Category Archives: News

SPS President’s Newsletter Column – Summer 2017

Hyperbole Over Nuance

by Mordecai Potash, M.D.

One of the ways I like to unwind is to watch HBO on my cellphone or tablet. Whether it’s Real Time, Last Week Tonight, Westworld, or Game of Thrones, I am captivated by HBO’s shows!

One show, VICE – and its online companion, VICE News –  has recently featured several stories that have to do with opioids and pain management. The stories do a great job of capturing the multi-faceted aspects of this issue. They also show how strict and unyielding policy solutions to current controversies in opioid-based pain management can make misery out of the lives of countless people.

Several stories have focused on the state of Maine, since it has one of the highest rates of opioid overdose deaths in the country [1]. One story, enticingly titled “The Men Who Catch Your Lobsters Are Self-Medicating with Heroin”, explored the high rate of heroin and other opioid abuse in the lobster fishing industry along rural, costal Maine [2]. It features fishermen who work seasonably and spend almost all their disposable income on heroin, pain pills, and other drugs. The problem has gotten so bad, that these fishermen commonly encounter replacements on their boats because their previous shipmates overdosed and died. As one fisherman put it in a VICE-linked article:

“On Monday morning, I’ll go to work, it will be me and a guy named Jesse, and then the next morning it will be me and a guy named Mike. I’ll say, ‘Oh, where’s Jesse?’ and they’ll say, ‘Oh, he didn’t make it through the night.” [3]

Once a fisherman wants help for substance abuse, there are huge obstacles to obtaining it. Many live and work in a part of costal Maine that is about the size of Delaware but has a population of only 30,000 people – or about 1/25th the population of Delaware. There are no detox beds at all in the area, so a night in an ER or a couple of days in jail is the closest they get to actual medication-assisted detox services. The closest real medication-assisted program at least a 45-minute drive away – way too far away to accommodate the dawn-till-dusk hours of working fishermen.

VICE is hardly the first program to highlight Maine’s opioid addiction problem. There have been many state and national health reports about its steep rise in opioid overdoses as well as an outstanding ten-part report by the Portland Press-Herald [1].

In response, Maine has adopted some of the strictest opioid prescribing restrictions in the country [4]. One provision mandates that Maine prescribers are not allowed to prescribe more than 100 morphine milligram equivalents (MME) to their patients unless they attest that the patients qualifies under a palliative-care exception. Many Maine prescribers are fearful that, unless a patient is actually dying, they will be prosecuted if they prescribe more than 100 MME. They have told their patients that they are not prescribing more than 100 MME under any circumstances – if they haven’t already totally cut of all their patients from pain medications. Dr. Steven Hull, the Director of Pain Rehabilitation at Mercy Hospital in Portland, Maine, is afraid that many chronic pain patients that were well-managed on opioid-based pain medications will become depressed and suicidal by the cutbacks.

Another VICE story titled “Treated like addicts – The crackdown on opioids has left pain patients suffering with chronic pain and stigmatized” reports on patients whose pain was well-controlled on opioid-based pain medication but are now being cut off from this treatment with horrendous results [5].  It documents one patient whose pain from adhesive arachnoiditis was well-controlled with fentanyl transdermal and oxycodone until her doctor began to prescriber her less and less medication at each visit without explanation. When the patient finally brought it up, she was told that new regulations required the progressive decrease. She says now “My pain is out of control… I mean I can stay alive, but my quality of life has dramatically decreased”.

Like any good reporting, this story also features an opposing viewpoint. In this case, VICE interviews a prominent physician who believes that chronic pain patients are mistaking pain relief with opioid dependence. In other words, every patient that believes he or she has responded to opioid-based pain medications is simply psychologically dependent on them.

The reporter documents that many patients see that doctor’s view as “fueling an anti-opioid hysteria that favors hyperbole over nuance and glosses over the complexities of treating many painful conditions” (my emphasis added). Another patient, who is also a retired physician, adds, “They’re confusing legitimate pain management with addiction. Those are completely separate venues.”

After a year and some changes since the CDC Opioid Guideline was released, we have certainly seen a lot of ‘hyperbole over nuance’ in the rush to stem the tide of opioid overdose deaths. In previous columns, I expressed at least a little bit of hope that these changes would still allow for the practice of opioid-prescribing to well-assessed and well-supervised chronic pain patients who simply do not respond to non-opioid medications. Now, I am not so sure.

This past year, I have informally spoken with many pain management colleagues who are seriously contemplating not prescribing opioid-based pain medications any longer. Some are contemplating leaving pain medicine all together forever and go back to practicing neurology, anesthesiology, or another specialty full-time. To be clear, I am not talking about a practitioner whose training consists of attending a pain conference once or twice. These are fellowship-trained, board-certified pain management specialists who have spent thousands of hours building up their pain management practice. And now, they are giving serious thought to closing down their pain practice for good – or at least dramatically changing it.

I can’t blame my colleagues. Those of us that continue to offer opioid-based pain management services find ourselves being attacked on all fronts.

On the insurance side, several health insurers are requiring oodles of prescriber documentation in order to approve the coverage of any extended release opioid pain medication – even ones on the insurance formulary. I have filled out a couple of these documents recently for my own patients. On each patient, I had to compile a dossier of urine drug screens, opioid agreements, treatment plans, substance use assessments, and other clinical documentation  – requiring about an hour per patient.

On the legal side, pain management specialists are terrified of being investigated or arrested if they continue to prescribe any amount of opioid-based pain medication. And that fear is not without foundation! There have been many investigations and arrests of opioid prescribing physicians, including several in the South [6]. Federal agencies also don’t shy away from declaring that this is just the start of their crackdown. In fact, the FBI very recently sent out a press release titled “Health Care Fraud Takedown – Nationwide Sweep Targets Enablers of Opioid Epidemic” [7].

