Symposia Abstracts

There is little question that health research is undergoing a paradigmatic shift with an increasing emphasis on stakeholder involvement, knowledge translation and knowledge mobilization. Entry into non-traditional research areas is often a necessity for widespread knowledge mobilization and represents unchartered territory, often with expertise developing by trial and error. The goals of this symposium are to: a) shed a new light on the role of partnerships with patients and other stakeholders in patient oriented research (not only for the purposes of knowledge translation and knowledge mobilization) as this role is often misunderstood; b) demonstrate how diversification of research expertise can become a necessity in the quest for implementation of widespread and permanent clinical change. Ways of effectively working with patient/stakeholder partners and of diversifying one’s research expertise (midcareer or later) in order to address obstacles to implementation of evidence-based practices will be presented.

There is little question that health research is undergoing a paradigmatic shift with an increasing emphasis on stakeholder involvement, knowledge translation and knowledge mobilization. Entry into non-traditional research areas is often a necessity for widespread knowledge mobilization and represents unchartered territory, often with expertise developing by trial and error. The goals of this symposium are to: a) shed a new light on the role of partnerships with patients and other stakeholders in patient oriented research (not only for the purposes of knowledge translation and knowledge mobilization) as this role is often misunderstood; b) demonstrate how diversification of research expertise can become a necessity in the quest for implementation of widespread and permanent clinical change. Ways of effectively working with patient/stakeholder partners and of diversifying one's research expertise (midcareer or later) in order to address obstacles to implementation of evidence-based practices will be presented.
Speaker 1 Abstract Title: Nothing about us without us: Adding the patient voice to Canadian chronic pain research to optimize health practices and patient outcomes Speaker 1: Mary Brachaniec, BScPT, MAHSR, Patient Partner, Canadian Pain Network, Riverview, NB, Canada, mary.brachaniec@gmail.com, @brachaniec_mary Speaker 1 Abstract: The Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR) focuses on research most relevant to patients and on timely implementation of findings to optimize health practices and outcomes. Patients are engaged as active partners working with other stakeholders in all aspects of the research cycle, including governance and oversight, research priority setting, project planning, and Knowledge Translation (KT) activities. The Chronic Pain SPOR Network (CPN) supports high impact Canadian research aiming to unlock the mysteries of pain and to elucidate effective treatment approaches for people with persistent pain. Each CPN Patient Partner brings his/her unique blend of experiences of living with chronic pain and in seeking treatment to improve quality of life and the ability to participate fully in society. This presentation will outline the role of one of our CPN patient partners, who serves as CPN KT Committee Co-chair, and as the first patient partner for the Pain in Older Adults Research team. This evolving role is a particularly good fit for her as caregiver for family members with dementia and persistent pain. Bringing the patient perspective to our research team helps ensure that the voice of this vulnerable population is heard. While patient engagement in health research is gaining momentum internationally, it is reasonably new to the Canadian pain research community. Exploring the opportunities and challenges faced by this CPN patient partner so far can elucidate next steps in moving muchneeded evidence into practice to improve the lives of countless Canadians with chronic pain.
Speaker 2 Abstract Title: The necessity of midto late-career research expertise diversification for achieving widespread clinical change: An example from the study of pain in dementia Speaker 2: Thomas Hadjistavropoulos, Ph.D., FCAHS, Department of Psychology and Centre on Aging and Health, University of Regina, Regina, SK, Canada. Thomas.Hadjistavropoulos@uregina.ca, @URHealthPsycLab Speaker 2 Abstract: A program of research on pain assessment in dementia serves as an illustration of the necessity of and entry into research diversification to achieve implementation goals. The research program begun with a series of largely lab-dependent investigations of pain behaviours characteristic of people with dementia. It progressed with development of clinically useful tools for pain assessment at the front line. Following convincing demonstrations of the validity and clinical utility of these tools, the program resulted in international interdisciplinary guideline development. Implementation of clinical solutions, using implementation science methodologies, succeeded in varying degrees but not on a large scale basis. Implementation challenges were largely related to resource barriers and insufficient frontline staff education on cutting edge assessment. Efforts to affect province-wide policy change were met with resistance largely due to concerns around cost and resources. Problem solving to implement change necessitated entry into areas that can reasonably be described as 'not-traditional" for a group of clinical scientists. These areas included, but were not limited to public policy research, development of automated computer vision technologies to address human resource limitations, estimation of the cost of pain in long-term care, and development of web-based platforms to educate rural front line staff in cutting edge assessment. The transition into these areas was rewarding and necessitated unlikely partnerships. A case will be made that, given increased emphasis on knowledge transfer and mobilization, mid-and late career research expertise diversification is a necessity for the implementation of successful and widespread evidence-based changes in clinical practices.
Speaker 3 Abstract Title: Digital health technologies to improve pain in young people: Opportunities and challenges for implementation Speaker 3: Jennifer Stinson, RN-EC, PhD, CPNP, FAAN, Research Institute, SickKids and Lawrence S. Bloomberg faculty of Nursing, University of Toronto, Toronto, Ontario, Canada, email: Jennifer.stinson@sickkids.ca, @DrJenStinson Speaker 3 Abstract: This presentation will highlight the strategies our lab used to gain the expertise in digital health technologies (i.e., how to employ a user-centred design approach to ensure patients are actively engaged in all phases; developing a common language across key stakeholders including mobile developers, researchers, clinicians and patients; and cultivating partnerships to ensure wide scale adoption and sustainability). Pain is common across all types of childhood cancers and nega-tively impacts health-related quality of life (HRQL). Despite available and effective pain treatments, cancer pain remains undermanaged. Children as young as 8 years are able to use electronic diaries to provide reliable and valid data; yet, no diary has been developed to capture the pain experience of pediatric cancer patients. Our lab has developed two real-time multidimensional cancer pain smartphone apps; Pain Squad that tracks cancer pain and Pain Squad+ that tracks and provides just-intime pain management advice. This presentation will briefly outline the steps in the development and evaluation of the usability (i.e., easy to use, understandable), feasibility (i.e., high adherence and acceptability, few technical difficulties) and psychometric properties of the Pain Squad app (convergent and discriminant validity, internal consistency and responsiveness) and the feasibility and effectiveness of Pain Squad+. The Pain Squad App is now freely available in the Apple store. This presentation will highlight the barriers and challenges in the development, evaluation, implementation and sustainability of mobile pain apps and discuss lessons learned.
Learning Objective 1: To familiarize participants with a vast array of expertise and partnerships that are often needed as part of efforts to implement new evidencebased approaches Learning Objective 2: To illustrate an approach toward meaningful engagement with patients as research partners Learning Objective 3: To illustrate, through specific examples from research with older adults and with children, how the necessity of expertise diversification was met and addressed by successful research groups. and clinical science. Dr. Price will provide a summary of his work on sex differences in hyperalgesic priming. Dr. Boerner will present her work on the role of sex and gender differences in children's pain experience and on the efficacy of psychological therapies for pediatric chronic pain. Dr. Fillingim will summarize his work examining the role of psychosocial factors (e.g., mood) and physiological variables (e.g., hormone levels) in explaining sex differences in both experimental and clinical pain responses in younger and older adults. The symposium will discuss sex-based methods of assessment in pain research and the challenges associated with the study of gender as it relates to pain. The symposium will stimulate discussion regarding the importance of a translational, developmental perspective to studying and understanding sex differences in pain across the lifespan.
Speaker 1 Abstract Title: Mechanistic sex differences in hyperalgesic priming models and their implication for chronic pain treatment Speaker 1: Theodore Price, PhD, University of Texas at Dallas, Behavior and Brain Sciences, Richardson, Texas, USA, theodore.price@utdallas.edu Speaker 1 Abstract: Hyperalgesic priming is a preclinical experimental paradigm that models the transition from acute to chronic pain. Male and female mice and rats both display robust hyperalgesic priming in response to a wide variety of inflammatory and nerve injury-inducing stimuli. While the magnitude and duration of the priming effect is often consistent between the sexes, the mechanisms driving this plasticity are highly sex specific. In males, our laboratory has discovered that microglial activation and dopamine D5 receptors signaling is a key promoter of plasticity that underlies hyperalgesic priming. In females, those mechanisms play a negligible role, while dopamine D1 receptors and CGRP-mediated signaling are femalespecific promoters of hyperalgesic priming. Interestingly, while many CNS-dependent plasticity mechanisms have a marked sexual dimorphism in this model, peripherally-mediated plasticity mechanisms seem to be shared by both sexes. For instance, AMPK activators, which reduce excitability of nociceptors after injury, have strong effects in both male and female mice. Our work highlights mechanistic differences between sexes in the transition from acute to chronic pain suggesting that different therapeutic strategies may be needed to treat chronic pain in males vs. females.
Speaker 2 Abstract Title: The role of sex differences and gender influences in pediatric pain Speaker 2: Katelynn E. Boerner, PhD, BC Children's Hospital, Mental Health, Vancouver, British Columbia, Canada, katelynn.boernerwall@cw.bc.ca, @KatelynnBoerner Speaker 2 Abstract: Sex differences in pain are well documented in adults, though far less is known about the presence of sex differences in pediatric populations, nor is the role of developmental factors well understood. As pain is a prevalent problem in children, and many adult chronic pain conditions have their origins in early developmental periods, there is a clear need to understand sex differences in childhood and adolescence. This presentation will begin with an overview of sex differences in pediatric clinical and experimental pain from a developmental perspective, highlighting the changes observed through childhood and adolescence, particularly in relation to puberty. Several of the potential mechanisms involved in the development of sex differences will be discussed. The results of an innovative experimental study will be presented, describing the effect of parental modeling of pain behaviours on their children, examining the impact of the sex of both the parent and child. The clinical implications of sex differences in pediatric pain will be described, including a recent meta-analysis of sex differences in the efficacy of psychological therapies for pediatric chronic and recurrent pain. In addition to describing observed male-female differences, throughout this presentation consideration will be given to the potential role of gender, in addition to sex, as a contributing factor to observed differences.
Pain in sport: lessons from the elite athlete Mark A. Ware, Amy Barrette, and Alan Vernec To be successful, the elite athlete must learn to have a relationship to pain through their intense training and competition, and possibly through injury and recovery. This symposium explores this relationship to a unique aspect of pain: pain as a necessary part of functional outcome. With a practicing athletic therapist, we will explore what physical and psychological approaches the elite athlete takes to working and training through pain. We will explore the guidelines for pain management in elite athletes, recently developed and published by the International Olympic Committee, and we will explore the inherent tension between pain pharmacotherapy and performance enhancement.
Speaker 1 Abstract Title: Athletes play through painwhat does that mean for rehabilitation specialists?
Speaker 1: Amy Barrette, M.Sc., CAT(C), CSCS, FMSC, Athletic Therapist/Thérapeute du sport, Drakkar de Baie-Comeau. amyfbarrette@gmail.com Speaker 1 Abstract: Aims: To explore the factors associated with sub-elite athletes playing through pain in gymnastics, rowing and speed skating. Methods: Semi-structured interviews were conducted with athletes, coaches and rehabilitation specialists. Coach participants were recruited through their Provincial Sport Organization. Injured athletes of the recruited coaches who were training for a major competition were then recruited. Rehabilitation specialists that were known to treat sub-elite athletes were recruited independently by email. Five coaches, four athletes and three rehabilitation specialists were studied. Athletes were photographed during a regular practice shortly before an important competition and all participants were interviewed after that competition. Photographs were used during the interview to stimulate discussion. Interviews were transcribed verbatim and thematic analysis followed using NVivo™ software. Results: The participant interviews revealed three main themes related to playing through pain. They are: Listening to your body, Decision making and Who decides.
Conclusion: When sub-elite athletes, striving to be the best in their sport continue to train with the pain of an injury, performance is affected in the short term and long-term consequences are also possible. Our study provides some insight into the contrasting forces that athletes balance as they decide to continue or to stop and sheds light on how the rehabilitation specialists they work with can have an impact on the decision-making process.
Speaker 2 Abstract Title: Analgesics, Sport and Anti-Doping Speaker 2: Alan Vernec, M.D. Dip. Sport Med. Medical Director, World Anti-Doping Agency, Montreal, Quebec, Canada; Alan.Vernec@wada-ama.org Speaker 2 Abstract: Narcotic analgesics are one of the original categories of doping substances in the IOC List of Prohibited Substances. Arguably however, the intention of banning narcotics in early days of sport was primarily for health and safety purposes. While many athletes have abused narcotics, objective evidence of performance enhancement is scant at best. This has led to an uneasy tension in the world of sports between legitimate medical use and abuse of narcotics and the best way to control it; a debate that has parallels in society at large. The World Antidoping Agency (WADA) maintains certain narcotics on the List of Prohibited Substances and receives regular and passionate demands from different stakeholders; some requesting that narcotics be entirely removed while others ask for the inclusion of more substances. In recent years, results from WADA monitoring statistics supports the conclusion that tramadol is being abused by some elite competitive cyclists. Among other permitted narcotic medications, tramadol is comparatively safe and has relatively low potential for addiction. WADA-appointed medical and scientific experts; as well as many stakeholders have maintained that tramadol has a legitimate place in the very broad world of sport that falls under the World Anti-doping Code. We will engage with the audience and explore ways forward: more clinical research, sport-specific anti-doping rules, and/or more athlete and physician education.
Speaker 3 Abstract Title: Cannabis in sport: enhancement, impairment or enjoyment? Speaker 3 Abstract: With changing societal attitudes towards cannabis, there are increasing calls for reconsideration of cannabis as a prohibited drug in sports performance. There is increasing awareness of the use of cannabis by professional athletes in a range of sports. This presentation will review the rationale for scheduling cannabis as a prohibited drug, summarize the literature on the performance enhancing or impairing effects of cannabis, and will explore the reasons for cannabis use by elite athletes. The use of cannabis in competition and training will be considered.
Learning Objective 1: Understand the importance and impact of pain in sports medicine Learning Objective 2: Appreciate the rationale for controlling analgesic use in training and competition Learning Objective 3: Discuss the lessons that can be learned about interdisciplinary pain management from the elite athlete CONTACT Mark A. Ware mark.ware@mcgill.ca; @drmarkaware

