Pennsylvania Physician First Renewal Ebook Continuing Educa…

This interactive Pennsylvania First Renewal Physician Ebook contains 6 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.

Pennsylvania Continuing Medical Education

2024 Pennsylvania Medical Licensure Series










InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.






BEST PRACTICES FOR TREATING PAIN WITH OPIOID ANALGESICS COURSE TWO | 2 CREDITS** CHILD ABUSE RECOGNITION AND REPORTING IN PENNSYLVANIA COURSE THREE | 2 CREDITS+ InforMed reports all Child Abuse credits to the Pennsylvania Licensing System (PALS). The date of completion submitted to PALS is the same date of completion that appears on your certificate.




*Satisfies Mandatory Requirement for Two (2) Credit Hours in Opioid Education - Pain Management **Satisfies Mandatory Requirement for Two (2) Credit Hours in Opioid Education - Prescribing Opioids +Satisfies Mandatory Requirement for Two (2) Credit Hours in Child Abuse

Program Options

Price Book Option




6 Credits PENN24CME

Alternatives to Opioids for Pain Management

$50 $50 $50

2 Credits


Best Practices for Treating Pain with Opioid Analgesics Child Abuse Recognition and Reporting in Pennsylvania

2 Credits


2 Credits


CME that counts for MOC Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities (see page iii for further details). InforMed currently reports to the following specialty boards: the American Board of Internal Medicine (ABIM), the American Board of Anesthesiology (ABA), the American Board of Pediatrics (ABP), the American Board of Otolaryngology–Head and Neck Surgery (ABOHNS), and the American Board of Pathology (ABPath). To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting. 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.

InforMed has joined the Elite Learning family Two of the nation’s top healthcare education providers have joined forces with one goal in mind: to offer physicians a state-of-the-art learning experience that fulfills your state requirements and empowers you with the knowledge you need to provide the best patient care. Here’s what you can expect from our new partnership: • COURSES: In addition to the mandatory courses you need to renew your state license, you’ll now have access to dozens of hours of elective courses and an expanded content library. • ACCOUNTS: You’ll also have access to a personalized learner account. In your account you can add, organize, and track your ongoing and completed courses. For instructions on how to set up your account, email us at • BOOK CODES: You may notice a book code on the back cover of the latest InforMed program you’ve received in the mail. When entered on our new site, this code will take you directly to the corresponding self-assessment. See more information below. How to complete Please read these instructions before proceeding. Read and study the enclosed courses and answer the self-as - sessment questions. To receive credit for your courses, you must provide your customer information and com - plete the mandatory evaluation. We offer three ways for you to complete. Choose an option below to receive credit and your certificate of completion. Scan this QR code to complete your CE now !

Fastest way to receive your certificate of completion


• Go to BOOK.CME.EDU . Locate the book code PENN24CME found on the back of your book and enter it in the box then click GO . • If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need 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. • To find additional elective hours, please visit PA.CME.EDU .

Enter book code



If you need help finding your code, Browse Book Code FAQs

By mail

By fax

• Fill out the answer sheet and evaluation found in the back of this booklet. Please include a check or credit card information and e-mail address. Mail to InforMed, PO Box 2595, Ormond Beach, FL 32175-2595 . • Completions will be processed within 2 business days from the date it is received and certificates will be e-mailed to the address provided.

• Fill out the answer sheet and evaluation found in the back of this booklet. Please include credit card information and e-mail address. Fax to 1-800-647-1356 . • All completions will be processed within 2 business days of receipt and certificates will be e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided.

• Submissions without a valid e-mail will be mailed to the address provided.






Pennsylvania Professional License Requirements

The Pennsylvania State Boards of Medicine and Osteopathic Medicine require all physicians (MD/DO) maintaining a current license to complete one-hundred (100) credits of continuing medical education during the current licensure cycle, unless exempt. For MDs at least twenty (20) of these credits shall be AMA PRA Category 1 Credits ™ and for DOs at least twenty (20) of these credits shall be AOA Category 1. A. The Pennsylvania Board of Podiatric Medicine requires all licensees to complete fifty (50) credits of continuing medical education of which at least thirty (30) shall be approved by Council on Podiatric Medical Education (CPME). The remaining hours can be AMA PRA Category 1 Credits™ or equivalent. CONTINUING MEDICAL EDUCATION REQUIREMENT FOR LICENSE RENEWAL


CHILD ABUSE Act 31 of 2014 states that all health-related licensees applying for the renewal of a license are required to complete at least two (2) hours of Board-approved continuing education in child abuse recognition and reporting requirements as a condition of renewal. OPIOID EDUCATION FOR LICENSE RENEWAL: All physicians (MD/DO), physician assistants (PA), and podiatrists (DPM) with a current DEA registration must complete two (2) credit hours in pain management, addiction, or the prescribing/ dispensing of opioids as a condition of biennial renewal; unless exempt. This continuing education requirement will count towards the total number of continuing education credits required for renewal. NEW LICENSEES: Licensees in the state of Pennsylvania are required to complete a total of four (4) hours of opioid education within 12 months of initial licensure; consisting of at least two (2) hours of education in opioid prescribing AND two (2) hours in pain management [or] identification of addiction. This is a one-time requirement. See page 70 for further details on the opioid education requirements.


