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Opioid Patient Protection Recommendations accepted for publication in Mayo Clinic Proceedings

October 1, 2020, CHICAGO, Illinois – A multidisciplinary consensus panel convened by the American Academy of Pain Medicine Foundation has issued new recommendations in Mayo Clinic Proceedings about ensuring patient protections when tapering opioids. The recommendations offer guidance to pain specialists and primary care providers—as well as patients, payors, and regulators—about the intricacies of opioid reduction.

In recent years, prescribers in the United States have made considerable efforts to reduce or discontinue opioids in patients who have taken them long term. While opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. The consensus panel recommendations include clear, evidence-informed steps providers can take to clarify the indications for tapering long-term opioids and how to ensure patient safety throughout each step of a taper.

“Clinicians face dilemmas when caring for patients taking opioids, as various guidelines, patient preferences, and clinical impressions of risks and benefits may be in conflict,” says AAPM Past President Edward Covington, MD, lead author of the AAPM Foundation project. “Our findings indicate that harm can result from abrupt tapers and emphasize the importance of balancing patient collaboration and desires with clinician responsibility to prescribe wisely.”

The consensus panel’s recommendations are the result of a rigorous and collaborative process, including consensus-building discussions, analysis, and interpretation of data. “We convened a consensus panel of experts in long-term opioid treatment, substance use disorders, and opioid reduction with the goal of providing useful criteria for dose continuation versus reduction along with strategies for the comfortable and humane tapering of opioids, when indicated,” Dr. Covington said.

Hear more from Dr. Covington by viewing this video interview he conducted with co-author Mark Sullivan, MD PhD.

Recommendations also address topics such as patient factors that increase risk with long-term opioid therapy, indications for tapering long-term opioids, common withdrawal symptoms, and buprenorphine initiation in patients on opioids for pain. Several of the panelists presented a Spotlight Session about this project at AAPM’s 2020 Annual Meeting. A recording of this session is available on demand in the AAPM Education Center at no cost for members and $25 for nonmembers.

About AAPM

The American Academy of Pain Medicine is the premier medical association for pain clinicians and their treatment teams with some 2,000 members. Now in its 36th year of service, the Academy’s mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy’s website at painmed.org.

About AAPM Foundation
The AAPM Foundation was created in 2011 to support the American Academy of Pain Medicine’s (AAPM) efforts. The Foundation supports AAPM’s core purpose to optimize the health of patients in pain and eliminate the major health problem of pain by advancing the practice and the specialty of pain medicine. Information is available on the Foundation’s website at aapmfoundation.org.

Congratulations to Inaugural AAPM Early Investigator Research Grant Recipient, Ben Alter, MD PhD

June 17, 2020, CHICAGO –   The AAPM Early Investigator Research Grant was created in partnership with US WorldMeds to support preliminary or pilot research projects relevant to a comprehensive, multidisciplinary, patient-centered approach to pain management. AAPM members who are early stage investigators were invited to submit proposals for the opportunity to receive a $15,000 one-year grant.

AAPM is pleased to announce Ben Alter, MD PhD as the recipient of AAPM’s inaugural Early Investigator Research Grant. The grant will support Dr. Alter’s research entitled Brain biomarker of endogenous analgesia in patients with chronic knee pain. Dr. Alter is an Assistant Professor and the Director for Translational Pain Research in the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. After studying medicine and neuroscience at Washington University, he completed training in anesthesiology at University of California, San Francisco and pain medicine at the University of Pittsburgh. 

Dr. Alter’s research explores how the brain modulates pain and how endogenous pain dampening systems can be systematically leveraged for novel pain therapies. The objective of his AAPM Research Grant-funded study is to assess whether functional near-infrared spectroscopy (fNIRS) can be used to detect changes in cortical activity during endogenous analgesia in patients with chronic knee pain from osteoarthritis. Using this alternative brain imaging technique will enable hemodynamic changes in the cerebral cortex to be measured by recording low-intensity infrared light absorption by hemoglobin over time. fNIRS is portable, scalable, can be collected in the ambulatory setting, and does not require supine positioning.

