I'll be presenting the introductory module on basic tenets of pain treatment. The objectives of this module are to describe the socio-psychobiological model of pain and how this impacts treatment approaches, review the evidence for pharmacological and non-pharmacological therapies for pain, and compare recommended strategies for managing common pain conditions. I'd like to start with a case. So this is a 53-year-old male who developed low back pain three days ago after playing golf. The pain's rated 9 out of 10. He's not doing regular morning walks due to his pain. There's no symptoms radiating to legs, no history of trauma, no bowel or bladder changes, no constitutional symptoms. The patient's tried over-the-counter ibuprofen with no relief. He's having trouble sleeping, has a history of alcohol use disorder in remission, and is currently being treated for depression with paroxetine. So we'll come back to this case later in the presentation. So some of the questions to think about. What's your initial approach to management of this patient? Would you recommend medications, and if so, which ones? Would you recommend non-pharmacological therapies, and if so, which ones? What if the patient doesn't improve after a week of initial therapies? What if he's still having pain after three months? So for treating acute and chronic pain, just some overarching concepts, acute pain is usually defined as pain that's been present for less than four weeks. Acute pain, for most patients, the natural history is for marked improvement over days to weeks. Analgesics tend to be more effective for acute than chronic pain. Chronic pain is usually defined as pain lasting more than three months. Symptoms tend to be persistent or recurrent over time. They also tend to be more difficult to treat. The socio-psychobiological perspective is important to understand when addressing patients with pain. Some of the key concepts include the fact that psychosocial factors are stronger predictors of people who transition from acute to chronic pain. They're also stronger predictors of severity and impact on function. Biological factors, such as imaging findings and lab tests, tend to poorly correlate with the likelihood of transitioning to chronic pain or severity. And therefore, treatment approaches for chronic pain must address psychosocial contributors to pain in order to be most effective. This means that we're taking more of a chronic illness management approach for pain. There are many factors that can impact and lead to persistent pain. So this slide shows a number of the issues that can contribute, including other physical problems, sleep disturbances, substance misuse, presence of functional disabilities, stress, cognitive distortions in terms of how people manage and cope with pain, and then psychological conditions like anxiety, depression, or PTSD. And you can see these arrows are bidirectional. This refers to the fact that these relationships go both ways. So, pain can worsen anxiety and depression, et cetera. This slide kind of illustrates the cycle of self-management in chronic illness. It really starts with a patient-provider shared plan of care. There's goal-setting, skill and knowledge acquisition by the patients, attempts to apply those skills to achieve functional or other goals. The goals are either achieved or not met. And then you revise the plan, as well as the goals, and then you come to decisions about the plan of care. And so, it's a continuous, ongoing cycle. I think this is a useful model to think about when thinking about management of chronic pain. There are many treatment options for pain. These include self-management, a number of medications, exercise and related interventions, so things like yoga, Pilates, et cetera, a number of physical modalities. So, these can include things like electrical stimulation or ultrasound, heat, transcutaneous electrical nerve stimulation, other things like that. There's cognitive behavioral therapies and other psychobehavioral interventions, a number of complementary and integrative therapies, so things like spinal manipulation, acupuncture, massage, some of the mind-body interventions, some mindfulness types of therapies, and also there are many other complementary and integrative therapies. There's a number of interventional therapies that can be used for pain, so various types of injections, for example. And then interdisciplinary rehab, which usually combines exercise and psychobehavioral interventions and may include other therapies, can be effective, particularly for people with more severe advanced symptoms or functional deficits. The approach to the treatment of pain varies for acute and chronic pain. For acute pain, a lot of it focuses on symptom relief and getting people through those first few days until they start to get better. We advise people to avoid prescribed bed rest. Early return to activity leads to faster improvement than prescribed bed rest. Superficial heat or cold, so hot packs or cold packs, can be helpful for symptom relief and over-the-counter analgesics can also be useful. A small proportion of people with acute pain do transition to chronic pain, and it's important to identify and address psychosocial risk factors early in order to