EFTA01114703

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 Appraoches to Pain Management ossification and Treatments: Master Class 18 Chronic Pain Problems Among the Medically Underserved 22 Taking a Better Look at Drug Interad in Challenging Populations RECAP Ig the Concept of the Integrated Research into the Intl linic Means Demonstrating Verifiable of Music and Neuroi Icy tion May Unlock Nel rry approach to pain management produces the best outcomes for patients. Clinicians who Treatments this approach must avoid repeating the mistakes of the past and concentrate on providing New data is demonstrating the heali service. of music and suggesting new applica management Schatrnan. "This strategy works because interdisciplinary pain Discrepant Goals in Pain management really does help nearly all stakeholders. The trick is int: Strategies for Balancing learning to demonstrate that: S tny everal presentations during PAINWeek rsician, and Other To ilustrate the challenges pain specialists face, Schatrnan will the ways in which the brain interacts 1 r Needs" (SIS-19) start by tracing the sad decline of interdisciplinary pain manage- , pail. On Tuesday, Michael B. Elko. ment and explaining why a nation that had more than 1,000 Daniel F. Cleary presented on the ways ii Ali ice' E. Schatman, PhD, CPE, DASPE integrated drics in 1998 has fewer than 100 today. can help to aleviate pero. OnWednesday, Reb Integrated pain management clinics initially opened, both spoke about how our brains can be positively y, September 8 inside hospitals and independently, because researchers consis- pail differently. The trend contrwed Friday n 1- 12:10pm tently found that coordinated teams of complementary pain spe- tin by Maio J. Trans, MD, PhD, Director Insi al 4, Mont-Royal Ballroom cialists—usually a physician, a psychologist, a physical therapist, a Brain Science; Department of Neurology, Dc nurse practitioner, and possibly several others—provide the best of Medicine at UCLA. Fis presentation, 'The care for serious chronic pain. Nesomodulation of Pain Responses," provided rdisciplinary pain dinics are an endangered Indeed, the research looked so good that insurers became (by how the human brain processes sound.VVhileT patient numbers keep dwindling, and their their standards) positively enthusiastic about pain clinics, many adze in the management of pain, he has pa Ming, all because financial considerations of- of which responded to the easy money by adding services and studies that have examined the correlation b elfare. padding bills. Worse, the flow of insurance money inspired under- that way it inpads our bodies. ernment would compel hospitals to main- qualified (and occasionally dodgy) practitioners to open their Tramo began by telling the audience tha: rce insurers to cover treatment, says Mi- own clinics to make a quick buck. sic as a healing power dates bock thousand! 1, PhD, CPE, DASPE, Executive Director of Costs rose. Outcomes worsened. Insurers began slashing mythology, Apollo was associated with both r Ethics in Pain Care. Until such mandates reimbursement rates and dropping coverage altogether. Clin- 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 rs to see things from the other anecdotal reports over the centuries about tio ameliorate pain and suffering across a wide rspective and show how he benefits eases, and clinical settings. Yes, it is important when dealing with any kind of anecdotal dc or desired course of action. This some of these recounted experiences have I- study of the correlation of music and healing works because interdisciplinary There is also a growing body of evidence nagement really does help nearly ized-controlled trials demonstrating music's of agement, said Tramo. He went on to discus holders. The trick is learning to ing the pathways by which the brain proces that, basically, our brains have an auditory N rate that. (con over, Schatman has some advice for cli- ics began losing money. Then many of them shut their doors. Experience the expanded Living Bey to revive the integrated pain program, Needlessly, according to Schatman. a "multimedia showcase that presen ore today at PAINWeek 2012 during his "Patients suffered because everyone got greedy," Schatman EFTA01114703 r rain management in America )ents touch on all aspects of the delivery of quality pain care—from the research laboratory to the exam room, from the courtroom ambers across the nation. are starting to worry about prescription drug abuse. He says to spot opioid abuse (or even potential abu that "Pain specialists may think they can't possibly hear any patients overcome any problems that develc ents in Law and Public more about the dangers of opioid abuse, but they haven't selors strike many as a natural fit for pain ilia ications for Pain Care heard anything yet. The issue has finally reached a tipping few insurers cover addiction treatment, whi 3" (SIS-20) point in terms of mainstream media coverage, which means a non-starter, until the Affordable Care Ac coverage will perpetuate itself, probably until the problem is law mandates coverage for addiction treatn mei C. Barnes, JD 'solved" in the public mind. Barnes notes that in the past year or financially feasible opportunities for pain p two, "nearly every major newspaper in America has published to serve patients better (and, potentially, r y, September 8 articles highlighting the fact that prescription opioid overdoses ity), either by hiring their own counselors or I 20pm kill more people each year than car crashes in some states," third-party treatment programs. ≥I 4, Mont-Royal Ballroom along with other now-familiar factoids about the effects of pre- "Most of the people in the audience prob scription opioid abuse and misuse. In the wake of these news to like hearing most of what I have to say," Bc reports, celebrity overdoses continuing to make headlines, and is different. This is a real opportunity for care nth isn't the only thing that will change how sensational media accounts of "addicted babies: Barnes says The greater legal risks faced by dinicians ciafists treat patients in the upcoming year. that "we've already seen an uptick in opioid-related legislation, oids "too freely" is another trend that should •ange of recent legal, financial, and cultural regulation, litigation, and prosecution. And more is coming. attendees, says Barnes. Criminal prosecutions an more to affect standards of care. Probably a lot more: mills and "careless" practitioners are on the nes, JD, managing partner of DCBA Law Another important trend is that pain advocacy groups are California stood trial for second-degree murd Igton, will outline the most relevant recent losing funding and power. Barnes says that concerns about patients overdosed. The local DA argued that n what they could mean for pain clinicians the opioid abuse problem were already deterring donors, even ment that there was nothing she could do tc in his presentation this evening, "Current before this year's public relations nightmare in which investiga- from taking a month's worth of pills in one da d Public Policy: Implications for Pain Care tions shined a spotlight on the close ties between some phar- ful omission, and thus justified the murder chc maceutical companies and advocacy groups. Oddly, these in- Civil suits are dso on the rise, both against dc legislators, regulators, and journalists have vestigations come just as drug makers—worried that efforts to companies. In one case, a family landed survh terested in pain management recently, and curtail opioid abuse will slash overall sales and profits—are cut- workers compensation policy after their relative iuch in the past year to exercise their power ting expenditures on pain advocacy. Pain advocacy groups are opioids for an on-the-job story overdosed. Insu is and their patients. thus losing money from all sides at the very moment when their ginreig to increase restrictions on coverage of c According to Barnes, tamper-resistant op make-or-break moment. This is an issue becc Pain specialists may think they can't studies suggest that new formulations do inc often quite dramatically—financial considerati possibly hear any more about the dangers from the market unless the government mand become tamper resistant. Today's tamper re of opioid abuse, but they haven't heard are more expensive, branded products. Man anything yet. The issue has finally reached pay for them, and most generic drug maker licensing fees to make their products tamper t a tipping point in terms of mainstream Finally, Barnes says that clinicians who pn soon need extra training courses. A couple media coverage. ready mandated new educational prograrr prescribes controlled substances. Many oche potentially influential events is huge: hun- message about the importance of treating pain is falling out ering it, as is the US Congress. •ds each year, certainly: says Barnes. "The of favor. As a consequence, Barnes warns that pain specialists "The first trend — growing public concern sense of them is to look for trends, and I've and advocates could see their ability to influence legislatures, drug abuse — underlies all the others," Barnes nes that people who treat pain really should insurers, and the public decline. bly drive more changes to the industry than a inderstand: Addiction treatment may become a major component of iccording to Barnes, is that more Americans pain care. Because their expertise would, in theory, allow them ued from cover) observe the effects in a controlled environment. Although it was a 4 respond to or get excited by sound. Based small-scale study (seven control babies, seven test babies), Tramo terprets these sounds, our body gives a natural said it prodcued some interesting results. The music "created a lot had the experience of going to the dentist and of stabiTrty and lowered the blood pressure of those infants that it g 11our teeth. How many of us have grabbed was played for: Although only two of the four babies who had clenched our hands to try and decrease the not heard the music stopped crying following the heel stidc, all four rt we are having in our mouths? Any of us who infants who hod been able to hear the music stopped crying. evoking the gate theory for pain. We are alo- 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. medication facts." Roger B. Fillingim, PhD, will discuss sex and hedule today features the four sessions of this Complementary and Alternative Medicine gender differences in pain management and explore possible answers to the question "Do we need pink and blue pills?" Today's Schedule of presentation that focus on pain medicine nurs- Cam-Ann Gibson, MD, and Ilene R. Robeck, MD, will exam- Recommended Cou resented by pain management experts from the ine key topics and challenges in evaluating and treating chronic *ion, the second half of the pharmacotherapy pain in veterans following deployment. for First-time PAINVI lule also includes a trio of sessions on regional Following the morning break, at 11:10am, Lora McGuire, cluing pelvic pain, arm and hand pain, and MS, RN, will explore topics in the management of postoperative Attendees ("phantom tooth pain"). The Special Interest pain, induding preemptive analgesia, special methods of delivery cover topics in pharmacy-based pain services, of pain control, and nonopioid, opioid, and adjuvant analgesics. ferences in pain management, new develop- Srinivas Nalamachu, MD, will discuss the clinical characteris- 7:OOam-8:OOam Kiblic policy, and the influence of various pain tics, assessment diagnosis, and treatment of arm aid hand pain. ',alders on the physician-patient relationship. Michael E. Schatrrtan, PhD, will talk about the evolving Nutrition and Pain: Simple R it 7:00am with Hal S. Blatman, MD, present- influence of non-patient and non-physician stakeholders in pain for Pain-Free Health thition aid pain that will explain the ways in management (insurance, hospital, pharmaceutical, implantable s in our patients' diets actually stop their bod- device, and urine drug testing industries, etc) and explain why Hal S. Blatman, MD nd get in the way of rehabilitation? Blatman these various actors must coalesce into a "mutually cooperative ecific nutrients that will augment healing and/ system' if the suffering of pain patients is to be ameliorated. 