According to Dr. Alter, recent evidence suggests that endogenous analgesia is diminished in chronic pain states. Interestingly, the brain circuitry implicated in endogenous analgesia also appears to change in chronic pain states, as measured by functional magnetic resonance imaging (fMRI) techniques. As such, both psychophysical tests thought to reflect endogenous analgesia and fMRI measures are potential chronic pain biomarkers. However, the relative importance of these changes to the pathophysiology of chronic pain remains unknown, partly due to a lack of prospective studies in patients in relation to their course of chronic pain. Major barriers to these studies are the cost and patient tolerability of repeated fMRI sessions.

Research shows that mechanistically relevant biomarkers may allow for personalization of chronic pain management. It is hoped that Dr. Alter’s research will lead to the discovery of the brain biomarker of endogenous analgesia in patients with chronic knee pain.

“I am honored to be selected for this grant. This pilot grant will jump start promising research that I hope will improve pain care for patients dealing with chronic pain. It was truly made possible with the mentorship and support of my friends and colleagues at Pitt and beyond,” commented Dr. Alter. AAPM wishes him and his team the best as they utilize this early investigator grant.

About AAPM

The American Academy of Pain Medicine is the premier medical association for pain physicians and their treatment teams with some 2,000 members. Now in its 37th year of service, the Academy’s mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy’s website at painmed.org

Guidance for Pain Fellows’ Education and Research During COVID-19 Published in AAPM Journal

April 30, 2020, CHICAGO – The official journal of the American Academy of Pain Medicine (AAPM), Pain Medicine, has published an article written by Board Members of the Association of Pain Program Directors (AAPD) titled “Maintaining high quality multidisciplinary pain medicine fellowship programs: Part I: Innovations in pain fellows education, research, applicant selection process, wellness and ACGME implementation during the Covid-19 Pandemic”. The article provides guidance and recommendations for pain program directors to continue trainee education and research while ensuring trainee well-being.

“The COVID-19 pandemic and associated social distancing requirements are having a profound impact on the health care system, including on the clinical duties of pain fellows,” says AAPM President Ajay Wasan, MD MSc. “Pain fellows are the future of our specialty, and it’s critical that we provide them with the resources and guidance they need to effectively complete their training and launch their careers.”

In addition to detailing alterations to ACGME policies and fellow education, research, and well-being during the COVID-19 pandemic, the article also provides recommendations for how program directors can conduct interviews with future fellows while maintaining social distancing.

Given the urgent need for this information to be publicly available to program directors and fellows across the country as quickly as possible, the article has been published and is freely accessible as an Accepted Manuscript. The Accepted Manuscript is the final draft author manuscript, as accepted for publication by the journal, including modifications based on referees’ suggestions but before it has undergone copyediting, typesetting, or proof correction. Within a few weeks, the Accepted Manuscript will be replaced by a corrected proof, known as the Version of Record. Neither the Accepted Manuscript nor the Version of Record may be hosted by any organization or journal other than Pain Medicine, but anyone is welcome to link to the guideline.

A panel of article authors will discuss their recommendations during a live webinar on Friday, May 1, 6-7:15 pm CT. This live CME activity is free, and registration is required by logging into an existing AAPM account or creating a new account. Learn more and register. A recording of the webinar will be available following the live event.

About AAPM

The American Academy of Pain Medicine is the premier medical association for pain physicians and their treatment teams with some 2,000 members. Now in its 37th year of service, the Academy’s mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy’s website at painmed.org

COVID-19 Pain Management Practice Guidelines Published in AAPM Journal

April 7, 2020, CHICAGO – The official journal of the American Academy of Pain Medicine (AAPM), Pain Medicine, has published a practice guidelines article titled “Pain Management Best Practices from Multispecialty Organizations during the COVID-19 Pandemic and Public Health Crises” to assist pain medicine providers, health care leaders, and regulatory bodies as they respond to the COVID-19 crisis.