New horizons in fibromyalgia
Mary-Ann Fitzcharles, Lynn Cooper, and Amir Minerbi Although fully accepted as a valid illness for more than two decades, fibromyalgia (FM) still presents many challenges for both patients and the health care community. This symposium will address a number of new concepts pertinent to FM. In the first instance we will describe a new approach to directing a research agenda for FM that involved the collaboration of patients and health care professionals. Taking into account the lived experience of persons with FM, a study was conducted to identify priorities regarding management of FM that require further study. Amongst the top ten priorities identified was the question of the effect of lifestyle interventions, including dietary manipulation, as a strategy to improve symptoms of FM. This will provide a segue into the second part of this symposium which will address the effect of diet as well as possible manipulation of the microbiome in FM and painful conditions. Finally, the very new concept that FM is a condition that spans many medical illnesses will be described. Although mostly recognized to occur as a comorbid condition with rheumatic conditions, the presence of comorbid FM in other medical conditions such as neurological, gastrointestinal, endocrine and other medical conditions will be discussed. We believe that these new insights will be important in the clinical care of persons with FM and will contribute to overall well-being of patients.
Speaker 1 Abstract Title: Listen to the patient when embarking on research PSP) methodology, patients and health care professionals have collaborated to identify uncertainties and gaps in the clinical care of persons with FM. The process of this exercise will be described and the results will be presented from the perspective of a patient who participated in this project. Ten top priorities were identified which can be used to guide clinically relevant research. Three broad themes emerged: the value of personalized targeted treatment and subgrouping of patients; the efficacy of various self-management strategies; and identification of the ideal health care setting to provide FM care. These prioritized questions highlight the importance of the patient perspective in not only collaborative care, but also in directing research. This is the first study that uses an established and transparent methodology to engage all FM stakeholders to help inform researchers, funding bodies and health regulators of clinically relevant gaps in patient care that require further study. Leading directly from the high priority given to examine dietary interventions by the fibromyalgia JLA process, the evidence for dietary adjustments will be examined. Every physician who has treated patients with chronic pain has been asked the question about the influence of dietary adjustments to help relieve symptoms. With preliminary hints that dietary factors may influence pain in general and inflammation in particular, the scope of the current literature regarding dietary interventions in patients with FM will be discussed. Evidence for various dietary interventions that are commonly sought by patients, including elimination of gluten, dairy products, or sugar, or supplementation with products such as omega-3, curcumin or other alternative products will be discussed. The evidence for dietary manipulation to reduce animal fat and the effect of a vegetarian diet will also be described. Finally, a possible mechanism involving the gut microbiota in modulating chronic pain will be introduced, and reference will be made to preclinical studies regarding effects observed by manipulation of the microbiome in animal models of pain. Participants will have an understanding of the current and up to date scope of scientific evidence for dietary manipulation in management of chronic pain. Pain can be inhibited or facilitated based on the emotional context in which it occurs. Better understanding of factors that make some individuals vulnerable to emotional facilitation of pain while others remain resilient can help us to design better interventions for individuals with pain and comorbid psychopathology. This symposium will take a multidisciplinary, multimethod, approach to understanding emotional risk and resilience across the lifespan. We will examine psychopathological co-morbidity in pediatric pain and the various cognitive, behavioral, social and physiological mechanisms that contribute to this maladaptive overlap, or alternatively, buffer outcomes. We will also examine neural mechanisms associated with both adaptive and maladaptive emotional coping in adults, with a particular emphasis on individual differences in both vulnerability and resilience to emotional facilitation of pain. Mechanisms underlying response to psychological interventions (cognitive-behavior therapy, mindfulness meditation), and their potential role in early intervention for vulnerable children and adults will also be discussed.

Speaker 3 Abstract Title: Fibromyalgia permeates all of medicine
Speaker 1 Abstract Title: The co-occurrence, impact, and mechanisms of internalizing mental health symptoms in pediatric chronic pain Speaker 1: Melanie Noel, PhD, RPsych, University of Calgary and Alberta Children's Hospital Research Institute, Departments of Psychology and Anesthesia, Calgary, Alberta, Canada, melanie.noel@ucalgary.ca @melanienoel Speaker 1 Abstract: Chronic pain in adolescence is highly prevalent, impairing, and poses an economic burden (14.8 billion) that exceeds the costs of asthma and obesity. Adolescent chronic pain is linked to higher rates of PTSD, anxiety, and depressive disorders into adulthood. We revealed for the first time that youth with chronic pain and their parents report significantly higher rates of clinically elevated PTSD symptoms as compared to pain free peers and higher PTSD symptoms are linked to worse pain and quality of life. Dr. Noel will present data on the prevalence rates of PTSD, anxiety and depressive symptoms, contrasting findings at the diagnostic and symptom level. Cross-sectional data demonstrating the mechanistic roles of sleep disturbance and catastrophic thinking about pain in the PTSD-pain relationship will be presented. Informed by the conceptual models of mutual maintenance that she co-developed, Dr. Noel will present data from a multisite longitudinal, patient-oriented study examining the role of modifiable mechanisms (e.g., sleep disturbance using actigraphy, attention and memory biases using eye-gaze tracking and experimental pain, genes using saliva samples, parent behaviors using daily diaries and lab-based observations) in the co-occurrence of internalizing mental health and chronic pain. The influence of mental health symptoms on functional outcomes from diagnosis to months later in the context of a tertiary-level pediatric chronic pain program will be presented. Data on the unique role of diagnostic uncertainty as a potential root of emotional distress in idiopathic chronic pain will be presented. Implications for treatment tailoring will be discussed.
Speaker 2 Abstract Title: Examining mechanisms for the interaction of pain and negative affect Speaker 2: Tim V. Salomons, Ph.D., University of Reading, School of Psychology and Clinical Language Sciences, Reading, United Kingdom. t.v.salomons@reading.ac.uk @head_like_egg Speaker 2 Abstract: There is increasing evidence at both the behavioural and neurobiological level that negative affect is not only frequently co-morbid with clinical pain, but may play a critical role in the transition from acute to chronic pain. As such, neuroscientific exploration of this overlap can illuminate clinical pain in two ways. First, by identifying the mechanisms through which changes in negative affect alter pain and second by characterizing individual differences in the degree to which an individual is responsive to emotional modulation of pain. Towards these goals, I will review data demonstrating that perceived control over pain alters both the emotional and neural response to pain, with individuals perceiving low control showing increased anxiety responses and greater activation in regions like the anterior cingulate and insular cortices. Furthermore, alteration of anxiety responses by perceived control was associated with individual differences in connectivity between subcortical regions involved in emotion (amygdala, nucleus accumbens) and ventromedial and ventrolateral regions of the prefrontal cortex. Subsequent data examining individual differences in emotional modulation of pain also implicates the amygdala, as functional connectivity of amygdala and sensory regions predicted the degree to which presentation of negative slides increased ratings of painful thermal stimuli. Finally, I will review laboratory findings demonstrating mechanisms through which an intervention aimed at alterning cognitive and emotional responses to pain (cognitive behavioural therapy) can reduce central sensitization and alteration of resting state functional connectivity resulting from prolonged exposure to noxious thermal stimuli.
Speaker 3 Abstract Title: Neural correlates supporting inter-individual dispositional differences in the subjective experience of pain Speaker 3: Fadel Zeidan, PhD, Wake Forest School of Medicine, Department of Neurobiology and Anatomy, Winston-Salem, NC USA, fzeidan@wakehealth.edu, @fadelzeidan Speaker 3 Abstract: The subjective experience of pain is modulated by interactions between sensory, cognitive and affective dimensions. Yet, the neural mechanisms supporting inter-individual differences in the relationship between dispositional affect and pain remain poorly characterized.
In two separate functional neuroimaging analyses employing an overlapping sample size (n = 76), we revealed brain processes supporting the relationship between a) trait mindfulness and b) depression and pain in response to noxious heat (49°C). In our first study, we found that trait mindfulness was inversely associated with pain intensity and unpleasantness ratings (ps = .005). Trait mindfulness is defined as the innate capacity to be aware of the present moment in a non-evaluative manner. We show that higher trait mindfulness was associated with greater pain-related deactivation of the posterior cingulate cortex, a central node of the default mode network, a neural network associated with facilitating self-referential processes. In our second project, higher depression scores (Beck Depression Inventory) were positively associated with pain intensity (r = .32; p = .006) and pain unpleasantness (r = .34; p = .003) ratings. Moderation analyses revealed that high activation in regions involved in the cognitive evaluation of pain (PFC; anterior insula) and sensory-discrimination (somatosensory cortex; insula) moderated the positive relationship between depression and pain intensity. Low activation in cognitive control regions such as the orbitofrontal cortex, anterior insula, and rostral anterior cingulate cortex moderated the relationship between depression and pain unpleasantness. These findings could be utilized to develop pain therapies to specifically target said mechanisms to enhance the self-regulation of pain.
Learning Objective 1: To understand the role of disordered affect in adolescent chronic pain and underlying mechanisms that maintains these comorbidities Learning Objective 2: To elucidate neural mechanisms through which emotional states interact with pain Learning Objective 3: To better understand individual differences in vulnerability to emotionally-mediated facilitation of pain

Using Neuroimaging to Predict Pain and Its Relief: Clinical Utility and Neuroethics
Karen Davis, Mojgan Hodaie, and Javeria Ali Hashmi Treatment of chronic pain can have varying degrees of success, likely due to individual factors that are not well understood. For example, both biological and psychosocial factors can impact the development of chronic pain and the efficacy of treatment on patients with chronic pain. The ability to predict pain relief prior to treatment represents an important advance to create personalized pain management. In this symposium, we explore the neural mechanisms underlying chronic pain and the potential to predict pain relief based on individual pre-treatment metrics of brain and peripheral nerve structure and function and the impact of behavioural and environment factors (e.g., context and expectation). We will also consider the neuroethics of such an approach as per the recent recommendations of the IASP task force on the use of brain imaging to diagnosis pain.
Speaker 1 Abstract Title: Moving forward from the recommendations of the IASP "task force on the use of brain imaging to diagnose pain" towards ethical applications to predict treatment outcomes  Neuroreport 1995). We now know that acute pain engages a complex and flexible system in the brain known as the dynamic pain connectome (Kucyi and Davis, Trends Neuroscience, 2015). Recent advances in machine learning approaches make it possible to develop models to predict pain based on neuroimaging data. The potential for misuse of imaging-based biomarkers of pain brought about an IASP task force to examine and make recommendations pertaining to the use of imaging to diagnose pain and the neuroethical and legal ramifications of such applications (Davis et al., Nature Rev Neurology 2017). However, the task force also emphasized the potential utility of imaging for prediction of chronic pain treatment outcomes. Thus, this talk will review the task force recommendations, provide data showing the potential to use brain imaging models to predict pain relief, and discuss how technology can be used in the future to develop a personalized approach to pain management in an ethical context. Speaker 3 Abstract: The central nervous system has an inbuilt capacity to modify pain intensity adaptively in relation to the context. As such, pain perception for the most part, does not directly reflect activity in peripheral nociceptive signals. Instead pain is a composite of topdown expectations/prior learning and bottom-up nociceptive processes. Studies on placebo response indicate that initiating a new treatment induces positive expectations and shifts mental states to be conducive for stronger analgesic responses. However, inability to build positive expectations and appropriate mental states (i.e., the right 'mind set') before starting treatment can negatively affect treatment outcomes. Previously, we and others have reported that expectation-effects on pain can be predicted by observing brain network properties at baseline. New data from our lab offers insights on the nature and extent to which top-down signals in the brain can modulate pain. This talk will discuss how mapping activity in topdown brain circuits in people with chronic pain and healthy subjects is expected to offer new directions for improving chronic pain diagnosis and treatment outcomes.
Learning Objective 1: To understand the IASP fMRI task force recommendations on the use of brain imaging to evaluate pain, and to appreciate the utility of brain imaging to prognosticate pain relief in individual patients for personalized pain management purposes Learning Objective 2: To understand the utility of using diffusion tensor imaging to identify structural features of the trigeminal nerve that relate to trigeminal neuralgia and that can be predictive of long term pain relief following radiosurgery. Learning Objective 3: Share new information on how brain mechanisms of pain modulation and placebo research offer new directions for improving chronic pain diagnosis and treatment.
CONTACT Karen Davis, PhD karen.davis@uhnresearch.ca From birth to death: Novel and evidence-based multi-method assessment of pain across the lifespan Kathryn A., Birnie, Britney Benoit, and Lucia Gagliese Pain is, by its very nature, a subjective experience. Despite many years of empirical inquiry and debate, effort to improve the assessment of pain remains an ongoing endeavour for researchers and clinicians alike. The relevance of this work continues given contemporary emphasis on patient-reported outcomes in medical care. The challenge of pain assessment is perhaps most notable amongst populations who are unable to verbally report on their pain experience, such as infants, young children, some elderly, and at the end of life. Herein lies the need for multi-method assessment of pain using observational and, more recently, neurophysiological methods. Valid, reliable, and interpretable assessment of pain remains at the crux of pain management for determining the need for and adequacy of interventions. This symposium will showcase new empirical research and rigorous systematic reviews to guide best clinical and research practice in the assessment of pain from infancy through childhood, adolescence, adulthood, and older people at the end-of-life. It presents examples of the assessment of pain using novel neurophysiological methods, as well as self-and observer-report. This symposium will be of interest to multidisciplinary clinicians and researchers in their selection and application of novel and evidence-based pain assessment methods across the lifespan.
Speaker 1 Abstract Title: The use of novel neurophysiological methods to assess pain in non-verbal infants Speaker 1: Britney Benoit, MScN RN PhD(c), Dalhousie University School of Nursing, Halifax, Nova Scotia, Canada, britney.benoit@dal.ca, @britney_benoit Speaker 1 Abstract: While infant pain assessment has historically relied on behavioural pain scores, use of neurophysiological imaging methods is emerging. This presentation will first describe the neurophysiological methods that have been used to construct the scientific knowledge base in the field of infant acute pain assessment as identified in a recent systematic review (Benoit et al., 2017). In this review, a systematic search of key electronic databases (CINAHL, PubMed, PsycINFO, EMBASE) was conducted to October 2015. Of the 2411 abstracts screened, 19 articles were retained and data on study methodology were extracted. Of the included studies, nine utilized near infrared spectroscopy (NIRS), two utilized functional magnetic resonance imaging (fMRI), and eight utilized electroencephalography (EEG) as the primary outcome. There was variability in research designs and procedures in those studies utilizing NIRS, whereas studies utilizing EEG and fMRI reported consistent methods across studies. Of the eight EEG studies, six reported event-related potentials (ERPs) as the primary outcome. All of the ERP studies identified a distinct nociceptive-specific potential, which was found to be stimulus intensity dependent, independent of sleep state, and present in preterm and full term infants. Of the neurophysiological methods used to date, ERPs appear to be the most consistently described indicator of infant nociception and hold promise as a valuable indicator to supplement existing bio-behavioural measures. This presentation will thus conclude by highlighting novel utilization of EEG ERPs in ongoing clinical trials evaluating pain-reducing intervention efficacy in neonates.

