Funding Announcements

APS 2012 Future Leaders in Pain Research Grants Program Recipients

APS established the Future Leaders in Pain Research Grants Program to fund research projects of doctorally prepared investigators who have not yet attained NIH RO1 level funding. The program's intent is to encourage research in pain that will add to the body of knowledge and to allow investigators to develop pilot data that will aid them in securing additional major grant funding. In 2012, APS awarded four grants of $20,000 each.

APS is pleased to announce the 2012 grant recipients:

Burel R. Goodin, PhD
University of Alabama-Birmingham
Birmingham, AL
"The Effects of Intranasal Oxytocin on Pain Sensitivity, Endogenous Pain Processing and Mood: A Randomized, Placebo-Controlled, Crossover Study"

Adam T. Hirsh, PhD
Indiana University–Purdue University Indianapolis
Indianapolis, IN
"The Influence of Patient Race, Provider Bias, and Contextual Ambiguity on Opioid Treatment Decisions"

Ohannes K. Melemedjian, PhD
University of Arizona
Tucson, AZ
"Mechanisms of Dysfunctional Mitochondria Evoked Pain"

David A. Seminowicz, PhD
University of Maryland
Baltimore, MD
"Brain Networks in a Rodent Model of Neuropathic Pain"

Rita Allen Foundation and APS Announce the 2013 Rita Allen Foundation Award in Pain: Applications Open November 1

The Rita Allen Foundation (RAF) and APS announce the 2013 Award in Pain. The RAF and APS may award two grants each in the amount of $50,000 annually for a period of up to 3 years to those research proposals demonstrating the greatest merit and potential for success.

Candidates must have completed their training and provided persuasive evidence of distinguished achievement or extraordinary promise in basic science research in pain. Candidates should be in the early stages of their career with an appointment at faculty level. The entire award is to be allocated to projects specifically chosen by the recipient. Overhead is not supported.

To learn more about the RAF Award in Pain, please visit the APS website where additional details and an application link will be posted beginning November 1.

Education

APS 2013 Save the Date

Join us in the Crescent City for next year's APS 32nd Annual Scientific Meeting May 8–11, 2013. For more information and updates, visit www.APSScientificMeeting.org.

Travel Funding for Young Investigators

APS is planning to offer the Young Investigator Travel Award for the 2013 meeting. A limited number of funding awards will be available to individuals presenting poster abstracts at the APS Annual Scientific Meeting, May 8–11, 2013, in New Orleans, LA. Applicants may be from any research training background (basic or clinical science, psychology, medicine, or biostatistics) and at any level in training, including students, residents, predoctoral trainees, postdoctoral fellows, or those who have completed their postdoctoral training with the past 3 years. All applicants must be APS members and must have an abstract accepted for presentation. Applications from nonmembers will not be considered.

The Young Investigator Travel Award application will be available on the APS website beginning December 14. To apply for funding, visit the APS website and complete the online application. Note that an applicant's abstract must be accepted for presentation in order to be eligible to submit an application for the Young Investigator Travel Award. The listing of accepted abstracts, by primary author, will be available on the APS website in late December. Please check the abstract acceptance list before applying for a Young Investigator Travel Award. Applications must be completed online by January 24, 2013. If you have difficulty completing the application, contact APS at 847.375.4715. Applications will be reviewed by the APS Scientific Program Committee, and recipients will be notified and awarded stipends in late February 2013. Those applicants selected for the 2013 meeting will receive their travel grants at the APS Annual Scientific Meeting.

Members

What is your area of specialty?
I work in the field of human pain neurophysiology. I am particularly interested in explaining biopsychological processes from a mechanistic point of view. For example, I have long been interested in placebo effects as they apply to healthy adults and to clinical pain populations. I am also very much interested in better understanding the neurophysiological changes associated with functional pain syndromes, such as fibromyalgia. Finally my work applies sophisticated electrophysiological recordings, including electromyography (EMG), galvanic skin response (GSR), and electroencephalography (EEG) recordings with source localization of brain generators.

