April 2012

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

Pain Management The Neurological Foundations of Pain

Yoga for Chronic Pain Cannabinoids and Pain How Prevalent Is Pain In The United States?

5 Pain policies for relief without abuse VOL. 85 NO. 3 April 2012

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IN THIS ISSUE

SAN FRANCISCO MEDICINE April 2012 Volume 85, Number 3

Pain Management FEATURE ARTICLES

MONTHLY COLUMNS

12 An Unpleasant Experience: Psychiatric Perspectives on Pain Eve R. Maremount, MD

4 Membership Matters

15 Pain in the Brain: The Neurological Foundations of Pain Judy Silverman, MD

18 Yoga for Chronic Pain: Understanding the Yogic Tools Used to Aid Chronic Pain Timothy McCall, MD 20 Cannabinoids and Pain: The Medical Application Explained Donald I. Abrams, MD 22 The High-Flying Dilemma: Chronic Pain and Addiction Murtuza Ghadiali, MD, and David Pating, MD

25 “Red Flags” in the ED: Pain Treatment versus the Painful Epidemic of Addiction Keith Loring, MD, and Steve Heilig, MPH

26 Pain in the United States: A Review of Our Country’s Experience with Pain Sean Mackey, MD, PhD 28 Wings to Fly: When Opiates Fail and Volkswagons Sail Dawn Gross, MD, PhD

30 Pain Policy: Five Public Policies That Will Lead to Pain Relief without Prescription Overdoses Celia Vimont

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

7 SFMS Advocacy Activities 9 President’s Message Peter J. Curran, MD

11 Editorial Gordon Fung, MD, PhD 32 Hospital News 33 Classified Ad 34 In Memoriam

OF INTEREST 31

Health Policy Perspective Contraception: Just What the Doctors Ordered Steve Heilig, MPH

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members Medicare Announces Extension of HIPAA 5010Â Enforcement The Centers for Medicare & Medicaid Services (CMS) announced that they would again extend the enforcement discretionary period, allowing practices an additional ninety days to become fully compliant with the use of HIPAA 5010 transaction standards. What this means for physicians is that while the implementation date of January 1, 2012, is still in effect, contractors will not reject claims submitted in the 4010 electronic formats until July 1, 2012.

Update Your Practice Information for the New SFMS Online & Print Pictorial Directory SFMS is excited to launch a new online, pictorial member directory in June, to coincide with the production of our print directory. Physician members will have the opportunity to promote their practices on customizable individual pages and connect with a larger patient base through our Physician Finder tool.

SFMS has sent out e-mail and mail notifications to all physician members currently engaged in the practice of medicine to update contact information for the directory. If you did not have your picture in the 2011 directory, or if your information is outdated, we encourage you to update your directory entry by contacting SFMS at lestrada@sfms.org or (415) 561-0850 extension 200.

Promote Your Practice with the SFMS Directory

Physician Networking Event a Huge Success!

More than forty San Francisco residents and physicians participated in the SFMS Spring Networking Mixer at 83 Proof on March 8. Attendees were able to meet local physicians to expand their professional networks and share experiences.

After the great attendance and positive feedback from all, SFMS is planning to organize similar social networking events in the coming months. Please check the SFMS blog or follow SFMS on Twitter (@SFMedSociety) for event details. SFMS would like to thank MIEC for its support of the Spring Networking Mixer.

Stephanie Oltmann, Pedro Aceves-Casillas, Shannon Udovic-Constant.

If you would like to reach 1,000 health care professionals in San Francisco, please consider placing an ad in the 2012 SFMS Member Directory. Members are eligible for an exclusive discount on quarter-page vertical ad placements. Advertising rates start at $395. To obtain the ad rate and contract agreement, contact Lauren Estrada at lestrada@sfms.org or (415) 561-0850 extension 200.

Become a Champion of Medicine, Participate in the 4/17 Legislative Leadership Conference

Join SFMS for the CMA Legislative Leadership Conference on April 17 at Sacramento Convention Center. Members have the unique opportunity to gain advocacy training and network with colleagues throughout California at this annual event.

The morning includes speeches from a number of key legislative leaders, including Governor Jerry Brown and Attorney General Kamala Harris. Attendees will go to the Capitol in the afternoon to meet with legislators on health care issues.

This event is offered at no cost to SFMS members.

Please email SFMS at info@sfms.org or call (415) 5610850 if you would like to attend this event.

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San Francisco Medicine April 2012

Anna Singleton, Meg Faughnan, Arti Desai

Man-Kit Leung, Gary Arsham, Terri Pickering www.sfms.org

Join SFMS in Support of AB 1746 A new report released by the Centers for Disease Control and Prevention’s National Center for Health Statistics found that about 16 percent of U.S. children’s daily calories come from sugar.

By sugar, the report means sugars in processed foods like soda, cakes, and ice cream. It also includes sweet substitutes like corn syrup, high fructose corn syrup, malt syrup, fructose sweetener, honey, molasses, anhydrous dextrose, crystal dextrose, and dextrin.

Please join SFMS and CMA to support AB 1746, which would ban the sale of sugary sports drinks on middle and high school campuses throughout California. We believe this bill will help fight childhood obesity and diabetes.

Bill to Provide Parents Immunization Information to Prevent Outbreaks

Aimed at reducing infectious disease outbreaks, Dr. Richard Pan (DSacramento) introduced AB 2109 to provide parents with health information that they can use to help keep their children and other members of the community safe and prevent epidemics like the 2010 pertussis outbreak that caused more than 9,000 infections, 800 hospitalizations, and ten deaths in California.

The number of unvaccinated children has grown over the last decade, partly because some parents fear there is a link between the shots and autism, a theory that has been repeatedly disproven in scientific literature. California is also one of twenty states that allows parents to sign a form that excludes their children from having to receive immunizations.

AB 2109 would simply ensure that parents receive accurate information about immunizations from a licensed health care practitioner before they decide if they will sign the form.

AB 2109 is sponsored by the California Medical Association (CMA), the American Academy of Pediatrics, and the California Immunization Coalition.

Assistance with EHR Adoption

Are you a primary care provider looking for assistance with Meaningful Use and EHR? SFMS is partnering with Lumetra, a local extension center for San Francisco, to fill available slots for priority primary care providers (PPCPs) to receive subsidized services from CalHIPSO. Please contact Jeff Gutman at jgutman@lumetrasolutions.com or (415) 6778447 to enroll reserve providers.

April 2012 Volume 85, Number 3 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD Sashi Amara, MD SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Lauren Estrada

BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Arti D. Desai, MD Roger S. Eng, MD Jennifer Gunter, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

Complimentary Webinars for SFMS Members

Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon UdovicConstant, MD Joseph Woo, MD

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

April 18: Best Practices for Managing Your Accounts Receivable • 12:15 pm to 1:15 pm April 23: California’s Public Health Insurance Programs • 12:15 pm to 1:15 pm April 25: 2012 Legislative Update • 12:15 pm to 1:15 pm May 2: Medicare Audits: How and Why • 12:15 pm to 1:45 pm

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD

In the last issue of San Francisco Medicine we published an obituary for Herman Noah Utley, MD. We have since learned that the correct spelling of the doctor’s last name was Uhley. We extend our sympathies to the family of Dr. Uhley along with an apology for the misprint.

CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

Correction: Herman Noah Uhley, MD

www.sfms.org

April 2012 San Francisco Medicine

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San Francisco Medicine April 2012

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SFMS Advocacy Activities A PROFESSIONAL VOICE FOR COMMUNITY HEALTH SINCE 1868 The San Francisco Medical Society (SFMS) has been involved in community health issues since the 1800s. As the only medical association in San Francisco representing the full range of medical specialties and interests, SFMS health advocacy has been broad. Via policy-making efforts with state and national medical and political leaders and an award-winning journal, SFMS has often been influential far beyond the city. The SFMS agenda and activities continue to focus on the community and the following areas of involvement: • Forming HealthShare Bay Area (see below) to improve patient care and reduce costs • Working with the physician community to promote the adoption of electronic health records to better serve patients • Advocating against cuts to Medi-Cal and Medicare reimbursement to provide continued access to care for all San Franciscans • Preserving the health care safety net and public health programs in times of severe budget cuts • Supporting antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies and smoking in restaurants and other businesses, and eliminating tax credits for films showing smoking • Supporting the Healthy San Francisco program and participating in legal defenses to preserve the program, while helping to monitor the program’s progress • Providing physicians for medical consultation for San Francisco schools and for volunteer care at community clinics • Working on legislation to allow minors, without parental consent, to receive vaccines to prevent STIs; to prevent bans on medical procedures such as circumcision; and more • Cosponsorship of the Hep B Free program in San Francisco • Advocacy for improving end-of-life care in the Bay Area via new policies, use of new advance directives (such as POLST), and educational outreach to physicians and patients

HOW SFMS SERVES THE COMMUNITY

HEALTHSHARE BAY AREA Working under the auspices of

the SFMS Community Service Foundation and guided by a diverse board of San Francisco and Bay Area health care industry professionals, the SFMS worked to develop HealthShare Bay Area to provide the infrastructure for a unified electronic health record system.

The project originally targeted San Francisco but now includes partners from the East Bay. This service allows providers to have access to secure community-wide patient data. It also permits patients to gain a complete view of their medical records, irrespective of where individual records may reside. HSBA will launch in 2012.

UNIVERSAL ACCESS TO CARE SFMS leaders have long advocated that every San Franciscan should have access to quality medical care. Recent SFMS participation in this effort has included the Mayor’s Health Care Reform Task Force, the San Francisco Health Care Services Master Plan Task Force, and the Mayoral Task Force, which designed the Healthy San Francisco program. SFMS also joined in the lawsuits to preserve that program. SFMS advocates www.sfms.org

have advocated for community clinics since the founding of the original Haight-Ashbury Free Clinics in the 1960s.

MEDICAL LIABILITY PROTECTION The CMA and SFMS were

instrumental in passing MICRA, which saves virtually every doctor many thousands of dollars in liability premiums annually and saves hospitals and health systems much more. We have successfully defeated repeated attacks on MICRA by trial lawyers through the years.

REBUILDING/PRESERVING SAN FRANCISCO GENERAL HOSPITAL SFMS spokespersons took a lead in advocating for full

funding of the seismic rebuild and in advising, as members of the Mayoral committee, where and how that would occur.

HIV PREVENTION AND TREATMENT The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, adequate funding, and more.

SCHOOL AND TEEN HEALTH SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service.

ENVIRONMENTAL HEALTH SFMS established a nationwide educational network on scientific approaches to environmental factors in human health; has advocated on reducing mercury, lead, and air pollution exposures; and much more.

REPRODUCTIVE HEALTH AND RIGHTS SFMS has been a state and national advocate for reproductive health and choice.

BLOOD SUPPLY SFMS has long been a partner of the Blood Centers of the Pacific and seeks to help increase donations.

ORGAN DONATION SFMS has been a leader in seeking improved

donation of organs to decrease waiting lists, via education and new polices regarding consent and incentives for organ donation.

OPERATION ACCESS SFMS is a founding sponsor of this local organization providing free surgical services to the uninsured and has provided office space, volunteers, and funds.

DRUG POLICY SFMS has been a leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration.

MEDICAL ETHICS SFMS has developed and promulgated for-

ward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policy makers, and the general public.

April 2012 San Francisco Medicine

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PRESIDENT’S MESSAGE Peter J. Curran, MD

California Death Penalty: Moral or Ethical Issue for Physicians?

California has executed thirteen death row inmates since 1992, following voter approval of the 1978 Senator Briggs ballot initiative to expand the scope of capital punishment in California, after the California Supreme Court had ruled the death penalty unconstitutional in 1972. Twice that number of inmates have died of suicide or homicide while awaiting capital punishment in prison.

Texas is a different story; seventeen criminals were executed in 2010 alone. Since 2006, there has been a moratorium on the death penalty in California, given concerns regarding the lethal injection protocol. Ballot-initiative-weary voters will likely have an opportunity to kill the death penalty in November with the SAFE California initiative, which takes a practical approach to repealing the death penalty and replacing it with life imprisonment without parole. The proponents of the measure estimate that it costs $184 million yearly to house and process the appeals of 725 death row inmates, with an appeal process that takes approximately twenty-five years to complete.

Physicians have long been involved with the business of capital punishment. Dr. Joseph-Ignace Guillotin, a French physician in the eighteenth century, was erroneously credited with inventing the device that bears his name when he said, “Now, with my machine, I cut off your head in the twinkling of an eye, and you never feel it!” Over half of the thirty-seven states that still have the death penalty on the books require physician participation in some way: authorizing the drugs for legal injection, supervising the execution, or confirming the death of the condemned. In California, physicians have been present in eleven of the executions by lethal injection. Governor Ernie Fletcher of Kentucky signed a death warrant for an inmate as a licensed physician. There has been a growing movement against physician participation in executions, although supporters claim that the expertise of physicians is necessary to avoid cases of botched execution by lethal injection (inadequate sedation with the three-drug cocktail presently used may lead to a sensation of suffocation due to the second drug, a paralytic, or excruciating pain from the third drug, potassium chloride). Physicians have also been called to perform intravenous cut-downs or central line insertions in cases where peripheral access is difficult.

