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May 2015

Officers (Term 2012-2016)

Chair: Daniel Carr (USA)
Vice Chair: Stephan Schug (Australia)
Treasurer: Brendan O'Donnell (USA)
Secretary: Jane Quinlan (UK)
Newsletter Editor: Robert I. Cohen (USA)
Newsletter Editor: Esther Pogatzki-Zahn (Germany)
Liaison, Intl Pain Registry: Ruth Zaslansky (Israel)
Liaison, PAIN OUT: Winfried Meissner (Germany)
Liaison, PAIN OUT: Debra Gordon (USA)
Advisor, Membership: Narinder Rawal (Sweden)
Liaison, IASP Council: Irene Tracey (UK)


Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions expressed in this SIG on Acute Pain newsletter have not involved any verification by the International Association for the Study of Pain (IASP)® or the SIG on Acute Pain of the findings, conclusions and opinions stated in this publication. Thus, opinions expressed in this publication are solely those of its author(s) and do not necessarily reflect those of IASP® or the SIG on Acute Pain, or of the Officers or Councillors of IASP® or of the Officers of the SIG on Acute Pain. No responsibility is assumed by IASP® or the SIG on Acute Pain for any injury, and/or damage to persons or property resulting, whether as a matter of product liability, negligence or otherwise, from any use of or reliance on any methods, products, instruction or ideas contained in this publication. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent verification of any diagnoses and drug dosages referenced in this publication.

In This Issue:
» Message from the Chair

» Acute Pain SIG Satellite Symposium at World Congress on Pain - "Faces or the Crowd: Variability and Diversity in Acute Pain Control"

» Minutes of the AP SIG Business Meeting held during 9 October 2014 at the IASP World Congress in Buenos Aires

» Women Need Not Suffer after Gynaecologic and Obstetric Surgery

» Interim Report and Request for Comments after Recent Approval of the Regional Anesthesiology and Acute Pain Medicine Fellowship by ACGME

» Defense and Veteran Center for Integrated Pain Medicine (DVCIPM) Annual Course May Inform Curriculum Development for New Acute Pain Medicine Fellowship

» New Drug Driving Law in England and Wales

» Sickle Cell Anemia – a Challenge for Acute Pain Control

» US National Pain Strategy Moves Closer to Finalization

» In Memory of Alon P Winnie MD
Message from the Chair

In a recent IASP survey on the future of its SIGs, one anonymous respondent compared SIGs to the prow of a boat, leading the way forward into new waters. I applaud this metaphor, as the Acute Pain SIG has for me always been an enjoyable and collegial venue for the exchange of early findings and emerging ideas with like-minded colleagues. As the art and science of acute pain continue to advance, we look forward to building upon this SIG's tradition in an era when the importance of optimal acute pain control is increasingly recognized. Our AP SIG Satellite Symposium in Buenos Aires (see immediately below) provided a venue for leading researchers and clinicians from around the world to explore and discuss the tension between calls for individualized care and the consensus approach to evidence-based practice that historically has been dominated by group statistics.

Right now, we are considering several possible topics to propose as a Satellite Symposium in association with the 2016 World Congress on Pain, in Yokohama, and I personally welcome AP SIG members' suggestions as to the topics they would wish to see covered in it. Feel free to email me Daniel.Carr@tufts.edu) with your suggestions.

This issue of the AP SIG Newsletter shows the potential of electronic capture to memorialize and share the talks from Satellite Symposia, and also presents newsworthy items from around the world. Our SIG members are in the vanguard of progress in every aspect of acute pain, from analgesic trials to data registries to public policy. I urge our readers to enjoy this issue and (with special thanks to Bob Cohen) its associated photo and video links.

