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WILLIAM'S  NOTATIONS
FROM THE WINE COUNTRY

Just returned from the 18^th Annual Napa Pain Conference at the Meritage Conference Center in Napa, CA. What an event! A special "thanks" to Dr. Eric Grigsby and the Napa Pain Institute for presenting such a fantastic event that gives the world of pain management an opportunity to not only converse with old colleagues and friends, but to establish new ones as well. And who wouldn't jump at the chance to taste some excellent wines with some of the country's preeminent pain clinicians? Superb!

This year's distinguished speakers were inspirational, and their topics were spectacular. I have had the pleasure of hearing a number of these doctors speak about a variety of topics over the years, yet I am still astonished by the histories, advances, and knowledge presented during their lectures. Notable among them, History of Intrathecal Therapy for Pain Control by Eliott S. Krames; Ultrasonography in Spine Interventions presented by Michael Gofeld, MD, DEAA; IT Gabapentin by Richard Rauck, MD; CSF Flow & Dynamics: Implications for IT Therapy by Eric Buchser, MD, DEAA; State of the Art Neuromodulation by Tim Deer, MD; Intrathecal Therapy Best Practices by Joshua Prager, MD, MS and Microdosing presented by Emil Annabi, MD.

Gabapentin

Dr. Rauck's lecture presented information and data revolving around the study of intrathecal gabapentin. The doctor indicated that there have been 20 published studies examining gabapentin in animal and human applications. Recently, the phase II study examined a 21-day continuous infusion of over 150 subjects. A very important aspect, for me, was the daily dosing of gabapentin. The trial dosages were 1, 6, 30 mgs per day. The outcome did not show significant clinical effectiveness, and the trial was subsequently discontinued. Dr. Rauck had many personal thoughts on this drug study ... but perhaps the most interesting came from the posed question of: "Wrong Study? Or Wrong Drug?" Very intriguing. Some patients responded well, but most described his/her pain as no different than a placebo dose. Gabapentin demonstrated no toxicities to the spinal cord. But this finding left a lot of questions and considerations, such as that asked by the participant next to me of, "What were the statistics for people who found great relief vs. the entire patient population?"

Micro-dosing

During the "Micro-dosing" panel, there was a fascinating discussion by Dr. Emil Annabi, Assistant Professor for the Department of Anaesthesia and Director of Pain Management at the University of Arizona. He highlighted the problems with intrathecal therapy such as dose escalation. He stated that in his practice the mean starting dose was roughly 2.7 mgs/day of morphine, while the mean dose of the last follow-up was 4.7 mgs/day. During a retrospective study of his patients, Dr. Annabi found that dose escalation going from 5 mgs to 9.2 mgs occurred roughly within 12 months. He gave his true to heart (and, refreshingly, honest) beliefs of pain management information and concepts in treating his patients. "What is micro-dosing?" he asked. Answer, "The lowest effective IT dose to achieve analgesia."  

He went on to discuss his patient population, reviewing his concerns and problems with IT therapy - specifically with ER visits, dose escalations, granuloma formations, and respiratory depression. Dr. Annabi understood that he needed to give new consideration to the paradigm for treating of his patients with intrathecal drugs for chronic pain. One of his most notable concepts was his "Let's give this a try" attitude. He makes the offer to his patients to consider micro-dosing, and expresses that if it doesn't work out, he will return to their original therapy. But he sensed that it would work.

In introducing this particular therapy of micro-dosing, Dr. Annabi would go through a strict detoxification period - taking his patients off the narcotics over a period of 6 weeks. He would then introduce opioids at significantly reduced doses. His goals for patients were: pain control, reduction in side effects, to increase activities of daily living, improvement of functionality, reduction of hospital visits, and, ultimately, increase their quality of life.

This particular subject is controversial, and he really spoke from the heart and from his convictions. He strongly believed that this was something working for his practice, and that one can't ignore it. He concluded by thanking Dr. Michael Castillo, Dr. William Witt, and Dr. David Caraway for being pioneers in considering micro-dosing for the treatment of chronic pain.

I was thrilled to see everyone at this years' event. If you didn't get the chance to attend, you HAVE to mark your calendars for next year's. Thank you Napa Pain Institute, the hardworking staff at Neurovations, and all of the generous sponsors! This event continues to grow each year.

If I didn't get a chance to see you at this event, please find me during the NANS Conference in Las Vegas this December ... or give me a call anytime.