Society

Mayday Scholarship Announcement

The Mayday Fund announced the selection of six experts in pain management to be named fellows of The Mayday Pain & Society Fellowship. The Fellowship provides leaders in the pain management field with tools and skills to advocate on behalf of better treatment for pain. Fellows learn how to better communicate with media and policymakers and raise visibility for their issues. Four of the recipients are APS members including

• Aaron Gilson, PhD MS MSSW, research program manager and senior scientist, University of Wisconsin Pain and Policy Studies Group

• Renee C. B. Manworren, PhD APRN PCNS-BC, nurse scientist, Division of Pain and Palliative Medicine, Connecticut Children's Medical Center; assistant professor of pediatrics, University of Connecticut School of Medicine

• Lisa M. Peters, MN RN-BC, clinical nurse specialist, Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital

• Seddon Savage, MD MS, medical director, Chronic Pain and Addiction Treatment Center, Silver Hill Hospital; director, Dartmouth Center on Addiction Recovery and Education, Geisel School of Medicine at Dartmouth

For more information or to view the press release announcement, visit the Mayday Fund website.

Collaborative on REMS Education: Action & Progress

The American Pain Society (APS) is playing a critical role in what will be an exciting and far-reaching response to the recent Food and Drug Administration's (FDA's) long-acting/extended-release opioid Risk Evaluation and Mitigation Strategies (REMS) educational requirement. In direct cooperation with multiple professional and related organizations with extensive interest in pain care as its partners, APS helped to create the Collaborative on REMS Education (CO*RE) and is poised to make significant contribution in pain education.

CO*RE will design, implement, and evaluate a competency-based curriculum, rooted in a comprehensive assessment of learner needs and based in clinical evidence and the principles of adult education. Targeting the primary care prescriber audience, CO*RE has developed both an online self-directed series of learning modules as well as the instructional framework for use in presenting this information live. Both will be available in early 2013, and it will be featured at a special session at the APS 32nd Annual Scientific Meeting in New Orleans.

The 10 CO*RE partners include

• American Academy of Hospice and Palliative Medicine (AAHPM)
  
• American Academy of Nurse Practitioners (AANP)
  
• American Academy of Physician Assistants (AAPA)
  
• American Osteopathic Association (AOA)
  
• American Pain Society (APS)
  
• American Society of Addiction Medicine (ASAM)
  
• California Academy of Family Physicians (CAFP)
  
• Healthcare Performance Consulting (HPC)
  
• Interstate Postgraduate Medical Association (IPMA)
  
• Nurse Practitioner Healthcare Foundation (NPHF).

The cooperative organizations that will support the interests of this initiative and seek to help distribute the content include

• American Academy of Family Physicians (AAFP)
  
• Council on Medical Specialty Societies (CMSS)
  
• State Medical Society Consortium (of 21 State Medical Societies).

Ongoing conversations with additional member organizations continue.

APS members were significant contributors to the development of the competency-based curriculum initially proposed to the FDA and more recently on the creation of content for the instructional modules aimed at addressing the FDA Blueprint.

Funding for this initiative will come in the form of educational grants from opioid manufacturers as will the decision on who receives these awards. CO*RE submitted a comprehensive grant submission in late September on behalf of its partners and more than 1 million members.

Clinical

CDC: Meningitis Outbreak Cases Climb to 119

The scope of the fungal meningitis outbreak is widening, with 137 cases in 10 states. As of October 12, the Centers for Disease Control and Prevention (CDC) reported 12 deaths from the outbreak tied to an epidural steroid injection. The rare form of meningitis has been linked to three lots of a steroid used to control back pain (read more).

Funding Announcements

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.

Call for New APS Grant Open Until October 15

APS is accepting applications for its new Sharon S. Keller Chronic Pain Research Grants program. The program was established by private investor David Keller in memory of his wife who died in 2011 and is supported by others who knew her battle with cancer, rheumatoid arthritis, chronic musculoskeletal pain, and the side effects of pain medicines. The program will award $150,000 in up to four 2-year research grants for eligible APS members who are within 6 years of completing their doctoral degrees toward projects with a high likelihood of leading to new treatments or increased or expanded access to treatment options. Applications are due by 12 am EST on October 15. Further information on the program eligibility and guidelines is available at www.ampainsoc.org/kellergrant.

