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13 Articles in Volume 18, Issue #7
A Commentary on Medical Cannabis
Are Abuse-Deterrent Opioids Appropriate for Your Pain Patient?
Behind the AHRQ Report
Challenges Facing Abuse-Deterrent Formulations
Demystifying Opioid Abuse-Deterrent Technologies
Editorial: Our Clinical Pain Neighborhood
Independent Pain Practice: A Case Example
Inside Performing Arts Medicine
Letters to the Editor: ACT Therapy; Compounded Topicals
Nerve Growth Factor and Targeting Chronic Pain
Pain Control for Athletes: What Works?
Quality Training: One Center’s Experience with Pain Assessment
The Importance of Developing Professional Relationships in Pain Practice

Editorial: Our Clinical Pain Neighborhood

When a passion for care leads to a career in pain practice, and a family of healthcare professionals work together, great things can happen.
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Jeff Gudin, MD

A commentary from Jeff Gudin, MD

I am thrilled, honored, and humbled to be Co-Editor at Large with Dr. Jeffrey Fudin for a journal that I have read since its inception in 2001. First off, to our predecessor, the legendary Dr. Forest Tennant, who was, and remains, known for taking only the most refractory pain patients that failed all conventional and interventional therapies. He made a science out of studying high-dose opioid therapies as well as hormonal deficiencies and supplementation for these challenging patients. And to my mentor at Yale, Dr. Lloyd Saberski, who was convinced in the 1990s that pain was an immunological phenomenon and that one day, pain specialists would be using advanced immunological therapies like modulators of interleukins, leukotrienes, prostaglandins, TNF alpha, and glial cells (sound familiar?). He looked patients in the eyes when he spoke to them and always promised to do his best to find them relief. These leaders were ahead of their time and encouraged my passion for pain management. 

Looking back to 1992, I was a surgical intern with little to no clinical knowledge standing at the bedside of a schoolteacher who was crying in pain from an open abdominal surgery she underwent that day. She had already received 50 mg of meperidine and the nurse called my senior surgical resident about this “problem” patient. Busy in the OR, the senior resident asked me to “quiet” this squeaky wheel. I felt awful for the patient who was clearly suffering, so I did what any good (clueless) intern would do and called back my resident for direction. He queried me about her last dose, given 4 hours prior, and then told me to reassure the patient that her next dose was only 2 hours away. No PCA device, no long-acting local anesthetic in the wound, no preoperative NSAIDs, no neuraxial analgesia, no IV acetaminophen, and certainly no preoperative preparation for the intense pain that ensued.

Over the next 25 years, while building a pain, addiction, and palliative care practice, I traveled the world to take part in care missions and lecture tours. To this day, what stands out the most is the amount of suffering that painful diseases can impart on good people. Chronic pain affects not just the patient but the entire family. Recent data out of the CDC suggests that the percentage of suicide decedents with chronic pain rose from 7.4% in 2003 to 10.2% in 2014, and those with chronic pain were far more likely to overdose on opioids (prescription and illicit) compared with individuals without chronic pain (16.2% versus 3.9%).1 We must be careful when evaluating this data as perhaps having access to opioids with severe pain may actually decrease a patient’s risk of suicide.

On a personal note, while I was educated in a climate of high-dose opioid therapy, I don’t actually think of opioids as great pain management drugs. While I have seen them silence the suffering of thousands of patients with both cancer and non-cancer pain syndromes, we know that these medications can be plagued with both bothersome and dangerous adverse effects. Many of us have also seen patients go to great lengths to obtain them for licit and even illicit purposes. This trust-breaking between patient and provider has been one of the greatest frustrations I have witnessed in pain care, and it has ruined care for many patients in true need.

When I chat with the real heroes of pain management—our colleagues on the frontlines who have lived through the opioid epidemic—they unanimously tell me that they spend the majority of their time tapering patients’ doses of opioids, even stable patients. There are many reasons, including arbitrary dose limits being imposed by regulatory authorities and by payors, but I believe this trend stems primarily from fear of sanctions.

Fortunately, as healthcare practitioners, I believe we are winning the war on prescription opioids. Among the more than 72,000 drug overdose deaths estimated in 2017, the sharpest increase was related to (street) fentanyl and fentanyl analogs (ie, synthetic opioids), with nearly 30,000 overdose deaths; deaths related to cocaine use are on the rise as well.2 Deaths related to prescription drug abuse have stabilized as clinicians are improving patient selection, medication plans, and the use of adjuvant therapies.

As an academic pain clinician and researcher, I can assure you that our analgesics of the future will lack the adverse effect profile that accompanies opioids, perhaps with even better effectiveness. I am proud of our R&D colleagues and have every faith that we will all see pain treatment revolutionized by new molecules and technology. We are also making great strides in integrating behavioral therapies into pain management. Just read the work coming out of Stanford’s Systems Neuroscience and Pain Lab, led by Beth Darnall, PhD, on catastrophizing and how this phenomenon creates not only mental chaos but also physiological and neurological changes in sensation and pain levels. By setting realistic expectations and maintaining optimism, we can help our patients conquer their pain.

Again, I would like to thank PPM for the opportunity to contribute to the journal and the field I love. In pain management, the saying, “It takes a village” couldn’t be more appropriate. To succeed, clinicians must collaborate with pharmacists, interventionists, advanced practice providers, behavioral therapy specialists, and more. And, on this note, I turn the page over to my friend and colleague, Dr. Fudin.

 


 

Jeffrey Fudin, PharmD

A commentary from Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, FFSMB

I am excited to share in Dr. Gudin’s comments, which seem to mirror our yearly banter at PAINWeek, popularized as the “Fudin/Gudin Debate.” I, too, am exhilarated over the opportunity to stand beside my longtime friend and peer, or should I say “evil twin” as Co-Editor-at-Large. Indeed, filling Dr. Tenant’s shoes will be a very tall task.

Although I never worked with him directly, Dr. Tenant approached me at a national pain conference just months after I founded Professionals for Rational Opioid Monitoring and Pharmacotherapy (PROMPT). I’ll never forget that day; with a thatch of white hair and kind smile, he, with his lovely wife, Miriam, said, “Hello, I’m Forest Tenant and I want to personally shake your hand for singlehandedly standing up to Physicians for Responsible Opioid Prescribing (PROP) to advocate for patients” who stand to be harmed by their misguided petition. Little did I know at the time that these words would foreshadow the problems, and solutions, yet to come. From that day forward, we often spoke about complex patient cases, the option for opioid serum monitoring with respect to predictive pharmacokinetics, and the importance of properly interpreting pharmacogenetic analyses.

Last updated on: October 5, 2018
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PPM Welcomes Dr. Fudin and Dr. Gudin as New Co-Editors
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