IASP Insight December 2012 by IASP

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Milan Congress breaks records PAIN in transition

December 2012 Volume 1, Issue 2 1

International Association for the Study of Pain® 1510 H Street NW, Suite 600 Washington, D.C. 20005 -1020 USA Email: iaspdesk@iasp-pain.org www.iasp-pain.org

insight

Features PAIN in transition......................4

Milan Congress breaks records..8

Newsletter Advisory Board Editor-in-Chief: Beverly Collett (UK) Huda Huijer Abu-Saad (Lebanon) Antoon de Laat (Belgium) Michael Nicholas (Australia) Graciela Rovner (Sweden) Yasuo Sugiura (Japan) Kathy Kreiter Executive Director Karen Smaalders Director of Marketing, Communications, and Membership

Departments Noteworthy.............................3 IASP relocates

Trainee spotlight....................3 Philip A. Spiegel IASP Congress scholar

Published biannually and distributed by the International Association for the Study of Pain Copyright 2012, International Association for the Study of Pain Please contact the IASP Secretariat for more information on submissions or email Insight@IASP-pain.org. The International Association for the Study of Pain is a not-for-profit, tax-exempt organization, incorporated in Washington, D.C., in May 1974 (ID no. 237416302). IASP is recognized by the World Health Organization as a Non-Governmental Organization (NGO) affiliate. Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions expressed have not involved any verification of the findings, conclusions, and opinions by IASP®. Thus, opinions expressed in IASP Insight do not necessarily reflect those of the Association or the Officers or Councilors. No responsibility is assumed by the Association for any injury or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instruction, or ideas contained in the material herein. Because of rapid advances in the medical sciences, the publisher recommends independent verification of diagnoses and drug dosages. For permission to reprint articles, please contact IASP.

Global learning.....................12 IHS & IASP collaborate

IASP reports...........................6 SIG on Pain in Childhood Granting relief......................10 Grant expands palliative care in Uganda

Chapter News.......................14 Australia developing pain management plan

IASP relocates to Washington, D.C. As IASP insight’s December issue was going to press, Seattle staff packed boxes in preparation for the move of the Association’s headquarters to Washington, D.C. In May 2012, IASP purchased the sixth floor of a nine-story office building located at 1510 H Street NW, in the heart of Washington, D.C.’s business district, in order to diversify investments and provide a more international setting to help the Association reach its strategic goals. During its December meeting in the US capital city, the IASP Council toured the office condominium, which was still under construction. IASP joins many other non-governmental health organizations and international associations that have selected the Washington, D.C. area as their home, including the American Academy of Nursing, the regional offices of the World Health Organization (WHO), American Psychological Association, National Institutes of Health (NIH), Pharmaceutical Research and Manufacturers Association (PhRMA), Endocrine Society, Biophysical Society, Society for Imaging Science and Technology, American Physiological Society, and Society for Neuroscience. IASP staff hope that members will visit the new office when their travels bring them to the D.C area. An accessible location, a spacious conference room, and nearby hotels will enable the Association to more easily host meetings at the new headquarters.

IASP’s new headquarters in Washington, D.C. are on the sixth floor of this office building on H Street NW.

International Association for the Study of Pain 1510 H Street NW, Suite 600 Washington, D.C. 20005-1020 USA With only three staff moving more than 4,400 kilometers across the country, much effort has been spent focused on hiring new staff and planning a transition that will not interrupt member services. Executive Director Kathy Kreiter, Membership Coordinator Marleda C. Di Pierri, and Grants Manager Irena Zlatanovic will be relocating to the new headquarters, joining new staff who have been hired in the D.C. area. Updated information on the new office, including a link to current staff contacts, is available on the IASP website at www. iasp-pain.org/headquarters.

Newsletter Advisory Board members met at the Milan Congress to plan future issues: Pictured, left to right: Yasuo Sugiura, Antoon de Laat, Huda Huijer Abu-Saad, Marketing, Communications, and Membership Director Karen Smaalders, Graciela Rovner, Michael Nicholas, and Editor-in-Chief Beverly Collett. IASP Council members in December voted to publish only one issue of IASP insight in 2013.

Noteworthy

IASP Council and officers in the new offices, from left to right: Jane Ballantyne, Eija Kalso, Ralf Baron, Michel Gold, Irene Tracey, Executive Director Kathy Kreiter, Rolf-Detlef Treede, Maged El-Ansary, Fernando Cervero, Michael Rowbotham, Germán Ochoa, José Castro-Lopes, Karen Davis, Eva Kosek, Cynthia Goh, Michael Nicholas, Judith Turner, C. Celeste Johnston, and Hiroshi Ueda. Not pictured: Herta Flor and Claudia Sommer.

PAIN in transition

A letter from the new Editor-of-Chief of PAIN

It is with great pleasure that I take over the position as Editor-in-Chief of PAIN from Allan Basbaum. Allan has done a superb job with the journal. His hard work, leadership, and vision have served the journal well. On a personal note, I must thank Allan for being extremely supportive and helpful in this transition period. I appreciate the opportunity that IASP insight has given me to discuss my background with PAIN and to articulate my current thinking about a vision and plan for PAIN.

