American Chronic Pain Association
May - June 2019
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From Injury to Recovery
Penney Cowan
Imagine that you have had a fall and broken your arm. The pain you feel due to the broken bone is
acute
pain---pain caused by an injury that is expected to lessen and eventually go away as the injury heals.
But when acute pain is not properly treated, there is a risk that it may transition into
chronic
pain. What began as a short-term inconvenience becomes a life-long issue.
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For many chronic pain conditions, it is not an easy process to get a diagnosis.
For some it can take years; at times, a cause is never found. Some of these cases may be due to a long-forgotten acute pain that has become chronic. As Ed Covington, MD, retired director of the Cleveland Clinic pain program has noted, it's not that diagnosticians are looking in the wrong place, it's that they are looking in the wrong time.
Medical science is studying the phenomenon but has no clear answers yet. According to C. Richard Chapman, PhD, Professor Emeritus of Anesthesiology at the University of Utah, Salt Lake City, “The question of the transition from acute to chronic pain is one of the most fundamental and enduring challenges in the field. We lack consensus on what the mechanisms are likely to be.”
Theories include over-sensitization of the peripheral and central nervous system, changes in the corticolimbic circuitry of the brain, and genetic factors. Research is also exploring the role played by demographic and psychosocial influences, trauma- or injury-related risk factors, and even self-efficacy---the personal belief of the person with pain in the outcome.
Whatever the underlying reason for the transition from acute to chronic pain, it just makes sense to take acute pain seriously. It can be all too easy to see this pain as secondary to the treatment of the initial injury or surgery. But don't let pain management be overlooked in the total course of treatment. Here are some steps you can take.
Talk with your provider about pain management during recovery.
There is an enormous gap in what we would hope a health care provider would do and what may happen. Pain management education is limited to most health care providers unless they specialize in pain medicine. And, given the time constraints of most office visits, pain management can be overlooked in the focus on the initial injury. Make sure your provider knows that this is important to you and that you need to discuss it.
Take your pain medications as directed.
It's wise to be cautious with strong pain medicines, but it's foolish to suffer needlessly. The pain medicines your provider has prescribed serve a function: to get you through the worst of the pain without stress and further trauma to your body. If you have doubts about taking them or about how often or long to take them, talk your concerns over with your provider.
Use your pain management techniques to enhance your medication's effectiveness.
Relaxation, pacing, distraction, and other pain self-management strategies can reduce your experience of pain and lessen your need for medications. Put them to work for you!
Follow your providers recommendations about physical therapy and exercise.
Many people avoid PT or exercise because they fear the pain or are concerned about causing more injury. PT is no fun. It's real work, but it serves a purpose. For example, flexing exercises following a knee replacement can be painful, but they prevent the formation of scar tissue and adhesion's that will inhibit future movement of the joint and cause future pain. If you have concerns about the safety of any activity, discuss them with your provider. It can be easier to do the hard work of PT if you understand the long-term goals of the treatment.
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Stay as active as possible during recovery.
When we hurt, it's natural to want to move as little as possible. Going from injury to recovery is not an easy process. While the ideal time frame would be no more than a few weeks after an injury, in reality may very well be months before a person returns to full function. In that time there is a great deal of deconditioning that occurs. Talk with your provider about activities that are safe for you and how soon you may resume them. Staying inert prolongs the hurt.
Some day we may better understand what causes acute pain to become chronic. Until we do, we can focus on promoting healthy healing following an injury or surgery. People with pain need to be active participants in their care from day one and stay involved. With the right guidance from our providers, we can reduce suffering and return to fuller function and quality of life.
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Don’t tell me, teach me!
I like to use this example. When you tell a person with pain to live with pain, this is what it might look like. If you asked me to solve the problem on the board, assuming it is not already solved, I would have no idea where to begin and spend an enormous amount of time in vain without success; much like a person with pain trying to live with it. However, if I took a few classes in geometry, algebra, worked my way up to differential equations, had a good teacher and worked really hard, I might actually have the ability to solve the problem. But someone had to teach me how to do it and I have to work with them so they could teach me all I need to know and what I need to do. The problem then was no longer impossible. Likewise, if you are provided the self-management skills to a person with pain, worked with them through the difficult days, supported their efforts, it might not seem like an impossible task.
It takes a team to move from patient to person. The person with pain needs to be an active participant in their care from day one and stay involved. Keep in mind that it is possible to live a full life with pain, but we, the person with pain, have to be at the center of care.
