Category Archives: News

President’s Message: Running Headlong into what You Thought Was Behind You

Harry J. Gould, III, MD, PhD

With the FDA’s blessing in mid-December on the administration of vaccines for COVID-19 and subsequent indications of downward trends in the rate of infections, hospitalizations and deaths associated with the virus came a feeling that the worst of the pandemic was past and we were on a return path to recover normalcy. Even with large numbers of individuals that chose not to be vaccinated, the falling numbers reflecting the impact of disease were encouraging and many businesses, organizations, and individuals began to abandon mitigation practices, i.e., social distancing and masking, and began returning to former practices and patterns of behavior. In-person visits in clinical practice began to replace the virtual platforms and we were again able to apply our mitigating strategies for reducing medication misuse, abuse and diversion, thereby lessening some of the provider’s anxiety associated with the impaired ability to identify potential problems related to opioid management.

Indeed, the Southern Pain Society’s (SPS) planning committee for the 2021 Annual Meeting, upon reviewing the trends in societal response to the vaccines, was cautiously optimistic and was looking forward to being able to hold our annual meeting in-person. Despite the committee’s best efforts to plan and deliver an informative and thought-provoking meeting that might also serve as an indicator that we were on the mend, the trend in disease statistics foreshadowed a lack of support for these efforts.  Due to the establishment and spread of variants of COVID-19 in the population, the rate of infections, hospitalizations and deaths shifted and by mid-August had returned to, and in many places surpassed, levels that had been recorded at the peak of the first wave of the pandemic.  By the late August, elective procedures and in-person appointments in clinics were again being replaced by virtual visits.  As a professional organization, the SPS could no longer be reasonably certain about ensuring individual safety for our participants, chose not to put individuals at risk of becoming seriously ill and postponed the 2021 meeting; perhaps a fortuitous decision in light of the additional complications imposed by Hurricane Ida.

The distractions of the last 18 months have emphasized the importance of maintaining and expanding efforts to improve patient safety and reliably delivering appropriate and effective care even in the face of adversity. As the pandemic continues, the SPS is expanding efforts to maintain and offer new opportunities to share ideas and express concerns, challenges, and potential solutions for the challenges facing our patients and practices. In offering opportunities to support scholarly activity and communication, like the recent virtual forum for abstract presentations.  We hope to encourage those with the wisdom and experience accrued through years of experience and those new to the field of pain medicine to come together and share ideas and experiences and hopefully create a forum for inquiry that will foster the pursuit of a better understanding of complex condition we strive to treat; its proper assessment; and optimal treatment options supported by evidence necessary for making the most appropriate management decisions.  I encourage you to follow our newsletter and postings on social media for opportunities as we continue to monitor the pandemic and set our sights on the future when we will be able to meet again with the pandemic behind us, even stronger than before. 

Long Haul COVID-19

Olivia Lee and Lawrence Robbins, MD

Introduction

Over 325 million doses of COVID-19 vaccines have been distributed in the United States, and much of the country is looking forward to a return to normalcy. For many, the widespread access to vaccines signaled the pandemic’s defeat, but for millions of COVID-19 survivors, the sequelae following acute infection will trouble them long after the country has returned to its normal state of affairs.

Recent studies have reported that up to 30% of COVID-19 patients experience persistent symptoms in the months following acute illness.1 Lingering myalgias, joint pains, headaches, shortness of breath, fatigue, dizziness, cardiac issues, and brain fog are just some of the reported symptoms.  These often continue long after the virus has been cleared from its host.2 Patients who experience lingering symptoms are collectively termed COVID-19 long-haulers, and diagnostic tests to quantify their disease status are being explored. Long haul COVID-19 has emerged as a growing challenge for physicians, who are working to identify effective treatment strategies for these chronic complications. This paper serves to briefly highlight diagnostic and therapeutic developments in the management of long haul COVID-19.

Demographics of Long Haul Covid Patients

Researchers have begun to establish a general profile of people with long hauling effects of COVID-19.. This may help identify those who are at the greatest risk for developing these chronic COVID-19 complications. Various studies have supported the notion that long haul COVID-19 disproportionately affects patients of older age, higher body mass index, female sex, or those with preexisting asthma.2,3 Female COVID-19 long-haulers are more likely than males to report anxiety, low mood, myalgia, fatigue, insomnia, and memory impairment.4

One study published in 2021 separated the most common symptoms into three “clusters” based on co-occurrence: Cluster A included myalgia and fatigue, Cluster B included low mood, anxiety, and sleep disturbance, and Cluster C included memory impairment, cognitive impairment, and attention deficit.4 Several reports indicate that the likelihood of experiencing these lingering symptoms may be independent from the severity of the acute COVID-19 infection. This suggests that the severity of the acute infection is not a reliable indicator of the risk for developing chronic complications.1,4

Diagnostic Measures

Currently there are no accepted diagnostic tests for long haul COVID-19.  Diagnosing this condition is dependent upon the patient’s history.5 Many COVID-19 long-haul symptoms are nonspecific and could be attributed to other conditions. Long haul COVID-19 is a diagnosis of exclusion. Alternative explanations for a patient’s nonspecific symptoms must first be considered.

Some studies have identified pro-inflammatory markers as being associated with long term COVID-19 illness. Increased levels of pro-inflammatory markers found in long haul patients include CRP, TNF-alpha, IL-1α, IL-1β, IL-6, IL-17A, IL-18, MCP-1, natriuretic peptides, ferritin, troponin, and D-dimer. 2,5,6 These biomarkers are nonspecific and present in other inflammatory conditions. The inflammatory markers have to be interpreted with caution. There are several papers that describe a paucity of pro-inflammatory markers in suspected cases of long haul COVID-19.2 The reasons for these inconsistencies is unknown and warrants further analysis. Despite this conflicting information, it may still be worthwhile to examine pro-inflammatory markers in suspected long haul COVID-19 patients.5 While these markers do not definitively diagnose long haul Covid-19, they provide supporting evidence.

