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Li AHY, Bhatia A, Gulati A, Ottestad E. Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts. Reg Anesth Pain Med 2023; 48:312-318. [PMID: 37080584 DOI: 10.1136/rapm-2022-104073] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 04/22/2023]
Abstract
Interventional pain management (IPM) options for refractory neuropathic pain (NP) have recently increased with availability of peripheral nerve stimulation (PNS) equipment and expertise. Given a lack of high-quality evidence and guidelines on this topic, we sought to understand the perception of physicians with expertise in treating NP regarding IPM and the role of PNS. We emailed a survey in March 2022 to international NP experts including pain medicine physicians, researchers, and leaders of 11 professional pain societies. No representatives from vendors of PNS systems were included in the design of the survey nor as respondents. Among 24 respondents (67% of those contacted), the distal common peroneal, tibial, and sural nerves were most frequently targeted (60%) with PNS. Persistent postsurgical pain of more than 3 months was the most common indication for PNS (84%). The aggregate NP treatment algorithm in order of median rank was non-opioid medications as first line, IPM including epidural/perineural steroid injections tied with transcutaneous electrical nerve stimulation as second line, pulsed radiofrequency (RF) tied with RF ablation/denervation as third line, temporary then permanent PNS as fourth line, followed by spinal cord stimulation, opioids, cryoablation, botulinum, peripheral nerve field stimulation, intrathecal targeted drug delivery, and others. Before offering PNS, 12 respondents (50%) indicated their preference for trialing non-neuromodulation treatments for 1-3 months. Twenty-two respondents (92%) agreed PNS should be offered early in the treatment of neuropathic pain. The most common barriers to PNS use were cost, lack of high-quality evidence in support of its use, lack of exposure to PNS in training programs, and lack of familiarity with the use of ultrasound guidance. PNS appears to have an increasing role in the treatment of NP but more research is needed on the outcomes of PNS to elucidate its role.
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Affiliation(s)
- Alice Huai-Yu Li
- Department of Anesthesia, Stanford University, Stanford, California, USA
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amit Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Einar Ottestad
- Anesthesiology and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Arora P, Dey S. Redefining pain interventions: Call it right! INDIAN JOURNAL OF PAIN 2022. [DOI: 10.4103/ijpn.ijpn_126_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Shanthanna H, Bhatia A, Radhakrishna M, Belley-Cote E, Vanniyasingam T, Thabane L, Busse JW. Interventional pain management for chronic pain: a survey of physicians in Canada. Can J Anaesth 2020; 67:343-352. [PMID: 31802414 DOI: 10.1007/s12630-019-01547-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The use of interventional pain management (IPM) modalities to alleviate chronic pain is increasing despite the lack of high-quality evidence. We undertook this survey to explore patterns, training, and attributes of IPM practice. METHODS We administered a 32-item survey via seven Canadian physician member organizations, whose members were engaged in the management of chronic pain. RESULTS Of 777 physicians contacted, 256 (33%) responded: 45 (6%) declined to participate and 211 (27%) agreed to participate; the number of participants answering any given question varied. One hundred and sixty-nine of 194 (87%) practiced IPM and 103 of 194 (53%) managed only non-cancer pain. Pain management training of ≥ six months was associated with higher odds of IPM training (odds ratio [OR], 2.98; 95% confidence interval [CI], 1.32 to 6.7), but not necessarily ongoing IPM practice (OR, 1.97; 95% CI, 0.74 to 5.3). A substantial percentage of physicians (108 of 168 [64%]) practiced IPM based only on training received during either their base residency program or courses. Only 48 of 186 (26%) felt that there were adequate opportunities for IPM training, and 69 of 186 (37%) believed that their colleagues practiced IPM in accordance with the best current evidence. CONCLUSIONS Our survey indicates that IPM practice and training were not uniform, and that interventional therapies for chronic pain may not be performed in accordance with the best available evidence. Our survey highlights a lack of IPM training opportunities, which may result in substandard training. Concerted efforts involving physician organizations and regulators are needed to standardize IPM training and develop clinical guidelines to optimize evidence-based practice.
