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Cognitive Behavioral Therapy for Chronic Pain

James L. McAbee, Ph.D.

Individuals living with chronic pain often present with myriad complaints and a decrease in quality of life driven, in many cases, by a lack of adaptive coping skills. Frequently, patients apply conventional wisdom, opting to reduce their activity levels and “resting” as a response to their pain and, in doing so, further reduce their functional capacity and involvement in daily life. These changes in behavior increase the likelihood of time spent ruminating over and brooding about their pain- “will this ever get better?”, “this might get worse”, “nothing seems to help me or my pain”, “I can’t do anything anymore”. Such thought patterns are known in the psychological literature as “Pain Catastrophizing” (Gatchel, 2017; Leung, 2012; Quartana, 2009), and are driven by fears associated with pain and a sense of helplessness/hopelessness when faced with demands to manage pain. This form of thinking leads to increased negative emotions such as anxiety and depression, which can also be influenced by decreased socialization and increased isolation. Patients can then experience physical deconditioning from inactivity and once they engage in some form of activity again they often misinterpret an increase in pain, any experience of new pain, or activity-related soreness as confirmation that that activity is “dangerous”, thus reinforcing the cycle of negative thinking and behaviors. Over time, if left untreated, this cycle leads to less time spent tending to the important territories of life, the boundaries of life shrink inward, and pain overshadows the land.

Cognitive Behavioral Therapy (CBT) is the most efficacious therapeutic intervention utilized by clinical psychologists and has been researched and validated across a multitude of diagnostic categories. CBT is a collaborative, problem-focused intervention that is intended to be delivered in a time-limited format, and which challenges the problematic thoughts/beliefs and behaviors which contribute to and/or maintain the patient’s presenting concern and negative emotions. A therapy session in this approach is more active than traditional psychotherapies and challenges the patient to make changes in both behavioral and cognitive patterns. In CBT the focus is on ‘doing’ things, not just ‘talking’ about things. CBT for Chronic Pain (CBT-CP) can help patients to break free from the chronic pain cycle, and evidence suggests that this modality of psychological intervention improves patients’ functioning and quality of life (Hoffman, Papas, Chatkoff, &Kerns, 2007; Morley, Williams, & Eccleston, 1999; Turner, Mancl, & Aaron, 2006).

As one can see in the cycle of chronic pain described above there are various entry points for intervention from a psychological perspective. In my clinical practice, the initial meeting with a patient is focused on normalizing the patient’s experience, reassuring them that they are not “crazy” nor are they meeting with a psychologist because their pain is “all in their head”, common concerns of patients referred to a pain psychologist. The information gathered via the clinical interview and the patient’s responses to screening instruments and questionnaires, their self-report of current difficulties and observations of their behavior permit more comprehensive feedback regarding the conceptualization of their situation and the opportunity to educate them about the rationale for how CBT-CP can be helpful. I find that when I reflect back to the patient my understanding of their condition (in their own words) paired with printed materials depicting the relationships of how chronic pain impacts their thoughts, feelings, and behaviors, and the cycle of chronic pain, patients are able to relate to the information, understand these connections and “see” problem areas in their lives, thus demystifying the process of treatment.

The overarching goals of CBT-CP are to promote adaptive coping by increasing self-efficacy in the management of pain, reduce avoidant behaviors, reduce “catastrophizing”, reduce negative or unhelpful beliefs about their pain, reduce negative mood symptoms, increase physical activity, to shift the perspective from pain to improved functioning, and to increase general quality of life despite having chronic pain. The intervention itself works toward achieving these goals through liberal use of psychoeducation about factors that perpetuate chronic pain and those which reduce the experience of chronic pain through the acquisition and development of adaptive coping skills. In essence, the goal of CBT-CP is to help patients reclaim the lost territories in their lives, and to have a life worth living despite chronic pain.

CBT-CP sessions are highly structured with the provider setting an agenda of important topics and specific skills to be introduced and developed during a session; however, assisting patients in the development of their own behavioral goals is equally, if not more, important. After all, the goal of CBT is to promote self-efficacy. Printed materials are always given in my practice to allow visual integration of the topics covered in session. Doing so allows patients to leave with information in hand which they can review between sessions. I find that this approach allows patients to remain connected to the material in their everyday environment and to return to the next session with any questions to be clarified. CBT-CP sessions are initially focused on increasing general activities to promote behavioral activation and increase functioning. The use of psychoeducation about how to properly pace activities without overexerting oneself (and possibly a few gentle reminders of the perils of inactivity) allow for development of specific, measurable, achievable, relevant, and time-limited goals (SMART Goals). Integration of scheduling pleasurable activities is also conducted in these early phases of treatment. In addition to increasing general activity, these “new” behaviors begin to inconspicuously challenge patients’ assumptions of “I can’t do anything”, and also begin to improve negative mood symptoms. As one patient eloquently stated, “I’m learning that I can do nothing and hurt, or I can hurt and do some things I enjoy”.

Of course, CBT would simply not be CBT without the “C”. Assisting patients to identify problematic, maladaptive, and unhelpful cognitive patterns is a critical component of the intervention. Providing patients with psychoeducation about the powerful influence thinking has on their behaviors and emotions helps to ground them in their own internal experiences and in their everyday lives. Normalizing problematic thinking can be a validating experience for patients. I always tell patients when reviewing a list of the 12 most common cognitive errors, “If you identify with these, congratulations, you have a normal brain!”. As we review the list together many patients will say, “oh yeah, I do that” and will frequently provide a recent example from their lives. However, simply identifying problematic thoughts is not enough for change to occur, it is essential to “do” something about it. The use of thought logs allows patients to identify their thoughts and beliefs about their pain in relation to a triggering event and their emotional, physical, and behavioral reactions. Once we have a “map” of this process, together the patient and provider can begin to collaboratively examine how thoughts and behaviors influence emotions and outcomes of the situation in question, and to decide what to “do” about it. Cognitive restructuring is the process of developing more balanced, adaptive, and helpful thought patterns which lead to more adaptive behaviors, reduction in negative emotions, and greater desired outcomes. Patients are then encouraged to experiment with these new patterns of thinking and behaviors to determine whether this change was effective. CBT-CP trains patients to become behavioral scientists in their own right- continuously positing hypotheses and testing new behaviors to (dis)confirm the null hypothesis.

Like any other field of healthcare, pain psychology is also concerned with significant and reliable change. In order to determine whether or not the intervention is effective, we must have a system of objective measurement. Therefore, empirical assessments of symptoms are given on an ongoing basis to track patients’ progress and to better inform treatment. Not only is CBT-CP an evidence-based practice, we generate our own practice-based evidence! These data can be utilized for various purposes in the context of treatment. For example, data can be used to challenge patients’ maladaptive beliefs that they are “not getting any better” when subjective reports of difficulties remain high despite the evidence of lower scores compared to the baseline. Equally important, it is quite validating for patients to witness positive change in their objective measures and enhances motivation for sustained behavioral change, particularly in cases where their pain scores remain unchanged, but their function and quality of life is improved.

CBT-CP is an effective intervention to complement a comprehensive approach to pain management. If you are a non-psychologist pain provider, you might find yourself asking, “how do I know that my patients are receiving ‘good’ CBT”. Aside from witnessing a change in your patients’ behaviors (i.e. increased behavioral activities, decreased “catastrophizing” talk, increased self-efficacy, improved mood), ‘good’ CBT is informed by ongoing assessment. It is important for clinicians to ask about patients’ experiences with their pain psychologist to determine the topics discussed and skills developed and ask them directly if they are routinely completing brief assessment measures and receiving feedback in treatment. I personally welcome collaboration with pain providers and encourage patients to sign release of information forms so that I can communicate with other members of the pain management team. This open communication allows for other providers to see what the patient and I are doing, and to provide them with practice-based evidence of patients’ progress. Moreover, it is helpful to hear other potential concerns that have developed over the course of treatment outside the initial referral or the patients’ reports which ought to be addressed in treatment. Speak with the psychologists to whom you refer routinely about how patients are progressing, although we “CBTer’s” are “doers”, we also enjoy talking with other providers.

References:

Gatchel, R. J., & Neblett, R. (2017). Pain Catastrophizing: What clinicians need to know. Practical Pain Management, 15(6). Retrieved from: https://www.practicalpainmanagement.com/pain/other/co-morbidities/pain-catastrophizing-what-clinicians-need-know

Hoffman, B.M., Papas, R.K., Chatkoff, D.K., & Kerns, R.D. (2007). Meta-analysis of psychological interventions for chronic low-back pain. Health Psychology, 26(1), 1-9. doi: 10.1037/0278-6133.26.1.1

Leung, L. (2012). Pain Catastrophizing: An updated review. Indian Journal of Psychological Medicine, 34(3), 204–217. http://doi.org/10.4103/0253-7176.106012

Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain, 80(1-2), 1-13. http://dx.doi.org/10.1016/S0304-3959(98)00255-3

Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review. Expert Review of Neurotherapeutics, 9(5), 745–758. http://doi.org/10.1586/ERN.09.34

Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation. Psychol. Assess., 7: 524–532.

