Knee Arthritis: Racial Differences in Treatment Patterns and Health Care Expenditures Interview with:
Stuart L. Silverman MD FACP FACR
Clinical Professor of Medicine, Cedars-Sinai Medical Center and UCLA School of Medicine
Medical Director, OMC Clinical Research Center
Beverly Hills, CA 90211

Dr. Silverman  What is the background for this study?

Response: As a practicing rheumatologist, I am aware that prior studies have shown variation in medical care, pain management and treatment with opioids by race and social economic status.  Suboptimal treatment of pain in patients with osteoarthritis (OA) may also disproportionately burden racial minorities and Medicaid recipients. 

Studies have shown that African Americans are nearly 1.5 times as likely to have symptomatic knee OA than White patients even when adjusting for other factors.  Similarly, they also have a higher prevalence of symptomatic and radiographic hip OA.  Analyses of Medicare data has shown evidence of persistent racial disparities for joint arthroplasty usage and surgical outcomes.

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Physicians Differently Prescribe Pain Relief Medications to White and Minority Patients Interview with:
Dan P. Ly M.D., M.P.P., Ph.D.
Division of General Internal Medicine and Health Services Research
David Geffen School of Medicine
University of California, Los Angeles  What is the background for this study?  What are the main findings?

Response: We know that minority patients were less likely to receive opioids than white patients, but this could have been due to minority patients seeing lower opioid-prescribing physicians. As far as I could tell, nobody had been able to examine whether the same physician prescribed opioids differently to their minority patients.

I find that this is the case: the same physician was less likely to prescribe opioids to their minority patients with new low back pain, and instead was more likely to prescribe NSAIDs to their minority patients. And unfortunately, this differential prescribing may have had the consequence of leading to more chronic opioid use in white patients.  

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Virtual Reality Can Provide Pain Relief for Children Getting IV Catheters Interview with:
Dr. Jeffrey I. Gold PhD
Director Emeritus of the Pediatric Pain Medicine Clinic
Children’s Hospital Los Angeles and Investigator
The Saban Research Institute
Children’s Hospital Los Angeles  What is the background for this study How is the VR utilized?

Response: Virtual Reality or digital therapeutics can have a profound impact on mitigating pain, anxiety, and distress associated with routine painful medical procedures, such as blood draw and IV placement.  What are the main findings? Would you explain what is meant by “triangulation of data”?

Response: Virtual Reality significantly reduces pain and anxiety in children undergoing PIVC placement compared to standard of care in two pediatric medical settings (radiology and the infusion center). The triangulation of data refers to collecting data on the patient, his/her caregiver, and the healthcare provider to examine the impact of the intervention from three different perspectives.

The current study demonstrated that an effective intervention for the patient can have a positive impact (ripple effect) on the caregiver and the healthcare provider, creating a more relaxed, calm, and less distressing medical experience.

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Study Identifies Three Patterns of Medical Cannabis Use for Pain

Dr. Deepika Slawek, Interview with:
Deepika Slawek, MD, MS, MPH 
Assistant Professor of Medicine, Division of General Internal Medicine
Montefiore Medical Center
Albert Einstein College of Medicine
Bronx, NY 10467  What is the background for this study?

Response: Medical cannabis has become increasingly available in the United States over the past 25 years and is commonly used for the management of pain. Little is known about the patterns of medical cannabis use by patients with chronic pain. This information could help providers anticipate patients’ needs and identify potential disparities in access.

We followed 99 adults in New York State who were newly certified for medical cannabis use and who were prescribed opioids over the course of 1 year. Using a latent class trajectory analysis, we identified clusters of participants based on 14-day frequency of medical cannabis use. We used logistic regression to determine factors associated with cluster membership including sociodemographic characteristics, pain, substance use, and mental health symptoms.

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Overdose Rates Increased When Pain Meds Prescribed by Multiple Providers Interview with:
Kao-Ping Chua, MD, PhD
Department of Pediatrics
Susan B. Meister Child Health Evaluation and Research Center,
Department of Health Management and Policy, School of Public Health,
University of Michigan Ann Arbor

Dr. Kao-Ping Chua  What is the background for this study?  What are the main findings?

Response: Having overlapping opioid and benzodiazepine prescriptions is a strong risk factor for opioid overdose even if these prescriptions are written by the same prescriber.

In this study of privately insured and Medicare Advantage patients, we show that the risk of overdose is even greater when the prescriptions are written by multiple prescribers. Specifically, the unadjusted risk of overdose on a day of overlap was 1.8 times higher when the prescriptions were written by multiple prescribers. After controlling for patient demographic characteristics, clinical co-morbidities, and prescribing patterns, the adjusted odds of overdose was 1.2 times higher, corresponding roughly to a 20% higher adjusted risk.

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“Empowered Relief” Program Equips Patients With Effective Pain Relief Skills Interview with:
Beth Darnall, PhD

Director, Stanford Pain Relief Innovations Lab
Associate Professor, Stanford University School of Medicine
Department of Anesthesiology, Perioperative and Pain Medicine
Psychiatry and Behavioral Sciences (by courtesy)
Wu Tsai Neurosciences Institute (affiliate faculty)
Palo Alto, CA 94304

Dr. Darnall  What is the background for this study?  What are the main findings?