Education

Save the Date for the 2013 APS Annual Scientific Meeting

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.

Submit Your Poster Abstract for the New Orleans Meeting

The Call for Poster Abstracts for the APS 32nd Annual Scientific Meeting in New Orleans, LA, is now available on the APS website. Abstracts can be submitted until 11:59 pm Pacific Time on Monday, November 5.

Please visit the Call for Poster Abstracts page to access the submission requirements and forms.

Summaries

The Journal of Pain Highlights

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

Geographic Variation in Opioid Prescribing in the U.S.
Douglas C. McDonald, Kenneth Carlson, and David Izrael; Abt Associates, Inc., Cambridge, MA

Regions of the United States with the highest rates of opioid pain medication prescribing are disproportionately represented in Appalachia and in western and southern states, according to research reported in The Journal of Pain.

In recent years, most attention related to opioids has been focused on the increasing epidemic of their abuse and little analysis has delved into the extent and underlying reasons for geographical differences in opioid prescribing in the United States. This study examined a large database of more than 135 million opioid prescriptions dispensed in 2008 by some 37,000 retail pharmacies. The research objectives were to determine if the prevalence of opioid prescribing varies significantly among states and counties and how much of the variations are attributable to differences in socioeconomic characteristics, patterns of healthcare utilization, prescriber availability, and state polices on prescribing monitoring.

Results of the analysis showed that for opioids prescribed nationwide in 2008: hydrocodone accounted for 53% of prescriptions; oxycodone, 21%; tramadol, 10%; propoxyphene, 9%; and codeine, 7%. Seventy-seven percent of the prescriptions were covered by third-party insurers, 8% were covered by Medicaid, and 15% were cash sales.

The study, conducted by Abt Associates of Cambridge, MA, concluded that geographical variation in opioid prescribing is explained by several factors not exclusive to one another. Counties with the highest prescribing rates for opioids were disproportionately located in Appalachia and in western and southern states. The number of available prescribers was the strongest predictor of prescription totals, but only one-third of the measured variation was explained by variables examined by the researchers. Also, geographic variation in prescribing for oxycodone was higher than other frequently prescribed opioids. However, the authors noted that aggressive marketing of extended-release oxycodone does not explain the overall increase in oxycodone prescribing and the geographic variation.

The study concluded that widespread geographic variation in opioid prescribing does not reflect difference in the prevalence of injuries, surgeries, and conditions requiring analgesic treatment. Low prescription rates could indicate undertreatment of pain while high rates could account for overprescribing and insufficient attention to risks for misuse. The wide prescribing variation also reflects weak consensus regarding appropriate use of opioids, especially for treating chronic, noncancer pain.

Role of P2X7 Receptor-Mediated IL-18/IL-18R Signaling in Morphine Tolerance: Multiple Glial-Neuronal Dialogues in the Rat Spinal Cord
Meng-Ling Chen, Hong Cao, Yu-Xia Chu, Long-Zhen Cheng, Ling-Li Liang, Yu-Qiu Zhang, and Zhi-Qi Zhao; Fudan University Institutes of Brain Science & State Key Laboratory of Medical Neurobiology, Shanghai, China

The effectiveness of the highly potent analgesic morphine is known to diminish over time following repeated administration. A team of Chinese scientists investigated the downstream mechanisms of P2X7R receptors in rats, which may underlie morphine tolerance.

The morphine tolerance mechanism has been considered to be multifactoral, and a previous study by the researchers showed that disruption of activity of spinal glia activity blocked the induction of tolerance to morphine analgesia, suggesting a novel glial mechanism. That study also reported a crucial role for the P2X7R receptor expressed by spinal microglia in the induction of morphine tolerance.

The current study demonstrated a spinal mechanism underlying morphine tolerance, in which chronic morphine triggered multiple dialogues between glial and neuronal cells in the spinal cord. This research may show potential new therapeutic targets for preventing morphine tolerance in the clinical management of pain.

Clinical Journal of Pain Highlights

The following highlights summarize selected articles from the October 2012 issue (Volume 28, Number 8).