Additionally, the biopsychosocial impact of COVID-19 long haul symptoms is an important consideration. Experiencing brain fog, fatigue, anxiety, depression, and other symptoms will generate more anxiety and depression.  The long haul syndrome sometimes resembles the post-traumatic syndromes observed following the Gulf War and 9/11.4 Thus, a psychological assessment may be indicated in evaluating cases of long haul COVID-19 to determine whether there are neuropsychiatric components that contribute.

Treatments

Several medications are undergoing clinical trials for treating long haul COVID-19: C-C Chemokine Receptor Type 5, (CCR5) antagonists, antiparasitics, and monoclonal antibodies. Physicians at various treatment centers report repurposing medications (including maraviroc, ivermectin, and leronlimab) for treating COVID-19 long-haulers. They provide mixed accounts of the efficacy of these medications. Ivermectin,  an antiparasitic medication, has demonstrated promising results in treating long haul COVID-19.7,8 Its clinical benefits in long-haulers may be attributed to its modulating effects on the immune system. Ivermectin’s suppression of IL-6 may be a key to its benefit.7

Psychotherapy may be helpful in dealing with the devastating consequences of COVID-19. Other avenues such as multi-disciplinary rehabilitation have demonstrated success in subsets of COVID-19 long-haulers. These interventions include stretching, light aerobic activity, breathing exercises, physical therapy, and behavior modification.2 These multi-disciplinary approaches are able to tailor the treatment plan to the individual. There are a growing number of clinics specializing in evaluating and treating long haul patients. 

Vagus nerve stimulation, used for headaches, epilepsy, and depression, has recently been explored as a potential adjunctive therapy for long-haul COVID-19 9. There are reports of improvement in COVID-19 long-haulers undergoing non-invasive vagus nerve stimulation.10,11

Conclusion

Physicians are in the early stages of understanding how to effectively manage long haul COVID-19. Researchers have begun to characterize the profile of long-haulers. Clinical assessment currently depends primarily upon patient histories. Scientists and long haul COVID-19 treatment centers are conducting research into the immune status of long haulers. A vigorous autoimmune response seems to be the likely culprit for the majority of symptoms.  Several pharmaceutical interventions are undergoing clinical trials, but there are no definitive results at this point. Many of the current recommendations are targeted towards symptom management.  Over time recommendations for testing and therapy will emerge.

About the authors: Olivia Lee is a fourth year medical student at Des Moines University. Her clinical interests include the interface of psychiatry and neurology. Lawrence Robbins is an assistant professor of neurology, Chicago Medical School. He is in private (neurology and headache) practice in Riverwoods, Illinois. Lawrence has contributed to 380 articles/abstracts, and written 5 books (on headache). Address correspondence to Lawrence Robbins at lrobb98@icloud.com.

Resources

  1. Logue JK, Franko NM, McCulloch DJ, et al. Sequelae in Adults at 6 Months after COVID-19 Infection. JAMA Netw Open. 2021;4(2). doi:10.1001/jamanetworkopen.2021.0830
  2. Yong SJ. Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments. Infect Dis (London, England). 2021:1-18. doi:10.1080/23744235.2021.1924397
  3. Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of long COVID. Nat Med. 2021;27(4):626-631. doi:10.1038/s41591-021-01292-y
  4. Sykes DL, Holdsworth L, Jawad N, Gunasekera P, Morice AH, Crooks MG. Post-COVID-19 Symptom Burden: What is Long-COVID and How Should We Manage It? Lung. 2021;199(2):113-119. doi:10.1007/s00408-021-00423-z
  5. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020;370. doi:10.1136/bmj.m3026
  6. Xiao N, Nie M, Pang H, et al. Integrated cytokine and metabolite analysis reveals immunometabolic reprogramming in COVID-19 patients with therapeutic implications. doi:10.1038/s41467-021-21907-9
  7. Zaidi AK, Dehgani-Mobaraki P. The mechanisms of action of Ivermectin against SARS-CoV-2: An evidence-based clinical review article. J Antibiot (Tokyo). June 2021:1-13. doi:10.1038/s41429-021-00430-5
  8. Aguirre-Chang G, Castillo Saavedra E, Yui Cerna M, Trujillo Figueredo A, Cordova Masias J. Post-Acute or Prolonged Covid-19 : Treatment With Ivermectin for Patients With Persistent , or Post-Acute Symptoms. ResearchGate. https://www.researchgate.net/publication/344318845_post_acute_or_prolonged_COVID-19_ivermectin_treatment_for_patients_with_persistent_symptoms_or_post_acute. Published 2020. Accessed June 29, 2021.
  9. Azabou E, Bao G, Bounab R, Heming N, Annane D. Vagus Nerve Stimulation: A Potential Adjunct Therapy for COVID-19. Front Med. 2021;8:625836. doi:10.3389/fmed.2021.625836
  10. Silberstein S. Non-Invasive Vagus Nerve Stimulation May Treat Migraine in Patients with COVID-19, According to Neurologist Stephen D. Silberstein, M.D. | Business Wire. https://www.businesswire.com/news/home/20210216005737/en/. Published February 16, 2021. Accessed June 27, 2021.
  11. Lawson A. MUSC study to address post-COVID neurological and psychiatric symptoms using at-home format | MUSC | Charleston, SC. https://web.musc.edu/about/news-center/2020/11/16/musc-study-to-address-post-covid-neurological-and-psychiatric-symptoms-using-at-home-format. Published November 16, 2020. Accessed June 27, 2021.

