, but I have much yet to learn. I have also recently had the opportunity to join a regional col- laborative focusing on the safe treatment of chronic pain in a primary care setting, but this program focuses on systems and learning how to collaborate with specialists t. goals. I am also working on ways to make these patients in the primary care setting primary care practitioners. Rudolph Virchow—a pioneer in social mi pathology—observed that 'medicine is poli medicine on a grand scale:This is nowhere ≤ tersection of socio-economic need, medical pain. I am neither a pain specialist nor a pair family doctor and a patient advocate. I have in the treatment of chronic pain because i patients need and will not get elsewhere. \A, my patients had pain, it is a fact of their—ar "I, like most of my peers, learned little about the management of chronic pain in medical school or r training. I have been actively trying to increase my knowledge in this area through face to face, online print resources, as well as interacting with specialis I have much yet to learn." processes more than therapeutic strategies. I hope that through resources like PainEDU and attending PAINWeek I can increase my skills, knowledge base, and strategies. I am especially in- terested in increasing my comfort with treating pain in patients with medical, psychiatric, and addictive comorbidities, and in lives, and managing it is not only an ethical many of the social and existential issues that to primary care medicine. I do the best I ca and I am trying to improve my skills in this the help I can get. Congratulations to the 2012 PainEDU.org PAINWeek Scholarship Recipients Visit the PainEDU.org website (www.PainEDU.orq) to learn more about the scholarship and read several of the prize-winning essays. Moshe Usadi, MD (grand prize winner) Charlotte Medical Center - Biddle Point Charlotte, NC Kelly Brewer, LCSW Center for Wellness & Pain Management Kalispell, MT Maria Foglio, RN Ashtabula County Medical Center Ashtabula, OH Maria Maldonado, /V Stamford Hospital Stamford, CT e Dahring, MSN, RN, CP Toni L. Glover, MSN, FNP-BC Rebecca A. Maxson, Pharm EFTA01114720 -y four women of reproductive age suffers from chronic pelvic pain. Pain Clinicians who want to provide comprehensive care to this po id the general diagnosis of chronic pelvic pain and learn more about the subtypes and etiologies of this complex condition. i" (REG-01) :en M. Fitzgerald, MD y September 8 )0am 14, Nolita 3 ions of pelvic pain are wide ranging. The yatively affects quality-of-life, jobs, relation- xtion. Additionally, it puts women at greater p invasive procedures such as laparoscopy 'sic Pain" symposium on Saturday morning 2, Colleen Fitzgerald, MD, will provide an related to clinical management of the condi- tion will be broad in scope," says Fitzgerald. ubtypes and etiologies; risk factors; patient symptoms; differential diagnosis—including ons, imaging, and other workups; treatment; Jerald will also talk about pregnancy-related medical help for pelvic pain are labeled Gagnoses that can be gynecologic, urologic, usculoskeletal, or psychological in nature. epends on the type of specialist seen. The -ien evaluating a woman who presents with tzgerald, is not to assign a general diagnosis Fain. "It should be broken down into a real or, in some cases, more than one diagnosis," uld like to help the audience think beyond gnosis and be more specific in terms of sub- w, because it makes a difference in terms gnosis of pelvic pain can be confusing. For may present as a musculoskeletal response woblem with an internal organ such as the eview treatment options, including medico- -ijections, surgical interventions, and comple- mentary alternative medicine possibilities. She plans on spend- ing a significant amount of time talking about rehabilitation and reasonable therapeutic goals. "Anyone who treats women with chronic pelvic pain knows that these are some of our toughest cases," says Fitzgerald. She attributes this to lack of training and guidelines and to the com- plexity of the problem. "Any time pain persists for more than six months, there is a large psychological overlay," she says. 1 am hopeful that many will attend the session just because pelvic pain is such an unknown; the field is really in its infancy in terms of understanding of causes: "The field is so new in research; we have some guidelines, but we don't have guidelines based on subtype yet," says Fitzger- ald. "Minimal guidelines exist