Since 1980, the American Medical Association has maintained a firm ethical stand against physician participation in capital punishment. Under its code of ethics, “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.” Specifically, physicians are prohibited from administering or supervising the use of drugs in lethal injection, witnessing an execution as a physician, accessing an www.sfms.org

intravenous site on the prisoner, or serving in a consulting role with devices or personnel used in executions. However, states are not bound to follow these guidelines, nor are they enforceable in death-penalty states. Some specialty societies, such as anesthesia, have terminated board certification status for physicians participating in executions. The Medical Association of New Jersey approved a resolution asking the AMA to advocate for the abolition of the death penalty by all jurisdictions in the United States, based on the argument that the current judicial process of determining capital punishment is flawed in a number of ways, including the use of false testimony from medical professionals. The current position of the California Medical Association mirrors the opinion of the AMA: opposing physician participation in executions without taking a moral position for or against the death penalty. Although challenged to do so by the courts, the state medical boards have not sanctioned physicians for being execution participants.

The future of the death penalty in California is unclear.

Since the Briggs bill passed in 1978, Californians have twice voted on the ballot and failed to repeal the death penalty. As recently as 2004, nearly two-thirds of the voters were in favor of the ultimate sentence in this state. It’s a billion-dollar industry with special interests lobbying on both sides of the argument. An estimated $4 billion has been spent over the past thirty years to execute thirteen prisoners in California, and another projected $1 billion will be spent over the next five years regardless of whether another inmate is executed after the moratorium is lifted. Win or lose in November, the SAFE California ballot initiative gives physicians in California an opportunity to consider where each of us stands individually on the death penalty: moral, ethical, or practical?

Dr. Curran is a cardiologist at Bareall & Associates and is director of Cardiovascular Rehabilitation at St. Mary’s Medical Center.

April 2012 San Francisco Medicine

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EDITORIAL Gordon Fung, MD, PhD

What Is Pain?

I remember clearly that during my third year in medical school, my attending instructed us that pain is a symptom. It is not a sign or a finding, and it is not a disease.

Our job as clinicians is to elicit symptoms and signs to diagnose the disease, and then to treat the disease that causes the pain. We need to learn as much as we can about all the different diseases and how they present, with all their protean manifestations and descriptions of pain, and then treat the problem to eliminate the symptoms of pain or weakness or fever.

As a symptom, pain can be described by the patient. However, there are no blood tests or X-rays or even ECG’s that can correlate with the amount of pain that someone experiences.

Like all symptoms, the perception of pain is as varied as are patients. For many types of pain, there is the typical presentation associated with a disease process. Let’s take a heart attack as an example. In this case, a deep pain in the chest beneath the breastbone is typical. It can be associated with radiation to the left axilla and down the left arm or up to the jaw, usually with a sense of weakness or even impending doom, and occasionally with a cold sweat or shortness of breath. It usually occurs in the early morning between 5:00 a.m. and 10 a.m., awakening the patient from sleep. Clinicians and patients have been taught that when they hear or feel this kind of pain, the patient should call EMS and be immediately triaged to the nearest STEMI center (a trauma center that has the capabilities to deal with a heart attack).

But over the past several years, we’ve learned that not all patients who have heart attacks present this way. Many women will not have the chest pain in the same place and may instead complain of an intense nausea with vomiting. Some people, especially diabetics or patients with sickle cell anemia, may not have any pain but are nonetheless having a heart attack. So focusing on the description of pain may not help diagnose the problem at all.

And in fact, we’re talking here only about acute pain. Yet for the most part, acute pain is not the issue when it comes to pain management.

The pain that requires a pain specialist or a team approach is chronic pain that can occur when the disease is incurable or protracted, such as metastatic cancer, neurologic diseases, muscle disorders, or even chronic headaches. Sometimes we know the cause, but the specific disease—postherpetic neurologic neuralgia, for example—lingers and causes untold misery. These types of pain have driven people to severe depression or even suicide. The tragedy is that the disease process may not be terminal, so the prospect of ever being pain free www.sfms.org

and returning to a productive life seems bleak, because there is no permanent cure for the cause of the pain. For those who have a terminal disease, it is suffering they must endure for the remaining time they have.

Recognizing these problems, the California legislature passed AB 487 in October 2001. It requires a one-time span of twelve hours of CME on pain management or care of the terminally ill, for all clinicians who deal with patients (exempting radiologists and pathologists), in order to renew their licenses. I learned a lot during my course and continue to use some of that knowledge with patients today. But I think the one takeaway that I got from the class was that there are now experts in the field who can help patients who are suffering from chronic pain. That is the origin of this month’s theme. I hope you enjoy some of these updates and recognize that pain and pain management affect everyone’s practice, as long as we’re dealing with patients.

Dr. Fung is a cardiologist and past-president of the SFMS, a clinical professor of medicine at UCSF, and is medical director of the Electrocardiography Lab at Moffit/Long Hospitals and of the UCSF Asian Heart and Vascular Center at UCSF, Mount Zion.

April 2012 San Francisco Medicine

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Pain Management

An Unpleasant Experience Psychiatric Perspectives on Pain Eve R. Maremont, MD

In the opening of her recent book, The Pain Chronicles, writer Melanie Thernstrom compares the current experience of chronic pain patients with the plight of individuals diagnosed with “consumption” on the eve of scientists discovering the true cause of their illness: “Surely the consumptives would

have felt relief, mixed with wonder, to finally know what their disease was—and what it was not. It was not a curse. It was not an expression of personality or a punishment. For better or worse, it was and is a disease.”

While there is increasing evidence for a neurobiological basis for chronic pain, the actual experience of patients dealing with it is still highly complicated by social stigma. As with conditions such as fibromyalgia, chronic fatigue syndrome, and “functional” bowel disorders, there are still more questions than answers about the true etiologies of these conditions. Inevitably, patients and their doctors are left grappling with uncertainty and frustration.

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All Pain Is Not Created Equal Pain complaints can be divided into two categories. Acute pain is usually associated with an identifiable tissue injury and typically resolves in conjunction with the healing of the injury.

Treatment interventions are targeted at pain reduction and limiting duration of injury. Acute pain may serve as a trigger for anxiety, PTSD, or even depression and consequently trigger a request for psychiatric consultation, particularly in the inpatient medical setting. In the absence of a major trauma (for example, acute pain associated with an assault), acute pain states are, by definition, time-limited.

Chronic pain, on the other hand, is a common complaint for patients across medical specialties. While commonly triggered by an injury or disease state, chronic pain persists beyond these initial conditions. The intensity of the pain may be out of proportion to the original injury or may arise in the absence of identifiable pathology. This latter scenario often leads to deep frustration on the parts of both patient and providers. www.sfms.org

Patients feel they are directly or indirectly being told that “it’s all in [your] head,” and providers feel helpless in the face of ineffective treatments and unclear diagnoses.

Pain Theories

The International Association for the Study of Pain (1994) defines pain as follows: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Leading theories of pain include the traditional or biomedical model (aka specificity theory), the pattern theory (aka intensity theory), the gate control theory, and the biopsychosocial theory.

Originally developed by Descartes in the seventeenth century, the traditional or biomedical model theorized pain as associated with a specific disease state or tissue injury, proportional to the extent of that disease or injury. In 1895, Von Frey postulated that a unique system of nerves was responsible for relaying information from peripheral pain receptors to a central pain center. It is easy to recognize the limitations of this model for explaining today’s chronic pain states.

Von Frey, along with Goldstein, went on to develop pattern theory, an expansion and revision of the traditional or biomedical model. In this view, there are no separate systems for pain.

Nerves carrying pain sensations are shared with other basic senses, such as smell and touch. Pain is still viewed as proportional to the amount of tissue injury.

In 1965, authors Melzack and Wall published their work on the gate control theory, which defined pain as a multidimensional experience. They believed that there are three systems involved in the creation of pain sensation: sensory-discriminative, motivational-affective, and cognitive-evaluative.

The subjective experience of pain is the result of an ongoing interplay among these three systems. Moreover, the CNS is a major player in pain processes and perceptions serving to filter, select, and modulate inputs.

An increasingly well-respected theory over the past twenty years has been the biopsychosocial model. In this view, there exists a complex interaction between biological, psychological, and social variables, with each variable affecting the others.

Moreover, in chronic pain states these interactions are ongoing. One can see that this model helps account for the diversity of pain and illness experiences that we see in clinical practice.

Psychiatric Comorbidity

It will not come as any surprise to practicing clinicians that psychiatric comorbidity is high in chronic pain states. This tends to be a bidirectional process, with pain worsening the symptoms of psychiatric illness and vice versa. Psychiatric illness may also complicate treatment via its impact on medication compliance, follow-through with diagnostic workups and rehab recommendations, and the physician-patient alliance.

The most common psychiatric illnesses in patients with chronic pain are depression and anxiety. Others include adjustment disorders, substance abuse/dependence, personality disorders, and somatoform disorders. The lifetime rate of depression in chronic pain patients is 54 to 65 percent, versus 17 percent in the general population. There is an even higher rate of depression in patients with multiple pain symptoms. Furwww.sfms.org

thermore, the level of subjective pain increases in proportion to the severity of a patient’s depression. While the evidence suggests that depression develops most often as a consequence of chronic pain, there are certainly cases where the cause-effect relationship seems to be reversed. It is not hard to fathom how chronic pain could lead to depression. The aversive nature of pain, the resulting physical impairment and disability, and the perception of invalidation by the medical profession are all likely suspects. Secondary losses in one’s professional or personal life may further contribute to depression.

Considering the biological sphere of the biopsychosocial model, it is increasingly felt that depression and pain may share a common physiological pathway. Evidence points to a descending system of pain modulation in the CNS, characterized by involvement of the periaqueductal gray and its connections to the limbic forebrain, midbrain, and brainstem; a relay system containing 5HT and NE neurons; and ability to modify/dampen pain inputs from the periphery. Depression and chronic pain are now thought to reflect 5HT and NE-depleted states—a view that turns out to have particular relevance when considering treatment approaches.

Anxiety disorders can also complicate a chronic pain disorder and frequently coexist with depression. While anxiety can be a common reaction to acute pain, it can become wholly disabling in chronic pain states. Consequences can include avoidance of potentially helpful diagnostic procedures or treatments, operant conditioning that leads to further avoidance, and cognitive effects such as decreased sense of self-efficacy and increased expectation of pain.

Perhaps most challenging for the clinician is the patient with coexisting chronic pain and substance use disorders. The lifetime prevalence of these is 23 to 41 percent in patients with chronic pain versus 17 percent in the general population. Often there is a prior history of substance abuse/dependence that the patient may or may not reveal to the clinician. Of note, comorbid psychiatric disorders are more common in these patients, possibly representing the patient’s attempt to “self-medicate.”

It is important to keep in mind the differences between physiological and psychological dependence—i.e., substance abuse/ dependence is not an inevitable consequence of chronic pain.

Signs of abuse, however, are useful for the clinician to recognize. They include premature requests to refill medication, lost or stolen medication, prescriptions from multiple providers, frequent ED or urgent care visits for medications, personality or behavioral changes (most often noted by family, loved ones), other signs of nonadherence (missed appointments, reluctance to consent to contact with prior providers).

Approaches to the Patient in Pain

While there is still much that we don’t know about chronic pain, it is increasingly understood to be a multidimensionally determined entity. With this in mind, the physician should include all of the following in his/her initial assessment of a patient: past medical history, medication history, history of past injuries (including surgeries), past psychiatric history (including history of trauma), social history, substance abuse history.

What are the patient’s fears or beliefs about their pain? Did

Continued on the following page . . .

April 2012 San Francisco Medicine

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An Unpleasant Experience Continued from the previous page . . . they perhaps witness a relative or close friend experience or even die in pain? What meanings do they attribute to their current symptoms? Are there conditioned cues or cognitions that could be helping to perpetuate the patient’s symptoms (for example, the patient understands his knee pain to worsen in cold weather, so at the first indication of falling temperatures he experiences heightened pain or anticipatory anxiety)? Are there cultural influences that either positively or negatively impact the patient’s experiences?

Pain management is most effective when the patient is actively engaged and motivated. Approaches may involve either or both nonpharmacological and pharmacological strategies.

Additionally helpful interventions include written contracts with firm limits and consequences that are enforced (i.e., no early refills), consistency, communication with PMD, involvement of significant others, physical therapy/exercise program, complementary and alternative medicine (CAM).

Leading nonpharmacological therapies for chronic pain include cognitive behavioral therapy (CBT), biofeedback, and hypnosis. CBT is based on the cognitive-behavioral model of chronic pain in which conditioned responses to pain are based on learned expectations (cognitions). The resulting behaviors then elicit certain negative responses from the environment that in turn reinforce the expectations. In this model, the patient’s perspective is thought to determine the pain experience via idiosyncratic beliefs/negative appraisals, emotional factors, social and cultural influences, and sensory phenomena.

The therapist aims to help the patient identify, evaluate, and revise maladaptive beliefs about themselves and their situations.

Patients are taught to recognize the connections between and consequences of their cognitions, emotions, and behavior.

Pharmacological treatments have typically included tricyclic antidepressants (e.g., amitriptyline, nortriptyline), SSRI’s, SNRI’s or “dual action” agents (venlafaxine, duloxetine), and antiepileptic medications (gabapentin). For antidepressants, the primary mode of action is thought to be via the descending pain pathways described above. Increasingly, the evidence has favored use of tricyclics and SNRI’s over SSRI’s for pain treatment. When using antidepressants, however, it is important for clinicians to be mindful of drug-drug interactions, including p450 inhibition and the risk of serotonin syndrome.