ANA2021 Registration Is Now Open!

ANA2021’s Virtual Annual Meeting is set for October 17-19 with an Opening Symposium on October 16 and registration is now open!

All full registrations include access to the ANA2021 Meeting Recordings package, ensuring you won’t miss out on the latest neurological research even if your schedule should change. Registration also includes complimentary access to the SIG Series featuring virtual presentations related to ANA’s Special Interest Groups. These 18 sessions will be presented on select dates throughout November and December so you can attend as many as you’d like. 

 

ANA2021 is the top meeting for academic neurologists and neuroscientists at every career stage to convene over groundbreaking research and best practices for success in the field. Click here to view the Advance Program. 

 

Don’t miss this opportunity to learn from and connect with the best and brightest in the field – register for ANA2021 today!

Adverse Effects and Clinical Trials: The System is Broken

The CGRP Monoclonal Antibodies for Migraine Are a Prime Example

Lawrence Robbins, M.D.

This letter is in response to an excellent July, 2020 article “Migraine and CGRP Monoclonal Antibodies: A Review of Cardiovascular Side Effects and Safety Profile” (Boldig and Butala) in the International Journal of Neurology and Neurotherapy. (1) There are a plethora of adverse effects (AEs) from the CGRP monoclonals (mAbs) that were not identified in the Phase 3 trials. Unfortunately we frequently encounter this with new drugs. It often takes several years to identify an accurate picture of the adverse effect profile.

The package insert (PI) for the CGRP mAbs, as with many of the new drugs, identifies few AEs. The reasons for this include:  1. trial investigators did not use a checklist of AEs (a checklist is almost never utilized during drug trials) 2. as with most drug trials, the studies were powered for efficacy but would need many more patients to accurately assess AEs 3. the studies do not extend long enough in order to identify the true adverse effect profile and 4. adverse effects become “disaggregated”.  For instance, one person may say they have malaise while another may state they suffer from fatigue. This adverse effect is disaggregated and subsequently not included in the PI. After the study is completed these effects may be reaggregated, but that method is not accurate.

To accurately assess AEs post-approval, we must examine multiple lines of evidence. The FDA/FAERS website is an important source of information. Unfortunately, the side effects listed are adverse events, not necessarily adverse effects. As of January 2021, (2.5 years post-launch) there were 40,378 adverse events catalogued from the four CGRP mAbs.  On the FDA website, serious adverse events include those that are life threatening, or that resulted in hospitalization. 5,562 serious adverse events were listed. These numbers are staggering, particularly considering that the vast majority of adverse effects, even serious ones, go unreported.  Erenumab resulted in the bulk of the adverse events. This is most likely because erenumab was the first to market and has been the CGRP mAb most widely utilized. Save for constipation, I do not believe that erenumab is necessarily more likely to produce adverse effects than are the other 3 mAbs. 

After the launch of the drug, another line of evidence is the available post-approval studies and case reports.  One of the observational studies concluded that adverse effects resulted in 33% of erenumab discontinuations (2). Another study described 63.3% of patients as having reported an adverse effect, but they concluded that the CGRP monoclonal antibodies were well tolerated. (3)

We published a study of 119 chronic migraine patients who had utilized one of the CGRP monoclonals. (4) We incorporated a checklist of 19 possible adverse effects. The patients were initially asked about adverse effects by posing the question, “Have you experienced any issues, problems, or side effects from the injection?” Subsequently the patients were interviewed regarding each possible adverse effect, utilizing the checklist. A determination was made, between the patient and researcher, as to whether the adverse effect was truly due to the use of the monoclonal. 66% of the patients identified at least one additional adverse effect via the use of a carefully chosen checklist. 18 patients had one additional adverse effect. 56 patients identified 2 to 8 additional adverse effects.

An additional line of evidence is the opinion of high prescribers of the drug. This is gleaned from chat boards of headache providers, private correspondence, and discussions during conferences. Some headache providers feel that the CGRP monoclonals are safe and adverse effects are infrequently encountered. Others believe, as I do, that the mAbs result in a number of deleterious effects.  There is no consensus at this time.

In addition to headache provider comments, the CGRP patient chat boards provide valuable insight into adverse effects. We assessed 2,800 patient comments regarding adverse effects. We judged 490 to be highly believable. The list of common adverse effects, as identified by the highly believable comments, aligns well with our other lines of evidence.

 After assessing the various post-approval lines of evidence, there are signals that the following adverse effects may result from the use of CGRP monoclonals: constipation, anxiety, injection site reactions, weight gain or loss, worsening hypertension, increased headache, insomnia, depression, hair loss, joint pain, fatigue, irritability, muscle pain or cramps, nausea, rash, sexual dysfunction, and tachycardia (or other heart irregularities).  Most likely there are others as well.  In addition, there have been cases of reversible cerebral vasoconstriction syndrome and stroke. Angina and myocardial infarction have also been reported. Thomas Moore, a leading expert in the acquisition of adverse effects of drugs, published a review of the CGRP monoclonals in the online journal QuarterWatch. QuarterWatch utilizes various resources, including FDA reports and published post-approval studies. (5) The report cites the “sheer number of case reports,” and concludes that “…it is likely that adverse effects of this migraine preventive were underestimated in the clinical trials.”