help prevent that transition in people who have those risk factors present. As I mentioned earlier, chronic pain is more difficult to treat. It doesn't tend to improve on its own, it tends to be long-lasting. A lot of the focus starts to shift towards improving function, so even when we use therapies, some pain is not completely relieved, but we can help people to regain function, ability to work, enjoy activities with their family, et cetera. Self-care is important, so helping patients to learn coping skills, use relaxation or meditation approaches, activity and exercise, again, identifying and addressing psychosocial contributors. There's a number of treatments that are available for chronic pain, and so some factors to consider when choosing among treatments are, of course, safety and efficacy. We like to emphasize active over passive modalities, so active therapies are those that, you know, the patients actively are engaged in or involve movement and functional activities, so these include things like psychobehavioral treatments, exercise therapies, interdisciplinary rehab. Passive therapies are more aimed towards symptom relief, and they're things that the patient receives, so things like medications, physical modalities, complementary and integrative therapies, and interventional treatments. These can be used as an adjunct or bridge to active therapies, but active therapies generally should be the prime modalities. Other factors to consider include cost, availability, patient adherence, and prior responses. So going through some of the specific types of therapies, so cognitive behavioral therapy is a psychological therapy. It integrates a cognitive component, so this refers to therapies that are aimed at restructuring maladaptive thinking patterns associated with counterproductive or irrational thinking patterns, coping behaviors, and emotions, so these include things like fear avoidance where people are worried that movement is harmful because it hurts or catastrophizing where people think they're never going to get better and they're only going to get worse and worse, so trying to correct some of these thinking patterns. There's also a behavioral component where we train individuals to replace undesirable behaviors with healthier behaviors, so this typically involves goal-setting, getting people to achieve functional goals. The objectives of CBT are for patients to go from overwhelmed to feeling like their pain is manageable, to take on a more active role in their care, of course, to reduce symptoms, and then importantly, to increase functional quality of life. Basic strategies for cognitive behavioral therapy include breaking the challenges into small pieces, setting achievable goals, right, we don't want the goals to be unrealistic, and to strategize solutions when people are running into challenges. We want to transform negative thoughts to positive statements, again, address fear avoidance and catastrophizing because we want people to move and to understand that pain does not necessarily indicate that they're causing damage. Patients need to learn strategies and engagement to help distract from pain, practice relaxation techniques, and then also practice situational coping strategies to prevent and reduce pain. Studies do indicate that CBT is effective, so for example, a systematic review of CBT for chronic pain found small to moderate effects on pain, this means one to two-point reductions on a zero to 10-point scale, as well as disability, mood, and catastrophizing versus usual care or waitlist. Some of the effects on mood were maintained at six months after treatment, and CBT has been found to be effective for specific conditions like low back pain. In practice, CBT, we usually recommend it as a time-limited course, this is typically eight to 10 sessions, there may be a refresher, you know, after several months or repeated refreshers. CBT can be group-based or individual. There are online self-guided programs like the FibroGuide at the University of Michigan. The basics of CBT can be implemented by, you know, different professionals, including primary care clinicians. In general, CBT may be more effective in people with psychosocial risk factors, but we think most people with CBT can benefit whether they have psychosocial risk factors or not. The Start Back screening tool was tested in a randomized controlled trial. This is a risk-gratified approach to use of CBT-informed physical therapy where we used more intensive CBT approaches in people who had more risk factors, and this was found to be more effective than usual care without risk stratification. There are a number of books for patients and non-psychology professionals to help implement CBT, and some suggestions are shown on the slide. Another therapy is meditation and relaxation. This can be a helpful technique for self-management and coping. It's often incorporated in CBT and utilizes CBT principles. The techniques involve distraction, reducing anxiety, reducing sympathetic arousal, reducing muscle tension, and altering central processing of pain. Evidence on effectiveness is limited, though some data, particularly for yoga and mindfulness-based relaxation, suggests that these therapies may be similar in efficacy to