American Academy of Pain Medicine (AAPM): Annual Meeting

POINT: Cannabis can relieve neuropathic pain.

As an oncologist, I treat cancer patients who have nausea, vomiting, weight loss, pain with and without opioids, insomnia, and depression. With cannabis, I can recommend that they try one medicine instead of five or six prescriptions that will interact either with one another or with their cancer chemotherapy.

Studies show that cannabis and cannabinoids are effective for peripheral neuropathic syndromes associated with HIV, multiple sclerosis, or posttraumatic or postsurgical causes. A study of diabetic neuropathy is ongoing; cannabis has not yet been studied for chemotherapy-induced neuropathy. Other data show that cannabis and cannabinoids may be synergistic with opioids in relief of chronic pain without altering pharmacokinetics.

We conducted a randomized, placebo-controlled study of cannabis for patients with HIV-related peripheral neuropathy at San Francisco General Hospital because preclinical studies and anecdotal patient reports said it was helpful. Average neuropathic pain scores in the week before being admitted to our research center were about 60 out of 100. After a 2-day run-in period, patients were randomized to smoke cannabis or placebo three times a day for 5 days. Among 50 patients who completed the study, neuropathic pain decreased by about 34% with cannabis versus 17% with placebo. Our threshold for a positive response was at least a 30% reduction in pain; this was reported by 52% on cannabis and 24% on placebo (Neurology 2007;68:515-21).

We also used a more objective heat-capsaicin method to assess pain. An area on the forearm was heated to 40°   C for half an hour and then capsaicin (the active ingredient in chili peppers) was applied. This creates an area of hypesthesia and allodynia that can be measured using a brush and a piece of foam while the patient looks in another direction.

On the heat-capsaicin tests, the area of hypesthesia or allodynia either increased or was the same after smoking placebo but decreased approximately 30% after smoking cannabis. We calculated that the number needed to treat to get a beneficial effect was 3.6, which is equivalent to that with gabapentin, the mainstay treatment for our patients with HIV-related peripheral neuropathy.

A crossover study in 28 patients with HIV-associated neuropathy at the University of California, San Diego found that pain decreased with cannabis versus placebo. The number needed to treat was 3.5. (Neuropsychopharmacology 2009;34:672-680).

Investigators at the University of California, Davis, randomized 38 patients with central and peripheral neuropathic pain to low- or high-dose cannabis or placebo. They found a linear analgesic dose response for both doses of cannabis, compared with placebo, and reported that the effect was not due to lysis of anxiety but to reduction of core nociception as well as emotional responses to pain. (J. Pain 2008;9:506-21).

A randomized, double-blind, four-period crossover study in Montreal looked at 23 participants with postsurgical neuropathic pain who inhaled increasing dosages of tetrahydrocannabinol (THC). Results showed that the average daily pain intensity was significantly lower and quality of sleep improved in the highest-dose THC group, compared with the placebo group (CMAJ 2010;182:e694-701).

We recently completed a study funded by the National Institute on Drug Abuse to look at effects of combined use of opioids and cannabis, in which we also assessed effects on pain.

We saw a significant 26% reduction in pain with the addition of vaporized cannabis in the cohort as a whole. Pain reduction was greater in the morphine group (a 31% decrease) compared with the oxycodone group (a 23% decrease). We saw no adverse safety effects. Although we know quite well that the study was too small to make a definitive claim, this was a tantalizing demonstration of potential synergy between opioids and cannabinoids, (Clin. Pharmacotherapeutics 2011;90:844-51).

Every 10 years since cannabis was removed from the medical formulary in 1942, some august government body in the United States looks at cannabis in medicine. They all conclude the same thing – that it’s a valuable medicine, and should be available. That usually goes ignored, however. An Institute of Medicine report in 1999 said the accumulated data indicate a potential therapeutic value for cannabinoid drugs in the treatment of pain, control of nausea and vomiting, and appetite stimulation.

Dr. Donald I. Abrams is a professor of clinical medicine at the University of California, San Francisco. He declared having nothing to disclose except that he went to college in the 1960s. This debate took place at the annual meeting of the American Academy of Pain Medicine.

COUNTERPOINT: But chronic use is harmful.

Marijuana doesn’t meet standards to be considered a medicine.

There’s a massive lack of standardization in the product. Compounds have very different, in some cases opposing, effects. Potency varies depending on the strain and how it was prepared.

There’s also no standardization around administration. Smoking or inhaling marijuana – the most common routes speed drug uptake and the effects of cannabinoids on reward processing, which increases addictiveness.

Smoking marijuana is carcinogenic and causes lung damage. Yes, a study suggested twice-a-month use doesn’t really change your lung capacity, but that changed with daily, frequent use. The typical use pattern is about four times per day, daily, in medical patients.

Pain studies looked at acute use of cannabis for a week or so. They haven’t looked at chronic effects. We don’t know the impact of tolerance and dependence in patients with chronic pain, or the effect of constant activation of reward circuits by marijuana on new behavior patterns over time. That’s typically what you have trouble with in chronic pain patients – getting them up, getting them going, getting them back into life. Marijuana could make that more difficult.

A meta-analysis of 18 randomized, double-blind, controlled trials of cannabis for chronic pain found a greater effect with cannabis than with placebo, but this was not huge. If a patient starts out with a pain score of 8 out of 10, it will drop to about 7.4 – a 7.5% reduction in score. We’re talking about going from severe to a little less severe pain. Patients on cannabis were much more likely to have alterations in perception, motor function, and cognitive function (Pain Med. 2009;10:1353-68).

In the crossover study of 23 patients that Dr. Abrams cites, low-dose and high-dose THC decreased pain, but there was no difference in the middle doses, compared with placebo. And look at the levels of pain scores: You’re going from an average of 6.1 to 5.4, from moderate pain to moderate pain. That’s less than 1 point on a 10-point scale, and you’re getting all of the adverse effects and behavioral changes in conjunction with that. Is that worth it?

The 28-patient crossover study he cites started with 34 patients. There were some serious cannabis-related issues, including acute psychosis and intractable cough, in the patients who didn’t complete it. One patient started using methamphetamine again. This is not a particularly low rate of problems.

We don’t have a lot of data to say what happens to patients with chronic pain who use marijuana over time. There are more data on what happens when people in the general population use marijuana chronically. The best characterized chronic effects include a motivational syndrome, poor concentration, attention and judgment, impaired social skills, introversion, deteriorating personal habits and depersonalization, mood disorders, anxiety disorders, insomnia, increased risk of schizophreniform illness and psychosis, more negative life events, and withdrawal.

Studies have found functional impairments related to chronic marijuana use. People who use marijuana over long periods of time develop at least partially persistent problems on neuropsychological tests – problems that don’t go away even if they stop using marijuana.

There’s also evidence of a relationship between cannabis and mood disorders. Cross-sectional studies show that people who use cannabis daily or near-daily are 3.4 times more likely to have major depression. Longitudinally, if you are diagnosed with cannabis dependence, you have a 6.4-fold increased chance of being diagnosed with major depression within a 12-month time period.

It appears that cannabis is inducing the mood disorders, not the mood disorders driving cannabis use. A Dutch study of 3,854 adults with no history of mood disorders found that cannabis use at baseline was associated with a doubling in risk for developing any mood disorder, a 60% increased risk for major depression, and a five-fold increased risk for bipolar disease (Addiction 2007;102:1251-60).

If cannabis use makes people tend toward mood disorders, and chronic pain patients tend toward mood disorders, how much harder are you making it by suggesting they try marijuana to get that 1-point decrease in pain?

Frequent marijuana use is associated with development of dependence. Withdrawal symptoms occur whenever drug levels start to decrease over time. Withdrawal starts within 2-4 hours, and symptoms last for weeks. Symptoms include irritability, anger or aggression, nervousness or anxiety, sleep difficulty, decreased appetite or weight loss, restlessness, depressed mood, and a variety of physical symptoms causing significant discomfort.

The main reasons that people say they want to use medical marijuana are to treat nervousness, anxiety, insomnia, and depressed mood. All of these potentially are withdrawal symptoms.

One study showed a vast majority of California patients seeking a physician’s recommendation for medical marijuana – well over 95% were already self-medicating with marijuana. We would expect that population to be dependent.

A separate study confirmed that 10 of the 15 "clinical benefits" reported by 1,746 medical marijuana users were the easing of problems that can be found on a list of withdrawal symptoms (J. Psychoactive Drugs 2011;43:128-35).

Chronic pain patients already have high comorbidity with depression, functional problems, and high rates of disability. Recommending medical marijuana increases risk in an already at-risk population.

Jodie Trafton, Ph.D., is director of the Program Evaluation and Resource Center in the Office of Mental Health Operations, Veterans Affairs Palo Alto (Calif.) Health Care System. The views expressed are those of Dr. Trafton and do not necessarily represent those of the Department of Veterans Affairs. She declared having no financial disclosures.

POINT: Cannabis can relieve neuropathic pain.

As an oncologist, I treat cancer patients who have nausea, vomiting, weight loss, pain with and without opioids, insomnia, and depression. With cannabis, I can recommend that they try one medicine instead of five or six prescriptions that will interact either with one another or with their cancer chemotherapy.

Studies show that cannabis and cannabinoids are effective for peripheral neuropathic syndromes associated with HIV, multiple sclerosis, or posttraumatic or postsurgical causes. A study of diabetic neuropathy is ongoing; cannabis has not yet been studied for chemotherapy-induced neuropathy. Other data show that cannabis and cannabinoids may be synergistic with opioids in relief of chronic pain without altering pharmacokinetics.

We conducted a randomized, placebo-controlled study of cannabis for patients with HIV-related peripheral neuropathy at San Francisco General Hospital because preclinical studies and anecdotal patient reports said it was helpful. Average neuropathic pain scores in the week before being admitted to our research center were about 60 out of 100. After a 2-day run-in period, patients were randomized to smoke cannabis or placebo three times a day for 5 days. Among 50 patients who completed the study, neuropathic pain decreased by about 34% with cannabis versus 17% with placebo. Our threshold for a positive response was at least a 30% reduction in pain; this was reported by 52% on cannabis and 24% on placebo (Neurology 2007;68:515-21).

We also used a more objective heat-capsaicin method to assess pain. An area on the forearm was heated to 40°   C for half an hour and then capsaicin (the active ingredient in chili peppers) was applied. This creates an area of hypesthesia and allodynia that can be measured using a brush and a piece of foam while the patient looks in another direction.

On the heat-capsaicin tests, the area of hypesthesia or allodynia either increased or was the same after smoking placebo but decreased approximately 30% after smoking cannabis. We calculated that the number needed to treat to get a beneficial effect was 3.6, which is equivalent to that with gabapentin, the mainstay treatment for our patients with HIV-related peripheral neuropathy.

A crossover study in 28 patients with HIV-associated neuropathy at the University of California, San Diego found that pain decreased with cannabis versus placebo. The number needed to treat was 3.5. (Neuropsychopharmacology 2009;34:672-680).

Investigators at the University of California, Davis, randomized 38 patients with central and peripheral neuropathic pain to low- or high-dose cannabis or placebo. They found a linear analgesic dose response for both doses of cannabis, compared with placebo, and reported that the effect was not due to lysis of anxiety but to reduction of core nociception as well as emotional responses to pain. (J. Pain 2008;9:506-21).

A randomized, double-blind, four-period crossover study in Montreal looked at 23 participants with postsurgical neuropathic pain who inhaled increasing dosages of tetrahydrocannabinol (THC). Results showed that the average daily pain intensity was significantly lower and quality of sleep improved in the highest-dose THC group, compared with the placebo group (CMAJ 2010;182:e694-701).

We recently completed a study funded by the National Institute on Drug Abuse to look at effects of combined use of opioids and cannabis, in which we also assessed effects on pain.

We saw a significant 26% reduction in pain with the addition of vaporized cannabis in the cohort as a whole. Pain reduction was greater in the morphine group (a 31% decrease) compared with the oxycodone group (a 23% decrease). We saw no adverse safety effects. Although we know quite well that the study was too small to make a definitive claim, this was a tantalizing demonstration of potential synergy between opioids and cannabinoids, (Clin. Pharmacotherapeutics 2011;90:844-51).

Every 10 years since cannabis was removed from the medical formulary in 1942, some august government body in the United States looks at cannabis in medicine. They all conclude the same thing – that it’s a valuable medicine, and should be available. That usually goes ignored, however. An Institute of Medicine report in 1999 said the accumulated data indicate a potential therapeutic value for cannabinoid drugs in the treatment of pain, control of nausea and vomiting, and appetite stimulation.

Dr. Donald I. Abrams is a professor of clinical medicine at the University of California, San Francisco. He declared having nothing to disclose except that he went to college in the 1960s. This debate took place at the annual meeting of the American Academy of Pain Medicine.

COUNTERPOINT: But chronic use is harmful.

Marijuana doesn’t meet standards to be considered a medicine.

There’s a massive lack of standardization in the product. Compounds have very different, in some cases opposing, effects. Potency varies depending on the strain and how it was prepared.

There’s also no standardization around administration. Smoking or inhaling marijuana – the most common routes speed drug uptake and the effects of cannabinoids on reward processing, which increases addictiveness.

Smoking marijuana is carcinogenic and causes lung damage. Yes, a study suggested twice-a-month use doesn’t really change your lung capacity, but that changed with daily, frequent use. The typical use pattern is about four times per day, daily, in medical patients.

Pain studies looked at acute use of cannabis for a week or so. They haven’t looked at chronic effects. We don’t know the impact of tolerance and dependence in patients with chronic pain, or the effect of constant activation of reward circuits by marijuana on new behavior patterns over time. That’s typically what you have trouble with in chronic pain patients – getting them up, getting them going, getting them back into life. Marijuana could make that more difficult.

