Category Archives: News

President’s Message on the American Pain Society

Dear SPS Member:

The members of the Board of Directors of the Southern Pain Society were saddened to read about the possible need for the American Pain Society to cease operations.  We have long appreciated the scientific contributions and clinical guidelines for pain management made by the APS. 

We also want to re-assure members of the Southern Pain Society that, thanks to your support, we continue to be a healthy and viable organization dedicated to “serve people with pain by advancing research and treatment and to increase the knowledge and skill of the regional professional community” of the 18 southern states and Puerto Rico. Although we were considered a regional society by APS, we were and continue to be a separate and distinct entity with our own corporate and tax identity.  There are no legal or financial ties to APS. 

We are finalizing our plans for our annual meeting dedicated to exploring an Integrative Pain Care: New Perspectives, which will be held this year in New Orleans from September 13-15.  Hopefully, you will join us there to learn about a variety of pain management options from our group of expert presenters. 


Ann Quinlan-Colwell, APN, PhD
Southern Pain Society


President’s Message, April 2019

Ann Quinlan-Colwell, PhD, APN

While reviewing the agenda for our upcoming annual Southern Pain Society meeting Integrated Pain Care: New Perspectives, after looking at the varied topics being presented and the backgrounds of the speakers, I was reminded of the concept that “it takes a village.”  Considering that phrase led me to investigate the term and asses if it was reasonable to  make that connection with our conference.  Surprisingly, the first definition I found was in the Urban Dictionary which explained the phrase it takes a village is used to describe the enormity of a difficult task or how many people are needed to “clean up the mess.”  Although that wasn’t the connection I initially made between our conference and the phrase, it certainly resonated with our intent for the conference in relation to the current dual opioid and pain crises.  Along with the attention the opioid crisis is receiving, those of us working daily with patients living with pain know that for many of them there is a simultaneous pain crisis.  As pain professionals we have a responsibility to help to “clean up” what many consider to be  “the mess” that resulted from the opioid crisis and now the consequential pain crisis.  We also are well aware that the task is far from easy (i.e. difficult).

Although it was tempting to be content with the Urban Dictionary definition, I knew there are other meanings.  When considered from ancient African culture, the phrase it takes a village means that there is a community responsibility to connect together to safely raise a child (or resolve a crisis).   As a community of pain management professionals, we have a community responsibility to advocate for and provide safe and effective pain management.  When discussing her book, It Takes a Village, Hillary Clinton explained the phrase as “we are all in this together.”  The diverse group of SPS attendees and speakers personify the Clinton explanation.  Similarly, the term is also frequently used as a metaphor to describe the need for a variety of people to join together to  achieve an optimal outcome.  Those were the connotations that were originally sparked in me when reviewing our conference agenda.   As an organization we are a multidiscipline group working together to improve pain management for all patients with pain. 

Today, we are faced with enormous healthcare challenges and we know we need many clinicians from numerous disciplines to work together to resolve the issues generated by the opioid and pain crises.  It is clear that the best option available is utilizing a multidisciplinary multimodal approach of pain management.  Such an approach when utilized immediately following trauma and/or postoperatively will not only promote optimal safe resolution of acute pain situations but will also help avert the development of subsequent chronic  pain.  For those people who are living with chronic pain, intentionally utilizing a variety of pharmacologic and complementary interventions is the most effective approach to control pain and optimize function.

This year the  annual SPS Conference will begin with Blake Fagan, MD taking us through the history of the opioid crisis.  Along with other presenters he will then discuss safe pain management with controlled substances as well as non-opioid analgesic options.  Dan Doleys, PhD, will guide us in the importance of pre-opioid screening prior to starting opioid therapy. Our key note address will be presented by Steve Stanos, DO from Swedish Medical System in Seattle.  Utilizing the extensive knowledge, he has acquired through his amazing career in pain medicine and his participation on numerous national task forces, Dr. Stanos will bring us to the crossroads we now find pain management.  He will then offer innovative solutions for safe and comprehensive care.  Our own past president Mordi Potash, MD will enlighten us about utilizing psychopharmacology as a way to manage pain. 

This year several professionals will discuss how to help patients manage pain with non-medication options.  Non-opioid interventions, with a focus on neuropathic pain, will be discussed by Misha Backanja, MD.  From LSU, Ashley Mullens, PhD will give a lively overview of therapeutic cannabis.  Jennifer Murphy, PhD will explain what is involved with pain psychology and the use of the cognitive behavioral therapy methods in which she trains healthcare providers nationally.  Eric Royster, MD, a local New Orleans physician, will describe interventional options for managing pain.  Dr. Stanos will then discuss the value of functional restoration for chronic pain through the biopsychosocial model. Consistent with the importance of function,  the many pain management options available through physical therapy will be shared by Monique Serpas, DPT.

Cutting edge topics will be intertwined.  Ken Mautner, MD will present on the role of platelet-rich plasma and stem cell therapies as pain management for orthopedic conditions.  Then Forest Tennant, MD will share information on hormonal care as an intervention for chronic pain.  Our time will conclude with Charles Figley, PhD sharing his important work on how as clinicians we can help our patients most effectively by developing resilience to compassion fatigue within ourselves. 

