The Official Publication of the Southern Pain Society
Spring 2016

Mission Statement

The Southern Pain Society is a regional section of the American Pain Society.(APS) and endorses and supports the mission and goals of APS. The Southern Pain Society's missions are to serve people with pain by advancing research and treatment, and to increase the knowledge and skill of the regional professional community.
Save The Date!
Registration Is Now Open
Registration is now open for our annual Meeting "Pain Management:  Are We Doing Anything Right?"  You can download our brochure, register for the meeting and book your hotel room all from our website  In addition you will find information on submitting abstracts for our poster session 

We have an exciting lineup of faculty and topics of interest to primary care, pain management providers, psychologists, nurses and other healthcare disciplines.  See you in NOLA!
The CDC Opioid Guideline:  Much Ado About Something (Important)
Mordecai Potash, MD
President Elect, SPS
The on-line publication of the Center for Disease Control and Prevention's (CDC) new guidelines for prescribing opioids for chronic pain on March 15 th has generated tremendous emotional responses among our SPS membership. Unfortunately, panic, fear, and confusion appear to be the most predominant responses. This is not surprising given the wide publicity covering the publication of the guideline itself in the  Journal of the American Medical Association ( JAMA ) [1], and the five accompanying editorial featured in JAMA [2,3],  JAMA Internal Medicine [4],  JAMA Neurology [5], and  JAMA Pediatrics [6].

Any member looking at the "comments" section of the March 15th new story announcing the guideline's release will find that we are far from the only ones experiencing an intense response. I read the comments section of the New York Times' article and found hundreds upon hundreds of comments from its readership expressing dread, frustration, and fear. The most heart-wrenching comment posts were from patients themselves as well as from rural prescribers who wondered what their patients would do if they implemented the guidelines' recommendations in an immediate and unyielding manner. The comments were so impassioned and numerous that the Times (and other national news outlets) are doing follow-up stories on these very issues and are seeking input from physicians on what the impact of this new guideline will be on their own practice (see URL

Like many major medical publications that are featured widely by the press, some of the most pronounced fears are not supported by the JAMA publications themselves but rather are fanned by some news media's stories about the JAMA publications or by some viewers' comments about the news media's stories, or by some bloggers' pieces about the viewers' comments. Like an alarmist's version of Six Degrees of Kevin Bacon, we get more and more panicked by what we think the guideline states- but haven't read the guideline ourselves. So, 'Step One' in replacing panic with thoughtful and deliberative consideration is to get the guideline (and the main editorials) itself.

To this end, the staff at the CDC and JAMA want to make the guideline and editorial content available to all healthcare providers, whether or not they are subscribers to JAMA and its affiliated journals. Simply by opening the URL will take the user to JAMA's "Pain Collection" page where the guidelines, editorials, and very interesting other content on pain management are located.

After finishing reading the guideline, my first thought was "none of this surprises me". And, it should not surprise you too. Or, if you have been to a REMS seminar in the past two years it shouldn't surprise you. Or, it shouldn't surprise you if you have read the Federation of State Medical Boards' Model Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain [7]. Or, it shouldn't surprise you if you looked at the guideline summary of pocket cards from the 2010 VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain [8]. Or, it shouldn't surprise you if you looked at the 2011 Institute of Medicine's report Relieving Pain in America [9]. Or, it shouldn't surprise you if you have perused the opioid guidelines from the states of Washington [10] or Utah [11]. Or, it shouldn't surprise you if you skimmed the 2009 APS/AAPM's Clinical Guideline for the use of Chronic Opioid Therapy in Chronic Noncancer Pain [12] - especially since Dr. Roger Chou was a key author in both the CDC and APS/AAPM guidelines.

Catch my drift? The guideline reflects the advice made by leading pain management publications and presentations made for the past several years - advice that has featured prominently at several SPS meetings as well as other regional and national pain management meetings. Now, there are some different suggestions coming from the guideline and accompanying editorials - but most of the new suggestions appear in the editorials and not the guideline itself. Furthermore, I thought the editorial writers did a good job explaining that they were expressing their opinions in the editorials that were born out of their individual clinical, academic, and administrative experiences.
So, let's take a cleansing breath - count to ten - and look at some of this content. There are twelve major recommendations made by the CDC guideline. The guideline itself expands on the explanation and evidence for each recommendation. Dr. Mitchell Katz has turned these recommendations into a box for his editorial in JAMA Internal Medicine [4]. I will provide my own summary of these recommendations, knowing that the guideline and box is readily available to our membership:

1. Non-opioid therapies should be used first. If opioids are used, it should be in conjunction with non-opioid based treatments and only if benefits of opioid therapy outweigh risks.
2. Realistic treatment goals should be established prior to starting opioids. Treatment should continue if improvements in function outweigh risks of treatment.
3. Before starting opioids and periodically during treatment, prescribers must discuss patients' responsibilities in managing opioid therapy.
4. When starting opioid therapy, clinicians should use immediate release opioids. Dr. Katz later states that he only uses immediate release opioids, period. But, this is not what the guideline itself says. Rather, the guideline is referring to making sure that the patient meets the clinical recommendation for opioid tolerance as emphasized in all REMS trainings; with opioid tolerance defined as at least 60mg per 24 hours of morphine milligram equivalent daily dosing (MME) for at least one week. Furthermore, the REMS trainings emphasize the need to follow dosing and conversation guidelines carefully for each and every extended release-long acting opioid product [13].
5. When opioids are started - use the lowest effective dose. Reassess the benefit versus risk for doses above 50mg MME and particularly when the daily opioid dosage is at or exceeds 90mg MME. Other guidelines have had similar warnings about MME dosing such as 200mg MME for APS/AAPM and 120mg MME for Washington State.
6. For acute pain, use only immediate release opiates, if opiates are even needed. In acute pain, prescribe an amount of opiates to be used for 3 to 7 days and not longer.
7. Clinicians should reevaluate the benefit versus harm of each dose increase within four weeks. Stable patients without dose change should still be seen within every three months. Taper or discontinue opioids if harms outweigh benefits.
8. Before starting and periodically during opioid treatment, clinicians should carefully assess risk factors for overdose and mitigate risks such as pregnancy, elderly patients, hepato-renal insufficiency, patients with mental health and / or substance abuse issues. Risk mitigation can include referral to mental health colleagues as a condition of opioid treatment.
9. Clinicians should review their patients' prescription drug monitoring program report at the onset of treatment and periodically during treatment.
10. Clinicians should order a urine drug screen test when starting opioid therapy for all patients. A follow-up urine drug screen is advised for all patients at least annually.
11. Avoid prescribing benzodiazepines and opioids concurrently whenever possible.
12. Clinicians should refer patients to a credible medication-assisted opioid dependence treatment program for substance abuse treatment should the need arise.
Several discussion points are made in both the guideline and editorials. Including all these topics is not the point of my article, but I do want to mention the following:
* The intended audience for the guideline is primary care providers, not pain management specialists. That is not to say the guideline and editorials are not relevant to pain management specialists, but it is important to note that we are not the chief intended audience. The guideline itself states:

The "CDC Guideline, 2016," is intended for primary care clinicians (eg, family physicians, internists, nurse practitioners, and physician assistants) who are treating patients with chronic pain in outpatient settings. The guideline is intended to apply to patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians or dentists, but use in these settings or by other specialists is not the focus of the guideline.

* The evidence supporting eleven of the twelve recommendations was weak to very weak. The CDC uses a four level system of evaluating clinical evidence as the basis for its recommendations (the GRADE system). 'Evidence Type 1' is the best level of evidence and 'Evidence Type 4' is the worse level of evidence. No recommendation was supported by type 1, one recommendation was supported by type 2, four recommendations were supported by type 3 and seven recommendations were supported by type 4 evidence. The CDC acknowledges the major and glaring limitations supporting its recommendations. However, the growing crisis of opioid-related morbidity and mortality demanded that some recommendations (however tenuously supported) emerge from the guideline. The lack of evidence should come as no surprise as this was a major finding of the Institute of Medicine's report. However, the lack of evidence was not a reason for lack of action on the CDC's part. As Dr. Thomas Lee states in his JAMA editorial [3]:

Pain management will never be easy or straightforward, but it is an intrinsic element of any effort to reduce patients' suffering... The CDC guidelines offer important recommendations for addressing that issue. The data will never be perfect. The measures will never be perfect. The guidelines will never be perfect. And neither will clinicians and their performance. But by acknowledging these imperfections and trying to get better with the tools available, physicians can more effectively reduce the suffering of patients.

* Improved communication between clinician and patient is an indispensable part of opioid safety. For there to be a better patient understanding of the acute and long-term risks of opioid treatment, there must be better communication. For there to be a better prescriber understanding of the patient's risk factors and level of overall functioning, there needs to be better communication. For the goals of opioid therapy to be jointly shared and understood by both prescriber and patient, there needs to be better communication. It is only within the framework of better communication that risk mitigation and improved safety and effectiveness can occur. No prescription drug monitoring program report, no urine drug testing result, and no opioid risk tool can take the place of sound & careful doctor-patient communication.