7:OOam-8:OOam luce pain? Debra J. Drew, MS, ACNS-BC, At 12:30pm, the schedule features the final two satellite events ie the challenges associated with pain assess- of PAINWeek 2012. The faculty of "Persistent and Breakthrough Pelvic Pain care setting, especially in special populations. Pain: Responsible Opioid Prescribing for Multidimensional Colleen M. Fitzgerald, MD sr, Phenyl!), BCPS, will give a talk on phar- Disorders" will consolidate clinically relevant scientific studies and pharmacokinetic evidence-based guidelines pain and paVia- into practical approaches to 8:10am-9:10am M. Fitzgerald, persistent pain and break- e epidemiology through pain assessment, Analgesia: What are the Op le chronic pelvic responsible opioid prescrib- Helen N. Turner, DNP, RN-BC, PCN s in pathophysi- ing, and repeated re-eval- diagnosis, and uation of patient outcomes. s and treatment "Mission: Pain Management 9:20am-10:20am irome. - The Efficient First Visit (An Speed Dating with Pharmaci ert A. Bonak- IDEAL® Clinical Encounter)" iew the preva- v/il discuss nociceptive, neu- 50 Top Medication Tips at Er nd most con- ropathic, and centrally-me- Mary Lynn McPherson, PharmD, BC 'pies as well as diated chronic pain; the risks ne patient con- and benefits of nonpharma- Kathryn A. Walker, PharmD, BCPS complementary cologic and pharmacologic spies in pain management. Helen N. Turner, treatments for chronic pain; barriers to the optimal use of opioid 11:10am-12:10pm 4S-BC, on the use of multimodal analgesia in analgesics in chronic pain; and methods for screening and risk miti- She will also cover various nonpharmaceuticol gation in the initial and follow-up care of patients with chronic pain. Pre- and Postop Pain Manag to be effective additions to multimodal pain At 2:10pm, Hal S. Blatman, MD, will present "a wide range of Lora McGuire, MS, RN McPherson, Phenyl!), BCPS, will elucidate options for treatment, recovery, and body maintenance fa a healthy cokinetic and phormacodynamic properties of aid pain-free life" for women at midge. Bill Paquin, CEO ofVertical mysterious methadone," covering a range of Health, will explore "the pivotal role that Web aid mobile applications 2:10pm-3:10pm propriate titration strategies as well as how to wi ploy to both increase the efficiency of physician practices and inverted from another drug to methadone? improve patient outcomes" in pain management. Edward S. Lee, Women on the Verge: Sleep, first of three satellite programs scheduled for MD, and Tu A. Ngo, PhD, MPH, will offer a plenary session focus- and Pain at Midlife 'atients and Your Practice: The Role of Drug ing on managing psychiatric comorbidties in chronic pain. Gary W. Hal S. Blatman, MD pin and Risk Management," sponsored by Alere Jay, MD, will present a master class on the differential diagnosis and hire Jennifer E. Bolen, JD, and Jeffery A. management of migrare and tension-type headache. issing practical approaches to incorporating Following the afternoon break, Carol P. Curtiss, MSN, 5:20pm-6:20pm comprehensive chronic pain and risk manage- RN-BC, will discuss key principles involved in balancing effective pain management and saeening for risk of substance misuse and VA Health Care: This is Not theft A. Bonakdar, MD, continues the addiction in persons with pain. Peter A. Foreman, DDS, will Your Father's VA id Alternative Medicine track with "Overview examine the difficult diagnostic and treatment challenges Lucile Burgo-Black, MD, and Stephi Dietary Supplements," during which he will associated with orofacial neuropathies. Mary Lynn McPherson, ace of supplement use in specific pain condi- PharmD, and Kathryn A. Walker, PharmD, will duke it out as MD, MPH EFTA01114705 rTeCT In leOTIenTS IGKIng Up10105 nor 'WV is Pain wescribe opioids should be aware of the symptoms of opioid-induced constipation PAINWeek Administ of the pharmacologic options for managing this condition Redza Ibrahim Advertising, Sponsorships, Satellite Events goid-kiduced Constipation: Considerations to of the most common adverse side effects associated with chronic 'propriate Early Targeted Therapy for Better Pa- opioid therapy,' Rhiner said that most patients with chronic pain Darryl Fossa Art Oiled on and Graphic Design ernes," a CME-accredited session yesterday at will experience OIC to some degree. In fact, OIC is reported in at focused on opioid-induced constipation, its up to 90% of patients with cancer pain and 80% of patients with Steve Porada Corporate Relations and the pharmacologic options that are co- chronic nonmalignant pain. She noted that because chronic pain rrect this condition, presenters Bil McCarberg, patients rarely develop a tolerance to OIC, most of them will re- Debra Weiner Course Development O; and Michelle Rhiner, RN-BC, MSN, provided quire some form of pharmacologic therapy for constipation (up motion that clinicians can apply to daily practice. to 94% of patients with advanced illness who take opioids need Holly Caster Editorial Services e session by talking about the scope of the laxatives, the most commonly used therapy for OIC). induced constipation (OIC). Because prescrip- Untreated or undertreated OIC can compromise pain manage- Michael Shaffer Exhibit Sales', Management most commonly used medications in the pain ment in patients with cancer. Rhiner said that surveys have shown alGative care settings, and because OIC is one that O1C can cause patients to switch to switch to a different opioid, Wanda Tarnoff Finance reduce their opioid dose (either in conjunction with their health care provider, or on their own without telling their provider), or even stop Keith Dempster Mock Relations taking opioids altogether. Patients with OIC also use more health coy resources (they have more hospital admissions and doctor visits, Benjamin R. Metzger, MD Meckal Direction use more home health services, etc). Rhiner said that OK also has a negative impact on quality of life and functionality in patients with Jeffrey Tamoff Operations and Technology chronic noncancer pain, leading to missed work, reduced productiv- ity, and compromised mental and physical health. Charles Brown Program Management Rhiner concluded her portion of the session by briefly review- ing normal colorectal functional processes. She said that bowel Patrick Kelly function is "governed by the enteric brain, an organ comprised of Web and Print Production 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- Pain Management 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 Jack Lapping vke President, Sales colon, but other components of the boweVgastrointestinal system, producing a spectrum of opioid-induced bowel dysfunction. This Steve Porcelli Director of Sales can indude cramping, bloating, decreased appetite, nausea and other symptoms in addition to constipation. She said that many of Cowie Payson Notional Accounts Manager these symptoms are often missed by patients and providers and not attributed to the patient's opioid therapy. Megan O'Connell Soles & Marketing Coordinator Assessing patients for OIC and selecting an appropriate Todd Kunkler Editor management option During his portion of the presentation, McCarberg discussed the Silas Inman Web Editor ients with chronic assessment and management of OK. He said that "there we no good diagnostic criteria for OIC." Although many patients and cli- Stephanie Ogozaly Assistant Web Ecitor experience OIC to nicians focus on stool frequency when discussing O1C, McCarberg said that this might not provide a complete picture because "there John Salesi gree. In fact, OIC is wide variabMty in stool frequency" from patient to patient. Thus, Art Director when assessing patients for O1C, clinicians should also focus on John Burke ed in up to 90% other factors, such as those outlined in the Rome III criteria for Group Director. Ciro,'otion & Production functional constipation. McCarberg reminded the audience that its with cancer these are not necessarily for O1C, just for functional constipation. There are no OIC-specific criteria: MJH & Associates I 80% of patients When assessing patients for O1C, taking a history is important Mike Hennessy to find out the patient's normal boweVdefecation routine in order Choir man /Chief Executive Officer/President mic nonmalignant to establish a baseline. "You have to ask the right questions" about Tighe Blazier Chief Operating Officer :cause chronic pain the patient's previous and current bowel pattern and activity level, their amount of daly fiber and fluid intake, and laxative use prior Neil Glasser, CPA/CFE EFTA01114706 The Rx Guardian itoring gives you the (normalized drug with other clinica indicate that if yo IGHTof Rx Guardian CDs" pain patient falls: • Within -2.0 to higher likeliho you to compare your patient to a database nts clinically assessed for adherence. I • Outside -2.0 to a possibility of Your patient's sta are tracked over t 25 identify patterns. ivardianC,D" with the new Rx Guardian INSIGHT Rel )vative tool to help assess adherence in your chronic pain patients. RECEDENTED SCIENCE • REVOLUTIONARY REPORTING WITH 'X GUARDIAN CD'" RX GUARDIAN INSIGHT REPORT lizes a proprietary, dynamic database of ■ Standard scores are tracked over time )re than one thousand chronic pain patients to help: lically assessed for adherence — Detect patterns of results that could indicate misuse, abuse, or diversion advanced proprietary algorithm creates formalized value based on your patient's — Identify possible drug metabolism is! ysiological variables Identify il licit drug use ur patient's normalized results are compared Identify the absence of medications this proprietary database to help you assess prescribed by you, as well as the presenc ur patient's adherence 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. hypothesize from what I've read about the mechanisms by Patients must also be willing to wait long p which particular compounds increase pain. But case after case start to see any benefits. Blatman cautions and Pain: Simple Rules for demonstrates a major impact. It's common for my patients with foods take weeks to work their way entirely lealth" (CAM-Ol) fibromyalgia to report that pain goes down by as much as half Others take as long as four months, and a when they eliminate all artificial sweeteners," Blatman says. bite of the wrong thing can set the clock bac S. Blatman, MD, DAAPM, ABIHM The insufficiently nutritious category includes many of the can see significant benefits just by cutting be y, September 8 usual suspects: sugar, potatoes, fruit juices, and many other ingredients I advise