🎙️ PainExam Podcast Show Notes Kratom (Mitragyna speciosa): What Pain Physicians Must Know for the Boards

In this episode, Dr. David Rosenblum reviews the current science, pharmacology, risks, and clinical relevance of Kratom — an herbal substance widely discussed by pain patients and increasingly appearing on pain-medicine board exams. The discussion focuses on evidence-based mechanisms, safety considerations, and counseling points essential for ABA/ABPM/ABIPP/FIPP board preparation.

🔍 Key Board-Relevant Takeaways 1. Pharmacology & Mechanism

• Kratom's primary alkaloids are mitragynine and 7-hydroxymitragynine.

• They act as partial mu-opioid receptor agonists and demonstrate G-protein biased signaling, which may reduce β-arrestin–mediated respiratory depression seen with full opioids.

• No FDA-approved medical use; pharmacokinetics and dose-response remain inconsistent.

2. Reported Effects

Potential Benefits (mostly anecdotal or preclinical):

• Analgesia for chronic pain

• Mood elevation and increased energy

• Reduction of opioid withdrawal symptoms

Major Limitations:

• No high-quality randomized controlled trials

• Not a recommended analgesic for evidence-based pain practice

3. Adverse Effects & Safety Concerns

Commonly reported:

• Nausea, vomiting, constipation

• Tachycardia, palpitations

• Hepatotoxicity in some users

• Dependence and withdrawal syndrome similar to mild-moderate opioid withdrawal

Serious risks:

• Product variability and contamination

• Potential interactions with CNS depressants

• Unpredictable potency of alkaloids

4. Regulatory Status

• Kratom is unregulated, with significant variability in purity and composition.

• FDA and multiple public-health agencies caution against its use due to safety concerns.

• Not recommended as a first-line or adjunct pain therapy.

5. What Boards Like to Test

Expect questions on:

• Mechanism: partial MOR agonist, G-protein bias

• Differences from classical opioids

• Adverse effects and withdrawal

• Toxicology and contamination risks

• Counseling patients who self-medicate

• Lack of clinical trial data and regulatory approval

🎓 Board Prep Resources

Prepare for the ABA, ABPM, ABIPP, FIPP, and AOBPM exams with the PainExam Board Review and full curriculum at the NRAP Academy: 👉 https://www.NRAPpain.org

🫁 Hands-On Ultrasound Training for Pain Physicians

Boost your procedural skills with live ultrasound-guided interventional pain and regional anesthesia workshops: 👉 https://www.nrappain.org/pages/ultrasound-training

📚 References (Condensed)

• Kruegel AC, Grundmann O. Neuropharmacology of kratom alkaloids. Neuropharmacology.

• Eastlack SC et al. Kratom: Pharmacology & clinical implications. Phytother Res.

• Striley CW et al. Health effects of kratom. Front Pharmacol.

• FDA Public Health Advisory on Kratom.

Educational Offerings & Learning Opportunities

PainExam / NRAP Academy Training & Programs:

• Neuromodulation & Regional Anesthesia Workshops

• Ultrasound-Guided Pain Procedures

• Regenerative Pain Medicine Training

• Virtual Pain Fellowship

• Pain Management Board Review & Question Banks

Learn More / Register: 🔹 https://PainExam.com 🔹 https://NRAPpain.org

Board Prep & Certification Support

Prepare for:

• ABA Pain Boards

• ABPM

• ABIPP

• Pain Management Board Certification Exams

• (No reference to FIPP included, per request)

Access Board Prep Courses & Q-Banks: ➡️ https://PainExam.com ➡️ https://NRAPpain.org

Clinical Practice

AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com 📞 Brooklyn: 718-436-7246

About the Host – David Rosenblum, MD

Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine.

He has:

• Developed regional anesthesia training programs

• Published widely in pain medicine literature

• Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more

• Helped over 3000 physicians pass pain board exams

• Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts

Awards (Selected):

• New York Magazine Top Doctors: 2016–2025

• Top Doctors NY Metro Area: 2016–2025

• Schneps Media Honors: Multiple Years

Connect with Dr. Rosenblum

• LinkedIn: https://www.linkedin.com/in/davidrosenblummd/

• Instagram: https://www.instagram.com/painexam/

• Facebook: https://www.facebook.com/david.rosenblum.16

• X (Twitter): https://x.com/AlgoSonic

Episode Call-to-Action

✅ Join the NRAP Community ✅ Register for an Upcoming Workshop ✅ Access Pain Board Review Training

Start here → https://NRAPpain.org | https://PainExam.com

Caudal Epidural Steroid Injection with PRP

Case Reports and a Testimonial!

Upcoming Training Courses and Services

• Regional Anesthesia and IV Vascular Access Courses:
• New York and Detroit locations scheduled
• Pain Management Board Preparation

Private Coaching Services:

• Ultrasound guidance Preceptorship

• Board preparation coaching

• Contact available via email [email protected] for interested physicians

PRP Caudal Epidural Research Review

• Study Overview: Randomized double-blind controlled pilot study comparing leukocyte-rich PRP versus corticosteroids in caudal epidural space

• 50 patients randomly assigned to two groups

• Treatment options: triamcinolone 60mg or leukocyte-rich PRP from 60ml autologous blood

• Follow-up assessments at 1, 3, and 6 months using VAS and SF-36 surveys

• Key Findings:

• Both treatments showed significant pain reduction compared to baseline

• Steroid group had lower VAS scores at one month

• PRP group demonstrated superior results at 3 and 6 months

• PRP group showed significant improvement across all SF-36 domains at 6 months

• No complications or adverse effects in either group during 6-month follow-up

Personal Treatment Experience

• Dr. Rosenblum received transforaminal PRP injection 9-10 weeks ago

• Gradual improvement noted from weeks 4-8, with more noticeable benefits from weeks 8-10

• Current status: minimal pain (0.5/10) only during weather changes

Clinical Practice Philosophy

• Treatment Approach: Minimalist philosophy focusing on turmeric, PRP, and Pilates

