Category Archives: Policy

President’s Message: Looking Back and Many Thanks

Tuesday, 20 September 2022 21:33
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Harry J. Gould, III MD, PhD

When I was reminded this time that the deadline for articles for the fall edition of the newsletter was approaching, I realized that my term as President of the Southern Pain Society is rapidly coming to its end.  Events that mark milestones in a career, tend to prompt one to pause and reflect upon whether time was well spent and whether efforts made were on a par with the challenge. It has been my great fortune and privilege to have been able to work as part of a fabulous team of caring, enthusiastic and dedicated individuals, committed to improving pain care and the quality of life for those in need. 

Realistically, I knew that we were not going to remedy the unfortunate, past, present and future sequela of the opioid crisis and eliminate entirely suffering in the population that is due to poorly or improperly managed pain.  I do believe, however, that despite the unforeseen challenges of the past 2 years, we as a society have done well.  We have continued to provide high quality education and opportunities for healthcare providers, trainees and patients that promote proper evaluation, appropriate management and a reduction in the risk of adverse effects for patients, family and society.

My primary regrets lie in having to use a virtual platform in lieu of an in person meeting in 2020 and for the cancellation of the meeting in 2021.  I have missed the in-person forum for reviewing and determining the current state of the art and for exchanging and developing new ideas.  As is probably true for most of us, I tend to be quite focused on my work and proximal goals and seem to live a largely secluded life in my own specialty ‘silo’ with minimal exchange between colleagues outside my immediate co-workers except for sharing greetings and acknowledgement when passing in the hallway.  With time and the lack of fresh input, efforts become routine and as a result, less exciting.  I recognized this early in my career, when I realized a significant boost of energy and excitement upon returning home from an annual meeting of one of my professional societies where the exchange of ideas and discussion, frequently in an informal setting, often over food and/or libation, made it possible for me to relax, to learn about what others were doing, to view my area of interest in a different light and to discover new ideas and questions to explore.  Over time, in person meetings have continued to provide an important mechanism to meet new people, to be involved in influencing how my field of interest develops and later, as lagniappe, to reconnect and catch up with old friends. This experience is much less likely to happen in meetings hosted on a virtual platform. 

As I pass the baton to our current President-elect, Thomas Davis MD,  I will have the great pleasure, as current President of the Southern Pain Society, of participating in our first in person annual meeting since the beginning of the COVID pandemic.  The meeting will take place October 7-9 in New Orleans at the Astor Crowne Plaza Hotel and offers an excellent program planned to cover a broad spectrum of topics of interest to healthcare providers and trainees from all specialties that care for patients with pain. 

As the title of the meeting suggests, “The Times They Are Still A-Changin’, we have witnessed the implementation of practice guidelines for opioid analgesics, a significant reduction in prescriptions written for opioid medications over the last 15 years, a mandated increase in education in the risks and use of opioid medications, an improvement in our assessment of potential medication misuse and abuse for risk mitigation, and an increased awareness of high risk medication combination, yet overdose deaths remain too high and too many patients still suffer from uncontrolled pain.  Clearly, the challenges evident in 1931 and expressed by Albert Schweitzer almost a century ago, “We must all die.  But that I can save him from days of torture, that is what I feel as my great and ever new privilege.  Pain is a more terrible lord of mankind than even death.” still remain.  The goals are worthy and warrant our continued efforts to achieve them. I encourage everyone to attend the meeting, to join with and support the Southern Pain Society and become involved as we prepare for the future and work toward improving our understanding of pain, to enable patients to become partners in their care and to achieve an improved quality of life without doing harm.

I look forward to seeing you at the meeting.

President’s Message: Progress in Mitigating the Negative Effects of the “Opioid Crisis”

Sunday, 11 July 2021 12:31
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Harry J. Gould, III, MD, PhD

On June 26, 2021, Johnson & Johnson confirmed that in 2020, as part of a $230M settlement with the State of New York, they discontinued promotion and distribution of opioid products in the State of New York. The settlement was made in response to efforts to mitigate the unprecedented overdose deaths associated with the excessive and often inappropriate use of opioid medications by reducing excess supply and encouraging activities such as improving the education of patients and clinicians to decrease demand.  The goal of this strategy is to ensure coverage for patients in need while decreasing the deleterious effects of misuse, abuse and diversion on patients, families, and society as a whole.

Since 2012, the limitation of supply coupled with specific guidelines for prescribing opioids for managing chronic pain has resulted in a steady and significant reduction in the number of prescriptions being written for opioid medications and a similar leveling or decrease in opioid related overdose death. Unfortunately, despite additional mandatory training in the use of opioid medications, the implementation of risk evaluation and mitigation strategies (REMS) programs and the publication of guidelines for prescribing opioid medications for chronic pain to improve both physician and patient education, overdose deaths continue to occur at unacceptably high levels.

Part of the observed positive trend is likely due to the increase in physician reluctance for prescribing opioid medications, a reduction in initiating treatment with opioid medications and the initial prescribing of lower doses for shorter periods of time. These shifts in prescribing patterns consequently, reduce the risk of developing dependency and reinforcing negative behavior patterns that favor continued opioid use.

For the unfortunate victims of the “opioid crisis” who suffer with the burden of dependency and substance abuse disorder, a reduction in opioid availability in the absence of affordable direction and guidance to sobriety, is often perceived by the patient as an abandonment by the medical community accompanied by an unreasonable loss of analgesic coverage. This perception too frequently presents an untenable challenge for the patients who seek a “solution” by obtaining “relief” from alternate, unreliable, and deadly sources. Further mitigation of the untoward opioid related death rate is thus likely to require additional commitment to providing affordable support for evaluation, rehabilitation, and substance abuse counseling. 

Although these early measures seem to be having or are likely to have a continuing mitigating effect, the fact that the current “opioid crisis” has been described as “the greatest healthcare crisis in U.S. history”, indicates that we are dealing with a problem of greater magnitude and complexity than anything that we have faced do date.  The problem is unlikely to be amenable to “quick fix” remedies and is likely to require the identification and mitigation of “deep-seated”, heretofore unrecognized root-cause weaknesses that are not typically considered problematic.

That said, one might pose the question, “Why has the current “opioid crisis” reached the level that it has? Opioid use disorder has been a problem in the past.” For generations, opioid preparations have been known to affect changes in sensory and emotional perception and cognition and have been used by sections of society for recreation or to escape from the pressures of life. Might there be a greater need in the 21st century for a larger portion of the population to escape, from pressures related to more frequent failed life expectations, from the effects of technical discoveries that afford improvements in productivity and the means for immediate gratification and consequently, for the increased demands for the, now expected, immediate responses that such advances inherently imposed, to name a few. As we look into the future, a closer look at where we are in the evolution and demands of society may be increasingly important to consider in managing pain and may well be required if we hope for significant further progress in reversing the “opioid crisis.”

