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14 Articles in Volume 19, Issue #1
Analgesics of the Future: NKTR-181
Antidote to CDC Guideline; Plantar Fasciitis; Patient Input
Assessing and Treating Migraine in Women and Men
Demystifying Opioid-Induced Hyperalgesia
Editorial: Have We Gone Too Far? Can We Get Back?
How to Compel Patients to Complete Home Exercises
Inflammation Targeted Nanomedicine
Intravenous Stem Cell Administration for Ileitis
Invasive Surgery: Effective in Relieving Chronic Pain?
Pain Catastrophizing: What Practitioners Need to Know
Pain Therapy Options for the Home
Regenerative Medicine
The Future of Pain Management: An Experts' Roundtable
Whole Body Vibration: Potential Benefits in the Management of Pain and Physical Function

The Future of Pain Management: An Experts' Roundtable

Industry leaders Jianguo Cheng, Stefan Evers, W. Clay Jackson, Lynn Kohan, William Maixner, Paula Marchetta, and more share their visions.
Pages 25-33

For our first issue of the new year, PPM asked leading industry members and practicing clinicians, including some of our editorial board advisors, to share their visions of what the pain management landscape may look like in the next 5 to 10 years. For example, how might patient assessment evolve? What treatment approaches are likely to fade away or become more prominent? Which looming regulatory expectations will impact providers the most? How might patient communication and provider interaction change for the better? And, how might medical training and specialization adapt to the changing times? Here’s what your peers predict…

 

Jianguo Cheng, MD, PhD, FIPP 
President, American Academy of Pain Medicine

The landscape of pain management will continue to evolve in the coming 5 to 10 years based on three nationwide initiatives: the work of the HHS Pain Management Inter-Agency Task Force mandated by the US Congress; the implementation of the National Pain Strategy led by the NIH; and the National Academy of Medicine's Action Collaborative on Countering the US Opioid Epidemic. With these major national efforts, we can expect that best practice will be promoted, modeled, and adopted.

Some of the key components of best practice will include team-based care models that emphasize patient-centered, multidisciplinary, and coordinated care for patients with high impact pain. We can also expect that gaps and inconsistencies will be identified in pain management as well as in the prevention and treatment of substance use disorders. New and comprehensive strategies to address the gaps will be proposed and implemented to improve access to care, patient and provider education, and bench-to-bedside research. It is highly expected that a strong scientific and programmatic foundation will be laid, on which evidence-informed clinical practice can continuously improve the efficacy, safety, and cost-effectiveness of pain care.

Stefan Evers, MD, PhD 
Honorary Secretary, International Headache Society

Just last year, two major publications of disease classifications were updated: the third edition of the International Headache Society’s (IHS) International Classification of Headache Disorders (ICHD-3), creating a worldwide classification system for all headache disorders, and the World Health Organization’s updated manual of diseases (the ICD-11) featuring a new chapter dedicated to chronic pain disorders, including chronic migraine and other chronic headache disorders. ICD-11 will be presented to the World Health Assembly this May for adoption. Both sets of information will help to increase awareness of these disabling conditions going forward.

Another key event that took place in 2018 after two decades of research was the introduction of calcitonin gene-related peptide (receptor) antibodies for the prevention of migraine and certain headaches to the market. Looking ahead, patients may no longer have to take a daily tablet but instead may be able to administer a single injection once per month or quarter to prevent and reduce migraine attacks.

IHS is also hopeful about the improvements being made to stimulation techniques for the treatment of migraine as well. After several years of trial-and-error, the first devices are coming to market, including noninvasive vagus nerve stimulation or stimulation of the supraorbital nerve. The efficacy of the devices is not excellent, but they may be used to support or supplement other treatment strategies. In this context, the use of Botulinum toxin is also likely to become more routine in the treatment of chronic migraine.

As these advances are to be applauded, there is still much to do. Migraine is a heterogenous disease and its genetic implications are still largely unknown. Looking ahead, the medical community may once and for all be able to identify certain subtypes of migraine using genetic techniques, which could then serve to tailor treatment plans. So far, early genome-wide association studies have shown that migraine is not only heterogenous with respect to the clinical picture but also with regard to underlying genetic mechanisms.

