This interactive Colroado Physician Ebook contains 10 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
Colorado Continuing Medical Education
COLORADO MEDICAL LICENSURE PROGRAM
MANDATORY TRAINING REQUIRED FOR COLORADO LICENSE RENEWAL PHYSICIANS (MD/DO) WHO PRESCRIBE OPIOIDS: • 8 CREDITS DEA REQUIREMENT (NEW) • 2 CREDITS PRESCRIBING OPIOIDS
INCLUDES: DEA’s New One-time MATE Requirement
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
CME DEADLINE: 4/30/2025
AVAILABLE ONLINE AT: CO.CME.EDU
COLORADO PHYSICIAN
Dear Colleagues, Effective June 27, 2023, renewing DEA-registered practitioners must complete eight (8) hours of one- time training on the treatment and management of patients with opioid or substance use disorders. All physicians (MD/DO) licensed by the state of Colorado who prescribe opioids must complete at least two (2) hours of training on prescribing opioids per C.R.S. 12-30-114, unless exempt. The training must include the following topics/areas: best practices for opioid prescribing according to the most recent version of the division’s guidelines for the safe prescribing and dispensing of opioids; recognition of substance use disorders; referral of patients with substance use disorders for treatment; and the use of the electronic prescription drug monitoring program. The InforMed Colorado Medical Licensure Program is designed to fulfill this mandatory requirement for physicians (MD/DO) in Colorado. Completion of this program satisfies the two (2) hour requirement on best practices for prescribing opioids as well as eight (8) hours on the DEA’s new one-time MATE requirement.
Thank you for choosing lnforMed as your CME provider. We strive to create a high quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards, The lnforMed CME Team
We are a nationally accredited CME provider. For all board-related inquiries please contact:
Colorado Medical Board | 1560 Broadway, Suite 1350 Denver, CO 80202 | (303) 894-7800
1-800-237-6999
BOOK.CME.EDU
BOOK CODE: MDCO1025
ii
What’s Inside
01
BEST PRACTICES FOR TREATING PAIN WITH OPIOID ANALGESICS, 2ND EDITION COURSE ONE | 2 CREDITS SATISFIES REQUIREMENT ON OPIOID PRESCRIBING PER C.R.S 12-30-114 The purpose of this course is to provide the fundamentals of acute and chronic pain management and a contextual framework for the safer prescribing of opioid analgesics that includes consideration of a full complement of nonopioid treatment options. SUBSTANCE USE DISORDERS: A DEA REQUIREMENT COURSE TWO | 8 CREDITS SATISFIES THE DEA’S NEW ONE-TIME MATE REQUIREMENT Physicians and Physician Assistants (PAs), care for patients with disorders in many healthcare settings. Individuals may seek care for an acute illness or worsening of a chronic condition. Often, pain is the leading reason for seeking medical care. Appropriate prescribing practices are critical for all medications, but controlled substances require special attention. The Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and the U.S. Department of Health and Human Services (HHS) all have a role in controlled medication schedules. Prescribers must understand federal and state requirements for all controlled substances. This course will provide a general review of federal and state-controlled substance regulations and the prescribing practices for controlled substances. Additionally, substance use disorders are complex phenomena affecting many lives. This course also reviews common substance use disorders, including alcohol, anxiolytics, stimulants, hallucinogens, and tobacco/vaping. However, the focus is on clinical safety considerations when prescribing non-cancer-related opioid medications for acute/chronic pain in adults. LEARNER RECORDS: ANSWER SHEET & EVALUATION REQUIRED TO RECEIVE CREDIT
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91
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Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs ABA American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0® MOC/MIPS CREDIT INFORMATION Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABOHNS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABOHNS American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC)
ABPath American Board of Pathology’s Continuing Certification Program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M
Activity Title
ABA
ABIM ABOHNS ABPath
ABP
Best Practices for Treating Pain with Opioid Analgesics, 2nd Edition Substance Use Disorders: A DEA Requirement
2 AMA PRA Category 1 Credits TM 8 AMA PRA Category 1 Credits TM
2 Credits LL 8 Credits LL
2 Credits MK 8 Credits MK
2 Credits SA 8 Credits SA
2 Credits LL 8 Credits LL
2 Credits LL+SA 8 Credits LL+SA
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, PS = Patient Safety
Table 3. CME for MIPS Statement Completion of each accredited CME activity meets the expectations of an Accredited Safety or Quality Improvement Program (IA PSPA_28) for the Merit-based Incentive Payment Program (MIPS). Participation in this Clinical Practice Improvement Activity (CPIA) is optional for eligible providers. DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
iv
How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the self-assessment questions. To receive credit for your courses, you must provide your customer information and complete the man- datory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE FASTEST AND EASIEST! • Go to BOOK.CME.EDU and enter code MDCO1025 in the book code box, then click GO. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your self- assessment. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
Enter book code
MDCO1025
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
BY MAIL Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options Price
Option
Code
Credits
ENTIRE PROGRAM • Best Practices for Treating Pain with Opioid Analgesics, 2nd Edition • Substance Use Disorders: A DEA Requirement
$100
MDCO1025
10 Credits
$50 Best Practices for Treating Pain with Opioid Analgesics, 2nd Edition $80 Substance Use Disorders: A DEA Requirement
MDCO02BP
2 Credits
MDCO08SD
8 Credits
1-800-237-6999
v
BEST PRACTICES FOR TREATING PAIN WITH OPIOID ANALGESICS, 2ND EDITION
COURSE DATES:
MAXIMUM CREDITS: 2 AMA PRA Category 1 Credit ™
FORMAT:
Release Date: 5/7/2024 Exp. Date: 5/7/2027
Enduring Material (Self Study)
TARGET AUDIENCE All health care professionals who participate in the management of patients with pain. COURSE OBJECTIVE To provide the fundamentals of acute and chronic pain management and a contextual framework for the safer prescribing of opioid analgesics that includes consideration of a full complement of non-opioid treatment options.
