The Pain Center Manual

219 Pages·2013·2.867 MB·English

by  Danielle Perret, Eric Chang, Justin Hata, Hamilton Chen, Bianca Tribuzio

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THE PAIN CENTER MANUAL a
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Danielle Perret, MD ta | CPerr H E
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Eric Chang, MD | Justin Hata, MD ent
Hamilton Chen, MD | Bianca Tribuzio, DO | Tr
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The Pain Center Manual is a concise resource that provides practical information
E N T E R
for daily use in pain practice. For quick reference or on-the-spot guidance in
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academic or community pain centers, these pages are fi lled with the informa-
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tion trainees and experienced practitioners need at their fi ngertips including
common medication dosages, titration schedules, dictation templates, assess- E
ment scales, guidelines for interventional procedures, and much more.

P
A team of experts from one of the country’s leading university pain centers
A
M
cover everyday management concerns such as methadone safety, prescription
A N UA L
writing for controlled substances, neuropathic medication adjuvants to con- I
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sider in pain management, and treatment suggestions for a wide spectrum of
chronic pain conditions. With an emphasis on ACGME standards and objec-
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tives, the manual offers the fundamental knowledge pain professionals need to
provide consistent and compassionate care. E
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The Pain Center Manual includes:
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• Quick reference tables for medications and other treatment modalities
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• Clinical pearls for the most common pain complaints
R
• Templates for consultations and interventional procedures

• Useful scales, algorithms, diagrams, and other essential reference M
materials for performing tests and procedures
• ACGME training guidelines A
N
Danielle Perret
U
Recommended Shelving Category: Physical Medicine &
Rehabilitation / Neurology/Anesthesia A Eric Chang | Justin Hata
ISBN 978-1-620700-21-1 L
Hamilton Chen | Bianca Tribuzio
11 W. 42nd Street
New York, NY 10036-8002
9 781620 700211
www.demosmedpub.com
The Pain Center Manual

