Category Archives: News

President’s Column: Living with Chronic Pain During the COVID-19 Pandemic

Ann Quinlan-Colwell, PhD, RNBC, DAAPM

During the last five years, the focus upon, and priority for effective management of pain have dramatically shifted.  After more than a decade of efforts to improve the awareness of pain and appreciate the need for pain management, health care system administrators and providers were keenly aware that pain management was an important health care need.  In addition, in 2013 they learned that the patient experience of care constituted 30% of the weight of value based purchasing (CMS, 2013).  At the same time, they realized that patient satisfaction with pain management was an important component of the general patient experience of care.  They also realized that patient satisfaction with pain management was an important component of the patient experience.  Pain was a strong focus of health care system administrators, clinicians.  Then in 2016, the opioid crisis emerged and served as a potent change agent.  The focus and attention of heath care system administrators and clinicians shifted from concern about patient satisfaction with pain to preventing opioid misuse and abuse.  It is not possible to know to what degree, on a visceral level the opioid crisis touched clinicians who had been taught to submerge their ophiophobic fears.  They now could quote support for not prescribing opioids or at least not as many opioids.  Although I have not done a literature comparison, it certainly seemed as time passed information about opioids and substance use disorder far supplanted information about pain in the literature during the last few years.  Then in 2019, two icons of pain management ceased to exist.  The loss of the American Pain Society and the Academy of Integrative Pain Management as sources of leadership, guidance and research were significant.  As we entered 2020, I was hopeful that we had suffered the worst blows to pain management.  Yet new challenges face us.

In January 2020, the 2019 novel coronavirus (COVD- 19) was reported in Lancet.  On the surface many may wonder what negative impact COVID-19 could have on people living with pain. Unfortunately, during this time the barriers that people living with pain face are bolstered and in some cases expanded.  Many people living with chronic pain have serious co-morbidities venturing outside their home is not recommended (Szalavitz, 2020). It is difficult to maintain a safe distance of 3 to 6 feet in community settings or stores.  As an example, last week, I was standing 6 feet behind a man in a supermarket who was 6 feet behind the person in front of him.  A late middle aged woman started to stand in front of me.  I explained that I was in line and maintaining safe space and social distancing.  She waved her hand and said “Whatever!”  She then proceeded not to respect space behind me.  She didn’t seem to understand or accept the concept of personal space and social distancing. Currently when it is necessary for people who live with pain to go outside for a clinician visit or to refill a prescription transportation options may be more limited, less safe or unavailable.  Some may feel they need to choose whether to comply with quarantines and go without pain medicine or break the quarantines to obtain the medicine (Szalavitz, 2020).

Last week, the following important information regarding opioid prescriptions during the COVID-19 pandemic was written by members of the Practical Pain Management Editorial Board (PPMEB, 2020): “with federal law superseding state law, and with the current coronavirus declared as a public health emergency, providers are in fact able to prescribe controlled substances, such as opioids, via telemedicine. The DEA’s Diversion Control Division has noted that, “For as long as the Secretary’s designation of a public emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided the following conditions are met: The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice; The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and The practitioner is acting in accordance with applicable Federal and State laws.”   Additional information is available at www.deadiversion.usdoj.gov/coronavirus.html.

Other limitations are facing people living with pain who are trying to access integrative therapies which help them to manage pain. Physical therapy, massage, chiropractic, yoga, tai chi, water aerobics, swimming and fitness centers are not currently accessible in many communities.  Again, technology can be of help for some.  There are apps on smart phones and tablets that guide yoga and tai chi.  There are dance and exercise videos available as well. Certain out-patient physical therapy groups are guiding family members and patients via teleconferencing while some nurses are working with patients with relaxation techniques over the telephone or via teleconferencing.  For most people, living during this COVID 19 pandemic is a stressful time that can lead to sleep difficulty, anxiety and depression. For people living with pain, each of those can  make the perception of pain more intense and/or can make it more difficult to manage.  Similar to yoga and tai chi, there are many apps on electronic devices to facilitate relaxation and promote sleep.  Psychological oriented hot lines are available to support people with anxiety or depression.  Some clinicians are modifying their work to a teleconferencing mode. Recently the Centers for Medicare and Medicaid Services (CMS) expanded access to and coverage for telehealth care including virtual check-in and e-visits provided by clinicians including physicians, nurse practitioners, and licensed clinical psychologists (Drakulich, 2020).

CMS.gov table available at https://www.practicalpainmanagement.com/sites/default/files/imagecache/lightbox-large/images/2020/03/26/03.17.2020%20Summary%20of%20Medicare%20Telemedicine%20Services%20Chart.png

Continuing patient education is imperative for clinicians and for people living with pain to learn about the new modifications for opioid prescribing and the expanded telehealth options.  It is also important for them to learn that there are a number of scams alleging to be from Medicare and Social Security.  People living with pain may be vulnerable to these and need to know to be cautious.  One patient with a long history of mental health issues, responded to a spam and unwittingly surrendered her Medicare coverage and agreed to a very pricey private insurance that did not meet her needs.  Fortunately, a strong patient advocate was able to intervene and reverse the agreement.

There is no doubt that during 2020 patients living with pain will be challenged with stress and barriers.  As professionals there are ways that we can be supportive and helpful.  We may even find that by meeting the challenges of COVID-19 we will learn new options for helping and caring for people living with pain.  We may even find that they may be more effective.

References:

Centers for Medicare & Medicaid Services. (CMS).  (2013). Hospital Value-Based Purchasing. Available at http://www.qualitynet.org/dcs/ContentServer?cid=1228772237147&pagename=QnetPublic%2FPage%2FQnetTier3&c=Page.  Accessed 3/30/2020.

Drakulich, A. (2020).  Telemedicine in the Time of Coronavirus.  March 16, 2020.  Practical Pain Management.

Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., … & Cheng, Z. (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet395(10223), 497-506.

Practical Pain Management Editorial Board. (PPMEB).   (2020).  Managing pain and related symptoms during coronavirus.  March 16, 2020.  Practical Pain Management.

Stephen, P. (2016). Study – Wilmington No. 1 in opioid abuse.  Star News.  https://www.starnewsonline.com/article/NC/20160421/NEWS/605049449/WM. Accessed 3/30/2020.

Szalavitz, M.  (2020). People who take opioid painkillers are getting skrewed thanks to coronavirus.  https://www.vice.com/en_us/article/z3b5nj/coronavirus-shows-just-how-cruel-our-drug-laws-are-for-pain-patients-and-methadone-users   Accessed: 3/30/2020.

