Annual Scientific Meeting

Risk Evaluation and Mitigation Strategies (REMS) for Extended-Release and Long-Acting Analgesic Opioids: Achieving Safe Use While Improving Patient Care

Recently, the U.S. Food and Drug Administration (FDA) requested a Risk Evaluation and Mitigation Strategy (REMS) plan that applies to all extended-release/long-acting (ER/LA) opioid analgesic medications to ensure that the benefits of these drugs outweigh the risks. The FDA has put ER/LA opioid REMS in place and requires that this information be incorporated into continuing education programming for those who prescribe these medications.

APS believes it is important to educate prescribers to effectively and safely prescribe ER/LA opioids to manage pain by sharing tools and resources.

In compliance with the FDA regulations, APS would like to invite you to a free continuing education course. This highly anticipated 3-hour REMS learning session will be held at the APS Annual Scientific Meeting on Saturday, May 11.

Learn the information you need to effectively assess the pain patient, develop a treatment plan, assess for risk of opioid abuse, and plan for ongoing assessment of the patient.

This session has been promoted not only to APS members, but also to local prescribers in the New Orleans metropolitan area. APS hopes to educate the appropriate prescribers, no matter their practicing location.

APS is able to offer this course and encourages you to attend so that you can continue to prescribe ER/LA opioids to your patients. Continuing education/contact hours will be available.

Registration is limited, so register now!

Event Feature: Nursing SIG Program

The Nursing Issues Special Interest Group (SIG) meeting will be May 8 at 2:30–4:30 pm at the APS 32nd Annual Scientific Meeting in New Orleans.

We are excited to have the following four nurses reporting on their research and quality improvement projects:

Do Self-Reported Analgesic Barriers Translate into Objective Analgesic Adherence for Cancer Pain?
Salimah Meghani, PhD MBE CRNP
This presentation will report on whether self-reported analgesic barriers translate into objective adherence to analgesia for African Americans and Whites. Analgesic barriers were elicited using the Barriers Questionnaire.

Postoperative Pain Time from Severe to Mild: Effect of Frequent and Multimodal Interventions
Fern FitzHenry, PhD RN
Management of postoperative pain remains a challenge despite continued attention by accrediting and standards organizations. This presentation will report on a retrospective study that analyzed data from the electronic records of postsurgical acute pain episodes at an academic medical center for a 2.5-year period.

The Pain Care Quality Study: One Hospital’s Experience
Patricia Brandon, RN-BC
Nurses play a critical role in promoting quality pain management by assisting patients in establishing a realistic comfort goal, administering analgesics and adjunctive measures as needed, evaluating effects, and advocating for patients. This presentation will report on a study that assessed patients’ perceptions about the quality of pain management.

Atomized Lidocaine Prior to Nasogastric Tube Placement
Michele Farrington, BSN RN CPHON^®, Moderator: Maureen Cooney, DNP
This presentation will report on a project to develop and implement an evidence-based practice to decrease discomfort and distress associated with placement of nonemergent nasogastric (NG) tubes in adult and pediatric patients. Patients who need an NG tube inserted are now screened by bedside nurses for appropriate use of atomized lidocaine.

The Nursing Issues SIG meeting has been designated for continuing nursing education. Nurses can earn 1.5 contact hours and 1.5 pharmacology hours. Nurses must attend the SIG meeting and complete the Nursing Issues SIG section of the online evaluation in order to receive credit.

If you have questions please contact

Kathleen Broglio, MN ANP-BC ACHPN CPE
Nursing SIG Chair
Pain and Palliative Care Nurse Practitioner
kathleen.broglio@gmail.com
808.561.6994

There’s Still Time to Register for the 32nd Annual Scientific Meeting

Join APS at the 32nd Annual Scientific Meeting in New Orleans, May 8–11. Register today to gain knowledge from 30 symposia, three in-depth workshops, and 17 special interest group (SIG) meetings.

Experience these additional valuable and exciting opportunities:

• Attend the complementary and alternative medicine (CAM) preconference symposium on Wednesday, May 8.
  