* Both the guideline and editorials recognize that the recommendations made will tax our already limited time and resources. In particular, Dr. William Renthal points out in his editorial that alternatives to opioid therapy in patients who have not adequately responded to NSAIDS and analgesics are often effectively unavailable to most patients [5]. Whether it is the availability or coverage for multi-disciplinary pain management, behavioral pain management, physical therapy, or other forms of pain management treatment - many patients are totally shut out from these options due to lack of coverage or lack of qualified provider available. As unfair as this situation is, it does not permit us to continue "as is". Even if improved prescriber-patient communications lead to only a decrease in the sharing of opioids among friends and family, that one outcome alone will dramatically decrease opioid-related morbidity and mortality.

Although the CDC guideline reflects evidence and recommendations from previous guidelines, its publication is a watershed moment in pain management. It is the beginning of a period of reappraisal by the whole medical community on the problems that our national efforts to bring about better pain control have wrought. For any SPS member who has attended just one of our conferences or read one of our newsletters, these problems should be of no surprise. However, we persist in being advocates for patients with chronic pain, and the providers that try to reduce their suffering, because we know that our work is deeply important - that our patients' well-being and very lives depend on our persistence. At the same time, we must engage in a vigorous and on-going discussion on the problems that have clearly emerged in pain management. We do this to protect the gains that our field have made, as well as to reduce the hazards it has also uncovered. Please join us in future newsletters and conferences as we continue to wrestle with these issues.


[1] D Dowell, TM Haegerich, R Chou. CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016. Journal of the American Medical Association (JAMA). doi:10.1001/jama.2016.1464. Published online March 15, 2016.
JAMA Editorials
[2] Y Olsen. Editorial: The CDC Guideline on Opioid Prescribing Rising to the Challenge. JAMA doi:10.1001/jama.2016.1910. Published Online: March 15, 2016.
[3] TH Lee. Editorial: Zero Pain Is Not the Goal. JAMA doi:10.1001/jama.2016.1912. Published online March 15, 2016.
[4] MH Katz. Editorial: Opioid Prescribing for Chronic Pain Not for the Faint of Heart. JAMA Internal Medicine. doi:10.1001/jamainternmed.2016.0664. Published online March 15, 2016
[5] W Renthal. Editorial: Seeking Balance Between Pain Relief and Safety. CDC Issues New Opioid-Prescribing Guidelines. JAMA Neurology. doi:10.1001/jamaneurol.2016.0535. Published online March 15, 2016.
[6] NL Schechter, GA Walco. Editorial: The Potential Impact on Children of the CDC Guideline for Prescribing Opioids for Chronic Pain. Above All, Do No Harm. JAMA Pediatrics. doi:10.1001/jamapediatrics.2016.0504. Published online March 15, 2016.
Other References
[7] Federation of State Medical Boards. Model Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. in Pain Policies and Online Educational Activities. URL, accessed on 03/27/2016
[8] Veterans Administration and Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. URL, accessed on 03/27/2016
[9] P. Pizzo, N Clark, and Institute of Medicine report committee. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press; 2011. URL, accessed on 03/27/2016
[10] Agency Medical Directors Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy, 2010 Update. URL, accessed on 03/28/2016
[11] Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids, 2008. URL, Accessed on 03/28/2016
[12] R Chou et al. American Pain Society in conjunction with the American Academy of Pain Medicine's Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain, Vol 10, Issue 2, Pages 113-130.e22; February 2009.
[13] See "Section 2" for definition of opioid tolerance and "Section 6" for ER/LA titration/dosing guidelines of the Curriculum Slide Deck, 3 hour at URL From ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care. Provided by The Collaborative for REMS Education.

Nominations are Open!

Nominations are now open for the 2016 elections.  We have several positions available: President Elect and 2 at-large directors.  Each term runs for 2 years starting in January 2017. We hope you will consider running for one of these positions, and nominate yourself or a colleague.  Please send your nominations to by June 15th.