COVID-19 and the SPS Annual Meeting

Lori H. Postal, RN, MHA

As COVID-19 continues to influence individual and corporate function worldwide, The Southern Pain Society leadership is working diligently to ensure the best plan for our upcoming Annual Meeting in September. We would like all to know that while information on the current unprecedented pandemic is evolving quickly, your health and safety remains our primary concern.  The SPS board is meeting virtually and regularly and is currently hopeful that the meeting can be held as scheduled and that you will attend. However, we are also preparing a variety of contingencies in the event that a change should be necessary.

As COVID-19 evolves and more information becomes available, we will keep you informed of updates and any further decisions through our website, social media platforms and emails.

Thank you for your membership, support and engagement as we work through this crisis.  Please take care of yourselves and your loved ones and especially those on the front-line caring for patients.

Determination of Adverse Effects In Clinical Trials

Lawrence Robbins,M.D.

The efficacy of new drugs is usually reasonably accurate. We have multiple scales for efficacy, and the studies are powered for clinical effect. However, the studies often produce inaccurate adverse event or adverse effect profiles. To determine the likely adverse effects, post-approval we have to piece together multiple lines of evidence. These include published studies, physician experience, the FDA/FAERS site reports, and patient experiences. The physician online chat boards have been very helpful in outlining common adverse effects. The moderated and controlled Facebook patient chat boards have also been somewhat useful. I have previously published on the adverse effects of the migraine monoclonal antibodies. We(myself and Brooke Phenicie,NP-C) recently published a “checklist of adverse effects” study involving the migraine monoclonal antibodies. (1,2,3). I report a brief summary of those results here.

Recap of Results and the Utility of a Checklist

Initially patients were asked about adverse effects, and then they were presented with a checklist. 79 of the 119 patients identified at least one additional adverse effect by use of a checklist. Many patients described multiple additional adverse effects. The majority of additional adverse effects were mild. This study demonstrates the value of a checklist of symptoms in the evaluation of adverse effects.

Monoclonal Antibodies for Migraine Prevention: The Acquisition of Adverse Effects

As of September 30, 2019, the U.S. Food and Drug Administration (FDA) Adverse Events Reporting System Dashboard lists 20,871 adverse events attributable to the 3 migraine monoclonal antibodies. 2,825 events were deemed serious, with some identified as life threatening. (4) Only a small proportion of actual adverse events are reported to the FDA. For only 1.3 years of use, these numbers are staggering. The FDA, as well as similar organizations in other countries, would do well to investigate these adverse events. Adverse events attributable to erenumab accounted for 16,215 (2,367 serious) of the total. Galcanezumab use resulted in 3,465 (284 serious) adverse events, while fremanezumab had 1,191 (178 serious) reports. (4) Erenumab was the initial mAb prescribed in the U.S., and is still the mAb most commonly utilized. This may be a primary reason for some of the discrepancy between erenumab and the other mAbs with regard to the number of reported adverse events. Over time we will be able to determine if one mAb truly carries an enhanced risk for adverse effects. These mAb numbers are significantly higher than those reported for onabotulinumtoxinA. OnabotulinumtoxinA only averages approximately 2,000 reports per year, with few serious issues (in the doses used for headache).
We have prescribed mAbs to over 1,200 patients and they have reported a multitude of adverse effects. Constipation (20% of patients in our study on erenumab, less among the other mAbs) is the most commonly reported AE. (5) At times the constipation is severe, greatly affecting quality of life. Other adverse effects across all 3 mAbs have included: worsening headache (6%), depression (4%), fatigue (4%), nausea (4%), joint pain (3%), and hair thinning or loss (3%). (2) We have encountered a serious adverse effect in 4 patients, including: 1. A 60-year-old woman who had an episode of reversible cerebral vasoconstriction syndrome, which resolved, 2. A 21-year-old woman with a history of hemiplegic migraine (none since 2015), on the birth control pill, who suffered a probable migraine-related stroke, with an 80% improvement over 5 months, 3. A 65-year-old woman, with a history of rheumatoid arthritis, who reported severe joint pains and fatigue, which resolved, and 4. A 31-year-old woman who suffered from severe neurologic symptoms, including hemiparesis. She also suffered from joint pain and fatigue. A complete work-up was negative, and she eventually fully recovered.
We have been in communication with many headache providers concerning their experience with the CGRP mAbs. Constipation is commonly described as an AE. The rate of constipation that these providers report varies between 10% and 80% of patients. Anecdotally, it appears that erenumab causes constipation at an increased rate over the other mAbs. One observational study concluded that adverse effects accounted for 33% of discontinuations from erenumab. (6) Most providers feel that the AEs in clinical practice outnumber those reported in the studies. There also are providers who have encountered very few adverse effects among their patients.

The CGRP monoclonal injections (primarily erenumab) were reviewed by Quarterwatch, a publication that evaluates new medications. They rely upon a number of sources, including post-approval studies and the FDA reports. Quarterwatch researchers cited the “sheer number of case reports.” They noted that a large number of patients had experienced adverse events. Constipation was the most prominent AE. Hair loss was also mentioned as generating a clear signal. (7)

Other AEs acknowledged by Quarterwatch included muscle cramps, muscle spasms, and arthralgias. Thirty-five cases of anaphylactic shock were recognized. Depression was also listed as a concern. They state that “depression warrants additional study.” The authors mentioned signals for cardiac events. These included arrhythmias, palpitations, tachycardia, and cardiac arrest. Cases of loss of consciousness were also described. (7)

Quarterwatch concludes that “….it is likely that adverse effects of this migraine preventive were underestimated in the clinical trials.” In addition, they state “…the long-term effects of blocking all the functions of a highly prevalent signaling molecule remain undetermined.”
Quarterwatch, in December 2019, reviewed the frequency with which adverse events are reported to the FDA. Quarterwatch estimates that, in general, only 1% of serious adverse effects are actually reported to the FDA. Side effects to generics are rarely reported. However, the newer branded biologics, such as the migraine mAbs, are reported more often. Still, there are many serious side effects to the mAbs that go unreported.

The patient online chat boards and support groups help to provide insight into “real world” experience. Many patients state that they have had excellent results, with no adverse effects. However, many adverse events are also described. I have reviewed 400 adverse effects that were felt to be credible. The most common AEs described online by patients include fatigue, constipation, hair loss, depression, anxiety, and nausea. Many patients attempt to discuss adverse effect with their physician, and often they are dismissed with phrases such as “That AE cannot be due to the drug. They are safe.”
The adverse effects that we gleaned from patient comments somewhat matches the AE profile reported in our previous studies. They are also similar to what is stated on the FDA Adverse Event Reporting Dashboard.

Interfering with the molecule CGRP carries a multitude of possible risks. Evolution has decided that CGRP is a vital compound throughout the body. CGRP plays an important role during stress. These compounds have not been studied under stressful conditions. The blood brain barrier does not protect certain key areas, such as portions of the hypothalamus and pituitary glands. (3) Studies of various hormones, particularly in younger patients, have not been published.

