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Bright Etumuse,1 Majesty Greer,2 Jane Onyemachi,1 Youshaa El-Abed,3 Sai Kamma,1 Jay D Shah,4 Henry Tuan Tran,1 Nasir Hussain,5 Thomas P Pittelkow,6 Ryan S D’Souza6 1University of Texas Medical Branch School of Medicine, Galveston, TX, USA; 2Howard University College of Medicine, Washington, DC, USA; 3Kansas City University, Kansas City, MO, USA; 4Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA; 5Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic 200 First St. SW, Rochester, MN, 55905, USA, Email Dsouza.ryan@mayo.eduBackground: As cannabis legalization expands nationally and globally, its use for chronic pain increases, prompting people to seek information on social media platforms like YouTube. This study evaluates the accuracy and quality of information of popular YouTube videos on cannabis for chronic pain.Methods: Using search terms related to cannabis for pain, the top 66 videos by view count were selected. Each video was classified as useful, misleading, or neither. The quality and reliability of each video were assessed using the modified DISCERN, mDISCERN, score and the Global Quality Scale, GQS. The video characteristics, usefulness classification, mDISCERN scores, and GQS scores were summarized. Continuous and categorical outcomes were compared using t-test and chi-square, respectively.Results: Of the 66 videos, 22.73% (n=15) were classified as useful, and 77.27% (n=51) were classified as neither. Of useful videos, 40.00% (n=6) were uploaded by physicians, 40.00% (n=6) were uploaded by corporations, and 6.67% (n=1) were uploaded by an independent user. Of videos classified as neither useful nor misleading, news sources uploaded 27.45% (n=14) of these videos (P=0.02). Physicians uploaded 37.50% (n = 18) of videos with a GQS score ≥ 3 (P=0.04), while independent users uploaded significantly more videos with a mDISCERN score < 3 (22.20%, P=0.02). Useful videos had a mean GQS of 4.00 ± 0.65 compared to a mean GQS of 2.76 ± 0.86 for videos deemed neither (P< 0.0001).Conclusion: This study suggests a moderate quality of YouTube content on cannabis use for chronic pain. Given cannabis’s growing popularity and potential for misinformation on popular social media platforms, healthcare professionals and organizations should consider uploading educational videos on this topic on YouTube.Keywords: social media, cannabis, medical cannabis, analgesics, YouTube

Addyson E Sand,1 Tyler E Powell,1 Helen T Marry,1 Heather R Rathbun,1 Jenna R Steege,1 Allison LeMahieu,2 Adam K Jacob,1 Ryan S D’Souza,1 Oludare O Olatoye1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USACorrespondence: Oludare O Olatoye, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA, Email Olatoye.Oludare@mayo.eduBackground: Patients receiving methadone, buprenorphine, and naltrexone for either chronic pain or substance use disorder (SUD) pose perioperative challenges. Due to their complex pharmacology, perioperative recommendations continue to evolve. Deviations from these recommendations may result in worse perioperative outcomes. A formal preoperative evaluation (POE) and optimization of patients on these medications are recommended to address these concerns.Methods: A single-center retrospective electronic health record review was performed with adult patients on methadone, buprenorphine, and naltrexone undergoing elective surgery between January 1, 2010 and December 31, 2020. The primary outcome of interest was the percentage of patients referred to the POE clinic for evaluation prior to the scheduled elective surgery. In addition, we assessed differences in variables (perioperative opioid, hospital length of stay, perioperative multimodal analgesics, perioperative complications, inpatient pain service consult, readmission within 30 days, cancellation of surgery, addiction medicine consult) based on POE clinic evaluation. This analysis was performed separately for patients prescribed these medications for SUD versus chronic pain. Continuous outcomes were analyzed using linear regression with generalized estimating equations (GEE) and robust variance estimates.Results: A total of 714 patients were included in the final analysis, of which 572 (80%) took buprenorphine, methadone, or naltrexone for chronic pain and 142 (20%) took these medications for SUD. Within the chronic pain and SUD subpopulations, 193 (34%) and 35 (25%) patients had formal POE clinic assessments, respectively. Among those taking these medications for chronic pain, POE clinic evaluation was associated with a higher likelihood for receiving non-opioid multimodal analgesics perioperatively (p = 0.016).Conclusion: Formal preoperative evaluations are currently underutilized in patients who take buprenorphine, methadone, or naltrexone for chronic pain or SUD. These patients may benefit from POE clinic assessment to optimize perioperative outcomes.Keywords: preoperative evaluation, chronic opioid therapy, substance use disorder, naltrexone, buprenorphine, methadone, perioperative pain management