Given all the heat that’s on us right now, it is no wonder my colleagues are thinking of giving it all up. The professional satisfaction a pain specialist gets when serious pain is made more manageable by opiates does not compare with the panicked dread of worrying about being arrested for providing that humane care.

I certainly hope that this column has not convinced even more of my colleagues to throw in the towel and to just offer trigger points and ESI’s as their sole contributions to pain management. Rather, I hope that it has reaffirmed to those that have been having these contemplations that they are not alone in these thoughts or fears!

Indeed, I think we have done a really good job of organizing our upcoming Southern Pain Society Conference to discuss these topics robustly.

On Friday, we will hear a talk on opioids and abuse deterrent formulations from Dr. Feng Zhang. Dr. Zhang and his team at the University of Texas have been responsible for developing the abuse deterrent formulations used in Oxycontin and Opana and have several new abuse-deterrent formulations in the pipeline as well. Dr. Zhang will undoubtedly explore what role will these abuse deterrent formulations have in stemming the tide of pain medicine overdose incidents.

On Saturday, we will be hearing from Duke University’s Dr. William Maixner. Dr. Maixner is the Director of Duke’s highly prestigious Center for Translational Pain Medicine. He will talk about translational medicine for chronic pain and how that multi-disciplinary, highly collaborative approach is speeding up the development of new treatments for complicated chronic pain patients.

Later on Saturday, we will be hearing from Dr. Hans Hansen – a “fan favorite” from last year’s conference! Dr. Hansen will reflect on the tectonic shifts that have changed the landscape of pain medicine since the CDC Guidelines were released year.

Then on Sunday, we will hear from my friend and colleague, Dr. Arwen Podesta. Dr. Podesta is an expert in holistic medicine, addictionology, and forensic psychiatry and will use these expertise areas to present the latest in the assessment and management of addiction issues in chronic pain.

So, you can see that we – along with our Southern Headache Society colleagues – have put together a program worthy of the multi-faceted challenges we face.

See you in New Orleans!

–Mordi

REFERENCES:

[1] Eric Russell. A deadly epidemic: Addiction to opioids has put an entire generation at risk. Portland Press Herald. http://www.pressherald.com/2017/03/26/lost-heroins-killer-grip-on-maines-people/  Published 03/26/2017

[2] See URL   https://tonic.vice.com/en_us/article/ev43gk/the-men-who-catch-your-lobsters-are-self-medicating-with-heroin

[3] See URL   http://www.pressherald.com/2017/04/02/lobstermen-under-siege-heroin-epidemic-feeds-on-an-iconic-way-of-life/

[4] Marina Villeneuve. Chronic Pain Patients Say Opioid Law Creates New Crisis. The Associated Press. Published on 04/22/2017 and accessed at URL   https://www.usnews.com/news/best-states/maine/articles/2017-04-22/chronic-pain-patients-say-opioid-law-creates-new-crisis

[5] See URL   https://news.vice.com/story/opioids-chronic-pain

[6] See the following URLs for recent local opioid prescriber arrests:
http://www.heralddemocrat.com/news/20170711/fbi-arrests-sherman-doctor
http://www.theadvocate.com/baton_rouge/news/article_d6c70fe8-67f5-11e7-b922-db0d97ccab9c.html
http://www.fox9.com/news/267649616-story

[7] See URL https://www.fbi.gov/news/stories/nationwide-sweep-targets-enablers-of-opioid-epidemic

Functional Restoration: Use, Value & Structure – Newsletter

by Geralyn Datz, PhD

The Opioid Epidemic has forced providers and insurers to re-evaluate the way chronic pain is treated both short and long term. As a result, there has been a renewed interest in non-medical based treatments that restore pain patients, particularly injured workers, to health and optimal function.

Chronic pain is a common presentation in work injury. Functional restoration, or Interdisciplinary Pain Rehabilitation (IDPR) is a non-medication based option that can restore patients with pain to higher function and return to work. This is an intensive treatment that occurs during a full day, and typically for 20 consecutive days (programs may vary slightly in their duration).  The programs are coordinated by a group of skilled healthcare providers, all of whom have experience in treating patients with pain.

As Director of a functional restoration program in Mississippi, a question I am often asked is, “Does it really work?” And, “more importantly, Is it worth it?” Treatments are all about value and return on investment (ROI). And if there is no perceived value, why would insurance pay for something that is fairly expensive compared to a single, stand alone treatment?

The use of chronic opioid therapy for all patients with pain is a good example of high expense and low return on investment.   While opioids can be appropriate in some circumstances, the consensus is that they are currently overprescribed as the only therapy for pain by physicians and are overused by patients. In addition, they can be easily obtained by non-medical users https://www.cdc.gov/drugoverdose/data/prescribing.html .

In the case of non-specific low back pain, neck pain, or “whole body” (musculoskeletal) pain, for example, opioids are not the recommended first line treatment, but are nonetheless often used as the only treatment. Extended use of opioids can contribute, ironically, to greater physical pain (in a process called opioid induced hyperalgesia), and reduced activity level, depression and greater disability. Opioids have been under scrutiny for contribution to addiction and overdose risks, and death.

These challenges all translate to poorer care of injured workers, increased time off work, and increased costs and difficult claims handling for employers and insurers.

With respect to cost, expenses related to opioid prescriptions per claim continue to grow in the United States.  The National Council on Compensation Insurance (NCCI) indicates that medical costs are now approximately 59 to 60 percent of workers’ compensation claims costs.  Opioid prescriptions account for at least 25% percent of these costs. 

As problematic as medication-only approaches are, at least they are familiar. For some insurers, and providers, the ‘Devil they know is better than the Devil they don’t know’, to borrow from an old saying. For some, it became “comfortable” to prescribe opioids as a sole therapy for chronic pain, as other treatments were either not known, understood, nor appreciated. We now know that no one treatment is best for pain. Using a multimodal or biopsychosocial approach, where the whole person is addressed, leads to the best recovery from pain.