The Phase 2 and 3 mAb studies significantly underreported the adverse effects. There are a number of reasons as to why they missed the adverse effects. Thomas J. Moore (Senior scientist, Institute for Safe Medication Practices) outlined this in his chapter “Assessment and Reporting of Harm.” (8) There are myriad scales and methods for describing efficacy in trials. With regard to adverse events or effects the methods for evaluation are lacking. Trial subjects are usually healthier, with fewer psychiatric and medical issues, than the patients we encounter in our offices. As compared to our chronic migraineurs, most of the study patients have used fewer preventive medications. For most of the mAb studies patients were simply asked, during follow-up visits, if they had any new symptoms or issues. This method may identify many of the serious AEs, but usually underreports milder issues. Psychiatric AEs often are not volunteered by the patient. Study personnel ideally should have a checklist of likely side effects. Patients should be asked, during each visit, about the predetermined items on the list. Adverse effects differ regarding duration of effect, severity of the AE, and how often it has recurred. It would be best if each adverse effect would be categorized as “mild, moderate, or severe.” The length of time that the AE remains is also important. (8) For instance, there is a major difference between the patient suffering from mild constipation for three days versus a person who suffers two months of severe constipation. The adverse event classification systems include the National Cancer Institute Common Terminology Criteria for Adverse Events, and the Medical Dictionary for Regulatory Activities (MedDRA).
The disaggregating of adverse effects leads to underestimating certain AEs. For example, fatigue may have a several synonyms, such as malaise or tiredness. “Fatigue” for one person is different from “fatigue” for the next person. (8) After completion of the study it is theoretically possible to re-aggregate these symptoms. However, re-aggregation is not accurate. Future trials should carefully define each probable adverse effect.

The studies are underpowered with regard to identifying AEs. Assuming the incidence of one particular AE is one in 1,000 patients, the study needs 3,000 patients in order to uncover one case, with 95% probability. If we want to uncover 3 cases, the study would require 6,500 patients. (9) The numbers in the monoclonal studies were inadequate. The studies also do not extend long enough to adequately assess adverse effects.

Going forward, studies should use a checklist of symptoms. In addition, carefully defining each possible adverse effect would help to avoid “disaggregation” of symptoms. We need to have a more accurate picture of adverse effects coming out of the studies.

References

1. Robbins L., Phenicie B. CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using a Checklist. Practicalpain management.com. March-April 2020.
2. Robbins L. CGRP monoclonal antibodies for chronic migraine: year 1 of clinical use. Practical Pain Management. 2019; 19(6):58-62.
3. Robbins L. CGRP antagonists: physiologic effects and serious side effects. Headache. 2018;58(9):1469-1471
4. FDA FAERS Website: https://fis.fda.gov/sense/app/d10be6bb-494e-4cd2-82e4-0135608ddc13/sheet/7a47a261-d58b-4203-a8aa-6d3021737452/state/analysis
5. Robbins L. CGRP monoclonal antibodies for chronic migraine. Practical Pain Management. 2019;19(2):45-52.
6. Robblee JV, Mendez N, Potter J, Slonaker J, Grimsrud KW, Starling AJ. Post-market observational study of patient experience with erenumab. In: Headache. 2019;59(supp 1):48.
7. A New Class of Drug for Migraine Prevention. In: Quarterwatch(a publication of The Institute for Safe Medication Practices)Aug. 2019; Available at: www.ismp.org/quarterwatch
8. Moore T, Assessment and reporting of harm. In: Fundamentals of Clinical Trials, fifth edition, by Friedman L, et al. Springer, 2015. Chapter 12,255-274.
9. Furberg BD, Furberg CD. Evaluating Clinical Research. All that Glitters is Not Gold (2nd edition). New York, NY: Springer, 2007, pp.17-18 10. Ashina M, Goadsby PJ, Reuter U, et al. Sustained efficacy and long-term safety of erenumab in patients with episodic migraine: 4+-year results of a 5-year, open-label treatment period. Presented at: 61st Annual Scientific Meeting of the American Headache Society; July 11-14, 2019; Philadelphia, PA. Oral IOR10.

People Who Take Opioid Painkillers Are Getting Screwed Thanks to Coronavirus

Quarantined people have to go out to get their prescriptions and can’t get a backup supply.
by Maia Szalavitz

Mar 24 2020, 6:00am

https://www.vice.com/en_us/article/z3b5nj/coronavirus-shows-just-how-cruel-our-drug-laws-are-for-pain-patients-and-methadone-users

SPS Treasurer Transition

As you may know or have read in our President’s Column, Dr. John Satterthwaite has stepped down from his long-standing role as SPS Treasurer and will remain on the board as a non-voting member. We are grateful for his 34 years at the financial helm of the organization and appreciate his wisdom, historical perspective and recommendations that have kept SPS healthy, financially sound and robust.

As such, we are pleased to announce the appointment of Randy Roig, MD as the Southern Pain Society’s new Treasurer. Dr. Roig has been on the SPS board as at-large director for the past year. Due to his extensive finance and non-profit experience, coupled with his leadership interest in our organization, Dr. Roig has stepped into his new role effective January 1, 2020. We are delighted to have his expertise. Dr. Roig will be on the 2020 SPS ballot as a nominee for formal election.
Dr. Randy Roig is a resident of New Orleans and is a summa cum laude graduate of the Tulane School of Engineering and the LSU School of Medicine in New Orleans. He completed his physical medicine and rehabilitation (PM&R) residency in 1996, serving as chief resident. He is holds American Board of Medical Specialties (ABMS) certifications in PM&R, spinal cord injury medicine, and pain medicine. He is presently practicing at the Southeast Louisiana Veterans Health Care System, where he is the Associate Chief of Staff for Education and Designated Education Officer, Assistant Chief of the PM&R Service, and Chief of the Pain Medicine Section. He is on the faculty of both LSU in New Orleans and Tulane University, as well as Emory University in Atlanta, Georgia. He serves as the program director for the pain medicine fellowship training program and clinician co-director of the course in musculoskeletal medicine and dermatology at LSU. He is volunteer Executive Editor of Rehab in Review, a monthly journal for the field of physiatry published by Emory University.

Dr. Roig has served on numerous nonprofit boards and committees within the medical community, including the Association of American Medical Colleges and the American Academy of Physical Medicine and Rehabilitation (AAPM&R). He also serves as co-chair of the Medical/Legal Interprofessional Committee of the Louisiana State Medical Society (LSMS) and the Louisiana State Bar Association.