Another reason migraine research still needs attention over the next 5 to 10 years is the disorder’s link with comorbidities. For example, there is an association between migraine and vascular disorders. Epidemiological research has suggested that migraine increases the risk for such disorders. If this proves true, a migraine treatment regimen may one day include the treatment of these risks as well. Could it be possible to minimize the risk for stroke or other vascular disorders increased by migraine, if we treat migraine properly? Or what about the comorbidity with depression? At least in some cases in the future, physicians should perhaps consider depression as a major objective of treatment in migraine patients. There are additional comorbidities, such as immunological disorders and restless legs syndrome, to be considered as well.

Overall, the future of migraine management will not exist unless we take time to educate our younger colleagues on how to diagnose and treat the disease, and how to perform effective, targeted research. At the moment, there is much enthusiasm among young medical students and researchers. If this excitement continues, we should not be anxious about the future of migraine and headache treatment.

W. Clay Jackson, MD, DipTh
President, Academy of Integrative Pain Medicine*

Patient assessment will evolve beyond the singular focus on the “pain score” to become more multimodal, with attention to qualitative and experiential domains. In addition, technologic advances will digitize the assessment process, extending the monitoring of patient experiences outside the brick-and-mortar locale of the clinic into the realm of digital biometric devices.

The pharmacocentric, opioiphilic, and allopathic-dominant model will be discredited, accompanied by a concomitant rise in integrative care, with attention to the biopsychosociospiritual components of the patient experience. Digital devices will allow for continuous feedback from the patient experience to the clinician’s counsel. Paternalistic models will yield to more collaborative care, as patients demand quality and choice in exchange for paying for a larger percentage of their care.

As electronic health records merge toward integrated platforms, digital crosstalk will allow for more integrative care across multidisciplinary platforms. And as the fee-for-service model is supplanted by value-based models of payment, incentives among stakeholders will align toward desired patient outcomes, rather than competing for patient visits.

Opioid therapy will continue to wane, particularly as a foundational treatment strategy. If this change is accompanied by a concomitant increase in integrative, non-opioid, and non-pharmacologic therapies, patients will benefit. This will be the key advocacy battle of the next decade.

Training programs will evolve to reflect practice reality—they will be integrative, multidisciplinary, and technophilic. Although pain management teams will continue to be physician-led, they will cease to be physician-centric, focusing on exploiting the good ideas of all team members equally.

Lynn Kohan, MD
Associate Professor of Anesthesiology & Fellowship Director, Univ. of Virginia School of Medicine / Chair & Founding Member, American Society of Regional Anesthesia and Pain Medicine Headache Special Interest Group

It is an exciting time to be in the field of pain management. We are leaving behind the era of opioid prescribing and entering a time of novel and advancing treatment options including rapid advances in drug development, neuromodulation, and the progression of focused ultrasound. While the developments in these novel therapies are exciting, the treatment model is moving beyond the development of single new agents/techniques. Instead, there is increased recognition of the complex multidimensional nature of chronic pain that acknowledges the wide range of individual variations in susceptibility to pain, and of cultural and emotional responses to pain and responses to treatment, as Worley wrote in Pharmacy and Therapeutics in 2016.

Scientists are also beginning to have a better understanding of pain pathways and pain-related targets, and thus are able to develop medications and techniques to help alleviate pain with reduced side effects. Researchers are moving away from categorizing pain based on a particular diagnosis, injury, or anatomic location. There is a growing belief that thinking about pain in terms of nociceptive versus neuropathic pain may be an oversimplification, and thus researchers are increasingly focusing on identifying pain-related phenotypes, which incorporate detailed descriptions of pain (such as burning, stabbing, aching, shooting), as Van Hecke, et al, wrote in Pain in 2015. Identifying these pain phenotypes may result in a better understanding of the neural mechanisms of pain and thus allow for more targeted treatments.

In addition, we are on the verge of understanding more about the use of gene therapy vectors as a tool for the development of molecularly selective pain therapies, as Pletchia, et al, wrote in Mayo Clinic Proceedings in 2016. Advanced neuroimaging techniques are being used to examine the emotional and cognitive factors that can alter one’s pain perception in addition to the underlying neuroplastic changes that occur in response to chronic pain. For instance, functional MRI is being used to try to evaluate pain in real time and provide information about how pain may possibly be controlled. In addition, transcranial magnetic stimulation may be used to determine how various brain regions impact pain processing, according to Worley. These techniques, in addition to the use of biomarkers, may lead to a time of neuroprognosis—a field that may allow physicians to determine which patients may respond to one treatment versus another.