When I speak to carriers and employers about functional restoration, this thinking style and their discomfort with change is often obvious.  Their initial confusion is related to wondering how could a treatment last ALL DAY, when we are “simply talking,” (or worse, “watching movies”, or “coloring”, also fears I have heard) for 20 consecutive days in a row. What a rip off!!  If that were what functional restoration was, I would have to agree.

However, true functional restoration could not be more different. True functional restoration is the combination of two highly skilled services: Cognitive Behavioral Therapy (CBT), a type of specialized psychotherapy, and intensive Physical Therapy (PT). Note the word “intensive”, because ordinary, 1 hour a day, run-of-the-mill PT won’t pass muster in a functional restoration program. On Day 1 of our program,  we tell patients, “You WILL have a flare up in this program. If you don’t, we are doing something wrong.” Amazingly, the majority of our patients go from barely moving to walking the equivalent of walking five miles a day  at program’s end.  It is not unusual for patients to also increase their strength by 500%. Now that’s PT!

Here’s some straight talk on what functional restoration is and isn’t.

Characteristics of Functional Restoration

  1. Functional restoration reduces medication intake, in particular opioids. This is perhaps the most important feature of functional restoration. Rule of thumb: If a patient’s medications did not change during a functional restoration program, you definitely just wasted a lot of money.

Functional restoration is about reducing reliance on medication and teaching patients to self manage pain. Some patients need to be treated prior to program enrollment to wean medications, either inpatient or outpatient.  It is not unusual to reduce patients from 400mg of opioids a day or more to zero opioids at the end of these types of program. This is done through appropriate weaning or detoxification, counseling, coordination with prescribers, and lots of coaching and education.

Many patients would prefer not to be on the medications they are on, and are yearning for a solution that restores their previous way of living.  However, with few choices and alternatives, they fear change. When given an alternative for a fuller, restored, healthier and more active life, many patients will jump at that chance.

  1. Functional restoration is very focused on Return to Work and Activity. If return to work or former job is not feasible, then it’s about Return to Life. As the name implies, these programs are about restoring function.

Effective programs spend time teaching patients about Return to Work (RTW). The literature shows that functional restoration has 75 to 88% RTW rates. This is because the program is designed to help patients overcome the mental and physical obstacles that prevent their recovery. Research shows if the employer is willing to work with the client, there is more success in returning the client to their original position, or some modified version of it.

  1. Functional restoration is an alternative to surgery, particularly when a patient doesn’t want, or doesn’t qualify for surgery. Many studies have shown that functional restoration is an effective alternative to spine surgery and other surgical procedures, and can produce greater benefits.

 Spine surgery is far more costly than functional restoration, and while it is often touted as an effective means to RTW, the data do not support this. Several well-performed studies have demonstrated that RTW rates after spinal fusion are relatively poor. In a 2011 Ohio Work Comp cohort, only 26% of those who had surgery RTW, compared to 67% of patients who did not have surgery. Of the lumbar fusion subjects, 36% had complications, 27% required another operation. Even more troubling, the researchers determined there was a 41% increase in the use of painkillers, with 76% of surgery patients continuing opioid use after surgery.

 One very interesting study allowed injured workers to enter a functional restoration program for 10 days, even despite being elective spine surgery candidates. After 10 days in the program, they could either continue the program, or quit it and have surgery. After 10 days, a whopping 74% of the enrollees voluntarily decided to stay with functional restoration and declined surgery.

 What this and other studies keenly show is that when people are given other options, more often than not, they will take them. Injured workers have no idea how to rehabilitate themselves. But when shown how to do so, this is when true recovery is possible.

 Typical functional restoration programs have a team of highly qualified providers. These providers deliver up to 3 hours of physical therapy a day, in addition to 3 hours of cognitive behavioral therapy a day, plus another one to two hours of other adjunctive treatments like yoga, meditation, mindfulness and self massage. The team should have meetings about patient progress, and should be available for consult. Many programs use a combination of Physical Medicine Physician (DO), clinical pain psychologist (PhD), Doctor of Physical Therapy (DPT), Physical Therapy Assistant (PTA), Licensed Clinical Social Workers (LCSW), certified yoga therapists (RYT), licensed massage therapists (LMT), and sometimes nutritionists (RD).

That’s a lot of people and there’s definitely no time for coloring!

  1. Functional restoration facilitates claim closure.

In the past functional restoration has been primarily used on tail claims, as a last resort. However functional restoration can be used at any time (early, middle or late) in the claim cycle, but is most beneficial for RTW within the first 8 months of injury. One study showed that the average cost savings of using functional restoration early in the claim cycle, total economic cost savings was $170,000. This translated to cost savings of 64% and productivity loss savings/disability savings of 80%.

In functional restoration, patients are taught to refocus their mind on recovery, return to life and return to work. Work gives us purpose, resources, and makes us feel worthwhile. Psychotherapy techniques used in these programs help empower patients to reclaim their lives from pain.

Incidentally, beware of functional restoration programs that, at discharge, immediately refer for other medical treatments, like spinal cord stimulators, spine surgery, or medication, and report that the program “didn’t work.” While there are some exceptions, these should be rare, and functional restoration is not designed to become a referral program for surgeries or other interventions.  The goal of functional restoration is to stabilize the patient, improve their mental and physical functioning, and make them LESS reliant on the medical system and more reliant on themselves.  Hopefully more insurers will be open to referring for multidisciplinary approaches as the tides change in pain treatment.

Geralyn Datz, PhD, is a licensed clinical health psychologist in Mississippi and Louisiana, and immediate past president of the Southern Pain Society. She is the Clinical Director of the Pain Rehabilitation Program as well as the President of Southern Behavioral Medicine Associates, PLLC, in Hattiesburg, MS.