• Connect with more than 400 poster presenters.
  
• Earn more than 15 hours of continuing education/contact hours in four discipline areas.
  
• Learn about innovative and compelling clinical and basic science research by attending the Clinical and Basic Science Data Blitz.

Interested in attending the 32nd Annual Scientific Meeting? Register now!

Back by popular demand—The Pain Sensations will be playing at Bourbon Heat on Thursday, May 9, at 8 pm.

The APS house band hopes you will join them in the French Quarter for a night of live music and fun! Support the Pain Sensations and purchase apparel!

Members

Member Spotlight Gonzalo Flores, LAc MAcOM GroundSpring Healing Center, PC Portland, OR www.groundspring.net

How has membership in APS been of value to you and your professional development?
Membership in APS provides a value-added benefit to discuss, debate, and collaborate with individuals both nationally and internationally on common issues we face in basic science and clinical theatre in the arena of pain. The intellectual roundtable discussions that I find in the lecture auditoriums and the hallways that lead to them are the kind of stimulation I seek in the practice of medicine. APS’s goals of research, education, treatment, and advocacy are the goals I share in my own profession. APS has afforded me the opportunity to elevate my own standards of research, clinical skills, and leadership in the fields of science and medicine.

What is your area of specialty?
Acupuncture and traditional East Asian medicine.

What initially sparked your interest in working in your field? Briefly describe your career path.
I come from a family of indigenous healers. I am a member of the Lipan Apache Tribe. I spent 8 years in Okinawa, Japan, and was fortunate enough to apprentice with traditional Okinawan physicians of Kampo, a traditional Japanese herbal medicine. I am the medical director at GroundSpring Healing Center, an integrated medicine clinic in Portland, OR.

What has been a highlight of your work? Perhaps you and your staff are proud of a certain project or accomplishment.
The highlight of my work is the ongoing collaboration with my colleagues in the basic sciences and clinical setting. The efforts to produce a combination of the best science and clinical application are a constant reminder of how important our work [is and how it] helps patients in the day-to-day clinical setting.

Is there a particular challenge that you've either overcome or hope to address soon?
The challenges that involve clinical efficacy, financial sustainability, and practice management are ones that affect all of us, from research to the clinic. The long-term challenge is to establish a successful model of integrative health care in the United States within larger-scale operations such as hospitals and academic healthcare institutions.

Who is your favorite role model and why?
I have two role models: Dr. Ji Sheng Han and Dr. Candace Pert. Both of these scientists are visionaries, leaders, intellectuals, and scholars that transcend many disciplines. Their collective contribution has influenced how we look at pain and neuroscience today. They tirelessly continue to work in their labs, write about their findings, and spark discussion on the frontiers of science and medicine.

Member Benefit: Continuing Education Opportunities

The intent of the APS continuing education (CE) program is to improve pain care by advancing the education of physicians, nurses, pharmacists, psychologists, scientists, and other professionals in the treatment of individuals with acute and chronic pain, and by supporting the development of pain research.

You have a variety of opportunities for CE available through APS. Not only do these opportunities meet requirements for the many disciplines represented in APS, but they are also focused around your interest in pain:

• Annual Scientific Meeting CE: Learn about the various CE credits available to APS Annual Scientific Meeting attendees.
  
• Annual Scientific Meeting Schedule: View a schedule of events and more information on the Annual Scientific Meeting in New Orleans.
  
• CE Mission Statement: Read APS’s Continuing Education Mission Statement.

If you have any questions regarding APS’s CE activities, please call 847.375.4715 or send an e-mail to info@americanpainsociety.org.

Summaries

The Journal of Pain Highlights

The following highlights summarize selected articles from April 2013 (Volume 14, Number 4).

Does Opiate Use in Traumatically Injured Individuals Worsen Pain and Psychological Outcomes?
Trevino, C. M., deRoom-Cassini, T, and Brase, K.; Medical College of Wisconsin, Milwaukee

According to new research published in The Journal of Pain, use of opioid analgesics can worsen pain in some traumatically injured patients, especially if they have comorbid psychological disorders.

