Activity 1: Principles of Neuropathic Pain Assessment and Management

Program Overview

Neuropathic pain presents the family physician with numerous challenges in terms of diagnosis and management. The condition is hard to differentiate from other chronic pain conditions, yet many physicians may be unaware of the existence of screening tools that can assist them in identifying neuropathic pain.^1,2 In a survey of AAFP LearningLink participants, 55 percent of respondents said they did not use neuropathic pain screening tools on a regular basis. In fact, 37 percent of respondents were not aware that these tools existed.³

Neuropathic pain is more difficult to treat than other types of chronic pain.⁴ Patients exhibit a more variable response to analgesics,⁵ and the different pain mechanisms involved in the condition mean that combination therapy is frequently required.⁶ Comorbid conditions such as sleep deprivation, anxiety and depression also affect response to treatment. Ultimately, many patients require multidisciplinary strategies to achieve adequate pain relief and return to normal functioning.^4,7,8

In this first activity, Principles of Neuropathic Pain Assessment and Management, the faculty describes a practical approach to the diagnosis and assessment of neuropathic pain, including the role of neuropathic pain screening tools. They discuss pharmacologic and nonpharmacologic management approaches, as well as outlining evidence-based treatment algorithms for the most common neuropathic pain syndromes. Finally, faculty members provide strategies for identifying and addressing common comorbidities.

1. Galer BS, Gianas A, Jensen MP. Painful diabetic polyneuropathy: epidemiology, pain description, and quality of life. Diabetes Res Clin Pract 2000;47:123-8.
2. Smith EL, Beck SL, Cohen J. The total neuropathy score (TNS): a tool for measuring chemotherapy-induced peripheral neuropathy. Oncol Nurs Forum 2008;35:96-102.
3. Data on file. AAFP Neuropathic Pain Baseline Assessment. January 2011.
4. Dworkin RH, O’Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132(3):237-51.
5. Portenoy RK, Foley KM, Inturrisi CE. The nature of opioid responsiveness and its implications for neuropathic pain: new hypotheses derived from studies of opioid infusions. Pain 1990;43(3):273-86.
6. Gilron I, Max MB. Combination pharmacotherapy for neuropathic pain: Current evidence and future directions. Expert Rev Neurother 2005;5:823-30.
7. Hall CG, Carroll D, Parry D, McQuay HJ. Epidemiology and treatment of neuropathic pain: the UK primary care perspective. Pain 2006;122:156-62.
8. Chen H, Lamer TJ, Rho RH, Marshall KA, Sitzman BT, Ghazi SM, et al. Contemporary management of neuropathic pain for the primary care physician. Mayo Clin Proc 2004;79(12):1533-45.

Intended Audience

This continuing medical education program is intended for family physicians and other primary care providers who care for patients with neuropathic pain. 

Learning Objectives

After completing this activity, family physicians will be better able to:

• Apply evidence-based recommendations for assessment and management of neuropathic pain in clinical practice.
• Recognize signs and symptoms of neuropathic pain to facilitate timely diagnosis and management.
• Differentiate among commonly encountered neuropathic pain conditions and their various causes in order to select appropriate treatments.
• Improve assessment of neuropathic pain in clinical practice, including assessment of comorbidities.
• Apply evidence-based strategies in the selection and use of first-, second- and third-line pharmacotherapy for patients with common neuropathic pain syndromes.
• Develop tailored treatment plans that address common and potentially debilitating comorbidities, such as depression and sleep disturbances.
• Implement practical approaches to monitoring treatment response, managing adverse effects and optimizing outcomes.

Faculty

Dawn Marcus, MD
Professor of Anesthesiology and Neurology
University of Pittsburgh Medical Center
Pittsburgh, PA

Penny Tenzer, MD
Vice Chair and Director of the Family Medicine Residency Program
University of Miami Miller School of Medicine
Chief of Service for Family Medicine
University of Miami Hospital
Miami, FL 

Matthew Schocket, MD
Anesthesiologist and Pain Management Specialist
Capitol Pain Institute
Austin, TX

CME Accreditation

This enduring material activity, Principles of Neuropathic Pain Assessment and Management, (the first activity in the Neuropathic Pain series), has been reviewed and is acceptable for up to 1 Prescribed credit(s) by the American Academy of Family Physicians. This activity conforms to the AAFP criteria for evidence-based CME clinical content. AAFP accreditation begins November 15, 2011. Term of approval is for two year(s) from this date with the option of yearly renewal.

The evidence-based CME content developed for this activity was based on practice recommendations that were the most current with the strongest level of evidence available at the time this activity was approved. Since some clinical research is ongoing, the American Academy of Family Physicians recommends that learners verify sources and review these and other recommendations prior to implementation into practice.