Dr Datz has authored scientific articles and book chapters on the topics of health psychology, pain treatment, the mind-body connection, and treatment of injured workers. She can be reached at drdatz@southernbmed.com

 

20 Years of the Integrative Healing Arts Network – Newsletter

by Michele Erich, MM, CCLS, MT-BC and Ann Quinlan-Colwell, PhD, RN-BC, AHNBC, DAAPM

News reports are replete with stories about the problems of opioid use disorder (OUD) and over dose deaths [1,2].  A reasonable approach to addressing this health care crisis is managing pain with a multi-modal approach rather than with opioid mono-therapy.  A multi-modal approach includes a variety of medications including appropriate use of opioids, non-opioid analgesics, co-analgesic agents and non-pharmacologic interventions [3].  Many people may be interested in non-pharmacologic interventions but don’t know much about them, don’t know where to find practitioners or can’t afford them. In addition, they are almost always thought of as interventions for chronic pain and not part of acute care or acute pain management.  One hospital in our region has shown leadership in offering non-pharmacologic interventions in the acute care arena.

This year New Hanover Regional Medical Center, a not for profit community hospital, celebrates the 20th anniversary of their Healing Arts Network (HAN) which has brought non-pharmacologic interventions to patients for the last two decades.  HAN originated as a vision to bring awareness to the use of complementary therapies and to open communication between patients and their physicians in regard to the different complementary therapies patients were considering incorporating into their plans for health and wellness.  The HAN also educated the public about appropriate qualifications of the therapist/practitioners who provide complementary therapies.  After a year or two as part of growth the HAN changed from referring to services as Complementary therapies to Integrative therapies.  The change emphasized the integration of HAN therapies into the medical model of care in both the acute care inpatient setting and outpatient setting.  Physician referrals and assessments are required and primarily address pan management, anxiety, depression, trauma and coping with a new diagnosis/prognosis or change in prognosis of a chronic illness.     

Interventions currently offered by the HAN are expressive therapy, music therapy, child life, massage therapy, therapeutic touch, tai chi/qi gong, yoga, craniosacral therapy and pet therapy.  These services are primarily offered to patients, but during the past year a plan was developed to offer stress relief to the employees of the medical center through chair massage and brief yoga and music therapy relaxation sessions.  Exploration is underway to expand services to further help employees take care of themselves by incorporating Integrative therapies into their own plans for health and wellness.  Expressive Therapy is provided by a Licensed Professional Counselor with a master’s degree in Expressive therapy.  Through Expressive therapy patients can begin to deal with their emotions related to the illness, injury or pain.  She often helps the patients find ways to relax and deal with the stress of their health conditions and hospitalization.  Imagery, breathing techniques, drawing and journaling are all introduced to patients teaching them some coping skills to take home after discharge and use as needed whenever stressed, in pain or anxious.   

Music Therapy is provided by a nationally board-certified therapist with 30 years of experience.  Through music therapy she can find ways to connect with patients who are in crisis, emotional distress or struggling with a diagnosis, treatment or unfamiliar experiences.  The connection between music, therapist and patient provides a safety net allowing the patients to confront their pain, fears or anxiety and begin to cope with their present situation.  Once an adult patient said, “Can you come home with me and play that music so I can relax?”  This patient had participated in breathing exercise with music and imagery to deal with his acute abdominal pain and was able to find relief during the music therapy sessions.  After one music therapy assisted procedural support with a pediatric patient the nurse said, “He actually fell asleep during that procedure.”.  “The music really helped.”    

Child Life offers support to children and families during their hospitalizations and outpatient treatments.  Through the use of music, imagery, art and play Child Life Specialist offer a positive outlet when a child is sick and hospitalized.  They also offer redirection and support during scary or painful procedures using music, breathing techniques, bubbles, Virtual Reality headsets, etc. Massage Therapy is provided by four licensed massage professionals who work on a contractual basis.  They provide full body and partial massages.  The focus is on pain management, relaxation and anxiety reduction and is tailored to the individual’s needs.  The massage is modified to work along with any limitations due to medical conditions, injuries, or medical equipment such as propping a pregnant woman with pillows, or avoiding massage to surgical sites, or modified positioning for a patient on a ventilator with limited mobility.  Partial massages are offered one to two times each week during treatments in the Chemotherapy/Infusion area as well as for patients in the inpatient oncology unit.

Therapeutic Touch (TT) is provided by trained individuals and can be incorporated into standard nursing care by those trained in TT.  Therapeutic touch is not as familiar as some of the other services in the HAN but patients report just as much relaxation and pain management benefits.  TT is a bit of a misnomer since generally the clinician never actually touches the person but rather works in the energy field surrounding the body. For patients dealing with extremely intense pain who can tolerate very little touch or movement It can be  preferred and can often help them to tolerate treatments.  TT has been used with patients from the NICU to palliative care.  Frequently, HAN is consulted by the wound care nurses to use TT to help patients having painful procedures or dressing changes.  Often the patients request TT intermittently between procedures to help with pain control as well.

Tai Chi/Qi Gong is offered by a middle-aged woman who was described by a young man as “that lady is very special; the coolest person I ever met.”  She teaches even patients who are confined to bed the basic techniques of Tai chi.  In addition to the benefit patients derive from Tai Chi in the hospital, they learn a technique that they can continue to use after discharge.  Another young man who lives with a chronic illness reported that he uses the Tai Chi he learned at NHRMC at home.  When he is re-hospitalized, he uses it with the “Relaxation Channel” on the television in his room and looks forward to learning more techniques.

Yoga is taught by two yoga practitioners with over 22 years combined experience and multiple specialty trainings including pregnancy yoga, restorative yoga and gentle yoga.  Sometimes patients who have “always wanted to try yoga” take the opportunity to do so.  Other times people who never thought of yoga, are willing to try it while in the hospital with the time and privacy to do so at no cost to the patient or their insurance.  One professional deep sea fisherman said that he would try anything to ease his pain and later reported that not only did the yoga help but that he would continue to use it to manage his pain.   They usually provide individual sessions but have offered yoga groups for women diagnosed with gynecologic cancers and adults hospitalized with mental health issues.  Both groups have been very well received.