Please join our “village” of pain management sages to support you and your local village of pain management caregivers.  Better yet, in the village spirit, consider bringing a colleague along to NOLA! You can return home as a team to invigorate and enlighten your own village of pain management professionals!   We look forward to seeing you in September!


Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P., … & Gilson, A. M. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113-130.

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.

Clinton, H. R. (2006). It takes a village.  Simon and Schuster.

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. Jama, 315(15), 1624-1645.

Gordon, D. B., de Leon-Casasola, O. A., Wu, C. L., Sluka, K. A., Brennan, T. J., & Chou, R. (2016). Research gaps in practice guidelines for acute postoperative pain management in adults: findings from a review of the evidence for an American Pain Society Clinical Practice Guideline. The Journal of Pain, 17(2), 158-166.

McAlindon, T. E., Bannuru, R., Sullivan, M. C., Arden, N. K., Berenbaum, F., Bierma-Zeinstra, S. M., … & Kwoh, K. (2014). OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis and cartilage, 22(3), 363-388.

Nuckols, T. K., Anderson, L., Popescu, I., Diamant, A. L., Doyle, B., Di Capua, P., & Chou, R. (2014). Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Annals of internal medicine, 160(1), 38-47.

Urban Dictionary. (2019). It takes a village.

Self Compassion

Ann Quinlan-Colwell, PhD, APN

In this third of a series of writings about compassion and pain management, this article focuses on self-compassion.  The premise is that it is essential for health care providers to have compassion for self as the foundation to empathically and compassionately care for patients, while promoting compassionate satisfaction and preventing compassion fatigue.

Self-compassion is connecting care and support for self during times of personal suffering (Neff & Knox, 2017).  Since compassion is being aware of the pain of another person without judgment and a desire to alleviate pain, self compassion is focusing that non-judgmental perception to appreciate self pain with a desire to alleviate it (Veneziani, Fuochi, & Voci, 2017).   Germer (2009, p. 33-34) explains self-compassion as “simply giving the same kindness to ourselves (during suffering) that we would give to others.” 

Neff identified three essential components of self-compassion as being “self-kindness versus self-judgment, common humanity versus isolation, and mindfulness versus overidentification” (2016, p. 1).  Similarly, Reyes (2012) noted that being aware of other people, being kind to oneself (i.e. self-kindness) particularly when suffering, being mindful and being wise are attributes of self-compassion.   See table 1 for characteristics of self-kindness as described by Reyes.

Characteristics of Self-kindness (from Reves, D. 2012)

  • Treating self kindly when suffering
  • Replacing self-criticism with caring and understanding
  • Accepting own faults
  • Releasing regrets and disappointments
  • Giving up illusions about what might have been
  • Forgiving self
  • Accepting responsibility
  • Avoiding guild
  • Restraining from punishing self

Contrary to being selfish, compassion for self is essential for developing sincere compassion toward patients and others (Dalai Lama, 2003).  It is “a useful regulation strategy in which painful feelings are not avoided but are instead held in awareness with kindness, understanding, and a sense of shared humanity” (Costa & Pinto‐Gouveia, 2013, 1580).  Unlike narcissism, self-compassion is considered to be a healthy self-care element that is not associated with egotism,  enhancement of self-image or excessively positive self-evaluations (Veneziani, Fuochi, & Voci, 2017).  In fact, the authors of an interesting study reported that individuals with greater self-compassion had less acceptance of their own moral transgressions (Wang, Chen, Poon, Teng, & Jin, 2017).  

Although research of the concept is limited, self-compassion is associated with lower levels of anxiety and depression (Costa & Pinto‐Gouveia, 2013). Self-compassion is associated positively with health-related quality of life which was demonstrated among people living with multiple sclerosis (Nery-Hurwit, Yun, & Ebbeck, 2018). Conversely the absence of self-compassion is associated with unhealthy behaviors. Self-compassion is reported to be inversely correlated with disordered eating (Maraldo, Zhou, Dowling, & Vander Wal, 2016). The researchers of a recent study reported an inverse relationship between self-compassion and developing substance use disorder (Phelps, Paniagua, Willcockson, & Potter, 2018).

Consider the pain management clinical situation in which a clinician is working with a patient to manage pain with a multimodal approach using acetaminophen, gabapentinoids and opioids. The patient overdoses on the gabapentinoids and opioids in addition to some benzodiazepines received from another provider who also prescribed other opioids.  The pain management clinician who never developed self-compassion is devasted by the news and berates self for not checking the prescription drug monitoring database (PDMP).  The clinician does not forgive self and ruminates about this situation becoming increasingly depressed and anxious. Eventually this very talented and compassionate clinician leaves pain management entirely. 

The situation described could have a very different outcome if the clinician cultivated self-compassion.  With self-compassion the clinician could review the situation, acknowledge the omission of not checking the PDMP and grieve the patient.  Yet with self-compassion the clinician can experience remorse and regret while also knowing that there was no intent to harm the patient.  With self-compassion the clinician can understand that time constraints and a lack of appreciation for the importance of the PDMP information led to not checking. With self-compassion the clinician can forgive self and vow to assiduously check the PDMP whenever prescribing opioids, thus becoming a more responsible pain management clinician for thousands of patients. With an understanding and cultivation of self-compassion, this talented clinician is also able to be appropriately compassionate for people living in pain and guide patients toward self-compassion.        