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Affiliation(s)
- Harsha Shanthanna
- The Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
- The Research Institute of St Joseph's Hospital, Hamilton, ON, Canada.
- Department of Anesthesia, Michael G. DeGroote School of Medicine, McMaster University, HSC-2V9, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- The Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Mohan Radhakrishna
- The Department of Physical Medicine and Rehabilitation, McGill University, Montreal, QC, Canada
| | - Emilie Belley-Cote
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St Joseph's Hospital, Hamilton, ON, Canada
| | - Jason W Busse
- The Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Perret D, Rosen C. A physician-driven solution--the Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain medicine. PAIN MEDICINE 2012; 12:1361-75. [PMID: 21914121 DOI: 10.1111/j.1526-4637.2011.01217.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.
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Affiliation(s)
- Danielle Perret
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, School of Medicine, Orange, California, USA
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Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med 2012; 2:106-16. [PMID: 24073101 PMCID: PMC3717820 DOI: 10.1007/s13142-011-0090-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The field of pain medicine has shifted from multidisciplinary rehabilitation to procedure-focused interventional pain medicine (IPM). Considerable controversy exists regarding the efficacy of IPM and its more narrow focus on nociception as an exclusive target of pain treatment. This topical review aims to examine pain research and treatment outcome studies that support a biopsychosocial model of pain, and to critique the clinical practice of IPM given its departure from the premises of a biopsychosocial model. A modern definition of pain and findings from clinical and basic science studies indicate that pain-related psychological factors are integral to pain perception. The clinical viability of IPM is challenged based upon its biomedical view of peripheral nociception as a primary source of pain and the potential of this viewpoint to foster maladaptive pain attributions and discourage the use of pain coping strategies among chronic pain patients. IPM should adopt a biopsychosocial perspective on pain and operate within a framework of multidisciplinary pain rehabilitation to improve its effectiveness.
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Affiliation(s)
- Randy S Roth
- />Department of Physical Medicine & Rehabilitation, University of Michigan Health System, 325 E. Eisenhower Pkwy, Ann Arbor, MI 48108 USA
- />Department of Physical Medicine & Rehabilitation, Ann Arbor Veterans Health Care System, Ann Arbor, MI 48105 USA
| | - Michael E Geisser
- />Department of Physical Medicine & Rehabilitation, University of Michigan Health System, 325 E. Eisenhower Pkwy, Ann Arbor, MI 48108 USA
| | - David A Williams
- />Chronic Pain and Fatigue Research Center, University of Michigan Health System, Ann Arbor, MI 48109 USA
- />Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI USA
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Schofferman J. Opinions and Testimony of Expert Witnesses and Independent Medical Evaluators. PAIN MEDICINE 2007; 8:376-82. [PMID: 17610460 DOI: 10.1111/j.1526-4637.2007.00318.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To clarify the guidelines and responsibilities of expert witnesses and independent medical evaluators (IMEs). DESIGN Literature review and personal opinion. SETTING There have been concerns about the objectivity of expert witnesses and IMEs due to potential financial conflicts of interest. RESULTS Medical-legal work such as expert witness testimony and independent medical evaluations are a recognized part of the practice of medicine. As such, the opinions and testimony of expert witnesses and IMEs should be held to the same scientific and ethical standards as clinical practice. The concept of "expert" differs when used by the legal system vs when used by physicians. Expert testimony should be based on the best available evidence and standards of care, which requires that experts stay current in their field of expertise, and revise old opinions as new information is published. Personal experience alone is rarely sufficient. A medical expert should be in active practice caring for the type of patient involved in the legal action or, alternatively, be able to demonstrate competence to provide an opinion in the specific area of interest. CONCLUSIONS Testimony should be honest and evidence-based. Testimony and reports should be accurate, impartial, and relevant. Both should be based on current scientific evidence, and avoid the role of advocate for the party. The physician should testify as if the opinions and their bases are subject to peer review.
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Affiliation(s)
- Jerome Schofferman
- SpineCare Medical Group, San Francisco Spine Institute, Daly City, California 0000, USA.
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