Ryan S D’Souza,1 Yeng F Her,1 Nasir Hussain,2 Jay Karri,3 Michael E Schatman,4 Aaron K Calodney,5 Christopher Lam,6 Thomas Buchheit,7 Brennan J Boettcher,8 George C Chang Chien,9 Scott G Pritzlaff,10 Christopher Centeno,11 Shane A Shapiro,12 Johana Klasova,1 Jay S Grider,13 Ryan Hubbard,14 Eliana Ege,15 Shelby Johnson,8 Max H Epstein,16 Eva Kubrova,8 Mohamed Ehab Ramadan,17 Alexandra Michelle Moreira,18 Swarnima Vardhan,19 Yashar Eshraghi,20 Saba Javed,21 Newaj M Abdullah,22 Paul J Christo,17 Sudhir Diwan,23 Leslie C Hassett,24 Dawood Sayed,6 Timothy R Deer25 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH, USA; 3Departments of Orthopedic Surgery and Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA; 4Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Precision Spine Care, Tyler, TX, USA; 6Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 7Department of Anesthesiology, Duke University, Durham, NC, USA; 8Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA; 9Department of Regenerative Medicine, GCC Institute, Torrance, CA, USA; 10Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 11Centeno-Schultz Clinic, Broomfield, CO, USA; 12Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA; 13Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA; 14Department of Sports Medicine, Anderson Orthopedic Clinic, Arlington, VA, USA; 15Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA; 16Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA; 17Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA; 18Department of Physical Medicine & Rehabilitation, University of Miami/Jackson Memorial Hospital, Miami, FL, USA; 19Department of Internal Medicine, Yale New Haven Health – Bridgeport Hospital, Bridgeport, CT, USA; 20Department of Anesthesiology & Critical Care Medicine, Ochsner Health System, New Orleans, LA, USA; 21Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; 22Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA; 23Department of Pain Medicine, Advanced Spine on Park Avenue, New York City, NY, USA; 24Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA; 25Department of Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA, Tel +1-(507)-284-9696, Fax +1-(507)-266-7732, Email dsouza.ryan@mayo.eduPurpose: Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial.Methods: The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of “disagree” or “abstain”, they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved.Results: Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies.Conclusion: In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose–response associations, and comparative analysis between different injectable biologics.Keywords: regenerative medicine, injectable biologics, platelet-rich plasma, mesenchymal stem cell, bone marrow aspirate concentrate, pain medicine

Dawood Sayed,1 Timothy R Deer,2,3 Vinicius Tieppo Francio,1 Christopher M Lam,1 Kamil Sochacki,4 Nasir Hussain,5 Tristan E Weaver,5 Jay Karri,6,7 Vwaire Orhurhu,8,9 Natalie Holmes Strand,10 Jacqueline Soicher Weisbein,11 Jonathan M Hagedorn,12 Ryan S D’Souza,12 Ryan R Budwany,2 Ahish Chitneni,13 Kasra Amirdelfan,14 Michael J Dorsi,15 Dan TD Nguyen,16 Christopher Bovinet,17 Alaa Abd-Elsayed18 1Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 2Pain Services, Spine and Nerve Center of the Virginias, Charleston, WV, USA; 3Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USA; 4Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA; 5Anesthesiology, the Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; 7Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA; 8Department of Anesthesiology, University of Pittsburgh Medical Center, Williamsport, PA, USA; 9Pain Medicine, MVM Health, East Stroudsburg, PA, USA; 10Anesthesiology and Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 11Interventional Pain Management, Napa Valley Orthopaedic Medical Group, Napa, CA, USA; 12Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 13Department of Rehabilitation & Regenerative Medicine, New York Presbyterian – Columbia & Cornell, New York, NY, USA; 14Director of Clinical Research, Boomerang Healthcare, Walnut Creek, CA, USA; 15Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA; 16Neuroradiology & Pain Solutions of Oklahoma, Edmond, OK, USA; 17The Spine Center of SE Georgia, Brunswick, GA, USA; 18Anesthesiology, University of Wisconsin, Madison, WI, USACorrespondence: Dawood Sayed, Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA, Tel +1 785-550-5800, Email dsayed@kumc.eduAbstract: Clinical management of sacroiliac disease has proven challenging from both diagnostic and therapeutic perspectives. Although it is widely regarded as a common source of low back pain, little consensus exists on the appropriate clinical management of sacroiliac joint pain and dysfunction. Understanding the biomechanics, innervation, and function of this complex load bearing joint is critical to formulating appropriate treatment algorithms for SI joint disorders. ASPN has developed this comprehensive practice guideline to serve as a foundational reference on the appropriate management of SI joint disorders utilizing the best available evidence and serve as a foundational guide for the treatment of adult patients in the United States and globally.Keywords: sacroiliac joint, sacroiliitis, chronic pain, best practices, radiofrequency ablation, sacroiliac joint fusion

Majesty Greer,1 Sai Kamma,2 Henry Tran,2 Bright Etumuse,2 Jay D Shah,3 Youshaa El-Abed,4 Jane O Onyemachi,2 Nasir Hussain,5 Thomas P Pittelkow,6 Ryan S D’Souza6 1Howard University College of Medicine, Washington, DC, USA; 2University of Texas Medical Branch School of Medicine, Galveston, TX, USA; 3Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA; 4College of Osteopathic Medicine, Kansas City University, Kansas City, MO, USA; 5Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA, Email Dsouza.ryan@mayo.eduIntroduction: Acupuncture is commonly used to treat chronic pain. Patients often access public social media platforms for healthcare information when querying acupuncture. Our study aims to appraise the utility, accuracy, and quality of information available on YouTube, a popular social media platform, on acupuncture for chronic pain treatment.Methods: Using search terms such as “acupuncture for chronic pain” and “acupuncture pain relief”, the top 54 videos by view count were selected. Included videos were > 1 minute duration, contained audio in English, had > 7000 views, and was related to acupuncture. One primary outcome of interest was categorizing each video’s usefulness as useful, misleading, or neither. Another primary outcome of interest was the quality and reliability of each video using validated instruments, including the modified DISCERN (mDISCERN) tool and the Global Quality Scale (GQS). The means were calculated for the video production characteristics, production sources, and mDISCERN and GQS scores. Continuous and categorical outcomes were compared using Student’s t-test and chi-square test, respectively.Results: Of the 54 videos, 57.4% were categorized as useful, 14.8% were misleading, and 27.8% were neither. Useful videos had a mean GQS and mDISCERN score of 3.77± 0.67 and 3.48± 0.63, respectively, while misleading videos had mean GQS and mDISCERN score of 2.50± 0.53 and 2.38± 0.52, respectively. 41.8% of the useful videos were produced by a healthcare institution while none of the misleading videos were produced by a healthcare institution. However, 87.5% of the misleading videos were produced by health media compared to only 25.8% of useful videos from health media.Discussion: As patients increasingly depend on platforms like YouTube for trustworthy information on complementary health practices such as acupuncture, our study emphasizes the critical need for more higher-quality videos from unbiased healthcare institutions and physicians to ensure patients are receiving reliable information regarding this topic.Keywords: acupuncture, chronic pain, social media, anesthesia, information dissemination, internet