When to Refer the Chronic Pain Patient to a Psychiatrist?

While many patients can be successfully managed by a PMD or pain specialist alone, the following are potential red flags that may suggest that the involvement of a psychiatrist would be helpful: history or ongoing evidence of psychiatric disorder; signs of significant psychosocial stress and/or poor coping; behavior that is negatively impacting treatment—e.g., medication adherence, follow-up, etc.; standard approaches for pain management proving ineffective. Given that these patients may already be sensitized to feeling rejected, it is important to normalize the patient’s situation and reassure him or her that you believe his or her experience of the pain is real. Furthermore, it may be helpful to explain how the multidisciplinary approach—with its goal of treating the “whole” person—ne14 15

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cessitates a comprehensive treatment plan that includes input from a mental health professional. Above all, the patient should be clear that you are not abandoning him or her but are simply hoping not to leave “any stone unturned” in their care.

Eve R. Maremont, MD, is assistant clinical professor of psychiatry at UCSF’s Langley-Porter Psychiatric Institute. She divides her time between teaching on the UCSF Psychiatric Consultation-Liaison Service, seeing patients at the UCSF Helen Diller Comprehensive Cancer Center’s Psycho-Oncology Program, and treating outpatients in her faculty practice. Prior to her move to San Francisco in 2010, Dr. Maremont served on the UCLA faculty, combining teaching on the Consultation Service and becoming the first psychiatrist-in-residence at the UCLA SimmsMann Center for Integrative Oncology, a clinical and teaching site for psycho-oncology. A native of San Francisco, she is a graduate of Harvard’s Combined Adult Psychiatry Residency Program at Massachusetts General and McLean Hospitals. Prior to her medical training, she worked as a screenwriter and executive in the film industry. Dr. Maremont would like to thank J. Jewel Shim, MD, who originated the presentation “Psychiatric Aspects of Pain,” on which this article is based.

References Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity. Arch Intern Med. 2003; 163:2433-2445.

Cheville A, Caraceni A, Portenoy RK. Pain: Definition and assessment. Pain: What Psychiatrists Need to Know. Massie MJ, ed. Washington DC: American Psychiatric Press, Inc. 2000.

Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington DC: American Psychiatric Press, Inc. 2000.

Gatchel RJ, Dersh J. Psychological disorders and chronic pain: Are there cause-and-effect relationships? Psychological Approaches to Pain Management, second edition. Turk DC, Gatchel RJ, eds. New York: The Guilford Press. 2002.

Gureje O. Psychiatric aspects of pain. Curr Opin Psychiatry.

2007; 20:42-6.

Mattia C, Paoletti F, Coluzzi F, Boanelli A. New antidepressants in the treatment of neuropathic pain. Minevra Anestesiol.

2002; 68:105-14.

McWilliams LA, Goodwin RF, Cox BJ. Depression and anxiety associated with three pain conditions: Results from a nationally representative sample. Pain. 2004; 11:77-83.

Metzack R. Pain: An overview. Acta Anesthesiol Scand.

1999; 43:880-4.

Thernstrom, M. The Pain Chronicles: Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing and the Science of Suffering. New York: Farrar, Straus and Giroux. 2010.

Turk DC. A cognitive-behavioral perspective on treatment of chronic pain patients. Psychological Approaches to Pain Management, Second Edition. Turk DC, Gatchel RJ, eds. New York: The Guilford Press. 2002.

Turk DC, Monarch ES. Biopsychosocial perspective on chronic pain. Psychological Approaches to Pain Management, Second Edition. Turk DC, Gatchel RJ, eds. New York: The Guilford Press. 2002. www.sfms.org

Pain Management

Pain in the Brain The Neurological Foundations of Pain Judy Silverman, MD

In a perfect world, the physician would treat acute pain, and chronic pain would never have the chance to settle in. In reality, this is not the case all of the time. ***** Every time he left my office, I felt as though I were missing something. My patient, with acute pain from an automobile accident, was becoming a chronic pain patient in front of my eyes. He was only twenty years old. A month before his first visit, a car ran a red light and struck his vehicle. Nauseated and in pain at the scene, he was taken by ambulance to the emergency department. As X-rays suggested a possible thoracic compression fracture, a CT was performed; it was normal. At my first evaluation there were no signs of neurologic injury. I was struck by his posture, with his whole body slumped and caved in as though to make himself as small as possible.

Over the two months I followed him, before he left the area, he described his pain as mid-thoracic and midline, without change. It did not get better or worse if he sat or walked or lay down. This pattern of pain suggests soft tissue injury, not a problem with a disc or a nerve. In physical therapy, he participated in stretching and strengthening exercises, moving more fluidly and working up a sweat by the end of each session. He did say the treatment was helpful, but he did not progress from one session to the next. He experienced nightmares of the crash and described hypervigilance while riding in a car.

He was no longer driving and commented that he didn’t feel www.sfms.org

safe even in his father’s Hummer. He did not follow through with my recommendations to add psychological support to his treatment. ***** What is pain? The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” We have several systems for defining pain: somatic versus visceral, nociceptive versus neuropathic, and sympathetically mediated, all of which can further be discussed as acute versus chronic.

We think of acute pain as being short-lived, resolving during the course of expected tissue healing. Chronic pain is defined as pain that persists after allowing time for the tissue to heal.

Persistent pain six months after onset is a commonly used time frame.

We are not able to predict who will recover and who will have issues with chronic pain after an injury. In fact, one component of dealing with people experiencing chronic pain is to get them to stop the very treatment we taught them to follow when their pain was acute. For example, after spraining an ankle, acute treatment is RICE: rest, ice, compress, and elevate.

Activity is reintroduced as the pain resolves. Acute pain can be a guide for how much activity to do. If the ankle hurts the first day returning to running, another day of rest and a shorter run the day after would be sound advice.

What Makes a Person Develop Chronic Pain?

During my residency in physical medicine and rehabilitation, one of our rotations was called PAIN. During this time we participated in a multidisciplinary pain clinic where we tried to define the pain generator for patients with chronic pain. In addition to selective blocking of nerve roots and facet joints, we evaluated the patients for changes in muscle function. I was fascinated to learn that the patients weren’t just weak and deconditioned but that they presented with alterations in muscle coordination, what is termed motor planning, similar to the alteration in function I was learning to evaluate and treat in my patients with brain injury. We were taught that weakness and overuse (due to this “un-coordination”) contributed to pain. We were exposed to the model that the experience of pain begins with nociceptor activation of a nerve.

Once transmitted to the brain, this sensory input, pain, combines with the patient’s emotional status to cause suffering.

How the patient responds, guarding the body part that hurts, stopping activity when there is pain, taking medicines and not working, are pain behaviors. As residents, we facilitated

Continued on the following page . . .

April 2012 San Francisco Medicine

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www.sfms.org

Pain in the Brain Continued from the previous page . . . the Functional Restoration Program, which aimed at increasing the strength, flexibility, and endurance of patients, mostly those with chronic low back pain, while decreasing their use of pain medications and eliminating “learned” pain behavior that was felt to be a reflection of the patients’ relationship to their families and work rather than a true statement of nociception or “pain.” This program used a biopsychosocial model, including a multidisciplinary team of physicians, physical and occupational therapists, and psychologists integrating treatment of the patient and his or her family. The program could be successful, but it had stringent admission requirements, the most notable being that the patient needed to want to participate; in essence, the patient wanted to change.

I realize now that this paradigm still focused on the duality of pain, acute versus chronic, and, as with my patient, it didn’t address the issue of how acute pain becomes chronic.

It also couldn’t answer my questions, as a young doctor, about why patients with chronic pain move as if they have a brain injury.

Now in the twenty-first century, we have technology to explore and answer some of these questions, changing the model of chronic pain and, ultimately, allowing better interventions to prevent acute pain from becoming chronic. First, we have learned from functional MRI and PET scans that the primary sensory cortex, the post-central gyrus, is not the only part of the brain to be activated in the presence of pain. Of sixteen areas of increased metabolic activity measured during a painful stimulus, there are nine cortical sites that are activated, including the prefrontal cortex, secondary motor cortex, amygdala, and limbic system. The amygdala and the limbic system respond rapidly, accessing the immediacy of a situation to prepare the body to fight or flee. These metabolic responses lead to activation of the sympathetic system. Simplistically, I think of them as the source of the “fear factor” for my patients with pain, supporting the IASP definition of pain being both physical and emotional.

We have learned in neuroscience that the brain is plastic.

Any time a person learns anything—a phone number, the plot of a novel, how to play the piano—a new synaptic pathway has evolved. Creating pathways, making new synapses, is the way the brain functions on a normal, day-to-day basis. Chronic pain represents this learning process gone awry.

At the time of an injury, the inflammatory response initiates changes to the nervous systems that, if not subsequently downregulated, persist. These changes occur in the periphery at the nerve terminals and regulate changes in neurotransmitter release. This process changes the quality of sensory input; for example, light touch reinterpreted as pain if the neurotransmitter substance P release is increased. At the level of the spinal cord, axons spread into layers of the dorsal horn in ways not seen in subjects without chronic pain. Activation of these spinocortical pathways increases pain input to the brain via systems that normally don’t attend to pain. This increase in pain input reinforces synaptic connections to “teach” the brain pain. In addition, we are learning that glial cell activation in the brain potentiates the development of new synapses www.sfms.org

as well as producing cytokines that influence neurotransmitter metabolism, enhancing reactivity in the brain. People with chronic pain given a painful stimulus, compared to pain-free controls, show an increased volume of activity in the brain, as seen on fMRI and PET scans in the areas involved with pain.

These anatomic changes suggest that the brain and nervous system have “learned” the lesson of pain. This finding is not limited to the idea of learned pain behavior but covers what people actually feel: pain. Allodynia, pain due to a stimulus that does not normally provoke pain, may be activation of a light touch receptor that induces a brain interpretation of pain given the underlying neuroplastic changes. Does “the threat of tissue damage,” the definition of pain from the IASP, reflect the message of pain in the brain activation of the amygdala and initiate a fight or flight response—in essence, fear? Can this change in how the brain functions account for my observation as a resident that the pain patients acted as if they had brain injuries? ***** My twenty-year-old patient left the Bay Area three months after his accident. He was still in pain, still afraid to move, still not able to drive. His tissues should have healed and he should have been able to return to his usual life. Some might say that the pain was “all in his head” when, in fact, the pain was instead in his brain.

Judy Silverman, MD, is board certified in physical medicine and rehabilitation and pain medicine. She practices at the St. Mary’s Spine Center, focusing on nonsurgical management of patients with back, neck, and chronic pain issues.

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Pain Management

Yoga for Chronic Pain Understanding the Yogic Tools Used to Aid Chronic Pain Timothy McCall, MD Yoga is probably not the first option you think of in pain management for those patients who either want to add alternative approaches or who cannot tolerate the side effects of conventional drug therapy. With the growth in popularity of this an-

cient Indian tradition, you’ve undoubtedly seen the ads and magazine covers featuring yoga poses, probably have patients taking yoga classes (and maybe had a few injured in them), and perhaps you’ve even tried a class at your gym. Ironically, those experiences might give you a misleading impression that could make you even less likely to recommend yoga to patients with chronic illness, including those in pain—and that would be a shame.

Unless you get around in the yoga world, you may not realize that yoga has tremendous potential as therapy, even for people who wouldn’t—and shouldn’t—attend the typical yoga class. Modified practices can be taught to people who are bedridden, the morbidly obese, those with spinal cord injuries, cancer patients undergoing chemotherapy, and women in their third trimester. The type of yoga popular in health clubs and many yoga studios is demanding—even acrobatic—requiring fitness, flexibility, and balance. The best of these classes, those that stress safety and teach poses in an anatomically precise way to avoid injury, can be wonderful as stress reduction and preventive medicine for those young and healthy enough to survive them. But these classes could be torturous and counterproductive to those in chronic pain from arthritis, disc disease, fibromyalgia, repetitive strain injuries, neurological conditions, and so on. This is where yoga therapy comes in.

Yoga therapy is the use of various yogic tools to improve health and well-being, and it can be targeted to help specific health conditions. These tools include yoga poses, breathing techniques, visualization, meditation (the Buddha was a yogi before he became the Buddha), and many others. Therapeutic yoga is typically taught one-on-one or in small groups and is personalized to the individual. Indeed, a good yoga therapist will repeatedly adapt the prescription to meet the client’s ever-changing needs. The goal is to teach the student a routine that they will take home and practice.

One of the central tenets of yoga is that change usually happens slowly and incrementally over a long period of time.

This is the key to both its effectiveness and its safety. It is frequently said that practicing ten minutes a day is much more valuable than ninety minutes once a week. It’s all about taking advantage of neuroplasticity to carve out new behavioral (and thought) patterns. Regular repetition over a long period of time, precisely what Patanjali recommended almost 2,000 18 19

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years ago in the classical yogic text the Yoga Sutra, is the best way to do that. In yoga, we believe the best way to change a bad habit is to replace it with a new one. When I use yoga as medicine, I work with students to ascertain how much they can realistically practice every day. For most people, twenty to thirty minutes is manageable, but if five minutes is all they can spare, we’ll start there. I know from experience that if I can just get someone going with the practice, their improved wellbeing will often be all the motivation they’ll need to keep it up.

