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10 Articles in this Series
Introduction
An AAPM 2019 Preview
APRNs/PAs in Pain Medicine SIG Gets Underway
Cannabis Has Entered Pain Management and Is Here to Stay: What Clinicians Need to Consider
Managing Pain in Marginalized Populations, including Ethnic Minorities, LGBTQ, and the Obese
Neuromodulation: A Roundtable on Current Best Practice & Key Questions
Pro/Con: CGRP Antibodies and Treatment Choice for Chronic Migraine
Pro/Con: Conservative Care is the Best Route for Chronic Pelvic Pain
Pro/Con: CRPS - Use Everything but Stimulation
Pro/Con: Ketamine for Complex Regional Pain Syndrome, Neuropathic Pain, and More
Pro/Con: Radiofrequency Denervation is Effective (The MINT Studies)

An AAPM 2019 Preview

Panelists at the American Academy of Pain Medicine (AAPM) annual meeting are expected to debate neuromodulation and discuss the rising role of psychologists in pain care. Here, Program Committee Co-Chairs Steven Cohen, MD & Patrick Tighe, MD, along with Academy President Jianguo Cheng, MD, PhD, share additional insight with PPM Managing Editor Angie Drakulich

Source: 123RF

PPM: The 2019 meeting theme is “state-of-the-art advancements.” What areas of pain management do you envision truly evolving in practical clinical application this year? What should attendees be looking for?

AAPM Co-Chairs: AAPM continues to explore novel, non-opioid approaches to treat pain and improve patient function. On the interventional side, recent media coverage of complications on neuromodulation has placed this treatment in the spotlight. Several developments in technology have occurred in this field, such as high-frequency spinal cord stimulation, MRI compatibility, DRG stimulation, and percutaneous paddle leads.

In addition, there are animal studies being performed to examine pre-emptive effects as well as randomized studies taking place on peripheral nerve stimulation, and there have been new indications for the use of SCS, such as non-neuropathic pain. As a result, there has been increased utilization, and increased recognition of the complications that may occur with neuromodulation—as well as new information on its possible limitations (eg, non-industry-sponsored studies have demonstrated lower responder rates).

The AAPM panel discussion on this topic will provide an open forum to discuss all of these issues, including selecting candidates, which technologies to use for various conditions, risk mitigation, study design (eg, pragmatic studies vs true placebo-controlled studies, which may be possible with high-frequency SCS), and whether or not neuromodulation may reduce opioid use.

A second area of international controversy and scrutiny revolves around the use of radiofrequency ablation after publication of the MINT study (Juch, et al, JAMA, 2017), the FACTS study (Cohen, et al, Anesthesiology, 2018), and the development of an international panel tasked with putting together facet block and radiofrequency ablation guidelines. There are several talks on this subject taking place at AAPM, including a plenary lecture and pro-con sessions.

Finally, our keynote will discuss the pros and cons of cannabinoid therapy for the treatment of pain. This is an important area of discussion given the potential impact not only for individual patients but also with respect to multifaceted public health concerns.

PPM: Regarding the special session on neuromodulation, what are you hoping may come out of the discussion? What areas need to be addressed in this specialty field sooner rather than later?

AAPM Co-Chairs: Several years ago, rising utilization and complications (eg, the fungal meningitis outbreak) led to increased scrutiny by regulators and payors on epidural steroid injections (ESIs). This is occurring now for facet joint radiofrequency ablation (NICE in the United Kingdom has commissioned a request for applications for a pivotal efficacy study) and is likely to affect neuromodulation in the next few years. Overutilization and poor technique (eg, inappropriate patient selection, use for conditions unlikely to respond, and the use of suboptimal technology) alter the risk:benefit ratio, and it is hoped that the special session will shed light on these issues.

PPM: This year’s meeting is also focusing on the crucial role of pain psychologists. As the industry moves more toward an integrative, transdisciplinary model of care, where do you see psychologists having the most impact and why? How do you anticipate both patients and insurance payors responding to this important element of pain care?

AAPM Co-Chairs: Historically, pain management has had a primary focus on reducing pain intensity. While this is certainly an important and laudable goal, we are increasingly aware of the need to consider pain management within the context of the patient’s broader functional status. A crucial aspect of that functional status is the patient’s emotional and behavioral well-being, which are issues that medical approaches can only partially, or even minimally, address.

Psychologists play a critical role in disentangling the many complex issues involving pain and mental health. At Johns Hopkins (where Dr. Cohen serves as director of medical education for the Pain Management Division), teams are submitting a proposal for the NIH HEAL initiative on opioid-sparing pain treatments, and, in a pragmatic study, they are evaluating pain-coping strategies/cognitive behavioral therapy, medications, and procedural interventions.

There is a huge overlap between depression/anxiety, sleep, and pain, and there is a growing recognition that the relationship is bilateral (ie, pain can cause sleep and psychiatric morbidity, but psychiatric illness and sleep disorders predispose individuals to chronic pain after an injury). It is difficult to evaluate these techniques in true placebo-controlled trials (although some effort has been made), and similar to medications and interventions, studies are plagued by lack of long-term outcomes and comparative-effectiveness evaluations.

Pain psychologists also may play a role in selecting patients for expensive and risky procedural interventions, such as phenotyping and quantitative sensory testing, which may be part of personalized medicine. Consultation with a pain psychologist has been required for many years before SCS, which is somewhat inconsistent with not requiring consultation before starting a patient on opioids or referring them for back surgery.

Seeing a psychologist for any reason was taboo in some cultures for the older generation of pain practitioners, many of whom now make decisions on treatment. This has changed, but it depends on how one “sells it.” Managing expectations is also crucial, as this step requires more active participation (rather than passively receiving an injection or taking a pill) and often proves better at improving patient quality of life and function rather than simply decreasing nociception and pain.

As the cost of medications (particularly biological treatments) and procedures continues to surge, with no relationship whatsoever to disability rates, we will need to show cost-effectiveness and objective measures of improvement (eg, medication reduction, return-to-work, less healthcare resource utilization) to continue to get buy-in for these treatments. Unfortunately, although it is widely acknowledged that integrative pain care is ideal, it is often not cost-effective. 

...

AAPM President Jianguo Cheng, MD, PhD, added that he is most excited about the planned presentations on HHS Best Practices Pain Management Task Force,  the National Academy of Medicine Action Collaborative on Countering the US Opioid Epidemic, and the Inter-Agency Pain Research Coordinating Committee. "These reflect critical and historical federal/national efforts to address the dual crises of chronic pain as a public health issue and the US opioid epidemic," he noted. "These initiatives are expected to have a major impact on patient care, education, research, and health policies. I am proud of the fact that AAPM is playing leadership roles in these initiatives." 

 

Stop by the PPM Exhibition Booth #210 to get the latest journal issue, including Dr. Cheng's and other industry leaders' visions for the future of pain management.

Next summary: APRNs/PAs in Pain Medicine SIG Gets Underway
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