CBT. There's a number of techniques, so meditation, which includes mindfulness or mantra-focused-based approaches, progressive muscle relaxation, autogenic training, hypnosis, guided imagery. Some therapies like yoga, tai chi, what we call mind-body therapies, these involve movement or exercise but also incorporate meditation or relaxation principles, so they're kind of combined approaches. There's a clinician playing an important role in promotion of self-care. These include active listening, educating patients about pain, the expected course, what to expect from treatments, goal-setting, et cetera, helping to link patients with resources, helping to problem-solve, using motivational interviewing techniques have been shown to be effective, more effective at getting patients to engage and adhere to treatments, and then being a cheerleader and cheering small as well as big successes. Exercise is another type of therapy. You know, this is one of the prime active therapies. It has effects on pain and function, and of course, exercise is good for general health. Getting people to move and exercise helps to reduce fear-avoidance behaviors, and there are many different types of exercise, so aerobics, strengthening, stretching, mixed techniques, McKenzie, motor control and stabilization, active trunk exercise, and others. There are related therapies like the Alexander Technique, Pilates, I previously mentioned yoga and Tai Chi. Exercise can also be supervised or done at home. They can be administered into groups or individually. Ideally, they're done within a CBT-informed framework, and so, again, you want people to understand that movement is helpful in setting goals and problem-solving, so, again, it's consistent and complementary, I would say, to a CBT-informed approach. There is variability in intensity, and this can be tailored to the patient. Exercise may cause some increase in pain in the short term, but, again, the long-term benefits, we think, outweigh those short-term pain, and in the long run, patients will benefit from the exercise. I mentioned that there are many different types of exercise. There's really no clear evidence that one type of exercise is better than others. Exercise has been shown to prevent low back recurrences, so in people who have repeated episodes, it may be particularly useful, and I think it's important for clinicians to recognize that exercise will only be effective if patients engage in it, and so it's important to encourage patients to use exercise or engage in exercises that they enjoy and will be able to continue. Supervised, individualized programs may be more effective, at least initially, though some highly motivated patients may do well on their own. Handouts and videos can be given for home exercise, and the key is to start slow and to use incremental increases. Interdisciplinary rehabilitation, as I mentioned before, at a minimum, should combine both physical and biopsychosocial treatment components. It's provided by professionals from at least two different specialties. Of course, the components and intensity of interdisciplinary rehab can vary quite a bit. There's related interventions that include functional restoration, work hardening. Usually, these are more in workman's compensation kinds of settings. And unfortunately, lack of availability and reimbursement remain an important barrier to use of interdisciplinary rehab. Studies show that interdisciplinary rehab is slightly to moderately more effective than non-interdisciplinary rehab for chronic pain at improving pain and function. The ideal components are uncertain, though again, we recommend exercise and CBT at a minimum. More intensive programs may be more effective than less intensive programs, but also more costly, in some cases much more costly. And because of the cost and resource implications, we usually reserve interdisciplinary rehab for patients who have failed standard treatments, who have severe functional deficits, or severe psychosocial risk factors. As I mentioned before, there are a number of physical modalities. These include a variety of primarily passive treatments, so superficial heat or cold, ultrasound, interferential therapy, shortwave diathermy, transcutaneous electrical nerve stimulation, or TENS, low-level laser therapy. These are all modalities where you basically apply some type of energy source to the surface over the muscles or soft tissues. Traction, taping, braces and supports, other things like magnets, et cetera. Unfortunately, the evidence for most physical modalities is limited and generally have failed to show consistent benefits. An exception is heat, which has been found to be similarly effective to NSAIDs for acute low back pain. Other modalities are not routinely recommended, but these therapies appear to be safe and some patients may experience or perceive benefit. So, it may be appropriate in patients who are really interested in using them to consider their use as an adjunct. We do recommend caution with certain types of traction, which can cause injuries. And again, if you are going to use physical modalities, use them in conjunction with active therapies. Be aware that there are some costs involved and discontinue if they're ineffective. As mentioned