A meta-analysis of 18 randomized, double-blind, controlled trials of cannabis for chronic pain found a greater effect with cannabis than with placebo, but this was not huge. If a patient starts out with a pain score of 8 out of 10, it will drop to about 7.4 – a 7.5% reduction in score. We’re talking about going from severe to a little less severe pain. Patients on cannabis were much more likely to have alterations in perception, motor function, and cognitive function (Pain Med. 2009;10:1353-68).

In the crossover study of 23 patients that Dr. Abrams cites, low-dose and high-dose THC decreased pain, but there was no difference in the middle doses, compared with placebo. And look at the levels of pain scores: You’re going from an average of 6.1 to 5.4, from moderate pain to moderate pain. That’s less than 1 point on a 10-point scale, and you’re getting all of the adverse effects and behavioral changes in conjunction with that. Is that worth it?

The 28-patient crossover study he cites started with 34 patients. There were some serious cannabis-related issues, including acute psychosis and intractable cough, in the patients who didn’t complete it. One patient started using methamphetamine again. This is not a particularly low rate of problems.

We don’t have a lot of data to say what happens to patients with chronic pain who use marijuana over time. There are more data on what happens when people in the general population use marijuana chronically. The best characterized chronic effects include a motivational syndrome, poor concentration, attention and judgment, impaired social skills, introversion, deteriorating personal habits and depersonalization, mood disorders, anxiety disorders, insomnia, increased risk of schizophreniform illness and psychosis, more negative life events, and withdrawal.

Studies have found functional impairments related to chronic marijuana use. People who use marijuana over long periods of time develop at least partially persistent problems on neuropsychological tests – problems that don’t go away even if they stop using marijuana.

There’s also evidence of a relationship between cannabis and mood disorders. Cross-sectional studies show that people who use cannabis daily or near-daily are 3.4 times more likely to have major depression. Longitudinally, if you are diagnosed with cannabis dependence, you have a 6.4-fold increased chance of being diagnosed with major depression within a 12-month time period.

It appears that cannabis is inducing the mood disorders, not the mood disorders driving cannabis use. A Dutch study of 3,854 adults with no history of mood disorders found that cannabis use at baseline was associated with a doubling in risk for developing any mood disorder, a 60% increased risk for major depression, and a five-fold increased risk for bipolar disease (Addiction 2007;102:1251-60).

If cannabis use makes people tend toward mood disorders, and chronic pain patients tend toward mood disorders, how much harder are you making it by suggesting they try marijuana to get that 1-point decrease in pain?

Frequent marijuana use is associated with development of dependence. Withdrawal symptoms occur whenever drug levels start to decrease over time. Withdrawal starts within 2-4 hours, and symptoms last for weeks. Symptoms include irritability, anger or aggression, nervousness or anxiety, sleep difficulty, decreased appetite or weight loss, restlessness, depressed mood, and a variety of physical symptoms causing significant discomfort.

The main reasons that people say they want to use medical marijuana are to treat nervousness, anxiety, insomnia, and depressed mood. All of these potentially are withdrawal symptoms.

One study showed a vast majority of California patients seeking a physician’s recommendation for medical marijuana – well over 95% were already self-medicating with marijuana. We would expect that population to be dependent.

A separate study confirmed that 10 of the 15 "clinical benefits" reported by 1,746 medical marijuana users were the easing of problems that can be found on a list of withdrawal symptoms (J. Psychoactive Drugs 2011;43:128-35).

Chronic pain patients already have high comorbidity with depression, functional problems, and high rates of disability. Recommending medical marijuana increases risk in an already at-risk population.

Jodie Trafton, Ph.D., is director of the Program Evaluation and Resource Center in the Office of Mental Health Operations, Veterans Affairs Palo Alto (Calif.) Health Care System. The views expressed are those of Dr. Trafton and do not necessarily represent those of the Department of Veterans Affairs. She declared having no financial disclosures.

POINT: Cannabis can relieve neuropathic pain.

As an oncologist, I treat cancer patients who have nausea, vomiting, weight loss, pain with and without opioids, insomnia, and depression. With cannabis, I can recommend that they try one medicine instead of five or six prescriptions that will interact either with one another or with their cancer chemotherapy.

Studies show that cannabis and cannabinoids are effective for peripheral neuropathic syndromes associated with HIV, multiple sclerosis, or posttraumatic or postsurgical causes. A study of diabetic neuropathy is ongoing; cannabis has not yet been studied for chemotherapy-induced neuropathy. Other data show that cannabis and cannabinoids may be synergistic with opioids in relief of chronic pain without altering pharmacokinetics.

We conducted a randomized, placebo-controlled study of cannabis for patients with HIV-related peripheral neuropathy at San Francisco General Hospital because preclinical studies and anecdotal patient reports said it was helpful. Average neuropathic pain scores in the week before being admitted to our research center were about 60 out of 100. After a 2-day run-in period, patients were randomized to smoke cannabis or placebo three times a day for 5 days. Among 50 patients who completed the study, neuropathic pain decreased by about 34% with cannabis versus 17% with placebo. Our threshold for a positive response was at least a 30% reduction in pain; this was reported by 52% on cannabis and 24% on placebo (Neurology 2007;68:515-21).

We also used a more objective heat-capsaicin method to assess pain. An area on the forearm was heated to 40°   C for half an hour and then capsaicin (the active ingredient in chili peppers) was applied. This creates an area of hypesthesia and allodynia that can be measured using a brush and a piece of foam while the patient looks in another direction.

On the heat-capsaicin tests, the area of hypesthesia or allodynia either increased or was the same after smoking placebo but decreased approximately 30% after smoking cannabis. We calculated that the number needed to treat to get a beneficial effect was 3.6, which is equivalent to that with gabapentin, the mainstay treatment for our patients with HIV-related peripheral neuropathy.

A crossover study in 28 patients with HIV-associated neuropathy at the University of California, San Diego found that pain decreased with cannabis versus placebo. The number needed to treat was 3.5. (Neuropsychopharmacology 2009;34:672-680).

Investigators at the University of California, Davis, randomized 38 patients with central and peripheral neuropathic pain to low- or high-dose cannabis or placebo. They found a linear analgesic dose response for both doses of cannabis, compared with placebo, and reported that the effect was not due to lysis of anxiety but to reduction of core nociception as well as emotional responses to pain. (J. Pain 2008;9:506-21).

A randomized, double-blind, four-period crossover study in Montreal looked at 23 participants with postsurgical neuropathic pain who inhaled increasing dosages of tetrahydrocannabinol (THC). Results showed that the average daily pain intensity was significantly lower and quality of sleep improved in the highest-dose THC group, compared with the placebo group (CMAJ 2010;182:e694-701).

We recently completed a study funded by the National Institute on Drug Abuse to look at effects of combined use of opioids and cannabis, in which we also assessed effects on pain.

We saw a significant 26% reduction in pain with the addition of vaporized cannabis in the cohort as a whole. Pain reduction was greater in the morphine group (a 31% decrease) compared with the oxycodone group (a 23% decrease). We saw no adverse safety effects. Although we know quite well that the study was too small to make a definitive claim, this was a tantalizing demonstration of potential synergy between opioids and cannabinoids, (Clin. Pharmacotherapeutics 2011;90:844-51).

Every 10 years since cannabis was removed from the medical formulary in 1942, some august government body in the United States looks at cannabis in medicine. They all conclude the same thing – that it’s a valuable medicine, and should be available. That usually goes ignored, however. An Institute of Medicine report in 1999 said the accumulated data indicate a potential therapeutic value for cannabinoid drugs in the treatment of pain, control of nausea and vomiting, and appetite stimulation.

Dr. Donald I. Abrams is a professor of clinical medicine at the University of California, San Francisco. He declared having nothing to disclose except that he went to college in the 1960s. This debate took place at the annual meeting of the American Academy of Pain Medicine.

COUNTERPOINT: But chronic use is harmful.

Marijuana doesn’t meet standards to be considered a medicine.

There’s a massive lack of standardization in the product. Compounds have very different, in some cases opposing, effects. Potency varies depending on the strain and how it was prepared.

There’s also no standardization around administration. Smoking or inhaling marijuana – the most common routes speed drug uptake and the effects of cannabinoids on reward processing, which increases addictiveness.

Smoking marijuana is carcinogenic and causes lung damage. Yes, a study suggested twice-a-month use doesn’t really change your lung capacity, but that changed with daily, frequent use. The typical use pattern is about four times per day, daily, in medical patients.

Pain studies looked at acute use of cannabis for a week or so. They haven’t looked at chronic effects. We don’t know the impact of tolerance and dependence in patients with chronic pain, or the effect of constant activation of reward circuits by marijuana on new behavior patterns over time. That’s typically what you have trouble with in chronic pain patients – getting them up, getting them going, getting them back into life. Marijuana could make that more difficult.

A meta-analysis of 18 randomized, double-blind, controlled trials of cannabis for chronic pain found a greater effect with cannabis than with placebo, but this was not huge. If a patient starts out with a pain score of 8 out of 10, it will drop to about 7.4 – a 7.5% reduction in score. We’re talking about going from severe to a little less severe pain. Patients on cannabis were much more likely to have alterations in perception, motor function, and cognitive function (Pain Med. 2009;10:1353-68).

In the crossover study of 23 patients that Dr. Abrams cites, low-dose and high-dose THC decreased pain, but there was no difference in the middle doses, compared with placebo. And look at the levels of pain scores: You’re going from an average of 6.1 to 5.4, from moderate pain to moderate pain. That’s less than 1 point on a 10-point scale, and you’re getting all of the adverse effects and behavioral changes in conjunction with that. Is that worth it?

The 28-patient crossover study he cites started with 34 patients. There were some serious cannabis-related issues, including acute psychosis and intractable cough, in the patients who didn’t complete it. One patient started using methamphetamine again. This is not a particularly low rate of problems.

We don’t have a lot of data to say what happens to patients with chronic pain who use marijuana over time. There are more data on what happens when people in the general population use marijuana chronically. The best characterized chronic effects include a motivational syndrome, poor concentration, attention and judgment, impaired social skills, introversion, deteriorating personal habits and depersonalization, mood disorders, anxiety disorders, insomnia, increased risk of schizophreniform illness and psychosis, more negative life events, and withdrawal.

Studies have found functional impairments related to chronic marijuana use. People who use marijuana over long periods of time develop at least partially persistent problems on neuropsychological tests – problems that don’t go away even if they stop using marijuana.

There’s also evidence of a relationship between cannabis and mood disorders. Cross-sectional studies show that people who use cannabis daily or near-daily are 3.4 times more likely to have major depression. Longitudinally, if you are diagnosed with cannabis dependence, you have a 6.4-fold increased chance of being diagnosed with major depression within a 12-month time period.

It appears that cannabis is inducing the mood disorders, not the mood disorders driving cannabis use. A Dutch study of 3,854 adults with no history of mood disorders found that cannabis use at baseline was associated with a doubling in risk for developing any mood disorder, a 60% increased risk for major depression, and a five-fold increased risk for bipolar disease (Addiction 2007;102:1251-60).

If cannabis use makes people tend toward mood disorders, and chronic pain patients tend toward mood disorders, how much harder are you making it by suggesting they try marijuana to get that 1-point decrease in pain?

Frequent marijuana use is associated with development of dependence. Withdrawal symptoms occur whenever drug levels start to decrease over time. Withdrawal starts within 2-4 hours, and symptoms last for weeks. Symptoms include irritability, anger or aggression, nervousness or anxiety, sleep difficulty, decreased appetite or weight loss, restlessness, depressed mood, and a variety of physical symptoms causing significant discomfort.

The main reasons that people say they want to use medical marijuana are to treat nervousness, anxiety, insomnia, and depressed mood. All of these potentially are withdrawal symptoms.

One study showed a vast majority of California patients seeking a physician’s recommendation for medical marijuana – well over 95% were already self-medicating with marijuana. We would expect that population to be dependent.

A separate study confirmed that 10 of the 15 "clinical benefits" reported by 1,746 medical marijuana users were the easing of problems that can be found on a list of withdrawal symptoms (J. Psychoactive Drugs 2011;43:128-35).

Chronic pain patients already have high comorbidity with depression, functional problems, and high rates of disability. Recommending medical marijuana increases risk in an already at-risk population.

Jodie Trafton, Ph.D., is director of the Program Evaluation and Resource Center in the Office of Mental Health Operations, Veterans Affairs Palo Alto (Calif.) Health Care System. The views expressed are those of Dr. Trafton and do not necessarily represent those of the Department of Veterans Affairs. She declared having no financial disclosures.

On 5 p.m. on the day before Thanksgiving, Dr. Alan Caroe, a general practitioner in Las Cruces, N.M., had to decide whether to prescribe an opiate medication to "a very smooth individual from out of town who had a story that was just barely plausible."

Dr. Caroe felt he had insufficient expertise in opioid management, an area that’s complex and difficult and fraught with risk but also an opportunity to help patients in chronic pain, he said in an interview. He needed a quick consultation, but who would answer the phone on that day, at that hour?

Experts at the chronic pain and headache clinic at Project ECHO (Extension for Community Healthcare Outcomes), that’s who. They walked him through the complex issues in the case, which led him to retract an opiate prescription that he initially had phoned into a pharmacy for this patient.

Sherry Boschert/IMNG Medical Media

Real-time consultations are only a part of Project ECHO, an award-winning program based at the University of New Mexico in Albuquerque. In addition, the program provides weekly videoconferences, not only to discuss cases but also to educate and mentor community physicians to take on frontline management of chronic diseases in their geographic areas.