Dr. Roig’s new role includes the financial stewardship of SPS and from our by-laws: “The Treasurer will be responsible for the custody of the Society’s funds and securities and for maintaining a full and accurate record of receipts and disbursements. He shall act within the confines of good business practices and under the supervision of the board of directors.”

Welcome!

Update on Gepants: New Abortives for Migraine

Lawrence Robbins,M.D.

Gepants are small molecule calcitonin gene-related peptide (CGRP) receptor antagonists. The preventive CGRP monoclonal antibodies(Aimovig, Emgality, Ajovy) are large molecules, delivered once per month as a SQ injection. Seven gepants have been developed since 2004. (1) Telcagepant was extensively studied, but withdrawn due to hepatotoxicity concerns. CGRP has many effects throughout the body. CGRP triggers a cascade of inflammatory mediators that feed into the trigeminovascular system. By blocking CGRP, the gepants stop the process prior to inflammation.

Regarding migraine, CGRP is an inflammatory compound. They will initially be utilized as migraine abortives, but eventually they will also be used to prevent migraine. The gepants may be helpful for 3 groups of migraineurs. They will be prescribed for a number of patients who found triptans (sumatriptan, rizatriptan, zolmitriptan, etc.) to be ineffective. In addition, gepants will be used for certain patients who cannot tolerate triptans. Finally, for those patients with significant cardiac or cerebrovascular risk factors, the gepants may be relatively safe, since they do not constrict cardiac or cranial arteries. While efficacy is modest, these are well tolerated medications.

The first gepant to come to market will be ubrogepant. Almost 2,700 patients participated in the ubrogepant ACHIEVE studies. (2,3) The doses have ranged from 25mg to 100mg. The t-max is 0.7 to 1.5 hours. Approximately 20% of patients who used the 50mg dose were pain free after 2 hours. While 25mg and 100mg tablets of ubrogepant were evaluated, it is likely that 50mg will be the primary dose. Ubrogepant was well tolerated, with 2% to 5% of patients reporting nausea, somnolence, dry mouth, dizziness, or upper respiratory tract infections. No serious adverse events were reported. The safety and tolerability were also explored in a 52 week extension study. Few adverse events, and no hepatotoxicity was reported. The effect of ubrogepant on the patient’s most bothersome migraine symptom was evaluated 2 hours post-dose. 39% of those treated with ubrogepant reported that their worst migraine symptom was resolved. The therapeutic gain for ubrogegepant (active drug vs. placebo) is relatively low, 6.4%-9.4%. In comparison, the therapeutic gain for sumatriptan is 16%-21%.

Rimegepant is another gepant, in development for abortive and preventive use. The dose is 75mg, with a t-max of 2 hours. In the 2 main trials, 19.4% of patients achieved pain freedom at 2 hours. (4) 37% of patients reported freedom from their most bothersome symptom. As with ubrogepant, no significant liver toxicity was reported. Adverse events were low, with nausea being reported by 1.4% of patients. The therapeutic gain for rimegepant is 5% to 7.6%.

A third gepant, atogepant, is currently being studied.

The gepants will be a useful alternative to triptans. Many patients find triptans to be ineffective. Some migraineurs cannot tolerate the adverse effects of the triptans. For certain patients with cardiovascular risk factors, triptans may not be completely safe. Gepants will be considered in these clinical settings. The initial (2 hour) efficacy rates are fairly low, but it appears that gepants may become more effective over 2 to 8 hours. During the trials, these were fairly well tolerated medications. It will take at least several years before we are able to accurately assess the true adverse effect profile of the gepants.

References

1. Olesen J, Diener H-C, Husstedt IW et al Calcitonin gene-related peptide receptor antagonist BIBN 4096 BS for the acute treatment of migraine. 2004. N Eng J Med 350:1104-1110.

2. Allergan Announces Positive Top Line Phase 3 Clinical Trial for Ubrogepant- an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine. Available at http://www.allergan.com/news/news/thomson-reuters/allergan-announces-positive-phase-3-resul.

3. Allergan Announces Second Positive Phase 3 Clinical Trial for Ubrogepant- an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine. Available at http://www.allergan.com/News/News/Thomson-Reuters/Allergan-Announces-Second-Positive-Phase-3-Clinica.

4. Biohaven Announces Successful Achievement of Both Co-Primary regulatory Endpoints in Two Pivotal Phase 3 Trials of Rimegepant an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine Available at https://biohavenpharma.com/wp-content/uploads/2018/03/CONFIDENTIAL-BIOHAVEN-PRESS-RELEASE-FINAL-v2.pdf.

Reducing Harm from Opioids – Lessons Learned

Lisa Edgerton, PharmD, BCPS, CPP, Olivia Herndon, MA, and Joseph Pino, MD, MHA

Wilmington is a community in southeastern North Carolina known for its beautiful beaches, historic river-walk district, and the largest domestic television and movie production facility outside of California. In April of 2016, this city also became recognized for something else.

In 2016, Castlight Health released a report titled “The Opioid Crisis in America’s Workforce.” The study noted those who abused opioids are more likely to live in the rural south with 22 of the top 25 cities in Southern states. Furthermore, it named Wilmington, NC as the city with the highest abuse rate in the United States. In response, our medical community mobilized and recruited partners from disciplines outside of healthcare to reduce harm from opioids in our region.

Through a “call to action” where more than 100 regional stakeholders and leaders, the Community Partners Coalition (CPC) was born. This CPC aims to improve collaboration and coordination between those who provide care to individuals seeking access to mental health and substance use services by aligning efforts in the region. A primary focus of the CPC was to improve safe medication disposal options in our region by expanding medication take-back events and permanent drop boxes.

The first medication take-back event was held at New Hanover Regional Medical Center (NHRMC) in March 2009. This event was held at one location on our hospital’s main campus in New Hanover county. NHRMC partnered with the Wilmington Sheriffs office and collected 140 pounds of medication at that event. This solo event continued biannually however, dates were chosen based upon availability of volunteer coordinators and coinciding community events. NHRMC continued to host this single site medication take-back event biannually through the Spring of 2017.

Through the support of the CPC, in the Fall of 2017, this event was expanded to 9 locations within 4 counties and collected 3,680 pounds of medication and 29,675 needles or sharps. This biannual medication take-back event has continued to grow now hosting 19 locations spanning 6 counties in our region.

In October 2019, we collected almost 6,000 pounds of medication, 43,000 needles or sharps and 178 medications, valued at $55,000, that were donated to a local clinic serving those without resources for re-dispensing. Expanding our medication take-back event to 19 locations did present some challenges along the way.

