Sunday, September 26, 2010

Thinking Outside the Traditional Box at AAPM

AAPMMore than 1,100 healthcare professionals interested in pain management gathered last week — September 21-24, 2010 — in Las Vegas, NV, for the 21st Annual Clinical Meeting of the American Academy of Pain Management (AAPM). This was considered to be an outstanding turnout for a meeting of this type and attendees were greeted by an extensive learning experience: 59 program presentations (almost all were CME/CEU accredited), 77 poster abstracts, and 73 exhibitors. There was a lot to hear, see, and do during an exhausting several days — some brief observations follow below.

Chaotic Overregulation of Pain Practice in America
An important aspect of this AAPM conference (not to be confused with the other AAPM — American Academy of Pain Medicine) that we appreciated was the eclectic, multidisciplinary mix of both program contents and attendees. For example, sitting around our table during a luncheon presentation focusing on “[Pain] Policy, Practice, and Action” were a pain physician, a family practitioner, an acupuncturist, a physical therapist, a nurse specializing in pain, a chiropractor, and two legislative representatives from a state pain program.

In regard to state programs, one of the featured speakers — Aaron M. Gilson, MS, MSSW, PhD, of the Pain & Policies Studies Group at the University of Wisconsin — explained at great lengths how there is very little consistency among state medical boards and legislation in the U.S. with respect to approaches and regulations governing the treatment of chronic or intractable pain. The overall impression is one of chaos, whereby a patient with chronic pain in one state may receive entirely different and possibly better treatment for the same condition compared with permissible treatment in a neighboring state (also see our note below about Washington State).

Gilson was briefly followed by Will Rowe of the American Pain Foundation with a call to action on several advocacy issues of importance: The FDA’s opioid REMS initiative, pain provisions in the new Health Care Reform Bill, and how insurance cost-containment practices are creating barriers to proper pain care. The latter has become a critical issue, as a major concern throughout the conference was that there are many effective treatments that insurance carriers will not cover and are unaffordable for a majority of patients on their own. Clearly, pain care delivery — at least in the U.S. — appears to be driven by the insurance industry (and secondarily by state or federal regulations), and we applaud the AAPM for addressing these challenging advocacy concerns head-on through open discussions and calls for action.

Mind Over Pain Does Matter
Another interesting aspect of the AAPM conference is that one can easily transition from program sessions focusing on traditional Western medicine to presentations of alternative, or integrative, approaches drawing from a variety of disciplines. Moving along one track, one can attend sessions on pharmacologic approaches for arthritic conditions or fibromyalgia and then move across the hallway to hear presentations on the benefits of acupuncture, yoga, diet and dietary supplements, and other complementary and alternative medicine (CAM) therapies.

For example, an interesting session titled “Integrative Medicine, Stress, and Pain” by Roberta Lee, MD — Vice Chair of the Department of Integrative Medicine at Beth Israel Medical Center in New York, New York — addressed the concept of how “superstress” responses (essentially recalcitrant toxic stress) affect chronic pain syndromes on physical, mental, and even genetic levels. Solutions focus on moving beyond traditional medicine to incorporate lifestyle interventions for achieving “allostasis,” or physiological stability.

Lee noted significant benefits of a Mediterranean diet, omega 3 fatty acids, fish oil, magnesium, and vitamin D3 supplements, relaxation aids (biofeedback, meditation), and even sleep (adults need 7 to 9 hours per night). Far from merely being imagined, psychogenic-stress-influenced pain affects brain wiring and genetic structure, and achieving allostasis can actually alter genetic expression and normalize brain function for better pain management. Fascinating concepts but the unanswered questions were (a) how can typical pain practices be structured to deliver these multimodal approaches and (b) who will pay for them?

Glia: A New Frontier of Pain Medicine?
During a keynote presentation, Linda R. Watkins, PhD — Professor and Director of the Inter-Departmental Neuroscience Program at the University of Colorado at Boulder — enlightened the audience on a subject that otherwise would be a stretch for all but elite researchers in the pain field. She focused on perspectives of glia (microglia and astrocytes) — essentially helper cells providing support and protection for neurons — as the new “bad guys” when it comes to pathological pain conditions and failures of opioids in relieving such pain.

Glia can become unfavorably activated, thereby influencing the generation and persistence of various pain conditions; so, deactivating glia can enhance pain management. Additionally, blocking glial action in certain circumstances has tremendous potential for enhancing opioid analgesia while reducing adverse opioid effects, including addictive potential, and stemming opioid tolerance.

Watkins noted that novel drugs are in development targeting glia and their proinflammatory byproducts, which have the potential to revolutionize pharmacotherapeutic approaches to pain management. While our synopsis here hardly does justice to this complex subject, this is a dramatically new line of research that is certain to be in the news in the years (or, maybe, months) ahead.

Miscellaneous Heard in the Hallways…
“The major side effect of integrative medicine approaches to pain is better health for a better life”. This was the final retort in a rather heated argument between two conference attendees about the relative merits of traditional pharmaceutical and interventional approaches compared with the many alternative, integrative modalities discussed during some of the conference presentations.

There was a lot of buzz among attendees about legislative actions underway in Washington State to limit opioid prescribing by healthcare providers and mandating referral to pain specialists (of which there are only a handful in the state) if a patient requires morphine-equivalent medication above a prespecified limit. Further fears of legislative influences on the practice of medicine were bolstered by rumored reports of a major healthcare center in Minnesota that proactively decided recently to eliminate all opioid medications from their prescribing formulary, rather than risk running afoul of regulatory agencies.

Heard at a breakout session… it seems to be somewhat of a secret that the AAPM for a number of years has had the only accreditation program specifically for pain clinics and practices in the U.S. We were told that their PPA, or Pain Program Accreditation, process has been successfully completed by more than 50 facilities and is rapidly growing. More info is available [here].

During the meeting, Endo Pharmaceuticals announced that they received FDA priority review for a new formulation of long-acting oxymorphone designed to resist crushing, breaking, powdering, or pulverizing. We assume this a modified version of Endo’s existing Opana® product. The FDA set the action date under the Prescription Drug User Fee Act (PDUFA) for January 7, 2011.

NOTE: We apologize for such a cursory presentation above of a content-rich educational adventure that lasted several days. Conferences like the AAPM Annual Clinical Meeting promise much and deliver even more than they promise — much more than the mind can digest at one time. Fortunately, we will all have another opportunity next year when the American Academy of Pain Management conference returns to Las Vegas, September 20-23, 2011. See their website for info at: --SBL