previously, there are a number of complementary and integrative therapies. These include chiropractic manipulation or mobilization, as well as osteopathic manipulation, acupuncture and related techniques like electroacupuncture or acupressure, massage. We previously talked about meditation, mindfulness, and then yoga and tai chi. There's many others. There's some evidence that spinal manipulation, acupuncture, and massage are more effective than no therapy and similarly effective versus exercise. These therapies have been found to be generally safe, though there should be caution with manipulation of the cervical spine. The evidence on effectiveness does vary for different pain conditions. For example, manipulation doesn't appear to be effective for fibromyalgia. There is variability in the techniques and number, frequency, or duration of sessions. So, even among the different therapies, there's different, for example, massage techniques, different acupuncture techniques, etc. So, this can be very hard to sort out. It's more complicated than giving somebody a drug at a certain dose and being able to measure what the effects are. So, the optimal techniques and dose are uncertain. There's often methodological shortcomings in the trials. They're often difficult to blind, etc. Some of these techniques can be done in primary care with training. There is enhanced access through the Affordable Care Act in terms of coverage. And I think it's important to be aware that some of the effects may be nonspecific because these are typically hands-on types of therapies and, you know, patient expectations of benefit probably influence their experience. In general, these therapies are less active than exercise or CBT. So, again, they should be considered primarily as an adjunct to active therapies. There's a number of medications that can be used. So, this lists some of the main classes, opioids, acetaminophen, NSAIDs, tramadol or tepentadol, which are a dual action. They have some opioid effects as well as some central effects, gabapentin and pregabalin, antidepressants, in particular tricyclics and SNRIs, skeletal muscle relaxants, benzodiazepines, a variety of topical agents, and others. In terms of an approach to medications, analgesics are generally more effective for acute pain than for chronic pain. For chronic pain, effectiveness for short-term pain is small to moderate and limited for function. Evidence is very limited on long-term effects. Again, you know, medications are also a passive type of treatment. They don't address any of the psychosocial factors that contributed to pain. So, we want to use them in conjunction with more active therapies in people with chronic pain. Decisions around medications should be individualized and based on the assessment of potential benefits and harms. Recognize that opioids carry special risks related to the addiction and overdose potential. They should be used cautiously in appropriately selected patients with proper monitoring. Again, consider prior response to medications, which may help predict future response. The type of pain can have some impact. So, for example, neuropathic pain tends to respond more to gabapentin slash pregabalin, as well as to some of the antidepressants. There are specific medications for some conditions, such as DMARs for rheumatoid arthritis, triptans for migraine headaches, and then consider comorbidities. So, for example, patients with depression and pain might benefit from an antidepressant with analgesic properties. For going through some of the individual classes, opioids, I think it's well recognized that opioids have become widely prescribed for chronic pain effects. There's moderate short-term effects on pain, small or inconsistent effects on function. The evidence on long-term benefits are very limited. And then, again, there's serious harms, including overdose, opioid use disorder, and we do have a separate opioid webinar for details on the approach to use of opioid therapy. Non-opioid analgesics, these include acetaminophen and NSAIDs. Acetaminophen is the most prescribed or used. It can be hepatotoxic. It's probably less effective than NSAIDs, and unfortunately, some randomized trials have shown that it's not effective for some conditions, like low back pain or osteoarthritis. NSAIDs, there are non-COX-2-selective as well as COX-2-selective NSAIDs. The non-COX-2-selective NSAIDs have increased risk of cardiac and GI toxicity, also renal and liver toxicity. There's some platelet inhibition effects. Nacroxin may be less cardiotoxic than others. Gastropathy, so GI side effects, tend to be the most limiting issue. For the COX-2-selective agents, these have less GI toxicity but maybe more cardiotoxic, so there is a trade-off there. The use of non-opioid analgesics may lower the need for opioids or lower the doses used. They appear to be effective for nociceptive pain and have some anti-inflammatory properties. They seem to be less effective for neuropathic pain. NSAIDs are first line for many pain conditions. The magnitude of effects appear to be small to moderate, but they're relatively safe for short-term use in appropriately selected patients. As mentioned, nacroxin appears to be less proteotoxic, so it may be a good first