Ensuring that persons experiencing pain have continued access to pain management services throughout this global pandemic is crucial. The Pain Medicine guidelines, which are supported by the medical societies and organizations listed below, addresses how pain medicine specialists can continue to offer vital pain care while also implementing strategies designed to keep themselves, their clinical staff members, and their patients safe.

“The need for providers and patients to responsibly address the COVID crisis must be balanced with the public health benefits inherent in the treatment of pain, as well as with the welfare of healthcare providers. Walking this ‘fine balance’ is critically important for pain specialists right now,” says AAPM President, Ajay Wasan, MD MSc, who co-authored the guidelines. “The purpose of this article is to offer guidance to help pain providers mitigate procedure risks, establish plans that protect clinicians and patients, implement telemedicine options, and triage procedures and clinical visits during the COVID-19 outbreak appropriately.”

Given the urgent need for this information to be publicly available as quickly as possible, the Pain Medicine guidelines article has been published and is freely accessible as an Accepted Manuscript. The Accepted Manuscript is the final draft author manuscript, as accepted for publication by the journal, including modifications based on referees’ suggestions but before it has undergone copyediting, typesetting, or proof correction. Within a few weeks, the Accepted Manuscript will be replaced by a corrected proof, known as the Version of Record. Neither the Accepted Manuscript nor the Version of Record may be hosted by any organization or journal other than Pain Medicine, but anyone is welcome to link to the guideline.

AAPM member and Director-at-Large Steven P. Cohen, MD spearheaded efforts to create this guideline and is its lead author. Dr. Cohen worked with representatives from the following associations to gather input and support for recommendations included in the article:

  • American Academy of Pain Medicine (AAPM)
  • American Academy of Physical Medicine and Rehabilitation (AAPMR)  
  • American Society of Anesthesiologists (ASA)
  • American Society of Regional Anesthesia and Pain Medicine (ASRA)
  • North American Neuromodulation Society (NANS)
  • Spine Intervention Society (SIS)
  • United States Military
  • Veteran Health Administration
  • World Institute of Pain (WIP)
A panel of guideline authors representing the multispecialty organizations that assisted in developing these recommendations will present a live webinar on Monday, April 13, 6-7:15 pm CT. This live CME activity is free, and registration is required by logging into an existing AAPM account or creating a new account. Learn more and register. A recording of the webinar will be available following the live event.

View a video conversation with two of the guidelines’ authors, ​Stephen P. Cohen, MD ​and ​Friedhelm Sandbrink, MD​. 

About AAPM

The American Academy of Pain Medicine is the premier medical association for pain physicians and their treatment teams with some 2,000 members. Now in its 37th year of service, the Academy’s mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy’s website at painmed.org

U.S. Surgeon General Vice Admiral Jerome M. Adams, MD MPH, to Discuss Pain Management and the Opioid Crisis During AAPM 2020

January 29, 2020, CHICAGO – The American Academy of Pain Medicine Program Committee is excited to announce that U.S. Surgeon General Vice Admiral Jerome M. Adams, MD MPH, will deliver a keynote address about the importance of pain management in combating the opioid crisis during AAPM 2020, the 36th Annual Meeting of the Academy, on Friday, February 28, 9:15 am, at the Gaylord National Resort & Convention Center in National Harbor, MD.

Dr. Adams is the 20th Surgeon General of the United States. His mission as the “Nation’s Doctor,” is to advance the health of the American people.

“Dr. Adams is an inspirational speaker with first-hand knowledge of the intersection of pain, opioid use, and addiction,” says Program Committee Co-Chair Steven P. Cohen, MD. “If there is one meeting you should attend in 2020, this is it!”