Turner, J.A., Mancl, L., & Aaron, L.A. (2006). Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial. Pain, 121(3). 181-194.

Catastrophizing and the Meaning of Pain: Why It Matters

by David Gavel, PhD

Consider this situation: A 51-year-old pipe-welder and father of 3 was in your office this morning to hear the results of an MRI related to complaints of progressively worsening back pain. He sits down and anxiously awaits your feedback as he writhes in pain. You inform him that imaging showed the presence of degenerative disc disease and briefly explain that his condition is present in some form with more than 90% of men over the age of 50 [1], many of whom are asymptomatic [2]. Before he even asks, you explain a variety of non-invasive treatment options for managing the pain and recommend that he consider limiting or altering activities that may speed up the “wear and tear” of his back. He expresses his understanding and heads home to inform his wife that “the doc said my back is disintegrating and I’ll never be able to work again. I don’t know how we’ll survive if I can’t work.”

Notice how the news received by the wife seems to be drastically different than the words you expressed in the office. In this scenario, during your conversation with him there was no conversation about employment, specific worsening of symptoms, or any direct orders to cease and desist all meaningful activity. So, what happened? How did your objective diagnosis and empirically supported recommendations turn into a convoluted message to the wife as if it was a game of telephone at a 7-year-old slumber party? The answer is catastrophizing, and it is explained by the cognitive model.

The cognitive model [3] is a widely accepted and well published framework for understanding the crucial role that internal thoughts and attitudes play in the daily experience of emotion and behavior. More specifically, the model proposes that over the course of our lifetime, we all develop patterns of thought that influence our understanding of the world around us and the meaning we place on events in our lives. Unfortunately, these thought patterns do not always work in our favor and certain dysfunctional thinking patterns tend to underline many of our most undesirable experiences. Among these dysfunctional patterns is the aforementioned catastrophizing. In a nut shell, catastrophizing is the tendency to draw erroneous and often irrational conclusions about the severity of a current situation or to believe that a future situation will end in the worst possible way. For example, after a seven-week romantic relationship ends, a 15-year-old screams “I’ll be alone forever in a house full of cats for the rest of my life!”. Or a middle-aged employee recklessly speeds through rush hour traffic with the thought “If I’m late, I’ll be fired, and we’ll be out on the street for sure.” In both examples, the individual expresses emotions and behaviors that seem unreasonable given the reality of the situation. But that reality is distorted by the worst-case scenario (i.e., belief) that keeps running through their mind (i.e., thought). And the result is a series of undesirable emotions and behaviors.

In the management of chronic pain, catastrophizing is linked to a host of negative physical [4] and psychological outcomes [5] and is a common reason why patients sit in my office and describe how their depression began after a medical provider said “Your back is the worst I’ve ever seen,” “You’ll just have to learn to live with the pain,” or “You will never be able to…(work, play, walk, run, function)…again.” Now to be clear, I have no way of knowing whether quotes like these are the exact words used by the treating medical provider or not. In fact, it is quite likely they are not, and I would like to go on believing that way. But when a patient sits in my office for a psychological evaluation after 8 years of chronic pain that nearly ended with a recent suicide attempt, it is almost irrelevant whether these exact words were ever spoken or not. What matters most is that the patient carrying these burdensome thoughts interpreted that meaning from the situation: “life as I know it, is over.” And like a church bell clanging through the empty halls of a cathedral, this sentiment rings loud and clear inside the mind of the patient and influences every aspect of life for the worse.

Fortunately, there are a number of very effective forms of mental health treatment of chronic pain (e.g. cognitive behavioral therapy for pain) but one does not have to be a psychologist or other mental health provider to help offset some of this influence with patients. In a brief informational blog post entitled “What’s in a Word? The Power of Language in Chronic Pain Treatment,” [6] physiotherapist Carol Miller discusses the influence of language in the assessment and treatment of pain. Ms. Miller encourages providers to use language to explore and understand the patients’ subjective beliefs about pain, expectations for their treatment, and goals for the future. Asking open ended questions or using norm-referenced pain screeners (e.g., Pain Catastrophizing Scale) are two effective and brief methods for eliciting thoughtful information about the patient experience. Furthermore, she offers the idea that understanding our own beliefs about chronic pain and how those beliefs are reflected in our language can lead to more effective patient encounters. Regarding catastrophizing, Ms. Miller’s recommendations for intentional focus on language can lead to invaluable opportunities for providers to clarify any erroneous conclusions a patient may have drawn about the implications of their condition. George Orwell once remarked that “if thought corrupts language, language can also corrupt thought.” If we accept that our spoken words are the outward expression of internal thought, then we must also accept that our words carry weight that bears meaning for the thoughts and lives of our patients.

[1] Teraguchi M, Yoshimura N, Hashizume H, et al. Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study. Osteoarthritis And Cartilage. 2014;22(1):104-110. doi:10.1016/j.joca.2013.10.019.

[2] Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR American journal of neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.

[3] Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY, US: Guilford Press.

[4] Talaei KM, Fischerauer SF, Lee S, Ring D, Vranceanu A. Pain Catastrophizing Mediates the Effect of Psychological Inflexibility on Pain Intensity and Upper Extremity Physical Function in Patients with Upper Extremity Illness. Pain Practice. 2017;17(1):129-140. doi:10.1111/papr.12494.

[5] Shim E, Song Y, Park S-H, Lee K-M, Go D, Hahm B-J. Examining the Relationship Between Pain Catastrophizing and Suicide Risk in Patients with Rheumatic Disease: the Mediating Role of Depression, Perceived Social Support, and Perceived Burdensomeness. International Journal of Behavioral Medicine. 2017;24(4):501-512. http://lynx.lib.usm.edu/login?url=http://search.ebscohost.com/login.aspx? direct=true&db=s3h&AN=124131574&site=ehost-live. Accessed October 10, 2018.
[6] https://ignitephysio.ca/blog/whats-in-a-word-the-power-of-language-in-chronic-pain-treatment/

The Homebound Adolescent Headache Patient

Larry Robbins, MD and Alison Alford, MD

Introduction: Which Adolescents Should Be On Homebound?

It is not uncommon for adolescents with severe headaches to be absent from school for long periods of time. Each child is unique, with multiple variables that include: frequency and severity of headaches, response to medication, psychological make-up, history of abuse, resilience and functioning, catastrophizing, stresses and response to stress, family and friends support system, and school support. In addition, family dynamics plays a role. The parents’ psychological condition is also an important factor.  

Traditional schooling is not for every child. Many adolescents with chronic headaches function significantly better at home. They do not have to contend with a stressful, noisy, bright environment throughout the day. The goal of finishing high school, one way or another, is sometimes easier through homebound. The downsides of homebound include: the patient is at risk for isolation (as social interactions are limited), and learning high school material can be more challenging at home. The decision to go on homebound is a complex and difficult one. There are some children on homebound that should be in school. Many adolescents require a tough love approach and must be pushed to go to school. Others do best with home schooling, or primarily online education. A modified school program, with very limited hours in school, works for some. In our experience, for most on homebound, it has been the correct decision.

Frequency and Severity of The Headaches

The nature of the headaches is important. NDPH (New Onset Daily Persistent Headache) is often more difficult to treat than is transformed migraine. Pain severity is only one contributing factor towards disability (along with catastrophizing, fear of pain, psychological make-up, resilience, etc). Daily headaches are more likely to lead to homebound than are episodic migraines. Family history may provide clues. If headaches are prevalent on both sides of the family, then it is more likely that frequent or daily headaches will occur in the child.  Most homebound adolescents with headaches suffer from chronic migraine.

Medications

When the preventive medications are effective, functioning is usually improved. For many with frequent or daily migraines, preventives are not effective over the long-term. They may work reasonably well for 3 to 6 months, but the dropout rate from 6 to 12 months is significant. Side effects often limit use. Even onabotulinum toxin A (Botox) may not provide adequate relief. It helps if abortive medications are effective, but the headache patient cannot “chase” the pain all day, every day.

Choosing medications is highly individualized. Algorithms do not work. We assess previous response and side effects to medications. Family history of medication response is helpful as well. For instance, if mom brings in her daughter, Heather, and we suggest topiramate, mom may say, “Yes, topiramate was a miracle for me!” Topiramate would then be a reasonable medication for Heather, because of genetic response to medications, and also the “placebo by proxy” factor. If the mom says, “No, topiramate was horrible, it almost killed me!” then it would not be a good choice. With that response, we may incur the “nocebo by proxy” response to topiramate.

Weight issues play a role in determining medication choice, as does energy level. Fatigue is often present among those with daily headaches, and we don’t want to exacerbate tiredness with our medication.       Comorbidites drive where we go with treatment. Medical comorbidities in adolescents include various GI issues, low blood pressure, tachycardia, asthma, and others. Psychiatric comorbidities help to determine our medication choices. For anxiety and depression, the SNRIs, such as duloxetine or venlafaxine, may help both headaches and moods (assuming mild bipolar is not present). Insomnia is commonly encountered in this population, and the older tricyclics are often helpful. Certain muscle relaxants may improve insomnia and pain. SSRIs may help with moods, but usually are ineffective for headache prevention.  