Background I was first invited to join PAIN’s Editorial Board by Patrick Wall in 1990 and served as an Associate Editor. I very frequently provided reviews for the journal during my tenure as an Associate Editor. When Ron Dubner took over as Editor-in-Chief he asked me to become Section Editor for Clinical Psychology and I served in that capacity throughout his tenure with the journal. Alan Basbaum invited me to continue in the role of Section Editor during his tenure as Editor-in-Chief. It is only recently (early 2011) that I rotated off the Editorial Board as a Section Editor and was replaced by Chris Eccleston. Finally, I have been a regular contributor to the journal for years and have extensive experience as an author submitting manuscripts and publishing articles in the journal.

Francis (Frank) J. Keefe, PhD (USA) is a professor of psychiatry and behavioral sciences, psychology and neuroscience, anesthesiology, and medicine at Duke University Medical Center, USA, and a faculty scholar at Duke Institute on Care at the End of Life.

A conversation Member News with Allan Basbaum

Since joining PAIN’s Editorial Board as An Associate Editor in 1990, my primary commitment to editing activities has been to the journal. As a Section Editor for PAIN I was actively involved in the journal review process. I also had the opportunity to regularly attend the meetings of PAIN’s Editorial Board. As a result, I have a good sense of the decisions and discussions that have shaped the journal’s policies over recent years.

Over the coming years, I believe PAIN needs to focus on three major goals. First, we should continue to focus on PAIN’s primary mission, i.e. to publish the best original basic and clinical science research on pain. Second, we need to build upon and enhance the journal’s success as the premier outlet for high quality basic science and clinical research in pain. Third, I believe we need to work with the Editorial Board as well as IASP leadership to develop initiatives aimed at allowing the journal to continue to progress, broaden its readership, and promote PAIN as a significant contributor to science, clinical practice, and public policy. These goals are synergistic such that activities focused on any one of these goals can influence and in turn be influenced by activities focused on the other two goals. 1. Publishing the best, original basic science and clinical science in the field: PAIN has emerged as the premier journal in the pain field precisely because it has focused on the goal of publishing the best original research on the nature, mechanisms, and treatment of pain. We need to continue policies that encourage submissions across the spectrum of research from the genetics of pain to epidemiology and from the bench to the bedside. For readers, the essence of PAIN is that one can read in one journal original research that spans a broad focus of articles of interest to a multidisciplinary audience. Thus, PAIN should retain its focus on publishing original high quality research as its first and primary goal. 2. Building upon and enhancing the journal’s success: Under the leadership of Drs. Basbaum, Dubner, and Wall, PAIN has become the

Allan I. Basbaum, PhD, FRS (USA) has been Editor-in-Chief of PAIN since 2003. He is Professor and Chairman of the Department of Anatomy, and member, of the Department of Physiology and W.M. Keck Foundation Center for Integrative Neuroscience, at the University of California, San Francisco, CA, USA. Q: Looking back at the last decade of PAIN, what are the largest and most significant changes you have seen?

interest in developing approaches to understanding, at the preclinical level, mechanisms that underlie the affective component of the pain experience. I refer here to many studies of cortical (e.g. anterior cingulate cortex) processing mechanisms.

A: The look of PAIN has certainly changed in a very positive way. The covers are dramatic and memorable. The inclusion of up to six commentaries per issue has changed the face of the journal, making some material more accessible to a more diverse audience. The Commentaries (and Topical Reviews) also provide an opportunity to bring more clinical material to the journal.

Q: What type of research will you be looking forward to in the coming years? A: In addition to the areas I just highlighted, there is also a clear need for better preclinical models that can be effective in the prediction of drug efficacy in the clinic. I believe that many of the existing models are very useful, but we definitely need a better approach to understanding ongoing pain. I envision more studies using viral vectors to deliver therapeutics, including gene therapy. Cell-based therapies are likely to increase.

In terms of the general pain field, unquestionably there has been a proliferation of pain-related journals, both clinical and basic science oriented. The breadth of technological approaches to pain research has increased tremendously, with basic science having a very intensive molecular perspective. And at the other end of the spectrum is the recent strong

Vision and plans for PAIN

Imaging studies are also now a major contributor to our understanding of brain mechanisms in the processing of pain.

