MPS 2016 Poster Abstracts

1: PCA Medication Record Update: Follow-up Evaluation

Authors: Monika K. Lach, PharmD, David M. Dickerson, MD, Pauline Lee, PharmD, Monica Malec, MD, Randall W. Knoebel, PharmD, BCOP

Institution: University of Chicago Medicine

Introduction:

Patient controlled analgesia (PCA) is a delivery system in which patients can self-administer predetermined doses of analgesic medications to relieve pain. When initiating a PCA, numerous variables need to be considered including patient characteristics and drug administration settings. In March 2016, PCA medication orders required assessment of opioid tolerance or naivety which triggered dosing recommendations through cascading logic.

Methods:

Via a single center, retrospective chart review the influence of standardized PCA orders on opioid dosing was evaluated for April 2015 and April 2016. Data collection included: PCA mode, loading dosing, demand dosing, and PCA dose frequency. Naloxone administration in this population was also assessed.

Results:

A total of 840 PCA orders were analyzed. 485 were in the pre-implementation group and 355 were post-implementation. Adult patients made up 90% of PCA orders. PCA orders with continuous infusion modes increased by 7.2% post-implementation (22.7% vs. 29.9%). Median loading doses were lower post-implementation in adult patients (7 mg vs. 3.5 mg). There was no difference in demand dose prescribed. Post-implementation, all pediatric lockout frequencies were greater than or equal to 10 minutes. In adult patients, frequencies of less than 10 minutes were reduced by 23% post-implementation (43% vs. 20%, p <0.001). Frequencies of less than 8 minutes were reduced by 7% in adult’s post-implementation (13% vs. 6%, p <0.002). There was also a 50% reduction in naloxone administrations for patients receiving a PCA (18 vs. 9, respectively).

Conclusions/Discussion:

These results suggest that PCA medication order standardization resulted in lower loading doses and reduction in lockout frequencies of less than 10 minutes, leading to a potential improvement in patient safety as indicated by a lower utilization of naloxone.

2: Factors of Spousal Support Related to Elevations in Chronic Pain

Authors:

Tracy Aneziris, M.A. Illinois School of Professional Psychology at Argosy University, Schaumburg

Samantha Harfenist, M.A. Illinois School of Professional Psychology at Argosy University, Chicago

Institution: Northshore Integrative Health Care, Illinois School of Professional Psychology at Argosy University, Schaumburg

Objective: Couples coping with chronic pain experience stressful changes in their relationship. While significant others support is known to be correlated with better outcomes for partners with chronic pain, specific factors positively and negatively related to recovery and comfort need further exploration. Methods: The Multidimensional Pain Inventory is a self-report measure examining the impact of pain on one’s life, ability to perform activities, and responses by significant others. On the significant other’s section, many items are related to partners or spouses avoiding, being frustrated with, or assisting their partner in order to create a total significant other support score. The poster will present data from 177 patients who completed the MPI as part of a pre-surgical evaluation and examine the relationship between significant other’s responses to patients’ pain and patient depression, anxiety, and pain measures. Results: The results indicated that there was multiple statistically significant relationships between variables. The primary relationship found was patients who rated their significant others as highly frustrated, also rated their significant others as being highly avoidant (r = .580, p< 0.01). Several other similar relationships were found and will be presented in the poster. Conclusions: This information may provide more clear direction for clinicians to understand what areas of strengths and weaknesses need to be focused on when working with couples coping with chronic pain. It is especially important to focus on reducing spousal frustration related to chronic pain, as it is significantly related to patient depression, level of assistance provided, and avoidance of patient from his/her spouse.

References:

Bruns, D., Kerns R. (2013). Managing Chronic Pain: How Psychologist can Help with Pain Management. Retrieved September 30, 2016, from http://www.apa.org/helpcenter/pain-management.aspx

Catalano, E. M. (1989). The Chronic Pain Control Workbook. The Clinical Journal of Pain, 5(4), 363-364.

Chronic Pain Information Page: National Institute of Neurological Disorders and Stroke (NINDS). (n.d.). Retrieved September 30, 2016, from http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm

Newton-John, T. R., & de C Williams, A. C. (2006). Chronic pain couples: Perceived marital interactions and pain behaviours. Pain, 123(1), 53-63.

Surah, A., Baranidharan, G., & Morley, S. (2013). Chronic pain and depression. Continuing Education in Anaesthesia, Critical Care & Pain, mkt046

3: Evaluation of Inpatient Pain Management for Vasoocclusive Crisis in Patients with Sickle Cell Disease

Authors: Angela Kerins PharmD, Hailey Soni PharmD, Samantha Bastow PharmD, David Gajdosik PharmD, Sumeet Deogan PharmD, Monica Malec MD, David Dickerson MD, Randall Knoebel PharmD

Institution: University of Chicago Medicine (UCM)

Introduction: Pain is the hallmark clinical manifestation of sickle cell disease vasoocclusive crisis (SCD VOC), with acute pain episodes being the most common reason for both pediatric and adult patients to seek medical attention. Furthermore, recent guidelines promote multimodal analgesia (MMA) to reduce opioid prescribing. The purpose of this study was to evaluate the current pain management strategies for the treatment of SCD VOC pain crisis at UCM.

Methods: This single center, retrospective study evaluated adult and pediatric patients admitted to UCM with a SCD VOC over a two-year period, from September 1, 2014- August 31, 2016. Data collection included the number of doses of opioids, gabapentinoids, NSAIDs, acetaminophen, topical lidocaine, intrathecal/epidural bupivacaine, and antidepressants (SSRIs, SNRIs and TCAs) administered. The primary objective of the study was to determine the percentage of patients treated with opioids alone compared to multimodal analgesia.

Results: A total of 283 patients with 1,009 hospital encounters were identified for the study. Opioid only management was identified in 17% of encounters. Non-opioid analgesics were administered including: gabapentinoids 14%, acetaminophen 54%, NSAIDs 55%, antidepressants 12%, local anesthetic 0.5%, lidocaine 15%, and ketamine 0.5%. There were 5% of patients who received opioids in combination with an NSAID, acetaminophen and a gabapentinoid medication.

Conclusion/Discussion: 83% of SCD VOC patients received an opioid plus non-opioid agent, while 17% received opioid monotherapy. However, there are still many patients that rely on opioids alone and there is room for improvement in expanding and standardizing the utilization of non-opioid medication options. The next step of this project will be to outline a SCD VOC pain crisis treatment pathway and re-analyze the above endpoints to compare the data before and after the pathway was implemented.

References:

1. Marret E, et al. Anesthesiology 2005;102:1249-1260

2. Ella N. Anesthesiology 2005;103:1295-1304

3. Okpala, E, et al. J R Soc Med 2002;95:456-458

4. Ballas, SK. Hematol Oncol Clin N Am 2005;19:785-802

4: Optimizing institutional care of inpatient drug delivery devices

Authors: Angela Kerins, PharmD, BCPS, Randall Knoebel PharmD, BCOP, David M. Dickerson, MD

Institution: University of Chicago Medicine (UCM)

Introduction: Intrathecal drug delivery (IDD) is an important component of the armamentarium to treat patients with refractory intractable pain or spasticity. Continuous intrathecal delivery of opioid medications allows for higher central nervous system concentrations, improved pain scores, and less frequent side effects when compared with systemic opioid administration. Guidelines and literature exist to assist with appropriate patient and drug selection for IDD, however, the process for implementation of IDD is highly variable posing potential risks for patients and institutions.

Methods: An interdisciplinary team including members of the pain medicine faculty, primary medical service, pharmacy and nursing was formed. The team sought to develop a standard process for IDD trialing, implantation, refill and identification of patients admitted to the hospital with IDD.