Increase Your Margin of Safety
Harry J. Gould, III, M.D., Ph.D.
Professor of Neurology and Neuroscience
LSU Health Sciences Center - New Orleans 

Over the last 20 years there has been a dramatic increase in the number of prescriptions being written for opioid analgesics for the management of chronic moderate to severe pain.  Unfortunately, the increased prescribing has resulted in a comparable increase in emergency room visits and deaths associated with overdoses following the inappropriate use of the medications provided.   Although it is often assumed that overdoses occur when medications are shared or abused, it is important to realize that many times overdose occurrences happen even when patients take medications as prescribed when they and their physicians are not fully aware of the inherent risks.
Overdose deaths associated with opioid medications generally occur when drug levels in the blood are high enough to suppress the body's drive to breathe resulting in fewer and less effective breaths being taken, i.e., respiratory suppression.  This causes a critical decrease in the amount of oxygen delivered to the tissues.   Clearly, the opioid contributions to respiratory suppression can be augmented when other sedating medications, like sleeping pills (benzodiazepines) or alcohol, are taken at the same time, but underlying conditions that compromise the respiratory system may also have a profound, albeit intuitively less obvious impact on one's ability to breathe.  Opioid medications, especially at high doses, can lead to chronically low levels of oxygen in the blood (hypoxemia) and can produce sleep apnea (spontaneous stoppage of breathing during sleep) or exacerbate this condition if it is already present.  Smoking and chronic obstructive pulmonary diseases like emphysema and asthma reduce the oxygen carrying capacity of the blood and place patients at added risk for opioid overdose.  Finally, the ability to breath is often significantly compromised at times when upper respiratory infections such as the flu and pneumonia are present.  The reduction in breathing efficiency at these times may be enough to effectively shift even a well tolerated dose of opioid medication into the toxic range.
Complications from opioid medications increase with increasing doses and chronic administration.  It should be remembered, however, that high doses are as much determined by the unique relationship between the individual patient and the drug taken as they are by the number of milligrams of drug taken.  Although standard guidelines state that doses exceeding 150 mg/day of morphine or doses of drugs with effects equivalent to 150 mg/day of morphine are high, many patients reach toxic levels at much lower doses.  Thus, safe and effective dosing must be individually determined.   Important history details related to prescription and over the counter medications currently being taken and to conditions that compromise respiratory function including asthma, emphysema, known sleep apnea, wheezing and snoring should be offered by the patient or elicited by the physician as a determinant of risk.  The development of snoring following the initiation of opioid treatment should not be ignored because it may well be an indicator of respiratory compromise.  Obesity is a frequent contributor to sleep apnea and should be taken into consideration prior to initiating opioid therapy.  Finally, it is important to report episodes of respiratory infections and with the guidance of the treating physician, consider lowering the dose of the opioid regimen while the infection is present.  
In the event that all attempts to identify potential risks fails to prevent an overdose and symptoms such as excessive drowsiness, difficulty to arouse, slowed or labored breathing or apneic events are observed, emergency overdose antidotes (naloxone injection) that can provide an important measure of time while obtaining emergency professional care are or will soon become available by prescription for home administration should the need arise.  Although this option has not been embraced by all parties, it seems prudent to discuss the risks and benefits of this treatment with your physician when considering embarking on a regimen of opioid therapy. 
Many unintended overdoses may be prevented if patients and their relations learn the risk factors, recognize the early signs of overdose and become active participants in the treatment.  It is hoped that the recognition of predisposing conditions will reduce the incidence of unintended negative outcomes and improve our ability to realize optimum quality of life. 

                          Upcoming Event
The University of Alabama at Birmingham presents NEW FRONTIERS OF PAIN RESEARCH In the 21st Century on October 14-15, 2015.  The fee for pre-registration will be $50 for faculty, staff and community members. No fees for students and trainees.  Read More

  Board of  Directors                  Committee Chairs             
President: Geralyn Datz, PhD                               E communication:  Geralyn Datz, Ph D      
President Elect:  Mordecai Potash, MD                Finance:  John Satterthwaite, MD             
Past President:  Leanne Cianfrini, PhD                Newsletter Editor:  Leanne Cianfrini, PhD    
Secretary:  Thomas Davis, MD                             Nominating: Leanne Cianfrini, PhD               
Treasurer:  John Satterthwaite, MD                      Program:  Mordecai Potash, MD
P. Lynn Bell, DO                                                    Executive Director:  Lori Postal, RN,, MHA
Jessica Merlin, MD 
Ann Quinlan-Colwell, PhD, RNBC                                 
Thank You
We hope you will enjoy future issues of the newsletter and will submit your articles, news of interest to the pain community and your comments. 

Bronze Supporter
Gold Supporter


Bronze Supporter

Southern Pain Society
PO Box 2764
Asheville, NC 28802
(828) 575-9275

Like us on Facebook    Follow us on Twitter