To expand our reach, leaders of the takeback event needed to engage in detailed planning and consider logistical challenges. We aligned our event dates to the Drug Enforcement Administrations (DEA) National Prescription Drug Take Back Day. Aligning with the DEA allowed us to plan for future events as these dates are standardized on the last Saturdays in April and October. Alignment also enabled law enforcement to register event locations in their national website. This site is searchable and provides a map of locations nearest to search area. Alignment with the DEA also connected us to our regional State Bureau of Investigation (SBI). This partnership enabled us to receive support including standard boxes used to collect medications at each take-back location. The SBI supplied NHRMC with 250 evidence boxes that were distributed to site leaders at each take-back location.

When planning to staff each of our sites, federal rules indicate that law enforcement must be present at each medication take-back location. When planning for our Fall 2017 expansion, we discovered that our hospital law enforcement officers could staff all NHRMC and affiliate locations. At the Fall 2017 event, we were able to utilize NHRMC police for 5 of the 9 locations. This allowed us to extend our partnership with local sheriff’s offices and expand to additional sites. We continue to collaborate with our regional county sheriff departments who provide an additional 1-2 law enforcement officers for each location.
NHRMC company police have been instrumental in not only staffing these events but also coordinating with regional law enforcement agencies. They collect and store the medication until the “burn day”. This often occurs 2-3 days after the takeback event. Our event has become so large that NHRMC law enforcement transports over 100 boxes of medication. As a result of our success, we have outgrown the transport capacity of our standard vehicles. We now either have to rent commercial trucks or borrow large box trucks from another department in our hospital.

In addition to organizing law enforcement to be present at each site, we decided we would accept needles or sharps at each of the 19 drop off locations. This became an issue for sites that were not affiliated with a health system because they did not have sharps containers at their locations. Prior to each event, NHRMC now donates sharps containers to each of these sites. Following the event, we now also coordinate with either law enforcement or a volunteer at the site to collect the sharps bins.

To raise awareness of this multi-county, multi-site drug takeback event, we approached our hospital’s marketing department to help us by advertising this event. They created a universal flyer listing each drop off location by county. This flyer is printed in a variety of sizes and is posted across our health system and to each of our drop-off location partners. We also advertise in advance of this event on social media, radio stations and local newspapers as well as media outlets on the day of the event. We also created a NHRMC webpage dedicated to medication disposal where we post our upcoming flyer and list locations of all area permanent drop boxes. Through this effort, we also learned that funeral homes, hospice care centers, veterinarian offices and churches are effective locations to advertise these events and added these sites to our marketing locations for future events. We also realized that we needed to create a Spanish-version of our flyer to appeal to other segments of our community and plan to do so for our next event.

We also discovered that we needed to develop a standard process to enable us to repurpose unused medication. Medication take-back locations staffed with NHRMC volunteers may collect any unused medications and can donate them to a charitable clinic. These medications must meet North Carolina repository rules and regulations to qualify for donation. Following the event, each unused medication collected is visually inspected by a pharmacist to ensure it meets all applicable federal guidelines for donated medications. By following this process, we could donate $ 55,000 of medication to one of our local, charitable clinics.

During our medication take-back expansion in 2017, NHRMC also installed three permanent medication drop boxes across several sites within our health system. Medication drop boxes were installed on the main campus within our Outpatient Pharmacy, at our free-standing emergency department located off campus, and at our critical access hospital located in a neighboring county. It was anticipated that the drop boxes would need to be emptied once a month. When first installed, the permanent drop box in our main hospital, which holds roughly 55 pounds of medication, needed to be emptied every 9-10 days. This was not anticipated. We now collect 1,600 pounds of medication in our 3 permanent medication boxes annually.

Like other communities across the country, Wilmington and our surrounding area have been significantly impacted by the opioid crisis. Through the development of the CPC and the leadership of NHRMC, we expanded our drug takeback events to multiple sites in multiple counties in our region. As a consequence of our success, we also discovered we needed to coordinate law enforcement at each location, establish safe storage, rent large trucks to transport thousands of pounds of medication collected at each event, develop a process to reclaim medication and manage high volume disposal of medication in permanently installed drop boxes across our health system. We are fortunate to have such an engaged community to collectively work to reduce harm from medication. Hopefully, these lessons learned will help you do the same.

Thank You, John Satterthwaite!

Ann Quinlan-Colwell, PhD, APN

Developing this president column is no small task. It is written to pay tribute to our friend and mentor Dr. John Satterthwaite who recently stepped down from serving as the treasurer of the Southern Pain Society during the last 34 years.  John nurtured and guided SPS while significantly impacting many SPS members in ways that can never be repaid. As Dr. Mordi Potash said so well: “it is an absolute truism that there would not be a Southern Pain Society in existence in 2020 if not for John Satterthwaite.” This was echoed by Lori Postal who recently wrote John Satterthwaite has served the Southern Pain Society as a “trusted mentor, historian, voice of reason and steward of our finances.” Not only is John a man of many talents who has contributed greatly to the world of pain management but he has paradoxical qualities as well.  Although he is often a wise sage when on the stage, he is equally comfortable and meaningful being the guide on the side.  He is often a man of few words yet a great storyteller. John has always reminded Dr. Geralyn Datz of “a firm but fair patriarch, if you are under his wing, he is protective and compassionate.”  Several people make the analogy of John steering and guiding the SPS ship. Dr. Harry Gould appreciated John’s welcoming spirit and guidance for the “kids in the candy shop” (the SPS Board of Directors) “to get the most with what we had” (financially). John’s devotion and perspective on the history and the mission of SPS have been priceless.  As I recount these observations and impressions I am nodding my head in agreement. John is an expert physician, teacher, patriarch, sage, guide, shepherd, steward, mentor, storyteller,  navigator, voice of reason, friend and so much more.

Dr. Eric Pearson particularly loves John’s “wisdom and amazing dry sense of humor” which was reflected in preparing for this column.  After sending John some questions about his life, he sent me the “answers to the essay test.”  He was the son of a Station Manager for Capital Airlines born in Clarksburg, W.V. but moving frequently during his childhood and teens.  He had several early occupational goals including being “a trash collector because you could ride on the outside of the truck,” an Air Force pilot and “several other questionable thoughts.” His focus changed while working summers as an orderly and surgical tech in the OR in Georgia, where the anesthesiologists encouraged him to consider anesthesiology instead of surgery which as a fan of the TV show Ben Casey, he found interesting.  In fact, he initially “thought of going into Thoracic Surgery, but the residency was too long, and “ultimately chose anesthesiology because you work in a climate-controlled area and can wear pajamas all day (ha-ha)… It is immediate treatment response medicine and sleeping patients don’t complain.”