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Have Pain - Will Travel
Tom Norris, ACPA Facilitator
Ever felt frustrated because chronic pain robbed you of the ability to get out and enjoy the world? Have you doubted that you could get out and travel because you were afraid of a pain flare-up?
Did you ever consider that you have a choice of either staying home and hurting or going somewhere exciting?
Although I have traveled around the world several times during my Air Force career, I am blessed with a wife who, when someone talks about traveling, will immediately pull out a suitcase and be ready to go. Traveling before chronic pain developed was no problem - just a matter of organizing. With chronic pain, traveling became quite problematic.
Initially, I gave up traveling with Marianne. That solved the basic problem of what to do, but caused more stress as I was lonely and unhappy. Traveling for Marianne wasn’t quite the same joy as traveling with me.
Finally, I figured I could try to make the effort to get out of bed and become mobile again. After building my strength again, we took off on a little trip - a month in Italy. Marianne carried my wheelchair up and down the flights of stairs to our apartments, museums, trains, and towns. We had a fantastic time, but I worried about the toll on Marianne and actually felt bad almost every other day, even with very strong medication I was taking.
After that trip, I realized that, if I wanted any type of quality of life, I needed to stop taking my very strong medication. After checking with all my doctors, I detoxed completely over six months and learned to live on epidurals, Physical Therapy and Lidocaine transdermal patches.
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Since then, we have traveled to Italy, Germany, England, Ireland, Wales, Portugal, France, Belgium, Spain, Morocco, Turkey, Greece, Canada, Scotland, South Africa, Singapore, Bali, Australia, New Zealand and many Stateside vacations, as well as taken Mediterranean and Alaskan cruises - all with chronic pain!
There are many sources for advice on how to travel with chronic pain. The following suggestions are what works for me. I encourage each individual to figure out what works for them!
As they say in the play “Auntie Mame,” “The world is a banquet and most . . . are starving to death!” Get out there and enjoy all that life has to offer!
If possible, plan a trip with a partner, someone who can assist you when you need help during scheduled activities.
Plan a trip within your physical limits, giving yourself a day to rest upon arrival and at least every other day. Plan activities at a pace that does not increase your stress. Map out the activities for each day. Enjoy the planning process and dream about all you will see!
Make sure you have your doctors’ approval for your planned itinerary. Ensure you have all needed checkups and procedures to make sure you are at your best weeks prior to departure.
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Make and use a checklist of needed medicines and needed support items.
- Ensure you have enough medications for your trip and return - don’t get caught needing a refill in the middle of your trip! Always carry at least two lists of your medications - one in your luggage and the other with you. (I always carry the actual containers the medicine comes in, as well as a photo of each medical container.)
- Carry all important documents and letters backed up on a USB, for security purposes.
- Carry your medications with you in a carry-on; be sure to consider any patches, pillows, eyeshades and supports you need to make certain you can travel in as much comfort as possible.
- Take advantage of seats with extra leg-room. On long, intercontinental flights, consider sleeper seats.
- Always use a wheelchair in airports to help deal with the stress and rigors of moving through terminals. I ask for wheelchair support when booking tickets. If you have mobility limits, make sure to either have a lightweight wheelchair with you or plan to rent one at each location.
- Use pre-check, if possible, to avoid waiting in long lines. (Global Entry or other certifications are worth the effort as it makes the check- in process shorter.)
- Wear comfortable shoes.
- Use airline lounges when possible.
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- Ensure you have a comfortable place to rest on a day with no scheduled activity. I avoid hotels and stay in “bed-and-breakfast, ” Air B&B, or Home Exchange venues. I can control my diet in these and rest easier in a home-type environment. This arrangement also reduces the problems of finding a comfortable chair in a restaurant and the stress of dealing with crowds.
- Be willing to rest on down-days!
- Continue to take care of yourself and PACE!
I know this all seems too much to do while living with chronic pain but you should try it. Take a day or weekend trip first, build up your stamina and confidence, and enjoy your life traveling with chronic pain.
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If you or someone in your family use an opioid to help manage pain, you know how important it is to treat these medications with the greatest care. The abuse, addiction, and loss of life that are tragically associated with opioids have become a serious crisis. Pharmaceutical companies that make opioid medications now offer versions of these drugs that are more difficult to misuse. They're called abuse-deterrent formulations or ADFs. They're designed to make it harder to crush, cut or dissolve the pills to create a faster high or to allow for other ways of abusing such as snorting or injection, and because ADFs are different, you may have questions or even some misconceptions.
