INR P.O. Box 5757 ♦ Concord, CA 94524 ♦ (925) 609-2820 ♦ (925) 687-0860

Understanding Pain: Migraines, Headaches, Neck & Low Back Pain

Instructor: Dr. Nikita Katz (M.D., Ph.D.)

Participants completing this program will be able to:

1) list the neurologic processes causing pain and suffering and the principles of pain assessment.

2) discuss treatment modalities for primary and secondary headaches, including migraines and rare cephalalgias.

3) list the “red flags” of medication abuse and approaches to reduce opioid addiction.

4) describe the differential diagnosis of dental vs. cervical and cervicogenic pain and the appropriate interventions for both.

5) list steps involved in the diagnosis and management of spinal pain, including physical and occupational therapy.

6) describe how the information in this course can be utilized to improve patient care and patient outcomes.

7) describe, for this course, the implications for dentistry, mental health, nursing, and other healthcare professions.

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- 1 -

Understanding Pain Migraines, Headaches, Neck, and Low Back Pain

• SOCRATES = mnemonic for pain assessment (far from ideal but often used): • Site – Where is the pain? Or the maximal site of the pain.

• Onset – When did the pain start, and was it sudden or gradual? Include also whether it is progressive or regressive.

• Character – What is the pain like? An ache? Stabbing?

• Radiation – Does the pain radiate anywhere?

• Associations – Any other signs or symptoms associated with the pain?

• Time course – Does the pain follow any pattern?

• Exacerbating/relieving factors – Does anything change the pain?

• Severity – How bad is the pain?

PAIN!

MOVE!

OUCH! WHY?

Frontal Cortex (interpretation)

Thalamus (ID/Relay)

“Suffering” Areas: Cingulate Gyrus

Pons (incoming data)

Cerebellum

• The International

Association for the

Study of Pain defines

pain as ―an unpleasant

sensory and emotional

experience associated

with actual or potential

tissue damage, or

described in terms of

such damage‖

• In clinical practice, pain

is alternately regarded

as a symptom of an

underlying condition, a

manifestation of a

disorder and as the

―Fifth Vital Sign‖

Pain, the 5th Vital Sign

- 2 -

SOCRATES (470-399 BC), a SCHOLAR • SOCRATES = mnemonic for pain

assessment (far from ideal but often

used): • Site – Where is the pain? Or the maximal

site of the pain.

• Onset – When did the pain start, and was

it sudden or gradual? Include also

whether it is progressive or regressive.

• Character – What is the pain like? An

ache? Stabbing?

• Radiation – Does the pain radiate

anywhere?

• Associations – Any other signs or

symptoms associated with the pain?

• Time course – Does the pain follow any

pattern?

• Exacerbating/relieving factors – Does

anything change the pain?

• Severity – How bad is the pain?

• SCHOLAR = mnemonic for

History of Present Illness

(HPI) and may be used for

pain assessment • Symptoms / Severity

• Characteristics

• Onset

• Location

• Aggravating Factors

• Remitting Factors

The Spectrum of Pain

• Nociception (nociceptive pain) —response of the sensory

nervous system to harmful or potentially harmful stimuli • Potentially damaging mechanical, thermal, and chemical stimuli are detected

by nociceptors found in the skin (greatest number), on periosteum, joint

surfaces, and in most organs (except, e.g., brain)

• Neuropathic pain — caused by lesions or a disorder of the

sensory nervous system, including peripheral nerves, the spinal

cord and the sensory/integrative areas of the brain (due to e.g.,

diabetes, vitamin deficiency, injury, MS, stroke)

• Psychogenic pain is caused, increased, or prolonged by mental,

emotional, or behavioral factors including somatization • Common ―vicious circles‖ link depression, anxiety, insomnias to development

or aggravation of chronic pain. The role of neurotransmitter signaling

imbalances is often emphasized, as are antidepressant/anxiolytic medications • Definitions adopted by the International Association for the Study of Pain‘s guidelines

- 3 -

Pain Pathology

• Hyperpathia — a painful syndrome characterized by an

abnormally painful reaction to a stimulus, especially a repetitive

stimulus, as well as an increased threshold

• Hyperalgesia — an abnormally increased sensitivity to pain • Often observed in opioid-tx pts and caused by opioid tx of pain

• Allodynia — central pain sensitization following normally non-

painful, often repetitive, stimulation. D-opioid receptors are

hypersensitive and d-targeting medication may help.

• Hypoalgesia — a decreased sensitivity to painful stimuli • Hereditary neuropathies and also in diabetes, hypertension, somatization +

exercise-induced and fear-induced hypoalgesia

• Chronic pain — either arbitrarily assigned temporal extent

(―longer than 3 or 6 months‖) or clinically-observed (―pain that

extends beyond the expected period of healing‖) • Epidemiology of chronic pain: between 10 and 50% of the population

Strength of the Noxious Stimulus

Magnitude o

f P

ain

Pain Pathology, 2

Schematic and simplified

depiction of:

Normal Nociception

Allodynia

Hyperalgesia

Hyperpathia

Pain Threshold

- 4 -

Sleep Deprivation and Pain

• Published studies indicate that sleep deprivation produces

hyperalgesic changes.

• Furthermore, sleep deprivation can interfere with analgesic

treatments involving opioids and serotoninergic mechanisms of

action.

• The hyperalgesic effects are due to the deprivation of specific sleep

stages such as deep sleep; however, in some cases they result from

a generalized disruption of sleep continuity (sleep architecture)

• The calculated effect size is comparable with effect sizes achieved

through pain treatment

• Sleep deprivation affects self-reported pain as well as pain threshold

• In one experiment no significant variations were observed in the

REM-deprivation group, suggesting a predominant role for slow wave

sleep rather than REM in pain perception

• Schrimpf et al., Sleep Medicine (2015) 16(11) pp. 1313-1320; Azevedo et al., PAIN (2011) 152(9) pp.

2052–2058

Supplemental Slide: Sleep Deprivation

• The outward appearance of sleep induced by antihistamines, other

sedatives, hypnotics and depressant chemicals, including alcohol,

benzodiazepines, barbiturates and opioids MAY be similar to deep

sleep;

• However, there is dramatic inhibition of the normal and necessary

processes of deep sleep (stage 3 NREM sleep).

• A total of 30.6 million adults (12.6%) reported benzodiazepine use:

25.3 million as prescribed and 5.3 million misuse. Misuse =17.2%

of overall use (https://doi.org/10.1176/appi.ps.201800321)

Deep Hypnotic/Toxic

- 5 -

Sleep Remedies for Chronic Pain Pts

• Valerian root = 400-800 mg = not habit-forming, no rebound

• Passion flower = tea from 2 g = useful in children

• 5-HTP = 100 mg or Tryptophan = 500 mg = not to use with SSRI/SNRI/TCA

• GABA = 300-900 mg = not to use with benzos, alcohol habit

• Melatonin = 3 mg sublingual 30 min QHS (darkness!) = avoid in infections

• OTC antihistamines are acceptable for occasional use only and are

contraindicated if their anticholinergic side effects pose a problem

• IF OTC + SLEEP HYGIENE are less effective, consider Rx hypnotics

• Trazadone, not scheduled

• Mitrazapine, not scheduled

• Ramelteon (Rozerem®), not scheduled

• Z-drugs (zolpidem, eszopiclone), schedule IV (habit forming)

• Suvorexant (Belsomra®) orexin antagonist, also schedule IV

• Benzodiazepines, textbook schedule IV • Short half-life, midazolam/Versed®, triazolam/Halcion® for sleep onset insomnia

• Longer half-life, alprazolam/Xanax®, clonazepam/Klonopin® for sleep maintenance;

• Longest half-life benzos may have lower risk of rebound and withdrawal but high risk of ‗spillover

effect‘, diazepam/Valium®, flurazepam/Dalmane®

―Aggressive‖ vs. ―Realistic‖ Palliation

• The Pain Ladder as formulated by the WHO in 1986 for the management of

cancer pain specifically consists of three steps with escalation if pain persists or

increases

• It also provides for the 2-stage administration of analgesics: at regular intervals

(―by the clock‖) for continuous pain relief and PRN (―by the need‖) for

breakthrough pain

• As recently as 2009 the FDA stated that ―According to the National Institutes of

Health, studies have shown that properly managed medical use of opioid

analgesic compounds (taken exactly as prescribed) is safe, can manage pain

effectively, and rarely causes addiction‖ (FDA.gov ―A Guide to Safe Use of Pain

Medicine‖)

Step 1:

MILD

Non-opioid

(e.g., acetaminophen) +

Optional adjuvant

(e.g., NSAID)

Step 2:

MODERATE

Weak opioid

(e.g., tramadol, codeine) +

Non-opioid

(e.g., acetaminophen) +

Optional

adjuvant

(e.g., NSAID)

+ PRN

weak opioid

Step 3:

SEVERE.

Strong opioid

(e.g., morphine,

oxycodone, fentanyl)

+ Non-opioid

(e.g., acetaminophen) +

Optional

adjuvant

(e.g., NSAID)

+ PRN

strong opioid

- 6 -

―Aggressive‖ vs. ―Realistic‖ Palliation, 2

• According to Drs. Pergolizzi (MD) and Gharibo (PhD): ―way too often, we are treating

the number on a pain score scale, rather than working to improve a patient‟s function‖ • Most people with pain desire a return to normal life with normal function, including work, hobbies, sexual activity,

sleep, and other activities that are taken for granted when accessing quality of life.

• According to Dr. McCarberg (MD): ―Statements from a pain specialist such as "There is

nothing more I can do," "You will need to learn to live with this pain," or "The doctor

who deals with this type of pain is a psychiatrist," are all dreaded phrases to the patient

with persistent pain

• The provider should instead promise continued support and, despite lack of treatment

efficacy, should not give up on the patient or stop being creative in providing help. • Appropriate statements include "Even though we have not found anything to stop your pain, I am still here for

you," and "You and I are going to continue to work on this pain problem to improve your function"

• For the patient with persistent pain, promise what you can deliver: comfort,

compassion, creativity, teamwork, a caring environment, and most of all, yourself as a

clinical professional.

• Educating the pt and setting realistic goals for pain levels, pain control and function

recovery is known to reduce risk of self-harm and suicidality.

• Since 2016 health care professionals are bound by the CDC guidelines for

management of pain emphasizing the realistic approach (detailed discussion follows).

Pain in a Complicated Patient

• Patients with dementia experience the same prevalence (25-50%) of

conditions likely to cause pain as seniors without cognitive impairment • Pain is often poorly assessed and addressed in those pts, as they suffer from reduced ability to

self-assess and to communicate.

• Persistent pain can lead to exacerbation of cognitive impairment and aggravation of psychosis

• Semi-objective and autonomic signs of pain must be assessed

• Similarly, pain in babies may be non-obvious

• Assessment instruments include mPAS, NPAS (Neonatal Pain

Assessment Scale) and CHIPPS (Children and Infants Postoperative Pain

Scale) • NPAS is especially effecive for infants <1 yo, ChIPPS is useful for post-operative pain

• ChIPPS score >4 requires analgesia

Item 0 1 2

Crying None Moaning Screaming

Facial expression Relaxed smiling Wry mouth Grimacing

Posture of the trunk Neutral Variable Rear up

Posture of the legs Neutral Kicking Tightened

Motor restlessness None Moderate Restless

- 7 -

Supplemental Slide: In Search of Objective Assessment of

Pain

• A traditional approach to evaluating pain—changes in basic

physiological parameters such as blood pressure or heart rate, is

often less reliable.

• Heart rate variability considers the time intervals between

consecutive heartbeats. It evaluates the relative contributions made

by the parasympathetic and sympathetic autonomic nervous system

(ANS).

• Pain ↓ parasympathetic and ↑ sympathetic ANS activity. • ANSAR is one modality that allows for assessment of the Para/Sympathetic balance.

• The infrared video-pupillometer measures the pupil response to

pain itself and compares it to light induced dilatation to establish the

sympathetic ANS response to pain.

• Approaches that best predict the presence and severity of pain are

those that combine autonomic responses with indicators of brain

activity such as EEG-entropy measurements. • They are also most technically challenging.

• Laycock H, Bantel C (2016) Objective Assessment of Acute Pain. J Anesth Clin Res 7:630.

Semi-Objective Assessment of Pain

• Nursing/other professional assessment may be semi-objective

when it utilizes approaches listed below: • Does the pt show nonverbal signs of pain such as crying or grimacing?

• Does the pt show autonomic signs of pain such as pupil dilation, sweating, dry

mouth, HR and BP instability?

• Does the pt watch the clock and ask for the pain medication or sedative at the

exact time it‘s due?

• Does the pt continually ask for the medication?

• Does the pt persistently ask to increase pain medication?

• Does the pt have a change in mood and behavior if they don‘t receive the

medication at the exact time?

• Have a conversation with the patient: do they want the medication because

they are in pain or because they can‘t sleep or are anxious?

