The Journal of Pain Highlights

The following highlights summarize selected articles from the July 2007 issue (volume 9, number 6).

Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy
Michael F. Flemming, Stacy Balousek, Cynthia L. Klessig, Marlon P. Mundt, and David D. Brown, University of Wisconsin and University of British Columbia

Some 4% of patients prescribed opioid pain medications by primary care physicians abuse the drugs, but the risk of addiction is small compared with the alternative of continuous pain and suffering from chronic noncancer pain, according to research reported in The Journal of Pain.

Researchers from the University of Wisconsin and University of British Columbia studied 801 patients in primary care practices throughout the state to identify the rate of substance use disorders and opioid abuse in persons who receive long-term opioid therapy from primary care physicians. The most common pain diagnoses in the sample were degenerative arthritis, low back pain, migraines, neuropathy, and fibromyalgia. Patients were between 18 and 81 years old with a diagnosis of chronic noncancer pain.

The primary finding was that the frequency of opioid abuse in this population was 3.8 % or about 1 in every 25 patients taking opioid medications. Also, the study reported there was a 24% rate of positive toxicology tests in the opioid-abusing group for illicit drugs and significant underreporting of drug use. Forty-six percent of patients with positive toxicology screens denied illicit drug use even though they were guaranteed anonymity during the interviews. This finding confirms previous studies that patients with chronic pain often mislead physicians about illicit drug use.

The data also showed a high percentage of subjects who abused opioids or other substances also engaged in specific aberrant drug behaviors, such as sedating oneself, using opioids for nonpain reasons, increasing doses without authorization, and feeling intoxicated when using opioids. Previous studies have shown that patients with a family or personal history of substance abuse are more likely to exhibit aberrant drug behaviors.

The authors concluded that considering potential benefits offered by opioids to patients with chronic pain, the 3.8 % risk of opioid addiction is small compared to the overall therapeutic benefits of opioid analgesics.

Self Efficacy Correlates with Leg Muscle Pain During Maximal and Submaximal Cycling Exercise
Robert W. Motl, Rachael C. Gliottoni, and Jennifer A. Scott, University of Illinois at Urbana Champaign

Are those with higher levels of self-efficacy about their ability to cope with pain better able to withstand increasing intensity of exercise-induced muscle pain? In this study, researchers from the University of Illinois sought to learn more about the psychological influences on muscle pain during exercise. They defined self-efficacy as “the belief in one’s capabilities to organize and execute the courses of action to produce a given attainment.”

The research team recruited 16 healthy and physically active women to participate in 30 minutes of a high-intensity cycling. The self-efficacy scale assessed beliefs in one’s capability to tolerate moderate to strong leg muscle pain during cycling without stopping.

Results showed that self-efficacy for tolerating pain was moderately to strongly and inversely associated with ratings of muscle pain intensity during the cycling exercise. The authors noted their findings support the need for future examinations of strategies for manipulating self efficacy for tolerating pain and possibly reducing muscle pain during exercise. Also, because pain is a possible barrier to exercise initiation and persistence, and thus often a limiting factor in physical therapy and rehabilitation, the authors noted that pain reduction through manipulation of self-efficacy might influence exercise adherence.

Burn Injury Pain: The Continuing Challenge
Gretchen J. Summer, Kathleen A. Puntillo, Christine Miaskowski, Paul G. Green, and Jon D. Levine, University of California–San Francisco

A review conducted by researchers at the University of California–San Francisco showed that although the unmet medical need for more effective pain management for burn patients was described 20 years ago, burn-injury pain remains a continuing challenge. Burn pain is largely undertreated and has been linked to debilitating chronic pain and stress-related disorders.

A reason suggested by the authors for the frustrating inability to control burn pain effectively is that pain levels from wound care and rehabilitation can vary during the three phases of burn recovery—acute, healing, and rehabilitation. The review examined burn pain and its management across the three stages of recovery.

The authors concluded that understanding the mechanisms that contribute to the intensity and variations of burn injury pain over time is crucial for proper pain management. Unfortunately, there is little clinical research to draw from identifying mechanisms of acute and chronic burn-injury pain. Unlike post-surgical pain that diminishes gradually, burn pain is highly variable and may increase over time before healing occurs.

The study reported that several types of analgesics are rarely used for burn patients, even though they appear to have pain-management potential. Clonidine, ketamine, lidocaine and methadone may decrease the need for potent opioids and lessen drug tolerance commonly observed in burn patients. Also, fentanyl has been shown to be most effective for managing pain during wound care procedures, but timing the delivery of this short-acting opioid is difficult without fear of overdosing.