Speaker 2 Abstract Title: Updated recommendations for the selection of selfreport of pain intensity measures in children and adolescents
Speaker 2: Kathryn A. Birnie, PhD CPsych, University of Toronto & The Hospital for Sick Children, Toronto, Ontario, Canada, kathryn.birnie@sickkids.ca, @katebirnie Speaker 2 Abstract: Over one decade ago, Pain published a systematic review of the psychometric properties of self-report pain intensity measures in children and adolescents (Stinson et al., 2006). That review directly informed recommendations of acute and chronic pain measurement in pediatric clinical trials (PedIMMPACT). Recent developments in pediatric pain necessitate an update of this earlier work, including: (1) growing use of the 11-point numerical rating scale in pediatric populations, and (2) electronic presentation of self-report scales as part of technology adoption. This presentation will share results of an updated systematic review evaluating the psychometric properties of self-report pain intensity measures in children aged 3-18 years to inform recommendations for measure selection. Measures were included if they met Cohen's criteria of "well-established assessment". Database searches identified >16,000 abstracts. A total of 80 eligible studies provided psychometric evidence for paper and electronic presentations of the Faces Pain Scale-Revised (and original Faces Pain Scale), Visual Analogue Scale, Wong Baker FACES Pain Scale (paper only), the 11-point Numeric Rating Scale (NRS), the Oucher Scale, the Pieces of Hurt Tool, and the Color Analogue Scale (CAS). All studies were coded for quality in evaluating measure reliability, validity, responsiveness, and interpretability using the COSMIN checklist. Quality of studies ranged from poor to excellent. Recommendations for measure selection will be presented by age (3-18 years) and type of pain (acute, postoperative, chronic). Four measures were strongly recommended for acute pain and two measures for postoperative pain; only weak recommendations could be made for self-report measures of chronic pain intensity.
Speaker 3 Abstract Title: The assessment of cancer pain in older people across the disease trajectory Speaker 3: Lucia Gagliese, PhD, York University, School of Kinesiology and Health Science, and Department of Anesthesia, University Health Network, Toronto, Ontario, Canada, gagliese@yorku.ca, @LGagliese Speaker 3 Abstract: Many older people with cancer experience moderate-to-severe pain, related to treatment and/or the disease process that interferes with quality of life, physical and social functioning, and emotional well-being. Despite this, the assessment of cancer pain in older people, especially those with cognitive impairment at the very end of life, has received limited empirical attention. This presentation will describe a narrative approach to pain assessment and will review assessment strategies that may be appropriate at different points in the disease trajectory. Obstacles to pain assessment in older people will be considered. It will be shown that despite the widely held belief that older people are more stoic about pain, among people with cancer at least, there are no age differences in pain-related stoicism. Data regarding the feasibility, validity, reliability, and sensitivity of single-item pain intensity scales and multidimensional measures of pain qualities, including neuropathic qualities (e.g., Short Form McGill Pain Questionnaire 2) for younger and older people with treatment-related and chronic cancer pain will be presented. Finally, a study of health care workers' assessment of cancer pain at the end of life in older people with delirium will be presented. The presentation will close with a consideration of future research and clinical directions.
Learning Objective 1: To discuss the methodological application, strengths, and limitations of neurophysiological methods to assess acute pain in infants, and highlight utilization in ongoing neonatal pain intervention trials. Learning Objective 2: To select recommended self-report measures of pain in children aged 3-18 years based on availability and quality of psychometric evidence, child age, and type of pain (acute, postoperative, chronic). Learning Objective 3: To explore assessment of pain intensity and qualities in older people with advanced cancer and at the end of life, including both self-report and observational measures. Cancer pain versus chronic noncancer pain. Are they the same? A for and against debate Jordi Perez, Dwight Moulin, and Charles E. Argoff All chronic pains are "malignant" but some do not have an oncological origin. Regardless of its origin, pain is best assessed and managed with individualized approaches. Some may argue that depending on the etiology of the disease causing the pain, the different approaches need to be adapted to best accommodate the particularities of the underlying disease, the treating team and the patients' characteristics including their caregivers. This symposium will focus on identifying if those particular differences should be taken into account when assessing and treating pain in patients with an active cancer versus those of chronic noncancer origin. Dr. Moulin is a Canadian pain physician with extensive experience in chronic cancer and noncancer pain states. He is a founding member of the Royal College subspecialty in Pain Medicine and lead the Canadian Consensus Guidelines in the Management of Neuropathic Pain. Dr. Moulin will serve as moderator for the debate between the other 2 speakers.
Dr. Charles Argoff specializes in chronic headaches and neuropathic pain. He is Neuropathic Pain Section co-editor for Pain Medicine, editor of multiple pain management textbooks and is particularly active in the media with educational presentations about chronic pain assessment and management. Dr. Argoff will defend that cancer pain and noncancer pain should be evaluated and treated in a broadly similar fashion.
Dr. Perez shares his practice between a cancer pain and a chronic non cancer pain clinic. He is board member of IASP SIG in Cancer Pain and directs one of the few Cancer Pain Fellowships in the world. Dr. Perez will defend that cancer pain should be seen as a different entity than noncancer pain. Speaker 1 Abstract Title: Introduction to the debate. Is cancer pain and chronic noncancer pain the same entity? Speaker 1 Abstract: Although severe chronic pain of any type can be debilitating, there are some fundamental differences between chronic non-cancer pain and cancer pain that could have an impact on diagnostic considerations and treatment. Cancer pain is usually of shorter duration and is more likely to involve progressive tissue destruction. It is also more likely to involve multiple pain syndromes and generators of pain. Although both types of pain are usually incurable, cancer pain carries the extra burden of impending loss of life which adds another dimension of suffering to the pain. This debate will explore these factors and others in determining the assessment and management of chronic non-cancer and cancer pain.
Speaker 2 Abstract Title: Cancer and noncancer pain should not be regarded as a different condition Speaker 2: Charles E. Argoff, MD, Professor of Neurology at Albany Medical College Director of the Comprehensive Pain Center at Albany Medical Center in New York, Albany, NY, USA, cargoff@nycap.rr.com Speaker 2 Abstract: What exactly is the difference between chronic cancer-related pain and chronic noncancer-related pain? Do we have a construct that we can use that helps us to distinguish that, and are we really helping ourselves in addressing the needs of our patients, and are we helping ourselves by making a clear dichotomy when the dichotomy may not exist in a chronic setting? It's time to consider not focusing on a dichotomy between cancer-and non-cancer-related pain, but realize that there are ways to approach each category. Many people with chronic cancer-related pain will also have non-cancer-related pain, and many people with non-cancer-related pain who have been treated for years will develop cancer. Many people may have lingering effects of cancer-related treatments that are not clearly related to active cancer. There are many permutations that must be considered, and so it's extremely important to take a universal approach to the safest and most effective ways of helping people and recognize that some of the guidance we receive, and some of the medicines that are available for so-called cancer-related pain, may not have been studied in individuals who had active cancer. We should address these concerns in a universal way, so that we are treating individuals and not categories, such as "cancer" or "noncancer," that have no solid foundation or evidence base for being separate categories.
Speaker 3 Abstract Title: Cancer pain is not the same as chronic noncancer pain There are significant differences in the assessment and the treatment of chronic pain depending on its etiology. The assessment of a chronic noncancer case must include the impact of pain on the daily function and the treatment plan must include plans to rehabilitate and recuperate physical and functionality. On the other side, the assessment of a cancer pain typically focuses on symptom assessment and comfort. The analgesic strategy aims towards improving quality of life rather than recuperation of function.
The goals of treatment differ significantly among these populations and as such the therapeutic complexity and aggressiveness varies accordingly.
The 3 steps ladder by the WHO was built for the management of cancer pain but not for chronic non cancer cases. In the last decade, the controversy about long term opioid therapy in chronic non cancer pain patients is growing with more administrative and legal implications being added recently to the debate. The use of coadjuvants is much less reported in the field of cancer than non-cancer pain management, on the other side, the aggressiveness of interventional pain procedures reported in cancer cases is far more obvious than in non-cancer pain syndromes.
This workshop will review those aspects that must be contemplated when assessing and treating a chronic pain of cancer versus non-cancer origin.
Learning Objective 1: To appraise the possible differences between cancer and noncancer pain and judge if they should be taken into consideration when assessing and treating a pain patient. Learning Objective 2: To review the evidences (or lack of) supporting the dichotomy between cancer and noncancer pain and focus on the particular management of each individual rather than categories. Learning Objective 3: To review the differential assessment and management recommended in cancer and noncancer pain populations including diagnosis and treatment modalities.

Magali Millecamps, Bradley Kerr, and Reza Sharif-Naeini
Neurodegenerative diseases are defined as hereditary and sporadic conditions which are characterized by progressive nervous system dysfunction. These disorders are incurable, debilitating conditions and their management mainly targets motor and cognitive impairments. However, a number of neurodevelopmental and neurodegenerative disease may specifically involve the somatosensory system, thus making pain a clinical concern for these patients. In many of these diseases, identification and assessment of sensory-disturbances may be hampered by concomitant impairments of cognitive and motor performance that leads to mismanagement (like rise of spontaneous neuropathic pain associated with Multiple Sclerosis, or the dangerous decrease in pain perception or expression in Christianson syndrome and Alzheimer's disease).
Animal models of neurodegenerative diseases can be of particular interest to mechanistically investigate sensory-disturbances associated with specific pathologies. In the present symposium, 3 speakers will bring new perspectives on 3 different animal models of neurodevelopmental and neurodegenerative disease. Dr Bradley Kerr will present the pathophysiology of neuropathic pain that develops in a rodent model of Multiple Sclerosis. Dr. Reza Sharif-Naeini will discuss the sensory-disturbances that occur in a rodent model of Christianson syndrome and present data on the potential underlying mechanisms. Dr Magali Millecamps will present work examining changes in acute and chronic pain perception/expression in a rodent model of Alzheimer Disease.
Speaker 1 Abstract Title: Using the mouse model experimental autoimmune encephalomyelitis (EAE) to understand the pathophysiology of neuropathic pain in Multiple Sclerosis Speaker 1: Bradley Kerr, PhD. University of Alberta, Department of Anesthesiology and Pain Medicine. Edmonton, AB, Canada, T6G2-G3. bradley.kerr@ualberta.ca Speaker 1 Abstract: Canada has some of the highest rates of Multiple Sclerosis in the world. This neuroinflammatory and neurodegenerative disease is associated with significant demyelination of axonal tracts in the brain and spinal cord. Demyelinating plaques underlie the pathological signs of weakness and paralysis that is most commonly associated with the disease. However, a significant proportion of patients with MS also develop sensory disturbances including neuropathic pain in the distal limbs and/or trigeminal neuralgia. The mouse model experimental autoimmune encephalomyelitis (EAE) is an autoimmune disease model that recapitulates many of the pathological features of MS including widespread leukocyte invasion of the CNS, demyelination and axonal injury. In this talk I will present data demonstrating that neuropathic pain behaviors are also a prominent feature of the EAE model. I will present data demonstrating that in mice with EAE, maladaptive neuronal plasticity in the primary sensory neurons of the dorsal root and trigeminal ganglia is a critical underlying feature in mice that exhibit these abnormal pain behaviours even in the absence of overt demyelination. Sex differences in these responses will also be discussed.
Speaker 2 Abstract Title: Progressive degeneration of nociceptors in a mouse model of Christianson syndrome Speaker 2: Reza Sharif-Naeini, PhD. McGill University, Department of Physiology & Cell. Montréal, Qc, Canada, H3G 0B1. Reza.Sharif@mcgill.ca Speaker 2 Abstract: Pain is a critical sensory signal that warns the host of impending injury. The regulation of pain sensing is a complex and tightly controlled mechanism. Consequently, genetic conditions that cause a reduction in pain sensitivity expose the patients to frequent injuries, self-mutilation, and shortened life expectancy. Such hyposensitivity to pain is observed in children diagnosed with Christianson Syndrome (CS), a rare but increasingly diagnosed neurodevelopmental and regressive form of X-linked intellectual disability. Christianson syndrome is caused by various mutations in the SLC9A6 gene encoding the sodium/proton exchanger NHE6, which is abundantly expressed in the central nervous system. How these mutations contribute to the elevated pain thresholds of CS patients has yet to be determined. Our studies examine the expression of NHE6 in the CNS and explore the somatosensory consequences of NHE6 loss-of-function in a mouse model of CS.
Speaker 3 Abstract Title: Investigating the acute and chronic pain experience during the development of Alzheimer's disease: a behavioural approach in a triple-transgenic mouse model Speaker 3: Magali Millecamps, PhD. McGill University, Faculty of Dentistry. Montréal, Qc, Canada, H3A 0G1. magali.millecamps@mcgill.ca Speaker 3 Abstract: Alzheimer's Disease (AD) is a chronic neurodegenerative disease characterised initially by difficulties in short-term memory. As the disease progresses, symptoms can include problems with language, disorientation, mood swings, loss of motivation, and self-neglect. In addition to cognitive decline and difficulties communicating distress, AD patients present with an average of 5 additional chronic pathologies, with a high prevalence of chronic pain conditions such as osteoarthritis (~70%) and neuropathic pain (~15%). Of concern, however, the consumption of analgesics is significantly lower than in cognitively intact adults. Pain assessment in AD patients relies upon caregivers' sensitivity and is frequently underor over-estimated, according to their relationship with the patient. While it has been commonly accepted that patients with AD have reduced pain perception, this hypothesis is now being questioned. There is an increasing body of literature highlighting our poor understanding of pain perception in AD.
In this presentation, pain experience will be investigated using a transgenic mouse model of AD with human mutations for both β-amyloid and tau components of the disease (3xTg-AD). Measures of cutaneous thresholds and changes in spontaneous behavior (including social behaviour, self-neglect, and body representation) will be evaluated during acute, sub-acute and chronic pain experience.
Learning Objective 1: To familiarize participants with the panoply of sensory disturbances that may be associated with neurodegenerative diseases. Learning Objective 2: To provide evidence of clinically-relevant changes in the pain experience in animal models of Neurodegenerative diseases and discuss possible underlying mechanisms. Learning Objective 3: To bring awareness of the concept that deficits in pain perception, pain neglect and decreases in the expression of pain are equally deleterious for patients with these disorders.  -11 [1988]), in which he expressed the urgent need to improve pain management for people across the lifespan. Unfortunately, cancer pain remains undertreated, especially in some of the most vulnerable populations, including children, older people, and those in the very last days of life. The objective of this symposium is to trace the history of cancer pain management over the past 30 years, and to describe the persistence of cancer pain undertreatment in these vulnerable populations, and across different phases of the cancer trajectory. Lucia Gagliese will discuss the historical context of cancer pain undertreatment and present recent data describing continuing pain undertreatment in older people with advanced cancer and among those with cognitive impairment at the very end of life. She will also explore some of the underlying causes of this undertreatment. Next, Lynn Gauthier will trace the history of pain management indices, discuss their limitations, and describe their validity, sensitivity, and specificity, and the development of a new, multidimensional index. Finally, Perri Tutelman will review the historical context of pediatric cancer pain undertreatment, present the current state of cancer pain management in this population, and describe findings from a novel social media campaign to address knowledge-to-action gaps in pediatric cancer pain management. Commonalities and differences across the lifespan will be highlighted and directions for future research will be proposed.
Speaker 1 -11 [1988]) in which he described the shocking inadequacy of cancer pain management for people of all ages. This presentation will provide an historical overview and current snapshot of the management of cancer pain. It will be shown that despite growing awareness of cancer pain, empirical evidence for a variety of treatment interventions, and the growth of palliative care and hospice services, many people with cancer continue to experience moderate-to-severe pain that impairs not only quality of life but also quality of death and dying. Reasons for this, including fear of addiction and hastened death, inadequate access to services, and the chasm between the fields of pain and palliative care will be explored. Finally, cancer pain at the end of life in an especially vulnerable group of older people, those with cognitive impairment, will be discussed. It will be shown that these patients may be especially likely to receive inadequate pain management and to die in pain, with healthcare workers often unable to assess pain in their final days of life. The presentation will close with a discussion of future directions linked to those proposed by Melzack 30 years ago.

