Pain Awareness Month
September is Pain Awareness Month

Last month, we surveyed members to find out how Pain Awareness Month is being celebrated throughout the country.

We asked members about obstacles to raising awareness of pain. Members cited challenges such as "getting people to listen," getting insurance companies to fund multidisciplinary pain treatment, understanding patient perceptions (e.g., cancer survivors who believe that once their cancer is gone they shouldn't have pain anymore), and lacking funding and resources.

Several members gave examples of some strategies they employ to raise pain awareness. Twenty-one percent of respondents advertise in the local media, 16% issue press releases, 11% offer experts as speakers and open their facilities to visitors for Pain Awareness Month. Others described some of their community outreach programs, including hosting pain awareness displays within their hospitals, offering community events, and providing resources about pain to libraries and bookstores.

Communication efforts focus on educating both clinicians and the public. Efforts to reach clinicians include publishing a "pain fact of the day" on facility Intranets and hosting pain information exhibits in physician lounges.

Members asked APS for more support to help raise pain awareness. Suggestions included an APS forum for sharing ideas and materials, getting APS more involved in clinician training, and getting more information out to the media and third-party payors.

Thanks to all who participated in the survey. Your suggestions for APS are being shared with the board for consideration.

APS encourages you to download a special screen saver that was created to help you raise pain awareness in your workplace. Download here. You can also adapt this sample press release to help get the word out about Pain Awareness Month.

NY Times Features Story on Methadone Risks

In an August 17 article in the New York Times, authors Erik Eckholm and Olga Pierce wrote about the rise in methadone use and some of the risks of the drug.

The article highlighted the deaths of several patients who had been legitimately prescribed methadone as treatment for pain and died unexpectedly after taking methadone. The article suggested that in some cases physicians started patients on too high a dose of methadone; in other cases physicians failed to properly warn patients about the risks of mixing methadone with benzodiazapines. Methadone has now become the fastest growing cause of death from opioids.

Cited in the story were pain experts and APS members including APS President Chuck Inturrisi, PhD, of Weil Cornell Medical Center and Howard A. Heit, MD, of Georgetown University who noted the merits of methadone when prescribed and used appropriately and cautioned about the unforgiving nature of the drug. Methadone is metabolized slowly and patient responses to it vary greatly—some physicians prescribe too much methadone too quickly and do not warn patients about the dangers of mixing alcohol with methadone or sedatives.

The NY Times piece notes that the rise in the use of generic methadone (prescriptions increased 700% from 1998 to 2006, according to Drug Enforcement Agency figures) is in part due to the fact that it is a less expensive alternative to other medicines such as OxyContin. APS member June Dahl of the University of Wisconsin noted in the story that third-party payors are partly at fault for favoring methadone for its cheaper cost.

This year the federal government began offering voluntary training classes that teach doctors the precautions they should take with methadone, such as titrating from low starting doses and screening patients for addictive behavior. Since April, the Substance Abuse and Mental Health Services Administration has sponsored voluntary training courses on the safe prescribing of opioids and is contracting with the American Society on Addiction Medicine to set up a mentoring program through which prescribing physicians can receive advice from addiction experts. The State of Utah has a plan to educate every doctor and pain patient in the state about safe use of methadone and other opioids.

Some government officials and doctors are suggesting that the Food and Drug Administration should do more and require prescribers to take a course before prescribing opioids.

To read the full story, click here.



Share Your Opinion With APS

Do you think the Food and Drug Administration should require training for opioid prescribers?
Please make your anonymous response to our survey, and add your comments on this issue, by clicking here. We will summarize results and anonymously publish responses.

IASP Congress Featured APS Members in Leading Roles

Known best as Mecca for golfers, Scotland was the global showcase for pain research late last month as it hosted 6,000 attendees at the 12th International Congress on Pain sponsored by the International Society for the Study of Pain (IASP). APS is the United States chapter of IASP and several of its members played prominent roles at the international meeting, which is held every 2 years.

Perhaps the most notable APS contributor was Jerry Gebhart, PhD, Center for Pain Research Director, University of Pittsburgh, and former APS President and longtime editor of The Journal of Pain. Gebhart assumed the reins as IASP President at the meeting and will serve a 2-year term.

Other APS members who made plenary session presentations at the IASP meeting were Jennifer Haythornthwaite, PhD, Mitchell Max, MD, Daniel Clauw, MD, and Tony Yaksh, PhD.

The presentation by Haythornthwaite, APS Treasurer and professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, had a provocative title, "It's a Belief. It's an Appraisal. It's Coping… No, It's Catastrophizing." In her talk, Haythornthwaite reviewed current evidence linking catastrophizing with clinical pain and pain-related outcomes and identified treatments that could change catastrophizing behavior. She also related some challenges to conducting further research to better understand the role catastrophizing might play in treating pain patients.