The aim is to act as a multiplier, and to expand the health system’s capacity to manage common, chronic, but complex diseases, Dr. Sanjeev Arora explained in a presentation at the annual meeting of the American Academy of Pain Medicine. New Mexico’s 1.8 million people are spread across 121,000 square miles, and 32 of the state’s 33 counties are listed as medically underserved areas.

Project ECHO began with a focus on improving the care of patients with hepatitis C, and its success has spawned Project ECHO programs for asthma, rheumatology, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, prevention of teenage suicide, high-risk pregnancy, childhood obesity, child psychiatry, psychotherapy, antibiotic stewardship, and ethics consultation. More than 400 clinical sites can now connect with Project ECHO.

The Project ECHO model has been cloned by the University of Washington in Seattle, the U.S. Veterans Health Administration, the U.S. Department of Defense, and the country of India, among other entities. The focus is not just on helping rural areas; the University of Chicago’s project works with urban physicians in the community to improve the care of black patients with difficult-to-treat hypertension, whose numbers would overwhelm the limited number of specialists.

When the project’s director, Dr. Arora, a gastroenterologist and hepatologist, founded Project ECHO in 2002, an estimated 28,000 people in the state had hepatitis C, and patients faced an 8-month waiting list to be seen at Dr. Arora’s specialty clinic, which often required traveling long distances. The project has conducted more than 500 "telehealth clinics" on hepatitis C, and has helped get more than 5,000 patients into hepatitis C treatment who previously had no access to care, said Dr. Arora, a professor of medicine at the University of New Mexico.

"We want to transform the nature of what primary care looks like in the United States," he said.

The quality of care these patients are getting in the community rivals the quality at the university, and minorities’ access to care is expanding, a prospective study of 407 patients found. A sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N. Engl. J. Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.

Patients who received care at the Project ECHO community sites, however, were significantly more likely to be racial/ethnic minorities (68%), compared with the university’s patients (49%), he said. The cure rate at community sites was significantly higher than cure rates reported in previous community-based studies of hepatitis C treatment, which hovered around 20%, he added. This may be a result of Project ECHO’s emphasis on best-practices protocols and other attributes.

"Project ECHO has brought so much balance. We’ve reduced variation in prescribing" practices for pain medications, for example, Dr. Joanna G. Katzman said in a separate presentation at the meeting. "The degree to which people have evolved blows my mind."

Dr. Katzman, director of Project ECHO’s chronic pain and headache clinic and a neurologist at the University of New Mexico, said that her weekly videoconference typically starts at noon so that primary care physicians can join in during their lunch break. Participants get free CME credits.

The project’s interdisciplinary team of experts and remote participants spend the first half-hour reviewing and discussing three or four cases that have been faxed in by remote participants, followed by 25-30 minutes of didactic presentations. A second hour covers more cases, for those who can stay on. Once a month, the videoconference includes a skills demonstration, such as a trigger point examination or a procedure. Community physicians who miss the live videoconference can watch a video of it later.

"It’s the best use of lunchtime that you can consider," said Dr. Caroe, the generalist in Las Cruces.

Since starting in 2009, Project ECHO’s chronic pain and headache clinic sessions have attracted 474 participants in 168 locations in multiple states, averaging more than six sessions per attendee. In all, 42% are physicians, 23% are nurses or physician assistants, and 35% are others including pharmacists and chiropractors.

Physician assistant Debra Newman worked for several years as a community health extension agent at a rural clinic in Espanola, N.M., with part of her salary paid by the clinic and part by Project ECHO. She managed hundreds of patients who were referred to her for everything from simple low back pain to fibromyalgia, rheumatoid arthritis, and failed back surgery syndrome.

"After sitting in on Project ECHO for years, I could manage many of these patients on my own," said Ms. Newman, now of Christus St. Vincent Regional Medical Center in Santa Fe, N.M. As a P.A., she could practice independently if a supervising physician was within 100 miles – but, she said, she still took complex cases to the teleconference for consultations.

Project ECHO is funded by grants from state and federal government sources and the Robert Wood Johnson Foundation. Large health care systems are cloning the model because they see that it’s a cost-effective way to provide specialty services to more patients without transferring them to specialty care, Dr. Arora said.

"It isn’t expensive if you think that you’re training someone out there to replace you," Dr. Rollin M. Gallagher said in a separate presentation at the meeting. Project ECHO inspired the creation of the similarly-modeled Veterans Affairs SCAN (Specialty Care Access Network), said Dr. Gallagher, deputy national program director for pain management in the Veterans Health Administration and director for pain policy and primary care research at Penn Pain Medicine at the University of Pennsylvania, Philadelphia.

Dr. Ilene R. Robeck runs what she calls a "poor man’s Project ECHO" that provides pain management education, mentoring, and consultations primarily to physicians at three Veterans Affairs medical centers in Florida. "As much as I thought [Project ECHO] was a fantastic program, the resources needed were really higher than the resources I had," she said in an interview.

Funded by a federal grant through September 2013, her project offers a weekly telephone audioconference and immediate access to expert consultations by phone – initiatives that stress the education of participants as much as individual case consultations.

"The results have been overwhelmingly positive," with close to 100 health care providers now calling in from VA facilities around the country each week, said Dr. Robeck of Bay Pines (Fla.) Veterans Affairs Healthcare System.

When Dr. Caroe first heard about Project ECHO, he listened to the weekly conferences by phone because the Internet connection for videoconferencing was too slow where he was practicing in Chaparral, N.M. He now videoconferences each week on a faster connection at his current practice in Las Cruces.

The nearest pain specialists are in Albuquerque (about 260 miles away and too far for many patients to travel for routine visits) or in El Paso, Tex. Crossing state lines for care can create problems with insurance.

He has no doubt that the skills he has gained through Project ECHO have benefited his patients. One 49-year-old female engineer had suffered nearly a lifetime of terrible migraine headaches. Prior to Project ECHO’s didactic and clinical presentations, Dr. Caroe had never heard of premenstrual migraine, and the patient had never noticed that her headaches regularly got worse 2 days before the start of her menstrual period.

"She went from monthly hell" to treatment with a low-dose, short-term estrogen patch to get her through her 4-day period of risk, he said. When she came in for a follow-up visit recently, she told him, "You changed my life."

Dr. Arora has received research funding from Genentech, Gilead, Pharmasset, Tibotec, Vertex, and ZymoGenetics. The other people interviewed for this story reported having no financial disclosures.

On 5 p.m. on the day before Thanksgiving, Dr. Alan Caroe, a general practitioner in Las Cruces, N.M., had to decide whether to prescribe an opiate medication to "a very smooth individual from out of town who had a story that was just barely plausible."

Dr. Caroe felt he had insufficient expertise in opioid management, an area that’s complex and difficult and fraught with risk but also an opportunity to help patients in chronic pain, he said in an interview. He needed a quick consultation, but who would answer the phone on that day, at that hour?

Experts at the chronic pain and headache clinic at Project ECHO (Extension for Community Healthcare Outcomes), that’s who. They walked him through the complex issues in the case, which led him to retract an opiate prescription that he initially had phoned into a pharmacy for this patient.

Sherry Boschert/IMNG Medical Media

Real-time consultations are only a part of Project ECHO, an award-winning program based at the University of New Mexico in Albuquerque. In addition, the program provides weekly videoconferences, not only to discuss cases but also to educate and mentor community physicians to take on frontline management of chronic diseases in their geographic areas.

The aim is to act as a multiplier, and to expand the health system’s capacity to manage common, chronic, but complex diseases, Dr. Sanjeev Arora explained in a presentation at the annual meeting of the American Academy of Pain Medicine. New Mexico’s 1.8 million people are spread across 121,000 square miles, and 32 of the state’s 33 counties are listed as medically underserved areas.

Project ECHO began with a focus on improving the care of patients with hepatitis C, and its success has spawned Project ECHO programs for asthma, rheumatology, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, prevention of teenage suicide, high-risk pregnancy, childhood obesity, child psychiatry, psychotherapy, antibiotic stewardship, and ethics consultation. More than 400 clinical sites can now connect with Project ECHO.

The Project ECHO model has been cloned by the University of Washington in Seattle, the U.S. Veterans Health Administration, the U.S. Department of Defense, and the country of India, among other entities. The focus is not just on helping rural areas; the University of Chicago’s project works with urban physicians in the community to improve the care of black patients with difficult-to-treat hypertension, whose numbers would overwhelm the limited number of specialists.

When the project’s director, Dr. Arora, a gastroenterologist and hepatologist, founded Project ECHO in 2002, an estimated 28,000 people in the state had hepatitis C, and patients faced an 8-month waiting list to be seen at Dr. Arora’s specialty clinic, which often required traveling long distances. The project has conducted more than 500 "telehealth clinics" on hepatitis C, and has helped get more than 5,000 patients into hepatitis C treatment who previously had no access to care, said Dr. Arora, a professor of medicine at the University of New Mexico.

"We want to transform the nature of what primary care looks like in the United States," he said.

The quality of care these patients are getting in the community rivals the quality at the university, and minorities’ access to care is expanding, a prospective study of 407 patients found. A sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N. Engl. J. Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.

Patients who received care at the Project ECHO community sites, however, were significantly more likely to be racial/ethnic minorities (68%), compared with the university’s patients (49%), he said. The cure rate at community sites was significantly higher than cure rates reported in previous community-based studies of hepatitis C treatment, which hovered around 20%, he added. This may be a result of Project ECHO’s emphasis on best-practices protocols and other attributes.

"Project ECHO has brought so much balance. We’ve reduced variation in prescribing" practices for pain medications, for example, Dr. Joanna G. Katzman said in a separate presentation at the meeting. "The degree to which people have evolved blows my mind."

Dr. Katzman, director of Project ECHO’s chronic pain and headache clinic and a neurologist at the University of New Mexico, said that her weekly videoconference typically starts at noon so that primary care physicians can join in during their lunch break. Participants get free CME credits.

The project’s interdisciplinary team of experts and remote participants spend the first half-hour reviewing and discussing three or four cases that have been faxed in by remote participants, followed by 25-30 minutes of didactic presentations. A second hour covers more cases, for those who can stay on. Once a month, the videoconference includes a skills demonstration, such as a trigger point examination or a procedure. Community physicians who miss the live videoconference can watch a video of it later.

"It’s the best use of lunchtime that you can consider," said Dr. Caroe, the generalist in Las Cruces.

Since starting in 2009, Project ECHO’s chronic pain and headache clinic sessions have attracted 474 participants in 168 locations in multiple states, averaging more than six sessions per attendee. In all, 42% are physicians, 23% are nurses or physician assistants, and 35% are others including pharmacists and chiropractors.

Physician assistant Debra Newman worked for several years as a community health extension agent at a rural clinic in Espanola, N.M., with part of her salary paid by the clinic and part by Project ECHO. She managed hundreds of patients who were referred to her for everything from simple low back pain to fibromyalgia, rheumatoid arthritis, and failed back surgery syndrome.

"After sitting in on Project ECHO for years, I could manage many of these patients on my own," said Ms. Newman, now of Christus St. Vincent Regional Medical Center in Santa Fe, N.M. As a P.A., she could practice independently if a supervising physician was within 100 miles – but, she said, she still took complex cases to the teleconference for consultations.

Project ECHO is funded by grants from state and federal government sources and the Robert Wood Johnson Foundation. Large health care systems are cloning the model because they see that it’s a cost-effective way to provide specialty services to more patients without transferring them to specialty care, Dr. Arora said.

"It isn’t expensive if you think that you’re training someone out there to replace you," Dr. Rollin M. Gallagher said in a separate presentation at the meeting. Project ECHO inspired the creation of the similarly-modeled Veterans Affairs SCAN (Specialty Care Access Network), said Dr. Gallagher, deputy national program director for pain management in the Veterans Health Administration and director for pain policy and primary care research at Penn Pain Medicine at the University of Pennsylvania, Philadelphia.

Dr. Ilene R. Robeck runs what she calls a "poor man’s Project ECHO" that provides pain management education, mentoring, and consultations primarily to physicians at three Veterans Affairs medical centers in Florida. "As much as I thought [Project ECHO] was a fantastic program, the resources needed were really higher than the resources I had," she said in an interview.

Funded by a federal grant through September 2013, her project offers a weekly telephone audioconference and immediate access to expert consultations by phone – initiatives that stress the education of participants as much as individual case consultations.

"The results have been overwhelmingly positive," with close to 100 health care providers now calling in from VA facilities around the country each week, said Dr. Robeck of Bay Pines (Fla.) Veterans Affairs Healthcare System.

When Dr. Caroe first heard about Project ECHO, he listened to the weekly conferences by phone because the Internet connection for videoconferencing was too slow where he was practicing in Chaparral, N.M. He now videoconferences each week on a faster connection at his current practice in Las Cruces.

The nearest pain specialists are in Albuquerque (about 260 miles away and too far for many patients to travel for routine visits) or in El Paso, Tex. Crossing state lines for care can create problems with insurance.

He has no doubt that the skills he has gained through Project ECHO have benefited his patients. One 49-year-old female engineer had suffered nearly a lifetime of terrible migraine headaches. Prior to Project ECHO’s didactic and clinical presentations, Dr. Caroe had never heard of premenstrual migraine, and the patient had never noticed that her headaches regularly got worse 2 days before the start of her menstrual period.

"She went from monthly hell" to treatment with a low-dose, short-term estrogen patch to get her through her 4-day period of risk, he said. When she came in for a follow-up visit recently, she told him, "You changed my life."

Dr. Arora has received research funding from Genentech, Gilead, Pharmasset, Tibotec, Vertex, and ZymoGenetics. The other people interviewed for this story reported having no financial disclosures.