What initially sparked your interest in working in your field? Briefly describe your career path.
My interest in the field of pain was sparked as I was finishing my PhD in cognitive aging at Concordia in Montreal and as I was completing my clinical training in neuropsychology. At the time, I realized I wanted to dedicate my career to research and was introduced to the field when I followed a course under the tutorship of Dr. Pierre Rainville at Université de Montreal. He quickly introduced me to Dr. Serge Marchand at Université de Sherbrooke, and from that point on I realized how critical the experience of pain and the suffering caused by prolonged pain is to our well-being. The fit with my background in psychology and neuroimaging seemed natural to me. I dedicated the rest of my (still young) career to exploring the phenomenon of pain in humans. Allow me to mention that the enthusiasm for research in pain communicated by both Drs. Rainville and Marchand was contagious and played a key part in sparking my interest in this field. I try to remember the importance of good mentorship and the importance of communicating passion for research as I supervise my own students.

What has been a highlight of your work? Perhaps you and your staff are proud of a certain project or accomplishment.
One of the projects I am particularly proud of is the very first research project I completed in the field of pain, where we showed that not only expectations of pain (i.e., more or less pain) modulate the subjective experience of pain (so far nothing new), but also the strength of descending pain inhibitory circuits originating in the midbrain and affecting spinal nociceptive transmission at multiple levels of the spinal cord (very new). Thus we were among the first to show that expectations do more than just influence the private experience of pain. Expectations also influence spinal nociceptive transmission before painful afferents even reach the brain. We published this finding in "Descending Analgesia: When the Spine Echoes What the Brain Expects" in PAIN back in 2007. Feedback from this publication has been tremendously positive.

Is there a particular challenge that you've either overcome or hope to address soon?
My future objective is to tackle the very tricky problem of predicting the development of refractory chronic pain. Why is it some of us evolve from acute to chronic pain states whereas others seem immune to this developmental trajectory? I want to apply pain neuroimaging to the mix of predictive variables and have already begun projects in this particular area of pain research. The future for patients looks promising as many of us are interested in bridging the gap between bench and bedside.

How has membership in APS been of value to you and your professional development?
APS membership and, in particular, annual APS meetings are a great way to keep up with the latest research and clinical advancements. Moreover, they are an excellent venue for networking and getting to meet people whose work you admire. I don't miss many meetings and certainly plan to attend many more in the future.

Member Benefit

Advocacy
APS has identified a broad agenda of pain issues. The APS Strategic Goals advocate to improve the care of patients with pain in numerous arenas. The society's goals in this activity are to advance the treatment of people in pain by ensuring access to treatment, removing regulatory barriers, and educating practitioners and policy makers in all settings about advances and economics of effective pain treatment.

• The APS Strategic Goals include

• establishing pain as a major health problem
  
• advocating for the prevention or relief of unnecessary pain
  
• promoting multidisciplinary research to increase knowledge of pain and pain relief mechanisms.

• Pain Care Coalition

• APS, the American Academy of Pain Medicine, and the American Association for the Study of Headache formally organized the Pain Care Coalition (PCC) in June 1998. The mission of the PCC is to work to influence federal healthcare policy via legislative, regulatory, and research avenues on behalf of people with pain by addressing quality-of-care and access-to-care issues.

• Position Statements: APS may choose to address controversial policies or significant clinical matters by publishing a position statement. View APS position statements here.

• Washington Wire on Health Care Issues: Subscribe to the Washington Wire on Health Care Issues, an e-mail and Web-published newsletter reporting highlights of important federal developments in health law and public policy. View the most recent issues of the Washington Wire.

Summaries

The Journal of Pain Highlights

The following highlights summarize selected articles from November 2012 (Volume 13, Issue 11).

Yoga Shown Effective for Treating Chronic Neck Pain
Andreas Michalsen, Hermann Traitteur, Rainer Lüdtke, Stefan Brunnhuber, Larissa Meier, Michael Jeitler, Arndt Büssing, and Christian Kessler; Charité University Medical Centre and Immanuel Hospital, Berlin, Germany

According to estimates, some 20% of the population suffers from chronic neck pain caused by a variety of structural dysfunctions in the neck, resulting in impaired quality of life and lost work time. A German study published in The Journal of Pain showed that yoga appears to be an effective treatment for neck pain and provides added benefits of improved psychological well-being and quality of life.