non-selective NSAID choice. The principle is to use the lowest dose of NSAIDs for the shortest duration to reduce proteo and GI toxicity. I recognize that NSAIDs may interfere with aspirin and antithrombotic effect, and to take them at least one half hour before taking aspirin. As I mentioned, acetaminophen was ineffective for acute low back pain in one well-conducted trial. Tramadol and tepentadol, again, these are dual mode of action agents. They have opioid agonist effects, as well as norepi or serotonin norepi reuptake inhibitor effects. Tramadol is a weak opioid mu receptor agonist. It's FDA Schedule IV as of August 2014. Tepentadol has stronger mu receptor affinity and it's FDA Schedule II because of this. There's no clear difference in efficacy or safety of these agents versus opioids. In general, tramadol can be approached like a weak opioid, and tepentadol can be approached like a stronger opioid. There is seizure caution with tramadol, abuse potential, and like opioids, long-term studies are lacking. Gabapentin and pregabalin are GABA analogs. These bind to the alpha-2-delta subunit of voltage-gated calcium channels. These inhibit neurotransmitter release. Pregabalin is a structural congener of gabapentin with superior absorption. This results in higher potency and more predictable effects. These are both first-line agents for neuropathic pain. Pregabalin is approved for fibromyalgia. Both drugs are increasingly used off-label for other non-neuropathic pain. Adverse effects include sedation, dizziness, or ataxia. There's no clear differences between gabapentin and pregabalin, though, again, the pharmacokinetics of pregabalin are more predictable, and we can generally use lower doses with it. Randomized trials indicate that these drugs are ineffective for low back pain with or without radiculopathy. They're often used off-label in the United States for anxiety or insomnia, but cautions are in order. There's potential increased overdose risk when used with opioids. Gabapentin has been best studied for both post-herpetic and diabetic neuropathy. It's FDA-approved for post-herpetic neuralgia. Gabapentin is titrated slowly from 300 milligrams a day up to 3,600 milligrams a day in divided doses. Higher doses are sometimes used in clinical practice, but this is off-label. Gabapentin is not absorbed well, and it can take two months for an adequate trial. As mentioned, it has a number of side effects, including sedation, weight gain, dizziness. And then risks, again, there is some risk of overuse in patients with substance use disorder, and it needs to be adjusted for renal dysfunction. Pregabalin is FDA-approved for use in fibromyalgia. It can be more quickly titrated to the maximum recommended dose than gabapentin. 300 to 600 milligrams have been shown to be, it's used for efficacy for post-herpetic and diabetic neuropathy, and better than for fibromyalgia and central neuropathic pain. It has similar side effects to gabapentin, perhaps a little bit less sedation, and then it's a Schedule V due to reports of euphoria, potential overuse. Other anti-seizure medications have long been used for neuropathic pain. They appear to have some direct analgesic effects plus calming, mood-stabilizing effects, but these are second- or third-line agents. The exception is carbamazepine for trigeminal neuralgia, also used for post-herpetic neuralgia. Oxtrabazepine is similar to carbamazepine. There can be some complicated interactions with these drugs. It's important to be aware that blood levels do not correlate well with pain efficacy, and to follow normal prescribing precautions, including checking liver tests and monitoring blood counts, et cetera. The adverse event profile of these other anti-seizure medications is generally more serious than with gabapentin and pregabalin. Antidepressants are first-line agents for neuropathic pain, though they're off-label for this condition, with the exception of duloxetine for diabetic neuropathy. Caution is advised with tricyclic antidepressants in older patients because of anticholinergic and cardiac effects. Antidepressants have best been studied in neuropathic pain, fibromyalgia, and headaches. The mechanism of action is to block reuptake of norepinephrine and serotonin, as well as other receptors and channels. The efficacy for neuropathic pain does not correlate with antidepressant response, and in fact, these drugs are effective in people with or without depression to begin with. SSRIs appear to be less effective for pain than TCAs and SNRIs. SNRIs specifically can be thought of as a kindler or gentler tricyclic. They lack the adrenergic, cholinergic, and sodium-channel effects of TCAs. This results in better tolerability and better safety profile. Drugs in this class include benlofaxine, duloxetine, and milnisipran. They're first- or second-line agents for neuropathic pain. Duloxetine is FDA-approved for fibromyalgia, diabetic neuropathy, and chronic musculoskeletal pain. This includes low back pain and chronic pain due to osteoarthritis. The pain efficacy may be no better at 120 milligrams than at 60 milligrams. However, antidepressant effects may require a higher dose. Milnisipran is FDA-approved for fibromyalgia. Head-to-head trials of these agents are