Dawood Sayed,1 Timothy Ray Deer,2 Jonathan M Hagedorn,3 Asim Sayed,4 Ryan S D’Souza,3 Christopher M Lam,1 Nasir Khatri,5 Zohra Hussaini,1 Scott G Pritzlaff,6 Newaj Mohammad Abdullah,7 Vinicius Tieppo Francio,1 Steven Michael Falowski,8 Yussr M Ibrahim,9 Mark N Malinowski,10 Ryan R Budwany,2 Natalie Holmes Strand,11 Kamil M Sochacki,12 Anuj Shah,13 Tyler M Dunn,11 Morad Nasseri,14 David W Lee,15 Leonardo Kapural,16 Marshall David Bedder,17,18 Erika A Petersen,19 Kasra Amirdelfan,20 Michael E Schatman,21,22 Jay Samuel Grider23 1Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 2Pain Services, Spine and Nerve Center of the Virginias, Charleston, WV, USA; 3Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 4Podiatry/Surgery, Susan B. Allen Memorial Hospital, El Dorado, KS, USA; 5Interventional Pain Medicine, Novant Spine Specialists, Charlotte, NC, USA; 6Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 7Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA; 8Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA; 9Pain Medicine, Northern Light Eastern Maine Medical Center, Bangor, ME, USA; 10OhioHealth Neurological Physicians, OhioHealth, Columbus, OH, USA; 11Anesthesiology and Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 12Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA; 13Department of Physical Medicine and Rehabilitation, Detroit Medical Center, Detroit, MI, USA; 14Interventional Pain Medicine / Neurology, Boomerang Healthcare, Walnut Creek, CA, USA; 15Pain Management Specialist, Fullerton Orthopedic, Fullerton, CA, USA; 16Carolinas Pain Institute, Winston Salem, NC, USA; 17Chief of Pain Medicine Service, Augusta VAMC, Augusta, GA, USA; 18Associate Professor and Director, Addiction Medicine Fellowship Program, Department Psychiatry and Health Behavior, Medical College of Georgia at Augusta University, Augusta, GA, USA; 19Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 20Director of Clinical Research, Boomerang Healthcare, Walnut Creek, CA, USA; 21Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 22Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 23Anesthesiology, Division of Pain Medicine, University of Kentucky College of Medicine, Lexington, KY, USACorrespondence: Dawood Sayed, Anesthesiology and Pain Medicine, the University of Kansas Medical Center, Kansas City, KS, USA, Tel +1 785-550-5800, Email dsayed@kumc.eduIntroduction: Painful diabetic neuropathy (PDN) is a leading cause of pain and disability globally with a lack of consensus on the appropriate treatment of those suffering from this condition. Recent advancements in both pharmacotherapy and interventional approaches have broadened the treatment options for PDN. There exists a need for a comprehensive guideline for the safe and effective treatment of patients suffering from PDN.Objective: The SWEET Guideline was developed to provide clinicians with the most comprehensive guideline for the safe and appropriate treatment of patients suffering from PDN.Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations for PDN. A multidisciplinary group of international experts developed the SWEET guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus to identify and compile the evidence for diabetic neuropathy pain treatments (per section as listed in the manuscript) for the treatment of pain. Manuscripts from 2000-present were included in the search process.Results: After a comprehensive review and analysis of the available evidence, the ASPN SWEET guideline was able to rate the literature and provide therapy grades for most available treatments for PDN utilizing the United States Preventive Services Task Force criteria.Conclusion: The ASPN SWEET Guideline represents the most comprehensive review of the available treatments for PDN and their appropriate and safe utilization.Keywords: diabetes, painful diabetic neuropathy, neuropathy, spinal cord stimulation, chronic pain, diabetic neuropathy