- 8 -

Classification of Headaches

• PRIMARY

• Migraine (± aura), Tension-Type HA, Cluster HA, ―stabbing‖ HA,

cough, exertional, sexual activity, hypnic, thunderclap

• SECONDARY

• Attributed to trauma, vascular disorder, CSF flow disorder,

substance use/withdrawal, mass effect, infection,

metabolic/homeostasis pathology, cranial disorders,

psychiatric/somatization

• CRANIAL NEURALGIAS and FACIAL PAIN

• Cranial neuralgias and central causes of facial pain (cold-

stimulus, post-herpetic neuralgia

• Headache NOS / Idiopathic

Supplemental Slide: Classification of Headache

(ICHD)

PRIMARY HEADACHES

• ICHD 1: Migraine (with, without aura; retinal; complications)

• ICHD 2: Tension-Type Headache (infrequent, frequent, chronic)

• ICHD 3: Cluster Headache & Trigeminal Autonomic Cephalalgias

• ICHD 4: Other Primary Headaches (stabbing, cough, exertional, sexual activity, hypnic,

thunderclap, hemicrania continua, and new daily persistent headache)

SECONDARY HEADACHES

• ICHD 5: Attributed to head/neck trauma (e.g., whiplash injury)

• ICHD 6: Attributed to cranial/cervical vascular disorder (e.g., TIA, SAH, AVM, GCA etc.)

• ICHD 7: Attributed to non-vascular intracranial disorder (e.g., idiopathic intracranial

hypertension, mass effect, SZ, Chiari 1 etc.)

• ICHD 8: Attributed to a substance or withdrawal (e.g., medication overuse headache, MSG-

induced, NO-donor induced, caffeine withdrawal, estrogen withdrawal etc.)

• ICHD 9: Headache due to infection (e.g., meningitis, abscess)

• ICHD 10: Headache attributed to disorder of homeostasis (e.g., high altitude, arterial

hypertension, pre-eclampsia, fasting etc.)

• ICHD 11: Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose,

sinuses, teeth, mouth or other facial or cranial structures (e.g., glaucoma, TMJ disorder,

toothache as trigger etc.)

• ICHD 12: Headache attributed to psychiatric disorder (e.g., somatization)

CRANIAL NEURALGIAS, FACIAL PAIN, NOS

• ICHD 13: Cranial neuralgias and central causes of facial pain (cold-stimulus, post-herpetic

neuralgia, occipital neuralgia, optic neuritis including of MS, structural lesions etc.)

• ICHD 14: Headache NOS

- 9 -

Neurologic Red Flags: Headache

• Headache beginning after 50 years of age • DDX: Temporal arteritis, mass lesion

• Sudden onset of headache • DDX: Subarachnoid hemorrhage, pituitary apoplexy, hemorrhage into a

mass lesion or vascular malformation, mass lesion (especially posterior

fossa mass)

• Headaches increasing in frequency/severity over time • DDX: Mass lesion, subdural hematoma, medication overuse

• New-onset HA with risk factors for HIV or cancer • DDX: Meningitis (chronic or carcinomatous), brain abscess (including

toxoplasmosis), metastasis

• Headache with signs of systemic illness (fever, stiff

neck, rash) • DDX: Meningitis, encephalitis, Lyme disease, systemic infection, collagen

vascular disease

• Focal neurologic signs or symptoms of disease (other

than typical aura) • DDX: Mass lesion, vascular malformation, stroke, collagen vascular

disease

• Papilledema • DDX: Mass lesion, pseudotumor cerebri, meningitis

• Headache subsequent to head trauma • DDX: Intracranial hemorrhage, subdural hematoma, epidural hematoma,

post-traumatic headache

Supplemental Slide: Workup of HA Red

Flags

• Headache beginning after 50 years of age • WU: Erythrocyte sedimentation rate, neuroimaging

• Sudden onset of headache • WU: Neuroimaging; lumbar puncture if neuroimaging is negative

• Headaches increasing in frequency and severity over time • WU: Neuroimaging, drug screen

• New-onset headache in a patient with risk factors for HIV

infection or cancer • WU: Neuroimaging; lumbar puncture if neuroimaging is negative

• Headache with signs of systemic illness (fever, stiff neck, rash) • WU: Neuroimaging, lumbar puncture, serology

• Focal neurologic signs or symptoms of disease (other than

typical aura) • WU: Neuroimaging, collagen vascular evaluation (including antiphospholipid antibodies)

• Papilledema • WU: Neuroimaging, lumbar puncture

• Headache subsequent to head trauma • WU: Neuroimaging of brain, skull and, possibly, cervical spine

- 10 -

Supplemental Slide: DDX of HA

• Identify:

• arteriovenous malformation

• choroidal plexus papilloma

• abscess.

A B

C

Overuse and Rebound HA

• Medication-overuse headache (MOH) is a chronic daily HA caused by

excessive use of acute medications.

• MOH most commonly occurs in pts who escalate doses of acute medications.

• MOH has been found to render headaches refractory to both pharmacological

and non-pharmacological prophylaxis and acute therapy for migraines.

• → Discontinuation of the medication that is overused

• → Combination of pharmacological (botulinum, calcitonin gene-related peptide

inhibitors) + non-pharmacological, behavioral and physical therapy

interventions. • Source: Kristoffersen and Lundquist. Ther Adv Drug Saf 2014;5(2):87-99

Class Example Overuse, dx

Analgesics ASA, APAP, NSAIDs >15 d/month

Combination Pain Relievers ASA+APAP+caffeine; ASA+butalbital+caffeine >10 d/month

Triptans, Ergotamines DHE, Sumatriptan, Zolmitriptan etc. >10 d/month (⁂)

Opioids Morphine, codeine, tramadol >10 d/month

Caffeine >200 mg/day daily or near-daily

- 11 -

Migraine: DDX

• Most commonly migraines are ddx from tension headaches, however, both types

coexist in many patients (!)

• MIGRAINE

• Pts seek medical care due to

severity, and frequency

• Disabling nature of migraines

• Commonly: unilateral, throbbing

severe pain (>7/10), may be

prolonged

• Nausea/vomiting common

• Worsening of pain with activity

• Photophobia

• Phonophobia

• 75% of migraineurs have neck pain

with attacks

• Migraine often presents with auras

(vision, taste, smell, skin sensation)

• TENSION-TYPE HEADACHE

• Tension-type headache is an

uncommon reason for patients to seek

medical care, unless it is very frequent

and severe

• > 90% of patients dx in primary care

with tension-type headache in fact

have migraine

• Attacks are generalized throughout

the head; often bilateral pressure-like

and non-throbbing pain.

• Photophobia or phonophobia are rare

(and cannot have both; otherwise it is

a migraine)

• A careful history and a diagnostic

headache diary are needed

Migraine Timeline

Phase Time Pain Symptoms

PRODROME FEW HOURS up to

DAYS NONE or Tension-type

Depression, Fatigue,

Concentration issues,

Frequent Urination, Food

Cravings, Difficulty

finding words/reading,

Insomnia, Photophobia,

Phonophobia, Nausea,

Sensitivity to smells

AURA 5-60 MINUTES USUALLY NONE

VISUAL, SKIN

SENSATION,

SMELL/TASTE, rarely

AUDITORY

MIGRAINE

ATTACK 4-72 HRS SEVERE

Typical symptoms +

anxiety, insomnia, neck

pain and stiffness

POSTDROME 24-48 HRS NONE or Tension-type

Fatigue, Depression or

Euphoria, Concentration

and Comprehension

issues

• Migraines with aura + smoking + estrogen use

(contraceptives, HRT) lead to elevated risk of ischemic

stroke, which should be evaluated in detail and addressed

in every patient

- 12 -

Preventive Medications for HA • Taken on a long-term basis to reduce frequency and/or severity of migraines and

other headaches.

• According to Dr. Steven Silberstein: “The bottom line is side effects. I tell the patient,

„This drug may have cognitive side effects in some people, may make you lose

weight, or here's one that may make you gain weight. Which one do you choose?‟”

Medication Class Generic Examples Side Effects

Beta-blockers Atenolol, Metoprolol, Nadolol

Propranolol, Timolol

Fatigue, Depression, Nausea, Insomnia,

Dizziness

Ca Channel Blockers Verapamil, Diltiazem, Nimodipine Weight gain, Constipation, Dizziness,

Low blood pressure

Tricyclic Antidepressants Amitriptyline, Nortriptyline, Imipramine Weight gain, Dry mouth, Sedation,

Decreased libido

SSRI Fluoxetine, Paroxetine, Sertraline Weight gain or loss, Decreased libido,

Withdrawal rebound

Anticonvulsants

Valproate, Gabapentin, Topiramate,

(Pregabaline)

Weight gain or loss (T); Sedation,

Skin rash

Serotonin Antagonists (Ergot) [Methysergide], Methylergonovine Not commonly used or not available; blood vessel

spasms, fibrosis (abdomen, heart etc.)

Alternative / Nutraceutic Magnesium, Riboflavin, Butterbur Diarrhea, GI upset, urine discoloration

Triptans for HA

• Triptans are acute medications for migraines and cluster headaches • They are not considered a cure and they are not effective for the treatment of tension–type

headaches.

• Available as oral, sublingual and nasal sprays (sumatriptan, zolmitriptan)

as well as suppositories, SC injection, iontophoretic patches, inhaled

powder (―breath powered‖) and needle-free injection (sumatriptan)

• Triptans are contraindicated in patients with symptomatic coronary artery

dx, uncontrolled hypertension, Raynaud‘s disease, peripheral artery

disease etc. • Most triptans (except suma- and zolmi-) are also contraindicated in patients younger than 18

• Not to be combined with ergot alkaloids or MAO inhibitors (including selective)

• SC sumatriptan has the most rapid onset of action and greatest efficacy but the most adverse

effects.

• Of the oral triptans, rizatriptan seems to have the greatest early efficacy.

• Almotriptan has a response rate similar to that of oral sumatriptan and may produce fewer

adverse effects.

• Naratriptan and frovatriptan, with their slow onset, high tolerability, and long half-lives, may

have a role in stopping prolonged migraine attacks and possibly in headache prevention.

• Eletriptan at higher doses (80 mg) has a response rate approaching that of rizatriptan but may

be limited by potential side effects. • Source: Adelman et al., Clinical Cornerstone 4(3), pp. 53-64

- 13 -

Botulinum Toxin for >15 HA/month • In addition to muscle tension relief, the toxin inhibits release of peripheral nociceptive

neurotransmitters (e.g., Substance P), suppressing the central pain processing systems

responsible for migraine headache.

• The typical (FDA-recommended) dosage is 155 units • Lowest retail price as of March 2019 is ~ $1200 per 200 units (covered by many insurance plans including MCare)

• EMLA or similar topical application may be used to reduce the pain of injection.

• Treatment lasts up to 10-12 weeks, can be repeated with no apparent diminishment of

efficacy

• Prevention of immune response and prevention of systemic absorption of the drug (cold

and pressure) translates into better efficacy and potentially longer duration.

• Side effects may include paralysis of unintended muscles, ptosis, facial asymmetry,

trouble swallowing, systemic muscle weakness, flu-like symptoms and, in very rare

cases, MI. • Source: Ramachandran and Yaksh. Br J Pharmacol. (2014) v.171(18) pp.4177–4192.

A. Corrugator: 5U x2; B. Procerus: 5U; C: Frontalis 10U x2; D: Temporalis: 20U x2;

E: Occipitalis 15U x2; F: Cervical paraspinal: 10U x2; G: Trapezius: 15U x2

CGRP Antibodies for HA

• Calcitonin gene-related peptide (CGRP) receptor

antagonists are anti-migraine agents approved by the

FDA as prophylaxis agents

• Monoclonal antibodies targeting the CGRP receptor —

Erenumab (Aimovig®)

• Monoclonal antibodies targeting the CGRP molecule —

Fremanezumab (Ajovy®) and Galcanezumab

(Emgality®) • Administered monthly or quarterly (Ajovy); average cost per year

$6000-7000

• Well-tolerated, with injection site reactions being the

most common complaint

• Reduction of monthly migraine days by ~3-4 and

monthly acute migraine medication days by ~1-3

• Clinical immunogenicity according to manufacturers is

~2.6-6.2% for Aimovig and 1.6% for Ajovy

• Review of FDA safety documents shows very small

potential for hypothyroidism and subsequent weight

gain. • https://www.accessdata.fda.gov/drugsatfda_docs/nda/2018/761089Orig1s000Me

dR.pdf; illustration is schematic and for educational purposes only

- 14 -

Supplemental Slide: Electric Current/Field

Therapies

• Cefaly is an external

Trigeminal nerve

Stimulation device (e-

TNS) for migraine

treatment (FDA

approved; Rx only)

• GammaCore is an

external Vagus nerve

stimulator (likely

parasympathetic

activator) for migraine

and cluster HA treatment

(FDA approved, Rx only)

• Multiple devices are

marketed; no

endorsement implied.

Supplemental Slide:

Magnetic Field

Therapy • Transcranial magnetic stimulation, or TMS, is a noninvasive form of brain

stimulation. TMS devices operate completely outside of the body and affect

central nervous system activity by applying powerful magnetic fields to specific

areas of the brain

• Five clinical trials involving 313 pts indicate that single-pulse TMS was effective

for the acute treatment of migraine with aura. No seizure activity was

noted/caused in these pts.