Low Back Pain Subgroups Using Fear-Avoidance Model Measures: Results of a Cluster Analysis
Jason M. Beneciuk, Michael E. Robinson, and Steven Z. George; University of Florida Departments of Physical Therapy, Clinical and Health Psychology, and Center for Pain Research and Behavioral Health

Psychological risk factors have been associated with the development and maintenance of chronic low back pain (LBP). Subgrouping strategies based on psychological models have been incorporated into previous studies investigating the effectiveness of psychosocial interventions for LBP. The purpose of this secondary data analysis from a clinical trial involving behavioral interventions for patients with acute or subacute LBP was to test the hypothesis that an empirically derived psychological subgrouping scheme based on multiple fear-avoidance model (FAM) constructs (i.e., pain catastrophizing, fear-avoidance beliefs, and fear of specific activities) would provide additional clinical outcomes in comparison with a single FAM construct.

Three distinct FAM subgroups (low-risk, high specific fear, and high fear and catastrophizing) emerged from cluster analysis. Subgroups differed on baseline pain and disability with the high fear and catastrophizing subgroup associated with more pain and disability than the low-risk subgroup.

The results of this study suggest that questionnaires measuring FAM constructs can be used to detect psychological profiles central to the FAM through cluster analysis techniques. Study findings indicate that cluster analysis methods may be more useful for identifying subgroups than are arbitrary dichotomization methods involving continuous measures. Data regarding this type of subgrouping methodology have the potential to be integrated into clinical decision-making processes associated with the targeting of appropriate psychological variables for early intervention.

Sensory Neuropathy May Cause Central Neuronal Reorganization But Does Not Respecify Perceptual Quality or Localization of Sensation
Federica Ginanneschi, Mauro Mondelli, and Alessandro Rossi; University of Siena Department of Neurological, Neurosurgical, and Behavioural Sciences, Clinical Neurophysiology Unit, and EMG Service, Local Health Unit 7

Extensive evidence supports the notion that changes in sensory input may induce physiological reorganization across the central nervous system (CNS) by modifying the efficiency and extent of synaptic connectivity.

This study investigated the topographic distribution of the subjective sensory symptom in three common human mononeuropathies: ulnar neuropathy at the elbow (UNE), carpal tunnel syndrome (CTS), and meralgia paresthetica (MP). Patients with diabetes, endocrine or connective-tissue disease, kidney dysfunction, or other neurological diseases were excluded from this study. Subjects include 86 patients with meralgia paresthetica, 86 patients with ulnar neuropathy at the elbow, and 203 patients with carpal tunnel syndrome.

In isolated CTS, this study's data confirm that some patients (10%) experience sensory symptoms that spread beyond the innervation territory of the nerve, seemingly supporting the possibility of "functional respecification" in CTS. In contrast, all patients who were affected by MP and isolated UNE experienced a peripheral projection of sensation that was always within the anatomic distribution of the lateral femoral cutaneous and ulnar nerves, respectively, providing evidence of postlesion "functional conservation." This study supports the notion that CNS reorganization after peripheral nerve injury in humans is an adaptive phenomenon with negligible or no functional relevance.

PAIN Highlights

The following highlights summarize selected articles from October 2012 (Volume 153, Number 10).

An Enriched-Enrollment, Randomized Withdrawal, Flexible-Dose, Double-Blind, Placebo-Controlled, Parallel Assignment Efficacy Study of Nabilone as Adjuvant in the Treatment of Diabetic Peripheral Neuropathic Pain
Cory Toth, Shefina Mawani, Shauna Brady, Cynthia Chan, CaiXia Liu, Essie Mehina, Alexandra Garven, Jennifer Bestard, and Lawrence Korngut; Hotchkiss Brain Institute Department of Clinical Neurosciences and the University of Calgary

Neuropathic pain (NeP) occurs as a result of damage or disease of the peripheral or central nervous system. A common cause of NeP is diabetic peripheral neuropathic pain (DPN) leading to distal extremity symptoms, disturbed sleep, and diminished quality of life. Although symptomatic therapies such as gabapentinoids, antidepressants, and opioids are available for treatment of NeP, many of these therapies remain suboptimal for quantity pain relief or are associated with adverse effects.

Uncertainty exists regarding the use of cannabinoids for the management of NeP and its associated symptoms. This study compared the efficacy of nabilone as adjuvant treatment for NeP attributable to DPN versus placebo using a randomized double-blind, placebo-controlled, parallel-assignment, flexible-dose comparison and an enriched-enrollment randomized withdrawal design.

