Category Archives: News

President’s Message May 2017 – Member Posts

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nothing is further from the truth!

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

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

See you in September!

  • Mordi

Innovation: Opioid Substance Use Disorder

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

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

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

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

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

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

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

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

Future plans include:

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

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

Reflections from Outgoing President Geralyn Datz, PhD

Happy New Year SPS Membership!

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

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

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

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

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

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

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

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

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

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

Sincerely

Geralyn Datz, PhD

Additional Educational Opportunities

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

Read More

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

Supporting the Southern Headache Society

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

We have an outstanding meeting planned this year.

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

Read More

Spring 2016 Newsletter

Enjoy our Spring 2016 Newsletter Read More

Winter Newsletter

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

Summer Newsletter

Dr. Mordecai Potash, MD has the lead article on Medical Marijuana in the Southern US.  He is also a featured speaker at our annual meeting coming up in September.  Hope you will join us!     Click here to read the newsletter.

COPE-REMS CME Course Available

We are pleased to offer a free COPE-REMS CME course.  Based at the University of Washington in Seattle, COPE-REMS is an engaging interactive program that used the latest technologies in video and online tools.  We hope you will take advantage of it.

Only 25% of physicians feel very confident in managing patients on opioids. 

When many of today’s physicians were in medical school, they learned that opioids were safe, and no dose seemed too high. Now, evidence-based practice paints a far more nuanced picture. More than 200 million prescriptions a year have contributed to widespread problems:

  • 33% of young adults say that prescription opioids are “easy to get,” with many taking their friends’ or parents’ pills.
  • Nearly 20% of U.S. veterans with PTSD are receiving higher-dose or multiple opioids, or early refills.
  • Increased prescribing to women of childbearing age has contributed to a 4-fold increase in neonatal abstinence syndrome

Take the free COPE-REMS course 
and gain more confidence when treating patients on opioid therapy.

Based at the University of Washington in Seattle, COPE-REMS is an engaging, interactive continuing education program that uses the latest technologies in video and online tools to train medical providers. 

Register today at:

http://www.trainingxchange.org/our-programs/cope-rems

Learn more at: www.COPEREMS.org

April Newsletter

Read More

Categories