Download Pain Management - Mississippi Professionals Health Program

PAIN MANAGEMENT
Kirk L. Kinard, D.O
September 26, 2014
Disclosures
 Southern Pain Society- Board of Directors
 SAS Research- study investigator (compounded
topical analgesics)
 ISIS, AAPM, SPS, ASA- active member
 MidSouth Pain Treatment Center- Medical
Director of Oxford location (Southaven-MS,
Germantown-TN, Jackson-TN)
Objectives
 Incorporate knowledge of more accurate “pain” terminology in





your documentation, development of targeted treatment
strategies, and verbal communications with pain patients
Identify how many of your own practice habits may be
contributing to the growing prescription drug abuse problem in
the U.S.
Modulate therapy for chronic pain patients by better addressing
psychological and behavioral issues
Utilize available screening tools to risk stratify patients prior to
initiating opioid therapy
Modify your practice standards to meet both state and federal
expectations for treating chronic pain patients
Apply knowledge of multidisciplinary approaches to chronic pain
management to assess your current limitations and assist with a
more timely and appropriate referral to a pain medicine specialist
“Pain Clinic”

On September 24, 2013, the Board adopted an amendment to the
Administrative Code Part 2640, Chapter 1: Regulations Pertaining to Prescribing,
Administering and Dispensing of Medication, to amend the registration of Pain
Management Medical Practices, Rule 1.15.

Physicians whose practice meet the definition of a Pain Practice may not operate in
Mississippi without the required registration from the Mississippi State Board of Medical
Licensure.

A Pain Management Medical Practice is defined in the regulation as a public or private
medical practice that provides pain management services to patients, a majority (more than
50%) of which are issued a prescription for, or are dispensed, opioids, barbiturates,
benzodiazepines, carisoprodol, butalbital compounds, or tramadol for more than one
hundred eighty days (180) days in a twelve month period.

The physician owner/operator/employee of a Pain Management Medical Practice must
register with the Mississippi State Board of Medical Licensure. Certificates, once issued, are
not transferable or assignable. Only the primary physician owner is required to register with
the Board.

All practitioners/employees associated with clinic in the treatment of pain management
patients, whether in the capacity as an owner / practitioner / employee should be listed on the
application. Each practice requires a separate application/certificate.
What/Who is a “Pain Specialist”?
 The American Board of Medical Specialties
 AMBS is the primary physician certification organization in
the United States
 certifies pain medicine fellowship programs that result in
subspecialty certification in Pain Medicine
 Anesthesiology, PM&R, Neurology, Psychiatry
 The American Board of Pain Medicine
 ABPM is not affiliated with the ABMS
 does not oversee fellowship training programs
 ABPM administers practice-related examination for
certification in Pain Medicine to qualified candidates who
have achieved specified requirements
Early Approaches to Pain Management
 Surgical/Procedural
 Trepanning (headache)
 Blood letting (acute side pain)
 Stimulation
 Eels
 Acupuncture
 Topicals
 Oil, sulfur rubs
 Life Style Change
 Sexual abstinence
 Exercise
 Hot spas
 Heliotherapy, rest
WHO Analgesic Ladder
The Problem of Undertreated Pain
 WHO: Undertreated pain is America’s #1
health problem
 # of patients with chronic pain in the U.S.
exceeds diabetes, heart disease and cancer
combined
 National Center for Health Statistics. Health, United States, 2006
with Chartbook on Trends in the Health of Americans. Hyattsville,
MD: US Department of Health and Human Services; 2006:68–71
Physiological effects of Pain
 Increased catabolic demands: poor wound healing,





weakness, muscle breakdown
Decreased limb movement: increased risk of DVT/PE
Respiratory effects: shallow breathing, tachypnea, cough
suppression increasing risk of pneumonia and atelectasis
Increased sodium and water retention (renal)
Decreased gastrointestinal mobility
Tachycardia and elevated blood pressure, myocardial
ischemia, dysrhythmia, hypercoagulation (CV)
 Endocrine: hyperglycemia
 Immunologic: Decrease natural killer/lymphocyte? cell
counts
Psychological effects of Pain
 Negative emotions: anxiety, depression,
irritability, rage, anhedonia
 Sleep deprivation
 Existential suffering: may lead to patients
seeking active end of life.
Why is pain so difficult to manage?