lacking, and tolerability may vary from agent to agent. Benlofaxine has been associated with hypertension. Skeletal muscle relaxants are a heterogeneous group. These are drugs classified by the FDA because of their use, not because they have a similar chemical structure or mechanism of action. As you can see from the slide, these drugs are actually quite different. So cyclobenzaprine is similar to a tricyclic antidepressant. Tizanidine is actually similar to clonidine, an antihypertensive drug. Orfenadrine is similar to diphenhydramine, which is an antihistamine. Carisoprodol is metabolized to a barbiturate, which has addiction potential, and we actually recommend avoiding its use. Abaclifen acts on GABA receptors, so similar in some ways, I guess, to pregabalin and gabapentin. And there are a number of other skeletal muscle relaxants. It's also important to recognize that these are, even though these are all skeletal muscle relaxants, they're actually approved for different indications. So some are approved for treatment of musculoskeletal conditions. So these are drugs like cyclobenzaprine, methicarbamol, orfenadrine, et cetera. And others are approved for treatment of spasticity. So this is from neurologic, you know, upper motor neuron injuries. And these include baclifen, dantrolene, and tizanidine. All skeletal muscle relaxants are sedating. They have not been well-studied for chronic pain. They're considered second or third-line agents for acute pain, primarily because of the sedation and central nervous system effects. It's important if you're gonna use skeletal muscle relaxants to be familiar with the properties of one or two that you plan to use. Cyclobenzaprine and tizanidine are the best-studied agents for chronic pain. We recommend that if they're used, to use them short-term, say less than one to two weeks. They may help with sleep. We really don't have good evidence on efficacy with long-term use. And again, we recommend avoiding carisoprodol due to the addiction potential. Benzodiazepines, we generally recommend avoiding use for treatment of acute or chronic pain. These act on GABA receptors. They're used off-label as muscle relaxers, but are not classified as skeletal muscle relaxants. They have sedating and anxiolytic effects, but risk of misuse or addiction. They're scheduled for drugs. Withdrawal can be severe and can result in seizures or death. And there's a high risk of overdose when used with opioids or other CMS depressants like alcohol. Evidence for use of benzodiazepines in pain is very limited. In general, other medications are recommended for treating anxiety or insomnia, particularly for long-term treatment. There are a number of topical agents. So these include topical lidocaine, which is effective for neuropathic pain, topical NSAIDs, which are effective for localized osteoarthritis. Head-to-head trials show that topical NSAIDs are similar in effectiveness to oral NSAIDs because they result in lower serum levels than oral or NSAIDs. They may result in fewer serious adverse events. The absorption of NSAIDs when administered topically really depends on the NSAID and the carrier. There are several FDA-approved formulations. You can compound NSAIDs. So those aren't FDA-approved formulations, but you can have a pharmacy compound an NSAID into a topical formula, but the absorption is often unknown or unclear. There's a number of topical salicylates, rubefacients. These are things that have surface effects and local effects from rubbing, so they don't have anti-inflammatory properties like the NSAID. This is like the Bengay people get over the counter and things like that. Really not absorbed beneath the skin. Effectiveness is really unclear. Some people like them. They think that it makes them feel better, but they really have not been shown to be effective in reducing pain. Topical capsaicin has been shown to be effective for musculoskeletal pain, also for neuropathic pain, though off-label for that. Capsaicin depletes substance P, results in initial flare or burning sensation, irritation of skin, as well as muscle membranes. Because no one drug is a magic bullet, polypharmacy often occurs. We do think clinicians should be aware of this and try to avoid it or minimize it. This means doing trials of individual drugs, being sure to stop drugs that are ineffective or causing side effects, and being aware of and avoiding drug-drug interactions. This is kind of a constant process, and I think we've all had the experience of having patients come to us or one of our own patients, and they've just accumulated a lot of drugs, and it can be very challenging to figure out what's working and what's not. So being aware, again, adding drugs one at a time. If they're not working, being sure to discontinue that and to record that in the chart. Few studies have examined drug combinations non-opioid analgesic combinations with opioids are quite common, so that's kind of the exception. And it's usually something like hydrocodone plus acetaminophen, or with a NSAID, this can also be with oxycodone. It's unclear if those combinations are more effective than an opioid or non-opioid alone, but again, they're very commonly used. There's a number of interventional pain procedures. These