• Medication Strategy: Low-dose naltrexone as go-to medication, avoiding long-term drugs with side effects

• Surgical Avoidance: Prioritizing conservative treatments over unnecessary surgical interventions

Emergency Department PRP Implementation

• Case Study Results: Ultrasound-guided caudal epidural steroid injection in ER setting

• 100% pain resolution achieved

• Patient discharged directly from ER

• Cost savings: reduced from $33,000 to $4,800 (approximately $28,000 savings)

• Training Opportunities: Private training sessions available for ER physicians interested in ultrasound-guided procedures

Patient Testimonial Highlights

• Case Background: Nurse with herniated disc from March, previously considering $30,000 surgery

• Treatment Outcome: PRP injection completed two months ago with nearly complete pain relief

• Reduced from multiple pain medications to one Advil daily

• Eliminated antalgic posture and muscle spasms

• Returned to full 12-hour hospital shifts without difficulty

• Overall quality of life restored to normal levels

David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.

Awards

New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025

Schneps Media: 2015, 2016, 2017, 2019, 2020

Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025

Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023

Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!

Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.

Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.

He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call

Brooklyn 718 436 7246

Reference

Irvan J. Bubic, Jessica Oswald, Ultrasound-Guided Caudal Epidural Steroid Injection for Back Pain: A Case Report of Successful Emergency Department Management of Radicular Low Back Pain Symptoms, The Journal of Emergency Medicine,Volume 61, Issue 3,2021,Pages 293-297,ISSN 0736-4679

Ruiz‐Lopez, Ricardo, and Yu‐Chuan Tsai. "A randomized double‐blind controlled pilot study comparing leucocyte‐rich platelet‐rich plasma and corticosteroid in caudal epidural injection for complex chronic degenerative spinal pain." Pain Practice 20.6 (2020): 639-646.

#prppain #paincme #sciatia #ultrasoundmsk #ultrasoundprp #epidural #nypaindoctor #prppainwindsor

Episode Overview

In this episode, Dr. David Rosenblum discusses the role of supplements and complementary strategies in the management of chronic pain. Drawing from clinical practice at AABP Integrative Pain Care, as well as his teaching and training programs, Dr. Rosenblum reviews how nutraceuticals, regenerative therapies, ultrasound-guided procedures, and neuromodulation can work together to improve patient outcomes and reduce opioid reliance.

This episode also highlights educational opportunities and exam-prep resources for pain fellows, residents, anesthesiologists, physiatrists, and APPs looking to expand their interventional pain, ultrasound, and regenerative medicine skill sets.

Key Topics Discussed

• Evidence and clinical rationale for select supplements in chronic pain management

• The role of ultrasound guidance in improving accuracy and safety in interventional pain procedures

• How regenerative medicine techniques such as PRP and BMAC are shaping personalized pain care

• Practical considerations when combining supplements with neuromodulation, RFA, or injections

• Patient case applications and real-world treatment planning

Educational Offerings & Learning Opportunities

PainExam / NRAP Academy Training & Programs:

• Neuromodulation & Regional Anesthesia Workshops

• Ultrasound-Guided Pain Procedures

• Regenerative Pain Medicine Training

• Virtual Pain Fellowship

• Pain Management Board Review & Question Banks

Learn More / Register:

www.AABPpain.com 🔹 https://PainExam.com 🔹 https://NRAPpain.org

Board Prep & Certification Support

Prepare for:

• ABA Pain Boards

• ABPM

• ABIPP

• Pain Management Board Certification Exams

• (No reference to FIPP included, per request)

Access Board Prep Courses & Q-Banks: ➡️ https://PainExam.com ➡️ https://NRAPpain.org

Clinical Practice

AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com 📞 Brooklyn: 718-436-7246

About the Host – David Rosenblum, MD

Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine.

He has:

• Developed regional anesthesia training programs

• Published widely in pain medicine literature

• Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more

• Helped over 3000 physicians pass pain board exams

• Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts

Awards (Selected):

• New York Magazine Top Doctors: 2016–2025

• Top Doctors NY Metro Area: 2016–2025

• Schneps Media Honors: Multiple Years

Connect with Dr. Rosenblum

• LinkedIn: https://www.linkedin.com/in/davidrosenblummd/

• Instagram: https://www.instagram.com/painexam/

• X (Twitter): https://x.com/AlgoSonic

Practical Takeaways

• Evidence strength varies widely; preclinical support is more robust than human RCT data for most supplements.

• Potentially reasonable adjuncts in select contexts

• Vitamin D: plausible benefit in deficiency states, including diabetic neuropathy and chronic pain-related quality-of-life factors; confirm deficiency and monitor.

• Magnesium: consider IV regimens for refractory neuropathic components (e.g., cancer pain, PHN); oral efficacy uncertain.

• Curcumin: consider as adjunct, especially formulated phytosome combinations; monitor for additive effects and tolerability.

• B vitamins: consider B12 in deficiency or neuropathy with suspected demyelination; overall human evidence limited.

• Zinc: mechanistic rationale with preclinical support; limited human data—consider deficiency correction rather than supraphysiologic dosing.

• Cautions and contraindications

• St. John's wort: significant drug–drug interaction potential via CYP/P-gp induction.

• Alpha lipoic acid: may cause hypoglycemia; monitor glucose, especially in diabetes.

• Agent-specific toxicity thresholds should guide safe upper limits; prioritize lab-confirmed deficiencies.

Risks, Limitations, and Research Gaps

• Heterogeneity in study designs, small samples, lack of controls, and multi-ingredient formulations limit causal inference.

• Need for large, well-designed RCTs stratified by neuropathic pain etiology (e.g., CIPN vs. DPN vs. PHN) with standardized outcomes.

• Translational gap between animal models and human clinical efficacy remains significant.

References

Frediani, Jennifer K., et al. "The role of diet and non‐pharmacologic supplements in the treatment of chronic neuropathic pain: A systematic review." Pain Practice 24.1 (2024): 186-210.