Best pain care integrates patient education and tools to help them manage pain and reduce their symptoms1. Multi-session psychological or “behavioral” pain treatment approaches, such as 8-session cognitive behavioral therapy (CBT), are effective for equipping people with pain management skills. However, our prior research showed that patient access to these treatments is often poor, in part due to the costs and time burdens (e.g., up to 16 hours of treatment time).2

Findings from our study suggest that a one-time 2-hour pain relief skills class (“Empowered Relief”) was non-inferior to 8-session CBT for reducing multiple symptoms, including pain catastrophizing, pain intensity, and pain interference at 3 months post-treatment. We also found the single-session pain class imparted substantial reductions for pain bothersome, sleep disturbance, anxiety, fatigue and depression.

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Including a Body Map Can Help Clinicians Manage Chronic Pain Interview with:
Ben Alter, MD, PhD
Assistant Professor
Director, Translational Pain Research
Division of Pain Medicine
Department of Anesthesiology and Perioperative Medicine
University of Pittsburgh Medical Center

Dr. Ben Alter  What is the background for this study?  What are the main findings?

Response: In the clinical environment, I am often asking patients where their pain is.  There is a large amount of research establishing that widespread or “all-over” pain is difficult to manage and impacts nearly every aspect of a patient’s life. In fact, a tally of body areas is involved with the diagnosis of fibromyalgia, although this is not the only diagnostic criteria. What wasn’t clear to us was whether patterns of pain across the body also impacted important facets of the pain experience.  

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Back Pain: SelfBACK app To Help Patients Find Pain Relief From Self-Managed Program Interview with:
Louise Fleng Sandal PhD
Adjunkt, Institut for Idræt og Biomekanik
SDU University of Southern Denmark

Dr. Sandal  What is the background for this study?

Response: Low back pain is a globally prevalent condition with a high economic cost. Many people seek help with primary care from their general practitioner, physiotherapist or chiropractor. Evidence-based guidelines on first line treatment include learning to self-manage, staying active, exercising and learning about the condition. However, many find this difficult without advice and support, but primary care physicians often lack the time and resources to support self-management.

Digital solutions, such as smartphone technology, utilizing artificial intelligence can be used to tailor self-management support to the individual and be available at the individuals convenience.

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Telehealth for Pain Care Broadens Access to Treatment for Veterans Interview with:
Jessica Chen, Ph.D. (pronouns: she/her)

Dr. Chen

Clinical Psychologist | VA Puget Sound, Seattle
Staff Psychologist | TelePain Clinic | VISN 20 Pain Medicine & Functional Restoration Center
Core Investigator | Health Services Research & Development | Seattle-Denver Center of Innovation
Assistant Professor | Department of Psychiatry & Behavioral Sciences University of Washington School of Medicine
Seattle, WA 98108  What is the background for this study?

Response: Chronic pain affects two-thirds of U.S. military veterans, and nearly 10% of veterans report severe pain that leads to significant distress or impairment. Within the Veterans Health Administration (VHA), interdisciplinary pain management has been the standard of care for high-impact, complex chronic pain, but rural patients are less likely to receive these services.

Telehealth provides an opportunity to address problems with accessing care in rural communities. In 2018, VA Puget Sound launched a regional pain telehealth program, TelePain, to bring interdisciplinary pain care using video telehealth to rural veterans in the Northwest.  

In this study, we examined the impact of implementing TelePain on access to pain care among rural patients living in Washington state from 2015-2019 and compared their access to urban patients. All patients had moderate to severe chronic pain, and we included patients with any type of pain (e.g., back, neck, migraines, fibromyalgia, etc.). This study is a retrospective cohort analysis of VA data.

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Migraine: Remote Electrical Neuromodulation For Pain Relief in Adolescents Interview with:
Andrew D. Hershey, MD, PhD, FAAN, FAHS
Endowed Chair and Director of Neurology
Professor of Pediatrics and Neurology
Director, Headache Center
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH 45229
University of Cincinnati, College of Medicine  What is the background for this study?

Response:  Migraine is a common and debilitating disease, affecting 1 in 10 children and adolescents worldwide. Refractory migraine in adolescents may be associated with poorer academic performance, reduced school attendance, and a negative effect on social interactions. Current acute treatments for adolescents with migraine are mostly pharmacological. These treatments may cause side effects, and their frequent use may potentially lead to medication overuse headache. Additionally, their efficacy may be variable or inadequate. Thus, there is a great unmet need for new safe and effective acute treatments for adolescents with migraine headaches.

Remote Electrical Neuromodulation (REN) is a non-pharmacological, non-invasive neuromodulatory treatment that has been approved by the US FDA for acute treatment of the headache attacks of migraine in patients 12 years of age or older. The REN device (Nerivio®) is a small stimulator controlled by the user via a smartphone application and activates one of the body’s own pain suppression system by inducing weak electrical currents. These currents stimulate nerve fibers in the upper arm to activate an endogenous descending pain inhibition mechanism termed Conditioned Pain Modulation (CPM). Clinical trials of REN have shown efficacy and safety of the treatment in adolescents 12 and older, as well as in adults.

The current study is the first to compare REN and standard-care treatments (over the counter medications and triptans) in adolescents.

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