Colleen M. Trevino and colleagues at Medical College of Wisconsin reported that previous research has shown that psychological functioning worsens with opioid use, and a study on veterans using opioids for pain showed that those with posttraumatic stress disorder (PTSD) and other comorbid psychopathologies are at higher risk for adverse outcomes, such as overdoses, self-inflicted injuries, and accidents linked with substance abuse. Further, the U.S. Centers for Disease Control and Prevention has reported that fatal overdoses involving opioids have increased sharply in the last decade and coincide with the national rise in opioid prescribing.

In traumatically injured patients, the authors noted it is unclear what percent of trauma patients still using opioids 4 months post-injury have better or worse pain and psychological outcomes compared to patients not taking opioids. The purpose of the study, therefore, was to determine if trauma patients who have chronic pain 4 months following their injuries and take opioids for pain can expect to experience more pain, anxiety, depression, PTSD, and other quality-of-life impairments compared to trauma victims who do not use opioids long term.

In total, 101 participants were recruited from a Midwest trauma center. Subjects had been admitted for trauma surgery, and 81 developed chronic pain after their injuries. Of those, 27 were still using opioids. The researchers compared outcomes among patients using opioids with those who did not.

Results showed there was significantly higher pain and poorer psychological outcomes in trauma patients who used opioids 4 months after their injuries occurred. The authors noted these findings contradict normal treatment strategies for using opioids to control chronic pain. There was no evidence showing differences in the development of chronic pain based on injury severity. Also, pain and psychopathologies among those taking opioids were not significantly affected by injury severity.

The authors concluded that a possible explanation for higher pain levels among those using opioids is similar to the phenomena of opioid-induced hyperalgesia, whereby long-term drug use can worsen pain symptoms. They advised healthcare providers who decide to prescribe opioids for pain to identify individuals at risk for comorbid adverse psychological outcomes.

Anxiety and Depression Are Associated with Migraine and Pain in General: An Investigation of the Relationships
Lighart, L., Marloes, M. J. G., Boomsma, D. I., and Penninx, B. W. J. H.; VU University Department of Biological Psychology, EMGO+ Institute for Health and Care Research, VU University Medical Center Departments of Psychiatry and General Practice, Leiden University Medical Center Department of Psychiatry, University Medical Center Groningen Department of Psychiatry, Amsterdam, The Netherlands

There is a well-documented relationship between migraine and anxiety and depression. Some research has shown that anxiety tends to precede migraine onset and that depression often follows. Other studies have shown there is a bidirectional relationship in which either migraine or depression occurs first or each disorder predicts the onset of the other.

A multisite Dutch research team evaluated data from the 2,981 participants in the Netherlands Study of Depression and Anxiety. They sought to answer two questions:

• Is there a specific relationship between migraine and anxiety and depression, or is the comorbidity independent of the anatomical site?
  
• Is there a consistent association between migraine and other pain disorders after correction for the well-known comorbidity of migraine, anxiety, and depression?

Results of the analysis showed the strongest associations were observed between anxiety and depression, and neck pain, chest pain, and strict migraines. Probable and mild migraines also were associated with anxiety and depression but weakly. Combined anxiety and depression was associated with a higher number of pain sites than anxiety or depression alone.

The authors also reported a consistent association between migraine and pain at other body sites, though the link was weaker after anxiety and depression were included in the model. After adjusting for the effects of comorbid anxiety and depression, neck, orofacial, and abdominal pain were found in migraine patients. The authors noted that these pain reports often are directly related to migraine itself. For example, neck pain is a highly prevalent symptom during a migraine attack.

The study concluded the data clearly demonstrate the important role of anxiety and depression in pain comorbidity in migraine patients. Anxiety and depression appear to be important factors that explain in part the comorbidity of migraine with other types of pain.

Pain Medicine Highlights

The following highlights summarize selected articles from Pain Medicine (Volume 14, Number 3, March Issue).

