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Author(s): Fishman, Scott M; Carr, Daniel B; Hogans, Beth; Cheatle, Martin; Gallagher, Rollin M; Katzman, Joanna; Mackey, Sean; Polomano, Rosemary; Popescu, Adrian; Rathmell, James P; Rosenquist, Richard W; Tauben, David; Beckett, Laurel; Li, Yueju; Mongoven, Jennifer M; Young, Heather M | Abstract: Background:"The ongoing opioid crisis lies at the intersection of two substantial public health challenges-reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications" [1]. Improved pain education for health care providers is an essential component of the multidimensional response to both still-unmet challenges [2,3]. Despite the importance of licensing examinations in assuring competency in health care providers, there has been no prior appraisal of pain and related content within the United States Medical Licensing Examination (USMLE). Methods:An expert panel developed a novel methodology for characterizing USMLE questions based on pain core competencies and topical and public health relevance. Results:Under secure conditions, raters used this methodology to score 1,506 questions, with 28.7% (432) identified as including the word "pain." Of these, 232 questions (15.4% of the 1,506 USMLE questions reviewed) were assessed as being fully or partially related to pain, rather than just mentioning pain but not testing knowledge of its mechanisms and their implications for treatment. The large majority of questions related to pain (88%) focused on assessment rather than safe and effective pain management, or the context of pain. Conclusions:This emphasis on assessment misses other important aspects of safe and effective pain management, including those specific to opioid safety. Our findings inform ways to improve the long-term education of our medical and other graduates, thereby improving the health care of the populations they serve.

Background Consensus indicates that a comprehensive, multimodal, holistic approach is foundational to the practice of acute pain medicine (APM), but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service, which is often unavailable or inconsistently applied. This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. Methods A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. Results The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers, hospital administrators, and other key stakeholders to convey the importance of APM. Conclusion This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.

Objective The purpose of this article is 1) to present the historical context and rationale for competency-based pain management education; and 2) to suggest learning tools that faculty might apply into their teachings and their institutions' pre-licensure curricula for promoting conceptual learning based on competency-based pain management education. Design Based on the well-documented need to improve the competency of health care professionals in pain assessment and management, an interprofessional group of health care providers collaborated and then convened in August 2012 to develop core competencies for pain management for the pre-licensure programs of study across health care disciplines. This interprofessional group of pain educators achieved consensus on a common set of pain-related competencies intended to be implemented across a variety of pre-licensure professional programs. Setting A group of the interprofessional faculty, who participated in the development of the core competencies for pain management, provides a follow-up of how to implement learning tools within teaching and curricula, based on competency education in pre-licensure health care. Results Broad questions about how to incorporate competencies into pre-licensure curricula, for all health provider pre-licensure programs, including how to assess competency across individuals and how to teach in ways that emphasize the demonstration of conceptual learning, remain unanswered. This article reviews how the use of competencies creates historical context for a shift from teaching to learning and concludes with suggestions and exemplars in applying core competencies for pain management in pre-licensure programs.

Boston, Massachusetts; ¶ Javelin Pharmaceuticals, Inc., Cambridge, Massachusetts, USA ABSTRACT Context. Opioid-induced bowel dysfunction (OBD) is characterized by constipation, incomplete evacuation, bloating, and increased gastric reflux. OBD occurs both acutely and chronically, in multiple disease states, resulting in increased morbidity and reduced quality of life. Objective. To compare the efficacy and safety of traditional and peripherally active opioid antago- nists vs conventional interventions for OBD. Design. We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE. Additional reports were identified from the reference lists of retrieved articles. Study Selection. Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD. Data Extraction. Data were extracted by two independent investigators and included demographic variables, diagnoses, interventions, efficacy, and adverse events. Results of Data Synthesis. Twenty-two articles met inclusion criteria and provided data on 2,352 opioid antagonist-treated patients. The opioid antagonist investigated was alvimopan (eight stud- ies), methylnaltrexone (six), naloxone (seven), and nalbuphine (one). Meta-analysis demonstrated that methylnaltrexone and alvimopan are efficacious in reversing opioid-induced increased gas- trointestinal transit time and constipation, and that alvimopan is safe and efficacious in treating postoperative ileus. The incidence of adverse events with opioid antagonists was similar to placebo and generally reported as mild-to-moderate. Conclusions. Insufficient evidence exists for the safety or efficacy of naloxone or nalbuphine in the treatment of OBD. Long-term efficacy and safety of any of the opioid antagonists is unknown, as is the incidence or nature of rare adverse events. Alvimopan and methylnaltrexone both show promise in treating OBD, but further data will be required to fully assess their place in therapy.