On 5 p.m. on the day before Thanksgiving, Dr. Alan Caroe, a general practitioner in Las Cruces, N.M., had to decide whether to prescribe an opiate medication to "a very smooth individual from out of town who had a story that was just barely plausible."

Dr. Caroe felt he had insufficient expertise in opioid management, an area that’s complex and difficult and fraught with risk but also an opportunity to help patients in chronic pain, he said in an interview. He needed a quick consultation, but who would answer the phone on that day, at that hour?

Experts at the chronic pain and headache clinic at Project ECHO (Extension for Community Healthcare Outcomes), that’s who. They walked him through the complex issues in the case, which led him to retract an opiate prescription that he initially had phoned into a pharmacy for this patient.

Sherry Boschert/IMNG Medical Media

Real-time consultations are only a part of Project ECHO, an award-winning program based at the University of New Mexico in Albuquerque. In addition, the program provides weekly videoconferences, not only to discuss cases but also to educate and mentor community physicians to take on frontline management of chronic diseases in their geographic areas.

The aim is to act as a multiplier, and to expand the health system’s capacity to manage common, chronic, but complex diseases, Dr. Sanjeev Arora explained in a presentation at the annual meeting of the American Academy of Pain Medicine. New Mexico’s 1.8 million people are spread across 121,000 square miles, and 32 of the state’s 33 counties are listed as medically underserved areas.

Project ECHO began with a focus on improving the care of patients with hepatitis C, and its success has spawned Project ECHO programs for asthma, rheumatology, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, prevention of teenage suicide, high-risk pregnancy, childhood obesity, child psychiatry, psychotherapy, antibiotic stewardship, and ethics consultation. More than 400 clinical sites can now connect with Project ECHO.

The Project ECHO model has been cloned by the University of Washington in Seattle, the U.S. Veterans Health Administration, the U.S. Department of Defense, and the country of India, among other entities. The focus is not just on helping rural areas; the University of Chicago’s project works with urban physicians in the community to improve the care of black patients with difficult-to-treat hypertension, whose numbers would overwhelm the limited number of specialists.

When the project’s director, Dr. Arora, a gastroenterologist and hepatologist, founded Project ECHO in 2002, an estimated 28,000 people in the state had hepatitis C, and patients faced an 8-month waiting list to be seen at Dr. Arora’s specialty clinic, which often required traveling long distances. The project has conducted more than 500 "telehealth clinics" on hepatitis C, and has helped get more than 5,000 patients into hepatitis C treatment who previously had no access to care, said Dr. Arora, a professor of medicine at the University of New Mexico.

"We want to transform the nature of what primary care looks like in the United States," he said.

The quality of care these patients are getting in the community rivals the quality at the university, and minorities’ access to care is expanding, a prospective study of 407 patients found. A sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N. Engl. J. Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.

Patients who received care at the Project ECHO community sites, however, were significantly more likely to be racial/ethnic minorities (68%), compared with the university’s patients (49%), he said. The cure rate at community sites was significantly higher than cure rates reported in previous community-based studies of hepatitis C treatment, which hovered around 20%, he added. This may be a result of Project ECHO’s emphasis on best-practices protocols and other attributes.

"Project ECHO has brought so much balance. We’ve reduced variation in prescribing" practices for pain medications, for example, Dr. Joanna G. Katzman said in a separate presentation at the meeting. "The degree to which people have evolved blows my mind."

Dr. Katzman, director of Project ECHO’s chronic pain and headache clinic and a neurologist at the University of New Mexico, said that her weekly videoconference typically starts at noon so that primary care physicians can join in during their lunch break. Participants get free CME credits.

The project’s interdisciplinary team of experts and remote participants spend the first half-hour reviewing and discussing three or four cases that have been faxed in by remote participants, followed by 25-30 minutes of didactic presentations. A second hour covers more cases, for those who can stay on. Once a month, the videoconference includes a skills demonstration, such as a trigger point examination or a procedure. Community physicians who miss the live videoconference can watch a video of it later.

"It’s the best use of lunchtime that you can consider," said Dr. Caroe, the generalist in Las Cruces.

Since starting in 2009, Project ECHO’s chronic pain and headache clinic sessions have attracted 474 participants in 168 locations in multiple states, averaging more than six sessions per attendee. In all, 42% are physicians, 23% are nurses or physician assistants, and 35% are others including pharmacists and chiropractors.

Physician assistant Debra Newman worked for several years as a community health extension agent at a rural clinic in Espanola, N.M., with part of her salary paid by the clinic and part by Project ECHO. She managed hundreds of patients who were referred to her for everything from simple low back pain to fibromyalgia, rheumatoid arthritis, and failed back surgery syndrome.

"After sitting in on Project ECHO for years, I could manage many of these patients on my own," said Ms. Newman, now of Christus St. Vincent Regional Medical Center in Santa Fe, N.M. As a P.A., she could practice independently if a supervising physician was within 100 miles – but, she said, she still took complex cases to the teleconference for consultations.

Project ECHO is funded by grants from state and federal government sources and the Robert Wood Johnson Foundation. Large health care systems are cloning the model because they see that it’s a cost-effective way to provide specialty services to more patients without transferring them to specialty care, Dr. Arora said.

"It isn’t expensive if you think that you’re training someone out there to replace you," Dr. Rollin M. Gallagher said in a separate presentation at the meeting. Project ECHO inspired the creation of the similarly-modeled Veterans Affairs SCAN (Specialty Care Access Network), said Dr. Gallagher, deputy national program director for pain management in the Veterans Health Administration and director for pain policy and primary care research at Penn Pain Medicine at the University of Pennsylvania, Philadelphia.

Dr. Ilene R. Robeck runs what she calls a "poor man’s Project ECHO" that provides pain management education, mentoring, and consultations primarily to physicians at three Veterans Affairs medical centers in Florida. "As much as I thought [Project ECHO] was a fantastic program, the resources needed were really higher than the resources I had," she said in an interview.

Funded by a federal grant through September 2013, her project offers a weekly telephone audioconference and immediate access to expert consultations by phone – initiatives that stress the education of participants as much as individual case consultations.

"The results have been overwhelmingly positive," with close to 100 health care providers now calling in from VA facilities around the country each week, said Dr. Robeck of Bay Pines (Fla.) Veterans Affairs Healthcare System.

When Dr. Caroe first heard about Project ECHO, he listened to the weekly conferences by phone because the Internet connection for videoconferencing was too slow where he was practicing in Chaparral, N.M. He now videoconferences each week on a faster connection at his current practice in Las Cruces.

The nearest pain specialists are in Albuquerque (about 260 miles away and too far for many patients to travel for routine visits) or in El Paso, Tex. Crossing state lines for care can create problems with insurance.

He has no doubt that the skills he has gained through Project ECHO have benefited his patients. One 49-year-old female engineer had suffered nearly a lifetime of terrible migraine headaches. Prior to Project ECHO’s didactic and clinical presentations, Dr. Caroe had never heard of premenstrual migraine, and the patient had never noticed that her headaches regularly got worse 2 days before the start of her menstrual period.

"She went from monthly hell" to treatment with a low-dose, short-term estrogen patch to get her through her 4-day period of risk, he said. When she came in for a follow-up visit recently, she told him, "You changed my life."

Dr. Arora has received research funding from Genentech, Gilead, Pharmasset, Tibotec, Vertex, and ZymoGenetics. The other people interviewed for this story reported having no financial disclosures.

PALM SPRINGS, CALIF. – The degree of sacroiliac joint pain relief provided by intra-articular steroid injection of the sacroiliac joint did not predict the duration of pain relief from subsequent radiofrequency ablation of the lateral branches that innervate the sacroiliac joint, judging from findings from a retrospective study of 80 patients.

Based on these results, patients who get only 25%-49% relief of pain from steroid injection of the sacroiliac joint (SISI) should not be disqualified from undergoing radiofrequency ablation of the lateral branches, Dr. Jianguo Cheng and his associates suggested in an award-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

The study retrospectively collected data on 87 patients undergoing radiofrequency ablation of the lateral branches who’d had a preoperative SISI between January 2006 and June 2009 at The Cleveland Clinic. The seven patients who were missing follow-up data were excluded from the final analysis.

In all, 60 of the 80 patients in the analysis reported at least 50% pain relief as a result of SISI (75%) and 20 patients reported less than 50% pain relief (25%). After radiofrequency ablation of the lateral branches, approximately 50% of all patients reported at least a 50% reduction in pain. The degree of pain relief from radiofrequency ablation did not differ significantly at follow-up visits 1, 3, 6, and 12 months between patients who had experienced 25%-49% pain relief after SISI and patients who reported 50% or greater pain relief after SISI, said Dr. Cheng, who is professor of anesthesiology and program director of pain medicine fellowship program of Cleveland Clinic Foundation.

The analysis adjusted for the effects of potential confounders. Patients who had experienced less than 50% pain relief after SISI were significantly younger than those with at least 50% pain relief after SISI (a mean of 52 years vs. 59 years) and significantly less likely to have had gradual onset of their chronic back pain (60% vs. 82%) and more likely to have had pain with extension or axial rotation (80% vs. 52%). Other characteristics did not differ between groups.

Although the efficacy of radiofrequency ablation of the lateral branches at 3 months was comparable to reports in the literature, the efficacy after 6 months was lower in the study compared with previous reports. Approximately 40% of patients in the study had at least a 50% reduction in pain 6 months after radiofrequency ablation compared with 52%-57% in published reports, Dr. Cheng said. This difference may be due to the older age of patients in the current study compared with previous ones (58 vs. 52 years on average), a higher rate of previous spine surgery (30% vs. 21%), and greater likelihood of multiple pain complaints and opioid use in the current cohort (70% vs. 46%), he suggested.

The current study is larger than most previous ones but is limited by its retrospective design, Dr. Cheng said.

In general, 16%-30% of cases of chronic lower back pain can be attributed to sacroiliac joint pain. Radiofrequency ablation of the lateral branches has emerged as a promising modality in recent years while other treatment modalities have provided mixed and often disappointing results, including pharmacotherapy, viscosupplementation, prolotherapy, chiropractic manipulation, intra-articular injections, and surgical fixation, he said. The findings of the current study should help inform pain interventionists in deciding who is a candidate for radiofrequency ablation.

Dr. Cheng reported having no financial disclosures.

PALM SPRINGS, CALIF. – The degree of sacroiliac joint pain relief provided by intra-articular steroid injection of the sacroiliac joint did not predict the duration of pain relief from subsequent radiofrequency ablation of the lateral branches that innervate the sacroiliac joint, judging from findings from a retrospective study of 80 patients.

Based on these results, patients who get only 25%-49% relief of pain from steroid injection of the sacroiliac joint (SISI) should not be disqualified from undergoing radiofrequency ablation of the lateral branches, Dr. Jianguo Cheng and his associates suggested in an award-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

The study retrospectively collected data on 87 patients undergoing radiofrequency ablation of the lateral branches who’d had a preoperative SISI between January 2006 and June 2009 at The Cleveland Clinic. The seven patients who were missing follow-up data were excluded from the final analysis.

In all, 60 of the 80 patients in the analysis reported at least 50% pain relief as a result of SISI (75%) and 20 patients reported less than 50% pain relief (25%). After radiofrequency ablation of the lateral branches, approximately 50% of all patients reported at least a 50% reduction in pain. The degree of pain relief from radiofrequency ablation did not differ significantly at follow-up visits 1, 3, 6, and 12 months between patients who had experienced 25%-49% pain relief after SISI and patients who reported 50% or greater pain relief after SISI, said Dr. Cheng, who is professor of anesthesiology and program director of pain medicine fellowship program of Cleveland Clinic Foundation.

The analysis adjusted for the effects of potential confounders. Patients who had experienced less than 50% pain relief after SISI were significantly younger than those with at least 50% pain relief after SISI (a mean of 52 years vs. 59 years) and significantly less likely to have had gradual onset of their chronic back pain (60% vs. 82%) and more likely to have had pain with extension or axial rotation (80% vs. 52%). Other characteristics did not differ between groups.

Although the efficacy of radiofrequency ablation of the lateral branches at 3 months was comparable to reports in the literature, the efficacy after 6 months was lower in the study compared with previous reports. Approximately 40% of patients in the study had at least a 50% reduction in pain 6 months after radiofrequency ablation compared with 52%-57% in published reports, Dr. Cheng said. This difference may be due to the older age of patients in the current study compared with previous ones (58 vs. 52 years on average), a higher rate of previous spine surgery (30% vs. 21%), and greater likelihood of multiple pain complaints and opioid use in the current cohort (70% vs. 46%), he suggested.

The current study is larger than most previous ones but is limited by its retrospective design, Dr. Cheng said.

In general, 16%-30% of cases of chronic lower back pain can be attributed to sacroiliac joint pain. Radiofrequency ablation of the lateral branches has emerged as a promising modality in recent years while other treatment modalities have provided mixed and often disappointing results, including pharmacotherapy, viscosupplementation, prolotherapy, chiropractic manipulation, intra-articular injections, and surgical fixation, he said. The findings of the current study should help inform pain interventionists in deciding who is a candidate for radiofrequency ablation.

Dr. Cheng reported having no financial disclosures.

PALM SPRINGS, CALIF. – The degree of sacroiliac joint pain relief provided by intra-articular steroid injection of the sacroiliac joint did not predict the duration of pain relief from subsequent radiofrequency ablation of the lateral branches that innervate the sacroiliac joint, judging from findings from a retrospective study of 80 patients.

Based on these results, patients who get only 25%-49% relief of pain from steroid injection of the sacroiliac joint (SISI) should not be disqualified from undergoing radiofrequency ablation of the lateral branches, Dr. Jianguo Cheng and his associates suggested in an award-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

The study retrospectively collected data on 87 patients undergoing radiofrequency ablation of the lateral branches who’d had a preoperative SISI between January 2006 and June 2009 at The Cleveland Clinic. The seven patients who were missing follow-up data were excluded from the final analysis.

