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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Neuropathic Pain: Incorporating New Consensus Guidelines into the Reality of Clinical Practice


GOAL
To provide healthcare professionals with information on the most recent developments regarding the treatment of neuropathic pain.

TARGET AUDIENCE
This activity is designed for primary care physicians, anesthesiologists, neurologists, physical medicine and rehabilitation professionals, nurse practitioners, physician assistants, clinical and consultant pharmacists, chain pharmacists, independent pharmacists, nurses in pain treatment facilities, hospital pharmacy directors, HMO and PPO P&T committee members, and hospital formulary committee chairpersons. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the University of Tennessee College of Pharmacy take responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, participants should be able to:

  • Describe the new neuropathic pain guidelines.
  • Discuss the current knowledge of etiologies of neuropathic pain.
  • Recognize the different presentations of neuropathic pain.
  • Diagnose neuropathic pain.
  • Implement the appropriate first-line treatment for neuropathic pain, based on the guidelines and the different pharmacokinetic and side-effect profiles of each medication, as well as their mechanisms of action.
  • Use topical analgesics in appropriate patients.
  • Determine strategies for implementing the guidelines in their own practice.
  • Understand when nonpharmacologic treatments are indicated.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Institute for Johns Hopkins Nursing is accredited by the American Nurses' Credentialing Center's Commission on Accreditation to provide continuing education for nurses. The University of Tennessee College of Pharmacy is approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award.

The Institute for Johns Hopkins Nursing designates this educational activity for a maximum of 2 contact hours.

This program is approved for 2 hours (0.2 CEUs) and is cosponsored by the University of Tennessee College of Pharmacy, which is approved by the American Council on Pharmacy Education as a provider of continuing pharmaceutical education. A statement of CE credit will be mailed within 4 weeks of successful completion and evaluation of the program. ACPE program #064-999-04-234-H01.

Each participant should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: July 15, 2004. Expiration date: July 15, 2006.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of the Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the University of Tennessee College of Pharmacy names implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Endo Pharmaceuticals.

Full Disclosure Policy Affecting CME Activities:
As sponsors accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses' Credentialing Center (ANCC), and the American Council on Pharmacy Education (ACPE), it is the policy of Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the University of Tennessee College of Pharmacy to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Peter S. Staats, MD
Pain Physician
Metzger Pain Management
Shrewsbury, New Jersey
Adjunct Associate Professor
Department of Anesthesiology and Critical Care Medicine
Department of Oncology
Johns Hopkins University School of Medicine
Baltimore, Maryland
• Dr Staats reports receiving grants/research support from Elan Corporation, Medtronic, Inc, and Pfizer Inc and serving as a consultant to Advanced Neuromodulation Systems, Inc,
Elan Corporation, Johnson & Johnson, and Pfizer Inc.

PARTICIPATING FACULTY

Charles E. Argoff, MD
Director
Cohn Pain Management Center
North Shore University Hospital
Bethpage, New York
• Dr Argoff reports receiving grants/research support from Allergan Inc, Elan Corporation, Endo Pharmaceuticals, Kadmus Pharmaceuticals, Inc, and Pfizer Inc; serving as a consultant to Eli Lilly and Company, Endo Pharmaceuticals, and Kadmus Pharmaceuticals, Inc; and receiving honoraria from Allergan Inc, Elan Corporation, Endo Pharmaceuticals, and Pfizer Inc.

Randall Brewer, MD
Faculty Neuroanesthesiologist
Division of Neurosurgical Anesthesia
Duke Pain & Palliative Care Center
Duke University Medical Center
Durham, North Carolina
• Dr Brewer reports receiving grants/research support from Merck & Co, Inc; serving
as a consultant to Endo Pharmaceuticals; and receiving honoraria from Endo Pharmaceuticals and Pfizer Inc.

Yvonne D'Arcy, MS, CRNP, CNS
Pain Management Nurse Practitioner
Pain and Palliative Care Outcomes Center
Suburban Hospital
Bethesda, Maryland
• Ms D'Arcy reports serving on the speakersÕ bureau for Endo Pharmaceuticals and
Purdue Pharma LP.

Rollin M. Gallagher, MD, MPH
Pain Medicine and Rehabilitation Center
Medical College of Pennsylvania Hospital
Philadelphia, Pennsylvania
• Dr Gallagher reports receiving grants/research support from Eli Lilly and Company, Endo Pharmaceuticals, excelleRx, Inc, and Janssen Pharmaceutica; and serving as a consultant to Elan Corporation, Eli Lilly and Company, Endo Pharmaceuticals, excelleRx, Inc, Janssen Pharmaceutica,
and Pfizer Inc.

William McCarberg, MD, FABPM
Director
Chronic Pain Management Program
Kaiser Permanente
Escondido, California
• Dr McCarberg reports serving on the speakers' bureau for Endo Pharmaceutials, Janssen Pharmaceutica, Pfizer Inc, and Purdue Pharma LP.

Lori Reisner, PharmD
Associate Clinical Professor of Pharmacy
Clinical Pharmacist
School of Pharmacy
University of California
San Francisco
• Dr Reisner reports serving as a consultant to Endo Pharmaceuticals and Janssen Pharmaceutica, and receiving honoraria from Pfizer Inc.

