APS Praises House's Passage of Veterans'
Pain Care Bill

APS is pleased to share the news that on May 22 the House passed a Defense Department authorization bill for fiscal year 2009 containing provisions of the Loebsack Military Pain Care Act. The Loebsack measure now goes to the Senate. The bill ensures that all active and retired members of the uniformed services who are treated at healthcare facilities are assessed for pain at the time of their admission and initial treatment and periodically throughout their care. Other provisions ensure that pain care is consistent with recognized means for assessment, diagnosis, treatment, and management of acute and chronic pain, including access to specialty pain services.

In addition, Representative Tim Walz (MN) has introduced the Veterans' Pain Care Act of 2008, which would provide similar improvements in pain care for veterans. The Walz bill awaits Senate action on a companion measure (S2162), which is on the Senate calendar for floor action in the near future.

In his statement for the Congressional Record, Walz said his bill will require the Department of Veterans Affairs (VA) to "develop and implement a comprehensive policy on pain management for veterans enrolled in the VA health care system and to carry out a program of research, training, and education on acute and chronic pain." A consensus statement by APS and several other professional and advocacy organizations stated: "Providing adequate pain management is a crucial component to improving military and veteran health care. A growing number of wounded veterans are experiencing long-term problems with chronic pain; left untreated, pain can have long-term consequences."

"Passage of this legislation is a major step forward in helping injured military personnel and passage of the Walz legislation would help veterans combat untreated and undertreated pain," APS President Chuck Inturrisi said. "Both bills offer a practical, affordable, and effective approach to helping wounded war veterans get the ongoing pain care treatments they need. We urge the conference committee to expedite deliberation and move them to the full Congress and the White House."

APS Annual Meeting

More than 1,400 attendees represented 29 countries at the 2008 Annual Scientific Meeting in Tampa, FL. Members and nonmembers from 48 states plus Puerto Rico attended. These attendees reflect the multidisciplinary nature of the society's membership—represented medical specialties included anesthesiology, neurology, physical medicine and rehabilitation, internal medicine, and others; other professional disciplines included psychology, nursing, pharmacy, basic science, and policy analysis.

In a recent membership survey, more than half of the respondents rated the annual meeting as a very important component of their membership. APS is committed to ongoing educational innovations at this meeting.

Many thanks to the scientific planning committee, faculty, presenters, sponsors, exhibitors, and everyone who contributed to this meeting's success. The following are just some of the session highlights from this year's meeting.

Plenary Session: Chronic Pain in Adults: Is It Influenced by Early Life Events?

During his plenary session, Gary Macfarlane, MD, professor of epidemiology at University of Aberdeen (Scotland) School of Medicine, explained that some pain patients believe that their pain stems from an adverse event that occurred during childhood and they more commonly remember such events than those who are healthy. Although some adults with chronic pain often say they experienced an adverse event in childhood (such as abuse), these events are no more common in this population than among adults who are pain free. According to MacFarlane, adults with chronic pain rarely say their symptoms came on later in life and some attribute their pain to a traumatic episode or pain experience in childhood. Macfarlane studied 17,000 British children born in 1958 and found that children who complained of multiple symptoms in childhood (abdominal pain, headache) were three times more likely to have chronic pain problems as adults than children who infrequently complained about pain. Also, babies who were treated in intensive care units and had invasive procedures showed different sensitivity to pain as children.

Wilbert E. Fordyce Clinical Investigator Lecture: From Poppies to Pill Popping: Is There a Middle Way?

Dr. Raja (shown here with APS President Judy Paice), this year's Wilbert E. Fordyce Clinical Investigator award recipient, spoke about access to care issues and patients.