Christopher L Robinson,1,&ast; Alexandra CG Fonseca,2,&ast; Efemena M Diejomaoh,3,&ast; Ryan S D’Souza,4 Michael E Schatman,5,6,&ast; Vwaire Orhurhu,7,8,&ast; Trent Emerick9,&ast; 1Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA; 2Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women’s Hospital, Boston, MA, USA; 3Department of Psychiatry & Behavioral Science, Meharry Medical College, Nashville, TN, USA; 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Rochester, Rochester, MN, USA; 5Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 6Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 7University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA; 8MVM Health, East Stroudsburg, PA, USA; 9University of Pittsburgh Medical Center, Department of Anesthesiology and Perioperative Medicine, Chronic Pain Division, Pittsburgh, PA, USA&ast;These authors contributed equally to this workCorrespondence: Vwaire Orhurhu, University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA, Email vwo569@mail.harvard.eduIntroduction: Amid a lack of effective chronic pain treatments, psychedelics have gained attention as a potential solution, although their Schedule 1 classification poses challenges. Psychedelics, such as lysergic acid diethylamide (LSD) and psilocybin, have gained popularity as alternatives and adjuncts for chronic pain treatment. Studies suggest that they may modulate pain processing through agonism primarily at the serotonin receptor, 5-HT2A. One of the first of its nature, we present an artificial intelligence (AI)-powered scoping review primarily focusing on evaluating psychedelics for chronic pain conditions such as cluster headache, phantom limb pain, and fibromyalgia.Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we used an AI-powered comprehensive search strategy utilizing the ChatGPT4.0 Bing chat to search Medline, Embase, Cochrane, and Google Scholar for articles addressing chronic pain. The query was performed on June 1, 2023, focusing on psychedelics for chronic, non-cancer pain including headache disorders. Inclusion criteria were English-only, peer-reviewed articles involving human participants > 18 years, focusing on chronic pain conditions (eg, phantom limb pain and cluster headache), using LSD, 2.5-dimethoxy-4-bromophenethylamine (2C-B), N, N-dimethyltryptamine (DMT), psilocybin, or mescaline. Exclusion criteria were reviews, editorials, and opinion articles and studies focusing on tetrahydrocannabinol/cannabis and/or ketamine.Results: A total of 186 unique database entries were retrieved, of which nine studies were included in the scoping review. These included four case reports/series, an open-label study, a cohort study, two online surveys, and a randomized, double-blind, placebo-controlled trial. They comprised three studies addressing phantom limb pain, four addressing cluster headaches, and two addressing fibromyalgia, spinal cord injury, complex regional pain syndrome, and lumbar radiculopathy.Conclusion: Psychedelics may have potential in alleviating pain symptoms secondary to a multitude of chronic pain conditions. However, further randomized, double-blind, placebo-controlled trials are needed to further explore and evaluate the role of psychedelics in chronic, non-cancer pain.Keywords: psilocybin, mescaline, lysergic acid diethylamide, headache, phantom limb pain, scoping review

Christopher L Robinson,1,&ast; Ryan S D’Souza,2,&ast; Cyrus Yazdi,1 Efemena M Diejomaoh,3 Michael E Schatman,4,5,&ast; Trent Emerick,6,&ast; Vwaire Orhurhu7,8,&ast; 1Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA; 3Department of Psychiatry & Behavioral Science, Meharry Medical College, Nashville, TN, USA; 4Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 6Department of Anesthesiology and Perioperative Medicine, Chronic Pain Division, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 7University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA; 8MVM Health, East Stroudsburg, PA, USA&ast;These authors contributed equally to this workCorrespondence: Vwaire Orhurhu, MVM Health, East Stroudsburg, Williamsport, PA, USA, Email vwo569@mail.harvard.eduAbstract: The integration of artificial intelligence (AI) in patient pain medicine education has the potential to revolutionize pain management. By harnessing the power of AI, patient education becomes more personalized, interactive, and supportive, empowering patients to understand their pain, make informed decisions, and actively participate in their pain management journey. AI tailors the educational content to individual patients’ needs, providing personalized recommendations. It introduces interactive elements through chatbots and virtual assistants, enhancing engagement and motivation. AI-powered platforms improve accessibility by providing easy access to educational resources and adapting content to diverse patient populations. Future AI applications in pain management include explaining pain mechanisms, treatment options, predicting outcomes based on individualized patient-specific factors, and supporting monitoring and adherence. Though the literature on AI in pain medicine and its applications are scarce yet growing, we propose avenues where AI may be applied and review the potential applications of AI in pain management education. Additionally, we address ethical considerations, patient empowerment, and accessibility barriers.Keywords: ethics, chatbots, machine learning, natural language processing, patient education

Jonathan M Hagedorn,1 Tony K George,2 Rohit Aiyer,3 Keith Schmidt,4 John Halamka,5 Ryan S D’Souza1 1Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Physical Medicine and Rehabilitation, University Orthopedic Associates, Somerset, NJ, USA; 3Integrative Sports & Spine, Long Beach, CA, USA; 4Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA; 5Mayo Clinic Platform, Mayo Clinic, Rochester, MN, USACorrespondence: Jonathan M Hagedorn, Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA, Tel +1-507-284-9696, Fax +1-507-266-7732, Email jonhagedornmd@yahoo.comAbstract: Artificial intelligence was introduced 60 years ago and has evolved immensely since that time. While artificial intelligence is found in nearly all aspects of our life, the use of artificial intelligence in the healthcare industry has only recently become apparent and more widely discussed. It is expected that artificial intelligence will allow improved disease recognition, treatment optimization, cost and time savings, product development, decision making, and marketing. For pain medicine specifically, these same benefits will be translatable and we can expect better disease recognition and treatment selection. As adoption occurs with this impressive technology, it will be imperative for the pain medicine community to be informed on proper definitions and expected use cases for artificial intelligence. Our objective was to provide pain medicine physicians an overview of artificial intelligence, including important definitions to aid understanding, and to offer potential clinical applications pertinent to the specialty.Keywords: artificial intelligence, pain medicine, chronic pain, education