Max, a visiting professor of anesthesiology, medicine, and human genetics at the University of Pittsburgh, reviewed research showing that variants in several genes are associated with pain phenotypes and support the hypothesis that pain susceptibility is partly genetic in origin. He related that genetic association studies may also be used to search for molecular mechanisms of common pain complications, such as depression, anxiety, and excessive motor inhibition. Max advised IASP attendees that to carry out whole genome association studies about pain, larger cohorts of patients must be studied and contributions by clinical epidemiologists to pain research should be expanded.

Clauw is professor of medicine at the University of Michigan and spoke about "Stress and Chronic Pain: Lessons Learned from Fibromyalgia." Claus said that while it has been known for many years that stress is capable of causing chronic pain, in the past decade research has shown that stress can be an underlying mechanism for fibromyalgia pain. He discussed the clinical relevance of this finding and probed the role environmental stressors and genetics play in the predisposition to fibromyalgia.

Yaksh is vice chair and research professor at the University of California–San Diego and gave the John J. Bonica Distinguished Lecture. In his lecture, "Understanding Pain Mechanisms," he reported that as scientific knowledge of spinal biology has increased, researchers have been able to use the pharmacological regulation of specific spinal systems to demonstrate the role of neurons and nonneural cells in transmitting messages that exhibit pain from acute and chronic tissue and nerve injury. He said that targeted regulation of spinal outflow could soon lead to prominent changes in various components of the pain experience, including anxiety and emotion.

APS President Charles Inturrisi also participated in the IASP meeting and noted that the research contributions of APS members are being recognized worldwide. "It certainly was evident from the strong APS presence at the IASP Congress that our members are making significant clinical and research contributions that are helping advance the science of pain and pain management in meaningful ways throughout the world."

APS Call for Paper and Poster Abstracts

The Call for Paper and Poster Abstracts for the 28th Annual Scientific Meeting, May 7-9, 2009, in San Diego, CA, is now available online at www.ampainsoc.org/meeting/annual_09/abstracts.htm. Abstracts can be submitted until 11:59 pm Pacific Time on Monday, October 27.

The Journal of Pain Highlights

The following highlights summarize selected articles from September 2008 (volume 9, number 9).

Acute Opioid Administration Improves Work-Related Exercise Performance in Patients with Chronic Low Back Pain
Douglas Gross, Yagesh Bhambhani, Mark Haykowsky, and Saifudin Rashiq; University of Alberta, Canada.

For workers with chronic low back pain, taking opioid pain medications can significantly improve their ability to lift and perform other work-related physical tasks, according to a study published in The Journal of Pain.

Low-back pain is a common cause of work absences and reduced productivity. While opioids appear to be effective for short term pain reduction, few clinical trials have been performed to evaluate their efficacy in the workplace.

A team of Canadian researchers evaluated 30 patients who had chronic low back pain for more than six months. In the double-blinded, random-ordered, placebo-controlled trial, subjects performed a lifting test twice, once after receiving intravenous fentanyl and once after taking a placebo. The goal of the study was to examine the impact of acute opioid administration on repetitive lifting and lowering exercise in workers with low-back pain.

Results of The Journal of Pain study showed opioids improved lifting performance between 15 and 48 percent. The authors concluded the performance improvement was due to reduced pain intensity. Pain reduction, as measured by pain scales, was indicative of clinically relevant analgesia achieved by the medication.

While the authors said their results are consistent with a previously published study, the controlled laboratory environment for this trial is very different from actual workplace conditions. Therefore, longer trials are needed to measure the effectiveness of opioids as an adjunct to functional restoration programs for workers with low-back pain.

A 14-Week, Randomized, Double-Blinded, Placebo-Controlled Monotherapy Trial of Pregabalin in Patients with Fibromyalgia
Lesley M. Arnold, I. Jon Russell, E.W. Dali, W. Rachel Duan, James P. Young, Jr., Uma Sharma, Susan A. Martin, Jeannette A. Barrett, and George Haig. Study sites included University of Cincinnati College of Medicine, University of Texas Health Science Center, University of North Dakota and Pfizer Global Research and Development, Ann Arbor, MI.

A medication to treat fibromyalgia, pregabalin (Lyrica), was effective at three different dosage strengths in a sample of 750 fibromyalgia patients studied in a nationwide trial. The findings were reported in The Journal of Pain.

All patients met diagnostic criteria for fibromyalgia set by the American College of Rheumatology. Three groups were given active doses of 300, 450, and 600 mg twice daily for 14 weeks and the fourth group received placebo. All patients stopped taking other medications for fibromyalgia during the trial.

Study results showed that significantly more patients in the three pregabalin groups had a 30-to 50-percent decrease in pain ratings compared to patients given placebo.