• The single-pulse TMS (sTMS) device has uncertain availability and in the USA

many insurance plans do not cover the device nor therapy sessions.

• In the UK the National Institute for Health and Care Excellence recommends that

sTMS should only be used for the treatment of migraine under the care of

a headache specialist. Other types of TMS are being researched for depression,

headache and other conditions as well as brain degenerative conditions.

• Multiple devices are marketed; no endorsement implied. • Source: Lan et al., J Headache Pain (2017); 18(1): 86.

- 15 -

Diet-Triggered HA

• Guideline-recognized trigger: caffeine (including medications) • Episodic migraine patients should limit caffeine intake to 200mg per day, while pts

with daily headaches should consider avoiding caffeine completely

• Reduce caffeine intake slowly, by 25% each week, to avoid caffeine withdrawal

symptoms • Scher et al. Neurology v. 63(11) pp. 2022-27

• Caffeine content: Starbucks 20 oz: 475 mg; KeVita Kombucha 15 oz: 80 mg; 5-hr

Energy 2 oz: 200 mg; Pepsi Zero Sugar 16 oz: 70 mg

• Other commonly cited food-borne migraine triggers include: • Chocolate

• Red wine

• Beer

• Aged cheese

• Cured meat (―no nitrites added‖ is deceptive, as celery salt contains NO3/NO2)

• Smoked fish

• Yeast extract

• MSG including yeast hydrolysate/autolysate/lysate and soy sauce

• Artificial sweeteners (Stevia and polyols (Xylitol, Eryrthitol) are less likely triggers

• NO3 — NO2 — NO (nitrate pathway), including fertilizer residues and activity of

oral anaerobic bacteria

Tension-Type HA

• Tension-type headache may be either episodic (frequent and infrequent) or chronic.

TTH affects approximately 1.4 billion people or 20.8% of the world‘s population.

Episodic tension headache usually is associated with a stressful event.

• Opioids or butalbital should NOT be used as the risk of habituation is high.

• Patients with tension-type headache are 26% weaker than controls with respect to neck

extension muscles, that they have a 12% smaller extension/flexion ratio, and that they

have a borderline significant difference in the ability to generate muscle force over the

shoulder joint • Physical therapy aiming to strengthen these muscles (when appropriate and the headache is not cervicogenic or

masking a cervicalgia) is recommended and may be curative

• Other modalities include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point

injections, occipital nerve blocks, stretching, and relaxation techniques

• A review of eleven studies involving 2,317 patients found evidence to support

acupuncture as a valuable, non-pharmacologic tool for episodic or chronic TTH. • Two of the studies reviewed compared acupuncture to treatment of acute headaches or routine care only and

found statistically significant and clinically relevant short-term (up to 3 months) benefits of acupuncture over

control for response, number of headache days, and pain intensity.

• On the other hand, another popular traditional tx (hot cupping of the shoulder areas) has

never been trialed and is potentially harmful (skin bruising, bleeding, aggravation of

pain) • Linde et al. Cochrane Database Syst Rev. 2009 Jan 21. CD007587.

• According to several studies, massage may also be an effective therapy for individuals

suffering from TTH.

- 16 -

Trigeminal Neuralgia and Ramsay-Hunt • Trigeminal neuralgia, also known as tic douloureux, is a distinctive facial

pain syndrome that may become recurrent and chronic. It is characterized

by unilateral pain following the sensory distribution of the Trigeminal (V)

cranial nerve and is often accompanied by a brief facial spasm or tic. • The pain commonly runs along the line dividing either the mandibular and maxillary nerves or the

maxillary and ophthalmic portions of the nerve

• Infrequently, adjacent dental fillings composed of dissimilar metals may

trigger attacks, and one atypical case followed tongue piercing (N Engl J

Med. 342(26):2003)

• Tx with anticonvulsants (typically, carbamazepine) is adequate for 75% of

pts; neurosurgical ablation is largely abandoned in favor of microvascular

decompression and radiofrequency thermorhizotomy.

• Ramsay Hunt syndrome type 2 is a disorder caused by reactivation of

varicella zoster virus (shingles) in the geniculate ganglion of the facial (VII)

nerve.

• Severe pain, facial nerve paralysis (unilateral), rash and dry mouth/taste

loss are presenting • Even with steroid and antiviral (acyclovir, 800 mg x 5/d) only 22% achieve full recovery of facial

nerve paralysis

• Prevention: vaccination against shingles with either live attenuated vaccine

(Zostavax®), or (since 2017, preferred, 2 doses recommended after 50 y)

an adjuvanated subunit vaccine, Shingrix®. No live virus is present in

Shingrix, thus no risk of shedding the virus and/or infecting other

(unvaccinated) patients.

anteroinferior cerebellar artery

trigeminal nerve

• Annual prevalence of about 2% in men and 1.5% in women • An astounding 500,000 cases of worker‘s comp per year

• Disk herniation, spinal stenosis, spondylolysis (defined as a defect or stress

fracture in the pars interarticularis of the vertebral arch) or spondylolisthesis

(slipping of vertebra, most commonly at L5) are observed

• Men and women are affected equally, but in those older

than 60 years, women report LBP symptoms more often

than men.

• Dehydration and degeneration of the discs stimulates the

synthesis of inflammatory agents (interleukins and

prostaglandins) and degradative enzymes (MM-proteases,

collagenase)

• Corticosteroids and NSAIDs inhibit the production of

prostaglandins from omega-6 fatty acids • O6FA are vastly overconsumed in the US — soybean, corn, sunflower,

safflower, and especially palm oil.

• Phospholipase A2 enzyme is elevated in herniated disks. It

accelerates disk degeneration and sensitizes pain receptors

• Increased phospholipase A2 has also been associated with

neuropsychiatric disorders such as schizophrenia and

developmental disorders spectrum.

• Inhibitors of this enzyme include vitamin E and chloroquine • Pharooqui et al. Pharmacological Reviews, 58 (3) 591-620; DOI:

https://doi.org/10.1124/pr.58.3.7

Severe L5-S1 disc degeneration with

severe disc space collapse and a large

anterior osteophyte (bone spur)

Annulus Fibrosus Nucleus Pulposus

Dura mater Spinal cord

Degenerative Disk Disease

- 17 -

Supplemental Slide: Some of the Causes of Neck and Low Back

Pain

• Structural • Facet joint arthritis or dysfunction

• Prolapsed intervertebral disc

• Annular tear

• Spinal stenosis

• Spondylolysis (defined as a defect or stress fracture in the pars interarticularis of the

vertebral arch) or spondylolisthesis (slipping of vertebra, most commonly at L5)

• Neoplasm (primary and secondary/metastatic)

• Referred pain to spine (usually Th or L) • From major viscera, retroperitoneal structures, urogenital system, aorta, or hip

• Infection

• Inflammatory • Spondyloarthropathies

• Sacroiliitis or sacroiliac dysfunction

• Metabolic • Osteoporotic verterbral collapse

• Paget‘s disease (dysregulated bone remodeling)

• Osteomalacia

• Hyperparathyroidism

Areas of Concern: C and L • Incidence of Sx by Cervical Root

• C7 = 70 %

• C6 = 21 %

• C8 = 8 %

• C5 = 2 %

• Incidence by Sx by Lumbar Root

• L1-3 = 3.4 %

• L4-5 = 49 %

• L5-S1 = 46 %

• Mechanical or activity-related spinal

pain is aggravated by static loading

of the spine (prolonged sitting or

standing), long-lever activities

(vacuuming or working with the arms

elevated and away from the body),

and levered postures (forward

bending of the lumbar spine)

• Pain may be reduced when

multidirectional forces balance the

spine (walking, changing positions)

and when the spine is unloaded

(reclining).

- 18 -

Dx/DDX Approach to Spinal Pain Pt

• Unrelenting pain at rest should suggest a serious cause, such as cancer or

infection

• Straight leg raising with the patient supine should produce ipsilateral leg

pain between 10° and 60°.

• Straight leg raising that produces pain in the opposite leg carries a high

probability of disk herniation.

• Open-back gowns give the physician only 1 view of the spine; therefore,

swimming attire is often appropriate for complete examination. • Leg-length discrepancy and pelvic obliquity, scoliosis, postural dysfunction with forward-leaning

head and shoulders, or accentuated kyphosis are commonly seen

• Waddell signs = technique to identify patients who have nonorganic or

psychogenic embellishment of their pain syndrome. • 1. Simulated rotation of the hips en masse with the lumbar spine without allowing for spinal

rotation; 2. Application of light pressure on the head; 3. Gentle effleurage of superficial tissues; 4.

Straight leg raising with the patient sitting versus supine

• As with all severe/chronic pain there exists a measurable risk of suicidal

ideation and suicidality. Effective coping skills, strong and supportive

relationships, and connectedness to social institutions are among the

strongest reducers of such risk.

Supplemental Slide: Electrophysiological

Diagnosis

• Nerve Conduction Study: • Latency, Amplitude, and

Duration of the compound

muscle action potential =

sum of individual muscle

fiber action potentials

• Nerve conduction

velocity (distance between

stimulating electrode and

recording electrode divided

by latency)

• Extremely informative in

demyelinating and

neuropathic conditions • Example: conduction block and

temporal dispersion = acquired

demyelinating neuropathy

• Needle myography (EMG) • Example: normal vs. chronic

denervated muscle recordings

A

D

L

Proximal

Distal

Muscle at rest

Muscle at rest

Slight

contraction

Slight

contraction

Full

contraction

Full

contraction

1 mV

Fibrillation

Giant unit

1 mV

5 mV Reduced pattern

- 19 -

Supplemental Slide: Diagnostic and Prognostic Red

Flags

• Pain unrelieved by rest or any

postural modification

• Pain unchanged despite treatment

for 2-4 weeks

• Writhing pain behavior

• Colicky pain or pain associated with

a visceral function

• Known or previous cancer

• Fever or immunosuppressed status

• High risk for fracture (eg, older age,

osteoporosis)

• Associated malaise, fatigue, or

weight loss

• Progressive neurological

impairment

• Bowel or bladder dysfunction

• Severe morning stiffness as the

primary complaint

• Patients unable to ambulate or care

for self

• Nonorganic signs and symptoms

• Dissociation between verbal and

nonverbal pain behaviors

• Compensable cause of injury

• Out of work, disabled, or seeking

disability

• Psychological features, including

depression and anxiety

• Narcotic or psychoactive drug

requests

• Repeated failed surgical or

medical treatment for LBP or

other chronic illnesses

Tx for Spinal Pain: Stages

• Primary nonoperative care consists of passively applied physical

therapy and pain coping strategies during the acute phase of soft-

tissue healing (< 6 wk)

• Secondary treatment includes spine care education and active

exercise programs during the subacute phase between 6-12

weeks with physical therapy and socio-behavioral-driven goals to

achieve preinjury levels of physical and psychosocial function and

a return to work.

• Tertiary treatment (after 12 weeks, if the patient remains

symptomatic) focuses on interdisciplinary care using cognitive-

behavioral methods to address physical and psychological

deconditioning and disability that typically develops as a result of

chronic spinal pain and dysfunction

- 20 -

Tx for Spinal Pain: Pharmacologic

• There is significant evidence that NSAIDs are more efficacious than a placebo

for reducing LBP in the short term, although the effects are not very strong • Gastrointestinal, renal, and potential cardiac toxicities must be considered with long-term NSAID use

• Muscle spasmolytics may provide benefit; however, sedation and dizziness are

common side effects and pts should be cautioned about them and weigh them

vs. potential benefits • Benzodiazepines may be appropriate for concurrent anxiety states, and in those cases, clonazepam is

often considered, as well as the nonbenzodiazepine muscle relaxants such as cyclobenzaprine

(Flexeril), carisoprodol (Soma), and tizanidine (Zanaflex) with the latter having centrally acting α2-

adrenergic activity at both the spinal cord and supraspinal levels

• Anticonvulsants (gabapentin, topiramate, levetiracetam, valproate) and

antidepressants (TCA, SSRI, SNRI) may be used when evidence suggests

neuropathy and/or pain pathology

• Opioids are associated with 5-24% patient-admitted aberrancy and are, thus, of

limited utility and very high risk of habituation and abuse

• A topical treatment for nociceptive and neuropathic pain is the 5% lidocaine

patch. The patch is an effective treatment for chronic LBP • Glucosamine +/- chondroitin are widely used by patients, but clinical data are limited and several trials

find that compared with placebo, glucosamine did not reduce pain-related disability after the 6-month

intervention and after 1-year follow-up. It is a shellfish product and may be associated with allergic

response.