An Essay on Diversity in the Field of Pain Medicine

Monday, 12 October 2020 12:58
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Benjamin Johnson, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reducing Harm from Opioids – Lessons Learned

Sunday, 12 January 2020 10:30
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Lisa Edgerton, PharmD, BCPS, CPP, Olivia Herndon, MA, and Joseph Pino, MD, MHA

Wilmington is a community in southeastern North Carolina known for its beautiful beaches, historic river-walk district, and the largest domestic television and movie production facility outside of California. In April of 2016, this city also became recognized for something else.

In 2016, Castlight Health released a report titled “The Opioid Crisis in America’s Workforce.” The study noted those who abused opioids are more likely to live in the rural south with 22 of the top 25 cities in Southern states. Furthermore, it named Wilmington, NC as the city with the highest abuse rate in the United States. In response, our medical community mobilized and recruited partners from disciplines outside of healthcare to reduce harm from opioids in our region.

Through a “call to action” where more than 100 regional stakeholders and leaders, the Community Partners Coalition (CPC) was born. This CPC aims to improve collaboration and coordination between those who provide care to individuals seeking access to mental health and substance use services by aligning efforts in the region. A primary focus of the CPC was to improve safe medication disposal options in our region by expanding medication take-back events and permanent drop boxes.

The first medication take-back event was held at New Hanover Regional Medical Center (NHRMC) in March 2009. This event was held at one location on our hospital’s main campus in New Hanover county. NHRMC partnered with the Wilmington Sheriffs office and collected 140 pounds of medication at that event. This solo event continued biannually however, dates were chosen based upon availability of volunteer coordinators and coinciding community events. NHRMC continued to host this single site medication take-back event biannually through the Spring of 2017.

Through the support of the CPC, in the Fall of 2017, this event was expanded to 9 locations within 4 counties and collected 3,680 pounds of medication and 29,675 needles or sharps. This biannual medication take-back event has continued to grow now hosting 19 locations spanning 6 counties in our region.

In October 2019, we collected almost 6,000 pounds of medication, 43,000 needles or sharps and 178 medications, valued at $55,000, that were donated to a local clinic serving those without resources for re-dispensing. Expanding our medication take-back event to 19 locations did present some challenges along the way.

To expand our reach, leaders of the takeback event needed to engage in detailed planning and consider logistical challenges. We aligned our event dates to the Drug Enforcement Administrations (DEA) National Prescription Drug Take Back Day. Aligning with the DEA allowed us to plan for future events as these dates are standardized on the last Saturdays in April and October. Alignment also enabled law enforcement to register event locations in their national website. This site is searchable and provides a map of locations nearest to search area. Alignment with the DEA also connected us to our regional State Bureau of Investigation (SBI). This partnership enabled us to receive support including standard boxes used to collect medications at each take-back location. The SBI supplied NHRMC with 250 evidence boxes that were distributed to site leaders at each take-back location.

When planning to staff each of our sites, federal rules indicate that law enforcement must be present at each medication take-back location. When planning for our Fall 2017 expansion, we discovered that our hospital law enforcement officers could staff all NHRMC and affiliate locations. At the Fall 2017 event, we were able to utilize NHRMC police for 5 of the 9 locations. This allowed us to extend our partnership with local sheriff’s offices and expand to additional sites. We continue to collaborate with our regional county sheriff departments who provide an additional 1-2 law enforcement officers for each location.
NHRMC company police have been instrumental in not only staffing these events but also coordinating with regional law enforcement agencies. They collect and store the medication until the “burn day”. This often occurs 2-3 days after the takeback event. Our event has become so large that NHRMC law enforcement transports over 100 boxes of medication. As a result of our success, we have outgrown the transport capacity of our standard vehicles. We now either have to rent commercial trucks or borrow large box trucks from another department in our hospital.

In addition to organizing law enforcement to be present at each site, we decided we would accept needles or sharps at each of the 19 drop off locations. This became an issue for sites that were not affiliated with a health system because they did not have sharps containers at their locations. Prior to each event, NHRMC now donates sharps containers to each of these sites. Following the event, we now also coordinate with either law enforcement or a volunteer at the site to collect the sharps bins.

To raise awareness of this multi-county, multi-site drug takeback event, we approached our hospital’s marketing department to help us by advertising this event. They created a universal flyer listing each drop off location by county. This flyer is printed in a variety of sizes and is posted across our health system and to each of our drop-off location partners. We also advertise in advance of this event on social media, radio stations and local newspapers as well as media outlets on the day of the event. We also created a NHRMC webpage dedicated to medication disposal where we post our upcoming flyer and list locations of all area permanent drop boxes. Through this effort, we also learned that funeral homes, hospice care centers, veterinarian offices and churches are effective locations to advertise these events and added these sites to our marketing locations for future events. We also realized that we needed to create a Spanish-version of our flyer to appeal to other segments of our community and plan to do so for our next event.

We also discovered that we needed to develop a standard process to enable us to repurpose unused medication. Medication take-back locations staffed with NHRMC volunteers may collect any unused medications and can donate them to a charitable clinic. These medications must meet North Carolina repository rules and regulations to qualify for donation. Following the event, each unused medication collected is visually inspected by a pharmacist to ensure it meets all applicable federal guidelines for donated medications. By following this process, we could donate $ 55,000 of medication to one of our local, charitable clinics.

During our medication take-back expansion in 2017, NHRMC also installed three permanent medication drop boxes across several sites within our health system. Medication drop boxes were installed on the main campus within our Outpatient Pharmacy, at our free-standing emergency department located off campus, and at our critical access hospital located in a neighboring county. It was anticipated that the drop boxes would need to be emptied once a month. When first installed, the permanent drop box in our main hospital, which holds roughly 55 pounds of medication, needed to be emptied every 9-10 days. This was not anticipated. We now collect 1,600 pounds of medication in our 3 permanent medication boxes annually.

Like other communities across the country, Wilmington and our surrounding area have been significantly impacted by the opioid crisis. Through the development of the CPC and the leadership of NHRMC, we expanded our drug takeback events to multiple sites in multiple counties in our region. As a consequence of our success, we also discovered we needed to coordinate law enforcement at each location, establish safe storage, rent large trucks to transport thousands of pounds of medication collected at each event, develop a process to reclaim medication and manage high volume disposal of medication in permanently installed drop boxes across our health system. We are fortunate to have such an engaged community to collectively work to reduce harm from medication. Hopefully, these lessons learned will help you do the same.

Personality and Pain: Which Came First?