Results: Key vulnerabilities identified within the IDD trialing and first fill after implantation included: non-standard written orders, manual calculations within pharmacy, a non-standard medication record within the electronic health record and a manual 1st and 2nd pharmacist check. Additionally, the team identified that there was no standard method to identify patients admitted to the hospital with an IDD device. Key best practices were recommended and implemented: a standard acute pain service progress note, replacement of manual calculations with an excel calculator, medication record development, provider order entry, and a chartable nursing record (flow sheet for implantable devices). Table 1 describes several vulnerabilities and best practices developed to address the specific issues.

Conclusion/Discussion: The complexity and acuity of IDD create institutional risk. Timely identification of patients receiving IDD can prevent injury related to the pump or medications within. Standardized practices for medication preparation and IDD patient care can be identified and implemented through interdisciplinary quality improvement processes.

Table 1. Vulnerabilities and proposed standardization for intrathecal drug delivery device management

Vulnerabilities Standardized PracticeMedication fill 1. Non-standard written

order2. Manual calculation3. Non-standard

medication record 4. Manual pharmacist 1st

and 2nd check

1. Standardized written order

2. Excel calculator developed

3. Medication record developed

4. Automated 1st and 2nd pharmacist check

Identification of IDD on admission

1. No standard way to identify patients

1. Developed screening question as part of admission process

2. Created placeholder medication record as means of communicating IDD in place

References:

1. Deer TR, et al. Pain Physician. 2011 May-Jun;14(3):E283-315; Lawson EF, Wallace MS. Curr Opin Anaesthesiol. 2012 Oct;25(5):572-6.

3. Knight KT, et al. Croat Med J . 2007 Feb;48(1):22-34. 4. Kosturakis BA, Gebhardt. Pain Physician. 2012 Nov-Dec;15(6):475-7.

5: Sedentary Behavior is Associated with Physical Impairment and Fatigue in Adolescents with Juvenile Fibromyalgia

Authors: Megan Pfeiffer, BS; Gregory D. Myer, PhD; Tracy V. Ting, MD, MSc; Sara E. Williams, PhD; Staci Thomas, MS; Katie Kitchen, BA; and Susmita Kashikar-Zuck, PhD

Institution: Cincinnati Children’s Hospital Medical Center

Introduction: Juvenile fibromyalgia (JFM) is a debilitating pain condition associated with high levels of physical impairment2, 3. Reduced participation in physical activity has been associated with a host of negative outcomes in various chronic pain conditions4 but has not been examined in teens with JFM specifically. The objective of the current study was to use accelerometry to evaluate relationships between physical activity and self-reported pain, fatigue, functioning, and depressive symptoms in adolescents with JFM.

Methods: Forty adolescents (Mage = 15.26, SD = 1.56) with JFM completed the Functional Disability Inventory, PROMIS Fatigue, Children’s Depression Inventory, average pain rating in the past week (0-10cm VAS). They also wore a waist-mounted accelerometer for seven days. Amount of time spent in sedentary activity and moderate-vigorous activity (MVPA) was examined1. Those who were in the high versus low levels of sedentary and MVPA (based on median splits) were compared on pain, fatigue, function and depressive symptoms.

Results: Overall, participants spend the majority of their day at a sedentary level (median = 13.17 hours per day) and engaged in about 1.5 hours of MVPA (median = 91.17 minutes). Those in the high sedentary group were significantly more impaired than those in the low sedentary category in terms of function (p = .035) and fatigue (p = .046). These differences were not seen when using median splits of MVPA.

Conclusions/Discussion: Adolescents with JFM who are more sedentary report greater impairment in daily function and high levels of fatigue. Intervention efforts directed at improving activity levels in adolescents with JFM are needed. Although MVPA appeared to meet guidelines of at least 30 minutes per day, it should be noted that most of this time was in moderate activity and not necessarily sustained activity. This study adds to the literature on the importance of physical activity participation in adolescents with chronic musculoskeletal pain.

1. ActiGraph. ActiLife 6.11.9, 2009-2015

2. Kashikar-Zuck S, Flowers SR, Verkamp E, Ting TV, Lynch-Jordan AM, Graham TB, Passo M, Schikler KN, Hashkes PJ, Spalding S. Actigraphy-based physical activity monitoring in adolescents with juvenile primary fibromyalgia syndrome. The Journal of Pain. 11:885-893, 2010

3. Kashikar-Zuck S, Lynch AM, Slater S, Graham TB, Swain NF, Noll RB. Family factors, emotional functioning, and functional impairment in juvenile fibromyalgia syndrome. Arthritis and Rheumatism. 59:1392-1398, 2008

4. Wilson AC, Palermo TM. Physical activity and function in adolescents with chronic pain: a controlled study using actigraphy. The Journal of Pain. 13:121-130, 2012

6: Pain Perception and Quality of Life Following a Structured, Interdisciplinary Smoking Cessation Intervention for Chronic Pain Patients

Authors: Linda Strozdas, PsyD, Candice Ryan, PsyD, Sarah Parnow, MA, Maria Torres, MD, Frank Yurasek, PhD, LAc, Azzam Alkhudari, MD, Taruna Penmetcha, MD, Abed Rahman, MD, Gunar Subieta, MD, & Peter Ji, PhD

Institution: Stroger Hospital of Cook County

Introduction: Research shows that a complex interaction exists between psychological factors, pain, and smoking behavior. Smoking cessation interventions like nicotine replacement therapy (the patch, gum, medications) as well as peer group support are known to help smokers achieve smoking cessation. This study sought to explore whether a protocol combining three structured interventions: 1) a psychoeducational/peer support group 2) acupuncture and 3) prescribed medication management using nicotine replacement therapy (NRT) for smoking cessation, alter pain perception and the psychological factors of depression, self-efficacy and pain catastrophizing.

Methods: Nicotine-dependent chronic pain patients (N = 31) receiving outpatient treatment at Stroger Hospital Pain Clinic participated and completed a tri-part interdisciplinary intervention designed for chronic pain patients who smoke. Using a pre-test, post-test design, participants completed measures assessing pain perception, depression, self-efficacy, and pain catastrophizing. Interventions included four weekly one-hour smoking cessation psychoeducational/support group sessions followed by auricular acupuncture. These sessions were augmented by Nicotine Replacement Therapy (NRT) prescribed by pain clinic physicians at session #2. A paired samples t-test was performed.

Results: Rumination, a component of pain catastrophizing, was significantly decreased at post-test (t = 2.15, p < .05). Pain self-efficacy significantly improved (t = 2.46, p < .05). There were no significant differences in pain perception or depression.

Conclusions/Discussion: A structured Interdisciplinary intervention for smoking cessation in chronic pain patients resulted in improvements in specific psychological variables of self-efficacy and pain catastrophizing. Chronic pain patients experienced improvements in their ability to cope with their pain and perform tasks despite their pain. They also experienced a reduction in rumination about their pain.

Borsbo, B., Gerdle, B., & Peolsson, M. (2010). Impact of interaction between self-efficacy, symptoms and catastrophizing on disability, quality of life and health in with chronic pain patients. Disability and Rehabilitation, 32, 1387–1396.

Hooten, M., Townsend, C. O., Hays, T., Ebnet, K. L., Gauvin, T. R., Gehin, J. M. … Warner, D. O. (2014). A cognitive-behavioral smoking abstinence intervention for adults with chronic pain: A randomized controlled pilot trial. Addictive Behaviors, 39, 593–599.

White, A. R., Rampes, H., Liu, J. P., Stead, L. F., Campbell, J. (2011). Acupuncture and related interventions for smoking cessation. Cochrane Database of Systemic Reviews, 1, 1–18.

Wittchen, H. U., Hoch, E., Klotsche, J. & Muehlig, S. (2011). Smoking cessation in primary care – a randomized controlled trial of bupropione, nicotine replacements, CBT and a minimal intervention. International Journal of Methods in Psychiatric Research, 20, 28–39.

