Issue Overview

Neuropathic Pain, October 2009; 15 (5)

Learning Objectives

Upon completion of this course, participants will be able to:

• Review current research on the mechanisms of neuropathic pain

• Clarify assessment of symptoms, signs, and consequences of prevalent neuropathic pain conditions

• Apply evidence-based treatments for neuropathic pain in clinical practice

• Identify research questions that need to be addressed to optimize treatment matching for patients with neuropathic pain

Core Competencies

• Patient Care
• Interpersonal and Communication Skills
• Professionalism
• Medical Knowledge
• Practice-Based Learning and Improvement
• Systems-Based Practice

Disclosures

FACULTY

JOHN D. MARKMAN, MD, Chair

Director, Neuromedicine Pain Management Center and Translational Pain Research, Departments of Neurosurgery and Neurology, University of Rochester School of Medicine, Rochester, New York

Relationship Disclosure: Dr Markman has received personal compensation for serving on the advisory board of Johnson & Johnson Services, Inc. Dr Markman has received research support from Endo Pharmaceuticals and Pfizer Inc. Dr Markman is a special government employee of the US Food and Drug Administration Center for Drug Evaluation and Research.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Markman discusses the unlabeled use of many procedures.

PHILLIP J. ALBRECHT, PhD

Assistant Professor, Center for Neuropharmacology and Neuroscience, Albany Medical College, Albany, New York

Relationship Disclosure: Dr Albrecht has received research support from Endo Pharmaceuticals.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Albrecht has nothing to disclose.

CHARLES E. ARGOFF, MD

Professor of Neurology, Director, Comprehensive Pain Program, Albany Medical College, Albany, New York

Relationship Disclosure: Dr Argoff has received personal compensation for activities with Eli Lilly and Company, Endo Pharmaceuticals, King Pharmaceuticals, Inc., Pfizer Inc, PriCara, Shire US, Inc., and Vertex Pharmaceuticals, Inc. Dr Argoff has received research support from Endo Pharmaceuticals and Pfizer Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Argoff discusses the unlabeled use of various medications.

MIROSLAV “MISHA” BACKONJA, MD

Professor, Department of Neurology, University of Wisconsin, Madison, Madison, Wisconsin

Relationship Disclosure: Dr Backonja has received personal compensation for activities with Abbott Laboratories, Inc., Eli Lilly and Company, Endo Pharmaceuticals, Grünenthal, Johnson & Johnson Services, Inc., Merck & Co., Inc., NeurogesX, and Valeant Pharmaceuticals, Inc. Dr Backonja has received research support from Eli Lilly and Company, Johnson & Johnson Services, Inc., NeurogesX, and Valeant Pharmaceuticals, Inc. Dr Backonja has received research support from Eli Lilly and Company, Endo Pharmaceuticals, Grünenthal, Johnson & Johnson, NeurogesX, and Valeant Pharmaceuticals, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Backonja has nothing to disclose.

MEREDITH BARAD, MD

Clinical Instructor/Research Fellow in Pain Management, Stanford University Medical Center, Stanford, California

Relationship Disclosure and Unlabeled Use of Products/Investigational Use Disclosure: Dr Barad has nothing to disclose.

RALF BARON, MD

Professor, Head Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany

Relationship Disclosure: Dr Baron has received personal compensation for consulting from Allergan, Inc., Eisai Inc., Genzyme Corporation, Grünenthal, Medtronic, Inc., Mundipharma, Pfizer Inc., Sanofi Pasteur, and Schwarz Pharma. Dr Baron has received grant/research support from Genzyme Corporation, Grünenthal, and Pfizer Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Baron discusses treatment approaches that have not been specifically investigated in large, controlled, randomized, clinical trials for complex regional pain syndrome.

TIMOTHY A. COLLINS, MD

Assistant Professor of Medicine, Division of Neurology, Duke University Medical Center, Durham, North Carolina

Relationship Disclosure: Dr Collins has received personal compensation for activities with GlaxoSmithKline and Pfizer Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Collins has nothing to disclose.