These advances, while some are still in their infancy, will likely contribute to the future of pain management. The goal of reaching the era of individualized pain management instead of trial-and-error techniques are within our grasp and are not inconceivable in the next decade.

PPM asked leading industry members and practicing clinicians to share what the pain management landscape may look like in the next 5 to 10 years. (Source: 123RF)

William Maixner, DDS, PhD
President, American Pain Society

Pain researchers are seeking a better understanding of the etiology of a variety of different pain conditions. When it comes to patient assessment, improved classification will lead to more personalized treatment for pain conditions. Individualized treatments will focus on interdisciplinary pain management protocols that follow a whole-patient focus.

There will be continued focus on reducing the use of opioids, and doctors will move away from routine prescribing of opioids in favor of combination therapies. New protocols will be followed for opioid weaning, and there should be greater utilization of cognitive behavioral therapies as part of interdisciplinary pain management programs.

Perhaps the most significant evolution of pain management strategy in light of regulations will occur from increased investments in pain research, such as the Helping to End Addiction Long-term (HEAL) Initiative. HEAL provides good resources for academia and pharma to work together in identifying drug candidates.

Paula Marchetta, MD, MBA
President, American College of Rheumatology

We will most likely see less and less use of opioids for the management of chronic pain, especially in view of the current opioid crisis and the changes in the regulatory environment as a result of it.

I think the team-based approach to managing chronic pain will become much more prominent. Both pharmacologic and non-pharmacologic therapies have long been used to help patients suffering from chronic pain. We often see that patients do best when several modalities are used in combination. Thus, the importance of the interdisciplinary team for coordinating care in pain management will become increasingly recognized by providers, as well as by patients. This approach allows different health professionals to combine forces in a structured way so that the pain management regimen for a specific patient can be customized and optimized.

With a team-based approach, there will be many more “touch points” for patient interaction with members of the interdisciplinary team. It will no longer just be the physician/prescriber taking care of the patient, but rather, pain management professionals working together will serve as resources to the patient for help and support.

 

 

Stephen L. Barrett, DPM, FACFAS
US Neuropathy Centers, Past President, Association of Extremity Nerve Surgeons

Looking specifically at lower extremity peripheral nerve pathology, I think pain management in the future will require not only an assessment of the actual pain generator/nerve pathology in the lower extremity but also its effect on the patient’s central nervous system (CNS). At this time, we are looking at patients with severe nerve pathology in their lower extremity from a global perspective. What is happening with their CNS and how we manage the peripheral injury with regard to that relationship will help us better understand what is happening from a central sensitization standpoint.

For example, a patient with 11 failed surgeries on their lower extremity is unlikely to be a successful surgical candidate on the 12th attempt. Today, clinicians are looking into functional MRIs of the brain, with referral to neurological specialists who can effectively treat brain pathology that is now recognized to be associated with depression, anxiety, and chronic pain. Implementation then can be instituted after neuronavigation is planned out with transcranial magnetic stimulation that successfully treats many of these psychiatric conditions. After the patient is treated for CNS pathology, we may begin to intervene with the lower extremity to reduce or eliminate the pain generator that was there in the first place.

Ultimate pain management requires a multidisciplinary approach and focus to treat the entire patient. In the future, and in some cases, even now, we will be able to accurately determine the true pain generator and to provide a comprehensive assessment of the patient, including their psychological status, sleep patterns, diet, nutrition, and metabolic status, pharmacological interventions, hormonal makeup, and exercise. Then, delivery of a customized treatment plan may be implemented.

David Cosio, PhD, ABPP
Anesthesiology/Pain Clinic, Jesse Brown VA Medical Center

There appears to be substantial dissatisfaction with the current state of pain management in this country among patients with chronic non-cancer pain. Psychology of the future will need to help address some of the sources of this dissatisfaction.

Psychologists can work to improve the delivery of pain treatment and ensure a strong future by:

  • helping to evaluate patients for comorbid mental health conditions
  • enhancing the efficacy of current pain treatment by
  • addressing common factors
  • helping to improve the communication between
  • patients and frontline providers
  • making treatment options such as Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), biofeedback, and hypnosis more accessible
  • evaluating the efficacy of current pain treatments through research.

It is when we view chronic pain from a biopsychosocial approach that we begin to understand the complexity of these conditions. It will be through continued education and the sharing of ideas across disciplines where we will witness a change in the field of pain medicine in the next decade.