10/31/2024 DO:

12/31/2024 DPM:

Disclaimer: The above information is provided by InforMed and is intended to summarize state CE/CME license requirements for informational purposes only. This is not intended as a comprehensive statement of the law on this topic, nor to be relied upon as authoritative. All information should be verified independently.


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 In addition to awarding AMA PRA Category 1 Credits TM , the successful completion of enclosed activities may award the following MOC points and credit types. To be awarded MOC points, you must obtain a passing score and complete the corresponding activity evaluation.


American Board of Internal Medicine’s Maintenance of Certification (MOC) program

American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC)



American Board of Pathology’s Continuing Certification Program


American Board of Pediatrics’ Maintenance of Certification (MOC) program

Table 2. Credits and Type Awarded

AMA PRA Category 1 Credits TM 2 AMA PRA Category 1 Credits TM 2 AMA PRA Category 1 Credits T M 2 AMA PRA Category 1 Credits T M

Activity Title


Alternatives to Opioids for Pain Management Best Practices for Treating Pain Management

2 Credits LL 2 Credits LL & PS 2 Credits LL

2 Credits MK 2 Credits MK & PS 2 Credits MK

2 Credits LL & SA

2 Credits SA 2 Credits SA & PS 2 Credits SA

2 Credits LL 2 Credits LL 2 Credits LL

2 Credits LL+SA 2 Credits LL+SA

2 Credits LL, SA, & PS

Child Abuse Recognition and Reporting in Pennsylvania 2 Credits LL+SA Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, PS = Patient Safety 2 Credits LL & SA

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.






Release Date: 1/2022 Exp. Date: 12/2024

2 AMA PRA Category 1 Credits ™

Enduring Material (Self Study)

TARGET AUDIENCE This course is designed for all physicians and health care professionals involved in the treatment and monitoring of patients with pain. COURSE OBJECTIVE This CME learning activity is designed to increase physician knowledge and skills about guideline-recommended principles for effectively managing chronic and acute pain conditions with non-opioid pain treatments with a focus non-opioid options for four common painful conditions: osteoarthritis, low-back pain, diabetic neuropathy, and fibromyalgia.

• Read the course materials. • Complete the self-assessment questions at the end. A score of 70% is required. • Ret urn your customer information/ answer sheet, evaluation, and payment to InforMed by mail, phone, fax or complete online at program website. HOW TO RECEIVE CREDIT:

Completion of this course will better enable the course participant to: 1. Explain the potential value of creating and using function-based treatment plans for patients with chronic pain conditions. 2. Discuss the general principles for initiating treatments for acute or chronic pain conditions. 3. Describe examples of non-opioid analgesic options for managing acute pain. 4. Describe examples of non-opioid analgesic options for managing chronic non-cancer pain. LEARNING OBJECTIVES IMPLICIT BIAS IN HEALTHCARE 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. ACCREDITATION STATEMENT InforMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. DESIGNATION STATEMENT 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.


FACULTY Paul J. Christo, MD, MBA Director, Multidisciplinary Pain Fellowship Program Associate Professor of Anesthesiology and Critical Care Medicine The Johns Hopkins University School of Medicine Annette Skopura, PHD



Medical Writer EnlightenMed

Opioid Education

ACTIVITY PLANNER Michael Brooks CME Director InforMed


This course satisfies two (2) hours of opioid education in pain management.

Licensed Pennsylvania physicians, physician assistants, and podiatrists seeking re-licensure must complete two (2) credit hours in pain management, addiction, or the prescribing/ dispensing of opioids. Unless exempted, this requirement must be completed as a condition of biennial renewal. New licensees are required to complete a total of four (4) hours of opioid education within 12 months of initial licensure consisting of at least two (2) hours of education in opioid prescribing AND two (2) hours in pain management OR addiction.