Monday, 21 October 2019 13:05
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James N. Weisberg, PhD

This article is adapted from a chapter in a soon to be published text:
Weisberg, J.N., Paul, C. & Twyner, C. Personality and Personality Disorders in Chronic Pain.  In Incayawar, M., Clark, M. & Maldonado-Bouchard, S. (Eds.). Overlapping Pain and Psychiatric Syndromes-Global Perspectives. New York, NY: Oxford University Press

Chronic pain is a significant health care issue at epidemic proportions in the United States1 and there is a high incidence of both clinical psychiatric disorders2,3 and personality disorders (PD) in the chronic pain population.4 This article will briefly summarize some of the important points pertaining to the prevalence and interplay between personality disorders and chronic pain.

Personality and Pain

The relationship between personality and pain can easily be traced to ancient Greece. More recently, in the late 19th century psychodynamic theorists discussed the connection between emotional factors and the experience of chronic pain.5 George Engel maintained that, while physical pain may result from underlying pathophysiology, the interpretation of pain is a psychological phenomenon and also noted that certain diagnoses, including Depression, Hysteria and Hypochondriasis were relatively common in people experiencing chronic pain.6 In an attempt to further characterize personality characteristics, the use of Minnesota Multiphasic Personality Inventory (MMPI)7 and its successors (MMPI-2, MMPI-2-RF) led to a plethora of research seeking to use psychometric tests quantify these early theorists, help predict treatment outcome from multidisciplinary treatment8, spine surgery9, spinal cord  stimulators10as well as  and pain-related disability11.  However, despite the hundreds of studies using the MMPI and its successors, there continues to be controversy regarding the applicability and appropriateness of in the chronic pain population.12,13

A number of other psychological inventories have been used in an attempt to describe and characterize individuals with chronic pain and to predict treatment outcomes. Some, but not all of these measures include the NEO Personality Inventory (Neuroticism-Extroversion-Openness Personality Inventory-NEO-PI) and its revisions,14-16 the Millon Clinical Multiaxial Inventory and subsequent revisions (MCMI; MCMI-IV)17,18 and the Temperament and Character Inventory (TCI).19

While psychological inventories have investigated different personality characteristics as they relate to pain, relatively few studies have investigated personality disorders in chronic pain. 

Personality Disorders and Chronic Pain

Whereas personality refers to the constellation of non-pathological characteristics in an individual’s patterns of thought, emotion, and behavior the DSM defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”20 Thus, the essential difference between a trait and disorder is the degree of distress and disruption caused.

Personality and personality disorders are likely the combination of biological, developmental, and environmental factors that become impacted by state-dependent variables such as mood and anxiety. The Diathesis-Stress model purports that individuals have underlying genetic vulnerabilities and possibly early life experiences that interact with stressors the individual encounters later in life.21  Depending on the nature of the stressors and the individual’s ability to cope with such stressors, the underlying vulnerability may or may not become expressed as a disease process. The diathesis-stress model was first applied to explain schizophrenia21 and depression.22  It has also been applied to the development of chronic back pain23 and the development of depression in chronic pain patients.2 Similarly, this model has been proposed to apply to personality disorders in chronic pain patients.24 Thus, combined with underlying traits and situational stressors brought on by chronic pain, an individual’s underlying personality traits and characteristics may become magnified to the extent the individual meets criteria for a personality disorder.

Epidemiology of Personality Disorders:

In its most recent edition, the American Psychiatric Association cites data from a national epidemiologic survey suggesting approximately 15% of US adults meet criteria for at least one personality disorder.25 A large epidemiological study found prevalence estimates for the different clusters suggest 5.7% for disorders in Cluster A (Paranoid, Schizotypal and Schizoid Personality Disorder), 1.5% for disorders in Cluster B (Histrionic, Narcissistic and Borderline Personality disorders),  6.0% for disorders in Cluster C (Avoidant, Dependent, Obsessive-Compulsive Personality Disorders), and 9.1% for any personality disorder, indicating frequent co-occurrence of disorders from different clusters.26

To date, approximately 15 studies have investigated the prevalence of personality disorders in chronic pain.  Some of the more seminal studies are highlighted here.  The first published study using a semi-structured interview to diagnose DSM-III personality disorders in chronic pain found 37% of their sample met criteria for at least one personality disorder with the most common diagnoses being histrionic PD (14%), dependent PD (12%) and borderline PD  (7%).27  Fishbain et al,28 using a semi-structured interview to diagnosis both DSM-III axis I and Axis II disorders, found 59% of their chronic pain sample met criteria for a personality disorder with most common diagnoses being dependent PD (17%), Passive-Aggressive PD (15%) and histrionic PD (12%).   Weisberg et al29 used a combination of clinical interview, treatment notes and both patient and family self-report measures to assess personality disorders in 55 chronic pain patients who were evaluated and treated at a comprehensive outpatient pain management program. They found that 31% met criteria for at least one PD and an additional 27% met criteria for PD-NOS which is used when an individual meets incomplete criteria for two or more personality disorders.  Similar to other studies, the most common diagnoses were borderline PD (13%) and dependent PD (11%).  These researchers suggest that obtaining longitudinal information from both the patient and an individual with a longstanding relationship with the patient might provide a more thorough assessment of the impact of state factors such as mood, anxiety, and stress on the presentation of personality.29 More recently, Conrad et al30 found that 41% of their chronic pain sample met criteria for a personality disorder diagnoses compared to 7% of their control group.  Most common were Borderline PD (11%) and paranoid PD (12%). The authors found clinical disorders, such as depression at a equally high rate, lending more credence to the importance of assessing personality in context of state factors.

In summary, the relatively few studies that have investigated personality disorders in various samples of patiens with  chronic pain have found prevalence rates from 31% to over 80%. However, as has been noted by previous researchers, due to a variety of factors including state-dependent variables, stressors unique to chronic pain, genetic and developmental influences and other known and unknown factors, significant caution must be used when making a personality disorder diagnosis in the individuals with chronic pain.  In addition, knowing premorbid functioning is crucial in understanding the multifactorial nature of the observed behavior.  Nontheless, the presence of a personality disorder increases the liklihood of co-morbid conditions, such as substance misuse and abuse and makes treatment of chronic pain that much more challenging to the pain clinician.

The Nexus of Personality Disorders in Chronic Pain and Substance Use Disorders:

There has also been a paucity of research on the interaction between personality disorders and substance use disorders in chronic pain.  One study investigated psychological comorbidities, including personality disorders, in chronic pain sufferers presenting to either a university emergency department or an urgent care clinic requesting opioids.31 Pertinent results demonstrated 18% likely had a personality disorder diagnosis and found that personality disorder was significantly related to opioid abuse.31 A recent study found the incidence of personality disorders to be 52% in those with co-occurring chronic pain and substance use disorders.32 The most common personality disorder was antisocial PD (22%) followed by avoidant PD (19%) and paranoid PD (16%). Although there is little literature on this topic, both of these studies suggest that personality disorders may be a moderating variable in the incidence of substance use disorders in persons with chronic pain.                                                                                                                                         

Treatment of Personality Disorders in Chronic Pain

While working with people living with either chronic pain or personality disorders can prove to be daunting to the clinician separately, working with those with the co-morbid diagnoses of both personality disorders and chronic pain can pose unique challenges and opportunities in regard to treatment. Although maladaptive behaviors are, by definition, problematic in a variety of settings, legitimate concerns may be disregarded as secondary to the manifestations of personality disorders or simply attributed to being “difficult.”