Speaker 2 Abstract Title: Steps Toward Validation and Refinement of the Pain Management Index
Speaker 2: Lynn Gauthier, PhD, Department of Family and Emergency Medicine, Université Laval and Centre de recherche du Centre hospitalier universitaire de Québec-Université Laval, Québec, Québec, Canada, lynn.gauthier@crchudequebec.ulaval.ca, @Doc_Peper Speaker 2 Abstract: For 25 years the Pain Management Index (PMI) has been the most widely used measure of the adequacy of cancer pain management. It relates the patient's report of worst pain intensity to the strongest prescribed analgesic according to the World Health Organization's Analgesic Ladder. Although the PMI has been widely adopted, a critical approach to its use has been lacking. A variety of other, unidimensional indices have been used, including patient reported pain relief and satisfaction, however, cross-measure comparisons of validity, sensitivity, specificity, and agreement are unavailable. In this presentation Dr. Gauthier will trace the history of cancer pain management indices and discuss their limitations. She will present data from two studies of their validity, specificity, sensitivity, and agreement in adults at different phases of the cancer continuum. It will be shown that the sensitivity, specificity, and agreement of existing indices are low and that the PMI functions differently across the cancer continuum, suggesting questionable construct validity: Although only 14.9% of patients with advanced cancer pain were undertreated according to the PMI, 90.4% received a strong opioid, yet 52.8% reported moderateto-severe average pain (≥4/10 on a numeric rating scale [NRS]). In contrast, 59% of women with pain due to breast cancer treatment 1 year after surgery were undertreated. None were prescribed an opioid and 30% reported moderate-to-severe average pain. Dr. Gauthier will describe the development of a multidimensional index which builds on the PMI, and provide directions for future research to improve measurement of the adequacy of cancer pain management.

Speaker 3 Abstract Title: Using Social Media to Address Knowledge to Action Gaps in Pediatric Cancer Pain
Speaker 3: Perri Tutelman, BHSc. (Hons), Dalhousie University, Department of Psychology and Neuroscience, Halifax, Nova Scotia, Canada, ptutel-man@dal.ca, @PerriTutelman Speaker 3 Abstract: As recently as 40 years ago, it was widely believed that children did not feel pain. Infants and young children routinely underwent major surgery without anesthesia, and few received adequate medication for postoperative pain relief. While anesthesia has since become a standard of pediatric surgical care, infants and children (including those with cancer) continue to experience preventable pain despite the availability of research evidence on how to manage it. In this presentation, Ms. Tutelman will review the historical context of undertreated pain in childhood, and the current state of pain and its treatment in children with cancer. Next, she will present data from the #KidsCancerPain campaign, a social media partnership with the Cancer Knowledge Network aimed at bridging knowledge-to-action gaps in pediatric cancer pain management by disseminating information directly to parents. Between July 2016-September 2017, the campaign shared evidence-based content on a variety of topics related to pediatric cancer pain (e.g., pain assessment, physical, pharmacological, and psychological cancer pain management strategies) to parents via 1 Thunderclap, 7 blogs, 3 videos, 9 social media images, 5 Facebook questions, and 1 Twitter chat. A survey evaluating the effectiveness of the campaign found that approximately 20-40% of parents reported that they became more familiar with pain control techniques, used new and more pain control techniques and felt more confident in managing their child's cancer pain as a result of the #KidsCancerPain campaign. Challenges, opportu-nities, and future directions regarding the use of social media as a knowledge translation strategy in pediatric oncology will be discussed.
Learning Objective 1: To understand the historical context of cancer pain undertreatment across the lifespan. Learning Objective 2: To describe the current state of cancer pain management and its assessment across the cancer continuum. Learning Objective 3: To summarize recent advances in assessment techniques and knowledge translation strategies to address the persistent problem of cancer pain undertreatment across the lifespan. Given the current concern about opioid prescribing and in the advent of the revised National Opioid Guidelines, the TPS has also become a referral centre created for high dose opioid patients looking for help to wean from their current regimen. Our novel opioid weaning roadmap along with our results over the initial 2 years from the TPS will be presented. This has led to an over reliance on opioids resulting in increased health complications and overdose deaths. As such, there is a growing need for programs to support care providers and patients who would benefit from opioid tapering. This presentation will highlight the role of the pharmacist in supporting patients undergoing an opioid taper. The pharmacist provides education about the risks associated with high dose opioids and highlights the health benefits of tapering off opioids. Opioid risk mitigation strategies, harms reduction and overdose prevention are also incorporated.
The pharmacist critically evaluates the the patient's pain, mood and sleep pharmacotherapies, monitors for opioid withdrawal, worsening pain, and/or function and provides recommendations on the rate of the taper and ways to optimize non-opioid pain medications. When the patient's care is ready to transition back to the community, the pharmacist will engage with their primary care provider (s) through mentorship, provision of a warm-line and sharing of resources and tools. The pharmacist outreach component is key in facilitating smooth transition of medication management from a specialty pain clinic back to the community.
Patient Speaker 4: Paul Ross -Patients will describe their journeys over the past two decades following multiple surgeries related to IBD and his struggles with the health care system as they tried to find a solution to their high dose opioid dependence which were "clouding their lives". Their involvement with the TPS and comprehensive interdisciplinary chronic pain program will be described in detail to the audience.
Learning Objective 1: To provide details regarding the pathway being used to wean patients patients from high dose opioids Learning Objective 2: To describe specific psychological techniques associated with opioid weaning Learning Objective 3: To describe the role of the pharmacist within this inter-disciplinary team. Speaker 1: Billie Jo Bogden, Patient Partner, bbog-den001@gmail.com Speaker 1 Abstract: There are many positive things that have emerged from the collective resolve to address the opioid crisis. Chief among them are guidelines for doctors prescribing opioids for chronic non-cancer pain and discussions of quality standards for the treatment of chronic pain. Another very important change in the landscape is a unified commitment to including people with 'lived experience' in the development of our response to this growing health and public safety concern. Authorities from all levels of government have signaled a desire to expedite change. However, responses differ considerably across the country and are further challenged by regional, cultural and geographic realities, affecting patients and their access to adequate pain therapy in different ways and to varying degrees.
Innovation in pain management requires change, something not always welcome in the chronic pain community. There have been many significant changes to the patient tool-kit over the past few years. Both the medical community and patients alike are not well informed. Fundamentally it will require a concerted effort to shift the way Canadians treat their pain and those who suffer with it.
Evidence-based decision making requires thorough and comprehensive analysis. Great strides have been made setting a solid framework for this research.
However, as we look beyond the data collection, education and awareness emerge among the most universal priorities. We can learn from the excellent examples that precede us, and together fashion a uniquely Canadian National Pain Strategy. Pain is poorly managed in Canada and the magnitude of the problem is increasing. There is a critical need for a national pain strategy. IASP hosted an international pain summit on 23rd September 2010. This led to the Declaration of Montreal and a consensus document regarding national pain strategies. One year later the Australian Pain Summit was held and in 2012 we held the Canadian Pain Summit in Ottawa. Prior to that meeting a stakeholders forum was held, a whitepaper was drafted and presented at the Summit where it was endorsed by 142 organizations including the CMA, CAN CIHR and CCSA. Argyle communications did an excellent job of lining up multiple media contacts and meetings with MPs including health critics of both opposition parties, top bureaucrats in the DVA and members of the Senate. Unfortunately we were not able to get a meeting with any sitting politician who might be willing to sponsor the necessary legislative activities. Since that time members of CPS and people with pain have continued to advocate for a national pain strategy while pushing for better access to pain care on a provincial level. There are several provinces where significant progress has been made. This presentation will review what we have learned and will begin to discuss how to build on what we have in order to accomplish a National pain Strategy for Canada.
Speaker 3 Abstract Title: Towards a Canadian National Pain Strategywhat can we learn from the Aussies! Speaker 3 Abstract: On 11 March, 2010, after 15 months of preparation, representatives of 150 organizations representing health professionals, consumers, industry and funders met at the Australian National Pain Summit. The Summit was held in the Federal Parliament House, Canberra and opened by the Minister for Health, the Hon. Nicola Roxon MP and unanimously supported the National Pain Strategy and agreed on priority objectives aimed at improving quality of life for people with pain and their families, and minimizing the burden of pain on individuals and the community.
The Strategy provided a case for change, policy context, and an action plan that provided possible solutions to the individual and community consequences of chronic pain.
Since that time, all State Governments have embraced the recommendations of the National Pain Strategy, with measurable improvements in patient experiences, health and well-being, and reductions in opioid use and health service utilization.
This presentation will discuss the lessons learned from the development and implementation of the Australian National Pain Strategy and how they might inform the successful development and implementation of a Canadian National Pain Strategy, to benefit not only to the one in five Canadians living with persistent pain, but their families, communities and the nation.
Learning Objective 1: To bring a patient perspective onto the issues around a national pain strategy Learning Objective 2: To chronicle the current Canadian state of development of a National Pain Strategy, from the perspective of one of the leaders of that process. Learning Objective 3: To discuss how the lessons learned in the development and implementation of the Australian National Pain Strategy might inform the development and implementation of a Canadian National Pain Strategy. The hub of services for the TAPMI network is the ambulatory multi-disciplinary centre at Women's College Hospital. Healthcare providers at the hub assess and triage pain patients to one of the partner hospitals or to the multidisciplinary team at the hub depending on the care they require. Each partner hospital offers distinct specialization in one aspect of pain management that together make TAPMI a comprehensive chronic pain service. TAPMI has develop a comprehensive program that addresses challenges and barriers to care and builds on the strengths of the partner programs. TAPMI services are designed around the patient's journey, supporting the patients and their primary care providers at home and in the community through to intake, treatment, and discharge.

ORCID
This symposium will discuss our process for 1) establishing a central intake and triage for 5 large academic pain programs, 2) engaging patients in program development and oversight and, 3) developing economically sustainable programs that meet the needs of our patients.
Speaker 1 Abstract Title: Highways to Help: Setting up the right infrastructure to get patients to the right providers the first time ON Canada, Jacqueline. Follis@wchospital.ca, @CoachFollis Speaker 1 Abstract: TAPMI was designed to improve a number of patient oriented health outcomes including access to care. Accordingly, one of TAPMI's key strategic priorities create a centralized referral and triage process for all five partner pain programs. This initiative not only integrates care across the 5 partner hospitals but also allows us to integrate with our primary care partners in the community. The common referral and triage pilot launched in February 2017.
The referral form and triage process was evaluated under a Quality Improvement (QI) framework with Plan-Do-Study-Act (PDSA) cycles. The areas we are focusing on include developing a common form that Speaker 3 Abstract: As chronic pain is so pervasive we must strive to efficiently implement evidenced based therapies. This talk will explore the ethical dilemmas in designing chronic disease programming where demand for services may exceed capacity. It will also explore how we can leverage new technologies to reach more patients with fewer healthcare dollars spent.
In 2015/16 TAPMI received over 4000 unique referrals for chronic pain services. To meet the demand for services, TAPMI is designing many of our programs to be delivered online, for those who are technologically advanced. Education and self-management are evidence based therapeutic interventions for chronic disease management that can easily be adapted for mass online consumption and still achieve positive outcomes for patients. We will present our model for online care delivery.
Learning Objective 1: Evaluate the benefits and barriers to access in establishing a centralized triage process Learning Objective 2: Discuss the importance of incorporating the patient in program design and oversight. Learning Objective 3: Explore ways of developing economically sustainable programs within the Canadian health care system CONTACT Tania Di Renna tania.direnna@wchospital.ca laura.pus@wchospital.ca Learning to fear pain: brain imaging and psychophysiological studies of the impact of anticipated pain on pain sensitivity and decision-making

Mathieu Roy, Pierre Rainville, Petra Schweinhardt, and Michael Meier
Pain has an important learning function: we learn to fear cues that are predictive of pain and will try to avoid pain whenever possible. However, avoidance often comes at a cost, in which case we need to decide whether or not we are willing to pay the price for avoiding pain. This symposium will examine the impact of learned fear of pain on pain sensitivity, how fear of pain is represented in the brain, and how fear of pain influences our decisions. Altogether, these three presentations will provide a better understanding of the neural and psychological mechanisms underlying the important influence of pain anticipation on behavior.