John noted that his  “involvement with pain was accidental.”  After practicing for 2-3 years, a neurosurgeon from Memphis, TN moved to the area and asked John to do epidural steroid injections.  As a result, other ortho and neuro doctors followed with similar request, and he became the first person in Greenville, S.C. to be “practicing pain.” Subsequently other surgeons asked if there were injections that could administered for “patients with an unusual pain with discoloration and extremity swelling.”  John’s interest was sparked in what was then RSD (reflex sympathetic dystrophy) which he began treating.  He was told by a local orthopedist that “we never had RSD in Greenville until you came to town.” 

John joined SPS in March of 1987 which qualified him as a Charter Member.  He clarifies: “at least that is what my certificate says.”  His intertest in RSD led him to  attend his first SPS meeting in 1989 because they had a day long program on “RSD” at the SPS regional section meeting, held in conjunction with APS.  Wearing his historian hat, John wrote: “attendance at the regional meetings tended to be greater than the APS meetings and we were subsequently uninvited to hold our meetings with APS.  The first independent SPS meeting was in 1991 in Chattanooga, TN.  I have been to each meeting since then except one.” 

“In 1989, the President of SPS Dan Hamaty, whom I knew because of his involvement with Pain Therapy Centers (PTC), asked me to become Treasurer which I accepted.”  Because of the involve tax and registration paperwork necessary to transfer the office, John continued to act in that capacity until 12/31/2019.  “If not for my current health issues, I would continue as I get to interact with some of the giants in the field and it is fun. I was asked to run for SPS President by Renee Rosomoff 1996, but declined because of this” (responsibility to the role of treasurer).

Because of his interest in pain, John developed a relationship with Dr. C. David Tollison who was a Clinical Psychologist specializing in pain.  Dr. Tollison set up a multidisciplinary pain treatment program in hospital system where John was located. This was the start of PTC of which John became Medical Director with Dave as Program Director.  “Due to the financial success of PTC, other hospitals in the region became interested.  We started a program in Charlotte with Dr. Hamaty as Medical Director, and at one time there were several programs in four states.  Unfortunately, with changing reimbursement, these programs ultimately died out.”

John noted that he has “been surrounded by some of the greats in the field of pain, but the person who has had the greatest influence was Dave Tollison.  We have practiced together for 30 years.  We have edited several books and spoken at many events.  One of my prized possessions is a copy of the 3rd edition of our “Practical Pain Management” which was translated into Chinese.  This was the third bestselling pain text behind Bonica and Raj.”  “Others especially Hu and Renee Rosomoff had a tremendous influence on my life in pain management as well.”

John felt fortunate to meet or work with Hu and Renee Rosomoff, Marty Grabois, Bert Ray, Stan Chapman, Peter Staats, Jeannie Koestler, Ben Johnson, Dan Doleys, Todd Sitzmann, and many other leaders and pioneers in the field of pain management during the last 30 years. He has many SPS related reminiscences.  His most “memorable SPS event was at a Board of Directors meeting in Charlotte in 1996.  President Renee Rosomoff was notorious for micromanaging and long meetings, but this one started at 11:00 am and was finally over at about 1:30 the next morning when someone (not one of us although I wish it had been) set off the fire alarm at the hotel.  Although we were still not finished, nobody went back to the meeting room following the “all clear”.  Even Renee’s husband Hu, who came to all Board meetings because of his love for the organization, had left much earlier.  (FYI, Hu Rosomoff was founding President of SPS, and subsequently served as APS President, AAPM President, and was a giant in the field of pain.  I was privileged to call him a friend.)”  Another favorite memory was that Hu and Renee “attended every Annual Meeting together.  They sat on the front row, in front of the speaker, so you knew they were listening.  After every speaker Hu would stand and provide commentary.  All of it useful, but sometimes critical.  I presented a talk on “Epidural and other steroid injections” at one of our meetings.  I knew Hu was a multidisciplinary treatment advocate.  Despite his being a neurosurgeon, he was very critical of procedures or medications for pain treatment.  His clinic in Miami was one of the leading multidisciplinary pain treatment facilities in the world.  When he stood up, I held my breath until he said my presentation was the most objective and comprehensive discussion on injections he had ever heard.  Quite a relief.”

A memory lane of pain management for John reflects significant change.  It also reflects the “honesty, genuineness, firm opinions rooted in his experience and desire for others to succeed” that Dr. Geralyn Datz described. He relays that today “it has become almost impossible to treat patients appropriately.  In the early years, we treated patients based on our understanding of the pain mechanisms and pathophysiology.  We experimented with injections, infusions, anticonvulsants, antidepressants, calcium channel blockers, anti-inflammatory, and other medications.  This laid the groundwork for much of what we use now or try to.  Now every pharmacist, insurer, lawyer, and government/insurance bean counter are practicing medicine and preventing, or impeding, treatment of patients.  Malpractice suits and regulatory agency threats are constant threats.  Cost effective has become the mantra instead of patient effective.  I agree with evidence-based medicine, but we had no evidence in the early years.  In fact, many of the studies now quoted began with a ‘what if we try this?’  That was our work.  It’s hard to formulate a treatment program with a bureaucrat or insurer standing in the way.  Yes, PT, complementary treatments, behavior modification are excellent alternatives to opioids, but no insurer will cover them.  Private practice is handcuffed by payors.”

When asked about the current opioid abuse/misuse crisis, John replied: “I think back to Russell Portenoy who basically asked, ‘what is the difference in pain from a vertebral fracture from metastatic cancer and from osteoporosis?’  Answer, there is none except the cancer patient will probably die sooner than the osteoporosis patient.  This was the beginning of the use of opioids for non-malignant pain.  Unfortunately, practitioners were unable or unwilling to appropriately screen and evaluate patients and prescribing went out of control.  It has become extremely difficult in this day of volume practice to appropriately evaluate who is a candidate for opioid use and who is not.  Evaluating who is and is not a candidate for chronic opioid use is not easy and is quite time consuming, and you must be able to say no.  Opioids are also being inappropriately prescribed for acute pain.  A postop hernia repair does not need 30 mg of  Oxycontin for pain management.  Back strain does not require initial treatment with opioids when other modalities have not been tried.  It is just quicker and easier to write a script than do a more complete evaluation and get other  treatments declined.  Finally, there are people who misuse or abuse opioids, and many practitioners do not take the time to weed them out.  Unfortunately, there is not a lab test for pain, and a history and physical have become relics of the past while lab studies, computers, and x-ray have taken over.”

If John could wave a magic wand to achieve a program/practice of perfect pain management, he would have two wishes.  “First, patients would be honest and not lie or manipulate, but this will never happen.  Second, there would be complete coverage for interdisciplinary treatment to include behavior modification, psychological evaluation, physical therapy, aquatic and other therapy, medications as indicated, injections as indicated, necessary evaluations and procedures, rehab and work hardening, and last but not least, any opioid prescriptions for longer than two weeks needs to be approved by a specialist. In fact, as many clinics do, no one should be placed on opioid therapy without a psychological evaluation from a qualified pain psychologist and undergo ongoing eval and treatment.”