against, but in most case foods with high glycemic indexes. only come from total abstinence: Blatman sr )0am As for the digestive tract disruptors, the list there includes Many patients, obviously, will sabotage th. '13, Castellano 1 excessive red meat and all wheat products. "The gut plays an ing here and there. Many end up simply at incredibly important role in good health," Blatman says. "The altogether. good flora that are inside of it break down your food so you "Patients obviously have the right to cho can absorb nutrients properly. They also keep your immune sys- but I make it clear to them that they are doir e owes much of its success to a quality that's tem working right which is why patients with autoimmune dis- ing to be in pain. I also make it clear to the I among foodstuffs: an utter inability to sup- eases get particular relief when they start eating a gut-healthy changes come before any unusually large )st forms of life. diet." Blatman says. ) eat it. Mold takes no root inside it. Even Blatman's dietary recommendations are simple. Sticking to "If they follow the diet religiously and the e it a miss. Industrial food makers, who have them, however, can be tricky. Many diets advise patients to cut try what I can to fix that. But if the pain isn't e a mirade ingredient that can cut costs and back on certain foods and ingredients. Blatman tells patients to a patient to eat better, then it certainly isn't k )ave made it one of the most common ingre- avoid them completely, a maxim that requires not only iron self- to risk his or her health by increasing the op discipline but also frequent detective work. Many of the forbid- and again," Blatman says. "This diet isn't an e humans den ingredients are found in a wide variety of foods, and often anything, but it produces very impressive res ,ond all turn up in unexpected places. Blatman remembers one patient and it can do the same for yours." pds" that who "gave up" wheat but saw no health benefits--because she says Hal had no idea about the wheat in her favorite soy sauce. DAAPM, argarine yedients make us will ex- "Eliminate problem foods and ingredients and youi hINWeek wesenta- patients will hurt less. They'll also respond better tc nd Pain: medications—and develop less tolerance—so you cal 'ain-Free prescribe lower doses and stop worrying about the actively Others kicking down your door." 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- EFTA01114708 fective 24-hour pain control' nce-daily oral dosing with e evening meal' )w incidence of dizziness V. id somnolence' 14311-Hil+)+0 :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? Watch how GRALI: nore information, r rin technology works 3e visit Booth 316. z Scan the barcode to view the video at 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, /0-1 • EFTA01114709 antuntunata tiacnue natast tat um %ea...maw at um picouniscin. Dizziness 10.9 2.2 Dose should be adjusted in patents with reduced renal function. GRALISE should not be Somnolence 4.5 2.7 h Gra less than 30 or in patents on hernodialysis. Headache 4.2 4.1 emetic neuralgia. GRALISE therapy should be initiated and nitrated as follows: Lethargy 1.1 0.3 ommended Titration Schedule In addition to the adverse reactions reported in Table 4 above, the followng adverse reactionswith Day 2 Days 3-6 Days 7-10 Days 11-14 Day 15 relationship to GRALISE were reported during the clinical development for the treatment of posthr 600 mg 900 mg 1200 mg 1500 mg 1800 mg 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 S hypertension, joint swelling, memory impairment. nausea, pneumonia, pyrexia, rash, seasonal all ated in patients with demonstrated hypersensitivity to the drug or its ingredients. 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 age Based on Renal Function have been reported n patients receiving other formulator's of marketed gabapentin. These adverse Once-daily dosing 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( GRALISE dose (once daly with evening meal) liver function tests, fever. hyponatrernia. jaundice. movement disorder, Stevens-Jdrison syndrome. 1800 mg followng the abrupt discontinuation of gabapentin immediate release have also been reported. The 600 mg to 1800 mg reported events were anxiety, insomnia, nausea, pain and sweating. GRALISE should not be administered 3digysis GRALISE should not be administered DRUG INTERACTIONS An increase in gabapentin AUC values has been reported when admiristmed with hydrocodone CAUTIONS with morphine. An antacid containing aluminum hydroxide and magnesium hydroxide reduced lt engeable with other gabapentin products because of differing pharmacokinetic profiles that of gabapentin immediate release by about approximately 20%, but by only 5% when gabapentir administration. The safety and effectiveness of GRALISE in patients with epilepsy has not been 2 hours after antacids. It is recommended that GRALISE be taken at least 2 hours following antaci (prior and Ideation Antiepileptic drugs (AEDs). including gabapentn. the active Ogredient in There are no pharmacokinetic interactions between gabapentin and the folowing antiepileptic drui risk of sticidal thoughts or behavior in patients taking these drugs for any indication. Patients carbamazepine. valproic add, phenobarbital. and naproxen. Cimefidne decreased the apparent or ir any ideation should be monitored for the emergence or worsening of depression, suicidal gabapentin by 14% and creatinine clearance by 10%. The effect of gabapentin immediate release nd/or any unusual changes in mood or behavior. 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 ation for Antiepileptic Drugs (including gabapentin, the active ingredient administered as a single tablet, except that the Cin, of norethindrone was increased by 13%. This Jed Analysis considered to be clinically significant. Gabapentil immediate release pharmacokinetic parameters Epilepsy Psychiatric Other Total with and without probenecid, indicating that gabapentin does not undergo renal tubular secretion t that is blocked by probenecid. vents per 1000 patients 1.0 5.7 1.0 2.4 its per 1000 patients 3.4 8.5 1.8 4.3 USE IN SPECIFIC POPULATIONS of events in Pregnancy Pregnancy Category C: Gabapentin has been shown to be fetotoxic in rodents, causi 3in placebo patients 3.5 1.5 1.9 1.8 ossification of several bales in the skull, vertebrae, forelimbs. and hindlimbs. There are no adequati nal drug patients controlled studies in pregnant women. This drug should be used dung pregnancy only if the potent atients 2.4 2.9 0.9 1.9 justifies the potential risk to the fetus. To provide information regarding the effects of in Omexpos' physicians are advised to recommend that pregnant patients taking GRALISE ergot in the North i *dal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials Antiepileptic Drug (NAAED) Pregnancy Registry. This can be done by calling the toll free number 1-I =dittos, but the absolute risk dif ferences were similar for the epilepsy and psychiatric and must be done by patients themselves. Information on the registry can also be found at the webs isiderng prescribing GRALISE must balance the risk of suicidal thoughts or behavior with aedpregnancyregistry.org/. Nursing Mothers Gabapentin is secreted into human milk folowiig less. Epilepsy and many other illnesses for wtich products containng active components A nursed infant could be exposed to a maximum dose of approximately 1 mg/kg/day of gabapentin. gabapenfin. the active component n GRALISE) are prescribed are themselves associated effect an the nursing infant is unknown. GRALISE should be used in women who are nursing only it tarry and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and clearly outweigh the risks. Pediatric Use The safety and effectiveness of GRALISE in the manag I treatment. the prescriber needs to consider whether the emergence of these symptoms postherpetic neuralgia in patients less than 18 years of age has not been studied. Geriatric Use y be related to the illness being treated. Patients, their caregivers. and families should be of patients treated with GRALISE n controlled clinical trials n patients with postherpetic neuralgia contains gabapentin %Mich is also used to treat epilepsy and that AEDs increase the risk of which 63% were 65 years of age or older. The types and incidence of adverse events were simile ehavior and should be advised of the need to be alert for the emergence or worsening of the groups except for peripheral edema, which tended to increase in incidence with age. GRALISE is depression. any unusual changes in mood or behavior, or the emergence of suicidal thoughts. substantially excreted by the kidney. Reductions in GRALISE dose should be made in patients wit bout self-harm. Behaviors of concern should be reported immediately( to healthcare providers. compromised renal function. (see Dosage and Administration]. Hepatic Impairment Because g actin Gabapentin should be withdrawn gradualy. If GRALISE is discontinued. this should metabolized, studies have not been conducted in patients with hepatic impairment. Renal Impai a minimum of 1 week or longer (at the discretion of the prescriber). Tumorigenic Potential is known to be substantially excreted by the kidney. Dosage adjustment is necessary in patients will vivo lifetime carcinogenicity studies, an unexpectedly high incidence of pancreatic acinar function. GRALISE should not be administered in patients with CrCL between 15 and 30 or in patier identified in male. but not female. rats. The cinical significance of this finding is triknoym. hemodmtysis [see Dosage and Admitistrafion]. 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 DRUG ABUSE AND DEPENDENCE fiscontinung the drug. However, no similar patient population untreated with gabapentin was The abuse and dependence potential of GRALISE has not been evaluated n human studies. :kground tumor incidence and recurrence nformaton for comparison. Therefore. the effect OVERDOSAGE in the incidence of new tumors in humans or on the worsenng or recurrence of previously A lethal dose of gabapentin was not identified in mice and rats receivng single oral doses as high as • Morn. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)! Signs of acute toxicity in animals included ataxia. labored breathing. Mosis, sedation, hypoactivity, c °silkily Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), also known Acute oral overdoses of gabapentin immediate release in humans up to 49 grams have been reports nsitivity. has been reported in patients taking antiepileptic drugs, including GRALISE. Some cases, double vision, slurred speech, drowsiness, lethargy and diarrhea were observed. Al patients een fatal or life-threatening. DRESS typically, although not exclusively. presents with fever, supportive care. Gabapentin can be removed by hemocfmtysis. Although hemodialysis has not been !nopathy in association with other organ system involvement. such as hepatitis. nephritis, the few overdose cases reported, it may be ndicated by the patient's cinical state or in patients wit elites. myocardits, or myositis. sometimes resembling an acute viral infection. Eosinophilia renal inpairment. 