The AAFP is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The American Academy of Family Physicians designates this enduring material for a maximum of 1 AMA PRA Category 1 credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Agenda

Introduction and Opening Remarks
Module 1. Understanding Neuropathic Pain
Module 2. Neuropathic Pain Syndromes
Module 3. Assessment and Diagnosis of Neuropathic Pain
Module 4. Treatment of Neuropathic Pain 
Closing Remarks

Disclosures

It is the policy of the AAFP that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

The AAFP and MedEd Architects, LLC staffs have indicated that they have no relationships to disclose relating to the subject matter of the activity. Drs. Marcus and Schocket returned disclosure forms indicating that they have no financial interest in or affiliation with any commercial supporter or providers of any commercial services discussed in this educational material. Dr. Tenzer returned a disclosure form indicating that she has served as a consultant to Forest Pharmaceuticals, Inc., on the topic of fibromyalgia and to Zogenix on the topic of pain.

Activity 2: Tailoring the Treatment of Neuropathic Pain: Case Studies

Program Overview

In this second activity, Tailoring the Treatment of Neuropathic Pain: Case Studies, faculty build on material discussed in the first activity, Principles of Neuropathic Pain Assessment and Management. Principles of diagnosis, assessment and management are reinforced using patient cases. The program focuses on the two most common forms of neuropathic pain: postherpetic neuralgia and painful diabetic neuropathy. In addition, the faculty members discuss a case of idiopathic neuropathic pain and how to approach diagnosis and management in complex situations. The final part of this program focuses on how to optimize patient outcomes. Topics discussed include the role of the multidisciplinary team, the importance of patient education, long-term treatment monitoring and practical advice on the use of opioids in neuropathic pain. 

Intended Audience

This continuing medical education program is intended for family physicians and other primary care providers who care for patients with neuropathic pain.  

Learning Objectives

After completing this activity, family physicians will be better able to:

• Apply evidence-based recommendations for assessment and management of neuropathic pain in clinical practice.
• Recognize signs and symptoms of neuropathic pain to facilitate timely diagnosis and management.
• Differentiate among commonly encountered neuropathic pain conditions and their various causes in order to select appropriate treatments.
• Improve assessment of neuropathic pain in clinical practice, including assessment of comorbidities.
• Apply evidence-based strategies in the selection and use of first-, second- and third-line pharmacotherapy for patients with common neuropathic pain syndromes.
• Develop tailored treatment plans that address common and potentially debilitating comorbidities, such as depression and sleep disturbances.
• Implement practical approaches to monitoring treatment response, managing adverse effects and optimizing outcomes.

Faculty

Dawn Marcus, MD
Professor of Anesthesiology and Neurology
University of Pittsburgh Medical Center
Pittsburgh, PA

Penny Tenzer, MD
Vice Chair and Director of the Family Medicine Residency Program
University of Miami Miller School of Medicine
Chief of Service for Family Medicine
University of Miami Hospital
Miami, FL 

Matthew Schocket, MD
Anesthesiologist and Pain Management Specialist
Capitol Pain Institute
Austin, TX

CME Accreditation

This enduring material activity, Tailoring the Treatment of Neuropathic Pain: Case Studies, (the second activity in the Neuropathic Pain series), has been reviewed and is acceptable for up to 1 Prescribed credit(s) by the American Academy of Family Physicians. This activity conforms to the AAFP criteria for evidence-based CME clinical content. AAFP accreditation begins November 15, 2011.  Term of approval is for two year(s) from this date with the option of yearly renewal.

The Evidence-Based CME clinical content designated for this activity was based on practice recommendations that were the most current with the strongest level of evidence available at the time this activity was approved. Since some clinical research is ongoing, the American Academy of Family Physicians recommends that learners verify sources and review these and other recommendations prior to implementation into practice.

The AAFP is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The American Academy of Family Physicians designates this Enduring material for a maximum of 1 AMA PRA Category 1 credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Agenda

Introduction and Opening Remarks
Module 1. Case One: Postherpetic Neuralgia
Module 2. Case Two: Diabetic Neuropathy
Module 3. Case Three: Idiopathic Neuropathic Pain
Module 4. Implementing Management Strategies
Closing Remarks

Disclosures

It is the policy of the AAFP that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

The AAFP and MedEd Architects, LLC staffs have indicated that they have no relationships to disclose relating to the subject matter of the activity. Drs. Marcus and Schocket returned disclosure forms indicating that they have no financial interest in or affiliation with any commercial supporter or providers of any commercial services discussed in this educational material. Dr. Tenzer returned a disclosure form indicating that she has served as a consultant to Forest Pharmaceuticals, Inc., on the topic of fibromyalgia and to Zogenix on the topic of pain.

In Chest Pain: What to Do with ACS?, the first video lecture of our four-part educational series on ACS, join Dr. Jasen Gundersen, a practicing family physician, as he launches our discussion into ACS. This activity will provide the foundation for subsequent programming by reviewing the pathophysiology and prevalence of ACS, the differential diagnosis and risk stratification, and evidence-based strategies for acute and post-ACS management.

This program is supported by an educational grant from Daiichi Sankyo, Inc. and Eli Lilly and Company.

The second activity in our 4-part series on ACS, the faculty explore the state-of-the art in antiplatelet therapy for ACS.

The third activity in our 4-part series on ACS, the faculty explore the state-of-the art in antiplatelet therapy for ACS.

The fourth activity in our 4-part series on ACS, the faculty explore the state-of-the art in antiplatelet therapy for ACS.