7: The Use of Sacred Turtle Abdominal Acupuncture For The Treatment of 46 Pain Patients

Authors: Frank Yurasek, PhD, MS, LAc; Tsegi Mololtsog, MD, MSAc (Mongolia)

Institution: Stroger Hospital of Cook County, Pain Management Center

Introduction: Abdominal Acupuncture, incorporating the body map of the Sacred Turtle diagram, is an Acupuncture Micro-System widely used throughout China and Europe. In 1992 Professor Zhiyan Bo, while treating a difficult case of Sciatica that had not responded to western medicine or traditional forms of acupuncture treatments, decided to treat his patient using the low back and hip points on the abdomen, based on the ancient theory of Biao and Li (External/Internal) dating back to 2,200 BC, with powerful results, Professor Bo’s research over the next 20 years showed that due to the abdominal area producing 80% of the body’s serotonin, pain, appetite, sleep, and mood were positively affected.

Our purpose of studying the use of Bo’s Style Abdominal Acupuncture was to measure its effect on Back Pain Patients in the reduction of pain and pain medication. An advantage of this remote form of needle stimulation, away from the site of pain, allowing for movement of the painful area of the body while the needles are retained, allowing for real-time pain assessment.

Methods: Stroger Hospital Acupuncture Patients with chronic pain received abdominal acupuncture every two weeks, were asked to identify their level of pain before and after treatment, using the Visual Analog Pain Scale (VAS). Patients were also asked how many days any reduction in pain lasted after their last treatment. Sacred Turtle Points used included Ren 12, 10, 6, Stomach 26, and hip knee and leg referral points based on the palpation of “ashii” (spontaneously sensitive) points.

Results:

Of the 37 patients receiving Abdominal Acupuncture for back pain:

5 patients had VAS reduction from 10/10 to 2/10

3 patients had VAS reduction from 7/10 to 0/10

12 patients had VAS reduction from 8/10 to 3/10

9 patients had VAS reduction from 7/10 to 2/10

5 patients had VAS reduction from 6/10 to 3/10

2 patients had VAS reduction from 7/10 to 6/10

1 patient had no change in VAS

26 patients reported that pain reduction lasted 3 to 7 days.

10 patients reported that pain reduction lasted 2 to 3 days.

Conclusions/Discussion:

Of 37 pain patients receiving abdominal acupuncture for back pain at 2 week intervals 36 had VAS pain reductions ranging from a high of 8 to a low 1 point, with no response from one patient. The effect lasted from 2 to 7 days. An advantage to this type of remote acupuncture stimulation, away from the area of pain, is that the patient can move that part of the body experiencing pain, allowing for needle adjustment or addition real-time, allowing more efficacious results. Preliminary findings suggest that a larger number of patients be treated with this method, on a more frequent basis, and a long enough period of time, in order to also track the influence of this therapy on their frequency and dosage levels of pain medication.

8: Opioid Bias, racism, and chronic pain patients

Authors: Samantha Harfenist and Tracy Aneziris

Institution: Northshore Integrative Healthcare; The Illinois School of Professional Psychology

Introduction: Clinicians frequently employ self-report measures to assess a client’s risk of opioid abuse. The Screener and Opioid Assessment for Patients with Pain was last revised in 2003. Given the importance of these tools in the care of chronic pain clients, such assessments should be evaluated to examine if there are biases in the measure that could negatively impact the person’s scores and treatment. The original SOAPP was based on 85 chronic pain patients (77% Caucasian), and the revised version (SOAPP-R) was based on 283 pain patients (85% Caucasian).

Methods: The SOAPP-R is a 24-item self-report measure used by clinicians to assess the risk of opioid abuse and provide insight into what types of long-term treatment clients require. 177 patient files were randomly selected from a collection of chronic pain patients in a multi-location private practice. The data was analyzed for possible racial and gender differences in the total SOAPP-R score.

Results: The results indicated that there was no significant difference among the scores of the Caucasian, African American, and Hispanic clients F(175, 115)=1.432; p=.034 or between the scores of men and women. Even though the files were randomly selected, there was a large disparity between the number of patients who were Caucasian (152), African American (15), and Hispanic (8).

Conclusions/Discussion: The results from this study indicate that there appears to be no significant racial or gender difference in SOAPP-R scores. However, a limitation of this study is the lack of racial diversity in the data set but additional data is being collected.

Butler, S. F., Fernandez, K., Benoit, C., Budman, S. H., & Jamison, R. N. (2008). Validation of the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). The Journal of Pain : Official Journal of the American Pain Society, 9(4), 360–372. http://doi.org/10.1016/j.jpain.2007.11.014

Bruns, D., Kerns R. (2013). Managing Chronic Pain: How Psychologist can Help with Pain Management. Retrieved September 30, 2016, from http://www.apa.org/helpcenter/pain-management.aspx

Catalano, E. M. (1989). The Chronic Pain Control Workbook. The Clinical Journal of Pain, 5(4), 363-364.Chronic Pain Information Page: National Institute of Neurological Disorders and Stroke (NINDS).

(n.d.). Retrieved September 30, 2016, from http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm

9: ELECTRIC CELL SIGNALING OF NERVES REDUCES THE NEED FOR OPIOIDS

Authors: Peter Carney, MD, FAANS, Richard Sorgnard, PhD, Robert Odell, MD, PhD, Robert Milne, MD

Institution: Peter M. Carney, M.D., F.A.A.NS., Morhea Technologies, Neuropathy and pain Centers of America, Milne Medical Center

Introduction: The opioid epidemic that currently faces America caused 47,050 drug overdose deaths in 2014 or 5.37 deaths an hour according to the CDC, and represents a serious threat to the health of all Americans. [1] Mindfulness-Based Stress Reduction, yoga, exercise, and cognitive-behavioral therapy represent non-narcotic treatments that have shown some success in reducing the use of narcotics. [2] Electric cell signaling of nerve cells has produced effective and safe results in reducing neuropathic pain. [3] This study reports that electric signaling of nerve cells reduces the use of opioids.

Methods: Sixteen patients with an average age of 52 (24-89) and a variety of pain syndromes involving their back, joints or nerves voluntarily consented to undergo treatment with electric cell signaling treatment (EST) [4] and sometimes combined EST with injections of local anesthetics (CET) [5]. These patients received, on average, 23.25 treatments (5-95) over a one to twelve month period of time.

Results: These sixteen patients experienced, on average, a 66% reduction in their use of opioids. 56% reduced their opioid use by at least 50% and 44% stopped their opioid use altogether. There were no adverse side effects.

Conclusions/Discussion: In this small pilot study 16 patients, who received EST and/or CET experienced a significant reduction in their use of opioids, with nearly 50% stopping their opioid use altogether for six months after treatment. These results document the need for further studies to validate the usefulness of EST/CET therapies.

References

1.) Rudd RA, Aleshire N, Zibbell JE, Gladden RM. “INCREASE IN DRUG AND OPIOID DEATHS – UNITED STATES, 2000-2014. MMWR Morb Mortal Wky Rep. 2016 Jan 1: 64 (50-51)1378-82.

2.) Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson MI, Hawkes RJ, Hansen KE, Turner JA. ‘EFFECT OF MINDFULNESS-BASED STRESS REDUCTION vs COGNITIVE BEHAVIORAL THERAPY OR USUAL CARE ON BACK PAIN AND FUNCTIONAL LIMITATIONS IN ADULTS WITH CHRONIC LOW BACK PAIN A RANDOMIZED CLINICAL TRIAL. JAMA 2016 235 #12: 1240-1249.

3.) Carney PM, “QUANTUM THEORY TREATS NEUROPATHY BETTER THAN PHARMACOLOGY”. THE PAIN PRACTITIONER WINTER 2014: 28-31.

4.) Odell RH Jr, Sorgnard RE. “ANTI-INFLAMMATORY EFFECTS OF ELECTRONIC SIGNAL THERAPY.” PAIN PHYSICIAN 2008 11: 891-907.