Tina L. Doshi, MD, MHS
Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University School of Medicine

The future of pain management will underscore the diverse, multidisciplinary nature of pain, and the necessity of a diverse, multidisciplinary approach to pain management. The medical community has shifted away from the simplistic view of “pain as symptom” to a more sophisticated understanding of “pain as disease.” Pain is not just an unfortunate consequence of some other pathology; pain is the pathology, and there is now greater awareness that pain management needs to be just as comprehensive, coordinated, and customized as treatment for hypertension, diabetes, or cancer.

Over the next few years, we will continue to add better tools to the pain treatment toolbox. We will no longer need to rely on the blunt instruments of opioids and steroids, and can instead turn to more selective pharmacotherapies (eg, CGRP receptor antagonists, Nav1.7 inhibitors) and more refined interventional techniques (eg, high frequency and burst stimulation, regenerative medicine). Complementary and alternative approaches will also become increasingly accessible, as we – and payors – recognize the importance of evidence-based, non-pharmacologic, non-procedural therapies for the management of chronic pain. As we develop more, better pain management options, we will also need to develop a better understanding of which pain treatment options benefit which pain patients. Research into the genetic, epigenetic, and pharmacogenomic modulators of pain will help us to implement personalized pain medicine treatments.

Finally, we will learn how we, as individuals, can shape pain management. Our own diverse backgrounds, biases, and experiences have a strong influence on how we care for our patients, beyond the medications we prescribe or procedures we perform. We are entering a time where the clinician must possess a heightened degree of self-awareness to be an effective healthcare provider. Moving forward, we should aim to understand how our individual actions and interactions with each other create the context in which patients can find relief from pain.

Robert J. Gatchel, PhD, ABPP
Clinical Faculty, Department of Psychology / Center for Excellence for the Study of Health & Chronic Illness, University of Texas at Arlington

I believe we already know what the future of pain management will look like. As reviewed by Noe, Kishino, and Gatchel in 2017, there is no doubt that appropriately-administered interdisciplinary pain management is effective,and may be successfully used in the present epidemic climate of chronic pain in this country, as well as in other countries around the world. Unfortunately, in the past, the outcomes of such programs have been significantly diluted by the plethora of “pain clinics” that emerged but which did not offer true interdisciplinary care. In an effort to remain profitable, many such clinics reduced the number of personnel required to run an effective interdisciplinary pain management program. Moreover, many third-party payors lumped together these clinics with true interdisciplinary pain management programs without realizing the major differences between the two. Simultaneously, in their cost-containment zeal, the only programs payors focused on were the ineffective clinics that were not truly interdisciplinary in nature. In effect, they threw out the “baby with the bath water.” As a result, payors need to be educated concerning what true interdisciplinary care is so that they may make better authorization decisions now and going forward.

 

In addition, better metrics are needed to document treatment outcomes. Two are suggested: the use of the Patient-Reported Outcomes Measurement Information System (PROMIS) combined with more objective socioeconomic outcomes (ie, return-to-work, medication and surgery rates, resolution of workers’ compensation and litigation claims); and subsequent decreases in healthcare utilization rates for the initial injury, which caused the pain in the first place.

In terms of other potential solutions, I recommend:

  • Promoting a major education campaign directed at insurance companies, as well as state and federal workers’ compensation boards, to demonstrate the positive outcomes of interdisciplinary pain management programs
  • Re-institute the importance of the Commission on Accreditation of Rehabilitation Facilities (CARF), but with more regular surveillance of those programs once they are accredited. In the past, CARF was viewed as a “Good Housekeeping stamp of approval” for pain management programs. Unfortunately, many CARF accredited programs “scammed” the system by having the full complement of interdisciplinary pain management personnel required during the CARF-accreditation process and visit, but then decreased the number of required personnel after accreditation, regressing back to single-modality pain clinics in order to save personnel costs. As a result, the outcomes from these diluted programs were poor, reinforcing many third-party payors’ perceptions of clinical ineffectiveness. Going forward, it must be demanded that, once accredited, CARF has routine, unannounced visits to programs to ensure compliance with the demands of true interdisciplinary pain management.
  • Develop reliable metrics related to “pay-for-performance.” There are two metrics that can be used for this purpose. The NIH invested approximately $60 million to develop PROMIS, which involves self-report measures that are often associated with chronic pain (eg, intensity, quality, interference, behavior, impact, physical function, depression, anxiety, fatigue, satisfaction with social roles, and sleep disturbance). PROMIS is psychometrically sound, and has been demonstrated to be both reliable and valid after large-scale testing. Moreover, the measures are anchored to a representative US population, and has a mean score of 50, and a standard deviation of 10. A statistical platform was developed to score and feed-back the results of patient-responses. These may be saved on a database that could be confidentially disclosed to document changes. 
 