Speaker 1 Abstract Title: Learned expectations and uncertainty facilitate pain during classical conditioning
Speaker 1: Pierre Rainville, Ph.D. Université de Montréal, Département de Stomatologie, Montréal, Québec, Canada, pierre.rainville@umontreal.ca Speaker 1 Abstract: Pain spontaneously activates adaptive and dynamic learning processes affecting the anticipation of, and the responses to, future pain. In a first study, we investigated the dynamic modulation of pain and the nociceptive flexion reflex (NFR) by fear learning in healthy human adult participants undergoing a classical conditioning procedure involving an acquisition, reversal and extinction phase. Results revealed a phenomenon of conditioned hyperalgesia: learned pain predictions increased pain and facilitated NFRs. In a second study, we examined the influence of meditation training on conditioned hyperalgesia in a sample of expert meditators. While skin conductance data indicated that both meditators and controls correctly learned cue-pain associations, conditioned hyperalgesia was absent in meditators, suggesting that meditation training can reduce the influence of expectations on pain processing. Finally, in a third experiment, we examined the relationship between cortisol and conditioned hyperalgesia. Results showed that higher salivary cortisol levels were associated with stronger conditioned analgesia. Altogether, these results indicate that learned pain associations can have a profound effect on pain processing and that meditation training may help mitigate the negative effects of conditioned fear of pain.
Speaker 2 Abstract Title: Exploring the validity of pain-related fear questionnairesa probabilistic fMRI machine learning approach Speaker 2: Petra Schweinhardt, Ph.D., and Michael Meier, Balgrist University Hospital, Department of Chiropractic, Zurich, Switzerland, petra.schwein-hardt@balgrist.ch Speaker 2 Abstract: Embedded in the fear-avoidance model of chronic low back pain (CLBP), pain-related fear (PRF) is characterized as a prognostic factor of disability. Currently, there are several questionnaires which assess pain-related fear but demonstrate weak construct validity. In this respect, brain research might lead to novel insights as individual variability in fear processing is hypothesized to be reflected in differentially and spatially distributed brain responses to distinct stimuli. During fMRI recording, 20 CLBP patients (7 females, mean age = 39.35) were asked to observe video clips showing potentially harmful and neutral activities for the back. Subsequently, for each questionnaire (Fear Avoidance Beliefs (FABQ) and Tampa Scale of Kinesiophobia (TSK) questionnaires, Pain anxiety symptoms scale (PASS)), we trained a gaussian process regression model by using amygdala activity patterns and leave-one-subjectout cross-validation with the aim to predict the respective questionnaire score on an unseen patient. Statistics were based model performance (R 2 , mean squared error MSE) and model selection (Bayes factors based on negative log marginal likelihood). For the harmful condition, only the FABQ questionnaire demonstrated a significant association with amygdala activity patterns (R 2 = 0.32, MSE = 4.13, p < 0.05), driven by a strong contribution of the FABQ-work subscale (R 2 = 0.48, MSE = 1.84, p < 0.05). In line with these results, related Bayes factors indicated a preference for the FABQ-work model. Importantly, questionnaire scores were not predictable by activity pattern evoked by neutral activity (all p's > 0.5). This neuroscientific approach might ultimately help in finding an optimum measure for pain-related fear.
Speaker 3 Abstract Title: No pain no gain: cerebral mechanisms underlying decisionmaking about pain Speaker 3: Mathieu Roy, Ph.D., McGill University, Psychology, Montreal, Québec/Canada, mathieu. roy.3@mcgill.ca Speaker 3 Abstract: All of the decisions that we take in our everyday lives are ultimately under the control of nature's "two sovereign masters": pleasure and pain. However, these two sources of motivation are often in conflict with one another: rewarding activities often comes at a price. This is especially true for patients with chronic pain, who often have to decide whether or not to engage in rewarding activities that could cause them pain. In order to take these difficult decisions, an abstract "value" representation of pain has to be computed and compared against the value of competing rewarda common currency is required to decide between goods of different nature, like pain and pleasure. In order to examine the relationship between pain intensity and its value, we conducted a decision-making experiment in which participants had to accept or reject monetary rewards associated with different levels of pain (e.g. 1.25$ for a pain at level 20/100). Results showed that pain value increases exponentially as a function of pain intensity, meaning that changes in pain intensity in the higher pain range (e.g. between 70/100 and 80/100) have more value than changes in the lower pain range (e.g. between 10/100 and 20/100). Moreover, participants scoring high on a fear of pain questionnaire accorded more value to pain, suggesting that fear of pain increases pain's aversive value. Finally, we conducted a brain imaging experiment to examine the cerebral mechanisms underlying decisions about pain and money. Results showed that medial prefrontal structures computed an abstract value representation common to both pain and money and used to make decisions about pain.
Learning Objective 1: To understand the neural and psychological mechanisms underlying the influence of learned expectations on pain perception. Learning Objective 2: To explore the cerebral underpinning of inter-individual differences in pain-related anticipatory fear. Learning Objective 3: To examine how people make decisions between anticipated pain and potential rewards.
CONTACT Mathieu Roy mathieu.roy.3@mcgill.ca Speaker 1 Abstract: Respiratory depression is an opioid-related adverse event which can lead to death. The monitoring of opioid administration to prevent this fatal adverse event is essential to ensure patient safety. Although opioid-related respiratory depression risk factors have been discussed in the literature (Jarzyna D, Pain Manag Nurs 2011;12(3):118-145), no tool exists to screen the patient's risk to develop this critical adverse event. Such a tool would be relevant to provide an appropriate monitoring of opioid administration in patients who are treated for acute pain. Indeed, opioid safety is a required organizational practice in hospital settings by Accreditation Canada. The goal of our research study is to describe predictive factors of opioid-related respiratory depression associated with the treatment of acute pain in adults. A total of 125 medical charts of patients who received naloxone for opioid-related respiratory depression will be matched to 125 medical charts of patients who were treated for acute pain with opioids but did not present respiratory depression. Logistic regression will be performed to identify predictive factors of respiratory depression. These findings will be used for the development of a tool for the screening of opioid-related respiratory depression.
Speaker 2 Abstract Title: Optimal opioid prescription for acute pain relief while limiting misuse and dependence Speaker 2 Abstract: Emergency medicine is now among the top 5 specialties prescribing opioid for outpatients under the age of 40. As a matter of fact, acute pain is often the way by which patients first encounter opioids. At the same time, prescribed opioid misuse, dependence, overdose, and death have all increased epidemically in the last 15 years in both the US and Canada. Rates of opioid overdose deaths in the US increased by 14% (from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014), to reach more than 3 times the rates of 1999. In Ontario, the number of deaths related to oxycodone (prescription opioid) overdoses increased five folds from 1991 to 2004. In recent years, the number of deaths caused by opioids prescribed for pain relief surpasses those resulting from heroin or cocaine use. However, 71% of opioid abusers received them through the diversion of prescription opioids (transfer of opioids to someone other than the holder of the initial prescription) and in 55% of cases these pills were obtained from unused medication of family members or friends. Only 4% obtained prescription opioids from a drug dealer. Diversion of pain medication may occur when a portion of the prescription opioids are unused. Recent literature suggests that prescription opioid diversion could be a major contributor to the opioid misuse epidemic. Therefore, prescribing an appropriate amount of opioid pills needed to treat acute pain while minimizing unused prescription opioids is essential and will be addressed in this presentation.
Speaker 3 Abstract Title: The effects of morphine intake on the endogenous pain control during the acute post-operative period The most important challenge in effective PCA use is low dose-demand ratio or a higher lockout interval demand, since both suggest unrelieved pain. Opioids have been first line of therapy for moderate to severe post-surgical acute pain. Morphine plays a role in engaging the descending inhibitory pain pathways in its analgesic efficacy. Endogenous analgesia can be investigated using the psychophysical paradigm of conditioned pain modulation (CPM), previously known as the diffuse noxious inhibitory control. Animal studies have shown alterations in descending pain control that are linked to the development of chronic post-surgical pain. Therefore, we evaluated the post-surgical PCA usage, the self-reported pain intensity and the effect of intravenous morphine on the efficacy of CPM five days after surgery, and six weeks after surgery in a cohort of 50 adolescents with idiopathic scoliosis who underwent spinal fusion surgery. Results suggesting a misuse of PCA will be discussed, as well as the interaction of morphine intake on the CPM efficacy during the acute and intermediate period after surgery. Listening to the first cries at birth, the primacy of the social context in human distress responding is clearly demonstrated by the innate predisposition to signal another when upset.
However, parents continue to play a critical role in shaping pain experiences and pain responses in children of all ages. Research is beginning to show an interaction of developmental stage and parent influence on pediatric pain responses. An important component of parenting the child in child is the parent's emotional well-being. Outside the pain context, it is well-known in developmental literatures that parents with mental health challenges can struggle to meet the demands of child rearing. This symposium explores this relationship specifically within the pediatric pain context. Drawing from new research across childhood (newborn, young child, adolescent), presenters will discuss biological, behavioural, and social influences on the child in pain, when a parent has mental health challenges.
Speaker 1 Abstract Title: Prenatal exposure to antidepressants, maternal mood disturbances and neonatal cardiac autonomic reactivity to an acute noxious event Speaker 1: Tim F. Oberlander, MD, FRCPC; University of British Columbia, Department of Pediatrics, University of British Columbia, Vancouver, BC Canada; toberlander@bcchr.ca, @oberlanderlab Speaker 1 Abstract: Long before birth, the capacity to regulate acute stress responses have already begun to take shape. This formidable process sets pathways that shape distress regulation across the early life span. Selective serotonin reuptake inhibitor (SSRI) antidepressants are commonly used in pregnant mothers for perinatal mood disturbances. These drugs inhibit the reuptake of serotonin (5HT) at presynaptic neurons, thereby increasing central synaptic 5HT levels. Serotonin plays an integral part in the neurodevelopment of stress regulation systems (cardiac autonomic, hypothalamic pituitary adrenal axis), thus it is conceivable that prenatal SSRI exposure alters 5HT levels during critical developmental periods in ways that shape subsequent stress regulation in response to an acute noxious event.
Importantly, prenatal SSRI exposure occurs in the context of maternal mood disturbances that also alters 5HT signaling and neonatal stress regulation. Distinguishing the impact of biological and social influences remains a critical challenge. Moreover, early changes in 5-HT signaling associated with genetic variations for SLC6A4 (encodes the serotonin transporter) also influences the development of stress regulation and might explain individual differences in stress regulation. This presentation will focus on distress regulation and pain reactivity during early infancy associated with prenatal SSRI exposure, maternal mood (pre-and postnatal) and variations for SLC6A4 showing a possible 'fetal serotonergic programming' effect that confers developmental risk for some infants, but for others may reflect a predictive advantage that may even "buffer" the child from maternal mood disturbances. We will examine why stress regulation among some but not all exposed infants are affected by prenatal SSRI exposure.
Speaker 2 Abstract Title: Understanding how parental mental health impacts the efficacy of parental management interventions for pediatric pain Speaker 2: Hannah Gennis, M.A., York University, Department of Psychology, Toronto, Ontario, Canada, hgennis@yorku.ca, @h_gennis; Rebecca Pillai Riddell, PhD, York University, Department of Psychology, Toronto, Ontario, Canada, rpr@yorku.ca, @drbeccapr Speaker 2 Abstract: When a healthy young child is in pain, parental behaviors are strongly predictive of infant pain-related distress regulation (Gennis & Pillai Riddell, 2017;Pillai Riddell, Gennis et al. in press). However, when a parent is challenged to regulate their own emotional distress due to mental health challenges, this could impact the efficacy of interventions to improve their pediatric pain management.
This presentation discusses analyses of a new RCT assessing the effect of an educational video during both 6-month and 18-month vaccinations (N = 128). The moderating role of parental psychological distress was examined. Psychological distress moderated the effect of video on child pain post-needle. Toddler parents with lower or average psychological distress in the treatment condition had children with less pain in the minutes following the needle.
These findings not only demonstrate the influence of parental psychological distress on the efficacy of parent-led pediatric pain interventions, it suggests the potential that higher psychological distress may make parents more vulnerable to being overwhelmed by interventions causing higher pain in young children. Implications will be discussed.
Speaker 3 Abstract Title: The largely neglected role of parental physical and mental health in pediatric chronic pain kathryn.birnie@sickkids.ca; @katebirnie Speaker 3 Abstract: The family context is central to chronic pain experience, and serves as a both a source of risk and resilience. Despite a longstanding recognition that parent behaviours play an integral role in children's coping with pain, attention has only recently turned to understanding the role of parents' own physical and mental health. Parents of children with chronic pain experience higher rates of pain and internalizing mental health disorders. Proposed mechanisms for specific intergenerational risk of chronic pain, include genetics, altered neurobiological development, social learning, general parenting and family health, and exposure to a stressful environment (Stone & Wilson, 2016). These mechanisms are purported to lead to chronic pain in the child, greater disability, and poorer psychological functioning through child vulnerabilities, such as altered pain processing, pain-related cognitions and affect, pain coping, physical health, and poor emotion regulation. Although largely untested, this conceptual model of transmission of chronic pain risk to offspring parallels intergenerational risk of mental illness, including depression, anxiety, and somatization. Importantly, the influence of parent physical and mental health problems on children does not appear to be condition specific. This talk will review accumulating theoretical and empirical evidence addressing parent physical and mental health in the risk, assessment, and treatment of pediatric chronic pain. New data will be presented testing an integrative model of parent physical and mental health in a large clinical registry of youth with chronic pain and their parents (n = 344 dyads). Implications to assessment and targeted interventions will be discussed.
Learning Objective 1: To understand the impact of maternal mood disturbances in pregnancy and antidepressant treatment on infant and child stress reactivity. Learning Objective 2: To stimulate discussion on the importance of understanding parental psychological distress when designing parent-led pain interventions for young children. Learning Objective 3: To present evidence for proposed mechanisms underlying relations between parent physical and mental health symptoms and child chronic pain and disability in children and youth. Cognitive biases are a core component of contemporary cognitive-affective models that try to explain pain experience, distress and disability in children and adults experiencing pain. The idea that children and adults with pain show cognitive biases for pain-related information, i.e. they selectively attend to pain-related information at the cost of other information (attentional bias), interpret ambiguous stimuli as pain-related (interpretation bias) or have biased memories for painful events (memory bias), has been particularly influential in this context. Notwithstanding the considerable progress made in the understanding of cognitive biases related to pain and threat, a number of questions remains unanswered and future challenges linger. A first challenge is to further delineate the characteristics of cognitive biases, including their content specificity and dynamics. A second challenge relates to the understanding of how cognitive biases interrelate with each other and possibly reinforce one another. A third challenge relates to the translation of findings on cognitive biases for pain into clear strategies and recommendations to optimize and evaluate pain treatment programs. Presenters in this symposium will address each of the above-mentioned lingering challenges by both critically reviewing the available evidence on cognitive biases in children and/or adults experiencing pain and presenting novel research using innovative study setups and unique methods for assessing and modifying cognitive biases in children and adults experiencing pain. The idea that people in pain selectively attend to pain-related information is a pivotal assumption in leading cognitive-affective models of pain. Research investigating attention bias for pain has most often assumed (implicitly or explicitly) that attention bias for pain-related information is a relatively stable phenomenon and relied on lab paradigms with low ecological validity. Within this presentation, Dr Van Ryckeghem will present a dynamic perspective on attention bias for pain, in which attention bias is understood as a dynamic phenomenon that fluctuates over time and contexts. Within this perspective, he will address limitations of earlier research that may explain inconsistent findings in the literature on attention bias for pain, provide suggestions for future research to increase ecological validity of attention bias paradigms and address the dynamics in attention bias for pain. In order to do so, Dr. Van Ryckeghem will present novel data of a number of experimental studies in which a novel paradigm (i.e., the somatosensory detection paradigm) is validated to investigate attention bias for painrelated information. The somatosensory detection paradigm has increased ecological validity by using actual bodily sensations and allows for the investigation of dynamics in attention bias. Results of these studies confirm the malleability of attention for (threat of) pain and further substantiate the call for a dynamic perspective on attention bias for pain, outlined within this presentation.

