Will Your Program Be an APS 2009 CCOE Award Recipient?

Clinical Centers of Excellence in Pain Management Awards Program is now accepting applications online through December 14, 2008.
The Clinical Centers of Excellence (CCOE) in Pain Management awards program, which was launched in 2006, annually awards U.S.-based multidisciplinary pain programs that provide the most distinguished and comprehensive pain care. Since 2007, 12 forward-thinking teams of healthcare professionals have been recognized as CCOE award recipients. Will your program be next?

Among meeting other award criteria, CCOE award recipients must demonstrate how their care is patient-centered, evidence-based, and safe; provide appropriate access to multidisciplinary and multimodal care; employ various therapeutic modalities; act as a local champion to improve pain management in systems of care; demonstrate innovation and serve as a model of excellence; and show a commitment to advancing the scientific knowledge related to pain.

If you feel your program is demonstrating excellence in these areas, APS wants to hear from you. Selection of awardees is judged on the quality of services provided and not the size or type of program. Attempts are always made to balance service excellence with available resources.

Looking ahead, APS plans to enhance the CCOE Program so that it continues to be a beacon for excellence in interdisciplinary pain care. Starting this year, APS will begin providing quantitative and qualitative reviewer feedback to unsuccessful applicants. APS also plans to leverage the considerable expertise and experience of CCOE awardees to highlight best practices and various models for providing high-quality interdisciplinary pain care to patients.

Applications for the 2009 CCOE Awards are being accepted through December 14, 2008. To learn more about the awards program and to submit an online application, please go to http://www.ampainsoc.org/awards/ccoe.htm.

Final Reminder: Paper and Poster Abstracts Due October 27

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.

Reminder: Nominate a Colleague for the 2009 Election

The nominations form for nominating potential election candidates is available on the APS Web site at www.ampainsoc.org. Open positions for 2009 are president-elect, treasurer, three directors-at-large, and seven nominating committee members. Position descriptions, the current list of board and nominating committee members, vacancies, and the disciplinary composition and geographic representation of the board are also available online. Nominees must be regular APS members. The nominations process will close on October 24.

Nominating and electing the leadership of APS is an important and fundamental responsibility of all society members. Your participation is important!

APS Members Weigh in on FDA Training for Opioid Prescribers

Last month APS surveyed members asking, "Do you think the Food and Drug Administration (FDA) should require training for opioid prescribers?"

The results reveal how hotly contested this issue is: 57% of respondents believe the FDA should require training for opioid prescribers whereas 43% disagreed. Some of those who oppose the training fear that it will further reduce patient access to effective pain management, increase the regulation of opioids over other drugs that can be equally dangerous, and increase anxiety among prescribers.

Those who support the training believe it might encourage prescribers who avoid opioids to prescribe them more because those prescribers would have more knowledge about the risks and benefits of opioids. Suggestions for training include reviewing basic concepts of pain assessment, screening for risk, and encouraging preventative follow-up and proper documentation. Several respondents who support required training believe it would translate into improved patient care if more healthcare providers are willing to treat pain in all patient populations. Some members stipulate that training should be targeted at only those who prescribe opioids for chronic pain and should include alternative treatments for chronic pain and criteria for when to refer patients to pain specialists.

Most survey respondents described themselves as being involved in pain management. They represented a variety of specialties including nursing, psychology, and medicine (e.g., anesthesiology, internal medicine).

Two Military Pain Care Acts and Mental Health Parity Bill Passed

Veterans Pain Care Policy Act and the Military Pain Care Policy Act
APS supports the recent actions by Congress and the President, which resulted in the enactment of two pain care bills, the Veterans Pain Care Policy Act and the Military Pain Care Policy Act of 2008.

“These measures are a vital step in making good pain care a national priority within the military healthcare systems. The brave men and women in military service and their families deserve no less,” said APS President Charles J. Inturrisi, PhD.

The Veterans Pain Care Policy Act (S 2160) originated the Senate and subsequently was added to the Veterans Mental Health and Other Care Improvements Act of 2008 (S 2162). It will fund pain care programs in VA facilities and offer pain management for veterans with long-term pain disabilities. “The VA pain bill has a 10-year requirement in which the VA must report to Congress every year and show the progress it has achieved in enhancing clinical care, research and training in pain management. This will help keep veterans pain issues top-of-mind in Congress,” said Inturrisi.