Both in the single-blind and randomized double-blind study phases, nabilone use was associated with improvements in pain relief, sleep efficacy, and quality of life. Nabilone demonstrated superiority to placebo with respect to a number of indices for neuropathic pain and its associated comorbidities for run-in phase nabilone responders.

The Relationship Between Pain and Depressive Symptoms After Lumbar Spine Surgery
Richard L. Skolasky, Lee H. Riley III, Anica M. Maggard, and Stephen T. Wegener; Johns Hopkins University Orthopaedic Surgery and Johns Hopkins University Physical Medicine and Rehabilitation

Depressive symptoms are common among patients seeking surgical care of degenerative conditions of the lumbar spine. These depressive symptoms can interfere with a person's ability to take part in normal work and recreational activities. The objective of this prospective cohort study was to examine the change in pain and depressive symptoms and to characterize the relationship between pain and depressive symptoms after lumbar spine surgery.

In this study, researchers assessed 260 patients undergoing lumbar spine surgery preoperatively and postoperatively (at 3 and 6 months) using a pain intensity numeric rating scale and the Patient Health Questionnaire Depression Scale. The relationship between change in pain (a 2-point decrease or 30% reduction from the preoperative level) and depressive symptoms was examined using standard regression methods.

Study results show that changes in pain intensity after surgery were associated with a reduction in depressive symptoms 6 months after surgery for patients with degenerative conditions of the lumbar spine. These authors suggest a staged approach to the management of depression in this population. First, patients should be carefully followed after surgery and their level of pain relief should be documented. Second, patients whose pain does not improve should be carefully assessed for depressive symptoms and appropriate treatment should be provided.

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.

Advocacy

Murky Funding Outlook for New Federal Government Fiscal Year

Robert Saner, Washington Counsel, Pain Care Coalition

Just before heading into recess for the elections, Congress passed and the president signed a Continuing Resolution (CR) to fund the government from October 1 through late March 2013. Discretionary programs, including The National Institutes of Health (NIH), get a 0.6% increase over a "base" rate, which is very close to if not identical to the current FY2012 funding for most programs. However, the CR has complex provisions preventing agencies, including NIH, from front-loading FY2013 expenditures, so as to preserve maneuvering room for both the Administration and Congress in the event

• an actual full year appropriations bill should be enacted for a particular agency
  
• the "sequester" kicks in on January 1, 2013
  
• there is a new deal after the elections designed to reduce the deficit and avoid the sequester.

Of these, the third option is most likely, but hardly, assured. Under the CR, NIH would need to tell the Appropriations Committees within 30 days how it intends to comply with these restrictions. While some in Congress, and maybe the president, seem prepared for a fiscal showdown late this year (a la Clinton and Gingrich in the '90s), there was no real appetite for it before November.

On a separate, but very much related track, the Office of Management and Budget (OMB) has projected what the impact would be if Congress fails to avert the sequester. For most nondefense discretionary programs, including NIH, OMB projects a cut of 8.2%. How this would be applied by NIH at the institute, program, and project or grant level is very unclear. Obviously, Congress and the Administration still hope to avert the sequester, by enacting some alternative deficit reduction measures in a "lame duck" session after the election.

In similar situations in the past, NIH has tended to fare better than most other discretionary spending programs, but some spending cuts are expected in early 2013. They would be considerably less than the dreaded sequester but nonetheless might be very painful to NIH funding prospects, particularly for new starts.

When the dust settles, NIH is likely to be at or below the FY 2012 level for FY 2013 as a whole. The worse the outcome, the more likely that most of the pain will fall on new grants not being funded as opposed to continuation projects, but NIH will likely have a high degree of discretion. For research areas like pain that are already fighting to get a bigger share of a no-longer-growing pie, it is not a positive outlook.

Members

What is your area of specialty?
I am a clinical pharmacist specialist in pain management/palliative care. I practice at the Moffitt Cancer Center in Tampa, FL, as a member of our multidisciplinary hospital-based pain and symptom management medical team.

What initially sparked your interest in working in your field? Briefly describe your career path.
My interest in pain management began when I was a pharmacist resident at Duke University Hospital where I worked extensively with their multidisciplinary inpatient pain management service. I was intrigued when I first discovered that often simple clinical strategies can have such a significant impact on something patients cared so much about—their pain control. After my general pharmacy residency at Duke, I completed a specialty pharmacy residency in pain/palliative care at the Moffitt Cancer Center where I continue to practice today.