CranioSacral Therapy (CST) uses light touch to release restrictions in the body and create balance.  A special process in CST called somatoemotional release can help relieve the lasting effects of trauma and illness.  A woman receiving treatments for cancer received CranioSacral Therapy and was so profoundly impacted by the reduction in her pain level, stress and tension as well as improved mood and overall well-being that she independently wrote a letter to the CEO of the medical center praising this service and the medical center.  She was also eager to participate in a local television news story to promote the Healing Arts Network and inform other patients of these services and benefits.

Pet therapy is “staffed” by volunteers who bring their specially trained and credentialed dogs.  The dogs must have completed the rigorous pet therapy certification training.   Their owners must go through the NHRMC volunteer training program and commit to bringing their dogs to the medical center at least 30 hours per year.  It is very impressive to observe the response that patients and families have to the special dogs.  One woman later reported that when one of the dogs visited it was the first time she had forgotten her head pain in over 30 years.  Another dog brought a young woman and her mother together sharing an interlude of smiling, giggling and petting the dog just days before the young woman died.

With Music Therapy, Expressive Therapy, Tai Chi/Qi Gong and Yoga patients are introduced to a variety of pain management and relaxation techniques.  Patients can learn the basics, expand upon them and continue to use them to manage pain and cope with challenges of life.  Patients are encouraged to explore resources in the community to further their use of these non-pharmacologic interventions as they strive for health and wellness.

Most recently, HAN joined with the Code Outreach Safety Team (COST) (see SPS issue Winter 2017) working with patients who are hospitalized for six to ten weeks for intravenous antibiotic therapy for serious infections resulting from IV SUD.  A challenge is that due to funding limitations, currently patients can have Tai Chi or yoga or massage once per week and must choose one.  While massage feels good, clinicians encourage the patients to at least try and learn a bit about Tai Chi and yoga because they can continue to use either or both integrative therapies to manage pain and cope with challenges after discharge.  The HAN is currently working with the COST to arrange weekly group yoga and Tai Chi.

The HAN Co-Founder (Michele Erich) not only coordinates the various activities and clinicians but she provides the Music Therapy and Child Life services as well as develops and updates policies and procedures, and complies with the Human Resource department requirements for maintaining all contracts with the HAN contractors.  She worked with the Electronic Medical Record team to create EMR documentation for herself and other HAN providers.  She also coordinates interactions with community groups who offer donations and activities.  Last month she coordinated “Christmas in July” with the local Parrothead fan club, bringing Santa in his sunglasses, summer shorts and Hawaiian shirt to brighten the day of the children hospitalized on the Pediatric unit.  She has also worked for several years with the medical center’s Foundation and Marketing department to receive generous donations of money from the Spirit of Children program, allowing her to furnish the teen side of the Pediatric playroom with an 8-foot high ‘basketball shoot to win game’, a Mustang car pinball machine, a Boom-A-Rang table air hockey game and a Rock-Ola Juke Box.  The most recent project involves the trial of Virtual Reality headsets from AppliedVR to help with pain management, distraction and relaxation during procedures and treatments for pediatric patients and adults receiving cancer treatments.    

To celebrate the 20th anniversary of the Healing Arts Network the clinicians are educating staff and visitors through internal flyers, and public display cases showcasing patient feedback and the services and benefits of the healing arts network.  In addition, there will be open yoga, tai chi/qi gong and music therapy drumming sessions held in the cafeteria courtyard and outside in front of the medical center allowing visitors and staff to participate in some of the services offered through the Healing Arts Network at New Hanover Regional Medical Center.  Certainly 20 years of patients having more fully integrative care as the result of an innovative vision that has been nurtured and has flourished is much to celebrate!

  Reference:

  1. Fleischauer, A. T. (2017). Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence—North Carolina, 2010–2015. MMWR. Morbidity and Mortality Weekly Report, 66.
  2. Rudd, R. A., Aleshire, N., Zibbell, J. E., & Matthew Gladden, R. (2016). Increases in drug and opioid overdose deaths—United States, 2000–2014. American Journal of Transplantation, 16(4), 1323-1327.
  3. Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., … & Griffith, S. (2016). Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain, 17(2), 131-157.

President’s Message May 2017 – Member Posts

“I would not recommend that you go into pain medicine… find something else rewarding to do.”

The honesty of that statement just exploded from my mouth – like it has been welling up to be spoken (or shouted) for many months.

I am at my clinic at Tulane University Medical Center, where for many years I have worked closely with senior / 4th year medical students who are about to graduate. These are students doing an elective in Ambulatory Medicine – a ‘hot topic’ for the American Academy of Medical Colleges. They have, therefore, completed all the core rotations – medicine, pediatrics, surgery, and the like. In short, they are as well trained as interns and residents. In fact, they are even better than interns and residents because none of the biting hours of internship have ground down their optimism and dedication (yet)!

These students have worked closely with me in my Tulane clinic where we continue to prescribe opioid-containing pain medicines to patients with responsive conditions. Of course, my clinic is also trying to integrate the lessons of the CDC Guideline [if you don’t already know this web address by heart, here it is] and other treatment recommendations as much as possible.

Students have found this rotation rewarding enough that it was featured as a locally-started innovative educational program through the Tulane  .

With this good publicity, you would think I would be singing the praises of our field of pain medicine to students, encouraging them to go into an area of organized that is valued (or at least highly featured) by our society. You would also think I would be crowing-on incessantly about the practice of pain medicine / pain management making an enormous positive contribution to the essential nature of ‘doctoring’. That essential nature being the improvement of the quality of life for patients when the condition they suffer from cannot be simply cured .

Rather, I have felt totally under siege – panicked – and worried that the ‘government ninjas’ will raid my clinic soon too. What not? They seem to have raided many other pain management clinics in the area. What makes me so special (answer: nothing)?

I am sure some “bad actors” have been rounded up in these pain clinic raids. But physicians, pharmacists, and clinics that I worked with for many years in providing pain care for complicated patients have also been ‘raided.’ These raids have left their patients scrambling for replacement providers and their colleagues (like me and you) in a panic that they will be next.