5.) Odell RH Jr, Sorgnard RE, Carney PM, Milne RD. “COMBINED ELECTROCHEMICAL TREATMENT FOR PERIPHERAL NEUROPATHY.” PRACTICAL PAIN MANAGEMENT 2015 15 #8: 47-56.

10: Emergency Department Patient Behavior Following Trauma Treatment

Author: Patrick J. Weis, PsyD

Institution: Mercy Hospital Springfield

Introduction: An emergency trauma event is a life changing event, but little is known about how patient treatment and health factors influence treatment trajectory and health outcomes such the emergence of chronic health conditions including chronic pain. In addition to the benefits of quality medical interventions, psychological factors are cited as having a determinative role in treatment response and long term rehabilitation (Bonanno, 2005; see also Kearns, et al., 2012; Livingston, Tripp, Biggs, & Lavery, 2009; Sullivan & Stanish, 2003). This retrospective study aimed to explore these variables and interactions within patients seen at a Level One Trauma Center situated within a regional health care system located in the Midwest region of the United States who were considered trauma surgery candidates. Patient outcomes were investigated in terms of pre-trauma and post trauma degree of system utilization and level of care.

Study Procedures:

Methods:

The study was a retrospective chart review identifying patients who were seen by a trauma surgeon and admitted from January 2010 to December 2014. Patient data was de-identified and there was no patient contact. An electronic search of the trauma registry identified 4,819 patients who were seen by a trauma surgeon and admitted between January 2010 and December 2014. The investigator followed all applicable privacy laws in order to protect a subject’s privacy and confidentiality.

Results:

The number of oral medication orders for analgesics narcotics was examined across the three periods. The rate of analgesic narcotic medication orders was statistically significantly higher during period 2 (M = 12.69, SD = 9.43) than under either Period 1 (M = 5.81, SD = 6.32) or Period 3 (M = 6.58, SD = 6.51), F (2,596) = 113.95, p < .001, η2p = .277.

Conclusions/Discussion:

These patients continued to suffer pain following post surgical recovery and including but not limited to psychological intervention.

References:

Bonanno, G.A. (2005). Resilience in the face of potential trauma. Psychological Science, 14(30), 135-138.

Kearns, M.C., Ressler, K.J., Zatzick, D., & Rothbaum, B.O. (2012).

Early interventions for PTSD: A review. Depression and Anxiety, 29, 833-842.

Livingston, D.H., Tripp, T., Biggs, C., & Lavery, R.F., (2009). A fate worse than death? Long term outcomes of trauma patients admitted to the surgical intensive care unit. Journal of Trauma, 67(2), 341-348.

Sullivan, M.J. & Stanish, W.D. (2003). Psychologically based occupational rehabilitation: the pain disability prevention program. Clinical Journal of Pain, 19(2) 97-104.

11: Physician’s Consideration of Drug Seeking in the Assessment of Pain

Authors: Andrea Williams, MS; Jennifer Schriver, Ph.D.

Institution: Indiana State University

Introduction: Chronic pain is the fifth most common complaint in primary care1,2. A major concern in pain management is the risk of addiction to opiate based medications (OBM), and legislation about prescription practices and monitoring have resulted in changes in the way that physicians assess and treat pain3. This study explores how practicing physicians (PP) and residents assess for drug-seeking behaviors (DSB) in pain patient populations in primary care.

Methods: A 52-item survey assessing physician’s training and assessment of pain patient’s DSB was distributed online to 300 primary care physicians nationwide and 30 family medicine residents from a local hospital. 55 physicians (37 males, 18 females) with a mean age of 41.93 years and average of 9.53 years post-residency completed the survey.

Results: Respondents indicated they worry about drug seeking approximately 36% of the time when treating pain patients. There were no significant differences between residents and PP in regards to level of concern about drug-seeking when pain was the primary complaint, the number of diagnostic aides used in the assessment of pain, and overall response patterns to the survey. Most residents and PP reported not utilizing formal assessment aids when drug seeking was suspected. Regarding training around issues of drug seeking, 68% of residents reported such training during their residency, and 96% of PP reported such training either during their residency or through continuing education. PP reported more comfort with taking a history and writing prescriptions for OBM compared to residents.

Conclusions/Discussion: Overall, residents and PP demonstrate similar levels of concern and assessment methods regarding drug-seeking behaviors in pain populations regardless of background in training. It appears that experience contributes to increased confidence in managing pain in a primary care setting. Considerations about how to increase confidence in earlier stages of career and improve effectiveness of assessment for DSB needs to be evaluated.

1. Sarzi-Puttini, P., Vellucci, R., Zuccaro, S., Cherubino, P., Labianca, R., & Fornasari, D. (2012). The appropriate treatment of chronic pain. Clinical Drug Investigation, 32(1), 21-33. doi:1173-2563/12/0001-0021/

2. Rinkus, K., & Knaub, M. (2008). Clinical and diagnostic evaluation of low back pain. Seminars in Spine Surgery, 20, 93-101. doi:10.1053/j.semss.2008.02.004

3. National Alliance for Model State Drug Laws (NAMSDL, 2016). Overview of state pain management and prescribing policies [PDF document]. Retrieved from National Alliance for Model State Drug website: http://www.namsdl.org/library/74A8658B-E297-9B03-E9AE6218FA0F05B0/

12: Management of Chronic Pain Secondary to Chronic Venous Disease in a Comprehensive, Multidisciplinary Pain Management Program: A Case Report

Authors: Jeffrey Cara, D.O., Pegah Safaeian, D.O., James Atchison, D.O.

Institution: Northwestern University/Rehabilitation Institute of Chicago

Introduction:

A 59-year-old male presented with a three-year history of worsening ankle, foot, and calf pain secondary to chronic venous insufficiency (CVI). The patient described the pain as 2 to 9 on the visual analogue scale – constant, aching, worsening throughout the day, exacerbated by walking, climbing stairs, and prolonged standing, but improved by elevation of his feet. Because his job required standing throughout most of a 12-hour shift, he was forced to go on leave.

Prior treatments included opioid medications, treatment of ulcers, and multiple rounds of venous stenting. His morphine equivalent daily dose (MEDD) was 135.

Physical examination was significant for purple toes and intact peripheral pulses bilaterally. A venous stasis ulcer was present over the right medial malleolus. Full strength and active range of motion were present in both legs. The patient was tender to palpation on the hard callused areas of his distal metatarsals.

Methods:

The patient enrolled in a four-week, comprehensive, multidisciplinary pain program for management of CVI pain, which included medical management, physical therapy, occupational therapy, pain psychology, nursing education, biofeedback, postural retraining, ergonomics, and physical conditioning.

The six-minute walk test (6MWT) and Patient-Specific Functional Scale (PSFS) were used to measure functional progress.

Results:

The patient’s 6MWT improved from 580 feet to 686 feet at discharge and to 897 feet by the four-week follow-up. He exceeded all goals on his PSFS, including standing for 30 minutes, navigating 10 stairs, and walking for 30 minutes. His MEDD decreased to 120. Moreover, he was able to return to work full-time.

Conclusions/Discussion:

CVI is traditionally treated by addressing the underlying cause (1,2,3,4). However, little has been written about the treatment of CVI pain when traditional approaches have failed to provide relief. This case demonstrates the efficacy of a comprehensive, multidisciplinary pain management program to reduce opioid burden, improve function, and reduce disability.

1. Frykberg RG, Banks J. Challenges in the Treatment of Chronic Wounds. Adv Wound Care (New Rochelle). 2015 Sep 1. 4 (9):560-582.

2. van Gent WB, Hop WC, van Praag MC, et al. Conservative versus surgical treatment of venous leg ulcers: a prospective, randomized, multicenter trial. J Vasc Surg. 2006 Sep. 44(3):563-71.

3. Wipke-Tevis DD, Sae-Sia W. Caring for vascular leg ulcers. Home Healthc Nurse. 2004 Apr. 22(4):237-47; quiz 248-9.

4. Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2012 Apr 18. 4:CD004123.