Costa, J., & Pinto‐Gouveia, J. (2013). Experiential avoidance and self‐compassion in chronic pain. Journal of Applied Social Psychology, 43(8), 1578-1591.

Dalai Lama.  (2003). Transforming the Mind: Teachings on Generating Compassion.  London, Thorsons, Hammersmith.

Germer, C. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. Guilford Press.

Maraldo, T. M., Zhou, W., Dowling, J., & Vander Wal, J. S. (2016). Replication and extension of the dual pathway model of disordered eating: The role of fear of negative evaluation, suggestibility, rumination, and self-compassion. Eating Behaviors, 23, 187-194.

Neff, K. (2016). Self-compassion. Mindfulness in Positive Psychology: The Science of Meditation and Wellbeing, Encyclopedia of Personality and Individual Differences. 37, 1-8.

Neff, K. D., & Knox, M. C. (2017). Self-compassion. V. Zeigler-Hill, TK Shackelford (eds.), Encyclopedia of Personality and Individual Differences, 1–8. DOI 10.1007/978-3-319-28099-8_1159-1.

Nery-Hurwit, M., Yun, J., & Ebbeck, V. (2018). Examining the roles of self-compassion and resilience on health-related quality of life for individuals with Multiple Sclerosis. Disability and Health Journal, 11(2), 256-261.

Phelps, C. L., Paniagua, S. M., Willcockson, I. U., & Potter, J. S. (2018). The relationship between self-compassion and the risk for substance use disorder. Drug and Alcohol Dependence, 183, 78-81.

Reyes, D. (2012). Self-compassion: A concept analysis. Journal of Holistic Nursing, 30(2), 81-89.

Veneziani, C. A., Fuochi, G., & Voci, A. (2017). Self-compassion as a healthy attitude toward the self: Factorial and construct validity in an Italian sample. Personality and Individual Differences, 119, 60-68.

Wang, X., Chen, Z., Poon, K. T., Teng, F., & Jin, S. (2017). Self-compassion decreases acceptance of own immoral behaviors. Personality and Individual Differences, 106, 329-333.

Chronic Migraine: 6 Months of Therapy with Erenumab (Aimovig)

Lawrence Robbins, M.D.

NOTE: This is a shortened version of an article published in the March issue of Practical Pain Management (available online).

Migraine is a relatively common illness, affecting 12% of the population. Chronic migraine (CM) is a frequently encountered subset of migraine, and presents certain difficulties in treatment. Those with CM have at least 15 headache days per month, with at least 8 days being migrainous in nature. In addition, medication overuse headache cannot be a major contributing factor to the headache pattern.  Many with CM do not do well with the usual preventive approaches, and suffer from refractory chronic migraine (RCM).  Patients with RCM have failed on at least 3 types of preventive medications. A number of our usual migraine preventive approaches have limited efficacy, and side effects often limit use. Additionally, effectiveness often diminishes over time. New preventive approaches are needed for chronic migraineurs.     

Calcitonin gene-related peptide (CGRP) is an important neuropeptide involved in the migraine process. CGRP receptors are ubiquitous in the sites that are involved in migraine pathogenesis. CGRP is involved in mast cell degranulation, neurogenic inflammation, and the subsequent vasodilation. During a migraine, CGRP levels usually rise.  For those with migraine, infusions of CGRP may precipitate an attack. During a migraine, trigeminal nerves that are activated may release CGRP, as well as other inflammatory compounds. The monoclonal antibodies (mAbs) that inhibit CGRP have been effective for a number of patients with chronic migraine.

Our current oral migraine preventives include antidepressants, anticonvulsants, and medications used for hypertension. These have limited efficacy, and often are not tolerated. Onabotulinumtoxin A is more effective than the oral preventives, and has few side effects. For those with chronic migraine, there is a need for more effective preventives. The CGRP monoclonal antibodies that may help to fill that role.

Erenumab-aooe (referred to as erenumab in this article), was the first CGRP mAb to become commercially available, in May of 2018. Erenumab is a subcutaneously administered once-per-month injection. There are currently 2 other mAbs available: fremanezumab and galcanezumab.  These are all large molecule mAbs, with little penetration through the blood brain barrier. Erenumab targets the CGRP receptor, while the others in this class affect the CGRP ligand. These large molecule mAbs have several major advantages, including little or no drug interactions. In addition, they are cleared through the reticuloendothelial system, and do not irritate the liver or kidneys. Demand for these newer preventives has been brisk, as there has been a paucity of effective therapies for those with chronic migraine. 

We evaluated the results of erenumab after the first 6 months of treatment. The first study involved 220 consecutive chronic migraine (CM)patients, after 3 months of therapy. 43% of all patients experienced 0 to 30% relief. 34% reported 30 to 70% relief, while 24% described 70 to 100% relief.  Among the 43% with only 0 to 30% relief, many did choose to continue with erenumab. Many of these patients did state that they were satisfied with 15 to 30% relief. Forty-eight patients dropped off of the erenumab after months 1 or 2.  Ten percent of patients reported almost complete (95 to 100%) relief over the 3 months. The patients in this study were relatively more refractory than those in the Phase 3 erenumab studies. These patients had all utilized at least 3 preventives, and almost all had tried onabotulinumtoxin A.  One hundred thirty-two of the patients were considered to have refractory chronic migraine.  In this study, the efficacy of erenumab was reasonable, even considering the relatively refractory population. We do not know how efficacy will hold up over time.