One closure is the recent law enforcement raid of Wilkinson Family Pharmacy in Chalmette, LA. This raid was carried in many local news outlets.

I certainly did not know of the shenanigans that have since leaked out into the press accounts. What I do know is that several complicated patients – with cancer, with organ transplant, and with other painful afflictions, have used Wilkinson Family Pharmacy for years. I also can affirm that the pharmacists and employees at Wilkinson were willing to go ‘above and beyond’ for many of my patients, giving me time to discuss the case with them and giving my patients time to ask questions about their medications in a way that the chain pharmacies just DON’T do!

Last Friday, I was furiously rewriting prescriptions for all the medications (controlled, not controlled – all of them) for my patients whose prescriptions were at Wilkinson’s and are now lost to the wind. St. Bernard Parish – an area that has both a history of intense drug abuse as well as intense lack of access to healthcare services – just lost one more service provider.

There have been other raids that have not made the media –so I don’t want to document the details because the information I am getting is through the unreliable grapevine. But, taken together, it leads me to wonder if the government has decided that our entire field of pain medicine / pain management is a scourge to society and that it is going to shut down that field, one provider at a time. The only way to avoid this fate – get out now anyway you can with your license, assets, and sanity intact.

Adding another element to this whole situation is the fact that most prescription alternatives to opioid containing medications don’t work well at all in relieving pain – almost always no better than placebo. An article, Trial of Pregabalin for Acute and Chronic Sciatica, published recently in the New England Journal of Medicine, agreed with several previous non-biased trials that Lyrica is no better than placebo for sciatica.

There also have been countless articles (unless you work for Cochrane Clinical Reviews – then you can count that high) on the real risks to life itself caused by long-term use of NSAID anti-inflammatories for pain control (see e.g. ‘TIME Health’ article on 03/15/2017 titled Common Pain Meds Are Linked to a Higher Risk of Heart Problems).

This whole situation has led to a situation where that safe and effective alternatives to opioids for the treatment of chronic pain are so sorely needed that the government is imploring pharmaceutical companies to spend billions more on looking for these types of drugs. As this April 17th article from the Detroit News does a good job summarizing, Big Pharma has responded with many trials. But, trials do not equal success. To this point, the quest for non-addictive AND highly-effective medications for the control of chronic pain is more in the realm of a Star Trek-like hope for future medicine. Instead, we labor and learn in the real world of actual modern-day medicine that has lots of non-addictive treatments for pain. But, are they highly effective to our patients as a whole? Using the same data yard stick that was used for compiling the CDC Guideline, the answer would be resounding “NO”!

If you think this whole situation has been terrifying for us, imagine for our patients! On March 13th, pain patient Alessio Venture wrote an honest and forthright assessment of this situation from his own vantage point – a person with horrific chronic pain whose only relief has come from opioid-based pain medications. Writing for Pain Network News, Mr. Ventura describes pain from 17 surgeries since 2008, including major back surgery, rotator cuff repair, biceps tendonitis, knee surgery and hernia surgery. He describes thorough and failed trials of Lyrica, Cymbalta, chiropractic, injections, NSAIDs, and acupuncture that led to failed pain relief and new problems like dramatic weight gain and depression.

Mr. Ventura is currently on Oxycontin and takes testosterone for the hormone changes caused by Oxycontin, and he has a life of quality. At least a life enjoyable enough to raise four children and work for decades as an engineer for Bell Labs. Like many patients I have treated, he describes his response to opioid-based pain medicine (even with its risks and side effects) as a “miracle” – especially when compared with how dismally the alternatives worked for him.

He is far from alone. In a recent survey published by Pain Network News of more than 3,000 patients with chronic pain, about 84% said their pain and quality of life has worsened since the new CDC Guidelines were implemented. 42% said they considered suicide because of how poorly their pain was treated, and 22% said they’re hoarding opioids because they’re unsure they will be able to get them in the future.

Just to show this patient dissatisfaction has not been artificially manufactured by Pain Network News for its own aims, there have been plenty of other articles about how terrified pain patients are. Just look at these recent news reports from several states including Ohio and Maine, from HMOs such as Kaiser Permanente and nationally in magazines like Reason Magazine.

These articles point out that there have been glaringly needed reforms to opioid prescribing in some situations, but the wholesale campaign now engaged in has created countless desperate and frightened individuals who have seen a life-preserving form of treatment snatched away from them with disastrous consequences.

This leads me back to my student – who has worked along-side me for two months. On our last day together, he tells me that his experience in my clinic has been the best experience he has had in medical school. He tells me that the patients he has encountered in our Tulane clinic feel heard, validated, and respected by our program. The student has been impressed with the several stories he has heard from patients about how they were considering suicide “before the treatment with Dr. Potash” and how their lives are immeasurably better now. The student tells me “this is why I went into medicine in the first place… this is what makes all that student loan debt seem worthwhile” and asks me how to best pursue a career in pain medicine after training.

I have had students ask me this before and I have been pleased to direct them towards residency programs with strong training in pain management for residents as well as fellowship opportunities. But, this time, I blurted out “I would not recommend that you go into pain medicine… find something else rewarding to do.”. The student looked shocked and started apologizing for whatever offense he had caused. He presumed that was why I was sternly directing him AWAY from a career in pain medicine – that I must have found him an unworthy candidate to follow the same patch I had chosen.

It took me some time, but I was able to explain to him that he is a great student now and will be a great doctor in a few short months. However, I did not want to feel responsible for him choosing a field that has been so crushingly hard to practice in over these last few years – a field that seems to be collapsing around us under the gravitational weight of criticism and castigation. I didn’t want to be responsible for his sleepless nights, having has so many fitful nights myself recently. I wanted, above all, for him to feel that he was practicing in an area of medicine that was respected by both colleagues and society as a whole and I don’t feel that way about the field of pain medicine / pain management currently.