include trigger point injections, diagnostic blocks and procedures, corticosteroid injections, a variety of ablative procedures, nerve blocks, intrathecal drug delivery, spinal cord stimulation, in the future, maybe deep brain stimulation, and others. It could be reserved for a patient with persistent severe pain, despite standard treatments. In some cases, people who are at high risk for opioids, so you don't want to use those if they're not improving. The evidence really varies for different interventional procedures. Have a lot of caution when the evidence is limited or doesn't clearly show benefit. Unfortunately, there have been a number of examples of interventional pain procedures that have been with opioids. Interventional pain procedures that have been widely used, but when rigorously studied, don't show large benefits. In general, the magnitude of benefits has been relatively modest and or limited in duration. So for example, for epidural steroid injections, there is some short-term benefits, but it's relatively small, and it usually lasts for two to four weeks, versus placebo or a sham injection. There are risks associated with invasive procedures. Some of these procedures are associated with long-term or permanent placement of hardware, again, with attendant risks, and of course, costs are a consideration. Now we're gonna go through some common pain conditions and evidence-based treatment recommendations. So these will be for low back pain, migraines, fibromyalgia, osteoarthritis, and neuropathic pain. For acute low back pain, again, most acute nonspecific low back pain will resolve over time without specific treatment. So the goal is to control pain and maintain functions while symptoms diminish on their own. Self-care is important, and this includes advice to remain active. We generally discourage bed rest. It's been shown that people who have prescribed bed rest tend to recover more slowly. Non-pharmacological therapy is generally preferred, so superficial heat, massage, acupuncture, spinal manipulation, but analgesics are often used, again, for symptom relief as an adjunct. Acetaminophen may be ineffective based on a well-done RCT, but it's safe in most patients. Opioids should be reserved for selected patients with moderate or severe pain, and for a time limited, such as three to five days in most cases. And then again, skeletal muscle relaxants should be used for a limited period of time. They may be most helpful in people with sleep issues related to pain. It's important to inform patients that back pain is common and that there's a high spontaneous recovery rate. At four weeks, 50 to 75% of patients will be recovered and more than 90% at six weeks. Chronic low back pain, again, self-care and education are important in all patients. Non-pharmacological therapies are preferred, and among those, we prioritize active modalities, so things like exercise or related modalities like yoga or tai chi, CBT, mindfulness-based stress reduction, and interdisciplinary rehab. This can be supplemented with less active therapies like spinal manipulation, acupuncture, massage. Medications, first line is NSAID. Second line includes the antidepressant SNRIs and Tramadol. Again, opioids, if they're used, patients need to be carefully selected and monitored, and the trial should be a short-term trial. Avoid benzodiazepines, systemic corticosteroids, and Carisoproto, and then treat any co-occurring psychiatric comorbidities, which is really important to help improvement. For migraine, acute treatment, aspirin, acetaminophen, and NSAIDs. These can be combined with caffeine. Anti-nausea medications can also be used, may be given by suppository for people who are having trouble taking oral pills. Triptans are a migraine-specific therapy. They are contraindicated in persons with uncontrolled high blood pressure, vascular disease who are pregnant, severe kidney or liver disease, familial hemiplegic migraine, or basilar migraine, that have a strong evidence base for treatment of acute migraines. Ergots can be combined with caffeine. They're not as effective as triptans and are associated with more nausea. It's important to recognize that medications are more effective if taken early and as larger single doses than repeated smaller doses. Non-oral routes may be necessary if nausea or vomiting are severe. Avoid medication overuse. This can result in rebound headaches. Opioids and barbiturates generally are not recommended. They're less effective than the treatments listed here. There's little evidence on effectiveness. There's abuse potential and risk of overuse headaches. For preventive treatment, again, a number of therapies. These include beta blockers, tricyclic antidepressants, anti-seizure medications, calcium channel blockers, the CGRP antagonists. Some of the side effects and issues are shown here. It's important to remember that preventive treatments can take three to four weeks to show effects. There are also some non-pharmacological treatments that may be helpful. These include CBT, relaxation training, biofeedback, and exercise therapy. It's important for patients to learn what their triggers are and how to avoid them, and there are some resources available for patients. For neuropathic pain, in