Q: What have been some of the highlights of your decade as the Editor-in-Chief of PAIN? A: The new covers The commentaries

premier journal for basic and clinical science in the area of pain. Based on this strong track record, PAIN is exceptionally well poised for the future. However, there are likely ways that things could be improved. Along with the editorial staff, we are examining the editorial and review processes to see if they could be streamlined or in any way further speeded up. We enhance our value to our contributors, readers, and the field at large if can provide even more timely review and publication of submissions. We also will be considering an array of strategies to ensure continued growth in the journal’s submissions and impact factor. 3. Developing new initiatives to advance the journal, broaden readership, and its impact on clinical practice and public policy: Recognizing that PAIN is on solid footing, potential new directions would need to be carefully considered. Along these lines, we are in the process of identifying a multidisciplinary team of advisors who can form a core Advisory Board for the journal. We will hold a series of meetings with the Advisory Board to consider and critically review a number of new steps to broaden the journal’s readership as well as it increase its influence on science, practice, education, and public policy. Over this time the Advisory Board will work with the Editorial Board and IASP leadership to develop a strategic plan that will serve to guide the journal’s activities in the years to come. Personally, it is a great honor and pleasure to have the opportunity to serve as Editor-in-Chief of PAIN. I thank the IASP membership and Board for this opportunity to serve the Association and look forward to working with all of you. If you have any questions or suggestions for the journal, please do not hesitate to contact me by email at keefe003@mc.duke.edu.

The impact factor going beyond 5 and staying there The dedication of the Section Editors The fact that we have been able to maintain reasonable balance in the publication content The strong move to on-line features; I would love to get better information as to who actually reads the print version. Is there a difference in demographics (clinician vs. basic scientist); does it make a difference in what part of the world you live? Q: What is the role of an international journal in the field of medicine? What should it be doing? A: There are general principles of clinical pain management that cut across countries, cultures, and language; the best practices and innovations should be published in an international journal. The science of pain, of course, has no country boundaries; the best scientific advances should be published so that the knowledge can be disseminated quickly and effectively. A high-quality journal also ensures that the information that is used by others in the design of new experiments is sound. The journal also fosters incredible dialogue across countries – dialogue that continues at the international meetings.

IASP reports

Special interest group on pain in childhood: we’re growing up!

provides free, open-access, peer-reviewed commentaries on pain in infants, children and adolescents. Book reviews and announcements of events related to pediatric pain are also accepted. Links are provided to Medline abstracts for articles cited or reviewed in PPL. Although widely embraced and supported by our membership early on, the responsibility and oversight of the letter was transferred to the SIG in 2008. Carl von Baeyer maintained a leading role for many years and currently serves as its editor, and more recently Deirdre Logan joined as an associate editor. The PPL is published online thrice yearly.

By Gary A. Walco

In 2005-2006, while Allen Finley was president of our SIG, IASP held out the Global Year of Pain in Children, one of the first of such efforts by the parent organization to raise awareness of different aspects of pain each year. This certainly helped raise the visibility of our SIG.

rotecting the well-being of the most vulnerable human beings is held at a high premium. Watching a young infant or child endure pain and related suffering for many, especially their parents, is virtually intolerable. But how do we come to understand the experience of pain in the young, especially those too developmentally immature to express themselves verbally? How do we know if medications that are shown to be beneficial in adults are safe and effective in infants and children? How do pain networks develop, and what may happen over the course of that trajectory that would make one vulnerable to pain problems, now or in the future? How do we disseminate our knowledge so that infants and children will not continue to be untreated or undertreated for pain? These questions and many others are the purview of pediatric pain specialists. It was only 30 years ago that premature infants, for example, underwent extensive surgical procedures without anesthesia, as many believed such young people did not have the capacity to experience pain and, if so, the effects were not remembered or long-lasting. People thought that because one could not meaningfully assess pain in the young, there was no way to measure the severity of the problem or assess outcomes for treatment. Although our knowledge has dispelled many of these fallacies, pain remains a highly charged emotional topic, and using science and data to influence practice and people’s perspectives is a critical starting point to invoke change. An array of professionals with varying fields of expertise and cultural values collaborated to define a field and move it forward.

Member News

Prior to 1988, several researchers and clinicians around the globe engaged in research and publishing. We communicated with one another, principally by mail, occasional telephone calls, and met very rarely face to face. The turning point came when Donald Tyler and Elliot Krane, two anesthesiologists at Seattle Children’s Hospital, organized the First International Symposium on Pediatric Pain. For those who attended, the occasion was momentous, as this was the first time many of the individuals who would go on to become the “founding mothers and fathers” of the field came together, recognizing that professionals representing a range of disciplines all spoke a similar language and had a great deal to contribute. Ever since, the field of pediatric pain has continued to be truly interdisciplinary in nature, and no one guild has any greater or lesser status than another.

From that beginning, important seeds were planted. Drs. Tyler and Krane titled their meeting the First International Symposium on Pediatric Pain, possibly implying they expected others to follow. Their prophecy proved quite correct, as there have been subsequent gatherings, initially every three years and now every two years, since that meeting: Montreal, 1991; Philadelphia, 1994; Helsinki, 1997; London, 2000; Sydney, 2003; Vancouver, 2006; Acapulco, 2010; Stockholm, 2013; and Seattle, 2015. The number of attendees continues to expand and the meeting typically spans four full days, plus an education day.