The mainstay of conservative treatment for neck pain is non-steroidal anti-inflammatory medication, and the evidence of its effectiveness is contradictory while negative side effects, such as hypertension and dizziness are well known. The authors noted that one type of yoga, lyengar yoga, has been shown effective in other pain syndromes, including low back pain. This activity uses supportive props and its sequences of postures can be tailored to address an individual’s medical problem. However, to date, no randomized controlled clinical trials have been published to assess the efficacy of lyengar yoga for adults with chronic neck pain.

Researchers at Charité-University Medical Center in Berlin and other sites in Germany and Austria studied 77 volunteer patients. Thirty-eight were assigned to the yoga group and 39 to a group treated with exercise. Unfortunately, the dropout rate was higher than anticipated as 24 subjects withdrew or were lost to follow-up. This reduced the study sample to 25 patients in the yoga group and 28 in self-care exercise. They were asked to complete a standardized questionnaire at the outset of the study, and after 4 weeks and 10 weeks of treatment.

The findings showed there was a significant and clinically important pre- to post-treatment reduction in pain intensity in the yoga group. The authors reasoned that yoga might enhance both the toning of muscles and releasing of muscle tension. Relaxation responses, therefore, could reduce stress-related muscle tension and modify neurobiological pain perception. They concluded, based on the study data, that lyengar yoga can be a safe and effective treatment option for chronic neck pain. The study results are consistent with the demonstrated benefits of yoga for treating low back pain.

High-Dose Opioid Treatment Associated with Mental Health and Medical Comorbidities
Amy M. Kobus, David H. Smith, Benjamin J. Morasco, Eric S. Johnson, Xiuhai Yang, Amanda F. Petrik, and Richard A. Deyo; Oregon Health and Sciences University

Most patients taking opioids for low back pain or other pain syndromes are prescribed low-to-moderate doses, but a substantial number are given higher doses. However, there is no consensus on an absolute limit because tolerance varies over time among individual patients. What is known, however, is higher does are associated with elevated risks for side effects, addiction, overdoses, and death. A study published by Oregon Health and Sciences University in The Journal of Pain showed that patients on higher doses of opioids had higher rates of psychiatric problems, co-prescriptions of sedatives, and healthcare services utilization.

For the study, the research team sought to examine correlates of higher dose opioid use among patients in primary care settings being treated for low back pain. The goals were to determine the prevalence of higher dose opioid prescribing, identify the demographic and clinical characteristics of patients receiving higher doses, and examine health services utilization patterns among high-dose users.

Electronic pharmacy and medical records were examined for 26,000 adults 18 and older diagnosed with low back pain, of which 61% received an opioid prescription. Among patients receiving long-term opioid treatment, nearly 9% received a higher dose in their final prescription. Patients receiving higher doses of opioid therapy were prescribed a median daily dose of 180 mg per day, which was 7 times greater than patients receiving lower doses.

The analysis showed that patients with chronic pain with comorbid psychiatric diagnoses were more likely to be prescribed opioids compared with patients without psychiatric problems. The authors found that the prevalence of mental health diagnoses increases with longer duration of opioid use. Studies have indicated a relationship between depression and persistent pain and that each could have a causative influence on the other. Thus, depression may lead to more opioid use and opioid use may cause or exacerbate depression. The authors concluded their results should prompt physicians to screen opioid therapy candidates for mental health and substance use disorders.

Another finding reported in the study showed that patients in the higher dose group were frequent consumers of medical services, including visits to emergency departments. Also, higher dose patients had the largest number of different prescribers, which could indicate continued uncontrolled pain, continuity of care problems, or “doctor shopping.”

Sigma-1 Receptors May Have Therapeutic Value for Neuropathic Pain
Francisco Rafael Nieto, Cruz Miguel Cendán, Cristina Sánchez-Fernández, Enrique José Cobos, José Manuel Entrena, Miguel Angel Tejada, Daniel Zamanillo, José Miguel Vela, and José Manuel Baeyens; University of Granada, Granada, Spain

A first-line chemotherapy drug, paclitaxel, is used to treat several cancers but frequently causes painful peripheral neuropathies. There are no established treatments to counteract the neuropathies, but models of paclitaxel-induced neuropathic pain in rodents allow for testing of new treatments.