Poor Assessment
Complicated Physiology
Secondary Psychological Manifestations
Co-morbid Pathologies
Compliance
Managed Care Limitations
Regulatory Concerns
Limited Analgesic Options
 Lack of knowledge 
Criminal Charges for Overtreatment of Pain
 Almost all are extreme
 Good clinicians practicing at extremes of the normal
curve
 Well intentioned clinicians practicing below standard
of care
 Clinicians practicing outside of medicine- Illegal
activities
Taxonomy of Pain
 “opium” is a Greek word meaning “juice,” or
the exudate from the poppy
 “opiate” is a drug extracted from the exudate
of the poppy (codeine, morphine)
 “opioid” is a natural semisynthetic (heroin) or
synthetic drug (all others) that binds to opioid
receptors producing agonist effects
Taxonomy of Pain












Acute/Chronic Pain
Tolerance
Dependence
Addiction/Pseudo-addiction
Pain Coping/Chemical Coping
Pharmacogenetics
Morphine equivalents/Opioid Conversions
Opioid Rotation
Opioid Induced Hyperalgesia (OIH)
End of Dose Failure (EODF)
Central/Peripheral Sensitization
Nociceptive/Neuropathic Pain
Tolerance
 decreasing pain relief with the same dosage
over time
 Not an impediment to long-term opioid use
 Experience with treating cancer pain has shown
that what initially appears to be tolerance is
usually progression of the disease.
Dependence
 WHO and DSM-IV-TR clinical guidelines for a
definite diagnosis of "dependence" require
stricter criteria
 Physical Dependence
 A physiological withdrawal state when drug use is
stopped or reduced, as evidenced by:
 the characteristic withdrawal syndrome for the
substance (opioids)
 chills, goose bumps, profuse sweating, increased pain,
irritability, anxiety, agitation, and diarrhea
 use of the same (or a closely related) substance with the
intention of relieving or avoiding withdrawal symptoms
Addiction
 A primary, chronic, neurobiological disease with genetic,
psychosocial, and environmental factors.
 Charicterized by one or more of the following:




Impaired control over drug use
Compulsive use
Continued use despite harm
Craving
 Physical dependence and tolerance are normal
physiological consequences of extended opioid therapy for
pain and should not be considered addiction.
Addiction vs. Analgesia
 Patients with addiction take increasing
amounts of abuseable drugs
 Function does not improve-usually worsens
 Patients with analgesia usually find a stable
(moderate) dose and Improved QOL
 Pain doesn’t completely abate
 balance of least pain/most function
 Function improves
Pseudo-addiction
 Due to insufficient analgesia




Under dosing/EODF
Non-opioid responsive pain
Tolerance
Opioid Induced Hyperalgesia (OIH)
 Looks like addiction




Irritability
Overutilization
Higher consumption of staff time
Requests for “what works for me”
Opioid-Induced Hyperalgesia
 Patients become “sensitized” to pain
 Allodynia
 Hyperalgesia
 Not a phenomenon exclusive to high
dose/intrathecal therapy
 Pain diminishes with opioid tapering
 May present as pseudo-addiction
General Perspective of Opioids
 Opioids seem to work
for some
 Opioids seem to be
ineffective for some
 Opioids seem to be
problematic for some
 It may be difficult to
know who is in which
group
Consequences of Opioid Therapy
Did You Know? CDC Report
 Nearly 7 million Americans are abusing prescription drugs
 More than the number who are abusing cocaine, heroin,
hallucinogens, Ecstasy, and inhalants Combined!
 Methadone deaths increased 7X
 Opioid Deaths
 2x cocaine
 5X heroin
 8O % increase in just 6 years
 Centers for Disease Control and Prevention, National Center for Injury Prevention and
Control. CDC’s Issue Brief: Unintentional Drug Poisoning in the United States.
http://www.cdc.gov/HomeandRecreationalSafety/Poisoning/brief.htm. 2010
Methadone: Good, Bad, and Ugly