Defining the group and its objectives Perhaps it was no accident that the first meeting was organized in Seattle, the original home of IASP. On the heels of the meeting, John Loeser provided encouragement for the group to form one of the organization’s first special interest groups (SIG), and Dr. Tyler became the first president. The group focused for many years on working with local organizing committees to sponsor the international symposia. The group came to define itself on the bases of some key objectives: to promote education about pain in children to share relevant information about children’s pain control to advance our ability to alleviate children’s pain from an international and interdisciplinary perspective to encourage research (particularly multicenter studies) and studies which focus on unique problems of pediatrics, including newborns.

Important contributions In line with these objectives, the group began a number of projects. The Pediatric Pain Letter (PPL) was founded in 1996 by Patrick McGrath and Allen Finley, through the Centre for Pediatric Pain Research, Dalhousie University and IWK Health Centre, Halifax, Canada. PPL

Also during his tenure as president, Allen Finley joined with Neil Schechter to launch ChildKind International, an organization aimed at recognizing health care organizations that demonstrate an institutional commitment to pain control for children and an educational culture that facilitates it. In recognition of its importance, IASP is providing funding to ensure a successful startup of the initiative. Our SIG currently endorses ChildKind, as well as many other key organizations with an interest in the field, including: the World Federation of Societies of Anaesthesiologists, the Canadian Pain Society, the National Association of Pediatric Nurse Practitioners, the International Pharmaceutical Federation, the Canadian Nurses Association, the Child Life Council, the Royal College of Nursing, and the International Children’s Palliative Care Network. It appears likely that the accreditation processes for individual institutions will begin within the next several months.

Recognizing excellence Our SIG also recognizes excellence by bestowing two awards. The Young Investigator Award recognizes those who made outstanding contributions early in their careers and include many who became giants in the field, such as KJS Anand, Klaus Olkkola, Bonnie Stevens, Christine Chambers, Anna Taddio, and Suellen Walker. In 2010, we initiated a Distinguished Career Award, aptly first given to Patrick McGrath, with another for Ken Craig to receive in 2013. The Mayday Fund graciously supported the latter award.

Fulfilling the commitment to educate Our SIG focuses on providing forums for education and the sharing of information. Under the direction of Elliot Krane and Genevieve D’Souza, the SIG held its first satellite symposium this year at the IASP World Congress on Pain in Milan. The excellent presentations and the subsequent, sometimes animated, discussions may literally change the direction of thought on key issues in the field. We look forward to more opportunities for such exchanges. However, without doubt, the crown jewel of the SIG’s enterprises remains the International Symposium on Pediatric Pain (ISPP). The 9th ISPP meeting will take place in Stockholm, Sweden, June 17 to 20,

2013. Suellen Walker and Jennifer Stinson will co-chair the scientific committee. The plenary speakers and topics include: Lindsey Cohen, PhD (University of Georgia, USA): Treatment of Acute Pain: An Evidence-Based Practice in Psychology Perspective Liesbet Goubert, PhD (Ghent University, Belgium): Psychosocial Determinants of Child Pain –Toward an Interpersonal Fear-Avoidance Model of Pain Jon Levine, MD (University of California, San Francisco, USA): Its Past, Enlightened to Perceive New Periods of Pain: Nociceptor Mechanisms in the Transition from Acute to Chronic Pain Gustavo Turecki, MD, PhD (McGill University, Canada): How Life Events Get “Under the Skin” – Insight into the Relationship between Life Adversity and Suicide Risk Anna Taddio, PhD (University of Toronto, Canada): KT Related to Immunization Lonnie Zeltzer, MD (University of California, Los Angeles, USA): Integrative Therapies and Chronic Pain James Elander, PhD (University of Derby, UK): Sickle Cell Disease Pain: How Can Behavioral Research Inform Transitions from Pediatric to Adult Hospital Care? In addition, an array of symposia and workshops on focal topics, as well as an education day, will provide an overview of state-of-the-art concepts and practices in pediatric pain. Stockholm in June is simply a delight, as this is one of the most beautiful capitals in the world, and an optimal time of the year. Please join us. The tradition of this excellent meeting will continue, as the 10th Anniversary edition will be held back in Seattle, where it all began.

Contact our SIG Finally, the leadership of the SIG always appreciates feedback, collaborations, and ways we can improve the work we do toward fulfilling our mission. More information is available at www.childpain.org, a website maintained by Carl von Baeyer. In addition, please contact a council member if you wish. This includes Gary A. Walco, President (gary.walco@seattlechildrens. org); Lonnie Zeltzer, Past-President; Carl von Baeyer, Presidentelect; Chantal Wood, Treasurer; Ananda Fernandes, Secretary; Sunny Anand, Christopher Eccleston, Ruth Grunau, Tiina Jaaniste, and María Antonieta Flores Muñoz. Gary Walco, PhD, ABPP (USA), is Director of Pain Medicine at Seattle Children’s, one of the leading pediatric research hospitals in the United States. He is a professor of anesthesiology and an adjunct professor of pediatrics and psychiatry at the University of Washington School of Medicine.