In all, 60 of the 80 patients in the analysis reported at least 50% pain relief as a result of SISI (75%) and 20 patients reported less than 50% pain relief (25%). After radiofrequency ablation of the lateral branches, approximately 50% of all patients reported at least a 50% reduction in pain. The degree of pain relief from radiofrequency ablation did not differ significantly at follow-up visits 1, 3, 6, and 12 months between patients who had experienced 25%-49% pain relief after SISI and patients who reported 50% or greater pain relief after SISI, said Dr. Cheng, who is professor of anesthesiology and program director of pain medicine fellowship program of Cleveland Clinic Foundation.

The analysis adjusted for the effects of potential confounders. Patients who had experienced less than 50% pain relief after SISI were significantly younger than those with at least 50% pain relief after SISI (a mean of 52 years vs. 59 years) and significantly less likely to have had gradual onset of their chronic back pain (60% vs. 82%) and more likely to have had pain with extension or axial rotation (80% vs. 52%). Other characteristics did not differ between groups.

Although the efficacy of radiofrequency ablation of the lateral branches at 3 months was comparable to reports in the literature, the efficacy after 6 months was lower in the study compared with previous reports. Approximately 40% of patients in the study had at least a 50% reduction in pain 6 months after radiofrequency ablation compared with 52%-57% in published reports, Dr. Cheng said. This difference may be due to the older age of patients in the current study compared with previous ones (58 vs. 52 years on average), a higher rate of previous spine surgery (30% vs. 21%), and greater likelihood of multiple pain complaints and opioid use in the current cohort (70% vs. 46%), he suggested.

The current study is larger than most previous ones but is limited by its retrospective design, Dr. Cheng said.

In general, 16%-30% of cases of chronic lower back pain can be attributed to sacroiliac joint pain. Radiofrequency ablation of the lateral branches has emerged as a promising modality in recent years while other treatment modalities have provided mixed and often disappointing results, including pharmacotherapy, viscosupplementation, prolotherapy, chiropractic manipulation, intra-articular injections, and surgical fixation, he said. The findings of the current study should help inform pain interventionists in deciding who is a candidate for radiofrequency ablation.

Dr. Cheng reported having no financial disclosures.

PALM SPRINGS, CALIF. – A single question asked of patients whose pain interferes with their activities may help identify those who also are depressed and rule out those without depression.

Investigators analyzed data on 5,595 participants in the National Epidemiologic Study for Alcohol and Related Conditions (NESARC) who said that pain interfered with their work inside and outside the home "quite a bit" or "extremely" during the past 4 weeks. When asked, "How much of the time during the past 4 weeks have you felt downhearted or depressed?" 33% answered, "None of the time" and 67% responded, "A little," "Some," "Most," or "All of the time."

The answers identified those with comorbid depression with a sensitivity of 84% and a specificity of 43%, Jana M. Mossey, Ph.D. and her associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine. The question provided a positive predictive value of 46% and a negative predictive value of 82%, reported Dr. Mossey, professor of epidemiology and biostatistics at Drexel University, Philadelphia.

In other words, a report of recent depressed feelings identified 84% of individuals who had depression currently or within the past 12 months. The strong negative predictive value shows that people who said they hadn’t been downhearted or depressed were highly unlikely to have depression and were unlikely to be underreporting their negative feelings.

The diagnosis of depression was ascertained in the NESARC study by assessing participants using the AUDADIS-IV (Alcohol Use Disorder and Associated Disabilities Interview Schedule IV), a fully structured diagnostic interview to assess mental disorders specified in the DSM-IV. Use of the AUDADIS-IV to identify depressive disorders allowed for an assessment of sensitivity and specificity that rarely is obtained in pain clinics, the investigators noted.

The AUDADIS-IV is as reliable as the Diagnostic Interview Schedule or the World Health Organization Composite International Diagnostic Interview for assessing Axis I disorders, previous studies suggest.

Participants in the NESARC study also were assessed using the 12-item Short Form Health Survey version 2 (SF-12v2), which provided the question about how much they had felt downhearted or depressed in the past 4 weeks (J. Clin. Psychiatry 2005;66:1206-15).

The NESARC study was conducted in a community setting (in individuals’ homes), but Dr. Mossey and her associates restricted their analysis to a sample that was similar to patients seen in pain clinics in terms of the degree to which pain intensity interfered with their activities. Previous studies found that 66% of 15,537 patients in one pain practice and 85% of patients in another pain practice reported that pain interfered with their activities "quite a bit" or "extremely," the investigators noted.

In the current retrospective analysis, the sensitivity, specificity, and negative predictive value of the depression question were similar across subgroups by age, sex, and race. Overall, participants had a mean age of 44 years, 63% were female, 54% were non-Hispanic whites, 24% were black, and 22% were other races.

The sensitivity of the depression question increased as participants’ self-rated health worsened, from a 73% sensitivity in those who reported excellent health to a 94% sensitivity in those who reported poor health. The specificity of the depression question decreased with poorer self-rated health, from a 71% specificity in people reporting excellent health to a specificity of 24% in those reporting poor health.

Although the depression question may provide a quick and easy way to screen for depression in patients with significant activity-limiting pain, its utility is somewhat challenged by a large number of false positives, Dr. Mossey suggested. Among those who reported being downhearted or depressed, 64% had no DSM-IV diagnosis of depressive disorder. More study is needed comparing the true and false positives.

Patients with chronic pain commonly have depression that often goes undetected or undertreated, which can negatively affect patients’ clinical course, coping mechanisms, and chances of recovering from the pain, previous studies have shown.

Dr. Mossey reported having no financial disclosures.

PALM SPRINGS, CALIF. – A single question asked of patients whose pain interferes with their activities may help identify those who also are depressed and rule out those without depression.

Investigators analyzed data on 5,595 participants in the National Epidemiologic Study for Alcohol and Related Conditions (NESARC) who said that pain interfered with their work inside and outside the home "quite a bit" or "extremely" during the past 4 weeks. When asked, "How much of the time during the past 4 weeks have you felt downhearted or depressed?" 33% answered, "None of the time" and 67% responded, "A little," "Some," "Most," or "All of the time."

The answers identified those with comorbid depression with a sensitivity of 84% and a specificity of 43%, Jana M. Mossey, Ph.D. and her associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine. The question provided a positive predictive value of 46% and a negative predictive value of 82%, reported Dr. Mossey, professor of epidemiology and biostatistics at Drexel University, Philadelphia.

In other words, a report of recent depressed feelings identified 84% of individuals who had depression currently or within the past 12 months. The strong negative predictive value shows that people who said they hadn’t been downhearted or depressed were highly unlikely to have depression and were unlikely to be underreporting their negative feelings.

The diagnosis of depression was ascertained in the NESARC study by assessing participants using the AUDADIS-IV (Alcohol Use Disorder and Associated Disabilities Interview Schedule IV), a fully structured diagnostic interview to assess mental disorders specified in the DSM-IV. Use of the AUDADIS-IV to identify depressive disorders allowed for an assessment of sensitivity and specificity that rarely is obtained in pain clinics, the investigators noted.

The AUDADIS-IV is as reliable as the Diagnostic Interview Schedule or the World Health Organization Composite International Diagnostic Interview for assessing Axis I disorders, previous studies suggest.

Participants in the NESARC study also were assessed using the 12-item Short Form Health Survey version 2 (SF-12v2), which provided the question about how much they had felt downhearted or depressed in the past 4 weeks (J. Clin. Psychiatry 2005;66:1206-15).

The NESARC study was conducted in a community setting (in individuals’ homes), but Dr. Mossey and her associates restricted their analysis to a sample that was similar to patients seen in pain clinics in terms of the degree to which pain intensity interfered with their activities. Previous studies found that 66% of 15,537 patients in one pain practice and 85% of patients in another pain practice reported that pain interfered with their activities "quite a bit" or "extremely," the investigators noted.

In the current retrospective analysis, the sensitivity, specificity, and negative predictive value of the depression question were similar across subgroups by age, sex, and race. Overall, participants had a mean age of 44 years, 63% were female, 54% were non-Hispanic whites, 24% were black, and 22% were other races.

The sensitivity of the depression question increased as participants’ self-rated health worsened, from a 73% sensitivity in those who reported excellent health to a 94% sensitivity in those who reported poor health. The specificity of the depression question decreased with poorer self-rated health, from a 71% specificity in people reporting excellent health to a specificity of 24% in those reporting poor health.

Although the depression question may provide a quick and easy way to screen for depression in patients with significant activity-limiting pain, its utility is somewhat challenged by a large number of false positives, Dr. Mossey suggested. Among those who reported being downhearted or depressed, 64% had no DSM-IV diagnosis of depressive disorder. More study is needed comparing the true and false positives.

Patients with chronic pain commonly have depression that often goes undetected or undertreated, which can negatively affect patients’ clinical course, coping mechanisms, and chances of recovering from the pain, previous studies have shown.

Dr. Mossey reported having no financial disclosures.

PALM SPRINGS, CALIF. – A single question asked of patients whose pain interferes with their activities may help identify those who also are depressed and rule out those without depression.

Investigators analyzed data on 5,595 participants in the National Epidemiologic Study for Alcohol and Related Conditions (NESARC) who said that pain interfered with their work inside and outside the home "quite a bit" or "extremely" during the past 4 weeks. When asked, "How much of the time during the past 4 weeks have you felt downhearted or depressed?" 33% answered, "None of the time" and 67% responded, "A little," "Some," "Most," or "All of the time."

The answers identified those with comorbid depression with a sensitivity of 84% and a specificity of 43%, Jana M. Mossey, Ph.D. and her associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine. The question provided a positive predictive value of 46% and a negative predictive value of 82%, reported Dr. Mossey, professor of epidemiology and biostatistics at Drexel University, Philadelphia.

In other words, a report of recent depressed feelings identified 84% of individuals who had depression currently or within the past 12 months. The strong negative predictive value shows that people who said they hadn’t been downhearted or depressed were highly unlikely to have depression and were unlikely to be underreporting their negative feelings.

The diagnosis of depression was ascertained in the NESARC study by assessing participants using the AUDADIS-IV (Alcohol Use Disorder and Associated Disabilities Interview Schedule IV), a fully structured diagnostic interview to assess mental disorders specified in the DSM-IV. Use of the AUDADIS-IV to identify depressive disorders allowed for an assessment of sensitivity and specificity that rarely is obtained in pain clinics, the investigators noted.

The AUDADIS-IV is as reliable as the Diagnostic Interview Schedule or the World Health Organization Composite International Diagnostic Interview for assessing Axis I disorders, previous studies suggest.

Participants in the NESARC study also were assessed using the 12-item Short Form Health Survey version 2 (SF-12v2), which provided the question about how much they had felt downhearted or depressed in the past 4 weeks (J. Clin. Psychiatry 2005;66:1206-15).

The NESARC study was conducted in a community setting (in individuals’ homes), but Dr. Mossey and her associates restricted their analysis to a sample that was similar to patients seen in pain clinics in terms of the degree to which pain intensity interfered with their activities. Previous studies found that 66% of 15,537 patients in one pain practice and 85% of patients in another pain practice reported that pain interfered with their activities "quite a bit" or "extremely," the investigators noted.

In the current retrospective analysis, the sensitivity, specificity, and negative predictive value of the depression question were similar across subgroups by age, sex, and race. Overall, participants had a mean age of 44 years, 63% were female, 54% were non-Hispanic whites, 24% were black, and 22% were other races.

The sensitivity of the depression question increased as participants’ self-rated health worsened, from a 73% sensitivity in those who reported excellent health to a 94% sensitivity in those who reported poor health. The specificity of the depression question decreased with poorer self-rated health, from a 71% specificity in people reporting excellent health to a specificity of 24% in those reporting poor health.

Although the depression question may provide a quick and easy way to screen for depression in patients with significant activity-limiting pain, its utility is somewhat challenged by a large number of false positives, Dr. Mossey suggested. Among those who reported being downhearted or depressed, 64% had no DSM-IV diagnosis of depressive disorder. More study is needed comparing the true and false positives.

Patients with chronic pain commonly have depression that often goes undetected or undertreated, which can negatively affect patients’ clinical course, coping mechanisms, and chances of recovering from the pain, previous studies have shown.

Dr. Mossey reported having no financial disclosures.

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – An intensive interdisciplinary outpatient program successfully treated 246 patients at high risk of substance abuse, alongside 230 low-risk patients, for their debilitating chronic pain.

At the start of the 3-week pain rehabilitation program, the two groups did not differ significantly in their duration of pain (nearly 12 years on average) or duration of opioid use (6 years on average). They reported similar levels of pain severity.

The high-risk patients, however, had significantly worse scores on measures of depression, pain interference with life, pain catastrophizing, and perceived control of life and pain. Despite comparable pain severity and duration, they were taking significantly greater morphine-equivalent doses of pain medications, compared with doses taken by low-risk patients (124 vs. 60 mg/day).

By the end of the program, which incorporated substance abuse education and support, both the high-risk and low-risk groups had improved in all these measures, and there was no longer any significant difference in scores between the two groups, Sarah E. Hayes reported in an award-winning poster and plenary session at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

The intensive program at the Mayo Clinic, Rochester, Minn. provides more than can be offered in a typical ambulatory setting, coinvestigator Dr. Michael Hooten said in an interview. The results suggest that high-risk patients can be included in pain rehabilitation programs without affecting treatment outcomes, said Dr. Hooten of the Mayo Clinic.