An ACPA survey of more than 1,000 people with pain about 68% of whom actually use an opioid found that nearly 69% had never heard of abuse deterrent formulations. You need to make an informed decision about any medication you elect to use including ADFs.
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CDC advises against misapplication of the
Guideline for Prescribing Opioids for Chronic Pain
Some policies, practices attributed to the Guideline are inconsistent with its recommendations
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CDC commends efforts by healthcare providers and systems, quality improvement organizations, payers, and states to improve opioid prescribing and reduce opioid misuse and overdose. However, some policies and practices that cite the Guideline are inconsistent with, and go beyond, its recommendations. In the NEJM commentary, the
authors outline examples of misapplication of the Guideline, and highlight advice from the Guideline that is sometimes overlooked but is critical for safe and effective implementation of the recommendations.
CDC is raising awareness about the following issues that could put patients at risk:
Misapplication of recommendations to populations outside of the Guideline’s scope.
The Guideline is intended for primary care clinicians treating chronic pain for patients 18 and older. Examples of misapplication include applying the Guideline to patients in active cancer treatment, patients experiencing acute sickle cell crises, or patients experiencing post-surgical pain
.
Misapplication of the Guideline’s dosage recommendation that results in hard limits or “cutting off” opioids.
The Guideline states, “
When opioids are started
, clinicians should prescribe the lowest effective dosage. Clinicians should… avoid
increasing
dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.” The recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.
The Guideline does not support abrupt tapering or sudden discontinuation of opioids
.
These practices can result in severe opioid withdrawal symptoms including pain and psychological distress, and some patients might seek other sources of opioids. In addition, policies that mandate hard limits conflict with the Guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient.
Misapplication of the Guideline’s dosage recommendation to patients receiving or starting medication-assisted treatment for opioid use disorder.
The Guideline’s recommendation about dosage applies to use of opioids in the management of chronic pain, not to the use of medication-assisted treatment for opioid use disorder. The Guideline strongly recommends offering medication-assisted treatment for patients with opioid use disorder.
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The Guideline was developed to ensure that primary care clinicians work with their patients to consider all safe and effective treatment options for pain management. CDC encourages clinicians to continue to use their clinical judgment, base treatment on what they know about their patients, maximize use of safe and effective non-opioid treatments, and consider the use of opioids only if their benefits are likely to outweigh their risks.
The Guideline includes guidance on management of opioids in patients already receiving them long-term at high dosages, including advice to providers to:
- maximize non-opioid treatment
- empathetically review risks associated with continuing high-dose opioids
- collaborate with patients who agree to taper their dose
- if tapering, taper slowly enough to minimize withdrawal symptoms
- individualize the pace of tapering
- closely monitor and mitigate overdose risk for patients who continue to take high-dose opioids
Patients may encounter challenges with availability and reimbursement for non-opioid treatments, including nonpharmacologic therapies (e.g., physical therapy). Efforts to improve use of opioids will be more effective and successful over time as effective non-opioid treatments are more widely used and supported by payers.
CDC developed the Guideline to be practical and created clinical tools to help primary care providers help patients manage pain more effectively and safely, while mitigating the potential risks of prescription opioids when needed. CDC has also created specific resources on tapering, dosage, and appropriate application of the Guideline such as:
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CDC Opioid Prescribing Guideline Mobile App
is designed to help providers apply the recommendations of the Guideline in clinical practice. It features a morphine milligram equivalent (MME) calculator, summaries of key recommendations, motivational interviewing techniques, resources, and a glossary.
CDC continues to help inform and improve clinicians’ ability to offer safer, more effective care based on the best available science. As part of that process, CDC is evaluating the adoption, use, and public health impact of the Guideline and its related resources.
Teens get most of the prescription drugs they misuse from family and friends. Get rid of expired, unwanted, or unused medicines before they become a problem. Check your medicine. There may be instructions for how to dispose of it properly.
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From National Institute for Aging
4 Types of Exercise
Exercise and physical activity fall into four basic categories—
endurance
,
strength
,
balance
, and
flexibility
. Most people tend to focus on one activity or type of exercise and think they’re doing enough. Each type is different, though. Doing them all will give you more benefits. Mixing it up also helps to reduce boredom and cut your risk of injury. Some activities fit into more than one category. For example, many endurance activities also build strength. Strength exercises can also help improve balance.