Daniel B. Carr, MD
Chair, IASP Acute Pain SIG
Professor of Public Health, Anesthesiology and Medicine
Director, Program on Pain Research, Education and Policy
Tufts University School of Medicine, Boston, USA


Acute Pain SIG Satellite Symposium at World Congress on Pain - "Faces or the Crowd: Variability and Diversity in Acute Pain Control"

After a year of planning, the AP SIG held a successful and enjoyable Satellite Symposium in Buenos Aires just before the opening of the World Congress on Pain. In his Welcome and Opening Remarks, AP SIG Chair Daniel Carr recounted milestones in Acute Pain science, policy and leadership spanning the 20 and 21st century. He set the challenge as the panels unfolded for members to consider the presentations in the context of our responsibility to understand the present and create the future. In particular, calls for individualized or personalized medicine emphasize individuals ("faces") whose differences from one another reflect genetic, epigenetic and environmental factors, the latter including social interactivity. On the other hand, one of the fundamental principles of modern evidence-based practice is its reliance upon pooled results ("the crowd") in such a way as to minimize the effects of outliers. Pooling of information is encouraged further by the ease of capturing large amounts of data ("big data") electronically during routine care. The purpose of the one-day satellite symposium was to bring together leaders in field of acute pain to present and discuss their individual perspectives on how personalized care may best be accomplished in a healthcare system built on population-based information. He also thanked research associates Saro Haroun and Lindsay R. St. Louis, both of Tufts University School of Medicine, for logistical support in organizing this AP SIG Satellite meeting, and AP SIG Newsletter Robert ("Bob") Cohen for meticulously preparing synopses of the presentations and organizing and posting the presenters' talks – even to the detail of applying dedicated software to enhance the audio quality. To view a video of Dan Carr's Welcome and Opening remarks and of Brendan O'Donnell introducing Andrew Moore, copy and paste the following URL into your browser: http://youtu.be/WD-kh5A8AeE. An album of photos taken throughout the day including at the post-meeting reception is viewable by copying and pasting the following link into the address line of your browser: https://flic.kr/s/aHskaHz5n7

Eddy Neugebauer and Brendan O'Donnell chaired the panel "Considering the evidence base for acute pain control: knowns and unknowns." As much of what we think we know is derived from published drug trials, special attention was given to study design and its implications for aggregation of data from prior trials, and improved standards for future trials.

In a tour-de-force presentation, Andrew Moore critically reviews evidence for treatment of acute pain using "Single-dose analgesic trials: 60 years in 20 minutes." He emphasizes the strengths of such trials including their elements of randomization, blinding, standard pain scores and patient-reported outcome. The design remains relevant, with recent estimation of effect magnitude through the inclusion of design elements of systematic review and meta-analysis. Share the lifetime perspective of a keen observer, immersed in the practice of statistics and scientific method by copying and pasting the following URL into your browser: https://youtu.be/bG9rFgHwJKk

Readers of the scientific literature in acute pain may be aware of a new focus on quality standards for publication. A long-term contributor to the ACTTION (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities and Networks) and IMMPACT (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) groups, Paul Desjardins summarizes the process by which small group consensus meetings of international experts in academics, government, industry, professional organizations as well as patient advocates, produced recommendations for standards for collecting, analyzing and reporting results in the literature and submission to government regulatory agencies. He described the many factors that could lead to a negative study and the unintended and serious consequences of bias against publishing negative results. He mentions the most important findings from the 35 journal publications to date from IMMPACT and ACTTION, including specific recommendations to take characteristics of individual subjects (e.g., whether they are strong or weak placebo responders) into account to strengthen study design. To view the video, copy and paste the following URL into your browser: https://youtu.be/8jJ6zGx2B4A

The panel "Individualizing care in a mean-minded world," chaired by Stephan Schug and Jane Quinlan explored the role of positive and negative expectation in the experience of acute pain.

The literature on placebo responses is rapidly growing, as is insight into the psychological and neurological mechanisms whereby placebo produces analgesia. Mary Korula reviews evidence how placebo response impacts study design, for example noting the value of an active control and potential disadvantages of using passive placebo controls exclusively. She also suggests how consideration of individual differences in response can improved study design and highlights potential ethical concerns when placebo response becomes part of study design. To view the video, copy and paste the following URL into your browser: https://youtu.be/WNWtyvDLetE

Luana Collocca presented recent evidence showing the consequences of unintended negative expectations created in subjects by investigator word choices during informed consent. She also describes the new ethical challenges to cause no harm and yet to fully disclose risk. Finally, how understanding and avoiding nocebo effect offers opportunity to improve treatment efficacy and patient relationships. To view the video, copy and paste the following URL into your browser: https://youtu.be/V0nGr6WGxYw

