Category Archives: President’s Notes

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

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. Pain161(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 Medicine382(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 Physician23, 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 Physician23, 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 Medicine21(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.

Thank You, John Satterthwaite!

Ann Quinlan-Colwell, PhD, APN

Developing this president column is no small task. It is written to pay tribute to our friend and mentor Dr. John Satterthwaite who recently stepped down from serving as the treasurer of the Southern Pain Society during the last 34 years.  John nurtured and guided SPS while significantly impacting many SPS members in ways that can never be repaid. As Dr. Mordi Potash said so well: “it is an absolute truism that there would not be a Southern Pain Society in existence in 2020 if not for John Satterthwaite.” This was echoed by Lori Postal who recently wrote John Satterthwaite has served the Southern Pain Society as a “trusted mentor, historian, voice of reason and steward of our finances.” Not only is John a man of many talents who has contributed greatly to the world of pain management but he has paradoxical qualities as well.  Although he is often a wise sage when on the stage, he is equally comfortable and meaningful being the guide on the side.  He is often a man of few words yet a great storyteller. John has always reminded Dr. Geralyn Datz of “a firm but fair patriarch, if you are under his wing, he is protective and compassionate.”  Several people make the analogy of John steering and guiding the SPS ship. Dr. Harry Gould appreciated John’s welcoming spirit and guidance for the “kids in the candy shop” (the SPS Board of Directors) “to get the most with what we had” (financially). John’s devotion and perspective on the history and the mission of SPS have been priceless.  As I recount these observations and impressions I am nodding my head in agreement. John is an expert physician, teacher, patriarch, sage, guide, shepherd, steward, mentor, storyteller,  navigator, voice of reason, friend and so much more.

Dr. Eric Pearson particularly loves John’s “wisdom and amazing dry sense of humor” which was reflected in preparing for this column.  After sending John some questions about his life, he sent me the “answers to the essay test.”  He was the son of a Station Manager for Capital Airlines born in Clarksburg, W.V. but moving frequently during his childhood and teens.  He had several early occupational goals including being “a trash collector because you could ride on the outside of the truck,” an Air Force pilot and “several other questionable thoughts.” His focus changed while working summers as an orderly and surgical tech in the OR in Georgia, where the anesthesiologists encouraged him to consider anesthesiology instead of surgery which as a fan of the TV show Ben Casey, he found interesting.  In fact, he initially “thought of going into Thoracic Surgery, but the residency was too long, and “ultimately chose anesthesiology because you work in a climate-controlled area and can wear pajamas all day (ha-ha)… It is immediate treatment response medicine and sleeping patients don’t complain.”

John noted that his  “involvement with pain was accidental.”  After practicing for 2-3 years, a neurosurgeon from Memphis, TN moved to the area and asked John to do epidural steroid injections.  As a result, other ortho and neuro doctors followed with similar request, and he became the first person in Greenville, S.C. to be “practicing pain.” Subsequently other surgeons asked if there were injections that could administered for “patients with an unusual pain with discoloration and extremity swelling.”  John’s interest was sparked in what was then RSD (reflex sympathetic dystrophy) which he began treating.  He was told by a local orthopedist that “we never had RSD in Greenville until you came to town.” 

John joined SPS in March of 1987 which qualified him as a Charter Member.  He clarifies: “at least that is what my certificate says.”  His intertest in RSD led him to  attend his first SPS meeting in 1989 because they had a day long program on “RSD” at the SPS regional section meeting, held in conjunction with APS.  Wearing his historian hat, John wrote: “attendance at the regional meetings tended to be greater than the APS meetings and we were subsequently uninvited to hold our meetings with APS.  The first independent SPS meeting was in 1991 in Chattanooga, TN.  I have been to each meeting since then except one.” 