Although some pain relief can come quickly in those who take up the practice, it is over the long term that dramatic improvements become possible. One reason is that yoga is so effective at dealing with stress. Enduring chronic pain can keep stress hormone levels elevated and the sympathetic nervous system repeatedly or chronically activated. Fight or flight may prepare you well for an imminent threat to life or limb, but it’s counterproductive when it comes to chronic pain. When you’re stressed, you tend to breathe more quickly and erratically, which, from a yogic perspective, keeps the mind on edge.

Stress contributes to muscle tension, increases anxiety, and depresses mood—all of which can make pain worse. Other mechanisms for reducing pain with yoga include increasing GABA (gamma-aminobutyric acid) levels, improving posture (particularly helpful for back and neck pain and carpal tunnel syndrome), and facilitating longer and more restful sleep.

Yoga includes an array of tools to calm the nervous system (as well as others to activate it, when that’s called for).

Simply learning to breathe slowly and deeply through your nose can make a surprisingly large difference. Learning to subtly increase the length of the exhalation relative to the inhalation tends to further increase parasympathetic dominance. Beyond its acute effects on shifting the autonomic nervous system from sympathetic to parasympathetic control, yoga over the long haul increases stress hardiness. Seasoned yogis undergo stressful experiences just like everyone else, of course, but things are much less likely to get to them.

The ongoing practice of yoga appears to repattern the stress response itself, which is now understood to be plastic. Many people who are chronically in pain live in a state of abnormally heightened reactivity. Their pain is real, but their response to even minor insult can be inappropriately strong, only fueling the fire. Yoga can also help those whose nervous systems don’t mount an adequate response to pain and other stressors to balance stimulation and relaxation. The longer and more steadily you practice yoga, the more profound the changes to the wiring of your brain and nervous system.

Crucial to the yogic perspective on pain relief is understanding the difference between pain and suffering. Pain is the www.sfms.org

physical hurt, whereas suffering is how our minds react to that pain, which often ends up exacerbating it. Patients imagine the worst. They worry that things will never improve. They decide their lives are over. That’s suffering. And it’s a problem that we doctors generally aren’t taught how to treat in medical school. But the relief of suffering has been a central aim of yoga for thousands of years, and ultimately the methodology of yoga is all about learning how to do just that. Ironically, suffering—just like pain itself—can keep the body’s stress reaction system activated, which in turn can worsen sleep, promote weight gain, fuel inflammation, and promote bad habits (such as not exercising or eating unhealthy food), all of which may serve to make the underlying physical condition worse.

Probably the most effective tool in the yoga toolbox for dealing with chronic pain is meditation. Meditation allows patients to gradually separate their physical experience of pain from their emotional response to it. Experienced meditators appear to be able to modulate pain sensations to a significant degree. Even those patients who believe they can’t meditate or who think they are “bad at it” appear to gain many of the physiologic (and presumably analgesic) benefits.

For those who prefer it, there are demystified versions like the Relaxation Response and Mindfulness-Based Stress Reduction (which are modeled on yogic mantra meditation) and Buddhist mindfulness practices. In my experience, the combination of various yogic tools including poses, breathing techniques, and meditation brings greater benefit than any single tool alone.

One of the lessons of yoga is that the body, mind, breath, and nervous system are all intertwined. In yoga, we use the body and breath, which we can control to some degree, to calm, stimulate, and ultimately strengthen the nervous system (and through it the mind), which is normally beyond our control. When your nervous system and mind are balanced www.sfms.org

in this manner, you are poised to react to whatever challenge arises, whether that challenge is chronic pain or the daily grind of practicing medicine in our dysfunctional health care system. Physicians who take up the practice will not only learn practices that could help their patients, but—by helping themselves relax, destress, and focus—may be better able to do their jobs at the highest possible level.

Timothy McCall, MD, is an internist and the medical editor of Yoga Journal. His book Yoga as Medicine, now in its twelfth printing, outlines the practice of yoga therapy and the science behind it. McCall lives in Oakland, teaches workshops on yoga as medicine around the world, and can be found on the Internet at www.DrMcCall.com.

Resources Yoga for Pain Relief: Simple Practices to Calm Your Mind and Heal Your Chronic Pain, by Kelly McGonigal, PhD. New Harbinger Publications, 2009. A science-based approach from a Stanford-based psychologist and yoga teacher.

Yoga as Medicine: The Yogic Prescription for Health and Healing, by Timothy McCall, MD. Bantam, 2007. Includes chapters on twenty different medical conditions, detailing the approach of many of America’s leading teachers.

Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness, by Jon Kabat-Zinn, PhD. Delta, 1990. A classic, by the creator of MindfulnessBased Stress Reduction.

International Association of Yoga Therapy. The group’s website, www.iayt.org, lists yoga therapists in different locations. It also publishes a peer-reviewed journal, the International Journal of Yoga Therapy, recently added to Medline.

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Pain Management

Cannabinoids and Pain The Medical Application Explained Donald I. Abrams, MD Cannabis is one of the oldest-known psychoactive plants. Contents of the tomb of a presumed shaman in northern China dating back 2,700 years include two receptacles containing the flowers of the female plant. Cannabis medications were produced by most

pharmaceutical companies in this country in the early part of the twentieth century, prescribed for putative analgesic, sedative, antispasmodic, and anti-inflammatory effects. Cannabis was removed from the U.S. Pharmacopoeia in 1942 following the passage of the Marijuana Tax Act and was classified as a Schedule I drug with high potential for abuse and no known medical use by the Controlled Substances Act of 1970.

Despite the ongoing prohibition against cannabis as medicine, much has been learned about how the plant’s main components— the cannabinoids—affect the body.

Two cannabinoid receptors have been identified. The CB1 receptor has its highest concentration in the central nervous system but is found diffusely in organs throughout the body. The CB2 receptor was initially identified in cells of the immune system— the spleen, B lymphocytes, and natural killer cells—suggesting it may play a role in immune function and inflammation. These receptors, members of the superfamily of seven-transmembranespanning G protein-coupled receptors, are found in virtually all animal species. Surely these receptors are not present solely to complex with plant cannabinoids from Cannabis species? Just as we produce endogenous opiates—the endorphins—so we also produce endocannabinoids, specifically anandamide and 2-arachidonyl-glycerol (2-AG). The endocannabinoids are produced on demand from cell membrane lipids, complex with the cannabinoid receptors, and effect changes within target cells. Upon docking with the CB1 receptor, endocannabinoid-induced signal transduction is thought to modulate pain, appetite, cognition, emesis, reward, neuroexcitability, and thermoregulation, as well as other functions. By way of the CB2 receptor, endocannabinoids impact pain, inflammation, immune function, and cell proliferation. Just as the endocannabinoids modulate pain via interaction with the cannabinoid receptors, the plant cannabinoids (phytocannabinoids) and synthetic cannabinoid receptor agonists and antagonists also effect processing of noxious stimuli.

Elevated levels of the CB1 receptor—like the opioid—are found in areas of the brain involved with nociceptive processing.

Analgesic effects of cannabinoids are not blocked by opioid antagonists, suggesting that they work by way of different receptors, although the two systems appear to cross talk. CB1 and CB2 agonists also have peripheral analgesic actions in addition to 20 San 21 SanFrancisco FranciscoMedicine Medicine April April2012 2012

their central effects. Finally, cannabinoids exert anti-inflammatory effects that may also provide relief from pain.

The plant contains at least seventy different twenty-onecarbon terpenophenolic cannabinoid compounds. Delta-9-tetrahydrocannabinol (THC) is the primary active ingredient and main psychoactive component in the plant. The other phytocannabinoids, as well as terpenoids and flavonoids, create an “entourage effect” to enhance the beneficial effects of THC and to reduce some of the potential adverse effects. Cannabidiol (CBD), for example, is a nonpsychoactive cannabinoid that is felt to have potent analgesic and anti-inflammatory effects. Although most strains of Cannabis geared toward recreational use have been enriched for THC, savvy medicinal consumers are now seeking strains high in CBD with lower THC to obtain desired pain relief without as much psychoactive effect.

Cannabis is effective in a rat model of neuropathic pain.

Current therapy for neuropathic pain is generally inadequate.

Opioids are often ineffective with high addiction potential in treatment of patients with chronic, non-life-threatening neuropathic conditions. In the past, patients with HIV infection were frequently troubled by painful peripheral neuropathy, caused either by the virus itself or some of the earlier antiretroviral therapies. Based on the preclinical model and anecdotal information from patients, we conducted a clinical trial of inhaled cannabis in fifty patients with painful HIV-related peripheral neuropathy.

For an objective “anchor,” we subjected the participants to a heatcapsaicin experimental pain model. After smoking the first study cigarette, the cannabis group experienced a 72 percent reduction in their neuropathic pain, versus a 15 percent reduction in the placebo group. Over the five-day study period, 52 percent of the cannabis group reached the threshold 30-percent reduction in their chronic neuropathic pain compared to only 24 percent in the placebo group. Finally, the area of secondary hyperalgesia in the experimental pain model was unchanged in the placebo group but did decline significantly in the cannabis cohort. The number needed to treat (NNT) in our study was 3.6, which is comparable to the NNT for gabapentin in other peripheral neuropathic pain syndromes. In a subsequent placebo-controlled, crossover dose-escalating study of cannabis for HIV neuropathy, Ellis also found the NNT was 3.5, suggesting that cannabis may be a useful agent in HIV-related neuropathy.

Two additional trials investigated cannabis in neuropathic pain of other etiologies. Wilsey looked at thirty-eight patients with neuropathic pain in complex regional pain syndrome. A linear analgesic dose response was seen in the high- and low-dose cannabis groups but not with the placebo. These investigators concluded that the effect was not anxiolytic but that the treatment reduced core nociception and the emotional response to www.sfms.org

pain equally. Ware looked at the effect of cannabis on posttraumatic and postsurgical neuropathic pain. Twenty-three patients inhaled different doses of cannabis (including 0 percent THC) three times daily for five days, with nine days of rest between doses. The average daily pain intensity was significantly lower on the highest THC strength (9.4 percent), with patients also reporting improved quality of sleep. An ongoing study funded by the University of California Center for Medicinal Cannabis Research is investigating cannabis in diabetic neuropathy. A study in chemotherapy-induced neuropathy is clearly warranted.

Cannabinoids and opioids share several pharmacologic properties including antinociception, sedation, hypothermia, hypotension, and inhibition of intestinal motility. Unlike opioid receptors, however, there is a dearth of cannabinoid receptors located in the brain stem, so respiratory suppression is not a risk of cannabinoid therapies. Cannabinoids interact with kappa and delta receptors in production of pain relief, while the analgesic effects of opioids are mediated by mu receptors but may be enhanced by cannabinoid effects. In mice and rats, THC greatly augments the analgesic effects of morphine in a synergistic fashion.

If such an interaction were reproduced in humans, enhanced and persistent analgesic effects at lower opioid doses with cannabinoid boosting could be possible.

To investigate the potential cannabinoid:opioid interaction, we conducted a classical pharmacokinetic interaction study involving ten patients with chronic pain on a stable dose of sustained-release morphine and eleven patients on sustainedrelease oxycodone. Patients inhaled vaporized cannabis three times daily for four days after their initial twelve-hour opioid area concentration versus time curve was obtained. Repeat opioid kinetics were drawn on day five. Despite no change in the oxycodone concentration curves and a mild decrease in the plasma levels of morphine after cannabis exposure, patients reported a significant 27 percent decrease in their chronic pain with the combination therapy, suggesting a possible pharmacodynamic—not pharmacokinetic—effect. A larger follow-on trial with pain as the primary endpoint, perhaps also investigating a high CBD strain of cannabis, is warranted.

Nabiximols (Sativex) is a whole-cannabis extract medicine with a standardized THC:CBD ratio, available in Canada and European nations. Originally approved for treatment of pain and spasticity associated with multiple sclerosis, nabiximols as an oromucosal spray is being evaluated in an ongoing phase III trial in the U.S., investigating the medication in patients with cancerassociated pain.

In the meantime, as an oncologist, I am faced daily with patients suffering from anorexia, nausea and vomiting, depression/anxiety, insomnia, and pain—on opioids or not. Instead of writing prescriptions for five or six different pharmaceuticals to address these troublesome symptoms, I can recommend that patients try a single agent: cannabis. Increasingly, patients with advanced disease receiving palliative care come with stories of how they were unpleasantly oversedated and cognitively altered by heavy doses of opioids, to the point that they were unable to effectively communicate with their loved ones during their precious final days. Many have weaned way down, or even come totally off of, their opiates while adding cannabis to their regimen.

A word about delivery systems is in order, as so many of my www.sfms.org

patients accessing medicinal cannabis at dispensaries feel that eating is good and smoking is bad, so they seek edible products.

First of all, there is really very little evidence that inhaling cannabis has significant deleterious pulmonary consequences—in fact, a recent study suggested potential benefit. Second, the pharmacokinetic profiles of ingested and inhaled cannabis are quite different. When taken by mouth, bioavailability is low (6–20 percent) and variable, with a peak concentration in 2.5 hours. First-pass metabolism through the liver creates a secondary metabolite, 11-OH-THC, which is also psychoactive. In addition, the terminal half-life of orally ingested cannabis is twenty to thirty hours. When inhaled, the peak plasma concentration is achieved in two-and-a-half minutes, with a rapid decline over the next thirty minutes, and much less of the secondary psychoactive metabolite is formed. Hence patients are much less likely to experience a dysphoric overdosing and more able to titrate the onset and magnitude of the effect through inhalation, with vaporization becoming an increasingly popular smokeless delivery system for this useful, albeit still misclassified as Schedule I, medicine.

