Category Archives: President’s Notes

President’s Message: Looking Forward

Friday, 13 January 2023 11:25
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Thomas Davis, MD

Welcome to 2023!  Each new year is a chance to put into perspective the past year, and begin anew with plans to build upon the foundation laid by our predecessors.

Harry Gould, MD, our immediate past president, with the help of our board, Lori Postal our executive director, our vendors, sponsors, and speakers have been able to guide us through perhaps the most turbulent period in Southern Pain Society’s 36 years. The last three years with Covid 19 and a rapidly changing healthcare landscape presented unprecedented challenges.

The Southern Pain Society’s annual meeting in New Orleans, “Pain Management: The Times They Are Still A-Changin’”, in October 2022, was our first live meeting in over 2 years. This meeting helped to reaffirm the importance of in-person collaboration. In a healthcare environment which is often demeaning and confrontational, with record burnout and colleagues who have lost their lives, SPS and the other societies of likeminded individuals can make a more hopeful existence and perhaps refocus where our focus should be: helping those who are suffering in pain.

How do we build an even more successful Southern Pain Society? I believe the seeds for greater involvement and proliferation of pain education have already been sown. This past meeting saw our largest number of residents, fellows, and student involvement with research abstracts. In no small part, was this due to the mentoring by board members such as Alethia Sellers, MD and Casey Murphy, MD.  Hopefully, we may see a greater number of mentors involved from other institutions throughout the south. Board member Norman Harden, MD, has been able to use an abundant and varied research background to offer peer review guidance, and plant yet another seed for greater involvement with the investigation of pain.

During the peak of Covid we were able to launch a YouTube channel, and maintain Facebook and social media presence. These outreaches are in their infancy but hopefully will grow with board and SPS members, speakers, and vendor support.

Our finance committee under Treasurer Randy Roig, MD, and President elect James Weisberg, PhD, continue to offer a steady hand in an environment not always friendly to non- profit societies. Our Secretary, Eric Royster, MD has utilized his breadth of abilities from conference committees and local knowledge of pain providers in Louisiana, to offer talks on interventional pain. All of these volunteers, plus the past presidents and board members, help to keep SPS vibrant. To those who are not involved but who are reading this, please consider joining us.

SPS has been successful because of our diversity of interests and practices, and because we acknowledge pain and that the treatment of the individual takes a community. I am hopeful that the forces that limit helping our patients can be minimized. To help these patients we need everyone to join us: students, residents, fellows, psychologists, nurses, interventionists, anesthesiologists, psychiatrists, orthopedists, sports medicine, neurosurgeons, physiatrists, rheumatologists, neurologists, primary care, dentists, physical and occupation therapists, chiropractors, pharmacists, researchers, vendors and sponsors, patient advocates and the family caregivers in the 18 states and territories that make up our Society.

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: A Fresh Approach to Pain Education

Monday, 25 July 2022 22:21
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Harry J. Gould, III MD, PhD

During the past 30 years, we have observed the prescribing habits of physicians swing from a position of avoidance of opioid medications in the late 80’s and early 90’s to a position of liberal and virtually indiscriminate prescribing of opioids in the first decade of this century.  This trend paralleled a similar rise in overdose deaths associated with prescription opioids that led to the development of Washington State’s Multiagency Guidelines for Prescribing Controlled Substances with the goal to improve the safety and effectiveness of opioid treatment for chronic non-cancer pain.  Concern about the over prescribing and overdose deaths motivated the Institute of Medicine’s investigation of pain in America, the Centers for Disease Control’s declaration that the “Opioid Epidemic”, was considered the greatest healthcare crisis in U.S. history and the release in 2016 of their Guideline for Prescribing Opioids for Chronic Pain.

The broad understanding and agreement that the problem exists coupled with a desire for a rapid solution led to varied interpretations of prescribing guidelines.  Imposed policies and benchmarks for treatment standards often exceeded the intended goals of the drafters of the guidelines.  Physicians’ fear of criminal sanctions and strict disciplinary consequences associated with failure to comply with guideline standards led to a dramatic decline in prescriptions issued for opioid medications.  Unfortunately, the rapid reversal of the pendulum related to opioid medications, while significantly reducing the availability of prescription opioid medications has not produced a parallel reduction in opioid-related overdose deaths and the pendulum representing improvement in patient care seems to have remained steady throughout this period of healthcare volatility. How can we move closer to our goal of providing appropriate and adequate care for our patients in pain and mitigate the problem of the untoward adverse effects of opioid medications on patients and on society as a whole? 

“Across health care and society alike, there are major gaps in knowledge about pain” was one of the important conclusions drawn from the Institute of Medicine’s investigation of the state of pain care in America.  This is an important focus, but moving the mark toward improved patient care takes time and a concerted effort from a vast number of healthcare providers who view the problem from varied perspectives and training, from administrators and regulators of practice standards and from the patients we are hoping to serve. Incumbent on the approach to developing strong, patient focused principles for pain management is understanding that there are many tools that are effective for treating pain, but not all tools are necessarily appropriate or effective for treating every pain problem.  Each patient should be properly evaluated and should be involved in setting reasonable goals and making decisions in their care.  The appropriate tool or tools for the problem and the rationale for implementation should be carefully selected and administered when optimum.      

