1. Pain : Updates and Mandates
Steven M. Lobel, MD
Medical Associates of North Georgia, Northside Hospital

2. Why ME?
Regional Representative, AAPM&R Resident Physicians Council
President, Residency Association of EVMS
Chief Resident, EVMS Department of PM&R
Chairperson, Resident Fellow Section, Medical Society of Virginia
Consultant to the Composite State Board of Medical Examiners for the subject of Pain Medicine
Consultant to the DEA, FBI, GBI, OIG
Consultant to the Cherokee Multi-Agency Narcotics Squad for the subject of Pain Medicine
Consultant to MCMC, a private peer review company. Reviews performed for disability, treatment authorization, and quality/appropriateness of care
Dartmouth Football, SGUSOM, UVA, EVMS, Emory

3. What is pain?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
ACUTE VS CHRONIC, whatever the patient says it is.

4. Medication Multiple classes Medico-legal risks Drug-Drug interactions
Path of least resistance.

5. Specific Drugs Main Classes: NSAID’s- mechanical pain
Motrin, Aleve, Celebrex, Mobic, Lodine, etc
Skeletal Muscle Relaxants- opiate sparing
Flexeril, Zanaflex, Baclofen, Robaxin, Parafon, Skelaxin
AED’s- neuropathic
Lyrica, Neurontin, Keppra, Lamictal, Tegretol, Trileptal
Antidepressants- neuropathic and nociceptive
Cymbalta, Savella, Elavil, Pamelor, Effexor
Opiates- narcotics- nociceptive more than neuropathic

6. NSAID’s
Several classes, variable safety profiles. ASA vs Voltaren. Indocin vs Celebrex.

7. NSAID Safety Not recommended over age 60 (for daily use)
Increased risk of MI, CVA
ACC June 2010
Eur Heart J. April 2010
When they compared this to preceding months without heart problems, they found that filling a prescription for any NSAID raised the risk of cardiac arrest by 31%.
Increased risk of GI bleed deaths per year
Increased risk of elevated LFTs and renal failure
All cause mortality from NSAIDs is likely deaths per year. Remember that.

8. Muscle Relaxants Zanaflex 2, 4mg Dose: 2-8mg tid prn Sedation
Baclofen 10mg bid upto 20mg qid. Augments Tegretol
Skelaxin
Flexeril 5,10mg Dose: 5-10mg tid prn Sedation
Robaxin
Parafon
Norflex
Soma Barbituate like substance, never Rx it.
BZD’s High abuse potential, never Rx it. It would appear to reviewer that you are medicating a patient to shut them up, not help them.

9. Opiates Legalized heroin? Risks and benefits
Abuse, addiction, diversion
Tolerance occurs quickly (2 weeks)
Side effects
WHO Stepladder approach outdated
Pain is the 5th vital sign (APS 1996, JCAHO 2000)
Let the party begin.

10. Opiates Morphine Hydrocodone Oxycodone
Hydromorphone, Oxymorphone (Opana off market)
Fentanyl, Butrans
Methadone, Demerol, Suboxone, Stadol
Ultram***, Nucynta
When they say Ultram does not work, double the dose and reassure.

11. 200,000 out of 12 million in 1880. Morphine 200th birthday.

13. Cough and MSO4 addiction.

14. 34000 OD 2015, from Rx drugs. Roughly 1600 were actually prescribed to the patient who died. Or 10% of the NSAID deaths.

15. Who is at fault?
ITS ALL YOUR FAULT!!!

16. E.R. or O.R.
It is not really your fault, but….

17. Administrative, malpractice, civil, criminal, state, federal.

19. New laws to the rescue Georgia (GA PDMP) Prescriber Requirement:
Effective January 1, 2018:
Prescriber Requirement:
Each GA prescriber with a DEA shall register to use the PDMP no later than January 1, 2018 and is encouraged to register as soon as possible after July 1, 2017
Beginning January 1, 2018, every new DEA prescriber registrants must register with the PDMP within 30 days of obtaining a DEA permit

20. New laws Effective July 1, 2018:
On or after July 1, 2018, any person initially prescribing a schedule II opioid or any benzodiazepine shall seek and review a patient’s PDMP information, then at least once every 90 days thereafter, unless the:
Rx is for 3 day supply and no more than 26 ‘pills’
Patient is an inpatient in a hospital, LTCF, hospice, personal care home.
Patient had out-patient surgery, and the Rx is for up to10 day supply or 40 ‘pills’
Patient is terminally ill and in an outpatient hospice
Patient is being treated for cancer
PDMP printed in chart for every Rx except #40 post-op, #26 at one follow up visit. Otherwise you are in violation.