HOW TO RECEIVE CREDIT: ● Read the course materials. ● Complete the self-assessment questions at the end. A score of 70% is required. ● Return your customer information/ answer sheet, evaluation, and payment to InforMed by mail, phone, fax or complete online at BOOK.CME.EDU .
LEARNING OBJECTIVES Completion of this course will better enable the course participant to: 1. Discuss pain and comorbidity assessments as appropriate to the individual patient and pain type and duration. 2. Discuss an individualized treatment plan utilizing or considering a full range of medication and non- medication options. 3. Identify risk or presence of OUD before initiating or continuing opioid therapy for pain. 4. Recognize signs and symptoms of OUD, strategies for optimal management, and when to refer to a specialist. ACCREDITATION STATEMENT InforMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics. DESIGNATION STATEMENT continuing medical education for physicians. IMPLICIT BIAS IN HEALTHCARE InforMed designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits ™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Book Code: MDCO1025
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FACULTY Melissa B. Weimer, DO, MCR, FASAM Assistant Professor Department of Internal Medicine Yale University School of Medicine Beth Dove Medical Writer Dove Medical Communications ACTIVITY PLANNER Michael Brooks CME Director, InforMed DISCLOSURE OF INTEREST
COURSE SATISFIES 2 Opioid Prescribing
COLORADO SPECIAL DESIGNATION This course satisfies one (2) credit hours in opioid eduction.
Every physician (MD/DO) licensed by the state of Colorado who prescribes opioids is required to complete at least two (2) hours of training on best practices for prescribing opioids prior to renewal unless exempt.
In accordance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education, InforMed implemented mechanisms, prior to the planning and implementation of this CME activity, to identify and resolve conflicts of interest for all individuals in a position to control content of this CME activity.
FACULTY/PLANNING COMMITTEE DISCLOSURE The following faculty and/or planning committee members have indicated they have no relationship(s) with industry to disclose relative to the content of this CME activity: ● Beth Dove ● Michael Brooks The following faculty and/or planning committee members have indicated they have relationship(s) with industry to disclose: ● Melissa B. Weimer, DO, MCR, FASAM has received honoraria from Path CCM, Inc. and CVS Health. STAFF AND CONTENT REVIEWERS InforMed staff, input committee and all content validation reviewers involved with this activity have reported no relevant financial relationships with commercial interests. DISCLAIMER *2024. All rights reserved. These materials, except those in the public domain, may not be reproduced without permission from InforMed. This publication is designed to provide general information prepared by professionals in regard to the subject matter covered. It is provided with the understanding that InforMed, Inc is not engaged in rendering legal, medical or other professional services. Although prepared by professionals, this publication should not be utilized as a substitute for professional services in specific situations. If legal advice, medical advice or other expert assistance is required, the service of a professional should be sought.
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Book Code: MDCO1025
THE CHALLENGE OF TREATING PAIN
The experience of pain brings great physical and emotional suffering with significant societal costs and can interfere with daily life and work. Some 51.6 million U.S. adults live with chronic daily pain, and 17.1 million experience high-impact chronic pain. 1 Pain is even more common in military veterans, particularly those who have served in recent conflicts: 66% reported pain in the previous three months, and 9% reported severe pain. 2 The national cost of pain is estimated at between $560 billion and $635 billion annually. 3 Pain that is unremitting and without adequate treatment can lead to a multitude of problems for the person who suffers, including anxiety, depression, disability, unemployment, and lost income. 3 Certain populations are more vulnerable than others to developing more severe chronic pain and disability, including women, older adults, and individuals from minoritized racial and ethnic backgrounds, 4 who are also at risk for having their pain undertreated. 4 People who lack access to optimal pain care experience more complications in medical and psychiatric conditions. 3 Failure to give adequate care for pain from injury or surgery can
prolong recovery times, leading to hospital readmissions and transition to chronic pain. 3 The challenge of managing acute and chronic pain is complicated by an ongoing public health crisis related to opioid overdose, a category that includes prescription opioids, heroin, and illicitly-produced fentanyl and its analogues. 5 Numerous families have endured tragedy in the form of opioid-related overdose deaths, which doubled from more than 21,000 in 2010 to more than 42,000 in 2016. 5 As of 2021, of the approximately 106,000 drug- related overdose deaths in the United States, over 80,000 of them involved opioids, more than 16,000 of which involved prescription opioids (Figure 1). 6 , 7 Over the past decade, the fatalities have been strongly driven by a proliferation of illicitly produced high-potency synthetic opioids, but prescription opioids and other sedating medications, particularly benzodiazepines, also contributed to fatal overdoses. 8 In all, more than 136 Americans die every day from overdoses that involve a prescription or illicit opioid. Moreover, overdose deaths spiked during the COVID-19 pandemic, particularly deaths involving synthetic opioids. 9
Figure 1: National Drug Overdose Deaths Involving Prescription Opioids
*Among deaths with drug overdose as the underlying cause, the prescription opioid subcategory was determined by the following ICD-10 multiple cause-of- death codes: natural and semi-synthetic opioids (T40.2) or methadone (T40.3). Source: Centers for Disease Control and Prevention, National center for Health Statistics. Multiple Cause of Death 1999-2019 on CDC WONDER Online Database, released 12/2020.