Therapy Modalities

• Physical therapy consists of hands-on treatment of the affected muscles and joints,

education on proper posture and movement to decrease pain, instruction on

stretching and strengthening exercises to restore mobility and strength, and

modalities such as electrical stimulation, cold/heat and ultrasound

• McKenzie exercises are one example, both historical and current: • Part of the common algorithm for low back pain (press-ups, seated/standing forward bend; cat-cow stretch;

lower back twist; lower back stretch (lumbar rocking)

• Part of the common algorithm for neck pain (sitting chin tuck; neck extension; side bending; neck rotation;

neck flexion; shoulder shrugs)

• A recent controversial meta-analysis indicated:

• Back School exercises and McKenzie's method were ineffective long term

• Osteopathic spinal manipulation proved effective in the short term when

performed on the L and T vertebrae, but not in the medium/long term

• Massage therapy proved effective in the short term

• Global postural reeducation was effective (study was of low methodological

quality) • Source: Cuenca-Martinez et al., Phys Ther Res. 2018; 21(1): 16–22

• Pain management education is known to be most effective in reduction of

incidence of chronicity, especially in low back patients. Social workers,

occupational therapists, psychologists and counselors are instrumental in patients‘

acquisition of such skills

- 21 -

Surgery for Spinal Pain

• Most herniated discs require no sx and ~90% of patients may heal on their

own within 1 to 6 months, yet chronicity is common and may motivate pt.

• Artificial disc replacement: Surgical replacement of a diseased or

herniated disc with a manufactured disc

• Discectomy: Surgical removal or partial removal of an intervertebral disc

• The average age of patients who undergo lumbar discectomy is 42 years.

• Laminectomy: Surgical removal of most of the bony arch, or lamina of a

vertebra

• Laminotomy: An opening made in lamina, to relieve pressure on the

nerve roots

• Spinal Fusion: Using bone grafted onto the spine creating a solid union

between two or more vertebrae; and in which instrumentation such as

screws and rods may be used to provide additional spinal support

• The focus moves towards minimally invasive spine surgery

• Such modalities as percutaneous laser discectomy claim as much as

78.4% success rate (questionable) • Choy et al. Spine 17 pp. 949-956

• Alternatives include percutaneous radiofrequency thermocoagulation

with claimed success rate of ~60%

• In one study percutaneous surgery was associated with dramatic reduction

of averages: blood loss (94 ml vs 458 ml for open sx) and hospital stays

(3.8 vs. 8.2) but somewhat increased infection rate (7.1% vs. 6.7%) • Sarkari et al. IJNT, Dec-2011

Therapeutic Injections

• Local anesthetics, corticosteroids, or other

substances may be directly injected into painful soft

tissues, facet joints, nerve roots, or epidural spaces.

• Local injections into paravertebral soft tissues,

specifically into myofascial trigger points, are widely

advocated • A double-blind study to compare local anesthetic with saline

injections and a prospective randomized double-blind study to

compare dry needling with acupressure applications of

lidocaine, corticosteroids, and vapor coolants revealed no

significant difference in therapeutic effects

• A retrospective evaluation showed initial relief in 50% of

participants, but only 14% of participants claimed relief at 6

months, and only 8% at 12 months.

• Another retrospective review, reported 56% with initial relief,

44% with continued relief at 3 months, and 35% after 6 months • Source: Manchikanti et al. Pain Physician 4(1):101-17

- 22 -

DDX: Orofacial vs. Cervicogenic Pain

• Temporomandibular Disorders (TMDs): often incorrectly referred to as ―TMJ‖,

encompass a broad category of conditions involving pain and/or dysfunction

of the jaw joints, the muscles of the jaw (masticatory muscles) or both • Complex temporomandibular disorders: these include joint replacement failures or other failed

multiple TMJ surgeries, comorbid disease states and neuropathic causes of pain

• Pain is often the most noted presentation of sleep bruxism (grinding/clenching

the teeth at night-time, often aggravated by sleep apnea.

• Orofacial dyskinesias and dystonias: involuntary movements or contractions

of muscle because of parafunctional nerve signals • Causes include medication toxicity, headache/neuralgia, systemic neurologic dx, somatization,

psychiatric dx

• Cervicalgia: facial pain arises because of spinal cord injury, peripheral nerve

injury, pain referral from muscles and ligaments and central reflex responses

• Management modalities include:

• Diagnostic anesthetic blocks

• Therapeutic anesthetic nerve blocks

• Muscle trigger point injections

• Temporomandibular joint mobilization

• Intraoral orthosis therapy (oral splints/night appliances)

PT/OT and Pain

• Withdrawal from PT/OT should be viewed as a potential “red flag” and may

coincide with relapse or aggravation of pt‘s condition. • Especially if PT/OT had reached the stage when the patient is being prepared for a meaningful life without the

substance and his/her life is in the state of being ―redesigned‖.

• Less Activity-Related therapies • Heat/ice packs

• Transcutaneous and percutaneous electric nerve stimulation (TENS/PENS)

• Iontophoresis: applying direct electric current in order to introduce ionized medication (e.g., Mg acetate, local

anesthetics) through intact skin

• Traction or deep-tissue massage

• Therapeutic ultrasound

• More Activity-Related therapies • Stretching

• Strengthening/pain relief exercises

• Low-impact aerobic conditioning

• Helps with frequent, recurrent episodes of low back pain and arthritis

• Helps restore function, improve mobility, and prevent or limit permanent physical

disabilities of patients suffering from injuries or diseases

• Occupational therapy is uniquely positioned to assist people who are struggling to

recover from substance abuse, by helping them to reestablish the roles and identities

most meaningful to them AND how substance abuse affects those roles and identities

(e.g., parenting, providing for family, activities that bring reward and satisfaction

without resorting to abusable substances).

- 23 -

Social Work, Occupational Therapy and Opioid Use

Disorder

• A recent study (2016) indicated that social work interventions are a

necessary part of an treatment effort and in improvement of general health

of opioid abusers.

• One of such approaches is motivational interviewing, which addresses the

person‘s ambivalence to change.

• Areas of concentration found to be especially effective included: • Reduction of anxiety, insomnia and somatic symptoms;

• Improvement of patients‘ self-understanding and self-recognition;

• Enhancement of social functioning.

• Effect was seen after no less than 10 sessions (individual and group therapy) in the setting of a

drug treatment program. • Source: Raheb et al., Psychology Research and Behavior Management Journal vol. 9, pp. 309-315

• Occupational Therapy should include one or more of the following

interventions to consider: • Assessment of substance use;

• Reorganizing daily routines;

• Compile interest inventory;

• Identify work-related goals;

• Create an action plan for goals

• Link to community resources

• When applicable: job site visits and advocacy for required job modifications/accommodations.

Supplemental Slide: The Opioid Crisis

• In 2006 healthcare providers wrote 72.4 opioid Rx per 100 persons

• In 2017 there were 58.5 Rx per 100 persons, a 19.2% reduction.

• In 2017, 17.4% of the U.S. population received one or more opioid

prescriptions, with the average person receiving 3.4 prescriptions.

• In 2016, an estimated 48.5 million persons in the U.S., or 18.0% of

persons aged 12 years and older, reported use of illicit drugs or misuse

of prescription drugs in the past year. • States with the highest opioid prescribing rates were Alabama (107.2), Arkansas (105.4),

Tennessee (94.4), Mississippi (92.9), and Louisiana (89.5).

• States with the lowest opioid prescribing rates were Hawaii (37.0), New York (37.8),

California (39.5), and Massachusetts (40.1)

• Between 2006 and 2017, the average daily MME per prescription

decreased from 59.7 to 45.3, an overall relative reduction of 24.1%

• BUT — Between 2006 and 2016, average days of supply per

prescription increased from 13.3 to 18.3 days, an overall relative

increase of 37.6%.

• Is the Nationwide Opioid Emergency CONTROLLED?

• Sources: https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf by CDC

- 24 -

Supplemental Slide: Opioid Crisis (2017-2018 Data)

• Preliminary data from the CDC shows that in most states overdose deaths increased by 5-10

percent. Improvement is seen in MA, RI, VT, OK, MS, KS, NM, UT, SD and MT, as well as NYC.

• However, NE, IN, NJ, NC are especially badly affected (~23-33% increases).

• Data for WY is known to the CDC to have been underreported on the state level.

• The epidemic could also intensify again. One worrying sign: there is some evidence that drug

distributors are finding ways to mix fentanyl with black tar heroin, which could increase death rates

in the West. If that becomes more widespread, the overdose rates in the West could explode as

they have in parts of the East.

• Preliminary data from the CDC suggests a 4% decrease of opioid deaths in 2018; however, this is

an October-October data, not January-December.

https://opioidmisusetool.norc.org

averaged data for 2012-2016

Acute and Chronic Pain Guidelines

• Opioids are NOT first-line or routine therapy for chronic pain

• Goals for pain and function need to be realistic: Establish and Measure.

• Non-opioid and non-medication is preferred: discuss benefits & risks of non-opioid Tx.

• Use Immediate Release Opioids as 1st line for acute pain; three days or less; more than 7 is

rarely needed

• Rx no more than needed: start low and go slow; no more than 50 MME/day for most cases, 90

MME for exceptional cases

• Do not prescribe ER for acute pain

• Follow up and re-evaluate risk of harm, reduce dose, taper/discontinue if/when needed

• Review state prescription monitoring program at first and every 3 months • BUT: there are incomplete interstate report mechanisms, no federal facilities data and no data on hospital and ER

administration.

• Urine testing at least annually • Identifies Rx compliance and undisclosed use/abuse

• Avoid concurrent benzodiazepine and opioid Rx

• Anesthetics such as ketamine/esketamine may be useful. • Benefits include dramatically reduced risk of respiratory suppression. Also, when used in approved doses it usually stimulates

rather then depresses circulation.

• Arrange tx for opioid disorder if needed

• Do not forget that all patient‘s clinical information is protected by law and cannot be released

unless valid consent from the pt or legal representative is obtained and/or on file. Issues with

opioids Rx are very sensitive and should not be discussed in the open when others can overhear

and/or react. • www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

- 25 -

Misapplication of the CDC Guideline

• On April 24, 2019 the CDC issued an official advisory regarding the Guideline for Prescribing

Opioids for Chronic Pain based on a NEJM article.

• The authors, Deborah Dowell, M.D., M.P.H., Tamara Haegerich, Ph.D., and Roger Chou,

M.D. asserted that:

• Examples of misapplication include applying the Guideline to patients in active cancer

treatment, patients experiencing acute sickle cell crises, or patients experiencing post-

surgical pain.

• The recommendation statement does not suggest discontinuation of opioids already

prescribed at dosages higher than 50 MME (or 90 MME in carefully justified cases).

• The Guideline does not support abrupt tapering or sudden discontinuation of opioids. These

practices can result in severe opioid withdrawal symptoms including pain and psychological

distress, and some patients might seek other sources of opioids.

• The Guideline‘s recommendation about dosage applies to use of opioids in the management

of chronic pain, not to the use of medication-assisted treatment for opioid use disorder. The

Guideline strongly recommends offering medication-assisted treatment for patients with

opioid use disorder.

• Patients may encounter challenges with availability and reimbursement for non-opioid

treatments, including nonpharmacologic therapies (e.g., physical therapy). Efforts to improve

use of opioids will be more effective and successful over time as effective non-opioid

treatments are more widely used and supported by payers. • Source: NEJM April 24, 2019 https://www.nejm.org/doi/full/10.1056/NEJMp1904190

• Source: https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

Endorphins and Pain

• Opioid peptides are ligands for opioid receptors in the PNS and CNS, e.g.,

endorphins • Opioids are exogenous mimics of these peptides.

• Three main opioid receptor types: • μ-opioid receptor — agonists such as morphine cause analgesia, sedation, reduced blood

pressure, itching, nausea, euphoria, decreased respiration, miosis (constricted pupils), and

decreased bowel motility

• δ-opioid receptor is less understood; however, it is strongly involved in chronic pain and

depressive disorders (cannabidiol exhibits agonism at this receptor = potentiation of endorphin-

mediated pain relief + antidepressant action) as well as protection from ischemia

• κ-opioid receptor — its agonists are strongly analgesic; also dissociative (Salvia divinorum,

ketamine) but also dysphoric and aversive, which may provide advantages in tx of opioid

addiction (e.g., buprenorphine/Subutex®)

• Opioid peptides derived from foods include casomorphins (from casein, a

milk protein), gluten exorphins and giladorphin (from gluten), soymorphin

and rubiscolins (from spinach). Their role in mental and developmental

disorders is being researched. • Source: ―Opioid receptors: Introduction‖. International Union of Basic and Clinical Pharmacology.

http://www.guidetopharmacology.org/GRAC/FamilyIntroductionForward?familyId=50; image: NIH/NIDA;

https://doi.org/10.1007%2Fs00210-006-0033-x

- 26 -

Opioid Toxicity and Interactions

• The opioid medications commonly present with side effects that

include sedation, dizziness, nausea, vomiting, constipation, physical

dependence, tolerance, and respiratory depression. • Less common side effects may include delayed gastric emptying, hyperalgesia,

immunologic and hormonal dysfunction, muscle rigidity, and myoclonus.

• Opioids metabolized by the drug metabolizing enzymes of the

cytochrome P450 (CYP450) system (codeine, oxycodone,

hydrocodone, fentanyl, tramadol, and methadone) are associated

with numerous drug-drug interactions that can result in either a

reduction in opioid effect or excess opioid effects. • Pts often believe that ―natural‖ remedies are non-interacting, which is false. Example: St.