Patients attend sessions 8 hours per day, 5 days per week, focused on functional restoration, withdrawal from opioids, and reduced polypharmacy rather than on attempted cures or interventional procedures for their chronic pain. Approximately 97% completely taper off of opioids, said Ms. Hayes, who conducted the study while she was a research associate at the Mayo Clinic and is now a student at New York University.

The interdisciplinary staff includes physicians, psychologists, pharmacists, nurses, physical therapists, and occupational therapists. The foundation of treatment is a cognitive-behavioral model that includes biofeedback, relaxation training, and stress management. Patients receive education in "chemical health" and in "wellness" topics such as sleep hygiene and healthy diets. Pain management training covers activity moderation and eliminating behaviors that cause pain. Family education and after-care assistance are provided.

Patients were identified as high risk if they had a history of using mood-altering substances, used pain medications in ways other than those prescribed, showed aberrant drug-related behaviors, had family members or health care providers who expressed concern, had a family history of substance abuse, or had other health risks (such as polypharmacy and high-dose opioid use).

At entry, they were significantly more likely than the low-risk group to have used opioids (75% vs. 46%), benzodiazepines (51% vs. 34%), or a combination of opioids, benzodiazepines, and sedative hypnotics (18% vs. 7%), and they were significantly more likely to be dependent on nicotine (37% vs. 10%), to have a history of heavy alcohol use (27% vs. 6%), and to be currently using cannabis (13% vs. 0.4%).

For the high-risk group, approximately 18 of the 120 hours in the program were devoted to a substance use curriculum that covered the physical and medical aspects of substance abuse, the cycle of pain and how substance use has become a part of that cycle, and how to manage high-risk situations and triggers for substance abuse. Patients explored their personal substance use patterns, family aspects, the effects of substance use on relationships, and their life goals.

"We’re increasingly noticing that chronic pain patients often have comorbid chemical dependency issues," Ms. Hayes said. Both chronic pain and substance abuse need to be addressed at the same time, she suggested.

The investigators plan to conduct longitudinal studies to identify how best to support high-risk patients after they complete the pain rehabilitation program.

The study included consecutive patients treated from February 2010 to May 2011. Patients averaged 45 years in age, ranging from 18 to 90 years. Back pain, fibromyalgia, and headache were the most common types of pain. Patients in the high-risk group were significantly more likely than those in the low-risk group to be living with back pain (27% vs. 21%) and significantly less likely to be living with fibromyalgia (15% vs. 21%).

Significantly fewer high-risk patients completed the 3-week program compared with low-risk patients (87% vs. 94%).

Functional status was assessed at the start and the end of the program using multiple tools including the Multidimensional Pain Inventory, the Center for Epidemiological Studies Depression Scale, the Pain Self-Efficacy Questionnaire, and the Pain Catastrophizing Scale.

A physician in the audience urged the investigators to mass market the tools to help chronic pain patients who are at high risk of substance abuse. "In the private setting, we don’t have the tools to provide the kind of program that you do," he said.

The investigators reported having no relevant financial disclosures.

PALM SPRINGS, CALIF. – An intensive interdisciplinary outpatient program successfully treated 246 patients at high risk of substance abuse, alongside 230 low-risk patients, for their debilitating chronic pain.

At the start of the 3-week pain rehabilitation program, the two groups did not differ significantly in their duration of pain (nearly 12 years on average) or duration of opioid use (6 years on average). They reported similar levels of pain severity.

The high-risk patients, however, had significantly worse scores on measures of depression, pain interference with life, pain catastrophizing, and perceived control of life and pain. Despite comparable pain severity and duration, they were taking significantly greater morphine-equivalent doses of pain medications, compared with doses taken by low-risk patients (124 vs. 60 mg/day).

By the end of the program, which incorporated substance abuse education and support, both the high-risk and low-risk groups had improved in all these measures, and there was no longer any significant difference in scores between the two groups, Sarah E. Hayes reported in an award-winning poster and plenary session at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

The intensive program at the Mayo Clinic, Rochester, Minn. provides more than can be offered in a typical ambulatory setting, coinvestigator Dr. Michael Hooten said in an interview. The results suggest that high-risk patients can be included in pain rehabilitation programs without affecting treatment outcomes, said Dr. Hooten of the Mayo Clinic.

Patients attend sessions 8 hours per day, 5 days per week, focused on functional restoration, withdrawal from opioids, and reduced polypharmacy rather than on attempted cures or interventional procedures for their chronic pain. Approximately 97% completely taper off of opioids, said Ms. Hayes, who conducted the study while she was a research associate at the Mayo Clinic and is now a student at New York University.

The interdisciplinary staff includes physicians, psychologists, pharmacists, nurses, physical therapists, and occupational therapists. The foundation of treatment is a cognitive-behavioral model that includes biofeedback, relaxation training, and stress management. Patients receive education in "chemical health" and in "wellness" topics such as sleep hygiene and healthy diets. Pain management training covers activity moderation and eliminating behaviors that cause pain. Family education and after-care assistance are provided.

Patients were identified as high risk if they had a history of using mood-altering substances, used pain medications in ways other than those prescribed, showed aberrant drug-related behaviors, had family members or health care providers who expressed concern, had a family history of substance abuse, or had other health risks (such as polypharmacy and high-dose opioid use).

At entry, they were significantly more likely than the low-risk group to have used opioids (75% vs. 46%), benzodiazepines (51% vs. 34%), or a combination of opioids, benzodiazepines, and sedative hypnotics (18% vs. 7%), and they were significantly more likely to be dependent on nicotine (37% vs. 10%), to have a history of heavy alcohol use (27% vs. 6%), and to be currently using cannabis (13% vs. 0.4%).

For the high-risk group, approximately 18 of the 120 hours in the program were devoted to a substance use curriculum that covered the physical and medical aspects of substance abuse, the cycle of pain and how substance use has become a part of that cycle, and how to manage high-risk situations and triggers for substance abuse. Patients explored their personal substance use patterns, family aspects, the effects of substance use on relationships, and their life goals.

"We’re increasingly noticing that chronic pain patients often have comorbid chemical dependency issues," Ms. Hayes said. Both chronic pain and substance abuse need to be addressed at the same time, she suggested.

The investigators plan to conduct longitudinal studies to identify how best to support high-risk patients after they complete the pain rehabilitation program.

The study included consecutive patients treated from February 2010 to May 2011. Patients averaged 45 years in age, ranging from 18 to 90 years. Back pain, fibromyalgia, and headache were the most common types of pain. Patients in the high-risk group were significantly more likely than those in the low-risk group to be living with back pain (27% vs. 21%) and significantly less likely to be living with fibromyalgia (15% vs. 21%).

Significantly fewer high-risk patients completed the 3-week program compared with low-risk patients (87% vs. 94%).

Functional status was assessed at the start and the end of the program using multiple tools including the Multidimensional Pain Inventory, the Center for Epidemiological Studies Depression Scale, the Pain Self-Efficacy Questionnaire, and the Pain Catastrophizing Scale.

A physician in the audience urged the investigators to mass market the tools to help chronic pain patients who are at high risk of substance abuse. "In the private setting, we don’t have the tools to provide the kind of program that you do," he said.

The investigators reported having no relevant financial disclosures.

PALM SPRINGS, CALIF. – An intensive interdisciplinary outpatient program successfully treated 246 patients at high risk of substance abuse, alongside 230 low-risk patients, for their debilitating chronic pain.

At the start of the 3-week pain rehabilitation program, the two groups did not differ significantly in their duration of pain (nearly 12 years on average) or duration of opioid use (6 years on average). They reported similar levels of pain severity.

The high-risk patients, however, had significantly worse scores on measures of depression, pain interference with life, pain catastrophizing, and perceived control of life and pain. Despite comparable pain severity and duration, they were taking significantly greater morphine-equivalent doses of pain medications, compared with doses taken by low-risk patients (124 vs. 60 mg/day).

By the end of the program, which incorporated substance abuse education and support, both the high-risk and low-risk groups had improved in all these measures, and there was no longer any significant difference in scores between the two groups, Sarah E. Hayes reported in an award-winning poster and plenary session at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

The intensive program at the Mayo Clinic, Rochester, Minn. provides more than can be offered in a typical ambulatory setting, coinvestigator Dr. Michael Hooten said in an interview. The results suggest that high-risk patients can be included in pain rehabilitation programs without affecting treatment outcomes, said Dr. Hooten of the Mayo Clinic.

Patients attend sessions 8 hours per day, 5 days per week, focused on functional restoration, withdrawal from opioids, and reduced polypharmacy rather than on attempted cures or interventional procedures for their chronic pain. Approximately 97% completely taper off of opioids, said Ms. Hayes, who conducted the study while she was a research associate at the Mayo Clinic and is now a student at New York University.

The interdisciplinary staff includes physicians, psychologists, pharmacists, nurses, physical therapists, and occupational therapists. The foundation of treatment is a cognitive-behavioral model that includes biofeedback, relaxation training, and stress management. Patients receive education in "chemical health" and in "wellness" topics such as sleep hygiene and healthy diets. Pain management training covers activity moderation and eliminating behaviors that cause pain. Family education and after-care assistance are provided.

Patients were identified as high risk if they had a history of using mood-altering substances, used pain medications in ways other than those prescribed, showed aberrant drug-related behaviors, had family members or health care providers who expressed concern, had a family history of substance abuse, or had other health risks (such as polypharmacy and high-dose opioid use).

At entry, they were significantly more likely than the low-risk group to have used opioids (75% vs. 46%), benzodiazepines (51% vs. 34%), or a combination of opioids, benzodiazepines, and sedative hypnotics (18% vs. 7%), and they were significantly more likely to be dependent on nicotine (37% vs. 10%), to have a history of heavy alcohol use (27% vs. 6%), and to be currently using cannabis (13% vs. 0.4%).

For the high-risk group, approximately 18 of the 120 hours in the program were devoted to a substance use curriculum that covered the physical and medical aspects of substance abuse, the cycle of pain and how substance use has become a part of that cycle, and how to manage high-risk situations and triggers for substance abuse. Patients explored their personal substance use patterns, family aspects, the effects of substance use on relationships, and their life goals.

"We’re increasingly noticing that chronic pain patients often have comorbid chemical dependency issues," Ms. Hayes said. Both chronic pain and substance abuse need to be addressed at the same time, she suggested.

The investigators plan to conduct longitudinal studies to identify how best to support high-risk patients after they complete the pain rehabilitation program.

The study included consecutive patients treated from February 2010 to May 2011. Patients averaged 45 years in age, ranging from 18 to 90 years. Back pain, fibromyalgia, and headache were the most common types of pain. Patients in the high-risk group were significantly more likely than those in the low-risk group to be living with back pain (27% vs. 21%) and significantly less likely to be living with fibromyalgia (15% vs. 21%).

Significantly fewer high-risk patients completed the 3-week program compared with low-risk patients (87% vs. 94%).

Functional status was assessed at the start and the end of the program using multiple tools including the Multidimensional Pain Inventory, the Center for Epidemiological Studies Depression Scale, the Pain Self-Efficacy Questionnaire, and the Pain Catastrophizing Scale.

A physician in the audience urged the investigators to mass market the tools to help chronic pain patients who are at high risk of substance abuse. "In the private setting, we don’t have the tools to provide the kind of program that you do," he said.

The investigators reported having no relevant financial disclosures.

PALM SPRINGS, CALIF. – The University of Louisville has had an acute pain service for nearly a decade, but for many hospitals in the United States this still is a new idea.

"What we’re seeing is the birth of a new modality in treatment" and possibly a new specialty, Dr. Laura Clark said.

An acute pain service (APS) primarily manages pain after traumatic injury or surgery. The basic aspects of an APS include standardization of analgesic techniques, increased pain monitoring and assessment, and the ability to respond to inadequate or excessive doses of analgesics.

Establishing an APS, however, takes a lot of persuasion and education, said Dr. Clark, professor of anesthesiology and director of acute pain and regional anesthesia at the University of Louisville (Ky.).

Hospital administrators must be convinced that an APS can benefit the hospital by increasing patient satisfaction (which is strongly associated with adequate pain relief) and by cutting costs through reducing nausea and vomiting, respiratory depression, the incidence of ileus (and thus the length of hospitalization), and the incidence of chronic pain.

Physicians and pharmacists need to be willing to accept an APS as part of the care team. Many anesthesiologists mistakenly think that a single nerve block that dissipates in 10 hours is sufficient acute pain management, she said. But more than anyone, surgeons need convincing, Dr. Clark said at the annual meeting of the American Academy of Pain Medicine.

Currently, a surgeon must request involvement of the APS and that request must be documented in order for the service to be covered by insurers. "That needs to change," she said.

To get surgeons on board, include them in developing protocols for all analgesic techniques, she suggested.

There are two groups that don’t need convincing about the benefits of an APS – patients and nurses, she said. Still, education of nurses and all staff about the APS is essential. Simply asking nurses to follow written orders is not sufficient, especially for the more advanced pain therapies. Good acute pain care requires a change in culture and attitudes; for example, nurses need to change empty bags of analgesics just as they change other bags of fluids.

Nurses can be certified in pain management, and "I recommend that you have your nurses do that," Dr. Clark said.

The need for better acute pain management has been established by major reports in the United States, England, Australia, Germany, Sweden, and elsewhere. At least eight published studies report that an APS improves pain relief, five studies report a lower incidence of side effects, and three studies suggest that an APS may reduce the incidence of persistent pain after surgery, she said.

One study reported reduced postoperative morbidity and mortality with an APS but noted that "the workload is considerable" (Anesthesia 2006;61:24-8).