“In 1989, the President of SPS Dan Hamaty, whom I knew because of his involvement with Pain Therapy Centers (PTC), asked me to become Treasurer which I accepted.”  Because of the involve tax and registration paperwork necessary to transfer the office, John continued to act in that capacity until 12/31/2019.  “If not for my current health issues, I would continue as I get to interact with some of the giants in the field and it is fun. I was asked to run for SPS President by Renee Rosomoff 1996, but declined because of this” (responsibility to the role of treasurer).

Because of his interest in pain, John developed a relationship with Dr. C. David Tollison who was a Clinical Psychologist specializing in pain.  Dr. Tollison set up a multidisciplinary pain treatment program in hospital system where John was located. This was the start of PTC of which John became Medical Director with Dave as Program Director.  “Due to the financial success of PTC, other hospitals in the region became interested.  We started a program in Charlotte with Dr. Hamaty as Medical Director, and at one time there were several programs in four states.  Unfortunately, with changing reimbursement, these programs ultimately died out.”

John noted that he has “been surrounded by some of the greats in the field of pain, but the person who has had the greatest influence was Dave Tollison.  We have practiced together for 30 years.  We have edited several books and spoken at many events.  One of my prized possessions is a copy of the 3rd edition of our “Practical Pain Management” which was translated into Chinese.  This was the third bestselling pain text behind Bonica and Raj.”  “Others especially Hu and Renee Rosomoff had a tremendous influence on my life in pain management as well.”

John felt fortunate to meet or work with Hu and Renee Rosomoff, Marty Grabois, Bert Ray, Stan Chapman, Peter Staats, Jeannie Koestler, Ben Johnson, Dan Doleys, Todd Sitzmann, and many other leaders and pioneers in the field of pain management during the last 30 years. He has many SPS related reminiscences.  His most “memorable SPS event was at a Board of Directors meeting in Charlotte in 1996.  President Renee Rosomoff was notorious for micromanaging and long meetings, but this one started at 11:00 am and was finally over at about 1:30 the next morning when someone (not one of us although I wish it had been) set off the fire alarm at the hotel.  Although we were still not finished, nobody went back to the meeting room following the “all clear”.  Even Renee’s husband Hu, who came to all Board meetings because of his love for the organization, had left much earlier.  (FYI, Hu Rosomoff was founding President of SPS, and subsequently served as APS President, AAPM President, and was a giant in the field of pain.  I was privileged to call him a friend.)”  Another favorite memory was that Hu and Renee “attended every Annual Meeting together.  They sat on the front row, in front of the speaker, so you knew they were listening.  After every speaker Hu would stand and provide commentary.  All of it useful, but sometimes critical.  I presented a talk on “Epidural and other steroid injections” at one of our meetings.  I knew Hu was a multidisciplinary treatment advocate.  Despite his being a neurosurgeon, he was very critical of procedures or medications for pain treatment.  His clinic in Miami was one of the leading multidisciplinary pain treatment facilities in the world.  When he stood up, I held my breath until he said my presentation was the most objective and comprehensive discussion on injections he had ever heard.  Quite a relief.”

A memory lane of pain management for John reflects significant change.  It also reflects the “honesty, genuineness, firm opinions rooted in his experience and desire for others to succeed” that Dr. Geralyn Datz described. He relays that today “it has become almost impossible to treat patients appropriately.  In the early years, we treated patients based on our understanding of the pain mechanisms and pathophysiology.  We experimented with injections, infusions, anticonvulsants, antidepressants, calcium channel blockers, anti-inflammatory, and other medications.  This laid the groundwork for much of what we use now or try to.  Now every pharmacist, insurer, lawyer, and government/insurance bean counter are practicing medicine and preventing, or impeding, treatment of patients.  Malpractice suits and regulatory agency threats are constant threats.  Cost effective has become the mantra instead of patient effective.  I agree with evidence-based medicine, but we had no evidence in the early years.  In fact, many of the studies now quoted began with a ‘what if we try this?’  That was our work.  It’s hard to formulate a treatment program with a bureaucrat or insurer standing in the way.  Yes, PT, complementary treatments, behavior modification are excellent alternatives to opioids, but no insurer will cover them.  Private practice is handcuffed by payors.”