During his tenure as Surgeon General, Dr. Adams has created several initiatives to tackle our nation’s most pressing health issues, including the opioid epidemic. Dr. Adams issued the first Surgeon General’s Advisory in thirteen years, urging more Americas to carry naloxone, an FDA-approved medication that can reverse the effects of an opioid overdose. Dr. Adams also released Facing Addiction in America: The Surgeon General’s Spotlight on Opioids, and a digital postcard calling for a cultural shift in the way Americans think about, talk about, and respond to the opioid crisis. His Surgeon General’s postcard recommends actions that can prevent and treat opioid misuse, and promote recovery.

Dr. Adams joins a slate of renowned AAPM 2020 speakers that includes Eric Schoomaker, MD PhD, the 43rd U.S. Army Surgeon General; Brian Hainline, MD, Chief Medical Officer for the NCAA; Francis J. Keefe, PhD, Editor-in-Chief of PAIN; James C. Eisenach, MD, immediate past Editor-in-Chief of Anesthesiology; Mark E. Epstein, DVM CVPP, Chairperson of the Pain Management Guidelines for Dogs and Cats; and many others. For full details about this meeting, including instructions on how to register, visit annualmeeting.painmed.org.

Members of the press interested in attending the meeting should contact Megan Drumm, AAPM Director of Marketing & Communications, at [email protected].

AAPM Endorses Pain Management Task Force Final Report on Best Practices for Treatment of Pain

June 5, 2019, CHICAGO – The American Academy of Pain Medicine Board of Directors (AAPM) enthusiastically endorses the HHS Pain Management Best Practices Inter-Agency Task Force Final Report, which calls for a balanced, individualized, patient-centered approach to pain care.

The Pain Management Best Practices Inter-Agency Task Force was authorized by Congress on a bipartisan basis with a charge to propose updates to best practices and issue recommendations that address gaps or inconsistencies in managing chronic and acute pain in light of the ongoing opioid crisis, one of the greatest public health crises of our time.

“We commend Task Force members for their dedication to create this comprehensive and impactful report,” says AAPM President, Tim Lamer, MD. “The Academy is especially proud of its four members who served on the Task Force, including Past Presidents Dr. Jianguo Cheng and Dr. Rollin M. Gallagher, as well as Dr. Halena Gazelka and Dr. Friedhelm Sandbrink.”

The Task Force final report emphasizes that there is no one-size-fits-all approach to treating pain, instead highlighting five broad categories for pain treatment: medications, interventional procedures, restorative therapies, behavioral health, and complementary and integrative health approaches. The report also highlights the unique challenges and disparities facing special patient populations, such as children, adolescents, and older adults.

Education at the public, patient, provider, and policymaker levels is identified as critical to delivering patient-centered care, optimizing patient functional outcomes, eliminating stigma, and reducing the risk associated with prescription opioids. Specifically, expanding clinician pain training – including by increasing postgraduate positions to train pain specialists – is suggested as a means of improving access to pain care.

“This report offers necessary insight and recommendations to address the ongoing dual crises of opioid overuse, abuse, and diversion and the prevalence of chronic pain among Americans,” says Dr. Lamer. “AAPM looks forward to working with its membership and federal agencies to advocate for enacting report recommendations, with the ultimate goal of promoting multidisciplinary pain care and improving the lives of patients suffering from chronic and acute pain.”

About AAPM

The American Academy of Pain Medicine is the premier medical association for pain physicians and their treatment teams with some 2,000 members. Now in its 36th year of service, the Academy’s mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy’s website at painmed.org.

CHOIR Results Demonstrate Shortest Path Between Primary Care and Pain Medicine for the Most Complex Patients

Feb. 18, 2016, PALM SPRINGS, Calif. –- The care of complex patients with pain exhibits a closer connection between primary care and the specialty of pain medicine than that seen with less complex patients, Stanford researchers reported today. Results presented in a scientific poster at the 32nd Annual Meeting of the American Academy of Pain Medicine described the construction of a network algorithm to better characterize the relationship between primary care and pain medicine.