for musculoskeletal causes." Pelvic girdle pain guidelines, such as the "2008 European Guidelines on Pelvic Girdle Pain," may not be applicable for every patient; it really depends on their diagnosis. In 2011, the American Uro- logical Association published guidelines for interstitial cystitis/ bladder pain syndrome. The group suggests general relaxation and stress management as first-line treatment, followed by second-line physical therapy and oral medication (eg, amitrip- tyline, cimetidine, hydroxyzine, or pentosan polysulfate). Fitzgerald contrasts those recommendations with standards- of-care for women with pelvic floor or myofascial pain. For those diagnoses, immediate first-line physical therapy is recom- mended. Since the evidence shows that physical therapy works, practitioners should try to avoid complex medications and po- tential drug-related side effects. To help attendees truly understand how to apply the infor- mation in practice, Fitzgerald will walk through the physical exam, differential diagnosis, and treatment selection using spe- cific patient examples. Fitzgerald will also offer some insight into the future of the field and talk about some recent progress made in understand- ing chronic pelvic pain. She says that "One of the things we are working on in research is to look at not just the organ as the problem—for example, the uterus, bladder, or muscle—but really looking at the whole patient as one who has gone into chronicity as a neurologic pain processing problem." Fitzgerald is part of a team that is using neuroimaging to evaluate the neurobiology of chronic pelvic pain. Their research has showed that women with chronic pelvic pcin actually have a different way of pro- cessing pain compared with the brains of normal healthy control women. "We found changes in the central ner- vous system that suggest the way to address this may be along the neuroaxis," says Fitzgerald. "Maybe the insult was initially to an organ or muscle, but over time, as pain signals get transmitted and perpetuated, the body's abil- how the central nervous system changes as pelvic pain. Colleen Fitzgerald, MD, is an associate p rics and gynecology and female pelvic medi, versity of Chicago and associate professor and rehabilitation at Northwestern Universii of Medicine. She specializes in treating and nancy-related musculoskeletal disease, won pain, and pelvic floor disorders. The important thing evaluating a woman presents with pelvic I is not to assign a ger diagnosis of chronic pain. It should be bri down into a real prir diagnosis or, in SOME more than one diagr EFTA01114721 acnes to rain management xist to treat pain and awareness is growing that non-pharmacologic approaches can be just as effective, if not more so, than pharmac this talk, clinicians will learn about some of the newer non-pharmacologic options for treating pain, and will also learn how combining a sensible medication plan can result in optimal pain relief. :What are the Options?" to N. Turner, DNP, RN-BC, AN y, September 8 loam 4 3, Gracia 7 orner, DNP, RN-BC, PCNS-BC, FAAN, Clinical ecialist, Pediatric Pail Management Oregon l Science University in Podicad, OR, will be pre- What are the Optionsr today at PAINM/eek talking about newer, non-analgesic approaches aid how they can best be combined with tra- I approaches to provide good pain relief. topic and days could be spent on analgesic es. There are two general categories of pain rmacologic and non—pharmacologic—and strong effort recently to get clinicians to use ?,s together. Ire has been a very heavy use of the pharma- d we know that some of the non-pharmaco- an in fad stand on their own. We also know er, you can often use much less medication, less dangerous for the patient," she says. n-pharrnacologic analgesia include physical I, massage, transcutaneous electronic nerve relaxation methods, biofeedback, hypnosis, uided imagery, and virtual reality. "We use a dual reality with kids," Turner says. "You can her mindset." *Ives having the child wear what looks like a .Imet that has a saeen inside. "You put the hel- n watch something. One of the more common on a mountcin, skiing, cod it comes with al of I. Their minds are able to actually go there on be present in that virtual space, and those kids he Publishers of ICAN JOURNAI. Of' QED CARE can block out almost everything going on around them. One of the children's hospitals in Ohio actually uses virtual reality when they are doing bum care, with phenomenal