Huang, Wei MD, PhD*,†; Shah, Shivani DO†; Long, Qi PhD‡; Crankshaw, Alicia K. MD†; Tangpricha, Vin MD, PhD§,∥. Improvement of Pain, Sleep, and Quality of Life in Chronic Pain Patients With Vitamin D Supplementation. The Clinical Journal of Pain 29(4):p 341-347, April 2013. | DOI: 10.1097/AJP.0b013e318255655d

Haddad, H.W., Mallepalli, N.R., Scheinuk, J.E. et al. The Role of Nutrient Supplementation in the Management of Chronic Pain in Fibromyalgia: A Narrative Review. Pain Ther 10, 827–848 (2021). https://doi.org/10.1007/s40122-021-00266-9

Abdelrahman, K.M.; Hackshaw, K.V. Nutritional Supplements for the Treatment of Neuropathic Pain. Biomedicines 2021, 9, 674. https://doi.org/10.3390/biomedicines9060674

Pain Exam Podcast Recent Conference Activities

• London Conference Weekend: Successfully attended and spoke at ISPN and SOMOS care conferences
• Somos Care Conference: Delivered presentation on pain management for primary care physicians
• Presentation consisted of 50+ slides with only one slide dedicated to opiates
• Emphasized shift away from opiate-based treatments in interventional pain management
• Recommended primary care physicians refer patients to pain specialists for comprehensive treatment options
• ISPN Conference: Participated in international pain management conference
• Met with doctors from London, Iraq, and various other countries
• Observed different international approaches to pain treatment including increased phenol use and varying regenerative medicine restrictions

Upcoming Events and Workshops

• New York-New Jersey Pain Conference: November (NRAP Academy booth presence)
• IV Ultrasound Placement Workshops: Monthly sessions in New York
• Regional Anesthesia and Ultrasound-Guided Interventional Pain Medicine Workshops:
• New York: December 13th, January 10th
• Florida (Fort Lauderdale/Hollywood): November 8th
• Detroit: January 18th, February 15th
• Alternative Options: Online ultrasound courses and shadowing opportunities available
  • Board Prep and NRAP Community at PainExam.com or NRAPpain.org
  • ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship

  Educational Offerings and Events

  • Training and Courses:

Research Review: ACL Treatment Study

• Study Focus: Non-surgical treatment of ACL tears using bone marrow concentrate (BMAC) and platelet products versus exercise therapy
• Key Findings:
• BMAC group showed significantly greater improvement in Lower Extremity Function Scale (LEFS) and Single Assessment Numeric Evaluation (SANE) scores at three months
• Sustained improvement in function and decreased pain maintained through two-year follow-up
• Patients reported median subjective improvement of 90% at final follow-up
• No significant improvements observed in exercise-only group during initial three months
• Treatment Protocol:
• Bone marrow harvest from posterior superior iliac crest (60-90ml from 6-8 sites)
• PRP preparation from 60ml whole blood
• Fluoroscopy-guided injection directly into ACL ligament
• Comprehensive 52-week rehabilitation protocol with activity restrictions

Clinical Practice Implications

• Current ACL Treatment Landscape: Over 400,000 ACL reconstruction surgeries performed annually in the US
• Surgical Limitations: Risk of graft failure, persistent instability, cartilage injury, and increased arthritis risk
• Return to Sport Statistics: Post-surgical rates vary significantly (33-92% return to sport, 65% return to pre-injury level)
• Practice Integration Considerations: Potential incorporation of BMAC/PRP protocols for ACL tears, though insurance coverage remains limited

David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.

Awards

New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025

Schneps Media: 2015, 2016, 2017, 2019, 2020

Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025

Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023

Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!

Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.

Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.

He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call

Brooklyn 718 436 7246

References

Centeno CJ, Berger DR, Pitts J, Markle J, Pelle AJ, Murphy M, Dodson E. Non-surgical treatment of anterior cruciate ligament tears with percutaneous bone marrow concentrate and platelet products versus exercise therapy: a randomized-controlled, crossover trial with 2-year follow-up. BMC Musculoskelet Disord. 2025 Sep 30;26(1):882. doi: 10.1186/s12891-025-09153-2. PMID: 41029301; PMCID: PMC12486544.

#pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp #aabppain

Project Sync / Status Update Summary Podcast Episode Overview

• The host discussed Transcutaneous Electrical Nerve Stimulation (TENS) as a recurring pain board topic and reviewed mechanisms, efficacy, and clinical considerations.

• Emphasis that TENS appears on pain boards annually and is a foundational topic from early podcast episodes.

• Board Prep and NRAP Community at PainExam.com or NRAPpain.org
• ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship

Educational Offerings and Events

• Training and Courses:

• Monthly ultrasound courses in New York and upcoming courses in Detroit covering ultrasound-guided regional anesthesia and chronic pain.

• Ultrasound Guided Acute and Chronic Pain course in November near Hollywood/Fort Lauderdale with venue pending confirmation.

• Multiple instructors to offer diverse perspectives; registration via the CME calendar at nrappain.org.

• Conferences and Teaching:

• New York–New Jersey Pain Conference in November (hosted by Soudir Duwan).

• ISPN conference in London next week, with ultrasound teaching participation by the host.

• Community and Coaching:

• Private coaching and shadowing opportunities available; contact via newsletter replies.

• Access to the NRAP community forum upon signup at nrappain.org for discussions on neuromodulation, regional anesthesia, and pain.

TENS: Mechanisms and Parameters

• Device and Parameters:

• TENS delivers adjustable pulse frequency and intensity; configurations include low (50–100+ Hz), and mixed frequencies.

• Mechanisms of Analgesia:

• Activation of large-diameter, non-noxious A-beta afferent fibers in the periphery, driving descending inhibitory pathways and reducing hyperalgesia.

• Board-relevant point: selective activation of A-beta fibers is frequently tested.

• Central effects:

• Reduces central excitability and nociceptive dorsal horn neuron activity in uninjured and injured models.

• Frequency-dependent opioid receptor mediation:

• High-frequency analgesia blocked by delta receptor antagonists.