Researchers at the University of Grenada in Spain explored the role that Sigma-1 receptors play in central sensitization and in models of mechanically induced neuropathic pain. They evaluated the preventative effect of repeated systemic subcutaneous administration of Sigma-1 receptor antagonists on the development of cold and mechanical allodynia in mice. They also tested whether acute administration of receptor antagonists reversed both types of paclitaxel-induced allodynia.

The main findings of the study showed that pharmacological and genetic knockout of Sigma-1 receptors inhibit neuropathic pain induced by paclitaxel in mice. This research provides the first available evidence that Sigma-1 receptors are involved in chemotherapy-induced neuropathic pain. The results raise the possibility of using the blockade of Sigma-1 receptor dependent mechanisms as an approach to preventative treatment of chemotherapy-induced neuropathic pain.

Pain Medicine Highlights

The following highlights summarize selected articles from October 2012 (Volume 13, Issue 10).

Reliability and Validity of Individual and Composite Recall Pain Measures in Patients with Cancer
Mark P. Jensen, Wei Wang, Susan L. Potts, and Errol M. Gould; University of Washington Department of Rehabilitation Medicine, University of West Chester; Endo Pharmaceuticals, Inc.

Recall ratings of pain intensity ("How would you rate the average intensity of your pain in the past week?") are commonly used in pain clinical trials. However, research conducted during the past decade has called into question the validity of such ratings. In particular, there is evidence that patients tend to overestimate the pain they experienced in the past.

This study sought to expand knowledge regarding the validity and reliability of recall pain intensity measures, with particular interest in the psychometric properties of a characteristic pain score created from the recall ratings of worst, least, and average pain. Using data from a published 14-day open-label crossover trial that included both multiple measures of current pain assessed each day and 2-day recall ratings assessed on the 7th and 14th day, researchers compared the reliability and validity of recall pain ratings with scores of "actual" pain derived from diary ratings. They hypothesized that the 2-day recall ratings of least, worst, and average pain would show a negligible overestimation (i.e., between 0 and 10 points on a 0–100 scale) of actual least, worst, and average pain scores derived from the responses in the daily diaries. They also hypothesized strong correlations (rs = ~0.79) between recalled and actual least, worst, and average pain. Finally, they hypothesized that the internal consistency of scores made up of multiple ratings would be high and similar to each other.

This study revealed four key findings. First, the recall ratings of least, worst, and average pain and a recall characteristic pain score were all negligibly higher than the "actual" scores of these intensity domains derived from the diaries. Second, all of the 2-day visual analog scale (VAS) recall measures of pain intensity demonstrated strong associations with the actual pain intensity scores derived from the diaries. Third, all of the pain intensity measures, including both recall ratings and measures derived from daily diary ratings, evidenced high levels of test-retest stability from 1 week to another. Fourth, the composite scores of average pain from individual VAS measures from the diaries tended to have stronger test-retest stability than the recall measures did. All of the composite scores representing usual pain, including a composite score of characteristic pain made up of three VAS recall ratings, evidenced very high levels of internal consistency.

These findings have important implications for the selection of pain intensity measures in clinical trials and raise important questions regarding the validity and reliability of pain intensity measurement.

How Does Use of a Prescription Monitoring Program Change Medical Practice?
Traci C. Green, Marita R. Mann, Sarah E. Bowman, Nickolas Zaller, Xaviel Soto, John Gadea, Catherine Cordy, Patrick Kelly, and Peter D. Friedmann; Rhode Island Hospital Department of General Internal Medicine; The Warren Alpert Medical School at Brown University; The Miriam Hospital; Connecticut Department of Consumer Protection; Rhode Island Department of Health Board of Pharmacy

Increases in fatal overdose and opioid-related emergency department visits and hospitalizations since the mid-1990s have been driven by a substantial growth in opioid analgesic prescriptions and nonmedical use of prescription opioids, among other variables. In Rhode Island and Connecticut, overdose has surpassed motor vehicle crashes to become the leading cause of unintentional injury death.

Prescription monitoring programs (PMPs) are an emerging tool with potential to influence risks to patients associated with abusable medications, especially prescription opioids. PMPs offer more detailed information than patients themselves or single-institution medical records often provide.

The aims of this study were to test for differences in PMP use in Rhode Island and Connecticut, which offer different levels of PMP prescriber accessibility; to explore the ways in which clinicians use PMP patient reports in clinical practice; and to examine the association between PMP use and clinician's responses in instances of suspected doctor shopping or diversion.

