Argoff, Charles E.

Facial pain disorders, most notoriously trigeminal neuralgia, cause substantial suffering, functional impairment, disability, and impaired quality of life. However, most pain medicine practitioners have had only limited education on the evaluation, diagnosis, and treatment of facial pain. Furthermore, this limited education often contains commonly held myths about facial pain diagnosis. These myths can result in misdiagnoses that lead to ineffective medications, interventions, or surgeries and prolonged pain. Therefore, the American Society of Regional Anesthesia and Pain Medicine’s Headache and Facial Pain Special Interest Group convened a multidisciplinary group of neurologists, anesthesiologists, and dentists to identify and dispel pervasive myths in facial pain diagnosis.

Abstract Objective To evaluate available evidence for the efficacy and safety of topical analgesics for neuropathic pain and to offer treatment guidance. Methods An expert panel searched PubMed (Medline) and reference lists of published articles for available literature assessing 8 categories of topical analgesics used to treat various neuropathic pain conditions. The panel rated the level of analgesic efficacy evidence for each treatment and considered safety, ease of use, and cost. The degree of consensus on the recommendations among the panelists was measured. Results There was strong evidence and high consensus that capsaicin 8% is effective for diabetic peripheral neuropathy and postherpetic neuralgia and that lidocaine is effective for postherpetic neuralgia. There was strong evidence and moderate consensus that capsaicin 8% could be effective for HIV-induced neuropathy. There was moderate evidence and high consensus that lidocaine is likely effective for diabetic peripheral neuropathy, idiopathic neuropathy, and postsurgical neuropathy and that capsaicin 8% might be effective for chemotherapy-induced peripheral neuropathy and complex regional pain syndrome. Evidence was weak for other topical medications, though the panel strongly agreed that antidepressants might help with postherpetic neuralgia, complex regional pain syndrome, postsurgical neuropathy, and post-traumatic neuropathy; that nonsteroidal anti-inflammatory drugs could help with postsurgical neuropathy; and that gabapentin might benefit vulvodynia. There was less agreement about whether antidepressants might benefit diabetic peripheral neuropathy, chemotherapy-induced peripheral neuropathy, and vulvodynia and whether capsaicin 8% could be effective for postsurgical neuropathy. Conclusions Recommendations were based on a survey and grading of existing literature and, when strong evidence was lacking, the collective clinical expertise of panelists.

Abstract Introduction The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. Methods This study involved 56 PDs of ACGME‐accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow‐up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. Results Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry‐related and professional society‐related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long‐term success. Fifty‐four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. Conclusion This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12‐month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Abstract Objective To assess routine application and clinical value of definitive urine drug monitoring (UDM) for drug detection, inconsistent drug use, and prescription adherence, along with a comparison to immunoassay screening (IAS). Methods Direct-to-definitive UDM performance was analyzed retrospectively in 5000 patient specimens. Drug findings, medication inconsistencies, and detection sensitivity were assessed, and definitive UDM versus IAS monitoring was studied. Results Definitive testing resulted in 18,793 drug findings with 28,403 positive drug and metabolite tests. Definitive testing expanded monitoring with 11,396 drug findings that would not be tested by IAS. The opioids accounted for the highest frequency of inconsistent positive drug-use findings, at 12%. Conversely, inconsistent negative drug findings, used as an index of prescription non-adherence, were determined in 1,751 of 15,409 monitored medications and included a high frequency of antidepressants and antipsychotics inconsistencies. Direct comparison of definitive UDM and IAS showed false-positives by IAS as well as a high rate of false-negatives that would be missed using current confirmation protocols. Conclusions Results from routine application of direct-to-definitive UDM demonstrate the clinical value of drug-use identification and the objective evaluation of inconsistencies in drug misuse and medication adherence in pain management and addiction medicine practice. Without conversion to direct-to-definitive UDM, continuing use of IAS will limit the scope of drugs being tested, will result in an indeterminate rate of false negatives and will require confirmation testing to eliminate the reporting of false-positive IAS tests. The findings in this study provide evidence-based support for recommended use of a direct-to-definitive drug testing protocol.