During his session, Srinivasa Raja, MD, professor of anesthesiology, Johns Hopkins University Medical School, urged clinicians and policy makers not to allow the small percentage of patients who abuse pain prescriptions to prevent legitimate pain patients from getting the care they need. He advocated finding stronger evidence about which patients will benefit most from these medications to help make better prescribing decisions. But he also acknowledged that most chronic pain patients do not rely solely on drugs for treatment. More studies show that multifaceted treatment involving physical and cognitive behavioral therapies and appropriate interventional strategies lead to the most favorable outcomes. According to Raja, the problem of prescription drug abuse should be approached through collaborations involving caregivers, regulatory and law enforcement agencies, and the pharmaceutical industry. Law enforcement and federal and state regulatory agencies need to strive for state-to-state consistency in regulating controlled substances and crack down on illegal Internet pharmacies and prescription thefts and forgeries. For pharmaceutical manufacturers, Raja explained that the key challenge is matching clinical needs for less addicting pain medication with drug development priorities. He concluded that public and professional attitudes need to evolve to recognize that opioids are effective for treating chronic noncancer pain and that very few legitimate pain patients abuse their medications. He calls for a middle-ground approach that protects the rights of patients and clinicians while upholding society's right to control medication abuse and diversion.

Evidence-Based Medicine for Evaluation and Management of Low Back Pain: Update on Guidelines from the American Pain Society

APS is expanding its evidence-based, clinical practice guideline on diagnosis and treatment of chronic low back pain to include recommendations on surgery and other interventional treatments. The expanded guideline was previewed in a symposium at the APS Annual Scientific Meeting. The second part of the APS guideline is based on a multidisciplinary panel's review and analysis of volumes of evidence related to diagnosis and treatment of low back pain with a number of interventional procedures and surgeries. Roger Chou, MD, director of the American Pain Society's Clinical Practice Guideline Program and associate professor of internal medicine, Oregon Health & Science University, noted that in addition to the multidisciplinary panel that formulated the guideline for evaluation and management of low back pain in primary care settings, additional experts with expertise on interventional therapies and surgeries for low back pain were recruited to review the evidence and formulate the expanded recommendations. The evidence is much better than 5-10 years ago and both the primary care and interventional recommendations will help physicians be more confident when evaluating possible therapies for low back pain. During the symposium, Chou and two panel cochairs, Richard Rosenquist, MD, assistant professor of anesthesiology, University of Iowa, and John Loeser, MD, professor, Department of Neurological Surgery, University of Washington, reported that for many interventional procedures the evidence from randomized controlled trials is mixed, sparse, not available, or showed no benefits. Accordingly, the expanded, evidence-based APS guideline will report:

• Invasive diagnostics, such as provocative discography, facet joint block and sacroliliac joint block tests, have not been proven to be accurate for diagnosing various spinal conditions, and their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain.
• Epidural steroid injections are an option for short-term pain relief for persistent radiculopathy (radiating low-back pain caused by a herniated disc).
• Other interventional therapies, such as local injections, prolotherapy, botulinum toxin (botox) injection, facet joint injection, sacroliliac joint injection, radiofrequency denervation, and intradiscal electrothermal therapy are not supported by convincing, consistent evidence of benefits from randomized trials.
• Surgery to treat radiculopathy and spinal stenosis is effective, though the benefits diminish over time.
• Effectiveness of surgery for nonradicular low back pain is less certain, with some studies showing no benefits compared to intensive interdisciplinary rehabilitation.

In addition, a significant proportion of patients experience suboptimal outcomes including persistent pain or functional deficits following surgery. The expert panel reaffirmed its previous recommendation that all low back pain patients stay active and talk honestly with their physicians about self-care and other interventions. "In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou. Recommendations from the first APS Clinical Practice Guideline on Low-Back Pain were intended for primary care physicians and appeared in the October, 2, 2007 issue of the Annals of Internal Medicine. For diagnosis, the first APS low back pain guideline advises clinicians to minimize routine use of X rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders. In addressing treatment options, it is recommended that medications used should be appropriate for the severity of baseline pain and functional impairment, and clinicians should carefully weigh potential benefits and risks of any drug and explain them. Also for various nonpharmacological treatments supported by the evidence-from spinal manipulation to massage therapy-the first guideline panel recommended they be considered for patients who do not improve with self-care options and prefer not to take pain medications.

Other Meeting Highlights

The Pain Sensations, an APS favorite, performed for attendees at Stump's Supper Club.

Highlights from The Journal of Pain

The following highlights summarize selected articles from May 2008 (volume 9, number 5).

Validation of the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
Stephen F. Butler, Katherine Fernandez, Christine Benoit, Simon H. Budman, and Robert Jamison; Brigham and Women's Hospital and Harvard Medical School, Boston, MA.