A recent study concluded that an APS is "likely" to be cost effective, but the investigators "didn’t even study what we do," Dr. Clark said. Key treatment techniques such as peripheral nerve blocks and epidural patient-controlled analgesia were not included in the study (Anesth. Analg. 2010;111:1042-50). Had it included those, she believes the study would have shown that an APS is very cost effective, she said.

Better studies with hard data are needed, she added.

The service ideally is physician directed but multidisciplinary, including physicians, nurses, pharmacists, and physical therapists. The most common but least desirable model of an APS in the United States includes a private physician or regionalist who may not do rounds unless called by a surgeon to manage a problem, Dr. Clark said. A second model that may be the most flexible and cost effective for around-the-clock care involves a nurse-led physician consult, in which the nurse makes daily rounds, reports to the physician, and implements therapy based on standard orders and protocols developed by the pain physician and surgeon.

The most common model in academic centers, and Dr. Clark’s favorite, is a physician-led team with a pain management nurse. The team makes rounds and decides on care. The pain physician may or may not be the regionalist. Medical residents are on call for the pain service. The pain nurse is involved in cases before, during, and after surgery and implements advanced pain management techniques, provides consultations, and coordinates with trauma, surgery, and critical care services.

Once you’ve convinced your institution and colleagues to establish an APS, make sure that someone on the APS can be reached by telephone at any hour of every day. Establish "acute pain champions" on every floor and in every area of the hospital, and make sure that at least one champion is available on every shift.

Running an APS can be challenging, but it’s a therapeutic tool that’s worth the effort, she said: "With our twice-a-day rounds, we often hear from the patients that we talk to them more than any other physician. It can be quite rewarding."

Dr. Clark has been a speaker for Covidien and Cadence and an adviser and researcher for Covidien.

PALM SPRINGS, CALIF. – The University of Louisville has had an acute pain service for nearly a decade, but for many hospitals in the United States this still is a new idea.

"What we’re seeing is the birth of a new modality in treatment" and possibly a new specialty, Dr. Laura Clark said.

An acute pain service (APS) primarily manages pain after traumatic injury or surgery. The basic aspects of an APS include standardization of analgesic techniques, increased pain monitoring and assessment, and the ability to respond to inadequate or excessive doses of analgesics.

Establishing an APS, however, takes a lot of persuasion and education, said Dr. Clark, professor of anesthesiology and director of acute pain and regional anesthesia at the University of Louisville (Ky.).

Hospital administrators must be convinced that an APS can benefit the hospital by increasing patient satisfaction (which is strongly associated with adequate pain relief) and by cutting costs through reducing nausea and vomiting, respiratory depression, the incidence of ileus (and thus the length of hospitalization), and the incidence of chronic pain.

Physicians and pharmacists need to be willing to accept an APS as part of the care team. Many anesthesiologists mistakenly think that a single nerve block that dissipates in 10 hours is sufficient acute pain management, she said. But more than anyone, surgeons need convincing, Dr. Clark said at the annual meeting of the American Academy of Pain Medicine.

Currently, a surgeon must request involvement of the APS and that request must be documented in order for the service to be covered by insurers. "That needs to change," she said.

To get surgeons on board, include them in developing protocols for all analgesic techniques, she suggested.

There are two groups that don’t need convincing about the benefits of an APS – patients and nurses, she said. Still, education of nurses and all staff about the APS is essential. Simply asking nurses to follow written orders is not sufficient, especially for the more advanced pain therapies. Good acute pain care requires a change in culture and attitudes; for example, nurses need to change empty bags of analgesics just as they change other bags of fluids.

Nurses can be certified in pain management, and "I recommend that you have your nurses do that," Dr. Clark said.

The need for better acute pain management has been established by major reports in the United States, England, Australia, Germany, Sweden, and elsewhere. At least eight published studies report that an APS improves pain relief, five studies report a lower incidence of side effects, and three studies suggest that an APS may reduce the incidence of persistent pain after surgery, she said.

One study reported reduced postoperative morbidity and mortality with an APS but noted that "the workload is considerable" (Anesthesia 2006;61:24-8).

A recent study concluded that an APS is "likely" to be cost effective, but the investigators "didn’t even study what we do," Dr. Clark said. Key treatment techniques such as peripheral nerve blocks and epidural patient-controlled analgesia were not included in the study (Anesth. Analg. 2010;111:1042-50). Had it included those, she believes the study would have shown that an APS is very cost effective, she said.

Better studies with hard data are needed, she added.

The service ideally is physician directed but multidisciplinary, including physicians, nurses, pharmacists, and physical therapists. The most common but least desirable model of an APS in the United States includes a private physician or regionalist who may not do rounds unless called by a surgeon to manage a problem, Dr. Clark said. A second model that may be the most flexible and cost effective for around-the-clock care involves a nurse-led physician consult, in which the nurse makes daily rounds, reports to the physician, and implements therapy based on standard orders and protocols developed by the pain physician and surgeon.

The most common model in academic centers, and Dr. Clark’s favorite, is a physician-led team with a pain management nurse. The team makes rounds and decides on care. The pain physician may or may not be the regionalist. Medical residents are on call for the pain service. The pain nurse is involved in cases before, during, and after surgery and implements advanced pain management techniques, provides consultations, and coordinates with trauma, surgery, and critical care services.

Once you’ve convinced your institution and colleagues to establish an APS, make sure that someone on the APS can be reached by telephone at any hour of every day. Establish "acute pain champions" on every floor and in every area of the hospital, and make sure that at least one champion is available on every shift.

Running an APS can be challenging, but it’s a therapeutic tool that’s worth the effort, she said: "With our twice-a-day rounds, we often hear from the patients that we talk to them more than any other physician. It can be quite rewarding."

Dr. Clark has been a speaker for Covidien and Cadence and an adviser and researcher for Covidien.

PALM SPRINGS, CALIF. – The University of Louisville has had an acute pain service for nearly a decade, but for many hospitals in the United States this still is a new idea.

"What we’re seeing is the birth of a new modality in treatment" and possibly a new specialty, Dr. Laura Clark said.

An acute pain service (APS) primarily manages pain after traumatic injury or surgery. The basic aspects of an APS include standardization of analgesic techniques, increased pain monitoring and assessment, and the ability to respond to inadequate or excessive doses of analgesics.

Establishing an APS, however, takes a lot of persuasion and education, said Dr. Clark, professor of anesthesiology and director of acute pain and regional anesthesia at the University of Louisville (Ky.).

Hospital administrators must be convinced that an APS can benefit the hospital by increasing patient satisfaction (which is strongly associated with adequate pain relief) and by cutting costs through reducing nausea and vomiting, respiratory depression, the incidence of ileus (and thus the length of hospitalization), and the incidence of chronic pain.

Physicians and pharmacists need to be willing to accept an APS as part of the care team. Many anesthesiologists mistakenly think that a single nerve block that dissipates in 10 hours is sufficient acute pain management, she said. But more than anyone, surgeons need convincing, Dr. Clark said at the annual meeting of the American Academy of Pain Medicine.

Currently, a surgeon must request involvement of the APS and that request must be documented in order for the service to be covered by insurers. "That needs to change," she said.

To get surgeons on board, include them in developing protocols for all analgesic techniques, she suggested.

There are two groups that don’t need convincing about the benefits of an APS – patients and nurses, she said. Still, education of nurses and all staff about the APS is essential. Simply asking nurses to follow written orders is not sufficient, especially for the more advanced pain therapies. Good acute pain care requires a change in culture and attitudes; for example, nurses need to change empty bags of analgesics just as they change other bags of fluids.

Nurses can be certified in pain management, and "I recommend that you have your nurses do that," Dr. Clark said.

The need for better acute pain management has been established by major reports in the United States, England, Australia, Germany, Sweden, and elsewhere. At least eight published studies report that an APS improves pain relief, five studies report a lower incidence of side effects, and three studies suggest that an APS may reduce the incidence of persistent pain after surgery, she said.

One study reported reduced postoperative morbidity and mortality with an APS but noted that "the workload is considerable" (Anesthesia 2006;61:24-8).

A recent study concluded that an APS is "likely" to be cost effective, but the investigators "didn’t even study what we do," Dr. Clark said. Key treatment techniques such as peripheral nerve blocks and epidural patient-controlled analgesia were not included in the study (Anesth. Analg. 2010;111:1042-50). Had it included those, she believes the study would have shown that an APS is very cost effective, she said.

Better studies with hard data are needed, she added.

The service ideally is physician directed but multidisciplinary, including physicians, nurses, pharmacists, and physical therapists. The most common but least desirable model of an APS in the United States includes a private physician or regionalist who may not do rounds unless called by a surgeon to manage a problem, Dr. Clark said. A second model that may be the most flexible and cost effective for around-the-clock care involves a nurse-led physician consult, in which the nurse makes daily rounds, reports to the physician, and implements therapy based on standard orders and protocols developed by the pain physician and surgeon.

The most common model in academic centers, and Dr. Clark’s favorite, is a physician-led team with a pain management nurse. The team makes rounds and decides on care. The pain physician may or may not be the regionalist. Medical residents are on call for the pain service. The pain nurse is involved in cases before, during, and after surgery and implements advanced pain management techniques, provides consultations, and coordinates with trauma, surgery, and critical care services.

Once you’ve convinced your institution and colleagues to establish an APS, make sure that someone on the APS can be reached by telephone at any hour of every day. Establish "acute pain champions" on every floor and in every area of the hospital, and make sure that at least one champion is available on every shift.

Running an APS can be challenging, but it’s a therapeutic tool that’s worth the effort, she said: "With our twice-a-day rounds, we often hear from the patients that we talk to them more than any other physician. It can be quite rewarding."

Dr. Clark has been a speaker for Covidien and Cadence and an adviser and researcher for Covidien.

PALM SPRINGS, CALIF. – Balancing pain relief against gastrointestinal side effects of opioid analgesics in treating acute pain is a major challenge, a nationwide survey of nearly 6,000 physicians suggests.

A total of 70% of physicians said they "usually" or "often" prescribe opioid analgesics for patients with moderate to severe acute pain. Alongside that, 63% said they also "usually" or "often" prescribe or recommend treatments to manage opioid-related side effects, especially GI side effects, Dr. Bill H. McCarberg and his associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine.

The survey also found that 65% of physicians said that patients who receive opioid analgesics for acute pain also take over-the-counter or prescription treatments to manage opioid-related GI side effects. A total of 20% of physicians rated unacceptable GI side effects as the top reason for discontinuing opioid analgesics, and 60% said GI side effects were the top or second-to-the-top reason for discontinuing opioids, reported Dr. McCarberg, a family physician and pain specialist at Kaiser Permanente, San Diego.

The data came from the Physicians Partnering Against Pain survey, which asked 5,982 physicians to identify 10-15 "typical patients who were returning for their first follow-up visits after treatment for moderate to severe acute pain. A majority of respondents (52%) were primary care physicians, 25% were pain specialists, and 23% were other medical specialists.

In all, 55% of physicians ranked unacceptable GI or other side effects as the most common reason patients discontinued opioids. More than 40% of physicians said that patients discontinued opioids, mainly because they believed that their pain had dissipated.

More than 15% of physicians said that they see more than 60 patients with moderate to severe pain in a typical week. More than 20% said they see 31-60 patients per week, more than 35% said they see 16-30 patients per week, and nearly 25% said they see 0-15 patients with moderate to severe pain in a typical week. A majority of physicians (55%) reported that more than 75% of their patients return for a follow-up visit after the initial acute pain treatment.

The participating physicians may not be representative of all U.S. practicing physicians, and there may be some recall bias affecting how well the results represent actual physician behavior.

Despite these limitations, the findings reflect the significant challenges that opioid-related side effects pose for managing moderate to severe acute pain, Dr. McCarberg said.

Janssen Scientific Affairs funded the study and Dr. McCarberg’s associates in the study were Janssen employees. Dr. McCarberg reported having no financial disclosures.

PALM SPRINGS, CALIF. – Balancing pain relief against gastrointestinal side effects of opioid analgesics in treating acute pain is a major challenge, a nationwide survey of nearly 6,000 physicians suggests.

A total of 70% of physicians said they "usually" or "often" prescribe opioid analgesics for patients with moderate to severe acute pain. Alongside that, 63% said they also "usually" or "often" prescribe or recommend treatments to manage opioid-related side effects, especially GI side effects, Dr. Bill H. McCarberg and his associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine.

The survey also found that 65% of physicians said that patients who receive opioid analgesics for acute pain also take over-the-counter or prescription treatments to manage opioid-related GI side effects. A total of 20% of physicians rated unacceptable GI side effects as the top reason for discontinuing opioid analgesics, and 60% said GI side effects were the top or second-to-the-top reason for discontinuing opioids, reported Dr. McCarberg, a family physician and pain specialist at Kaiser Permanente, San Diego.

The data came from the Physicians Partnering Against Pain survey, which asked 5,982 physicians to identify 10-15 "typical patients who were returning for their first follow-up visits after treatment for moderate to severe acute pain. A majority of respondents (52%) were primary care physicians, 25% were pain specialists, and 23% were other medical specialists.

In all, 55% of physicians ranked unacceptable GI or other side effects as the most common reason patients discontinued opioids. More than 40% of physicians said that patients discontinued opioids, mainly because they believed that their pain had dissipated.

More than 15% of physicians said that they see more than 60 patients with moderate to severe pain in a typical week. More than 20% said they see 31-60 patients per week, more than 35% said they see 16-30 patients per week, and nearly 25% said they see 0-15 patients with moderate to severe pain in a typical week. A majority of physicians (55%) reported that more than 75% of their patients return for a follow-up visit after the initial acute pain treatment.

The participating physicians may not be representative of all U.S. practicing physicians, and there may be some recall bias affecting how well the results represent actual physician behavior.