Does Pain Score in Response to a Standardized Subcutaneous Local Anesthetic Injection Predict Epidural Steroid Injection Outcomes in Patients with Lumbosacral Radiculopathy? A Prospective Correlational Study
Cohen, S. P., Mao, J., Vu, T., Strassels, S. A., Gupta, A., Erdek, M. A., Christo, P. J., Kurihara, C., Griffith, S. R., Buckenmaier, III, C. C., and Chen, L.

Despite the prominence of epidural steroid injections (ESIs) as the most studied, analyzed, and frequently performed pain-alleviating intervention, systematic reviews remain mixed regarding their efficacy. Very few studies, however, have sought to analyze factors associated with ESI outcomes.

Previous studies have found psychosocial variables to have the greatest predictive value for poor treatment outcomes for low-back pain in general. These researchers developed a noninvasive psychophysical test to evaluate the clinical relevance of opioid-induced hyperalgesia. This measuring tool, which involves patient-reported verbal pain scores in response to a standardized local anesthetic (LA) injection administered immediately before a pain-management procedure, blends psychological parameters such as expectations and somatization with physical parameters such as nociceptive threshold and tolerance. The objective of this pilot study was to determine whether a standardized clinical LA injection performed in the context of reducing the discomfort of a lumbosacral ESI can predict treatment outcome. Investigators hypothesized that higher pain scores in response to the standardized clinical stimulus would be associated with poorer outcomes following ESI.

In this multicenter study, 103 patients received two ESIs 2 weeks apart. Before receiving their first injection, subjects rated the pain intensity of a standardized subcutaneous injection of lidocaine prior to the full dose. Numerical rating scale pain scores were correlated with leg and back pain relief and functional improvement through 3-month follow up.

This study’s results indicate that higher subcutaneous pain scores were weakly correlated with poorer ESI outcomes in patients with clinically confirmed lumbosacral radiculopathy. The data suggest that a quick and simple assessment of subcutaneous pain score might be used in the future in conjunction with other variables not evaluated in this study (e.g., facial expression, heart rate response, and psychosocial factors) to predict interventional treatment outcomes for patients with sciatica. Baseline pain and disability scores were also positively associated with subcutaneous pain score. This raises the possibility that patients who respond poorly to treatment may do so because of low intrinsic pain thresholds and/or high subjective pain responses.

Pulsed and Conventional Radiofrequency Treatment: Which Is Effective for Dental Procedure-Related Symptomatic Trigeminal Neuralgia?
Kim, J. H., Yu, H. Y., Park, S. Y., Lee, S. C., and Kim, Y. C.

Many patients develop dental treatment-related symptomatic trigeminal neuralgia. However, the effectiveness of pulsed radiofrequency (PRF) treatment and conventional radiofrequency thermocoagulation (RFTC) for treatment of this disorder has not been determined. This retrospective study was conducted to compare the effectiveness and complications of PRF and RFTC in these patients. Fifty-four patients who experienced symptomatic trigeminal neuralgia after a dental treatment were managed by PRF or RFTC. Data were collected by reviewing their medical records and administering a questionnaire. Patients’ characteristics; the dental procedures that caused the trigeminal neuralgia; and baseline and posttreatment pain intensity, duration of pain relief, complications, and treatment satisfaction were evaluated.

RFTC treatment produced longer pain relief than PRF treatment. No patients were able to discontinue their medication after PRF in this study; the mean pain relief duration without medication in the RFTC group was 10.8 months. The complication rate in the RFTC group was higher than in the PRF group, however. Hypesthesia, although not a serious condition, was the most common complication in the RFTC group.

Instances of reported hypesthesia did not lead to a lower satisfaction rate. By contrast, in the PRF group, the effect and effective period were insufficient. RFTC for the treatment of dental treatment-related symptomatic trigeminal neuralgia can be effective and result in high satisfaction and relatively long-term relief of pain without medication and the need for other treatments.

PAIN Highlights

The following highlights summarize selected articles from Pain (Volume 154, Number 4, April Issue).

