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CME

Unraveling the Mechanisms and Clinical Consequences of Pain: Recent Discoveries and the Implications for Pain Management: A Case-Based Interactive Expert Forum

  • Authors: Tong Joo Gan, MBBS, FRCA, FFARCS; Clifford Woolf, MD, PhD; Timothy J. Brennan, MD, PhD; Henrik Kehlet, MD, PhD; Nagy A. Mekhail, MD, PhD
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Target Audience and Goal Statement

This activity has been designed to meet the educational needs of physicians and other healthcare providers, including pain specialists and orthopedic surgeons involved in the care of patients experiencing pain.

Optimal management of pain requires a lucid understanding of their pathophysiology. Recent research has defined many aspects of the underlying mechanisms that give rise to the inflammatory pain response, as well as the central and peripheral effects that promote sensitization and resultant pain. However, in spite of these achievements, numerous questions surrounding the etiology and pathophysiology of pain remain unresolved.

During this interactive forum, comprising leading investigators in the fields of anesthesia, surgery, and pain management, current and novel data regarding the mechanisms of pain and the consequences associated with insufficient treatment will be discussed. In addition, several case studies will be presented, and current therapeutic perspectives regarding complete patient management in these cases will be examined.

Upon completion of this activity, participants will be able to:

  1. Explain the pathophysiology behind inflammation and pain in the central nervous system and periphery
  2. Discuss recent discoveries surrounding the pathophysiology of pain
  3. List the multiple systemic effects associated with pain
  4. Discuss appropriate management strategies for patients in pain


Author(s)

  • Timothy J Brennan, MD, PhD

    Associate Professor, Departments of Anesthesia and Pharmacology, Roy J. and Lucile A. Carver School of Medicine, University of Iowa, Iowa City, Iowa

    Disclosures

    Disclosure: Grants/Research Support: Pharmacia Corporation, Pfizer Inc
    Consultant: Pharmacia Corporation, Pfizer Inc

  • Tong Joo (TJ) Gan, MBBS, FRCA, FFARCS

    Associate Professor of Anesthesiology, Duke University Medical Center, Durham, North Carolina

    Disclosures

    Disclosure: Grants/Research Support: Pharmacia Corporation, Pfizer Inc
    Consultant: Pharmacia Corporation, Pfizer Inc
    Speakers' Bureau: Pharmacia Corporation, Pfizer Inc

  • Henrik Kehlet, MD, PhD

    Professor of Surgery, University of Copenhagen School of Medicine; Department of Surgical Gastroenterology, Hvidovre Hospital, Hvidovre, Denmark

    Disclosures

    Disclosure: Consultant: Pharmacia Corporation, Pfizer Inc

  • Nagy A Mekhail, MD, PhD

    Chairman, Department of Pain Management, Cleveland Clinic Foundation, Cleveland, Ohio

    Disclosures

    Disclosure: Consultant: Pharmacia Corporation
    Speakers' Bureau: Pfizer Inc

  • Clifford Woolf, MD, PhD

    Director of Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Charleston, Massachusetts

    Disclosures

    Disclosure: Grants/Research Support: Pfizer Inc
    Consultant: Pharmacia Corporation, Pfizer Inc


Accreditation Statements

    For Physicians

  • This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The Postgraduate Institute for Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    The Postgraduate Institute for Medicine designates this educational activity for a maximum of 3.0 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

    The American Medical Association has determined that non-US licensed physicians who participate in this CME activity are eligible for AMA PRA category 1 credit.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit:

  1. Read the target audience, learning objectives, and author disclosures.
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CME

Unraveling the Mechanisms and Clinical Consequences of Pain: Recent Discoveries and the Implications for Pain Management: A Case-Based Interactive Expert Forum

Authors: Tong Joo Gan, MBBS, FRCA, FFARCS; Clifford Woolf, MD, PhD; Timothy J. Brennan, MD, PhD; Henrik Kehlet, MD, PhD; Nagy A. Mekhail, MD, PhDFaculty and Disclosures
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Epidemiology of Pain

Introduction Presented by Tong Joo Gan, MBBS, FRCA, FFARCS

Welcome to the expert panel round table discussion on unraveling the mechanisms and clinical consequences of pain. I'm T.J. Gan, Associate Professor of Anesthesiology and Director of Clinical Research at Duke University Medical Center. We have a group of experts here today, truly leaders in this field, to address various aspects of pain mechanisms, as well as pain management. It gives me great pleasure to introduce our panel today. On my immediate left is Dr. Clifford Woolf; he's a professor with the Department of Anesthesiology and Critical Care at Mass General Hospital, Harvard Medical School. We have Dr. Timothy Brennan, Associate Professor of Department of Anesthesiology and Pharmacology from the University of Iowa. Dr. Henrik Kehlet, Professor of the Department of Surgery, Gastroenterology, from University of Copenhagen School of Medicine from Denmark. And we have Dr. Nagy Mekhail, Chairman of the Department of Anesthesiology from Cleveland Clinic Foundation. I'd like to startoff the program with an overview of pain and what is the impact of pain on society.

