1. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
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2. Continuing Education Credit: TEXT: 501-406-0076
AR-IMPACT website: arimpact.uams.edu
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Facebook: AR-Impact
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3. Continuing Education Credit: TEXT: 501-406-0076
Faculty Disclosure of Financial Relationships:
The planners of this RSS, Corey Hayes, Michael Cucciare, Johnathan Goree, Leah Tobey, Teresa Hudson and Cathy Buzbee have no financial relationships with commercial interests to disclose.
A planner of this RSS, Shona Ray-Griffith, MD, has a financial relationship with a commercial interest to disclose: Neuronetics, Inc. – Contracted Research.
The speaker of this RSS Masil George, MD has no financial relationships with commercial interests to disclose.
The accreditation compliance reviewers of this RSS, Karen Fleming, Courtney Bryant and Cathy Buzbee, RNP, have no financial relationships with commercial interests to disclose.
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4. Continuing Education Continuing Education Credit: TEXT: 501-406-0076
Accreditation: In support of improving patient care, University of Arkansas for Medical Sciences is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Credit Designation: The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The University of Arkansas for Medical Sciences designates this live activity for a maximum
of 1 ANCC contact hour. Nurses must attend the entire session in order to receive credit.
This knowledge-based activity will provide pharmacists up to 1.0 contact hours or 0.1 CEU.
ACPE# JA L04-P
AAFP Credit: Submit your AMA credit •
Pharmacists: Please us your NABP number and month and day of birth
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5. Influences Upon the Decision to Adopt Office Based Buprenorphine Treatment in Rural Settings: A Qualitative Study
NIH-funded study about access to medication-assisted treatment for OUD in primary care settings
Currently recruiting PCPs in rural areas in Arkansas and Kentucky
Telephone interviews to collect PCP opinions, perceptions, and experiences
Interested in talking to both PCPs not doing MAT for OUD (e.g., buprenorphine) AND those who are providing MAT for OUD
Interviews can be scheduled at your convenience (early morning and after-hours time slots available!)
Upon completion of the interview participant will receive modest compensation for their time
Questions? Interested in participating? Please contact KaSheena Winston at or by

6. Comorbidities in Chronic Pain
Masil George, MD
Associate Professor, UAMS Department of Geriatrics
Associate Professor, UAMS Division of Medical Humanities
Director, Geriatric Palliative Care Program, UAMS
Medical Director, Baptist Hospice
5/22/19

7. Objectives List common comorbid conditions with chronic pain
Describe ways to optimally assess comorbid conditions
Establish treatment goals for follow up visit

8. Clinical Case
Mr. Jones is a 72 year old man with PMH of HTN, DM, COPD, CHF, OA
On appropriate medications (Lisinopril, Coreg, ASA, Metformin,
lasix, gabapentin)
He is a retired high school teacher, quit smoking 20 years ago, compliant with medications, sedentary lifestyle, married (48 years), he has 4 grand children
He complains of aching pain in his right hip (4 months) and burning under both of his feet (8 months)

9. What is Chronic pain?
Pain that persists past the normal time of healing
3 months- used as transition from acute to chronic pain
6 months- used in research
International Association for Study of Pain, second edition (Revised)

10. Join Poll Everywhere
376-07
masilgeorge681

12. Common Comorbid Conditions in Chronic Pain
Reduced quality of life
Insomnia
Mood disorders (Depression/ Anxiety)
Miscellaneous (fear of falling, cognitive impairment, driving safety)

13. Health Related Quality of Life
CDC has defined HRQOL as “an individual’s or group’s perceived physical and mental health over time.”
Self-assessed health status is also a more powerful predictor of mortality and morbidity than many objective measures of health.
Since 2003, the CDC HRQOL– 4 has been in the Medicare Health Outcome Survey (HOS).