13: Cooled Radiofrequency Ablation of the Genicular Nerves for Chronic Pain due to Knee Osteoarthritis: A Prospective Survey Study

Authors:Zachary L. McCormick, MD,1 Marc Korn MD,2 Rajiv Reddy MD,3 Austin Marcolina BS,4 David Dayanim MD,5 Ryan Mattie MD,6 Daniel Cushman MD,7 Meghan Bhave MD,2 Dost Khan MD,2 Geeta Nagpal MD,2 David R. Walega, M.D.2

Institution:

Northwestern Memorial Hospital

Introduction:Chronic pain from knee osteoarthritis (OA) is typically managed with anti-inflammatory medications, analgesics, physical therapy, and intra-articular injections. Total knee arthroplasty (TKA) may follow, yet this is associated with perioperative and post-operative risks, including chronic pain.

If conservative management fails, genicular nerve radiofrequency ablation (RFA) is an innovative treatment option, especially for poor surgical candidates or those wishing to avoid TKA. The procedure involves thermal lesioning of genicular nerves, which transmit afferent pain signals from the anterior knee joint capsule.

While RFA outcome literature exists for zygapophysial and sacroiliac joint pain, less has been published regarding genicular nerve RFA. Primary knee OA patients were examined to determine 6-month clinical outcomes of genicular nerve cooled radiofrequency ablation (C-RFA) and identify factors that predict clinically significant treatment responses.

Methods:A cross-sectional survey and retrospective chart review study of knee OA patients was conducted at an academic pain center. Patients with ≥50% pain relief following diagnostic genicular nerve blocks who subsequently underwent genicular nerve C-RFA were included.

Standardized telephone surveys were administered ≥6 months after C-RFA. Pain Numeric Rating Scale (NRS), Medication Quantification Scale III (MQSIII), Patient Global Impression of Change (PGIC), and TKA data were collected. Logistic regression was used to identify factors that predicted favorable responses.

Results:Thirty-five patients (52 knees) met inclusion criteria. Thirty-five percent [95% CI 22% to 48%] of these encounters met the definition of clinical success, reporting ≥50% reduction in NRS score, >3.4 point reduction in MQSIII score and PGIC score consistent with “very much improved” or “improved” and had not undergone TKA.

Conclusions/Discussion:The data suggest modest success with C-RFA for chronic pain from knee OA when using a threshold of >50% relief from diagnostic blocks. Multivariate logistic regression analysis demonstrated that pain duration <2 years and >80% pain relief from diagnostic blocks predict greater likelihood of clinical success.

2. Pedersen AB, Mehnert F, Sorensen HT, Emmeluth C, Overgaard S, Johnsen SP. The risk of venous thromboembolism, myocardial infarction, stroke, major bleeding and death in patients undergoing total hip and knee replacement: a 15-year retrospective cohort study of routine clinical practice. Bone Joint J. 2014 Apr;96-B(4):479- 85. DOI: 10.1302/0301-620X.96B4.33209.

3. Franco C, Buvanendran A, Petersohn J, Menzies R, Menzies L. Innervation of the Anterior Capsule of the Human Knee. Implications for Radiofrequency Ablation. Regional Anesthesia and Pain Medicine. 2015;5(4):363-8.

4. Choi WJ, Hwang SJ, Song JG, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial. Pain. 2011; 152(3):481-7.

14: Assessing self-efficacy of muscle spasms control and its impact on intensity of pain-tension- spasm-pain cycle within an Interdisciplinary Pain Management Program

Authors: Felix Laevsky, MS, Christine Gagnon, PhD, James Atchison, DO

Institution: Rehabilitation Institute of Chicago

Introduction: Patients with chronic pain participating in our interdisciplinary treatment program frequently report experiencing muscle spasms. Most of these patients are unaware that muscle spasms are a part of the vicious cycle of pain and muscle tension and lack the skills for controlling spasms. We seek to assess how relaxation and biofeedback training may help patients to reduce muscle spasm, improve their confidence to control them, and to determine whether this reduction in muscle spasm leads to a reduction in intensity of vicious cycle components.

Methods: Measures included; 1) a modified version of the Chronic Pain Self-Efficacy Scale (CPSS) with an additional question about the patient’s certainty to control spasms; 2) the patients reports on changes in muscle spasms; and 3) numeric rating scales (0 “no pain or tension” to 10 “worst imaginable”) to assess pain and tension pre- and post-treatment.

Results: The majority of patients (68%) reported that their spasms improved at the end of treatment (19% same and 4% worse; 10% not assessed). Patients indicated improved control over their spasms and pain, a reduction in severe pain, and reduced levels of average pain and muscle tension, (all P’s < .01). Moreover, the improvements were similar regardless of antispasmodic medication usage (all P’s > .79). Improved confidence to manage muscle spasms was significantly associated with reductions in average pain and tension and increased efficacy to control pain (all p’s < .05, r’s 0.21 – 0.34).

Conclusions/Discussion: Examination of patient reports and data shows that patients receiving training in relaxation and biofeedback as part of an interdisciplinary pain program demonstrated improved muscle spasms symptoms and increased confidence in their ability to control them.

Overall it appears that improved control of muscle spasms helped to narrow pain-tension- spasm-pain cycle.

15: The Relationship Between Pain Resilience and Pain-Related Unemployment in a Cross-Sectional Analysis

Authors: Brett Ankawi, P. Maxwell Slepian, Christopher R. France

Institution: Ohio University

Introduction: Financial costs associated with chronic pain total $600 billion annually in the United States. Over half of this cost can be attributed to reduced worker productivity. Psychological research has traditionally focused on constructs that negatively impact one’s ability to work; however, there has been a recent shift to investigate the impact of positive constructs. Currently, no research has investigated the relationship between worker status and pain resilience, the ability to effectively function emotionally and physically when coping with pain.

Methods: Individuals who self-reported chronic pain (N = 1,098) were recruited using Amazon’s Mechanical Turk and completed an online battery of measures. A hierarchical logistic regression was conducted with the binary dependent variable (“have you been unemployed 1 month or longer due to pain”). Pain intensity, pain interference, and depressive symptoms were included in the first block of the model. Scores on the Pain Resilience Scale and Pain Catastrophizing Scale were entered into the second block.

Results: Together, the measures in the first block were significantly related to work status, χ2(3) = 313.93, p < 0.01. The addition of the second block significantly improved the model, Δχ2(2) = 26.00, p < 0.01. When controlling for other factors, increased pain resilience was associated with a significantly decreased likelihood of having been unemployed as a result of pain, OR = 0.96, 95% CI = 0.94 - 0.98, p < 0.01.

Conclusions/Discussion: The present study was the first to investigate the role of pain resilience in pain-related unemployment. When controlling for other factors, increased pain resilience was negatively related to unemployment due to pain. A limiting factor of this study was its cross-sectional nature; future research should aim to look at these variables in a longitudinal design. Further, the development of resilience-focused interventions may promote patients with chronic pain to return to work.

References :

Gaskin, D. J., & Richard, P. (2012). The economic costs of pain in the United States. J Pain, 13(8), 715–724. Journal Article. http://doi.org/10.1016/j.jpain.2012.03.009

Slepian, P. M., Ankawi, B., Himawan, L. K., & France, C. R. (2016). Development and initial validation of the pain resilience scale. Journal of Pain, 17(4). http://doi.org/10.1016/j.jpain.2015.12.010

16: The Biopsychosocialspiritual Impact of Chronic Pain in Adolescence: A Proposed Model for Psychotherapeutic Intervention

Author: Melissa E. A. Geraghty, Psy.D.

