Intensive Review Course is Intense!

Day one was an excellent and fast paced day in the dungeon of the Hyatt in downtown Chicago. It appears the leaders at AAHPM have mastered Atul Gwande’s “Checklist Manifesto” as everything appeared smooth from the start.

Over 680 participants and close to 300 on the waiting list; thirteen 30 minute sessions with two 30 minute panel discussions breaking up the day; 7 speakers… really, what could go wrong? If anything did go wrong, the cover up was superb.

Now to the content of the course- great refresher and some excellent new information was shared. For those of you not attending the course or those at the course who experienced post-prandial coma and missed some points- here are a few highlights from a couple of today’s lectures:

v Pathophysiology of Pain (Eduardo Bruera)-

• Have a clear understanding of incidental pain and how this is different from treatment of break through pain
• Only area of pain we can measure is “Expression” which has five components: cognitive status, mood, beliefs, cultural, biography
• Have an idea of inhibitory modulators of nociception and excitatory modulation of nociception

v Pain Assessment and Barriers (Michael Preodor)-

• Understand the barriers at the Provider, patient/family, system levels
• Understand difference between addiction, dependence, pharmacologic tolerance, pseudo-addiction and diversion

v Principles of Pain Management (Eduardo Bruera)

• Pain is multidimensional- if pain is increasing, one must do a complete assessment
• Risk factors for developing Opioid Induced Neurotoxicity (OIN)include
  • High opioid dose
  • Prolonged opioid exposure
  • Pre-existing delirium
  • Dehydration
  • Renal failure
  • Presence of other psychoactive drugs
• Diagnosis of OIN
  • Cognitive failure
  • Severe sedation
  • Hallucinosis/ delirium
  • Myoclonus/grand mal seizures
  • Hyperalgesia/ allodynia

v Pediatric Sessions (Jeanne Lewandowski)

• Start low, titrate quickly
• Half of all pediatric deaths occur in the first year of life, of which half are in the first month
• Unable to declare a child dead by neurologic criteria (brain dead) in the first week of life
• Participation of the ill child in decision making is ideal- term used in “assent”

Articles some of the speakers suggested we read:

1. Zisook, S, Shear K. Grief and bereavement: what psychiatrists need to know; Work Psychiatry 2009 June; 8(2):67-74
2. Himelstein, BP: Palliatve Care for infants, children, adolescents, and their families. J Pall Med 9(1) 2006, 163-181
3. Lo B, Ruston D, Kates LW et al. Discussing Religious and spiritual issues at the end of life: a practical guide for physicians. JAMA 2002; 287(6)749-754
4. Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306:639-45
5. Smith HS. Opioid Metabolism; Mayo Clin Proc 2009; 84(7):613-24
6. Hanks, G et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. Journal of Clinical Oncology 19(9); 2542-54, 2001, May

So, we are off to a great start! Let’s see what tomorrow brings….

Tanya Stewart MD FAAHPM