In conclusion to reflect the wonderful Satterthwaite wisdom that Eric Pearson noted, John offered a few pearls and words of wisdom for pain management clinicians.  He stressed that “the key word is clinician.  Remember you are a professional.  If you are a one trick pony, one trick is all you have.  If the only thing you have is a hammer, you will be useless for anything but a nail.”  “Pain has been defined by the IASP as An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. The proposed new 2019 definition is: An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury.  In those definitions notice three factors: actual or potential tissue injury, sensory experience, emotional experience.  Each of these aspects needs to be addressed.  Injections, pills, or counselling only deal with one issue.  Pain is a complex issue so there is no simple answer or treatment.  So, stop trying to hammer that bolt through the steel plate with your hammer.”

The 2019 Southern Pain Society Conference – A Most Memorable Event

Ann Colwell-Quinlan, PhD, APN

The 2019 Southern Pain Society (SPS) conference was held September 13 through 15 in New Orleans.  We enjoyed reconnecting with those who attended previous conferences and meeting a number of first-time attendees. It was great to have a new attendee share that “this is great – so much better than I ever expected.” 

This was definitely a conference during which it would be difficult to find someone who didn’t learn at least a few new things and/or wasn’t encouraged to think about things in a new way.  A slate of well-informed speakers shared their knowledge with the attendees. 

The speakers enlightened us about the various new perspectives and options of integrated pain care.  The conference commenced on Friday afternoon with Dr. Blake Fagin providing education on prescribing controlled substances as well as how to appropriately treat patients with Substance use disorder.  Using numerous examples, he made the Louisiana mandated three hour Controlled Dangerous Substance education enjoyable while meeting the state requirements for content.  Dr. Steven Stanos opened the Saturday program by escorting us through the history of how pain professionals arrived at a new crossroads of pain management.  He then led us to comprehensively provide safe pain care.  Appreciation for and aspects of comprehensive pain management were discussed from a psychological aspect by Dr. Jennifer Murphy.  Then Dr. Jeffrey Sibrack explored the role of the endogenous opioid system with pain management. 

We learned about some innovative options on the horizon.  Dr. Ashley Mullens updated the group on the Therapeutic Cannabis Program at the LSU AgCenter including some very interesting research studies using cannabis with zebra fish and rodents.  A very timely evidence based presentation about using stem cells for pain management was given by Dr. Amadeus Mason.  Then Dr. Forest Tennant explored the role of hormones in pain control.  Monique Serpas, PT, DPT shared the various analgesic techniques used by physical therapists. She and Dr. Stanos both discussed the importance of function in pain control. In a sense Dr. Dan Doleys brought us full circle by updating on screening for opioid use disorder prior to starting opioids.  We concluded with Dr. Charles Figley educating us about and encouraging us to pursue commitments to self-care personally and to support other members of SPS in pursuing the same for themselves.  We also were fortunate to view several excellent posters.

For me our annual business meeting was an amazing event.  First, I had the pleasure to present the President’s Award for Distinguished Service to the SPS to Dr. Thomas Davis who has served as secretary of SPS for many years as well as co-chair of this amazing 2019 conference.  During that time Dr. Davis has always had a calm, even, well-balanced approach to any issue that arose. Then, Dr. John Satterwaite presented the 2019 Hubert L. and Renee S. Rosomoff Award for Excellence in Pain.  I can only remember having an intense emotional response when I heard him say my name.  To say that I was speechless is an underestimation.  I doubt there is any greater honor than to be recognized for excellence by professional peers and partners.  Now that I have regained cognition, I am extremely honored and appreciative to have been selected to receive this prestigious award.  I also am very appreciative for all of the wonderful teachers, mentors, peers and especially patients who have taught me so much about working with people who live with pain.   It certainly is incentive to continue to work with SPS to pursue our mission “to serve people with pain by advancing research and treatment and to increase the knowledge and skill of the regional professional community.” 

My appreciation also goes to our planning committee led by Drs. Geralyn Datz and Thomas Davis; the SPS board, our Executive Director Lori Postal, the amazing presenters, Lisa and Wilma from MAHEC; and Chris Hall who did his magic with the audio visuals  for all of their efforts in making the 2019 SPS conference a fantastic experience.

Disparities in Pain and Pain Care: Combating Bias in Practice

Jennifer L. DelVentura, Ph.D., ABPP
Jennifer L. Steiner, Ph.D., ABPP

In a post in a previous issue of this newsletter, titled “Gender disparities in Pain and Pain Care,” we explored the evidence that women are not only at higher risk for pain and pain conditions but that their pain appears to be underestimated and, in some cases, undertreated compared with men’s pain. Similar patterns are evident in diagnosis and treatment of pain in racial/ethnic/SES minority patients, ranging from differences in prevalence and severity of pain in these groups to differential access to resources and pain care.

While there are many factors operating at different levels (community, institutional/systemic, familial/social, individual) contributing to these disparities, the impact of provider biases on pain care is of particular interest for us, as clinicians.  Biases are ubiquitous, often unconscious, and a normal part of human cognition, but they are not innocuous.  They may even be inconsistent with conscious beliefs—e.g., one may deny having negative beliefs about minority groups, but still evidence presence of unconscious biases in decision-making.  But importantly, with awareness and effort biases are malleable.  It is our task as ethical, caring providers to strive to minimize the impact of harmful biases on patient care.   

Using measurement tools normed for minority populations

One approach to reducing impact of biases involves using pain assessment tools normed for minority patient populations.  Even seemingly unbiased tools may be interpreted and rated differently by minority groups.  Take for example the widely-used numerical pain rating scale with verbal anchors (e.g., “moderate,” “severe” or “worst pain imaginable”) to describe pain intensity.  While these scales appear bias-free, their use rests on the assumption that we all interpret pain descriptors in the same way.  Yet this may not be true, as is demonstrated in a study by Campbell and colleagues[1], comparing pain ratings to thermal stimuli in men vs. women and white vs. black participants.  Findings indicated that when using a generic numerical pain rating scale, women and black participants rated the stimuli as significantly more painful than their counterparts.  However, when participants were allowed to individualize the rating scale by moving the verbal anchors to reflect their subjective interpretation of pain, group differences in pain ratings were no longer significant[1] suggesting group differences in how these anchors were interpreted, perhaps attributable to culture, socialization, or other factors.