Milan Congress breaks records

early 7,800 people from 115 countries gathered in Milan, Italy, to attend the 14th World Congress on Pain, breaking all previous attendance records and exceeding expectations by more than 20 percent. Just about half of the delegates traveled to Italy from outside of Europe. Almost 2,200 abstracts, a record number, were submitted by those seeking to present their posters in Milan. Financial aid and awards soared almost 75 percent, with 425 trainees and developing country attendees receiving assistance. But since numbers don’t tell the whole story, take a look at these photos taken by official Congress photographer Linda Ferrari of Milan to glimpse some of the meeting’s highlights: the captivating plenary lectures, intense conversation, superb entertainment, delicious food, new friendships and connections, and wonderful Italian hospitality.

Congress delegates enjoyed a feast of Italian specialties from the various regions of Italy at Monday’s Welcome Ceremony.

More than 60 trainees and mentors participated in a popular new event, Connection Rx, which allowed newcomers to the field of pain to meet and converse with experienced clinicians and researchers.

Outgoing President Eija Kalso makes her final address to the General Assembly as incoming President Fernando Cervero waits his turn.

If you would like to review more photos or listen to a Congress recording of a plenary lecture or workshop, visit our Milan Congress page at www.iasp-pain.org/Milan where you will find links to the Congress Flickr site and to the portal site for Congress recordings. And don’t forget to mark your calendars for October 7-11, 2014, when IASP travels to Buenos Aires for the 15th World Congress on Pain.

Tango dancers from Buenos Aires gave attendees a preview of the 15th World Congress on Pain.

Serge Marchand, author of Phenomenon of Pain, signs copies of his recently published English translation at the IASP booth.

Plenary lecturer Ru-Rong Ji, Chief of Pain Research at Duke University Medical Center, presented on “Glia and Pain.” Local Arrangements Committee Chair Paolo Marchettini, Scientific Program Committee Chair Irene Tracey, and outgoing President Eija Kalso enjoy the President’s Reception. Milan’s Congress featured a record number of poster presentations in the Exhibit Hall.

Background photo: Delegates at the Welcome Ceremony in the Milano Convention Centre. Cover photo: IASP’s booth in the Exhibit Hall.

Granting relief

Expanding palliative care in Uganda Hospice Africa Uganda (HAU) is the model hospice for Hospice Africa, which was founded in 1992 with a mission is to promote the relief of suffering in Africa through the support of palliative care. HAU provides palliative care to cancer patients from diagnosis and to HIV/AIDS patients during critical illness and end of life, in the home. IASP supported Hospice Africa Uganda (HAU) efforts to spread palliative care to rural areas by funding the tuition of six health care workers over the past three years. Last year, four students funded by IASP held fulltime jobs while they visited patients at home in the evening and studied for their bachelor’s degrees in palliative care in areas with little or no internet service. It is a constant struggle to find funding to train more nurse prescribers (who are specialists in palliative care), explains IASP member Anne Merriman, MBE, FRCPEdin, FRCPI, MCommH (Uganda), Director of Policy and International Programs for HAU. Hospice Africa aims to get funding to educate health care workers from all over Africa to become leaders in their countries in order to reach more and more patients through their clinical service, management, their public health approach, and advocacy with the government. She continues: “These students are also setting up training programs so that more palliative care experts and prescribers are available in their own countries, thus the founding mission is carried forward, bringing pain relief and thus opening the door to holistic care and comfort, to those at this special part of life.” Palliative care is still not even reaching 10% of those in need in Uganda, says Merriman. “We estimate that a further 20,000 may be looked after by those we have trained and are working in health facilities and other hospices in Uganda,” she said. In December 2012, 1,659 patients were involved in the Hospice Africa Uganda program, and 21,189 have been cared for since HAU began working with patients in 1993. Teaching services also began in 1993, targeting undergraduate medical and nursing students and already practicing health professionals. As a result of IASP’s support of their second-year tuition, four students are now in their third and final year of the BSc program at the Institute of Hospice and Palliative Care in Africa (IHPCA), conferred by Makerere University:

Moses Byomuhangi works long hours as a Clinical Officer in a large (Health Center 4) clinic with 30 beds in a remote district in Uganda that has no internet service. At 5 p.m., he starts to visit palliative care patients in their own homes on a motorcycle donated by UK parishioners. “It would have been impossible for me to study if [IASP] had not paid for my school fees,” says Byomuhangi, “and that would mean palliative care would not have reached our district where we have a population of over 300,000 people and some of them are in need of palliative care.” Byomuhangi wants to earn a master’s degree in palliative care after graduating with a BSc in palliative care. His dedication to the field earned him the designation as the district’s palliative care focal person: He started a CME for palliative care at his workplace, and opened up a palliative care unit for patients during the past year. Last year, he was able to provide care for more than 60 patients. Byomuhangi was married this year, and received a special gift from a doctor in Ireland, who donated proceeds from a book of poems that he wrote to buy Byomuhangi a new motorbike for visiting patients. Edith Nandutu, a member of the Uganda People’s Defense Forces (UPDF) at the General Military Hospital (GMH), already had a diploma in clinical palliative care, but is now working to increase her knowledge and train additional staff. In spite of everyday challenges that include a lack of funds, no dedicated palliative care staff, little access to internet and computers, and transportation for home visits dependent on an old motorcycle with limited fuel, Nandutu is pleased that her palliative care group has registered over 70 patients, primarily army personnel suffering from cancer and/or AIDS.