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Endurance
Endurance, or aerobic, activities
increase your breathing and heart rate. They keep your heart, lungs, and circulatory system healthy and improve your overall fitness. Building your endurance makes it easier to carry out many of your everyday activities. Endurance exercises include:
- Brisk walking or jogging
- Yard work (mowing, raking, digging)
- Dancing
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Strength
Strength exercises
make your muscles stronger. They may help you stay independent and carry out everyday activities, such as climbing stairs and carrying groceries. These exercises also are called “strength training” or “resistance training.” Strength exercises include:
- Lifting weights
- Using a resistance band
- Using your own body weight
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Balance
Balance exercises
help
prevent falls
, a common problem in older adults. Many lower-body strength exercises will also improve your balance. Balance exercises include:
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Flexibility
Flexibility exercises
stretch your muscles and can help your body stay limber. Being flexible gives you more freedom of movement for other exercises as well as for your everyday activities, including driving and getting dressed. Flexibility exercises include:
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The Great Now What
Maggie (33) had it all: brains, beauty, an education, a fiancé, and plans for a family. Then a rare stroke leaves her with permanent disabilities. She leaves school, loses her body, her voice, her face, her vision, her man, her money, her ability to work, and nearly -- her mind. She links up with other artists and performers with disabilities, chronic illness and chronic pain. Creating theatre and art together, they inspire a community to heal and connect with empathy, compassion, and humanity. #ArtHealsPain
Teaser video here:
Surviving a stroke is just the beginning for a young actress who seemingly had it all. With the support of other trauma survivors and the healing power of art, she learns to reclaim a powerful and unexpected identity.
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Stroke statistics
- 15 million people suffer a stroke each year worldwide.
- Stroke is the #4 killer and the #1 cause of long-term disability in the USA.
- There are over 7 million stroke survivors in the USA.
- Stroke kills 2x as many women as breast cancer each year, yet breast cancer receives 2.5x the amount of research funding.
- Only 10% of stroke survivors make a full recovery.
- Strokes in young people are on the rise – 1 out of 3 three strokes each year occur between infancy and middle age.
- Thoughts of suicide are higher in stroke survivors as compared to those with heart attack, diabetes, or cancer.
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What Does Blood Pressure Have to Do with Chronic Pain?
By Sophia Stone, TMJA contributing author
To understand this possible connection, you have to consider how blood pressure is normally controlled by the nervous system. Barring the lifelong habits of some Buddhist monks or yogis, people normally have no conscious ability to control their blood pressure. That is the job of the
autonomic nervous system
(ANS) which encompasses two complementary branches: the sympathetic and parasympathetic nervous systems.
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The sympathetic branch is popularly known as the "fight-or-flight" system, which drives up your heart rate and blood pressure in tense or stressful situations. The parasympathetic, in contrast, is the "rest-and-digest" system that helps you relax and enjoy a hearty dinner. Normally the two systems operate as checks on each other so that neither one over-reacts. However, if that happens, or if one or the other system consistently fails to respond to stimuli appropriately, it could mean your ANS is dysfunctional. A common example of this is
orthostatic hypotension
, the failure of the sympathetic nervous system to ramp up blood pressure in a reflex response to a change in position when you move from lying down or sitting to a standing position. Without the reflex increase in pressure, the low blood pressure you experience when you stand can cause you to feel dizzy or even faint.
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Now researchers think there might be a relationship between chronic pain and the sensory nerve cells, called baroreceptors, that trigger that reflex. "Baro" is the same root as in barometer, the device used to measure atmospheric pressure. Baroreceptors in arterial walls and at other circulatory sites react to changes in the mechanical forces exerted by the blood circulating through the vessels. In their review paper
Contribution of Baroreceptor Function to Pain Perception and Perioperative Outcomes
, Heberto Suarez-Roca and colleagues examine the evidence for how baroreceptors may contribute to chronic pain.
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Hypertension and Hypoalgesia
To begin with, the authors note that there's a sizeable body of evidence linking high blood pressure (hypertension) to reduced pain sensitivity (hypoalgesia). A number of experiments have also shown that inducing hypertension in animal models (sometimes by providing high salt diets) can lower their perception of pain, and that this is reversed by restoring their blood pressure to normal. Moreover, patients with chronic hypertension have also been shown to have higher pain thresholds. It's also not uncommon for hypotensive individuals (people with normally low blood pressure) to experience
thermal
hyperalgesia
-a heightened sensitivity to pain at high temperatures.