Furthermore, an estimated 4% to 6% of people who misuse prescription opioids transition to non-prescribed opioid and/or illicit opioid use. 13-15 Approximately 75% to 80% of people who use heroin misused prescription opioids first. 13,14 Healthcare practitioners (HCPs) play a key role in facilitating appropriate use of opioids and other sedating medications when prescribed for acute and chronic pain. Pain care is most effective when it combines multiple disciplines and utilizes a broad range of evidence-based pharmacologic and nonpharmacologic treatment options. 16,17 Opioids are associated with small improvements in pain and function versus placebo when used up to six months; however, evidence of longer-term effectiveness is limited, whereas increased harms from use beyond six months appear to be dose dependent. 5 Moreover, nonopioid options may bring equivalent or better patient outcomes with less risk: a comparative effectiveness review of evidence performed by the Agency for Healthcare Research and Quality found no difference in improvement in pain, function, mental health status, sleep, or depression when opioids versus nonopioid medications were used up to six months. 5
These grim statistics illustrate how important it is to keep potential public health consequences in mind when prescribing any type of controlled substance, including opioids. The economic burden of opioid misuse reaches $78.5 billion a year in healthcare, lost productivity, addiction treatment, and criminal justice costs. 10 As of 2023, more than 3 million Americans had an opioid-use disorder (OUD) involving prescription or illicit opioids. 11 Of people age 12 or older in 2019, there were: 5 ● 1.6 million new individuals who misuse prescription pain relievers. ● 949,000 new individuals who misuse prescription sedative-hypnotics. ● 901,000 new individuals who misuse prescription stimulants. Many people who misuse opioids are not receiving regular medical care or prescribed opioids. Most people who are prescribed opioids for pain treatment do not misuse their medications. However, roughly 21% to 29% of patients prescribed opioids for chronic pain do misuse them, and between 8% and 12% of them develop an OUD. 12
Book Code: MDCO1025
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At the same time, there is a recently recognized potential for harm in suddenly discontinuing or rapidly tapering doses in patients who have been on long-term opioids or in forcing patients who have been stable on higher doses to reduce to a set threshold dose. 3,18-20 It is also critical that HCPs recognize and optimally manage OUD when present. Distressingly few people who need treatment for substance- use disorder (SUD) are able to access it, and far more people need treatment for OUD than receive it. In 2019, using adjusted estimates of past-year OUD prevalence, there was a gap in medication for OUD receipt for 8,986,485 individuals. 21 Solutions will include more accessibility of OUD treatment, including greater access to medications to treat OUD, and measures to prevent prescription and illicit drug misuse from developing in the first place. 22 For acute pain and for some chronic pain, unresponsive to non-opioid therapies, opioids may form part of a customized treatment plan. A subset of patients may benefit from treatment with opioids long term, for example, during severe exacerbations of pain during the course of chronic conditions. 23 More than ever, HCPs are called on to optimize a range of available therapies and reserve opioids for when the benefits are expected to outweigh the risks and nonopioid options are inadequate.
This educational activity is built on core messages of the U.S. Food and Drug Administration’s (FDA’s) Blueprint for the Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS). It provides guidance on safely prescribing opioid analgesics, including all extended-release and long- acting (ER/LA) and immediate-release/short-acting (IR/ SA) formulations. It is targeted to all HCPs who treat and monitor patients with pain, not prescribers alone. It stresses the importance of competence in considering and using a broad range of pharmacologic and nonpharmacologic therapeutic options for managing pain as well as in recognizing and managing OUD when indicated. The goal is to equip HCPs to recognize and manage any adverse events that may arise when a trial of potentially long-term opioids is part of a comprehensive treatment plan. Self-Assessment Question 1 Which percentage of patients prescribed opioids for chronic pain develop an opioid use disorder (OUD)?
a. 4% to 8% b. 8% to 12% c. 12% to 16% d. 16% to 20%
PAIN DEFINITIONS
● As existing independently of the ability to express its presence verbally, that is, verbal description is only one of several behaviors to express pain, and inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain. There are no precise clinical markers for pain, which is experienced by the individual as a constellation of biological, psychological, and social factors that include race and ethnicity (Figure 2). 3 This biopsychosocial model is now preferred to an earlier era’s biomedical model of pain care, which primarily aimed medical, procedural, and surgical treatments at a presumed biological pain generator in an attempt to fix or numb pain. 23 Given pain’s complexity, it is important to perform a thorough patient evaluation so that the presumed or differential diagnosis is accurate in order to select the best therapeutic option. 3
The International Association for the Study of Pain (IASP) revised its pain definition in 2020 to better convey pain’s nuances and complexities and to improve its assessment and management. The IASP defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” 24 The IASP further describes pain as follows: 24 ● As a personal experience that is influenced to varying degrees by biological, psychological, and social factors. ● As a separate phenomenon from nociception that cannot be inferred solely from activity in sensory neurons. ● As a concept learned through the life experiences of individuals. ● As an experience that should be respected. ● As serving an adaptive role that may, nonetheless, have adverse effects on function and social and psychological well-being.
