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An Overview of the Decade of Pain Lecture From AAPM 2008: An Expert Interview With P. Prager, MD, MS

Posted 02/27/2008

P. Prager, MD, MSAuthor Information

Editor's Note:

The American Academy of Pain Medicine (AAPM) 24th Annual Meeting took place from February 12 to 16, 2008, in Orlando, Florida. During this meeting, new information about the diagnosis, treatment, and management of acute pain, chronic pain, and breakthrough pain (BTP) was presented. Darlene Field, PhD, Medscape Neurology & Neurosurgery Scientific Director, discussed the highlights of the "Decade of Pain" keynote address with P. Prager, MD, MS, Director, Center for the Rehabilitation of Pain Syndromes (CRPS), and Immediate Past President, North American Neuromodulation Society (NANS) . Dr. Prager delivered the "Decade of Pain" lecture at the 2007 annual meeting of the AAPM.

Medscape: Can you discuss some important findings presented at the AAPM meeting you just attended -- specifically, was any new knowledge shared at the Decade of Pain lecture given by Dr. Cousins?

P. Prager, MD, MS: The keynote lecture at the meeting was given by Dr. Cousins, who is Professor and department head of Anesthesia and Pain Management, University of Sydney, Sydney, Australia. Dr. Cousins made 3 main points in his lecture. The first point was that pain is a disease in its own right. The concept of persistent pain as a disease entity leads us toward new specific treatments aimed at physical, psychological, and environmental components of the disease, and takes into account the possibility of a genetic predisposition to experience pain. Dr. Cousins explained that persistent pain has a prevalence of 1 in 5 in the general population, and the studies conducted by the Pain Management Research Institute of Sydney, Australia, indicate that pain leads to an annual cost of $1.85 billion per million of the population.

The second point made was that the medical community has now recognized that additional specialty training in pain management is absolutely necessary. There are too few true pain medicine specialists being trained, and many patients have limited or no access to effective pain treatment.

Dr. Cousins' final main point was that pain management needs to truly become a fundamental human right. To achieve this goal, we need parallel initiatives in medicine, law, ethics, and politics.

Medscape: Did Dr. Cousins offer any evidence to lend credence to the fact that pain itself is a disease?

Dr. Prager: Well we always knew that persistent pain is very different from acute pain and we can now demonstrate those differences with imaging studies of the brain. A functional magnetic resonance image (MRI) of a patient with chronic pain will appear quite different from that of a MRI of a patient with acute pain. For example, an imaging study just published last week in the Journal of Neuroscience demonstrated that chronic pain harms cortical areas, indicating that chronic pain has a widespread impact on overall brain function (Figure).[1] Several areas of the brain in patients in chronic pain fail to deactivate during the attention task compared with healthy patients.

Figure. The pictures below are brain fMRI data (right images of the brain are seen from the head's midline, left images are from the side) showing the average brain activity during the entire task. Colors illustrate how much activation (red-yellow) or deactivation (dark/light blue) was found at each brain location during the attention task. The main result here is that brain images of patients in chronic pain exhibit a significantly smaller territory of brain deactivating (ie, in blue) during the task than healthy individuals. For more information, see www.chialvo. net. Reprinted with permission from Dante R. Chialvo, MD.

Figure 1. (click image to zoom)

If pain persists despite reasonable efforts to manage it by the patient's general practitioner and specialists, then consultation with a board-certified pain medicine specialist is absolutely necessary. Because pain is a disease, it is important to manage the pain early on to prevent the pain from becoming a persistent problem, with all of the attached disease changes that occur.

Medscape: After listening to the Decade of Pain lecture, what do you think is in store for the future of pain management?

Dr. Prager: As we look toward the future of pain management, the treatment of persistent pain will be markedly different from how we currently treat it. Instead of using drugs like morphine that only provide symptom relief, newer drugs will aim at the disease process. Dr. Cousins mentioned a new class of drugs in development, subtype selective sodium channel blockers. Pain-sensing neurons of the peripheral nervous system express several sodium channel subtypes, and pharmacologic agents that target the Na 1.8 selective small molecule sodium channel are currently in development.

Medscape: Was there any discussion of the role of genetics in pain medicine?

Dr. Prager: Yes, Dr. Cousins presented some really fascinating data that suggest that genetic analysis of patients may indicate who would be predisposed to persistent pain, for example after a mastectomy, vs who wouldn't. If the genetic analysis demonstrates a patient to be at risk for chronic pain, then more aggressive maneuvers would be necessary related to that surgery; whereas, somebody whose genetics would not predispose him or her to persistent pain wouldn't need the same intensity of treatment (prophylaxis) .

Genetic analysis to determine who is prone to chronic pain vs who is not is a very new concept. It is also very costly. To do a complete genetic analysis of a patient at this time costs about a million dollars, which is much less than it used to be. As a matter of fact, recently had a genetic analysis completed on himself, being one of the first ever to take advantage of the Human Genome Project. Right now we are still a long way from determining which genes would make someone more susceptible to experiencing pain than others.

Medscape: Is there anything else you would like to mention? Particularly, any important take home messages from Dr. Cousin's lecture?

Dr. Prager: Yes, there were some very compelling data presented from a study done at Kaiser Permanente Northwest that I would like to mention.[2] In an analysis of 1997 and 1998 data in Salem, Oregon, Kaiser Permanente Northwest was able to demonstrate that by having a pain service (a multidisciplinary pain management group) to serve their community, they were able to reduce emergency room visits by 43%. Patients with chronic pain who think their pain is discounted by physicians often overuse medical services like emergency departments to identify the cause of their pain or to prove to physicians that their pain is real.

Supported by an educational grant from PriCara, Division of Ortho-McNeil- JanssenPharmaceu ticals Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.