This discussion has revolved around short-term adverse effects. Long-term effects, which are unknown at this time, remain a serious concern. CGRP has been important in various species for 400 million years. We ignore evolution at our peril. There are a multitude of beneficial effects partially mediated by CGRP. These include protecting our cardiac and cerebrovascular systems through vasodilatory effects(particularly during stressful conditions), resisting the onset of hypertension, decreasing oxidative stress in the aorta, improving circulation in the face of heart disease (including heart failure), aiding with wound healing, burns, and tissue repair, minimizing the effects of sepsis, aiding in the healing of GI ulcers, protecting the GI mucosa, affecting GI motility, contributing to flushing and thermoregulation, aiding with cold hypersensitivity, regulating bone metabolism, protecting the kidneys in certain pathologic conditions, playing a role in regulating insulin release, affecting metabolism and body weight, and helping to mediate the adrenal glucocorticoid response to acute stress in the mature fetus. (6) The hypothalamic-pituitary-adrenal axis may be affected by CGRP, and this has not been adequately studied. If these mAbs are to be used in adolescents, we must first study the hormonal effects.

 The package inserts often do not reflect the reality of the AE profile. I believe that the FDA should overhaul the guidelines as to how adverse events are acquired in formal studies. This situation has been harmful to patients. This is not unique to the mAbs. We should work towards improving the early identification of an accurate adverse effect profile. Certain adverse effects, such as sexual adverse effects, or depression, are missed in formal studies.

The CGRP monoclonal antibodies have been beneficial for many migraineurs. The efficacy of these mAbs rivals that of onabotulinumtoxinA. However, CGRP plays a crucial role in many physiological processes. There is evidence for a multitude of deleterious effects that result from blocking CGRP. Long-term effects are completely unknown. We should be cautious and judicious in our use of the CGRP monoclonal antibodies.

Disclosure: L. Robbins is a speaker for Abbott Labs, Teva, and Amgen.

 

References

 

  1. Boldis K, Butala, N (2020) Migraine and CGRP Monoclonal Antibodies: A Review of Cardiovascular Side Effects and Safety Profile. International Journal of Neurology and Neurotherapy 7:101: DOI:10.23937/2378-3001/1410101
  2. Robblee J, Devick K, et al. (2020) Real-World Patient Experience with Erenumab for the Preventive Treatment of Migraine.  Headache 60:9, p. 2014-2025. https://doi.org/10.1111/head.13951
  3. Alex A, Vaugh C., Rayhill M (2020) Safety and Tolerability of 3 CGRP Monoclonal Antibodies in Practice: A Retrospective Cohort Study. Headache 60:10, p. 2454-2462. https://doi.org/10.1111/head13956
  4. Robbins L, Phenicie B, (2020) CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using a Checklist. Practical Pain Management 20:2, p. 48-52.  (online at practicalpainmanagement.com, March/April, 2020)
  5. Moore T. (2019) Aimovig, Ajovy, and Emgality. QuarterWatch Reports 24:16, p. 2-4.
  6. Robbins L (2018) CGRP Antagonists: Physiologic Effects and Serious Side Effects (Letter). Headache 58:9, p. 1469-1471.

Back to the Basics: Managing Pain Months After COVID-19

Harry Gould, MD, PhD

A year ago, the United States was in the midst of understanding and dealing with the complexities of the “Opioid Epidemic”, what until then had been considered the greatest healthcare crisis in U.S. history. Although improvements in some aspects of the crisis were starting to be realized as a result of the development of best evidence-based practice guidelines and the implementation of regulatory mandates for prescribing and monitoring treatment response, we were a long way from achieving our goal; to provide optimum care and improve quality of life for those in pain without causing harm to the patients, the healthcare system or society as a whole.

In many cases, the strides that had been made in mitigating the opioid crisis did not come without their own problems. The change of assessment, prescribing and monitoring standards imposed an unacceptable burden on many well-meaning physicians, who wished to help without harming their patients, but realized that compensation for the time necessary to comply with essential regulatory demands was inadequate. Because compensation issues were accompanied by fear of reprisal for non-compliance, many chose not to provide care for their patients’ pain problems, thus limiting patients’ options for identifying resources for appropriate evaluation and management of ongoing and persistent problems or for complications associated with previous inappropriate misuse, abuse or prescribing of treatments. The resulting uncertainty of care set the stage for frustration, stress, anxiety, anger and depression, each confounding factors in the management of uncontrolled pain.  

If addressing these options weren’t enough of a challenge, a new crisis, “the 2019-nCoV virus (COVID-19) pandemic” emerged in the population. The virulence of the virus, the uncertainty about its course and management, the frustration, stress and depression associated with individual isolation and distancing and the additional limitations on access to proper evaluation, delays in initiating possible condition-limiting treatment, follow up and monitoring of patients requiring controlled medications acutely added to the already present confounding factors that have hindered optimal recovery from the opioid crisis for both patients and practitioners alike.

Unfortunately, the distribution of promising new vaccines and potential control of the current pandemic may not completely eliminate the negative influence that the virus has had on delivering pain care. We are learning that a significant number of individuals, the “long-haulers,” who have survived a COVID-19 infection report experiencing persistent cardiac, pulmonary, renal, psychologic and neurologic problems consistent with direct or indirect multisystem injury as a result of the virus. The distribution and mechanism of injury producing the pain is unknown and likely multifactorial, but presentations are frequently multifocal and possess features of nociceptive and neuropathic pain with a hint of psychogenic quality consistent with organic central and/or peripheral nervous system involvement and the influence of post-traumatic psychosocial stress associated with contracting and fighting the disease. Optimal management of these complex pain problems will likely require a return to the basics promoted by John Bonica and others, that of a comprehensive and multimodal evaluation and the orchestration of pharmacologic, interventional, physical and psychological treatment modalities at all levels of the healthcare system.