The authors concluded that “Research is needed to identify the underlying mechanisms for burn-injury pain over time. Only with this knowledge will burn care providers be able to target specific mechanisms that contribute to the variable intensity that makes this type of pain such a difficult management problem.”

Pain Medicine Highlights

The following highlights summarize selected articles from the May/June 2007 issue (volume 8, number 4).

Proposed New Diagnostic Criteria for Complex Regional Pain Syndrome
R. Norman Harden, MD, Stephen Bruehl, PhD, Michael Stanton-Hicks, MB BS DMSc FRCA ABPM, Peter Wilson, MB BS, Rehabilitation Institute of Chicago, Northwestern University, Vanderbilt University School of Medicine, Cleveland Clinic, Mayo Clinic

The authors provide an update on international efforts to further develop the diagnostic criteria for complex regional pain syndrome (CRPS). The CRPS criteria were originally introduced and published in 1994 by a consensus group of the International Association for the Study of Pain (IASP). A consensus group had created the criteria to provide a standard methodology to make decisions about whether unidentified pain conditions represent CRPS. To date, adoption of the criteria has been sporadic, and the full benefits of having the IASP criteria have not been realized.

In 2003, an international group of 35 professionals met in Hungary to discuss the CRPS diagnostic criteria. A model was developed to “test the accuracy of the IASP/CRPS criteria for discriminating between 117 patients meeting IASP criteria and 43 neuropathic pain patients with established non-CRPS etiology.” Diagnostic sensitivity was high (0.98), but specificity was poor (0.36). Results suggested that the CRPS criteria are sensitive and rarely miss a case of CRPS, but the lack of specificity in the criteria leads to overdiagnosis in some cases. Authors noted that in the clinical setting “sensitivity is extremely important” whereas in the selection of research samples, “specificity is crtitical.”

As a result of the Hungary meeting, the international group proposed statistically-derived revisions to the CRPS criteria: They proposed two sets of diagnostic criteria, which differ only in the decision rules employed for clinical versus research settings. These new criteria are being submitted to the IASP Committee for Classification of Chronic Pain and will require further validation.

Mind-Body Interventions for Chronic Pain in Older Adults: A Structured Review
Natalia E. Morone, MD MSc, and Carol M. Greco, PhD, University of Pittsburgh

It is estimated that up to 50% of community-dwelling older adults have chronic nonmalignant pain that is inadequately treated. Poor physician training in treating pain in older adults and the increased susceptibility of older adults to medication side-effects contribute to undertreatment. Because they are likely to be safe, mind-body therapies may help reduce pain and its emotional and psychological burden with minimal side-effects in this population.

The authors conducted a structured review of eight mind-body interventions for older adults with chronic nonmalignant pain. They reviewed 381 articles for interventions that included biofeedback, progressive muscle relaxation, meditation, guided imagery, hypnosis, tai chi, qi gong, and yoga. Fourteen articles included adults aged 50 or more, and fourteen studies were controlled trials (of these only two focused on pain in older adults). The controlled trials tended to “have small numbers of participants and lacked a comparison group.” The authors noted that is likely because of the infancy of the field of mind-body medicine.

Studies showed a significant overlap in the interventions, which are often used in combination. To analyze this, the authors categorized the mind-body interventions as relaxation-based, concentration-based, and movement-based.

The authors found that “there is some support for the efficacy of relaxation for reducing pain of osteoarthritis, and limited support for meditation and tai chi for improving function or coping for chronic low back pain or osteoarthritis, respectively.” They recommend future trials on older adults with chronic nonmalignant pain and “secondary analyses comparing older and younger subjects of previously published trials.”

NIH Funding for Women’s Health Research

The NIH Office of Research for Women’s Health has set aside $1.5 million in fiscal year 2008 to fund applications for research related to sex and gender differences and women’s health. The topics of interest include sex and gender differences in pain perception, and analgesic responses, understanding and managing chronic pain conditions that primarily affect women, and genetic factors underlying sex, and gender differences in nociception and pain perception.

Click here for more information.

Harold Wolff-John Graham Award: An Award for Headache/Facial Pain Research

The American Academy of Neurology (AAN) presents the award called the "Harold Wolff-John Graham Award: An Award for Headache/Facial Pain Research" to recognize individuals who have submitted research results in the field of headache and facial pain. It is named in honor of two famous headache researchers and clinicians who made outstanding contributions to the field of research in headache and inpatient care.

For more information, click here.