14. CDC Health Related Quality of Life Questionnaire

15. PEG scale 3 item scale to assess pain intensity and interference
Ideal for primary care
Practical and useful tool to improve assessment and monitoring of chronic pain 
Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009

16. PEG scale

17. Brief Pain Inventory
Purpose: To assess the severity of pain and the impact of pain on daily functions
Population: Patients with pain from chronic diseases or conditions such as cancer, osteoarthritis and low back pain, or with pain from acute conditions such as postoperative pain
Assessment areas: Severity of pain, impact of pain on daily function, location of pain, pain medications and amount of pain relief in the past 24 hours or the past week
Responsiveness: Responds to both behavioral and pharmacological pain interventions
Method: Self-report or interview
Time required: Five minutes (short form), 10 minutes (long form)
Scoring: No scoring algorithm, but "worst pain" or the arithmetic mean of the four severity items can be used as measures of pain severity; the arithmetic mean of the seven interference items can be used as a measure of pain interference

18. Stress
Reductions in the brain growth factor, brain-derived neurotrophic factor, and synaptic protein synaptophysin
Neuroinflammation and stress, secondary to chronic pain, induce depression and anxiety
CRPS-induced changes in the amygdala, perirhinal cortex, and hippocampus

19. Stress
Fracture/cast mice manifest changes in measures of thigmotaxis (indicative of anxiety) and working memory reflected in neuroplastic changes in amygdala, perirhinal cortex, and hippocampus.
Structural changes and synaptic plasticity including changes in dendritic architecture and decreased levels of synaptophysin and brain-derived neurotrophic factor in specific brain regions.
A causal link between chronic pain, stress, anxiety, and hippocampal function.
This work supports the potential use of therapeutic interventions that not only directly target sensory input and other peripheral mechanisms, but also attempt to ameliorate the broader pain experience by modifying its associated cognitive and emotional comorbidities.
Tajerian, M, Leu, D, Zou, Y, Sahbaie, P, Li, W, Khan, H, Hsu, V, Kingery, W, Huang, TT, Becerra, L, Clark, JD Brain neuroplastic changes accompany anxiety and memory deficits in a model of complex regional pain syndrome.. Anesthesiology. (2014). 

20. Anxiety PSS 10 – Perceived Stress Scale, 10 item questionnaire
Beck Anxiety Inventory, 21 items
Chiu YH, Lu FJ, Lin JH, Nien CL, Hsu YW, Liu HY. Psychometric properties of the Perceived Stress Scale (PSS): measurement invariance between athletes and non-athletes and construct validity. PeerJ. 2016

21. Depression Beck Depression Inventory
Patient health questionnaire (PHQ 9, PHQ 2)
Geriatric Depression Scale

22. Sleep – Epworth Sleepiness Scale

23. Scoring of Epworth Sleepiness Scale
0-5 Lower Normal Daytime Sleepiness
6-10 Higher Normal Daytime Sleepiness
11-12 Mild Excessive Daytime Sleepiness
13-15 Moderate Excessive Daytime Sleepiness
16-24 Severe Excessive Daytime Sleepiness

24. AD 8 Questionnaire
1. Problems with judgment (e.g., problems making decisions, bad financial decisions, problems with thinking) 2. Less interest in hobbies/activities 3. Repeats the same things over and over (questions, stories, or statements) 4. Trouble learning how to use a tool, appliance, or gadget (e.g., VCR, computer, microwave, remote control) 5. Forgets correct month or year 6. Trouble handling complicated financial affairs (e.g., balancing checkbook, income taxes, paying bills) 7. Trouble remembering appointments 8. Daily problems with thinking and/or memory TOTAL AD8 Adapted from Galvin JE et al, The AD8, a brief informant interview to detect dementia, Neurology 2005:65: Copyright The AD8 is a copyrighted instrument of the Alzheimer’s Disease Research Center, Washington University, St. Louis, Missouri.

25. Miscellaneous Comorbidities
Fear of falling- PT, Assistive devices
Cognitive impairment- Optimize medical management, Clinical exam (SLUMS, MOCA, MMSE), Labs (TSH, B12), Imaging (CT, MRI of brain)
Driving safety- Driving Evaluation

26. Clinical Case- Panel and General Discussion
Mr. Jones is a 72 year old man with PMH of HTN, DM, COPD, CHF, OA
On appropriate medications (Lisinopril, Coreg, ASA, Metformin,
lasix, gabapentin)
He is a retired high school teacher, quit smoking 20 years ago, compliant with medications, sedentary lifestyle, married (48 years), he has 4 grand children
He complains of aching pain in his right hip (4 months) and burning under both of his feet (8 months)

27. Motivational Interviewing
If a patients asks for information/advice, go ahead and give it
If ambivalent, consider starting by asking permission (i.e., “knock on the door before you enter”)
Consider using Ask-Provide-Ask

28. Establishing Goals- Process of change
Acknowledge challenges
Recognize and praise progress
Encourage change
Develop an Action Plan
Provide written summary
Self compassion
Masil George

29. Case Conference and Feedback
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