Natalie Strand,1 Ryan S D’Souza,2 Jay Karri,3 Hemant Kalia,4 Jackie Weisbein,5 Brian J Kassa,6 Nasir Hussain,7 Ahish Chitneni,8 Ryan R Budwany,9 Jonathan Hagedorn,2 Jason E Pope,10 Timothy R Deer,11 Dawood Sayed,12 Alaa Abd-Elsayed13 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; 2Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 3Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA; 4Department of Physical Medicine and Rehabilitation, Rochester Regional Health, Rochester, NY, USA; 5Napa Valley Orthopaedic, Napa, CA, USA; 6Resident in the Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine at the Rehabilitation Institute of Michigan, Detroit, MI, USA; 7Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 8Department of Physical Medicine & Rehabilitation, New York-Presbyterian, New York, NY, USA; 9Resident in the Department of Anesthesiology, West Virginia University, Charleston, WV, USA; 10Interventional Pain Management, Evolve Restorative Center, Santa Rosa, CA, USA; 11Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV, USA; 12Department of Anesthesiology, The University of Kansas Medical Center, Kansas City, KS, USA; 13Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USACorrespondence: Natalie Strand, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA, Email Strand.Natalie@mayo.eduAbstract: Cannabinoids have recently gained a renewed interest due to their potential applicability to various medical conditions, specifically the management of chronic pain conditions. Unlike many other medications, medical cannabis is not associated with serious adverse events, and no overdose deaths have been reported. However, both safety and efficacy data for medical cannabis treatment of chronic, nonmalignant pain conditions are lacking. Therefore, representatives from the American Society of Pain and Neuroscience summarize the evidence, according to level and grade, for medical cannabis treatment of several different pain conditions. Treatment of cancer-related pain has prospective evidentiary support for the use of medical cannabis. Although 3 large and well-designed randomized controlled trials investigated cannabis treatment of cancer-related pain, the evidence yielded only a grade D recommendation. Neuropathic pain has been investigated in prospective studies, but a lack of high-quality evidence renders cannabis treatment for this indication a grade C recommendation. Both safety and efficacy data are lacking for use of medical cannabis to treat chronic nonmalignant pain conditions.Keywords: analgesia, chronic pain, marijuana treatment, neuralgia, postoperative pain

Jillian A Maloney,1 Ryan S D’Souza,2 Skye A Buckner Petty,3 Michal J Turkiewicz,4 Debarshi Sinha,4 Ajay Patel,5 Natalie H Strand1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; 2Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 3Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA; 4Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA; 5Department of Rehabilitation & Regenerative Medicine (Patel), New York-Presbyterian Hospital-University Hospital of Columbia and Cornell, New York, NY, USACorrespondence: Jillian A Maloney, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA, Email Maloney.jillian@mayo.eduPurpose: Data are lacking on the factors that contribute to job satisfaction among pain medicine physicians. We sought to determine how sociodemographic and professional characteristics relate to job satisfaction among pain medicine physicians.Methods: In this nationwide, multicenter, cross-sectional observational study, an electronic questionnaire related to job satisfaction was emailed in 2021 to pain medicine physicians who were members of the American Society of Anesthesiologists or the American Society of Pain and Neuroscience. The 28-item questionnaire asked physicians about sociodemographic and professional factors. Eight questions related to job satisfaction were based on a 10-point Likert scale, and 1 question was a binary (yes/no) variable. Differences in responses based on sociodemographic and professional factors were assessed with the Kruskal–Wallis rank sum test for Likert scale questions and with the Pearson χ2 test for yes/no questions.Results: We determined that several variables, including gender, parental status, geographic location, specialty, years of practice, and volume of patients, are associated with pain medicine physicians’ outlook on job satisfaction. Overall, 74.9% of respondents surveyed would choose pain medicine as a specialty again.Conclusion: High rates of poor job satisfaction persist among pain medicine physicians. This survey study identified several sociodemographic and professional factors that are associated with job satisfaction among pain medicine physicians. By identifying physicians at high risk for poor job satisfaction, healthcare leadership and occupational health agencies can aim to protect physicians’ well-being, enhance working conditions, and raise awareness about burnout.Keywords: economics, outcomes, pain management

Yeng F Her,1 Eva Kubrova,2 Gabriel A Martinez Alvarez,2 Ryan S D’Souza1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, 55905, USA; 2Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Rochester, MN, 55905, USACorrespondence: Ryan S D’Souza, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA, Tel +507-284-9696, Email Dsouza.ryan@mayo.eduAbstract: Pain originating from the intervertebral disc (discogenic pain) is a prevalent manifestation of low back pain and is often challenging to treat. Of recent interest, regenerative medicine options with injectable biologics have been trialed in discogenic pain and a wide variety of other painful musculoskeletal conditions. In particular, the role of bone marrow aspirate concentrate (BMAC) and culture-expanded bone marrow derived mesenchymal stromal cells (BM-MSCs) in treating discogenic pain remains unclear. The primary objective of this systematic review was to appraise the evidence of intradiscal injection with BMAC and culture-expanded BM-MSCs in alleviating pain intensity from discogenic pain. Secondary outcomes included changes in physical function after intradiscal injection, correlation between stromal cell count and pain intensity, and anatomical changes of the disc assessed by radiographic imaging after intradiscal injection. Overall, 16 studies consisting of 607 participants were included in qualitative synthesis without pooling. Our synthesis revealed that generally intradiscal autologous or allogeneic BMAC and culture-expanded BM-MSCs improved discogenic pain compared to baseline. Intradiscal injection was also associated with improvements in physical functioning and positive anatomical changes on spine magnetic resonance imaging (improved disc height, disc water content, Pfirrmann grading) although anatomical findings were inconsistent across studies. However, the overall GRADEscore for this study was very low due to heterogeneity and poor generalizability. There were no serious adverse events reported post intradiscal injection except for a case of discitis.Keywords: BMAC, discogenic pain, bone marrow mesenchymal stromal cells