Tufts-New England Medical Center, Boston, Massachusetts, USA ABSTRACT Objective. Limited evidence supports the efficacy of spinal cord stimulation (SCS). Therefore, it is crucial to assess the usefulness of this invasive procedure before implanting permanent electrodes in each patient. An N-of-1 trial is an experiment in which a single participant undergoes periods of comparative treatments. We illustrate how an N-of-1 trial design may permit clinicians to conduct such an assessment in an individual patient. Design. Case report. Setting. University teaching hospital. Patients. A 61-year-old man patient with refractory postherpetic neuralgia scheduled for SCS implantation. Interventions. Percutaneous octapolar lead placement into the epidural space for SCS at T5-T6, and placement of transcutaneous electrical nerve stimulator (TENS) electrodes upon the painful area on the patient's back. We provided electrical stimulation via TENS or SCS according to a computer-generated random number list. Each stimulation period lasted 5 hours, followed by 1 hour of rest. Outcome Measures. At the end of each period, a blinded assessor evaluated the degree of pain relief, pain intensity, area of stimulation, and the patient's satisfaction. The study had a 5-day duration. Results. In this patient, spinal stimulation was equally efficacious as TENS. Conclusions. We encourage clinicians to perform an N-of-1 trial in every patient before implanting permanent electrodes for SCS.

Many factors contribute to pain after landmine injury. In preclinical models, both tissue injury and nerve injury are able, within a few tens of minutes, to initiate a cascade of processes that may culminate in persistent pain [1–3]. Initially mechanical and thermal activation of nociceptors appear at the site of damage, and are quickly followed by inflammatory activation [1,3]. Ectopic and perhaps ephaptic activity can quickly add to the neuronal chaos [4]. These processes become the source of high-intensity, long-duration impulses and this intense nociceptive barrage leads almost immediately to changes in the dorsal horn of the spinal cord, particularly in the second-order transmission cells [5–8]. Experimental inflammation activates gene expression in the dorsal horn within 20 minutes [2]. Ligating the isolated rat sciatic nerve within hours leads to novel gene expression in the dorsal horn and to swelling and inflammation in the nerve itself [9]. In virtually every instance of landmine injury, sufficient time elapses before initial care so that the patient must be viewed as already being in a subacute phase of pain and thus is no longer suitable for “acute” or “preemptive” intervention. The concept of “preemptive” analgesia for later medical procedures, such as stump revision or re-amputation, may be applicable. Yet even then, patients already have well-established “wind-up” or “sensitization” processes that are mediated through multiple mechanisms. Because treatment with any form of analgesic is rarely begun within hours if not days after the initial trauma, virtually every mechanism recognized to generate subacute and “chronic” pain in preclinical models and clinical practice has ample time to develop in the patient. As time passes after any injury, additional sources of persistent pain may occur as a result of active pathophysiological processes (such as infection or …

Case Presentation: D.J. is a 58-year-old right-hand-dominant Caucasian woman who presented with a history of posterior interbody fusion (PLIF) L2-S1 in 2000 secondary to severe spinal stenosis L3-L5, severe degenerative disc disease of the lumbar spine L2-S1 with a Grade II dynamic anterolesthesis L3 on L4 and Grade I retrolesthesis L5 on S1. She awoke from the L2-S1 PLIF with severe burning dysesthesias across the lower aspects of the lumbar region and into the right buttock/posterior lateral right lower extremity; the lumbar dysesthesias lessened but did not completely cease (i.e., burning pain in the lumbosacral region continued, but sharp pain ceased); the right buttock and leg did not change (see Figure 1). Figure 1 Pain diagram. She trialed physical/manual therapy, aquatic therapy, epidural steroids (three series of three), gabapentin (3,600 mg/day), nortriptyline (100 mg qHS) without benefit. She presented taking the following medications: Fentanyl Transdermal 150 µg/h q2days Hydrocodone/acetaminophen 10/500 mg 2 tab q4h Tizanadine 8 mg qHS Metaxalone 800 mg QID Naproxen Sodium 250 mg BID 0.625 mg conjugated estrogens/2.5 mg medroxyprogesterone qday Gliburide 10 mg qAM She characterized the axial back pain as “constant,” “burning,” “searing,” “aching,” and “stabbing” with interposed “shooting” pain. She reported radiation of pain into the right buttocks and posterior/posterior lateral aspect of the right lower extremity utilizing similar descriptors. Over the 4–6 months preceding examination, she described a “popping” sensation in the low back with certain movements that worsens the right leg radicular symptoms. She reported pain 24 hours/day with only intensity fluctuations. She rated pain utilizing the Brief Battery for Health Improvement (version 2) (BBHI-2) (see Figure 2). Figure 2 BBHI. PTSD = post-traumatic stress disorder. Past Medical History: Adult-onset diabetes, hyperlipidemia. Past Surgical History: Anterior cervical discectomy and fusion (ACDF) C5-C72000; L2-S1 PLIF 2000. Allergies: Codeine/Morphine (rash). Social: Common law marriage with grown …

Pain Medicine has its roots in multiple primary specialties and has developed into a discrete specialty with disparate practice styles. Its identity is in flux and is threatened by forces that may fragment this new field before it can set firm roots. The public health crisis of under treated pain parallels medicine's struggle to adequately classify Pain Medicine as a specialty. We review the case for Pain Medicine as a discrete discipline, with specialized knowledge, treatments, training and education. Without recognition of the specialty of Pain Medicine, and resolution of the fragmentation of the field throughout healthcare, medicine's approach to the current problem of under treated pain is likely to continue to be inadequate.