What has been a highlight of your work? Perhaps you and your staff are proud of a certain project or accomplishment.
I am most proud of the residents, fellows, and students that I have been honored to precept over the approximately 10 years I have been in practice. By giving them the knowledge and insight that I gained through my academic and clinical training in pain management, they not only become significantly better at understanding the impact that uncontrolled pain can have on patients but also have more insight and clinical skills to manage it. To me, this is one of my greatest professional accomplishments.

Is there a particular challenge that you've either overcome or hope to address soon?
My biggest clinical challenge is predicting patients' response to analgesic pharmacotherapy regimen before they take their first dose. In the future, my hope is that clinical and basic science research will help us better understand the mechanisms behind this phenomenon. Knowing these mechanisms could improve the safety and efficacy of all pharmacological pain management treatment strategies.

Who is your favorite role model—and why?
APS Past President Chuck Inturrisi, PhD, has been a great friend and professional role model for me over the past few years. His accomplishments in the field of opioid pharmacology and pharmacokinetic modeling have significantly improved our current understanding of many opioids that we use on a daily basis to improve the pain control of our cancer patients.

How has membership in APS been of value to you and your professional development?
My membership in APS, besides being so much fun, has provided significant value to my professional development as a pain management specialist. The best thing about APS is its members! The quality and caliber of members that I have had the opportunity to meet, network with, and work alongside is unmatched. Where else can you sit down with a world's leading expert and have a casual conversation about levorphanol? Ever since my first APS Annual Scientific Meeting, I knew APS was the professional society for me.

Member Benefit

Clinical Practice Guidelines
APS develops and disseminates a series of evidence-based clinical practice guidelines on the management of complex pain problems to be used by patients, payers, and providers. The Clinical Practice Guidelines Program is a comprehensive, multidisciplinary, ongoing effort to develop guidelines and assure their dissemination and implementation. It adheres to state-of-the-art scientific principles of guideline development and evaluation. APS members can access the current and archived guidelines on the APS website.

Guidelines Currently Available
Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline from the American Pain Society

• Guideline
  
• Evidence Review [PDF]

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

• Guideline
  
• Evidence Review [PDF]

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society, Annals of Internal Medicine, 2 October 2007, Volume 147 Issue 7 Pages 478–491

• Guideline
  
• Evidence Review [PDF]

Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease, 1999

• Guideline

Call for Nominations

The APS Nominating Committee is seeking your nominations for election to positions on the 2013 Board of Directors and Nominating Committee.

The president-elect, treasurer, and three directors-at-large will be elected to take office at the 2013 Annual Scientific Meeting. Additionally, seven members will be elected to the 2013 Nominating Committee, including three past presidents and four members at large.

View position descriptions, eligibility, and the nomination form on the APS nominations page.

Nomination(s) are due by November 12. Thank you for participating in the selection of new leaders for APS.

In the Media

Many Hospitalized Children Experience Severe Pain: Report (U.S. News & World Report)

Poor Pain Control for Cancer Patients (New York Times)

1 in 8 with Fibromyalgia Uses Medicinal Cannabis (MSNBC)

New Back Pain Gene Identified in Largest Genetic Study of Its Kind (ScienceDaily)

Evidence Does Not Back-Up Spinal Manipulation for Acute Lower Back Pain, Review Finds (ScienceDaily)

Resveratrol May Preserve Pain-Relieving Effects of Morphine (ScienceDaily)

Watson Issues Voluntary Nationwide Recall of Hydrocodone Bitartrate and Acetaminophen Tablets, USP 10 mg/500 mg Due to the Potential for Oversized and Superpotent Tablets (PR Newswire)

National Survey Shows Decline in Non-Medical Prescription Drug Misuse, Rise in Heroin Use (American Society of Addiction Medicine)

Spine Surgery Study First to Incorporate Independent Review of Adverse Events (Pain Medicine News)

Researchers Outline Effective Approaches as Prescription Painkiller Overdoses Mount (Medical News Today)

Study Finds Interdisciplinary Approach to Monitoring and Managing Pain Improves Patient Care and Satisfaction (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.