A third year student at the Institute of Hospice and Palliative Care, Moses Byomuhangi visits a patient. Inset: Moses Byomuhangi and a volunteer for Hospice Africa Uganda on the donated motorcycle that allows palliative care workers to visit rural patients in their homes.

Esnath Msowoya, a research nurse at the University of North Carolina Project-Malawi (UNC Project), eventually plans to complete her master’s degree in palliative care with the dream of opening up a palliative care clinic in the northern part of Malawi-Karonga District. The UNC Project-Malawi results as the collaboration between the University of North Carolina at Chapel Hill and the Malawi Ministry of Health. The mission of the UNC Project-Malawi is to identify innovative, culturally acceptable, and affordable methods to improve the health of the people of Malawi, through research, health systems strengthening, prevention, training, and care.

Patrick Lukula, who had both a certificate and a diploma in palliative care and experience working as an HIV coordinator in charge of home-based care, enrolled in the BSC degree course after he “discovered that management of terminal illnesses was still challenging.” He now supervises a Health Center 3 in the Kibuku District, and hopes to move to a Health Center 4 in order to start and organize palliative care for his district. His current school work allows him to develop the knowledge and skills required for optimal service. Like his fellow students, Lukula says IASP funding was critical to continuation of his studies, which suffers from other challenges such as unstable power supply, unreliable internet, and difficulty traveling (the university library, which has many books needed to study, is five districts away).

“As a palliative care provider and trainer, I will continue helping my fellow Malawians in terms of care and training in the provision of quality palliative care to enable those in need of the services to die with dignity and without pain,” Msowoya said.

The grants from IASP over the last few years have also supported two nurse prescribers (2010) employed by HAU to build their capacity as trainers both at the Institute and for clinical training of degree and diploma students. They both hold the Diploma in Clinical Palliative Care

(DCPC) from IHPCA and are active as trainers, one as an associate lecturer in IHPCA in Kampala, and one as a Clinical Officer and Clinical Trainer at HAU’s satellite, Mobile Hospice Mbarara in SW Uganda. As the students funded by IASP are all from Uganda, “your funding has made an impact on their Districts where they work and on the country as a whole,” explains Merriman. They receive follow-ups through continuing medical education, meetings, and standards of care through the Palliative Care Association of Uganda (PCAU), founded at HA in 1999 and now operating as an independent NGO working closely with HAU. This year, IHPCA is setting up its first research unit, which will be looking more closely into the use of morphine and the outcomes for our patients, among many other areas. A master’s program will commence in 2013 to be available to doctors and other health professionals who want to become specialists in palliative medicine, especially for pain control, Merriman said. “This is now a human right, but it is far from being achieved for those in need in Africa today.”

Global learning

Trainee spotlight

IHS & IASP collaborate on successful symposium

First Philip A. Spiegel IASP Congress trainee scholar Philip A. Spiegel’s parents, Stuart and Carrie Spiegel, seen here at the award presentation for Dina Juarez-Salinas at the 14th World Congress on Pain in Milan, Italy, told the first award recipient: It is our hope that Philip’s memory will live on in the spirit of your work as you progress towards finding ways to ease people’s pain.

F Symposium organizers Arne May and Ralf Baron

Trainees from around the world gathered in Hamburg to learn about headache.

rom 22 countries all over the world, young scientists traveled to Hamburg, Germany, for the first joint symposium of the International Headache Society (IHS) and IASP held October 5-7, 2012. Travel and accommodation were provided for close to 100 trainees attending the three-day symposium to improve their knowledge of pain mechanisms, diagnosis, and management of headache and other chronic pain states and to identify commonalities and dissimilarities of headache and other chronic pain states. Organized by Arne May, MD, PhD (Germany), representing IHS, and Ralf Baron, Dr med (Germany), representing IASP, the event was designed not only to educate trainees but to introduce IHS and IASP members to one another so that they better understood the backgrounds of the organizations. Throughout the course of the weekend, members of both societies discussed many topics with one another, and explored potential cooperation and synergies between the societies for the future.

he Philip A. Spiegel IASP Congress Trainee Scholarship was established in 2011 by IASP and the friends and family of Philip A. Spiegel, a young medical researcher and IASP member from California, USA, who died December 22, 2010. He suffered from Complex Regional Pain Syndrome and was planning to enter medical school to study pain management. The first scholarship was awarded to Dina Juarez-Salinas, a PhD candidate in the neuroscience program at the University of California, San Francisco (USA). Soon after she joined the lab of Dr. Allan Basbaum, her team transplanted neural precursor cells destined to become inhibitory interneurons into the spinal cord of nerve-injured mice.