terms of pharmacologic treatment, first-line therapies are tricyclic antidepressants, SNRIs, gabapentin or pregabalin, and then topical lidocaine. This slide shows optimum doses and estimated numbers needed to treat, which are pretty close for most of the therapies, maybe slightly better for the tricyclic antidepressants, but again, more side effects with those. Second-line therapies include opioids, and then third lines are some of the other anti-seizure medications like lamotrigine and carbamazepine and topical capsaicin. For osteoarthritis, non-pharmacologic treatments are generally tried before medications. These include exercise, weight loss, patient education. Yoga, CBT, orthoses, and acupuncture are options, and acupuncture should be considered as an adjunct. In terms of medications, first-line medications include acetaminophen, oral NSAIDs, topical NSAIDs or capsaicin, and duloxetine. Interarticular glucocorticoids can be used if acetaminophen and NSAIDs are insufficient, and second-line therapies include opioid analgesics, intraarticular hyaluronic acid, glucosamine, and chondroitin. And then for fibromyalgia, there's three FDA-approved medications. These are pregabalin, duloxetine, and milnacipram. There's some details there about the numbers needed to treat, which appear to be the lowest for milnacipram, but again, little, few studies that directly compare these agents. Moderately intense aerobic exercise or strength training has also been shown to be useful. Cognitive behavioral therapy, interdisciplinary rehab, acupuncture, and biofeedback. Other meds that have been used and may work, though the evidence is limited, include amitriptyline or nortriptyline, gabapentin, venlafaxine, again, an SNRI, a combination of tramadol plus tylenol, tizanidine, which is a skeletal muscle relaxant, or compounded naltrexone, which is a opioid antagonist. So going back to the case, the patient was initially treated for the acute low back pain. There were no neurological signs or symptoms, education, reassurance, heat, advice to remain active. He was offered three days of skeletal muscle relaxant to help with sleep and continued his over-the-counter NSAID. He returned to the clinic, failed to improve after one week. He recorded stress at work and at home, poor sleep, mood doing worse, excuse me. He's afraid of walking or exercising due to concerns of damaging his back. At that point, he was switched from his current antidepressant which was an SSRI to an SNRI, duloxetine, and this medication was titrated up. He was switched from over-the-counter NSAID to a prescription dose of naproxen, 500 milligrams twice a day, and the contribution of psychosocial factors to his pain as well as coping strategies including fear avoidance were discussed. Again, failed to improve after three months. At this point, he was referred for supervised exercise therapy and cognitive behavioral therapy. He was also interested in acupuncture and referred to acupuncture as adjunctive therapy. At his five-month visit, he reported that the pain and function had improved. He was back to playing golf and walking daily with a home exercise program. Mood has improved and the pain was still present but manageable. So in conclusion, numerous medications and non-pharmacological therapies are available for pain. For acute pain, the prognosis is generally favorable. The main goals are symptom relief and early activity and self-care. Chronic pain should be approached from a sociopsychobiological perspective. This means assessing psychosocial risk factors and addressing them if they're present. Self-care, focusing on active treatments, in particular exercise and CBT, treating any psychiatric comorbidities, considering the benefits and harms of therapies and supporting evidence when choosing therapies, understanding the first-line options for common pain conditions, using condition-specific medications when they're available, considering costs and taking into account patient preferences when different options are present. So that concludes this presentation. There's a number of references shown on these slides for those who are interested. I'd like you to be aware of two resources offered through PCSS that may be of interest to you. First, PCSS's mentor program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from our mentor directory, or we are happy to compare you with one. To find out more information, please visit our website using the web link noted on this slide. Second, PCSS offers a discussion forum which is comprised of our PCSS mentors and other experts in the field who help provide prompt responses to clinical cases and questions. We also have a mentor on call each month. This person is available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. This slide simply notes the consortium of lead partner organizations that are a part of the PCSS project. Finally, please reference this slide for our contact info website and Twitter and Facebook handles to find out more about our resources and educational offerings.

pain treatment

socio-psychobiological model

pharmacological therapies

non-pharmacological therapies

acute pain

chronic pain

psychosocial factors

cognitive behavioral therapy

evidence-based recommendations