Figure 2: The Biopsychosocial Model of Pain 1
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Book Code: MDCO1025
Pain is protective and essential for survival when understood as a warning signal that something has gone wrong in the body. However, when pain persists indefinitely the central nervous system (CNS) begins to sense, transmit, modulate, and interpret the pain experience differently. 17 When the nociceptors, or sensory receptors, become sensitized, they discharge more frequently. In peripheral sensitization, this state of heightened neuronal excitability occurs at the site where the pain impulse originated in the body; in central sensitization, it occurs in the spinal neurons, Pain classifications Pain can be categorized in several ways, including by type, duration, etiology, and pathophysiology: ● Acute pain is a physiologic response to noxious stimuli with a sudden onset and expected short duration. 3 It commonly occurs as a result of burn, trauma, musculoskeletal and neural injury, and after surgery or other procedures in the perioperative period. 3,23 Acute pain flares may also occur periodically in the course of chronic pain and medical conditions. 3 Anxiety and distress may exacerbate the acute pain experience. 25 ● Chronic pain lasts longer than normal healing and is generally diagnosed after persisting or recurring for longer than three to six months. 17 ○ Chronic pain’s many possible causes include injuries, malignancies, chronic diseases, medical treatments or surgeries, or inflammation that appears as a result of injury or chronic disease. ○ Chronic pain may occur in the absence of a defined injury or cause. ○ Anxiety, depression, and stress are known to complicate the chronic pain experience. 3 ○ Chronic relapsing pain conditions have periods of remission and frequent relapses (e.g., various degenerative, inflammatory, immune-mediated, rheumatologic, and neurologic conditions such as multiple sclerosis [MS], trigeminal neuralgia, Parkinson’s disease, complex regional pain syndrome [CRPS], porphyria, systemic lupus erythematosus, lumbar radicular pain, migraines, and cluster headaches). 3 New diagnostic categories for chronic pain Accurately diagnosing a pain condition can be challenging, particularly when the etiology or pathophysiology of the pain is not clearly understood. To systematically gather together all relevant codes for the management of chronic pain, new diagnostic categories in the International Statistical Classification of Diseases and Related Health Problems (ICD-11) took effect in January 2022. 27 These diagnostic categories are intended to assist HCPs in reaching an accurate diagnosis to better create an optimal treatment plan. Per ICD-11, chronic pain is considered primary when pain has persisted for more than three months, is associated with significant emotional distress and/or functional disability and is not better accounted for by
which begin to fire spontaneously, resulting in pain that intensifies and lasts far longer than the stimulus applied. 17 Sensitization can result in hyperalgesia, where response to pain-causing stimuli is intensified, and allodynia, a pain response to stimuli that normally are not painful. 17 Therefore, the resulting pain comes not just from an injury site but from neural impulses. The pathologies created by central sensitization can persist and continue to generate pain impulses indefinitely, far outlasting pain’s usefulness as a warning signal. ● Nociceptive pain is the normal response to any type of stimulus that results in tissue damage and includes visceral and somatic pain. 17 Examples of nociceptive or inflammatory pain include postoperative pain, osteoarthritis, mechanical low back pain, sickle cell crises, and pain from traumatic injuries. ○ Visceral pain is nociceptive pain that arises from the body’s organs and may be cramping, throbbing, and/or vague. 17 Examples are pain related to myocardial infarction, pancreatitis, or cholecystitis. ○ Somatic pain , whether superficial or deep, is nociceptive pain that results from issues within the bone, joints, muscles, skin, or connective tissue; it may be localized and stabbing, aching, and/or throbbing. 17 Examples include mechanical low back pain, osteoarthritis, and muscle sprain or strain. ● Neuropathic pain results from damage to or abnormal processing of the CNS or peripheral nervous system and may be sharp, stabbing, burning, tingling, and/or numb. 17 Certain neuropathic pain conditions may be diagnosed as chronic pain before the three-month mark. 26 Examples include diabetic neuropathy, regional pain syndrome, or trigeminal neuralgia. 6 ● Referred pain spreads beyond the initial injury site and can have both nociceptive and neuropathic features. 17 ● Chronic pain may be primarily nociceptive or neuropathic or have mixed nociceptive- neuropathic characteristics. another condition. Thus, in chronic primary pain, the pain is the chief complaint and disease. A diagnosis of somatic symptom disorder is not made on the basis of unexplained pain alone but requires positive psychiatric criteria. The six subgroups of chronic primary pain are: 27 ● Chronic primary pain. ● Chronic widespread pain (e.g., fibromyalgia). ● Chronic primary visceral pain (e.g., irritable bowel syndrome). ● Chronic primary musculoskeletal pain (e.g., nonspecific low-back pain). ● Chronic primary headache or orofacial pain (e.g., migraine, tension-type headache, trigeminal autonomic cephalalgias). ● Chronic regional pain syndrome.