“We attempted to measure patient complexity by the number of specialty clinics each patient goes to and by their psychological distress,” said lead author Ming-Chih Kao, MD, PhD, a clinical assistant professor within the Stanford University School of Medicine in Palo Alto, Calif. “We found that the nature of care coordination is structurally different for complex patients. For complex patients who also have chronic pain, the coordination between primary care and pain medicine is particularly essential to the overall delivery of care.” 
The research team previously reported results that found the main driver of patient experience depends less on the individual provider than on the overall coordination among the clinic, the primary care physician and all others who participate in delivery of care. Building on that work, the researchers further studied the nature and role of care coordination for the pain medicine specialty, focusing on the organizational aspects and the multi-faceted nature of healthcare delivery for patients with many needs. 
In data analyzed from the Collaborative Health Outcome Information Registry (CHOIR), a total of 11,941 patients with chronic pain were seen across 160 clinics in 38 specialties and primary care. Each specialty represented a vertex on the network. Graph theory-based statistical methods were used to measure the collaborative relationships among specialties in this network.
The researchers discovered that the shortest path of three included dermatology and orthopedics (mean 3.47 +/- SD 0.54). Interestingly, though, for the 1,806 patients who visited at least six specialties, pain medicine and primary care were consistently strongly connected with shortest path distance of one (p<0.001). The finding was persistent for patients with more complexity.

“In our observation, pain medicine is at once closest to primary care and farthest from it,” Dr. Kao said, explaining that for the common pain complaints seen in primary care — back pain, neck pain and headache — pain medicine specialists typically get referrals only after several other specialties have been tried and failed.
The CHOIR platform is a learning health system created at Stanford in partnership and with funding through the National Institutes of Health. As a platform for learning health systems, CHOIR captures not only patient-reported outcomes but also clinical data in the electronic medical record system. More information on the CHOIR platform is at choir.stanford.edu.
“This work highlighted the power of combining clinical data with patient-reported outcomes,” Dr. Kao said.

Poster 175 – Network of Coordinated Care: Collaborative Relationship of Pain Medicine with Primary Care for Complex Patients with Pain: A Large-Scale Network Study Using a Learning Health System Platform

Intradiscal Biacuplasty Sustains Long-term Superiority Over Conservative Treatment for Discogenic Low-Back Pain

Feb. 18, 2016, PALM SPRINGS, Calif. – Patients treated with intradiscal biacuplasty (IDB) for discogenic back pain maintained benefits a year later, and those who crossed over to IDB treatment mid-study reported similar gains, study investigators reported. The results were presented today in a scientific poster at the 32nd Annual Meeting of the American Academy of Pain Medicine.

Contrary to the majority of chronic pain interventions, the minimally-invasive IDB demonstrated long-term benefit with no procedure-related complications, said Michael Gofeld, MD, the principal investigator and senior author. 
“The results were not only statistically significant, but — more importantly — clinically meaningful,” said Dr. Gofeld, a practicing chronic pain management specialist and anesthesiologist at St. Michael’s Hospital and Women’s College Hospital in Toronto, Canada, and an associate professor of Medicine at the University of Toronto. “Without addressing disc pathology, pain and function do not get better.”
Every year, up to one in five Americans suffers from low-back pain (LBP), and discogenic pain due to degeneration of the intervertebral discs is a chief cause (Zhang et al Int J Biol Sci 2009;5:647–58). Sufferers are often forced to choose between conservative treatment, which includes medications such as nonsteroidal anti-inflammatory drugs and physical therapy, or more invasive fusion surgery, often with limited success or the risk of complications.
This study followed 22 patients from the original IDB and comprehensive medical management (IDB+CMM) group of a prospective, randomized, multi-center, open-label trial for an additional six months. In the original trial, the combination of IDB+CMM overwhelmingly exceeded CMM alone at six months on measures of pain, function, quality of life and global impression of change. The investigators found that statistically and clinically significant improvements over baseline were sustained at 12 months on all measures, with pain reduction of more than 2 points on the visual analog scale and a decrease of 14 points on the Oswestry Disability Index. The quality of life index also improved.
In addition, the 25 patients who elected to cross over from CMM to the active treatment group responded similarly in terms of pain reduction and improved functional status. Importantly, without IDB, patients in the CMM group did not show improvement, Dr. Gofeld said.