Information science has reached a point where advances in data storage and processing power can be leveraged by increasingly sophisticated algorithms permitting never before imagined insight into process and outcome. Robert Cohen and Marcus Komann chaired a panel on "Big data and other systems approaches to population-based care". These systems approaches provide health care institutions and government agencies with powerful tools to assess quality of care outcomes for aggregated populations and individual centers, even wards, and thereby drive change leading to improved practice. To view this introduction copy and paste the following URL into your browser: https://youtu.be/Hhw6aM5tlWM

In 2009 a major four year health collaborative project was launched with European Union funding of 2.9 million Euros dedicated to the "Improvement in Postoperative Pain Outcome (PAIN OUT.) Marcus Komann reviews the challenges and major successes that have allowed PAIN OUT to continue independently since 2013 with the support of 17 participating institutions located worldwide in 11 countries. Standardized tools such as the International Pain Outcomes Questionnaire (IPO) and web-based entry of patient demographics and outcomes yielded a 40,000 patient data set registry by the end of 2013. Patient satisfaction with pain treatment correlates included patient involvement in treatment decisions and relationship with caregivers, and not just the pain experience per se. To view the video, copy and paste the following URL into your browser: https://youtu.be/VTeEQVeekOw

Progress in the development and use of outcome registries supporting decision-making and care at point of treatment, a charge for relief of pain in the US by the Institute of Medicine, was reviewed by Sean Mackey. He described a cutting edge project, the Collaborative Health Outcomes Information Registry (CHOIR). Its structure combines electronic (smartphone, etc) patient input with Computer Adaptive Testing. He demonstrated CHOIR's application to quality of care assessment for institutions, and to support real time medical decision-making for individualized patient care. To view the video, copy and paste the following URL into your browser: https://youtu.be/ebjPmgcio60

Deb Gordon addressed progress in overcoming barriers and providing incentives to drive change in healthcare organizations seeking to change provider practice patterns. She reviewed opportunities to use systems science to effect change and provided examples of success, such as development of care pathways for treatment of acute pain resulting from specific surgical trauma. To view the video, copy and paste the following URL into your browser: https://youtu.be/z2fQXNCb_V0

In the concluding panel, chaired by Daniel Carr and Gillian Chumbley, examples of success in achieving "Personalized acute pain control through national initiatives," are cited from North America, Europe and Australia.

Lessons learned and next steps in the United States to prevent and treat acute pain and its chronification were reviewed by Rollin "Mac" Gallagher. He summarized the challenges and opportunities for managing care transitions ranging from preventing and treating acute pain associated with injury and subsequent surgical treatment, through rehabilitation to full function. The US Department of Defense and Veterans Health Administration collaborated in a process leading to evidence based design changes. For example, the model of a medical home and stepped care is linking primary care, pain medicine and pain rehabilitation for warfighters and civilians. Viewers interested to learn more about this topic are referred to the 30 October 2014 Boston Medical Library's 39th Annual Garland Lecture, where both Drs. Gallagher and Chester "Trip" Buckenmaier speak on pain control in 21st century warfare. To view the video, copy and paste the following URL into your browser: https://www.countway.harvard.edu/events/21st-century-war-continuum-pain-and-other-sequelae or http://video.med.harvard.edu/MediaPlayer/Player.aspx?v={B7DF36A7-D322-4707-A205-1AA1E8B8A54C}. Note that Dr, Buckenmaier authored the tribute to Alon Winnie reprinted at the end of this newsletter.

In the prior issue of this AP SIG Newsletter, Eddy Neugebauer summarized the breaking news that the German Physicians Congress passed a resolution that management of acute and chronic pain is a national priority. He now provides a further update and reviews the process, listing twenty major collaborative milestones over 26 years leading up to this success. These include procedure specific postoperative pain management (e.g., through the PROSPER working group), benchmarking with external audits, recognition that pain is an ideal parameter for hospital care assessment with support from a legal system recognizing physicians have a statutory duty to treat pain. To view the video copy and paste the following URL into your browser: https://youtu.be/QYzrqol-sIA