This survey found that for healthcare professionals with electronic PMP access (as is available in Connecticut), more than 50% use it at least monthly, whereas only 16% of those who have to call, send a fax, or provide a written request to access a PMP (as is necessary in Rhode Island) use the program at least monthly. Healthcare professionals accessing electronic PMP data tend to use it to screen for abuse and doctor shopping and as a clinical tool for discussing a patient's health status. The form of the PMP was critical to its uptake; a paper-based PMP in Rhode Island was accessed to a far less extent than the electronic PMP in Connecticut.

Findings indicate that PMP users take a more active approach to detecting abuse and doctor shopping in their practices than nonusers, and the tools employed and responses to detected concerns prioritize medical over legal action. When facing a suspicious pattern of behavior in a patient, PMP users in this study were more likely to screen for drug abuse, refer to treatment or to another provider, and revisit a pain treatment agreement, and they were less likely to employ inappropriate actions (such as initiating a treatment agreement after a concern about diversion or doctor shopping was raised), decide in favor of inaction, or engage law enforcement. Results indicate a need for better communication to providers about PMPs, user-friendly education materials, and continuing medical education content.

PAIN Highlights

The following highlights summarize selected articles from November 2012 (Volume 153, Issue 11).

Experimental Hypoglycemia is a Human Model of Stress-Induced Hyperalgesia
Christopher H. Gibbons, Gail K. Adler, Istvan Bonyhay, and Roy Freeman; Harvard Medical School Beth Israel Deaconess Medical Center Department of Neurology; Harvard Medical School Brigham and Women's Hospital Department of Medicine Division of Endocrinology, Diabetes and Hypertension

Hypoglycemia is a physiological stress that leads to the release of hormones such as catecholamines, glucocorticoids, and proinflammatory cytokines. In euglycemic animal models, these factors are associated with stress-induced hyperalgesia.

An episode of hypoglycemia results in neurobiological changes that may persist for days. Antecedent hypoglycemia impairs the counterregulatory metabolic and autonomic responses to subsequent hypoglycemia, increasing susceptibility to a vicious cycle of recurrent hypoglycemia.

These researchers hypothesized that the stress of antecedent experimental hypoglycemia would result in a posthypoglycemic state characterized by enhanced pain sensitivity consistent with stress-induced hyperalgesia. In two separate 3-day admissions separated by 1–3 months, healthy study participants were exposed to two 2-hour euglycemic hyperinsulinemic clamps or two 2-hour hypoglycemic hyperinsulinemic clamps. Thermal quantitative sensory testing and thermal pain assessments were measured the day before and the day after euglycemia or hypoglycemia.

This study's results demonstrate that experimental hypoglycemia evoked by exposure to a hypoglycemic hyperinsulinemic clamp results in enhanced pain sensitivity to a cold stimulus, enhanced pain sensitivity to a warm stimulus, and enhanced temporal summation to repeated heat pain stimuli. These data suggest that antecedent hypoglycemia gives rise to a state of enhanced pain sensitivity that is consistent with stress-induced hyperalgesia. These findings may have implications for understanding functional pain disorders such as fibromyalgia, interstitial cystitis, and irritable bowel syndrome, which have a well-established association with stress and may in some patients represent central sensitization.

Predictors of Postoperative Movement and Resting Pain Following Total Knee Replacement
Barbara A. Rakel, Nicole Petsas Blodgett, M. Bridget Zimmerman, Nyla Logsden-Sackett, Charles Clark, Nicolas Noiseux, John Callaghan, Keela Herr, Katharine Geasland, Xiaoyan Yang, and Kathleen A. Sluka; The University of Iowa College of Nursing: The University of Iowa College of Public Health Department of Biostatistics; The University of Iowa College of Medicine Department of Orthopedics and Rehabilitation; The University of Iowa College of Medicine Department of Physical Therapy and Rehabilitation Science

More than 500,000 total knee replacements (TKRs) are performed each year in the United States. The pain caused by this procedure can be severe during the immediate postoperative period, and the severity of this early pain is predictive of persistent pain 4–22 months following knee arthroplasty. Movement pain, which is more severe than resting pain, significantly correlates with a patient's ability to perform postoperative recovery activities, and accounts for a significant portion of the variance in functional outcomes 2 months after orthopedic surgery.