The need for the pain clinician to screen for personality disorders is rooted in the understanding that the manifestations of a personality disorder in a person living with chronic pain can be exacerbated or unmasked by the individual’s pain condition according to the diathesis-stress model.24  In addition, the need for vigilance and awareness with these conditions is considerable as these patients are at higher risk for various adverse outcomes, including substance use disorders. 31 Attempting to detangle the personality disorder from the chronic pain state with the goal of treating one or the other may be difficult at best.

Cognitive-Behavioral Therapy for chronic pain (CBT-CP) has been well documented in the literature to be one of the most effective treatments for chronic pain.33-35 Acceptance and Commitment Therapy (ACT)36, has been shown to benefit patients with personality disorders that had failed in previous treatment with significant improvements in personality pathology and quality of life.37 ACT for chronic pain has also been effective at decreasing pain intensity, anxiety, and disability38 The use of CBT-CP and ACT may be a potential avenue for treatment, but research designed to investigate these interventions among people with coexisting chronic pain and personality disorders is lacking.

Dialectical Behavior Therapy (DBT), a current mainstay of treatment of borderline personality disorder, focuses on the development of coping skills with the ultimate goal of improving emotional regulation and control.39 However, as with other therapeutic modalities, there is minimal evidence for treatment for DBT in those with chronic pain and comorbid personality disorders.

Given the common elements between Cognitive-Behavioral Therapy and Dialectical Behavior Therapy, it stands to reason that a hybrid model combining elements of both CBT-CP with DBT might be a highly successful approach to maximizing treatment potential in patients with co-morbid chronic pain and personality disorders, especially borderline personality disorder.

Summary: 

In summary, it is important to assess patients not just for depression, anxiety and other clinical psychiatric disorders, but for personality traits and disorders in order to better understand the impact personality may have on the expression of their pain perception, medication use and coping styles.  Understanding the role personality disorders may play in the complexities of chronic pain should result in the tailoring of multimodal treatments for chronic pain that emphasize non-opioid medical management, cognitive-behavioral and physical therapies.

References

  1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC)2011.
  2. Banks SM, Kerns RD. Explaining the high rates of depression in chronic pain: A diathesis-stress framework. Psychological bulletin. 1996;119(1):95-110.
  3. McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain. 2003;106(1-2):127-133.
  4. Weisberg JN. Personality and personality disorders in chronic pain. Curr Rev Pain. 2000;4(1):60-70.
  5. Breuer J, Freud S. Studies on hysteria. Original work published 1893-1895 ed. New York, NY: Basic Books; 1957.
  6. Engel GL. Psychogenic pain and pain-prone patient. Am J Med. 1959;26(6):899-918.
  7. Hathaway SR, McKinley J. Minnesota Multiphasic Personality Inventory. Minneapolis, MN: University of Minnesota Press; 1943.
  8. Kleinke CL, Spangler AS, Jr. Predicting treatment outcome of chronic back pain patients in a multidisciplinary pain clinic: methodological issues and treatment implications. Pain. 1988;33(1):41-48.
  9. Block AR, Ohnmeiss DD, Guyer RD, Rashbaum RF, Hochschuler SH. The use of presurgical psychological screening to predict the outcome of spine surgery. The Spine Journal. 2001;1(4):274-282.
  10. Block AR, Marek RJ, Ben-Porath YS, Kukal D. Associations Between Pre-Implant Psychosocial Factors and Spinal Cord Stimulation Outcome: Evaluation Using the MMPI-2-RF. Assessment. 2017;24(1):60-70.
  11. Gatchel RJ, Polatin PB, Mayer TG. The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine. 1995;20(24):2702-2709.
  12. Fishbain D, Cole B, Cutler R, Lewis J, Rosomoff H, Rosomoff R. Chronic pain and the measurement of personality: Do states influence traits? Pain Medicine. 2006;7(6):509-529.
  13. Turk DC, Fernandez E. Personality assessment and the minnesota multiphasic personality inventory in chronic pain: underdeveloped and overexposed. Pain Forum. 1995;4(2):104-107.
  14. Costa PT, McCrae RR. The NEO Personality Inventory Manual. Orlando, FL: Psychological Assessment Resources; 1985.
  15. Costa PT, McCrae RR. Revised NEO Personality Inventory (NEO–PI–R) and NEO Five-Factor Inventory (NEO–FFI) professional manual. Odessa, FL: Psychological Assessment Resources; 1992.
  16. McCrae RR, Costa PT, Jr., Martin TA. The NEO-PI-3: a more readable revised NEO Personality Inventory. J Pers Assess. 2005;84(3):261-270.
  17. Millon T. Millon Clinical Multiaxial Inventory. Minneapolis, MN: National Computer Systems; 1977.
  18. Millon T, Grossman S, Millon C. Millon Clinical Multiaxial Inventory-IV: MCMI-IV. Bloomington: NCS Pearson; 2015.
  19. Cloninger C, Svrakic, DM., Przybeck, TR. A psychobiological model of temperment and character. Archives of general psychiatry. 1993;50:975-990.
  20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: Author; 2013.
  21. Meehl PE. Schizotaxia, schizotypy, schizophrenia. American Psychologist. 1962;17:827-838.
  22. Monroe SM, Simons AD. Diathesis-stress theories in the context of life stress research: implications for the depressive disorders. Psychological bulletin. 1991;110(3):406-425.
  23. Flor H, Turk DC. Etiological theories and treatments for chronic back pain. I. Somatic models and interventions. Pain. 1984;19(2):105-121.
  24. Weisberg JN, Keefe FJ. Personality disorders in the chronic pain population: Basic concepts, empirical findings, and clinical implications. Pain Forum. 1997;6(1):1-9.
  25. Grant BF, Hasin DS, Stinson FS, et al. Prevalence, correlates, and disability of personality disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2004;65(7):948-958.
  26. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological psychiatry. 2007;62(6):553-564.
  27. Reich J, Tupin JP, Abramowitz SI. Psychiatric diagnosis of chronic pain patients. Am J Psychiatry. 1983;140(11):1495-1498.
  28. Fishbain DA, Goldberg M, Meagher BR, Steele R, Rosomoff H. Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain. 1986;26(2):181-197.
  29. Weisberg JN, Gallagher RM, Gorin A. Personality disorder in chronic pain: A longitudinal approach to validation of diagnosis. Paper presented at: 15th Annual Scientific Meeting of the American Pain Society; November 1996, 1996; Washington, DC.
  30. Conrad R, Schilling G, Bausch C, et al. Temperament and character personality profiles and personality disorders in chronic pain patients. Pain. 2007;133(1-3):197-209.
  31. Wilsey BL, Fishman SM, Tsodikov A, Ogden C, Symreng I, Ernst A. Psychological comorbidities predicting prescription opioid abuse among patients in chronic pain presenting to the emergency department. Pain Medicine. 2008;9(8):1107-1117.
  32. Barry DT, Cutter CJ, Beitel M, Kerns RD, Liong C, Schottenfeld RS. Psychiatric Disorders Among Patients Seeking Treatment for Co-Occurring Chronic Pain and Opioid Use Disorder. J Clin Psychiatry. 2016;77(10):1413-1419.
  33. Majeed MH, Sudak DM. Cognitive Behavioral Therapy for Chronic Pain-One Therapeutic Approach for the Opioid Epidemic. J Psychiatr Pract. 2017;23(6):409-414.
  34. Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153-166.
  35. Knoerl R, Lavoie Smith EM, Weisberg J. Chronic Pain and Cognitive Behavioral Therapy: An Integrative Review. West J Nurs Res. 2016;38(5):596-628.
  36. Cederberg JT, Cernvall M, Dahl J, von Essen L, Ljungman G. Acceptance as a Mediator for Change in Acceptance and Commitment Therapy for Persons with Chronic Pain? Int J Behav Med. 2016;23(1):21-29.
  37. Chakhssi F, Janssen W, Pol SM, van Dreumel M, Westerhof GJ. Acceptance and commitment therapy group-treatment for non-responsive patients with personality disorders: An exploratory study. Personality and mental health. 2015;9(4):345-356.
  38. McCracken LM. Learning to live with the pain: Acceptance of pain predicts adjustment in persons with chronic pain. Pain. 1998;74(1):21-27.
  39. Wilks CR, Korslund KE, Harned MS, Linehan MM. Dialectical behavior therapy and domains of functioning over two years. Behaviour research and therapy. 2016;77:162-169.