When asked about the current opioid abuse/misuse crisis, John replied: “I think back to Russell Portenoy who basically asked, ‘what is the difference in pain from a vertebral fracture from metastatic cancer and from osteoporosis?’  Answer, there is none except the cancer patient will probably die sooner than the osteoporosis patient.  This was the beginning of the use of opioids for non-malignant pain.  Unfortunately, practitioners were unable or unwilling to appropriately screen and evaluate patients and prescribing went out of control.  It has become extremely difficult in this day of volume practice to appropriately evaluate who is a candidate for opioid use and who is not.  Evaluating who is and is not a candidate for chronic opioid use is not easy and is quite time consuming, and you must be able to say no.  Opioids are also being inappropriately prescribed for acute pain.  A postop hernia repair does not need 30 mg of  Oxycontin for pain management.  Back strain does not require initial treatment with opioids when other modalities have not been tried.  It is just quicker and easier to write a script than do a more complete evaluation and get other  treatments declined.  Finally, there are people who misuse or abuse opioids, and many practitioners do not take the time to weed them out.  Unfortunately, there is not a lab test for pain, and a history and physical have become relics of the past while lab studies, computers, and x-ray have taken over.”

If John could wave a magic wand to achieve a program/practice of perfect pain management, he would have two wishes.  “First, patients would be honest and not lie or manipulate, but this will never happen.  Second, there would be complete coverage for interdisciplinary treatment to include behavior modification, psychological evaluation, physical therapy, aquatic and other therapy, medications as indicated, injections as indicated, necessary evaluations and procedures, rehab and work hardening, and last but not least, any opioid prescriptions for longer than two weeks needs to be approved by a specialist. In fact, as many clinics do, no one should be placed on opioid therapy without a psychological evaluation from a qualified pain psychologist and undergo ongoing eval and treatment.”

In conclusion to reflect the wonderful Satterthwaite wisdom that Eric Pearson noted, John offered a few pearls and words of wisdom for pain management clinicians.  He stressed that “the key word is clinician.  Remember you are a professional.  If you are a one trick pony, one trick is all you have.  If the only thing you have is a hammer, you will be useless for anything but a nail.”  “Pain has been defined by the IASP as An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. The proposed new 2019 definition is: An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury.  In those definitions notice three factors: actual or potential tissue injury, sensory experience, emotional experience.  Each of these aspects needs to be addressed.  Injections, pills, or counselling only deal with one issue.  Pain is a complex issue so there is no simple answer or treatment.  So, stop trying to hammer that bolt through the steel plate with your hammer.”

President’s Message, July 2019

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.

Thrown Off the Pendulum

by Mordecai Potash, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

SPS President’s Newsletter Column – Summer 2017

Hyperbole Over Nuance

by Mordecai Potash, M.D.

One of the ways I like to unwind is to watch HBO on my cellphone or tablet. Whether it’s Real Time, Last Week Tonight, Westworld, or Game of Thrones, I am captivated by HBO’s shows!

One show, VICE – and its online companion, VICE News –  has recently featured several stories that have to do with opioids and pain management. The stories do a great job of capturing the multi-faceted aspects of this issue. They also show how strict and unyielding policy solutions to current controversies in opioid-based pain management can make misery out of the lives of countless people.

Several stories have focused on the state of Maine, since it has one of the highest rates of opioid overdose deaths in the country [1]. One story, enticingly titled “The Men Who Catch Your Lobsters Are Self-Medicating with Heroin”, explored the high rate of heroin and other opioid abuse in the lobster fishing industry along rural, costal Maine [2]. It features fishermen who work seasonably and spend almost all their disposable income on heroin, pain pills, and other drugs. The problem has gotten so bad, that these fishermen commonly encounter replacements on their boats because their previous shipmates overdosed and died. As one fisherman put it in a VICE-linked article:

“On Monday morning, I’ll go to work, it will be me and a guy named Jesse, and then the next morning it will be me and a guy named Mike. I’ll say, ‘Oh, where’s Jesse?’ and they’ll say, ‘Oh, he didn’t make it through the night.” [3]

Once a fisherman wants help for substance abuse, there are huge obstacles to obtaining it. Many live and work in a part of costal Maine that is about the size of Delaware but has a population of only 30,000 people – or about 1/25th the population of Delaware. There are no detox beds at all in the area, so a night in an ER or a couple of days in jail is the closest they get to actual medication-assisted detox services. The closest real medication-assisted program at least a 45-minute drive away – way too far away to accommodate the dawn-till-dusk hours of working fishermen.

