Op-Med is a collection of original articles contributed by Doximity members.
Virtual Platform: Goodnight Vegas, Hello Webinar
I have been attending pain medicine and rehabilitation medical education conferences since I was a fourth-year medical student. This year, in-person conferences have been modified to offer a virtual schedule, and PAINWeek 2020 was no different. While typically in Las Vegas, I had the opportunity to attend the conference last weekend from home, and it was excellent but certainly different.
In addition to the obvious benefits of continuing medical education, networking is a key benefit of attending these conferences. I recall scoring residency interviews as a medical student by networking. In training, I enjoyed going to residency-sponsored conferences, presenting posters, and workshops. Since being in practice, I have truly enjoyed learning from the leaders in my field. Socializing is an additional benefit I enjoyed in the setting of the conference. It allowed me to relax with other colleagues as we showed off and gushed over very difficult to obtain sacroiliac joint arthrograms with perfect contrast spreads (to my non-pain management colleagues reading this, even though you call us “needle jockeys,” yes, we are just as geeky as you). The spontaneity and personal connections you make when deciding which Las Vegas casino to visit in between courses is missing from remote programs. Now, your educational weekend is reduced to changing baby diapers in between virtual sessions. The experience is similar to watching a basketball game at home. Certainly, not the same thing as being courtside, but a great alternative. The COVID-19 pandemic has taught us that there are alternative and equally effective models. I virtually attended a number of sessions highlighted below and found that I was still able to learn and grow as a physician through PAINWeek 2020.
Hot Interventions: peripheral nerve stimulation, SI joint fusions, interbody fusions, neuromodulation upgrades, and so much more!
In the words of Dr. Sean Li, while discussing cutting edge interventional treatments, “peripheral nerve stimulation (PNS) is like teaching an old dog new tricks.” PNS was ubiquitous during PAINWeek 2020, and I must admit I got extremely excited about the research studies, the different indications, and the technical skills discussed. PNS for various primary headaches, post-herniorrhaphy pain, even end-stage fibromyalgia, and believe it or not — vagal nerve stimulation for COVID-19-related dyspnea and reduced respiratory flow. Yes, we are truly frontline. Many sessions discussed refractory painful diabetic neuropathy, and the use of new and mighty high-frequency 10kHz neuromodulation revealed improved pain, quality of life, and objective neurological function. The interspinous process decompression device (Vertiflex) also made an appearance multiple times. The highlight of this treatment is that it led to an 85% reduction in opioid use over five years. Personally, the least exciting interventional technique discussed was minimally invasive sacroiliac joint fusion. Probably a controversial statement, but why would anyone want to fuse a joint that is relatively immobile when we know fusions cause further deterioration of adjacent structures? While speaking about fusions, Dr. Jay Joshi spoke at length about treatment options for patients who have suffered from failed back surgeries, which occurs in 20–40% of patients. These patients are still candidates for interventional spine procedures such as facet or sacroiliac joint rhizotomy, or neuromodulation therapies. Thank you, Dr. Joshi, for having the same opinion as me: intrathecal pain pumps should not be done at all. Another controversial statement, I know. This is one time where I wish we were together so I could see the expressions of colleagues in the conference room when he said this.
Do you even prescribe?
I am proud to say my practice is narcotic-free for non-cancer, chronic pain patients, and I am glad to learn that I am not a rare breed. There are non-narcotic and innovative medications for patients who do not respond to interventions or are non-interventional candidates. We have more alternatives for chronic pain beyond gabapentinoids and NSAIDs. Dr. Neel Mehta’s lecture on Low Dose Naltrexone (LDN) explained that its clinical use has expanded to refractory diabetic neuropathy (a very hot topic during the conference), fibromyalgia, pain associated with Crohn’s disease, multiple sclerosis, and cancer. LDN is a subtherapeutic dose of naltrexone and cannot be used with opioids. When taken at low doses, it exhibits a paradoxical effect, which includes analgesia and decreased inflammation. Another medication worth discussing is Qutenza (8% capsaicin), which is highly potent and has been used to treat post-herpetic neuralgia. It comes in a cutaneous patch that delivers 8% capsaicin and works by desensitization of the Transient Receptor Potential Vanilloid 1 receptor, which is involved in neuropathic pain signaling. The patch remains in place for 30 minutes, then is removed, and the skin is cleaned with an accompanying gel. It burns, so it is recommended to use an EMLA cream prior to patch application. It is hot off (pun intended) the FDA approval list in July 2020 for painful diabetic peripheral neuropathy.
Multidisciplinary or Transdisciplinary: That is the question…
While all these interventions are cutting edge, and we learn more about treating chronic pain conditions, it has become increasingly obvious that we must work together. Interventional and non-interventional pain specialists, primary care providers, surgeons, physical therapists, and behavioral health specialists need to collaborate and customize treatment to meet specific patient needs. During the different sessions, the message was clear that chronic pain has a high association with depression, anxiety, and sleep disorders. Dr. Pryzbylkowski’s talk on behavioral health emphasized the resources required to treat these comorbidities in achieving an optimal outcome in pain management. The transdisciplinary pain management approach is a natural advancement of the biopsychosocial model of an interdisciplinary pain management program. We already know that chronic pain modifies the central nervous system’s biochemical architecture, which results in more pain with less provocation. This is termed “central sensitization” and manifests as pain hypersensitivity, enhanced temporal summation, and dynamic tactile allodynia. We need a transdisciplinary approach to treating patients with central sensitization, and the utilization of cognitive-behavioral therapies is a critical part of a multimodal treatment plan for chronic pain. Eventually, this model will decrease the overall cost of care and increase the number of patients who can be served.
In summary, I had a great time attending PAINWeek2020: Live Virtual Conference. The conference was well-represented by many disciplines and had a variety of sessions to keep all attendees interested. Thank you to all the presenters and staff who put the meeting together. Their dedication, research, and hard work were evident, and while I would love to talk about more sessions, I have to go change another diaper.