John‘s Wort is a potent inducer of CYP450 and will cause increased elimination and

metabolism of e.g., methadone and oxycodone.

• Grapefruit juice is a potent deactivator of CYP450 and will cause elevated levels of

these medications (by up to 70%) and elongated half-lives (by up to 20%). Abusers

utilize this phenomenon to extend/potentiate their ―high‖.

• Conversely, opioids that are not metabolized by that system (morphine, oxymorphone,

and hydromorphone) tend to be involved in fewer CYP450-associated pharmacokinetic

drug-drug interactions.

Opioid Recommendations

• Avoid opioids if the patient has any of the

following: • Significant respiratory depression (e.g. respiratory failure),

acute or severe asthma in an unmonitored setting or in the

absence of resuscitative equipment, known or suspected

paralytic ileus or hypersensitivity (e.g. anaphylaxis)

• Current substance use disorder as defined by DSM 5

(except tobacco) or past opioid use disorder

• History of opioid overdose

• Pattern of aberrant behaviors (―Red Flags‖)

• Use great caution at any dose, monitor more

frequently and consider prescribing take-home

naloxone if the patient has one or more of the

following risk factors: • Mental health disorder per DSM 5

• Family or personal history of substance use disorder

• Medical condition that could increase sensitivity to opioid-

related side effects

• Current use of benzodiazepines or tobacco (―orange flag‖)

• Be aware of withdrawal risks (usually in hours

after the last dose) and risks to both the patient

and personnel • www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

• Frequently “lost” or “stolen” Rx • Frequently cancelled or missed

appointments • Use of other drugs of abuse, alcohol,

etc. • Seeking drugs from multiple providers • Using Rx for euphoria or relief of

anxiety • Rx forgery • Selling or sharing Rx drugs • Unauthorized & repeated increase of

dosage • History of overdose • Aggressive demands to increase the

dose • Altering route of administration (i.e.

injecting/snorting oral formulations) • Arrest for DUI or drug-related activities • Prescription looks "too good” or signs

of forgery (erasures, corrections) are visible; also quantities, directions or dosages differ from commonly seen; abbreviations are wrong or directions written in full with no abbreviations

• http://www.painphysicianjournal.com/current/pdf?articl

e=NDIwMw%3D%3D&journal=103

- 27 -

Supplemental Slide: Opioid Abuse

Pathways • Acute pain managed with opioids BUT no attempt to manage with

non-opioids and no referral to PT/OT • Withdrawal from PT/OT if attempted

• Management of emotional pain with opioids

• Management of psychologic and psychiatric dx with opioids OR

self-medication with opioids

• Management of neurologic conditions: insomnia, pain pathology

(e.g., fibromyalgia) or self-medication for such conditions

• Reduction of everyday activities (occupations) with concurrent

withdrawal from social activities

• Accelerated chronicity of pain

• Unrealistic expectations re. pain reduction and function restoration

• Development of ―pseudoaddiction‖ (actual or perceived inadequate

pain control) (the concept is controversial)

• Development of use/abuse disorder (―addiction‖)

• Use of CYP450 inhibitors to prolong/strengthen action of opioids

Efficacy and MME • The efficacy of physical

pain relief (but not

emotional pain relief or

suffering relief) of NSAIDs

may be superior to that of

opioids.

• Inverse NNT used here for

simplification purposes

• MME = morphine miligram

equivalent, used to

recalculate doses of

opioids and may be of

limited use to assess

dosing of non-opioid

medications

• 2016 guidelines: no more

than 50 MME in most

cases; 90+ is seen as

exceptional • Cochrane Database of Systemic Reviews, (6).

doi:10.1002/14651858.CD010210.pub2 and McPherson:

Demystifying Opioid Conversion Calculations: A Guide for

Effective Dosing. American Society of Health-System

Pharmacists.

• https://www.cms.gov/Medicare/Prescription-Drug-

Coverage/PrescriptionDrugCovContra/Downloads/Opioid-

Morphine-EQ-Conversion-Factors-April-2017.pdf

Pain Relief Efficacy (Measured Semi-Objectively)

Drug(s) NNT Inverse NNT

Ibuprofen 200 mg + APAP 500 mg 1.6 62.5%

Diclofenac 100 mg 1.8 55.6%

Celecoxib 400 mg 2.1 47.6%

Naproxen Sodium, 550 mg 2.7 37.0%

Tramadol 50 mg 8.3 12.1%

Analgesic ~10 MME Half-life

Acetaminophen 3600 mg 1-4 hrs

Aspirin 3600 mg 3-9 hrs

Ibuprophen 2220 mg 1.3-3 hrs

Naproxen 1380 mg 12-20 hrs

Diclophenac 160 mg 1-4 hrs

Celecoxib 200 mg (?) 7-13 hrs

Codeine 67-100 mg 2.5-3 hrs

Tramadol ~100 mg 6-8 hrs

Morphine

10 mg 2-4 hrs

Oxycodone 6.66 mg 2-4 hrs (IR)

Fentanyl TD*** 3.7 mcg/hr ~7 hrs (TD)

- 28 -

Supplemental Slide: Therapeutic

Approaches

• Therapeutic ultrasound causes increase in local blood flow that can be

used to help reduce local swelling, chronic inflammation, and improve

healing of affected tissues. It is very unlikely to cause adverse effects.

• TENS (transcutaneous electric nerve stimulation) significantly decreases

pain-related cortical activations, reducing the perception of pain and the

subjective experience of suffering. The researchers utilized the

sophisticated functional MRI of the brain to measure activation of the

suffering-processing areas of the cortex.

• Acupuncture: in one large scale study, the incidence of complications

from acupuncture was 3.76% (74 patients out of 1,968 studied); however,

the most common problem was skin bruising (~50% of all events), no

serious or life-threatening complications were recorded.

• Spirituality is an important component of healing • The spiritual dimension of health is an important part of health and is defined as the aspect of

human well-being which integrates and regulates internal powers and causes feeling of

intimacy with the Transcendental, as well as with self, society and environment

• Healing touch is not accepted scientifically; however, sporadic research indicates improvement

in pain levels and comfort associated with this ―energy-based‖ harmless intervention

Supplemental Slide: Methadone and

Buprenorphine

• Both Methadone (M) and Buprenorphine (B) are used for pain

control and in opioid detoxification as well as long-term

medication-assisted treatment of opioid use disorder

• M has higher toxicity (respiratory, long QT)

• B presents with the ‗ceiling effect‘ that reduces risk of overdose

and respiratory suppression • B: agonist (binds m-receptor (relieves acute pain); antagonist of k-receptor (may

modulate depression); antagonist of d-receptor (may modulate response to stress)

• B is less sedating than M, does not affect sex hormone levels

• Suboxone contains naloxone to deter misuse (injecting/snorting)

• B binds the m-receptor 5.3x stronger than naloxone; continuing

infusion of naloxone may be needed to control B overdose • B might cause withdrawal in recent users as it displaces heroin at m-receptor.

• Analgesia in B users is very challenging and may require the use

of fentanyl. • www.cliniciansbrief.com/sites/default/files/attachments/MEDS_Bupreorphine.pdf; DOI:

10.1002/14651858.CD002207.pub4

- 29 -

Supplemental Slide: Discussion with Pts with Opioid Rx

• FDA‘s guide on what consumers should ask about new opioid prescriptions

offers sample questions and ways to get the conversation started.

1. Why do I need this medication—is it right for me? • According to FDA, the conversation could begin: ―What medication are you giving me? If it‘s an

opioid, are there non-opioid options that could help with pain relief while I recover?‖

• If pain is best managed with a prescription opioid, then:

2. How long should I take this medication?

FDA asserts that patients should find out when and how to stop using, or taper

off, opioids. Follow-up questions can include: • a.Is this the lowest dose and the smallest quantity I may need?

• b.How can I reduce the risk of potential side effects from this medication?

• c.What if I have a history of addiction?

• d.What about the other medications I‘m taking?

• e.How should I store my opioid medicine?

• f.What should I do with unused opioid medicine?

• g.Can I share this medication with someone else?

3. Can I have (a prescription for) naloxone? • Patients receiving a new prescription for an opioid medicine should discuss whether they should

receive a prescription for naloxone, an antidote for opioid overdose. Patients should be aware of

naloxone and how it can be obtained

THC and Pain

• A fMRI study at the University of Oxford (60 datasets)

was interventional and the participants actively

consumed THC (15 mg tablet) after receiving a

chemical burn (capsaicin, with full consent)

• With THC, participants did not report a change in the

average perception of pain, but the pain caused less

suffering

• There were also changes in activity of the right

amygdala that were 'primed' by pain. Associated

emotional states = AAA (anger, aversion to self,

anxiety)

• A recent fMRI study (2018, n=22) indicated that as

opposed to recreational use, medicinal use in adults

(average age 50 years) does not appear to have a

detrimental effect on task performance as evidenced

by changes in brain activation patterns in cingulate

and frontal cortex

• Separate research indicates that cancer pts prefer

cannabis as it relieves pain, weight loss and nausea

more effectively. Development of tolerance was noted

as pts increased their THC dose by ~0.2 mg every

week. • Lee et al., DOI: 10.1016/j.pain.2012.09.017; illustrations by N. Katz; Gruber et

al. https://doi.org/10.3389/fphar.2017.00983

Anterior Cingulate

Cortex (―suffering‖)

Right Amygdaloid

Body (emotive

content)

Effects of cannabis

(THC)

Effects of burn pain

- 30 -

Cannabidiol: Approved by FDA

• Epidiolex (Cannabidiol oral) is approved for two forms of childhood

epilepsy (Lennox-Gastaut and Dravet) • Initial statement: CBD does not appear to have abuse potential (!) but final schedule is V.

• In addition to the anti-epileptic activity, CBD is found to be a

serotonergic modulator, which may explain its efficacy in neuropathic

pain, as well as multiple neurologic and psychiatric conditions.

• CBD is a competitive antagonist at CB1 receptor (THC is an

agonist) and also acts on the 5-HT1A receptor with effects on

decreased aggression, drug-seeking, impulsivity and appetite. • It also increases sleep latency, sex drive and arousal but inhibits

erections/vasocongestion.

• 5-HT1A alternative drugs include buspirone (Buspar®), Lurasidone (Latuda®) and

Aripiprazole (Abilify®) • Source: US FDA, goodrx.com; FDA document UCM604736; DeGregorio et al., PAIN: August 27, 2018

doi: 10.1097/j.pain.0000000000001386; Zanelati et al. (2010) British Journal of Pharmacology. 159 (1):

122–8.

CBD THC

Supplemental Slide: APAP = a

Cannabinoid ?!

• Combinations of APAP with other neuroactive substances show surprisingly strong

analgesic effect. • APAP-Tramadol (92%↑) and APAP-Mophine (240%↑)

• The results of a study of chronic pain associated with spinal cord injury show that

combination of APAP with Gabapentin (Neurontin ®) increases the efficacy by

154%.

• Blockade of the cannabinoid receptor CB1 nearly completely negated the supra-

additive efficacy of the APAP-Gabapentin combination. • Source: Hama & Sagen, Neuropharmacology 58(4-5): 758–766.

• AM404 (amide of APAP+AA, an omega-6 fatty acid) is a cannabinoid reuptake

inhibitor. Synergistic effects with THC and other cannabinoids may be expected and

needs additional studies.

• Omega-3 fatty acids act as cannabinoid depletion agents and may reduce the

efficacy of APAP and the potential toxicity of cannabis-derived cannabinoids. • Source: Partland et al., https://doi.org/10.1371/journal.pone.0089566

THC

APAP+ω6FA

- 31 -

The Mind and Pain

• Cognitive behavioral therapy is a useful and empirically

based method of treatment for pain disorders that can

decrease reliance on the excessive use of opiates

• Interventions may include relaxation training, scheduling pleasant

activities, cognitive restructuring, and guided exercise — all in the

context of an "empathic and validating" relationship with the

therapist. Acceptance and commitment aspects are often

emphasized.

• Mindfulness is the psychological intervention and practice of

bringing one's attention to experiences occurring in the present

moment.