The purpose of this study was to determine which preoperative characteristics predict moderate-to-severe movement and resting pain immediately following TKR using a comprehensive set of physiological and psychological variables. Researchers hypothesized that younger patients with higher preoperative pain intensity, pain sensitivity, trait anxiety, pain catastrophizing, and depression would be more likely to experience moderate-to-severe postoperative movement pain than older patients with lower scores on these variables preoperatively, and that these predictors would be similar for resting pain.

Participants were asked to rate the pain in their surgical knee on a vertical, 21-point numerical rating scale (NRS) upon which 0 indicated "no pain" and 20 indicated "the most intense pain imaginable."

Movement pain on postoperative day 2 highly correlated with resting pain, suggesting that movement pain is additive and builds on the level of resting pain. High preoperative pain was a significant predictor of high pain (at rest and during movement) following TKR. Screening positive for depression prior to surgery also was a significant predictor of postoperative resting pain and postoperative movement pain when preoperative movement pain was removed from the analysis.

These results suggest that younger patients with higher preoperative pain and depression are more likely to have more pain following TKR. Pain catastrophizing and anxiety were not predictive of postoperative pain as hypothesized. Efforts to prevent or decrease preoperative pain, cutaneous pain sensitivity, and depression, such as earlier surgery or aggressive use of combination therapies prior to surgery, may facilitate postoperative pain control and improve functional outcomes following TKR.

Research

Call for CCOE Applications

Applications are now being accepted online for the APS Clinical Centers of Excellence (CCOE) in Pain Management Awards. The CCOE Program annually awards the APS Center of Excellence mark to interdisciplinary healthcare teams that provide the most distinguished, comprehensive pain care. Pain management programs from across the United States, large and small, rural and urban, community and university-based, are all eligible to apply. Selection of awardees is based on judgment of the quality of services provided and not the size or type of the program.

The 2007, 2008, and 2009 CCOE program recipients who have not already received the award for a second time are eligible to apply. Past recipients must provide evidence of sustained excellence and fulfillment of CCOE assessment criteria.

APS has recognized 33 Clinical Centers of Excellence since its inception in 2007. This distinction is one of APS's highest honors in the area of clinical treatment. To learn more about the program, past recipients, and how to apply, visit the APS website. The application deadline is November 30.

In the Media

Botox Shows Promise Against Persistent Neck, Shoulder Pain (U.S. News & World Report)

Parents May Be Taking Concussion Symptoms Too Lightly: Survey (U.S. News & World Report)

Unrealistic Fear of Surgery Prevents People from Getting Even Basic Back Pain Help (MSNBC)

FDA Approves Drug for Earlier-Stage Arthritis Treatment (Fox News)

Experts Suggest Lower Initial Doses of ER Oxymorphone in Elderly (Pain Medicine News)

FDA Warns of Risk for Death from Codeine Use in Some Children Following Surgeries (Pain Medicine News)

Vitamin D Battles Aromatase Inhibitor–Induced Joint Pain (Pain Medicine News)

For Shoulder Block, Site May Not Matter for Patient Satisfaction (Pain Medicine News)

New York Law Targets Painkiller Abuse (Anesthesiology News)

Up to 1 in 6 Patients Report Pain 12 Months Postsurgery (Anesthesiology News)

Drug Shortages Spark Use of Compounders (MedPage Today)

Is Immediate and Long-Term Pain After a Motor Vehicle Collision Hereditary? (Science Daily)

Foot, Knee, and Hip Pain a Problem in Obese Children (Science Daily)

Chronic Electrical Stimulation at Acupressure Points May Relieve Stomach Woes for Diabetics (Science Daily)

Abuse of Nonmedical Analgesics Up 40% (Medical News Today)

Honeybee Bites Can Act as Anesthetics (Medical News Today)

Animal Study Suggests that Social Contact May Ease Pain Related to Nerve Damage (Medical News Today)

Instant Pain Relief for Burns Provided by New Dissolvable Oral Strip (Medical News Today)

Call for Submissions

Do you have a topic that is relevant to APS members? Is there a member who is doing work that APS should spotlight? Is there a funding opportunity APS members need to know about? Please submit stories, events, and more to enews@americanpainsociety.org for consideration.