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11 Articles in this Series
A PAINWeek 2019 preview with EVP Debra Weiner
Comparing Marijuana and Hemp
Fibromyalgia: What’s New in Diagnosis and Pain Management
Life Hacks to Teach Patients with Chronic Pain
Managing Pain (and Function) in Osteoarthritis: Are Patients and Physicians on the Same Page?
Marijuana: How to Proceed When Controlled Substances are Involved
Menopause Comes with More than Mood Swings - It Deserves its Place Among Chronic Pain Conditions
More APPs Are Coming to the Forefront of Pain Care
Motivational Interviewing and Its Extension into Pain Management
Revisiting Documentation
Side Chat: Modern Analgesic Trials

More APPs Are Coming to the Forefront of Pain Care

Advanced Practice Providers, or APPs, made up approximately 25% of the 2,000-plus attendees at PAINWeek in 2018, and at this past fall’s conference, every seat was filled during the APP track sessions. The new section formally began about 5 years ago, recognizing the need to develop content unique to APP practice in pain management and to showcase multidisciplinary practice that includes collaboration of care. As more and more APPs take a leading role in pain management, the value and scope of the focused sessions continue to grow. Here, in a spinoff of my usual APP column in this journal, I am sharing questions that advanced practice provider speakers received from their audiences during the PAINWeek 2019 APP Track, along with their reply.



Brett B. Snodgrass, FNP-C, CPE, FACPP, FAANP, lectured on "The Importance of Chart Documentation in the Chronic Pain Patient." There is nothing more important than excellent chart documentation when it comes to defense against possible litigation over standards of care. While traditionally centered around physicians, the importance of clear and thorough chart documentation is an ongoing learning need of APPs as well. Snodgrass said that chart documentation and, specifically, the idea of “time-stamping” is one of her most requested presentations.

She shared: “Time-stamping is the amount of time you spend in the chart – each visit is documented. When you are reviewing x-rays or MRIs, that time is documented. So often, an attorney may ask how long it takes a provider to read an x-ray or other diagnostic test and then he or she compares the answer to how long the provider in question actually looked at that film, with the goal of decreasing credibility. It is important to remember that if you are completing charts days or even weeks after seeing a patient, this activity is time-stamped and could bring into question what you really remember from that specific visit. In addition, the process of supervising or collaborating physicians cosign charts is time-stamped as to the amount of time and what time the physician did this.” (See also, “Revisiting Documentation” for clinicians with Michael Barnes, JD).

Acute Services

Mechele Fillman, MSN, NP-C, shared her years of experience and expertise in creating not one but three acute pain services organized and run by APPs to meet the needs of patients in the most vulnerable circumstances: those struggling with post-surgical pain. She shared real-life experiences, clinical pearls, and suggestions for avoiding some obvious pitfalls. Her lecture was justly titled, "Starting an Acute Pain Service is Harder Than you Think: aka, OMG, Why Did I Agree to Do This Again?" 

One audience member shared that she was the only pain nurse in her practice, expected to cover consults between three different hospitals, maintain proficiency with nursing education, and keep hospital pain policies up to date. She asked, “Can an established acute pain service really save a hospital money and improve outcomes?” Fillman’s response: “Outcomes from the American Society of Anesthesiologists and American Association of Nurse Anesthetists would argue that an established acute pain service will save hospitals money by decreasing length of stay and improve outcomes with regards to patient satisfaction and less surgical complications related to delayed mobility secondary to poorly managed pain.” (See Mallick-Searle's column on APPs and Acute Pain Services.)