To this point, a new program to address the problem of provider and patient education has begun a trial run at the Louisiana State University Health Sciences Center in New Orleans.  The program is a longitudinal study targeting physicians in training in various specialties.  The program is administered to residents-in-training across the entire spectrum of their training and focuses on pain as it applies to their specialty. It measures levels of understanding of pain, its evaluation and management at each level of training and as they progress through their program toward certification. The initial trial runs focused on residents in obstetrics and gynecology and in orthopedics.  As a point of reference, patient assessment and education is approached at stages of evaluation and planning, pre-operative instruction, intraoperative and post-operative care and discharge planning for procedures that are frequently performed or are particularly problematic within their area of specialty.  Issues related to pain, its management and patient education are discussed and reviewed in the laboratory including gross dissection and classroom with attending faculty with expertise in the basic science of anatomy, pharmacology and physiology and in the clinical sciences with specialty training in pain medicine, anesthesiology, physiatry, psychiatry and the appropriate surgical specialty.  Basic knowledge is assessed before and after each training session and will similarly be evaluated throughout residency training.  It is hoped that the participants in the program will gain a better understanding of how to better evaluate pain, how and why certain management tools are selected, when they should be applied and how to help their patients understand and participate in their own care. 

The cohort of trainees was selected because residents in training are at the steepest part of their educational growth curve where information provided and reinforcement of the basics is likely to have the greatest effect.  It is also appreciated that residents play a major role in mentoring and laying down the foundations of practice for medical students at the earliest stage in medical training and a level where the emphasis on training compared to the prevalence and influence on pain healthcare is very low. In this teaching role, the residents are likely to have challenges to newly learned principles and be able to reinforce what they have learned. Finally, residents are in a position to challenge and inform attending physicians of recent advances in arts complimentary to their specialty.  I am encouraged, thus far, with the progress that this program has made and look forward to the possibility that it may impact some of the negative perceptions that we inherit when embarking on a career in pain medicine.

The Bipolar Spectrum In Pain Patients: Recognition and Management

Thursday, 13 January 2022 21:29
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Olivia Lee and Lawrence Robbins, MD

Introduction to Bipolar Disorder

The broadening concept of the bipolar spectrum has evolved over the years. We no longer view bipolar primarily as characterized by mania. Bipolar disorder is a chronic psychiatric illness that is broadly categorized in the DSM-V into several subtypes – bipolar I and bipolar II – depending on the presence of depressive, manic, or hypomanic features. It may occur in at least 4.4% of the population, but this number is likely to underestimate the true prevalence.1 There are major issues in identifying the milder bipolar presentations.2 Bipolar disorder often co-occurs with other psychiatric illnesses, creating innumerable patient presentations that may not fit neatly into the boxes of the two subtypes. The word “bipolar” is misleading and creates a stigma of severe mental illness.  There certainly is underdiagnosis for the milder forms. Most patients do not suffer from classic manic symptoms. The milder “hypomanias” are subtle and mild in comparison to true mania. For most patients there is a significant lag time from the onset of milder bipolar symptoms and diagnosis.

The classic mania that defines bipolar I is easily recognized.  Symptoms of mania include euphoric mood, grandiosity, distractibility, flight of ideas, thoughtlessness or risk-taking, and excessive involvement in pleasurable activities (i.e., sex, gambling, spending). Patients in the midst of a manic episode may also take on an excessive number of activities and exhibit pressured speech, excessive speech, irritability, and insomnia.3 These behaviors cause serious impairment to daily functioning and often last for several days or longer. Acutely manic patients are also high risk for harm to themselves or others.4

Milder hypomania is less likely to impair everyday functioning. However, it is also hypomania that is more commonly missed for a variety of reasons.4 Hypomania and the milder end of the bipolar spectrum have various presentations, complicating the diagnosis. These patients may have persistently agitated personalities, with frequent depression or excessive energy but not meeting the classic diagnostic criteria for bipolar I or bipolar II. Brooding, irritable pessimism may be a manifestation of the milder end. They often have a family history of bipolar disorder or depression. Many do not identify or remember a clear hypomanic episode. Diagnosing and treating these patients greatly improves  quality of life and reduces mortality risk from suicide. The clinical stakes for missing bipolarity are enormous.

Speaking with a “significant other” is vital for teasing out mild hypomanic symptoms.4 Most patient simply complain of depression. Signs of mild bipolar disorder may include a history of early onset depression(prior to age 18), severe bouts of depression, rapid onset depression for no apparent reason, poor response to trials of antidepressants (including complaints of being up all night, mind racing, etc.), agitation, anger, high anxiety, hypersomnia or (less likely) insomnia, and irritability. Family history of severe depression, hospitalization, and other bipolar traits is helpful. The “bipolar reaction” to antidepressants may give insight into underlying bipolar disorder.4 Family history of a bipolar reaction to antidepressants may also be a clue. An opposite reaction to other drugs may be present, such as being anxious or wired from benzodiazepines or sleeping pills. Depression is often the primary problem in bipolar II disorder; it is much more pervasive than are the highs of hypomania. Comorbid moderate or severe anxiety may further compound impairment seen in bipolar depression and increase suicidal tendencies by up to 35%.5 Suicide and substance abuse are commonly found among those with untreated bipolar.