The Military Pain Care Policy Act of 2008 (HR 4565), which originated in the House of Representatives, is intended to improve pain care for armed services personnel and their families. The bill authorizes the Department of Defense to implement a pain-care initiative, requires that all military health facilities assess their patients for pain, ensure they receive appropriate pain care, and refer chronic pain patients to specialty pain management services and to comprehensive multidisciplinary pain management when appropriate.

“APS was pleased to work with the Pain Care Coalition in the effort to secure passage of this legislation to provide effective pain management services to wounded troops coming home from Iraq and Afghanistan and for veterans with pain conditions who served our country honorably in other wars,” Inturrisi added. “We express our deepest thanks to the members of Congress who served as sponsors for the bills and helped move them through the legislative process and to the President for signing them into law today.”

Mental Health Parity
The Mental Health Parity bill was tied to the financial rescue plan that Congress recently passed.

The bill includes the following provisions:

• Health plans that provide mental health or substance use disorder benefits must provide the same financial requirements (e.g., deductibles, co-pays, coinsurance) and treatment limitations (e.g., frequency of treatment, days of coverage, lifetime limits) for those disorders as most other medical and surgical conditions.
  
• Out-of-network benefits for mental health and substance use disorders must match those provided for medical and surgical benefits.
• State parity laws will be protected by the current HIPAA standards. The Department of Labor will annually audit compliance with the parity bill and inform state regulators about the effects on state laws (with the goal of protecting state parity laws).
• Plans will be able to medically manage the benefits and determine the scope of coverage, but they will be required to provide patients with the terms of the medical necessity criteria and reasons for denials.
• To protect against unfair medical management, the Government Accountability Office will study the specific coverage rates for mental health and addiction, the diagnoses most commonly excluded from coverage, and coverage costs.
• The Act would exempt employers with 50 employees or fewer and plans whose costs increase more than 2% in the first year or 1% in any subsequent year (the exemption would only apply for 1 year, after which point the plan would need to reinstate parity again).

The Journal of Pain Highlights

The following highlights summarize selected articles from the October 2008 issue (volume 9, number 10).

Domain-Specific Self-Efficacy Mediates the Impact of Pain Catastrophizing on Pain and Disability and Obese Osteoarthritis Patients
Rebecca A Shelby, Tamara J. Somers, Francis J. Keefe, Jennifer J. Pells, Kim E. Dixon and James A. Blumenthal, Duke University Medical Center

Chronic pain patients with strong feelings of self-efficacy regarding physical activity are less fearful about pain and, therefore, adjust better and have less disability impairment.

Researchers at Duke University Medical Center studied 192 patients with osteoarthritis of the knees who reported knee pain persisting 6 months or longer and were overweight or obese. They evaluated whether the patients' levels of self-efficacy would influence their overall fear of pain (catastrophizing) and subsequent outcomes, such as disability. Previous studies have recognized patient self-efficacy as an important variable in understanding how patients adjust to pain. They also have shown that reductions in pain catastrophizing are linked with pain relief, better physical functioning, and improved psychological adjustment. In addition, strategies to enhance self-efficacy in arthritis patients have been shown to reduce disability.

The authors reported that self-efficacy mediated the relationship between pain catastrophizing and overall adjustment to chronic pain. They concluded that the impact of pain catastrophizing leads to greater physical disability from arthritis pain through lowered self-efficacy for physical function and greater psychological disability through lowered self-efficacy for managing psychological symptoms. The authors recommended that the problem can be addressed with cognitive therapy techniques to reduce distorted, irrational, or overly negative thinking and with strategies to enhance self-efficacy, such as skills development and improvement, observations of others, and recognition of personal achievements.

Common Chronic Pain Conditions in Developed and Developing Countries: Gender and Age Differences and Comorbidity with Depression-Anxiety Disorders
Adley Tsang, Hong Kong Mood Disorders Center, and multiple coauthors representing several institutions worldwide

Chronic pain conditions are common in both developed and developing nations, but prior studies regarding chronic pain and its association with mental disorders were conducted mainly in Western countries and yielded generally consistent findings. These studies determined that mood and anxiety disorders are associated with chronic pain. Researchers from several institutions worldwide, led by the Hong Kong Mood Disorders Center at The Chinese University of Hong Kong, investigated the association of chronic pain with depression and anxiety disorders by analyzing data from 18 surveys conducted in 17 countries that participated in World Mental Health Surveys (WMHS).

