Michael M. BOTTROS MD
Recent technological advances have prompted the increasing use of ultrasound for anatomical visualization during pain management procedures. Dr. Bottros reviews the basics of ultrasound, its application in a range of pain management procedures, and discusses its efficacy in relation to other techniques including CT and fluoroscopy.
Mary Lynn MCPHERSON PharmD, BCPS, CPE, FASPE
In patients with advanced illness, pain medication regimens may be inappropriately prolonged, due to clinical inertia or misperceptions over continued benefit. This segment considers the process for evaluating the medication decision in advanced illness, and insight into compassionate patient and caregiver discussion on this sensitive topic.
Melissa DURHAM PharmD
Although prescription medications are of great benefit to many patients with chronic non-cancer pain, there are significant complications for patients who are either addicted or in recovery. Dr. Durham, a clinical pharmacist, professor of pharmacy, and medication prescriber, considers the relationship between addiction and pain medications, the implications for prescribers, and the impact on the […]
Roger B. FiLLiNGiM PhD
Although pain affects people of all ages, older adults are at increased risk for chronic pain and resultant disability, as well as for transition from acute to chronic pain. In a “graying” America, it is important for clinicians to understand age-related influences on pain. Dr. Fillingim considers some of the biological and psychosocial factors, and […]
- Orthopedic Residents and Older Patients: Communications Training Improves Outcomes
The Hospital for Special Surgery (HSS) in New York has implemented a program to improve orthopedic surgery residents’ communications proficiency when interacting with older patients, and a recent evaluation of both residents and patients indicates positive reaction from both constituencies. The study results were presented at the Council of Orthopaedic Residency Directors meeting earlier this month. The training is targeted to third year residents, and is designed to sensitize them to some of the special needs of their older patients and to correct negative perceptions that these practitioners may have about them. Mathias Bostrom, MD, orthopedic surgeon and residency program director for HSS, commented, "This ongoing program has been valuable on many levels, but fundamentally helps our residents become more caring physicians, and not just surgeons." Charles Cornell, MD, clinical director of orthopedic surgery at HSS, added, "Inadequate communication between doctor and patient is well documented to be a source of patient harm, risk of complications, and poor patient satisfaction with their care.” The 2-part HSS communications program includes exploration of issues involved in aging as well as negative stereotypes about older adults, and possible biases stemming from past personal and professional experiences. Residents are also coached on presenting information to their older patients. 64 residents participated in the training from 2009 to 2015. In a pre- and posttraining evaluation, significant positive changes were noted in residents’ knowledge of aging, in attitudes toward older patients, and in level of anxiety accompanying treatment of them. A similar evaluation of 674 patients also found that 96% felt the prepared residents demonstrated sensitivity in caring for them. Read more about practitioner/patient communication here. Read more about the HSS training program and the evaluation results here.
- Medical Marijuana: Conflicting State and Federal Statutes Remain a Challenge for Practitioners and Patients
Almost half of the United States have now legalized the medical use of marijuana for conditions that include chronic pain, although it remains illegal under federal law, and regulatory hurdles in the US have impeded the conduct of cannabis research. Two prominent publications currently feature guidance to practitioners in the use of medical marijuana to address these concerns and others. In April of this year, the Federation of State Medical Boards (FSMB) unanimously adopted a set of policy recommendations developed by a 2015 workgroup that are intended to provide guidance to practitioners in the use of medical marijuana in treatment. A summary of these recommendations was published online earlier this month in The Journal of the American Medical Association (JAMA). Authored by FSMB President and CEO Humayun J. Chaudhry, DO, MACP, and colleagues, the summary addresses the dilemma confronting prescribing practitioners in the face of conflicting state and federal regulations regarding the use of marijuana. In 2013, the US Department of Justice advised states and localities that have authorized marijuana use to implement enhanced regulatory and enforcement systems to guard against resultant threats to public safety and health. Although the evidence for the efficacy of medical marijuana in the treatment of medical conditions including chronic pain remains scant, heightened public interest in the question creates a challenge for practicing clinicians. The 10 recommendations adopted by the FSMB include measures designed to ensure rigorous patient evaluation and informed decision-making; careful and complete documentation of treatment plans that include marijuana; regular re-assessment of patient response to treatment; registration with the appropriate oversight agencies or registries; special attention to patients with known or suspected substance abuse histories; and freedom from conflicts of interest including affiliation with a dispensary or cultivation center. Separately, the June edition of the Journal of Pain carries an article from the American Pain Society also providing guidance to clinicians on medical marijuana for pain conditions. Lead by author Seddon Savage, MD, medical director, Silver Hill Hospital Chronic Pain and Recovery Center, and with coauthorship by PAINWeek faculty member Michael Schatman, PhD, CPE, DASPE, the article reviews clinical, research, and policy issues related to herbal cannabis to counsel clinicians in advising and caring for patients who use it. From the article abstract, “Whether or not individual professionals support the clinical use of herbal cannabis, all clinicians will encounter patients who elect to use it and therefore need to be prepared to advise them on cannabis-related clinical issues despite limited evidence to guide care.” To access the painweek.org library of information on medical marijuana, tap here. Read a news summary of the recommendations here, with access to the journal article and the full FSMB guidelines, here. The article abstract from the American Pain Society may be read here.