Comorbidity of Chronic Pain and Bipolar Disorder

Bipolar disorder patients who also suffer from chronic pain are challenging. Almost 24% of bipolar patients may present with chronic pain.6 The comorbid pain decreases quality of life. Patients with bipolar disorder and chronic pain often respond poorly to treatment and have an increased risk of suicide.6 One study that assessed the relationship between pain and bipolar disorder recommended a pain assessment as part of the routine care for patients suffering from bipolar.6  It requires a multidisciplinary approach to adequately treat these patients. Other than the pain physician/provider, psychotherapists constitute a vital part of the team.

Comorbidity of Migraines and Bipolar Disorder

The comorbidity of migraine with mood disorders has been well documented.  There have been a number of clinic based studies as well as epidemiologic samples from community populations.7 Migraine and depression share some of the same pathophysiology.  Antidepressants or mood stabilizers may alleviate both conditions. In the majority of migraine patients who suffer from depression, anxiety is a complicating factor. The anxiety disorder often precedes the age of onset of migraine, with depression following afterward. Migraine or other pain may exacerbate depression, and depression fuels migraine and pain.  This is in addition to the shared environmental and genetic factors linking migraine and depression.

Emerging data is identifying the relationship between bipolar disorder and migraine. From 25 to 35% of bipolar patients suffer from migraine as well.6  This association may be due to shared pathophysiologic mechanisms.

Treatment Approaches for Bipolar Disorder

It may take some time to find the effective medication, or medications, for a given patient. Mood stabilizers often are the mainstay of treatment, and sometimes help the  headaches. The anticonvulsants, lithium, and the atypicals constitute the 3 classes of mood stabilizers. Lamotrigine is the most commonly used antiepileptic for bipolar, but does not help headaches. Lamotrigine may be beneficial for some with neuropathic pain. Divalproex sodium is effective for mania, hypomania, depression associated with bipolar disorder, and for migraine prevention. Divalproex has been well studied for these conditions and is one of the most commonly used migraine preventives. Carbamazepine and oxcarbazepine are antiepileptics that have utility as mood stabilizers, but not for migraine prophylaxis. They may alleviate neuropathic pain. Oxcarbazepine is somewhat safer than the original carbamazepine. Gabapentin has been effective in high doses for some patients with milder bipolar symptoms. Gabapentin is effective for certain pain syndromes, but not for migraine.

Lithium carbonate is an underutilized mood stabilizer. Low doses of lithium do not usually cause hypothyroidism or irritate the kidneys. With appropriate monitoring these risks can usually be avoided.  Lithium sometimes alleviates cluster headaches.  Lithium has also been evaluated for conditions such as multiple sclerosis and Alzheimer’s.8

Divalproex sodium, carbamazepine, and oxcarbazepine may produce teratogenic effects. Divalproex is more likely than the others to result in birth defects, particularly at doses above 500mg daily. Lamotrigine may be the best choice of an antiepileptic during pregnancy.  Lithium taken during pregnancy is fetal cardiac anomalies, but this is rare.  Lithium may be indicated for bipolar during pregnancy disorder under appropriate circumstances.8–10 For women who were stable on lithium prior to pregnancy, discontinuation during pregnancy may lead to relapse.10

Atypical antipsychotics are also a mainstay for bipolar symptoms.11 These agents include the general categories of “pines”, “dones”, “pips” and “rips”. These include clozapine(the first atypical), olanzapine, quetiapine, risperdone, lurasidone,  brexpiprazole, aripiprazole, and cariprazine.These are efficacious in treating mania and are prescribed as monotherapy or in combination with another mood stabilizer.12 The atypical side effects are many and varied. These include metabolic syndrome (insulin resistance, dyslipidemia, hypertension), weight gain, fatigue, “brain fog”, and extrapyramidal symptoms (akathisia, acute dystonia, dyskinesia/parkinsonism, and tardive dyskinesia).13 Patients on atypical antipsychotics  should receive routine bloodwork.  Signs of EPS may go unnoticed by some patients, rendering it important to ask specific questions. There certainly are concerns about the atypical antipsychotics during pregnancy, but in low doses these have resulted in minimal problems in the newborns.

As previously mentioned, lamotrigine is a very commonly prescribed mood stabilizer for bipolar disorder. It is one of the only effective medications for bipolar depression.14 Initiating a patient on lamotrigine requires a slow titration due to the rare (1:3,000: according to the German rash registry) but lethal side effects of Stevens Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN).15 SJS/TEN are variants of the same hypersensitivity reaction, differentiated by the percent of skin surface area that is affected (<10% in SJS, >30% in TEN). This rare rash is characterized by painful blisters, peeling skin, and tissue necrosis. The SJS rash often occurs in unusual areas, such as the palms of the hands, soles of the feet, or mucous membranes. A “regular” drug rash may occur in up to 10% of patients. Signs of SJS/TEN typically occur within 8 weeks of initiation and warrant immediate discontinuation of lamotrigine.15 Many of the anticonvulsants carry the risk of SJS/TEN, such as divalproex, carbamazepine, and oxcarbazepine.