The equipment to perform IDB, a technique that uses cooled radiofrequency to destroy culprit nociceptive nerves in degenerative spinal discs, was first developed by Baylis Medical Company in Canada and was approved by the U.S. Food and Drug Administration in 2007. Dr. Gofeld, who performed the first procedures in Canada, explained that patients who benefit have the following features:

  • LBP without sciatica
  • Disc degeneration that is limited to 1-2 levels
  • Preservation of at least 50 percent of disc height
  • No significant herniation
Now that clinical benefits have been established through this and previous research (Kapural et al Pain Med 2013;14:362-73, Kapural et al Pain Med 2015;16:425-31, Desai et al Spine 2015 [Epub ahead of print]), barriers to insurance coverage must be addressed, Dr. Gofeld said. “Once both efficacy and effectiveness are established in such a rigorous research setting, the procedure should be approved by payers. It has no CPT (Current Procedure Terminology) code, and the access for patients remains difficult.”

Poster 123 – Long-Term Results (12-Months) of a Prospective, Multicenter, Open-Label Clinical Trial Comparing Intradiscal Biacuplasty to Conventional Medical Management for Discogenic Lumbar Back Pain

Funding: Kimberly Clark Corporation 

More Evidence of the Power of Mesenchymal Stem Cell Transplant to Block Opioid-Induced Hyperalgesia and Tolerance

Feb. 18, 2016, PALM SPRINGS, Calif. – Cleveland Clinic researchers have found new evidence that modulating neuroinflammation with stem cell transplants may prove to be an effective strategy to treat both opioid tolerance (OT) and opioid-induced hyperalgesia (OIH). The latest results in this line of inquiry, which may have the potential to transform opioid therapy for pain, are on view today at the 32nd Annual Meeting of the American Academy of Pain Medicine.

The investigators found that the development of OT and OIH was effectively prevented in rats by either intravenous (IV) or intrathecal mesenchymal stem cell (MSCs), which were transplanted before morphine treatment. Furthermore, established OT and OIH were significantly reversed when the timing of the transplants followed repeated morphine injections.

“We have demonstrated that MSC transplantation promises to be a potentially safe and effective way to prevent and reverse two of the major problems associated with opioid therapy,” said Jianguo Cheng, MD, PhD, professor of  anesthesiology and director of the Cleveland Clinic Pain Medicine Fellowship Program.

“This emerging therapy has enormous potential to profoundly impact clinical practice. It may improve the efficacy of opioid therapy, reduce the risk of opioid overdose and save lives,” he said. 

Neuroinflammation that involves activation of microglia and astrocytes in the central nervous system contributes greatly to OT and OIH. Both OT, in which higher doses become necessary, and OIH, a heightened pain response, can limit effectiveness and compromise safety during opioid therapy to treat pain. The anti-inflammatory and immune modulatory properties of MSCs have been previously demonstrated. Last year, the same scientific research team reported that intrathecal MSC transplant reduced OIH and OT in rats. For the current study, the investigators further tested the anti-tolerance and anti-hyperalgesia effects of MSC, this time by IV application and in mice as well as rats.

The IV transplant was given seven days before or 14 days after the initiation of daily morphine injections to test both the preventive and therapeutic effects of MSCs. Investigators evaluated OT and OIH by foot withdrawal thresholds in response to mechanical or thermal stimulation. They also examined multiple safety parameters, including normal locomotion, body weight gain, liver and kidney function, and vital organ pathology exams.

Using immunohistochemistry, they found that the treatments significantly reduced the activity of microglia and astrocytes in the spinal cord. The analysis of safety measures revealed no abnormalities in the animals’ vital organs or functions. The investigators are planning a preclinical investigation in preparation for clinical trials.