• Low-frequency analgesia blocked by mu receptor antagonists (spinal cord and rostral ventral medulla).

• Additional receptor involvement: muscarinic M1/M3, GABA-A, and cannabinoid (CB1) receptors; blockade reduces or prevents TENS analgesia depending on frequency.

• Peripheral effects:

• High-frequency TENS reduces injury-related increases in substance P in DRG neurons.

• Blockade of peripheral opioid and CB1 receptors can prevent analgesia from both low- and high-frequency TENS.

• Clinical dosing considerations:

• Adequate dosing (timing, frequency of use, intensity achieving strong but non-painful paresthesia) influences efficacy.

• Analgesia has rapid onset/offset and may require repeated administration throughout the day for sustained relief.

Evidence and Efficacy Summary

• Clinical experience suggests potential adjunctive benefit for acute pain, but systematic reviews are conflicting; more rigorous studies are needed.

• For board preparation, the critical takeaway is A-beta fiber activation.

Key Takeaways for Board Prep

• TENS targets large-diameter non-noxious A-beta afferents to reduce nociceptive signaling.

• High-frequency TENS: analgesia mediated via delta opioid receptors; blocked by delta antagonists.

• Low-frequency TENS: analgesia mediated via mu opioid receptors; blocked by mu antagonists in spinal cord and RVM.

• Additional receptor systems influencing TENS efficacy include muscarinic (M1/M3), GABA-A, and CB1.

Action Items Review TENS mechanisms with emphasis on A-beta fiber activation for board prep. Verify and publish final venue details for the November Florida ultrasound course. Share registration links and schedules for Detroit and New York ultrasound and chronic pain courses via CME calendar. Prepare teaching materials for ISPN London ultrasound sessions next week. Update board prep resources on painexam.com and nrappain.org with current TENS evidence and dosing guidance. Promote NRAP community forum access and private coaching/shadowing opportunities through the newsletter.

David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.

Patients can go to www.AABPpain.com or call 718 436 7246

Awards

New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025

Schneps Media: 2015, 2016, 2017, 2019, 2020

Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025

Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023

References

Johnson M. Transcutaneous Electrical Nerve Stimulation: Mechanisms, Clinical Application and Evidence. Rev Pain. 2007 Aug;1(1):7-11. doi: 10.1177/204946370700100103. PMID: 26526976; PMCID: PMC4589923.

Vance, C.G.T.; Dailey, D.L.; Chimenti, R.L.; Van Gorp, B.J.; Crofford, L.J.; Sluka, K.A. Using TENS for Pain Control: Update on the State of the Evidence. Medicina 2022, 58, 1332. https://doi.org/10.3390/medicina58101332

#painnyc #painbrooklyn #prpbrooklyn #prpspine #regionalanesthsia #pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp

Exploring the Efficacy of BMAC and ADSC Injections in Knee Osteoarthritis

Hosts: David Rosenblum,MD

Overview: In this episode, we delve into a recent study published in the Indian Journal of Orthopaedics that compares the therapeutic efficacy of Bone Marrow Aspirate Concentrate (BMAC) and Adipose-Derived Stem Cells (ADSCs) for treating knee osteoarthritis (OA). The study aims to provide insights into the effectiveness of these regenerative treatments and their correlation with mesenchymal stem cell (MSC) cellularity.

Key Points Discussed:

1. Background on Osteoarthritis:

   • Definition and impact of OA, particularly in older populations.
   • Overview of traditional treatments and the shift towards regenerative medicine.

2. Study Objectives:

   • To compare the efficacy of BMAC and ADSC injections in symptomatic knee OA patients.
   • To analyze MSC quantity and quality in harvested tissues from both sources.

3. Methodology:

   • Description of the study design involving 60 patients with knee OA.
   • Details on patient demographics, injection protocols, and follow-up assessments (VAS, WOMAC, ROM).

4. Results:

   • Significant improvements in clinical scores for both BMAC and ADSC groups at 6 months.
   • Discussion on the lack of significant correlation between MSC quantity and treatment efficacy.
   • Insights into the success rates of MSC cultures from both bone marrow and adipose tissue.

5. Conclusions:

   • Both treatments demonstrated clinical improvements, with no substantial differences between them.
   • BMAC showed higher MSC counts and faster recovery rates, but further research is needed to understand the underlying factors affecting efficacy.

6. Implications for Clinical Practice:

   • Considerations for clinicians when choosing between BMAC and ADSC treatments.
   • Future directions for research in regenerative therapies for knee OA.

References:

• Vitali, M., Ometti, M., Montalbano, F., et al. (2025). Bone Marrow Aspirate Concentrate (BMAC) Versus Adipose-Derived Stem Cells (ADSCs) Intra-articular Injection Therapeutic Efficacy in Knee OA Correlated to Their Mesenchymal Stem Cell (MSC) Cellularity: An Exploratory Comparative Pilot Study. Indian Journal of Orthopaedics. https://doi.org/10.1007/s43465-025-01525-z

Listener Engagement:

• Join the conversation! Share your thoughts on BMAC and ADSC treatments for knee OA on social media using #JournalClubPodcast.
• Don't forget to subscribe for more discussions on the latest research in orthopaedics and regenerative medicine.