 

Patients with bipolar spend the vast majority of their time in depression rather than in mania. Many of these patients require combination therapy to target depressive symptoms. Lamotrigine and quetiapine are two of the atypicals that may be effective in managing depressive episodes.16 While lithium is a first line therapy for mania, it has also shown efficacy in preventing relapse of depressive episodes and decreasing suicidality.16 Combination therapy of olanzapine and fluoxetine has been approved by the FDA for treating depression associated with bipolar I disorder.16 Lurasidone is an atypical that has shown promise for the depression.4,17 Antidepressants usually result in either no effect, or the typical “bipolar” response (up all night, wired, mind racing). Occasionally they are helpful. Emerging therapies include, among others, ketamine, TMS, and microdosing (primarily psilocybin).16

Conclusion

It is crucial to recognize psychiatric disorders in our pain patients. Patients with unrecognized personality disorders or bipolar disorder often suffer from poor outcomes. Patients with the milder end of the bipolar spectrum frequently are diagnosed and treated as if they suffer from “regular” depression. They generally do not do well on antidepressants.  Patients with psychiatric comorbidities, such as bipolar, require a multidisciplinary approach. The medications that treat psychiatric conditions may also be helpful for the pain conditions as well.

ABOUT THE AUTHORS

Olivia Lee is a fourth year medical student at Des Moines University. Her clinical interests include the interface of psychiatry and neurology. Lawrence Robbins is an associate professor of neurology, Chicago Medical School. He is in private (neurology and headache) practice in Riverwoods, Illinois. Lawrence has contributed to 390 articles/abstracts and written 5 books (on headache). Address correspondence to Lawrence Robbins at lrobb98@icloud.com.

Sources

  1. Harvard Medical School. National Comorbidity Survey (NSC).; 2007.
  2. Kessler RC, Wai TC, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington D.C: American Psychiatric Press; 2013.
  4. Culpepper L. The diagnosis and treatment of bipolar disorder: Decision-making in primary care. Prim Care Companion J Clin Psychiatry. 2014;16(3). doi:10.4088/PCC.13r01609
  5. Amuk OC, Patel RS. Comorbid Anxiety Increases Suicidal Risk in Bipolar Depression: Analysis of 9720 Adolescent Inpatients. Behav Sci (Basel). 2020;10(7). doi:10.3390/BS10070108
  6. Stubbs B, Eggermont L, Mitchell AJ, et al. The prevalence of pain in bipolar disorder: A systematic review and large-scale meta-analysis. Acta Psychiatr Scand. 2015;131(2):75-88. doi:10.1111/acps.12325
  7. KR M, DE S. Comorbidity of migraine and psychiatric disorders. Neurol Clin. 1997;15(1):115-123. doi:10.1016/S0733-8619(05)70298-X
  8. L L, B C, A N, et al. Lithium Use During Pregnancy in a Patient With Bipolar Disorder and Multiple Sclerosis. Clin Neuropharmacol. 2020;43(5):158-161. doi:10.1097/WNF.0000000000000407
  9. Jones SC, Jones I. Pharmacological Management of Bipolar Disorder in Pregnancy. CNS Drugs. 2017;31(9):737-745. doi:10.1007/s40263-017-0452-x
  10. Yacobi S, Ornoy A. Is lithium a real teratogen? What can we conclude from the prospective versus retrospective studies? A review. Isr J Psychiatry Relat Sci. 2008;45(2):95-106.
  11. JR C, PE K, W M, et al. A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of bipolar I or II depression. Am J Psychiatry. 2005;162(7):1351-1360. doi:10.1176/APPI.AJP.162.7.1351
  12. Canadian Agency for Drugs and Technologies in Health. Combination Atypical Antipsychotics in Adolescents or Adults with Bipolar Disorder with Psychotic Features: A Review of Clinical and Cost-Effectiveness and Guidelines.; 2016. https://pubmed.ncbi.nlm.nih.gov/27831672/. Accessed August 15, 2021.
  13. Stroup TS, Gray N. Management of Common Adverse Effects of Antipsychotic Medications. doi:10.1002/wps.20567
  14. Ng F, Hallam K, Lucas N, Berk M. The Role of Lamotrigine in the Management of Bipolar Disorder. Vol 3.; 2007.
  15. Messenheimer J, Mullens EL, Giorgi L, Young F. Safety review of adult clinical trial experience with lamotrigine. Drug Saf. 1998;18(4):281-296. doi:10.2165/00002018-199818040-00004
  16. Yalin N, Young AH. Pharmacological treatment of bipolar depression: What are the current and emerging options? Neuropsychiatr Dis Treat. 2020;16:1459-1472. doi:10.2147/NDT.S245166
  17. Ostacher M, Ng-Mak D, Patel P, Ntais D, Schlueter M, Loebel A. Lurasidone compared to other atypical antipsychotic monotherapies for bipolar depression: A systematic review and network meta-analysis. World J Biol Psychiatry. 2018;19(8):586-601. doi:10.1080/15622975.2017.1285050