 

 

Disparities in Pain and Pain Care: Combating Bias in Practice

Monday, 21 October 2019 12:53
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Jennifer L. DelVentura, Ph.D., ABPP
Jennifer L. Steiner, Ph.D., ABPP

In a post in a previous issue of this newsletter, titled “Gender disparities in Pain and Pain Care,” we explored the evidence that women are not only at higher risk for pain and pain conditions but that their pain appears to be underestimated and, in some cases, undertreated compared with men’s pain. Similar patterns are evident in diagnosis and treatment of pain in racial/ethnic/SES minority patients, ranging from differences in prevalence and severity of pain in these groups to differential access to resources and pain care.

While there are many factors operating at different levels (community, institutional/systemic, familial/social, individual) contributing to these disparities, the impact of provider biases on pain care is of particular interest for us, as clinicians.  Biases are ubiquitous, often unconscious, and a normal part of human cognition, but they are not innocuous.  They may even be inconsistent with conscious beliefs—e.g., one may deny having negative beliefs about minority groups, but still evidence presence of unconscious biases in decision-making.  But importantly, with awareness and effort biases are malleable.  It is our task as ethical, caring providers to strive to minimize the impact of harmful biases on patient care.   

Using measurement tools normed for minority populations

One approach to reducing impact of biases involves using pain assessment tools normed for minority patient populations.  Even seemingly unbiased tools may be interpreted and rated differently by minority groups.  Take for example the widely-used numerical pain rating scale with verbal anchors (e.g., “moderate,” “severe” or “worst pain imaginable”) to describe pain intensity.  While these scales appear bias-free, their use rests on the assumption that we all interpret pain descriptors in the same way.  Yet this may not be true, as is demonstrated in a study by Campbell and colleagues[1], comparing pain ratings to thermal stimuli in men vs. women and white vs. black participants.  Findings indicated that when using a generic numerical pain rating scale, women and black participants rated the stimuli as significantly more painful than their counterparts.  However, when participants were allowed to individualize the rating scale by moving the verbal anchors to reflect their subjective interpretation of pain, group differences in pain ratings were no longer significant[1] suggesting group differences in how these anchors were interpreted, perhaps attributable to culture, socialization, or other factors.

The Campbell et al [1] study points to the need for measures modified for or normed to different populations.  Indeed, a few measures with such norms do exist.  For example, for psychologists, the MMPI-II-RF and Millon Behavioral Medicine Diagnostic [2], offer a multitude of specific patient group norms divided by gender (but not ethnicity).  Additionally, several behavioral measures of functioning that are commonly used by physical therapists now have more extensive norms for different populations. The unipedal stance (UPST) now has norms for age and gender [3] and several other common tests such as the timed up-and-go test and single limb stance test have established significant differences based on age [4-6].  However, most measures lack norms specific to race/ethnicity, and thus this remains an important area of development for the field of pain management.  Because such minority group norms are not widely available, it is crucial to be aware of the inherent limitations of our commonly used measures.

Provider-level strategies for managing bias

But what else can providers do to reduce impact of bias on patient care?  Social psychology research offers valuable insights into strategies for addressing biases in our work.  Based on this research, Burgess and colleagues [7] put forth a multi-step, evidence-based framework for addressing biases in healthcare, parts of which we will briefly summarize here.

First, fostering providers’ internal motivation for change is foundational to this model and involves bringing awareness to the presence of biases in our work.  This can be done using techniques like the implicit association test (IAT, [8, 9], a measure of response latency that evaluates the strength of an association between pairs of contrasting concepts and is believed to tap into implicit connections between concepts in the brain. The IAT takes advantage of the brain’s inherent tendency to pair concepts together in service of faster processing, the more closely two concepts are linked together for an individual, the faster the person should be able to respond when one component of the pair is activated in the brain. It is a computer-administered task that has been used to highlight unconscious biases or preferences for people that belong to particular social groups (race, gender, religion., etc.), however, it is important to note that there is some debate as to what the IAT actually measures, and whether implicit bias is correlated with explicit bias and/or explicit behavior [10, 11]. Nevertheless, completing an IAT for a number of variables, i.e. gender, race, size, etc. (at projectimplicit.net)[1] may offer some insight into our own associations and may inform self-reflection.