There were a considerable number of side effects reported by the 220 patients. Constipation was the most prevalent, at 20%.  The constipation was severe in some patients, requiring treatment. At least 4 patients discontinued the erenumab primarily due to constipation. Nausea (7%) was also described, as was an increased headache (5%). The nausea usually resolved, but with an increase in headaches, the erenumab was usually discontinued. Fatigue (5%) was sometimes severe, requiring discontinuation of the medication. Joint pain (3%) sometimes accompanied the severe fatigue.

Depression (3%) was sometimes exacerbated after erenumab was started. Anxiety (2%) also occurred was described. Diarrhea was seen in 2% of patients, and several patients experienced severe diarrhea. Injection site reactions (2%) were mild, not requiring discontinuation.

We observed 3 serious side effects. One 21-year-old had a probable migraine-related stroke. Her cognitive symptoms have improved, but she is left with mild to moderate dysgraphia. She had a history of hemiplegic migraine (although none for 3 years), and had been using erenumab for 4 months. She was also on a low dose birth control pill that contained estrogen.   The second patient is a 31-year-old with severe neurologic symptoms, which began 2 weeks after her 2nd erenumab injection. She also suffered from severe fatigue, with joint pains. Symptoms did eventually resolve (but they recurred 3 months later, off of the medication). The third patient suffered severe fatigue and joint pain 3 weeks after receiving the erenumab. She had a history of rheumatoid arthritis, which had been in remission. She eventually improved with corticosteroid therapy.   The erenumab was probably a factor in these serious side effects. Serious side effects are a major concern with these CGRP monoclonal antibodies.

 The second study evaluated 26 poor responders (0 to 15% relief) versus 26 patients with an excellent outcome (70 to 100% relief). Both of these groups consisted of relatively refractory patients, with a history of headaches that averaged 28 years. The location of headaches for both groups was primarily both anterior and posterior. Sixteen of the 26 in the poor response group reported neck pain, and 10 in the excellent group. Central sensitization syndromes were more commonly encountered in the excellent group (11 vs. 5 patients). Most patients suffered from anxiety. Depression (15 in the poor group, 17 in the excellent group) was frequently encountered, although less than anxiety. Insomnia was commonly encountered as well. Sixteen of the poor response group was considered to have refractory chronic migraine, while only 7 in the excellent group had been diagnosed with RCM. The poor response group was more likely to have moderate (6 vs. 2) or severe refractory chronic migraine (6 vs. 1) than in the excellent response group. This author has published on separating RCM into mild, moderate, and severe. We used a 10-point scale to determine the level of refractoriness. It may be clinically useful to separate refractory patients into these different levels. All of these patients had tried onabotulinumtoxin A therapy. Eight of the poor group had responded well, while 12 in the excellent group did well with onabotulinumtoxin A. A number of the patients continued with onabotulinumtoxin A, along with the erenumab.  The majority of patients had a positive response to triptans. In the poor response group, 18 had good responses to opioids, while only 8 of the excellent group responded to opioids. A number of the patients had responded well to butalbital compounds (12 and 10 patients).

The third study evaluated those 50 patients who had completed 6 months of therapy. The average relief started with 36% and 35% for the initial 2 months, but slowly declined to 27% by the end of the 6th month. Patients who averaged 0 to 15% relief for the first 2 months were assessed. They continued to do poorly, with 13/15 patients experiencing 0% to 15% after 6 months. Only one patient improved significantly over time.  Similarly, most of the patients(N=9) who did very well (70% to 100% relief) for the first 2 months generally continued to have success. After 6 months, 6 of these 9 patients maintained the excellent relief.

The 2 main issues with CGRP mAbs for migraine prevention are: 1. will these remain reasonably effective over time, and 2. what is the true side effect profile. The efficacy question will only be answered after several more years of treatment. Regarding side effects, this author has major concerns about the various risks that could arise due to blocking of CGRP on a chronic basis. The following are some concerns.

CGRP most likely is an inhibitor of platelet aggregation. Blocking this effect may increase the chance for cardiac or cerebrovascular effects. As of Sept. 30th, 2018, there were at least 6 cerebrovascular events listed on the FDA site.  This author has put in a Freedom of Information Request for details on those events.  This author has heard about several other erenumab-related strokes, yet to be officially reported, in addition to the one reported in this study.

 CGRP plays some role in the prevention of hypertension, and may be somewhat protective for cardiovascular disease. CGRP is a powerful vasodilator, particularly in the meningeal and cerebral arteries. Blocking CGRP may lead, under certain circumstances, to intracerebral vasoconstriction.  It is possible that other related compounds, such as amylin or adrenomedullin, may help compensate for the loss of CGRP. In addition, various vasodilators may also help to mitigate negative effects from CGRP antagonism. These include nitrous oxide, vasoactive intestinal peptide, and others.  CGRP also is important in neovascularization.  CGRP enhances recovery from ischemia by stimulating angiogenesis. CGRP helps to prevent secondary lymph edema, and enhances lymphangiogenesis. The adverse health consequences on the above systems, by blocking CGRP, are unknown.