Fall Regional Meetings

Eastern Pain Association
If you’re going to present state-of-the-art advances in pain treatment and research, it’s best to do so in an ultra state-of-the-art facility. For that reason, the Eastern Pain Association (EPA) will hold its annual meeting, Innovations in Pain Medicine—The Future is Now, September 7–8, 2007, at the New York Academy of Sciences headquarters, located on the 40th floor of 7 World Trade Center in Manhattan. The venue provides spectacular city views as well as cutting-edge audio and visual technologies. On Friday, September 7, plenary lectures will focus on past and present innovations in osteoarthritis, cytokine-induced illness behavior as it relates to pain and depression, the effects of analgesic therapy on bone fracture healing, and CNS immunologic mechanisms for chronic pain. Other presentations that day include a popular roundtable discussion on promising pharmaceuticals in development; a free lunchtime lecture on Obstetrics: Pain Fibers (but not pain) Speed Labor and Protect Against Chronic Pain by Dr. James Eisenach, this year’s recipient of EPA’s prestigious John J. Bonica Award; and a dinner lecture by APS President Judy Paice. On Saturday, lively discussion is anticipated for an interactive session on Interdisciplinary Treatment of Pain, Focus on Fibromyalgia. “Each year the EPA selects a single, common pain problem and presents it from the perspective of several disciplines,” says EPA President Donald Manning, MD PhD. “This year we have a full-day program on fibromyalgia, with presentations on clinical diagnosis, psychological care, basic science mechanisms, and emerging therapeutics.” Early registration is available through August 2. Call 804/282-0063 or e-mail epa@societyhq.com.

Photo courtesy of The New York Academy of Sciences/David Sundberg

Southern Pain Society
Treating pain patients with complex behavioral and medical issues? Then you may want to attend the Southern Pain Society’s Annual Scientific Meeting, Evaluating and Treating the Pain Patient with Complex Problems, on September 29–30, 2007, at the Gaylord Opryland Hotel in Nashville, TN. Designed specifically for pain specialists and primary care specialists alike, this meeting will focus on evaluating and treating chronic pain patients with complicating behavioral or medical issues, including addiction, personality disorders, and endocrine disorders. Special highlights include presentations by Drs. Joshua Prager and Howard Heit. Joshua Prager, MD MS, is director of the California Pain Medicine Center and Center for Rehabilitation of Pain Syndromes at UCLA and is current president of the North American Neuromodulation Society. Howard Heit, MD FACP FASAM, is an internationally recognized pain specialist and addictionologist who practices gastroenterology and internal medicine at Georgetown University in Fairfax, VA. Attendees are encouraged to bring their families to this very family-friendly destination. To register, contact Sherri DeZwaan at 615/515-1311 or fax her at 615/515-1335.

Midwest Pain Society
Some of today's most important and timely pain care topics will be addressed at the Midwest Pain Society's 31st Scientific Meeting on October 26-27, 2007, at Northwestern University Medical Center in Chicago. Both clinicians and researchers will benefit from interdisciplinary discussions on topics ranging from the role of trauma in acute and chronic pain to new approaches to headache care, translational research in pain, pain in Iraq war veterans, and innovations in interventional pain management. On October 26th APS President Judith Paice, PhD RN, will present "Pain Management: The Essence of Humanity." Located just blocks away from Chicago's Magnificent Mile and the Lake Michigan shoreline, the Conference Center of Northwestern Memorial Hospital offers modern facilities, along with easy access to hotels, shopping, museums, and other attractions. Register by October 1 by calling Midwest Pain Society at 847/375-4730 or faxing your registration form to 888/809-6849.

Volunteer Spotlight: Charles Inturrisi, PhD

In May 2008, Chuck Inturrisi will become APS President succeeding Judy Paice. Inturrisi’s acceptance of the position will mark another milestone in his 25-year involvement with APS.

“I first became interested in APS through my collaborations with Ray Houde, a founding member and Kathleen Foley. I gradually became more active. When Rich Payne was president, he asked me to chair the Scientific Program Committee for the Vancouver meeting and from that point I knew I wanted to have a leadership role.”

Inturrisi was elected to the APS Board in 2004 and became president-elect this year. “It has been an exciting time to be on the board because of what we accomplished in strategic planning,” he said. “I’m excited about our vision to turn research into relief and our plan to move APS forward in becoming the preeminent pain organization for research, treatment, education, and advocacy.”

As a researcher and teacher in pharmacology, Inturrisi has seen the APS meeting rise in stature, especially in the field of analgesic drug development research. “Many of us attended APS and the clinical pharmacology meeting in alternating years. However, APS now is the best meeting by far for researchers and clinicians interested in analgesic drug development,” he said. “Every year there is a lot of new research presented at APS about new analgesics, and neuroscience research also is becoming more prominent.”