To give an example of what such an exercise might look like we invite you to consider the following sentences (adapted from the group exercise described in Holm et al., 2017) and count how many are true for you:

  • I can feel confident that others feel that I am qualified upon first impression.
  • I can speak in a roomful of medical providers and feel that I am heard.
  • My age adds to my credibility.
  • When I report pain or physical symptoms to my doctor, I can feel confident that my race or gender identification will not work against me.
  • When I report pain or physical symptoms to my doctor, I can feel confident that others will take them seriously and not assume I am motivated by secondary gain.
  • I can feel confident that if a family member requires hospital or emergency treatment they would be treated with dignity and respect even if they don’t mention my connection with the hospital.

Consider what you notice here.  How many feel true for you? And how might this reflect privilege (or lack thereof) in a healthcare environment? The intention here is not to blame or shame individuals who carry privilege, but rather to consider how this privilege might impact our experience and the quality of care we receive [7, 12].

Now, we invite you to bring to mind a patient or acquaintance with minority group affiliations (race, gender, age, SES). Then with this patient in mind, read through and consider these sentences again from this person’s perspective.  How many of these might feel true to this person?  And in turn, how might this impact actual or perceived care?  The answers and experience might be rather different in this case, and may be uncomfortable for us to consider.  Indeed, it is common for exercises like the above to elicit some negative emotions and internal discomfort (e.g., cognitive dissonance).  However, when elicited in a safe, nonjudging environment, these negative emotions can serve to motivate behavior change.  

Other strategies and considerations for providers

Other steps in the Burgess et al [7] model include increasing contact and comfort with minority groups, and facilitating perspective-taking and empathy for minority group patients—e.g., imagining situations from the patient’s perspective.  However, empathy can suffer due to stress, burnout, and time (e.g., over the course of one’s career).  Even when great strides have been made in reducing the impact of biases and increasing awareness of one’s biases, as creatures of habit we tend to regress back into old patterns if not careful.  Thus, self-care and becoming attuned to our own needs is vital to reducing bias in our work.  It is important that providers practice recognizing signs of burn-out within themselves and routinely re-assess for potential biases. At a systems level, this perhaps highlights the need for greater resources, i.e. advocating for lighter patient caseloads, more time with patients, more time for education (such as seminars or experiential trainings) of this nature both during graduate-level training and at the post-licensure level, and more.

All considered, it is important to note that perfection is neither expected nor realistic in efforts to reduce negative impacts of biases.  Rather, we should strive to reduce biases through practice of empathy, perspective-taking, awareness, and seeing patients as individuals rather than through the lens of group membership.

References

  1. Campbell, T.S., et al., Relationship of ethnicity, gender, and ambulatory blood pressure to pain sensitivity: Effects of individualized pain rating scales. The Journal of Pain, 2004. 5(3): p. 183.
  2. Millon, T., et al., Millon Behavioral Medicine Diagnostic. 2001, Minneapolis, MN: NCS Assessments.
  3. Springer, B.A., et al., Normative values for the unipedal stance test with eyes open and closed. J Geriatr Phys Ther, 2007. 30(1): p. 8-15.
  4. Hirano, K., et al., Impact of low back pain, knee pain, and timed up-and-go test on quality of life in community-living people. J Orthop Sci, 2014. 19(1): p. 164-71.
  5. Bohannon, R., Single limb stance times: a descriptive meta-analysis of data from indivdiuals at least 60 years of age. . Topics in Geriatric Rehabilitation, 2006. 22(1): p. 70-77.
  6. Steffen, T.M., T.A. Hacker, and L. Mollinger, Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther, 2002. 82(2): p. 128-37.
  7. Burgess, D., et al., Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med, 2007. 22(6): p. 882-7.
  8. Greenwald, A.G., D.E. McGhee, and J.L. Schwartz, Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol, 1998. 74(6): p. 1464-80.
  9. Nosek, B.A., A.G. Greenwald, and M.R. Banaji, Understanding and using the Implicit Association Test: II. Method variables and construct validity. Pers Soc Psychol Bull, 2005. 31(2): p. 166-80.
  10. Lane, K.A., et al., Understanding and using the implicit association test: IV. Implicit Measures of Attitudes, 2007: p. 59-102.
  11. Hofmann, W., et al., A meta-analysis on the correlation between the implicit association test and explicit self-report measures. Pers Soc Psychol Bull, 2005. 31(10): p. 1369-85.
  12. Holm, A.L., et al., Recognizing Privilege and Bias: An Interactive Exercise to Expand Health Care Providers’ Personal Awareness. Acad Med, 2017. 92(3): p. 360-364.

[1] Projectimplicit.net is run by a non-profit organization and collects the data for scientific purposes.

[2] The Cultural and Linguistic Competence Health Practitioner Assessment (CLCHPA) through the Georgetown University National Center for Cultural Competence can be found at https://nccc.georgetown.edu/assessments/.  Please note that the assessment and website are temporarily out of service for revisions

President’s Message, July 2019

Wednesday, 26 June 2019 00:27
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Ann Quinlan-Colwell, PhD, APN

As a result of the opioid crisis, during the last few years we have faced many changes that we never expected. Patients and families have been devastated. Some are dealing with Opioid Use Disorder, while others are dealing with pain and withdrawal after abruptly stopping prescription opioids. Shocking are notes posted on physician’s doors stating: “We do not prescribe opioids.” Shocking in a different way was the demise of the Academy of Integrated Pain Management and potential demise of the American Pain Society. These changes are both dreadful and sad.

Similarly, many in our region have been impacted by severe weather crises such as tornados, floods and hurricanes. As a result of hurricane Florence, families are dealing with changes ranging from loss of homes to financial burdens. The effects of the hurricane are dramatic in our local landscape. Many of the majestic tall pines are gone which has dramatically changed the day to day rides through the area. It has been very easy to lament their loss. This week, I realized that following the cleanup, where the tall pines used to stand, now small maples, azaleas, struggling magnolias, smaller pines, and a variety of plants and shrubs are flourishing. Importantly, the remaining tall pines, clearly have an important position. Ironically, they seem stronger where they stand. At the same time, we need to ensure that the emerging bamboo doesn’t indiscriminately overgrow all else.

Using the landscape as a metaphor, I encourage us to continue to explore and support the many pharmacologic and non-pharmacologic options for pain management. As members of the Southern Pain Society, we care for patients using multimodal approaches. We are in a unique position to advocate for optimal multimodal pain management that includes opioids when appropriate and necessary. Similar to the tall pines and bamboo, opioids need not be the dominant, and should not be the only or excessive treatment. Yet they certainly do have an important role for many patients in many situations. Our members are pain management experts with varied experiences, specialties and knowledge. We have a responsibility to share balanced, multimodal information, both clinical and scientific, with our membership as well as clinicians in our region.