Cost may be an issue with certain medications. For instance, onabotulinum toxin A (Botox) is only officially indicated age 18 and up. However, many adolescents receive Botox (off label) for chronic migraine, but it is costly. Patient preferences play a major role in choosing therapies; many patients (and their parents) want only “natural” treatments, or do not wish to take daily preventives.

Psychological Conditions

Anxiety and/or depression are conditions commonly seen in homebound adolescents. Psychotherapy is our most valuable therapy for many of the patients.  Stresses and family dynamics need to be explored. For adolescents with significant depression, the mild end of the bipolar spectrum should be considered. We do not want to prescribe antidepressants prior to assessing for the soft signs of bipolar. Soft signs of bipolarity include: early depression, positive family history, persistent agitation and anger, mild hypomanias, poor or opposite response to antidepressants (and certain other medications), mind racing, hypersomnia (insomnia may occur but is less frequent), and other traits. The family history may include severe depression, hospitalization, mania, opposite reaction to certain drugs (such as antidepressants), and abuse of drugs or alcohol. The quality of the mind racing is helpful to determine. With anxiety, minds will race with worries. The patient in the bipolar spectrum often will simply have racing thoughts, regardless of worry or anxiety. Bipolar I with manic episodes is usually easily diagnosed; it is the softer end of the bipolar spectrum that is frequently missed.

A history of abuse (physical, emotional, or sexual) as a child predisposes to chronic severe pain. A stressful childhood may influence the sensitive, developing brain chemistry. This may also predispose to psychiatric conditions as well.

Personality disorders, or personality disorder characteristics, may be diagnosed prior to age 18. For those diagnosed with personality disorders at age 16, at least 1/3 of the patients will be significantly improved by age 30. Most with personality disorders have a spectrum of traits. These include: splitting and inability to see “greys” (black and white thinking), poor sense of self, abandonment issues, anger, irritability, thin-skinned (families are “walking on eggshells”), impulsivity, self-harm, suicidal thoughts, ultra-rapid cycling of moods, lack of empathy, narcissism, drama, chaos, severe loneliness, constant spending, and other traits. We would only diagnose a probable personality disorder in an adolescent if these behaviors were moderate to severe, persistent, and pervasive. Certainly, many of these personality traits coincide with typical adolescent behaviors, but it is the severity and persistence of the behaviors that raises the possibility of a personality disorder.

Factitious disorders occasionally are encountered among homebound adolescents. True conversion disorder occurs, but is rare. Neurologic symptoms may take various forms, such as: headache, weakness or paralysis, non-epileptic seizures, motor tics, and tremors.

The psychiatric health of the parents is important.  The most difficult situations occur when a parent has a personality disorder. Mild factitious disorder by proxy (“factitious disorder imposed on another”) is occasionally present. With the mild form, the parent (usually the mother) is not actually directly poisoning the adolescent. She will drag the child to various healthcare providers, with a variety of medical complaints, including headache. The parent almost always has a personality disorder, usually borderline.  When confronted by the physician, the parent (and adolescent in tow) usually flees the office, never to be seen again. When the factitious disorder by proxy (“factitious disorder imposed on another”) is mild, a non-confrontational “dialectical by proxy” approach sometimes is effective. After high school, if we can achieve a separation of adolescent from parents, headaches and behaviors usually improve. The major problem that occurs is when both the parent and child have a personality disorder. In those situations, the patient is likely to continue living at home in a dysfunctional state, even into adulthood.

Catastrophizing and Acceptance

Catastrophizing is often a major contributor towards disability. We can, as physicians, therapists, and parents, work on “dialing down the catastrophizing dial.”  We often see “catastrophizing by proxy,” where the parent makes statements such as, “My child has severe daily headaches, nobody has pain like this, he can’t possibly go on like this…” Fear of pain, and passive (vs. active) coping, are also important contributors toward disability.

Acceptance is also an important concept. We try and work towards “acceptance, but not resignation.” Lack of acceptance by the parent (“lack of acceptance by proxy”) is frequently encountered. As with any chronic pain condition, accepting that there is not a miracle “aha moment cure” is important. Lack of acceptance leads to a constant search for the magic cure, and can result in visits to many various types of providers. The road to acceptance may take various pathways. Along with acceptance, we also emphasize that the headaches are very treatable, and may improve or resolve naturally.

Resilience and Coping

Resilience often has an underlying genetic basis. The serotonin transporter gene has 2 “arms,” short or long. Each person has 2 “arms.” Two long arms predicts a tendency towards higher resilience. Two short arms often leads to a lower level of resilience. Tests for long arm-short arm of this gene are commercially available. The genetic basis for resilience has been studied mostly in the setting of moderate to severe childhood stress or abuse. Various psychological conditions also play a major role in resilience. In addition, modeling of resilience (or lack thereof) by the parents is important.  

Resilience and coping vary widely among adolescents. One patient may have severe stress at home, severe 24/7 headaches, and never miss a day of school. The next person may have mild pain, and be out of school for years. We don’t want to “punish” adolescents for their lack of resilience or coping. However, improving coping is always a major goal. We usually need to have the patient, physicians, therapists, teachers, and parents all working together. As with adults on disability, improving coping is not easily accomplished.

Active coping is a key, along with improving self-efficacy. We must encourage coping strategies outside of simply taking medication. These include seeing therapists, exercise, meditation, etc.

It Takes A Village

While medications may be important, it’s also important that we take a multidisciplinary approach. Individual psychotherapy is often our most effective tool for helping the adolescent patient. Therapists may help with the usual adolescent stresses, coping, insomnia, and family issues. Parents and siblings are profoundly affected by the adolescent with chronic pain. Family therapy may be beneficial. Not all adolescents, or parents, are ready for psychotherapy. Sometimes it takes repeated efforts to convince the family of the benefits of therapy.

Physical therapists can be helpful with posterior head pain, or with associated neck or back pain. Working on posture, stretching, and exercise is important.

Biofeedback is time intensive and expensive, but may be very helpful. Meditation is easier to learn, and may be more accessible for patients than biofeedback. For the patient with sleep issues, working on “sleep rules” and improving sleep may benefit mood and headache.

We are not simply treating one child in isolation. Along with the family, we are also working with the school. Teachers and school staff are important “villagers” in our multidisciplinary approach. 

Returning To School

When a homebound child returns to school, it is helpful to ease back slowly. Late starts, shortened days and no gym(or limited physical activity) may help. Extra time on exams may be appropriate. If the adolescent is at least willing to return to school part time, we will do our part and help to facilitate the return.  A 504 medical plan may help.  Permission to leave class early may minimize exposure to loud noise. Eating lunch in an alternative location may minimize the loud noises. Some students find sunglasses, usually a mild tint, to be very beneficial.  For students on homebound, some communities offer select classes off-site, with a small group of students. This small setting may also work for science lab classes. It may take a combination of home schooling, part time regular high school, and summer classes as well.  The primary goal is to achieve a high school degree, either through the local high school, or via the GED.

Conclusion

 Our approach with refractory adolescent headache patients has evolved over time. While the “tough love” approach is best for a minority of patients, many adolescents do well with partial or full homebound programs. It “takes a village,” and we favor a multidisciplinary approach. Once high school is finished, most adolescent headache patients improve and do fairly well.

Author’s Bio:  Lawrence Robbins, M.D. is the author of 5 headache books. The latest is “Advanced Headache Therapy.” He has had 320 articles/abstracts published. Dr. Robbins is in private headache practice in Riverwoods, Ill.  Web:  Chicagoheadacheclinic.com

Alison Alford, M.D. is a board certified pediatric headache specialist in Richmond, VA. She has co-authored a chapter in Pediatric Epilepsy (subject=felbamate) by Pellock, et al.   Dr. Alford is in private practice at the Pediatric Headache Center of Richmond. Pediatricheadachecenter.com

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  1. Milde-Busch, A., Boneberger, A., Heinrich, S., Thomas, S., Kuhnlein, A., Radon, K., Straube, A., von Kries, R. Higher prevalence of psychopathological symptoms in adolescents with headache. A population-based cross-sectional study. Headache (2010), 15:738-748. doi: 10.1111/j.1526-4610.2009.01605.x.
  1. Bellini, B., Arruda, M., Cescut, A., Saulle, C., Persico, A., Carotenuto, M. … Guidetti, V. Headache and comorbidity in children and adolescents. Headache Pain (2013), 14, 79. doi: 10.1186/1129-2377-14-79.
  1. Arruda, M.A., Bigal, M.E. Behavioral and emotional symptoms and primary headaches in children: A population-based study. Cephalalgia (2012), 14, 1093-1100. doi: 10.1177/0333102412454226.
  1. Bruijin, J., Locher, H., Passchier, J., Dijkstra, N., Arts, W.F. Psychopathology in children and adolescents with migraine in clinical studies: A systemic review. Pediatrics (2010), 14, 323-332. doi: 10.1542/peds.2009-3293.
  1. Brazelon, E. A question of resilience. New York Times Magazine, April 30, 2006.

