This interactive Florida Physician Ebook contains 6 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
Florida Continuing Medical Education
Florida Medical Licensure Program
SATISFIES BOARD-APPROVED CONTROLLED SUBSTANCE PRESCRIBING REQUIREMENT BOARD-APPROVED 2 HOURS Controlled Substances/Opioids 2 HOURS
SATISFIES MEDICAL ERROR REQUIREMENT Medical Errors
SATISFIES DOMESTIC VIOLENCE REQUIREMENT 6 TOTAL AMA PRA Category 1 Credits TM 2 HOURS Intimate Partner Violence
Need to complete the DEA’s new one-time MATE requirement? See page i for more details.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
FL.CME.EDU
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
FLORIDA
01 BEST PRACTICES FOR TREATING PAIN WITH OPIOID ANALGESICS, 2ND EDITION COURSE ONE | 2 CREDITS SATISFIES BOARD-APPROVED CONTROLLED SUBSTANCES/OPIOIDS REQUIREMENT 30 MEDICAL ERRORS AND THE UNITED STATES HEALTHCARE SYSTEM COURSE TWO | 2 CREDITS SATISFIES MEDICAL ERRORS EDUCATION REQUIREMENT 43 INTIMATE PARTNER VIOLENCE: COMPASSIONATE CARE, EFFECTIVE ASSESSMENT COURSE THREE | 2 CREDITS SATISFIES DOMESTICS VIOLENCE TRAINING REQUIREMENT
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LEARNER RECORDS: ANSWER SHEET & EVALUATION REQUIRED TO RECEIVE CREDIT
Program Options
Price
Option
Code
Credits
ENTIRE PROGRAM • Best Practices for Treating Pain with Opioid Analgesics, 2nd Edition • Medical Errors and the United States Healthcare System • Intimate Partner Violence: Compassionate Care, Effective Assessment
$50
MDFL0625 6 Credits
$20 • Best Practices for Treating Pain with Opioid Analgesics, 2nd Edition $20 • Medical Errors and the United States Healthcare System $30 • Intimate Partner Violence: Compassionate Care, Effective Assessment
MDFL02BP 2 Credits MDFL02ME 2 Credits MDFL02IP 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 the solution. Scan the QR code or go to https://uqr.to/deamate to get started. Effective June 27, 2023 , renewing DEA-registered practitioners must complete 8 hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Get the training you need in a self-paced, convenient format with a course specifically designed for physicians to meet the Drug Enforcement Administration (DEA)’s new requirement under the Medication Access and Training Expansion (MATE) Act. Need to complete the DEA’s new requirement under the Medication Access and Training Expansion (MATE) Act? 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 office@elitelearning.com. • 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-assessment questions. To receive credit for your courses, you must provide your customer information and complete 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 !
• Go to BOOK.CME.EDU . Locate the book code MDFL0625 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 elective hours, please visit FL.CME.EDU ONLINE FASTEST AND EASIEST!
Enter book code
GO
MDFL0625
If you need help finding your code, Browse Book Code FAQs
• 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. • Submissions without a valid e-mail will be mailed to the address provided. BY MAIL
1-800-237-6999
BOOK.CME.EDU
BOOK CODE: MDFL0625
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INFORMED TRACKS WHAT YOU NEED, WHEN YOU NEED IT
Florida Professional License Requirements
MANDATORY DOMESTIC VIOLENCE CME As part of every third biennial renewal period, all licensees shall complete two (2) hours of training in domestic violence. MANDATORY MEDICAL ERRORS CME As a condition of biennial renewal the State Board of Medicine requires each person licensed as a physician (MD) to complete two (2) hours relating to prevention of medical errors which includes a study of root cause analysis, error reduction and prevention, and patient safety. GENERAL PHYSICIAN CME REQUIREMENTS Every physician licensed pursuant to Chapter 458, F.S., shall be required to complete 40 hours of continuing medical education courses approved by the Board in the 24 months preceding each biennial renewal period as established by the Department. All of the above mandatory CME requirements may be included in the total general hours required for renewal. MANDATORY CONTROLLED SUBSTANCES CME All physicians (MD/DO) that have a current DEA registration to prescribe controlled substances must complete a board-approved two (2) hour course on prescribing controlled substances/opioids .
We are a nationally accredited CME provider. For all board-related inquiries please contact:
Department of Health Board of Medicine 4052 Bald Cypress Way Bin C-03 Tallahassee, FL 32399-3253
LICENSE RENEWAL DATE: 1/31/2025
ELECTRONIC TRACKING OF CE
P: (850) 245-4131 F: 850-488-0596
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.