• Mindfulness meditation modulates pain through the action of

endorphins and may be useful in chronic pain management,

especially in non-opioid setting • Journal of Psychiatric Practice, November 2017 DOI: 10.1097/PRA.0000000000000262;

American Journal of Medicine, 2016, 129(7), 755‐758

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NOTES

NOTES

Continuing Education Seminar INR Corporation NAME:____________________________________________

(please print) DATE: __________________________________________

Examination PROFESSION: ___________________________________

Course Title: Understanding Pain SEMINAR LOCATION: ________________________________ INSTRUCTOR: ______________________________________

For each item below please circle the correct response. Circle only one response per item. 1. SOCRATES approach to pain assessment does not include which of the following:

a) Site of pain or injury b) Radiation of pain elsewhere c) Exacerbating factors d) Orientation in time and place

2. Neuropathic pain is defined as: a) Pain due to chemical stimulation of the skin b) Pain due to lesions of the somatosensory

nervous system c) Pain due to behavioral factors, including

somatization d) All of the above

3. Allodynia is a variant of pain pathology characterized by:

a) Increased pain threshold with suppressed pain response

b) Decreased pain threshold with increased pain response

c) Non-painful stimuli causing pain d) Both A & C

4. Chronic pain is defined as: a) Pain arising from a missing limb, damaged

organ or surgical incision b) Pain that generally lasts longer than 3 – 6 months c) Pain that extends beyond the expected healing

time d) Both B & C

5. Endorphin-like (opioid) peptides have been derived from which foods:

a) GMO Corn (maize) b) Soybeans (soya) c) Canola seed d) Extra virgin olive oil

6. Sleep, induced by depressants such as alcohol and opioids is:

a) A sufficient substitute for natural sleep architecture b) Deficient in deep sleep (stage 3 Non-REM sleep) c) Deficient in REM sleep and dreaming d) Both A & C

7. Sleep deprivation may induce which pain pathology:

a) Allodynia due to deficiency of RAM sleep b) Hyperpathia due to frequent awakenings c) Hyperalgesia due to deep sleep deficiency d) Both A & B

8. Neurologic “Red Flags” in a patient with a headache include:

a) Headache beginning after 50 years of age b) Headache with fever, neck stiffness and skin rash c) Headache with vision loss other than typical aura d) All of the above

9. Hard to treat medication-overuse headache may be

due to the use of: a) OTC migraine combinations (e.g., Excedrine(R) b) Analgesics such as acetaminophen (e.g., Tylenol(R) c) Opioids such as tramadol (Ultram(R) d) All of the above

10. The percentage of patients who develop immune response (neutralizing antibodies) while on CGRP antagonists is:

a) Less than 1% b) Between 1.6% and 6.2% c) Between 6.2% and 9.1% d) More than 30%

Continuing Education Seminar INR Corporation NAME:_____________________________________________

(please print) DATE: ____________________________________________

Examination PROFESSION: _____________________________________

Course Title: Understanding Pain SEMINAR LOCATION: ______________________________ INSTRUCTOR: _____________________________________

For each item below please circle the correct response. Circle only one response per item. 11. Orofacial pain may be the presentation of which

disorders: a) Temporomandibular disorders b) Orofacial dyskinesias and dystonias c) Cervicalgia and cervicogenic pain d) All of the above 12. Spondylolisthesis refers to: a) Tumor of the intervertebral disk with no subluxation b) Arthritis or dysfunction of the facet joints of the spine c) Tear of the annulus fibrosus with local inflammation d) None of the above 13. Among other body parts, C7 and L5 roots innervate:

a) Thumbs and big toes b) Ring finger and little toes (fifth toes) c) Elbows and knee caps d) All of the above

14. Electrophysiological diagnostic procedures include: a) Needle myography b) MRI of the limb without and with contrast c) Nerve conduction studies d) Both A & C

15. In low back pain the use of opioids is associated with: a) 70% or higher risk of addiction b) Admitted 5 – 24% aberrancy c) Objectively observed 50 – 56% aberrancy d) All of the above

16. The CDC opioid guidelines emphasize:

a) Immediate release opioids for acute pain for 3 days b) The use of extended release for the first 7 days of

acute pain c) Urine testing at least annually d) All but B

17. Which amount of tramadol (Ultram(R) is assumed equianalgesic with 1 mg of morphine (oral)? a) 2 mg b) 5 mg c) 10 mg d) 15 mg

18. The three questions patients should ask about opioid prescriptions include: a) Can I have naloxone prescribed or dispensed? b) Should I travel to another state if I need more medication? c) How do pharmacies report dispensed opioids to the database? d) All of the above

19. THC, one of the active ingredients in cannabis has been shown to:

a) Bind to the opioid receptors in the right amygdala

b) Decrease the degree to which pain bothers the patient

c) Work especially well for victims of chemical burns

d) All of the above

20. A preparation of CBD, another component of cannabis:

a) Is FDA-approved for rare forms of epilepsy b) Is a Schedule V drug c) Is a serotonin receptor 1A ligand d) All of the above

Continuing Education Seminar INR Corporation NAME_____________________________________________

(please print) DATE _____________________________________________

Examination PROFESSION ______________________________________

Course Title: Understanding Pain SEMINAR LOCATION: _______________________________ INSTRUCTOR: _____________________________________

For each item below please circle the correct response. Circle only one response per item. 21. Which is likely to be most improved with intensive

patient pain management education? a) Acute pain recurrence b) Disability, including long-term c) Suicide risk d) Incidence of chronic low back pain 22. Social workers, nursing home administrators and

other health care professionals may disclose confidential information:

a) With a valid consent from the client or a person legally authorized to consent on behalf of a client b) When requested by 3rd party payers (e.g., life insurance) c) When requested by immediate family members d) All of the above

23. Withdrawal symptoms may begin as early as __________ after the drug was last taken.

a) Hours b) Days c) Weeks d) None of the above

24. Protective factors that buffer against the risk of suicide in chronic pain sufferers include which of the following? a) Effective coping skills b) Strong and supportive relationships c) Connectedness to social institutions d) All of the above

25. Motivational interviewing is a client-centered counseling style that:

a) Addresses a person’s ambivalence to change b) Focuses on abstinence and spirituality c) Seeks to assure adherence to opioid

replacement therapy d) Explores the origins of addictive personality

disorder

26. Chronic migraines with aura are: a) Associated with elevated risk of ischemic stroke b) More common in women than in men c) Predictors of higher incidence of Parkinson’s disease d) Both A & B

27. Pain is a complex presentation that may contain components of: a) Nociceptive b) Neuropathic c) Psychogenic d) All of the above

28. Universal interventions in prevention, especially that of substance abuse are:

a) Targeted to individuals who are already using substances but have not developed a substance use disorder

b) Aimed at a subgroup determined to be at high-risk for substance use

c) Aimed at all members of a given population d) None of the above

29. Socio-behavioral manifestations of CBD action on 5-HT1A receptor include:

a) Deceased aggression b) Reduced drug-seeking c) Reduced impulsivity d) All of the above

30. In a drug treatment program social work interventions, both individual and group, needed to last: a) At least 3 – 5 sessions b) No less than 10 sessions c) No less than 3 months d) Both B & C

Continuing Education Seminar INR Corporation NAME_____________________________________________

(please print) DATE _____________________________________________

Examination PROFESSION ______________________________________

Course Title: Understanding Pain SEMINAR LOCATION: _______________________________ INSTRUCTOR: _____________________________________

For each item below please circle the correct response. Circle only one response per item. 31. The nationwide opioid emergency brought to

focus which of the following: a) Social worker’s concentration on improvement of patients’ self-understanding and self-recognition b) Enhancement of social functioning c) Excellent availability of opioid-related rehabilitation d) Both A & B 32. Social factors that contribute to opioid abuse pathways are: a) Reduction of everyday activities (occupations) b) Withdrawal from social activities c) Unrealistic expectations re. pain reduction and function restoration d) All of the above 33. Social “red flags” related to the risk of opioid abuse may include:

a) Use of other drugs of abuse and alcohol b) Sharing opioids with relatives and acquaintances c) Altering the route of administration of the drug

(snorting) d) Both A & B

34. Social and behavioral interventions are useful in low back pain patients as soon as: a) The patient presents with acute pain b) The patient presents with chronicity c) Only in patients with suspected somatization d) Both B & C

35. Fire Cupping, a traditional medicine treatment, popular in some social groups, is: a) Known to have proven efficacy in chronic low back pain b) In clinical trials shown to have uncertain long-term outcomes c) In many patients shown to be potentially harmful d) All of the above

(This page left blank intentionally)

Continuing Education Seminar INR Corporation NAME______________________________________________

(please print) DATE ______________________________________________

Questionnaire PROFESSION _______________________________________

Course Title: Understanding Pain SEMINAR LOCATION:________________________________ INSTRUCTOR: ______________________________________

I. Please circle the appropriate number indicating the extent to which you agree or disagree with the following statements. The rating scale ranges from 1 to 5, where 1 = strongly disagree and 5 = strongly agree.

Strongly Disagree

Strongly Agree

A. The course content was consistent with stated learning objectives. 1 2 3 4 5 B. The course content was appropriate for the intended audience. 1 2 3 4 5 C. To what extent did you achieve each of the course’s major objectives?

1) list the neurologic processes causing pain and suffering and the principles of pain assessment. 1 2 3 4 5 2) discuss treatment modalities for primary and secondary headaches, including migraines and rare cephalalgias.

1 2 3 4 5

3) list the “red flags” of medication abuse and approaches to reduce opioid addiction. 1 2 3 4 5 4) describe the differential diagnosis of dental vs. cervical and cervicogenic pain and the appropriate interventions for both..

1 2 3 4 5

5) list steps involved in the diagnosis and management of spinal pain, including physical and occupational therapy.

1 2 3 4 5

6) describe how the information in this course can be utilized to improve patient care and patient outcomes.

1 2 3 4 5

7) describe, for this course, the implications for dentistry, mental health, nursing, and other healthcare professions.

1 2 3 4 5

D. The length of time to complete this course matches the number of CE credits approved. 1 2 3 4 5 E. The teaching and learning methods, including active learning strategies, were appropriate. 1 2 3 4 5 F. The instructor was knowledgeable of the subject and was well qualified. 1 2 3 4 5 G. The learning assessment activities, including the post-test, were appropriate. 1 2 3 4 5 H. Overall, the seminar met my educational needs, and the educational materials were useful. 1 2 3 4 5 I. Useful, new knowledge was presented at this program. 1 2 3 4 5 J. The physical facilities were conducive to learning. 1 2 3 4 5

___________________________________________________________________________________________________________________________________ II. I would recommend this course to a professional colleague. Yes ________ Not sure ________ No ________ III. I would recommend this instructor to a professional colleague. Yes ________ Not sure ________ No ________ IV. Did this course provide you with helpful and useful information to change your practice? Yes _______ No _______ If yes, how do you intend to change your practice? ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Copyright 2019, INR (Institute for Natural Resources). All rights reserved.

V. The presentation was balanced and free of commercial influence or bias.

Yes ________ No________

If no, please explain: VI. How much did you learn as a result of this CE program? VII. How useful was the content of this CE program for your practice or other professional development? VIII. Please use this space for additional comments.

Very Little

Great Deal

1 2 3 4 5

Not Useful

A Little Useful

Some what Useful

A Good Deal Useful

Extremely Useful

UP-06-2019

Category a: Home-study Books (Please complete the purchase form on page 8)

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also v is i t WWW.INRSEMINARS.COMHealth UpdateHOME-STUDY COURSES

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WEB_ Page 1 2012020

Globesity: Ten Things You Didn’t Know Were Making You Fat by Clare Fleishman, MS, RD

5 CONTACT HOURS *Not for Dietetic (rD/rDN) creDit (credit available for other professions)It is estimated that 1.4 billion adults—one in three across the globe—are overweight. Registered dietitian and health writer Clare Fleishman explores surprising new suspects contributing to our planet’s expanding girth. This important work examines how we live in a new century and why obesity has become a major

killer from the American Midwest to the cities of Europe and across the deserts of Africa.

Healing Power of Sleep - 2nd Editionby Mary O’Brien, MD

5 CONTACT HOURSMillions of us struggle with sleep several nights a week, if not every night. In The Healing Power of Sleep, Dr. O’Brien explains the basics of sleep architecture, the effects of common illnesses on sleep, how our daily habits can help or hinder sleep, and straightforward solutions.

The Hungry Brainby Laura Pawlak, PhD, MS

5 CONTACT HOURSThe Hungry Brain explores new discoveries about the brain’s hunger for pleasure and calories—the so-called “irresistible” foods—and how one can control temptation. The book discusses the latest scientif ic f indings about nutrients that speed memory processing and protect against Alzheimer’s disease—including a brain homework plan and a

grocery list to make it happen!

Integrative Healingby Z Altug PT, DPT, MS, CSCS

4 CONTACT HOURS Connect your mind and body for maximum wellness with this beginner's guide to Eastern and Western philosophies of body movement. Licensed physical therapist and health writer, Dr. Ziya Altug shows you exactly how to achieve total wellness by incorporating mindfulness and meditative practice into a healthy lifestyle. His book is filled with practical exercise photographs, tables, checklists and charts to help

patients and clients track their progress toward their wellness goals. This book is one of the winners of the 2018 Clinician Non-Research Publication Award from the California Physical Therapy Association.

Love Me Trueby Jason B. Whiting, PhD, LMFT

4 CONTACT HOURSThis course will explore ways partners get caught in patterns of subtle and blatant deception. It will use fun stories from real couples and examples from research to examine how cognitive and emotional processes cause blindness and rationalization, and distort couples’ perceptions. This course will identify research-based strategies to increase trust and connection, and professionals can use this information

to identify and appropriately address issues related to self-deception and honesty in the individuals with whom they work.