Although opioid pain medications are effective for treating chronic pain, many physicians are reluctant to prescribe them because they fear patients will become addicted to them or will abuse them. Harvard researchers may have an answer to this problem with a new screening tool, published in The Journal of Pain, to predict which pain patients are most likely to exhibit aberrant medication-related behavior.

The estimated prevalence of addiction to any substance in pain patients is approximately 10%, yet most physicians who prescribe potent pain drugs have little training in addiction or confronting aberrant drug behavior. Even though substance abuse is evident in chronic pain patients, potential addiction risk does not outweigh the benefit of effective pain management. Optimal use of opioids, therefore, requires physicians to evaluate potential drug-abuse risks in their patients. But how?

Researchers at the Pain Management Center at Harvard's Brigham and Women's Hospital sought to improve deficiencies in screening questionnaires used to identify which chronic pain patients could be at risk for abusing their pain medication. The purpose of the study was to develop and validate a new, revised version of the standard questionnaire (Screener and Opioid Assessment for Patients with Pain), but with enhancements to include patient self-reports with provider observations and toxicology results.

Fifty-five chronic pain patients were randomly selected to complete the new screening survey from a group of 283 that had completed the standard questionnaire. The researchers determined that the revised survey elicited information critical for determining which chronic pain patients may have problems with long-term opioid therapy. From an initial pool of 142 items, the final questionnaire was reduced to 24. They probed for problems with mood, temperament, feelings of impatience and frustration. Several items were related to attitudes about pain medication.

The authors concluded the revised screening tool is an improvement on the original questionnaire in identifying drug abuse risk potential among chronic pain patients. It was found to be more reliable and less susceptible to deception.

A Psychophysical Study of Auditory and Pressure Sensitivity in Patients with Fibromyalgia and Healthy Controls
Michael E. Geiseer, Jennifer M. Glass, Ljubinka D. Rajcevska, Daniel J. Clauw, David A. Williams, Paul R. Kileny, and Richard H. Gracely; University of Michigan, Ann Arbor

Fibromyalgia is a chronic pain condition that causes widespread pain and tenderness throughout the body. A University of Michigan study, published in The Journal of Pain, shows that fibromyalgia is associated with central nervous system abnormalities that are evidenced by patients' elevated sensitivity to auditory and pressure sensations.

The Michigan researchers studied 31 subjects to determine whether there is a global central nervous system problem underlying sensory processing in fibromyalgia patients. They noted that few studies have employed different stimuli in consistent ways and levels of intensity to measure pain sensitivities in this patient group. In this study, fibromyalgia patients and normal subjects were exposed to random auditory and pressure stimuli.

Consistent with prior research, the fibromyalgia subjects in the study showed greater sensitivity to auditory tones and reported higher sensitivity to daily sounds. Significant associations were also observed between the auditory and pressure responses and support the claim that such abnormalities maybe related to a common pathophysiological mechanism. They also noted that fibromyalgia subjects perceived auditory stimuli to be of the same intensity as felt by control subjects, even though their actual intensity level was lower.

The authors concluded that fibromyalgia is associated with a central nervous deficit in sensory processing. Further research is needed to examine the mechanisms governing these perceptual abnormalities.

The Mediating Role of Depression and Negative Partner Reponses in Chronic Low Back Pain and Relationship Satisfaction
Samantha E. Waxman, Dean A. Tripp, and Ricardo Flamenbaum; Queen's University, Kingston, Ontario

It is well documented that chronic low back pain has a negative effect on relationships. Also, the quality of relationships may influence the pain experience. In this study, the authors looked at the role of psychosocial variables as mediators of pain.

Several previous studies have reported the benefit of social support in chronic pain. However, no studies have examined potential mediators of the association between pain and relationship satisfaction in patients with chronic low back pain. Fifty-four subjects in southeastern Ontario with chronic low back pain were studied. They completed several survey instruments, such as the Multidimensional Pain Inventory, Short-form McGill Pain Questionnaire, Pain Catastrophizing Scale, and the Dyadic Adjustment Scale. Mediation analyses were conducted for each psychosocial variable to determine their roles as mediators in the association between pain and relationship satisfaction.