21. New laws
Prescribers who violate the requirement to check the PDMP will be held administratively liable to their licensing board     
Prescribers making sure inquires shall notate same in the patient’s medical record
A prescriber issuing opioid prescriptions shall provide information to patients on the risks of using opioid and information on proper disposal of opioid
Informed Consent and Agreement for Treatment

22. Fox News Clip

23. But what if? Turf them after 2nd script.
Finding a good pain doctor is hard.
Most make money off procedures
Many are poorly trained.
Some are pill mills.
Many use NP or PA to see the folks for pills and order the procedures for the doc to do. This is bad for everyone.
Communication is key. Repeat: “That is not how I treat pain.”
Set expectations at 2nd visit or earlier.

24. Chronic pain-(not you)
UDS, SOAPP-R, Pharmacy call, Database checks, Outside records, ICAT. Serial exams with functional goals documented as well as 4 A’s and 4 C’s.
Aberrant behaviors, analgesia, activity levels, adverse effects
Continued use despite harm, cravings, compulsive use, and loss of control
Defer to PCP or Pain Physician if already on meds.
Communication and documentation are essential.

25. Clinical psychology You have TMD, it can hurt
How you deal with the hurt makes you who you are.
When you cannot cope, there is additional help
It’s homework for your psyche.
Reversing the downward spiral.

26. Procedures for pain Neurolytic
Stellate block-Diagnostic/Therapeutic/Neurolytic
Sphenopalatine block
Neurolytic
Gasserian block-Diagnostic/Therapeutic//Neurolytic
Neuromodulation

27. Stellate
OBJECTIVE: The goal of the present study is to verify the efficacy of stellate ganglion block (SGB) in the treatment of facial pain that can be found in different pathological syndromes, and also to examine whether the efficacy is dependent upon when this therapy is administered.
PATIENTS: Fifty patients (divided into two randomized groups) with facial pain caused by traumas, iatrogenic issues, herpes zoster, or neurological pathologies participated in this study.
DESIGN AND INTERVENTIONS: The first group (N = 25) was treated with SGB produced by 10 administrations of 10 mg of levobupivacaine given every other day, followed by one administration per month for 6 months thereafter. The second group was treated with meds.
RESULTS: Before treatment, the mean visual analog scale (VAS) pain score for the first group was 8.89; after the 10th block treatment it was just 0.2, and it remained at that reduced level for the 6th and 12th months. Before treatment, the mean VAS pain score for the second group was 8.83; after the 20th day on medication it was reduced to 4.1, after 6 months it was 5.7 and after 12 months it was 4.9.
CONCLUSIONS: It does not work unless you do too many to be worthwhile.

28. SPG
The sphenopalatine ganglion and its involvement in the pathogenesis of pain has been the subject of debate for the last 90 years.
Current indications for blockade of the sphenopalatine ganglion include sphenopalatine and trigeminal neuralgia, migraine and cluster headaches, and atypical facial pain.
The techniques for blockade range from superficial to highly invasive. Efficacy studies, though few and small, show promise in patients who have failed pharmacologic or surgical therapies.

29. SPG

30. SPG

31. SPG

32. SPG

33. A New Look at Sphenopalatine Ganglion Blocks for Chronic Migraine
This simple, inexpensive procedure may provide a relatively low-risk option for the treatment of chronic migraines. By Soma Sahai-Srivastava, MD and Kellie Spector, BS. Practical Pain Management. 2016

34. gasserian
Done as diagnostic block with minimal dose of local anesthetic while using conscious sedation.
Therapeutic procedure could ensue using pulsed or thermal radiofrequency.
Other options include glycerol, phenol, or alcohol.

35. gasserian

36. Gasserian

37. gasserian
Radiofrequency gasserian rhizotomy should be considered with caution in patients with atypical facial pain.
In this subset of patients, long-term prognosis has not been optimistic, and significant psychosocial comorbidity may be present.
This is why you do not refer for the procedure, you refer for evaluation for the procedure.

38. Neuromodulation
High Lateral Cervical Spinal Cord Stimulation (SCS) for Neuropathic Facial Pain: Report of 10 Cases
Leads placed at C1-2 were able to reduce pain in 100% of V3, 88% of V2, and 0% of V1.
5/8 patients studied had 81% relief on average.

39. Neuromodulation

40. Neuromodulation
Peripheral nerve stimulation and/or field stimulation is a useful technique in alleviating facial pain and refractory headache syndromes
Wires placed in the subcutaneous tissues or directly over peripheral nerves modify the afferent signal with a pleasant paresthesia
Readily performed, reversible, and non-destructive.