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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 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.
ABIM
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)
ABOHNS
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 TM 2 AMA PRA Category 1 Credits T M 2 AMA PRA Category 1 Credits TM 2 AMA PRA Category 1 Credits TM
Activity Title
ABA ABIM ABOHNS ABPath
ABP
Best Practices for Treating Pain with Opioid Analgesics, 2nd Edition Medical Errors and the United States Healthcare System
2 Credits LL 2 Credits LL 2 Credits LL
2 Credits MK 2 Credits MK 2 Credits MK
2 Credits SA 2 Credits SA 2 Credits SA
2 Credits LL 2 Credits LL 2 Credits LL
2 Credits LL+SA 2 Credits LL+SA
Intimate Partner Violence: Compassionate Care, Effective Assessment 2 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.
iii
BEST PRACTICES FOR TREATING PAIN WITH OPIOID ANALGESICS, 2ND EDITION
COURSE DATES: MAXIMUM CREDITS:
FORMAT:
Release Date: 4/2024 Exp. Date: 2/2027
2 AMA PRA Category 1 Credits ™
Enduring Material (Self Study)
TARGET AUDIENCE
HOW TO RECEIVE CREDIT:
All health care professionals who participate in the management of patients with pain.
• Read the course materials.
•
Complete the self-assessment questions at the end. A score of 70% is required.
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.
• R eturn your customer information/ answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU .
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 nonmedication 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. 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.
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FACULTY
COURSE SATISFIES
Chadwick Rawana, MD Professor, Fanshawe College
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Melissa B. Weimer, DO, MCR, FASAM Assistant Professor Department of Internal Medicine Yale University School of Medicine Beth Dove Medical Writer Dove Medical Communications
CONTROLLED SUBSTANCES/OPIOIDS
This activity is approved by the Florida Boards of Medicine and Osteopathic Medicine and satisfies the mandatory educational requirement on controlled substances/opioids. CE Broker Provider #: 20-1202180 SPECIAL BOARD APPROVAL The Florida Boards of Medicine and Osteopathic Medicine require all physicians (MD/DO) with a current DEA registration to complete a minimum of two (2) hours of CME on controlled substances/opioids through a board approved course.
ACTIVITY PLANNER Michael Brooks CME Director InforMed
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:
The following faculty and/or planning committee members have indicated they have relationship(s) with industry to disclose:
•
Chadwick Rawana, MD
• Melissa B. Weimer, DO, MCR, FASAM has received honoraria from Path CCM, Inc. and CVS Health.
• Beth Dove • Michael Brooks
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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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 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 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 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.
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
Figure 1. National Drug Overdose Deaths Involving Prescription Opioids* Among All Ages, 1999-2019 5
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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, 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. 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
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%
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°
The correct answer is b. Rationale: Between 8% and 12% of patients prescribed opioids for chronic pain develop an opioid use disorder (OUD). Pain Definitions 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 • 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 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.
°
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 • 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.
Figure 2. The Biopsychosocial Model of Pain 1
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° 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. 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 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 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 cancer-related pain • Chronic neuropathic pain • Chronic secondary visceral pain • 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 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 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 b. Physiological c. Psychological d. Social factors The correct answers are a, c, and d. Rationale: Biological, psychological, and social factors influence pain according to the International Association for the Study of Pain (IASP). Barriers to Effective Pain Care 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 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 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
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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 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 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 nonopioid pharmacologic treatments. What follows are examples of each (not an exhaustive list) and a brief discussion of the evidence base underpinning these options. 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. 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. 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 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 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
Table 1. Noninvasive, Nonpharmacologic Approaches to Pain Management 3
Restorative
Behavioral Health
Complementary and Integrative
• 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
• Acupuncture • Massage, manipulative therapies • Mindfulness-based stress reduction • Spirituality • Tai chi
• Emotional awareness and expression therapy • Self-regulatory/psychophysiological approaches: ° Biofeedback ° Relaxation training ° Hypnotherapy
• Yoga • Reiki
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• 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 • 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 • Vertebral augmentation, which uses various techniques, including injecting cement into vertebral compression fractures that are painful and refractory to treatment 3 • Interspinous process spacer devices, which can provide relief for patients with lumbar spinal stenosis with neuroclaudication. 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 • 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 psychophysiological approaches, which include biofeedback, relaxation training, and hypnotherapy, help patients develop control over their physiologic and psychological responses to pain. 3 ° or
• Self-regulatory
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 alter attentional processes and heighten physical and psychological relaxation, have empirical support in pain management. 3
°
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, 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 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
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