Stephan Schug provided an insider's view to the extensive literature review and collaborative processes by which the Australian and New Zealand College of Anaesthetists (ANZCA) updates their acclaimed monograph "Acute Pain Management - Scientific Evidence." The current 2010, 3rd edition, is available for free download at: https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf - He cautions that with more than 500 pages, electronic review is preferable to printing. With the approaching completion of the planned 5 year revision cycle, the 4th edition will likely include more than 50 pages of "key points" for best practice. Well designed meta-analyses will receive highest strength rating and "N" will show references new since the prior edition. Scientific evidence for personalizing acute pain care is also reviewed in the 4th edition. To view the video copy and paste the following URL into your browser: https://www.youtube.com/watch?v=AbErzq5AJEk

Sean Mackey described two high-level interprofessional national initiatives in the US during the past 4 years. The first, prepared by the Institute of Medicine and published in 2011, provided a "blueprint for transforming prevention, care education and research". More recently, the US National Institutes of Health has taken the IOM initiative one step further to prepare a detailed "National Pain Strategy" (NPS) for its implementation. He provided a uniquely well-informed perspective on these large-scale efforts, having been a member of the first panel and co-chair of the second. Dr. Mackey recently gave an interview with Lynn Webster discussing the recently released NPS draft. To listen, copy and paste the following URL into your browser: http://www.lynnwebstermd.com/interview-with-dr-sean-mackey-national-pain-strategy/ or https://soundcloud.com/lynn-webster-md/interview-with-dr-sean-mackey-national-pain-strategy. See the "news flash" article below by Robert I. Cohen for further details on the NPS.

An added presentation was given by Robert I. Cohen from Beth Israel Deaconness Medical Center, one of the hospitals caring for patients injured by the 2013 Boston Marathon bombing. There was a high survival among those seriously injured. He mentioned many factors, including a high degree of institutional readiness and a robust disaster plan, the latter honed by simulated disaster training three times every year. The first victim was admitted within 8 minutes after the explosion and all critical patients had been admitted by 50 minutes. This flood of severely injured victims led the hospital to activate its Mass Casualty Service. A dedicated multidisciplinary team met each morning to review each patient's status and adjust therapy accordingly. Evening meetings were dedicated to systems issues and challenges facing the acute pain medicine team. The team was kept small to maximize continuity of care, a decision, however, that increased the risk of secondary psychological trauma in caretakers. The Social Work Department initiated a hospital wide support program to prevent, screen, identify and treat this secondary trauma. Their work has been honored and the institution's response was cited as an example of best practice and is serving as a model for ongoing community disaster planning. To view the video, copy and paste the following URL into your browser: http://youtu.be/gMUl3CGl2cs

Videos and Synopses prepared by
Robert I. Cohen MD,
Editor, AP SIG Newsletter
Assistant Professor of Anaesthesia, Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Beth Israel Deaconess Medical Center, Boston, USA
and
Daniel Carr MD,
AP SIG Chair and Organizer Satellite Symposium


Minutes of the AP SIG Business Meeting held during 9 October 2014 at the IASP World Congress in Buenos Aires

Delegates present:

  • Dan Carr – USA (Chair)
  • Stephan Schug – Australia (Vice-chair)
  • Brendan O'Donnell – USA (Treasurer)
  • Jane Quinlan – UK (Secretary)
  • Rachel Anderson - UK
  • Samir Ballas - USA
  • Adriana Cadavid - Columbia
  • Gillian Chumbley - UK
  • Ruth Day - UK
  • Deb Gordon - USA
  • Marcus Komann - Germany
  • Mary Korula - India
  • Elizabeth Ogboli-Nwasor - Nigeria
  • Rachel Townsend - UK
  • Jennifer Wright - UK

Prof Carr thanked Prof Neugebauer and Prof Schug for their help in organising the satellite meeting, which was felt by all to have been excellent. The venue was just large enough to comfortably accommodate all attendees. Although a couple of speakers had to cancel due to travel delays, there were enough stimulating discussions to fill the time perfectly. There was a suggestion that we could investigate publishing the talks from the satellite meeting to provide wide access to their expertise: this could be via the European Journal of Pain, Pain Research Forum or, more likely, on the IASP AP SIG website. It was pointed out that the IASP website presently requires log in from IASP members which would restrict the access to IASP members only, rather than wider public access. The AP SIG newsletter could provide a means of publishing abstracts, slides or videos of the presentations. Because posting all SIG Newsletters would seem to be a means to attract new members to both IASP and its SIGs, Dr Carr said he would raise this possibility with IASP leadership.