Like the variety of flora that is now emerging in the sunlight in our region, our 2019 SPS conference will highlight a variety of integrative approaches to more effectively manage pain. Some presentations will focus on interventions that have at times in the past were overshadowed by opioid monotherapy practices, but now are growing stronger with greater light being shown on them. Others will be innovative options that are emerging through this new landscape. It seems very appropriate that our conference will be in NOLA where recovery from Katrina was so dramatic. We look forward to sharing the emerging landscape of integrative pain management with you in NOLA in September.

Is Compassion Fatigue the Adversary of Compassionate Pain Management?

Tuesday, 23 October 2018 09:42
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Ann Quinlan-Colwell, PhD, RNC, AHNBC, DAAPM

In the last newsletter, compassion was discussed as the possible ghost of pain management.  Intrinsic in that possible relationship is the potential ingredient known as compassion fatigue which is described by Sinclair and colleagues (2017) as “a work-related stress response in healthcare providers that is considered a ‘cost of caring’ and a key contributor to the loss of compassion in healthcare.”   The stress response involved in compassion fatigue is believed to evolve while caring for patients, clinicians repeatedly experience, in a secondary manner, the traumatic events and/or suffering of patients.  Although, there is no identified theoretical basis, empirical validation or measurement, there is general consensus that compassion fatigue is real and does clinically exist internationally (Sinclair et al, 2017).  It is certain that for a clinician to experience compassion fatigue, the clinician must first have compassion and experience compassion with patients. Ironically, the terminal result of compassion fatigue is that such an originally compassionate caregiver, no longer feels empathic or nurturing toward others, and no longer feels energetic or enthusiastic about the profession once so loved.

The term was first used in 1992 by a nurse educator, C. Joinson, who coined the term compassion fatigue to describe the burnout she observed among healthcare providers.  Today, although compassion fatigue is at times considered a branch of burnout (Sabo, 2011), it is generally considered different from burnout (Lanier, 2017).  In 1995, Dr. Charles Figley (Tulane University) described compassion fatigue occurring as the result of secondary traumatic stress occurring among caregivers when caring for people who are suffering as a result of a traumatic event.  He described the secondary traumatic stress/compassion fatigue as being similar to the post traumatic stress disorder (PTSD) experienced by the traumatized person.  In fact, the symptoms attributed to PTSD and compassion fatigue are remarkably similar (See Table 1). 

Table 1

Post Traumatic Stress Disorder Symptoms

Compassion Fatigue Symptoms
   

Upsetting thoughts

Intrusive thoughts

Irritable

Irritability

Flashbacks

Traumatic memories

Upset by memories

Anger

Trouble sleeping

Insomnia or difficulty sleeping

Nightmares

Nightmares

Concentration difficulties

Difficulty concentrating or focusing

Jumpy

Startle reactions

Overly careful

Hypervigilant

Emotional distance

Patient/client avoidance

Overly careful

Self-doubt and questioning self

Loss of interest

Depressed mood

Avoid activities

Isolating self

Memory difficulties

 

Taken from:

Foa, Johnson, Feeny, & Treadwell, (2001).

Taken from:

Fidley, 1995; Fidley, 2002; Sabo, 2011; Sinclair, et al, 2017

Figley defined compassion fatigue “as a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e.g. anxiety) associated with the patients … a function of bearing witness to the suffering of others”  (Figley, 2002, p. 1435).  The Compassion Fatigue Self Test of Psychotherapists was developed by Figley and later adapted by others with one version adapted with the permission of Figley available via http://www.community-networks.ca/wp-content/uploads/2015/07/Self-Assessment-Tools-Compassion-Fatigue-Feb-22-2010.pdf   In his Compassion Stress and Fatigue Model, Figley (1995, 1997, 2002) described ten variables which combine to result in compassion fatigue and which can be modified to avoid or mediate the development or experience.  The ten variables are listed in Table 2 along with a brief description of each one.

Table 2 Variables of Figley Compassion Stress and Fatigue Model

Model Variable

Description  of variable

Empathic ability

The ability to appreciate pain in another person.

Empathic concern

The impetus to respond to the pain of another person.

Exposure to the patient

Directly being exposed to and experiencing the emotional energy of the suffering person.

Empathic Response

Using insight to share the perspective of the suffering person in an effort to ease the pain and suffering of the person.

Compassion Stress

The effect of the energy expending during the empathic response which can result in negative effects on the well- being of the caregiver.

Sense of Achievement

The satisfaction with compassionate efforts that are experienced by the caregiver who has clear boundaries and concepts of responsibility. 

This variable is protective against compassion fatigue and promotes compassion satisfaction.

Disengagement

The ability, between encounters, to put space between self and the suffering patient and let go of the qualities associated with the suffering experience.  It also involves the clinician in fully engaging in his or her own life. 

When utilized this variable also is protective against compassion fatigue. 

Prolonged Exposure

Over time the persistent belief of responsibility for the person and the associated suffering.  The more intense the exposure with limited interruptions the greater the compassion fatigue.

Traumatic Recollections

These are memories of other experiences or the experiences of other patients which trigger emotional and stressful reactions (i.e. anxiety or depression).

Life Disruption

The unanticipated events that necessitate change in routine or schedule which normally occur in life.  However, when combined with the other variables, the likelihood of compassion fatigue developing increases.

 

Taken from: Figley, 2002, pp. 1436 – 1438.

Although the concept descriptor, compassion fatigue, was only coined 25 years ago, compassion fatigue is now considered an occupational hazard of health care workers (Mathieu, 2012).  Estimates of prevalence range as high as 40% in Intensive Care Units (van Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015).  Not only is it a general occupational hazard, but among clinicians who strive not only to do well, but to at all times to do their best,  Figley noted it is a “disorder that affects those who do their work well” (Figley, 1995, p. 5).  Traumatologist Eric Gentry proposed that many who enter caregiving professions suffer from compassion fatigued prior to even starting their profession because they previously learned to care for others rather than learning to care for self (Lanier, 2017).

Equipped with this knowledge, it seems reasonable to conclude there is an ethical responsibility to educate those who are at greatest risk (i.e. all clinicians) to be able to empathically and compassionately care for patients while promoting compassionate satisfaction and preventing compassion fatigue.  As a first step in addressing this responsibility, the next segment of this series will address the concept of self-compassion and the final segment will discuss restoring compassion in the work of pain management.  Now that you have read about the dilemma, hopefully, you will return to read about viable resolutions.

 

References

Abendroth, M., (Jan 31, 2011) “Overview and Summary: Compassion Fatigue: Caregivers at Risk” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Overview and Summary. DOI: 10.3912/OJIN.Vol16No01OS01

Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge.

Figley, C.R. (1997). Burnout in families: The systemic costs of caring. Boca Raton: CRC Press

Figley, C. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Psychotherapy in Practice, 58(11), 1433-1441.

Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376-384.