President’s Message–Looking Ahead to 2022

Thursday, 13 January 2022 21:10
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Harry J. Gould, III MD, PhD

Once again, it is time to begin a brand new year.  Since I stepped into the role of president of the Southern Pain Society, we as a society have experienced moments of promise with the release and early encouraging responses to vaccines to thwart the COVID-19 pandemic. These advances fostered the hope of resuming in person meetings, but the resurgence of the pandemic due to the delta variant dictated that this was not to be.  Despite the setback, we were able have a very successful, albeit virtual, poster session in September through the hard work of the board and MAHEC organizers who are dedicated to fulfilling the mission of the SPS to serve people living with pain by advancing research and treatment and to increase the knowledge and skill of the regional professional community.

Clearly with the emergence of the omicron variant, 2022 will not be without its challenges, but the planning committee is optimistically anticipating that we will be able to host our annual meeting at the Astor Crowne Plaza in New Orleans, October 8-10, in person.  The committee has doubled their efforts to identify major challenges and topics of special concern to patients and pain practitioners in all specialties during these extraordinary times of isolation, to pull together a program that will offer ideas to help mitigate the challenges and improve the delivery of pain care to those in need. Of particular interest in 2022 will be a first look at the Reflex Sympathetic Dystrophy Syndrome Association’s review and update of the challenges and management of complex regional pain syndrome that is scheduled to be released just prior to the meeting. Topics addressing the role of ketamine in pain management, approaches to the treatment of migraine headache and beyond, the challenges of managing cancer pain in the midst of the ‘opioid crisis’, and the delivery of pain care in times of isolation are being explored to round out the program, to stimulate thought and provide a basis for discussion.  I encourage everyone to ‘Save the Date’, register for the meeting and even consider actively participating by submitting an abstract to inform and draw attention to concerns or observations that may be helpful to colleagues in their practice and stimulate discussion. I hope to see you there.

President’s Message: Running Headlong into what You Thought Was Behind You

Friday, 15 October 2021 11:40
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Harry J. Gould, III, MD, PhD

With the FDA’s blessing in mid-December on the administration of vaccines for COVID-19 and subsequent indications of downward trends in the rate of infections, hospitalizations and deaths associated with the virus came a feeling that the worst of the pandemic was past and we were on a return path to recover normalcy. Even with large numbers of individuals that chose not to be vaccinated, the falling numbers reflecting the impact of disease were encouraging and many businesses, organizations, and individuals began to abandon mitigation practices, i.e., social distancing and masking, and began returning to former practices and patterns of behavior. In-person visits in clinical practice began to replace the virtual platforms and we were again able to apply our mitigating strategies for reducing medication misuse, abuse and diversion, thereby lessening some of the provider’s anxiety associated with the impaired ability to identify potential problems related to opioid management.

Indeed, the Southern Pain Society’s (SPS) planning committee for the 2021 Annual Meeting, upon reviewing the trends in societal response to the vaccines, was cautiously optimistic and was looking forward to being able to hold our annual meeting in-person. Despite the committee’s best efforts to plan and deliver an informative and thought-provoking meeting that might also serve as an indicator that we were on the mend, the trend in disease statistics foreshadowed a lack of support for these efforts.  Due to the establishment and spread of variants of COVID-19 in the population, the rate of infections, hospitalizations and deaths shifted and by mid-August had returned to, and in many places surpassed, levels that had been recorded at the peak of the first wave of the pandemic.  By the late August, elective procedures and in-person appointments in clinics were again being replaced by virtual visits.  As a professional organization, the SPS could no longer be reasonably certain about ensuring individual safety for our participants, chose not to put individuals at risk of becoming seriously ill and postponed the 2021 meeting; perhaps a fortuitous decision in light of the additional complications imposed by Hurricane Ida.

The distractions of the last 18 months have emphasized the importance of maintaining and expanding efforts to improve patient safety and reliably delivering appropriate and effective care even in the face of adversity. As the pandemic continues, the SPS is expanding efforts to maintain and offer new opportunities to share ideas and express concerns, challenges, and potential solutions for the challenges facing our patients and practices. In offering opportunities to support scholarly activity and communication, like the recent virtual forum for abstract presentations.  We hope to encourage those with the wisdom and experience accrued through years of experience and those new to the field of pain medicine to come together and share ideas and experiences and hopefully create a forum for inquiry that will foster the pursuit of a better understanding of complex condition we strive to treat; its proper assessment; and optimal treatment options supported by evidence necessary for making the most appropriate management decisions.  I encourage you to follow our newsletter and postings on social media for opportunities as we continue to monitor the pandemic and set our sights on the future when we will be able to meet again with the pandemic behind us, even stronger than before. 

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.”