Is Compassion Fatigue the Adversary of Compassionate Pain Management?

Ann Quinlan-Colwell, PhD, RNC, AHNBC, DAAPM

In the last newsletter, compassion was discussed as the possible ghost of pain management.  Intrinsic in that possible relationship is the potential ingredient known as compassion fatigue which is described by Sinclair and colleagues (2017) as “a work-related stress response in healthcare providers that is considered a ‘cost of caring’ and a key contributor to the loss of compassion in healthcare.”   The stress response involved in compassion fatigue is believed to evolve while caring for patients, clinicians repeatedly experience, in a secondary manner, the traumatic events and/or suffering of patients.  Although, there is no identified theoretical basis, empirical validation or measurement, there is general consensus that compassion fatigue is real and does clinically exist internationally (Sinclair et al, 2017).  It is certain that for a clinician to experience compassion fatigue, the clinician must first have compassion and experience compassion with patients. Ironically, the terminal result of compassion fatigue is that such an originally compassionate caregiver, no longer feels empathic or nurturing toward others, and no longer feels energetic or enthusiastic about the profession once so loved.

The term was first used in 1992 by a nurse educator, C. Joinson, who coined the term compassion fatigue to describe the burnout she observed among healthcare providers.  Today, although compassion fatigue is at times considered a branch of burnout (Sabo, 2011), it is generally considered different from burnout (Lanier, 2017).  In 1995, Dr. Charles Figley (Tulane University) described compassion fatigue occurring as the result of secondary traumatic stress occurring among caregivers when caring for people who are suffering as a result of a traumatic event.  He described the secondary traumatic stress/compassion fatigue as being similar to the post traumatic stress disorder (PTSD) experienced by the traumatized person.  In fact, the symptoms attributed to PTSD and compassion fatigue are remarkably similar (See Table 1). 

Table 1

Post Traumatic Stress Disorder Symptoms

Compassion Fatigue Symptoms

   

Upsetting thoughts

Intrusive thoughts

Irritable

Irritability

Flashbacks

Traumatic memories

Upset by memories

Anger

Trouble sleeping

Insomnia or difficulty sleeping

Nightmares

Nightmares

Concentration difficulties

Difficulty concentrating or focusing

Jumpy

Startle reactions

Overly careful

Hypervigilant

Emotional distance

Patient/client avoidance

Overly careful

Self-doubt and questioning self

Loss of interest

Depressed mood

Avoid activities

Isolating self

Memory difficulties

 

Taken from:

Foa, Johnson, Feeny, & Treadwell, (2001).

Taken from:

Fidley, 1995; Fidley, 2002; Sabo, 2011; Sinclair, et al, 2017

Figley defined compassion fatigue “as a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e.g. anxiety) associated with the patients … a function of bearing witness to the suffering of others”  (Figley, 2002, p. 1435).  The Compassion Fatigue Self Test of Psychotherapists was developed by Figley and later adapted by others with one version adapted with the permission of Figley available via http://www.community-networks.ca/wp-content/uploads/2015/07/Self-Assessment-Tools-Compassion-Fatigue-Feb-22-2010.pdf   In his Compassion Stress and Fatigue Model, Figley (1995, 1997, 2002) described ten variables which combine to result in compassion fatigue and which can be modified to avoid or mediate the development or experience.  The ten variables are listed in Table 2 along with a brief description of each one.

Table 2 Variables of Figley Compassion Stress and Fatigue Model

Model Variable

Description  of variable

Empathic ability

The ability to appreciate pain in another person.

Empathic concern

The impetus to respond to the pain of another person.

Exposure to the patient

Directly being exposed to and experiencing the emotional energy of the suffering person.

Empathic Response

Using insight to share the perspective of the suffering person in an effort to ease the pain and suffering of the person.

Compassion Stress

The effect of the energy expending during the empathic response which can result in negative effects on the well- being of the caregiver.

Sense of Achievement

The satisfaction with compassionate efforts that are experienced by the caregiver who has clear boundaries and concepts of responsibility. 

This variable is protective against compassion fatigue and promotes compassion satisfaction.

Disengagement

The ability, between encounters, to put space between self and the suffering patient and let go of the qualities associated with the suffering experience.  It also involves the clinician in fully engaging in his or her own life. 

When utilized this variable also is protective against compassion fatigue. 

Prolonged Exposure

Over time the persistent belief of responsibility for the person and the associated suffering.  The more intense the exposure with limited interruptions the greater the compassion fatigue.

Traumatic Recollections

These are memories of other experiences or the experiences of other patients which trigger emotional and stressful reactions (i.e. anxiety or depression).

Life Disruption

The unanticipated events that necessitate change in routine or schedule which normally occur in life.  However, when combined with the other variables, the likelihood of compassion fatigue developing increases.

 

Taken from: Figley, 2002, pp. 1436 – 1438.

Although the concept descriptor, compassion fatigue, was only coined 25 years ago, compassion fatigue is now considered an occupational hazard of health care workers (Mathieu, 2012).  Estimates of prevalence range as high as 40% in Intensive Care Units (van Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015).  Not only is it a general occupational hazard, but among clinicians who strive not only to do well, but to at all times to do their best,  Figley noted it is a “disorder that affects those who do their work well” (Figley, 1995, p. 5).  Traumatologist Eric Gentry proposed that many who enter caregiving professions suffer from compassion fatigued prior to even starting their profession because they previously learned to care for others rather than learning to care for self (Lanier, 2017).

Equipped with this knowledge, it seems reasonable to conclude there is an ethical responsibility to educate those who are at greatest risk (i.e. all clinicians) to be able to empathically and compassionately care for patients while promoting compassionate satisfaction and preventing compassion fatigue.  As a first step in addressing this responsibility, the next segment of this series will address the concept of self-compassion and the final segment will discuss restoring compassion in the work of pain management.  Now that you have read about the dilemma, hopefully, you will return to read about viable resolutions.

 

References

Abendroth, M., (Jan 31, 2011) “Overview and Summary: Compassion Fatigue: Caregivers at Risk” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Overview and Summary. DOI: 10.3912/OJIN.Vol16No01OS01

Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge.

Figley, C.R. (1997). Burnout in families: The systemic costs of caring. Boca Raton: CRC Press

Figley, C. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Psychotherapy in Practice, 58(11), 1433-1441.

Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376-384.

Gentry, J. E..  Baranowsky, A. & Dunning,   (1997).  Compassion Fatigue Article: Accelerated Recovery Program (ARP) for compassion fatigue.  Traumatology Institute. Online Training for Trauma Professionals.

Joinson, C. (1992). Coping with compassion fatigue. Nursing 22(4), 116-122.

Lanier, J. (2017).  Running on empty: Compassion fatigue in nurses and non-professional caregivers. The Bulletin Indiana State Nurses Association, 44(1), 10-14.

Mathieu, F. (2012). The Compassion Fatigue Workbook. NY, NY: Taylor and Francis Group.

Sabo, B., (Jan 31, 2011) “Reflecting on the Concept of Compassion Fatigue” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 1. DOI: 10.3912/OJIN.Vol16No01Man01

Sinclair, S., Raffin-Bouchal, S., Venturato, L., Mijovic-Kondejewski, J., & Smith-MacDonald, L. (2017). Compassion fatigue: A meta-narrative review of the healthcare literature. International Journal of Nursing Studies, 69, 9-24.

Todaro-Franceschi V.  (2013). Compassion Fatigue and Burnout in Nursing New York, NY: Springer Publishing Company.  ISBN: 978-0826109774

van Mol, M. M., Kompanje, E. J., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PloS one, 10(8), e0136955.

Is Compassion the Ghost of Pain Management?

by Ann Quinlan-Colwell, PhD, RNC, AHNBC, DAAPM

Twenty years ago, when she read my holistic tee shirt with the numbers “2 + 2 = 5” the young store clerk smiled and confided “I wasn’t good at math either.”  That tee shirt exemplified the holistic concept: the whole is greater than the sum of the parts. That holistic concept is particularly true when working with people with pain management.  Historically, the interactions between health care providers and patients involved a therapeutic component that enhanced the beneficial effect of the medications and treatments which were provided (Decety & Fotopoulou, 2015).  Today, when they sense empathy and compassion from clinicians, patients continue to report greater satisfaction, less anxiety, and feeling safer, with improved outcomes demonstrated (Dempsey, 2018; Quinlan-Colwell, 2009; Vogus & McClelland, 2016). 

The term and concept of compassion are discussed frequently in health care.  Although no definition for the word compassion is provided in the 10th Edition of the Mosby Medical Dictionary, in that resource, compassion is listed as a component of “ego strength”,  “emotional support”, “nursing assessment”, being “sympathetic”, and “waking imagined analgesia” (envisioning and focusing on an enjoyable past experience).  Nursing theorist Delores Krieger teaches that compassion is not only essential for working with someone using the energetic modality of Therapeutic Touch®, but that without compassion Therapeutic Touch® is not possible. 