Debra B. Gordon, RN, DNP, FAAN, also focused on acute pain with a talk on "Active Substance Use Disorder & Case-Based Challenges in Acute Pain Management." She found that many audience members were interested in learning how to use “micro-inductions” to start buprenorphine in the hospital, including in patients with opioid use disorder (OUD). In addition to referring attendees to Hammig’s paper on microdosing buprenorphine (see Hammig, Abuse and Rehabilitation, 2016), Gordon shared the following:

“The precise methods for starting a person on medication-assisted treatment for OUD while they are still in hospital and experiencing acute pain, requiring full mu opioid agonists, are still being developed, but the practice does seem feasible. In fact, a hospitalization is an important opportunity to engage patients in life-saving addiction treatment or, at the very, to least provide counseling on harm-reduction strategies. Patients with acute traumatic or necrotizing soft tissue infections related to heroin use can be challenging due to changes in sensitization and hyperalgesia, behavioral issues related to fear of pain, judgement, or withdrawal. It wasn’t so many years ago that these patients would be admitted to a hospital and ‘detoxed.’ However, the medical community now better understands how detoxifying a person does little to treat the disease of addiction and, in fact, can put them at greater risk for overdose and death. Best practices are available today to prevent and manage withdrawal, using methadone and buprenorphine to ‘stabilize’ so that the patient can better engage in a discussion about how addiction treatment is planned and coordinated. This process can begin in supportive environment while also providing a balanced and rational multimodal regimen to treat the acute pain.”

Opioid-Sparing Strategies

Garry Brydges, PhD, DNP, MBA, MSN, CRNA, ACNP-BC, FAAN, gave a talk on "Enhancing Recovery After Surgery: How Certified Nurse Anesthetists Are Improving Outcomes." He focused on how the healthcare community is at a crossroads as the opioid crisis rages in America and how certified registered nurses are leading the way in providing effective pain management while preventing opioid abuse and addiction. Brydges was asked, “How much of an impact on outcomes can a Certified Registered Nurse Anesthetist [CRNA] make in enhanced recovery after surgery [ERAS] programs?” His reply: “CRNAs have implemented opioid-sparing strategies throughout their practice. The combination of regional anesthesia techniques and multimodal pain management strategies offer a disproportionately high benefit to the patient throughout the perioperative phase and throughout their inpatient stay. CRNAs can reduce postoperative nausea and vomiting, postoperative ileus, postoperative cognitive dysfunction, length of stay, and 30-day readmission rates. In addition, CRNAs offer increased patient satisfaction, early ambulation, early nutrition consumption, and reduced workload on nursing personnel.”

Nutrition Management

I rounded out the track with a talk on the new science of the little village within us that affects many aspects of emotional and physical health: the microbiome.More and more research is showing that what we eat affects our mental well-being and directly impacts the way we respond to and are affected by physical pain. My lecture was titled, No Guts No Glory: Mystery of the Microbiome. I was asked, “What is the best way to counsel a patient regarding the health of their microbiome?”My reply was to counsel patients about sensible eating, exercise and stress reduction, all of which affect the health of the microbiome. The jury remains undecided about the routine use of probiotics for health and wellness. However, patient counseling should include the recommendation of a diet rich in pre- and pro-biotic foods. Additionally, I put forth a challenge to each member of the audience to reduce their intake of gluten by 50% for 6 weeks and to see how much better they felt. ‘You will be so much more likely to be confident and believable/earnest in your counseling if you ‘live the experience,’ I explained. Conditions that may be improved with a reduction of gluten in the diet include: gluten-sensitive irritable bowel syndrome, nonceliac gluten sensitivity and neuropathy, schizophrenia or other mental health conditions, atopy, fibromyalgia, endometriosis, obesity, athletic performance, and sleep.

Of note, Ravi Prasad, PhD, guided APP participants through the techniques and importance of motivational interviewing in pain management. This directive, patient-centered counseling style for eliciting behavior change helps patients to explore and resolve ambivalence. His lecture was called, Achieving Change from Within: Use of Motivational Interviewing. See what he had to say.


*Comments made at the live sessions have been modified for style and clarity. Theresa Mallick Searle, RN-BC, ANP-BC, has served as leader of the conference's APP Track since its inception.


Next summary: Motivational Interviewing and Its Extension into Pain Management
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