Unique analgesic properties (NMDA)
Low euphoria index
Cheap
long t1/2
 QTc Prolongation
 According to CDC
 2% of all opioids prescribed for pain in US
 30% of opioid OD deaths in US
Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control. CDC’s Issue Brief: Unintentional Drug
Poisoning in the United States.
http://www.cdc.gov/HomeandRecreationalSafety/Poisoning/brief.htm
. 2010
Alarming Rise in Teen Use
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
CDC’s Issue Brief: Unintentional Drug Poisoning in the United States.
http://www.cdc.gov/HomeandRecreationalSafety/Poisoning/brief.htm. 2010
 OPIOIDS
 Formulations
 Short Acting
 Intermediate
 Long Acting
 Route
 PO
 IV/IM
 Transdermal/Buccal/Sublingual
 Neuraxial
 Intranasal
Efficacy of Opioids
Summary of evidence:
 Many trials found opioids moderately effective for pain relief and
slightly to moderately effective for functional outcomes
compared to placebo in patients with chronic noncancer pain.

almost all data are on short-term (≤12 weeks) outcomes (level of
evidence: high).
 About half of patients discontinue opioids in long-term

primarily observational studies (level of evidence: moderate).
 Compared to antidepressants or non-steroidal anti-inflammatory
drugs, one systematic review found oxycodone and morphine
slightly more effective for pain relief in two trials, but found no
differences between propoxyphene, codeine, or tramadol and
the non-opioids

(6 trials) (level of evidence: moderate).
 APS-AAPM Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
 www.AmericanPainSociety.org
Complexities of Opioid Therapy








Variable response
Multiple formulations/doses
Drug-drug interactions
Extensive documentation
Regulatory concerns, fears (rational?)
Side effects
OIH (hyperalgesia)
Abuse, misuse, diversion
2013 FSMB Model Policy
 The revised Model Policy makes it clear that the state
medical board will consider inappropriate management of
pain, particularly chronic pain, to be a departure from
accepted best clinical practices, including, but not limited
to the following:






Inadequate attention to initial assessment to determine if
opioids are clinically indicated and to determine risks associated
with their use in a particular individual with pain
Inadequate monitoring during the use of potentially abusable
medications
Inadequate attention to patient education and informed consent
Unjustified dose escalation without adequate attention to risks or
alternative treatments
Excessive reliance on opioids, particularly high dose opioids for
chronic pain management
Not making use of available tools for risk mitigations
Patient Selection!!!!!!!
 Medical Necessity
 Risk factors for abuse
 Co-morbidity
 Failure of conservative alternatives
 Informed consent/education
 Primary endpoint
 Exit strategy
What tools should we use for screening?
 Thorough history
 Physical examination
 Communication with referring providers
 Lab/Imaging
 Communication with pharmacies
 PDMP
 Opioid agreement
 Questionnaires/Psych Assessment!!
 SOAPP-R, ORT, CAGE, COMM, DAST…
 Urine toxicology screens
 POC (IA),GC-MS, LC-MS
2013 FSMB Model Policy
 Patient Evaluation and Risk Stratification:
 Assessment of the patient’s personal and family
history of alcohol or drug abuse and relative risk for
medication misuse or abuse should be part of the
initial evaluation
 Ideally completed prior to a decision as to whether to
prescribe opioid analgesics
 Done through a careful clinical interview
 Treatment of a patient who has a history of substance
use disorder should, if possible, involve consultation with
an addiction specialist before opioid therapy is initiated
(and follow-up as needed)
 Also should inquire into any history of physical, emotional or
sexual abuse, because those are risk factors for substance
misuse
Screening Questionnaires
 Should be used with/without formal risk
assessment
 A Comparison of Various Risk Screening
Methods in Predicting Discharge From Opioid
Treatment. Clin J Pain Volume 28, Number 2,
February 2012
 Could not identify a “best ” screening tool
 Tailor to specific circumstance
 SOAPP-R “less susceptible to deception”
Screening Questionnaires
 BRI (Brief Risk Interview)
 DIRE (Diagnosis, Intractability, Risk, Efficacy
score)
 ORT (Opioid Risk Tool)
 COMM (Current Opioid Misuse Measure)
 PMQ (Pain Medication Questionnaire)
 Highly touted
 http://www.opioidrisk.com/node/507.
SOAPP-R
 Screener and Opioid Assessment for
Patients with Pain - Revised
 24-item patient-completed questionnaire
 revision of the SOAPP (Butler, Fernandez, Benoit, et.
al., 2008).
 Uses a five-point rating scale in asking questions
about such topics as:
 impulsivity, legal problems, past substance abuse and past
sexual abuse
 classifies patients in risk categories of Low and High risk
 while it refers to a Medium category in the SOAPP-R manual,
there has been no validation on the use of the Medium category
 One link to a copy is:

http://www.opioidrisk.com/node/610
Screening Questionnaires
 http://www.integration.samhsa.gov/clinical-
practice/screening-tools
 Drug/Alcohol Use
 Depression
 Bipolar Disorders
 Anxiety
 Suicide
 Trauma
Documentation- Initial Workup
 Required
 H&P- touch the patient!
 OSA, COPD, CHF!
 Diagnostic/Therapeutic/Lab results
 Treatment objectives/Endpoint
 Complete relief not likely
 Improved function/QOL
 Informed Consent/Agreement
 Women of child-bearing age/pregnant!




Planned Treatments/Meds (date, type, #,dose)
Instructions
UDS results
DIAGNOSIS
 Adapted from: Schneider J. Opioid Prescribing Part I: A Practical Guide to Appropriate
Documentation. Prac Pain Mgmt.2014;14(1):34-37
Documentation- Initial Workup
 Recommended Additional
Old Records- especially relevant to complaint
Pain Intensity Level- each visit
Level of Function/QOL- each visit
Pt. subjective complaints/Providers observations
Pt. explanation for any aberrant behaviors (early
refills, lost/stolen, multiple pharmacies, etc.)
 PDMP Results (mandatory in TN)
 Description of provider’s thought process when
making changes/reccs, ordering tests, interpreting
UDS results





 Adapted from: Schneider J. Opioid Prescribing Part I: A Practical
Guide to Appropriate Documentation. Prac Pain
Mgmt.2014;14(1):34-37
Documentation- Follow up
 “5 As” of Pain Medicine





Analgesia
Adverse reactions
Activity
Aberrant behavior
Affect
 Pill counts
 Physical Exam
 Review Terms
So, I think the patient has too many red flags…and they “just took their last dose yesterday”…Now
what?

A patient having been prescribed opioids by a previous provider is not, in and of itself,
a reason to continue opioids

Weaning opioids is not always indicated when they are to be discontinued



opioids are not present in UDS
drug diversion suspected (“lost or stolen”, doctor shopping, etc.)
When additional prescribing thought to constitute more risk to the patient or to
the community than the potential for withdrawal syndrome

Offer a treatment plan/referral which does not include or promise a prescription for a
controlled substance

Clonidine can be administered 0.1-0.2mg orally every 6 hours or with a
transdermal patch at 0.1mg/24hours.
 Hypotension and anticholinergic side effects may be encountered
http://www.samhsa.gov/treatment/
 Substance Abuse and Mental
Health Services Administration
 Hotlines
 Treatment Facility Locators
Opioid Rotation
Example:
A patient is receiving 200mg of oral morphine daily (chronic
dosing)
because of side effects a switch is made to oral
hydromorphone 25 - 35mg daily
This represents a 33 to 50 percent reduction in dose compared
to the calculated 50mg conversion dose produced via the
equianalgesic calculator.
This new regimen can then be titrated to effect
LOW AND SLOW!!!!
Incomplete Cross-Tolerance
 tolerance to a currently administered opiate that
does not extend completely to other opioids
 will tend to lower the required dose of the second opioid
 exists between all of the opioids and the estimated
difference between any two opiates could vary
widely
 inherent dangers of using an equianalgesic table and the
importance of viewing the tabulations /dosing tables as
estimates
 reducing the dose of the new opiate by 33 to 50 percent to
account for this incomplete cross-tolerance.
Morphine Equivalent Dose (MED)
 Equipotent dose of any opioid in terms of morphine