The study's findings suggest that chronic low back pain may promote increased perceived negative responses by a partner, which in turn may be associated with decreased relationship satisfaction. Similarly, the authors noted that depression linked with chronic low back pain is associated with decreased relationship satisfaction. Based on their findings, the authors recommend that addressing the style of interactions and communication between couples may lessen the dissatisfaction with intimate relationships among chronic pain patients.

School Impairment in Adolescents with Chronic Pain
Deirdre E. Logan, Laura E. Simons, Michelle J. Stein, and Laura Chastain; Children's Hospital, Boston and Harvard Medical School

Little is known about the role of pain as an influence on a child's ability to perform in school. Some studies have shown that children with chronic pain have more absences, on average about 1 to 3 days a month. But few researchers have looked beyond school absence rates to evaluate school functioning in children with pain conditions.

The researchers tested three hypotheses for their study of 220 Boston-area students ages 12-17:

• Higher school absence rates will be associated with other indicators of school impairment, including poor academic performance, lower perceived academic performance, and teacher-reported school adjustment.
• Greater school impairment will be associated with older age and greater pain intensity.
• Multiple reports of school impairment will be positively inter-correlated.

The authors used school attendance records, descriptions of accommodations for students with chronic pain, and teacher ratings of academic competence to assess student performance.

Many adolescents with chronic pain missed significant time from school, showed a decline in academic performance, and perceived their pain to be an impediment to their success. Researchers determined that variables of school impairment are intercorrelated; one domain is associated with similar patterns in other domains of school functioning. For example, frequent absences pose a risk for low academic achievement and subsequent long-term social disability.

The study also found that pain intensity and duration were unrelated to school functioning in these subjects.

Clinical Journal of Pain Highlights

The following highlights summarize selected articles from the
June 2008 issue (volume 9, number 1).

Attributions Regarding Unmet Treatment Goals After Interdisciplinary Chronic Pain Rehabilitation
Thomas P. Guck, PhD,* James C. Willcockson, PhD,† Rex L. Schmidt, PsyD,† and Christopher M. Criscuolo, MD†

*Department of Family Medicine, Creighton University School of Medicine, Omaha, NE
†Pain Center, University of Nebraska Medical Center, Omaha, NE

The goal violation effect (GVE), a component of the relapse process model, occurs when patients make internal, stable, global, and uncontrollable rather than external, unstable, specific, and controllable attributions about the causes for unmet goals. GVE consistent attributions lead to guilt and self-blame, reduce self-efficacy, and increase the probability that a lapse will lead to a full-blown relapse. This study was designed to determine if chronic pain patients make attributions regarding the causes of unmet goals consistent with the GVE and to determine differences for the GVE and the individual attributions making up the GVE among unmet coping skills, medication, exercise, social, and work goals.

In the last week of an interdisciplinary pain program, patients stated 4-6 treatment goals. After 6 months, 100 patients rated the cause for their unmet goals using 7-point scales to assess whether they made internal, stable, global, and uncontrollable attributions. The GVE for each of the five goal types was above the midpoint toward model consistent attributions. A multivariate analysis of variance was significant for goal type (p < .0001). No significant differences were found among goal types for the GVE or the stable or global attributions. However, work and social goals were found to have lower internal attributions compared with coping, medication, and exercise goals. Internal and uncontrollable attributions for causes of unmet goals varied with goal type, which has implications for the design of relapse prevention strategies.

Multidisciplinary Rehabilitation Treatment of Patients with Chronic Low Back Pain: A Prognostic Model for Its Outcome
Marije van der Hulst, MD,*† Miriam M. R. Vollenbroek-Hutten, PhD,* Karin G. M. Groothuis-Oudshoorn, PhD,* and Hermie J. Hermens, PhD*‡

*Roessingh Research and Development, University of Twente, Enschede, The Netherlands
†Rehabilitation Center "Het Roessingh," University of Twente, Enschede, The Netherlands
‡Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands

In the chronic low back pain (CLBP) population, various treatment programs exist. Understanding the factors that predict treatment outcomes may identify treatment suitable for individual patients. This study was designed to determine whether treatment outcome in CLBP can be predicted by a predefined multivariate prognostic model based on consistent predictors from the literature and to explore the value of potentially prognostic factors.