Podcast Summary

This episode of the Pain Exam Podcast, hosted by Dr. David Rosenblum, discusses an interesting article about Ketorolac injections for musculoskeletal conditions. The podcast covers:

• Ketorolac is an NSAID that provides analgesic and anti-inflammatory effects through inhibition of prostaglandin synthesis

• Multiple studies comparing Ketorolac injections to corticosteroids and hyaluronic acid for various conditions

• Research shows Ketorolac injections are equally effective as corticosteroids for subacromial conditions, adhesive capsulitis, carpal-metacarpal joint issues, and hip/knee osteoarthritis

• Ketorolac may be a safer alternative to steroids for certain patients, though it has its own contraindications for those with renal, gastrointestinal, or cardiovascular disease

• Dr. Rosenblum considers the potential of using Ketorolac injections directly at pain sites rather than intramuscularly

Upcoming Courses and Conferences

• Ultrasound courses in New York and Costa Rica (check unwrappedpain.org)

• Private ultrasound sessions available

• Dr. Rosenblum will be speaking at Pain Week about ultrasound in pain practice and PRP

• Presenting at a primary care conference in London

• Teaching ultrasound at ISPN

• LAPS conference in Chile (Dr. Rosenblum won't attend this year)

• Ketorolac Injections: An Effective Alternative for Musculoskeletal Pain Management

  Musculoskeletal conditions such as bursitis, adhesive capsulitis, and osteoarthritis affect millions and often require injectable therapies to reduce pain and inflammation. Traditionally, corticosteroid injections have been the mainstay treatment. However, concerns over side effects like tendon rupture, cartilage damage, and systemic hyperglycemia have prompted exploration of alternatives. A recent narrative review by Kiel et al. (2024) highlights ketorolac—a parenteral nonsteroidal anti-inflammatory drug (NSAID)—as a promising substitute for corticosteroids in musculoskeletal injections.

  Warning: OFF Label use of Ketorolac discussed. Please consult your physician.

  See full article for details.

  Subacromial Ketorolac Injections for Shoulder Pain

  Subacromial bursitis and impingement syndrome are common causes of shoulder pain and disability. Several randomized controlled trials have shown that subacromial ketorolac injections provide pain relief and functional improvement comparable to corticosteroids:

  • Goyal et al. demonstrated significant reductions in pain scores after subacromial injection of 60 mg ketorolac versus 40 mg methylprednisolone, with no difference in outcomes between groups.
  • Taheri et al. found similar short-term pain relief at 1 and 3 months with either ketorolac or corticosteroid subacromial injections.
  • Kim et al. reported equivalent clinical improvement in rotator cuff syndrome patients receiving ketorolac or triamcinolone injections.
  • Min et al. noted ketorolac led to better forward flexion and patient satisfaction at 4 weeks compared to corticosteroids.

  These studies support ketorolac as an effective agent for subacromial injection, offering an alternative for patients where corticosteroid use is limited.

  Intra-articular Ketorolac Injections for Adhesive Capsulitis and Osteoarthritis

  Adhesive capsulitis (frozen shoulder) and osteoarthritis of the hip, knee, and carpometacarpal joint are often treated with intra-articular corticosteroids. Ketorolac injections have shown comparable efficacy in these conditions:

  • Akhtar et al. found intra-articular ketorolac significantly reduced shoulder pain at 4 weeks in adhesive capsulitis compared to hyaluronic acid.
  • Ahn et al. reported similar pain relief between intra-articular ketorolac and corticosteroid injections in adhesive capsulitis, with ketorolac providing superior shoulder mobility at 3 and 6 months.
  • Koh et al. showed that adding ketorolac to hyaluronic acid injections in carpometacarpal osteoarthritis resulted in faster onset of pain relief compared to hyaluronic acid alone.
  • Park et al. observed equivalent functional improvements with intra-articular ketorolac or corticosteroids in hip osteoarthritis.
  • Jurgensmeier et al. demonstrated similar symptom improvement at 1 and 3 months post-injection for ketorolac and triamcinolone in hip and knee osteoarthritis.
  • Xu et al. and Bellamy et al. confirmed ketorolac's comparable pain relief and functional benefits to corticosteroids for knee osteoarthritis, with ketorolac being more cost-effective.
  • Lee et al. noted quicker pain reduction with intra-articular ketorolac combined with hyaluronic acid versus hyaluronic acid alone in knee osteoarthritis.
  aSafety and Pharmacologic Considerations

  Ketorolac's anti-inflammatory action stems from cyclooxygenase inhibition, reducing prostaglandin synthesis. Its half-life is approximately 5.2–5.6 hours, and it is metabolized in the liver. Unlike corticosteroids, ketorolac avoids systemic hyperglycemia and cartilage damage risks. Animal and in vitro studies suggest ketorolac may protect cartilage by inhibiting inflammatory cytokines.

  While gastrointestinal, renal, and cardiovascular risks associated with NSAIDs remain considerations, localized intra-articular and subacromial ketorolac injections may limit systemic exposure and adverse effects. Mild, transient post-injection pain has been reported but resolves without intervention.

  Conclusion

  Ketorolac injections, administered intra-articularly or subacromially, are a safe, effective, and economical alternative to corticosteroids for managing common musculoskeletal conditions. Their comparable efficacy in reducing pain and improving function, combined with a more favorable side effect profile, makes ketorolac an appealing option for clinicians and patients alike. Further research is warranted to fully elucidate long-term safety and optimal dosing strategies.

  FAQS

  Ketorolac Injections for Musculoskeletal Conditions: Frequently Asked Questions

  Musculoskeletal pain from conditions like bursitis, adhesive capsulitis, and osteoarthritis often requires injectable treatments. Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is emerging as a promising alternative to corticosteroids. Below are common questions and answers based on a recent narrative review by Kiel et al. (2024).

  1. What is ketorolac and how does it work?

  Ketorolac is a parenteral NSAID that reduces pain and inflammation by inhibiting cyclooxygenase enzymes, which decreases prostaglandin synthesis. It can be administered orally, intramuscularly, intravenously, or by injection directly into joints or around bursae.

  2. How effective is ketorolac for musculoskeletal conditions?

  Studies show ketorolac injections provide significant pain relief and functional improvement comparable to corticosteroids in conditions like:

  • Subacromial bursitis and shoulder impingement (subacromial injections)
  • Adhesive capsulitis (frozen shoulder) (intra-articular injections)
  • Osteoarthritis of the hip, knee, and thumb carpometacarpal joint (intra-articular injections)
  3. What evidence supports subacromial ketorolac injections?

