Category Archives: News

Is Compassion the Ghost of Pain Management?

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

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

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

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

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

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

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

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

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

 REFERENCES

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

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

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

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

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

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

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

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

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

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

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

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

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

Atlanta 2018–Our Most Relevant Conference

by Mordecai Potash, MD

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

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

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

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

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

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

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

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

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

See you in Atlanta!

– Mordi

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

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

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

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

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

CGRP Antagonists: Long-term Side Effects

    by  Lawrence Robbins, M.D.

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

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

 CARDIOVASCULAR AND PULMONARY SYSTEM:   

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

CENTRAL NERVOUS SYSTEM (Within the Blood Brain Barrier):

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

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

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

 GASTROINTENSTINAL SYSTEM: 

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

SKIN, WOUND HEALING, BURNS, AND BONE HEALTH:

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

RENAL, SEPSIS, DIABETES/OBESITY:

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

PREGNANCY, ARTHRITIS AND OTHER PAINS, AND AGING:

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

MISCELLANEOUS ISSUES:

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

BIBLIOGRAPHY

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

Thrown Off the Pendulum

by Mordecai Potash, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

In the Spotlight: Geralyn Datz, PhD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Highlights of the 2017 Annual Meeting

Cory Shum, recipient of the President's Award

Cory Shum, recipient of the President’s Award

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

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

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

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

Trying out the VR equipment

Trying out the VR equipment

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

 

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

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