Barely a week goes by without at least one, often multiple, mainstream news articles about the practice of pain management. Just the other day, there were a number of stories about a huge federal multi-state crackdown on “rogue prescribing” of opiate pain medications by 76 doctors which led to them being arrested for fraud and a long list of other charges. We also read of a dramatic increase in raids on nationally prominent specialists in opiate dependence who prescribe buprenorphine.
The monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) are a valuable addition to our preventives. However, there are significant conceivable long-term adverse effects associated with them. We will have a better feel for the true risks in 10 years. For each patient, we have to decide whether the benefits outweigh the possible risks. With luck, it may come to pass that the biologics targeting CGRP carry very few long-term risks.
Patients with moderate-to-severe personality disorders (PD) Are frequently seen in medical practices. It is increasingly important to recognize, limit and manage those with aggressive types of PD. Likewise, it is crucial to recognize those who fit the bipolar spectrum. In particular, the mild end of the spectrum is often missed. The clinical stakes for missing bipolar are enormous. This article delves into recognizing and managing patients whose pain treatment is complicated by psychological concerns.
In the two years that have passed since the CDC Opioid Guideline was released, many pain management thought leaders have conceptualized this guideline as a pendulum that was to swing patient care from an extreme of opioid permissiveness to a more thoughtful middle-ground of opioid allowance within limitations. That middle ground was supposed to permit opioid prescribing in chronic pain for well-selected and well vetted patients whose dosing is within reasonable limits. Are the guidelines working?
Medication overuse headache (MOH) is very frequently diagnosed; however, the MOH diagnosis is often overused. Patients are labeled as having MOH when what they actually suffer from are refractory headaches, without medication overuse (MO). Current diagnostic criteria for MOH only require abortive medication use on 10 or 15 days of each month (depending upon the medication). No evidence is needed showing that the abortive actually causes an increase in headache.
Migraine is a very common and disabling illness. Picking an agent that is best for each individual patient requires considering the patient’s history, lifestyle, comorbid conditions, and individual preferences. A recurring headache that is of moderate or severe intensity, and is triggered by migraine-precipitating factors, usually is considered to be migraine. Precipitating factors can include stress, certain foods, weather changes, smoke, hunger, fatigue, hormones, and so on.
One of the biggest challenges with using a solitary approach such as pharmacotherapy, including opioid therapy, for the patients with pain, is that chronic pain is best treated through a multimodal approach. Pain affects the whole person. Patients and practitioners need to learn techniques to adapt to and manage the pain, not just take it away temporarily. There is a push to teach active self management strategies, such as sleep restoration, pacing, conquering worry and anxiety, and how to minimize depression in the face of pain.
We had a spectacular meeting in September at the Crowne Plaza Hotel in New Orleans. We collaborated with the Southern Headache Society and included breakout sessions for both chronic pain and headache providers. The opening session on Friday afternoon included talks and panel discussions around the relationship between payors and providers, patient disability issues and managing chronic pain in the cognitively impaired patient.
One of the ways I like to unwind is to watch HBO on my cellphone or tablet. Whether it’s Real Time, Last Week Tonight, Westworld, or Game of Thrones, I am captivated by HBO’s shows! One show, VICE – and its online companion, VICE News – has recently featured several stories that have to do with opioids and pain management. The stories do a great job of capturing the multi-faceted aspects of this issue. They also show how strict and unyielding policy solutions to current controversies in opioid-based pain management can make misery out of the lives of countless people.
The Opioid Epidemic has forced providers and insurers to re-evaluate the way chronic pain is treated both short and long term. As a result, there has been a renewed interest in non-medical based treatments that restore pain patients, particularly injured workers, to health and optimal function. Chronic pain is a common presentation in work injury. Functional restoration is a non-medication based option that can restore patients with pain to higher function and return to work. True functional restoration includes Cognitive Based Therapy (CBT) and intensive physical therapy.