As incoming president of the Southern Pain Society, I look forward to–and encourage others to work with me to — learn from healthcare providers and basic and clinical scientists from all specialties to improve and refine assessment skills, to identify viable treatment options and management planning and to provide continued education for clinicians in practice and those new to the field, in the hope of optimizing the quality of life for patients in pain.

Case Sample: Bipolar, Chronic Migraine, Epilepsy, and IBS-D

Lawrence Robbins, MD

Individuals suffering from chronic pain often have psychiatric comorbidities. For instance, among those with chronic migraine approximately 9% fit into the bipolar spectrum. (1) This article discusses a representative case of a patient with chronic migraine and bipolar disorder as well as epilepsy and irritable bowel syndrome.

Caitlin is a 28-year-old female who has experienced frequent depressive states since age 14. Caitlin finally was diagnosed at age 26 to be on the mild end of the bipolar spectrum (DSM-5: Other Specified Bipolar and Related Disorder: 296.89). She presents with her depression in remission. She is on quetiapine 50mg and 100mg of lamotrigine, each once per day.  

The patient has moderate chronic migraine and describes daily mild to moderate daily headache. She has a moderate migraine twice weekly, and a severe migraine attack once a month. She takes 8 OTC aspirin/acetaminophen/caffeine tablets (Excedrin) daily.

Caitlin reports significant occipital and neck pain. She has had tonic-clonic epilepsy since age 12. Her seizures are infrequent, and since being placed on lamotrigine she has had no further seizures. Caitlin also has moderate irritable bowel syndrome, primarily with diarrhea (IBS-D).

Work-up as negative, including MRI of her brain, routine blood tests (including thyroid), and the neurology examination.

What Additional History May be Helpful?

In this case scenario, relevant factors to consider and further investigate include:

  • Frequency and severity of the patient’s headaches
  • the past response to medications and family history of response (family history of medication response brings in the “placebo by proxy” and “nocebo by proxy” responses)
  • Potential sensitivities or side effects to medications
  • Psychiatric comorbidities
  • Medical comorbidities
  • GI issues (in this case, IBS-D)
  • Any complaints related to sleep, fatigue, or insomnia
  • The patient’s job requirements, social support, and any financial/insurance concerns that may impact her treatment
  • Patient preference for medication (eg, they may not wish to take daily medication, or may request to use natural remedies)

In addition, a history of the specifics of this patient’s depression would be helpful. The details of her moods, hypomanic symptoms, triggers, etc. are important if an adjustment to psychiatric medication is appropriate. (2)

Is the Patient Suffering from Medication Overuse Headache?

It is also worth considering whether the patient may have medication overuse headache (MOH) which is often conflated with medication overuse (MO). Medication overuse is arbitrarily viewed as consuming certain abortive medications (eg. combination analgesics, triptans, opioids, butalbital compounds) at least 11 days per month. If patients simply take NSAIDS, MO is defined as consuming the NSAIDS at least 15 days per month.

A determination of MOH is more complex as it tends to be poorly defined and over-diagnosed. (3) To determine if MOH is present, a careful history has to be taken as to the effect the drug had on the person’s headaches. The drug (in this case, Excedrin) must be withdrawn to see if the headaches improve. Caitlin reports taking 8 Excedrin on a daily basis, each of which contains 65 mg of caffeine. It would be helpful to determine how much additional caffeine she consumes.

We should attempt to limit her caffeine intake to 150 or 200 mg daily. While small amounts of caffeine help many patients, other migraineurs cannot tolerate even minimal amounts. 

To read the rest of this article, please click here

https://pro.psycom.net/psychopharmacology/case-bipolar-migraine-epilepsy

In Memory and Appreciation: Dr. John Satterthwaite

Ann Quinlan-Colwell, PhD, APN

It is with deep sadness that we recognize the life and contributions of  John Satterthwaite, MD who transitioned from this earthly world last month.  John’s perspective on the history and devotion to the mission of SPS were priceless. Many have no doubt that the SPS would not exist today it were not for the careful nurturing and stewardship of John during the last 34 years.  During those years, like the captain of a beloved ship he steered and guided SPS as he served as treasurer and  historian. 

As important as his contribution in those roles, John was so much more to many of us in the SPS.  Through his teaching, mentoring, guidance, and voice of reason, he significantly impacted numerous SPS members in ways that can never be repaid.  Not only was John a man of many talents who contributed greatly to the world of pain management but he had paradoxical qualities as well.  Although he was often a wise sage when on the stage, he was equally comfortable and meaningful being the guide on the side.  He was often a man of few words yet a great storyteller with an amazing sense of humor..

John was an expert physician, teacher, patriarch, sage, guide, shepherd, steward, mentor, storyteller,  navigator, voice of reason, friend, and so much more. You will be greatly missed, our dear friend.

An Essay on Diversity in the Field of Pain Medicine

Benjamin Johnson, MD

I would like to thank our president, Ann Quinlan-Colwell, PhD, APN, for the invitation to write an article regarding diversity in our field of pain medicine.  As the first president of the Southern Pain Society possessing African-American heritage, I was overwhelmed with the sage advice and enthusiastic support that I received from the “parents” of the Southern Pain Society, Hugh and Renee Rosomoff, as well as the board of directors and past presidents during my term of office.   In this brief article, I will address the issue of diversity in pain medicine in two parts: first, my own personal experience; and then offer some strategies to consider for the purpose of increasing diversity in the field of pain medicine.