Media Mazeby Eric Rasmussen, PhD

4 CONTACT HOURSThis course will explore the prevalence of children’s media use, many of the media effects that are of most concern to those interested in the well-being of youth, and the social scientific theories that explain how children’s brains cognitively and emotionally process media content. Finally, the course identifies specific strategies that can be taken to help youth avoid the potentially negative effects, and enjoy the potentially

positive effects, of media exposure.

Pain Reliefby David Cosio, PhD, ABPP

4 CONTACT HOURSHaving worked as a pain clinic psychologist for over 10 years, Dr. David Cosio shares a wealth of strategies for dealing with this evergrowing epidemic in everyday circumstances—without relying on addictive medications. Pain Relief combines new insights into the perception of pain with practical, interdisciplinary treatments. Discover key coping skills for helping people with chronic pain, steps to

creating a comprehensive pain management plan, and over 20 different available pain management modalities.

Screen Savvyby Ryan J. Anderson, PhD

4 CONTACT HOURSThis course will help the reader examine the impact of common digital media usage on individuals, families, and society. Course participants will learn about both positive and negative effects of modern media, and will explore the concerning trends of societal norms in this area. Readers will receive an in-depth explanation of process addictions and the phenomenon of Internet Gaming Disorder (IGD). Guidelines and strategies

for creating a sustainable relationship with digital media are set forth.

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(WEB)

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Category a: Home-study Books (continued)

Buy more, Save more: Buy all 16 BookS, Save $75

FREESPECIAL OFFER: for a limited time at webinar ONLY!

*w/any purchase: “Addiction – 4th edition” *Limited to one per customerw/purchase of $99 or more: “Emotional & Social Intelligence – 2nd edition”w/purchase of $199 or more: Pain Relief (See page 8 for more details)

WEB_ Page 2 2012020

Successful Aging - 2nd Editionby Mary O’Brien, MD

4 CONTACT HOURSThis home-study course describes the best ways to age healthfully and improve your patients’ quality of life at any age, including tips on how to cultivate a youthful attitude, safeguard against stress and chronic illness, improve dietary and exercise habits, maximize memory and beef up energy, enhance financial security, and live a long and rewarding life.

Sugar, Salt & Fat - 2nd Editionby Gina Willett, PhD, RD

4 CONTACT HOURSThis home-study course outlines the various factors that make foods palatable. It provides evidence that the "hyperpalatability" of our current food supply is undermining our normal satiety signals, motivating the drive to eat even when there is no physiologic need for food. This course presents evidence that repeated exposure to high quantities of palatable foods (i.e., those high in sugar, fat and salt) can

alter the brain in ways similar to drugs of abuse, essentially "rewiring" the brain to promote compulsive eating and loss of control over food.

Yoga Formaby Romy Phillips, MFA , E-RYT500, C-IAYT

*Not for ce creDit*Learn to use traditional yoga routines to relieve the pain from common injuries and conditions. With simple lists of asanas and sample sequences for different proficiency levels and physical limitations, this in-depth guide to teaching and sharing yoga is perfect for yoga instructors and fitness and healthcare professionals. Learn which specific poses to suggest for injury prevention as well as which to recommend for those

who are struggling with spinal or back injuries.

The Fearless Mindby Craig L. Manning, PhD

*Not for ce creDit*Life is a performance whether you're on the field, in the courtroom, or running a household. But many of us, when asked to perform, are overcome by fear. We lose our confidence and allow our insecurities to hinder us. In The Fearless Mind, sports psychologist Dr. Craig Manning will help you overcome your fears, expel anxiety, build confidence, and become a high-performing individual no matter what your field. Learn

how to unlock your mind and reach your greatest dreams. There are many mental pathways to performance, but there is only one pathway to true success having a fearless mind.

Weight Perfect - 3rd Editionby Mary O’Brien, MD

6 CONTACT HOURSThis home-study course describes the newest research on losing weight and maintaining weight loss for life. The book provides details about the connection between weight gain and medical conditions, and obesity and sleeplessness. It also gives information about popular weight loss plans, describes scientific studies on the effectiveness of these plans, and discusses research on the connection between

emotions, cravings and overeating.

Irritating the Ones You Love by Jeff Auerbach, PsyD

4 CONTACT HOURS Irritating the Ones You Love explores how “unconscious” reasons control so much of our choices and behavior in relationships—the hidden reasons we are drawn to particular partners, and how, unknowingly, the past affects our reactions in present situations. This book provides tools to help readers uncover the hidden influences on them so that they can choose partners for the “right” reasons, grow as human beings, stop

making the same mistakes when issues arise with their partner, and make their relationships more intimate and happy.

Living to be 100 - 2nd Editionby Michael Howard, PhD

4 CONTACT HOURSDo you want to live the longest, healthiest, happiest life you can with the best mental and physical functioning? This home-study course is literally about the secret to life: the lifestyle choices you can make that wll increase the odds of having the longest and healthiest life you can. You will find out that there are 16 lifestyle characteristics that these oldest people tend to have in common, no matter where they live in the world.

Major Depression & Bipolar Disorders - 3rd Editionby David Longo, PhD

4 CONTACT HOURSThis book contains a synopsis of the genetic, biological, and psychological theories pertaining to bipolar spectrum disorders. An update of diagnostic considerations, assessment instruments, and evidence-based treatment techniques commonly employed in diagnosing, assessing, and treating bipolar spectrum disorder patients is provided. The most recent literature is presented throughout the book

concerning the appropriate data-based applications, outcomes, and limitations of the assessment and treatment procedures.

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Category B: Good deals Home-study packages

...continued on next page

FREESPECIAL OFFER: for a limited time at webinar ONLY!

*w/any purchase: “Addiction – 4th edition” *Limited to one per customerw/purchase of $99 or more: “Emotional & Social Intelligence – 2nd edition”w/purchase of $199 or more: Pain Relief (See page 8 for more details)

WEB_ Page 3 2012020

Category C: Hot topics 3 contact hours (Please complete purchase form on page 8)

Webinar Price $20Regular Price $30

• Addiction: Alternatives to Abstinence - 4th Ed. (B. Sternberg, PhD): Identifies the three major treatment models for addictive behaviors and a brief history of each: a) the moral model, b) the medical model, c) the harm reduction model.

• Alzheimer's - 3rd Ed. (M. O’Brien, MD): Describes Alzheimer’s disease. Identifies the 10 warning signs of Alzheimer’s disease.

• Antioxidants: A Balancing Act with Free Radicals - 3rd Ed. (N. Katz, MD, PhD): Identifies what free radicals and antioxidants are, their functions, and how they interact.

• Appetite Control & Suppression (G. Willett, PhD, RD): Describes how appetite is normally regulated. Cites how appetite can become dysregulated and contribute to weight gain and obesity.

• Autism - 3rd Ed. (N. Katz, MD, PhD & B. Sternberg, PhD): Describes the differences between the previous DSM-IV, and the current DSM-5 in terms of how autism, autism spectrum disorder (ASD), and related disorders are viewed and diagnosed,

• Brain Food - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Discusses how foods and vitamins may improve memory and brain function. Describes how the DASH and Mediterranean diets may play a key role in brain health.

• Cancer Prevention - 4th Ed. (A. St. Charles, PhD, RD, LDN & M. O’Brien, MD): Describes the lifestyle and dietary changes that can help prevent the development of cancer. Discusses the benefits and drawbacks associated with some of the tools used to screen for cancer.

• Caring for Patients with Alzheimer’s & Other Dementias - 2nd Ed. (B. Sternberg, PhD): Lists methods to assist patients with memory and communication problems.

• Cognitive Behavior Therapy - 3rd Ed. (M. Howard, PhD): Identifies the major components of cognitive behavioral therapy and the causative relationship between environmental events, thoughts, emotions, and behavior.

• Diabetes: A Comprehensive Overview - 2nd Ed. (A. St. Charles, PhD, RD, LDN): Describes the key features of prediabetes, type 1, type 2, and gestational diabetes. Identifies the hormones involved in blood glucose control.

• Eating Right at Midlife & Beyond (A. St. Charles, PhD, RD, LDN): Identifies the physiological changes that typically occur with age. Outlines a healthy eating plan for older adults.

• Emotional & Social Intelligence - 2nd Ed. (B. Sternberg, PhD): Explains the concept of emotional intelligence. Describes the relationship between emotions and the brain. Explains the concept of social intelligence and its components.

• Fibromyalgia - 3rd Ed. (N. Katz, MD, PhD): Examines fibromyalgia treatments. Reviews the pathogenesis, etiology, and clinical presentation of fibromyalgia. Discusses the role of sleep disorders in the clinical management of fibromyalgia.

• Gluten & the Brain - 2nd Ed. (A. St. Charles, PhD, RD, LDN): Discusses the role gluten may play in contributing to celiac disease and non-celiac glucose sensitivity. Lists the main food sources of gluten.

Depression & the Brain by N. Katz, MD, PhD15 CONTACT HOURS Loss of Control: Fighting Back with Full Strength - 2nd Edition

by B. Sternberg, PhD (3 hrs) Neurotransmitters: The Bridges of the Brain - 2nd Edition (3 hrs) Poles Apart: Unipolar vs. Bipolar Depression - 3rd Edition (3 hrs) Achieving Remission in Depression - 3rd Edition (3 hrs) Eating Disorders - 3rd Edition (3 hrs)

Tranquility Time by N. Katz, MD, PhD15 CONTACT HOURS Stop Losing Sleep - 4th Edition (3 hrs) Stimulants: Caffeine, Amphetamines, etc. - 4th Edition (3 hrs) Anti-Anxiety Drugs - 4th Edition (3 hrs) Non-Traditional Approaches: Anxiety, Insomnia, & Depression -

4th Edition by B. Sternberg, PhD (3 hrs) Brain & Stress: PTSD & Adjustment Disorder - 4th Edition (3 hrs)

Women’s Healthby M. O’Brien, MD15 CONTACT HOURS Menopause - 5th Edition (3 hrs) Migraines & Headaches - 5th Edition (3 hrs) Insomnia - 5th Edition (3 hrs) Chronic Pain - 5th Edition (3 hrs) Depression - 5th Edition (3 hrs)

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NEWLY

UPDATED!

NEWLY

UPDATED!

REMINDERS1. Health Update courses are approved by most licensing boards. Approvals may vary within each profession and each state. Books are approved for varying numbers of CE hours.

To claim CE credit, complete the examination and mail the examination page to BIOMED. Your diploma/certificate will be forwarded to you within three working days of receipt of your exam. It is your responsibility to notify your licensing board to receive credit.

2. Most home studies will be accepted up to three years after purchase. Although courses within a package may be “split” among several people, only one diploma will be issued per submitted exam. Only the original exam page will be accepted. BIOMED and most professional licensing boards will not accept photocopies or faxes of the examination page. Credit will not be issued for unused home studies. Copies of exam will be accepted for an additional fee based on the number of contact hours. Please attach check to copy. If you have any questions, please call BIOMED at (800)229-4997.

Single Home-study Courses Available Only from INR Webinars!Webinar Price $20 Regular Price $30 3 contact hours

(Please complete purchase form on page 8)

BIOMED

WEB_ Page 4 2012020

• Hospice & Palliative Care (M. O’Brien, MD): Discusses the goals and challenges involved in palliative care. Describes major symptoms encountered in terminal illness and treatment options.

• Humor & Healing - 2nd Ed. (B. Sternberg, PhD): Discusses the use of humor in health care settings and the role of humor for health care professionals.

• Inflammation - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Differentiates between acute and chronic inflammation. Identifies the mechanisms of combating infection/disease.

• Irritable Bowel Syndrome - 4th Ed. (M. O’Brien, MD): Identifies the differences between functional gastrointestinal disorders and inflammatory bowel diseases.

• Keeping Balance & Preventing Falls - 3rd Ed. (M. Howard, PhD): Lists causes and health hazards of falls. Outlines methods of preventing falls among the elderly.

• Knee Pain - 4th Ed. (R. Hullon, MD, JD): Describes the anatomical structure of the knee. Identifies the different types of knee injuries and their manifestations. Differentiates between major and minor injuries and the causes of knee pain. Explains strategies for preventing knee pain.

• Leg & Foot Pain (W. Schroeder, PhD, OTR, & W. Dubner, DPM): Describes how leg and foot pathologies can impair functional ability. Outlines evidence-based interventions for each condition.

• Low Back Pain - 5th Ed. (R. Hullon, MD, JD): Defines low back pain. Describes the prevalence of this condition within the U.S. Identifies the different causes of low back pain. Describes some of the treatment approaches employed. Discusses ways to prevent low back pain.

• Medical Ethics - 4th Ed. (R. Hullon, MD, JD): Explains the issues surrounding patient consent, including formed consent, voluntary consent, and competent consent.

• The Mediterranean Diet - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Describes the food-based guidelines that make up the Mediterranean pyramid. Explains the significance of physical activity, diet, and social interaction as part of the Mediterranean way of life.

• Memory Loss & Forgetfulness - 3rd Ed. (B. Sternberg, PhD): Identifies the memory changes that take place in normal aging. Discusses how mild cognitive impairment (MCI) differs from memory loss in normal aging and from dementia.