Plans were discussed for the APSIG satellite meeting to be held in conjunction with the IASP World Congress in Japan in 2016. It is unfortunate that IASP administrators are no longer able to assist in arranging these meetings, so it falls to the SIG to find their own venue. This will be difficult to organise in Japan and may prove expensive. This SIG meeting in Buenos Aires cost $6000-$7000, with no charge for attending the meeting. Higher costs in Japan may mean that we would have to charge for the 2016 SIG meeting. Professor Schug kindly agreed to talk to the IASP president informally to investigate the possibility of IASP administration taking over the organisation of the SIG meetings. Dr Carr agreed to poll potential Ap SIG satellite meeting attendees as to their thoughts as to a variety of venues both in Japan and in destinations convenient to Japan (e.g., Hawaii).

The AP SIG will also be submitting a proposal for a topical workshop for the 2016 World Congress, with a deadline to submit proposals in July 2015. 2016 will be IASP's Global Year against Chronic Post-Surgical Pain, which would provide a good topic for the workshop, and will also require the preparation of factsheets for the IASP website.

Current SIG officers will reach the end of their 4 year term in 2016. There are approximately several hundred SIG members at present. Dr O'Donnell (treasurer) will check the figures. It was felt that we should aim to increase the number and diversity of AP SIG members. To this end, we could raise our profile by using links to the AP SIG website from other external websites such as PAIN OUT, ESRA, ASRA, British Pain Society, American Academy of Pain Medicine, Indian Society for the Study of Pain etc.

Prof Carr thanked Bob Cohen for his help with the newsletter and for stepping in at short notice to speak at the satellite meeting on the timely subject of pain management in survivors of the Boston Marathon bombings – including the effects of this trauma upon caregivers and medical institutions.

Prof Schug spoke about the forthcoming new edition of the ANZCA Acute Pain Management: Scientific Evidence. The fourth edition is supported by the IASP AP SIG and will be launched in Yokahama in 2016.

We plan to publish an APSIG newsletter in Spring 2015 and will see whether we can attach speakers' slides from the satellite meeting.

The meeting closed with all those present giving a very warm thank you to Prof Carr for all of his work organising the excellent AP SIG satellite meeting and the very enjoyable evening reception.

Jane Quinlan MB BS FRCA FFPMRCA,
Secretary IARS AP SIG
Consultant in Anaesthesia and Acute Pain Management
Nuffield Division of Anaesthetics, John Radcliffe Hospital, Oxford, UK


Women Need Not Suffer after Gynaecologic and Obstetric Surgery

2nd International PAIN OUT Symposium Focussed on Pain Management in Obstetric and Gynaecologic Surgery

In November 2014, the 2nd international symposium of the PAIN OUT project (Improvement in postoperative PAIN OUTcome) took place in Brussels. The symposium was held in cooperation with the International Association for the Study of Pain (IASP), the German Society of Anaesthesiology and Intensive Medicine (DGAI), and the German Pain Society.

Thematic priorities were expert discussions on pain management after gynaecologic surgery and caesarean section. Caesarean Delivery is one of the most painful surgical procedures. Hysterectomy is another frequent procedure which is associated with severe pain and negative effects on function. Half of the women report severe pain after Caesarean delivery on the first day after surgery. In surgery as a whole, around 30 – 50 % of patients suffer from moderate to severe pain postoperatively. As around 250 million surgical procedures are carried out per year across the world, the significance of postoperative pain is enormous, causing needless suffering, and draining societal resources. Acute pain after surgery can lead to postoperative complications, prolong the length of stay in hospital, and may become chronic.

World-leading pain specialists, gynaecologists and obstetricians discussed results of the PAIN OUT data in this field, state-of-the-art treatment approaches, and consequences of insufficient pain management. A study describing a successful quality improvement strategy employed in the clinical routine was described. Other topics highlighted gender differences in pain experience, and a comparison of quality of pain management between the U.S. and Europe.