The WMHS data allowed comparison of the prevalence of chronic pain conditions in developed and developing countries. The researchers determined from the survey that there is a significant association between chronic pain conditions and mental disorders in both developed and developing countries. However, a large majority of those with chronic pain in the samples did not meet diagnostic criteria for a depressive or anxiety disorder. The authors noted this suggests that pain is an independent illness entity rather than a somatic presentation of masked mental disorders.

Although there were large differences in pain prevalence rates among countries surveyed, the differences between developed and developing countries were modest. In addition, depressive and anxiety disorders were found to be much less prevalent in developing countries than in developed countries, and there was a higher prevalence of chronic pain conditions among women and older patients.

PAIN Highlights
A New Feature of APS E-News!

The following highlights summarize selected articles from the August 2008 issue (volume 138, number 1).

Hypoalgesia in Schizophrenia Is Independent of Antipsychotic Drugs: A Systematic Quantitative Review of Experimental Studies
Stephane Potvin and Serge Marchand; Department of Neurosurgery, Faculty of Medicine, University of Sherbrooke, Quebec, Canada.

Schizophrenia has often been reported to cause diminished sensitivity to pain. Potvin and Marchand's article examines 12 studies to examine whether schizophrenia patients have diminished pain responses and to study what influence outside factors might have in causing pain or a psychiatric condition.

Comprehensive meta-analysis showed that pain thresholds were increased in schizophrenia patients. Preliminary study results showed that patients had a blunted response to pain, emotions, and even pleasure, though these results are tentatively based on only a few studies.

The reviewers found that electrical and thermal stimuli produced considerable effects, particularly in electrical stimuli cases. However, few studies exist that examine both pain intensity and pain effect. The benefit of Potvin and Marchand's 12-study review is the expanded scope offered by such a large study. However, the review was limited—there was a small subset of studies from several of the secondary analyses and heterogeneous sets of studies from most other analyses.

The authors concluded that patients with schizophrenia do have a diminished response to pain, at least pain that is experimentally induced, and drug-free patients have a tendency for hypoalgesic responses as well. Further research is needed.

Localized or Widespread Musculoskeletal Pain: Does It Matter?
Yusman Kamaleri,¹ Bård Natvig,¹ Camilla M. Ihleback,² Dag Bruusgaard ^1
(1) Section for Occupational and Social Insurance Medicine, Institute of General Practice and Community Medicine, University of Oslo, Norway
⁽²⁾ The Research Unit, The Norwegian Back Pain Network, Unifob Helse, University of Bergen, Norway

Musculoskeletal pain is often studied in isolated pain sites, despite many indications that widespread musculoskeletal pain is more prevalent and has deeper implications for patient functionality. This study sought to determine whether it matters if pain is diagnosed as localized or widespread and if localized pain even exists at all.

Questionnaires were collected in Norway for seven age brackets, ranging from 24-76 years of age. Responses were received for 3,179 participants, who self-reported on their level of pain and discomfort. Data relied heavily on the honesty and willingness of participants to report their pain. Neck pain, low back pain (LBP), shoulder pain, and headaches were the most frequently noted areas of pain. Women had the highest percentage of neck pain; men reported LBP pain more than any other location.

Of the participants, 16.8% reported localized pain and 17.3% reported pain in at least five sites. Of those who reported localized pain, the study found that fitness, daily, and social activities were rarely affected. However, the relationship between the number of pain sites and functional ability was very strong, with functional ability decreasing as the number of pain sites increased.

Localized pain does exist, the authors conclude, but research concentrating solely on localized pain will miss an important dimension because the consequences of pain are much greater in those with widespread musculoskeletal pain.

Clinical Journal of Pain Highlights

The following highlights summarize selected articles from the September 2008 issue (volume 24, number 7).