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, CLINICAL PHARMACOLOGY lough rash is not evident. If such signs or symptoms are present, the patient should be Pharmacokinetics AbsomPtion and Sioavalability Gabapentin is absorbed from the proximal small . GRALISE should be discontinued it an alternative etiology for the signs or symptoms saturable L-amino transport system. Gabapentin bioavaiabifity is not dose proportional: as the dose Laboratory Tests Clinical trial data do not indicate that routine monitoring of clinical bioavailability decreases. When GRALISE (1800 mg once daily) and gabapentin immediate release s necessary fa the sate use of GRALISE. The value of monitoring gabapentin blood times a day) were administered with high fat meals (50% of calories from fat), GRALISE has a bight been established. 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. S ence Because clinical trials are conducted under widely varying conditions, adverse reaction NONCLINICAL TOXICOLOGY itical trials of a drug cannot be directly compared to rates in the cinical trials of another Ca rcinogenesis, Mutagenesis, Impairment of Fertility Gabapentin was given in the diet to rr :t the rates observed in practice. A total of 359 patients with neuropathic pain associated 600. and 2000 mg/kg/day and to rats at 250. 1000. and 2000 mg/kg/day for 2 years. A statistic ilgia have received GRALISE at doses up to 1800 mg daily during placebo-controlled cfrical increase in the incidence of pancreatic acinar cell adenoma and carcinomas was found in male rat . in patients with postherpetic neuralgia, 9.7% of the 359 patients treated with GRALISE high dose; the no-effect dose for the occurrence of carcinomas was 1000 mg/kg/day. Peak plasm its treated with placebo discontinued prematurely due to adverse reactians. In the GRALISE of gabapentn in rats receiving the high dose of 2000 mg/kg/day were more than 10 times higher ost common reason for discontinuation due to adverse reactions was dizziness. Of GRALISE- concentrations in humans receiving 1800 mg per day and in rats receiving 1000 mg/kg/day peal :perienced adverse reactions in clinical studies, the majority of those adverse reactions were concentrations were more than 6.5 times higher than n humans receiving 1800 mg/day. The pant ate'. Table 4 lists all adverse reactions, regardless of causally, occurring n at least 1% of carcinomas did not affect survival, did not metastasize and were not locally invasive. The relevana It pain associated with postherpetic netralgia in the GRALISE group for which the incidence to carcinogenic risk in humans is unclear. Studies designed to investigate the mechanism of gabag placet:0 group 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 nergent Adverse Reaction Incidence in Controlled Trials in Neuropathic Pain gabapentin has the ability to increase cell proliferation in other cell types or in other species, ncbc therpetic Neuralgia (Events in at Least 1% of all GRALISE-Treated Patients and Gabapentn did not demonstrate mutagenic or genotoxic potential in 3 in vitro and 4 in vivo assays. in the Placehn Gronnl 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 ee way headache specialists think about the relationship ops," he says. "So what starts as possibly rand Tension-Type Differential Diagnosis and ant" (MAS-06) T 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 becomes centralized." In addition to reviewing TTHA pathophys ments, Jay will talk about diagnostic criteria spectrum; a straight line with tension-type headaches (BHA) mon TTHAs. Certain types of headaches a y W. Jay, MD, FAAPM, DAAPM at one end and migraines at the other end. Everything in be- reproducible patterns of pericranial muscle tc tween were gradations," says Gary W. Jay, MD, FAAPM. He ger point activation. "Pericranial muscle ten y, September 8 says that the question nowadays is whether they are essentially multiple etiologies, but arises most commont 10pm one headache with two different clinical pictures. myofascial pain syndrome: says Jay. Myofa ≥l 4, Nolita 3 To bring attendees of PAINWeek 2012 up to speed on the along the masseter muscle refer pain to the latest trends in headache medicine, Jay will present a two-hour Trigger points may also elicit autonomic dysf, master class, "Migraine and Tension-Type Headache: NOT Two in the sternodeidomastoid muscle where tri<. Ends of a Spectrum!: on Saturday afternoon. During this com- sociated with lacrimation and redness, in ad prehensive session, he will review the pathophysiologies and "An example of what often happens i≤ varieties of migraine headaches and TTHAs, as well appropri- comes in with temporomandibular joint (TMJ ate treatment options. multiple surgeries for it, and the real problen According to Jay, a major challenge faced by health care the TMJ is being referred by a muscle: says providers who treat patients with headache is recognizing the In cases like this, "It is the job of the physi multiple forms of TTHAs and migraines. "I will review what we what the patient needs: Physicians need to know about what happens in the brain, particularly different origin of the pain. Jay hopes to convey the m forms of migraine headaches: says Jay. the right questions is an important part of tre When many people think about migraines, they still think headaches. "Patients don't know what to tell of the classical migraine headache—typically, a woman with a them what you need to know: he says. one-sided throbbing headache who has pain that is triggered Gary W. Jay is a neurological consultai by sound or light. Jay says that there are "multiple types of mi- in pain and disorders of the central nery graine and they can occur with or without aura." He also notes president-elect of the Eastern Pain Associati. that the nature of aura varies widely, Aura is visual in 80 to 85 tion of the American Pain Society. He is a f percent of patients; patients can have neurological aura that the American Academy of Pain Manageme may elicit speech difficulty or even hemiplegia." Academy of Pain Medicine. He was one of I To successfully address patients' needs and to avoid induc- the American Academy of Pain Medicine in 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 ;sfully address you something is happening, you need to be able to make a decision on whether to meet them at the emergency room ' needs and to as soon as possible: Jay says. In some visual auras, patients may develop transient monocular vision loss. This presents simi- lining treatment- larly to amaurosis fugax, a transient ischemic attack involving a retinal artery. During his session, Jay will discuss strategies for idverse outcomes, confidently and accurately assessing these types of episodes and others. Is need to be able Earlier this year, the American Academy of Neurology and nine the type of the American Headache Society jointly published updated evidence-based guidelines on preventive pharmacologic treat- e their patient is ment for episodic migraine headaches. The guideline authors used stringent evaluation criteria to review existing evidence. 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. are often used to measure patient pain—represents one exam- ting. During her presentation, Drew will provi ple of a challenging pain assessment scenario. Because blood for using the DIRE scale. "Primary care phys anent in Acute Care" (NRS-01) pressure and pulse are not reliable pain indicators, providers very helpful because they are trying to make are often left feeling helpless when trying to manage pain guess on how to help their patients after thi Ira Drew, MS, ACNS-BC, RN-BC in this setting. "There are some observational tools that can of the hospital," she says. be introduced in the ICU that provide a better way to assess Drew cautions that comprehensive pain a y, September 8 whether or not a patient has pain, rather than relying on unreli- time to do properly. "But a good pain asses OOam able variables," she says. "Pain assessment and management time in the end because it will get a patient ≥l 3, Gracia 7 become complex when a patient cannot tell you what they are without adverse events in the beginning," sF feeling. The fad that pain is a totally subjective and complex try to take shortcuts because we are busy c experience amplifies the difficulties: assessment up front it can lead to a lot of For some challenging populations, nurses and physicians redundancy later on and a lot of adverse at. ,ent is gaining traction as an important faun- may believe that pain assessment is not possible. But, Drew tient: She compares assessment with obtair :ment of pain management. In August 2012, asserts that there is no such thing as a patient who cannot be cal history and conducting a thorough ph) ommission issued a Sentinel Event Alert re- assessed. "I would like to debunk that notion: she says. "There "These take time, too; yet if you miss some m of opioids in the hospital setting. This pub- he need to assess and monitor pain as part management program. I think as a pain community we are realizing how li specialists on this topic, Debra Drew, MS, will present "Pain Assessment in Acute Care" those simple, unimodal pain measures are, especic ek 2012. The presentation will provide an ossessment, including tools and approaches patients with chronic pain. I think there is going to cial populations relevant to acute care set- eed to understand the complexities of the evolution where we will be focusing more and mor KI all its facets before they can design a plan omfortable," says Drew. pain and functional status. nize the importance of viewing pain assess- that involves much more than administering iestionnaire to assign a score to the patient's is always something you can consider for each patient; some badly for the patient: ion of good pain management begins with patients are more complex than others, but they can all be Drew also plans on talking about the emi assessment," says Drew. "Is the 0-10 pain in- assessed: Drew will recommend approaches to consider for a of functional status as it relates to pain. In J think of when you think of pain assessment? variety of special populations. ment focused on pain intensity. "I think as a r lot is 'yes,' you may be missing the boat: Drew's presentation will also offer attendees a summary of are realizing how limited those simple, unimc entation, Drew will review the latest findings assessment tools with which many providers are not comfortable are, especially for patients with chronic pain,' pain assessment and discuss some of the or familiar. Along with general background information on these there is going to be an evolution where ted with pain assessment in special popula- tools, she will provide a framework for how and when to use more and more on pain and functional sta children and the elderly), as well as patients them in practice. She will also offer clinical examples throughout some of these earlier tools: The focus will st >us, ventilated, or developmentally delayed. the presentation to supplement the information provided. patients with activities of their daily lives. )atients who can't verbalize their pain, who She will also relate assessment to patient selection for chron- Debra Drew, MS, ACNS-BC, RN-BC is a Is what they are feeling or can't speak," says ic opioid analgesia. The Diagnosis, Intractability, Risk, Efficacy cialist for pain management at the Univei cuss how to optimally assess pain when you (DIRE) scale is an example of a tool that can be used to help Medical Center, Fairview. In addition to he lenging population: practitioners decide whether their patient is a good candidate bilities, she is involved in patient and staff e. pain of patients in the intensive