Unlike previous studies of the drug, this trial also addressed other aspects of fibromyalgia, such as determining efficacy for improving sleep. Sleep disturbance is a major problem for a large majority of fibromyalgia patients. In all three drug treatment groups, subjects reported significant improvements in the quality of their sleep, as measured by daily sleep quality diaries.

From the data, the authors concluded that pregabalin is an important treatment option for fibromyalgia patients.

Clinical Journal of Pain Highlights

The following highlights summarize selected articles from the
July/August 2008 issue (volume 24, number 6).

Predicting Opioid Misuse by Chronic Pain Patients: A Systematic Review and Literature Synthesis
Dennis C. Turk, PhD,¹ Kimberly Swanson, PhD,¹ and Robert J. Gatchel, PhD ABPP^2
(1) Department of Anesthesiology, University of Washington, Seattle, WA
⁽²⁾ Department of Psychology, University of Texas, Arlington, TX.

Recent statistics show that opioid abuse increased 71% from 1997 to 2002, suggesting that some physicians prescribe opioids without fully understanding the risks of addiction associated with them. Six published articles and 9 published studies were reviewed to examine relevant content that might help a clinician predict aberrant behaviors in chronic pain patients (CPP).

MEDLINE articles were searched from 1966 through 2007, with the limits of English-language journals and opioid-related search terms. Based on the results of past studies, some predictors of opioid misuse include a history of substance abuse, mood disorders, a history of legal problems, and clinical observations.

Additionally, the article details several screening questionnaires that have been created to help identify individuals at risk, including the Prescription Drug Use Questionnaire, Physician Opioid Therapy Questionnaire, and The Screening Instrument for Substance Abuse Potential.

The research does not conclusively say whether any of these interview methods or predictors are most important for predicting potential opioid misuse, although younger age, history of legal problems, and positive urine toxicology screens seemed to be "moderately positive" indicators. Future studies would benefit by including more specific information regarding the predictability of each questionnaire or predictor.

Individual Differences in Opioid Efficacy for Chronic Noncancer Pain
Joseph L. Riley, III, PhD, and Barbara A. Hastie, PhD; Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL.

Chronic noncancer pain affects a large percentage of the population (approximately 20%), yet has no set path for treatment. Clinicians generally are divided on the subject of opioid usage because of the risk for opioid dependence; consequently, many physicians prescribe opioids only as a last-ditch effort, while others prescribe opioids as a first line of attack. Authors Riley and Hastie conducted a review of opioid studies to determine which groups of people might be ideal candidates for opioid treatment.

The studies showed a variety of treatment options available to patients with pain, including physical therapy, rehabilitation, acupuncture, and electrical stimulation, with opioid treatment being the least widely accepted method. No single tool exists to properly provide profiles for opioid addiction, but one study of 98 patients showed 28% became opioid abusers. The highest predictors were a long history of substance abuse, depression, and younger age. Of the studies that exist, most do not show an associated risk based on sex, race, literacy, disability, and socioeconomic status.

The article explores genetic factors and neural links between pain, mood, and opioid efficacy. Some of the limitations of the literature studies include the lack evidence to predicting positive response and opioid efficacy, as well as outcome of successful opioid treatments, such as functional restoration, decreased depression, and improved quality of life. The study concludes that the field of pain medicine has many avenues still unexplored in the search for successful pain treatment.

Funding Opportunities

NIH Funding Opportunity Announcement for Chronic Fatigue Syndrome: Pathophysiology and Treatment (R01)

This funding opportunity announcement (FOA) issued by the Office of Research on Women's Health (ORWH) and co-sponsoring Institutes and Centers (ICs) of the National Institutes of Health (NIH) encourages investigator(s)-initiated applications that propose to examine the etiology, diagnosis, pathophysiology, and treatment of chronic fatigue syndrome (CFS) in diverse groups and across the lifespan. Innovative applications that address gaps in the understanding of the environmental and biological risk factors, the determinants of heterogeneity among patient populations, and the common mechanisms influencing the multiple body systems that are affected in CFS are encouraged. The NIH is particularly interested in funding interdisciplinary research that will enhance our knowledge of the disease process and provide evidence-based solutions to improve the diagnosis, treatment, and quality of life of all persons with CFS. Specific areas of pain research that are identified in this FOA include the possibilities for one to

• Conduct case-control comparisons of CFS with syndromes such as fibromyalgia, interstitial cystitis, chronic pelvic pain syndrome, irritable bowel syndrome, and other multisystem illnesses that have similar or overlapping symptomatology
• Explore the potential relationship of CFS with other chronic pain syndromes
• Elucidate the factors/mechanisms mediating common symptomatology in CFS: cognitive deficits, chronic pain, and/or inability to sustain physical exertion
• Explore the relationships of fatigue and CFS to biochemical mediators associated with frailty in the elderly, such as pro-inflammatory cytokines.