Despite these limitations, the findings reflect the significant challenges that opioid-related side effects pose for managing moderate to severe acute pain, Dr. McCarberg said.

Janssen Scientific Affairs funded the study and Dr. McCarberg’s associates in the study were Janssen employees. Dr. McCarberg reported having no financial disclosures.

PALM SPRINGS, CALIF. – Balancing pain relief against gastrointestinal side effects of opioid analgesics in treating acute pain is a major challenge, a nationwide survey of nearly 6,000 physicians suggests.

A total of 70% of physicians said they "usually" or "often" prescribe opioid analgesics for patients with moderate to severe acute pain. Alongside that, 63% said they also "usually" or "often" prescribe or recommend treatments to manage opioid-related side effects, especially GI side effects, Dr. Bill H. McCarberg and his associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine.

The survey also found that 65% of physicians said that patients who receive opioid analgesics for acute pain also take over-the-counter or prescription treatments to manage opioid-related GI side effects. A total of 20% of physicians rated unacceptable GI side effects as the top reason for discontinuing opioid analgesics, and 60% said GI side effects were the top or second-to-the-top reason for discontinuing opioids, reported Dr. McCarberg, a family physician and pain specialist at Kaiser Permanente, San Diego.

The data came from the Physicians Partnering Against Pain survey, which asked 5,982 physicians to identify 10-15 "typical patients who were returning for their first follow-up visits after treatment for moderate to severe acute pain. A majority of respondents (52%) were primary care physicians, 25% were pain specialists, and 23% were other medical specialists.

In all, 55% of physicians ranked unacceptable GI or other side effects as the most common reason patients discontinued opioids. More than 40% of physicians said that patients discontinued opioids, mainly because they believed that their pain had dissipated.

More than 15% of physicians said that they see more than 60 patients with moderate to severe pain in a typical week. More than 20% said they see 31-60 patients per week, more than 35% said they see 16-30 patients per week, and nearly 25% said they see 0-15 patients with moderate to severe pain in a typical week. A majority of physicians (55%) reported that more than 75% of their patients return for a follow-up visit after the initial acute pain treatment.

The participating physicians may not be representative of all U.S. practicing physicians, and there may be some recall bias affecting how well the results represent actual physician behavior.

Despite these limitations, the findings reflect the significant challenges that opioid-related side effects pose for managing moderate to severe acute pain, Dr. McCarberg said.

Janssen Scientific Affairs funded the study and Dr. McCarberg’s associates in the study were Janssen employees. Dr. McCarberg reported having no financial disclosures.

PALM SPRINGS, CALIF. – Low testosterone levels were nearly five times more likely in men on long-acting or sustained-release opioids, compared with equipotent short-acting or immediate-release formulations, judging from the findings of a study of 81 men on daily opioids for chronic pain.

Neither the age of the patient nor the total daily dose of opioid significantly affected the risk of hypogonadism, Dr. Andrea Rubenstein reported in her award-winning poster and a plenary presentation at the annual meeting of the American Academy of Pain Medicine.

With her associates, Dr. Rubenstein reviewed records on the morning measurements of total testosterone levels in men who were on a stable dose of an opioid for at least 3 months and who had no history of hypogonadism. In all, 46 of the 81 men had total testosterone levels below 25 ng/dl (57%), consistent with published reports of a high rate of hypogonadism in men on chronic opioid therapy ranging from 54% to 86%.

Previous studies, however, evaluated only men on sustained-release or intrathecal formulations and could not identify what aspect of opioid use may be contributing to hypogonadism.

The current study found that 34 of 46 men on long-acting or sustained-release opioids had low total testosterone levels (74%), compared with 12 of 35 men on short-acting or immediate-release opioids (34%), a significant difference, said Dr. Rubenstein, an anesthesiologist and pain specialist at Kaiser Permanente Medical Group, Santa Rosa, Calif.

After adjusting for the effects of dosage and body mass index (BMI), men on long-acting or sustained-release opioids were 4.8 times more likely to have low testosterone levels, compared with men on short-acting or immediate-release formulations.

Higher BMI had a small but significant association, increasing the risk for hypogonadism by 13%.

Opioid-related androgen deficiency has been documented in one fashion or another since the 1970s, and appears to come on quickly, within days or weeks of starting chronic opioid therapy, she said.

"This phenomenon is not new, even though it’s kind of a hot topic this year," Dr. Rubenstein said.

For the past 20 years, the trend has been to put more and more patients on long-acting opioids because these were believed to be safer than short-acting formulations. If the association between hypogonadism and long-acting opioids holds up in further studies, "it will be the first evidence of a difference in safety, though not in the direction we had thought," she said.

Dr. Steven Linder of the Veterans Affairs Healthcare System Hospital, Palo Alto, Calif., commented on the study in an interview at the poster presentation. The V.A. is seeing a large number of young veterans with spinal and other injuries who are on long-term opioids, and often these patients are not screened for hypogonadism. Dr. Rubenstein’s study is an important reminder to check testosterone levels in men on long-acting or sustained-release opioids, he said.

If unrecognized and untreated, hypogonadism can lead to osteoporosis, low libido, lower function and mood, insulin resistance, increased pain, and obesity. Often, these are managed with other medications that contribute side effects, Dr. Rubenstein said.

"The last thing we need in a guy on 40 mg of methadone for back pain is to get osteoporosis of the spine," she said.

Patients in the study included 25 on hydrocodone, 8 on continuous-release oxycodone, 10 on immediate-release oxycodone, 12 on continuous-release morphine, 4 on the fentanyl patch, 14 on methadone, and 8 on off-label sublingual buprenorphine. (Only the patch form of buprenorphine is approved to treat pain.)

The study was limited by its small size, "but in the opioid literature, 81 is a nice number," she said. The study also is limited by its retrospective design, potential bias if the symptoms of hypogonadism played a role in the initial referral, and questionable generalizability if the men at this tertiary-care pain clinic are not representative of men with chronic pain in the general population.

The investigators next will repeat the study on a much larger sample of patients, and if the association is replicated, will design a prospective study to see if changing opioid therapy modifies the risk for hypogonadism. The findings of the current study are too preliminary to generate recommendations, she said.

The current study excluded patients with a history of cancer, HIV, or endocrine disease other than hypothyroidism.

Dr. Rubenstein and her associates reported having no financial disclosures.

PALM SPRINGS, CALIF. – Low testosterone levels were nearly five times more likely in men on long-acting or sustained-release opioids, compared with equipotent short-acting or immediate-release formulations, judging from the findings of a study of 81 men on daily opioids for chronic pain.

Neither the age of the patient nor the total daily dose of opioid significantly affected the risk of hypogonadism, Dr. Andrea Rubenstein reported in her award-winning poster and a plenary presentation at the annual meeting of the American Academy of Pain Medicine.

With her associates, Dr. Rubenstein reviewed records on the morning measurements of total testosterone levels in men who were on a stable dose of an opioid for at least 3 months and who had no history of hypogonadism. In all, 46 of the 81 men had total testosterone levels below 25 ng/dl (57%), consistent with published reports of a high rate of hypogonadism in men on chronic opioid therapy ranging from 54% to 86%.

Previous studies, however, evaluated only men on sustained-release or intrathecal formulations and could not identify what aspect of opioid use may be contributing to hypogonadism.

The current study found that 34 of 46 men on long-acting or sustained-release opioids had low total testosterone levels (74%), compared with 12 of 35 men on short-acting or immediate-release opioids (34%), a significant difference, said Dr. Rubenstein, an anesthesiologist and pain specialist at Kaiser Permanente Medical Group, Santa Rosa, Calif.

After adjusting for the effects of dosage and body mass index (BMI), men on long-acting or sustained-release opioids were 4.8 times more likely to have low testosterone levels, compared with men on short-acting or immediate-release formulations.

Higher BMI had a small but significant association, increasing the risk for hypogonadism by 13%.

Opioid-related androgen deficiency has been documented in one fashion or another since the 1970s, and appears to come on quickly, within days or weeks of starting chronic opioid therapy, she said.

"This phenomenon is not new, even though it’s kind of a hot topic this year," Dr. Rubenstein said.

For the past 20 years, the trend has been to put more and more patients on long-acting opioids because these were believed to be safer than short-acting formulations. If the association between hypogonadism and long-acting opioids holds up in further studies, "it will be the first evidence of a difference in safety, though not in the direction we had thought," she said.

Dr. Steven Linder of the Veterans Affairs Healthcare System Hospital, Palo Alto, Calif., commented on the study in an interview at the poster presentation. The V.A. is seeing a large number of young veterans with spinal and other injuries who are on long-term opioids, and often these patients are not screened for hypogonadism. Dr. Rubenstein’s study is an important reminder to check testosterone levels in men on long-acting or sustained-release opioids, he said.

If unrecognized and untreated, hypogonadism can lead to osteoporosis, low libido, lower function and mood, insulin resistance, increased pain, and obesity. Often, these are managed with other medications that contribute side effects, Dr. Rubenstein said.

"The last thing we need in a guy on 40 mg of methadone for back pain is to get osteoporosis of the spine," she said.

Patients in the study included 25 on hydrocodone, 8 on continuous-release oxycodone, 10 on immediate-release oxycodone, 12 on continuous-release morphine, 4 on the fentanyl patch, 14 on methadone, and 8 on off-label sublingual buprenorphine. (Only the patch form of buprenorphine is approved to treat pain.)

The study was limited by its small size, "but in the opioid literature, 81 is a nice number," she said. The study also is limited by its retrospective design, potential bias if the symptoms of hypogonadism played a role in the initial referral, and questionable generalizability if the men at this tertiary-care pain clinic are not representative of men with chronic pain in the general population.

The investigators next will repeat the study on a much larger sample of patients, and if the association is replicated, will design a prospective study to see if changing opioid therapy modifies the risk for hypogonadism. The findings of the current study are too preliminary to generate recommendations, she said.

The current study excluded patients with a history of cancer, HIV, or endocrine disease other than hypothyroidism.

Dr. Rubenstein and her associates reported having no financial disclosures.

PALM SPRINGS, CALIF. – Low testosterone levels were nearly five times more likely in men on long-acting or sustained-release opioids, compared with equipotent short-acting or immediate-release formulations, judging from the findings of a study of 81 men on daily opioids for chronic pain.

Neither the age of the patient nor the total daily dose of opioid significantly affected the risk of hypogonadism, Dr. Andrea Rubenstein reported in her award-winning poster and a plenary presentation at the annual meeting of the American Academy of Pain Medicine.

With her associates, Dr. Rubenstein reviewed records on the morning measurements of total testosterone levels in men who were on a stable dose of an opioid for at least 3 months and who had no history of hypogonadism. In all, 46 of the 81 men had total testosterone levels below 25 ng/dl (57%), consistent with published reports of a high rate of hypogonadism in men on chronic opioid therapy ranging from 54% to 86%.

Previous studies, however, evaluated only men on sustained-release or intrathecal formulations and could not identify what aspect of opioid use may be contributing to hypogonadism.

The current study found that 34 of 46 men on long-acting or sustained-release opioids had low total testosterone levels (74%), compared with 12 of 35 men on short-acting or immediate-release opioids (34%), a significant difference, said Dr. Rubenstein, an anesthesiologist and pain specialist at Kaiser Permanente Medical Group, Santa Rosa, Calif.

After adjusting for the effects of dosage and body mass index (BMI), men on long-acting or sustained-release opioids were 4.8 times more likely to have low testosterone levels, compared with men on short-acting or immediate-release formulations.

Higher BMI had a small but significant association, increasing the risk for hypogonadism by 13%.

Opioid-related androgen deficiency has been documented in one fashion or another since the 1970s, and appears to come on quickly, within days or weeks of starting chronic opioid therapy, she said.

"This phenomenon is not new, even though it’s kind of a hot topic this year," Dr. Rubenstein said.

For the past 20 years, the trend has been to put more and more patients on long-acting opioids because these were believed to be safer than short-acting formulations. If the association between hypogonadism and long-acting opioids holds up in further studies, "it will be the first evidence of a difference in safety, though not in the direction we had thought," she said.

Dr. Steven Linder of the Veterans Affairs Healthcare System Hospital, Palo Alto, Calif., commented on the study in an interview at the poster presentation. The V.A. is seeing a large number of young veterans with spinal and other injuries who are on long-term opioids, and often these patients are not screened for hypogonadism. Dr. Rubenstein’s study is an important reminder to check testosterone levels in men on long-acting or sustained-release opioids, he said.

If unrecognized and untreated, hypogonadism can lead to osteoporosis, low libido, lower function and mood, insulin resistance, increased pain, and obesity. Often, these are managed with other medications that contribute side effects, Dr. Rubenstein said.

"The last thing we need in a guy on 40 mg of methadone for back pain is to get osteoporosis of the spine," she said.

Patients in the study included 25 on hydrocodone, 8 on continuous-release oxycodone, 10 on immediate-release oxycodone, 12 on continuous-release morphine, 4 on the fentanyl patch, 14 on methadone, and 8 on off-label sublingual buprenorphine. (Only the patch form of buprenorphine is approved to treat pain.)

The study was limited by its small size, "but in the opioid literature, 81 is a nice number," she said. The study also is limited by its retrospective design, potential bias if the symptoms of hypogonadism played a role in the initial referral, and questionable generalizability if the men at this tertiary-care pain clinic are not representative of men with chronic pain in the general population.

The investigators next will repeat the study on a much larger sample of patients, and if the association is replicated, will design a prospective study to see if changing opioid therapy modifies the risk for hypogonadism. The findings of the current study are too preliminary to generate recommendations, she said.

The current study excluded patients with a history of cancer, HIV, or endocrine disease other than hypothyroidism.

Dr. Rubenstein and her associates reported having no financial disclosures.