Attending the PAIN OUT meeting were (from left to right):

  • Winfried Meissner, Jena, Germany
  • Patricia Lavand`homme, Brussels, Belgium
  • Narinder Rawal, Örebrö, Sweden
  • Michael Stark, Berlin, Germany
  • Richard Chapman, Salt Lake City, USA
  • Esther Pogatzki-Zahn, Muenster, Germany
  • Hans-Ullrich Gerbershagen, Utrecht, Netherlands
  • Ulrike Stamer, Bern, Switzerland
  • Jorge Cruz, Jena, Germany
  • Ruth Zaslansky, Berlin, Germany

Esther Pogatzki-Zahn MD,
Co-editor, AP SIG Newsletter
Professor of Anesthesiology, Department of Anesthesiology, Intensive Care Medicine and Pain Management, University Hospital Muenster, Muenster
and
Winfried Meissner MD,
Associate Professor, Head of Pain Unit, Department of Anaesthesiology and Intensive Care Medicine, Friedrich-Schiller-University Jena, Germany


Interim Report and Request for Comments after Recent Approval of the Regional Anesthesiology and Acute Pain Medicine Fellowship by ACGME

The immediate prior issue of the AP SIG Newsletter described an ongoing effort in the US to develop a new, accredited fellowship in regional anesthesiology and acute pain medicine. In late 2014, the US Accreditation Council for Graduate Medical Education's (ACGME's) Board of Directors approved this as the newest subspecialty fellowship of anesthesiology eligible for accreditation. We are now in the early stages of developing the draft program requirements to be used in evaluating programs for accreditation. This step is pending selection of the program requirements committee by the ACGME. Once the draft program requirements are presented to the fellowship directors group, there is expected to be a period for comment and revision before the requirements are finalized.

Edward R. Mariano, MD MAS
Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Associate Chief of Staff, Inpatient Surgical Services
VA Palo Alto Health Care System, USA


Defense and Veteran Center for Integrated Pain Medicine (DVCIPM) Annual Course May Inform Curriculum Development for New Acute Pain Medicine Fellowship

Next steps in development of the Acute Pain Medicine/Regional Anesthesia Fellowship since the recent approval for US ACGME certification include development of a robust comprehensive curriculum. Unlike other pain fellowships, the graduate of the Acute Pain Medicine/Regional Anesthesia Fellowship will play a critical role in the surgical home with representation in most surgical subspecialties. The comprehensive programs and resources being developed by the US DVCIPM are available to be used as a starting point.

For over a decade, DVCIPM has provided annual training events focused on delivering acute pain medicine education to civilian and Department of Defense providers. Unlike many acute pain medicine courses that focus on regional anesthesia and new drug formulations, DVCIPM programs also include alternative and integrative care techniques useful in the treatment of acute pain. This balanced approach better positions the fellow for leadership in a surgical home where economics and quality are as important fundamentals of pain medicine as pharmacologic and interventional treatments. Participants in DVCIPM courses include active duty and civilian established providers, but also residents, with the intent of expanding practice patterns and principles early in a resident's education.

Michael L. Kent, MD LCDR MC USN
Staff Anesthesiologist/Regional Anesthesia Acute Pain Medicine Navy Physician
Walter Reed National Military Medical Center Bethesda, USA


New Drug Driving Law in England and Wales

A new offence of drug driving came into force in England and Wales on the March 2, 2015 this year. The main purpose was to mirror the offence of drink-driving, considering the common themes of poor concentration, slow reaction times and compromised decision making. Included on the list of screened-for drugs is morphine. The legislators acknowledge that a zero limit for morphine would be punitive to those taking it for legitimate reasons, so have set a blood limit of 80mcg/ml which equates to approximately 209mg of morphine per day. This level was chosen as being, in theory, above the normal therapeutic range for patients taking morphine for pain relief. The offence has a "medical defense" whereby mitigation will be given to those who can show that a higher dose is sanctioned by a prescriber. This new law places a burden of responsibility on pain clinicians who need to ensure that their patients are aware of the new law.