This column may seem like the worse advertisement ever written for attending our September 25th annual conference (and our first time hosting our conference in conjunction with the Southern Headache Society).

Nothing is further from the truth!

This column is really an urgent call to attend this meeting – to send in your registration now and participate in the conference enthusiastically… like groupies for Hamilton! You may not need to sing every line at the conference (truth is – there will be zero singing), but there has never been a more urgent time for the networking, education, and advocacy that our conference will provide.

We are practicing a time of profound professional uncertainty. Yet we still have unbreakable obligations to our patients. Their lives would be unequivocally damaged if we just ‘cut and run’ away from our practices. Although we face enormous challenges – with new ones seeming to spring up daily – let us meet these challenges together. As Ben Franklin said, “We must hang together or surely we shall hang separately”.

See you in September!

  • Mordi

Innovation: Opioid Substance Use Disorder

by Ann Quinlan-Colwell, PhD, RN-BC, DAAPM

During 2014, patients were admitted more frequently with diagnoses of soft tissue abscesses, epidural abscesses, and endocarditis. Two common denominators, among many of these patients, were a history of self-administering opioids intravenously and now needing intravenous (IV) antibiotics for prolonged periods of time. This combination posed a challenge for health care providers who believed that it was not prudent or safe to discharge patients with a port or peripherally inserted catheter (PICC) line for IV access when the patient was known to abuse opioids intravenously.  Thus, the patients with these dual diagnoses -serious infections requiring IV antibiotics and substance use disorder- were admitted to the hospital for administration of IV antibiotics for six to twelve weeks. 

Two additional concerns arose. Many providers believed that it was important to control pain and to work with these patients, encouraging them to work toward sobriety.  In many instances this was reasonable and opportune since some of the very ill and scared patients demonstrated greater motivation to seriously consider abstinence and sobriety.  The providers consulted the Pain Management Clinical Nurse Specialists (CNS) to help control the patients’ pain while minimizing opioids and then wean the opioids to discontinuation whenever possible.      

Two cardiovascular surgeons who saw the patients with endocarditis invited a team to meet to address how to best work with the patients with endocarditis resulting from IV substance use (IVSU).  The initial group included the cardiovascular surgeons, infectious disease (ID) physician, cardiology administrator, cardiology nurse administrator, behavioral health administrator, substance abuse counselor, pharmacist, social worker, case manager and pain management CNS.  An addictionologist and community provider of buprenorphine were consulted.

Since patients were also being admitted for non-cardiac infections resulting from IVSU, the team expanded to coordinate with the medical center Code Outreach physicians.  Code Outreach is the established process through which the medical center coordinated interdisciplinary care of patients who were frequently evaluated in the emergency department (ED) and/or admitted.  Eventually, the Code Outreach team assumed primary oversight for interventions, patient care, and group activities. 

The intervention and group is now known as the Code Outreach Special Team or “COST”.  It consists of the two Code Outreach physicians, a pharmacist, the substance abuse counsellors, pain management CNSs, case management, cardiac nurse coordinator and one social worker (MSW). This MSW follows all the patients who are admitted to receive long term IV antibiotics to treat infections resulting from IVSU. Each patient in this category is reviewed weekly by the COST.  At the weekly meetings, the patients’ condition, challenges, pain management, progress toward goals, discharge needs/plans as well as the barriers to achieving these are discussed.  The plan of care is amended as needed. A template was developed for an individualized COST note to be created during the meeting and entered into the electronic medical record for the patient. This COST note is available to all professionals providing care and working with the patient. 

Each of the patients is also individually followed at least weekly by the pain management CNS, substance abuse counsellors and MSW.  The team, especially the MSW, works closely with methadone maintenance programs and providers of buprenorphine in the community to identify resources to connect with the patient prior to discharge.  While hospitalized, the substance abuse counsellors, MSW and pain management CNS work with the patients to encourage and support sobriety.  Recently, the team has located an Alcoholic Anonymous/Narcotics Anonymous group to conduct meetings for this group of patients while hospitalized. 

The pain management CNS works with the patients to control their acute pain which generally requires some opioids as part of a multi-modal analgesic plan of care (MMA-APOC).  As resolution of the acute infection resolves, the focus changes to weaning opioids and progressing to a non-opioid MMA-APOC.  Patients are encouraged to learn non-pharmacologic ways to control pain including square breathing, relaxation, distraction, and exercise.  The medical center Healing Arts Network are consulted for patients to learn tai chi and/or yoga and receive massage. 

Future plans include:

  • the MSW being dedicated full time to working with these patients
  • securing a room for the AA/NA meetings
  • identifying a physician to initiate prescription of buprenorphine for interested patients
  • developing a care plan or care trajectory that provides for consistency with room for individual care
  • educating all medical center staff about the COST, clinical note and care plan
  • increase funding for Healing Arts Network to increase support of non-pharmacologic interventions and education
  • increase interactions with community treatment and behavioral health providers and facilities
  • increase interaction and expand work with families of patients followed by the COST
  • collect and analyze data to determine effectiveness of COST activities
  • obtain grant funding to improve and formalize the COST and increase resources

The dedication and work of the member of the Code Outreach Special Team is acknowledged.

Reflections from Outgoing President Geralyn Datz, PhD

Happy New Year SPS Membership!

It is with excitement that I look forward to the new year of 2017. But also some sadness as I step away from the role as president. It has been a wonderful two years with the organization serving in this role. As I reflect back on my time served, I marvel at what has happened both within the society and within health care as a whole during my term.

One major development of growth during the time of my presidency was a much greater attention to mental health in the problem of chronic pain.  As a pain psychologist, this is a movement I watch with great interest. I hope our membership noticed it as well, because it has been truly revolutionary.  I have been practicing a dozen years, and in the last 2 years there has been a real excitement around pain psychology. There have been many more peer reviewed articles discussing the use of psychological self-care strategies, meditation, relaxation and the importance of educating the person with pain about what pain is and what chronic pain is not.