Book Code: MDCO1025
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Chronic pain is secondary when it may, at least initially, be a symptom of an underlying disease. A diagnosis may be made independent of biological or psychological contributors, unless another diagnosis better fits the symptoms. The six subgroups of chronic secondary pain are: ● Chronic posttraumatic and postsurgical pain. ● Chronic secondary headache and orofacial pain. ● Chronic secondary musculoskeletal pain. Chronic neuropathic pain is further subdivided by whether its origin is peripheral or central. 26 Peripheral neuropathic pain is caused by a lesion or disease of the peripheral somatosensory nervous system and includes: 26 ● Trigeminal neuralgia, which is an orofacial pain condition of the trigeminal nerve with shooting, stabbing, or electric-shock-like pain that starts and ceases abruptly, and is triggered by innocuous stimuli. ● Chronic neuropathic pain after peripheral nerve ● Chronic cancer-related pain. ● Chronic neuropathic pain. ● Chronic secondary visceral pain. injury which is caused by a peripheral nerve lesion with history of nerve trauma, pain onset in temporal relation to the trauma, and pain distribution within the innervation territory. ● Painful polyneuropathy, which is caused by metabolic, autoimmune, familial, or infectious diseases, exposure to environmental or occupational toxins, or treatment with a neurotoxic drug (as in cancer treatment) or can be of unknown etiology. ● Postherpetic neuralgia, which is pain persisting for more than three months after the onset or healing of herpes zoster. ● Painful radiculopathy, which stems from a lesion or disease involving the cervical, thoracic, lumbar spine, or sacral nerve roots, commonly caused by degenerative spinal changes but also by numerous other injuries, infections, surgeries, procedures, or diseases. ● Other, not covered by the foregoing codes, which includes carpal tunnel syndrome and disorders for which information is still insufficient to assign a precise diagnosis. The multimodal, multidisciplinary treatment approach is recognized as optimal for pain care; nevertheless, barriers to accessing this type of care for patients are numerous and entrenched in the healthcare delivery system. It should be fully recognized that HCPs are asked to provide optimal pain care and lessen the risks from opioids in an environment that frequently provides inadequate support for practitioners and scant access for patients. A task force of healthcare associations convened by the American Medical Association to study and make recommendations to improve patient pain care described evidence-based care as “ensuring patients have access to the right
Central neuropathic pain is caused by a lesion or disease of the central somatosensory nervous system, and the pain may be spontaneous or evoked. 26 Central neuropathic pain conditions include: 26 ● Chronic central neuropathic pain associated with spinal cord injury. ● Chronic central neuropathic pain associated with brain injury. ● Chronic central post-stroke pain. ● Chronic central neuropathic pain caused by MS. ● Other, specified and unspecified. Conditions may be referenced under more than one category as with chronic painful chemotherapy- induced polyneuropathy, classed as cancer-related pain (by etiology) and also as neuropathic pain (by nature). Although it is clinically useful to speak of chronic pain, it is important to remember that pain is a dynamic experience whose onset, maintenance, and exacerbation are not confined to set temporal categories. 28 Thus, patients who experience significant pain that lasts beyond typical healing periods or the three-month diagnostic period for chronic pain may improve with conservative measures. Conversely, some types of neuropathic pain or sudden onset pain from injury or disease does not require three months before treating the condition as chronic as the pain is likely to persist or recur indefinitely. 26 Because pain can be both a symptom and a disease, an accurate diagnosis is vital to treating the biologic source of pain when it is known and to expediting timely management of pain of uncertain origin. 28 All subtypes of chronic pain should be understood to have multiple biological, psychological, and social factors that contribute to the individual’s pain experience, in keeping with the biopsychosocial framework. Self-Assessment Question 2 Which factors influence pain according to the International Association for the Study of Pain (IASP)? Select all that apply. a. Biological. treatment at the right time without administrative barriers or delay.” 29 Insurance barriers to providing optimal patient care are present in the policies of public and private payers and pharmacy chains as well as pharmacy benefits managers. These barriers include delays and denials from prior authorization, step therapy, treatment quantity limits, high cost-sharing, coverage limits and restrictive access for nonopioid and nonpharmacologic treatments for pain, and strict opioid limits enforced without regard to individual patient need. 29
b. Physiological. c. Psychological. d. Social factors. BARRIERS TO EFFECTIVE PAIN CARE
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Book Code: MDCO1025
Barriers to the provision of nonpharmacologic therapies in particular include coverage that is absent or inadequate, unreceptive attitudes of HCPs and patients, and shortages of pain and behavioral healthcare specialists. 30 An Inter-agency Task Force convened by the Department of Health and Human Services (HHS) to recommend best practices in pain care proposed several ways of addressing gaps: 3 ● Create clinical practice guidelines to better incorporate evidence-based complementary and integrative therapies into practice. ● Improve insurance coverage and payment for different modalities on the basis of the best practices identified in new guidelines. ● Improve coverage and payment for multidisciplinary team care coordination. ● Expand access to treatment and geographical coverage via the use of telemedicine and other technological delivery methods for psychological and behavioral health interventions. ● Increase the number and training of qualified practitioners in behavioral health and other Treatment options for managing pain The HHS Inter-Agency Task Force on best practices in pain management categorizes options for pain treatment as medication, restorative, interventional, behavioral health, and complementary and integrative. 3 Medications include opioid and Nonpharmacologic options for pain A number of evidence-based nonpharmacologic treatments are recommended, either used alone or in combination with other modalities within a treatment plan that is individualized and draws from multiple disciplines (Table 1). 3,32,33 Nonpharmacologic options should not be considered “alternatives” to opioids but are encouraged as part of a comprehensive pain plan in keeping with the evidence base, patient access to competent practitioners, and adequate insurance coverage and reimbursement.