care unit for long-term opioid therapy. It takes into account factors like and institutional committees on pain and pa ologic measures like blood pressure or pulse substance abuse history and characteristics of the home set- tinued from cover) I serve the patients who very much need us, ers compensation policy, and the insurer's primary goal will costs a fortune because he keeps seeking new the stakeholders what's changed and what be returning the patient to productive employment. In such for years on end: an care can do for them: cases, pain clinicians should bombard the insurer with studies Hospitals, likewise, have their own spec very starts with verifiable efficiency. that show how interdisciplinary pain treatment restores patient cerns, which caregivers need to consider bef will never roll again, so Schatman notes that function better than any alternative. open (or, in many cases, reopen) pain clini to provide integrated pain care must learn to If, on the other hand, a patient is injured at home, the medi- no plausible way to argue that hospital p< hey confine their efforts to clinically-validated cal bills will fall to a regular health insurer that will focus pri- become directly profitable again, but he d ted at reasonable costs. marily on minimizing long-term costs. In such cases, caregiv- pain clinics could generate indirect profits clinicians can responsibly offer payers far bet- ers should bombard the insurer with studies that show cost able hospital employees from their existing EFTA01114712 ation in this area of pharmacology is necessary for improving outcomes and maximizing treatment options. he conference room where Thomas 8. Gregory, PharmD, lady because metabolic enzymes in our bodies T 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 Muscle mass must also be considered due to patterns. Comorbidities must be taken into co renal dysfunction, for instance, can cause seric the breakfast spread just to be in here early this morning." (Luckily patients on chronic opioid therapy. The cost of there were still leftover urns of coffee and trays of croissants for be a factor, and not just in terms of the pat those who waited for the session to end to grab breakfast.) about whether the medication allows the patir If there is one thing that serves as a common denominator for mal daily routine," said Gregory. all PAINWeek 2012 attendees—which includes physicians, phar- As far as medication pharmocokinetics is r macists, nurse practitioners, physician assistants, and even social sorption rate of opioids must be considered workers—it is a unified interest in the dosing strategies, side effects, istered transdermally via a patch, Gregory s and patient and medication variables associated with opioids. will vary depending on age. During this part That is exactly what Gregory spoke about during his engaging one of the audience members asked Gregor presentation. to be the best method for disposing of opioic Beginning with the patient and medication variables, Gregory said that although there is no one correct a started by discussing the importance of knowing the distinction rules and regulations governing disposal vary between opioids that are pure agonists, which have no ceiling ef- he thinks that patches should be absorbed fect and are not problematic in terms of increasing dosage (until and that the diffused drug should then be side effects become intolerable) and those that are partial ago- drain. He added that attendees should mak• nists, which can have a ceiling effect (ie, once a plateau dose is out what their states' rules and regulations achieved, there will be no further analgesic activity). they were abiding by the law. Gregory also touched on many different aspects of patient vari- The discussion segued into various opioid cic ables in opioid therapy. He said that clinicians who are prescribing or administering opioids must consider a patient's age, particu- (contin, 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 EFTA01114713 )nge in patient condition, or even health care dtiondly bioequivalence between routes of administration must be iregory reminded the audience that when they considered before beginning the 5-step opioid conversion process: Gregory conveyed a significant amount of nge a patient's dosage formulation or route of Lion about opioids during his session, and le• necessary to review opioid equianalgesic dos- 1. Gbbally assess pain complaint. number of excellent instructions, resources, an : said should "serve as a guide and not a gos- 2. Determine total daily dose of current °plaid. motion on dosing, conversion charts, and man s cross tolerance is not universal in nature. He 3. Decide which opioid analgesic will be used for the new agent of specific scenarios, such as what health care and consult established conversion tables to determine new )e aware of when switching patients from one dose. 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. In fact, Bonakdar says that discussions about CAM happen entary and Alternative so infrequently that the National Institutes of Health has de- 3verview and Effective veloped a packet to guide doctors and patients on how to n Pain" (CAM-02) 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 ert Bonakdar, MD providers lack of motivation to use CAM. The presentation will ry, September 8 include useful information about a variety of CAM interven- 10am tions that are backed by strong evidence. "I will go into a host of treatments and help providers know what to consider, and more al 3, Castellana 1 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. :ult to define because it consists of diverse The inclusion of CAM in practice guidelines represents ad- ns and it is constantly changing. Many vancement in the fields of CAM and pain management.At the oaches have gained attention as safe and same time, this development has actually posed some barri- les or adjuncts to pharmacologic interven- ers to implementation because not all of the guidelines are in agement of chronic pain. With increasing agreement. "Part of my talk will be about how to arrive at a of CAM and integrative medicine is men- bottom line you are comfortable suggesting to your patient: sed in evidence-based guidelines. Despite says Bonakdar. "Along with practical advice for how to use the ations, many practitioners remain hesitant guidelines, I will talk about who is a good candidate for CAM: into their own practice or to discuss CAM Providers also need to be updated and aware of impor- tant safety issues related to CAM usage. When using CAM ; MD, will present "Complementary and Alter- approaches that are backed by trial evidence, for example, eerview and Effective Therapies in Pain"on Sat- Bonakdar recommends using the standardized version used in Meek 2012. His presentation will review exist- the trial. He will review this and other safety considerations that In many cases, physi imendations for CAM use and offer guidance must be kept in mind during patient selection and follow up. nt these recommendations in practice. "The key Financial considerations may play a role in whether patients and are learning about C engage patients and discuss CAM approaches providers pursue CAM therapies. if you ask most physicians who most out of them in conjunction with everything have not considered bing through their office whether any of approaches on the fl lending: says Bonakdar. these interventions would be covered, they would think no," says ration of CAM as part of mainstream treat- Bonakdar. "My clink tries to put everything through insurance and especially treatment ,v+ paradigm for many physicians. in many we have found reasonable reimbursement." He wil discuss reim- may not have learns are learning these approaches on the fly, bursement and other financial factors that may be posing a barrier flts we may not have learned about in to integrating CAM recommendations into finical practice. about in medical sch sidency, or fellowship: says Bonakdar. This In terms of cost-effectiveness of CAM, not many analyses ncies and fellowships are starting to incor- have been performed. Bonakdar says, "There can be cost sav- residency, or fellows iodologies into their training programs. In ings, but the care needs to be coordinated: Cost savings will ts Bonakdar, "Physicians need to get more not be achieved if a patient goes to a CAM provider three Physicians need to gi :AM, especially if the evidence is saying we times a week indefinitely. "If a patient is self-choosing a CAM therapy, it may not be cost-effective because there is no over- comfortable with CA EFTA01114714 and BTP, and multidisciplinary approaches tha Cir EVENTS Persistent and Breakthrough Pain: Responsible range of biopsychosocial causes and sympton Opioid Prescribing for Multidimensional Disorders Time: Saturday, September 8, 12:30-2:00pm persistent pain and BTP. nts and Your Practice: The Role of Room: Level 4, Gracia I Chronic Pain and Risk Management Mission: Pain Management —The CE/CME certified: YES eptember 8, 8:25-9:55an Meal served: YES (lunch) First Visit (An IDEAL® Clinical En era Ballroom Preregistration required: N/A Time: Saturday, September 8, 12:30-2:00p I: NO Supported by an educational grant from Teva Pharmaceutical Room: Level 4, Gracia 1-4 3 (breakfast) Industries Ltd. CE/CME certified: YES squired: NO This activity was designed to "consolidate clinically relevant Meal served: YES (lunch) re Toxicology scientific studies and evidence-based guidelines into practical Preregistration required: N/A otion, Jennifer E. Bolen, JD, and Jeffery A. approaches to persisten pain and BTP assessment, responsible Supported by educational grants provided by Gudin, MD, will discuss practical opioid prescribing, and repeated and Mallinckrodt, the pharmaceuticals bui approaches to incorporating drug re-evaluation of patient outcomes.°The The faculty will discuss the underlying pothopl screening into comprehensive chronic faculty of Michael J. Brennan, MD; Jeffrey transmission mechanisms associated with noci pain and risk management plans. A. Gudin, MD; Douglas C. Schottenstein, pothic, and centrally-mediated chronic pain; c They will also address key topics in MD; and David M. Simpson, MD, MAN, five risks and benefits of nonphormocologic ai legal and regulatory considerations will discuss the diagnostic criteria for treatment options for chronic pain; explain hog for drug testing frequency, docu- BTP pain and clinical characteristics of barriers to the optimal use of opioid analgesic mentation, and the interpretation of its subtypes, strategies for indMdual- chronic pain; and assess methods for screenin results. izing opioid therapy for persistent pain lion in the initial and follow-up care of patient Vaillulballialifies•••••••••••••••• •41 .