Introduction: Fifteen to twenty percent of people nineteen years of age and under live with chronic pain (Painaction, 2012). Despite the prevalence of chronic pain in adolescence, studies primarily intertwine findings with pediatric and adult populations. This is a limitation as the adolescent population has different treatment needs. Adolescence itself is a diverse age group due to differences in biology, psychological functioning, social interactions, and spirituality. A psychotherapeutic program stemming from the biopsychosocialspiritual model, with a concentration on the role of the clinical health psychologist, was developed for late adolescence (i.e., ages 16 to 18).

Methods: A literature review analyzed the effects of chronic pain on an adolescent’s quality of life. Each component of the biopsychosocialspiritual model was discussed in order to understand the complexity of chronic pain in adolescence (e.g., neural and cognitive processes, fear-avoidance, etc.). The theoretical orientation that supported the presented psychotherapeutic program model was Acceptance and Commitment Therapy (ACT), which focused on values, goal setting, mindfulness, behavioral change, and acceptance of pain.

Results: The findings indicated that the inclusion of adolescents in research with pediatric and adult populations does not serve the adolescent population well. This inclusion diminishes the difficulties and capabilities of the adolescent in chronic pain, making treatments that are empirically sound difficult to find and consequently implement. The psychotherapeutic program model included interventions such as the integration of an interdisciplinary team, psychoeducation of pain, and creating an energy conservation plan. It was founded that clients working within an acceptance-based model with the incorporation of mindfulness engage in more value driven behaviors, thus increasing their overall quality of life.

Conclusions/Discussion: This study showed that adolescents in chronic pain must have treatment that is tailored to their biopsychosocialspiritual needs in order to improve quality of life and overall physical functioning.

References:

Adams, H. E., Bernat, J. A., & Luscher, K. A. (2002). Borderline personality disorder: An overview. In P. B. Sutker, & H. E. Adams (Eds.), Comprehensive handbook of psychopathology (pp. 491-507). New York, NY: Kluwer Academic.

Ainsworth, B. E., Haskell, W. L., Leon, A. R., Jacobs, D. R., Montoye, H. J., Sallis, J. F., & Paffenbarger, R. S., Jr. (1993). Compendium of physical activities: Classification of energy costs of human physical activities. Medical Science and Sports Exercise, 25(1), 71-80.

Aldrich, S., Eccleston, C., & Crombez, G. (2000). Worrying about chronic pain; Vigilance to threat and misdirected problem solving [Abstract]. Behaviour Research and Therapy, 38(5), 457-470.

Alfano, D. P., Nielsen, P. M., & Fink, M. P. (1993). Long-term psychosocial adjustment following head or spinal cord injury. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 6, 117-125.

NC = NOT FOR COMPETITION

NC 1: Ultrasound-Guided Transversus Abdominis Plane Block for the Treatment of Chronic Abdominal and Pelvic Pain: A Case Report

Authors: Ranjit Sandhu, MD; Alyssa Risk, DO; Samir Fuleihan, MD

Institution: Wayne State University/Detroit Medical Center

Introduction: The Transverus Abdominis Plane (TAP) block is commonly used in the perioperative settingto manage acute postoperative pain. Its utility for abdominal pain has been well documented, but its role in pelvic pain remains to be studied. Furthermore, its usage in managing chronic pain is limited. We are presenting a unique application of the TAP block for the management of chronic abdominal and pelvic pain.

Methods: N/A

Results: The patient is a 35 year old female with a past medical history of endometriosis and uterine fibroids and a surgical history significant for total abdominal hysterectomy with left salpingooophorectomy. The patient presented with abdominal and left sided pelvic pain that began after the hysterectomy in 2009. The patient underwent imaging studies but a definitive cause of her pain was never discovered.Medical treatment of her pain included hydrocodone, pregabalin, and amitriptyline. She also underwent a series of left paravertebral blocks, T11-L3, with no improvement. An ultrasound guided left TAP block was preformed using 20cc of 0.5% Bupivicaine. The patient’s preprocedure VAS was 8/10. Immediately following the injection she reported a VAS of 0/10. At 24 hours and again at 4 weeks post-injection, the patient reported a VAS of 0/10. The patient had marked improvement of her ability to perform daily activities and required less opioids.

Conclusions/Discussion:

The nerves that course through the transversus abdominis plane include the intercostal nerves (T7-T11),subcostal nerve (T12), and iliohypogastric and ilioinguinal nerves (L1). The intercostal nerves supply the anterolateral abdominal wall, while the subcostal, iliohypogastric, and ilioinguinal nerves are involved in the innervation of the pelvis. Our results show TAP blocks have promising utility for chronic pain patients. The more clinical experiences and data we have regarding TAP blocks, the more effectively we can utilize it in the management of chronic abdominal and pelvic pain.

Mark J. Young, Andrew W. Gorlin, Vicki E. Modest, and Sadeq A. Quraishi, “Clinical Implications of the Transversus Abdominis Plane Block in Adults,” Anesthesiology Research and Practice, vol. 2012, Article ID 731645, 11 pages, 2012.

Willard, F. H., & Schuenke, M. D. (2013). The Neuroanatomy of Female Pelvic Pain. In Pain in Women: A Clinical Guide(pp. 17-58). New York, NY: Springer.

Catherine Gerrard and Steve Roberts, “Ultrasound-Guided Regional Anaesthesia in the Paediatric Population,”ISRN Anesthesiology, vol. 2012, Article ID 169043, 7 pages, 2012. doi:10.5402/2012/16904316: Delivery of Pain

NC2: Do Weather Changes Affect Outpatient, Pain Management Clinic Attendance?: A Five-Year Longitudinal Analysis

Authors: David Cosio, Ph.D. & Amy Demyan Ph.D.

Institution: Jesse Brown VA Medical Center

Introduction: Adherence to appointments has been found to be a strong predictor of successful chronic disease self-management, yet up to 30% of health appointments are missed. Patients with chronic, non-cancer pain often attribute their pain and nonadherence to prescribed treatment regimens to weather. The current study investigated weather indices as possible factors of missed pain management treatment appointments. The aims of this five-year study was 1) to investigate if weather the day before, the day of, and/or the day after a scheduled pain education class affected attendance and 2) to identify the specific measures of weather change that predicted attendance.

Methods: A total of 911 Veterans participated in the Pain Education School program at the Midwestern U.S. VA medical center between November 6, 2009 and October 31, 2014. Of the 260 calendar weeks, 14 classes were cancelled due to national holidays, resulting in 246 possible classes. End-of-day summaries of meteorological conditions of the city and state of the study were collected for the day before, the day of, and the day after the scheduled appointment using the Old Farmer’s Almanac. Chicago was optimal as a variable weather site.

Results: A stepwise linear regression was conducted to evaluate which measures of weather change were necessary to predict attendance in a pain education program. At step 2 of the analysis, temperature change for the day after class and the wind-chill for the day of class were significantly related to attendance, F(2, 240) = 6.93, p = .01. No significant differences were found for season, F(3, 197) = 2.04, p = 0.11, nor class module, F(12, 197) = 0.25, p = 0.99, on patient attendance.

Conclusions/Discussion: This study found support for the influence of cold temperatures and weather sensitivity on pain appointment attendance. These findings have the potential to help enhance treatment compliance.

References:

• Ishii, K., Hosogane, N., Hikata, T., et al. (2014). Does the change of weather condition influence pain level of symptoms in the patient’s lumbar diseases? Spine Journal, 14, 141S-142S.

• Smedslund, G. & Hagen K. (2011). Does rain really cause pain? A systemic review of the association between weather factors and severity of pain in people with rheumatoid arthritis. European Journal of Pain, 15, 5-10. doi:10.1016/j.epain.2010.05.003

• Tewari, S., Brousse, V., Piel, F., et al. (2015). Environmental determinants of severity in sickle cell disease. Hematologica, 100, 1108-1116.

• Timmermans, E., van der Pas, S., Schaap, L., et al. (2014). Self-perceived weather sensitivity and joint pain in older people with osteoarthritis in six European countries: Results from the European project on osteoarthritis. BMC Musculosketetal Disorders, 15, 66.