Brain Imaging Reveals that Engagement of Descending Inhibitory Pain Pathways in Healthy Women in a Low Endogenous Estradiol State Varies with Testosterone
Vincent, K., Warnaby, C., Stagg, C. J., Moore, J., Kennedy, S., and Tracey, I.

The combined oral contraceptive pill (COCP) is used by millions of women worldwide both as a contraceptive and as treatment for a number of gynecological conditions. However, COCP use can exacerbate migraine and has been implicated in the development of other chronic pain conditions including vulvodynia, temporomandibular joint dysfunction, and endometriosis. Modern COCP formulations produce a low-endogenous-estradiol, low-progesterone environment similar to the early follicular phase of the natural menstrual cycle, with a variable effect on serum androgen levels.

In this study, researchers used behavioral measures and functional magnetic resonance imaging to investigate the response to experimental thermal stimuli in healthy women, in both a natural and COCP-induced low-endogenous-estradiol state, to investigate whether alterations in central pain processing may underlie these observations in COCP users. Although COCP users overall did not require lower temperatures to obtain a fixed pain intensity, alterations in the brain response to these stimuli were observed. In a subgroup of COCP users with significantly reduced serum testosterone, however, lower temperatures were required.

Overall, COCP users had lower estradiol, progesterone, and testosterone levels, but higher cortisol levels than controls. These data did not demonstrate that COCP users require a lower temperature to obtain a fixed pain intensity rating compared to controls in a low-estradiol, low-progesterone state. However, COCP users with reduced testosterone levels did require lower temperatures. These findings suggest that failure to engage descending inhibition at the level of the rostral ventromedial medulla may be responsible for the reduction in temperature required in women with reduced circulating testosterone. These data support the idea that exogenous testosterone can be used to improve analgesia in such patients. These findings also suggest that future studies should be undertaken to investigate both the influence of COCP use on the development of chronic pain and the potential of testosterone as an analgesic in patients with chronic pain and low-serum-androgen levels.

The Role of Circulating Sex Hormones in Menstrual Cycle-Dependent Modulation of Pain-Related Brain Activation
Veldhuijzen, D. S., Keaser, M. L., Traub, D. S., Zhuo, J., Gullapalli, R. P., and Greenspan, J. D.

Sex differences in pain sensitivity have been consistently reported, but the basis for these differences is not completely understood. This study assessed how pain-related neural processing varies across the menstrual cycle in normally cycling, healthy women, and whether menstrual cycle effects are based on fluctuating sex hormone levels.

Fifteen subjects participated in four test sessions during their menstrual, midfollicular, ovulatory, and midluteal phases. Brain activity was measured while nonpainful and painful stimuli were applied with a pressure algometer; serum hormone levels confirmed that scans were performed at appropriate cycle phases in 14 subjects.

The main findings of this study were the following: lower pressure pain thresholds were found for follicular compared with other phases, but no cycle-related changes in pain ratings were found; cycle changes in pain-related brain activation were found for several brain regions not traditionally associated with pain perception; and cycle-related changes in pain sensitivity measures and brain activation were only partly explained by circulating sex hormone levels.

This study demonstrated that pain-related brain activation varies significantly across the menstrual cycle in some regions, despite a lack of significant variation in the level of pain evoked. Consistent with these observations, brain regions showing significant menstrual cycle effects were not associated with pain perception, but more likely with cognitive or motor function. The predominant pattern was either weaker activation or stronger negative signal change during the menstrual phase than during the follicular or luteal phases, particularly in several frontal regions. This suggests that brain regions implicated in cognitive pain modulation or more general bodily awareness are most susceptible to menstrual cycle effects. When correlating the sex hormone data with pain-related brain activations, only a partial overlap was found, indicating that significant cycle effects in pain-related activation are generally independent from hormone levels.