DISCLOSURE OF INTEREST In accordance with the ACCME Standards for Commercial Support of CME, 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:

• Paul J. Christo, MD, MBA has received honoraria from GlaxoSmithKline, Daiichi Sankyo, and BTG International. The following faculty and/or planning committee members have indicated that they have relationship(s) with industry to disclose:

• •

Annette Skopura, PHD

Michael Brooks


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.


create objective treatment goals. This impact takes many forms, including reductions or dysfunctions in physical activity, concentration, emotional stability, interpersonal relationships, and sleep. These impacts, in turn, degrade functioning at work or in the home, which can lead to depression, anxiety, insomnia, and even suicide. Even relatively modest pain reductions can lead to significant functional improvements. 10 A 20% reduction in a pain score (i.e., roughly two points on the standard 0-10 pain scale) may be acceptable if it produces significant functional benefits for a patient. Function-based treatment goals, rather than pain relief goals, offer two primary advantages to clinicians: • Treatment decisions are based on outcomes that can be objectively demonstrated to both clinician and patient (and, possibly, to the patient’s family) • Individual differences in pain tolerance become secondary to the setting and monitoring of treatment goals, since subjectively perceived levels of pain are not the primary focus in determining functionality. Function-based treatment plans are especially valuable in the context of prescribing opioid pain medications, because such goals may help determine whether a patient has an opioid use disorder, but they serve many useful purposes even when treatments do not involve opioids. Functional decline itself may result from a range of problems, including inadequate pain relief, non-adherence to a regimen, function-limiting side effects, or untreated affective disorders. Sometimes impaired functioning is the result of an opioid use disorder (OUD), and these objective results may shed valuable light on an otherwise confusing presentation of pain symptoms. It’s important to set realistic functional goals. Progress in restoring function is usually slow, irregular, and gains are typically incremental. Chronic non-cancer pain is often marked by long- standing physical and psychological deconditioning, and recovery may require reconditioning that may take weeks, months, or years. It is much better to set goals that are slightly too low than slightly too high. Raising goals after a patient has “succeeded” in achieving them is far more motivational and encouraging than lowering goals after a patient has “failed” (although one should not use the word “fail” or “failed” in actual practice). Treatment initiation A central tenet of pain management, whether for acute or chronic pain, is to aim for a tolerable level of pain that allows the patient maximum physical and emotional functioning with the lowest risk of side effects, progression to chronic pain, or misuse or abuse. 10 This requires a careful balancing of patient-related factors (e.g., comorbidities, medical

history, risk of abuse) and drug-related factors (e.g., potency, mechanism of action, expected side effects). A commonly-recommended way to achieve this balance is with multimodal analgesia, in which several therapeutic approaches are used, each acting on different pain pathways, which can reduce dependence on a single medication and may reduce or eliminate the need for opioids and attendant risks/side effects. 11 Multimodal analgesia can produce synergistic effects, reduce side effects, or both. One example of multimodal analgesia is the use of both an NSAID and acetaminophen, plus physical approaches (e.g., cold, compression, or elevation) to manage postoperative pain. Demonstrated benefits of multimodal analgesia include earlier ambulation, earlier oral intake, and earlier hospital discharge for postoperative patients, as well as higher levels of participation in activities necessary for recovery (e.g., physical therapy). 11 The many pharmacologic and non- pharmacologic approaches to treating acute and chronic pain should be employed using the following general principles: • Identify and treat the source of the pain, if possible, although pain treatment can begin before the source is determined • Use the simplest approach to pain management first. This generally means using non-pharmacologic approaches as much as possible and/or trying medications with the least severe potential side effects, and at the lowest effective doses • Create individualized treatment plans if therapy is expected to last longer than a week • Reserve opioid analgesics for moderate-to- function-based, severe acute pain unresponsive to non-opioid therapies or moderate-to-severe chronic pain in patients who have been assessed for risk of abuse or dependence and for whom previous trials of both drug and non-drug approaches have failed to provide an adequate response. Managing patient expectations Patients in pain are understandably worried that the pain will persist or get worse with time. Physicians can reduce such fears and set realistic expectations for treatment effectiveness and healing with clear, compassionate communication couched in terms patients can easily understand. It can be helpful, for example, to share with patients the fact that most forms of acute pain (e.g., nonspecific low back pain) are self-limiting, subside within weeks, and do not require invasive interventions. (In a systematic review of 15 prospective cohort studies, 82% of people who stopped work due to acute low back pain returned to work within one month.) 12