The Campbell et al [1] study points to the need for measures modified for or normed to different populations.  Indeed, a few measures with such norms do exist.  For example, for psychologists, the MMPI-II-RF and Millon Behavioral Medicine Diagnostic [2], offer a multitude of specific patient group norms divided by gender (but not ethnicity).  Additionally, several behavioral measures of functioning that are commonly used by physical therapists now have more extensive norms for different populations. The unipedal stance (UPST) now has norms for age and gender [3] and several other common tests such as the timed up-and-go test and single limb stance test have established significant differences based on age [4-6].  However, most measures lack norms specific to race/ethnicity, and thus this remains an important area of development for the field of pain management.  Because such minority group norms are not widely available, it is crucial to be aware of the inherent limitations of our commonly used measures.

Provider-level strategies for managing bias

But what else can providers do to reduce impact of bias on patient care?  Social psychology research offers valuable insights into strategies for addressing biases in our work.  Based on this research, Burgess and colleagues [7] put forth a multi-step, evidence-based framework for addressing biases in healthcare, parts of which we will briefly summarize here.

First, fostering providers’ internal motivation for change is foundational to this model and involves bringing awareness to the presence of biases in our work.  This can be done using techniques like the implicit association test (IAT, [8, 9], a measure of response latency that evaluates the strength of an association between pairs of contrasting concepts and is believed to tap into implicit connections between concepts in the brain. The IAT takes advantage of the brain’s inherent tendency to pair concepts together in service of faster processing, the more closely two concepts are linked together for an individual, the faster the person should be able to respond when one component of the pair is activated in the brain. It is a computer-administered task that has been used to highlight unconscious biases or preferences for people that belong to particular social groups (race, gender, religion., etc.), however, it is important to note that there is some debate as to what the IAT actually measures, and whether implicit bias is correlated with explicit bias and/or explicit behavior [10, 11]. Nevertheless, completing an IAT for a number of variables, i.e. gender, race, size, etc. (at projectimplicit.net)[1] may offer some insight into our own associations and may inform self-reflection.

To give an example of what such an exercise might look like we invite you to consider the following sentences (adapted from the group exercise described in Holm et al., 2017) and count how many are true for you:

  • I can feel confident that others feel that I am qualified upon first impression.
  • I can speak in a roomful of medical providers and feel that I am heard.
  • My age adds to my credibility.
  • When I report pain or physical symptoms to my doctor, I can feel confident that my race or gender identification will not work against me.
  • When I report pain or physical symptoms to my doctor, I can feel confident that others will take them seriously and not assume I am motivated by secondary gain.
  • I can feel confident that if a family member requires hospital or emergency treatment they would be treated with dignity and respect even if they don’t mention my connection with the hospital.

Consider what you notice here.  How many feel true for you? And how might this reflect privilege (or lack thereof) in a healthcare environment? The intention here is not to blame or shame individuals who carry privilege, but rather to consider how this privilege might impact our experience and the quality of care we receive [7, 12].

Now, we invite you to bring to mind a patient or acquaintance with minority group affiliations (race, gender, age, SES). Then with this patient in mind, read through and consider these sentences again from this person’s perspective.  How many of these might feel true to this person?  And in turn, how might this impact actual or perceived care?  The answers and experience might be rather different in this case, and may be uncomfortable for us to consider.  Indeed, it is common for exercises like the above to elicit some negative emotions and internal discomfort (e.g., cognitive dissonance).  However, when elicited in a safe, nonjudging environment, these negative emotions can serve to motivate behavior change.  

Other strategies and considerations for providers

Other steps in the Burgess et al [7] model include increasing contact and comfort with minority groups, and facilitating perspective-taking and empathy for minority group patients—e.g., imagining situations from the patient’s perspective.  However, empathy can suffer due to stress, burnout, and time (e.g., over the course of one’s career).  Even when great strides have been made in reducing the impact of biases and increasing awareness of one’s biases, as creatures of habit we tend to regress back into old patterns if not careful.  Thus, self-care and becoming attuned to our own needs is vital to reducing bias in our work.  It is important that providers practice recognizing signs of burn-out within themselves and routinely re-assess for potential biases. At a systems level, this perhaps highlights the need for greater resources, i.e. advocating for lighter patient caseloads, more time with patients, more time for education (such as seminars or experiential trainings) of this nature both during graduate-level training and at the post-licensure level, and more.

All considered, it is important to note that perfection is neither expected nor realistic in efforts to reduce negative impacts of biases.  Rather, we should strive to reduce biases through practice of empathy, perspective-taking, awareness, and seeing patients as individuals rather than through the lens of group membership.

References

  1. Campbell, T.S., et al., Relationship of ethnicity, gender, and ambulatory blood pressure to pain sensitivity: Effects of individualized pain rating scales. The Journal of Pain, 2004. 5(3): p. 183.
  2. Millon, T., et al., Millon Behavioral Medicine Diagnostic. 2001, Minneapolis, MN: NCS Assessments.
  3. Springer, B.A., et al., Normative values for the unipedal stance test with eyes open and closed. J Geriatr Phys Ther, 2007. 30(1): p. 8-15.
  4. Hirano, K., et al., Impact of low back pain, knee pain, and timed up-and-go test on quality of life in community-living people. J Orthop Sci, 2014. 19(1): p. 164-71.
  5. Bohannon, R., Single limb stance times: a descriptive meta-analysis of data from indivdiuals at least 60 years of age. . Topics in Geriatric Rehabilitation, 2006. 22(1): p. 70-77.
  6. Steffen, T.M., T.A. Hacker, and L. Mollinger, Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther, 2002. 82(2): p. 128-37.
  7. Burgess, D., et al., Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med, 2007. 22(6): p. 882-7.
  8. Greenwald, A.G., D.E. McGhee, and J.L. Schwartz, Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol, 1998. 74(6): p. 1464-80.
  9. Nosek, B.A., A.G. Greenwald, and M.R. Banaji, Understanding and using the Implicit Association Test: II. Method variables and construct validity. Pers Soc Psychol Bull, 2005. 31(2): p. 166-80.
  10. Lane, K.A., et al., Understanding and using the implicit association test: IV. Implicit Measures of Attitudes, 2007: p. 59-102.
  11. Hofmann, W., et al., A meta-analysis on the correlation between the implicit association test and explicit self-report measures. Pers Soc Psychol Bull, 2005. 31(10): p. 1369-85.
  12. Holm, A.L., et al., Recognizing Privilege and Bias: An Interactive Exercise to Expand Health Care Providers’ Personal Awareness. Acad Med, 2017. 92(3): p. 360-364.

[1] Projectimplicit.net is run by a non-profit organization and collects the data for scientific purposes.

[2] The Cultural and Linguistic Competence Health Practitioner Assessment (CLCHPA) through the Georgetown University National Center for Cultural Competence can be found at https://nccc.georgetown.edu/assessments/.  Please note that the assessment and website are temporarily out of service for revisions

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