My own introduction to medicine began with my family physician; and accelerated when I began to work as an electronmicroscopist with a Polish nephrologist in Chicago, Dr. Robert Muercke, who pioneered the percutaneous renal biopsy in the US.  While teaching me to interpret renal histopathology from his percutaneous renal biopsies, he encouraged me to pursue a career in medicine; and his letters of recommendation were instrumental in helping me to gain admission into the University of Illinois College of Medicine.

My first experience with blatant racism occurred during the process of applying for admission into medical school.   My undergraduate college (0.5% black enrollment) declined to write a letter of recommendation (the dean’s letter) for me to the medical schools, stating that they were afraid that I would adversely affect their percentage of successful admissions to medical school if I did not gain admission. 

My next major experience with overt racism came during my general surgery residency.  As a medical student, I had received high ratings in my advanced surgical rotations, and was strongly encouraged to pursue a career in general surgery.   I enrolled into a University of Illinois affiliated program that had a pyramidal structure. There were eight residents during the first two years of the program, and then only four residents were chosen to complete the last two years of the residency.  In my class, the eight residents consisted of four white males, one white female, and three black males.  At the end of two years, the four white males were chosen to complete the final years.  At this point, I interviewed with the Navy and applied for an anesthesiology residency at the Navy Hospital – San Diego.  While considering this move with my family, I was contacted by the general surgery residency director, who wanted to know if I was interested in re-joining the surgery program.  I suspected that the parent program had notified them that their resident selection results were somewhat suspect.  I decided to accept the anesthesiology residency program position with the Navy, which turned out to be one of the best decisions of my professional life. 

Regarding my experience in the noble field of pain medicine, I have been blessed to come in contact with several mentors of color, who have been instrumental in shaping my career. Dr. Winston Parris and the late Dr. Richard Payne are two mentors whose influence on me has been especially noteworthy.  Their involvement in the field of pain medicine since the Bonica era gave them a unique perspective, which they were eager to share with me. They gave freely of their knowledge, expertise and wisdom in both academic and private practice environments.  Due to their example, inspiration and encouragement, I have had the privilege to influence and mentor other physicians of diverse cultures and nationalities, including my African-American colleagues, in the wonderful field of pain medicine.  Additional mentors of diverse backgrounds, such as Gabor Racz, Prithi Raj, Claudio Feler and others have welcomed me into their practices to share their priceless wisdom and experience. This level of mentorship is crucial for the purpose of attracting diversity into our noble profession. 

Our president, Dr. Ann Quinlan-Colwell, asked me to address the question of what we as providers can do to increase diversity of our specialized field of pain medicine.   This is a complex issue, but I will offer some possible practical strategies for us to consider.  I will approach this subject from a broad perspective, and then offer some more specific concepts.

Before addressing possible strategies to increase diversity in our field of pain medicine, I would like to try to define a term that is often used when discussing the issues of diversity and disparity, that is the term “systemic racism”.  One sociological definition, by Eduardo Bonilla-Silva is the reference to systems in place that perpetuate racial injustice.  As defined, systemic racism has three primary components:

  1. Historic specificity: the systems adapt to changing conditions to maintain the disenfranchisement of a group of people
  2. A distinct structural phenomenon: the practices and behaviors are “baked” into the system itself; therefore the people in the system are consciously or unconsciously an essential part of the system. Regardless of intention, most people participate in some way, usually by being either passive or neutral.
  3. The system provides advantages for some, and disadvantages for others.

In view of this definition, the answer to solving a systemic problem involves a systemic solution. 

The effects of systemic racism occur in some of our most fundamental structures:

  1. Where you live
  2. What kind of education you’re able to receive
  3. How or if your family acquires wealth
  4. The quality of healthcare you can easily access
  5. How likely it is to face violent and deadly policing
  6. Your access to voting
  7. Where you worship

As we can see from the above definition, the issue of increasing diversity in the field of medicine, specifically pain medicine is only a part of a very large and systemic challenge.  In the next section, I will attempt to suggest how we as individuals can be a part of the solution, as opposed to being an unconscious participant in the problem.

Although I realize that the field of pain medicine is perhaps the best example of a truly multi-disciplinary field of healthcare, I will use the field of medicine as an example, since I know it best.  A number of years ago, I attended a meeting hosted by the Association of American Medical Colleges (AAMC), which dealt with determining strategies of increasing diversity in medical schools.  One of the key points brought out at this summit meeting was that the pipeline for medical school begins in pre-school, if not in utero.  Factors such as maternal health and nutrition, the quality of elementary and undergraduate education, and other socioeconomic conditions all weigh heavily on an individual’s ability to gain entry into medical school.  Potential physicians fall out of this pipeline anywhere along the pathway, as the above-mentioned variables adversely affect them.  Factors such as poor nutrition, dysfunctional families, substandard housing, poorly funded education, and economic deprivation, many of which are the result of systemic racism, all reduce the viable pool of physician candidates.  Therefore, the field of pain medicine is adversely affected as well. Although I’m using medicine as an example, other components of our multidisciplinary specialty, such as psychology, nursing, pharmacology, and others all suffer in similar manner.

What can we as citizens in this country do about such a pervasive and multifactorial problem?

First, it is important to be politically knowledgeable and active. 