President’s Message: Thoughts on Addressing Disparity in the Midst of the “Opioid Crisis”

Thursday, 08 April 2021 14:24
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Harry J. Gould, III, MD, PhD

Pain occurs in both acute and chronic forms. In its acute form, pain is a modality that is essential for survival and is the signal that most frequently brings people to the attention of the healthcare professional.  Many cases of simple acute pain are readily treated without difficulty by physicians, practitioners in paramedical fields, and in many instances, by the lay public. Unfortunately, all too frequently problems that present as simple complaints of acute pain are the result of more a significant problem that if not accurately diagnosed and effectively treated can become a chronic condition that destroys the fabric of existence, not only for the individuals suffering the pain, but for families, loved ones, and society as a whole. In spite of its prevalence, there is a general lack of recognition that unassessed or poorly managed pain in and of itself is a problem about which we should be concerned and because of its prevalence the problem is also accompanied by substantial disparity for patient access to adequately trained providers, early evaluation and proper treatment.

For proper pain control and rationale management, society relies heavily on trained physicians and healthcare professionals for guidance. Unfortunately, the number of patients needing relief from intractable pain far exceeds the number of healthcare providers who are adequately trained to meet that need. The management of complex pain problems, thus, all too frequently falls to those with limited training in assessment and treatment strategies and little familiarity with modalities used for pain control.

In the early part of this century, the predominant treatment offered for pain control was largely a pharmacologic modalities. Unfortunately, a significant portion of the pharmacologic options included agents used by a section of society for unintended reasons e.g., affecting changes in sensory and emotional perception and cognition for recreation, which led to inconsistent, often inadequate, management of pain for those in need and the current “opioid crisis.” Because of concern for legal reprisal and the recognition that the additional time required to comply with important monitoring regulations is not accompanied by a comparable increase in compensation, fewer practitioners have been willing to treat pain or they have shifted focus and limited the offered treatment modalities to more lucrative, unidimensional approaches, thereby further exacerbating the already significant disparity between practitioners and patients for access to comprehensive evaluation and care.  The problem is further exacerbated by social limitations related to direct cost of physician visits, necessary absences from employment responsibilities to make and keep appointments, potentially additional need for care of children and transportation to care. These limitations result in delays in obtaining expert assessment, in the timely implementation of appropriate treatment and the increased likelihood of establishing chronicity of the problem with its inherent increase in co-morbid health conditions, higher costs for prolonged treatment and the development of maladaptive behaviors associated with the recognition of secondary gains.

Oddly enough, the COVID-19 pandemic and its requisite need to adapt in order to provide “social distanced” care for patients, may have enabled more physicians and healthcare administrators to recognize a possible next step in the reduction of healthcare disparity in that that when appropriately applied, telemedicine platforms can be very effective in organizing and implementing routine care in their practice and provide more uniformity of care in the communities they serve. Clearly, in person visits will always be essential in patient care and remains the preferred option for many patients and physicians alike, but it is also recognized that the virtual-visit can provide a viable option when offered for practices where access to care is limited and widespread disparities prevail.

Practitioners have noted that with the virtual-visit platforms, patients seem to be more compliant with their follow-up visits. They have also found that the virtual-visit platforms can make it possible to more easily manage schedules in the event of patient tardiness or failure to show. The primary weakness of virtual platforms is the lack of a physical exam and a significant reduction in the practitioner’s ability to assess patient affect and body language, making it more difficult to recognize undisclosed problems that should be addressed. 

Patients also have found virtual-visits satisfying. Although many continue to prefer in person visits, many have noticed improved convenience and a significant reduction in associated costs related to needs to take time off from work (visits can be done on a break at the office), to arrange for daycare, to lost time related to traveling significant distances and dealing with heavier than accustomed to traffic often found in urban centers where the specialists tend to locate their practices. There is also less downtime spent in waiting rooms especially when times are greater than normal when the doctor is delayed or other patients have arrived late or have extra needs.    

From the specialist’s perspective, especially for specialists in pain medicine, a limitation to broader utilization of virtual technology to improve the patient to specialist ratio is that frequently referrals for specialist evaluation and recommendations are assumed, even for routine pain problems, to be a complete transfer of care accompanied by assumption of responsibility for the patient’s primary care, implementation of pain care and routine follow up. Because referrals for pain issues can come from virtually all medical specialties, this approach rapidly fills the specialist’s available appointment slots thus limiting the ability to accept new referrals because of the requisite need for maintaining routine follow-up visits to monitor response to care and patient compliance.

A more effective approach might be to gather a team of specialists that could work with primary providers to evaluate a patient, develop an appropriate treatment plan and in the process impart many of the basic skills of assessment and treatment thus empowering the physician to be able to care for his/her own patient. Potentially, the patient could be exposed to a broader range of treatment options, experience less long-term morbidity related to frequent and extended trials of an ineffective “hammer and nail” approach to care and would benefit from the earlier implementation and response to appropriate management options provided closer to home by a physician with whom they have developed a relationship. Because of the collaborative relationship that is established between the primary physician and the team of specialists, the patient would have access to a network of additional treatment resources, if needed, and the specialist would benefit from having more time to be available to collaborate with other primary providers and to work on more complicated, less routine, pain problems.