Leonard B. Goldstein, DDS, PhD
Assistant VP, Clinical Education Development, AT Still University

While pain is a universal human experience, multiple changes are on the horizon. Each pain patient must take ownership of their pain and become an active participant in treatment. As time moves forward, we should see a much smaller dependence on pharmaceuticals, especially opioids, as they are replaced by non-addictive medications or combinations of non-opioids.

I predict growth in a few key areas: exercise and movement therapies (eg, yoga & Tai Chi); manual therapy (eg, manipulation by osteopathic physicians, chiropractors, and physical therapists); and behavioral/cognitive therapies such as mindfulness, CBD, and ACT. These treatments will likely be more utilized as part of a comprehensive, multimodal treatment plan, delivered by an interprofessional team of pain management experts from multiple specialties and philosophies. This approach may include other growing interventions as well, such as low-level laser therapy, biofeedback, qigong, and homeopathy.

Jay Joshi, MD, DABA, DABA-PM, FABA-PM
National Pain Centers, Vernon Hills, IL


Over the next decade, the field of pain management will evolve drastically in ways that are different than the dramatic change we’ve seen over the past decade. Ten years ago, the pain care field was relatively unknown to the public and misunderstood within the medical profession. Today, pain management is either praised as a specialty that reverses torture or is chastised as a field that simply prescribes opioids and performs sham procedures.

Our ability to assess patients will likely be more entrenched in technology. With artificial intelligence and wearables becoming more integrated into our daily lives, we may find that our ability to assess patients will be dependent on this new technology. We will see improvements in interventional pain management options as well as medication options. I doubt we will see any resurgence in opioid-based pain management. Cannabis will be here to stay and, if not managed correctly, will serve up the next “epidemic.”

Communication between providers and patients will also change as telemedicine will not only become common, but will be expected by the majority of patients. It will seem relatively barbaric to have a patient take a half or full day off of work to see a physician in person to have a 15-minute-or-less discussion.

Training for physicians who specialize in pain management will continue to change and evolve. There will be a time when physicians who want to call themselves “pain management specialists” will actually have to complete an accredited residency and fellowship in pain management. The days of anyone prescribing pain medication or giving an injection and calling themselves a “pain expert” will be over.

Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE
Pharmacy Practice and Science, University of Maryland School of Pharmacy

I wish I could predict where we’ll be in 5 to 10 years in pain management but, unfortunately, that’s not one of my superpowers! I can, however, offer my opinion on where I hope we’ll be in a decade or less... I strongly believe that practitioners today need to be as skilled at the clinical management of pain as they are in risk minimization. Patient assessment should include not only a thorough assessment of the pain complaint, but also screening for predictors of aberrant behavior with controlled substances. I hope that five years from now, the pendulum will have swung back to middle ground, and primary care once again will provide care to chronic pain patients.

Nothing in life is all or nothing, including the use of controlled substances. The use of non-pharmacologic, multimodal interventions is essential and, in 5 years, I believe we’ll have better evidence to guide practitioners in selecting these modalities. Providers will no longer be uncomfortable having difficult conversations with patients about the appropriate use of controlled substances, and they will have honest and open communication with patients, and other providers.

Pain management should be included in every professional curriculum—medical, nursing, pharmacy, and others. With more than 100 million Americans experiencing pain, it’s unlikely that this field is going to go away. Predicting regulatory expectations, on the other hand, may require the use of a Magic 8 ball! My hope is that we can find our way through the heightened regulatory scrutiny and work together (ie, clinicians, those who promulgate regulatory expectations, and law enforcement) to provide safe and effective pain management that safeguards the best interests in individual patients and society as a whole.

Srinivas R. Nalamachu, MD
Mid America PolyClinic, KS

In light of all the new regulations from the state and federal governments, we are facing a lot more hurdles with patient care in treating chronic pain—hurdles that I hope our profession will overcome in the next decade. For instance, while a majority of PCPs do not want to prescribe opioids for the management of chronic pain anymore, there are not enough pain clinics that are willing to fill the gap. In addition, a great majority of patients referred to pain clinics are co-prescribed benzodiazepines, sometimes for no apparent reason. This has become a challenge as those patients are at a much higher risk for adverse events and it is a difficult process to wean patients off of these medications.

