1. RAISING PAIN AWARENESS Easing Your Patients’ Pain An overview of pain, treatment options, and the physicians who specialize in treating pain

2. RAISING PAIN AWARENESS ANS has partnered with the National Pain Foundation (NPF), a non-profit organization founded to advance functional recovery of pain patients, to create this educational presentation.

3. RAISING PAIN AWARENESS  3 out of 4 Americans have experienced chronic or recurring pain or have a family member who has experienced such pain. 1  Almost 62% of pain sufferers have had their pain for a year or more. 1  A majority of adults (57%) have experienced chronic or recurring pain, including 54% of adults aged 18–34. 1 Long-term pain affects most of your patients.

4. RAISING PAIN AWARENESS Topics included in this presentation  Recognition of pain as a major health issue in the United States  Pain management as a medical specialty  Advanced treatments for pain  Referrals to interventional pain physicians

5. RAISING PAIN AWARENESS Pain in the United States

6. RAISING PAIN AWARENESS Types and definitions of pain  Acute Pain  Accompanies tissue injury or pathology  Comes on quickly but lasts a short time  Varies in severity and intensity  Chronic Pain  Continues a month or more beyond usual recovery period  Goes on for months or years due to a chronic condition  Difficult to define onset

7. RAISING PAIN AWARENESS Types and definitions of pain  Nociceptive Pain  Caused by irritation to special nerve endings (nociceptors)  Can be dull or sharp  Can be mild or severe  Neuropathic Pain  Caused by a malfunction of the nervous system  Result of injury, disease, or trauma  Can be sharp, intense, and constant  Can be dull, aching, and throbbing

8. RAISING PAIN AWARENESS Millions of Americans suffer with pain…  50 million Americans are partially or totally disabled by chronic pain. 2  9 out of 10 Americans (aged 18 and older) suffer with pain at least once a month. 2  77% of pain patients strongly agree that new options are needed to treat their pain 7  50% of Americans (aged 65 and older) suffer with pain on a daily basis. 2

9. RAISING PAIN AWARENESS …and chronic pain is a costly problem.  36 million per year miss work due to pain. 2  Pain costs almost $100 billion annually. 3  Pain results in over 50 million lost workdays. 3  50% of chronic pain patients have lost a job due to their illness 7  Workers lose an average of 4.6 hours per week of productive time due to a pain condition. 4

10. RAISING PAIN AWARENESS Lower Back Pain 40% Osteoarthritis Headaches Migraines Fibromyalgia 75% 26% Chronic pain is associated with many conditions. 5 12%

11. RAISING PAIN AWARENESS Pain management as a medical specialty

12. RAISING PAIN AWARENESS Interventional pain management medicine  Growing as a new specialty  Includes evaluation and treatment of acute and/or chronic pain  Requires that pain physicians receive at least one year of training in pain management post medical degree  Requires knowledge of all of chronic pain therapy options

13. RAISING PAIN AWARENESS Pain assessment process Physicians should address  Types of pain  Distribution of pain  Patient’s current pain state  Effects of patient’s current treatment  Appropriate tools available for pain evaluation

14. RAISING PAIN AWARENESS Treatment steps to consider  Focus early treatment on quickly reversing the problem.  Identify the best methods of treatment.  Define distinct goals for the patient.  Pain reduction  Improved function  Enhanced quality of life

15. RAISING PAIN AWARENESS Physicians who often specialize in pain management  Anesthesiologist  Neurosurgeon  Neurologist  Orthopedic surgeon  Physiatrist (PM&R)  Rheumatologist Other pain practitioners  Acupuncturist  Chiropractor  Physical therapist  Psychiatrist, psychologist, or professional counselor

16. RAISING PAIN AWARENESS Challenges facing pain physicians  Managing the patient’s pain when a cure does not exist  Identifying ways to manage pain by using a chronic pain treatment continuum

17. RAISING PAIN AWARENESS

18.  Medications  Physical therapy  Counseling Treatments early in the continuum This presentation will focus on the more advanced treatments used by pain physicians.

19. RAISING PAIN AWARENESS Advanced treatments for pain

20. RAISING PAIN AWARENESS Advanced treatments: Injections Nerve blocks—An injection of local anesthetic and/or steroids that is applied directly to the nerve that serves an area of pain

21. RAISING PAIN AWARENESS Advanced treatments: Injections Epidural steroid injections—An injection of steroids into the epidural space to alleviate chronic pain in the low back or leg

22. RAISING PAIN AWARENESS Advanced treatments: Injections Facet joint injections—An injection procedure used to block or decrease pain that originates in the spinal facet joints

23. RAISING PAIN AWARENESS Advanced treatments: Medical devices Neurostimulators— Implantable devices that use low-level electrical impulses to interfere with the transmission of pain signals to the brain

24. RAISING PAIN AWARENESS An overview of neuromodulation  A system typically consist of three components designed to work together  Leads—very thin cables that deliver electrical impulses to nerves near the spinal cord  Generator—the part of the system that sends electrical energy through the lead  Controller—the device that determines the level of stimulation

25. RAISING PAIN AWARENESS SCS patient selection process  Correctly diagnosed  Failed lower-level therapies  Successfully passed psychological evaluation  Patient is motivated  Patient is educated

26. RAISING PAIN AWARENESS SCS trial overview  Leads are implanted in the epidural space  An external power source is used to evaluate  Pain relief  Paresthesia coverage  Power requirements  Programming needs  System requirements  Patients can use the programmer to control stimulation to cover their pain areas

27. RAISING PAIN AWARENESS Why use spinal cord stimulation (SCS)?  Effective pain management method  Minimally invasive procedure that can be reversed  Possible reduction or elimination of pain medications  International recognition and use

28. RAISING PAIN AWARENESS Advanced treatments: Medications Systemic opioids—Narcotics are used for patients with severe chronic pain who have not responded to more conservative therapies and for whom surgery has failed or is not an option.