Donald I. Abrams, MD, is chief of hematology-oncology at San Francisco General Hospital and professor of clinical medicine at University of California San Francisco.

References Abrams DI, Jay C, Shade S, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham M, Petersen K. Cannabis in painful HIV-associated sensory neuropathy: A randomized, placebo-controlled trial.

Neurology. 2007; 68:515-521.

Abrams DI, Couey P, Shade SB, Dhruva A, Kelly ME, Benowitz NL. Cannabinoid:opioid interaction in chronic pain. Clinical Pharmacology and Therapeutics. 2011; 90:844-851.

Carter GT, Flanagan AM, Earlywine M, Abrams DI, Aggarwal SK, Grinspoon L. Cannabis in palliative medicine: Improving care and reducing opioid-related morbidity. Am J Hosp Palliat Care.

2011; 28:297-303.

Elikottil J, Gupta P, Gupta K. The analgesic potential of cannabinoids. Journal of Opioid Management. 2009; 5:341-357.

Ellis RJ, Toperoff W, Vaida F, van den Brande G, Gonzales J, Gouaux B, Bentley H, Atkinson JH. Smoked medical cannabis for neuropathic pain in HIV: A randomized, cross-over clinical trial.

Neuropsychopharmacology. 2009; 34:672-680.

Guindon J, Hohmann AG. The endocannabinoid system and pain. CNS Neurol Disord Drug Targets. 2009; 8:403-421.

Leung L. Cannabis and its derivatives: Review of medical use. J Am Board Fam Med. 2011: 24:452-462.

Russo EB. Taming THC: Potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. British Journal of Pharmacology. 2011; 163:1344-1364.

Ware MA, Wang T, Shapiro S, Robinson A, Ducruet T, Huynh T, Gamsa A, Bennett CJ, Collet JP. Smoked cannabis for chronic neuropathic pain: A randomized controlled trial. CMAJ. 2010; 182:E694-701.

Pletcher MJ, Vittinghoff E, Kalham R, Richman J, Safford M, Sidney S, Lin F, Kertesz S. Association between marijuana exposure and pulmonary function over 20 years. JAMA 307:173-181, 2012.

April 2012 San Francisco Medicine

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Pain Management

The High-Flying Dilemma Chronic Pain and Addiction Murtuza Ghadiali, MD, and David Pating, MD

For the past two decades, the clinically indicated use of opiates has been framed by two competing mandates: the need to effectively treat pain and the ever-increasing need to prevent addiction and overdose. Beginning in 1995, the newly formed American

Pain Society set out guidelines to improve the management of pain, stating, “ . . . if pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated.” In 1999, the Veterans’ Administration mandated the self-assessment of pain as “the fifth vital sign” in an attempt to improve quality throughout its 1,200 nationwide facilities. Since then, many governmental bodies, including the Medical Board of California (2007), have not only mandated training for the management of pain but have also encouraged physicians to actively treat pain with opiates.

Yet, as the recognition and treatment of acute and chronic pain grows, so too has the demand for prescription opiates.

Riding the coattails of this national love affair with pain medication, pharmaceutical companies have obliged the public’s demand for opiates by providing a liberal supply of stronger and longer preparations, including the highly abusable opiate OxyContin. OxyContin is now the second-leading drug of abuse in the U.S. Taken together, misuse and abuse of opiates is an unprecedented epidemic, resulting in more than 40,000 overdose deaths in 2011, exceeding the number of annual 22 23

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deaths from auto accidents.

As addiction experts, we see this proliferation of opiates as a major public health problem. This problem has multiple underpinnings. First, the unbridled, consumer-driven demand for opiates has not been balanced by adequate evidence-based pain management strategies. In addressing the “vital sign” of pain, even pain experts do not agree whether opiates are indicated for such conditions such as chronic headaches, fibromyalgia, menstrual cramps, and even nonrheumatoid arthritis, particularly if the real goal of treatment is functional improvement, not just relief from pain. Second, on the supply side, pharmaceuticals have enormous incentive to recoup their deferred drug development investment. When large manufacturers, such as Purdue Pharma, makers of OxyContin, hit upon a cash cow, they are amply rewarded with the opportunity to make billions. This, combined with unregulated pharmaceutical sales over the Internet that allow the purchase of nonprescribed opiates with the click of a mouse, has created the current environment: a drug addict’s paradise. Florida is now the leading U.S. supplier of OxyContin to the rest of the country, most of it used for nonmedical “recreational” purposes.

As addiction physicians charged with helping patients in trouble with the dual issues of pain and addiction, we see a complicated entanglement of different interests in which doctors are caught in the middle. A patient came to us after “being cut off of meds by her doctor.” She came with MRI in hand, talking about her need for half a gram of OxyContin a day “just to hug her small child at night.” She didn’t understand why her family was concerned (although after drinking wine every night with her dinner she was completely incoherent) and why they wanted her to “get help.” Our first visit was a long and difficult consult, but it ended in her deciding to come for outpatient addiction treatment and get a chronic pain consult.

After consulting with the chronic pain physician, we decided to start buprenorphine for pain, which ended up working well for the patient. The therapists found her very resistant at first www.sfms.org

but have seen a change in her line of thinking over the course of six weeks. She eventually stabilized on a moderate dose of buprenorphine and feels that her life and pain are more manageable than before.

This case turned out well. Not all do. It’s important to remember that opiates are only one modality to treat pain, as is noted in the Medical Board guidelines for prescribing controlled substances for pain (http://mbc.ca.gov/pain_guidelines.html).

Many times we are asked to consult on cases when either the patient or doctor has become dissatisfied. We find that a step-by-step approach is best for handling patients with complicated pain and potential addiction. It is well described by an airplane analogy: “We must decide how to land the plane before we take off.” This translates to our encouraging all physicians to consider, prior to prescribing opiates, 1) whether there is a legitimate condition that warrants use of opiates (a defined destination), 2) whether there are reasonable risks and benefits to prescribing of opiates (takeoff), and 3) whether there are clear requirements for their successful discontinuation (landing).

For patients suspected of or at risk for abuse, prior history or family history of substance abuse is the best clinical predictor of risk at takeoff. When flying high with opiates for acute pain, it is prudent to use the smallest and shortest effective course of opiates. For most acute conditions, two to three weeks is a more than adequate duration of flight. If patients require opiates for two to three months or more, it is prudent to screen for risks of addiction.

At this point, to avoid being labeled zealots, we must remind our colleagues that most patients who are prescribed opiates do not abuse them—most patients will safely discontinue their opiates (auto-land) in reasonable course. Contrariwise, studies do suggest that up to 10 percent of patients do misuse their medications. Indications of misuse may include increasing dosage or early refills, reports of lost or stolen medications or frank drug seeking. While some aberrant drug-seeking behavior may result from the undertreatment of pain (aka pseudo-addiction), in our experience the reasons for drug seeking are often unclear and may even include patients who take additional opiates not for pain but for the “stress or coping” with pain.

Again, our motto is: Do not fly a plane that you cannot land.

For patients who need opiates for more than two to three months or if you are in the transitional no-man’s-land between acute and chronic pain, a SOAPP-5 (Screener and Opiate Assessment for People with Pain) is a good compass to fly by. SOAPP-5 is a five-item questionnaire that helps assess, on a scale of 0 to 4, the potential for opiate misuse (Figure 1).

Patients with SOAPP-5 > 4 have high potential for abuse and should be given a shorter leash or monitored more frequently.

If a patient manifests aberrant behaviors, we recommend an early consultation with a chronic pain physician. It’s important to be descriptive of the behavior without making a stigmatizing diagnosis unless one is certain (e.g., diagnosing addiction for an early refill or lost prescription or taking more than prescribed). Pain contracts using the universal precauwww.sfms.org

tions for pain management (e.g., regular screening for addiction and good documentation) are also helpful. If you suspect an addiction, a referral to an addiction medicine specialist is essential to determine who might safely stay on opiates as long as they capably treat and manage their addiction. Addiction is characterized by the loss of control and compulsion to use the drug and not simply withdrawal and tolerance. Lastly, urine toxicology adds little to the picture, except when you need to prove the patient is taking opiate medications as prescribed (and not selling or giving them away), or to make sure they are not abusing other recreational drugs.

In summary, we support the effective management of pain, but we also endorse the prudent assessment and management of the risk of addiction. For the one in ten individuals who may misuse or abuse their opiates, we recommend screening for substance abuse or family history of abuse, or more formally using the SOAPP-5 tool. Most importantly, we encourage our colleagues who treat acute and chronic pain to document their reasoning for initiating opiates and to continually demonstrate their prudence by monitoring compliance, treatment efficacy, and the achievement of functional improvement.

Murtuza Ghadiali, MD, and David Pating, MD, are supervising addiction medicine physicians at Kaiser-San Francisco’s Chemical Dependency Recovery Program.

References Mularski RA, White-Chu F et al. Measuring pain as the fifth vital sign does not improve quality of pain management. J Gen Intern Med. 2006; 21(6):607-612.

Chou R, Fanciullo GJ et al. Opioids for chronic noncancer pain: Prediction and identification of aberrant drug-related behaviors: A review of the evidence for an American Pain Society and American Academy of Pain clinical practice guideline. J Pain.

2009 Feb;10(2):131-46.

Fishman SM. Responsible Opioid Prescribing: A Physician’s Guide. Waterford Life Sciences. Washington DC. 2009.

Figure 1: SOAPP Tool Please answer the questions below using the following scale:

0 = Never | 1 = Seldom | 2 = Sometimes | 3 = Often | 4 = Very Often

1. How often do you have mood swings?

2. How often do you smoke a cigarette within an hour after you wake up?

3. How often have you taken a medication other than the way it was prescribed?

4. How often have you used illegal drugs in your lifetime (for example marijuana, cocaine, etc . . .) in the past five years?

5. How often, in your lifetime, have you had legal problems of been arrested?

If the sum of questions is greater than or equal to 4, the SOAPP Indication is positive. If it is less than 4, it is negative.

April 2012 San Francisco Medicine

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Pain Management

“Red Flags” in the ED Pain Treatment versus the Painful Epidemic of Addiction Keith Loring, MD, and Steve Heilig, MPH Every emergency clinician knows them, and most learn to dread them—the patients who might be “drug-seekers” or might be in real physical pain—or might be both. How to screen the addicts from the “legitimate”

pain patients? These are not entirely mutually exclusive diagnoses. Addiction is painful—it has even been likened to slavery. And many addicts started as honest people in physical pain. Medication diversion and abuse has become a major epidemic. The CDC notes that fatal overdoses of opioid analgesics occur every nineteen minutes in this country—and for every such death, 461 people report nonmedical use of these meds, and thirty-five visit an emergency department (MMWR, 2012; 61:1).

The CDC notes that “persons at greater risk for overdose frequently visit emergency departments seeking drugs” and proposes targeting “(1) high-dosage medical users, and (2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion,” noting that up to three-fourths of opioid abusers report their drugs were prescribed to somebody else.

Such data and warnings are hardly new, but they do indicate that vigilance is more important than ever. So, on the frontlines, what are the warning signs?

The primary red flags are well known: patients who arrive after business hours, especially at the end of the week, and even more especially at the beginning of a long weekend; patients with stated allergies to several common nonopioid pain medications, except the one that begins with a “D”; patients who ask for a specific opiate by name, dose, and dosing interval; patients who just moved here or are from out of town; and patients whose medication was “lost or stolen.”

Faced with these and a multitude of other patients for whom pain is the chief complaint, objectivity and consistency in approach are paramount. A quick set of questions is generally sufficient to devise an appropriate diagnostic and treatment plan that minimizes overprescription of narcotics, adequately treats patients with real pain, and helps identify patients for whom the disease of addiction should be considered and addressed: Is the pain new or long-standing? Is the pain associated with an obvious or clinically identifiable physical abnormality or disease process? Is the pain being treated on an outpatient basis and if so, by whom?

What medications, if any, has the patient used to treat the pain? The answers place patients in one of four categories: 1) Acute pain associated with an obvious medical or surgical cause. This category of patients is straightforward, and the major focus on their pain should be to achieve adequate relief with whatever medication is necessary.

2) Acute pain with no clear or objectively identifiable physical abnormality or disease process. This category of patients is the most likely to include the drug-seeker or addict who www.sfms.org

is wise to the system and is even willing to undergo an involved workup in order to obtain opiate pain medication. These patients will go from hospital to hospital in hopes of staying under the radar. A clinician has to be willing to research the patient’s visit history at his or her own and other emergency departments in order to begin to address the possibility of drug-seeking in the patient.

This is also where a program such as CURES (http://oag.ca.gov/ cures-pdmp) in California can be helpful.

3) Chronic pain that is untreated. This group of patients is easy to identify and very difficult to manage. Chronic pain is complex, often requiring treatment by a specialist. These patients need to establish care with a pain specialist but often will not or cannot.

They return to the ED for pain control, get variable treatment each time, and create increasing frustration for everybody. The pattern can be broken, but this requires coordination and agreement among ED staff to ultimately be willing to withhold pain medication. For this to occur, patients need to be informed in writing in their discharge instructions and it must be documented in their ED record that they will no longer be given narcotic medications in the ED without the approval of a primary physician or pain management specialist.