The effects of CGRP mAbs on hormones has not been studied. The hypothalamus and pituitary are not, for the most part, protected by the blood brain barrier (BBB). CGRP is present in these areas. In theory, CGRP antagonism could result in various hormonal effects. The choroid plexus, involved in CSF production, also is not protected by the BBB. In addition, the area postrema, involved in nausea and vomiting, is not protected by the BBB.  Circumventricular organs, important in homeostasis of various functions, are also not protected. Studies have yet to be done regarding the effects of CGRP mAbs on these areas.

 CGRP is involved with skin blushing, flushing, cold sensitivity, itch, edema, and thermoregulation. After surgery, or after a serious burn, healing may be impaired by the CGRP mAbs. CGRP does play a role in the metabolism of bone, and is involved with bone healing. In diabetics, by antagonizing CGRP, there may be a higher risk for coronary artery disease. In the GI tract, CGRP has myriad functions. CGRP is involved in motility, and in protecting the gastric mucosa. Constipation may occur with CGRP antagonism, and to a lesser degree, diarrhea. None of the above effects have been studied, with regard to the CGRP mAbs.

We do not want to use these medications during pregnancy. There may be more risk to the CGRP mAbs in later stages of pregnancy. Preliminary studies in animals have not revealed major issues with the newborn animal.

 A number of patients have reported severe fatigue from erenumab.  Additionally, joint pain has been an issue for some patients. It is possible that the hypothalamic-pituitary-adrenal (HPA) axis may be involved with these side effects, as the HPA axis is not protected by the BBB. There have been no studies of CGRP mAbs and the HPA axis.

As of December 31, 2018, 7300+ possible side effects had been reported to the FDA; over 800 were deemed serious.  Only a fraction of side effects are officially reported to the FDA. It is very concerning that we have a paucity of studies on the serious consequences of blocking CGRP for long periods of time. 

Until we know more, it is prudent to screen patients for risk. Informed consent should be obtained. Patients at increased risk may include those with risk factors for stroke, including the usual risk factors (lipids, HTN, diabetes, family history, cigarettes). In addition, at higher risk may be patients with clotting abnormalities, positive lupus anticoagulant, or positive anticardiolipin antibodies. It is possible that hemiplegic migraine, or those with frequent auras, may represent an increased risk as well. Certain birth control pills may be a problem, although this is controversial. Patients with recent surgery, or who have suffered a recent fractured bone, should possibly delay the use of the CGRP mAbs. Those with active GI ulcers, or with inflammatory disease of the GI tract, may also be at an increased risk. Because of the possible hypothalamic and pituitary effects, patients with various hormonal issues may be affected.  The effects on bone growth, as well as on hormones, cautions against using these treatments in children and adolescents.  We need studies in all of these areas.

There are major limitations to this study. It is retrospective, and studies #2 and #3 had limited numbers of patients. The patients are relatively refractory, as compared to most migraineurs. We relied on diaries and calendars, as well as patients’ self-reported histories. These are not always accurate. Most, but not all, of the patients maintained calendars of their migraine days. We were not able to ascertain whether each of the reported side effects was due to the erenumab. This is basically an observational study, with no control group.

The major strength of this study is that the patients were not selected for any purpose other than migraine treatment. They represented a “real life” group of migraineurs, albeit relatively refractory. We also were able to tease out and complete an analysis of poor responders vs. excellent responders. The 6- month results may be helpful in understanding efficacy over longer periods of time.