29. RAISING PAIN AWARENESS  Cryoanalgesia—Applying extreme cold to nerves to disrupt their ability to transmit pain  RF lesioning—Applying radio-frequency generated heat to nerves to disrupt pain transmission  IntraDiscal Electrothermal Therapy (IDET)— Applying heat to seal cracks and fissures in a dehydrated disc Advanced treatments: Ablative procedures

30. RAISING PAIN AWARENESS Advanced treatments: Medical devices Implantable drug pumps—Devices that deliver medications directly to the cerebrospinal fluid in the intrathecal space surrounding the spinal cord

31. RAISING PAIN AWARENESS Advanced treatments: Surgery Neuroablation— Surgery that permanently blocks chronic pain by destroying nerves and tissues near the source of pain

32. RAISING PAIN AWARENESS Referring patients to pain physicians

33. RAISING PAIN AWARENESS Pain patients often need specialized care.  Pain accounts for 80% of all physician visits. 2  Only 48% of pain patients felt they were getting enough information on the most effective ways to manage chronic pain. 7  86% of chronic pain sufferers report an inability to sleep well. 7  60% of pain patients experience breakthrough pain one or more times daily. 7

34. RAISING PAIN AWARENESS Pain patients often need specialized care.  14% of pain sufferers say that they are satisfied with their current medications. 7  22% of chronic pain patients have changed physicians 3 or more times. 6  The main reasons for changing physicians have to do with the physicians’ attitudes, knowledge, and abilities. 6

35. RAISING PAIN AWARENESS Pain physicians can help patients with  Chronic back, neck, and shoulder pain  Chronic headaches and migraines  Chronic trunk and limb pain  Repetitive motion pain  Arthritis  Fibromyalgia  Complex regional pain  Cancer pain

36. RAISING PAIN AWARENESS Other criteria for referring patients to pain specialists  Multiple symptoms or sources of pain  Unresponsive to conservative therapies  Deteriorated functional status  Uncomfortable prescribing or monitoring opioid treatment

37. RAISING PAIN AWARENESS Choosing a pain physician for referrals Verify that the physician is certified by, or a member of, a pain-related professional organization:  American Academy of Pain Medicine (AAPM)  American Board of Pain Medicine (ABPM) Subspecialty certifications  American Board of Anesthesiology (ABA)  American Board of Physical Medicine & Rehabilitation (ABPMR)  American Board of Psychiatry & Neurology (ABPN)

38. RAISING PAIN AWARENESS Benefits of referring patients to pain physicians  Better outcomes for patients  Enhances effectiveness of primary care treatment plans  Improves patient/physician relationships

39. RAISING PAIN AWARENESS Conclusions  The wide range of treatments available today allows a patient to receive effective pain relief quickly.  Cooperation between primary care physicians and pain management specialists ensures that patients receive appropriate treatments for their pain.  An increased understanding of pain helps physicians improve the quality of life for chronic pain patients.  Physicians have the power to change the course of their patients’ lives.

40. RAISING PAIN AWARENESS For additional educational and support information, please visit www.ans-medical.com or www.NationalPainFoundation.org

41. RAISING PAIN AWARENESS References 1.Americans Talk about Pain, conducted by Peter D. Hart Research Associates for Research!America, August 2003. 2.Pain in America: A Research Report, conducted by the Gallup Organization for Merck, June 1999. 3.Voices of Chronic Pain, survey released by the American Pain Foundation for Endo Pharmaceutical, June 2006. 4.Stewart, W.F., J.A. Ricci, E. Chee, D. Morganstein, & R. Lipton. “Lost Productive Time and Cost Due to Common Pain Conditions in the U.S. Workforce.” Journal of the American Medical Association, Vol. 290, No. 18, 2003, p. 2443-2454. 5.National Pain Survey, conducted by Louis Harris and Associates for Ortho-McNeil, 1999.

42. RAISING PAIN AWARENESS References 6.Chronic Pain in America: Roadblocks to Relief, conducted by Roper Starch Worldwide Inc. for the American Pain Society, the American Academy of Pain Medicine, and Janssen Pharmaceutica, January 1999. 7.Voices of Chronic Pain, conducted by American Pain Foundation, May 2006. “JCAHO Focuses on Pain Management,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/news+room/health+care+issues/jcaho+ focuses+on+pain+management.htm. http://www.jcaho.org/news+room/health+care+issues/jcaho+ focuses+on+pain+management.htm Stamatos, J., Painbuster: A Breakthrough 4-Step Program for Ending Chronic Pain, First Edition, New York, NY: Henry Holt & Company, LLC, 2001.