results. Their use of medication in doing that has dedined significantly," Turner says. Turner adds that people are just beginiing to understand the connection between body and mind. "There are tons of knowledge out there around opioids and the traditional pain medicines, and there's getting to be more understanding about some of the ad- juvants, like antidepressants and anticonvulsants. But knowledge about non-pharmacologic methods is still a little behind," she says. "Even something like acupuncture is still considered to be voodoo by some people; however, there is a lot of science now to support that acupuncture is not voodoo. But it's taking time to catch on,"Turner says. In her presentation, Turner says a main goal will be to show her audience how the non-drug and drug modes of analgesia can work well together. She says, "We shouldn't just reach for the med- ications; we need to incorporate those other modalities, as wel." Turner is a pediatric pain specialist. She says that it is harder for adults to adapt to non-pharmacological methods of pain control "because we have forgotten how to play. We dampen our imagination, and we can be very skeptical. Some of these non-drug modalities can be harder to believe in for older peo- ple, whether you are the provider or the patient, and that can be challenging to deal with. I've got it really easy with kids; they are open to anything. Plus, a lot of the non-pharmacological approaches are technologically based, which kids love." Different types of pain respond to different types of analgesia, and this can often be due to the person's past experience of pain, she says. "Pain is a very subjective experience and is based on the individual's life experience with pain and pain treatment, and all of that plays into how they deal with pain and how their body and mind have been programmed. If pain is very fear- based, it will be completely different than pain in someone who doesn't mind getting hurt because they were doing rock climbing or something they really want to do," says Turner. Being able to identify what the patients' stressors are, and helping them manage those stressors, are important aspects of pain management. "It's incredibly complex.. hardly scratch- ing the surface with this talk, because there is so much you can go into. My intent is more to increase awareness and to think uirey lllll meat and Coat In rp., (1111.11111b el Pettunintsb To examine the treatment benefits, cost concerns, and potential insurance coverage strategies for pertuzumab, AJMCs Co-Editor- in-Chief, Michael E. Chernew, PhD, moderated this audio cane) discussion with Lee N. about adding these other modalities of trea to reach for the medications," she says. Nevertheless, Turner will be discussing me adjuvant medications that, when added to trc as the opioids and anti-inflammatories, can he effectively. She will also discuss the role of ow gesics. "Many consumers think that the types you can buy in the drug store without a dock weaker. That is not necessarily the case. Indei "Pain is a very subje, experience and is be the individual's life e with pain and pain ti and all of that plays they deal with pain c their body and mind been programmed." especially if you have inflammation, a non-sti to get that inflammation down: she says. Her talk promises to give lots of food forth "I won't have time for a lot of detail, but awareness about all of the options. Right n4 common buzz word in the pain world, and analgesia. Ifs using multiple methods to get and it encompasses a wide variety of aspect, psycho, social, and spiritual aspects of the p. View the latest issue, which includes original research on the dinical and economic outcomes MANAGED CARE® 7.7 411 EFTA01114722 Rheumatoid Arthritis and Opioids PAI LIV provides frontline pain professionals with resources and infc ns to improve patient care. It's your connection to articles, live cor coverage, resources, and video interviews with key opinion leaders Site Features Include: Social media options available on each page Fresh content added daily A news updates, clinical trials, twitter, interactive polls all available in one easy loca EFTA01114723 na rainative care >otential drug-drug interactions in the pain and palliative care settings requires a proactive approach that relies on the proper tools or le patient's medications and pain care needs. kinetic and ynamic Drug Interactions in dilative Care" (PHM-06) tryn A. Walker, PharmD, BCPS, CPE y, September 8 OOam ≥I 3, Castellano 2 erapy for patients with chronic pain or re- liative care is typically complex and prone : for drug-drug interactions (DDIs). In 2011, icted a retrospective chart review (N = 631 potential drug interactions among its in a palliative care setting. Patients in .n have advanced disease and are receiv- :ations. In the 2011 study, a median of 14 prescribed per patient during the hospital ker, PharmD, BCPS, CPE, will present "Nor- 'harmacodynamic Drug Interactions in Pain e this morning at PAINWeek 2012. During le will review the basic pharmacology of fre- int drug interactions relevant to these popu- y, she will offer guidance on how to monitor interactions. rtant when seeing a pain or palliative care 'ing an issue to rule out whether it is some- e is causing or something that needs to be cer. "Whether to order additional medication iedication is not a straightforward decision." wstanding drug interactions plays a big part ,blems, "I will review the kinds of drug inter- Jers should worry about in these settings." a on DDIs among pain and palliative care substantive imparts a particular challenge to w these patients. at some providers assume that pharmacists )I before prescriptions are filled and admin- "I don't see a lot of providers routinely con- in practice," she says. But, pharmacists may er is aware of the interaction and, practically mot call the doctor for every potential drug to convince people that it is better to think ant DDIs for these populations before pre- ns and to keep in mind the red flag drugs thlems: says Walker. Automated DDI check- it providers are often overwhelmed by the al DDIs flagged by these systems; deciding nically relevant is difficult. .w.e how to check for DDIs using recommend- Walker says that if the potential for DDI exists, "it does not mean that you cannot use the drug, you just have to use it with a plan."This means that if a provider decides to use a medicine with a potential for interaction, he or she needs to know what to monitor and consider dosing and administration schemes that may prevent or minimize interactions. "For example, some interactions are based on timing," she points out. "If you give the drugs at different times, you may avoid an interaction." For many drugs, providers only pay attention to a sub- set of potential interactions or complications related to that drug. One example of this is methadone. "It is a compli- cated drug to use, in general: says Walker. "People worry family's whole plan for end-of-life care." "Palliative care patients are so complex; a to prevent additional burden to these pati says Walker. Drug effects can make a big dif of-life experience. "Our duty is still to do n. days a patient has left, a time that may be t in their life," she says. Kathryn A. Walker, PharmD, BCPS, CPE fessor at the University of Maryland Schoo a palliative care clinical specialist at MedSt< Hospital. She serves on the palliative med and oversees the hospital's pain consult tec "I am hoping to convince people that it is better to think about thi important drug-drug interaction these populations before prescri medications and to keep in minc flag drugs that may cause probli about dosing, administration, and monitoring because they are all complicated." But, Walker cautions that methadone is prone to many drug interactions that are not widely rec- ognized. "Many drug interactions for methadone often go overlooked," she says. Bleeding risk for patients on warfarin is another common concern. "Sometimes providers focus on whether or not to keep a patient on warfarin, but they neglect to consider oth- er things that may impact bleeding," she says. Bleeding risk is one of the most recognized DDIs. Yet, oversedation, confusion, and delirium are common results of DDIs that can be quite scary to families and patients. "Even if a patient is not aware, these symptoms can alarm families, making them worry about whether they can care for the patient at home; it can change a io EFTA01114724 Fly and modem Las Vegas French brasserie with an emphasis on quality ingredients' d traditional fare that is accessible yet provocative, deticious yet chic" Doily spe- dude beef wellington, housemade sausage, a selection of offal, and dayboat torte flambee, steak tartore, roasted beets, and French onion soup. Lunch entrees lame, oxtail benedict, steamed nvicw1c, and roasted lamb sandwich. Diners con -course "Quick Lunch° Dinnerstandouts include the roasted bone marrow and ox- commended9, brick