Even though we are all busy practitioners with demanding, high stress positions, we must remember that we are still functioning members of society.  In a democratic society, we must be active participants in order to be agents of change. As an example, I used to be a volunteer anesthesiologist in the Philippines for a medical group called Operation Smile.  On several trips, I had the pleasure of working with some politically active women on the island of Negros Occidental.  I found out that they were so influential in their local communities, that if they backed a political candidate, the other candidates might as well give up!  It is this kind of political influence that can make a difference in our communities and nation.  We can accomplish this through our local civic organizations, churches, and other areas of influence.  Although the results of political activity are not always instant or readily observable, the long-term effects can be substantial. One of the things that I admire about the American Society of Interventional Pain Physicians (ASIPP) is their emphasis on political activity.  On an annual basis, member pain physicians have travelled to our nation’s capital to speak personally with our senators and members of Congress and inform them of how their legislative activity affects us as providers, as well as the patients who put their well-being into our hands. 

More specifically, what we can do as individual providers is to be role models and mentors to young potential pain medicine providers of diverse backgrounds and cultures.  Such activities as local career fairs, school classroom activities, medical student mentoring, and hosting of medical students or pain fellows in our practices can inspire our youth to enter our chosen field.  I know from experience that such activities can interfere with a practice’s operational efficiency; but it is a meaningful contribution to our communities and career specialties.  An added value is that such activities help to ameliorate the stigma that a pain practice can have in the community.  I have personally participated in each of the above-listed activities, and I can say without hesitation that having an individual thank you for inspiring them into a fulfilling career can really brighten your day.  I am a direct beneficiary of scientists who allowed me to work in their laboratories during my summers in high school, which introduced me to the field of electronmicroscopy and subsequently into medicine.  An additional benefit is the positive affirmation of pain medicine as a legitimate specialty within our communities.  These activities can also bring in new patients without spending marketing dollars.

I trust that this brief article has introduced you to some of the challenges in regard to creating diversity in our wonderful and fulfilling field of pain medicine.  Hopefully, we will have some stimulating discussions on these topics in the future.  My hope is that we can all be agents of change in our spheres of influence.

Transitioning from 2020 to 2021 – “The Times They are a Changing”

Ann Quinlan-Colwell, PhD, APN

For most of us, this past year has been tumultuous to say the least.  In at least some way, we have all been impacted by the COVID-19 pandemic, protests and the underlying circumstances that initiated them.  We are very fortunate that Dr. Ben Johnson wrote a thoughtful and insightful article in this issue regarding diversity in health care and with pain management in particular.  Every day, I learn about yet another way the pandemic has affected people and health care.  Many of our colleagues are reporting “Post COVID Stress Disorder” (PCSD).   Health care providers are struggling to maintain practices using virtual telehealth where possible.  Some have had to curtail performing “non-essential” analgesic procedures due to required personal protective equipment not being available.  Advanced practice nurses have been re-assigned from pain management to work in critically low staffing areas caring for patients acutely ill with COVID-19.  Still others have effectively been told that pain management is “not an essential service and in the interest of being financially responsible we are eliminating your position.”

Clearly, we are yet to witness the immense impact of chronic illness experienced by the COVID survivors who are being referred to as “the long haulers.”  This population will be particularly challenging since many of them have underlying co-morbidities or risk factors that are painful or increase the risk of experiencing pain. Many who have suffered pulmonary damage and complications will be at increase risk for medication related respiratory depression.  Since many people who have had COVID-19 reported neurological symptoms, we can hypothesize that neuropathic pain may be a long term consequence.  We are beginning to see literature discussing managing chronic pain during the pandemic  (Cohen, et al, 2020; Eccleston, et al, 2020; El-Tallawy, et al, 2020; Manchikanti, Kosanovic, & Vanaparthy, 2020;  Morgan & Dattani, 2020; Pradère, et al, 2020; Puntillo, et al, 2020; Soin & Manchikanti, 2020; Song, et al, 2020; Shanthanna, et al, 2020).

It is most certainly a time to amass resources to adjust our perspectives and our usual ways of functioning.  The more proactive we can be, the more internal resources we will have to best support people living with pain who are most certainly struggling. Functioning from a scientific perspective, garnering the evidence and supportive literature is basic (see reference list).  During this time with a certain degree of social and even professional isolation, it is also important to remain connected with other professionals.  The Southern Pain Society provides an excellent platform for doing so.  In addition to this newsletter, on November 13th and 14th we are scheduled to share amazing information during part one of our first ever Southern Pain Society Virtual Meeting.  The timely title of the meeting is: “Perspectives, Concerns and Options for Managing Pain” with presentations by a variety of internationally known faculty including Drs. Rollin Gallagher, George Singletary, Perry Fine, Jay Kaplan, Esther Bernhofer, and Misha Backonja.  We certainly hope to connect with you virtually to learn from these pain management professionals.

In addition, we have a special group of professionals serving on the SPS board of directors who work throughout the year to support information and education about pain management.  With annual regularity, the board composition is preparing to change.  As they step down from their board positions, we extend great appreciation to past president Mordi Potash, MD and director Joe Tramontana, PhD for their years of dedicated service.  During the next year, Dr. Harry Gould, III will assume the role of SPS president as I transition to past president and our long time treasurer Dr. Thomas Davis will become president elect.  We are thrilled that Drs. David Gavel and James McAbee will continue as directors and Dr. Randy Roig will continue as treasurer while Dr. James Weisberg will assume the role of secretary.  We are most pleased to welcome Drs. Michele Simoneaux and Eric Royster as new board members.  Without a doubt, this SPS board will work cohesively to continue to advance research and treatment of pain while increasing the knowledge and skill of all those in our professional community as we hopefully experience the end of the COVID-19 pandemic and move forward.  During this transition period, I encourage all to do everything possible to be safe and remain well.