Objective Dermal inflammation from many causes may produce a reversible period of hyperalgesia (increased sensitivity to pain perception) or allodynia (pain from innocuous stimuli). Hyperalgesia and allodynia have received relatively little attention in clinical trials of acute pain. We sought to quantitate tactile allodynia and thermal hyperalgesia in outpatients presenting with acute dermal injuries. Design We performed a randomized clinical trial to compare standard methodology for the assessment of hyperalgesia with two novel simple quantitative techniques. Patients After Institutional Review Board approval, 40 patients presenting with acute chemical, thermal, mechanical, or infectious skin injury were subjected to a series of tests at the site of injury, an intact mirror site, and a noninjured ipsilateral control site. Outcome Measures Quantitative thermal sensory testing (Medoc sensory analyzer) was followed by a 5-second application, in random order, of copper rods preheated in water to 40°C, 43°C, 46°C, and 49°C. Pressure testing was conducted with a 1.25-inch diameter commercially available pressure transducer gauge. Results The observed pattern of responses was remarkably consistent among testing methods. All challenges with the four different temperatures elicited pain scores on a visual analog scale markedly greater at the injured than at the mirror or control site (P < 0.001 vs control). Pressure discomfort thresholds followed a similar pattern. Conclusions We conclude that hyperalgesia is a prominent contributor to discomfort in acute dermal injury and hence is a legitimate therapeutic target. Quantitation of the contribution of thermal hyperalgesia and tactile allodynia and assessment of their management is feasible using simple, rugged, low-cost methods. This inexpensive methodology may be useful in everyday clinical practice as well as in clinical research evaluating pharmacological agents to manage hyperalgesia.

Objective. To determine the prevalence, characteristics, and effects of chronic persistent pain on burn survivors. Design. Mail survey Setting. Respondents' homes Patients. All members of the Phoenix Society for Burn Survivors Interventions. None Outcome Measures. Twenty-three questions on the prevalence of pain and its characteristics, including the short form of the McGill-Melzack Pain Questionnaire Results. Of 1,500 members who received the survey, 358 (24%) responded. Respondents had burns covering an average of 59% of their bodies. Time between the injury and the survey averaged 12 years. On the survey, 52% of respondents reported ongoing burn-related pain, and 46% were able to characterize their pain with one or more of 15 characteristics. Two-thirds (66%) reported that pain interfered with their rehabilitation, and 55% reported that pain interfered with their daily lives. Asked “what makes the pain worse now?,” the most frequent reply (15%) was “the weather” (including “hot” or “cold”). Various physical activities (e.g., walking, bicycling) were also mentioned, along with nerve regrowth, contractures, remembering the accident, and depression. “Things that make your pain better now” included “nothing,” a variety of over-the-counter analgesics, “rest,”“exercise,”“yoga,”“acupuncture,”“family and friends,” and “God.” In coping with their pain, most respondents found family the most helpful, although nurse(s) received almost as high a rating. Conclusions. Pain associated with burn trauma continues to be of considerable significance in the lives of burn victims long after the initial injury and hospitalization. Little research has been done on this population.

The sociocultural dimensions of pain are as significant as its nociceptive machinery [1–7]. Andrew Greer, speaking through the voice of the African American woman protagonist in his latest novel, has said “I do not know what joins the parts of an atom, but it seems what binds one human to another is pain”[8]. In this issue of Pain Medicine , Murinson and colleagues [9] report an innovative approach to addressing the gap between the universal recognition of pain as a fundamentally intersubjective experience [10–12] and its presentation within the medical curriculum—if presented at all—as ordinary biomedical knowledge to be absorbed passively in large lecture halls. They describe their “greater vision for the course (as one) that … would build opportunities for emotional development … spur students to more deeply acknowledge the affective consequences of strong pain, (and) begin to recognize their own emotional responses to pain in self and others”[9]. To do so, they supplemented core knowledge about nociceptive and analgesic mechanisms, assessed by conventional standardized testing, with “socio-emotional” activities conducted in small groups. The latter activities consisted of written narrative, assessment of personal affective responses to nociceptive …