Epidemiology of Pain

  • Pain is the most common reason for a patient to seek medical attention. In fact, about 1 in 6 of the visits to the primary care physicians is because of acute pain. Chronic pain affects about a third of the US population.

  • slide

    Slide 1.

    Patients in Pain Epidemiology

    (Enlarge Slide)
  • Pain can be broadly divided into acute and chronic. Acute pain tends to have an identifiable cause, and it often is relieved following the removal of that cause. Examples of acute pain are postsurgical pain, sports-related injury, trauma, lower back pain, as well as acute headache. Chronic pain, however, is more complex. It tends to have less identifiable causes, and therefore, the focus of the management has been to improve symptoms and preserve functionality as well as psychological act function. Examples of chronic pain include musculoskeletal pain, pain from malignancy, chronic infections, osteoarthritis, rheumatoid arthritis, lower back pain and chronic headache.

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    Slide 2.

    Conditions Associated With Pain

    (Enlarge Slide)

Chronic Pain

  • Let us look at what is the impact of chronic joint symptoms and arthritis. It was estimated in 2001 about 33% of the chronic pain syndromes, approximately 70 million adults in the United States, suffer from this condition. Physicians diagnose arthritis in about 10% of the population, and if you include chronic joint symptoms, this goes up to about 12%.

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    Slide 3.

    Chronic Joint Syndromes and Arthritis Prevalence in the United States, 2001

    (Enlarge Slide)
  • Now, lower back pain is a very common problem. Annually, about 15% to 45% of adults suffer from lower back pain, and the lifetime prevalence is estimated to be at least 70%. It affects the segment of the population that is most productive: adults from the age of 35 to 55 years of age. And it is associated with substantial disability. Lower back pain has an enormous economic consequence as a result of absenteeism, as well as increase in utilization of healthcare resources.

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    Slide 4.

    Low Back Pain Background

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  • Now, it is estimated that some of the causes of chronic disability--for example arthritis and rheumatism, as well as back pain and spine problems--accounts for the highest percentage, about 35%, of the total chronic disability is as a result of these chronic pain syndromes.

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    Slide 5.

    Causes of Chronic Disability (US)

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  • Now what is the impact on society? Chronic pain such as musculoskeletal pain can increase medical expenses, result in lost income and reduced productivity. The quality of life is affected. Activity of daily living is impaired. Chronic pain can cause mood changes and decreased involvement in activities, and it is estimated that the cost to the society--both for direct and indirect cost--for all the musculoskeletal conditions amounts to over $200 billion, a staggering sum indeed.

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    Slide 6.

    Societal Effects of Musculoskeletal Pain

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Acute Pain

  • What about acute pain? Are we better at managing acute pain? It is estimated that about 70 million surgical procedures are performed in the United States, by the CDC in 1996. With the increasing popularity of ambulatory procedures, the percentage of ambulatory procedures compared to the inpatient is dramatically increased, about 60% to 65% patients being done in an ambulatory basis.

  • slide

    Slide 7.

    Number of Inpatient and Outpatient Procedures in the United States, 1996

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  • We recently conducted a national survey to look at the incidence and severity of pain following a surgical procedure. We found that over 50% of patients had either moderate, severe, or extreme pain following surgery before discharge from hospital. And if you look at incidence following discharge, this went up to about 60%. So indeed, it is a major problem.

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    Slide 8.

    High Postoperative Pain Levels

    (Enlarge Slide)
  • Another study, by Coley and colleagues, looked at the incidence of readmissions following ambulatory surgery. And the group found that over 38% of that cause is the result of pain. And the largest population of that group had orthopaedic surgery.

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    Slide 9.

    Readmissions from Same-Day Surgeries

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  • Now, we always assume that following an ambulatory procedure, pain subsides rapidly following discharge. And this may not be so. In a study where they looked at pain at 7 days postoperatively and found that 25% of patients undergoing ambulatory procedures experienced pain that is moderate to severe; and when they were asked about their average pain, about 13% said that they experienced the pain as being moderate to severe. Interestingly, only 10% of these patients were still using an analgesic.

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    Slide 10.

    Postsurgical Pain Experience

    (Enlarge Slide)
  • Now with the improvement and advancement in pain medication as well as delivery of pain medication, are we better at treating pain following ambulatory procedures? The study that we performed a couple of years ago was not dissimilar from a previous study that was done in the early 1990's by Carol Warfield and her group. Indeed, this suggests that pain management hasn't improved significantly over the last decade or so.

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    Slide 11.

    1993 and 1999 Postoperative Pain Levels

    (Enlarge Slide)

Summary

  • So in summary, acute and chronic pain are very common. Pain has a significant societal as well as economic impact. And pain is still poorly managed, and I think there is still much room for improvement. Thank you.

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    Slide 12.

    Summary

    (Enlarge Slide)