References:

Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, L. T. C., Chen, Y., Hooten, W. M., … & King, L. T. C. (2020). Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine.

Dylan, B., & Sears, J. (1964). The times they are a-changin’ (Vol. 8905). Columbia.

Eccleston, C., Blyth, F. M., Dear, B. F., Fisher, E. A., Keefe, F. J., Lynch, M. E., … & de C Williams, A. C. (2020). Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain161(5), 889.

El-Tallawy, S. N., Nalamasu, R., Pergolizzi, J. V., & Gharibo, C. (2020). Pain Management During the COVID-19 Pandemic. Pain and therapy, 1-14.

Fauci, A. S., Lane, H. C., & Redfield, R. R. (2020). Covid-19—navigating the uncharted.

Gates, B. (2020). Responding to Covid-19—a once-in-a-century pandemic?. New England Journal of Medicine382(18), 1677-1679.

Manchikanti, L., Kosanovic, R., , & Vanaparthy, R.,  (2020). Steroid distancing in interventional pain management during COVID-19 and beyond: Safe, effective and practical approach. Pain Physician23, S319-S350.

Morgan, C., & Dattani, R. (2020). Should I use steroid injections to treat shoulder pain during the COVID-19 pandemic?. JSES international.

Pradère, B., Ploussard, G., Catto, J. W., Rouprêt, M., & Misrai, V. (2020). The Use of Nonsteroidal Anti-inflammatory Drugs in Urological Practice in the COVID-19 Era: Is “Safe Better than Sorry”?. European Urology.

Puntillo, F., Giglio, M., Brienza, N., Viswanath, O., Urits, I., Kaye, A. D., … & Varrassi, G. (2020). Impact of COVID-19 pandemic on chronic pain management: Looking for the best way to deliver care. Best Practice & Research Clinical Anaesthesiology.

Soin, A. & Manchikanti, L. (2020). The effect of COVID-19 on interventional pain management practices: A physician burnout survey. Pain Physician23, S271-S282.

Song, X. J., Xiong, D. L., Wang, Z. Y., Yang, D., Zhou, L., & Li, R. C. (2020). Pain management during the COVID-19 pandemic in China: Lessons learned. Pain Medicine21(7), 1319-1323.

Shanthanna, H., Strand, N. H., Provenzano, D. A., Lobo, C. A., Eldabe, S., Bhatia, A., … & Narouze, S. (2020). Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel. Anaesthesia.

Casey A. Murphy, MD Receives Award

John R. Satterthwaite, MD

Dr. Hu Rosomoff, the founding President of SPS, would take any opportunity to speak during each Annual and Board meeting until his health prevented him from attending.  Hu was a veritable fountain of clinical wisdom, as well as a provider of historical perspective into the Society.  Now, as the “Old Guy” from the Board I would like to exercise my “Rosomoff privilege” to briefly walk down memory lane.

I began in private practice of anesthesiology in Greenville, SC in 1980, not even knowing what pain management was. At the request of a local surgeon I began using injections, primarily epidurals, to treat pain in about 1983. At that time, only 2 or 3 pain fellowships existed.  Wanting to learn more about the treatment of pain and what others were doing, I began going to meetings and joined SPS in 1987 as a Charter Member after attending the combined ASP and SPS meetings. Yes, we had joint meetings in those days.

These meetings and interactions with leaders in the field like Dr. Rosomoff, Marty Grabois, John Loeser, and multiple others helped me expand my knowledge base and clinical skills. Historically at that time, use of opioids was frowned upon, functional restoration was encouraged, surgery and injections were not that popular, and off label medication use was common, leading to many currently acceptable treatments for pain problems today.

I was asked to become SPS Treasurer in 1989, a position on the Board which I held until 2019 when I was forced to retire, due to pulmonary fibrosis. During my time on the Board, I had the honor and privilege to work closely with many of the top names in the field of pain.  I will not try to name them all because I am sure I would leave some out.  Suffice it to say, their names would be familiar to all. In those 30 years, many young practitioners came to our meetings, became excited, joined, and were encouraged to become more active in the Society. In fact, all of the current Board members and officers became involved in this way.

Why is this important?

It is the role of the Society to recruit, teach, support, and mentor young clinicians to blossom and become the future leaders in the field of pain management. It is up to us as a Society to develop, teach, and maintain high standards of practice for the care and protection of our patients.  We must nurture and encourage these young people to carry on and lead us through the turbulent times of the 21st Century. 

I am quite humbled that the Society has named this Early Career Award for me.  This award recognizes young clinicians who have shown excellence in leadership, education, and research in the field of pain.  They are our future. 

I am honored to be able to present this first John R. Satterthwaite, MD Early Career Award to Casey A. Murphy, MD

Dr. Murphy completed his training at Louisiana State University, finishing medical school in 2013, followed by a PM&R residency and Pain Medicine Fellowship, finishing in 2018. He was inducted into AOA Honor Medical Society and is a member of multiple professional societies, including SPS.

He is on the faculty at LSU and Tulane and is a staff physician at the VA in New Orleans. He serves as the Program Director of the LSU Pain Medicine Fellowship, this only 2 years after completing his own fellowship training. He  has completed numerous research projects and studies, some of which have been presented at SPS meetings. He has developed a special interest in the medical management of cancer pain and continues to pursue this project to completion.

In addition to teaching and mentoring trainees, speaking, pursuing his research, and running a department, Dr, Murphy still finds time to spend with his wife Sarah and his two young children in New Orleans.

You can see by his history how dedicated he has been in the past 7 years since medical school. It is my honor to present this first annual award to Dr. Casey A. Murphy.

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