References/ For Further Reading

  1. Lassen LH, Haderslev PA, et al. CGRP may play a causative role in migraine. Cephalalgia 2002; 22:54-61
  2. Tepper, S. Anti-Calcitonin Gene-Related Peptide (CGRP) Therapies: Update on a previous review after the American Headache Society 60th Scientific Meeting, San Francisco, June 2018. Headache 2018; 58:276-290
  3. Reuter U. Anti-CGRP antibodies: a new approach to migraine prevention. Lancet Neurol. 2014; 13(9):857-859
  4. Tepper SJ, Ashina M, Reuter U, et al. Safety and efficacy of erenumab for preventive treatment of chronic migraine: A randomized, double-blind, placebo-controlled phase 2 trial. Lancet Neurol 2017; 16: 425-434.
  5. Goadsby PJ, Reuter, U, et al. A controlled trial of erenumab for episodic migraine N Engl J Med 2017; 377:2123-2132
  6. Dodick DW, Ashina M, et al. ARISE: A Phase 3 randomized trial of erenumab for episodic migraine. Cephalalgia 2018; January ( ahead of print)
  7. Reuter U, Goadsby PJ, et al. Efficacy and safety of erenumab in episodic migraine patients with 2-4 prior preventive treatment failures: Results from the Phase 3b LIBERTY study. Emerging science platform presentation and poster 009. American Academy of Neurology meeting, Los Angeles, April 24, 2018(abstract).
  8. Depre C, Antalik L, et al. A randomized, double-blind, placebo-controlled study to evaluate the effect of erenumab on exercise time during a treadmill test in patients with stable angina. PO-01-198. Cephalalgia 2017; 37(Supplement 1):340-341.
  9. Tepper SJ, Pascual J, et al. Analysis of blood pressure following short-term and long-term treatment with erenumab. Poster 105. 68th American Academy of Neurology meeting, Los Angeles, CA, April 25, 2018(abstract)
  10. Headache classification committee of the international headache society (HIS). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013.
  11. Refractory chronic migraine: a consensus statement on clinical definition from the European Headache Federation. J Headache Pain 2014; 15:47.
  12. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edition), Washington, D.C.
  13. Robbins, L Refractory chronic migraine: long-term follow-up using a refractory rating scale. J Headache Pain 2012; 13:225-229.
  14. Matsumato Y, Ueda S, et al. CGRP inhibits human platelet aggregation. Japan Circulation J 1996;60(10):797-804.
  15. FDA Medwatch adverse drug site:  (erenumab aooe).
  16. Russell, FA, King, R et al. Calcitonin Gene-Related Peptide: physiology and pathophysiology Physiol Rev 2014;94:1099-1142.
  17. Majima, M, Ito, Y, et al. CGRP/CGRP receptor antibodies: potential adverse effects due to blockade of neovascularization Trends in Pharmacological Sciences 2018 (e published)
  18. Brain S, Grant A Vascular actions of Calcitonin Gene-Related Peptide and Adrenomedullin Physiol Rev 2004;84:903-934
  19. Deen M, Correnti E, Kamm K, et al. Blocking CGRP in migraine patients-a review of pros and cons. J Headache and Pain 2017;18(1):96.
  20. Gangula PR, Zhao, et al. Pregnancy and steroid hormones enhance the vasodilation responses to CGRP in rats. Am J of Physiol Heart Circ Physiol 1999;276:H284-H288.


Recruiting: Pain Psychologist Behavioral Medicine Institute

Behavioral Medicine Institute (BMI) is a 20+ member, multi-specialty group practice based in Knoxville with a long-established referral base and innovative practice models including embedded clinicians in local medical practices. 

We are currently seeking a skilled and motivated clinician to add to our team of psychologists working embedded in a local, anesthesiology-based pain center which has received a Center of Excellence award from the American Pain Society. The opportunity is full time, we offer a supportive, collegial atmosphere and the opportunity for ongoing training and consultation to develop and practice specialty behavioral health skills, including:

  • Psychological Evaluations on all new patients
  • Pre-Surgical Psychological Evaluations
  • Behaviorally-Based Chronic Pain Management
  • Group Therapy
  • Individual Therapy
  • CBT-Insomnia
  • Biofeedback
  • Chronic Illness Management

The ideal candidate will have excellent clinical, organizational, and interpersonal skills as well as competence in assessment, consultation, and evidence-based treatment. We have a strong commitment to quality and to patient-centered care, and we embrace the Biopsychosocial model. 

BMI offers:  Very competitive, productivity-based reimbursement, strong referral streams, high tech practice resources including state-of-the-art EHR, practice management, and communication tools,  as well as a supportive, team-oriented, collegial environment for professional development. We provide strong on-site administrative support including insurance verification, scheduling, and pre-authorizations. You will have access to BMI’s adjacent multi-specialty practice environment which includes prescribers for children, adolescents, and adults. Both W-2 and 1099 employment options are available.

We believe that, with the recent realization by payers of the value of behavioral health, this is an exciting time to be a psychologist. We aspire to locate ourselves on the cutting edge of behavioral health care. Will you join us? 


  • Independent licensure as a Psychologist
  • Medicare-eligible
  • Familiarity with evidence-based treatments
  • Familiarity with models of integrated behavioral healthcare, motivational Interviewing, health coaching, and management of chronic illnesses
  • Must be comfortable with utilizing clinical practice technology (EHR, etc.)
  • Must be comfortable practicing in a fast paced environment
  • Must be comfortable working as part of a multi-disciplinary team 

BMI is a lifestyle-driven practice and we value creating balance between life and work.  BMI was formed in 1990 by Dr. Keith Hulse

If you are interested in learning more about us, please contact us, and include a copy of your CV: C. Keith Hulse, Ph.D., BMI, 6231 Highland Place Way, Suite 101, Knoxville, TN 37919, or


Chronic Pain and the People We Love

Dave Gavel, PhD

A few nights ago, I was talking with my wife about something fairly benign – probably weekend plans or paying the light bill – when she suddenly got a look on her face that I know very well. It was that solemn, glaze-eyed look that says, “I’m so over this.” Like any good spouse would do, I asked, “What’s wrong? Are you ok?” Her eyes snapped to and she gave a slight smile accompanied by the quietly murmured, “I’m fine.” This was obviously not the case so I interpreted her response to mean that something was wrong, but she was not interested in a sharing hour so it would probably be best for me to leave it alone. So naturally, I asked again, and again. This did not go over well but she was neither unkind nor amused by my inquiries. I spent the next two hours introspectively scanning memories of the last two days for anything offensive I could have done while she sat quietly watching a movie. Then, just before we nodded off for the night, the truth came out with an emotion that only someone who has ever sat quietly in agony could express. She informed me that while we were talking, her jaw, compromised by severe temporomandibular joint disorder (TMJ), slipped out of socket and caused excruciating pain to shoot through her face and into her head. I am aware of her TMJ condition and the pain flare ups it causes during more days than not. So why did she not just tell me? “I didn’t want you to know because you treat me different when I’m hurting and I didn’t want that,” she exclaimed. This is not a new concept to me. I hear evidence of it from my patients nearly every day. But this was the first time it hit home, and it hit like a ton of bricks.