At the same time, insurance companies are trying to limit the dose of opioids, quoting the CDC guideline as an excuse. Large chain pharmacies are coming up with their own policies that limit or decline the number of pills that can be prescribed, placing undue burden on the clinic staff to communicate with pharmacies repeatedly.

In addition, as more states liberalize the tetrahydrocannabinol usage for medical and/or recreational purposes, clinicians are struggling to accommodate patients’ requests. We are more concerned than ever about patients’ safety when they take opioids and marijuana together. As these rules and regulations become more complex, patients may be left at a loss.

Kern A. Olson, PhD
Pain Psychologist, Portland, OR

The role of pain psychologists has been evolving over the past decade and now is the time to become more assertive in patient selection and assessment.

First, our physician providers need to appreciate and welcome psychological input before performing elective surgery and prescribing opioid pain medicine. It makes common sense that one would want to know whether there are risk factors that could influence favorable outcomes.

My advice to pain psychologists is to assume the role of physician extender and assure the referring physician you are there to help. A recent survey of medical schools in the US asked how much time in 4 years of medical school is devoted to the issue of pain. The answer was 1 hour, and since this is an average, my guess is that some schools spend no time on the study of pain. Yet, pain is still the number one reason individuals go to the doctor. I hope my physician friends will lobby their medical schools to correct this issue.

Elmer G. Pinzon, MD, MPH, DABIPP
University Spine and Sports Specialists, Knoxville, TN

Patient assessment is likely to evolve through the use of new diagnostics and methods that are connected to information technology and the multimedia sources available in our offices and homes. For instance, provider-patient communication may transform into more web and TV-based options, including educational opportunities for both providers and patients.

Some older—and some newer—approaches to managing pain will become more prominent, including the use of alternative medicine options, nutraceuticals, non-narcotic medications, durable medical equipment, acupuncture, and fitness methods. Due to regulatory changes, our practice strategy and operations will continue to evolve to place more emphasis on interventional, musculoskeletal pain management techniques and less emphasis on narcotic-based techniques.

To help control our physician burnout epidemic, I can only hope that our regulatory community will place new measures on controlling the time-consumption of electronic health records.

C. Norman Shealy, MD, PhD
International Institute of Holistic Medicine, Fairgrove, MO

Pain management expanded in the 1960s with electrotherapy and biofeedback. In the 1990s, unfortunately, the expansion was with opioids and mood-altering drugs, which created far worse problems. Now, we are on the threshold of major improvements to reduce physiologic stress and narcotic addiction. Refinements in electrotherapy are likely to include pulsed electromagnetic frequency, which has become more popular and effective than transcutaneous electrical nerve stimulation; Sapphire enhanced Scalar may be equally beneficial as it reduces all biochemical reactions to stress.

Joseph Shurman, MD
Pain Management/Palliative Care, Scripps Memorial Hospital

If one believes in cycles, pain management has been in a downcycle since the year 2000. With the reversing of the aging population and approximately 50% of patients over age 50 experiencing chronic pain, we are due for an upward turn. On the positive side, the AMA recently came through with a very critical article of the CDC guideline on opioid prescribing and how it is being used in medical board reviews, hospital privileges, etc. New technologies are being developed to deal with the overdose issue. Some countries, including Canada, have established injection sites where patients on heroin/fentanyl or other opioids can go and be maintained until they can be placed in an appropriate addiction center; they appear to be getting good results. There is a desperate need for centers and specialists in the US that accept insurance/Medicare to see pain patients with OUD or who just want help to get off opioids. If they rise to the occasion and these trends continue positively, pain patients will rise both politically and through the media.

Pain management expanded in the 1960s with electrotherapy and biofeedback. In the 1990s, unfortunately, the expansion was with opioids and mood-altering drugs, which created far worse problems. Now, we are on the threshold of major improvements to reduce physiologic stress and narcotic addiction. Refinements in electrotherapy are likely to include pulsed electromagnetic frequency, which has become more popular and effective than transcutaneous electrical nerve stimulation; Sapphire enhanced Scalar may be equally beneficial as it reduces all biochemical reactions to stress.

*In late January 2019, after this issue went to press, AIPM announced it would be dissolving.

Last updated on: March 4, 2019
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