Introduction Across specialties, physicians are concerned about opioid pain medication misuse, they find managing patients with chronic pain stressful, express concern about patient addiction, and say they have insufficient training in prescribing opioids. 1 It is increasingly understood that although opioids can effectively control pain, addiction can be a consequence of prolonged use, and long-term opioid therapy is often overprescribed for patients with chronic non-cancer pain. 2 Many of the problematic issues surrounding the use of opioids for chronic pain are equally compelling and urgent in the treatment of acute pain. For example, a number of studies demonstrate an increased risk of new persistent opioid use in opioid-naïve patients after having been prescribed opioids for acute pain. 3-6 Physicians are constantly challenged to provide optimum pain relief for those suffering from acute and chronic pain in an era dominated by a profound opioid crisis. In 2020 an average of 252 people were dying every day from opioid-related overdoses. 7 In this context it is essential that clinicians become familiar with the wide array of non-opioid analgesic treatment options (both pharmacologic and non-pharmacologic) for acute and chronic pain conditions. Clinicians need to understand the relatively recent evidence showing that opioids may not be very effective for relieving chronic pain in the long-term and, in fact, may be associated with increased pain, reduced functioning, and opioid dependence. 8,9 This CME learning activity focuses on the evidence supporting the effectiveness of non-opioid therapies, suggests strategies for assessing and managing patients with both chronic and acute pain, and takes an in-depth look at non-opioid options for four common painful conditions: osteoarthritis, low- back pain, diabetic neuropathy, and fibromyalgia.

General strategies for pain management

The importance of function-based pain treatment plans Formal treatment plans are seldom needed for treating acute pain conditions, but they may be extremely valuable when treating patients with chronic pain, regardless of the specific treatment options being considered. The plans should include the goals of therapy and should be written carefully because pain is inherently subjective. Since pain cannot be measured objectively, framing treatment goals solely in terms of pain relief means that such goals cannot be objectively confirmed. Although a patient’s subjective pain and suffering are obviously important, only the functional impact of the pain can be measured and used to


Regular communication with patients may be helpful. A systematic review of 14 controlled trials of patient education interventions for low back pain showed that structured messaging by providers can reassure patients more than usual care/ control education both in the short and long term. 13 Messaging was significantly more reassuring to patients when delivered by physicians as opposed to other primary care practitioners, and such communication reduced the frequency of primary care visits. Non-opioid options for acute pain The initial choice for treating acute pain conditions should not involve opioids because, as noted above, many of the problems and risks associated with managing chronic pain with opioids are also in play when managing acute pain with opioids. For example, a number of studies demonstrate increased risk of new persistent opioid use in opioid-naïve patients after having been prescribed opioids for acute pain. 3-6 Although the risk of opioid misuse in patients prescribed opioids for acute post-surgical or post-procedural pain is relatively small (roughly 0.6% per year) 14 , the volume of such procedures (approximately 48 million ambulatory surgeries or procedures in 2010) 15 means large numbers of patients (i.e., approximately 160,000) may develop misuse, abuse, or overdose every year. Non-drug treatments for acute pain The degree to which it is possible to treat acute pain without opioids depends on the severity, type, and origin of the pain, but many

non-pharmacological approaches can be very effective and their use avoids the potential side effects and risks associated with pharmacological interventions. 16 Physical methods of pain management can be helpful in all phases of care, including immediately after tissue trauma (e.g., rest, application of cold, compression, elevation) and later in the healing period (e.g., exercises to regain strength and range of motion). Non-pharmacologic methods can include: 16 • Application of cold (generally within first 24 hours) or heat • Compression • Elevation • Immobilization • Relaxation exercises • Distraction/guided imagery • Acupuncture • Massage • Electroanalgesia (e.g., transcutaneous electrical nerve stimulation) • Physical therapy • Yoga Physical therapy may be useful for a range of musculoskeletal issues and can be helpful in recovering from acute pain-producing traumas initially treated with other methods. A 2018 study reported that patients with low back pain who first consulted a physical therapist were less likely to receive an opioid prescription compared to those who first saw their primary care physician. 17

Exercise therapy can take many forms, including walking, swimming or in-water exercise, weight training, or use of aerobic or strength-training equipment. According to a review by the Centers for Disease Control and Prevention (CDC), conditions that may improve with exercise therapy include low back pain, neck pain, hip and knee osteoarthritis pain, fibromyalgia, and migraine. 18 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1.

Non-opioid pharmacologic treatments for acute pain

Acetaminophen and NSAIDs Mild-to-moderate acute pain generally responds well to oral non-opioids (e.g., acetaminophen, non- steroidal anti-inflammatories [NSAIDs], and topical agents). Although they are weaker analgesics than opioids, acetaminophen and NSAIDs do not produce tolerance, physical dependence, or addiction and they do not induce respiratory depression or constipation. The choice of medication may be driven by patient risk factors for drug-related adverse effects. If acetaminophen or NSAIDs are contraindicated or have not sufficiently eased the patient’s pain or if functioning has not improved despite maximal or combination therapy, other drug classes (e.g., opioids) may be considered. Non-opioid analgesics are not without risk, particularly in older patients. The FDA recommends that the total adult daily dose not exceed 4,000 mg in patients without liver disease (with a lower ceiling for older adults – generally 3,000 mg). 19

Case Study 1

Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow.