evidence-based complementary and integrative disciplines. ● Provide better education as well as time and financial support for primary care practitioners who give patients the sole available pain care in many parts of the country. Another barrier to pain care is the stigma in living with chronic pain, which is often cited by patients and their caregivers as a difficulty worsened by lack of objective biomarkers for pain, the invisible nature of the disease, and societal attitudes that equate acknowledging pain with weakness. 31 Compassion, empathy, and trust within a practitioner-patient relationship are key to navigating these challenges. It can help to offer education to the patient regarding the underlying disease processes of pain and to encourage them to seek help early for pain that persists beyond the expected time frame. When opioids are indicated, it is strategic to counsel patients that opioids are an appropriate part of their pain treatment plan so that the stigma of the societal opioid crisis does not interfere with appropriate treatment and good outcomes for the patient regarding opioid use. 23 nonopioid pharmacologic treatments. What follows are examples of each (not an exhaustive list) and a brief discussion of the evidence base underpinning these options. Frequently covered modalities for chronic pain include cognitive behavioral therapy (CBT), physical therapy, certain injections, exercise, and electrical stimulation. 32 Patients may find it helpful to combine approaches that include nutritional support, healthy lifestyle changes, patient education, sleep hygiene instruction, and relaxation and visualization techniques. The noninvasive nature and low side effect profile of nonpharmacologic treatments suggest they should be used first and preferentially.
Table 1. Noninvasive, Nonpharmacologic Approaches to Pain Management 3 Restorative Behavioral Health
Complementary and Integrative • Acupuncture • Massage, manipulative therapies • Mindfulness-based stress reduction • Spirituality • Tai chi
• Physical therapy • Occupational therapy • Physiotherapy • Therapeutic exercise • Transcutaneous electric nerve stimulation • Massage therapy • Traction • Cold and heat • Therapeutic ultrasound • Bracing • Chiropracty
• Cognitive behavioral therapy • Acceptance and commitment therapy • Mindfulness-based stress reduction • Emotional awareness and expression therapy • Self-regulatory/ psychophysiological approaches: ○ Biofeedback ○ Relaxation training ○ Hypnotherapy
• Yoga • Reiki
Book Code: MDCO1025
Page 7
Restorative therapies Physical and occupational therapy are recommended for acute and chronic pain and are best combined as part of a multidisciplinary treatment plan after a thorough assessment. 3 Traction is frequently used as part of physical therapy and, although evidence that it is clinically effective is lacking, the HHS Inter- Agency Task Force suggests it should be investigated separately and considered as a treatment modality for low-back or neck pain. 3 Unfortunately, despite evidence of improved outcomes, use of these physical and occupational therapies are frequently challenged by incomplete or inconsistent reimbursement policies, and policymakers have been asked to look more closely at improving payer polices. 3 There is high-quality evidence that therapeutic exercise improves outcomes over bed rest. 3 Principally investigated as a treatment for spinal pain, therapeutic exercise has been shown to help patients function better and to help them overcome the anxiety and fear of movement that worsen pain and disability. Transcutaneous electric nerve stimulation research is plagued by a lack of high-quality, unbiased studies, and overall evidence of efficacy is limited. 3 It has been investigated for treatment of acute low-back Interventional options Interventional pain management describes a variety of techniques that vary in terms of their invasiveness. Techniques may use image-guided technology to help diagnose and treat sources of acute and chronic pain. Such treatments may help minimize the use of oral pain medication, including opioids, but have risks as well as advantages that should be understood and discussed with patients. Low complexity interventions include: ● Trigger point injections, usually composed of an anesthetic like lidocaine, which disrupt the tense bands of skeletal muscle fibers that produce pain and can be used to treat headaches, myofascial pain syndrome, and low-back pain. 3 ● Joint injections, often of corticosteroid into various joints, which are useful for inflammatory arthritis and basal joint arthritis. 3 ● Peripheral nerve injections, which are injections of local anesthetic agents or other medications by single injection or continuously by catheter, frequently delivered perioperatively and also useful for treatment or prevention of peripheral neuropathies, nerve entrapments, CRPS, headaches, pelvic pain, and sciatica. 3 Medium complexity interventions include: ● Facet joint nerve blocks as common diagnostic and therapeutic treatments for facet-related spinal pain of the low back and neck. 3 ● Epidural steroid injections to deliver anti- inflammatory medicine to the epidural space, which are frequent treatments for back and radicular pain and have been shown to reduce need for healthcare visits and surgeries, although risks should be weighed and discussed with the patient. 3