Anxiety, Mood, and Behavioral Disorders Among Pediatric Patients with Juvenile Fibromyalgia Syndrome
Susmita Kashikar-Zuck, PhD,^1,3 Irina S. Parkins, PhD,¹ Thomas Brent Graham, MD,^2,3 Anne M. Lynch, PhD,^1,3 Murray Passo, MD,^2,3 Megan Johnston, BA,¹ Kenneth N. Schikler, MD,⁶ Philip J. Hashkes, MD,⁴ Gerald Banez, PhD,⁵ and Margaret M. Richards, PhD^5
(1) Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
⁽²⁾ Rheumatology Division, Cincinnati Children's Hospital Medical Center
⁽³⁾ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
⁽⁴⁾ Department of Rheumatic and Immunologic Disease, The Cleveland Clinic Foundation, Cleveland, OH
⁽⁵⁾ Department of Pediatrics, The Cleveland Clinic Foundation, Cleveland, OH
⁽⁶⁾ Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY

Fibromyalgia syndrome (FMS) is the twelfth-most-common new patient diagnosis in pediatric clinics. Because of its frequency, the authors set out to determine how common mood disorders behave in patients who also have fibromyalgia. In addition, researchers were interested in knowing whether the psychiatric symptoms were caused by the psychiatric pain patients live with or whether the same risk factors for chronic pain also cause FMS. The review was conducted by interviewing patients and their parents or primary caregivers, and then measuring their symptom severity based on global ratings.

Seventy children agreed to take part in the study. To be included, individuals had to be between the ages of 11 and 18 years, be diagnosed with musculoskeletal pain at three or more sites for 3 or more months, have severe pain in at least five tender point sites upon manual palpation, and have at least three associated symptoms. Patients were required to have informed consent from their parents or guardians.

Participants completed weekly diaries and interviewed with a licensed psychologist. Symptoms were measured based on several rating measures, such as the Juvenile Primary Fibromyalgia Syndrome (JPFS) Symptom Severity, Global Physician Rating, and the K-SADS-PL interview. The findings showed an increase in pain ratings in patients who had a mood disorder. The research also suggested that disorders such as anxiety disorder are very treatable, and in fact, will lower the probability of adult mood difficulties if treated as a child. The area of medication for JPFS is not largely understood; currently, there are no FDA-approved drugs available for use in children and adolescents with JPFS.

Sex Differences in Presentation, Course, and Management of Low Back Pain
John Francois Chenot, MD PhD, Annette Backer, MD MPH, Corinna Leonhardt, PhD, Stefan Keller, PhD MSc, Norbert Donner-Banzhoff, MD PhD MSc, Jan Hildebrandt, MD PhD, Heinz-Dieter Basler, PhD, Erica Baum, MD, Michael M. Kochen, MD PhD MPH, and Michael Pfingsten, PhD; Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL

In this study examining how one's sex alters the management of low back pain (LBP), researchers found that LBP is generally associated with a higher frequency in women in spite of their healthier lifestyle and the limited amounts of heavy lifting they perform.

Approximately 3,400 patients were included in the study examining sex differences in relation to LBP, which has a higher prevalence in those who are overweight, have low levels of social support, are physically inactive, smokers, elderly, blue collar workers, and from lower socioeconomic groups. The study collected sociodemographic and disease-related data from a questionnaire distributed to patients at the start of study. Patients were assessed at 4 weeks, 6 months, and 12 months, using a variety of surveys measuring pain, functional capacity, and depression.

Pain was measured using a modified von Korff procedure, functional capacity was measure with the Hannover Functional Ability Questionnaire (HFAQ), and depression was measured with a version of the Center for Epidemiologic Studies Depression Scale (CES-D).

Age did not prove to be a relevant difference between the sexes. The study showed that men reported a higher severity of pain, but women more often had chronic LBP, a longer duration of the pain, and were more likely than men to have a higher depression score. One explanation for these discrepancies in LBP between men and women could be the result of different sex role beliefs, pain coping, and mood. Further research should examine whether women with LBP might have greater healthcare needs.