Although compassion clearly is important in health care, it is often poorly understood or even misunderstood.  To effectively discuss compassion, it is essential to understand what it is and what it is not. As with pain, compassion is multifaceted with various components and supported by a number of theoretical positions (Goetz, Keltner, & Simon-Thomas, 2010). The Merriam Webster Dictionary defines compassion as “sympathetic consciousness of others’ distress together with a desire to alleviate it” (N.A., 2018).  Merriam Webster also defines sympathy as  “feelings of pity and sorrow for someone else’s misfortune,” and defines empathy as “the ability to understand and share the feelings of another.”  With all due respect to Merriam Webster, considering those definitions, I suggest that compassion is not “sympathetic consciousness of other’s distress,” but rather it is conscious awareness of another’s distress together with concern for the other and a desire to alleviate the distress.  This definition is essentially consistent with Goetz and colleagues definition of “compassion as the feeling that arises in witnessing another’s suffering and motivates a subsequent desire to help“ (2010, p. 352). 

Thus, with compassion there is not only a conscious awareness of the distress of another, but there is also caring about the pain and suffering of another combined with communication of that concern, with an impetus to ease the suffering and improve the status of the other.  It is that desire and stimulus to help the other which especially distinguishes compassion from empathy (Chierchia & Singer, 2017).  Thus, it is manifesting the emotion or experience of compassion into a therapeutic response/action which distinguishes compassion as a particularly unique trait or emotion different from other emotions.

Even though it can be associated with and related to love, anguish or sadness, from an evolutionary perspective, compassion is a particular emotion or state unlike love, anguish or sadness (Goetz, Keltner, & Simon-Thomas, 2010; Kagan, 2014).  It is an innate aptitude which has been refined in the brains of mammals to facilitate a particular connection with others for the purpose of survival (Decety & Fotopoulou, 2015; Goetz, Keltner, & Simon-Thomas, 2010; Kagan, 2014; Wright & Pendry, 2016).  Compassion is not a quality unique to humans, which is well known by humans who live with animals.   It is most likely the very rare person who lives with animal pets who has not experienced his or her pet acting with compassion when the owner was ill, injured, grieving or emotionally distressed.  Compassion is the source and reason why the healthy and informed members of a group or society care for those who are vulnerable.  Compassion then is first experienced with the care received as infants, and that compassion conveys senses of trust and mutuality which support meaningful relationships (Goetz, Keltner, & Simon-Thomas, 2010).  In health care compassion not only facilitates, but is essential for healing, and was described by Delores Krieger as being the quality “that powers the engine of a healing relationship” (Hanley, Coppa, & Shields, 2017, p. 375).

Today, that aged holistic tee shirt is a reminder that good health care and effective pain management are more than just writing a prescription or administering a pill or administering a therapy, or providing education.  Compassion is a basic premise of health care and the reason for working with people living with pain, it is how 2 + 2 becomes 5.  Too often patients living with pain feel undertreated, frustrated, labelled, and judged, while health care providers feel frustrated and burned out, and  while health care system leaders feel they need to acquiesce to electronic medical record documentation, time constraints, government regulations and accreditation agencies. As a result, too often the whole seems even less than the sum of the parts (2 + 2 = 3) with medications and treatments not working as well as expected.

Although the majority of  patients and health care providers believe compassion is a critical component of health care, many believe it is often missing in U.S. health care today which led to the identification of a current compassion crisis (Trzeciak, Roberts, & Mazzarelli, 2017). It is curious to ponder whether it is just an interesting coincidence that this compassion crisis is co-occurring at the same time as the opioid crisis or if rather there is a correlation between the two crises. Today, compassion often seems to be the ghost of pain management begging to be re-actualized to enhance pain management and make the whole analgesic effect greater than the sum of the parts. 

This is the first of a series of explorations of compassion in pan management. The next segment will be a discussion of compassion fatigue followed by developing self compassion and finally the importance of restoring compassion in the work of pain management.

 REFERENCES

Burnell, L. (2009). Compassionate care: A concept analysis. Home Health Care Management & Practice, 21(5), 319-324.

Chierchia, G., & Singer, T. (2017). The Neuroscience of Compassion and Empathy and Their Link to Prosocial Motivation and Behavior. In Decision Neuroscience (pp. 247-257).

Decety, J., & Cowell, J. M. (2014). The complex relation between morality and empathy. Trends in Cognitive Sciences, 18(7), 337-339.

Decety, J., & Fotopoulou, A. (2015). Why empathy has a beneficial impact on others in medicine: unifying theories. Frontiers in Behavioral Neuroscience, 8, 457.

Dempsey, C. (2018). The Antidote to Suffering: How Compassionate and Connected Care Can Improve Safety, Quality, and Experience. NY, NY: McGraw Hill.

Goetz, J. L., Keltner, D., & Simon-Thomas, E. (2010). Compassion: an evolutionary analysis and empirical review. Psychological bulletin, 136(3), 351-374

Hanley, M. A., Coppa, D., & Shields, D. (2017). A Practice-Based Theory of Healing Through Therapeutic Touch: Advancing Holistic Nursing Practice. Journal of Holistic Nursing, 35(4), 369-381.

Kagan, S. H. (2014). Compassion. Geriatric Nursing, 35(1), 69-70.

No Author (N.A.). (2018).  Compassion. Merriam-Webster Dictionary. https://www.merriam-webster.com/dictionary/compassion.  Retrieved

Quinlan-Colwell, A. D. (2009). Understanding the paradox of patient pain and patient satisfaction. Journal of Holistic Nursing, 27(3), 177-182.

Trzeciak, S., Roberts, B. W., & Mazzarelli, A. J. (2017). Compassionomics: Hypothesis and experimental approach. Medical hypotheses, 107, 92-97.

Vogus, T. J., & McClelland, L. E. (2016). When the customer is the patient: Lessons from healthcare research on patient satisfaction and service quality ratings. Human Resource Management Review, 26(1), 37-49.

Wright, V., & Pendry, B. (2016). Compassion and its role in the clinical encounter–An argument for compassion training. Journal of Herbal Medicine, 6(4), 198-203.

Atlanta 2018–Our Most Relevant Conference

by Mordecai Potash, MD

Barely a week goes by without me seeing at least one, and often multiple, mainstream news articles about the practice of pain management. Just the other day, there were a number of stories about a huge federal multi-state crackdown on what was called “rogue prescribing” of opiate pain medications by 76 doctors which led to them being arrested and charged with fraud and a long list of other charges [1]. Earlier in the month, I read an article about a dramatic increase in raids of offices of doctors who prescribe buprenorphine to treat opiate dependence [2]. Those targeted by that set of raids included a past-president of the American Society of Addiction Medicine and other nationally prominent specialists in opiate dependence.

In the past I would reassure myself that I would not be “raided” or even audited because I did right by my patients – taking my time to interact with them and create a treatment plan that was updated at each visit. Now, I am far less sure that doing this good care and good documentation will protect me from being raided by the DEA or other federal agencies that have been involved in this on-going national crackdown on prescribers of opiate medications [3].

If there is one thing these articles have confirmed to me, it is that the planning committee of the Southern Pain Society (SPS) has assembled  an incredibly relevant program for our annual meeting. David M. Vaughn, Esq., CPC, is going to speak about Recent Government Audit Areas for Pain Management which should give us some insight into what federal regulators are considering before they generate an audit in these turbulent times in pain management.

A few of the doctors interviewed in these articles point to the CDC Opioid Guidelines as a benchmark goal they are trying to get their patients to achieve. For example, they are trying to get all their patients off opioid and benzodiazepam combinations and get all their patients on opioid doses of 90 milligram morphine equivalents or less. The SPS conference will feature Sanford M. Silverman, MD, addressing CDC Guidelines: Be Careful What You Wish For. Dr. Silverman will undoubtably give an expert critique of how the guidelines have been applied to direct patient care since they were released one and a half years ago.

I am very happy that we are going to feature a talk on medical / therapeutic marijuana by James Taylor, MD, titled Hemp, Hemp Hurray! Could Medical Hemp be a solution to the Opioid Crisis? I am even happier that we have this relevant talk considering that some other prominent national pain organizations have recently been compelled to cancel their own talks on medical marijuana [4].

We will also feature other speakers who will examine the turbulent environment in pain management presently. We will feature Kate M. Nicholson, JD, talking about Treatment Under Pressure: A Patient and Policy Perspective. Also featured will be Daniel F.  Lonergan, MD, who will address Managing Chronic Pain in an Opioid Epidemic Environment. I am truly looking forward to both these talks because hardly a day goes by that I do not think about the changes in pain policies that are afoot in state and national levels and how do I manage pain compassionately in an environment that increasingly sees all opioid prescribing as contributing to a national epidemic.

If these topics aren’t enough to convince you to register now for SPS 2018, let me also point out that we have not one but two talks from David Hanscom, M.D., of the Swedish Neuroscience Institute. Dr. Hanscom was our star at last years’ successful conference and is going to discuss two topics at this year’s meeting: The Myth of Back Pain Surgery: What We Know vs. What We Are Doing and Solving Chronic Pain with a Self-directed Structured Approach.