Ruth is a 66 year old female with history of right knee pain from osteoarthritis that was becoming progressively worse and limiting her activity. Ruth lives in a two-story home and has enjoyed sports and being physically active. She underwent a right total knee replacement three days ago and is scheduled to start physical and occupational therapy soon. Ruth was discharged with a prescription for oxycodone 10 mg q4-6 hrs. which she has been taking, although she complains of constipation. She is afraid to take more oxycodone because she says she’s afraid of becoming addicted, but is also anxious about getting off the opioids. She has come for a check of the incisions, which are healing well, but she is very worried that the physical therapy will be too painful to bear.

1. What might you be able to communicate to Ruth to help allay her anxieties?

2. What alternatives to the oxycodone might you suggest that Ruth try?

3. How can you and Ruth create a plan, or record, that will provide some objective measures of progress, both in terms of pain relief as well as function?


The FDA currently sets a maximum limit of 325 mg of acetaminophen in prescription combination products (e.g., hydrocodone and acetaminophen) in an attempt to limit liver damage and other potential ill effects of these products. 32 Topical capsaicin and salicylates can both be effective for short term pain relief and generally have fewer side effects than oral analgesics, but their long-term efficacy is not well studied. 20,21 The burning sensation from topical capsaicin can be difficult to tolerate. Topical aspirin can help reduce pain from acute herpes zoster infection. 22 Topical NSAIDs and lidocaine may also be effective for short-term relief of superficial pain with minimal side effects. Topical agents can be simple and effective for reducing pain associated with wound dressing changes, debridement of leg ulcers, and other sources of superficial pain. 22


Adjunct in opioid-tolerant patients with sickle cell crisis Adjunct in patients with obstructive sleep apnea

The goal of body weight reduction is a baseline weight loss of 7%-10% by calorie reduction and increased activity using a balanced diet with less than 30% of calories from fat, 15%-20% from protein, and 45%-60% from carbohydrates. 30 Passive options Acupuncture involves the stimulation of specific points on the body, most often involving skin penetration with fine metallic needles manipulated by hand but sometimes also including electrical stimulation or low intensity laser therapy. Potential adverse events include minor bruising and bleeding at needle insertion sites. 31 Transcutaneous electrical nerve stimulation (TENS) involves mild electrical pulses applied cutaneously. The electrical stimulation from TENS may block or disrupt pain signals to the brain, reducing pain perception. TENS machines can be used at home or in conjunction with other interventions like physical therapy. Cognitive and behavioral options Cognitive behavioral therapy (CBT) is a structured, time-limited (typically 3-10 weeks) intervention focused on how thoughts, beliefs, attitudes, and emotions influence pain and can help patients use their minds to control and adapt to pain. This therapy includes setting goals, often with recommendations to increase activity to reduce feelings of helplessness. 32 Meditation Mindfulness meditation programs typically include a time-limited (8 weeks; range 3-12 weeks) trainings with group classes and home meditation. The objective is to inculcate a long-term practice that helps patients refocus their minds on the present, increase awareness of self and surroundings, and reframe experiences. 33,34 Injection-based interventions Several types of injection therapies can help to ease pain and provide durable relief. In the spine, multiple pain generators can be targeted: facet joints, discs, nerves, and muscles. 35 Parts of the sympathetic nervous system can be accessed with therapeutic injections for patients with visceral pain, and injections into specific joints with steroid or viscosupplements can reduce joint pain. 35 Epidural steroid injections, radiofrequency ablation, pulsed and cooled radiofrequency procedures, and neuromodulation treatments (spinal cord stimulation, peripheral nerve stimulation) all have an important role in reducing chronic pain. 36-38