Only “Pain Specialist” may prescribe MED >200mg in TN
> 120mg MED must be seen by a physician in TN
 11 times more likely to die of overdose
 Used for opioid rotation
 No MED chart can adequately account for the patient-specific
responses
Adverse events from taking any opioid can be dose-independent and
may begin at low doses.
 Factors affecting variable responses:

 age, gender, genetic variability in drug metabolism, drug-drug
interactions, opioid tolerance and organ dysfunction such as renal and
hepatic impairment, adrenal insufficiency, hypothyroidism, and abnormal
levels of protein binding
Morphine Equivalents
Equianalgesic Dosing
 Use guides to equianalgesic dosing such as the
Philadelphia VA guidelines
 Not reliable for fentanyl and buprenorphine
PATCHES
 Methadone may present special concerns and
avoiding its use may be warranted if not familiar
with using methadone in chronic pain
 The VA has a special protocol for methadone
prescribing because of safety concerns
How useful is urine screening?
 Recommendation by FSMB
 POC immunoassay for illicit drugs and opioid class
 High “cut-off” values = less sensitive than confirmation
with GCM or LCM (mass spectrometry)
 Standard of Care?
 Confirmation necessary?
 Metabolite for timing of dose
 Class breakdown
 Be aware of false+/- (communicate with lab)
Urine Drug Screening
 Baseline
 Document Last dose
 expect neg if > 5 half-lives/PRN dosing
 Dipstick --- Confirm
 Follow-up
 Random?- double void technique
 Better off with random pill counts
 Every 6 months minimum
Neonatal Abstinence Syndrome
 Black Box Warning on CII opioids for women of
childbearing age
 Informed consent
 Taper before third trimester
 Mother may be tried for criminal negligence in some
states
 Immunity if enter into treatment program before birth (TN)
Rescue Treatment- Opioid Toxicity
 Naloxone
 Direct Mu receptor antagonist
 IV Naltrexone
 PO, Auto-injector, Atomizer Mist
 Beware of recrudescence!
Opioid Tapering
 Safe tapering may follow several general
paths (2 to 3 week tapering regimen should
be adequate in most cases)
 Reduce the each daily dose by 10%
 Reduce the dose by 20% every 3-5 days
 Reduce the dose by 25% per week
 Avoid reducing the daily dose by > 50% at any
given interval
Opioids in Renal Failure
Opioid
Comments for Patients With ESRD
Morphine
•
•
Oxycodone
•
•
Comments for Patients Requiring Dialysis
Active metabolites accumulate and can
•
contribute to adverse CNS effects; not
•
recommended
If necessary, dose reduction and careful
monitoring for adverse effects is imperative
Minor, but active and potent, metabolite
oxymorphone may accumulate
Dose reduction and careful monitoring for
adverse effects is recommended
•
•
Accumulation of active metabolites; not
recommended
Dialysis effective in removing both parent drug
and active metabolites, although CNS depressant
effect of morphine-6-glucuronide may persist
after dialysis
Variable reports of adverse effects in patients
requiring dialysis; use with extreme caution
Limited data; likely at least partially dialyzed
Fentanyl
No active metabolites; likely safe
No active metabolites; likely safe
Not likely to be removed by dialysis
Meperidine
•
Risk of adverse effects from accumulation
of neuroexcitatory metabolites; not
recommended
•
•
Active neuroexcitatory metabolites; not
recommended
Limited data; likely removed by dialysis
Methadone
•
•
No active metabolites; likely safe
As in patients without renal disease,
standard dosing precautions apply
No active metabolites, likely safe
Not dialyzed; because of long and variable half-life of
parent compound, caution indicated
Hydrocodone/ Hydromorphone
•
Hydrocodone is metabolized to
hydromorphone; the neuroexcitatory 3glucuronide metabolite may accumulate
Dose reduction and careful monitoring
recommended
Metabolites may accumulate but can be effectively
removed with dialysis; use caution and adjust dose as
necessary
One active metabolite, norbuprenorphine,
with minor analgesic activity and ceiling
effect for respiratory depression
Limited data; likely safe
•
•
•
Buprenorphine
•
•
Limited data; likely safe
Limited data; parent compound and metabolite
not likely to be dialyze
ANALGESICS
Management Modalities
Pharmacotherapy
NSAIDs
Steroids
Co-analgesics
Opioids
Anticonvulsants Antidepressants
Muscle
Relaxants
Others
ADJUVANT ANALGESICS
ANTIDEPRESSANTS
 Certain antidepressants
have analgesic properties
independent of their
effects on mood
 The onset of analgesic
effect is faster than the
onset of antidepressant
effect
 SNRIs appear superior
I think Descartes was onto something
ADJUVANT ANALGESICS
ANTICONVULSANTS
 “Membrane stabilizers”
 Preferable initial agent for neuropathic pain
 gabapentin, tegretol, topirimate, pregabalin
ADJUVANT ANALGESICS
OTHER
 Baclofen
 Tizanadine
 Nortriptyline
 Careful with off-label use (APN limitation)
ADJUVANT ANALGESICS
TOPICAL
Lidocaine (Patch)
NSAIDs (Gel / Patch/ Drops)
Capsaicin (Cream/Patch)
Compounded Agents (cream)
NON-PHARMACOLOGIC THERAPIES
 Self-Care
 TENS
 Acupuncture
 Psychotherapy
 Physiotherapy
 Nerve Blocks/Ablations
 Spinal Cord/Peripheral Field Stimulation
 Surgery
NON-PHARMACOLOGIC THERAPIES
TENS
NON-PHARMACOLOGIC THERAPIES
Psychotherapy
 Multiple psychological treatments may be
helpful and should be maximized