- Achieving Better Treatment Outcomes for Spinal Cord Compression Surgery
A new model has been developed to assist in the prediction of possible complications following surgery for cervical spondylotic myelopathy (CSM), a common condition causing compression of the spinal cord in the neck. The model identifies 4 factors that are associated with elevated risk for postsurgical complications and is derived from an international study of 479 patients who underwent surgery for CSM. A total of 89 incidences of surgical complication, in 78 patients, were identified. The researchers, from Toronto Western Hospital, considered a wide range of clinical and surgical factors and applied a “complication prediction rule” to narrow and identify those most likely to associate with postprocedure complications. The study is reported in the July issue of Neurosurgery. CSM is the most common cause of spinal cord dysfunction in the elderly. Patients with CSM may experience pain and stiffness in the neck, as well as numbness and weakness in the arms and legs, arising from pressure on the spinal cord or nerve roots. Surgery has proven significantly effective in halting progression of these symptoms and improving patients’ quality of life, but complications from the procedure occur in 11% to 38% of patients. The 2 most prominent predictors of complication, according to the study, are the presence of ossification of the posterior longitudinal ligament (OPLL), and/or pre-existing diabetes. Additional factors contributing to risk of complication include other pre-existing medical conditions such as cardiovascular disease, and longer duration of surgery. The researchers conclude, "Surgeons can use this information to discuss the risks and benefits of surgery with patients, to plan case-specific preventive strategies, and to ensure appropriate management in the perioperative period." Read more about spinal cords, here. A news story about the recommendations, with link to the journal article, may be read here.
- Study Finds Worse Outcomes for Patients on Long-term Opioid Therapy
Results of a small study of patients with sickle cell disease suggest that long-term opioid therapy may be contraindicated for treatment of their chronic pain. The study, conducted by researchers from Johns Hopkins found that patients who were prescribed long-term opioid therapy tended to score worse on measures of pain, fatigue, and activity levels than did those who were not on opioids. The team assessed 83 people with sickle cell disease, 57 women and 26 men. All were over age 18, with average age 39. 29 patients were prescribed long-term opioids and 54 were not. After 90 days, the opioid therapy cohort reported pain intensities at a level 3 times higher than the non-opioid group, as well as 2 times the level of fatigue. Study author C. Patrick Carroll, MD, director of psychiatric services for the Johns Hopkins Sickle Cell Center for Adults noted “We need to be careful and skeptical about giving increasing doses of opioids to patients with sickle cell disease who are in chronic pain if it isn’t effective. Too little is known about the effects of long-term opioid management of chronic pain.” The findings were published online earlier this month in a special sickle cell disease supplement of the American Journal of Preventive Medicine. Sickle cell disease, a genetic blood disorder affecting predominantly African Americans, causes extreme acute pain that is frequently treated with intravenous opioids medications. Adult patients with the disease frequently develop chronic pain as well, and the reasons for the progression are not well understood. As advances in treatment of sickle cell disease have led to longer patient lifespans, the incidence of chronic pain has increased, and again is often treated with long-term opioid therapy. But in addition to elevated pain and fatigue, the study cohort who received long-term opioids showed higher levels of central sensitization, which may play a role in the development of chronic pain among patients with sickle cell disorder. Read a news story about the findings here. The journal abstract may be read here.
Department of Public Health and Community Medicine
Tufts Medical Center