VICE is hardly the first program to highlight Maine’s opioid addiction problem. There have been many state and national health reports about its steep rise in opioid overdoses as well as an outstanding ten-part report by the Portland Press-Herald [1].

In response, Maine has adopted some of the strictest opioid prescribing restrictions in the country [4]. One provision mandates that Maine prescribers are not allowed to prescribe more than 100 morphine milligram equivalents (MME) to their patients unless they attest that the patients qualifies under a palliative-care exception. Many Maine prescribers are fearful that, unless a patient is actually dying, they will be prosecuted if they prescribe more than 100 MME. They have told their patients that they are not prescribing more than 100 MME under any circumstances – if they haven’t already totally cut of all their patients from pain medications. Dr. Steven Hull, the Director of Pain Rehabilitation at Mercy Hospital in Portland, Maine, is afraid that many chronic pain patients that were well-managed on opioid-based pain medications will become depressed and suicidal by the cutbacks.

Another VICE story titled “Treated like addicts – The crackdown on opioids has left pain patients suffering with chronic pain and stigmatized” reports on patients whose pain was well-controlled on opioid-based pain medication but are now being cut off from this treatment with horrendous results [5].  It documents one patient whose pain from adhesive arachnoiditis was well-controlled with fentanyl transdermal and oxycodone until her doctor began to prescriber her less and less medication at each visit without explanation. When the patient finally brought it up, she was told that new regulations required the progressive decrease. She says now “My pain is out of control… I mean I can stay alive, but my quality of life has dramatically decreased”.

Like any good reporting, this story also features an opposing viewpoint. In this case, VICE interviews a prominent physician who believes that chronic pain patients are mistaking pain relief with opioid dependence. In other words, every patient that believes he or she has responded to opioid-based pain medications is simply psychologically dependent on them.

The reporter documents that many patients see that doctor’s view as “fueling an anti-opioid hysteria that favors hyperbole over nuance and glosses over the complexities of treating many painful conditions” (my emphasis added). Another patient, who is also a retired physician, adds, “They’re confusing legitimate pain management with addiction. Those are completely separate venues.”

After a year and some changes since the CDC Opioid Guideline was released, we have certainly seen a lot of ‘hyperbole over nuance’ in the rush to stem the tide of opioid overdose deaths. In previous columns, I expressed at least a little bit of hope that these changes would still allow for the practice of opioid-prescribing to well-assessed and well-supervised chronic pain patients who simply do not respond to non-opioid medications. Now, I am not so sure.

This past year, I have informally spoken with many pain management colleagues who are seriously contemplating not prescribing opioid-based pain medications any longer. Some are contemplating leaving pain medicine all together forever and go back to practicing neurology, anesthesiology, or another specialty full-time. To be clear, I am not talking about a practitioner whose training consists of attending a pain conference once or twice. These are fellowship-trained, board-certified pain management specialists who have spent thousands of hours building up their pain management practice. And now, they are giving serious thought to closing down their pain practice for good – or at least dramatically changing it.

I can’t blame my colleagues. Those of us that continue to offer opioid-based pain management services find ourselves being attacked on all fronts.

On the insurance side, several health insurers are requiring oodles of prescriber documentation in order to approve the coverage of any extended release opioid pain medication – even ones on the insurance formulary. I have filled out a couple of these documents recently for my own patients. On each patient, I had to compile a dossier of urine drug screens, opioid agreements, treatment plans, substance use assessments, and other clinical documentation  – requiring about an hour per patient.