• Dose °

Bolus IV: up to 0.35 mg/kg Infusion: up to 1 mg/kg/hour


• Contraindications °

Poorly-controlled cardiovascular disease

° ° ° ° °

Pregnancy Psychosis

Severe hepatic disease

Elevated intracranial pressure Elevated intraocular pressure

Non-opioid options for chronic non-cancer pain

Non-pharmacologic approaches Physical rehabilitative and surgical approaches, procedural therapies (e.g., injections, nerve blocks), complementary therapies, and use of approved/cleared medical devices may all be potentially effective either alone or as part of a comprehensive pain management plan, particularly for musculoskeletal pain and chronic pain. 26 Movement-based options Muscle-strengthening, stretching, and aerobic exercise (e.g., walking, aquatics) may all be helpful for patients in chronic pain. Recommended exercise programs typically occur one to three times a week for a total of 60-180 minutes per week, but any regimen must be carefully tailored to a patient’s existing level of physical conditioning, comorbidities, and cognitive status. 27-29 Additional movement-based options include: • Physical therapy supervised by a licensed physical therapist, which can include resistance, aerobic, balance, and flexibility exercises as well as elements of massage, manipulation, or transcutaneous electrical nerve stimulation. • Tai chi, a mind-body practice that combines controlled movements, meditation, and deep breathing. “Chair tai chi” can be an option for patients with limited mobility. • Yoga, exercises or a series of postures designed to align muscle and bones, and increase strength and flexibility. It can also relax mind and body through breathing exercises and meditation. Gentler forms of yoga that may be more appropriate for older patients include Iyengar, Hatha, or Viniyoga. Weight loss Some pain syndromes, such as knee osteoarthritis, are worsened by obesity. For some patients, pain due to this condition is improved by reducing body weight, which lowers physical stresses on affected joints.


Anticonvulsants, gabapentin, pregabalin, oxcarbazepine, and carbamazepine, are often prescribed for chronic neuropathic pain (e.g., post-herpetic neuralgia and diabetic neuropathy) although evidence for efficacy in acute pain conditions is weak. 23 A 2017 trial, for example, randomized 209 patients with sciatica pain to pregabalin 150 mg/day titrated to a maximum of 600 mg/day vs. placebo for 8 weeks. 24 At 8 weeks there was no significant difference in pain between groups (mean leg pain intensity on a 0-10 scale 3.7 with pregabalin vs. 3.1 with placebo, P=0.19). Potential side effects of anticonvulsants include sedation, dizziness, and peripheral edema. Pregabalin and gabapentin also have some abuse potential in the general population because some users report euphoric effects. Abrupt cessation of anticonvulsants may precipitate withdrawal symptoms. 23 such as Ketamine Ketamine has been used as a general anesthetic since the 1960s, but its use in subanesthetic concentrations for analgesia has grown rapidly in recent years, due, in part, to efforts to reduce the risks of chronic opioid use. 25 Ketamine has been successfully used to treat such acute pain conditions as sickle cell crises, renal colic, and trauma. 25 In 2018 the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists released joint recommendations for subanesthetic ketamine (including transdermal ketamine) for acute pain with the following guidelines: 25 • Indications ° Perioperative use in surgery with moderate to severe postoperative pain


Perioperative use in patients with opioid tolerance


Non-opioid drug approaches In addition to the non-opioid pharmacologic options reviewed above, evidence suggests efficacy for the following drug classes in the context of treating chronic non-cancer pain: • Antidepressants ° serotonin and/or norepinephrine reuptake inhibitors ° tricyclic antidepressants (TCAs) ° selective serotonin reuptake inhibitors (SSRIs) • Topical lidocaine or capsaicin • Possible cannabinoid-based therapies Serotonin norepinephrine reuptake inhibitors SNRIs such as duloxetine, venlafaxine, and milnacipran are characterized by a mixed action on norepinephrine and serotonin, though their exact mechanism of action for pain reduction is unknown. Side effects (e.g., nausea, dizziness, and somnolence) may limit treatment. Routine monitoring for blood pressure (duloxetine and venlafaxine), heart rate (venlafaxine), and drug interactions (duloxetine) is recommended. SNRIs can be very helpful in patients who have central sensitization. TCAs TCAs inhibit reuptake of norepinephrine and serotonin, but their mechanism of action for pain relief is unknown. Examples of TCAs studied for the management of chronic pain include amitriptyline, desipramine, and nortriptyline. Side effects, such as anticholinergic effects (e.g., dry mouth, constipation, dizziness) and QTc prolongation can limit the use of TCAs in elderly patients. The majority of side effects occur at the typically higher doses used to treat depression. SSRIs SSRIs, such as citalopram, fluoxetine, and paroxetine, block the reuptake of serotonin in the brain, making more serotonin available in the synapse. The mechanism of SSRIs for pain remains unknown. Compared to SNRIs and TCAs, there is relatively little evidence to support the use of SSRIs in treating chronic pain conditions. 39 Potential side effects of SSRIs include weight gain, sexual dysfunction, and QTc prolongation, especially with citalopram. Topical lidocaine Topical lidocaine inhibits the conduction of nociceptive nerve impulses. Irritation at the application site is the most common side effect. The most common products for chronic pain management are lidocaine 5% patches, available by prescription, and lidocaine 4% patches available OTC.