A speaker and a moderator from either IHS or IASP covered a variety of topics, including neurophysiology, genetics, functional imaging, epidemiology, nitric oxide, neurostimulation, CGRP and vascular biology, and neurogenic inflammation. The event was by invitation only; speakers nominated trainees to attend, and both IASP and IHS nominated trainees as well.

“I decided to pursue a professional career in neuroscience because I think of the nervous system as one of the most important scientific frontiers,” said JuarezSalinas. “The central nervous system is such an enigma and the complexity and power it possesses has always fascinated me. We are studying the most powerful biological and computational system that exists, which I think is pretty remarkable.”

At the end of the weekend, participants evaluated their experience. Around 90% desired a continuation of the collaboration between the two associations, and indicated that the symposium represented a great start to the beginning of this partnership.

Juarez-Salinas presented her data during a poster session at the 14th World Congress on Pain (see sidebar). “As a pain researcher, this conference is the conference to go to,” she reports. The scholarship helped her attend the Milan Congress, which was her first conference that concentrated exclusively on pain. “This experience meant a lot to me,” she said. Seeing how many different people from all over the world are tackling this huge problem felt empowering, she said.

“In a way the meeting put everything in “context” for me,” said research fellow Nasim Maleki, PhD (USA). “I’m sure most of the trainees like me who attended the meeting felt the same. It also was the first meeting ever that I saw people so engaged from early in the morning to very late at night! I don’t how you did it but you did it and it was amazing and very enjoyable. I just wanted to thank you so much for providing such an amazing learning opportunity for people like me who are new to the field. I think in those three days you beautifully portrayed a roadmap of where we stand now and what the unmet needs are and how merging ideas would lead to better solutions.” Eija Kalso, Immediate Past President of IASP, praised the highly interesting discussions with young researchers that followed the high-quality presentations, as well as the juxtaposition of various topics, such as headache versus pain in general. She said that a partnership with IASP and IHS is beneficial since everyone learns from each other, and both organizations have their special strengths. In particular, she believes IHS excels in its classification, and she is proud of IASP’s multidisciplinary approach to pain. To continue the successful collaboration, the IASP Council voted in December to provide funding for a second headache symposium to be held in 2014.

Dina Juarez-Salinas, PhD candidate

Before this conference, Juarez-Salinas attended the last five annual Society for Neuroscience (SfN) meetings. She found IASP’s Congress more focused and much more clinical. “My favorite part of the Milan Conference was definitely meeting other people in pain research and networking, she reports. Meeting people from all walks of pain research, especially people involved in clinical research, was very inspiring for Juarez-Salinas. “I found this meeting unique in that sense - to have clinicians and scientists in such a collaborative environment and sharing their findings and experiences was very special. This meeting provided a platform for scientists to interact with a multidisciplinary group of doctors and researchers. “Because pain itself is an emotional response, I find it very important to consider clinical research in each component of pain, from the sensory side all the way to the emotional coping that pain requires. I think this meeting really provided a place for interactions between people in these fields that wouldn’t normally occur,” she said.

Area of research: Neuropathic pain is a chronic, debilitating disease characterized by mechanical allodynia and spontaneous pain. Because symptoms are often unresponsive to conventional methods of pain treatment, new therapeutic approaches are essential. One of the major contributors to persistent neuropathic pain is a loss of spinal cord dorsal horn inhibitory circuits, many of which involve interneurons that express gamma aminobutyric acid (GABA). Here we describe a potentially diseasemodifying therapeutic approach that restores GABAergic tone in the spinal cord and ameliorates the symptoms of neuropathic pain. To do this, we used fresh embryonic mouse medial ganglionic eminence (MGE) cells (at E12.5-E14.5) derived from transgenic mice that express green fluorescent protein (GFP) under the control of the promoter of the GAD67 enzyme. One week after spared nerve injury, we injected mice with GFP+ MGE cells (transplanted group) or medium alone (no cells, control group), in the lumbosacral spinal cord, ipsilateral to the injury. Mechanical thresholds were recorded before (baseline) and once a week (for 4 weeks) after transplantation. To study inflammatory pain, mice received 1% formalin, 4 weeks after MGE transplantation. Transplantation of GABAergic interneurons from the MGE into the adult mouse spinal cord completely reverses the mechanical hypersensitivity produced by peripheral nerve injury, without altering baseline thresholds. Underlying this improvement is a remarkable integration of the MGE transplants into the host spinal cord circuitry (demonstrated in our transgenic lines of transneuronal tracer mice). Transplanted cells make connections with both primary afferent and spinal cord neurons and express the Fos protein in response to peripheral stimulation. Moreover, the transplants normalized GAD65 mRNA levels, which typically decrease after peripheral nerve injury. We conclude that the therapeutic effect of MGE transplants is GABAmediated. By contrast, MGE transplants were not effective against inflammatory pain. Therefore, MGE-derived GABAergic interneurons overcome the spinal cord hyperexcitability that is a hallmark of nerve-injury induced neuropathic pain. Our findings indicate that GABAergic precursor cells have the essential properties for a cell-based therapy, particularly when loss of inhibitory control is a major contributor to the clinical condition.