Ryan S D’Souza,1 Julie G Pilitsis,2 Brendan J Langford,1 Vwaire Orhurhu,3 Nasir Hussain,4,5 Chelsey M Hoffmann,1 Magdalena Anitescu,6 Stephanie Vanterpool,7 Rushna Ali,8 Kiran Patel,9 Susan M Moeschler1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA; 2Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, FL, USA; 3Department of Pain Medicine, University of Pittsburgh, Pittsburgh, PA, USA; 4Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA, USA; 5Department of Anesthesiology, The Ohio State University, Columbus, OH, USA; 6Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA; 7Department of Anesthesiology, University of Tennessee, Knoxville, TN, USA; 8Division of Neurosurgery, Spectrum Health, Grand Rapids, MI, USA; 9Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA, Email Dsouza.ryan@mayo.eduBackground: Speaker gender representation at medical conferences is a significant site of gender disparity. Our primary objective was to quantify the proportion of female speakers and compare plenary session opportunities by gender at the North American Neuromodulation Society (NANS) Annual Conference.Methods: Data from the 2017– 2021 NANS Annual Conference presentations were abstracted. Primary outcomes included gender composition of speaker slots, gender composition of individual speakers, and comparison of plenary speaker slots by gender. Secondary outcomes included comparisons of session size, age, professional degree, and number of presentations per speaker based on gender.Results: Gender composition of annual speaker slots was (% slots presented by women): 2017:14.6%; 2018:20.5%; 2019:23.5%; 2020:21.0%; 2021:41.4%. Annual gender composition of individual speakers was (% women): 2017:18.7%; 2018:20.6%; 2019:24.6%; 2020:24.9%; 2021:33.8%. Of all speaker slots, the percentage of plenary slots did not differ based on gender, with 11.4% presented by female speakers versus 11.2% presented by male speakers (OR 1.0, 95% CI 0.7– 1.5, P=0.893). Compared to male speaker slots, there was an association of lower age (43.9± 5.6 vs 50.8± 8.9, P< 0.001), lower odds of holding a single doctorate degree (OR 0.3, 95% CI 0.2– 0.5, P< 0.001), and lower odds of holding a dual MD/PhD or DO/PhD degree (OR 0.3, 95% CI 0.1– 0.5, P< 0.001) in female speaker slots. Compared to male speakers, there was an association of higher number of presentations per female speaker at the 2021 NANS Annual Meeting (2.48± 1.60 vs 1.79± 1.30, P=0.008).Conclusion: Although the volume of female speaker slots and individual speakers trailed behind their male counterparts, female speaker representation steadily increased at each subsequent annual NANS meeting. We identified no difference in plenary session slots based on gender.Keywords: education, leadership, academic advancement, chronic pain, neuromodulation, gender

Corey W Hunter,1,2 Timothy R Deer,3 Mark R Jones,4 George Chiang Chien,5 Ryan S D’Souza,6 Timothy Davis,7 Erica R Eldon,2 Michael F Esposito,8 Johnathan H Goree,9 Lissa Hewan-Lowe,2 Jillian A Maloney,10 Anthony J Mazzola,2 John S Michels,4 Annie Layno-Moses,7 Shachi Patel,11 Jeanmarie Tari,1 Jacqueline S Weisbein,12 Krista A Goulding,13 Anikar Chhabra,13 Jeffrey Hassebrock,13 Chris Wie,10 Douglas Beall,14 Dawood Sayed,15 Natalie Strand10 1Ainsworth Institute of Pain Management, New York, NY, USA; 2Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 3The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 4Interventional Spine and Pain, Dallas, TX, USA; 5County Medical Center, Ventura, CA, USA; 6Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA; 7Source Healthcare, Santa Monica, CA, USA; 8Interventional Spine and Pain Institute, Vero Beach, FL, USA; 9Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 10Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 11Delmarva Pain and Spine Center, Newark, DE, USA; 12Napa Valley Orthopaedic Medical Group, Napa, CA, USA; 13Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA; 14Comprehensive Specialty Care, Oklahoma City, OK, USA; 15Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USACorrespondence: Corey W Hunter, Email chunter@ainPain.comAbstract: Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.Keywords: knee, knee pain, genicular nerve, ablation, regenerative medicine, platelet-rich plasma, dorsal root ganglion, peripheral nerve stimulation

Chelsey M Hoffmann,1 Ryan S D’Souza,1 Jonathan M Hagedorn2 1Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Pain Medicine, iSpine Pain Physicians, Maple Grove, MN, USACorrespondence: Chelsey M Hoffmann, Tel +1 507-422-6378, Fax +1 507-266-7732, Email Hoffmann.chelsey@mayo.eduObjective: To describe the team approach of an interventional pain management practice, with particular emphasis on advanced practice providers (APPs), in the selection, education, care, and management of peripheral nerve stimulation (PNS) patients.Materials and Methods: We devised an APP guide to PNS based on an in-depth search of multiple databases for studies on neuromodulation, pain management, and APPs.Results: Of 65 articles captured in the search strategy, three articles were pertinent to the topic of APP involvement in neuromodulation. More specifically, only one of the three publications on neuromodulation discussed APP involvement in PNS. This single publication was from 1995 and focused on electrical stimulation of the trigeminal ganglion using a permanent percutaneously placed electrode.Conclusion: PNS is growing in clinical indication and use for both acute and chronic pain conditions. With the increasing need for APPs in both general and specialty medicine, it is imperative that APPs are well educated on PNS. Here, we have outlined ways in which APPs can optimize the care of PNS patients and how the skillset of the APP in a PNS practice can potentially improve patient outcomes.Keywords: advanced practice provider, peripheral nerve stimulation, interventional pain management, nurse practitioner, physician assistant