  Randomized controlled trials found:

  • Goyal et al. and Taheri et al. reported similar pain reduction and functional outcomes between ketorolac and corticosteroids for subacromial injections.
  • Kim et al. and Min et al. observed comparable or better patient satisfaction and shoulder mobility with ketorolac versus corticosteroids.
  4. How does intra-articular ketorolac compare to corticosteroids for adhesive capsulitis?
  • Akhtar et al. showed ketorolac reduced shoulder pain more than hyaluronic acid.
  • Ahn et al. found ketorolac and corticosteroids equally effective for pain relief, with ketorolac providing better shoulder mobility at 3 and 6 months.
  5. What about ketorolac for osteoarthritis?
  • Ketorolac combined with hyaluronic acid provided faster pain relief than hyaluronic acid alone in thumb carpometacarpal joint osteoarthritis (Koh et al.).
  • Intra-articular ketorolac had similar efficacy to corticosteroids in hip (Park et al., Jurgensmeier et al.) and knee osteoarthritis (Bellamy et al., Xu et al.).
  • Ketorolac injections were more cost-effective compared to corticosteroids (Bellamy et al.).
  6. Are ketorolac injections safe?

  Ketorolac's side effects are similar to other NSAIDs, mainly involving gastrointestinal, renal, and cardiovascular risks. However, localized intra-articular and subacromial injections may reduce systemic exposure. Animal studies suggest ketorolac does not harm cartilage and may protect against inflammatory damage. Mild, transient local pain post-injection is possible but usually resolves without treatment.

  7. What are the limitations of ketorolac use?

  Ketorolac is not suitable for patients with:

  • Renal impairment
  • Gastrointestinal ulcers or bleeding risk
  • Cardiovascular disease or hypertension
  • NSAID hypersensitivity, especially in asthma or chronic urticaria patients

  Clinicians should assess individual risks before choosing ketorolac injections.

  8. How does ketorolac's pharmacokinetics affect its use?

  Ketorolac has a plasma half-life of about 5.2 to 5.6 hours and is metabolized in the liver. Pharmacokinetics for subcutaneous or intra-articular administration are less defined but systemic absorption occurs. Its relatively short half-life supports repeated dosing if needed.

  9. Why consider ketorolac over corticosteroids?

  Ketorolac avoids corticosteroid-associated risks such as tendon rupture, cartilage damage, and steroid-induced hyperglycemia. It is also more cost-effective, making it a favorable option for patients and healthcare systems.

  10. What further research is needed?

  More large-scale, long-term studies are needed to fully understand ketorolac's intra-articular effects, optimal dosing, and safety profile compared to corticosteroids and other treatments.

  Summary: Ketorolac injections, whether intra-articular or subacromial, offer a safe, effective, and economical alternative to corticosteroids for managing various musculoskeletal conditions. This makes ketorolac an important option in pain management and inflammation control.

  Reference:

  Kiel J, Applewhite AI, Bertasi TGO, Bertasi RAO, Seemann LL, Costa LMC, Helmi H, Pujalte GGA. Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review. Clinical Medicine & Research. 2024;22(1):19-27. DOI: https://doi.org/10.3121/cmr.2024.1847

  Disclaimer: This Podcast, website and any content from NRAP Academy (PMRexam.com) otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.

Summary

In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures.

Chapters Introduction to the Pain Exam Podcast and Topic Overview

Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease.

Upcoming Conferences and Educational Opportunities

Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities.

Overview of Postherpetic Neuralgia

Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life.

Treatment Options Overview

Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics.

Phases of Herpes Zoster and Definitions

Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash.

Incidence and Risk Factors

Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia.

Impact on Quality of Life

Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia.

Literature Review and Pathophysiology

Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia.

Central Sensitization and Nerve Damage

Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome.

Different Phenotypes and Classification

Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration.

Deafferentation Phenotype

Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial.

Diagnosis and Physical Examination

Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients.

Sensory Testing and Assessment

Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons.

Prevention Through Vaccination

Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions.

Treatment Objectives

Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation.

Antiviral Medications

Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised.

Benefits of Antiviral Therapy

Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible.

Corticosteroids and Opioids

Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction.

Methadone and Antidepressants

Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction.

Antiepileptics and Pharmacological Treatment Summary

Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011.

Topical Agents

Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group.

Intracutaneous Injections

Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study.

Summary of Local Anesthetics

Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy.

Interventional Treatments: Epidural and Paravertebral Injections

Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster.

Comparative Studies on Injection Approaches

Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster.

Timing of Interventions and Continuous Epidural Blockade

Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality.

Interventions for Postherpetic Neuralgia

Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence.

Summary of Epidural and Paravertebral Injections

Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy.

Pulsed Radiofrequency (PRF) Evidence

Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy.

PRF Studies for Acute Herpes Zoster

Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group.

PRF for Trigeminal Neuralgia

Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group.

PRF Compared to Other Interventions

Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate.

Summary of PRF and Final Recommendations

Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature.

Sympathetic Blocks and Conclusion

Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia.

Personal Clinical Approach and Closing

Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast.

Q&A

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Highlights

David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.

Awards

New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025

Schneps Media: 2015, 2016, 2017, 2019, 2020

Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025

Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023

Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!

Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.

Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.

He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call

Brooklyn 718 436 7246

Reference

Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary

In this Pain Exam Podcast episode, Dr. David Rosenblum discusses a journal club article on low volume neurolytic retrocrural celiac plexus blocks for visceral cancer pain. The study reviewed 507 patients with severe malignancy-related abdominal pain, with data retained for 455 patients at the 5-month mark. Dr. Rosenblum explains that the procedure involves injecting 3-5ml of 6% aqueous phenol at the T12-L1 level under fluoroscopic guidance, with an average procedure time of 16.3 minutes. The study found significant pain relief lasting up to six months, reduced opioid consumption, and improved quality of life for patients with primary abdominal cancer or metastatic disease. Dr. Rosenblum shares his personal experience with celiac plexus blocks, including the trans-aortic approach he trained on, and mentions his interest in ultrasound-guided approaches. He also announces upcoming teaching engagements at ASPN, Pain Week, and other conferences, as well as CME ultrasound courses available through nrappain.org. Additionally, he mentions a new community page on the website where users can share board preparation information, though he emphasizes that remembered board questions should not be posted as he is a board question writer himself.