Notice
In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that they have referenced the following unlabeled/unapproved uses of drugs or devices:

Dr Argoff—antidepressants, anticonvulsants.
Dr Reisner—gabapentin, lidocaine, and tricyclic antidepressants.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty.  Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Expanding The Current Management Of Neuropathic Pain
Peter S. Staats, MD*

Sir William Osler was quoted as saying, "He who knows syphilis knows medicine." Today's analogy might be "Whomever knows pain knows medicine."

The years 2000 to 2010 mark the Decade of Pain Control and Research, as mandated by the US Congress. This effort has several important initiatives including the National Pain Care Policy Act of 2003, increased funding for research into the causes and treatment of pain, and public awareness programs.1 We hope that this effort will do for pain what Ronald Reagan and Charlton Heston have done for Alzheimer's disease, namely increasing awareness of the disease and therefore improving understanding of the pain patients experience.

Another important initiative of the Decade of Pain Control and Research is to increase professional awareness of the prevalence, causes, and treatment of pain. We see many statistics showing that pain is the most common reason for physician office visits and that at least 1 of every 5 Americans is affected by chronic pain.2 Yet, this basic human sensory experience can be the source of shame as well as personal and professional disability with sometimes drastic psychological, social, and financial repercussions. In most cases, chronic pain never fully remits and is often under- or untreated. Thus, the continued complaints of pain can elicit anger and resentment by friends, family, and coworkers, resulting in shame by the afflicted. Pain is not a disease that can be seen or even visually measured.  Much like Alzheimer's disease, there remain many unanswered questions and outright ignorance of the pain experience, leading to the anger and resentment of those not experiencing a chronic, lifelong condition.

Neuropathic pain—ie, pain caused by disease or dysfunction of the nervous system—is perhaps one of the most frustrating disorders to treat, for both the patient and the healthcare provider, including pain specialists. The diagnosis is not always obvious, the treatment algorithms heretofore nonexistent and not widely known, and the treatments themselves are often only partially able to remit the pain.

As with so many diseases—chronic and acute—primary care providers (ie, physicians, nurses, and pharmacists) are the "first face" of medicine for the patient. With a seemingly ambiguous condition such as neuropathic pain (ie, pain with no associated or resulting tissue damage), many primary care practitioners feel unable to treat pain patients. Neuropathic pain is the perfect example of why the Decade of Pain Control and Research is so important.

In November 2003, an August panel of pain specialists published the first set of guidelines for neurologists on treating neuropathic pain.3 The guidelines provide a direct path for choosing first-line therapies for neuropathic pain based on an extensive review of the literature, in line with our current drive toward evidence-based medicine. A reprint of these guidelines is included in this issue of Advanced Studies in Medicine.

Yet, for the primary care provider, how do these guidelines fit in to their practice, for the first encounter with a patient not yet diagnosed with neuropathic pain? To answer these needs, we convened our own panel of pain specialists from neurology, anesthesiology, primary care, nursing, and pharmacy. We discussed and debated the ways in which the guidelines for neurologists could be transformed and applied to everyday primary care clinical practice, where neuropathic pain patients are most often seen. Importantly, a member of our panel, Dr Charles Argoff, was one of the coauthors of the neuropathic pain guidelines.

The result of our discussions is a comprehensive resource to provide practical information on diagnosis, treatment, and long-term management of neuropathic pain in primary care. Most neuropathic pain patients can be effectively treated and managed in a primary care setting, if the providers have the appropriate tools. Our recommendations, also published in this issue of Advanced Studies in Medicine, are meant to complement the neurology guidelines, by addressing not only evidence-based medicine but also the wealth of our panel members' clinical experience on the realities of treating and managing neuropathic pain.

Of note, we review the 5 recommended first-line therapies, but also offer our own recommendations on second-line approaches because, as is all too often the case in medicine, one algorithm does not fit all patients. We spend a longer amount of time discussing opioids than the other 4 first-line drugs, not to discourage or encourage their use. Rather, our intent is to provide an in-depth, realistic discussion and necessary information to dispel myths on opioid use, so primary care practitioners can confidently prescribe them for appropriate patients.

In the end, there remain only a few important principles for neuropathic pain management: most medications by themselves will not provide complete pain relief (polypharmacy is common), the definition of "treatment success" must be redefined by both the healthcare practitioner and the patient, and the role of the healthcare provider is to not only provide clinical expertise but also instill hope in the patient such that all clinical encounters (as discussed in our recommendations) are "psychotherapeutic."

REFERENCES
1. The American Pain Society Web site. Available at: www.ampainsoc.org. Accessed May 9, 2004.
2. Nelson R. Decade of pain control and research gets into gear in USA. Lancet. 2003;362(9390):1129.
3. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol. 2003; 60(11):1524-1534.

*Pain Physician, Metzger Pain Management, Shrewsbury, New Jersey; Adjunct Associate Professor, Department of Anesthesiology and Critical Care Medicine and Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Peter S. Staats, MD, Metzger Pain Management, 160 Avenue-at-the-Commons, Shrewsbury, NJ 07702. E-mail: pstaats@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.