Chapter news Australia

Australia developing pain management plan By Michael Nicholas The 2010 Declaration of Montréal (subsequently endorsed by the IASP Council) describes access to pain management as a basic human right. Yet, access to such services in most countries is generally unevenly distributed, often with long delays. Australia is no exception.

In recognition of this regrettable situation, the Honorary Jillian Skinner MP, New South Wales (NSW) State Health Minister, recently announced (July 2012) that she was committing more than A$26 million of new funding over the next four years for a strategic statewide Pain Management Plan. The plan will support the development of pain management services in regional areas, enhance existing teaching services, and support research into chronic pain. It is the hope that this plan may provide a model or inspiration for other nations considering ways of developing and implementing a population-wide pain management service. Pain management is often represented as something that occurs at a small or clinical level. Rarely has any large state (NSW has a population of seven million spread unevenly over 800,000 sq. km) attempted to develop a broad and accessible pain service. A small multidisciplinary group of pain clinicians and staff from the newly-formed Agency for Clinical Innovation (ACI) developed the NSW plan over the past year, in order to provide independent, clinicianinformed advice to the state Health Ministry. The implementation process is now in full swing and the new services are expected to begin operating within the next six months.

of pain problems across the state and evaluation of pain management outcomes at standardized intervals. The measures will cover the core domains of pain severity, pain-related disability, mood state, pain self-efficacy and pain catastrophizing. Data will also be collected on demographics, medication and other health service usage.

Briefly, the initial plan contains four main elements:

Four multidisciplinary pain services from tertiary-referral hospitals based in Sydney, and one in the next largest NSW city (Newcastle), will receive funding to act as mentors for five regional hospitals (in smaller population centers, 50-400 km away) to help them develop their own multidisciplinary pain service. A central element of the new services will include a pain management program aimed at promoting greater pain self-management among participating patients. The mentor hospitals will provide supervision and training for staff in the new services, as well as expedited access of more complex patients from the rural service to the city service. Other regional hospitals will be added to the program as funding and training resources become available.

Educational material will be developed and disseminated among community-based primary care health services to enhance awareness of pain management options across the state. This will include a standardized, state-wide referral form for pain management services and should facilitate the referral process.

Recurring funding will be made available for the establishment of a centralized database on core pain measures to be gathered from all pain management services. This will allow for a description

Recurring funding for research on chronic pain and educational resources will be provided at a lead hospital pain management center (the University of Sydney’s Pain Management Research Institute at the Royal North Shore Hospital in Sydney). Across the state, this will act as a resource for basic and translational research, as well as pain education.

The plan is intended to reduce regional variation in services and to facilitate access to more specialized services as needed. It is also expected that the plan will enable the development of an integrated model of care for pain management across the state and provide at least the first steps towards realizing the aims of the Declaration of Montréal. Michael Nicholas, PhD (Australia), is an associate professor at the Pain Management Research Institute at the University of Sydney at Royal North Shore Hospital, St. Leonards, Australia.

To read a full report on the plan, please visit: http://www.health.nsw.gov. au/pubs/2012/nsw_pain_management_plan_.html

About the Declaration of Montréal

Delegates to IASP’s International Pain Summit, held September 2, 2010, in Montréal, Canada, began the process that led to the Declaration of Montréal, a declaration that access to pain management is a fundamental human right. Endorsed by IASP and many other international health organizations and individuals around the world, the declaration calls out the following rights and obligations:

The right of all people to have access to pain management without discrimination.

The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed.

The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals.

The obligation of governments and all health care institutions, within the scope of the legal limits of their authority and taking into account the health care resources reasonably available, to establish laws, policies, and systems that will help to promote, and will certainly not inhibit, the access of people in pain to fully adequate pain management. Failure to establish such laws, policies, and systems is unethical and a breach of the human rights of people harmed as a result. The obligation of all health care professionals in a treatment relationship with a patient, within the scope of the legal limits of their professional practice and taking into account the treatment resources reasonably available, to offer to a patient in pain the management that would be offered by a reasonably careful and competent health care professional in that field of practice. Failure to offer such management is a breach of the patient’s human rights.

After passage of the Declaration, IASP members continued to work on developing a Desirable Characteristics of National Pain Strategies to provide core elements for any national pain strategy. The finished document is intended to act as an impetus to clinicians, educators, administrators, and governmental or professional organizations involved in the establishment and maintenance of standards for pain services. It recommends that any national strategy should consider four areas: Pain Education; Patient Access and Care Coordination; Monitoring and Quality Improvement; and Pain Research. For the full text of the Declaration, and to view the list of signatories, please visit: www.iasp-pain.org/Advocacy/ Declaration. A list of IASP recommendations for Desirable Characteristics of National Pain Strategies may be found at www.iasp-pain.org/Advocacy/DesirableCharacteristics.

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