Gentry, J. E..  Baranowsky, A. & Dunning,   (1997).  Compassion Fatigue Article: Accelerated Recovery Program (ARP) for compassion fatigue.  Traumatology Institute. Online Training for Trauma Professionals.

Joinson, C. (1992). Coping with compassion fatigue. Nursing 22(4), 116-122.

Lanier, J. (2017).  Running on empty: Compassion fatigue in nurses and non-professional caregivers. The Bulletin Indiana State Nurses Association, 44(1), 10-14.

Mathieu, F. (2012). The Compassion Fatigue Workbook. NY, NY: Taylor and Francis Group.

Sabo, B., (Jan 31, 2011) “Reflecting on the Concept of Compassion Fatigue” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 1. DOI: 10.3912/OJIN.Vol16No01Man01

Sinclair, S., Raffin-Bouchal, S., Venturato, L., Mijovic-Kondejewski, J., & Smith-MacDonald, L. (2017). Compassion fatigue: A meta-narrative review of the healthcare literature. International Journal of Nursing Studies, 69, 9-24.

Todaro-Franceschi V.  (2013). Compassion Fatigue and Burnout in Nursing New York, NY: Springer Publishing Company.  ISBN: 978-0826109774

van Mol, M. M., Kompanje, E. J., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PloS one, 10(8), e0136955.

President’s Message January 2017 – Mordecai Potash, MD

Friday, 05 May 2017 11:56
0 Comments

It is my great pleasure to author my first column as President of the Southern Pain Society. In trying to find some inspiration for this column, I went through my New York Times’ collection of articles about chronic pain. I have long been a print and then digital subscriber to the Times, and now have amassed a collection its articles about chronic pain, pain management, and palliative care issues (with thanks to my father-in-law, who dutifully sends to me any article that escaped my eye).

Looking at these articles chronologically, it shows the great arc of change that our field has been through during our professional careers. From one practice standard and swinging to another – pain management as a field and as a professional practice has experienced marked changes and intense scrutiny that few fields of medicine have undergone over the last thirty years.

Just looking at the headlines (not even the articles themselves) will give you a good taste of this:

  • August 26, 1985 – “Helping Families Deal With Chronic Pain”
  • March 28, 1993 – “Patients in Pain Find Relief, Not Addiction, in Narcotics”
  • July 29, 2001 – “The Alchemy of OxyContin”
  • December 21, 2001 – “Few States Track Prescriptions As Way to Prevent Overdoses”
  • November 25, 2003 – “The Delicate Balance Of Pain and Addiction”
  • October 19, 2004 “Doctors Behind Bars: Treating Pain Is Now Risky Business”
  • May 30, 2006 – “Doctors Struggle to Treat Mysterious and Unbearable Pain”
  • March 27, 2007 – “Trafficker or Healer? And Who’s the Victim?”
  • June 17, 2007 – “Doctor or Drug Pusher”
  • August 29, 2007 – “A Surplus of Treatment Options, Few of Them Good”
  • May 13, 2008 – “Back Pain Eludes Perfect Solutions”
  • November 05, 2009 – “Treating the Pain Epidemic”
  • April 09, 2012 – “Tightening the Lid On Pain Prescriptions”
  • May 21, 2016 – “Prescription Dip Seen as Advance in Opioid Battle”
  • March 16, 2016 – “New Standards for Painkillers Aim to Stem Overdose Deaths “
  • November 23, 2016 – “If the Doctor Orders Marijuana, Will Insurers Pay?”
  • December 29, 2016 – “Ethics and Pain: It’s Complicated”

See what I mean? From recognizing that many were languishing unnecessarily due to pain; to beginning to recognize the societal trade-offs that would stem from aggressive pain management; to re-evaluating the legitimacy of providers who treat patients’ pain zestfully; to recognizing that effective pain management treatments are often elusive or expensive (or both); to trying to craft new guidelines to stem prescription abuse; to grappling with the impact of the medical cannabis movement; and to finally recognizing that our field is inherently complicated and perennially chock-full of contradictions.

Many of these articles have the term “double-edge sword” in their text, either as an interview quote or as a journalistic conclusion. This term does capture the dichotomy of our work – the very treatments that can be nearly life-saving for one of our patients can be ineffective for another, or even life-destroying. This dichotomy is true whether our treatments include extended release opiates, nerve blocks, rhyzotomies, kyphoplasties, spinal stimulators, infusion pumps, mindfulness exercises, or any other treatment that we render.

I personally know patients that have had such positive responses to each of these treatments, the word ‘miracle’ tumbles out repeatedly as they describe their response. I also know patients that would describe each of these treatments as having ruined their lives, leaving them even more disabled and embittered than prior to treatment (well, truth be told, I don’t know anyone who would describe ‘mindfulness’ as ruinous – just a hippy-born, navel-gazing, fantastic waste of time).

As we start 2017, the arc of change continues. Many state legislatures and healthcare payers / insurers are considering tremendous regulatory changes in light of both the CDC’s recommendations on opiates for the treatment of chronic pain and the nation’s changing attitudes towards the use of cannabis for the treatment of pain. Several recent articles have suggested a “swap” of chronic opiates for chronic cannabis – suggesting that this would lead to less societal pain such as traffic accidents and overdose deaths [1]. Even as some authors suggest these changes, disturbing reports about dramatic increases in traffic accidents, accidental childhood exposure, intense side effects, and – yes – overdose deaths are appearing in medical [2] and legal reports [3].

I am not “poo-pooing” medical marijuana. Rather – if there is anything the last 30+ years has demonstrated to us over and over again – it is that there are no easy answers in pain management. An approach that may work wonders for one patient may fail miserably in another. What remains the truest ‘answer’ is the ethos that I have seen demonstrated over and over again from our colleagues, in our newsletters, and at our conferences. We treat our patients with zealous compassion, encouraging that they deserve to live a life free of intense daily suffering, and advocating to institutions about preserving and enhancing treatment options for people with chronic pain.

I guarantee you that 2017 will bring new challenges to this ethos. But I also guarantee you that we have together faced similar challenges in the past and that our organization will continue to educate and promote our highest healing ideals.

REFERENCES

[1] Eric Sarlin. Study Links Medical Marijuana Dispensaries to Reduced Mortality From Opioid Overdose. NIDA Notes, published 05/17/2016 and accessed at  https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose
[2] Howard S. Kim, et al. Cyclic Vomiting Presentations Following Marijuana Liberalization in Colorado. Academic Emergency Medicine. Volume 22, Issue 6, June 2015, Pages 694–699
[3] Rocky Mountain High Intensity Drug Trafficking Area. The Legalization of Marijuana in Colorado: The Impact. Volume 2 / August 2014. http://www.rmhidta.org/html/August%202014%20Legalization%20of%20MJ%20in%20Colorado%20the%20Impact.pdf

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