Coincidentally, just such a program, Project ECHO, has been developed, trialed and was successfully launched in 2003 at the University of New Mexico Health Sciences Center in Albuquerque. For those who are interested in learning more about Project ECHO and how it might help your practice while contributing to a reduction in the disparity of pain care for many in our community, we will have the good fortune to hear Joanna Katzman, M.D. speak on “Pain Management in 2021: Exploring the Benefits of ECHO Pain Telementoring and Direct Telehealth for Your Practice” at the upcoming annual meeting of the Southern Pain Society. The meeting will be held in person in New Orleans, from September 10-12, at the Astor Crowne Plaza. I encourage you to register for the meeting on our website, www.southernpainsociety.org, and join me in the ‘Big Easy’ to hear more. I look forward to seeing you there.

Back to the Basics: Managing Pain Months After COVID-19

Saturday, 09 January 2021 14:05
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Harry Gould, MD, PhD

A year ago, the United States was in the midst of understanding and dealing with the complexities of the “Opioid Epidemic”, what until then had been considered the greatest healthcare crisis in U.S. history. Although improvements in some aspects of the crisis were starting to be realized as a result of the development of best evidence-based practice guidelines and the implementation of regulatory mandates for prescribing and monitoring treatment response, we were a long way from achieving our goal; to provide optimum care and improve quality of life for those in pain without causing harm to the patients, the healthcare system or society as a whole.

In many cases, the strides that had been made in mitigating the opioid crisis did not come without their own problems. The change of assessment, prescribing and monitoring standards imposed an unacceptable burden on many well-meaning physicians, who wished to help without harming their patients, but realized that compensation for the time necessary to comply with essential regulatory demands was inadequate. Because compensation issues were accompanied by fear of reprisal for non-compliance, many chose not to provide care for their patients’ pain problems, thus limiting patients’ options for identifying resources for appropriate evaluation and management of ongoing and persistent problems or for complications associated with previous inappropriate misuse, abuse or prescribing of treatments. The resulting uncertainty of care set the stage for frustration, stress, anxiety, anger and depression, each confounding factors in the management of uncontrolled pain.  

If addressing these options weren’t enough of a challenge, a new crisis, “the 2019-nCoV virus (COVID-19) pandemic” emerged in the population. The virulence of the virus, the uncertainty about its course and management, the frustration, stress and depression associated with individual isolation and distancing and the additional limitations on access to proper evaluation, delays in initiating possible condition-limiting treatment, follow up and monitoring of patients requiring controlled medications acutely added to the already present confounding factors that have hindered optimal recovery from the opioid crisis for both patients and practitioners alike.

Unfortunately, the distribution of promising new vaccines and potential control of the current pandemic may not completely eliminate the negative influence that the virus has had on delivering pain care. We are learning that a significant number of individuals, the “long-haulers,” who have survived a COVID-19 infection report experiencing persistent cardiac, pulmonary, renal, psychologic and neurologic problems consistent with direct or indirect multisystem injury as a result of the virus. The distribution and mechanism of injury producing the pain is unknown and likely multifactorial, but presentations are frequently multifocal and possess features of nociceptive and neuropathic pain with a hint of psychogenic quality consistent with organic central and/or peripheral nervous system involvement and the influence of post-traumatic psychosocial stress associated with contracting and fighting the disease. Optimal management of these complex pain problems will likely require a return to the basics promoted by John Bonica and others, that of a comprehensive and multimodal evaluation and the orchestration of pharmacologic, interventional, physical and psychological treatment modalities at all levels of the healthcare system.

As incoming president of the Southern Pain Society, I look forward to–and encourage others to work with me to — learn from healthcare providers and basic and clinical scientists from all specialties to improve and refine assessment skills, to identify viable treatment options and management planning and to provide continued education for clinicians in practice and those new to the field, in the hope of optimizing the quality of life for patients in pain.

Transitioning from 2020 to 2021 – “The Times They are a Changing”

Monday, 12 October 2020 12:31
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Ann Quinlan-Colwell, PhD, APN

For most of us, this past year has been tumultuous to say the least.  In at least some way, we have all been impacted by the COVID-19 pandemic, protests and the underlying circumstances that initiated them.  We are very fortunate that Dr. Ben Johnson wrote a thoughtful and insightful article in this issue regarding diversity in health care and with pain management in particular.  Every day, I learn about yet another way the pandemic has affected people and health care.  Many of our colleagues are reporting “Post COVID Stress Disorder” (PCSD).   Health care providers are struggling to maintain practices using virtual telehealth where possible.  Some have had to curtail performing “non-essential” analgesic procedures due to required personal protective equipment not being available.  Advanced practice nurses have been re-assigned from pain management to work in critically low staffing areas caring for patients acutely ill with COVID-19.  Still others have effectively been told that pain management is “not an essential service and in the interest of being financially responsible we are eliminating your position.”