Jane Quinlan MB BS FRCA FFPMRCA
Consultant in Anaesthesia and Acute Pain Management
Nuffield Division of Anaesthetics, John Radcliffe Hospital, Oxford, UK


Sickle Cell Anemia – a Challenge for Acute Pain Control

Sickle cell anemia (SCA) is an inherited disorder of the structure of the hemoglobin molecule. The disease is a triumvirate of pain syndromes, anemia and progressive organ damage. Recurrent acute vaso-occlusive painful crises, however, are the hallmark of the disease and usually occur first around the age of six months and recur periodically throughout the life of affected patients. The pain, usually sharp and/or throbbing, involves any part of the body with the low back and extremities being the most common sites. Stress of any kind or infection may precipitate crises but often no precipitating factor is found. Severe pain is often treated in the Emergency Department and /or the hospital. On average adult patients with SCA are hospitalized about 6 times per year and the mean length of hospital stay is 7 days. Moreover, about 15% of discharged patients are readmitted within two weeks after discharge. Pain management includes non-opioid and opioid analgesics and various adjuvants. Psychosocial support is underutilized. Physical dependence and tolerance are commonly observed and often misdiagnosed as addiction. About 60% of adult patients continue to have persistent pain between crises that may mimic chronic pain. Effective interventions are needed to better manage acute sickle cell pain.

Samir K. Ballas MD FACP
Emeritus Professor of Medicine and Pediatrics
Thomas Jefferson University, Philadelphia, PA

Reference: Ballas S.K. Sickle Cell Pain, 2nd edition 2014, IASP Press Washington DC

"Editors note": Dr Ballas is the recipient of the American Academy of Pain Medicine Presidential 2015 Patient Advocacy Award. The Patient Advocacy Award recognizes activity of an individual in advocating for appropriate evaluation and treatment of patients suffering from pain. This award was created to honor those healthcare professionals whose deeds reflect their recognition of the importance and impact of the specialty of Pain Medicine.


US National Pain Strategy Moves Closer to Finalization

The Editors strongly encourage readers to review the recently-released draft of the US National Pain Strategy, http://iprcc.nih.gov/docs/DraftHHSNationalPainStrategy.pdf published by the Department of Health and Human Services (HHS.)

Dan Carr and Trip Buckenmaier served on the Oversight Panel for which Sean Mackey was a Co-Chair. Satellite symposium presenter Rollin "Mac" Gallagher also played a leadership role in this effort. Initiated in 2010 by an act of the US Congress, this ongoing effort convened by the National Institutes of Health (NIH) has released for comment a new detailed national strategy to implement the 2011 Institute of Medicine (IOM) blueprint (see above) calling for "…a cultural transformation in pain prevention, care, education and research."

Though a concise 71 pages, it is evidence-based, well referenced, and clearly written. It has a rich appendix useful to governmental and nongovernmental organizations working to improve pain care. Contents of the appendices include pain education core competencies, learning objectives for public education on pain in general, and the safe use of pain medications. As described above, an earlier public version of this information was presented at the IASP AP SIG satellite symposium in Buenos Aires last fall by Mac Gallagher and Sean Mackey in the panel on "Personalized acute pain control: national initiatives."


In Memory of Alon P Winnie MD

(AAPM member since 1990)
"Life is either a daring adventure or nothing." - Helen Keller (1880 – 1968)


From left: Scott M Croll MD, Alon P Winnie MD and Chester 'Trip' Buckenmaier III MD

I have never been one much impressed by celebrity. During my years haunting the halls of Walter Reed Army Medical Center (WRAMC) as a military clinician, I have brushed against my share of celebrities out visiting wounded veterans. I have witnessed the back of Tom Hanks' head, I have noted that Jon Stewart is indeed short, and I scared the hell out of Sheryl Crow when we met face-to-face rounding a hallway corner on a hospital ward (I have that effect on women). During my time at WRAMC, I had many such encounters, and even cared for the occasional national figure. None of these events really impressed me, and I often failed to even mention these interactions, much to the chagrin of my wife and family. This background explains why my wife was so amazed when I received a phone call one evening at home from Alon Winnie, MD in 2004. She laughed at me following the call, as she had never seen me so star-struck before.