Inturrisi added that after every APS meeting he brings back new ideas to share with colleagues and to apply in his teaching. His current research interests are focused on using molecular genetics to identify new pain signaling genes. “The overall goal is to find new and more precise pain targets beyond the opioid receptors we already know about. So we can modify pain signals with a resulting therapeutic benefit and help develop new analgesics with fewer side effects than the opioids,” he said.

Looking ahead to next year, Inturrisi said he will continue to encourage more APS members to become actively involved. “The board has benefited greatly from the input we have received from our SIGs, and I hope we can expand member participation in SIGs to increase information sharing. We rely on SIGs as expert resources.”

He added that APS will become more active in its advocacy role. “There are several important issues we will address on behalf of the pain community, such as controlling abuse of prescription medications, opposing limits on prescribing opioids, the crisis in funding for pain research, and the never-ending fight for better reimbursement for chronic pain care,” said Inturrisi.

Call for Interest in Information Technology SIG

The Information Technology SIG has been inactive for several years. APS is exploring the current level of interest in this SIG. If you are interested in participating in a group that will explore the role of information technology in the study of pain, contact APS at info@ampainsoc.org or 847/375-4715.

Final Reminder: APS Call for Symposia

The Call for Symposia and Corporate Satellite Symposia for the APS 27th Annual Scientific Meeting, May 7–10, 2008, is now available on the APS Web site. The deadline for the receipt of all proposals is Friday, July 27, 2007. Session moderators and faculty will be notified of their proposals' status in October 2007.

APS Future Leaders in Pain Management Small Grants Research Program

Applications due July 27.

Applications for the 2007 Future Leaders in Pain Management Small Grants Research Program are due July 27. This year APS will again award five grants in the amount of $20,000 each to those research proposals demonstrating the greatest merit and potential for success. This grant program has been established 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.

Research Topics
Proposed research projects should be in one of the following five areas of inquiry.

• Use of analgesic medications
• Unwanted effects of pain treatment related to analgesic therapy
• Neuropathic pain
• Mechanisms of pain
• Education and nonpharmacologic interventions or approaches to improve pain management.

Eligibility
To be eligible for an APS Future Leaders in Pain Management Small Grant, applicants must be APS members within 6 years of completing their doctoral degree and not yet been awarded major NIH or foundation grant funding.

Deadlines
Applications may be submitted online and are due by midnight July 27, 2007. Grant awards will be announced October 1, 2007. Funds will be awarded for a 2-year grant period that will begin upon satisfactory execution of the grant agreement between APS and the sponsoring institution, and the receipt of IRB approval.

APS gratefully acknowledges Cephalon and Endo Pharmaceuticals for their support of this program.

For additional information, visit ampainsoc.org/news/052407_smallgrants.htm or contact APS at 847/375-4715 or info@ampainsoc.org.

Pain Awareness Month

Look for Your Poster

September is Pain Awareness Month. Once again this year APS is sending posters to members to honor the occasion. This year’s poster features the APS vision. Hang your copy in your facility and share the APS vision all year long.

Members will receive one poster with the August issue of The Journal of Pain. To order extra copies, call APS at 847/375-4715. Members can request up to five copies of the poster for free (while supplies last!).

FDA Approves Lyrica to Treat Fibromyalgia

Last month, the FDA approved Lyrica as the first drug treatment for fibromyalgia. Lyrica has been shown to relieve fibromyalgia pain for some patients and increase daily functions.

The FDA approved Lyrica for the treatment of fibromyalgia based on two clinical trials that included about 1,800 fibromyalgia patients. The trials backed Lyrica's use in treating fibromyalgia at doses of 300 milligrams or 450 milligrams per day, according to the FDA.

Sources: WebMD Medical News: "Lyrica May Help Ease Fibromyalgia Pain." WebMD Medical News: "Lyrica May Relieve Fibromyalgia Pain." News release, Pfizer.

Senate Increases NIH Budget

On June 20, a Senate spending panel agreed to give the National Institutes of Health a $1 billion raise in 2008, a 3.5% increase that would bring NIH's budget to $29.9 billion. Although that's only half of what biomedical research advocates are hoping for, the increase is slightly more than the House has approved. Both bills would reverse President George W. Bush’s request for a $279 million cut.

This bill was championed by Senator Tom Harkin (D-Iowa) at the Pain Care Coalition’s (PCC) request. Special credit goes to PCC Chair Rick Rosenquist and APS Board Member Kathleen Sluka, both of the University of Iowa, who met jointly with Senator Harkin's staff in Washington, DC in early May to make the case for why the NIH needs to increase its efforts in pain.