• Neck & Shoulder Pain - 3rd Ed. (R. Hullon, MD, JD): Defines the differences in presentation of signs and symptoms among neck and shoulder disorders.

• Omega-3 Fatty Acids - 3rd Ed. (N. Katz, MD, PhD): Covers the benefits and risks associated with the popular dietary supplement, omega-3 fatty acids. Examines the role of these acids in preventing heart disease and breast cancer and brain health.

• On Loss & Grief - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Identifies emotional, cognitive, behavioral, social, and physical responses to loss. Discusses the role of grief counseling and when it may be useful.

• Osteoporosis (A. St. Charles, PhD, RD, LDN): Describes the signs and symptoms of osteoporosis and its main risk factors. Identifies the role of diet and exercise in the prevention and treatment of bone loss.

• Pet Therapy - 3rd Ed. (B. Sternberg, PhD): Describes the aspects of the relationship between humans and their pets that contribute to health and well-being.

• Positive Psychology - 3rd Ed. (B. Sternberg, PhD): Describes the origin and goals of the “positive psychology.” Lists the factors that contribute to happiness and life satisfaction.

• The Power of Walking - 2nd Ed. (M. O’Brien, MD & A. St. Charles, PhD, RD, LDN): Describes the health benefits of walking. Explains how walking can reduce the risk of various diseases, including diabetes, heart disease, cancer, depression, and dementia.

• Probiotics - 3rd Ed. (B. Sternberg, PhD & C. Fleishman MS, RD): Discusses how probiotics affect the healthy immune system. Identifies good food sources of probiotics and prebiotics.

• Psychology of Bullying - 3rd Ed. (B. Sternberg, PhD): Describes individual, family, and social factors related to child and youth bullying. Discusses cyber bullying and associated problems.

• Reducing Stress - 3rd Ed. (B. Sternberg, PhD): Explains how the body responds to and processes stress. Understands the impact of stress on risk for heart disease and the physiological mechanisms that may mediate this link. Identifies a number of interventions for reducing stress.

• Skin Care, Allergies, & Wrinkles - 3rd Ed. (B. Hayes, MD, PhD, FAAD): Explains the diagnosis and newest treatments for skin conditions and skin allergies. Describes new laser treatments for wrinkles and other skin conditions.

• Social Anxiety- 2nd Ed. (B. Sternberg, PhD): Defines social anxiety. Describes the symptoms, causes, and treatment strategies for social anxiety.

• Understanding Anxiety- 3rd Ed. (B. Sternberg, PhD): Explains the difference between normal anxiety and an anxiety disorder. Describes the causes of anxiety.

• Understanding Cholesterol - 2nd Ed. (A. St. Charles, PhD, RD, LDN): Lists the various lipid components of total cholesterol and describes how they are formed in the body. Describes the physiological function of each lipid faction.

• Vitamin D: Vitamin, Hormone, & Protector - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Describes the role that vitamin D may play in the physiological function of various systems. Lists the current guidelines for supplementation of vitamin D.

• Vitamins, Minerals, & Supplements (A. St. Charles, PhD, RD, LDN): Identifies the vitamins and minerals needed for growth and normal development. Discusses the drawbacks/concerns of over-supplementation.

9012016PWV_Non-CA—5

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Obesity, Diet, & Behaviorby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Explain the complex nature of body fat and why both too much and too little are deleterious to health. 2) Describe how genes, eating behavior, macronutrients, physiology, microorganisms, and the environment

interact to produce obesity. 3) Outline how the food industry’s production of hyperpalatable foods fuels sweet, fat, and salt addiction and the obesity epidemic. 4) Identify the most effective diets that could produce long-lasting results in weight loss.

Opioids & Marijuanaby Nikita Katz, PhD, MDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Outline the neurologic, genetic, and social mechanisms of opioid abuse, especially in relation to the nationwide, opioid health emergency. 2) List diagnostic signs and psychological “red flags” common in opioid abuse and opioid

overdose. 3) Summarize the current guidelines for the use of opioids in patients with acute and chronic pain. 4) List the parameters of opioid use and abuse to be documented in all clinical, dental, and health care settings. 5) Explain opioid replacement therapy and the use of opioid antagonists in acute overdose.

Probiotics, Food, & the Immune Systempresented by Laura Pawlak, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Identify the human microbiota, including benecial bacteria (probiotics). 2) Describe the effects of probiotics with regard to the digestive, nervous, and immune systems. 3) List the pro- and anti-inflammatory influences, including those

influences related to such substances as essential lipids and amino acids. 4) Compare and contrast approaches used to reduce inflammation. 5) Recognize ways to prevent disease and disability in the aging population.

PTSD, Trauma, & Anxiety Disordersby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the structure and function of neurons, glia, neurotransmitters, and brain regions. 2) Explain how the brain produces and is affected by anxiety, trauma disorders, and depression. 3) Determine how stress

is the foundation for anxiety, PTSD (post-traumatic stress disorder), trauma, and many depressions. 4) Describe the new criteria for the diagnosis of PTSD, trauma disorders, and anxiety disorders.

The Science of Fat & Sugarby Laura Pawlak, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Identify metabolism and physiology of lipids and carbohydrates in health and disease as well as in the aged individual. 2) List the approaches to a patient suffering from metabolic disease from the nursing,

pharmacological, psychological, and physical therapy standpoints. 3) Compare and contrast appetite suppressants and other medications that induce weight loss. 4) Discuss the recent discoveries in neurochemistry and neuroscience of the link between behavioral pathology and metabolic disease. 5) Compare and contrast the healthy and the potentially dangerous weight loss strategies and long-term effects of fad diets.

The Sleep-Loss Epidemicby Raj Hullon, MD,JDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the stages, cycling, and circadian rhythms of sleep. 2) Cite evidence connecting sleep deprivation and sleep disorders to heart disease, stroke, diabetes, and dementia. 3) List the major sleep medications

with their uses and adverse effects. 4) Describe the connection between dental pain and sleep disruption. 5) Cite the diagnostic criteria, symptoms, course, and treatment for the major sleep disorders.

Better Habits, Better Healthby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how personality types, core beliefs, and behavioral habits affect chronic illness. 2) Discuss the most common chronic illnesses and the key factors in prevention and management. 3) Explain how stress, anxiety,

and depression influence chronic illnesses. 4) Describe practical behavioral habits for coping with disabling chronic conditions like pain, cancer, arthritis, and other diseases. 5) List ways to help patients develop healthier habits in terms of nutrition, activity, preventive medical and dental care, and emotional well-being.

Brain Health: Mood, Metabolism, & Cognitionby Gina Willett, Ph.D., R.D.VIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe key factors that are essential for a healthy brain, and how these impact both cognitive function and mental health. 2) Characterize Alzheimer’s disease as a neurodegenerative disorder of the brain; characterize

depression as a neuropsychiatric disorder of the brain. 3) Describe how obesity and diabetes impact cognitive and mental health.

Brain Trauma, Concussion, & Dementiaby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the brain structures and functions that are most vulnerable to trauma. 2) Outline the major steps in assessing patients with brain trauma and predicting disability. 3) Discuss key clinical features of concussions,

penetrating head injuries, and blast injuries. 4) Describe the relationship between brain trauma and dementing illness such as Alzheimer’s and chronic traumatic encephalopathy. 5) Outline the rehabilitation strategies most likely to improve outcomes in patients with brain trauma. 6) Discuss the practical steps to prevent brain trauma from motor vehicle accidents, falls, and sports.

Coping with Chronic Pain by David Cosio, PhD, ABPPVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Explain the current state of pain management in the United States. 2) Describe the multidisciplinary approach to pain management. 3) Summarize the 23 different pain management modalities currently available. 4) Describe

steps to create a comprehensive pain management plan. 5) List the five key coping skills for helping chronic pain patients. 6) Discuss treatment options for chronic dental and facial pain.

The Gut-Brain Connectionby Gina Willett, PhD, RDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Explain the concept of the gut-brain axis, and its implications for health and disease. 2) Describe how microbes and their metabolites communicate with the body and the brain. 3) Explain how the microbiome-gut-

brain axis influences the development of neurodegenerative, neuropsychiatric, and neurodevelopmental disorders. 4) Describe how microbial metabolites regulate immune and metabolic pathways in the body, and how this may impact risk of allergies, autoimmune diseases, obesity and diabetes. 5) Explain how the ecology of the oral microbiome impacts both gut and systemic health; discuss implications for modern-day oral healthcare.

Inflammation, Chronic Illness, & the Brainpresented by Michelle Albers, PhD, RDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Identify clinical signs & symptoms of inflammation. 2) Demonstrate the connections between inflammatory processes and chronic illness. 3) Describe the role of inflammation in specific illnesses such as heart

disease, COPD, diabetes, arthritis and dementia. 4) List practical strategies to reduce levels of inflammation in clinical practice. 5) Explain the rationale for good dental prophylaxis and skin care in patients with chronic illness.

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Stress, Resilience, & Happinessby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how perception, thinking, emotions, and memory combine to produce cognitive appraisals and behavior. 2) Outline the causes, components, and management of psychological stress. 3) Define resilience and

explain the factors that compose the ability to “bounce back” from stressful events 4) List the major components of the positive-psychology approach to increasing life satisfaction. 5) Determine the elements of happiness and optimism and how to apply them to increase well-being.

Understanding Addictionsby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the main brain functions that contribute to addictive behavior. 2) Explain the major ways that addiction changes the brains of addicts. 3) Describe how drugs mimic and alter neurotransmitters which provoke the

psychological effects of addiction. 4) Explain the difference between drug dependence, tolerance, and addiction. 5) Describe the clinical consequences of addiction to food, opioids, street drugs, and alcohol. 6) List and compare the major treatment options for legal and illegal drug addictions.

Understanding Aging & Longevityby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how the biopsychosocial model of health and how disease impacts aging, health, life span, and longevity. 2) Explain the differences between normal aging and age-related disease and their effects on life span

and longevity, including periodontal disease. 3) Determine the effects of genetics, epigenetics, and the environment on aging. 4) Describe how the body and brain age at the cellular, tissue, organ, and organ system levels. 5) Determine the causes of recent increases in life expectancy in the world and the United States.

Understanding Diabetesby Gina Willett, PhD, RDVIDEO PRESENTATION - 2 DVDS (6 contact hrs)Participants completing this course will be able to: 1) Compare and contrast the different forms of diabetes. 2) Explain why the number of cases of Type 2 diabetes is expanding worldwide. 3) Describe how gut health impacts metabolic health and diabetes risk. 4) Outline potential

complications of diabetes as well as appropriate interventions. 5) Characterize how insulin resistance and Type 2 diabetes are linked to other conditions such as cognitive decline, depression, cancer sleep disorders, and periodontal disease.

Understanding Mental Disordersby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how the brain produces behavior and how learned patterns of behavior become a personality. 2) List the personality disorders and explain how they disrupt relationships. 3) Determine how to diagnose and treat the

major anxiety disorders, including dental anxiety, and outline the effects of early life stress, medical disorders, and medications on anxiety. 4) Describe the characteristics of posttraumatic stress disorder and obsessive-compulsive disorder and explain why they are no longer grouped with anxiety disorders.

Understanding Painby Nikita Katz, PhD, MDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) List the neurologic processes causing pain and suffering and the principles of pain assessment. 2) Discuss treatment modalities for primary and secondary headaches, including migraine and rare cephalagias.

3) List the “red flags” of medication abuse and approaches to reduce opioid addiction. 4) Describe the differential diagnosis of dental vs. cervical and cervicogenic pain and the appropriate intervention for both. 5) List steps involved in the diagnosis and management of spinal pain, including physical and occupation therapy.

Mindful Stress Reduction Practices by Kent HowardAvailable Format: VIDEO PRESENTATION - 1 DVD (not for cE crEdit) This DVD introduces stress reduction techniques using: Tai Chi and Qi-Gong Chair-Assisted Yoga Stretches Meditation Postures and Practices Breathing Techniques for Relaxation

Mindful Stress Reduction Volume II by Kent HowardAvailable Format: VIDEO PRESENTATION - 1 DVD (not for cE crEdit) This DVD includes more stress reduction techniques, including meditative movement routines and mindful breathing exercises.

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� 1. Better Habits, Better Health (dVd) - NEW! � 2. Brain Health (dVd) � 3. Brain Trauma, Concussion, & Dementia (dVd) � 4. Coping with Chronic Pain (dVd) � 5. The Gut-Brain Connection (dVd) � 6. Inflammation, Chronic Illness, & the Brain (dVd) � 7. Obesity, Diet, & Behavior (dVd) � 8. Opioids & Marijuana (dVd) � 9. PTSD, Trauma, & Anxiety Disorders (dVd) � 10. Probiotics, Food, & the Immune System (dVd) � 11. The Science of Fat & Sugar (dVd) � 12. The Sleep-Loss Epidemic (dVd) � 13. Stress, Resilience, & Happiness (dVd) � 14. Understanding Addictions (dVd) � 15. Understanding Aging & Longevity (dVd) � 16. Understanding Diabetes (dVd) � 17. Understanding Mental Disorders (dVd) � 18. Understanding Pain (dVd) - NEW!

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