Cannabinoid preparations With medical cannabis now legal in 34 states and recreational use legal in 11 states and the District of Columbia (as of May, 2020) 40 , there has been increased interest among patients for the use of cannabis or cannabis derivatives (e.g., cannabidiol [CBD]) for chronic pain relief. The CB1 and CB2 receptors have been shown to mediate the analgesic effects of cannabinoids 41 and some evidence suggests a potential benefit for chronic pain. A 2017 National Academies of Science report, for example, concluded that “conclusive or substantial evidence” supports a beneficial role for cannabis or cannabinoids for treating chronic pain, 42 and a 2018 Cochrane review of the existing literature evaluating cannabinoids (cannabis, CBD, or combinations) suggests that these agents are moderately effective for neuropathic pain with adverse effects that are less than, or comparable to, existing non-opioid analgesics. 43 A systematic review of both randomized trials (47) and observational studies (57) in patients with chronic non-cancer pain published through July 2017 found moderate evidence that cannabinoids can exert analgesia. 44 Cannabis preparations, however, may pose both short-term and long-term risks. Short-term effects include impaired memory, motor coordination, and judgment. Paranoid ideation and psychotic symptoms, while rare, may occur with high doses of THC. Possible long-term effects include impaired brain development in young adults, potential for habituation, increased risk of anxiety or depression, and cannabis use disorder. Abrupt cessation of marijuana in long-term users may cause withdrawal symptoms such as anxiety, irritability, craving, dysphoria, and insomnia. There is an increased risk of chronic bronchitis, respiratory infections, and pneumonia with inhaled products. 45 FDA-approved cannabinoids include dronabinol (Marinol), indicated for second-line treatment of chemotherapy-induced nausea and vomiting, and anorexia-associated weight loss in patients with HIV. Nabilone (Cesamet and Syndros) are indicated for chemotherapy-induced nausea and vomiting. Common side effects include dizziness/vertigo and euphoria. Dronabinol may cause nausea/vomiting, abdominal pain, and abnormal thinking. Nabilone may cause ataxia and dry mouth. 45,46,47 None of these are indicated for the treatment of pain, although some emerging evidence suggests that THC has analgesic and/or antispasmodic properties that can ameliorate some types of acute or chronic pain (e.g., lumbar pain/spasms). 42 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2 ON THE NEXT PAGE.

Disease-specific guidance

Osteoarthritis Exercise and physical activity

A 2018 Cochrane review of 21 randomized trials including 2,372 patients with hip, knee, or hip and knee osteoarthritis (OA) found that exercise- based interventions reduced pain scores (on a 0-20 scale) by a mean of 1.2 points after about 45 weeks (6% absolute reduction compared to non-exercise treatments; 95% CI: -9% to -4%). 48 Physical functioning improved by 5.6 points on a 0-100 scale but the result was not significant (5.6% absolute reduction; 95% CI: -7.6% to 2%). Exercise interventions were diverse and included tai chi, physical therapy, strength training, and aerobic exercise (e.g., walking, cycling). The importance of clear patient education about the potential benefits of exercise for patients with OA was suggested by results from a review of 12 qualitative studies, conducted as part of the same Cochrane review. The authors noted that patients are often worried that they might hurt themselves by exercising, or that the exercise might worsen their symptoms. Patients wanted providers to give better information about the safety and value of exercise as well as exercise recommendations tailored to individual patient needs and abilities. 48 A 2019 trial randomized 171 adults aged ≥60 years with knee OA to a 12-week home-based exercise intervention plus health education vs. health education only. 49 The exercise intervention involved group training sessions plus at-home strength and flexibility exercises to be done 30-40 minutes/day, three days per week. At 12-week follow-up, mean pain scores on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) dropped 3.06 points in the intervention group vs. 1.46 points in the control group (P=0.007), and stiffness level decreased one level vs. no change (P=0.008). Weight loss Weight loss interventions studied for OA typically focus on joint stress or injury rather than pain. However, in the Intensive Diet and Exercise for Arthritis (IDEA) randomized trial, the investigators assessed pain as a secondary outcome. 30 The study included 545 older adults with knee OA and overweight randomized to one of three approaches: diet plus exercise, diet alone, or exercise alone. At 18 months the diet plus exercise intervention was associated with greater pain reduction than the diet or exercise alone groups. In the diet plus exercise group 38% of patients reported little or no pain compared with 20% and 22% of patients with diet or exercise alone, respectively (P=0.002 for both comparisons). 30 WOMAC function scores improved significantly in the diet plus exercise group compared to the diet group and the exercise alone group. 30


Case Study 2

Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow.

