Category Archives: President’s Notes

The Bipolar Spectrum In Pain Patients: Recognition and Management

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

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  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington D.C: American Psychiatric Press; 2013.
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  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
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  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.
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  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

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

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”

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”

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

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”

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

 

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