Faculty Bibliography

Over the last 30 years, pain has become one of the most dynamic areas of medicine and a public health issue. According to a recent Institute of Medicine report, pain affects approximately 100 million Americans at an estimated annual economic cost of $560 to $635 billion and is poorly treated overall. The American Board of Medical Specialties (ABMS) recognizes a pain subspecialty, but pain care delivery has struggled with increasing demand and developed in an inconsistent and uncoordinated fashion. Pain education is insufficient and highly variable. Multiple pain professional organizations have led to fragmentation of the field and lack of interdisciplinary agreement, resulting in confusion regarding who speaks for pain medicine. In this Perspective, the authors argue that ABMS recognition of pain medicine as an independent medical specialty would provide much needed structure and oversight for the field and would generate credibility for the specialty and its providers among medical peers, payers, regulatory and legislative agencies, and the public at large. The existing system, managed by three ABMS boards, largely excludes other specialties that contribute to pain care, fails to provide leadership from a single professional organization, provides suboptimal training exposure to pain medicine, and lengthens training, which results in inefficient use of time and educational resources. The creation of a primary ABMS conjoint board in pain medicine with its own residency programs and departments would provide better coordinated training, ensure the highest degree of competence of pain medicine specialists, and improve the quality of pain care and patient safety.

BACKGROUND: Fibromyalgia is a disease process without an obvious etiology. While some evidence suggests that adverse experiences in childhood contribute to its development, specific evidence has been equivocal. METHODS: A total of 36 patients with fibromyalgia from the greater New York area were recruited and surveyed using the Centers for Disease Control's Behavioral Risk Factor Surveillance System survey, and questions from the section on adverse childhood experiences were administered. The results were compared to those obtained from over 400,000 people surveyed by the Centers for Disease control each year, and were monitored for statistically significant differences. RESULTS: A statistically significant difference was noted among the control group, suggesting that individuals reported growing up with someone who was depressed when the respondents were between the ages of 0 and 18 years old. Moreover, respondents reported that they were hit by their parents in some way, were insulted or cursed at by their parents, and had been forced to have sex with someone at least 5 years older than them or with an adult. No correlation was found with the following variables and the development of fibromyalgia: growing up with divorced or separated parents; growing up with someone sentenced to serve time in jail; or having parents that abused each other. Additionally, statistically significant differences were found for the following categories: lack of emotional support; life dissatisfaction; fair or poor health; physical, mental or emotional disability; and being divorced or not married. DISCUSSION: Using this well-validated survey, it became clear that at least six specific adverse childhood experiences were correlated with the development of fibromyalgia. Data pertaining to disability, quality of life, life satisfaction, number of days of depression, emotional support, and marriage status illustrated the extent of subjective disability that these patients feel every day.

OBJECTIVE: The authors recently determined that early and longer term mortality after initiation or reinitiation of intrathecal opioid therapy is higher than previously appreciated: 0.088% within 3 days, 0.39% at 1 month, and 3.89% at 1 year. These rates were 7.5 (confidence interval, 5.7-9.8), 3.4 (confidence interval, 2.9-3.8), and 2.7 (confidence interval, 2.6-2.8) times higher, respectively, at each interval than expected based on the age- and gender-matched general U.S. population. A substantial portion of this excess mortality is probably therapy related and cannot be entirely accounted for by underlying demographic or patient-related factors, or by device malfunctions. We also analyzed multiple complementary internal, governmental, and insurance databases to quantify mortality and to identify medical practice patterns that appear to be associated with patient mortality risks, and to suggest measures for physicians and health care facilities to consider in order to reduce those risks. Both of those objectives involve judgments, which may be controversial and are subject to practical limitations. RESULTS: Multiple clinical and patient- or therapy-related factors appear to increase the risk for early post-implant mortality. Specific risk mitigation measures associated with each factor include: close attention to the starting intrathecal opioid dose (or restarting dose after therapy interruption); avoidance of outpatient implant or other device procedures that involve less than 24-hour monitoring for respiratory depression; supervision of concomitant opioid, respiratory depressant, or other central nervous system active drug intake early post-implant and chronically in the outpatient setting; and careful programming or dosage calculations and decisions in order to avoid the unintentional administration of high intrathecal opioid drug doses. CONCLUSIONS: Mortality after initiation of or device interventions in intrathecal drug delivery patients appears to occur as a result of multiple factors that present possible mitigation opportunities for physicians and health care facilities

Complex Regional Pain Syndrome (CRPS) is a neuropathic disease that presents a continuing challenge in terms of pathophysiology, diagnosis, and treatment. Recent studies of neuropathic pain, in both animals and patients, have established a direct relationship between abnormal thalamic rhythmicity related to Thalamo-cortical Dysrhythmia (TCD) and the occurrence of central pain. Here, this relationship has been examined using magneto-encephalographic (MEG) imaging in CRPS Type I, characterized by the absence of nerve lesions. The study addresses spontaneous MEG activity from 13 awake, adult patients (2 men, 11 women; age 15-62), with CRPS Type I of one extremity (duration range: 3months to 10years) and from 13 control subjects. All CRPS I patients demonstrated peaks in power spectrum in the delta (<4Hz) and/or theta (4-9Hz) frequency ranges resulting in a characteristically increased spectral power in those ranges when compared to control subjects. The localization of such abnormal activity, implemented using independent component analysis (ICA) of the sensor data, showed delta and/or theta range activity localized to the somatosensory cortex corresponding to the pain localization, and to orbitofrontal-temporal cortices related to the affective pain perception. Indeed, CRPS Type I patients presented abnormal brain activity typical of TCD, which has both diagnostic value indicating a central origin for this ailment and a potential treatment interest involving pharmacological and electrical stimulation therapies

New concerns have appeared recently in regard to the increasingly complex relationship between physicians and the pharmaceutical or devices industry. The American Academy of Pain Medicine (AAPM) Council on Ethics has discussed the issue, especially focusing on the implication of conflicts of interest for Pain Medicine, and published several recommendations for specific professional situations that the Pain Medicine physician may encounter