Mike, 21, presents to a primary care clinic as a new patient. On his intake form, the clinic nurse has written that the patient made an urgent appointment yesterday with a chief complaint of “back pain.” When you enter the room, Mike appears not to be in acute distress as he is texting on his phone. The patient briefly winces when he stands up from his chair to shake your hand. He sits back down and tells he is generally healthy but that two years ago, he fell while working on a roof. You express concern, but he shrugs it off, saying that he fell into the bushes, which broke his fall, but that he did hurt his back. At the Emergency Room the ER attending diagnosed him with a muscle injury, prescribed oxycodone, and sent him home to rest. However, the patient says he continues to have chronic back pain and would like another prescription for oxycodone so that he can go back to work.

1. Given the subjective nature of pain, how can a clinician more objectively assess the kind of pain reported by patients such as Mike?

2. What kinds of non-opioid treatments might you suggest Mike try before writing a new prescription for oxycodone?

3. What types of functional goals might be appropriate as part of a treatment plan for Mike?

Tai chi A meta-analysis of 15 randomized trials in patients with musculoskeletal pain (80% OA) found tai chi to be moderately effective in improving both pain and disability at up to 3 months compared to no intervention. 50 No statistically significant differences were observed at 3 months to 1 year, or >1 year. A randomized trial with 204 adults with symptomatic knee OA compared 12 weeks of twice- weekly tai chi vs. standard physical therapy and followed patients for 52 weeks. Both study arms showed significant improvements from baseline pain scores at 52 weeks, but there was no statistically significant difference between groups in terms of pain or function. 51 Yoga A review of 12 studies (including four RCTs) involving 589 patients with OA symptoms comparing a variety of yoga regimens to usual care found suggestions that pain, stiffness, and swelling were reduced. No effect on physical function was observed. 52 A randomized trial of 131 older adults with lower extremity OA compared twice-weekly sessions of chair yoga vs. a health education program. 53 At 3-month follow-up, participants in the yoga group showed greater reductions in pain interferences (P=0.01) compared to control. During the intervention, patients in the yoga group had reduced pain on the WOMAC scale and improved gait speed compared to the control group, but the differences were not sustained at 3-month follow-up. 53

Acupuncture A Cochrane review of six randomized trials evaluating acupuncture in 413 patients with hip OA found conflicting evidence on its effects on pain and function. 54 In analysis of two trials with 105 patients comparing acupuncture to sham acupuncture there were no significant differences after 5-9 weeks in pain or function. One trial, however, that compared 13 weeks of acupuncture plus routine primary care vs. routine primary care alone in 137 patients found reduced pain and improved function. Two trials reported minor side effects with acupuncture, mostly bruising, bleeding, or pain at needle insertion site. An unblinded trial randomized 221 adults with hip or knee OA to acupuncture, sham acupuncture, or mock electrical stimulation. 55 After five weeks of treatment no significant differences in mean improvements on a 0-100 pain scale were found for any comparisons. Acupuncture trials can be particularly susceptible to placebo effects, as illustrated in a study comparing needle or laser acupuncture to no acupuncture or sham laser treatment in 282 patients with chronic knee pain (mean age 63). After 12 weeks of treatments, needle and laser acupuncture reduced self-reported knee pain more than no acupuncture (control) but not more than sham acupuncture, suggesting strong placebo effects. The benefits were not sustained at one year follow up. 31

Massage A review of seven randomized trials with 352 participants suggests that massage may be better than no treatment for reducing OA pain. 56 The trials were diverse with respect to outcomes, massage techniques, and patient populations. Clinical effect sizes for pain were moderate with about a 20-point reduction in WOMAC scores from a baseline of 50-60 points. The functional benefits were less clear; some trials showed no benefit while others showed improvements in the 50-foot walk test. 56,57 Self-management education programs Small effects were noted in three meta-analyses of studies evaluating self-management education programs, though the benefits were not considered clinically important. Arthritis-specific programs included techniques to deal with problems associated with arthritis, appropriate exercises and medications, nutrition, and effective communication with healthcare providers and family. Other non-drug interventions TENS has been used for pain relief for decades, but studies evaluating effectiveness have shown mixed results. Data from four trials, including two RCTs, showed no statistical improvement in pain over placebo. 58 CBT interventions typically address comorbid conditions, such as insomnia and depression. A systematic review, without meta-analysis, of four trials involving CBT or CBT-like pain coping skills trainings found inconsistent evidence for reduced pain at 12-month follow-up. 59


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