The Pain Center Manual
Danielle Perret, MD
Assistant Dean for Resident Affairs
Director, Fellowship Program in Pain Medicine
Associate Director, Residency Training Program in
Physical Medicine and Rehabilitation
Associate Clinical Professor
Department of Anesthesiology and Perioperative Care
Department of Physical Medicine and Rehabilitation
UCI Center for Pain Management
University of California-Irvine
Eric Chang, MD
Assistant Professor In-Residence
Division of Pain Medicine
Department of Anesthesiology and Perioperative Care
Department of Physical Medicine and Rehabilitation
Department of Orthopedics
Reeve-Irvine Research Center for Spinal Cord Injury
University of California-Irvine
Justin Hata, MD
Chief, Division of Pain Medicine
Director, Residency Training P rogram in Physical
Medicine and Rehabilitation
Associate Clinical Professor
Department of Anesthesiology and Perioperative Care
Department of Physical Medicine and Rehabilitation
Medical Director
UCI Center for Pain Management
University of California-Irvine
Hamilton Chen, MD
Pain Medicine Fellow
Department of Anesthesiology and Perioperative Care
UCI Center for Pain Management
University of California-Irvine
Bianca Tribuzio, DO
Pain Medicine Fellow
Department of Physical Medicine and Rehabilitation
UCLA/West Los Angeles-VA
New York
Visit our website at www.demosmedpub.com
ISBN: 9781620700211
e-book ISBN: 9781617051845
Acquisitions Editor: Beth Barry
Compositor: Exeter Premedia Services Private Ltd.
© 2014 Demos Medical Publishing, LLC. All rights reserved. This book is protected by
copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in
any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the publisher.
Medicine is an ever-changing science. Research and clinical experience are continually
expanding our knowledge, in particular our understanding of proper treatment and drug
therapy. The authors, editors, and publisher have made every effort to ensure that all infor-
mation in this book is in accordance with the state of knowledge at the time of production
of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors
or omissions or for any consequences from application of the information in this book and
make no warranty, expressed or implied, with respect to the contents of the publication.
Every reader should examine carefully the package inserts accompanying each drug and
should carefully check whether the dosage schedules mentioned therein or the contrain-
dications stated by the manufacturer differ from the statements made in this book. Such
examination is particularly important with drugs that are either rarely used or have been
newly released on the market.
Library of Congress Cataloging-in-Publication Data
Perret, Danielle, author.
The pain center manual / Danielle Perret, Eric Chang, Justin Hata, Hamilton Chen,
Bianca Tribuzio
p. ; cm.
Includes bibliographical references.
ISBN 978-1-62070-021-1—ISBN 978-1-61705-184-5 (e-book)
I. Chang, Eric, author. II. Hata, Justin, author. III. Chen, Hamilton, author.
IV. Tribuzio, Bianca, author. V. Title.
[DNLM: 1. Pain Management—Handbooks. 2. Pain—drug therapy—Handbooks.
3. Pain Measurement—Handbooks. WL 39]
RB127
616′.0472—dc23
2013033816
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13 14 15 16 17 / 5 4 3 2 1
Contents
Preface ix
I. MEDICAL MANAGEMENT OF CHRONIC PAIN 1
Opioids 1
Signs of Opioid Withdrawal 2
Opioid Overnarcotization 2
Notes on Opioid Abuse 2
Opioid Withdrawal Protocol 3
Opioid Screening Tools: SOAPP® Version 1.0–14Q 7
Narcotic Conversions 9
Methadone 10
Safety Considerations 10
Prescribing Methadone 11
Methadone Risk Factors 12
P450 Inhibitors 13
QT Prolonging Drugs 14
Urine Drug Toxicity (UDT) Screens 15
Interpretation of Urine Toxicity Results 15
Types of UDT 17
Controlled Substance Rx Writing Skills 19
Common Medications Used in Pain Management 21
Suggested Outpatient Medication Prescriptions 24
Sample Titration Schedules 29
Metabolic Considerations for Medications 31
Medication Safety in Renal Failure, Pregnancy, Geriatrics 33
Interventional Pharmacology 35
2010 ASRA Recommendations for Anticoagulation in
Pain Medicine Procedures 37
Emergency Pharmacology 39
Intrathecal Pump 40
Systemic Effects of Local Anesthetics 43
Traditional Neurolytic Spinal Blocks 45
Botox Injections for Migraine 46
II. DIAGNOSTIC PEARLS FOR PAIN MANAGEMENT 51
How to Present Pain 51
Headaches 52
Cranial Nerve Notes and Pain Boards Association 56
Facial Pain Neuralgias 60
v
vi Contents
Pelvic Pain Neuralgias 62
Gynecologic Conditions That May Cause or Exacerbate Chronic Pelvic
Pain by Level of Evidence 63
Nongynecologic Conditions That May Cause or Exacerbate Chronic
Pelvic Pain by Level of Evidence 64
Radiology Pearls 65
Disc Pathology Pearls 66
Spinal Pain Differential 67
Complex Regional Pain Syndrome (CRPS) Pearls 68
Treatment Considerations for Common Pain Presentations 69
III. NOTES AND TEMPLATES 75
Initial Consultation Template 75
Follow-Up Visit Template 80
Interventional Procedure Templates 84
IV. BILLING AND CODING 141
New Patient Billing and Coding 141
Follow-Up Patient Billing and Coding 142
V. SCALES AND OTHER REFERENCE MATERIALS 143
Regional Landmarks 143
Vertebral Levels 144
Brachial Plexus 145
Lumbosacral Plexus 147
Upper Extremity Innervations 152
Lower Extremity Innervations 153
PM&R/Neurology Exam Guide 154
Dermatomes 155
Physical Exam Tests and Acronyms 156
Therapy Contraindications 157
P&O Reference 158
Research Critical Appraisal Questions 159
Sample Procedure Log Form 161
Sample Patient Safety Log 162
Pain Scale Reference 163
Resources 164
VI. ADULT LEARNING IN PAIN MEDICINE 165
ACGME Training Standards 165
ACGME Fellowship Requirements 165
ACGME Fellowship Procedure Requirements 166
ACGME Core Competencies 167
Contents vii
Sample Reading Assignments 171
Other Suggested Reading Materials 173
Goals and Objectives 174
Residents 174
Fellows 179
Subspecialty Goals and Objectives 181
Suggested Formal Fellow Evaluation Systems 185
Sample Pain Medicine Curriculum 186
Suggested Didactics Program 187
Cognitive Objectives 191
References 201
Index 203

Preface
Welcome to Pain Medicine done right. Patients in pain expect excep-
tionally qualified and compassionate care. Determining the appropriate
approach for each patient is a nuanced art, but a solid grasp on the base
knowledge can put this goal within reach.
This concise handbook is your continuous guide to the best prac-
tices reflective of academic pain management. It’s not an encyclopedia,
but it is full of pearls of knowledge for quick reference and on-the-spot
training in both academic and community-based medicine. For the med-
ical student or resident rotating through Pain, fellow in training, aca-
demic faculty, or private attending, this manual is your guide to our best
practices. In these pages, you’ll find common medication dosages, pro-
cedure templates, pharmacotherapies, and other useful diagnostic and
treatment strategies, all reflective of interdisciplinary multimodal Pain
Medicine techniques we use in the University of California chronic pain
clinic and procedure suites. You’ll also find a guide to the Accreditation
Council for Graduate Medical Education (ACGME) standards, objectives,
and suggested readings. Where large textbooks fail to offer practical
guidelines for everyday pain management, this resource fills in the gaps.
This is the manual we rely on, every day, because it works. We hope
it becomes a trusted resource for you as well.
Danielle Perret, MD
Assistant Dean for Resident Affairs
Director, Fellowship Program in Pain Medicine
Associate Director, Residency Training Program in
Physical Medicine and Rehabilitation
Associate Clinical Professor
Department of Anesthesiology and Perioperative Care
Department of Physical Medicine and Rehabilitation
UCI Center for Pain Management
University of California-Irvine
ix