Poster 233 – Intravenous Transplantation of Bone Marrow–Derived Mesenchymal Stem Cells Attenuated Activation of Glial Cells and Reversed Opioid Tolerance and Opioid-Induced HyperalgesiaFunding: US Department of Defense Grant and Cleveland Clinic Anesthesiology Institute Research Fund

Sphenopalatine Ganglion Block is Found Fast, Effective and Safe for Postdural Puncture Headache in Obstetric Patients

Feb. 18, 2016, PALM SPRINGS, Calif. – New research suggests that sphenopalatine ganglion block (SPGB) relieves disabling headache from dural puncture faster than the usual care of epidural blood patch (EBP) and lacks the potential for rare but profound complications that can accompany EBP. A non-invasive treatment with minimal side effects, SPGB is a highly effective treatment for accidental postdural puncture headache (PDPH) in obstetric patients, according to results from a retrospective analysis on view today in a scientific poster at the 32nd Annual Meeting of the American Academy of Pain Medicine.

At 24-48 hours, both treatments were similarly effective; however, SPGB was associated with greater headache relief at 30- and 60- minutes post-treatment, said lead author Preet Patel, MD, a research fellow at Rutgers – Robert Wood Johnson (RWJ) Medical School in New Brunswick, N.J. He said advantages of SPGB include its relative ease of administration and lower complication rates.

“One of the advantages of SPGB is that you will know relatively quickly if it is providing headache relief for your patient,” Dr. Patel said. “If the block is not effective within the first three hours, you can switch to the more invasive EBP.” And if it does work, he said, the new mothers can avoid the complications that can appear days or weeks later with EBP and enjoy a quicker recovery, “which is absolutely critical in this population.”

Disabling headache from dural puncture can follow the administration of spinal anesthesia. According to the International Headache Society, PDPH worsens with sitting upright, improves with reclining and is accompanied by neck stiffness, tinnitus, photophobia or nausea. When conservative measures such as oral medications or caffeine fail to relieve the often-severe headache pain, EBP is the usual treatment choice. Unfortunately, EBP can lead to significant complications on rare occasions, including motor and sensory deficits, meningitis, hearing loss,

Horner’s Syndrome and subdural hematoma (Snidvongs & Shah JRSM Short Reports 2012;3:68, Beilin & Spitzer A A Case Rep 2015;4:163-5, Kardash et al Reg Anesth Pain Med 2002;27:433-6). 

Dr. Patel described the history of SPGB use for headache relief, including migraine and cluster headache, going back for over 100 years but said it had not been previously adequately studied for PDPH treatment.

The investigators reviewed 72 records over 17 years of women without a previous history of primary headaches who had experienced PDPH during childbirth. Thirty-three women received SPGB (with EBP available upon request), and 39 women received routine EBP. The women were similar in age, height, BMI and potential risk for suffering complications from general anesthesia.

The superior pain relief with SPGB was observed at the earliest time points: 55 percent of those receiving SPGB had recovered from headache at one-half hour post-treatment compared with 21 percent in the EBP treatment group. At one hour post-treatment, 64 percent of SPGB recipients had recovered vs. 31 percent in the EBP treatment group. At 24 hours, 48 hours and one week post-treatment, no differences were seen in pain relief. However, EBP recipients experienced higher complication rates, including nine patient emergency-room visits, three complaints of backache radiating to the leg, one vasovagal reaction and one complaint of temporary hearing loss.

Dr. Patel said that although the study is small and retrospective, the results are ample evidence to ask anesthesiologists to consider using the non-invasive SPGB for the treatment of PDPH in obstetric patients before they consider using the more invasive EBP. The research team in the Department of Anesthesiology at Rutgers – RWJ is planning a prospective study and hopes to report data within three years.
Poster 145 – Sphenopalatine Ganglion Block (SPGB) Versus Epidural Blood Patch (EBP) for Accidental Postdural Puncture Headache (PDPH) in Obstetric Patients: A Retrospective Observation
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