ROBERT H. DWORKIN, PhD

Professor of Anesthesiology, Neurology, Oncology, and Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York

Relationship Disclosure: Dr Dworkin has received personal compensation for activities from Allergan, Inc., Alpharma, Inc., Arcion Therapeutics, Inc., Astellas Pharma Inc., AstraZeneca, BioLineRx, Cara Therapeutics, Cervelo Pharmaceuticals Inc., Durect Corporation, Eisai, Inc., Eli Lilly and Company, Endo Pharmaceuticals, Forest Pharmaceuticals, Inc., Genzyme Corporation, Grünenthal, Johnson & Johnson Services, Inc., KAI Pharmaceuticals, Inc., King Pharmaceuticals, Inc., Merck & Co., Inc., NeurogesX, Neuromed, Nuvo Research Inc., Ono Pharmaceutical Co., Ltd., Pfizer Inc., Philips Respironics, Solace Pharmaceuticals, UCB, Inc., and XTL Biopharmaceuticals Ltd. Dr Dworkin has received research support from Arcion Therapeutics, Inc., NeurogesX and the US NIH. Dr Dworkin is a special government employee of the US Food and Drug Administration Center for Drug Evaluation and Research.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Dworkin discusses the unlabeled use of medications that have shown efficacy in at least one type of neuropathic pain in one or more high-quality randomized controlled trials. No drugs have been approved by the US Food and Drug Administration for the treatment of neuropathic pain.

ROY L. FREEMAN, MD

Professor of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Relationship Disclosure:Dr Freeman has received personal compensation for consulting activities from Chelsea Therapeutics, Eli Lilly and Company, Eisai Inc., GlaxoSmithKline, Pfizer Inc, Solace Pharmaceuticals, Takeda Pharmaceutical, UCB, Inc., and XTL Biopharmaceuticals Ltd. Dr Freeman has received personal compensation in an editorial capacity from Autonomic Neuroscience—Basic and Clinical.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Freeman has nothing to disclose.

MICHAEL D. GREICIUS, MD, MPH

Assistant Professor, Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford, California

Relationship Disclosure: Dr Greicius has received personal compensation for activities from Forest Laboratories, Inc., for serving on a patient safety monitoring panel.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Greicius has nothing to disclose.

ROSS S. HANSON, BS

Research Fellow, Neuromedicine Pain Management Center and Translational Pain Research, Departments of Neurosurgery and Neurology, University of Rochester School of Medicine, Rochester, New York

Relationship Disclosure: Mr Hanson has nothing to disclose.

Unlabeled Use of Products/Investigational Use Disclosure: Mr Hanson discusses the unlabeled use of many procedures.

SEAN MACKEY, MD, PhD

Associate Professor, Division Chief, Pain Management, Stanford University Medical Center, Stanford, California

Relationship Disclosure: Dr Mackey has received personal compensation from Pfizer Inc for serving as a consultant and speaker.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Mackey has nothing to disclose.

DENNIS NALESCHINKI, MD

Resident Physician, Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany

Relationship Disclosure: Dr Naleschinski has received honoraria for speaking from Genzyme Corporation, Grünenthal, and Pfizer Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Naleschinski discusses treatment approaches that have not been specifically investigated in large, controlled, randomized, clinical trials for complex regional pain syndrome.

ALEC B. O’CONNOR, MD, MPH, FACP

Assistant Professor of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York

Relationship Disclosure: Dr O’Connor has received research support from Endo Pharmaceuticals, the Mayday Fund, and the US NIH.

Unlabeled Use of Products/Investigational Use Disclosure: Dr O’Connor discusses the unlabeled use of medications that have shown efficacy in at least one type of neuropathic pain in one or more high-quality randomized controlled trials. No drugs have been approved by the US Food and Drug Administration for the treatment of neuropathic pain.

FRANK L. RICE, PhD

Professor, Albany Medical College, Albany, New York; President and CEO, Integrated Tissue Dynamics, LLC, Rensselaer, New York

Relationship Disclosure: Dr Rice has received personal compensation for activities with General Electric Company and Regeneron Pharmaceuticals, Inc. Dr Rice has received research support for his work on peripheral neuropathies from AstraZeneca, Endo Pharmaceuticals, and Vertex Pharmaceuticals, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Rice has nothing to disclose.