Since then, I have been reflecting on the perspectives of individual with chronic pain within their social relationships. Naturally, individuals with chronic pain grow accustomed to living their lives and adapting their world to accommodate significant physical discomfort. Social relationships are not exempt from this influence. Like any  physical ailment, chronic pain often leads patients to the natural conclusion that they must prioritize their activities to preserve their physical and emotional resources for only the most important aspects of life. For many, this means that any non-essential social contact becomes limited. Church social hours with casual friends, annual family reunions, and monthly outings with coworkers become expendable. The primary reason for many is that pain makes these events less enjoyable. But a close second reason is that many get tired of answering questions like “how are you feeling?” or “can I help you with that?” Every social interaction with people, especially those who were in a patient’s life before pain began, becomes a fresh reminder of how pain has changed their lives for the worse and it is simply easier for the mind and the body to avoid these interactions. But what about relationships that are not so easily avoided like spouses, children, or even co-workers?

Social norms and common decency typically dictate that individuals in pain or discomfort are provided with special comforts or considerations from those around them. That is why children recovering from tonsillectomy get to eat ice cream for 5 days straight and a spouse who pulls a muscle gets a break while the rest of the household picks of some slack. However, unlike these temporary conditions, chronic pain is an enduring condition and to apply the same social laws would mean that an individual living with chronic pain is to be treated differently as a rule, rather than the exception. In the example with my wife, her sentiment struck a chord with me because it shined a big fat spotlight on the ugly truth that what I perceive as well-meaning actions can actually be adding insult to injury (pun intended). The logic goes like this. I love my wife and do not want to make her pain worse. I know my wife’s jaw hurts with increased movement. Thus, I try not to engage her in as much conversation when I know it is bothering her. This makes sense, right? Here is another one. My wife is in pain. I know from professional experience that pain increases the likelihood for one to become irritable or frustrated. Thus, I walk on proverbial egg shells to prevent contributing to worsening her mood and call it “giving you space.” In both examples, I can describe my actions as logically well-intended.  But logic has little to do with the emotions of interpersonal relationships and reality is that my actions can have a negative impact on her emotional and physical condition.

The implications of the social phenomena discussed above are rooted in the reality that the human experience is best conducted in the presence of others and to deprive that nature has unintended consequences. Researchers have documented that a lack of satisfying social relationships can directly affect negative changes such as emotional discomfort (e.g., sadness, longing, loneliness), physiological distress (e.g., sleep disturbances, unhealthy appetite/eating patterns), and mental anguish (e.g., depression, anxiety).  Other research studies have shown that individuals with positive social support and healthy interpersonal relationships are at a lower risk for certain chronic health conditions, tend to heal faster from acute medical conditions, and are less prone to chronic forms of mental health problems. Researchers have even demonstrated that one of the strongest indicators of the  likelihood of an injured workers to return to work is not the severity of their injuries.  Rather the nature of their relationships with supervisors at the time of injury is a driving factor such that those with hostile or non-supportive relationships are less likely to return to work.

In summary, it is important as providers, spouses, children, and friends engaged in the lives of individuals with chronic pain that we recognize that patients are social beings in need of adequate social support. Such support may involve a helping hand or simply understanding the need to  skip an event. At other times, it may mean remembering that the person in pain is still the person we knew before the injury and he or she likely still wants our time and attention, even if it comes in different forms.

President’s Message, January 2019

Ann Quinlan-Colwell, PhD, APN

As we enter this last year of the second decade of the 21st century, clinicians working with patients who experience pain confront the challenge of providing safe and effective pain management while facing numerous barriers to doing so. During the past few years pain management in the US has been dramatically affected by the opioid crisis. This is true for patients and clinicians alike. It is tempting to lament the resultant changes, barriers  and difficulties; however, without appropriate action such lamenting will only deter from working to improve pain management options and care. 

As I prepare to assume the presidency of the Southern Pain Society, I encourage us to set a goal to renew/redesign our efforts to optimize safe and effective pain management for all people experiencing pain.  An initial three-layered effort toward accomplishing this goal is to (1) clarify the barriers/issues that exist, (2) assess what is involved with them and (3) identify strategies to meet the challenges. Although there are numerous challenges, barriers and issues, I suggest we address the following during 2019. 

First, the current focus to develop standardized approaches, assessment, and plans of care is appropriate and effective when working with patients with many clinical diagnoses and conditions.  However, the challenge of utilizing a single standardized approach for managing all patients with pain is that pain is a highly complex and personal experience with a wide range of potential etiologies and complicating factors.  Trying to use a standardized plan of care for all patients, even those with similar diagnoses, is like issuing a single sized uniform to all employees working at an organization regardless of individual body size or measurement.  Pain management clinicians are challenged to educate and advocate organization administrators and health care colleagues to adopt patient specific multimodal approaches for managing pain.      