roasted chicken, slow-cooked veal, a classic bouillabaisse, and r. Comme Ca also offers a multi-flighttistronomystasting menu. Diners will also find ers in Las Vegas, handmade pastas, delectable charcuterie and cheese plates, and lice menu. The tipplers among our readers will not want to miss Comme Ca's menu afted classic cocktails shaken with Chef David Myers) modem sensibility" rtion: 00pm (Monday-Thursday) )0pm (Friday-Sunday) OOpm (Friday-Sunday) urger concept" that was "tailor-made for The Cosmopolitan of Las Vegas with :sh, natural and organic ingredients," Holsteins serves custom-crafted specialty Je sausage, and "riffs on traditional American snacks and appetizers, as well as lakes and sides.' Start things off with a high-octane "bam-boozled shake"(one of Bowl,' combines Crunch cereal with Absolut Vanilla) and a selection from wises indude southern fried chicken fingers-n-waffles, buffalo wings, onion rings, fhe "Tiny Buns menu features sliders, crispy pork belly, lobster rolls, and meat- Jaleo Looking to take a break from steaks, pastas, and heavierfaret Then an evening of at Joleo may be just what you're looking for. Choose from a selection of small (sausages and cured meats, including the famous lemon Iberico ham made frc quesos (including several varieties of sheep's and goat's milk cheeses), Eocadillos I es), &auras (chicken, ham, dates—just about everything tastes better fried), and • dishes), and other dossic ta pas. And, as the menu says, Chef Jose Andres lcnows plates, too," induding some of the best paella you will ever hove (in fact, Jale changes throughout the day). Hours of Operation: Sunday-Thursday: 5:00pm-11:00pm Friday-Saturday: 5:00pm-12:OOam Scarpetta Described os a modem Italian restaurant with an earthy-yet-sophisticated cuisine,Scarpetta featuresso satisfying and soulful menu of seasonally-inspired 'tali offerings indude braised short ribs, creamy potent] with mushrooms, and other c course selections include duck & foie gins ravioli, black tonarelli with king crab ar and short rib agnolotti. For the main course (pelt), diners at Scarpetta can chc of northern Italian-inspired dishes, including several fish entrees, Colorado lam duck breast. Scarpetta also offers a delectable °signature tasting menu," as well EFTA01114725 F i sIARRWST PERIOD OF TI E healthy wom n PAIN SEX:HAY American Chronic Pain Association • EDUCATE before,./te fOU MEDICATE? Cadtembnignii lationel Council on Patient Information. and Education Tioe MINE www.talkaboutrsoro National Kidney Foundation rican Academy of SICIAN ASSISTANTS LOMA PAL narnformIng Cate Americal7Aeademy Nurse P scririoners IHEvv iv ALTH CONCERN The management of pain and inflammation—whether acute or chronic—requires proper consideration and attention to individu patients' therapeutic needs and the issues that may affect apprc and effective treatment. Nonsteroidal anti-inflammatory drugs (N whether over the counter (OTC) or by prescription, are some of most commonly used and effective drugs for pain relief, but, like medication, only appropriate use can maximize their therapeu. benefit while minimizing risk 1 2 Unfortunately, prescription and OTC NSAID use often falls out of explicit but simple guidance. The US Food and Drug Admir European Medicines Agency, and numerous medical societies recommend their use at the lowest effective dose for the shor period of time required to provide therapeutic effect.3 Data demonstrate an unequivocal relationship between dose duration of NSAID use and the increased risk of gastrointestin renal, and cardiovascular adverse events.' Only by following g for use, taking patients' clinical needs and risk factors into acc fully understanding what medications patients may be taking, educating them about what NSAIDs are, and facilitating an or dialogue can we maximize the therapeutic benefits of NSAIDE minimize the likelihood of adverse events, and prevent patient: from living in pain due to fear of pain medications. The Alliance for Rational Use of NSAIDs—a public health coati aims to bridge the gap between guidance and clinical practice educating health care professionals and the public at-large to ensure appropriate and safe use of NSAIDs. Please join us in our efforts to ensure appropriate and relief for people with pain. To download educational m; and learn more about the Alliance for Rational Use of visit Alliance for Rational Use of NSAIDs Bill McCarberg, MD Chairman. Alliance for Rational Use of NSAIDs EFTA01114726