On the legal side, pain management specialists are terrified of being investigated or arrested if they continue to prescribe any amount of opioid-based pain medication. And that fear is not without foundation! There have been many investigations and arrests of opioid prescribing physicians, including several in the South [6]. Federal agencies also don’t shy away from declaring that this is just the start of their crackdown. In fact, the FBI very recently sent out a press release titled “Health Care Fraud Takedown – Nationwide Sweep Targets Enablers of Opioid Epidemic” [7].

Given all the heat that’s on us right now, it is no wonder my colleagues are thinking of giving it all up. The professional satisfaction a pain specialist gets when serious pain is made more manageable by opiates does not compare with the panicked dread of worrying about being arrested for providing that humane care.

I certainly hope that this column has not convinced even more of my colleagues to throw in the towel and to just offer trigger points and ESI’s as their sole contributions to pain management. Rather, I hope that it has reaffirmed to those that have been having these contemplations that they are not alone in these thoughts or fears!

Indeed, I think we have done a really good job of organizing our upcoming Southern Pain Society Conference to discuss these topics robustly.

On Friday, we will hear a talk on opioids and abuse deterrent formulations from Dr. Feng Zhang. Dr. Zhang and his team at the University of Texas have been responsible for developing the abuse deterrent formulations used in Oxycontin and Opana and have several new abuse-deterrent formulations in the pipeline as well. Dr. Zhang will undoubtedly explore what role will these abuse deterrent formulations have in stemming the tide of pain medicine overdose incidents.

On Saturday, we will be hearing from Duke University’s Dr. William Maixner. Dr. Maixner is the Director of Duke’s highly prestigious Center for Translational Pain Medicine. He will talk about translational medicine for chronic pain and how that multi-disciplinary, highly collaborative approach is speeding up the development of new treatments for complicated chronic pain patients.

Later on Saturday, we will be hearing from Dr. Hans Hansen – a “fan favorite” from last year’s conference! Dr. Hansen will reflect on the tectonic shifts that have changed the landscape of pain medicine since the CDC Guidelines were released year.

Then on Sunday, we will hear from my friend and colleague, Dr. Arwen Podesta. Dr. Podesta is an expert in holistic medicine, addictionology, and forensic psychiatry and will use these expertise areas to present the latest in the assessment and management of addiction issues in chronic pain.

So, you can see that we – along with our Southern Headache Society colleagues – have put together a program worthy of the multi-faceted challenges we face.

See you in New Orleans!

–Mordi

REFERENCES:

[1] Eric Russell. A deadly epidemic: Addiction to opioids has put an entire generation at risk. Portland Press Herald. http://www.pressherald.com/2017/03/26/lost-heroins-killer-grip-on-maines-people/  Published 03/26/2017

[2] See URL   https://tonic.vice.com/en_us/article/ev43gk/the-men-who-catch-your-lobsters-are-self-medicating-with-heroin

[3] See URL   http://www.pressherald.com/2017/04/02/lobstermen-under-siege-heroin-epidemic-feeds-on-an-iconic-way-of-life/

[4] Marina Villeneuve. Chronic Pain Patients Say Opioid Law Creates New Crisis. The Associated Press. Published on 04/22/2017 and accessed at URL   https://www.usnews.com/news/best-states/maine/articles/2017-04-22/chronic-pain-patients-say-opioid-law-creates-new-crisis

[5] See URL   https://news.vice.com/story/opioids-chronic-pain

[6] See the following URLs for recent local opioid prescriber arrests:
http://www.heralddemocrat.com/news/20170711/fbi-arrests-sherman-doctor
http://www.theadvocate.com/baton_rouge/news/article_d6c70fe8-67f5-11e7-b922-db0d97ccab9c.html
http://www.fox9.com/news/267649616-story

[7] See URL https://www.fbi.gov/news/stories/nationwide-sweep-targets-enablers-of-opioid-epidemic

President’s Message January 2017 – Mordecai Potash, MD

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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