If for some crazy reason that is still not enough reason to make your reservations for our SPS 2018 conference, right now, let me remind you that the national media is well documenting efforts to bring new, non-opioid, pain management treatments to market [5]. We are going to highlight the role of neuromodulation to bring attention to new treatments available to fight pain when B Todd Sitzman, MD, MPH, talks on Advance Techniques in Neuromodulation.

So, I hope my column has convinced you to join us in the great city of Atlanta for SPS 2018 because we have assembled an incredibly relevant conference. Never have the pressures in pain management felt so compelling and urgent and therefore, there has never been a greater reason to educate yourself on how to apply best policies to your own practice. We have put together a conference that will do exactly that. The only thing missing is for you  to send in your reservation confirming that you will join us, as we explore the shifting paradigm of safe and effective pain management for all!

See you in Atlanta!

– Mordi

[1] https://www.washingtonpost.com/world/national-security/more-than-600-charged-in-nations-largest-heath-care-fraud-investigation/2018/06/28/fe45113a-7ae3-11e8-93cc-6d3beccdd7a3_story.html?noredirect=on&utm_term=.bcb6db69bc38

[2] https://tonic.vice.com/en_us/article/8xevwb/dea-raids-addiction-doctors

[3] https://www.nbcdfw.com/news/local/Dallas-Physician-Operator-Arrested-For-Largest-Health-Care-Fraud-Scheme-in-DOJ-History-486996811.html

[4] https://abcnews.go.com/Health/wireStory/pain-medicine-group-cancels-doctor-training-marijuana-56072497

[5] http://www.businessinsider.com/pharmaceutical-companies-developing-non-opioid-pain-medications-2018-6

CGRP Antagonists: Long-term Side Effects

    by  Lawrence Robbins, M.D.

 (Note: this article will be published in full in Practicalpainmanagment.com)

 INTRODUCTION: The monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) are a valuable addition to our preventives. However, there are significant conceivable long-term adverse effects associated with them. We will have a better feel for the true risks in 10 years. For each patient, we have to decide whether the benefits outweigh the possible risks. With luck, it may come to pass that the biologics targeting CGRP carry very few long-term risks. Certainly, these have been safe compounds for the short-term.  Three- year safety data has recently been presented. This paper discusses some of the possible long-term issues, concerns, and questions.

 CARDIOVASCULAR AND PULMONARY SYSTEM:   

  1. CGRP plays an important role in resisting the onset of hypertension (HTN); how relevant is this when prescribing to young patients, particularly those at higher risk for HTN? How much does vascular dilation redundancy matter (with other vasodilator mediators, such as PGs and NO, compensating for the loss of CGRP)?
  2. With the onset of HTN, there is a compensatory release of CGRP: how relevant is this, and what effects do the antagonists have? In the face of HTN, CGRP release may become attenuated over time.
  3. CGRP may delay or protect against the development of C-V disease. For which patients is this relevant?
  4. CGRP depletion may produce oxidative stress in the aorta; how clinically relevant is this?
  5. If CGRP is knocked out, and the vasodilator effects are diminished, do other compounds (nitrous oxide, substance P, prostaglandins) help to compensate (primarily at the resistance vessel level)?
  6. We need angiographic (and other) studies in patients with CAD, ideally prior to and after treatment with the antagonist. Are further studies planned?
  7. Could smaller cardiac or cerebral infarcts become more dangerous resulting from the protective effects of CGRP being blocked? CGRP protects against ischemia, cell death, and vascular inflammation in various organs (heart, brain, GI, kidney).
  8. CGRP plays a role in heart failure. Infusion of CGRP improves circulation in the face of heart disease. Regarding microvascular growth, CGRP is an angiogenic facilitator. Should patients at high risk for failure, or with actual heart failure, not be prescribed these medications?
  9. There is evidence that CGRP helps to protect the heart, and this effect is lessened in the presence of diabetes. For patients with both diabetes and CAD, should CGRP inhibitors be withheld?
  10. CGRP levels decline with age (although there may be a bimodal effect) and CGRP helps to protect the myocardium; should CGRP inhibitors be withheld in older patients, particularly for those with heart disease?
  11. Do the Amylin 1 receptors (or other calcitonin-group receptors) help to “cover” for the loss of beneficial effects, particularly vasodilatory, after the blocking of CGRP?
  12. With regards to the C-V system, is there a difference between antagonizing the ligand of CGRP, and blocking the receptor?
  13. Regarding advanced CAD, how important is CGRP as a vasodilator? CGRP levels are increased during myocardial infarction. Could antagonizing CGRP lead to a more severe infarct? There was an erenumab study of 90 patients with stable angina, who were given 140mg IV as a one-time dose. There were no problems found in the 3 months post-infusion. Are there further studies planned?
  14. How clinically relevant is CGRP in the cerebral vasculature?
  15. Is CGRP a vasodilator in both smaller and larger cerebral arteries?
  16. CGRP and pulmonary HTN: CGRP is abundant in the lung; for high- risk individuals, would blocking CGRP increase the chance of developing pulmonary HTN?

CENTRAL NERVOUS SYSTEM (Within the Blood Brain Barrier):

  1. There is slight penetration of these large molecule mAbs into the CNS, from 0.1% to 1%; is this clinically relevant as to MOA of the mAbs? Probably not, but certainly it is possible.
  2. Botox does undergo transcytosis (tracking along the axon from the trigeminal ganglion, into the brainstem): does this occur with mAbs? Most likely it does not, but it may happen to a small degree. Radioisotope studies to identify elements of the mAb in the brainstem would be helpful.
  3. How effectively does the peripheral (trigeminal ganglion) effects of the mAb dampen down central sensitization, and/or cortical spreading depression?

CENTRAL NERVOUS SYSTEM (Outside of the Blood Brain Barrier):

  1. The anterior pituitary contains CGRP. Evidence exists indicating that CGRP may play some role in stimulating ACTH. What is the possible effects on CGRP antagonism for the various hormones (GH, TSH, FSH, LH, ACTH, MSTH, and prolactin)? Should we be hesitant to prescribe for adolescents(off-label), due to possible effects on growth hormone? Should we measure hormone levels in those adolescents prescribed the mAbs?
  2. We do not know about the effect on those with thyroid disease: Should the mAbs be used with caution in those with thyroid disease?
  3. Should studies be done evaluating FSH, LH, and ACTH levels before and after these antagonists?
  4. What is the effect on prolactin? Should those with pituitary microadenomas be restricted from use?
  5. Might there be an effect on melatonin levels?
  6. The choroid plexus: could CGRP knockout affect CSF production? Would the CSF inflammatory homeostasis, partially controlled by the choroid plexus, be affected? Can this be evaluated?
  7. The median eminence: could CGRP knockout affect hypothalamic hormone release (of CRF, TRH, DA, GHRH, and GnRH)? Should these be tested?
  8. Area postrema (part of the circumventricular organs): would regulation of nausea/vomiting be affected?

 GASTROINTENSTINAL SYSTEM: 

  1. (beta) CGRP is primarily present in the GI system (versus alpha CGRP), and CGRP is important for mucosal protection. What is the effect of antagonizing CGRP on the GI mucosa?
  2. CGRP is involved in the healing of GI ulcers. Should antagonists be restricted for those with ulcers?
  3. For those with, or at high risk for, Inflammatory Bowel Disease (IBD), should these antagonists be restricted?
  4. CGRP acts in a biphasic manner on GI motility. Should the antagonists be used with caution for those with moderate or severe IBS?

SKIN, WOUND HEALING, BURNS, AND BONE HEALTH:

  1. CGRP contributes to flushing and thermoregulation; what are the effects of blocking CGRP on these functions?
  2. What clinical effect results from dampening the CGRP effects on local skin edema and itch? CGRP can inhibit allergic conditions, such as certain types of dermatitis (irritant dermatitis). What effects on dermatitis might be seen by inhibiting CGRP?
  3. CGRP facilitates tissue repair and wound healing. These effects are mediated via vasodilation, upregulating VEGF expression, and by limiting inflammatory processes. CGRP also promotes revascularization. What effect does blocking CGRP have on wound healing?
  4. CGRP plays some role in regeneration of the skin, via promoting proliferation of keratinocytes. Will skin be able to regenerate as well after CGRP is diminished?
  5. For those with burns, CGRP and SP facilitate acute edema formation. What is the clinical relevance of knocking out CGRP for those with more severe burns?
  6. CGRP may regulate bone metabolism through stimulation of osteoblastic differentiation, as well as an effect on osteoclastic formation. Amylin and calcitonin are also vital for bone health. Might the CGRP antagonists inhibit normal bone growth and metabolism? Does diminishing CGRP play a role in healing of bone?

RENAL, SEPSIS, DIABETES/OBESITY:

  1. Renal effects: during dialysis, CGRP levels are raised, possibly as a defense mechanism. How does antagonizing CGRP affect the person undergoing dialysis? CGRP may protect against renal damage in certain pathological conditions. In light of kidney disease, should the CGRP antagonists be used sparingly?
  2. CGRP levels are raised during sepsis. If a patient on an antagonist becomes septic, would the therapy change?
  3. CGRP is active within the pancreas and is involved with the regulation of insulin release; the effect may be to reduce insulin levels, which (in theory) may result in hyperglycemia. Would antagonizing CGRP theoretically help with diabetes?
  4. CGRP knockout may affect metabolism, energy use, and body weight. Could the CGRP mAbs affect body weight? Could this be included in long-term post-approval studies?