Speaker 1 Abstract Title: Attention bias for pain: A dynamic perspective
Speaker 2 Abstract Title: Cognitive biases for pain in the pediatric period  , 2016). Pain memories are highly malleable, particularly in childhood, and this fragility has critical implications for coping, prevention, and intervention. Dr. Noel will present novel experimental and clinical data examining the factors that shape pain memories in the pediatric period. She will present a developmental framework outlining the cognitive and social factors that influence children's pain learning and memory development (Noel et al., 2015). She will present new quantitative and qualitative data examining child, parent, and dyadic factors that influence the development of pain memory biases. Using prospective data from cohorts of children and adolescents undergoing surgery, Dr. Noel will demonstrate how parent-child interactions (reminiscing about past painful experiences) and cognitive-affective (catastrophic thinking, anxiety) and behavioral (sleep disturbance) factors influence pain memories and pain trajectories. Data on the role of attention, interpretation, and memory biases for pain as mechanisms underlying co-occurring mental health issues (anxiety, depression, PTSD) and adolescent chronic pain will be presented. Finally, new data on the efficacy of a novel, parent-led memory reframing intervention for post-surgical pain will be presented.
Speaker 3 Abstract Title: Does ABM training improve outcomes in patients with chronic musculoskeletal pain? an overview of the area and first look at a large ABM RCT with fibromyalgia Speaker 3: Gordon J. G. Asmundson, BA (Hons), MA, PhD, University of Regina, Anxiety and Illness Behaviour lab, Faculty of Arts, Regina, Saskatchewan, Canada, gordon.asmundson@uregina.ca Speaker 3 Abstract: Contemporary models of chronic musculoskeletal pain emphasize the importance of fear, anxiety, avoidance, and biases in attention in the development and maintenance of chronic musculoskeletal pain. Despite mixed evidence for attentional biases for pain-related threat cues in patients with chronic pain, researchers have predicted that changing this putative attentional bias through targeted interventions might improve pain-related outcomes. One such intervention is commonly referred to as attentional bias medication (ABM), a modified version of the dot-probe paradigm that is designed to train patients to shift attention away from pain-related stimuli. The purpose of this presentation is threefold. First, we will summarize the mixed finding with respect to the attentional bias literature in chronic pain. Second, we will provide a brief overview of the small but growing number of trials assessing ABM training in chronic pain, again highlighting their mixed nature. Finally, we will present findings from a recently completed RCT of ABM training in a sample of 117 patients randomized to either an ABM (n = 63) or control (n = 54) condition. Recommendations for future research and clinical applications will be discussed in the context of the extant literature.
Learning Objective 1: Understand the current state-ofthe-science on attention bias for pain and address the malleability and dynamic nature of attention bias for pain. Provide an insight in factors influencing attention bias for pain. Learning Objective 2: To understand the role of cognitive biases in children's acute and chronic pain experiences and the efficacy of a novel, parent-led memory reframing intervention for children's post-surgical pain. Learning Objective 3: To get an understanding of the available evidence for the use of attention bias modification to reduce pain experience and disability, and its applicability in chronic pain patients.
Pain is known to all through personal experience, but efforts to understand and control pain require a common understanding and effective communication. A widely endorsed and used definition was published by IASP in 1979, with its origins dating to the 1960s. It has been proposed that burgeoning evidence on the nature of pain and its clinical management necessitates revision (Williams & Craig, 2016) and debate has ensued.
Strengths of the IASP definition include its attempt to accommodate all types of pain, an emphasis on a complex subjective experience, including sensory and affective features, avoidance of a requirement for tissue damage, and its usefulness across scientific and clinical settings. Criticisms include use of the weak descriptor "unpleasant", which trivializes most clinical pain, an emphasis on self-report, limiting application to those who are nonverbal and/or nonhuman species, and failure to acknowledge the important cognitive and social components of painful experience, evident in both human and nonhuman species. Notes accompanying the published definition also are incompatible with current understanding. In this symposium, strengths and limitations of the IASP definition will be examined, along with proposals addressing potential revisions. Reference: Williams, A. C. de C. & Craig, K.D. (2016). Updating the definition of pain. Pain, 157, 2420-2423.
Speaker 1 Abstract Title: Pain, and its definition, in non-human animals Speaker 1: Jeffrey Mogil, Ph.D., McGill University, Depts. of Psychology and Anesthesia, Montreal, QC CANADA, jeffrey.mogil@mcgill.ca @jeffreymogil. Speaker 1 Abstract: The current IASP definition of pain includes a footnote pointing out that the inability to communicate verbally does not negate the possibility that an individual is experiencing pain. Although this footnote was not intended to apply to non-human animals, it certainly could. Many in the pain research community would still argue that the word "pain" be reserved for humans, and that animals only possess "nociception". I take great exception to this characterization, and will discuss the issue of whether nonhuman animals have pain, and whether any new nomenclature should take this into account. As has been argued by others, the current definition casts pain as something either inferred from actual or potential tissue damage, or something that is "described". A new definition might instead be based on behaviour, and such a definition could apply cross-species.
Speaker 2 Abstract Title: Cognitive contributions to pain experience: Implications for the definition of pain Speaker 2: Michael Sullivan, Ph.D., McGill University, Department of Psychology, Montreal, Quebec, Canada Michael.Sullivan@McGill.ca Speaker 2 Abstract: Over the past two decades, evidence has accumulated highlighting the important contributions of cognition to the experience of pain. Cognitive factors related to attention and appraisal appear to be inextricably linked to the experience of pain. Research has revealed that variables such as catastrophizing, hypervigilance, and self-efficacy show stronger relations with pain experience than injury-related or medical status variables. In spite of the strong empirical base linking cognitive factors to pain experience, the current IASP definition does not include cognition as an integral component of pain experience. The IASP definition of pain alludes to a possible role of psychological factors in its description of pain as a 'subjective' experience. However, the term 'subjective' falls short the degree of precision that is required of a definition intended to guide research and practice. This presentation will briefly summary research supporting the role of cognitive factors in the experience of pain. On the basis of available literature, different options will be proposed for updating a definition of pain that will include specific cognitive processes as integral elements of pain experience. It will be argued that an updated definition of pain that includes a central role for cognitive processes would be more in line with current scientific knowledge and would have heuristic value in guiding new avenues of research and practice.

Speaker 3 Abstract Title: Is pain a social experience?
Speaker 3: Kenneth Craig, O.C., Ph.D., University of British Columbia, Department of Psychology, Vancouver, British Columbia, Canada, kcraig@psych.ubc.ca Speaker 3 Abstract: The evolved human brain permits the complexities of cooperation and competition unique to human society. Humans, and other social animals, continuously monitor physical and social environments to ensure safe, effective and appropriate interactions. Human pain includes the reflexive/automatic features conserved in ancestors and progenitor species, as well as the volitional capabilities associated with executive controls. Pain may be managed well, but it represents preeminent social challenges when significant others fail to recognize pain, find assessment challenging, or provide inadequate, ineffective or inappropriate care. Use of language to conceptualize and communicate distress best represents socialized features of pain experience. In the course of development, pain language and nonverbal expression become more specific and articulate in familial/ethnic contexts through verbal instruction and observational learning. Variable capacities for selfmanagement reflect resilience or vulnerability. Lack or loss of a capacity for self-control are recognizable during cognitive impairment. Social contexts, past and present, determine implicit and explicit features of pain.
Embedded features include what is attended to and recalled, as well as the nature and severity of emotional distress. Social norms determine care seeking (are caregivers or antagonists present?), perception of the immediate and long-term social impact of injury), and voluntary exposure to self-injury or painful health care. Narrative accounts of painful experience often include interpersonal references. Recognition of social components in the definition of pain will enhance scientific understanding and development of effective care.
Learning Objective 1: To understand how decades of research and evolving practice have left the IASP definition of pain outdated. Learning Objective 2: To consider inclusion of cognitive and social components as features of pain, as well as established sensory and affective components.

Learning Objective 3: To foster consideration of revised versions of the definition.
Mechanism-informed management for complex regional pain syndrome Francois Gobeil, Janet Holly, and Tara Packham There are a number of potential pathophysiological mechanisms proposed to play a role in the development and perpetuation of complex regional pain syndrome (CRPS). This contributes to the variability seen in clinical presentation in this population. Given this variability, clinicians may be unsure what treatments would be most effective for individual clients. This symposium will present a critical synthesis of the literature, and propose a both a medical and rehabilitation version of a mechanism-specific management algorithm to guide personalized treatment of CRPS. Levels of evidence for the proposed treatments will be identified. The symposium will also discuss areas where the evidence is minimal and opportunities exist for further research to advance treatments around specific mechanisms. To further guide treatment decisions and support client satisfaction with care, clinicians also need to be able to link assessment findings to potential mechanisms, and measure the effectiveness of tailored treatment. We will therefore also discuss optimal outcome measures to measure treatment effectiveness from a mechanistic approach. Finally, we will discuss how this links to the newly proposed core outcome measurement set proposed by the CRPS special interest group of the International Association for the Study of Pain.

Speaker 1 Abstract Title: Mechanisms and Management
Speaker 1: Francois Gobeil, MD, FRCP, CSSS Pierre Boucher, Dept. of Anesthesia, Longueuil, Quebec, Canada, fgobeil@videotron.ca Speaker 1 Abstract: A variety of overlapping pathophysiological mechanisms have been proposed in the contemporary literature to underpin the symptoms and course of complex regional pain syndrome. Several recent publications have summarized these mechanisms into a framework to describe mechanistic approaches to management. Dr. Gobeil will discuss the most recent understanding of CRPS and a model of personalized approaches reflecting this paradigm. Indeed, despite poor results with the existing therapeutic modalities, pharmacology, invasive procedures, and other interventions, there continues to be consensus that a multidimensional model is the best way to manage chronic pain. We will present a holistic view, taking a stepwise approach, to challenge participants to think differently and change the historical medical paradigm about the management of this complex and disabling condition where rehabilitation remains mandatory.
Speaker 2 Abstract Title: Evidence-based rehabilitation strategies for CRPS Speaker 2: Janet Holly, MSc, PT, The Ottawa Hospital Rehabilitation Centre, Senior Physiotherapist, Locomotor stream, Ottawa, Ontario, Canada. jholly@toh.ca, @innerchildca Speaker 2 Abstract: Results of a systematic literature search addressing mechanism-informed rehabilitation evidence will be shared during this section of the symposium. Only research studies which were randomized controlled trials, systematic reviews, and clinical practice guidelines addressing rehabilitation of CRPS were used to compile the evidence for a mechanistic treatment approach. The synthesized data extracted from the rehabilitation-specific papers, will be linked to an algorithm for mechanism-specific management to present a synthesis of the evidence. A discussion of future research opportunities will direct attention to the need to generate evidence for those mechanisms where no higher level evidence (or simply no evidence) currently exists.
Consideration of mechanism-appropriate rehabilitation interventions based on the symptom presentation of the individual client should assist clinicians to select the most appropriate and effective treatments from the body of evidence supporting rehabilitation of CRPS. Janet Holly will share clinical examples of how this can be operationalized in practice.