Visit http://grants.nih.gov/grants/guide/pa-files/PA-08-246.html for more information.

NIH Funding Opportunity Announcement Requests for Exceptional, Unconventional Research Enabling Knowledge Acceleration (EUREKA) (R01)

To encourage exceptionally innovative research, this FOA solicits applications from investigators who want to test novel, unconventional hypotheses or pursue major methodological or technical challenges. The potential impact of the proposed research must be substantial, in terms of both the size of the scientific community affected and the magnitude of its impact on that community. The investigator should anticipate beginning and completing the project during the term of the award, since this FOA is not for support of ongoing research or for pilot projects, and awards are not renewable. If it is the hypothesis that is novel, the investigator should be able to prove or disprove that hypothesis by the end of the funding period. If it is the methodology or technology that is exceptionally innovative, the investigator should be able to develop it by the end of the funding period or demonstrate conclusively that the approach is not feasible.

The rationale for EUREKA is that for science to move forward in leaps rather than in incremental steps, investigators must have opportunities to test unconventional, potentially paradigm-shifting hypotheses, and to attempt to use novel, innovative approaches to solve difficult technical and conceptual problems that severely impede progress in a field. However, applications proposing such research are difficult to evaluate in comparison to more typical investigator-initiated R01 research grant applications, in which the emphasis tends to be more on the feasibility of the proposed research than on its novelty.

Visit http://grants.nih.gov/grants/guide/rfa-files/RFA-GM-09-008.html for more information.

Vulvodynia Career Development Award

The Dr. Stanley C. Marinoff Career Development Award was established to encourage medical professionals to pursue their clinical and/or academic interest in vulvodynia. The award provides seed money for one of the following: medical research, establishment or enhancement of a vulvar pain clinic, or writing about vulvodynia for a publication. The NVA's intent is to encourage the development of medical professionals in this field and enable them to pursue further clinical or academic opportunities.

The award is open to all medical and allied healthcare professionals. If the applicant is affiliated with a university, he/she can have a clinical or full-time faculty appointment up to the level of assistant professor.

The award is $7,500. The applicant's academic or clinical institution is encouraged to contribute at least a matching amount. The grant may be used to fund any direct costs relevant to the project. NVA does not permit any amount of the award to be spent on overhead or indirect costs.

Applicants should submit a brief letter of intent by Friday, October 17, 2008 to Chris Veasley at chris@nva.org. After receipt of the applicant's letter of intent, NVA will mail him/her guidelines for submitting a full proposal. The final application is due on Friday, November 21, 2008. The award recipient will be announced by February 2009.

COPR 2009 Nomination Process Is Now Open

The National Institutes of Health (NIH) is seeking nominations to fill vacant appointments to the 2009 Council of Public Representatives (COPR) roster. Nominations are due Friday, September 26, 2008, and are available online at http://copr.nih.gov/nomination.asp.

New members will be notified of their conditional appointments in time for the April 2009 COPR meeting. All nominees will be notified regarding the final appointees in the summer of 2009.

The COPR advises the NIH Director on cross-cutting issues related to medical research and health issues of public interest that ultimately promote individual, family, and community health. Examples of broad issues explored by the Council include community engagement in research, public trust in the research enterprise, enhancing public awareness and education about NIH, clinical trials recruitment issues, and aspects of the NIH Roadmap for Medical Research, such as reengineering the clinical research enterprise.

The COPR consists of up to 21 individuals who are selected from among the diverse communities that benefit from, and have an interest in NIH research, programs, and activities. Members typically serve on the COPR for 4 years. To be considered for the COPR, nominees must have some interest in the work of NIH and must be in a position to communicate regularly with the broader public about COPR and NIH activities. Nominees must also be willing to fully participate in biannual COPR meetings, regular conference calls, and work group activities throughout the year.

To request a nomination form e-mail COPR1@palladianpartners.com.
More information is available at http://copr.nih.gov/.

New Resources Available on NIH Pain Consortium Web Site

The NIH Pain Consortium Web site is available at http://painconsortium.nih.gov. It has news and events, initiatives, and other resources related to pain research at the NIH. Recent highlights include an article on complementary and alternative medicine and fibromyalgia from the July 2008 newsletter of the National Center for Complementary and Alternative Medicine (NCCAM), a discussion of chronic musculoskeletal pain from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and a news article on a recent study related to neuropathic pain from the National Institute of Neurological Disorders and Stroke (NINDS).

Pain in the News

Medical Specialists Meet to Assess the Past, Present and Future of Urogenital Pain
http://www.newswise.com/articles/view/543710/?sc=mwhp

Hormone Replacement Therapy (HRT) Improves Sleep, Sexuality and Joint Pain in Older Women
http://www.newswise.com/articles/view/543577/?sc=mwhp

Click here to read more pain-related news in the media.