A second need is to provide accurate education regarding the various recent pain management guidelines.  It is imperative to understand that guidelines are simply “an indication or outline of policy or conduct” (Meriam Webster, 2018).  Thus, they are not mandates for prescription or rules or recipes for every patient experiencing pain. Rather, the guidelines are intended to provide guidance for clinicians when using professional assessment and critical thinking skills to provide optimal pain management for each person experiencing pain.   

An effective way to use guidelines is to incorporate them with ethical practice and the individual patient needs. The numerous patients who have been managing chronic pain for months or years with prescription opioids, need careful assessment.  Many patients who live with chronic pain have learned that certain opioids “are the only thing that helps my pain.”  Past experiences and the fear of pain may be paralyzing for such patients. Regardless of what any guideline may outline, if continuation of the opioid supports an individual to function at the highest level possible with minimal or no side effects, continuing the opioids at effective but not excessive dosing is ethically appropriate.  In such a case continuation of opioids supports autonomy of the patient while doing good and doing no harm, compared to discontinuation of the opioid causing deterioration of function and quality of life.  If, however, another person is concerned about opioid use and wants “to get off them” the clinician has the ethical responsibility to work with the person to utilize a multimodal approach to manage pain and reasonably taper opioids.  Caring for such a patient in that way also respects autonomy of the patient while doing good and doing no harm. 

At the same time, the ethical responsibility to prevent chronic pain needs to be highlighted and needs to be an important priority of future health care.  Clinicians need to be educated that unrelieved acute pain is a major cause of chronic pain.  Similar to current mandates of managing other conditions with the goal of preventing hospital acquired infections, health care organizations need to consider the multimodal management of acute pain with the goal of preventing chronic pain.  Primary care clinicians need to educate patients about the importance and how to prevent or minimize the likelihood of developing chronic pain through weight management, physical activity, flexibility training, good body mechanics and appropriate management of chronic diseases such as diabetes which may lead to chronic pain when poorly controlled.  All clinicians need to be educated regarding the valuable roles of non-opioid medications and non-pharmacologic interventions in managing acute pain as well as in preventing chronic pain.  

Efforts are needed to advocate for evaluation and subsequent reform of insurance company re-imbursement of non-opioid medications and non-pharmacologic interventions including cognitive behavioral and physical therapy consultations and follow up.  Clinicians need to advocate for enhanced financial re-imbursement for the time involved in providing individualized pain management both in general practice and among pain management specialists.  Advocacy is also need for government support of multimodal pain management efforts and pain management research.  It is imperative to remember the primary method of promoting the necessary changes in health care, including pain management, is through communicating with and voting for senators and representatives who will support the needed changes.

Finally, incumbent to achieving the essential changes needed to answer these challenges are for all clinicians who care for patients with pain to actively update themselves regarding new advances and education regarding multimodal pain management efforts.  The mission of the Southern Pain Society in part is to “increase the knowledge and skill of the regional professional community.”  From that perspective the Board of Directors of the Southern Pain Society works to continually provide education through our quarterly newsletter, twitter and Facebook communications, our new Speakers Bureau, and most excitingly through the innovative presentations at our annual convention which will be in New Orleans September 13-15 this year.  Finally, I invite you to contact us with any questions, concerns, or suggestions of how we can better meet your needs.  You are also invited to submit entries for the SPS newsletter and abstracts to present posters in NOLA.   Hope to see you there!

Cognitive Behavioral Therapy for Chronic Pain

James L. McAbee, Ph.D.

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

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

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

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

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

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

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

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


Gatchel, R. J., & Neblett, R. (2017). Pain Catastrophizing: What clinicians need to know. Practical Pain Management, 15(6). Retrieved from:

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

Leung, L. (2012). Pain Catastrophizing: An updated review. Indian Journal of Psychological Medicine, 34(3), 204–217.

Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain, 80(1-2), 1-13.

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

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

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

Catastrophizing and the Meaning of Pain: Why It Matters

by David Gavel, PhD

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

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

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

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

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

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

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

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

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

[5] Shim E, Song Y, Park S-H, Lee K-M, Go D, Hahm B-J. Examining the Relationship Between Pain Catastrophizing and Suicide Risk in Patients with Rheumatic Disease: the Mediating Role of Depression, Perceived Social Support, and Perceived Burdensomeness. International Journal of Behavioral Medicine. 2017;24(4):501-512. direct=true&db=s3h&AN=124131574&site=ehost-live. Accessed October 10, 2018.

The Homebound Adolescent Headache Patient

Larry Robbins, MD and Alison Alford, MD

Introduction: Which Adolescents Should Be On Homebound?

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

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

Frequency and Severity of The Headaches

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


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

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

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

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

Psychological Conditions

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

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

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

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

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

Catastrophizing and Acceptance

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

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

Resilience and Coping

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

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

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

It Takes A Village

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

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

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

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

Returning To School

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


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

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

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


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