*The Health Institute and † New England Medical Center, Boston, Mass Objective. To meet the growing demand for objective outcomes measurement during treatment of chronic pain, we developed an instrument to track outcomes of individual patients. Method. In a 2-phase study, existing and novel outcomes instruments were applied in an interdisciplinary pain management program. In the initial phase, 408 patients were administered the Short Form 36-item questionnaire and during phase 2, 437 patients (87 of whom were followed) were given an expanded (191-item) questionnaire. Results. When applied to individual patients, the Short Form 26-item questionnaire lacked measurement reliability for assessment of treatment outcomes and sensitivity to upper extremity or facial pathology, and failed to separate limitations of work versus everyday activity. A novel group of scales derived from responses to 61 questions, including the Short Form 36-item questionnaire, proved sufficiently reliable for routine follow-up of individual chronic pain patients. Conclusions. This new Treatment Outcomes in Pain Survey allows assessment of individual patient outcomes, and aggregate or individual clinician performance, during interdisciplinary treatment of chronic pain.

Worldwide, the need for more effective treatment for pain has steadily gained recognition as the cornerstone of patient-centered care. Nationally, the Institute of Medicine’s (now Academy) report on Relieving Pain in America [1] and the National Pain Strategy [2] both specify a need to treat pain comprehensively, and to better educate clinicians across disciplines as to the importance of multidisciplinary pain care. Despite the psyche’s integral role in the experience of pain, few individuals or professionals are aware that pain is defined as an aversive “sensory and emotional experience,” [3] and even fewer understand how to address the emotional aspects of the pain experience. We underscore the ethical imperative to orient students, the public, medical care providers, and mental health professionals to the integral role of psychological factors in the experience of pain. In doing so, we hope to have the opportunity to steer the health of the population toward more effective treatment for pain. Anecdotally, pain specialists and many primary care providers have long experienced difficulty referring individuals with chronic pain to psychologists skilled in pain treatment, or to therapists who address pain in the psychotherapeutic context. In part, the difficulty was attributed to a lack of health care insurance coverage for psychological services, or to strict limitations in coverage that rendered treatment insufficient and ineffective. Enactment of the Mental Health Parity Act, an aspect of the Patient Protection and Affordable Care Act [4], has led to improvements but barriers persist …

The launch of a new section on acute pain in this journal [1], followed by the formation of a new Special Interest Group on this topic by the academy [2], have helped break down compartmental thinking separating acute pain medicine and the management of long-term or recurrent painful conditions. The physiological circumstance of ischemia lies at the crossroads between acute and chronic pain, offering an opportunity for mutually beneficial crosstalk between those who primarily focus upon acute vs chronic pain. Ischemia can befall any organ to produce deleterious, disastrous, or even fatal consequences. Cardiac ischemia responds to thoracic epidural analgesia, which has been applied perioperatively during cardiac surgery as well as chronically in the treatment of outpatients with angina [3]. Chronic symptomatic ischemia of the spine and lumbar nerve roots, i.e., neurogenic claudication of the lower extremities as seen in spinal stenosis, is less responsive to epidural analgesia. Since the invention of this technique by Bier in 1908, deliberate tourniquet ischemia of an extremity has been combined with instillation of local anesthetic …

Objective. We report a case of opioid-induced neurotoxicity (OIN) in an actively dying hospice patient, its reversal and improved analgesia that followed opioid dosage reduction made possible after addition of IV ketamine. We briefly review the diagnosis and treatment of OIN. Setting. OIN, particularly when associated with high dose opioid therapy in palliative care, may pose difficult diagnostic and treatment challenges. Few publications from end-of-life settings provide systematic approaches to management of OIN. Patients. We describe a case of OIN in a hospice patient receiving medical care at home while actively dying. Intervention. Addition of IV ketamine and reduction of the patient's high-dose opioid regimen. Results. The patient's pain was controlled within 24 hours of initiation of IV ketamine while the total opioid dose was reduced. His symptoms of OIN (delirium, tremor, myoclonus, and hallucinations) also rapidly subsided. Conclusion. OIN should be considered as an etiology of CNS dysfunction occurring with prolonged, high-dose opioid therapy. This case highlights the opioid-sparing and analgesic properties of low-dose ketamine, allowing reversal of OIN in the home hospice setting.

Gifted physician, surgeon, researcher, teacher and sculptor Robert George Addison died peacefully with his wife Beverly at his side, surrounded by family in Bradenton, Florida, on March 15, 2012. He was 90. Dr. Robert G. Addison served at the Northwestern University Medical School since 1953 as clinical professor in the Department of Orthopaedic Surgery and later, in the Department of Physical Medicine & Rehabilitation. Dr. Addison maintained an active private practice as an orthopedic surgeon until joining the Rehabilitation Institute of Chicago as a full-time staff member in 1974. At the Rehabilitation Institute of Chicago (RIC), Dr. Addison has served as medical director, chief of …