In March of 2016, the CDC guidelines also emphasized the use of mental health, specifically psychology and the use of cognitive behavioral therapy as alternatives to opioids as first line treatment for chronic pain. The CDC pointed to research showing that cognitive behavioral therapy, mental health counseling, or even a combination of these with nonopioid treatments (e.g. acetaminophen, non-steroidal anti-inflammatory drugs, physical therapy) were effective ways to decrease the risk of opioid co-dependence and potential death.

The mental health provisions of the “21st Century Cures Act,” signed by President Obama in December 2016, establishes several new milestones for mental health.  A new assistant secretary for mental health in the Department of Health and Human Services will be placed, as well as a chief medical officer, which elevates behavioral health in the context of overall health policy. This is sorely needed! The Cures Act also provides funding for grants in critical areas like suicide prevention and to address the nation’s critical opioid crisis.

Perhaps most powerfully, the provisions of the Cures Act aims to provide stakeholder education and protect consumers by ensuring compliance with existing laws, specifically, the Mental Health Parity and Addiction Equity Act, both of which are designed to prevent health plans from imposing less favorable benefits for mental health and substance abuse disorders than for medical and surgical benefits.

This year, Beth Darnall, PhD, a pain psychologist at Stanford, will be discussing self management strategies for chronic pain at the American Academy of Pain Medicine Meeting in Orlando, and will be hosting an innovative panel discussion about using these techniques directly with pain patients in any setting. Dr. Darnall has been very active in bringing pain psychology to the public eye through her media presence, her research at Stanford with Sean Mackey, MD, PhD, and her books “Less Pain, Fewer Pills,” and “The Opioid Free Pain Relief Kit”.

This past November 2016, I was very encouraged to see several talks dedicated to the biopsychosocial model and the topic of “Mental Health and Pain”, at a national worker’s compensation conference. Even just hearing the words “mental health” at an industry / carrier conference was so refreshing I almost stood up from my seat and clapped!  For any of you who have treated personal injury claimants, you realize what a long time this is in the making. It is very important that industry and insurance companies recognize the value of mental health and how to rehabilitate the whole person with pain, because they are the lynchpin of reimbursement and service delivery.

At SPS, we are doing our part on a regional level to broaden our scope of teaching pain management from both a mental health and medical perspective. I was overjoyed to bring Dr. David Hanscom (www.backincontrol.com) to the SPS 2016 meeting. The response to him from our membership was so incredible. We had so many attendees tell us how valuable hearing his perspective was, from hearing about his own journey as a neurosurgeon, as well as someone with pain, to them as providers. I have recently begun partnerships with several primary care providers in my own area, where we co-treat patients, using the philosophy of Dr. Hanscom, as well as ideas directly from cognitive behavioral therapy. It is so exciting how we have significantly changed these patient’s lives. I recently co-treated a patient who attended very brief cognitive behavioral treatment and three sessions with his primary care provider. The patient has been using the tools of cognitive behavioral therapy as well as Dr. Hanscom’s book. The patient has experienced over a 50% reduction in pain without a single medication change. Cases like these challenge us to rethink our approach to chronic pain. We are now working on a weaning regimen for his medications in light of his recent gains. Incredible!

We have been faced with many challenges in the last two years. The opioid epidemic, insurance coverage changes, the large number of chronic pain patients needing to be seen, and the lack of pain specialist access. These are all issues that we as a Society will continue to make a priority as an organization and brainstorm solutions that help our Frontline providers.  We are working to forge new interdisciplinary relationships to address the ever-present treatment challenges in pain. As further evidence of this, our 2017 meeting “Head to Toe,” SPS is partnering with the Southern Headache Society (SHS), an organization of primarily neurologists, to share ideas and innovations in head pain and beyond. It is very rewarding to see this collaboration come to fruition after two years of hard work!

I hope that these stories inspire you as they have me. I hope you continue to attend our meetings. Please continue to challenge us and stimulate us with your feedback and topics of Interest. I look forward to the partnership with the southern headache society that has been germinating for several years. It will be truly an exciting time in New Orleans this fall. Look for me and I will be looking for you! As always reach out if you have questions or feedback.

Sincerely

Geralyn Datz, PhD

Additional Educational Opportunities

In support of our colleagues in pain management, here are some other important meetings coming up that may be of interest to you.  

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Kentucky Pain Society Inaugural Meeting November 12, 2016 at the Griffin Gate Marriott in Lexington Kentucky.  Read More

Supporting the Southern Headache Society

Dear member of the Southern Pain Society:
The Southern Headache Society is excited about our collaboration with your group, as we plan a jointly-sponsored meeting in 2017 in New Orleans. Meanwhile, we would like to invite you to join us at our annual CME meeting this year, which will be held one week before your own Annual SPS meeting (if you can only attend one, of course you should attend SPS).

We have an outstanding meeting planned this year.

Peter Goadsby MD, the world’s leading researcher in migraine basic sciences, will be our keynote speaker. He is a brilliant lecturer.
 
There will be numerous talks of clinical interest to the general pain community, including talks on interventional therapies for headache, traumatic brain injury, psychiatric co-morbidities, and resilience. Saturday afternoon offers parallel workshops, one of which will be a practical demonstration of common injection techniques for headache.
 
Special Bonus: Pre-Meeting Symposium on Friday 9/23, by Dr. Andrew Newberg, author of “How God Changes Your Brain,” speaking on the topic of his most recently released book, “How Enlightenment Changes Your Brain.” This Pre-Meeting Symposium has a separate registration fee.
 
Take advantage of earlybird registration and register now.
 
Please book your hotel rooms early. We have a limited room block, and Asheville hotels are usually 100% occupied this time of year.
 
Hope to see many of you there, Morris Maizels, MD

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Spring 2016 Newsletter

Enjoy our Spring 2016 Newsletter Read More

Winter Newsletter

Enjoy our Winter Newsletter in a new electronic format!  Read More

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