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Highlights Introduction and Upcoming Events

Dr. David Rosenblum introduces the Pain Exam Podcast and shares information about upcoming events. He mentions teaching ultrasound at ASPN in July, attending Pain Week in September, and participating in the Latin American Pain Society conference. Dr. Rosenblum also promotes his CME ultrasound courses available at nrappain.org and mentions he's considering organizing another regenerative medicine course in fall or winter. He offers private training for those wanting more intensive ultrasound instruction.

Board Prep Community Announcement

Dr. Rosenblum announces a new community page on the nrappain.org website for board preparation. He explains that registered users can access free information and keywords relevant to board exams. He emphasizes that users should not post remembered questions as this would be inappropriate, noting that he himself is a board question writer for various pain boards. Dr. Rosenblum mentions that a post about phenol in this community inspired today's podcast topic.

Journal Article Overview on Celiac Plexus Block

Dr. Rosenblum introduces a journal article on low volume neurolytic retrocrural celiac plexus block for visceral cancer pain, a retrospective review of 507 patients with severe malignancy-related abdominal pain. He explains that the study assessed pain relief provided by this procedure, its duration, reduction in daily opioid consumption, and quality of life improvements. The patients received neurolytic blocks without previous diagnostic blocks due to multiple comorbidities, which Dr. Rosenblum acknowledges is sometimes necessary with very sick patients despite the typical preference for diagnostic blocks before neurolysis.

Dr. Rosenblum's Personal Experience with Celiac Plexus Blocks

Dr. Rosenblum shares his personal training experience with trans-aortic celiac plexus blocks, where a needle is inserted through the aorta after confirming no plaques or aneurysms are present. He describes it as a safe and effective procedure despite sounding intimidating. He mentions he's only performed a handful of these procedures and doesn't do many now as an outpatient pain doctor.

Study Methods and Results

Dr. Rosenblum details the study methods, noting that of 507 patients studied, data for 455 was retained at the end of the review. Patients were evaluated before and after the neurolytic retrocrural celiac plexus block under fluoroscopic guidance. Assessment included procedure duration, pain scores (0-10 scale), daily opioid consumption, and quality of life improvement. Follow-up was completed six months after the procedure, showing improved pain scores, reduced opioid consumption, and better quality of life throughout the study period. Some pain returned during months 4-6 due to disease progression and the anticipated duration of the neurolytic agent. The study noted a 6.7% initial vascular contrast uptake during the procedure while using digital subtraction angiography with fluoroscopy.

Study Limitations and Conclusions

Dr. Rosenblum discusses the study's limitations, including the need for a larger sample size and a prospective trial with a control group, though he acknowledges this is unrealistic given the patient population. He mentions that a proven quality of life questionnaire would be beneficial, and that comparing alcohol, phenol, and RF thermocoagulation would be interesting to evaluate duration effects and side effects. The study concluded that low volume neurolytic retrocrural celiac plexus block with phenol is safe, providing up to six months of pain relief for abdominal pain due to primary malignancy or metastatic spread.

Detailed Procedure Technique

Dr. Rosenblum explains the detailed procedure technique used in the study. The retrocrural celiac plexus was targeted at L1 level with aim towards T12. Anterior and posterior radiographic imaging aligning the spinous process of T12-L1 junction was used with 15-20 degree oblique rotation. Local anesthetic (1% lidocaine with sodium bicarbonate) was infiltrated along the injection path. A 22 or 25 gauge 3.5-7 inch curved spinal needle was used depending on patient body habitus. Dr. Rosenblum notes he typically uses a 6-inch Chiba needle or 25 gauge spinal needle for such procedures.

Procedure Execution and Monitoring

Dr. Rosenblum continues describing the procedure, noting that the needle was advanced to the anterior border of T12-L1 under multiple imaging views. Contrast dye studies verified spread and location, with digital subtraction angiography used to check for intravascular uptake. A test dose of 1ml of 0.5% bupivacaine with epinephrine per site was administered, which Dr. Rosenblum finds interesting as he typically doesn't mix bupivacaine with epinephrine. After confirming no vascular uptake, 3-5ml of 6% aqueous phenol was injected in 1ml aliquots while communicating with the patient. The average procedure time was 16.3 minutes with minimal or no sedation. Patients remained prone for 30 minutes afterward to avoid neuroforaminal spread, as phenol is heavier and more viscous than alcohol.

Post-Procedure Care and Study Evaluation

Dr. Rosenblum explains that patients were monitored in recovery for one hour for adverse events and their ability to eat and void easily. They were discharged once hospital post-anesthetic criteria were met and received a follow-up call 24 hours later. Dr. Rosenblum praises the study and notes that the procedure looks similar to a lumbar sympathetic plexus block, which is also a sympathetic block.

Ultrasound Considerations and Alternative Approaches

Dr. Rosenblum shares his interest in ultrasound-guided celiac plexus blocks but acknowledges concerns about bowel perforation. He mentions a conversation with an interventional radiology colleague who suggested a transhepatic approach. Dr. Rosenblum recalls scanning a very thin patient where the aorta was easily visible and close to the anterior abdominal wall, making the celiac plexus potentially accessible if bowel perforation, liver bleeding, or gallbladder perforation could be avoided. He shares an experience with a patient suffering from severe pancreatitis pain who received temporary relief from a paravertebral thoracic nerve block at T8-T10, noting that paravertebral blocks provide some sympathetic spread.

Conclusion and Community Resource Reminder

Dr. Rosenblum concludes by recommending the article, noting its well-written analysis and graphs showing morphine consumption dropping over months following the procedure. He suggests neurolytic procedures are underutilized because they sound intimidating. He again encourages listeners to check out the community he created with separate chat rooms for regenerative medicine, regional anesthesia, and pain boards, where users can share keywords but not specific board questions. Dr. Rosenblum reminds listeners about upcoming courses and his website resources, mentions an upcoming PRP lecture, and asks for five-star reviews if listeners enjoy the podcast. The episode ends with a standard medical disclaimer.