•••••• •••••• 4 •••••••••••••••• ••• •••••••••• *•••••••• OM1 ra • •imi..1•1 aso I •••••••••••••••adabad.aiefte wave creshe be•••••• •1•Isa I •••••••••••%•••• lt••••••••Mie....0.. an bliai ••••••••••••••••••••••••., tot mo, list adelli•••••••••••••••••••••••••••••••••••11amn• 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. (VA)/Department of Defense (DOD) VA/DOD Clinical Practice "We have many patients coming back fr lyment Chronic Pain Guideline for Management of Post-Traumatic Stress, with spe- Iraq and Afghanistan with chronic pain probl ies" (VHA-02A) cial attention to chronic pain. "Many people assume that all of these patier limited scientific evidence supports specific care and treat- by the VA; however only 50% of returning Ti-Ann Gibson, MD, and Ilene R. ment of PTSD and chronic pain, and this challenges providers to foot into a VA. The rest are cared for by outsi investigate and research potential treatment options. This pre- many of the patients who do get seen by VA sentation will focus on the techniques and strategies to address seek care by outside providers, so outside y September 8 not only PTSD and chronic pain, but other conditions, induding understand the dynamics of what happens • :20am substance dependence and depression," Gibson says. and their comorbidities, even if they are beinc 4, Nolita 1 way by the VA." Importantly, 100% of the family member erans are seen by outside providers, and al s in Iraq and Afghanistan have had a tre- the VA. Unfortunately, many of the problems s impact on US troops and their loved ones. All veterans who have veterans also impact their families, Robeck n, :terans are returning home with physical in- honorably served our important for non-VA providers to understc motional difficulties, such as post-traumatic what is involved in terms of chronic pain in ;D). country have earned and their families: !012, two specialists in caring for returning It can be challenging to treat post-deplo) M. Gibson, MD, DAAPM, Chief of Spe- and truly deserve the with comorbidities, and this makes it imperati ion, Mental Health and Behavioral Sciences viders to learn what the VA has learned at mes A. Haley Veterans' Hospital in Tampa, most comprehensive, returning veterans, Robeck says. beck MD, Co-Chair of the National Primary "The important thing to keep in mind is t rce in St. Petersburg, FL will be presenting individualized, and holistic patients are young and resilient and when Chronic Pain Comorbidities" in a Plenary ately, they respond to treatment. This fad fu treatment approaches that importance of learning about their problen n will review the prevalence of PTSD and can be made available to what the VA has learned about treating t heoretical models that explain the mainte- what resources are available for co-manage xlitions, and the challenges faced by pro- address their physical and she says. s who care for these patients. In addition, Outside providers should know that it i! k will present Department of Veterans Affairs emotional conditions. 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 produce symptoms of opioid withdrawaft. Several short-term trials us- The most common adverse effects associi nith OK requires a "professional and sensitive ing a range of doses and frequency of administration of oral naloxone altrexone use reported by patients in contr ize any potential embarrassment for patients: in patients with OIC have produced mixed results, wih some producng abdominal pain (28.5% of patients), flatulent patients, especialy older patients, ore uncom- signifiord increases n stool frequency and improvement in symptoms. sea (11%). Other adverse effects reported >ut defecation. Many will attempt to self-treat Some reversal and analgesia and/or opioid withdrawal symptoms diarrhea, and hyperhidrosis. and other medications. were observed in most of the trials. Another option for OIC, alvimopan, does n ms ore "the current stcn- Methybotirexcne is approved for the brain barrier and demonstrates higher bindinc. revernon and trwhnent annulment of OICn patients with advanced ceptors than methylnaltrexone. It is approved I >erg. Although there are ilness who are receiving paktive care and time to upper and lower GI recovery followi guideines for the use of have demonstrated nsufficient response to surgery: Peppin said that alvimopan is "a hos IcCarberg said that the laxative therapy. It is currently available for states (e, only surguuns can write for it). is to initiate Inzuliteent subcutaneous administration. Peppin said The chloride-channel activator lubiprostor of stool softeners and that iuetliylnaltrexone "does not stinulate proved for use in chronic idiopathic constip< recommended that &II- the bowel, it just returns it to normal," which women. In one 12-week trial of lubiprostone in 4 bulk-forming agents in is why it is important to take the patient's k noncancer pain and OIC, 26% of patients fails to produce a satis- history to know what the patient's normal bowel function. The most common adverse eff cians can treat with PEG bowel process and routines are. nausea, and abdominal pain. approach doesn't work, In one study, nearly half of patients According to Peppin, there are currently sets try an opioid receptor with OC treated with inelnInaltiexone therapies in trials for OIC, induding prucalopr nettiyhaltrexone. Doses plus laxative therapy achieved rescue-free which is an oral PEGylated naloxol conjuga r all forms of treatment. Icaation after three doses (0.15 mg/kg) ad- promising results in a short-term trial of park OK, but you have to ministered over five days. In another study, ducing increased frequency of spontaneous b loses of bowel stimulants patients with advanced Less (riducting patients during the first week of therapy. rberg said. patients with cancer, ordovascular dis- >f laxative use ridude pain, flatulence, nausea, ease, COPD, and Alzheimer's disease or dementia) who were receiving Peppin concluded the presentation by reminding perianal soreness. Mother important consider- opioid therapy and who also had OIC were treated with repeated dos- • OIC is a significant and ncreasingly commi mediations is onset of action. McCarberg said ing of either placebo plus laxatives or inutliyInaltiexone plus laxatives. bents with chronic pain >refer laxative agents that have a shorter onset Nearly half (48%) of patients treated with methybotirexcne demon- • OIC can compromise a patient's quality of owel predictability is very important for patients, strated taxation response within four hours of receiving their first dose. effectiveness of pain management the faster acting litutilient: Saline laxatives More than half (52%) of patients treated with nr thylnaltrexone dem- • Laxatives we the main therapy for preventioi ours to take effect, bowel stimulants take 6-12 onstrated bxation response within four hours after two or more of their of OIC, but their usefulness may be limited b Jute and osmotic laxatives can take 1-3 days. first four doses of the medication Peppin noted that the data indcates adverse effects that "you may have to by up to four doses before seeing a response: • There is not much data on treatment for OK ie and other agents for opioid-induced In another trial invoking patients with chronic noncancer pain 6n- • Peripheral mu-opioid receptor antagonists in clucing back pain, cervicaVneck pain, fbromyalgia, hip pain, and reversing analgesia, producing "rapid laxat ed issues in the management of OIC during osteoarthrilis) who were receiving opioid therapy and who also advanced illness without inducing opioid with ssion, offering information about the clinical had OK were treated with either placebo or methylnaltrexone (12 central analgesic effects" side effects of oral nalxone, methylnaltrexone, mg QD or QOD). More than one-third (34%) of patients achieved • There are a number of phcrmacologic agent iprostone, and other agents. rescue-free bowel movement within four hours after receiving the:- 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 pain. So, when you talk about GI pain in relation to diabetes, you're essentially tal 4 symptoms: Michael Bottros, MD, said during his PAINWeek 2012 presentation, gastroperesis: and GI Pain." Hs tak focused on the prevalence of GI symptoms associated with Bottros stressed the importance of performing a thorough differential diagno sed treatment options as well as possible future research areas to prevent or treat It will enable the physician to be sure that they have not missed any major prob with diabetes. with these patients, as it will be a diagnosis of exclusion. To make a diagnosis, phy the session was of particular use and interest because of the effect this particular a physical examination and imaging studies to rule out other causes. Scintigrar s having in health care as they have repeated hospital admissions. "These patients objectively measure gastric emptying. hospital and they describe upper GI pain," Bottros said. "They have nausea, they Although advances have been made in understanding the cellular changes t so we tend to think that most of the problems... occur n the upper GI tract. That's condition, there are few treatments for diabetic gastroparesis. Pharmacologic tn the condition include antiemetic agents, tricyclic antidepressants, and anticonvuk I the neuronal degeneration and changes that affect the gastrointestinal tract that opioids should be used sparingly with these patients. "Management of dic ptiros said that, in this patient population, the prevalence of upper and lower GI needs to focus on assessing the severity of the disorder, correcting nutritional dysft ; and there is a considerable amount of turnover in symptoms. Over time, as a 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: Physicians should remember that any procedure done solely to determine eligi :e, MD, highlighted the process of clinical trial design. During the session, Wallace a part of the research and requires patient consent before the procedure. A trial phases, discussed the purpose and role of institutional review boards, and Wallace also highlighted the guiding principles of the Belmont Report on the e Its of informed patient consent. for the protection of participants in clinical trials, which include: I clinical trials related to the development of analgesics, Wallace said physicians pf institutional review board guideines and federal regulations as well as ethical • Beneficence: Clinical trials should do no harm, maximize possible benefits anc arch with human subjects. "One of the biggest hurdles with trial design is the issue should be applied at an individual level for participating patients as well as at Wallace said. hat the history behind institutional review board regulations dates back to Nazi • Justice: Clinical trials should have fair distribution of the benefits and burdens development of the Nuremberg Code. "Individuals should be treated as autono- the participant selection should involve groups that will benefit from the resea is a group," Wallace told attendees. "So we do these clinical trials, and we tend nient' populations. ngs in the population, and you forget the individual. You have to look at each 'kat trial: Wallace emphasized to attendees that if the risks outweigh the benefits, the trial ated that some patient populations are entitled to certain protections that be approved by the institutional review board. He also stressed the importance c sic clinical trial design and development more difficult. Children, people The general accepted principle is that, if it is practicable to get consent, consen titles, and prisoners require special consideration.. seeing more and more and documented. the pediatric population: Wallace said. -There is actually a movement of Some of the elements of informed consent indude on explanation of the purpc should be. We need better analgesics for children. We shouldn't be excluding a description of the procedures, the risks and benefits, the expected duration of j reminder that pcnicipation is voluntary. urdle for clinicians designing clinical trials in pain management is folding partici- Wallace's presentation examined the difficulties of designing clinical trials while part to doing finical trials is patient recruiting,"Wallace told the audience. it's just tance of maintaining participant autonomy and maximizing societal benefit. By £0 CME/CE Credit Instructions for PAINWeek Artillit %COY fart* PC'.1111 aa(II 11.1.POS 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 • soisas'Et 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. caltit Bearende On pan Mr 'rename practitioners. Please click the link in the e-mail, and you will be taken to a listing of evaluations for courses in y, -•• claimant Onel Wen afe have participated. In the event courses are missing or additional courses have been recorded, y 'Ilergnigen casino he loan amides .6 rani log - a 11m 0704.