PREGNANCY, ARTHRITIS AND OTHER PAINS, AND AGING:

  1. Early in pregnancy, CGRP levels are minimal in the fetus: what are the risks if CGRP antagonists are given prior to pregnancy? Later in pregnancy, CGRP may play a role in mediating the adrenal glucocorticoid response to acute stress in the more mature fetus. Circulating CGRP levels (in the mother) are increased during pregnancy, peaking in the last trimester. CGRP levels are lower with pre-eclampsia. There was a prenatal and postnatal study in monkeys with erenumab. The animals received 50mg/kg of erenumab every 2 weeks. No effects were apparent on the fetus or infant, with regards to growth and development. The follow-up was through 6 months after delivery.  Towards the end of pregnancy, CGRP plays a role in cervical ripening, and is present in the placenta and fetus: how would lessening CGRP affect the latter stages of pregnancy? Could a CGRP mAb render it more difficult to become pregnant?  Do the mAbs affect sperm in any fashion? There is a CGRP pregnancy registry that is being organized: is it coordinated among the various companies, and how does one access it?
  2. Arthritis: could CGRP antagonism possibly help with rheumatoid or osteoarthritis? How about other pain syndromes, such as fibromyalgia, or peripheral neuropathy? What is the state of studies for these conditions?
  3. CGRP levels may decline as one ages, although circulating levels may be increased in certain individuals. There may be a bimodal effect. Would the mAbs have more (or less) risk at age 70? At age 85 or 90?

MISCELLANEOUS ISSUES:

  1. The receptor occupancy of erenumab is approximately 89%. The blocking of the CGRP ligand (by the other 3 mAbs) is approximately 85%. Do these occupancy levels steadily decline over the weeks/months, or is there a precipitous fall off at some point? Is this clinically relevant
  2. Nerve growth factor (NGF) influences CGRP. What clinical relevance, if any, does NGF have regarding the mAbs? Also, TRPV1 agonists may help to regulate CGRP; what is the importance of this?
  3. Differences between the ligand antagonists (3 compounds in development) and the receptor antagonist (one is on the market): receptors (that CGRP may attach to) other than the CGRP receptor may compensate for loss of the CGRP receptor; on the other hand, antibodies directed at the ligand of CGRP would also block the effects at the other (particularly AMY 1) receptors. What is the clinical relevance of these differences between the ligand and the receptor antagonist?
  4. With other meds (example: methysergide), we had patients take a “drug holiday” every 6 months. Does that make sense with these CGRP antagonists, at least until we are sure of long-term safety? Would doing this produce more antibodies, after re-introduction? There would also be the risk that, after re-introduction, the mAb would not be as effective.
  5. Informed consent: should we obtain this from patients? (I think we should.) What should we put in the informed consent?
  6. Monitoring of adverse events: we should encourage reporting to the company or to the FDA. As with a pooled pregnancy registry, are there any plans for a pooled “mAb” adverse event registry?
  7. Should we develop a “CGRP Antagonist Risk Assessment Scale”?

BIBLIOGRAPHY

  1. Russell, F., King, S., Smillie, J., Kodji,X., Brain,S. Calcitonin gene-related peptide: physiology and pathophysiology.  Physiol Review.  2014  94: 1099-1142.
  2. Iyengar,S., Ossipov,M., Johnson,K.   The role of calcitonin gene-related peptide in peripheral and central pain mechanisms including migraine Pain.  2017 Apr; 158(4): 543-559.
  3. Edvinsson,L. The trigeminovascular pathway: role of CGRP and CGRP receptors in migraine headache. 2017  57:47-55.
  4. Deen,M, Correnit,E., et al. Blocking CGRP in migraine patients- a review of pros and cons.  The Journal of Headache and Pain.  2017  18:96.
  5. Walker,C., Hay, D. CGRP in the trigeminovascular system: a role for CGRP, adrenomedullin and amylin receptors?  British Journal of Pharmacology.  2013 170: 1293-1307.
  6. Benemei,S., Nicoletti,P., Capone,J., Geppetti,P. CGRP receptors in the control of pain and inflammation.  Current Opinion in Pharmacology. 2009 9:9-14.

Thrown Off the Pendulum

by Mordecai Potash, MD

In the two years that have passed since the CDC Opioid Guideline was released, many pain management thought leaders have conceptualized this guideline as a pendulum that was to swing patient care from an extreme of opioid permissiveness to a more thoughtful middle-ground of opioid allowance within limitations. That middle ground was supposed to permit opioid prescribing in chronic pain for well-selected and well vetted patients whose dosing is within reasonable limits. After all, the CDC guideline’s authors made it clear that they were not trying to create a new standard of care in pain management, but instead give clinicians recommendations to make their own clinical approaches to pain management treatments safer and more effective.

However, there are several recent publications to suggest that – far from finding a balanced middle ground – the pendulum has swung abruptly in the opposite direction with patients being thrown off long-established opioid treatments because of providers’ stark fears and frustrations.

In a ‘Perspective’ published in the New England Journal of Medicine, Dr. George Comerci and his colleagues at the University of New Mexico reported that their interdisciplinary pain service has been inundated with patients who were compliant with their pain medicine treatment for years or decades but had their lives thrown into turmoil when their doctors abruptly adopted strict “no opioid” policies [1]. The article also pointed out that even when physicians are willing to continue to prescribe opioids for stable patients, health insurance companies require a mountain of prior authorization paperwork to be filled out for these patients.

In my own outpatient practice, I have encountered – and spent countless hours – filling out these cumbersome prior authorization forms. By taking between 45 minutes to one hour per form, what the insurance companies label as a tool to help the prescriber has instead become an onerous burden dissuading providers from continuing opioid treatment.

In another article published in Reason Magazine, Jacob Sullum and his colleagues wrote an amazingly comprehensive description of the many facets of our country’s current opioid crisis [2]. They pointed out that although opioid-containing pain medications has led to misuse or addiction issues in some chronic pain patients, this has not happened nearly as frequently as portrayed in the media. Mr. Sullum pointed to the 2014 results of a survey from the National Survey on Drug Use and Health that suggested that a little more than 2% of chronic pain patients end up misusing their pain medications to the point of substance use disorder. This number is far less than is quoted by Governor Chris Christie, the point-man of the Trump Administration on the opioid crisis. The article also points out that opioid prescriptions have been dropping since 2010, even as opioid abuse has been sky-rocketing with heroin and black-market fentanyl which account for the spike in opioid abuse – not prescription medications.

The Reason Magazine article makes it clear there is some relationship between permissive opioid prescribing and the rate of national opioid abuse. But that the relationship is not a straight-forward one and often depends on other factors such as educational attainment and employment options.

Dr. Sanford Silverman does an outstanding job expanding on these ideas in his newly published article “CDC Guidelines: Be Careful What You Wish For” [3]. Dr. Silverman points out that we are really dealing with two epidemics when we look at what is being called the opioid crisis – there is the epidemic of prescription opioid abuse which has been declining since 2010 and a separate epidemic of illicit heroin, fentanyl, and other illicit opioids which has been increasing dramatically since 2010.

Dr. Silverman points out that the strict regulatory changes affecting states like Maine and Rhode Island – as well as changes in major health insurers like CVS Caremark – will decrease precipitously the number of opioid prescriptions being written for patients but will likely do nothing to combat opioid overdose deaths in the state. What is needed is easily accessible medication-assisted treatment for patients whether they developed addiction from illicit drug use or prescription use. So far, medication assisted treatment remains out of reach for most patients.

Dr. Silverman also points out that the CDC Guidelines were primarily geared for helping the primary care provider dealing with acute pain complaints. This type of patient is very different that the type of patients that we pain clinicians usually encounter. Our typical patient has seen several, if not dozens, of previous pain management providers with mixed success and are often coming to us already on high dose opioid therapy (what Dr. Silverman calls “legacy patients”). If we are to follow the CDC Guideline strictly, we are supposed to reduce the dose of pain medications to 90 morphine milligram equivalents per day. But, for many of these patients, this is not a realistic goal and would present real harm to the patient if attempted. The real question is what can we do for these patients that acknowledges their current treatment regime and response to that treatment while also acknowledging changing standards of care in opioid-based therapy for chronic pain.

Well, I am delighted to tell you that our September annual conference will go a long way in answering the conundrums raised by these three articles – with our conference theme on ‘Balanced Approaches to Acute and Chronic Pain’.

Dr. Silverman will be speaking on the CDC Guideline and the points he raises in his article. Our conference will also feature Keith C. Raziano, M.D., Physicians Pain and Rehab, Sandy Springs, GA, who will be speaking on Maximizing Functional Outcome and Minimizing Chronic Pain. The popular author and orthopedist David A. Hanscom, MD, at the Swedish Neuroscience Institute will be speaking on Solving Chronic Pain with a Self-directed Structured Approach.