APS Studies Outcomes of Essentials Course

APS recently surveyed more than 200 participants of its 2006, 2007, and 2008 Essentials in Pain Management Course to determine outcomes that the course has had on clinical practice. For the past several years, the 2-day course for third- and fourth-year residents and fellows in anesthesiology, neurology, family practice, emergency medicine, and physical rehabilitation medicine, has been held in conjunction with the APS Annual Scientific Meeting. The course is designed to provide attendees with a foundation that, along with participation in the APS Annual Scientific Meeting, offers residents and trainees significant knowledge in pain management education and research.

Survey results indicated that the majority of respondents (89%) made changes in their clinical practice as a result of participating in the course. Seventy-two percent stated that they added "some to several" diagnostic, treatment, or management techniques to their practice, whereas an additional 17% made significant changes in their diagnostic, treatment, or management approaches. In addition, 98% of respondents indicated that they have more knowledge and a better understanding of the basic mechanisms of acute and chronic pain because of their participation in the course.

In 2009, APS, with support from Endo Pharmaceuticals, will again provide approximately 100 residents and fellows with the opportunity to participate in the course. Charles Argoff, MD, chair of the course committee, along with a group of distinguished colleagues, is currently assembling topics and faculty for the upcoming program. Program directors will receive letters of invitation later this fall and will be encouraged to submit names of residents for the course committee's consideration and complete an application, which includes the submission of letters of recommendation.

IASP Global Year Against Cancer Pain

This month, the International Association for the Study Pain (IASP) launches its Global Year Against Cancer Pain, which kicks off on October 20. This year's initiatives are being chaired by APS Past President Judy Paice, PhD RN FAAN, and IASP President-Elect Eijo Kalso, MD DMedSci. Look for information about the Global Year, which will be posted soon on the IASP Web site, www.iasp-pain.org.

NIH Update

Zerhouni Steps Down from NIH Director Role
Elias A. Zerhouni, MD, the National Institutes of Health (NIH) director, recently announced his plans to step down at the end of October 2008 to pursue writing projects and explore other professional opportunities.

Zerhouni is a physician scientist and a world-renowned leader in radiology research. His tenure as NIH director began in 2002. He is known for his initiatives that pushed scientists to focus on patient care and his efforts to encourage cooperation across agencies. One hallmark of his tenure was the NIH Roadmap for Medical Research, which brought together all 27 of the NIH Institutes and Centers to fund major projects.

A controversial aspect of Zerhouni's tenure involved a years-long Congressional investigation of agency scientists who mixed government research positions with private consulting roles. In 2005, Zerhouni banned agency scientists from consulting for pharmaceutical and device companies.

Raynard S. Kington, MD PhD, deputy director of NIH, is expected to serve as the agency's interim director for the remainder of the Bush administration.

New NIH Policy on Resubmission (Amended) Applications
The NIH recently released a new policy that will enhance success rates of new and resubmitted applications by decreasing the number of allowed grant application resubmissions from two to one. This policy is a part of a continuing series of changes to the NIH peer review system that follow an in-depth review and a year-long, self-assessment that concluded in June 2008. This new policy will help ensure earlier funding of high-quality applications and improve efficiencies in the peer review system.

NIH analysis indicates that an increasing number of meritorious applicants that were ultimately funded had to resubmit their applications multiple times, increasing burden on applicants and reviewers. NIH's previous policy allowed research applicants two attempts to improve their original applications based on feedback from peer reviewers. In times of budgetary constraint, however, data reveal a reduction in the number of awards made to original applications. An increasing number of projects were funded only after one or more resubmissions. This trend has been increasing over recent years. In 2006, successful applicants needed to apply on average twice as many times than in 2002 to get funded. To address these inefficiencies and extra burden on the entire community—and to fund meritorious applications earlier—the NIH will phase out second amendments for new applications submitted beginning January 25, 2009.

The new policy, http://grants.nih.gov/grants/guide/notice-files/NOT-OD-09-003.html, applies to all NIH grant programs.

APS Bulletin Online

The current issue of the APS Bulletin (volume 18, number 2) is now available online. Here are links to some highlights of this issue:

President's Message
Charles E. Inturrisi, PhD
The APS Strategic Plan

Pain Clinic Perspectives
New Clinical Practice Guidelines on Low Back Pain
Steven Stanos, DO, Department Editor
Jane Martinsons, Staff Writer

Outgoing President's Message
Judy Paice, PhD RN FAAM
APS: A Dynamic Presence