••• ••••••••••••••• scromi paskor Oran dr net 0000 Mts.. wise the ability to edit the courses you wish to evaluate. =wow sylltaileiaiin n ~MI •••••••••••••••• adairchinica, empty .ad S To ensure accuracy and streamline issuing of credit for the various disciplines at PAW len••••41rrt •••••••••••• sernisa snap. or owl mt pierarn, mead pis ores voided ISSIO reosSligh (Sr =NS etaArint 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 ccrealallen SPECIAL NOTE TO PHARMACISTS: Please note: pharmacy learners will not be eligible to receive partial credit. Individual courses in keel_ attended in their entirety in order to be eligible to receive credit for those 1.0 or 2.0 credit hour s wave GAO If you still need to create an NABP e-Profile and obtain an ID number, please visit http://www.n Sp li• •••=11. OAS "SD Si. en •••••••••••••PPOSIONSINELS PIIII~L•••••••••••••• ••••••••••••••• pm% • •• https://store.nabp.net/OA HTML/xxnabpibeGblLogin.jsp. EFTA01114719 ipecialist and I do not want to be. I am a fam- patients elsewhere would have been referred to specialists. learning how to collaborate with specialists t. try to care for my patients in as comprehen- While I believe that my partners and I usually rise to the occa- goals. I am also working on ways to make 35 possible. While I certainly value and make sion and meet this demand, I fear that this is not often enough these patients in the primary care setting believe that in many cases a patient's medical the case when it comes to chronic pain. This is detrimental to primary care practitioners. fectively satisfied within the boundaries of a our patients health and well-being. Rudolph Virchow—a pioneer in social mi dical home. Furthermore, my patients are un- I, like most of my peers, learned little about the manage- pathology—observed that 'medicine is poli nsured. I am fortunate to have the support of ment of chronic pain in medical school or residency training. medicine on a grand scale:This is nowhere ≤ ilitates my patients access to medical supplies I have been actively trying to increase my knowledge in this tersection of socio-economic need, medical its access is limited. Finally, by education and area through face to face, online, and print resources, as well pain. I am neither a pain specialist nor a pair lining, I am as much a humanist as a scientist. as interacting with specialists, but I have much yet to learn. I family doctor and a patient advocate. I have pg on specific diseases or injuries, my job is to have also recently had the opportunity to join a regional col- in the treatment of chronic pain because i ny patients medical reality within the context laborative focusing on the safe treatment of chronic pain in a patients need and will not get elsewhere. \A, .omote their well-being. primary care setting, but this program focuses on systems and my patients had pain, it is a fact of their—ar 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 "I, like most of my peers, learned little about the -e comfortable and willing to prescribe pain her narcotic, non-narcotic, disease-modify- management of chronic pain in medical school or r Ian some other physicians. My interest in the stems from my belief that I am obligated to training. I have been actively trying to increase my t of my ability those processes that threaten knowledge in this area through face to face, online eing. To deny these obligations would be no ring their heart disease or diabetes. print resources, as well as interacting with specialis nomic and demographic factors lead to an .e of endocrine and cardiovascular disease I have much yet to learn." 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 processes more than therapeutic strategies. I hope that through lives, and managing it is not only an ethical >nsultants are limited in what interventions resources like PainEDU and attending PAINWeek I can increase many of the social and existential issues that d are sometimes hesitant to do so for eco- my skills, knowledge base, and strategies. I am especially in- to primary care medicine. I do the best I ca ico-legal and logistical reasons. My practice terested in increasing my comfort with treating pain in patients and I am trying to improve my skills in this eat I treat medical disease to a level at which with medical, psychiatric, and addictive comorbidities, and in 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 Maria Foglio, RN Maria Maldonado, /V Center for Wellness & Pain Management Ashtabula County Medical Center Stamford Hospital Kalispell, MT Ashtabula, OH 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. mentary alternative medicine possibilities. She plans on spend- how the central nervous system changes as i" (REG-01) ing a significant amount of time talking about rehabilitation pelvic pain. and reasonable therapeutic goals. Colleen Fitzgerald, MD, is an associate p :en M. Fitzgerald, MD "Anyone who treats women with chronic pelvic pain knows rics and gynecology and female pelvic medi, that these are some of our toughest cases," says Fitzgerald. She versity of Chicago and associate professor y September 8 attributes this to lack of training and guidelines and to the com- and rehabilitation at Northwestern Universii )0am plexity of the problem. "Any time pain persists for more than six of Medicine. She specializes in treating and 14, Nolita 3 months, there is a large psychological overlay," she says. 1 am nancy-related musculoskeletal disease, won hopeful that many will attend the session just because pelvic pain, and pelvic floor disorders. pain is such an unknown; the field is really in its infancy in terms ions of pelvic pain are wide ranging. The of understanding of causes: yatively affects quality-of-life, jobs, relation- "The field is so new in research; we have some guidelines, but xtion. Additionally, it puts women at greater we don't have guidelines based on subtype yet," says Fitzger- p invasive procedures such as laparoscopy ald. "Minimal guidelines exist for musculoskeletal causes." Pelvic girdle pain guidelines, such as the "2008 European Guidelines 'sic Pain" symposium on Saturday morning on Pelvic Girdle Pain," may not be applicable for every patient; 2, Colleen Fitzgerald, MD, will provide an it really depends on their diagnosis. In 2011, the American Uro- related to clinical management of the condi- logical Association published guidelines for interstitial cystitis/ tion will be broad in scope," says Fitzgerald. bladder pain syndrome. The group suggests general relaxation ubtypes and etiologies; risk factors; patient and stress management as first-line treatment, followed by symptoms; differential diagnosis—including second-line physical therapy and oral medication (eg, amitrip- ons, imaging, and other workups; treatment; tyline, cimetidine, hydroxyzine, or pentosan polysulfate). Jerald will also talk about pregnancy-related Fitzgerald contrasts those recommendations with standards- of-care for women with pelvic floor or myofascial pain. For medical help for pelvic pain are labeled those diagnoses, immediate first-line physical therapy is recom- Gagnoses that can be gynecologic, urologic, mended. Since the evidence shows that physical therapy works, usculoskeletal, or psychological in nature. practitioners should try to avoid complex medications and po- epends on the type of specialist seen. The tential drug-related side effects. -ien evaluating a woman who presents with To help attendees truly understand how to apply the infor- tzgerald, is not to assign a general diagnosis mation in practice, Fitzgerald will walk through the physical Fain. "It should be broken down into a real exam, differential diagnosis, and treatment selection using spe- or, in some cases, more than one diagnosis," cific patient examples. uld like to help the audience think beyond Fitzgerald will also offer some insight into the future of the gnosis and be more specific in terms of sub- field and talk about some recent progress made in understand- w, because it makes a difference in terms ing chronic pelvic pain. She says that "One of the things we gnosis of pelvic pain can be confusing. For are working on in research is to look at not just the organ as may present as a musculoskeletal response the problem—for example, the uterus, bladder, or muscle—but woblem with an internal organ such as the really looking at the whole patient as one who has gone into chronicity as a neurologic pain processing problem." The important thing eview treatment options, including medico- Fitzgerald is part of a team that is using neuroimaging to -ijections, surgical interventions, and comple- evaluate the neurobiology of chronic pelvic pain. Their research evaluating a woman has showed that women with chronic pelvic pcin actually presents with pelvic I have a different way of pro- cessing pain compared with is not to assign a ger the brains of normal healthy control women. "We found diagnosis of chronic changes in the central ner- vous system that suggest the pain. It should be bri way to address this may be down into a real prir along the neuroaxis," says Fitzgerald. "Maybe the insult diagnosis or, in SOME was initially to an organ or muscle, but over time, as pain more than one diagr signals get transmitted and perpetuated, the body's abil- 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. can block out almost everything going on around them. One of about adding these other modalities of trea :What are the Options?" the children's hospitals in Ohio actually uses virtual reality when to reach for the medications," she says. they are doing bum care, with phenomenal results. Their use of Nevertheless, Turner will be discussing me medication in doing that has dedined significantly," Turner says. adjuvant medications that, when added to trc to N. Turner, DNP, RN-BC, Turner adds that people are just beginiing to understand the as the opioids and anti-inflammatories, can he AN connection between body and mind. "There are tons of knowledge effectively. She will also discuss the role of ow out there around opioids and the traditional pain medicines, and gesics. "Many consumers think that the types y, September 8 there's getting to be more understanding about some of the ad- you can buy in the drug store without a dock loam juvants, like antidepressants and anticonvulsants. But knowledge weaker. That is not necessarily the case. Indei 4 3, Gracia 7 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 orner, DNP, RN-BC, PCNS-BC, FAAN, Clinical to support that acupuncture is not voodoo. But it's taking time ecialist, Pediatric Pail Management Oregon to catch on,"Turner says. l Science