Speaker 3 Abstract Title: Measuring up: CRPS mechanisms and measures
Speaker 3: Tara Packham, PhD, OTReg(Ont), McMaster University, Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Ontario, Canada. packhamt@mcmaster.ca, @TaraLPackham Speaker 3 Abstract: Using this framework, recommended components of assessment to inform comprehensive rehabilitation of CRPS will be presented. Results of a systematic review of measurement properties of tools for CRPS will also be briefly discussed, and the differing needs for outcome measurement in clinical trials vs clinical care highlighted. While all 3 speakers participated in the development of an international con-sensus-based core research measures set (COMPACT) for measuring change in CRPS, Tara Packham will describe their ongoing work with the International Association for the Study of Pain Special Interest Group on CRPS. Development of a patient-reported outcome measure for individual client monitoring in CRPS will also be described. Finally, recent findings on the elements that patients find key in helping to determine recovery or control in CRPS will be shared.
Learning Objective 1: Attendees will be able to link medical treatment approaches for the treatment of CRPS to current understandings of the proposed disease mechanisms. Learning Objective 2: Attendees will understand the potential links between rehabilitation interventions and disease mechanisms, and will be able to apply this knowledge for selecting interventions for individual patients. Learning Objective 3: Attendees will be introduced to COMPACT, a proposed core measurement set for CRPS clinical research, and gain insights into selecting and using evaluation findings to inform tailored approaches to management based on a mechanistic approach.
The Effect of a Mindfulness-based Stress Reduction Program on Psychosocial Functioning, Cognitive Impairment, and Brain Activity in Breast Cancer Survivors with Chronic Neuropathic Pain Patricia A. Poulin, Samantha Kenny, Alicia Duval, and Eve-Ling Khoo It is estimated that 26,300 women will be diagnosed with breast cancer in 2017 where 20-50% will develop chronic neuropathic pain (CNP) following treatments. CNP is notoriously difficult to treat and it is often associated with other disorders such as depression, anxiety, and insomnia. Previous mindfulness studies have shown improvement in psychological distress and physical functioning among cancer survivors. The objective of this symposium is to improve understanding of the evidence supporting the use of mindfulness in chronic neuropathic pain, as well as to improve understanding of the impact of mindfulness training on cognition and brain function. We present the results of a randomized controlled trial with breast cancer survivors who were one year post-treatment experiencing neuropathic pain for at least 6 months (n = 118, mean age = 53.27, SD = 10.58), with attention to effects on pain intensity, pain interference, cognition, and patient global impression of change. We also present results of our functional neuroimaging study demonstrating changes in activity in areas of the brain involved in the regulation of attention and emotion as well as bodily perception.
Speaker 1 Abstract Title: The effects of mindfulnessbased stress reduction on pain, intensity, global impression of change and daily functioning Speaker 1: Samantha Kenny, B.A., The Ottawa Hospital Research Institute, Ottawa, ON, Canada, saken-ny@ohri.ca Speaker 1 Abstract: It is estimated that 26,300 women will be diagnosed with breast cancer in 2017, and 20-50% will develop chronic neuropathic pain (CNP) following treatments. CNP is often associated with other disorders such as depression, anxiety, and insomnia. Previous mindfulness studies have shown improvement in psychological distress and physical functioning among cancer survivors. We conducted a randomized controlled trial with breast cancer survivors who were one year post-treatment experiencing neuropathic pain for at least 6 months (n = 118, mean age = 53.27, SD = 10.58). Patients were randomized to either the Mindfulness-based stress reduction intervention or waitlist condition. Participants completed the Brief Pain Inventory, Patient Global Impression of Change, and the Five Facets of Mindfulness Questionnaire.
We report immediate post-intervention results: we found significant improvement in pain severity (F = 4.44, p < .05), global impression of change (F = 8.29, p < .01), and mindfulness facet non-judgment (F = 4.54, p < .05). We also saw a trend in improvement of functioning (F = 2.23, p = .14). MBSR appears to be a promising intervention to relieve pain symptoms, at least in the short term, among breast cancer survivors living with chronic neuropathic pain. Longer term follow-up data is necessary.
Speaker 2 Abstract Title: Mindfulness-based stress reduction: A potential treatment for cancer-related cognitive impairment Speaker 2: Alicia Duval, B.Sc., University of Carleton, Psychology, Ottawa, ON, Canada, AliciaDuval@cmail. carleton.ca Speaker 2 Abstract: Many patients recovering from breast cancer report adverse cognitive effects of cancer and cancer treatment. This study was conducted to determine if a Mindfulness-based stress reduction (MBSR) intervention for neuropathic pain would have incidental beneficial effects on cognition inbreast cancer survivors. We used a randomized controlled design; participants were randomized to an MBSR group or a waitlist control group. Participants were 73 women, breast cancer survivors, who were 1 year post-treatment. Cognitive assessment was conducted prior to, 2 weeks following, and 3 months after the intervention time point for all participants. Cognition was measured objectively with CNS-Vital Signs (CNS-VS), a 30-minute computerized test that assesses attention, memory, executive function, and processing speed. Cognition was also measured subjectively with the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog; Version 3) and the Prospective-Retrospective Memory Questionnaire (PRMQ). Data were analyzed using hierarchical linear modeling. There was no change across sessions in CNS-VS or in FACT-Cog scores and no group difference in the trajectory of these scores across sessions. However, there was a group-by-time interaction on the PRMQ (p = .048), such that the MBSR patients showed a reduction in cognitive complaints after the intervention that was not evident in the controls; this was driven by a change in the prospective memory subscale of the PRMQ. These results suggest that MBSR training benefits prospective memory in BC patients, even when memory is not the target of the intervention.
Speaker 3 Abstract Title: Neurological changes in breast cancer survivors with chronic neuropathic pain post mindfulness-based stress reduction Speaker 3: Eve-Ling Khoo, B.Sc., The Ottawa Hospital Research Institute, Ottawa, ON, Canada, ekhoo@ohri.ca Speaker 3 Abstract: Chronic neuropathic pain (CNP) affects up to 50% of breast cancer survivors and is often associated with mental health disorders including depression and anxiety. Although there is currently no cure for CNP, mindfulness has been shown to be related to decreased levels of pain and psychological distress. Previous neuroimaging studies that looked at participation in Mindfulness-based stress reduction (MBSR) found changes in brain areas involved in attention, memory and emotional processing. As part of a larger randomized control trial looking at the effects of mindfulness training among breast cancer survivors with CNP, this study evaluates the impact that MBSR has on the brain activity during emotional processing. Twenty-one women (Mean age = 52.2 11 treatment, SD = 11.1) with CNP following breast cancer treatment were randomized (9 treatment, 10 control) and completed an Emotional Stroop task (EST) while undergoing functional magnetic resonance imaging (fMRI) pre and post-MBSR. Each participant's EST fMRI data was post-processed and analyzed individually followed by group comparisons, using Statistical Parametric Mapping 8. There was significantly less activity within the treatment group post-MBSR in the primary and secondary somatosensory cortices (bilateral). Furthermore, compared to controls post-MBSR, participants in the treatment condition had significantly less activity in the caudate tail (bilateral) and in the right mid-anterior insula. These empirical results demonstrates that MBSR can significantly affect areas of the brain involved in attentional, emotional and interference processes, which may explain the physical and psychological benefits observed.
Learning Objective 1: Understand the evidence for the use of mindfulness in chronic neuropathic pain. Learning Objective 2: Understand the impact of mindfulness training on cognitive function among patients with chronic neuropathic pain following cancer treatment. Learning Objective 3: Understand the impact of mindfulness training on brain function during pain related cognitive task. The negative physical, emotional and social consequences and the high health-care costs related to chronic pain are well known. Unfortunately, there are still patients with poor pain control even after optimal pharmacologic and non-pharmacologic interventions, who may also suffer from opioids and other analgesics side effects. Few review articles and meta-analyses, suggest that cannabinoids may benefit patients with neuropathic and/or cancer pain. However, the scattered base of evidence in addition to the report of neuro-behavioural side effects from synthetic or natural forms of Tetrahydrocannabinol (THC) leave clinicians still perplexed about recommending or using cannabis medicine as a complementary tool for pain management. Starting from the available evidence, pain clinicians, through this symposium, will be provided with practical information on: a) the pharmacology of cannabinoids, b) initiation of treatment, including choice of THC: Cannabidiol (CBD) ratios and plant provenance (i.e. indica vs. sativa), c) titration and monitoring of cannabinoids treatments along with adjustment of concurrent analgesics. The description of a Canadian cannabis clinic, will provide an example where patient care is integrated with research and education, via an interdisciplinary approach. The review of two "first-inclass" clinical trials looking at the safety and efficacy of either cannabis oil capsules or inhaled cannabis on chronic pain, will highlight the efforts to overcome shortcomings of previous studies. Finally a patient's testimonial will describe how cannabis-based interventions initiated and monitored through the above clinic can make significant differences in the lives of chronic pain patients. Our team responded to these challenges in 2014 by launching a multi-disciplinary cannabis-specialty clinic in Montreal. Our infrastructure is both comprehensive and diverse as we attempt to investigate or answer every cannabis question in a supportive and welcoming environment that fosters learning and collaboration between healthcare and frontline professionals.
Our clinic receives referrals and supporting documents from treating physicians and triages patients based on inclusion and exclusion criteria. More than 3000 patients have been assessed by our team of pain, palliative care and family physicians. If eligible for medical cannabis a treatment plan is developed and supported by our team of nurses, cannabis educators, drug counsellors and administrative staff. Patients must agree to participate in our research program and are then guided through the recommended products according to a progressive and individualized plan.
Education tools to support adherence and persistence of this complex treatment were modeled after the MOATT educational tool. Patients self-assess, monitor and titrate under close supervision of our team of professionals. Clinical outcomes are observational and our treatment protocols are now developed into clinical trials.
This model of cannabis practice is comprehensive and adaptive to hospital sites, long-term care facilities and pain clinics, we hope to share it with interested physicians and health care professionals.
Speaker 2 Abstract Title: Research on medical cannabis for chronic pain: current challenges and future directions Montreal, Quebec, Canada, maria.arboleda@mail. mcgill.ca, @DrMFArboleda Speaker 2 Abstract: The use of cannabinoids for chronic pain is still limited by the lack of adequate research evidence. Even though a recent meta-analysis suggests a clinically relevant benefit from medical cannabis for the relief of neuropathic pain, most studies are still limited by small sample sizes and short study durations. Furthermore, the available literature provides very little indications on the type of cannabinoid (i.e. Tetrahydrocannabinol (THC) rich vs. a Cannabidiol (CBD) rich strain) and the dose to be used to obtain better efficacy and safety profiles in the management of particular chronic pain syndromes.
In order to overcome the above limitations, we are conducting two first-in-class randomized, placebo-controlled, clinical trials: a study to evaluate the effect of inhaled cannabis to improve health-related quality of life in 946 patients with uncontrolled pain from advanced cancer. In this trial, among other patient-related outcomes, we are also assessing pain and symptom control, coping skills and caregivers' quality of life. We are also running a study to determine the safety and efficacy of specific formulations of medical cannabis oil in the treatment of 160 patients with chronic pain. In particular, we are evaluating the clinical impact of different ratios and concentrations of THC:CBD on pain levels, side effects and on the amount and type of concomitant pain medications. From the review of these two studies, we will discuss suggestions for future trials.