Fact is, most of my heroes are figures from history. Alon Winnie was different. Born in May 16th, 1932 in Whitefish Bay, Wisconsin, Alon has described his childhood as happy, and he had a passion for both music and medicine. His life was challenged greatly during his internship training at Cook County Hospital, IL, when the strong young man was incapacitated by poliomyelitis and confined to a wheelchair. Alon had an interest in anesthesia and proved, despite many naysayers, that he could master the specialty, regardless of his physical limitations. His love of human anatomy and keen desire to ease the pain in his patients would lead to one of the most celebrated careers in medical history. Among his many accomplishments, perhaps one of the most significant was his recognition that human nerve plexuses are enclosed in fascial compartments and this anatomical fact could be exploited through the injection of local anesthetics to render regions of the body insensate to pain. This discovery formed the basis of modern regional anesthesia, and Alon is credited with describing many of the block procedures that are still used today. Dr. Winnie's career is distinguished for many other contributions, his mind was indeed tireless, but his work in pain would prove most influential to my career and impact on so many wounded military.

By the time I came to medicine, Alon Winnie was literally a living legend. As my own interests within the house of medicine turned to regional anesthesia, pain, and pain management, the influence and impact that Alon had on these fields of study were inescapable. As a military anesthesiologist, I believed there was untapped potential for many of the blocks Alon had developed to enhance the care of wounded on the modern battlefield. Of course, Alon's thinking along these lines pre-dates my own by many decades as he commented to fellow residents after his first few successful brachial plexus blocks, "how useful such single injection techniques would be on the battlefield, especially since the use of a catheter would allow analgesia to last as long as necessary."1 I certainly admired Dr. Winnie's accomplishments in the face of significant personal adversity, but did so from a distance. As a young anesthesiologist at various national meetings, I would see Alon always surrounded by a who's – who of notable physicians, a crowd that necessitated my distance at the time.

After September 11th, 2001, I essentially packed up Alon's ideas and took them to war with numerous other like-minded followers of the pathway to improved pain management. Standing on Alon's figurative shoulders and applying his lessons, military providers brought positive change to pain management in the wounded soldier after many decades of benign neglect. Alon's insight personally gave me the key to achieving a meaningful career in military medicine, and the gift of being able to make a difference in wounded veterans' lives.

Fortunately, I was smart enough to recognize his tremendous contribution to military medicine and would look for opportunities to celebrate Dr. Winnie's efforts in my lectures and writing. When teaching residents I would often invoke the Wayne's World "We are not worthy!" when discussing Alon's impact on medicine. Which explains my star-struck expression that so bemused my wife when Alon called to discuss my efforts with regional anesthesia in the Iraq conflict. It was surreal to have such a medical giant, from my perspective, calling me at home to praise me for my efforts to bring regional anesthesia to the battlefield. Alon had a deep respect for those in the military, and the fact that his work was making a difference in many wounded soldiers' lives was intensely satisfying for him. I know this because I had the profound honor of listing myself among Alon's many friends. He made a special effort to support the training and education of physicians who cared for soldiers. Despite years of failing health and limited mobility, he still travelled, at significant personal discomfort, to military training events even after he had stopped going to national meetings. From time to time he would call me, and I would keep him abreast of efforts to improve pain management in soldiers.

Alon, my friend and mentor, my celebrity, died on January 18th at the age of 82. While I will miss our talks, it is hard to feel sad about a life so well lived. Alon's life was a daring adventure which he lived no matter what adversity was separating him from his goals. I felt more alive when I was in his presence, and enjoyed just being around him. I suspect I was not alone in this feeling as evidenced by the crowd that always seemed to gather around him at various professional events. My only regret is I did not come to personally know Alon until late in his life, thus I have the feeling I missed so much. I take solace in the fact that the legacy of his adventure will go on in the many physician's he has trained and the patients they will care for.

Thank you Alon, for the example of a life well lived as you join the tapestry of medicine's greatest.

1 The Military Advanced Regional Anesthesia and Analgesia Handbook. Buckenmaier CC and Bleckner L. eds. 2009. Bordon Institute. Page IX.

Original source: U.S. Pain Medicine, February 2015
Chester 'Trip' Buckenmaier III, MD, COL (ret), MC, USA
Professor Anesthesiology
Co-Editor Acute Pain Medicine section, Pain Medicine
Editor-in-Chief, U.S. Medicine

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