JAMES A. RUSSELL, DO, FAAN

Associate Clinical Professor of Neurology, Tufts University School of Medicine, Lahey Clinic, Burlington, Massachusetts

Relationship Disclosure: Dr Russell has received personal compensation for activities with Schlessinger Associates.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Russell has nothing to disclose.

DAVID WALK, MD

Associate Professor, University of Minnesota, Minneapolis, Minnesota

Relationship Disclosure: Dr Walk has received personal compensation from Eli Lilly and Company and Pfizer Inc for speaking activities.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Walk discusses the unlabeled use of medication in the treatment of neuropathic pain.

MULTIPLE-CHOICE QUESTION WRITERS

RONNIE BERGEN, MD

Assistant Professor of Clinical Neurology, University of Arizona College of Medicine; Southern Arizona VA Health Care System, Tucson, Arizona

Relationship Disclosure and Unlabeled Use of Products/Investigational Use Disclosure: Dr Bergen has nothing to disclose.

JULIE E. HAMMACK, MD, FAAN

Assistant Professor, Mayo Medical College, Mayo Clinic, Rochester, Minnesota

Relationship Disclosure and Unlabeled Use of Products/Investigational Use Disclosure: Dr Hammack has nothing to disclose.

Methods of Participation and Instructions for Use

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills. In Continuum, the process of absorbing, integrating, and applying the material presented is as important as, if not more important than, the material itself.

The goals of Continuum include disseminating up-to-date information to the practicing neurologist in a lively, interactive format; fostering self-assessment and lifelong study skills; encouraging critical thinking; and, in the final analysis, strengthening and improving patient care.

Each Continuum issue is prepared by distinguished faculty who are acknowledged leaders in their respective fields. Six issues are published annually and are composed of the syllabus text, a set of multiple-choice items with preferred responses, case-based sections pertaining to ethical and practice issues related to the issue, and a patient management problem.

The syllabus text emphasizes clinical issues emerging in the field in recent years. Case reports and vignettes are used liberally, as are tables and illustrations. A CD-ROM of patient case vignettes relating to the issue topic accompanies one issue each year.

The practice of neurology presents a series of ethical challenges for the clinician. These rarely have simple or straightforward solutions, but require careful consideration by the neurologist. The ethical perspectives in neurology section provides a case vignette that raises one or more ethical questions related to the Continuum topic. Discussion follows the case to help the reader understand and resolve the ethical dilemma.

In addition to the lifelong learning of new clinical and scientific knowledge, neurologists must understand the constantly evolving environment in which they practice. Changes occur rapidly in reimbursement and regulatory areas, in the integration of evidence-based medicine, and in the implementation of patient safety measures into clinical practice. The practice issues in neurology section presents a case-based example of these issues as they relate to the clinical topic.

The patient management problem, a clinical scenario designed to challenge the practitioner, follows the multiple-choice items. Management options are offered at each of several decision points, and explanations for each option are provided. In addition, a weight or “value” is listed, indicating the option’s relative strength or weakness. The patient management problem should help sharpen critical thinking skills used daily in the clinical practice of neurology.

The text can be reviewed and digested most effectively by establishing a regular schedule of study in the office or at home, either alone or in an interactive group. If program subscribers use such regular and perhaps new study habits, Continuum’s goal of establishing lifelong learning patterns can be met.

Multiple-choice items accompany each syllabus text. They are not intended as an examination but rather as a means of stimulating thought and helping you assess your general understanding of the course material. Subscribers may complete the questions online. Your responses will be kept completely confidential. Then, review the preferred response and critique for each multiple-choice item.

The opinions of subscribers play a vital role in the future development of the program. Let us know what you think of each issue, using the comment section provided on the answer form. Upon submission of the evaluation at the end of the multiple-choice items, you earn up to 10 hours of American Medical Association (AMA) Physician’s Recognition Award (PRA) Category 1 Credit™. A transcript of credits earned will be available to you on the AAN website within two business days. (Note: Participants have up to 3 years from the date of publication to earn CME credits for each issue, unless otherwise notified by the AAN.)