Research

Young Investigator Award Recipients

APS is pleased to grant Young Investigator Travel Awards to 61 trainees to attend the 2013 APS Annual Scientific Meeting. These individuals will present their research during designated poster sessions. The APS Annual Scientific Meeting creates a milieu in which scientists and clinicians can share relevant information from differing perspectives, frequently leading to advances in science and clinical care. Funding for the 2013 Young Investigator Travel Award program is made possible by grants from the National Institute of Neurological Disorders and Stroke (NINDS), National Cancer Institute (NCI), and National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

Society

APS Welcomes the 2013 Board of Directors

APS is pleased to announce the winners of the 2013 election:

SIG Updates

Please join the Ethics SIG on Thursday, May 9, at 5:15–6:15 pm at the APS 32nd Annual Scientific Meeting for a lively panel presentation on “The Industry Conundrum: Ethical Considerations Regarding Industry Funding of APS.” The panel will be moderated by Beth Darnall, PhD, the 2013 incoming chair of the Ethics SIG. Panelists include

• Renee Manworren, PhD APRN PCNS-BC, who, as an APS Board member, will represent the viewpoint of APS
  
• John Peppin, PhD, who will discuss conflicts of interest between industry, research, and education
  
• Michael Schatman, PhD, executive director of the Foundation for Ethics in Pain Care, who will discuss conflicts of interest between industry, research, and education
  
• Michael F. Jarvis, PhD, who, as the Volwiler Senior Research Fellow and associate director for Early Discovery Pain Global Pharmaceutical Research and Development for Abbott, will represent the industry viewpoint.

Audience discussion is encouraged! Join the discussion about the benefits and challenges of industry within the context of APS and learn about the measures APS has in place to minimize conflicts of interest.

The Clinical Trials SIG will be meeting in New Orleans on May 8, 2013, as part of the APS Annual Scientific Meeting. We had good support at last year’s meeting and expect an even better turnout at this year’s session.

Over the past 20 years, between 45% and 80% of late-phase analgesic clinical trials have been negative. Most of these trials have been on opioid reformulations or reformulations of other drugs with presumed efficacy. Why do we have such a high failure rate? Undoubtedly, experimental error and suboptimal trial design play a role. The purpose of our SIG is to discuss methodological problems with and putative solutions for analgesic trial conduct. When trials fail, too often the carnage is swept under the rug and a golden opportunity to learn is lost.

Dr. Neil Singla and Dr. Nathaniel Katz will discuss the latest data and recommendations on clinical trial design, minimizing variability, and reducing placebo response. What works, what doesn't work, and what evidence is there to separate the two?

This SIG works best when we have participation from a large group of interested parties who have experience in clinical trial success—and, yes, who have also experienced their share of failures.

Please join us and learn with us!

Regional Society Updates

Southern Pain Society
The Southern Pain Society will be hosting its annual meeting, “Advancing Pain Therapy: Beyond the Basics,” September 20–22, 2013, at Harrah’s New Orleans. More information along with the brochure will be available on the society’s website, www.southernpainsociety.org, in May.

Midwest Pain Society
2013 Robert G. Addison, MD, and E. Richard Blonsky, MD, Research Grants
All applications must be received no later than the end of business on Monday, October 14, 2013. Late or incomplete applications will not be considered. Questions regarding this grant application should be directed to Steven J. Krause, PhD, 216.445.0620 or krauses@ccf.org.

The 37th Midwest Pain Society Scientific Meeting will be held October 25–26, 2013, at Northwestern University, Chicago, IL. Instructions for the call for abstracts are located at www.americanpainsociety.org/societies/mps. The deadline for submissions is September 30. For more information, please e-mail April.vallerand@wayne.edu.

For more information on all of APS’s regional societies, please visit the Regional Societies page of www.americanpainsociety.org.

In the Media

Make Sure You’re Getting Your Pain News from APS
SmartBrief

In previous issues of APS e-news, you have been able to rely on In the News for links to articles related to the field of pain sourced from various media. APS recently launched its inaugural issue of APS SmartBrief, a free digital digest of easy-to-read summaries specifically designed to bring you the most important and timely news stories on pain research, science, treatment, policy, and trends.

APS SmartBrief is available to you with the option to share and forward to your colleagues. We hope you find this new member benefit valuable and subscribe 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.