Natalie Strand,1 Ryan S D’Souza,2 Jonathan M Hagedorn,3 Scott Pritzlaff,4 Dawood Sayed,5 Nomen Azeem,6 Alaa Abd-Elsayed,7 Alexander Escobar,8 Mark A Huntoon,9 Christopher M Lam,5 Timothy R Deer10 1Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Scottsdale, AZ, USA; 2Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 3iSpine Pain Physicians, Burnsville, MN, USA; 4Department of Anesthesiology and Pain Medicine, Division of Pain Medicine, University of California-Davis, Sacramento, CA, USA; 5The University of Kansas Medical Center, Kansas City, KS, USA; 6Florida Spine & Pain Specialists, Bradenton, FL, USA; 7Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; 8Comprehensive Centers for Pain Management, Toledo, OH, USA; 9Department of Anesthesiology, Virginia Commonwealth University, Henrico, VA, USA; 10The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Natalie Strand, Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Scottsdale, AZ, USA, Tel +1 480-301-8000, Fax +1 480-342-2986, Email strand.natalie@mayo.eduAbstract: The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.Keywords: post-amputation pain, low back pain, peripheral neuropathy, chronic postoperative pain

Mehul J Desai,1,2 Nasir Khatri,3,4 Jonathan M Hagedorn,5 Natalie Strand,6 Ryan S D’Souza,7 Vinicius Tieppo Francio,8 Alaa Abd-Elsayed,9 David W Lee,10 Erika Petersen,11 Johnathan H Goree,12 Jacqueline S Weisbein,13 Timothy R Deer14 1International Spine, Pain & Performance Center, Washington, DC, USA; 2George Washington University, School of Medicine & Health Sciences, Washington, DC, USA; 3University of Kansas, Department of Anesthesiology, Kansas City, KS, USA; 4Novant Spine Specialists, Division of Interventional Pain Medicine, Charlotte, NC, USA; 5iSpine Pain Physicians, Maple Grove, MN, USA; 6Mayo Clinic, Division of Pain Medicine, Phoenix, AZ, USA; 7Mayo Clinic, Department of Anesthesiology, Rochester, MN, USA; 8University of Kansas, Department of Rehabilitation Medicine, Kansas City, KS, USA; 9University of Wisconsin, Department of Anesthesiology, Madison, WI, USA; 10Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 11University of Arkansas, Department of Neurosurgery, Little Rock, AR, USA; 12University of Arkansas, Department of Anesthesiology, Little Rock, AR, USA; 13Interventional Pain Management, Napa Valley Orthopaedic Medical Group, Napa, CA, USA; 14Spine & Nerve Centers of the Virginias, Charleston, WV, USACorrespondence: Mehul J Desai, International Spine, Pain & Performance Center, 2021 K St NW Suite 615, Washington, DC, 20006, USA, Email drdesai@isppcenter.comAbstract: Social media has revolutionized internet communication and become ubiquitous in modern life. Though it originated as a medium for friendship, social media has evolved into an ideal venue for professional networking, scientific exchange, and brand building. As such, it is a powerful tool with which interventional pain physicians should become familiar. However, given the permanence and visibility of online posts, it is prudent for interventional pain physicians to utilize social media in a manner that is consistent with the ethical and professionalism standards to which they are held by their patients, employers, peers, and state medical boards. While there are extensive publications of professional codes of conduct by medical societies, there is a paucity of literature regarding social media best practices guidelines. Further, to date there have been no social media best practices recommendations specific to interventional pain medicine physicians. While not exhaustive, the aim of this document is to provide recommendations to pain physicians on how to maintain an effective professional and ethical online presence. Specifically, we provide guidance on online persona and professional image, patient–physician interactions online, patient privacy, industry relations, patient education, and brand building.Keywords: professionalism, social media, ethics, best practices, LinkedIn, Instagram, Twitter, Facebook

Ryan S D’Souza, Jennifer Eller, Chelsey Hoffmann Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA, Email Dsouza.ryan@mayo.eduPurpose: There is a paucity of data on pain diagnoses and analgesic utilization in medically underserved areas (MUAs). This study compared the prevalence of pain diagnoses and analgesic medication use between MUAs and non-medically underserved areas (N-MUAs) in Southern Minnesota and Western Wisconsin using the Rochester Epidemiology Project (REP) database.Methods: Five-year prevalence per 100 people (January 1, 2011 to January 1, 2016) was extracted from the REP database for multiple pain diagnosis variables and analgesic medications. Primary outcomes included comparison of five-year prevalence of each pain diagnosis and analgesic between MUA and N-MUA; and association between index of medical underservice (IMU) score and five-year prevalence for each pain diagnosis and analgesic. Linear regression models were performed to assess associations and significance thresholds were adjusted per the Bonferroni approach to account for multiplicity.Results: The prevalence per 100 people for a diagnosis of chronic pain was similar between MUAs and N-MUAs (13.8 ± 2.5 vs 14.6 ± 2.0, P = 0.543). Similarly, prevalence per 100 people for other specific pain diagnoses including nonspecific chest pain, abdominal pain, lumbago, somatoform disorder, and painful respiration did not differ based on MUA status. In terms of analgesic use, prevalence per 100 people for use of opioids, non-opioid analgesics, salicylates, and NSAIDs did not differ based on MUA status. An association between higher IMU scores and lower prevalence of painful respiration was identified, although this was not significant after significance threshold adjustment per the Bonferroni method.Conclusion: Our data suggest that there are no differences in several pain diagnoses and analgesic utilization between MUAs versus N-MUAs, and that the IMU score did not predict changes in prevalence of pain diagnoses or analgesic utilization. Future powered and national database studies are warranted to increase validity of findings to other populations outside of Southern Minnesota and Western Wisconsin.Keywords: medically underserved area, vulnerable populations, chronic pain, opioid, analgesia, pain management