Depression Activity 1

More than 23 million Americans, or nearly 8 percent of the population, have diabetes. (1) A total of 1.6 million new cases of diabetes were diagnosed in people ages 20 years or older in 2007. (1) Diabetes and its complications are major causes of morbidity and mortality in the United States. However, it is not inevitable that more Americans develop type 2 diabetes, nor is it inevitable that people with diabetes experience the long-term complications such as lower limb amputations, kidney failure, and premature death. There are successful interventions for delaying and potentially preventing the development of type 2 diabetes, managing type 2 diabetes effectively, and preventing complications responsible for diminished quality of life and shortened life expectancy. Family physicians largely determine the quality of diabetes care in the United States and, as such, are instrumental in proving primary prevention and risk reduction efforts.

1. National diabetes statistics, 2007. National Diabetes Information Clearinghouse,, National Institute of Diabetes and Digestive and Kidney Diseases. http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#allages. Accessed April 29, 2009.

This program is supported by an educational grant from GlaxoSmithKline, Sanofi-Aventis, and Takeda Pharmaceuticals North America.

In Quality Management of Type 2 Diabetes: Approach to Medical Treatment, the first video discussion of our educational series on type 2 diabetes, join Dr. John Russell, a practicing family physician, as he poses his burning clinical questions about diabetes management to Dr. Serena Cardillo, an endocrinologist at the Hospital of the University of Pennsylvania. Their discussion will focus on the subtleties of using antihyperglycemic medications, challenges and considerations when introducing insulin, use of blood glucose monitoring to guide treatment and the importance of CVD risk reduction.

This program is supported by an educational grant from GlaxoSmithKline, Sanofi-Aventis, and Takeda Pharmaceuticals North America.

In the third activity of our series on type 2 diabetes, The Role of Diabetes Education in Optimizing Glycemic Control and Improving Outcomes in Type 2 Diabetes, Frances Love, MSN, RN, CDE, BC-ADM, provides her perspective as a diabetes educator regarding the essential elements of diabetes education and discusses the applicable practice guidelines. Video dramatizations demonstrate appropriate patient instruction about blood glucose monitoring and insulin injection techniques.

This program is supported by an educational grant from GlaxoSmithKline, Sanofi-Aventis, and Takeda Pharmaceuticals North America.

In Challenging Cases in Effective Management of Type 2 Diabetes, faculty present three patient scenarios (adolescent, mid-life and elderly) likely to be seen and managed in a primary care setting. While typical, each case integrates a degree of complexity related to diagnosis, treatment or both. Join Dr. John Russell, a practicing family physician, and Dr. Serena Cardillo, an endocrinologist at the Hospital of the University of Pennsylvania, as they discuss these cases, examine important issues and guidelines related to their management, and offer family physicians insights into more challenging aspects of diabetes care.

This program is supported by an educational grant from GlaxoSmithKline, Sanofi-Aventis, and Takeda Pharmaceuticals North America.

Intensifying Insulin Therapy in Type 2 Diabetes: Strategies for Family Medicine

This video presentation is the first activity in the series and provides family physicians with vital information on how to improve processes and outcomes in pain management including recognition and treatment of pain, and management of pain in patients with current, past, or potential for substance abuse.

This program is supported by an educational grant from

In the second activity faculty will address primary concerns of family physicians regarding the management of chronic pain in patients at risk or with a history of addiction. Emphasis will be placed on risk assessment, treatment approach, diversion and addiction behaviors, and medical legal considerations when prescribing opioid therapy in high-risk patients. Discussants will review tools and resources available to assist the family physician throughout this process.

This program is supported by an educational grant from

In the third activity in our chronic pain series, Dr. Penny Tenzer and Dr. Dawn Marcus provide practical strategies to address pain management issues commonly faced in family practice, including fitting chronic pain management into the time constraints of an office visit and minimizing staff burnout.

This program is supported by an educational grant from

Disparities in Care: Special Populations in Pain Management, the fourth activity in the AAFPlearninglink.org Chronic Pain series will provide insight into how age, gender and ethnicity impact the diagnosis and management of pain and discuss specific tools and strategies to facilitate pain management in these patient populations.

This program is supported by an educational grant from

Practical Aspects of Chronic Pain Management: A Case-based Approach, the fifth activity in the AAFPlearninglink.org Chronic Pain series includes 3 case vignettes that are used to demonstrate and reinforce issues and challenges family physicians often encounter when treating patients with chronic pain: 1) managing a new patient requesting a refill of pain medication, 2) negotiating treatment goals and managing residual pain, and 3) caring for elderly patients with chronic pain. Knowledge and concepts reviewed in the previous 4 activities within this series will be applied.

This program is supported by an educational grant from

In Managing Coexisting Pain and Depression, the sixth activity in the AAFPlearninglink.org Chronic Pain series, a video case dramatization is used to demonstrate the process of care when chronic pain and depression are present. Dr. Judith Turner and Dr. Michael Klinkman will use the case to discuss clinical decision-making, the therapeutic partnership, diagnostic and monitoring tools, and strategies to effectively manage depression in patients with chronic pain.

This program is supported by an educational grant from

Fibromyalgia: Challenges in Pain Management

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