Clearly, we are yet to witness the immense impact of chronic illness experienced by the COVID survivors who are being referred to as “the long haulers.”  This population will be particularly challenging since many of them have underlying co-morbidities or risk factors that are painful or increase the risk of experiencing pain. Many who have suffered pulmonary damage and complications will be at increase risk for medication related respiratory depression.  Since many people who have had COVID-19 reported neurological symptoms, we can hypothesize that neuropathic pain may be a long term consequence.  We are beginning to see literature discussing managing chronic pain during the pandemic  (Cohen, et al, 2020; Eccleston, et al, 2020; El-Tallawy, et al, 2020; Manchikanti, Kosanovic, & Vanaparthy, 2020;  Morgan & Dattani, 2020; Pradère, et al, 2020; Puntillo, et al, 2020; Soin & Manchikanti, 2020; Song, et al, 2020; Shanthanna, et al, 2020).

It is most certainly a time to amass resources to adjust our perspectives and our usual ways of functioning.  The more proactive we can be, the more internal resources we will have to best support people living with pain who are most certainly struggling. Functioning from a scientific perspective, garnering the evidence and supportive literature is basic (see reference list).  During this time with a certain degree of social and even professional isolation, it is also important to remain connected with other professionals.  The Southern Pain Society provides an excellent platform for doing so.  In addition to this newsletter, on November 13th and 14th we are scheduled to share amazing information during part one of our first ever Southern Pain Society Virtual Meeting.  The timely title of the meeting is: “Perspectives, Concerns and Options for Managing Pain” with presentations by a variety of internationally known faculty including Drs. Rollin Gallagher, George Singletary, Perry Fine, Jay Kaplan, Esther Bernhofer, and Misha Backonja.  We certainly hope to connect with you virtually to learn from these pain management professionals.

In addition, we have a special group of professionals serving on the SPS board of directors who work throughout the year to support information and education about pain management.  With annual regularity, the board composition is preparing to change.  As they step down from their board positions, we extend great appreciation to past president Mordi Potash, MD and director Joe Tramontana, PhD for their years of dedicated service.  During the next year, Dr. Harry Gould, III will assume the role of SPS president as I transition to past president and our long time treasurer Dr. Thomas Davis will become president elect.  We are thrilled that Drs. David Gavel and James McAbee will continue as directors and Dr. Randy Roig will continue as treasurer while Dr. James Weisberg will assume the role of secretary.  We are most pleased to welcome Drs. Michele Simoneaux and Eric Royster as new board members.  Without a doubt, this SPS board will work cohesively to continue to advance research and treatment of pain while increasing the knowledge and skill of all those in our professional community as we hopefully experience the end of the COVID-19 pandemic and move forward.  During this transition period, I encourage all to do everything possible to be safe and remain well.

References:

Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, L. T. C., Chen, Y., Hooten, W. M., … & King, L. T. C. (2020). Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine.

Dylan, B., & Sears, J. (1964). The times they are a-changin’ (Vol. 8905). Columbia.

Eccleston, C., Blyth, F. M., Dear, B. F., Fisher, E. A., Keefe, F. J., Lynch, M. E., … & de C Williams, A. C. (2020). Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain, 161(5), 889.

El-Tallawy, S. N., Nalamasu, R., Pergolizzi, J. V., & Gharibo, C. (2020). Pain Management During the COVID-19 Pandemic. Pain and therapy, 1-14.

Fauci, A. S., Lane, H. C., & Redfield, R. R. (2020). Covid-19—navigating the uncharted.

Gates, B. (2020). Responding to Covid-19—a once-in-a-century pandemic?. New England Journal of Medicine, 382(18), 1677-1679.

Manchikanti, L., Kosanovic, R., , & Vanaparthy, R.,  (2020). Steroid distancing in interventional pain management during COVID-19 and beyond: Safe, effective and practical approach. Pain Physician, 23, S319-S350.

Morgan, C., & Dattani, R. (2020). Should I use steroid injections to treat shoulder pain during the COVID-19 pandemic?. JSES international.

Pradère, B., Ploussard, G., Catto, J. W., Rouprêt, M., & Misrai, V. (2020). The Use of Nonsteroidal Anti-inflammatory Drugs in Urological Practice in the COVID-19 Era: Is “Safe Better than Sorry”?. European Urology.

Puntillo, F., Giglio, M., Brienza, N., Viswanath, O., Urits, I., Kaye, A. D., … & Varrassi, G. (2020). Impact of COVID-19 pandemic on chronic pain management: Looking for the best way to deliver care. Best Practice & Research Clinical Anaesthesiology.

Soin, A. & Manchikanti, L. (2020). The effect of COVID-19 on interventional pain management practices: A physician burnout survey. Pain Physician, 23, S271-S282.

Song, X. J., Xiong, D. L., Wang, Z. Y., Yang, D., Zhou, L., & Li, R. C. (2020). Pain management during the COVID-19 pandemic in China: Lessons learned. Pain Medicine, 21(7), 1319-1323.

Shanthanna, H., Strand, N. H., Provenzano, D. A., Lobo, C. A., Eldabe, S., Bhatia, A., … & Narouze, S. (2020). Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel. Anaesthesia.

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