That said, there are questions surrounding this relationship that have yet to be answered. For example, it's been shown that hypoalgesia persists in patients even after hypertension has been corrected with blood pressure medication. A possible explanation could be that the mechanisms that improve pain tolerance are maintained even after blood pressure is reduced in hypertensive patients. Other studies have shown that hypoalgesia may
precede
hypertension, such as one interesting report that pain sensitivity at age 14 is predictive of blood pressure later in life. One explanation here is that venous pressure, not just arterial pressure measured in blood pressure readings, may be in part responsible.
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Baroreceptor Sensitivity
While the mechanisms are not well understood, the authors make the case that baroreceptors are the mediators of hypertension-induced hypoalgesia. During systole (the upper reading in a blood pressure measurement), blood is expelled from the heart into the arteries, causing blood pressure to rise and the arterial walls to stretch to accommodate the greater volume of blood. The arterial wall stretching stimulates the baroreceptors to act to restore pressure to a resting pressure, essentially to maintain "homeostasis," a balance in pressure neither too high or too low. Baroreceptors orchestrate these pressure changes by signaling the parasympathetic nervous system to relax the arterial walls to relieve the strain and lower blood pressure or, when blood pressure is too low, signaling arteries to constrict so that the circulating blood will exert mechanical forces on the arterial walls and increase pressure. Normally baroreceptor function involves subtle adjustments in both arms of the ANS.
Interestingly, hypoalgesia associated with hypertension peaks during systole (coinciding with maximum blood pressure) as opposed to diastole (the bottom measurement of blood pressure when the heart relaxes and there is minimum blood pressure). Thus, pain sensitivity is reduced in the systolic phase of the cardiac cycle during
maximum
baroreceptor load, suggesting that altered pain perception may be a function not only of absolute blood pressure, but also of the sensitivity of baroreceptors that regulate blood pressure. A failure of baroreceptors to respond appropriately to arterial stretch is a form of early autonomic dysfunction, and it has also been linked to greater sensitivity to pain.
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It's complicated
. A number of factors affect baroreceptor function. The receptors' sensitivity varies by age, sex, phase of the menstrual cycle, pregnancy, and circadian rhythms. For example, cardiac baroreceptor sensitivity is 50% lower in women, where it is thought to be due to estrogen's effects on the central nervous system and peripheral arteries. More relevant to chronic pain, reduced baroreceptor sensitivity has been shown to be associated with greater sensitivity to pain. The finding that baroreceptor
activation
elicits hypoalgesia further suggests that baroreceptors may explain the causal relationship between hypertension and attenuated pain sensitivity.
Baroreceptors and Chronic Pain: Possible Mechanisms
Three mechanisms have been proposed to explain baroreceptors' effects on pain perception: endogenous opioids (i.e., the brain's own pain-relieving molecules), adrenergic receptors in the brain, and the process of inflammation.
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Endorphins
. In the first camp, it's thought that baroreceptor stimulation may activate opioid networks in the brain, which is supported by the finding that hypertensive patients have higher circulating levels of endogenous opioids. (called endorphins) in the brain, particularly in response to stresses like pain or exercise. This endorphin rush helps mask physical pain and is also thought to explain the euphoric feeling of a runner's high. It turns out that baroreceptor stretching may be a less painful means of opening the endorphin floodgates!
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Stress hormones
. Another possible mechanism is the activation of receptors for epinephrine and norepinephrine (also known as adrenaline and noradrenaline) in the brain. These are stress hormones produced by sympathetic nervous system activation of the adrenal glands in response to short-term stress. Norepinephrine levels have been shown to be elevated, along with pain tolerance, in people with high blood pressure. In other words, high levels of stress hormones in hypertensive individuals may be acting on receptors in the brain to blunt their perceptions of pain.
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I
nflammation
. According to a third mechanism, baroreceptors' effects on pain perception may be explained by the close relationship between ANS dysfunction and chronic inflammation. Reduced baroreceptor sensitivity, has been shown to correlate with markers of inflammation that are a likely source of pain. While chronic inflammation is normally thought of as a
cause
of ANS dysfunction, the reverse relationship has also been shown in some autoimmune and inflammatory conditions. For instance, those at risk of rheumatoid arthritis (an autoimmune condition) are more likely to show signs of autonomic dysfunction and over-activation of the sympathetic nervous system before they develop arthritis, and reducing sympathetic over- activity in hypertensive individuals also reduces inflammation. There is also extensive evidence that activating baroreceptor reflexes can attenuate inflammatory pathways, and conversely that baroreceptor and autonomic dysfunction trigger inflammation in part by activating sympathetic nerves that release painful inflammatory chemicals. That is to say that when baroreceptors don't work properly, our sympathetic nervous system gets fired up and releases inflammatory molecules that cause pain.