Data were derived from a randomized, controlled trial on the effect of a multidisciplinary rehabilitation program for CLBP compared with usual care. The outcome measures were the Roland and Morris Disability Questionnaire (primary) and the Physical and Mental Component Summary Scales (secondary), derived from the Short Form Health Survey. Outcomes were expressed as the differences between baseline and follow-up (8 weeks and 6 months) values. A confirmatory and an exploratory model were defined with baseline predictors. Of the 163 patients who participated in the study, more pain was prognostic for more improvement in the rehabilitation group. The results of this study do not support the construction of a clinical prediction model. Future confirmative studies of homogeneous rehabilitation treatments and outcome measures are needed to illuminate relevant prognostic factors.

APS Board Meeting

The APS Board of Directors met on Tuesday afternoon, May 6. Among other things, they reviewed the outcomes of the 2007–2008 work plan noting the success of the Centers of Excellence, the Young Investigator travel grants, and the Small Grants programs. The Board also spent a significant portion of time discussing their renewed commitment to and future potential of the Clinical Practice Guidelines program and the upcoming publication of the Low Back Pain and Opioid guidelines.

On Wednesday, members from both the outgoing and incoming Board convened to affirm the strategic vision and mission of the Society and to set priorities for 2009.

APS 28th Annual Scientific Meeting
Save the Date: May 7-9, 2009

The APS Annual Scientific Meeting is an excellent way to stay current and tap into the multidisciplinary resources APS has to offer. Join us May 7-9, 2009, in San Diego, CA!

Call for Symposia and Call for Corporate Satellite Symposia
Visit the APS Web site to access the submission forms for the Call for Symposia and the Call for Corporate Satellite Symposia for the 28th Annual Scientific Meeting, May 7-9, 2009, in San Diego. The deadline for proposals for both calls is July 25, 2008.

The Call for Paper and Poster Abstracts will be available on the APS Web site beginning September 1. Please watch future issues of APS E-News for updates.

Oncology Nursing Society Trish Greene
Research Grant

The purpose of this grant is to promote oncology nursing research in the areas of pain assessment and pain management. The principal investigator must be actively involved in some aspect of cancer patient care, education, or research. Funding preference is given to projects that involve nurses in the design and conduct of the research activity and that promote theoretically based oncology practice. Note: If drug therapy is part of the research design, a Purdue Pharma, L.P. product must be used in at least one area of the treatments being employed. For more information and to download the application forms visit
http://www.ons.org/awards/foundawards/green.shtml

Mattel Continues Grant Program
Deadline: July 15, 2008

Mattel and the Mattel Children's Foundation have announced they will continue the Mattel Domestic Grantmaking Program, which provides funding for organizations benefiting children in the United States.

Mattel's funding priorities include programs that directly and effectively impact children with demonstrated needs (physical, financial, emotional, and health related); preferences to programs with demonstrated results; and organizations that use creative and innovative methods to address a locally defined need directly impacting children.

Preference will be given to organizations or programs that align with Mattel's philanthropic priorities: learning (increasing access to education for underserved children and, in particular, innovative strategies to promote and address literacy); health (supporting the health and well-being of children, with particular emphasis on promoting healthy, active lifestyles); and girl empowerment (promoting self-esteem in young girls, up to age 12).

Applicants must be 501(c)(3) tax-exempt public charity organizations (or have a fiscal sponsor with tax-exempt status) and must directly serve children in communities within the United States. Grants will range from $5,000 to $25,000 each for one fiscal year. Funds may be applied to programs or general operating costs. Visit the Mattel Web site for complete program guidelines, online eligibility quiz, and grant application.

Pain in the News

As an ongoing feature, APS E-News will now include links to articles from the lay press that cover pain and related topics.

Migraine Increases Risk Of Severe Skin Sensitivity and Pain

FDA Panel Rejects Cephalon Pain Drug on Risks of Misuse

Update Your Contact Information

The APS Online Membership Directory is available year-round to keep you connected to your colleagues. To ensure your listing is accurate, log on to the Members Only section of the APS Web site.

Enter your Web ID (for first-time visitors, this is your Member ID) and password and click "Update Your Own Member Record."

If you need assistance, please contact APS Member Services at 847/375-4715.

Please note: APS does not sell or distribute your personal information.