University in Podicad, OR, will be pre- In her presentation, Turner says a main goal will be to show her "Pain is a very subje, What are the Optionsr today at PAINM/eek talking about newer, non-analgesic approaches audience how the non-drug and drug modes of analgesia can work well together. She says, "We shouldn't just reach for the med- experience and is be aid how they can best be combined with tra- ications; we need to incorporate those other modalities, as wel." the individual's life e I approaches to provide good pain relief. Turner is a pediatric pain specialist. She says that it is harder topic and days could be spent on analgesic for adults to adapt to non-pharmacological methods of pain with pain and pain ti es. There are two general categories of pain control "because we have forgotten how to play. We dampen rmacologic and non—pharmacologic—and our imagination, and we can be very skeptical. Some of these and all of that plays strong effort recently to get clinicians to use non-drug modalities can be harder to believe in for older peo- ?,s together. ple, whether you are the provider or the patient, and that can they deal with pain c Ire has been a very heavy use of the pharma- be challenging to deal with. I've got it really easy with kids; they d we know that some of the non-pharmaco- are open to anything. Plus, a lot of the non-pharmacological their body and mind an in fad stand on their own. We also know approaches are technologically based, which kids love." er, you can often use much less medication, Different types of pain respond to different types of analgesia, been programmed." less dangerous for the patient," she says. and this can often be due to the person's past experience of n-pharrnacologic analgesia include physical pain, she says. "Pain is a very subjective experience and is based I, massage, transcutaneous electronic nerve on the individual's life experience with pain and pain treatment, relaxation methods, biofeedback, hypnosis, and all of that plays into how they deal with pain and how their especially if you have inflammation, a non-sti uided imagery, and virtual reality. "We use a body and mind have been programmed. If pain is very fear- to get that inflammation down: she says. dual reality with kids," Turner says. "You can based, it will be completely different than pain in someone who Her talk promises to give lots of food forth her mindset." doesn't mind getting hurt because they were doing rock climbing "I won't have time for a lot of detail, but *Ives having the child wear what looks like a or something they really want to do," says Turner. awareness about all of the options. Right n4 .Imet that has a saeen inside. "You put the hel- Being able to identify what the patients' stressors are, and common buzz word in the pain world, and n watch something. One of the more common helping them manage those stressors, are important aspects of analgesia. Ifs using multiple methods to get on a mountcin, skiing, cod it comes with al of pain management. "It's incredibly complex.. hardly scratch- and it encompasses a wide variety of aspect, I. Their minds are able to actually go there on ing the surface with this talk, because there is so much you can psycho, social, and spiritual aspects of the p. be present in that virtual space, and those kids go into. My intent is more to increase awareness and to think uirey MANAGED CARE® lllll meat and Coat In rp., (1111.11111b el Pettunintsb 7.7 411 he Publishers of To examine the treatment benefits, cost ICAN JOURNAI. Of' concerns, and potential insurance coverage strategies for pertuzumab, AJMCs Co-Editor- QED CARE in-Chief, Michael E. Chernew, PhD, moderated View the latest issue, which includes original this audio cane) discussion with Lee N. research on the dinical and economic outcomes 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. Walker says that if the potential for DDI exists, "it does not family's whole plan for end-of-life care." kinetic and mean that you cannot use the drug, you just have to use it with "Palliative care patients are so complex; a ynamic Drug Interactions in a plan."This means that if a provider decides to use a medicine to prevent additional burden to these pati dilative Care" (PHM-06) with a potential for interaction, he or she needs to know what says Walker. Drug effects can make a big dif to monitor and consider dosing and administration schemes of-life experience. "Our duty is still to do n. tryn A. Walker, PharmD, BCPS, CPE that may prevent or minimize interactions. "For example, some days a patient has left, a time that may be t interactions are based on timing," she points out. "If you give in their life," she says. y, September 8 the drugs at different times, you may avoid an interaction." Kathryn A. Walker, PharmD, BCPS, CPE OOam For many drugs, providers only pay attention to a sub- fessor at the University of Maryland Schoo ≥I 3, Castellano 2 set of potential interactions or complications related to that a palliative care clinical specialist at MedSt< drug. One example of this is methadone. "It is a compli- Hospital. She serves on the palliative med cated drug to use, in general: says Walker. "People worry and oversees the hospital's pain consult tec 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 = "I am hoping to convince people 631 potential drug interactions among its in a palliative care setting. Patients in that it is better to think about thi .n have advanced disease and are receiv- :ations. In the 2011 study, a median of 14 important drug-drug interaction prescribed per patient during the hospital these populations before prescri ker, PharmD, BCPS, CPE, will present "Nor- 'harmacodynamic Drug Interactions in Pain medications and to keep in minc e this morning at PAINWeek 2012. During le will review the basic pharmacology of fre- flag drugs that may cause probli 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 about dosing, administration, and monitoring because they cer. "Whether to order additional medication are all complicated." But, Walker cautions that methadone iedication is not a straightforward decision." is prone to many drug interactions that are not widely rec- wstanding drug interactions plays a big part ognized. "Many drug interactions for methadone often go ,blems, "I will review the kinds of drug inter- overlooked," she says. io Jers should worry about in these settings." Bleeding risk for patients on warfarin is another common a on DDIs among pain and palliative care concern. "Sometimes providers focus on whether or not to substantive imparts a particular challenge to keep a patient on warfarin, but they neglect to consider oth- w these patients. er things that may impact bleeding," she says. Bleeding risk is at some providers assume that pharmacists one of the most recognized DDIs. Yet, oversedation, confusion, )I before prescriptions are filled and admin- and delirium are common results of DDIs that can be quite "I don't see a lot of providers routinely con- scary to families and patients. "Even if a patient is not aware, in practice," she says. But, pharmacists may these symptoms can alarm families, making them worry about er is aware of the interaction and, practically whether they can care for the patient at home; it can change a 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- EFTA01114724 Jaleo Fly and modem Las Vegas French brasserie with an emphasis on quality ingredients' Looking to take a break from steaks, pastas, and heavierfaret Then an evening of d traditional fare that is accessible yet provocative, deticious yet chic" Doily spe- at Joleo may be just what you're looking for. Choose from a selection of small dude beef wellington, housemade sausage, a selection of offal, and dayboat (sausages and cured meats, including the famous lemon Iberico ham made frc torte flambee, steak tartore, roasted beets, and French onion soup. Lunch entrees quesos (including several varieties of sheep's and goat's milk cheeses), Eocadillos I lame, oxtail benedict, steamed nvicw1c, and roasted lamb sandwich. Diners con es), &auras (chicken, ham, dates—just about everything tastes better fried), and • -course "Quick Lunch°Dinnerstandouts include the roasted bone marrow and ox- dishes), and other dossic ta pas. And, as the menu says, Chef Jose Andres lcnows commended9, brick roasted chicken, slow-cooked veal, a classic bouillabaisse, and plates, too," induding some of the best paella you will ever hove (in fact, Jale r. Comme Ca also offers a multi-flighttistronomystasting menu. Diners will also find changes throughout the day). 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 Hours of Operation: afted classic cocktails shaken with Chef David Myers) modem sensibility" Sunday-Thursday: 5:00pm-11:00pm Friday-Saturday: 5:00pm-12:OOam rtion: 00pm (Monday-Thursday) )0pm (Friday-Sunday) OOpm (Friday-Sunday) Scarpetta urger concept" that was "tailor-made for The Cosmopolitan of Las Vegas with Described os a modem Italian restaurant with an earthy-yet-sophisticated :sh, natural and organic ingredients," Holsteins serves custom-crafted specialty cuisine,Scarpetta featuresso satisfying and soulful menu of seasonally-inspired 'tali Je sausage, and "riffs on traditional American snacks and appetizers, as well as offerings indude braised short ribs, creamy potent] with mushrooms, and other c lakes and sides.' Start things off with a high-octane "bam-boozled shake"(one of course selections include duck & foie gins ravioli, black tonarelli with king crab ar Bowl,' combines Crunch cereal with Absolut Vanilla) and a selection from and short rib agnolotti. For the main course (pelt), diners at Scarpetta can chc wises indude southern fried chicken fingers-n-waffles, buffalo wings, onion rings, of northern Italian-inspired dishes, including several fish entrees, Colorado lam fhe "Tiny Buns menu features sliders, crispy pork belly, lobster rolls, and meat- duck breast. Scarpetta also offers a delectable °signature tasting menu," as well EFTA01114725 IHEvv iv F i IsARRWST PERIOD OF ALTH TI E CONCERN The management of pain and inflammation—whether acute or chronic—requires proper consideration and attention to individu healthyn patients' therapeutic needs and the issues that may affect apprc wom and effective treatment. Nonsteroidal anti-inflammatory drugs (N whether over the counter (OTC) or by prescription, are some of PAIN SEX:HAY most commonly used and effective drugs for pain relief, but, like medication, only appropriate use can maximize their therapeu. benefit while minimizing risk1 2 American Chronic Pain Association 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 te Tioe MINE EDUCATE before,./ Cadtembnignii Data demonstrate an unequivocal relationship between dose fOU MEDICATE? duration of NSAID use and the increased risk of gastrointestin lationel Council on Patient Information. and Education www.talkaboutrsoro 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, National Kidney educating them about what NSAIDs are, and facilitating an or Foundation 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 Americal7Aeademy rican Academy of educating health care professionals and the public at-large to Nurse P scririoners SICIAN ASSISTANTS ensure appropriate and safe use of NSAIDs. LOMA PAL narnformIng Cate 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 Bill McCarberg, MD Use of NSAIDs Chairman. Alliance for Rational Use of NSAIDs EFTA01114726