Reference

https://www.painphysicianjournal.com/current/pdf?article=NTQwOA%3D%3D&journal=113

PRP in the Epidural Space for Radiculopathy

Brooklyn Based Pain Physician, David Rosenblum, MD known for his work publishing and teaching Regenerative Pain Medicine and Ultrasound Guided Pain Procedures hosts this podcast covering the latest and most advanced concepts in Pain Medicine.

Summary

Dr. David Rosenblum delivered a comprehensive lecture covering several key topics in pain management. He discussed his upcoming speaking engagements at PainWeek, ASPN and great upcoming meetings like the Latin American Pain Society, and other conferences. Dr. Rosenblum shared his extensive experience with PRP (Platelet-Rich Plasma) epidural injections, reviewing multiple research studies that support their efficacy. He highlighted three significant studies: a randomized control trial comparing PRP epidural injections to traditional treatments, a CT-guided epidural PRP study, and a 2025 meta-analysis comparing PRP to steroids. Dr. Rosenblum emphasized that PRP treatments are showing comparable or better results than traditional steroid injections, with potentially fewer required treatments and longer-lasting relief. He noted that while PRP is currently not covered by insurance, it represents a growing trend in 'natural' treatment approaches that patients increasingly prefer.

Chapters Introduction and Upcoming Events

Dr. Rosenblum announced his upcoming lectures at Pain Week focusing on ultrasound and regenerative medicine, followed by presentations at the Latin American Pain Society in Chile and the New York, New Jersey Pain Conference. He mentioned the SoMeDocs online pain conference accessible through nrappain.org, and upcoming ultrasound training sessions in New York City.

PRP Epidural Research Review

Dr. Rosenblum discussed a randomized control trial involving 30 patients receiving transforaminal epidural injections. The study showed that PRP patients demonstrated significant improvements in leg pain scores at 6, 12, and 24 weeks. He noted that while the study didn't use contrast, he personally prefers using contrast diluted with saline for better visualization.

CT-Guided Epidural Study Analysis

Dr. Rosenblum reviewed a study comparing CT-guided epidural PRP versus steroid injections, questioning the necessity of CT guidance. The study included 60 patients and showed similar results between PRP and steroid groups at six weeks, though he criticized the short follow-up period, noting that PRP typically takes months to show full effects.

Meta-Analysis Discussion

Dr. Rosenblum presented a 2025 meta-analysis comparing PRP to steroids in epidural injections. The analysis included 310 patients across five RCTs, demonstrating comparable efficacy between PRP and steroid injections without increased adverse events. He emphasized that his clinical experience shows patients typically require fewer PRP injections compared to steroid treatments.

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References

Wongjarupong, Asarn, et al. ""Platelet-Rich Plasma" epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial." BMC Musculoskeletal Disorders 24.1 (2023): 335.

Bise, Sylvain, et al. "Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain." European radiology 30 (2020): 3152-3160.

Muthu S, Viswanathan VK, Gangadaran P. Is platelet-rich plasma better than steroids as epidural drug of choice in lumbar disc disease with radiculopathy? Meta-analysis of randomized controlled trials. Exp Biol Med (Maywood). 2025 Feb 4;250:10390. doi: 10.3389/ebm.2025.10390. PMID: 39968415; PMCID: PMC11832311.

Summary

Dr. David Rosenblum delivered a comprehensive lecture on gender differences in opiate effects and prescribing practices. He discussed several key studies examining how opiates affect males and females differently, both in animal models and humans. Dr. Rosenblum shared findings showing that morphine has stronger analgesic effects in males, while females experience longer-lasting effects. He also addressed racial disparities in opiate prescribing, noting that white patients are more likely to receive opiates. From his personal clinical experience in Brooklyn, Dr. Rosenblum observed that certain populations tend to be at higher risk for opiate abuse. The lecture covered gender-specific risk factors for opiate misuse, with women tending toward emotional/psychological factors and men showing more behavioral issues.

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Chapters Introduction and Upcoming Conferences

Dr. Rosenblum introduced himself as the host of the Pain Exam Podcast and announced several upcoming conferences including ASPN in July, PainWeek in September, and other events where he will be teaching ultrasound and regenerative medicine.

Board Preparation and Opiate Topics

Dr. Rosenblum discussed his role in board preparation through painxam.com and nreppain.org. He emphasized that opiates are a frequently tested topic across different board examinations (FIP, ABPM, ABIP, ABA).

Gender Differences in Opiate Effects - Animal Studies

Dr. Rosenblum presented research showing that in animal studies, morphine exhibited stronger analgesic effects in males, while females showed longer-lasting effects and could tolerate higher doses. He noted that physical dependence was more severe in male rats during spontaneous withdrawal.

Racial and Gender Disparities in Opiate Prescribing

Dr. Rosenblum discussed a 2025 study revealing racial disparities in opiate prescribing, with white patients more likely to receive opiates. He shared his personal clinical experience in Brooklyn, noting that young white males were often higher-risk for abuse.

Gender-Specific Risk Factors for Opiate Misuse

Dr. Rosenblum detailed how women tend to show emotional and psychological risk factors for opiate misuse, while men demonstrate more behavioral risk factors. Women were more likely to report distress and past trauma, while men showed higher rates of criminal behavior and substance abuse history.

References

Djurendic-Brenesel, Maja, et al. "Gender-related differences in the pharmacokinetics of opiates." Forensic science international 194.1-3 (2010): 28-33.

Kosten, Thomas R., Bruce J. Rounsaville, and Herbert D. Kleber. "Ethnic and gender differences among opiate addicts." International Journal of the Addictions 20.8 (1985): 1143-1162.

Cicero, Theodore J., Shawn C. Aylward, and Edward R. Meyer. "Gender differences in the intravenous self-administration of mu opiate agonists." Pharmacology Biochemistry and Behavior 74.3 (2003): 541-549.

Jamison, Robert N., et al. "Gender differences in risk factors for aberrant prescription opioid use." The Journal of Pain 11.4 (2010): 312-320.