Stress management
Relaxation training
Hypnosis
Cognitive-behavioral therapy
 Biofeedback
 Coping
 Behavior modification
 Supportive psychotherapy
NON-PHARMACOLOGIC THERAPIES
Physiotherapy
 Commonly prescribed techniques
 Work hardening
 Exercise
 PT/OT
 Massage/Heat/US/Iontophoresis
 Spinal Manipulation
NON-PHARMACOLOGIC THERAPIES
Acupuncture
PAIN TREATMENT CONTINUUM
Diagnosis
Oral Medications
PT, Exercise, Rehabilitation
Behavioral Medicine
Corrective Surgery
Therapeutic Nerve Blocks
Oral Opiates
Implantable Pain Management Devices
Neurostimulation
Intrathecal Pumps
Neuroablation
Is the pain blockable?
WHO Analgesic Ladder
“Fourth Step?”
Interventional Techniques
 Interventional Techniques
Intraarticular /Bursa Injections




Major Joint
Sacroiliac Joint
Ischial/Trochanteric Bursa
Carpal Tunnel
Nerve Blocks




Ganglion
Plexus
Peripheral
Trigger Point/Botox
Spinal Procedures








Epidural Steroid/LA Injections
Facet Joint Block
Discography
Vertebro/Kyphoplasty
Epidural Adhesiolysis
Intradiscal therapies
Radiofrequency Neurolysis
Percutaneous Disc Decompression/Nucleoplasty
CASE 1
 20 y/o male track athlete with mechanical
LBP
Facet Joint Innervation
Sacroiliac Joint
Implantable Devices
 Spinal Cord Stimulator
 Peripheral “field “ Stimulator
 Intrathecal Pump
CONCLUSION
 Treatment Goals:
 Use multiple treatment modalities
 Increase function
 Reduce pain behaviors/disability behaviors
 Treatment without unacceptable side effects
 Total removal of pain may not be possible
 Know when and how to refer to a specialist
So, Dr. Kinard, if you’re so great then why did
the patient I referred to you call me on the
way home from your office visit asking me to
call in a refill for their pain medication?
 Non-compliance with our plan





Functional rehab
Psych assessment
Missed appointments
Inconsistent urine screens
Unacceptable/aberrant behavior
Ending the Physician-Patient Relationship

Appropriate steps to terminate the physician-patient relationship include:
1. Giving the patient or patient’s representative written notice, which may be by certified mail,
return receipt requested, or other reasonable proof. A copy of the letter should be included in the
medical record.
2. Providing the patient with a brief and valid reason for terminating the relationship.
3. Agreeing to continue to provide care for a reasonable period of time (at least 30 days) in order
to allow the patient to obtain care from another physician.
4. Providing recommendations to help the patient locate another physician of like specialty.
5. Offer to transfer records to the new physician upon signed authorization and include an
authorization form with the letter.
6. A physician assistant or nurse practitioner may not independently terminate the physicianpatient relationship.
 SWWW.MSBML.MS.GOV/POLICIES
Resources




FSMB.ORG
MSBML.MS.GOV
DEADIVERSION.USDOJ.GOV
SAMHSA.GOV/TREATMENT
 Substance Abuse and Mental Health Services Admn.
 THEACPA.ORG
 PAINMED.ORG
 American Academy of Pain Medicine
 Guidelines, forms, references, educational patient
resources
References
 Found as footnote in slide
 Stated in substance of slide