As if that isn’t enough, we will also host talks on several other areas including Catastrophic Injury Across the Continuum, and Advanced Techniques in Neuromodulation. Taken together, we have assembled an array of nationally prominent speakers presenting on exciting and practice-relevant topics.

So, I hope that you keep fighting the good fight for your patients, who I am sure appreciate everything that you do for them. I also hope that you plan to join us from September 21st to 23rd at the Sheraton Atlanta Hotel to recharge your batteries, reconnect with colleagues, and learn how excellence in pain management is still achievable even during these trying times!

[1] G Comerci, J Katzman, D Duhigg. Perspective. Controlling the Swing of the Opioid Pendulum. New England Journal of Medicine, published 02/22/2018 and accessed at http://www.nejm.org/doi/full/10.1056/NEJMp1713159

[2] Jacob Sullum. America’s War on Pain Pills Is Killing Addicts and Leaving Patients in Agony. Reason Magazine, April 2018 issue. Accessed at https://reason.com/archives/2018/03/08/americas-war-on-pain-pills-is

[3] Sanford M Silverman. CDC Guidelines: Be Careful What You Wish For. Interventional Pain Management Reports. Volume 2, Number 1, Pages 1-8. Accessed at http://www.ipmreportsjournal.com/current/pdf?article=MTcw&journal=7

 

In the Spotlight: Geralyn Datz, PhD

I had an opportunity to sit down with Geralyn Datz, PhD, past president of SPS, after her session on “Biopsychosocial Approaches to Treating Chronic Pain and Headache” at our recent meeting in New Orleans.

One of the topics you addressed in your talk was how there has been attention to the overemphasis on medications, particularly opioids, to manage pain. Tell us more about how we can be better at teaching patients how to actively cope with chronic pain?

One of the biggest challenges with using a solitary approach such as pharmacotherapy, including opioid therapy, for the patients living with pain, is that chronic pain is best treated through a multimodal approach. This is because pain affects the whole person. Patients and practitioners need to learn techniques to adapt to and manage the pain, not just take it away temporarily. There is a push to teach active self management strategies, such as sleep restoration, pacing, conquering worry and anxiety, and how to minimize depression in the face of pain. Simply taking a pill is a passive strategy and it is does nothing to teach the patient about the very important mind, body, and behavior connections that exist with chronic pain. Many treatment centers and insurers are including psychologists in the pain treatment conversation because of the understanding that this discipline offers time tested ways of dealing with these issues.

Similarly, the first thing to consider when talking about opioids is that they are designed to be a delivery system, a pharmaceutical, which provides analgesic relief for a certain period of time. As a result, medication is time-limited. When patients deal with a medical problem like chronic pain, they have a constant, day-long, often years-long, process of discomfort and limitations. There will naturally be times where the patient has more or less analgesic effects, and in different people these effects vary widely in duration. Furthermore, the data on opioids for long term pain management and relief in non-cancer pain is rather weak. A Cochrane review showed that in some carefully selected populations, there was relief long term. However, for the great majority of patients, adverse effects and side effects were many, and relief was generally poor, and less than 30%. There is also evidence to suggest that opioids can increase pain when taken long term (opioid induced hyperalgesia), which is obviously completely counterproductive to the goal of pain relief.  As a result, multi-modal approaches that teach coping skills and ways to overcome the impact of pain are crucial.

You shared that the biopsychosocial model of treatment is becoming more recognized by providers and insurers, compared to the biomedical model, which dominated for many years. Can you elaborate on that?

For many years the biomedical model of treatment has prevailed in treating patients living with pain. This model is based on some very early research about acute pain. It basically holds that there is a one-to-one correspondence between the extent of injury and the amount of pain experienced. Therefore, large injuries lead to large pains, and small injuries lead to small pains. This model also assumes that surgery and medications can fix pain.  While this is sometimes true, this model fails to appreciate what we now know about the central nervous system. We know that chronic pain is a complex and dynamic process, and it involves a person’s thoughts, beliefs, experiences; and these all can influence pain for better or worse. In addition, conditions such as depression and anxiety can arise from the presence of pain, and these also can intensify pain through interactions of the brain with the body. 

To address chronic pain effectively, we must address the person’s reactions to it and teach ways to overcome it, including retraining the brain away from the unpleasant pain signals. This is a psychological process involving education, training in thinking and new behaviors, and coaching.

We know that there is a very strong co-occurrence between chronic pain and conditions like depression and anxiety. You spoke about in this in your talk. What can you tell our readers?

Chronic pain is an unpleasant physical and emotional experience. The emotional suffering related to chronic pain, as well as the many changes it can bring about to a person’s life—job loss, financial distress, changes to activities of daily living, limitations, and reliance on other people—all can become very discouraging, frustrating and overwhelming. These circumstances frequently result in the development of clinical depression and anxiety. Co-occurrence rates of depression and anxiety in chronic pain patients are very high.

Another psychological diagnosis that is common to patients living with pain is post traumatic stress disorder. Patients with PTSD actually do experience higher rates of chronic pain and generally will not recover with medical approaches alone. It is worth noting that a person can also have a premorbid psychological diagnosis and then develop pain, and the pain in turn exacerbates the psychological diagnosis. It is extremely important to have psychologists involved in pain treatment for these reasons. Psychologists and specialized mental health professionals are experienced in providing evidence based treatments for depression and anxiety, and these can be adapted for patients with pain. Some of these treatments can be delivered in 8 to 16 sessions and are very effective and inexpensive to deliver.

Can you explain the process of treating pain from a psychological perspective?

I will focus on cognitive behavioral treatment of chronic pain because this approach is considered the gold standard for treating chronic pain. The psychological approach to treating chronic pain involves tailoring treatment to the person with chronic pain who is sitting in front of you. By that, I mean that each person has their own set of thoughts, feelings and behaviors related to managing (or not) their pain. This includes assumptions and fears, such as what to do and what not to do, whether they are willing to experience more pain, and whether they perceive the pain as a signal of harm. In addition, patients with pain also typically have strong feelings of resentment and anxiety about pain, because they perceive it as unnatural and unwanted. In the psychological treatment of pain these thoughts, feelings, behaviors, and assumptions are identified, targeted and modified so that the person experiences less distress related to all of these.

We know that cognitive behavioral treatments (CBT) create quantifiable changes in the brain, and that these changes are distinct to CBT. These effects are lasting and result in long term success. Ideally the psychological and medical perspectives work together. They really shouldn’t be independent. The best results are achieved through collaborative care.

In your talk, you discussed Biopsychosocial Laws and other changes in the healthcare landscape. What do you see as essential health care delivery system changes in the treatment of chronic pain?

I see that we need big changes in insurance and reimbursement practices in health care delivery. These will enable better collaboration between medicine and psychology. It should be easier to refer to psychologists and mental health than it is. We need to remove barriers that slow down this process. In addition, mental health is subject to higher copays and deductibles and a greater financial burden to patients. Also, the reimbursement for medical psychology type services should reflect the specialized training that must occur to deliver these types of treatments, and be reimbursed at a higher level. Finally, the stigma of referring to mental health should be addressed. Some providers are hesitant to refer to mental health due to fears of being misunderstood by their patients. Other providers are still ignorant of what psychology can do to help them and their medical patients. Finally, patients themselves are fearful of being labeled or being judged as crazy or weak for attending psychotherapy. These stigmas need to be addressed systematically through education and collaboration. In our clinic, while many people may hesitate to be referred, once they arrive and have an opportunity to be heard, and hear how ‘normal’ what they experience really is, the relief and healing that occurs is truly amazing to watch. We need more approaches that are personalized, and tailored to patients’ needs and presenting problems, because that is the basis of true rehabilitation.

Highlights of the 2017 Annual Meeting

Cory Shum, recipient of the President's Award

Cory Shum, recipient of the President’s Award

We had a spectacular meeting in September at the Crowne Plaza Hotel in New Orleans. This year we collaborated with the Southern Headache Society and included breakout sessions for both chronic pain and headache providers.

The opening session on Friday afternoon included talks and panel discussions around the relationship between payors and providers, patient disability issues and managing chronic pain the cognitively impaired patient.

Our keynote speaker, Dr. William Maixner kicked off Saturday morning with 2 talks around the advances in translational research and new methods of diagnosing and caring for the complex pain patient.  Speakers throughout the rest of the weekend covered a range of topics from enhancing our understanding of the impact of the environment, opioid guidelines and abuse deterrent formulations, neuromodulation, biopsychosocial approaches, headache treatments, to the business side of practicing.

A particularly interesting highlight was a discussion about virtual reality (VR) and its use in pain patients.  Many attendees tried out the VR gear available in the exhibit hall. 

Trying out the VR equipment

Trying out the VR equipment

We send a big “thank you” to the 30 vendors and grant supporters who helped make this meeting so successful!  We now turn our attention to the 2018 meeting in Atlanta.  “Balanced Approached to Acute and Chronic Pain” is shaping up nicely, so mark your calendars for September 21-23.

 

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