NC 3 National Institutes of Health Pain Consortium Centers of Excellence in Pain Education - Assessment of a burning mouth syndrome learning module to instruct future health professionals

Authors: McKenzie Ferguson, Kevin Rowland, Cyril Pandarakalam, Chris Herndon, Raymond Tait, Rebecca Luebbert

Institution: Southern Illinois University Edwardsville (Edwardsville and Alton, Illinois); St. Louis University (St. Louis, MO)

Introduction:

The National Institutes of Health (NIH) Pain Consortium created the Centers of Excellence in Pain Education (CoEPEs) to develop, evaluate, and promote pain management curriculum resources for students of many health disciplines. A learning module was developed on the topic of burning mouth syndrome (BMS), a condition characterized by intense burning sensations within the oral cavity, usually localized to the tongue and lips. Individuals with painful, enigmatic conditions, such as BMS, often are evaluated by numerous healthcare professionals sometimes over a period of years before a definitive diagnosis is reached. Following diagnosis, a multidisciplinary approach for treatment and monitoring is warranted. The purpose of this research is to assess the effectiveness of a learning module on BMS.

Methods:

Educational content has been incorporated into existing healthcare professional curricula. Students will complete 1) pre-assessment questions; 2) the full, interactive BMS learning module developed by our CoEPE and 3) post-assessment questions (same as pre-assessment) and 4) script concordance assessments. Script concordance focuses on the ability of the student to demonstrate clinical reasoning. In our assessment, three different clinical vignettes will be presented in which the student applies knowledge to make clinical decisions and manage a patient under uncertain conditions. Script concordance tests aim to measure the degree of concordance between examinees and an expert reference panel. The test uses a method of combined scores to account for variability in the responses made by an expert panel in order to determine the score awarded to the student. The score is calculated according to the number of panel members who chose a particular response. All assessments are administered via Qualtrics and anonymized. This project was approved as exempt from IRB review.

Results:

Results to be presented at the poster presentation.

Conclusions/Discussion:

Conclusions to be presented at the poster presentation.

References:

Fournier JP, Demeester A, Charlin B. Script concordance tests: guidelines for construction. BMC Medical Informatics and Decision Making. 2008;8:18.

NC 4: Education through Picture-Telephone Videoconferencing for Veterans with Chronic, Non-cancer Pain

Authors: David Cosio, Ph.D. & Erica Lin, Pharm.D.

Institution: Jesse Brown VA Medical Center

Introduction: Almost a quarter of Veterans nationwide live in rural communities, which may negatively impact their health related quality of life compared to their counterparts in urban areas. Clinical care at ‐a distance is progressing as a model and is being used more frequently to treat disease in rural areas. Technology-assisted treatments may provide a comparable alternative to face-to-face interventions. The purpose of the pilot study was to propose the feasibility and potential efficacy of using picture-telephone (PICTEL) videoconferencing technology to disseminate a pain education program to rural Veterans with chronic, non-cancer pain.

Methods: The pilot study had a sample of 463 Veterans aged 18-88 years old with mixed idiopathic, chronic, non-cancer pain conditions who participated in the Pain Education School program either face-to-face (N=350; 76%) or via PICTEL (N=113; 24%) at a Midwestern VA Medical Center between January 8, 2010-November 4, 2011. As a part of quality management, measures (Readiness Questionnaire, Patient Pain Questionnaire, and Patient Health Questionnaire) were completed by participants of the face-to-face and PICTEL interventions at the introduction and conclusion of the program.

Results: Preliminary findings propose there was no significant difference between the face-to-face and PICTEL interventions on the stage of readiness, F (1,429)=0.01, p=0.92; knowledge about pain, F (1,429)=0.56, p=0.46; experience of pain, F (1,429)=0.03, p=0.87; and depressive symptoms, F (1,429)=0.99, p=0.32. However, a significant difference was found between the pre- and post-measures of the participants’ stage of readiness, F (1,429)=29.81, p=0.00; their experience, F (1,429)=17.49, p=0.00; and their depressed mood, F (1,429)=11.19, p=0.01, regardless of how the intervention was delivered. The current presentation will also detail logistics, the technology used, troubleshooting, best practices and etiquette, workload capture, and lessons learned.

Conclusions/Discussion: The current program may prove to be an avenue by which rural Veterans can bypass identified barriers and realize self-management goals.

• Heapy AH, Higgins D, Cervone D, Wandner L, Fenton BT, Kerns RD. A systematic review of technology‐assisted self management interventions for chronic pain: Looking across treatment modalities. Clin J Pain. 2015; ‐31(6): 470-492.

• Lieberman G, Naylor MR. Interactive voice response technology for symptom monitoring and as an adjunct to the treatment of chronic pain. Transl Behav Med. 2012; 2(1): 93-101.

• Steel K, Cox D, Garry H. Therapeutic videoconferencing interventions for the treatment of long-term conditions. J Telemed Telecare. 2011; 17(3): 109-117.

• Weeks WB, Wallace AE, Wang S, Lee A, Kazis LE. Rural-urban disparities in health-related quality of life within disease categories of Veterans. J. Rural Health. 2006; 22(3): 204-211.

Industry Abstract A: Sustained Effectiveness of Intrathecal Ziconotide Use as the First Agent in Pump in Patients With Severe Chronic Pain

Authors: Richard L Rauck, MD1; Timothy Deer, MD2; Gladstone McDowell, MD3; Philip Kim, MD4; Mark Wallace, MD5; I-Zu Huang, MD6; Fannie Mori, MS6; Geertrui F. Vanhove, MD, PhD6; Michael F. Saulino, MD, PhD7;

Institutions:1Carolinas Pain Institute and The Center for Clinical Research, Winston-Salem, NC; 2The Center for Pain Relief, Charleston, WV; 3Integrated Pain Solutions, Columbus, OH; 4Center for Interventional Pain and Spine, LLC, Newark, DE; 5University of California, San Diego, La Jolla, CA; 6Jazz Pharmaceuticals, Palo Alto, CA; 7MossRehab, Elkins Park, PA

Introduction: The Patient Registry of Intrathecal Ziconotide Management (PRIZM) evaluates effectiveness and safety of intrathecal ziconotide in clinical practice.

Methods: PRIZM is an open-label, long-term, multicenter, observational study of adult patients with severe chronic pain. This interim subset analysis (as of 07/10/15) of ziconotide as the first versus second-or-later intrathecal agent reports change from baseline over time (month 3, 6, 9, and 12) in “average pain for the past 24 hours” on an 11-point Numeric Pain Rating Scale (NPRS; primary efficacy endpoint).

Results: Thirty patients were still active in the study at month 12 (n=93 enrolled). Of those, 21 had NPRS scores at all above timepoints; 13/21 patients (61.9%) received ziconotide as first-in-pump (FIP+), whereas 8/21 (38.1%) did not (FIP-). Mean (SD) baseline NPRS scores were 7.4 (1.3) and 8.3 (1.2) in FIP+ and FIP- patients, respectively. Mean percentage change (SE) in NPRS scores for FIP+ and FIP- patients were -19.2 (7.9)% and -12.2 (7.8)% at month 3, -30.8 (7.2)% and -4.3 (4.0)% at month 6, -22.8 (9.3)% and -22.3 (7.4)% at month 9, and -32.7 (9.7)% and -5.4 (11.4)% at month 12, respectively. The most common adverse events (AEs; in ≥10% of patients overall) were peripheral edema (38.5% in FIP+ versus 0% in FIP-), amnesia (30.8% versus 12.5%), auditory hallucination (30.8% versus 25.0%), nausea (30.8% versus 0%), balance disorder (23.1% versus 12.5%), headache (23.1% versus 0%), memory impairment (23.1% vs 12.5%), urinary tract infection (23.1% versus 0%), confusional state (15.4% versus 25.0%), diarrhea (15.4% versus 12.5%) , dizziness (15.4% versus 12.5%), and pruritus (15.4% versus 12.5%).