4) Chronic pain that is being treated. Once identified, these patients should never be given pain medication unless approved by their own physician. Patients with chronic pain who are under treatment by a pain specialist generally contract that they are never to go to the ED for pain treatment. Some still try, in hopes that the ED is too busy to contact their physician. But for the emergency physician, that is always a call worth making.

No matter which category of patient, the disease of addiction can be present. Sensitivity to this possibility is crucial; saying nothing only contributes to a patient’s willingness to remain in denial of the problem. For addicted patients, it is critical to have a current list of resources that includes addiction specialists (see http:// www.csam-asam.org/member/search).

To “do no harm,” clinicians need to walk a razor’s edge between treating pain, a long-neglected arena, and contributing to the abuse and addiction epidemic. Most of the time, this can be achieved. But in this realm especially, clinical persistence and patience are essential virtues. We serve the patient’s short-term interests when we adequately treat pain. We perform a greater service to their long-term interests whenever we are instrumental in helping achieve the diagnosis and appropriate treatment of a hidden condition such as addiction.

Keith Loring, MD, is an emergency physician at St. Mary’s and CPMC Davies hospitals, an SFMS board member, and an active member of the San Francisco Emergency Physicians Association. Steve Heilig is with the SFMS and is a former Robert Wood Johnson drug policy fellow.

April 2012 San Francisco Medicine

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Pain Management

Pain in the United States A Review of Our Country’s Experience with Pain Sean Mackey, MD, PhD More than 100 million Americans suffer from chronic pain, a condition that costs between $560 and $635 billion dollars per year in medical expenses and lost productivity, according to the recently

released report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, from the Institute of Medicine (IOM) of the National Academies.

The IOM’s involvement in examining pain as a public health problem was mandated by the U.S. Congress’ 2010 Patient Protection and Affordable Care Act, which required the Department of Health and Human Services (HHS) to enlist the IOM’s help. HHS charged the IOM with assessing the state of the science regarding pain and recommending how to advance the field. HHS directed the IOM to carry out five specific goals and be guided by seven underlying principles.

Goals

• Review and quantify the public health significance of pain.

• Identify barriers to appropriate pain care and strategies to reduce such barriers.

• Identify demographic groups and special populations; discuss related research needs, barriers to completing needed research, and opportunities to reduce such barriers.

• Identify and discuss what scientific tools and technologies are available.

• Discuss opportunities for public-private partnerships in the support and conduct of pain research, care, and education.

Underlying Principles

• Pain management is a moral imperative; pain needs to be better assessed and treated using interdisciplinary and comprehensive approaches.

• Although pain is often a symptom of a disease, when pain becomes chronic, it can become a disease in itself.

• Large amounts of existing knowledge about effective pain treatment need to be better disseminated.

• Pain is better prevented than treated; more resources should be directed at effectively preventing chronic pain.

• Use of opioids is a conundrum; their benefits and potential adverse effects need to be balanced.

• Collaboration between patients and clinicians needs improvement.

• Public health- and community-based approaches to pain care are of great value.

• In response to the mandate, the IOM formed a nineteenmember committee whose overriding conclusion is that effectively treating pain is a moral imperative. The committee’s report presents a detailed blueprint for improving the state 26 27

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of pain care, education, and research in the U.S. and beyond to the global community.

Members of the committee represented multiple fields of medicine, ethics, epidemiology, psychology, and public health.

The committee used varied methods to obtain and process information, including reviewing literature and conducting public workshops intended to obtain key stakeholders’ perspectives. In these workshops the committee discussed numerous important topics: data collection; public–private partnerships; cultural views of pain; financing and resources for pain care; basic science of pain and approaches to pain treatment; regulation of pain drugs; and personal testimony from people living with pain, their caregivers, and other stakeholders. Via a website, the IOM sought public input and read more than 2,000 responses. Realizing better data about pain’s economic burden was needed, the committee commissioned a research paper to better assess this burden.

In addition to specifying the quantity of American pain sufferers and the huge direct and indirect medical cost, the report made clear that pain is a uniquely individual and subjective experience—one not often directly related to the amount of nociception or injury observed.

Due to the complexity of chronic pain and the challenges in treating it, the committee agreed that a comprehensive and interdisciplinary (e.g., biopsychosocial) approach is the most important and effective one to pursue. Unfortunately, such care is difficult to obtain because of structural barriers, including financial and payment disparities.

To address the complexities of this national health care crisis, the IOM committee called for a cultural transformation as to how government agencies, private foundations, health care associations and payors, health care professionals, patients, and the public prevent, assess, treat, and understand pain. Accordingly, the committee’s report outlined sixteen recommendations grouped under four key areas—public health challenges, pain care, education of providers, and research—and specified a blueprint for accomplishing the four recommendations listed below by the end of 2012.

The HHS Secretary should create a comprehensive, population-level strategy for pain prevention, treatment, management, and research. This strategy should contain the following elements: www.sfms.org

• Coordinate efforts across both public and private sectors.

• Create a research agenda.

• Improve pain assessment and management programs.

• Ensure that the Interagency Pain Research Coordinating Committee and the NIH Pain Consortium (a group of NIH institutes with an interest in pain) cooperate in reaching out to private-sector participants as appropriate.

• Enhance public awareness of chronic pain.

HHS and other entities including the VA, DoD, and large health care providers should reduce barriers to pain care, especially for populations disproportionately affected by and undertreated for pain.

Enlist pain-specialty and primary-care professional organizations in supporting collaboration between pain specialists and primary care clinicians; educate primary care providers as to when to refer patients to pain centers.

Ask NIH to designate as lead institute an existing institute that includes pain as a central part of its mission. This lead institute should be responsible for the following: advancing pain research, including assessing NIH’s overall effectiveness in this area; assuming leadership of the Pain Consortium and increasing its scope; and identifying funding needs. Furthermore, require the Pain Consortium to do the following: conduct more frequent, structured, and productive meetings; improve the process for reviewing pain-related grant proposals; work with pain-advocacy groups to help identify public needs related to treatment and management; and improve and expand public-private partnerships.

Some have asked why the committee did not address other equally important aspects of pain, such as our national problem of chronic prescription opioid misuse and abuse or the formation of a national institute of pain. The committee acknowledged and described the problem of opioid misuse and abuse; however, an in-depth examination with specific recommendations was beyond the committee’s charge. Likewise, the committee discussed in its report the creation of a pain institute and concluded that creating one at this time is not feasible.

We now have a wonderful opportunity to advance IOM’s report recommendations and encourage all physicians to support the report’s important messages. Please read the complete IOM report, including its executive summary at http:// www.iom.edu/Reports/2011/Relieving-Pain-in-America-ABlueprint-for-Transforming-Prevention-Care-Education-Research.aspx.

Sean Mackey, MD, PhD, is an associate professor of anesthesia (and of neurology and neurological sciences, by courtesy) at Stanford University. Dr. Mackey’s primary research interest involves the use of advanced research techniques such as functional and structural neuroimaging, psychophysics, and neurobehavioral assessment to investigate the neural processing of pain and neuronal plasticity in patients with chronic pain. The research mission of the lab is to “predict, prevent, and alleviate pain.” Dr. Mackey has served as investigator and as principal investigator for multiple NIH and foundation grants to research chronic pain and to investigate novel analgesics for acute and chronic pain. Additionally, Dr. Mackey has recently received an NIH K24 grant focused on mentoring INC. junior investigators to have successful careers. Dr. Mackey has published more PLACEMENT FIRM than sixty peer-reviewed articles and book chapters. He annually presents papers and lectures at both national and international pain medicine, neurosci~ Physician Assistants ence, and anesthesiology meetings and has been interviewed extensively by the popular press (http://paincenter.stanford.edu/press).

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April 2012 San Francisco Medicine

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Pain Management

Wings to Fly When Opiates Fail and Volkswagons Sail Dawn Gross, MD, PhD

“I am so lucky.”These were not the words I expected

to hear from the teenage-like thirty-eight-year-old man tethered to his bed with intractable nausea and vomiting due to complete bowel obstruction from his incurable colon cancer.

But Brian was anything but expected.

Brian White was, in fact, white, but more so now due to lack of sunshine having the opportunity to kiss his face and body. He was too tall for his bed, reaching upwards of 6’3”, and I all too often bumped his size-16 feet dangling over the sides of the bed. His constant companions, Mooch (the sure-footed American shorthaired gray cat) and Dexter (the unflappably loyal, though less-than-dexterous, beagle) and their ability to discover space in this overcrowded bed never ceased to amaze me.

Brian was raised solely by his mother, Gale. His father had helped him discover the power of drugs as a young teen, when innocence still trumped common sense. Brian’s tolerance to medications would be like nothing I had ever encountered. His source of pain was, likewise, off the charts. His ability for gratitude ultimately transcended all.

I quickly learned his most recent hospital admission had provided him with endless pokes and prods, tests and procedures, resulting in profound weight loss, fatigue, and frustration. Most notably, Brian had significant pain, the physical source of which was obvious when one examined his abdomen. But the impact of that mass, clearly reaching beyond the direct nerve endings it pressed against, was now infiltrating Brian’s heart and soul, making pain management anything but straightforward.

In hospice and palliative medicine, pain is the first symptom we ask about and assess, even when people are not able to answer. We do this because we know pain, whether physical, spiritual, or emotional in nature, overrides all other sensations. Until pain is controlled, we are unable to address any other concerns or wishes. When pain is quelled people can come back to life . . . not cured, but rather back to how they know themselves to be. This is when palliative and hospice care really take flight.

Within days of Brian’s return home, his pain medication requirements demanded aggressive intervention, such that a continuous infusion of opioids was needed. Even then, this only took the edge off of his pain. Eventually his pain medications were escalated to the maximum capacity of the largest delivery pump. Adjunctive IV medications were soon added to potentiate the effect, providing enough relief so Brian could reengage with life. I finally got to see Brian smile and hear him joke. This glimmer of joy reminded Gale of how he used to be.

She longed to embrace this once-joyful child. His exuberant

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San Francisco Medicine April 2012

happiness was most visible at the age of four when she owned a sky-blue VW Bug. Gale remembered how Brian would say, “Open the windows,” referring to the push-out triangular windows on the front doors of the car, “so I can fly.”

With Brian’s improved pain management he began to ask for simple things: food, friends, and “…maybe even a little sex. I may be tired but I’m still horny.” At that last statement I couldn’t help but notice Brian’s gaze focused toward the opening in my blouse as I finished leaning over him to examine his abdomen. Somehow, his words didn’t seem crass or embarrassing. They seemed human, and Brian’s mom seized the opportunity to start nurturing her son’s starving constitution.

“Perhaps we can have one of your girlfriends come over in a few days if you’re feeling up to it.”

Brian began to eat everything in sight. I knew this was mostly due to the steroids I had started him on and that it would be short-lived. So Brian and his mom lived it up. Breakfast burritos, Whoppers, Little Lucca roast beef sandwiches, sloshed down with giant gulps of Coca-Cola. Popcorn and pizza at any hour of the day were fair game. And though the TV was on nearly 24/7, I can’t say Brian ever actually seemed to be watching. “Maybe it just keeps him feeling normal,” Gale commented when I asked.

During this honeymoon period, the period of pain relief before the bowel obstruction, I got to see the love Brian had for his mother. How after each request he made of her, or even every few minutes when no request was made, he would sing out, “I love you, Mom,” and her immediate, rhythmic reply was, “I love ya, Brian.” Like a heart beating in unison. It was as if time stood still. And even though they each knew it wouldn’t last, asking me in private nearly every visit, “How much more time?” neither let it get in the way of being present to the moment at hand.

Just shy of three months at home, football-teams’-worthof-food devoured, hours of television absorbed (or not), everything began to fail as the cancer continued to grow. Brian developed relentless nausea and vomiting from the bowel obstruction and, as a result, his pain became intractable. No medication would halt this now, and Brian refused to return to the hospital for any more invasive procedures. Not surprisingly, he became very fatigued and very angry, yelling at Gale and even kicking Dexter off the bed. (Mooch seemed to sense the changed environment and chose to stay clear, perched atop the recliner in the living room). Brian refused my visits altogether, Gale explaining when I would call, “He says nothing is helping, so what’s the point?” His resignation only feeding into my own sense of helplessness, I racked my brain (as well as those of many of my colleagues, medical, social, and spiritual) www.sfms.org

for some insight. But Brian continued to refuse to see anyone except one favorite nurse. And therein lay the magic.

Brian did want to be with people, and people wanted to be with Brian. And in the end, focusing on what made Brian happy, even in the face of chronic pain and suffering, is what saved him as well as the rest of us.

Brian’s birthday was fast approaching, but so were his finals days. I have learned that waiting for such milestones to arrive may result in missed opportunities instead of joyful celebrations. With this in mind, I seized the first model of a VW bug I could lay my hands on and left it on the doorstep, respecting Brian’s wish not to see me.

Gale phoned me later and said Brian appreciated the car and welcomed my visits again.

I didn’t even bother asking him about his pain; I simply sat with him and held his hand. And that is when he said, “Thank you, Dawn. Thank you for caring. I am so lucky.” He knew I wasn’t going to be able to take his pain away. Suddenly it didn’t matter. Being alive and not being alone was all that he wanted now.