Speaker 3 Abstract Title: How medical cannabis changed my life?
Speaker 3: Daphnée Elisma, Patient, Law student and Quebec representative Canadian for Fair Access to Medical Marijuana (CFAMM). Montreal, Quebec, Canada, delisma@hotmail.com Speaker 3 Abstract: Daphnée Elisma is a law student and Quebec representative of the Canadian for Fair Access to Medical Marijuana (CFAMM) a federal non-profit patient advocacy organization. Ms. Elisma uses medical cannabis products to palliate the disabling symptoms of complex regional pain syndrome following a breast cancer surgery in 2014, and to treat chronic migraines caused by complications of a brain aneurysm in 2010.
Ms. Elisma struggled to find solutions to treat her pain and improve her quality of life, suffering through years of debilitating side effects from opioid medications and other pharmacological treatments. After researching the potential of medical cannabis, she spent three years searching for a physician who would support her with a medical cannabis prescription. Striving to return to her studies, she has found a specific medical cannabis treatment regime that manages her pain, reduces her anxiety and improves her sleep quality without any cognitive side effects.
The challenges for Ms. Elisma to maintain her treatment under the Access to Cannabis for Medical Purposes Regulations (ACMPR) continue. Medical cannabis is not recognized as a therapeutic product, is not covered by private and public insurance plans and is currently subject to sales tax. Her passion for justice led her to CFAMM to fight for patient rights to access medical cannabis and to ensure that next year's cannabis legislation will protect and improve access for medical patients. She urges the government to invest in cannabis research to support health care practitioners to understand its benefits and risks.
Learning Objective 1: Provide pain clinicians with key practical information on initiation and titration of cannabinoids for the management of chronic pain. Learning Objective 2: Provide pain clinicians with a Canadian model of a specialized medical clinic, where excellence in cannabis-related research, training of health professionals and patient care is achieved by an interdisciplinary team approach.
Learning Objective 3: Describe current and future examples of research on medical cannabis for chronic pain. Particular emphasis will be given on showing the efforts made to overcome the methodological limitations of previous studies, which may have hindered the clinical benefits of cannabis in chronic pain (as they will be reported in the patient's testimonial). In and Out: the role of spinal cord circuits in the processing of sensory information and its relay to the brain Reza Sharif-Naeini, Stephanie C. Koch, Steven A. Prescott, and Artur Kania The dorsal horn of the spinal cord is the first relay in the transmission of sensory information from the periphery to the brain. This region is comprised of a complex network of excitatory and inhibitory interneurons, as well as projection neurons that relay the information to supraspinal centers. The complex nature of this circuitry has hampered research efforts aimed at understanding how changes in the function of these networks can lead to chronic pain. However, recent developments of genetic tools to manipulate neuronal activity have significantly helped these research efforts.
In the present symposium, 3 speakers will present recent findings based on genetic manipulations, anatomical tracing, behavioral analyses and electrophysiology, and bring new perspectives on the importance of inhibitory neurotransmission in the dorsal horn and the relay of spinal sensory information to the brain. Dr. Koch will present data on a subset of dorsal horn inhibitory neurons which is an essential part of the inhibitory feedback circuit necessary for walking gait.
Dr. Prescott will report on latest findings on how dysregulation in chloride homeostasis impact circuit-level pain processing. And finally, Dr. Kania will present recent findings on the central role of projection neurons in the establishment of somatotopy in nociceptive topognosis and the relationship between the sensory and effective components of pain.
Speaker 1 Abstract Title: Genetic dissection of a sensory-evoked motor reflex Active feedback from mechanosensory afferents has been shown to be necessary to allow the dynamic control of movement and sensory-motor reflexes in a context-dependent manner. This sensory information, arising from cutaneous and proprioceptive afferents, is integrated at the level of the spinal cord, and must be selectively filtered to allow task specific behaviors to be mounted. We have identified a subpopulation of spinal inhibitory interneurons expressing the nuclear orphan receptor RORβ, which form an integral part of a lowthreshold afferent inhibitory feedback circuit necessary for securing a fluid walking gait. Using a combination of genetic manipulations, anatomical tracing, behavioral analyses and electrophysiology, we show that these interneurons selectively gate cutaneous and proprioceptive afferents. Interfering with RORβ IN function leads to an altered motor gait, which is characterized by exaggerated flexion movements and driven by aberrant cutaneous and proprioceptive input. Inactivation of RORβ in inhibitory neurons leads to reduced presynaptic inhibition and changes to sensory-evoked reflexes. Inhibitory RORβ interneurons therefore provide a key insight into the suppression of cutaneous and proprioceptive sensory input in the generation of context-driven behaviors.
Speaker 2 Abstract Title: Disruption of circuitlevel pain processing by chloride dysregulation in the spinal dorsal horn pathological disrupted, such as occurs if synaptic inhibition is reduced. This so-called disinhibition arises in large part from chloride dysregulation caused by hypofunction of the potassium-chloride co-transporter KCC2 but it remains unclear how such changes alter sensory processing at the circuit level. Here, we show that chloride dysregulation does not render inhibition paradoxically excitatory but does unmask vast amounts of subliminal excitatory input. Because excitatory interneurons receive more subliminal excitatory input than do inhibitory interneurons, they are disproportionately affected by disinhibition despite both cell types experiencing equivalent chloride dysregulation. Consequently, mechanical allodynia arises when spatial summation of low threshold inputs by excitatory interneurons and downstream projection neurons is dramatically increased upon circuit-wide changes in chloride regulation.
Speaker 3 Abstract Title: DCC is required for the development of nociceptive somatotopy and topognosis in mice and humans Speaker 3: Artur Kania, Ph. D., Institut de recherches cliniques de Montréal, McGill University, Université de Montréal. Montréal, QC, Canada, artur.kania@ircm. qc.ca Speaker 3 Abstract: Avoidance of environmental dangers depends on accurate nociceptive topognosis or the ability to localize painful stimuli. This is likely mediated by somatotopic maps arising from topographically organized point-to-point connections between the body surface and the central nervous system. To test whether somatotopy of spinal ascending projections is necessary for nociceptive topognosis, we created a conditional knockout mouse lacking expression of the netrin1 receptor Dcc in the spinal cord. These mice have increased numbers of ipsilateral spinothalamic connections and exhibit aberrant activation of the somatosensory cortex in response to unilateral stimulation. Such animals displayed mislocalized licking responses to formalin injection, suggesting impaired topognosis. Similarly, humans with DCC mutations experience bilateral sensation evoked by unilateral somatosensory stimulation. Collectively, our results provide functional evidence of the importance of somatotopy in nociceptive topognosis and provides insight into the relationship between sensory-discriminative and motivational-affective components of pain.
Learning Objective 1: To familiarize participants with the novel approaches that enable the dissection of dorsal horn circuits. Learning Objective 2: To present participants with the latest findings on the changes that dorsal horn circuits undergo after peripheral nerve injury. Learning Objective 3: To highlight the importance of inhibitory neurotransmission in the dorsal horn of the spinal cord, and how its perturbation can lead to the precipitation of chronic pain.
CONTACT Reza Sharif-Naeini Reza.sharif@mcgill.ca are declining. In response to government pressure to curb opioid prescribing there are disturbing trends emerging; physicians refusing to prescribe opioids fearing reprisal from professional bodies, suicides by pain patients for whom opioids were cut off, patients suffering from acute opioid withdrawal in Emergency Departments, and patients seeking illicit opioids to treat their pain. There is a need to inform Canadians about the risks of opioid use, support better prescribing practices, reduce easy access to unnecessary opioids, support alternative treatment options for pain, and improve evidence to inform policy and reduce availability of street drugs.
Speaker 1 Abstract Title: An epidemic that's not easy to reverse: the U.S. opioid epidemic Speaker 1: Jane C Ballantyne MD FRCA, Professor, Anesthesiology & Pain Medicine, Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, USA, jcb12@uw.edu Speaker 1 Abstract: It was at least two decades after chronic opioid therapy was first popularized in the U.S. before it became clear there was a problem. Abuse and death rates were rising alarmingly not only for patients, but also because of the sheer volume of unused, un-safeguarded opioids in the community. The U.S. Center for Disease Control (CDC) declared opioid abuse an epidemic in 2012, and intervened with its own guideline suggesting restrictions on medical use in 2016. Many other initiatives are aimed at improving pain and addiction education, research and treatment. Yet the statistics on abuse and death rates are not encouraging. For this session I will describe why, when an epidemic of drug abuse takes hold, it is extremely difficult to reverse.
Speaker 2 Abstract Title: Quality standards (Health Quality Ontario 2018); Opioid prescribing for acute and chronic pain Speaker 2: Jason Busse, BSc, MSc, DC (CMCC), PhD Associate Professor, Department of Anesthesia, McMaster University, Hamilton, Ontario bussejw@mcmaster.ca, @JasonWBusse Speaker 2 Abstract: Jason Busse served as the co-Chair for Health Quality Ontario's new Quality Standards on Opioid Prescribing for Acute and Chronic pain, which are due for release in March 2018. He will discuss the new standards, the evidence behind the associated recommendations, and implications for practice. Jason was also the Principle Investigator for the 2017 Canadian opioid guidelines for chronic non-cancer pain, and will discuss recommendations which have the potential for misapplication (e.g. recommended dosing limits for new patients, tapering legacy patients using high doses of opioids), or which are affected by resource issues (e.g. optimizing non-opioid therapy before exploring a trial of opioids, engaging multidisciplinary support for patients struggling to taper their opioid dose).
Speaker 3 Abstract Title: Opioid crisis; National and provincial strategies Speaker 3: Hance Clarke MD PhD FRCPC, Staff Anesthesiologist, Director Pain Services, Medical Director of The Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, hance.clarke@uhn.ca, @Drhaclarke Speaker 3 Abstract: Building on the Health Quality Ontario new opioid prescribing Quality Standards created for acute and chronic pain described by Dr. Busse, this presentation will provide insight into National and Provincial Strategies currently underway to tackle the "opioid crisis". Committees have been formed which involve multiple stakeholders (i.e. law enforcement, College Regulatory bodies, Ministry, Physicians, Emergency Medical Services, Public Health etc.). Insights from illicit fentanyl working groups, the provincial emergency opioid task force, and results from surveys and guidelines created by the Best Practices in Surgery (BPIGS) perioperative opioid stewardship group will be presented.
Learning Objective 1: Describe contributory causes to the opioid crisis, and why this crisis is hard to reverse. Learning Objective 2: Describe new quality standards that may improve the safety and effectiveness of opioid prescribing for pain. Learning Objective 3: Describe national and provincial initiatives currently underway to tackle the "opioid crisis" while maintaining the interests of people living with chronic pain. development of oxaliplatin-induced pain, by interacting with Toll-like receptors 4 in hematopoietic cells, including macrophages. These results unravel a mechanistic association between the gut microbiota and chemotherapy-induced pain, supporting the existence of gut-brain axis. Gut microbiota is influenced by dietary factors and environmental factors. As such, it may serve as a gateway for environmental factors to modulate pain perception.
Speaker 3 Abstract Title: Gut microbiota composition and function in fibromyalgia patients vs. healthy controls Speaker 3: Amir Minerbi, MD, PhD, Clinical Research Fellow, Alan Edward Pain Management Unit, McGill University Health Centre, Montréal amir.minerbi@mail.mcgill.ca Speaker 3 Abstract: Despite the abundant evidence of the role of the human gut microbiome in health and disease few studies have addressed its relevance to chronic pain in humans. Here we describe an ongoing study, aiming to explore a possible association of the gut microbiota and fibromyalgia. Fibromyalgia was chosen as a model for chronic dysfunctional pain due to its high prevalence and its association with young, often otherwise healthy women. In our study 100 patients with fibromyalgia and 100 controls are being recruited. Patients are individually assessed by pain specialists to verify the diagnosis. Controls are further divided to dietary and genetic controls. Participants undergo a comprehensive evaluation including symptom severity, physical activity and dietary assessments. Gut, urine and saliva samples are taken for microbiome analysis, and a serum sample is taken for metabolome analysis. The results will be used to characterize the microbiota composition and function in fibromyalgia patients as compared to healthy matched controls. Finally, computer learning algorithms will be used to identify patients based on their microbiota composition. We hope that this study may pave the way for a better mechanistic understanding of fibromyalgia and to possible future treatments.
Learning Objective 1: An introduction to the world of gut microbiome and its effects on human health and diseases. Learning Objective 2: Learn of the role of the gut microbiome in the development of neuropathic pain in an animal model. Learning Objective 3: Discuss the possible association of the gut microbiome composition and function and chronic pain in humans. Health Canada has funded the Canadian Coalition for Seniors' Mental Health (CCSMH) to develop national guidelines for substance use disorders among older adults. This session will present and seek feedback on preliminary drafts of evidence-based clinical guidelines focused on the prevention, screening, assessment and treatment of Cannabis and Opioid Use Disorders among older adults. The presentation and facilitated discussion will discuss the unique physiological, psychological, social and pharmacological circumstances of older adults which make them more vulnerable to the effects of substances. As clinicians and community based individuals, we encounter problematic substance use as well as Substance Use Disorder among seniors in our daily work. Problematic substance use occurs frequently among seniors often unintentionally through over prescription of substances, polypharmacy, and substance misuse. Misuse, dependency and addiction of substances among seniors is often associated with other mental illnesses including depression, anxiety disorders and dementia and can be effected by psychosocial issues often experienced by older adults such as loneliness, bereavement and the existence of chronic illness and/or disability.
Session Speakers will focus their presentations on areas of controversy and challenges that have arisen in our work thus far in an effort to elicit guidance and feedback from conference attendees.
Speaker 1 Abstract Title: Cannabis use disorder among older adults -Supporting clinicians in the new era of legalization Ontario; Canada; jonathan.bertram@camh.ca Speaker 1 Abstract: The use of cannabis, for both medicinal and non-medical purposes, among older adults is increasing. Many older adults partake in recreational cannabis use while others have incorporated its use as part of their health strategies to do things like manage pain or to stimulate appetite. Therapeutic vs recreational use is difficult to distinguish in these instances.
Cannabis as a substance is not currently regulated in Canada. The potency, purity and side effects of any given 'dose' are difficult to anticipate and control. Other issues of concern in this field include potential side effects of cannabis use including increased levels of anxiety, depression, cognitive impairment and paranoia as well as the risk of dependency and negative experience associated with withdrawal. A recent report from CCSA (2016) highlighted cognitive changes with cannabis use which are of particular concern in older adults. Chronic use of cannabis is also associated with increased risk of developing psychosis. Concerns about driving and the use of cannabis has also been raised by Canadian Police Forces as legalization approaches.
The proposed symposium session will present draft recommendations from the upcoming Clinical Guidelines on the Prevention, Screening, Assessment and Treatment of Cannabis Use Disorder Among Older Adults. We will discuss areas of controversy and concern and will elicit feedback from session participants with regard to our direction and progress to date towards the development of national guidelines.
Speaker 2 Abstract Title: Opioid use disorder among older adults -Balancing pain alleviation with concerns of dependency Service; Geriatric Psychiatrist, The Ottawa Hospital, krabheru@toh.on.ca Speaker 2 Abstract: American and Canadian surveys indicate that while primary care physicians recognize the important role that opioids play in pain management, they are concerned that opioid prescribing may contribute to overdose and addiction as well as to an increased likelihood of falls and sedation among the elderly. Additional concerns with regard to opioid medicines include the risk of comorbidities and high incidence of polypharmacy. There is considerable controversy regarding appropriate versus excessive prescription of opiates for older adults (U.S. Centers for Disease Control & Prevention, 2016).
It is estimated that as many as 57% of older adults experience chronic pain (Institute of Medicine). Opioidbased medicines are often the most viable option for the management of severe chronic pain in older adults.
The Canadian Coalition for Seniors' Mental Health is working with an interdisciplinary team of health professionals across Canada to develop clinical guidelines to describe safe prescribing of opioids among seniors.
The proposed symposium session will present draft recommendations from the upcoming Clinical Guidelines on the Prevention, Screening, Assessment and Treatment of Opioid Use Disorder Among Older Adults. We will discuss areas of controversy and concern and will elicit feedback from session participants with regard to our direction and progress to date towards the development of national guidelines.

Speaker 3 Abstract Title: Pain management for older people
Speaker 3: Andrea D. Furlan, MD, PhD, Staff Physician and Senior Scientist, Toronto Rehabilitation Institute (UHN); Scientist, Institute for Work & Health; Associate Professor, Department of Medicine, University of Toronto, andrea.furlan@uhn.ca Speaker 3 Abstract: At last census, Statistics Canada reports that over 15% of our population was over 65 years old. By 2024, older adults will account for 20.1% of the population, by 2036, they will make up at least one quarter of our population. Older adults often experience chronic pain.