pain, postpartum pain, phantom limb pain, and knee osteoarthritis, and, despite limited evidence, can be considered among the safer self-care options with appropriate patient education. 3 Massage therapy includes Swedish, shiatsu, and deep tissue or myofascial release types. A systematic review found massage can be effective in the general population for pain, anxiety, and to improve health-related quality of life compared to sham, no treatment, and active comparators. 34 The application of cold and heat is a standard approach in relieving the symptoms of acute pain. Evidence supports use of cold therapy to reduce pain after surgery and heat wraps to relieve pain symptoms and increase function in acute low-back pain. 3 The evidence has not been robust that therapeutic ultrasound is more effective than placebo for musculoskeletal pain conditions; however, recent findings show it can be effective in relieving knee osteoarthritis. 3 Nonrigid bracing may improve function and is unlikely to cause muscle atrophy when used for short periods. 3 ● Radio-frequency ablation, which uses needles to deliver high-voltage bursts of energy near nerves to block pain transmission and has shown promise for cervical radicular pain. 3 ● Regenerative/adult autologous stem cell therapy, which is a promising area of research for many painful conditions. 3 ● Cryoneuroablation, which uses a cryoprobe to freeze sensory nerves at the source of pain to provide long-term pain relief and may be considered for numerous intractable pain conditions that include paroxysmal trigeminal neuralgia, chest wall pain, phantom limb pain, neuroma, peripheral neuropathy, knee osteoarthritis, and neuropathic pain caused by herpes zoster. 3 ● Neuromodulation, which delivers stimulation to central or peripheral nervous system tissue and has shown efficacy in low-back and various headache disorders. 3 High complexity interventions include: ● Spinal cord stimulators, which are devices to deliver a form of neuromodulation that has demonstrated efficacy in low-back and lower extremity pain. 3 ● Intrathecal pain pumps, which can deliver opioids (and other medications) into the spinal fluid with fewer side effects and at lower doses than with oral opioids, although significant side effects such as delayed respiratory depression, granuloma formation, and opioid-induced hypogonadism can occur. 3
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Book Code: MDCO1025
● Vertebral augmentation, which uses various techniques, including injecting cement into vertebral compression fractures that are painful and refractory to treatment. 3 Behavioral health options There is ample evidence that chronic pain is both associated with and complicated by psychiatric, psychological, and social factors that exert tremendous influence over the pain experience and the success of treatment. 35-37 The higher the impact of pain, the worse the disruption to the person’s relationships, work, physical activity, sleep, self- care, and self-esteem. 3 Those with comorbidities that include depressive and anxiety disorders face additional challenges that complicate treatment by worsening pain and quality of life and rendering the activities of daily living more difficult. An estimated 30% of patients with chronic pain also have an anxiety disorder, such as generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), and agoraphobia. 3 Furthermore, high levels of depression and anxiety worsen pain and pain-related disability. 38 Patients with chronic pain have more disability than patients with other chronic health conditions. 3 In addition, patients with chronic pain are at increased risk for psychological distress, maladaptive coping, and physical inactivity related to fear of reinjury. 35 Behavioral therapies are valuable for helping patients cope with the psychological, cognitive, emotional, behavioral, and social aspects of pain. Common behavioral health approaches include: ● Behavioral therapy for pain, which seeks to reduce maladaptive pain behaviors, such as fear avoidance, and increase adaptive behaviors with the goal of increasing function; it has demonstrated effectiveness (and cost- effectiveness) for reducing pain behaviors and distress and improving overall function. 3 ● CBT, which focuses on shifting cognitions and improving pain coping skills in addition to altering behavioral responses to pain; CBT is effective for a variety of pain problems (including low-back pain and fibromyalgia), helps improve self-efficacy, reduces pain catastrophizing, and improves overall functioning. 3,33,39 Complementary and integrative health approaches These therapies can be overseen by licensed practitioners and trained instructors and are used as standalone treatments or in combination with a multidisciplinary plan. 3 The following treatments may be considered for acute and chronic pain, according to patient status: 3 ● Acupuncture, which involves manipulating a system of meridians where “life energy” flows by inserting needles into identified acupuncture points; with its origins in Chinese medicine, acupuncture is received by an estimated 3 million Americans each year. 49 There is growing evidence of the therapeutic value of acupuncture in pain conditions that include osteoarthritis, migraine, and low back,
● Interspinous process spacer devices, which can provide relief for patients with lumbar spinal stenosis with neuroclaudication. 3
● Acceptance and commitment therapy, which emphasizes observing and accepting thoughts and feelings, living in the present moment, and behaving according to one’s values; it differs from conventional CBT in that psychological flexibility is created through accepting rather than challenging psychological and physical experiences. 3,40,41 ● Mindfulness-based stress reduction (MBSR), which stresses body awareness and training in mindfulness meditation (i.e., nonjudgmental awareness of present-moment sensations, emotions, and thoughts), typically delivered in group format; research suggests effectiveness for coping with a variety of pain conditions (including rheumatoid arthritis, low back pain, and MS) as well as improvements in pain intensity, sleep quality, fatigue, and overall physical functioning and well-being. 3,39,42-46 ● Emotional awareness and expression therapy, which is an emotion-focused therapy for patients with a history of trauma or psychosocial adversity who suffer from centralized pain conditions; patients are taught the effect of unresolved emotional experiences on neural pathways involved in pain and how to adaptively express those emotions. 3 Research indicates a positive impact on pain intensity, pain interference, and depressive symptoms. 47 ● Self-regulatory or psychophysiological approaches, which include biofeedback, relaxation training, and hypnotherapy, help patients develop control over their physiologic and psychological responses to pain. 3 ○ Biofeedback, which provides real-time feedback about physiologic functions such as heart rate, muscle tension, and skin conductance and has evidence of effectiveness for chronic headache in adults and children. 3,48 ○ Relaxation training and hypnotherapy, which neck, and knee pain; however, existing clinical practice guidelines differ in their evidence analysis and recommendations for acupuncture use. 3 Risks are minimal when performed by a licensed, experienced, well-trained practitioner using sterile needles. 3 ● Massage and manipulative therapies, including osteopathic and chiropractic treatments, which may be clinically effective for short-term relief and are recommended in consultation with primary care and pain management teams. 3 Despite the paucity of rigorous studies, the lack of detail on massage types, and the smallness of sample sizes, positive effects of massage are recognized for alter attentional processes and heighten physical and psychological relaxation, have empirical support in pain management. 3