When the clock struck midnight on Brian’s thirty-ninth birthday, with decorations covering the walls of his room, Gale sang “Happy Birthday” and Brian smiled and knew the day had arrived. His voice now raspy due to extreme fatigue, he still offered his ever-present, now softly whispered, “I love you, Mom,” followed by Gale’s ever-ready “I love ya, Brian” reply. In the morning his two favorite nurses and uncle joined his mom and sang again, showing him all the presents and cake they had brought him, knowing all along he would never use them or ever take a bite. But that wasn’t the point.

As the morning wore on Brian developed a change in his level of consciousness, signs that his death was approaching.

I pressed into Brian’s giant, now skeletal hand a tiny custompainted sky-blue Beetle with triangle windows I had fashioned so they could point out the front doors. Brian slowly turned his head my way, opened his eyes and mouthed some words while his mother’s cupped hand covered her own as she closed her eyes in disbelief.

www.sfms.org

Over his final days, Brian continued to have intermittent signs of pain, for which we continued to provide aggressive intervention with medications that I would have anticipated would have fully sedated five men, but not so for Brian. Perhaps Brian’s body had developed physiologic tolerances to medication due to his history of substance abuse. But I also wonder if his body, now no longer numb, actively fought to maintain sensations: joy, love, nausea, and pain, all of which were of equal evidence that he was still alive. Brian intermittently regained consciousness and when he did, it was always to utter his love and thanks, with Gale’s harmony echoing in return.

Shortly after his death, I phoned Gale to see how she was doing, ask about the services, and say how much I missed them both. She shared how she decided to bury Brian with the sky-blue Beetle and thanked me for all my care and kindness.

But this time, she concluded with the same pitch and rhythm, “I love ya, Dawn,” as she hung up the phone.

Dawn Gross, MD, PhD, became a hospice physician with VITAS after her father passed away in 2006. Prior to this she trained as a hematologist and bone marrow transplant physician/scientist at Stanford, completing her postdoctoral research at UCSF. She earned her MD and PhD in immunology at Tufts and her BA from USC. An author of numerous papers, her Science publication was highlighted as one of the top ten breakthroughs of the year, resulting in her invitation to lecture nationally and internationally. More recently she has joined UCSF as an attending physician with the palliative care service.

She is gratefully married to a medical school classmate and is the proud mother of their three spirited children. Dr. Gross is a member of the board of directors of the Zen Hospice Project in San Francisco and is a volunteer caregiver there, as well as a physician volunteer for the RotaCare Clinic in San Rafael.

The author wishes to thank Gale White for allowing this story to be shared, and to acknowledge and thank Julia Wallace, Awtar Khalsa, and Japa Kaur for their invaluable editing and writing support.

April 2012 San Francisco Medicine

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Pain Policy Celia Vimont

Five Public Policies That Will Lead to Pain Relief without Prescription Overdoses Major policy changes are needed to resolve the tension between providing adequate pain relief and tackling the epidemic of prescription opioid overdoses, according to drug policy expert Keith Hum-

phreys, PhD. At the recent American Academy of Pain Medicine meeting, he laid out five policies that can achieve a realistic balance.

“Some of the policies are relatively easy to implement, while others involve changing cultural norms, which is much more difficult,” said Humphreys, professor of psychiatry and behavioral sciences at Stanford University School of Medicine and a former senior policy advisor at the White House Office of National Drug Control Policy.

According to the National Institute on Drug Abuse, from 1991 to 2009, prescriptions for opioid analgesics increased almost threefold, to more than 200 million. The Drug Abuse Warning Network system, which monitors drug-related emergency department visits and drug-related deaths, found that emergency room visits related to the nonmedical use of pharmaceutical opioids doubled between 2005 and 2009.

The five policies that Dr. Humphreys recommends are: Implement prescription monitoring programs. “Some of the initial programs were slow and clunky, but we are now seeing systems, such as the one in New York, that are starting to make a difference,” he says.

Use the reimbursement power of insurance programs to lock “doctor shoppers” into a single prescriber. “If an insurer sees someone have five doctors writing them pain pill prescriptions, they can designate one provider as the patient’s pain doctor,” notes Humphreys.

Make prescription recycling a standard practice. “I remember when recycling bottles and cans was considered a strange thing, but now everyone does it,” he says. “Prescription take-back days won’t be fully effective until they become the cultural norm. Dropping off unused pills needs to be something everyone does when they go to the drugstore.”

Make it easier for drug companies to develop abuse-resistant drugs. “Pharmaceutical companies who are trying to do the right thing need to spend hundreds of millions of dollars to develop a pill that becomes inert when crushed, and then they have to apply for a New Drug Application. We need the Food and Drug Administration to create an accelerated review process for these new formulations.”

Change opioid-related medical practice. “We need to educate patients and providers that opioids are not the only treatment for pain,” Humphreys says. “There are other options, including different types of medications and physical therapy.

We also need to educate prescribers in the emergency room and in dental offices that they shouldn’t automatically write a thirty-day prescription for opioids. They have to start thinking about how much medication a patient really needs.”

With so many people dying of prescription drug overdoses, a response of doing nothing isn’t an option, he emphasizes. “I tell doctors that change is coming, and they can get involved, or else an uninformed policy maker may do it for them, with potentially bad results.”

Reprinted with permission from Join Together, a collaboration of the Boston University School of Public Health and The Partnership at Drugfree.org, dedicated to advancing effective drug and alcohol policy, prevention, and treatment.

You are Cordially Invited to a Reception to Meet Your Legislators and Support CALPAC and SFMS PAC Stephen Follansbee, MD; Richard Wolitz, MD; Robert Margolin, MD; Andrew Calman, MD; Man-Kit Leung, MD, and the leadership of the California Medical Association/CALPAC and the San Francisco Medical Society/SFMS PAC cordially invite you to a gathering.

The purpose of this reception is to encourage physicians to learn more about how they can support and work with their state and local PACs as well as to get better acquainted with their legislators. There will be wine and hors d’oeuvres as well as the opportunity to network with other SFMS and CMA members.

Thursday, May 3, 2012, 6:00 pm to 7:30 pm, at the home of Stephen Follansbee, MD and Richard Wolitz, MD

If you are already a CALPAC member, we encourage you to upgrade your membership level by paying the difference between your current level and the upgrade plus $50 for SFMS PAC. For details on CALPAC participation levels, event location, and to register for this event, please RSVP no later than May 1, 2012, to Posi Lyon, (415) 561-0850 extension 260, or plyon@sfms.org.

30 San 31 SanFrancisco FranciscoMedicine Medicine April April2012 2012

www.sfms.org

Health Policy Perspective Steve Heilig, MPH

Contraception: Just What the Doctors Ordered A Medical Voice in the Political Debate Contraception exploded onto the front pages this February. But it was not about any new medical break-

through, much as there is room for improvement regarding effective contraceptive options. It was a political and religious debate. But what is controversial about contraception at this late date? Who pays for it, as it turns out. As one headline read, “Changes to Contraceptive Coverage Rules Draw Mixed Reaction,” thus winning an understatement award.

Almost all women, including Catholics, ignore religious leaders on this issue if said leaders say “don’t”—when they have a choice. And most men support that practice. The most incisive perspectives in this realm seem to come mostly from women—political leaders, doctors, nurses, and just plain folks. Regarding the current debate, many note that Catholic authorities are trying to have it both ways, claiming all the financial privileges of a church but wanting to ignore any strings that might be attached. Others observe that behind this debate lurked abortion politics—even though one proven way to reduce abortions is to make contraception as easily available as possible.

Among politicos, the gender split seems pronounced as well. Three female senators wrote to the Wall Street Journal defending the contraceptive mandate. Some female politicians even felt compelled to boycott the male-dominated House hearing on the topic. Kris Long, a nurse writing in the New York Times, said, “As a former employee of a Catholic-run hospital, I find it appalling that the party of ‘individual rights’ would stand up for a religious bias rather than for the nonCatholic employees who are deprived of the right to choose health insurance commensurate with private needs and beliefs. Why should I not be allowed birth control through my insurance because my boss has a problem with it?”

Organized medical voices have been notably muted in this debate. But the contraceptive mandate did not spring anew out of the White House. It is an old idea, long supported among health care policy wonks for both clinical and economic reasons and, last summer, given strong endorsement by the Institute of Medicine (IOM) of the National Academy of Sciences. Their report “Clinical Preventive Services for Women: Closing the Gaps” focuses on preventive care for women, including contraception.

In medical circles the report was hardly controversial.

But sensing that the IOM recommendations might be more controversial in nonscientific arenas, the SFMS delegation to the CMA unanimously adopted the statement that follows in September, with three (female) SFMS physicians as authors (their names omitted here for safety reasons). www.sfms.org

CONTRACEPTION AS A FULLY COVERED HEALTH INSURANCE BENEFIT Whereas, the United States Institute of Medicine in July 2011 strongly recommended that “the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity” be a fully covered benefit of all health insurance plans; and Whereas, the costs of contraception have long been identified as a barrier to many women’s optimal use of contraception, with negative impacts on their health and in terms of unwanted pregnancies, as well as discriminatory implications; and Whereas, the Federal administration has just mandated that contraception be a covered benefit, but health insurance industry representatives have voiced their opposition to this measure and might try to repeal it; now be it RESOLVED: That the California Medical Association supports the coverage, without co-payments, of all FDA-approved contraception methods and sterilization as a mandated health benefit of all health plans.

We suspected there might be some opposition at the CMA’s October meeting, but in the open debate, our draft policy was strengthened to include voluntary sterilization. It is a concise statement, regarding a private medical matter between women and their physicians. The importance of this mandate is highlighted by recent reports showing that religious control of hospitals in some areas is growing, with resultant restrictions on some services. Obviously the SFMS and CMA do not intend to wade into religious conflicts. But the specter of any organizations responsible for medical coverage being able to cherry-pick what they’d pay for—note that some faiths oppose transplants, vaccines, and so on—makes denying coverage of contraception a bad precedent.

Ironically, the same week that contraception hit the news, a report was released by the widely respected group Save the Children confirming the tragic fact that one out of four children are malnourished, and many of them are starving to death—at a rate of one every five minutes. Some would say these issues are related.

More recently, at least two more states have passed laws favoring disproven “abstinence-only” sex education—again, over the objection of medical groups (and educators, for that matter), and despite predictions that this will increase unwanted pregnancies and abortions in those states. A New York Times columnist labeled all this as “politicians swinging stethoscopes.”

Perhaps those opposed to contraception could more usefully direct their resources and energies toward the ongoing tragedies of starvation, unwanted pregnancies, and preventing abortion via proven approaches. To those ends, perhaps they could listen to what doctors know and think. But I won’t hold my breath.

April 2012 San Francisco Medicine

31

HOSPITAL NEWS KAISER

Veteran’s

CPMC

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Rokeach, MD

At Kaiser Permanente, we understand that chronic pain is a common condition with significant personal, financial, and health consequences. As an organization, we have developed guidelines and clinical protocols to help members with chronic pain to cope and function day to day. Locally, in San Francisco, our Chronic Pain Management Program uses a multidisciplinary team to offer members a variety of pain management treatments and self-coping skills to help relieve symptoms, allow a higher quality of life, and return them to routine activities.

Many adults who enroll in the Chronic Pain Management Program come to our medical center after having exhausted standard medical treatment options. The overarching goals of the program are adequate pain control, reduction in suffering, the establishment of effective social support, and improved functioning. This includes, when appropriate, the ability to work and carry out what are considered normal, daily living tasks.

Because chronic pain is a complex problem that requires more than one mode of care to manage, we take a multidisciplinary approach, which combines unique contributions from psychology, internal medicine, pharmacology, physical therapy, and acupuncture.

This combined effort has proven to be a very effective treatment modality for most people.

Chronic Pain Management Program participants learn a variety of nonpharmacologic pain management skills, including physical, psychological, and psychophysiological means.

By learning to reduce the suffering and interference associated with chronic pain, participants can experience a significantly increased quality of life and independence.

As part of the treatment plan, we offer participants pain education classes, which provide a comprehensive overview of pain management strategies that are essential to their overall well-being. Actively engaging members in their healing and management processes helps ensure more sustainable and successful outcomes.

Tenofovir, one of the most effective and commonly prescribed antiretroviral HIV/AIDS medications, is associated with a significant risk of kidney damage and chronic kidney disease that increases over time, according to a study of more than 10,000 patients, led by researchers at the San Francisco VA Medical Center. The principal investigator is Chief of General Internal Medicine Michael G. Shlipak, MD, MPH. Lead author is researcher and statistician Rebecca Scherzer, PhD. Tenofovir decreases viral load and increases immune cell count in people infected with the virus. It is currently considered the preferred first-line treatment for HIV because of its potency, overall low toxicity, and dosing convenience.

The study included an analysis of VA electronic health records. Findings revealed that for each year of tenofovir exposure, risk of protein in urine—a marker of kidney damage— rose 34 percent, risk of rapid kidney function decline rose 11 percent, and risk of developing chronic kidney disease rose 33 percent. These risks remained after controlling for other kidney disease risk factors such as age, race, diabetes, hypertension, smoking, and HIV-related factors.

Patients were tracked an average of 1.2 years after they stopped taking tenofovir.

They remained at elevated risk for at least six months to one year compared with those who never took the drug, suggesting the damage is not quickly reversible.

HIV increases the risk of kidney damage, while modern antiretroviral treatments clearly reduce that overall risk. For an otherwise healthy patient, benefits of tenofovir are likely to exceed risks. For patients with a combination of kidney disease risk factors, tenofovir may not be the right medication. Early detection is the best way to determine when tenofovir risks begin to outweigh the benefits.