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Postoperative pain
. Baroreceptor and ANS dysfunction are predictive of postoperative pain in surgical patients and have also been associated with a number of chronic conditions, including hypertension, diabetes, atherosclerosis, obesity, obstructive sleep apnea, cardiovascular disease, and chronic kidney disease, many of which are associated with chronic pain. An existing model for these associations is that increased sympathetic nervous system activity promotes a state of chronic inflammation and pain, which is associated with elevated inflammatory mediators and stress hormones. Chronically elevated levels of stress hormones may desensitize baroreceptors, making them less effective and setting the stage for ANS dysfunction.
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Baroreceptors and TMD.
Heightened pain and baroreceptor dysfunction are also more prevalent in chronic musculoskeletal pain conditions such as temporomandibular disorder (TMD), fibromyalgia, and chronic back pain. These chronic pain states are frequently associated with signs of autonomic dysfunction. For example, orthostatic hypotension is common among fibromyalgia patients, whose reduced baroreceptor sensitivity has been shown to correlate with the severity of their symptoms and to be about 35% lower compared to healthy women. It may not be a coincidence that women have both lower baroreceptor sensitivity and a greater incidence of chronic pain conditions like TMD and fibromyalgia; such disparities in baroreceptor or autonomic function may help explain sex differences in chronic pain incidence and treatment responses.
Given this evidence, the authors pose the important question: can baroreceptor function and blood pressure status be considered risk factors for chronic pain and perioperative outcomes? Currently, there are a few things that can be done to improve baroreceptor function. Vagal nerve stimulation is one option, and other interventions (e.g., fluid management, acupuncture, cardiovascular conditioning, biofeedback, etc.) are also being explored. More research-and less invasive treatment-are crucially needed, as it appears that baroreceptor function may represent a promising link between autonomic dysfunction and chronic pain, and quite possibly could pave the way for new approaches to treating chronic conditions.
Reprinted with permission from the TMJ Association
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ACPA Newton, NJ, Chapter
This was the second year for Newton Chapter to participate, at a large insurance company corporate office, Selective Insurance.
The county sponsored, and registration is $5.00 for seniors/older Americans and limited to the first 200 that register.
Tables are complementary and there was approximately 50 exhibitors. Hospitals, senior residences, county and local related non-profits were some of the exhibitors.
Our table was at the far end from entrance like we were our first year exhibiting, and beyond us was a table for NJ Senator, which a Newark representative from his office was there.
We saw about 75 people and handed out about 50 pieces of literature including hand out for June 6th Diet talk by local very large grocery chain dietitians.
We arrived at 7:15 am to set up. Doors opened to public approximately 8:30 am, and coffee and continental breakfast was provided. Lunch was provided about 1:15 to 2:30 pm. Teresa furnished a $15.00 gift card for grocery shopping, as a drawing, and our name was acknowledged at the drawing during lunch.
We made a few good contacts with both hospitals and one of the senior residences. Plans to attend again next year with plans to attract more attention.
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NEW - ACPA Support Groups:
Sheila Perkins - Toledo OH
Andy Tabako - St. Cloud MN
Shanelle Osmondson - Valcenia CA
Katie Yavuz - Castle Rock CO
Marily Charles - Bailey CO
Kerry Zahn - Easton PA
Kerry Zahn - Phillipsburg NJ
Ezzat Moghazy - Denver CO
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Gifts given to the ACPA in loving memory:
Kendrick Fuller
Given by Teresa Burns
Given by Laurinda Fuller
Given by Heidi Vonderhellen
Given by Janis & Michael Allen Family
Kiki Sepp
Given by Mr. & Mrs. Dick Palmer
Lillian V Green
Given by Judith & James Carlson
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Fall 2019 Combined Federal Campaign (CFC)
Consider directing your donation to the American Chronic Pain Association this year.
CFC Code number is:
10549
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You shop.
Amazon gives.
Shopping on line helps the American Chronic Pain Association
If you use Amazon for your on-line shopping, you can now support the ACPA. It is simple just go to AmazonSmile and select American Chronic Pain Association as your charity from the drop down menu.
- Amazon donates 0.5% of the same price of your eligible AmazonSmile purchases to the charitable organization of your choice.
- AmazonSmile is the same Amazon you know. Same products, same prices, same service.
- Support American Chronic Pain Association by starting your shopping at smile.amazon.com
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