Book Code: MDCO1025
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various pain conditions that include postoperative pain, headaches, and neck, back, and joint pain. 3,50- 53 ● MBSR, which is also discussed under behavioral health approaches, and which has evidence of statistically significant beneficial effects for low- back pain and is shown in a meta-analysis to significantly reduce the intensity and frequency of primary headache pain. 39,54 ● Yoga, which uses stretching, breathing, and meditation and has been shown to be therapeutic in the treatment of various chronic pain conditions, particularly low-back pain. 55-58 Risks are minimal, and yoga can generally be practiced safely, especially when delivered in group settings. 3,59 ● Tai chi, which originated as a Chinese martial art and uses slow movements and meditation, and which has demonstrated long-term benefit for osteoarthritis and other musculoskeletal pain conditions. 60,61 Like yoga, it is generally safe and
has the benefits of a group setting and availability via telehealth. 3 ● Spirituality, which encompasses a broad range of resources and practices, such as prayer and meditation, has growing evidence of benefit for people with pain. 62 It has long been integral to palliative and supportive care, and is gaining support as a means to help patients cope with and manage ongoing pain. 3 Self-Assessment Question 3 Which factors influence pain according to the International Which noninvasive, nonpharmacologic approaches to pain management would be categorized as restorative?
a. Acupuncture. b. Biofeedback. c. Mindfulness-based stress reduction. d. Physical therapy.
NONOPIOID PHARMACOLOGIC OPTIONS FOR PAIN
Numerous nonopioid pharmacologic therapies are available for pain, and these should be tried or considered, alone or in combination, before initiating long-term opioid therapy. 3 Acetaminophen (ACET) is used to treat mild-to- moderate pain without inflammation. All ACET products carry an FDA-required black box warning highlighting the potential for severe liver damage and potential for allergic reactions. 63 HCPs and patients should be aware of the dose levels from all prescribed and over-the-counter medication sources to avoid exceeding the recommended daily dosage. Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen, naproxen, and cyclooxygenase-2 (Cox-2) inhibitors and are used to treat mild-to-moderate pain and inflammation. Indications are numerous and include arthritis, bone fractures or tumors, muscle pains, headache, and acute pain caused by injury or surgery. 3 Nonselective NSAIDs are those that inhibit the activity of both COX-1 and COX-2 enzymes and can be associated with gastritis, gastric ulcers, and gastrointestinal (GI) bleeding. 3 COX-2 inhibitors have fewer GI adverse effects. 1 Risks are elevated with NSAIDs for heart attack, stroke, GI bleeding or perforation, and renal and cardiovascular abnormalities, particularly at higher doses and longer duration of use. 64 Anticonvulsants, such as gabapentin and pregabalin, have mild-to-moderate benefit for neuropathic pain syndromes, including postherpetic neuralgia and peripheral neuropathy, and are also commonly used to treat migraine and as part of a multimodal approach to treating perioperative pain. 3 Adverse effects include drowsiness, cognitive slowing, 32 and a risk of misuse, particularly in people with a history of misusing opioids. 62 Gabapentin dose should be adjusted in chronic kidney disease. Antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic
antidepressants, are used in low doses for insomnia and neuropathic pain. Doses are typically lower for analgesia than those required to treat depression. SSRIs (e.g., fluoxetine, sertraline, citalopram, and paroxetine) have less analgesic effect compared with other antidepressant classes. 3 SNRIs (e.g., venlafaxine, duloxetine) are effective for a variety of chronic pain conditions, including musculoskeletal pain, fibromyalgia, and neuropathic pain, and are associated with less drowsiness, memory impairment, and cardiac conduction abnormalities than tricyclic antidepressants. Tricyclics (e.g., desipramine, nortriptyline, amitriptyline) are initiated at low doses and gradually titrated to effect. Depending on class, risks and adverse effects may include dry mouth, dizziness, sedation, memory impairment, orthostatic hypotension, urinary retention, cardiac conduction abnormalities, sexual dysfunction, weight gain, emotional blunting, and suicidal thoughts. 3,32 Second- generation tricyclic antidepressants (e.g., nortriptyline) tend to be better tolerated than the first generation (e.g., amitriptyline). Withdrawal reactions are possible when antidepressants are suddenly stopped. Musculoskeletal agents for pain and muscle spasm are for short-term use with sedation being a common adverse effect. Common medications used in pain treatment include baclofen, tizanidine, and cyclobenzaprine. Particular risks are notable with carisoprodol (toxicity, unclear therapeutic benefit) and benzodiazepines (SUD, respiratory depression leading to overdose) when prescribed in combination with opioids. 32 Considering the risks with carisoprodol and benzodiazepines and the availability of other agents, these medications are not recommended to treat pain from muscle spasm. 3 Topical medications include lidocaine, ketamine, capsaicin, and anti-inflammatory drugs such as ketoprofen and diclofenac. Anti- inflammatory topicals are proven beneficial for musculoskeletal pain, as is capsaicin for neuropathic pain. 32
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Book Code: MDCO1025
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