Alaa Abd-Elsayed,1 Nomen Azeem,2 Pooja Chopra,3 Ryan S D’Souza,4 Dawood Sayed,5 Timothy Deer6 1Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; 2Florida Spine & Pain Specialists, Tampa, FL, USA; 3Bux Pain Management, Danville, KY, USA; 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA; 5Department of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 6The Spine and Nerve Centers, Charleston, WV, USACorrespondence: Alaa Abd-Elsayed, Department of Anesthesiology University of Wisconsin Madison, WI, USA, Email alaaawny@hotmail.comObjective: The objective of this study was to survey current clinical practice related to lumbar radiofrequency (RFA) for the treatment of zygapophyseal (facet)-mediated low back pain.Methods: Survey questions regarding the clinical practice of lumbar RFA were created and piloted by the American Society of Pain and Neuroscience (ASPN) leadership. After revision for clarity, health-care professionals worldwide who hold membership status within the ASPN Society and who offer lumbar RFA in their clinical practice were recruited to participate in this online survey. All responses were tabulated and summarized descriptively.Results: A total of 329 participants responded in the survey. Most participants specialized in anesthesiology (68.4%) and physical medicine and rehabilitation (21.8%) and had been practicing pain management for more than five years (70.5%). Of physician respondents, 27.5% did not complete an Accreditation Council for Graduate Medical Education (ACGME)-accredited pain medicine fellowship and 16.5% were not board-certified in pain medicine. The majority of providers (69.7%) reported that they perform two diagnostic medial branch blocks prior to proceeding with lumbar RFA. Bupivacaine 0.5% was the most common medication utilized for both the first (37.4%) and second (37.1%) diagnostic blocks. There were 32.6% of total respondents who reported not utilizing contrast dye when performing diagnostic blocks. The vast majority of providers (91.4%) reported using conventional RFA for lumbar medial branch neurotomy.Conclusion: This survey study provides a summary of the application of lumbar RFA for the treatment of axial low back pain in the real-world setting. We highlight a significant portion of providers who perform lumbar RFA yet do not have pain fellowship training at an ACGME-accredited institution or do not maintain current pain medicine board certification. We also report deviations from standard practice, specifically the type of local anesthetic used for comparative diagnostic blocks and the omission of contrast injection during diagnostic blocks.Keywords: radiofrequency ablation, low back pain, medial branch block, survey, clinical practice

Jonathan M Hagedorn,1 Joshua Gunn,2 Ryan Budwany,3 Ryan S D’Souza,1 Krishnan Chakravarthy,4 Timothy R Deer5 1Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 2Ethos Research & Development, Newport, KY, USA; 3West Virginia University, Charleston, WV, USA; 4University of California – San Diego, San Diego, CA, USA; 5The Spine & Nerve Centers of the Virginias, Charleston, WV, USACorrespondence: Timothy R DeerThe Spine & Nerve Centers of the Virginias, Charleston, West Virginia, 25301, USATel +1 304-347-6120Email doctdeer@aol.comObjective: Decision-making in chronic pain patients involves a combination of subjective and objective criteria, including patient history, physical examination, imaging, and patient response to prior treatments, clinical experience, probabilities, and recognition of patterns. However, there is a distinct lack of objective laboratory biomarkers in use in routine clinical care. The objective was to review the literature to identify and describe specific biomarkers in chronic pain management.Methods: This is a narrative review of the literature regarding the use of laboratory biomarkers in chronic pain. A librarian-assisted literature search of the PubMed, Science Direct, and Google Scholar databases was performed and resulted in 304 possible manuscripts. We included manuscripts assessing laboratory collected biomarkers from urine, serum, cerebrospinal fluid, and saliva. After screening and review of the initial literature search results, a total of 75 manuscripts were included in the narrative review.Conclusion: The studies reviewed suggested that specific biomarkers may help identify those patients at risk of disease development and function as a prognostic indicator for disease progression and treatment response. However, additional research is necessary before specific recommendations can be made, and current clinical decision-making is modified.Keywords: chronic pain, biomarkers, outcomes

Jonathan M Hagedorn, Thomas P Pittelkow, Christine L Hunt, Ryan S D’Souza, Tim J Lamer Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Tim J LamerDepartment of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN 55905, USATel +1-507-284-2511Email Lamer.Tim@mayo.eduAbstract: Cancer and cancer treatment-related chronic pain affect a significant number of patients. The etiology of this pain is diverse and may include nociceptive and/or neuropathic characteristics. Treatment is often multifactorial and may require advanced interventional techniques, such as spinal cord stimulation (SCS). This narrative review provides a thorough overview of cancer-related pain mechanisms and the use of SCS for cancer-related pain. Additionally, a review of the precautions that should be considered when caring for this patient population is provided with recommendations for safe care when utilizing these techniques.Keywords: spinal cord stimulation, cancer pain, neuromodulation, radiation, chemotherapy, surgery