Conclusion: These data suggest a greater sustained treatment response for up to 12 months when ziconotide was initiated as first-line intrathecal therapy versus second-or-later agent in the pump. The AE profile at this interim analysis was consistent with prescribing information.

Support: Jazz Pharmaceuticals.

Acknowledgment: The authors thank Amy Young for statistical programming.

Disclosures: available on request

Industry Abstract B: Effectiveness and Safety of Intrathecal Ziconotide as the First Agent in Pump for Adult Patients With Severe Chronic Pain

Authors: Richard L. Rauck, MD1; Michael F. Saulino, MD, PhD2; Timothy Deer, MD3; Philip Kim, MD4; Gladstone McDowell, MD5; I-Zu Huang, MD6; Fannie Mori, MS6; Geertrui F. Vanhove, MD, PhD6; Mark Wallace, MD7

Institutions: 1Carolinas Pain Institute and The Center for Clinical Research, Winston-Salem, NC; 2MossRehab, Elkins Park, PA; 3The Center for Pain Relief, Charleston, WV; 4Center for Interventional Pain and Spine, LLC, Newark, DE; 5Integrated Pain Solutions, Columbus, OH; 6Jazz Pharmaceuticals, Palo Alto, CA; 7University of California, San Diego, La Jolla, CA

Introduction: The Patient Registry of Intrathecal Ziconotide Management (PRIZM) evaluates effectiveness and safety associated with intrathecal ziconotide use in clinical practice settings.

Methods: PRIZM is an open-label, long-term, multicenter, observational study of adult patients with severe chronic pain who meet ziconotide prescribing information criteria. This interim subset analysis (data as of 7/10/15) of ziconotide as the first versus second-or-later intrathecal agent in pump reports percentage change from baseline to month 6 and month 12 in “average pain for the past 24 hours” on an 11-point Numeric Pain Rating Scale (NPRS; primary efficacy endpoint) and Patient Global Impression of Change (PGIC) score at months 6 and 12.

Results: Enrollment closed at 93 patients (6/30/15). Fifty-one patients (54.8%) received ziconotide as the first agent in pump (FIP+), whereas 42 (45.2%) did not (FIP-). Mean (SD) baseline NPRS scores were 7.4 (1.9) and 7.9 (1.6) in FIP+ and FIP- patients, respectively. Mean (SEM) percentage changes in NPRS scores at month 6 were –29.4% (5.5%) in FIP+ (n=26) and 6.4% (7.7%) in FIP- (n=17) patients and at month 12 were –34.4% (9.1%) in FIP+ (n=14) and –3.4% (10.2%) in FIP- (n=9) patients. Improvement from baseline, measured by PGIC score, was reported in 69.2% of FIP+ (n=26) versus 35.7% of FIP- (n=14) patients at month 6 and 85.7% of FIP+ (n=7) versus 71.4% of FIP- (n=7) patients at month 12. The most common adverse events (AEs; ≥10% of patients overall) were nausea (19.6% vs 7.1%; FIP+ vs FIP- patients, respectively), confusional state (9.8% vs 11.9%), and dizziness (13.7% vs 7.1%).

Conclusions: Greater improvements in efficacy outcomes were observed when ziconotide was initiated as first-line intrathecal therapy versus second-or-later intrathecal agent in pump. In this interim PRIZM analysis, the AE profile of ziconotide was consistent with the prescribing information. Support: Jazz Pharmaceuticals.

Acknowledgment: The authors thank Amy Young for statistical programming.

Disclosures: available on request

Industry Abstract C: Safety and efficacy of intrathecal ziconotide in patients with complex regional pain syndrome

Authors: Richard L. Rauck, MD,1 I-Zu Huang, MD,2 Mark Wallace, MD,3

Institutions: 1Carolinas Pain Institute and The Center for Clinical Research, Winston-Salem, NC 2Jazz Pharmaceuticals, Palo Alto, CA; 3University of California, San Diego, CA;

Introduction: This posthoc analysis evaluated safety and efficacy of intrathecal ziconotide in the subpopulation of complex regional pain syndrome (CRPS) patients who received ziconotide in a long-term (≥3 months), open-label, multicenter study.

Methods: The study enrolled patients with chronic, severe, noncancer pain with a demonstrable neurological basis, or pain related to cancer or AIDS or their treatment. Ziconotide was administered via continuous intrathecal infusion at an initial dose of ≤2.4 mcg/d, titrated to patient response (max < 2.4 mcg/d). Efficacy was measured through Visual Analog Scale of Pain Intensity (VASPI) score (from 0 mm [“least possible pain”] to 100 mm [“worst pain imaginable”]), assessed twice weekly to month 1, at discontinuation of ziconotide, post-discontinuation follow-up, and study termination. The primary efficacy outcome was change in VASPI score from baseline to month 1.

Results: Of the CRPS patients (n=75/644 in the overall study population), 62.7% were female and mean (standard deviation [SD]) age was 42.2 (12.2) years. Mean baseline (SD) VASPI score was 74.9 (16.6) mm. Mean (SD) percentage change from baseline VASPI score was -16.8% (40.1%) at month 1 (n=57). The proportion of treatment responders (≥30% reduction in VASPI from baseline) at month 1 was 29.8% (17/57 patients). The most common adverse events (AEs) among all-treated CRPS patients (≥30% of patients) were nausea (70.7%), headache (61.3%), dizziness (50.7%), pain (49.3%), confusion (40.0%), somnolence (38.7%), and memory impairment (34.7%). The most common serious adverse events (≥5% of patients) were depression (5.3%) and pneumonia (5.3%).

Conclusion: Intrathecal ziconotide reduced mean VASPI scores at month 1 in patients with CRPS. The AE profile of ziconotide was consistent with the prescribing information.

Intrathecal ziconotide may be an effective treatment option for patients with severe chronic pain related to CRPS. Analyses are ongoing in assessing ziconotide efficacy at later time points.

Support: Jazz Pharmaceuticals.

Acknowledgment: The authors thank Amy Young for statistical support.

Disclosures: available on request

Industry Abstract D: Predictors of Attrition from a Behavioral Medicine Treatment for Chronic Pain in a Primary Care Setting

Authors: Matthew J. Jasinski1, Olga M. Slavin-Spenny2, J. Bruce Hillenberg2, Elie Mulhem2, Alina Stevenson2

Institution: 1 Wayne State University, 2 Beaumont Health System

Introduction: Behavioral medicine treatments for chronic pain have been found to be effective in research trials, but remain underutilized in clinical settings. Attrition continues to be a significant contributor to the low uptake of these effective treatments, but its antecedents are not fully understood. This study examined the course and predictors of attrition in group therapy for chronic pain.

Method: We recruited 50 patients (74% female; M Age = 49.8, SD = 13.4; 70% White) as part of a randomized controlled trial of an Acceptance and Commitment Therapy group treatment for chronic pain in a primary care setting. The main aim of the treatment is to increase psychological flexibility of individuals living with chronic pain. Demographic data was recorded at baseline and attendance was recorded for each of the six sessions. Analyses involved descriptive statistics and predictors of attrition.

Results: Patients attended an average of 2.48 (SD = 2.33) sessions (41%). 30 patients attended session 1. Those 30 patients attended an average of 58% of the remaining five sessions. Those who missed session 1 had an average attendance of 3% for the remaining five sessions. Prior (self-reported) mental health history (p = .027) and consuming 3+ drinks of alcohol per week (p = .008) predicted better average attendance across the six sessions. Having diabetes was marginally significant for predicting session 1 attendance (p = .051).

Discussion: This study suggests that patients with a history of mental health treatment or behavioral health concerns may be more receptive to a behavioral health intervention for chronic pain. This study also underlines the importance of guiding patients to commit to attend the first session, as this could have a positive effect on decreasing attrition.

References: To be included on poster