The researchers call for increased screening for kidney damage in patients taking tenofovir, especially those with other kidney disease risk factors.

32 33

San Francisco Medicine April 2012

It’s a long way from Rwanda to the California Campus, but for fifteen-year-old JeanClaude Nshimyimana it was a life-changing trip. His mother was dead, his father was in prison, and Jean-Claude was living almost as a recluse because birth defects had left him with a cleft palate and other facial deformities. A Christian missionary group from the Bay Area changed all that. After befriending Jean-Claude, the group tried to arrange for CPMC plastic surgeon Roy Kim to fly out with a team to perform surgery in Rwanda. When that proved impossible to arrange, they flew Jean-Claude to the Bay Area, where Dr. Kim and a team of volunteers—all of whom donated their time in an operating room provided

by CPMC—repaired his cleft palate. Dr. Kim would like to thank the following individuals: Drs. Larry Feld, Eileen Aicardi, Ed Eisler, Bryant Toth, and Jordan Horowitz, plus all of the OR staff who helped with Jean-Claude’s case.

Jean-Claude has returned to Rwanda and we wish him all the best. For the full story, please go to http://www.sfgate.com/cgi-bin/article. cgi?f=/c/a/2012/02/04/MN5T1N2PPL.DTL. Congratulations to the many CPMC physicians who were recently named among Marin magazine’s Top Doctors for 2012. The rankings are based on surveys of more than 4,000 licensed doctors across all specialties in San Francisco and Marin counties.

All doctors on this list were both candidates and eligible voters in the peer-to-peer voting poll. Physicians were asked to vote for the physician(s) they considered to be the best in their field. Doctors were allowed to cast an unlimited number of votes across all specialties—they could vote for as many doctors as they wished, regardless of medical specialty—but they could only vote for the same doctor once. To see a complete listing of CPMC physicians who made the list, please log onto http://www.cpmc.org/about/press/ news2012/topdoctors.html.

www.sfms.org

HOSPITAL NEWS St. Mary’s

Saint Francis

Francis Charlton, MD

Patricia Galamba, MD

Pain is not only the most common complaint registered during a visit to the doctor but it is also the symptom that has been universally experienced by all of us. We have all felt pain at one time or another. It would seem that it should be relatively easy to treat a symptom both so prevalent and familiar.

We have a wide array of treatment modalities from which to choose: heat, ice, massage, PT, acupuncture, chiropractic, US, electromagnetic, and pharmacologic.

Treatment of pain with drugs is certainly the most challenging and complex path, albeit the path of least resistance from most patients. “Please, just give me a pill and make it better.” But is the pain acute or chronic, somatic or neuropathic, generalized or localized, musculoskeletal or visceral? What are the comorbidities? What else is the patient taking? Is there evidence of an addiction-/ abuse-prone personality type? What are the potential toxicities of the considered medications? Which method of delivery: topical, oral, or parenteral? Is it on the formulary?

We all want to do right by our patients, but it is not always readily apparent whether their requests for narcotics, for instance, is in their best medical interests.

Assembly Bill 507 stipulates that physicians who refuse to prescribe opiates for “pain or a condition causing pain, including, but not limited to, intractable pain” are required by law to inform the patient that there are physicians who do treat severe chronic intractable pain with methods that include the use of opiates. The American Cancer Society sponsored this bill to “eliminate ambiguities and inconsistencies in the Intractable Pain Treatment Act that negatively affect appropriate clinical interpretation.” The fact that legislation exists regarding pain management is telling in itself. Specialists are available. We should use them more often for the benefit of our patients.

www.sfms.org

SFMS Letter to Jerry Brown In January the SFMS sent the following letter to Governor Jerry Brown in support of the CURES program. This is just one example of how the SFMS is working to support physicians and their patients.

With this month’s theme on the subject of pain, I decided to corner one of my new young colleagues, Hoylond Hong, MD. Dr. Hong is a physiatrist who completed his residency in physical medicine and rehabilitation at Stanford University, followed by a pain medicine fellowship at the University of Michigan in Ann Arbor. Dr. Hong evaluates and treats acute and chronic pain patients in the Saint Francis Pain Center, located across the street from the main hospital. Dr. Hong and his colleagues treat patients with varying pain issues, from seemingly common musculoskeletal injuries to complex neurological disorders.

“Patients with pain can be challenging because of the subjective nature [of pain], and [they] are best cared for when a multidisciplinary approach is used,” says Hong. Incorporating additional providers and their expertise can be important in obtaining a diagnosis. “The first step in treating acute or chronic pain is developing a working diagnosis and determining the cause of the pain.

We have so many diagnostic tools, including imaging, nerve conduction with electromyography studies, etc. Getting a firm diagnosis permits us to treat the root issue rather than just symptoms.

We as patients have been programmed to simply take a pill to make our symptoms better and not necessarily address the underlying cause. Information and education are the most important tools we have in treating pain.” For now, our pain specialists use treatments including medications, physical and behavioral therapies, and diagnostic and therapeutic injections. The medication choices are diverse, including nonsteroidal antiinflammatories, anticonvulsants, muscle relaxants, and opioids, to name a few. Physical therapy can strengthen the body, and psychological therapy plays an important role in treating potential coexisting anxiety and depression. Injections can be both diagnostic and therapeutic and can often disrupt a patient’s pain cycle. According to Dr. Hong, “The best outcomes are from treatment programs specific to that patient, with a goal of optimizing function.” As we all know, everyone reacts differently to pain, and that‘s why it has become the fifth vital sign. Thanks, Dr. Hong, for sharing your thoughts and time.

January 13, 2012 Governor Jerry Brown c/o State Capitol, Suite 1173 Sacramento, CA 95814

Dear Governor Brown: On behalf of the San Francisco Medical Society (SFMS), I am writing to urge you to support the CURES (Controlled Substance Utilization Review and Evaluation System) program in the state of California. This program allows health care providers to track controlled substance prescriptions in order to prevent substance abuse and diversion. The program had nine staff members until recently, when all staff was cut as a cost-saving measure. One new staff member has been hired but has not yet been trained. As of the beginning of January 2012, there were 3,000 provider applications waiting to be processed.

The SFMS Board of Directors has agreed to support this position for the sake of our physicians and patients. This is directly in line with a resolution passed by the CMA House of Delegates and sent to the American Medical Association’s (AMA) House of Delegates, which recently adopted the resolution. It asks the AMA to promote physician training and competence in the use of controlled substances. The CURES program helps physicians prescribe controlled substances responsibly and prevent abuse of the health care system.

Thank you for your consideration in this matter.

Sincerely, Peter J. Curran, MD SFMS President

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April 2012 San Francisco Medicine

33

In Memoriam Catherine (Cathy) Kyong Ponce, MD, passed away on May 23, 2011, in San Francisco with her husband Bruce Ponce by her side. Cathy was born and raised in Shanghai in the 1940s and left to study in Taiwan through the efforts of her father and uncle. She completed her internship in internal medicine in St. John, New Foundland, in Canada and then went to work at the I.W.K. Children’s Hospital in Halifax, Nova Scotia. In 1974, Cathy received a fellowship at the University of Charleston in South Carolina, where she spent two years training in pediatric infectious disease and immunology and met her future husband. In 1984 the pair moved to San Francisco where she spent the reminder of her working as a solo private consultant in pediatrics and infectious disease.

Enrique Francisco Agorio, MD, MPH,

a retired pediatrician, passed away peacefully at his home in San Mateo on June 20, 2011, surrounded by his family. Born in Uruguay, he graduated from medical school in Montevideo.

He did his pediatric residencies at McGill University Montreal Children’s Hospital and the Jewish General Hospital in Montreal, Canada, and then held a position at Johns Hopkins Hospital in Baltimore, Maryland, while working on his MPH. Upon completion he moved to Los Angeles where he worked as a pediatrician and acting medical director at the East Los Angeles Child and Youth Clinic. In 1973, Enrique and his family moved to San Francisco where he began his private practice in the Mission District and served the community for over thirty years. He was a staff member at St. Luke’s Hospital and Seton Medical Center. Enrique enjoyed traveling, cooking and gardening; was an artist and a fantastic and animated storyteller.

Gilbert W. Cleasby, MD, a long-time

resident of San Francisco, was born in Everett, Washington in 1927. After obtaining a degree in pharmacy from the University of Washington and his MD degree from Northwestern University, Dr. Cleasby came to San Francisco in 1952 for internship at Letterman Hospital. Following military service in Korea, residency in ophthalmology at Stanford University and fellowship study at Columbia University, he joined Drs. Hans Barkan and Jerome Bettman in practice in San Francisco in 1958. Dr. Cleasby subsequently engaged in clinical practice and in teaching at CPMC until his retirement in 2000.

John C. Bennett, MD, chief of the radiology department at St. Mary’s Medical Center for nearly twenty-five years and a Catholic lay 34

leader active in charitable and civic organizations, died November 20, 2011, at his home in San Rafael. He was 90 years old. Dr. Bennett was a prominent Bay Area radiologist for four decades. He was also a clinical professor at UCSF, where he joined the faculty in 1953 and continued to teach until 2009. He served on the Board of Advisors of the Dominican School of Philosophy and Theology, Berkeley, and was a lector and long-time parishioner at St. Anselm’s Parish in San Anselmo. In recent years, he was a volunteer for Handicapables of Marin, which provides services for residents of Marin with physical or mental disabilities. Dr. Bennett enjoyed skiing, sailing and hiking. While in the army, he learned to fly light planes, and, in his 50s, became a licensed glider pilot. He is survived by his wife of fifty-three years and his four children.

Lawrence Joe, MD, passed away peacefully at home with his loving family by his side on October 27, 2011, at the age of 94. Dr. Joe practiced medicine until Dec. 31, 2010, when he finally decided to retire at the youthful age of 93. He served his Chinatown community in his medical practice at the same location on Pacific Avenue in San Francisco for sixty-four years. He was a native San Franciscan and a pioneer in Chinatown medical practices. He often made house calls in the early days of his practice and had the philosophy that if you took the time to tell the patient what you were trying to do to help him or her, he or she would cooperate more. He is survived by his loving wife of 67 years, Pearl, his sons, and their families.

Michael B. Bunim, MD, passed away on August 5, two days before his 67th birthday, after a long illness as a result of heart surgery in 2008 when he suffered an anoxic brain injury.

He graduated from Columbia University College of Physicians and Surgeons in 1969. In 1973, he completed his residency training in Internal Medicine at Kaiser San Francisco. From 1975 on, he was an instructor in Clinical Medicine at the UCSF. He had a private practice in medicine at Mt. Zion Hospital, then CPMC, and eventually returned to Kaiser in 1988 where he dedicated himself to his patients for over twenty years until his early retirement in 2009 due to the brain injury. He met his wife Cindy in 1983 when they both lived on Telegraph Hill in San Francisco.

After years traveling the world together, they moved to Marin County and got married. In 1995, Michael became a father when Alyssa was born and then again in 1997 when Jay was born.

His children were his greatest joy in life.

San Francisco Medicine April 2012

Ronald B. Low, MD, passed into the land of peace and tranquility on August 15, 2011. Ronald was born in San Francisco, a proud member for the brigade of Chinese American physicians born at Chinese Hospital and who subsequently returned to the community to work with its people. He attended public school, Lowell High School, UC Berkeley and then to Northwestern University of Medicine. He received his Pediatric training at UCSF and became Board certified in the practice of Pediatrics for thirty-five years. He was a longtime active member of the SFMS. Russell J. Tat, MD, Passed away peacefully

at home in February, 2011. Born in Seattle, Russell graduated from the University of Oregon Medical School, then came to San Francisco and married Carol Sherwin. He served in WWII, then returned to practice internal medicine and hematology. Russell was loved by his patients for his caring bedside manner, and his colleagues for his brilliance and sense of humor. He was associated with Mt. Zion Hospital for forty-five years.

He is survived by his wife, two children, and their families.

Samuel Lloyd Scarlett, MD, age 96, died

on November 2, 2011. Born in Suisun Valley, CA, he was married to Florence McCormack Scarlett for fifty seven years. A graduate of Stanford University Medical School, Dr. Scarlett was Chief Assistant Surgeon and a clinical professor at St. Bartholomew’s Hospital and Medical School in London, England, from 1942 to 1944. Dr. Scarlett practiced internal medicine and allergy and immunology at 490 Post for forty one years.

Vernon Clyde Harp, Jr., MD, passed away on October 12, 2011, at the age of 92. He was husband to the late Florence “Tookie” Grimm Harp and then Mary Margaret Casey Harp. He began his medical training by attending Cal Berkeley and then UCSF, before serving his internship at SF General. Vernon completed his residency in cardiology at UCSF before establishing his private practice at 490 Post, 450 Sutter, and then 4141 Geary Blvd. During this time, Vernon taught medicine at UCSF as an associate clinical professor. In 1954, Vernon joined the SFMS where he served as President in 1957. A skilled trumpeter, Vernon started playing at the age of six. Not only did he play, Vernon became an avid collector of historic brass horns when a friend gave him a flugelhorn that had been buried in a German village, hidden to avoid being melted down for munitions during World War II. Over the years, Vernon has collected and restored over 50 horns, which can all be played. www.sfms.org

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We Celebrate Excellence – Corey S. Maas, MD, FACS CAP Member and founder of “Books for Botox®” community outreach program, benefitting the libraries of local underfunded public schools

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