ALICIA RICHMOND: So now, I just would hopethat in terms of the task force, we’ve heard from the public and the poignant commentsthat were made and, as we move through the day and a half, that you take their commentsto heart. I know that Dr. Singh is also going to begiving a synopsis later of the public comments that we’ve received written from the firstmeeting as well as the second. DR. VANILA SINGH: Right now, though, we will beintroducing our next speaker.Alicia, is that right? And that is on our DOD representative, Dr.Paul Cordts, who was kind enough to accept our invitation to come here. In fact, at our first meeting, we did nothave a Department of Defense representatives, so we were very excited to have him. In essence, Dr. Paul Cordts, M.D., is appointedas the Deputy Assistant Director of Medical Affairs Defense Health Agency US Departmentof Defense since May 2018. Dr. Cordts retired from the US Army MedicalCorps in 2014 after 30 years of service, where he served as a physician and a leader at everylevel of army medicine. He served as hospital commander in Fort Stewart,Georgia and Fort Campbell, Kentucky. Additionally, Dr. Cordts was deployed as–a small thing called a vascular surgeon to Operation Iraqi Freedom.But Dr. Cordts really is an essential voiceas we are an interagency best practices task force, and that is with DOD, and so we arethrilled that he can be here today and share that insight. I’ve spoken to him, and I think you’re goingto enjoy what he has to say. Thank you so much. [APPLAUSE] DR. PAUL CORDTS: OK, let’s see here. OK, well, good morning distinguished membersof the task force and guests. I thank you Dr. Singh for that introduction. We’ve spoken on the phone. I’m here with my team today and my colleaguesin the back, but we’re very happy to be here to share an update from the Department ofDefense and our pain management strategy.I wasn’t at the first task force meeting,so we’re very happy to have this opportunity. So let’s get started. Next slide. So this is an overview of the military healthcare system. Our system supports 9.4 million beneficiariesthrough a combination of military hospitals and clinics. And we provide care, both in the militaryhospitals but also in our care network, where over half of our care is provided. As you see in the upper left-hand corner,we have a very active pharmaceutical services with more than 128 million prescriptions filledannually.And opiates make up about 4.5% of that total–roughly 5 million opioid prescriptions per year. Across the United States, there are over 191million opioid prescriptions written annually. Next slide. So the Department of Defense and our partnersare on the forefront of national efforts to accelerate the evolution of pain managementthrough a comprehensive pain management strategy. We’re working in DOD to affect a culture ofchange in pain management that focuses on a biopsychosocial approach to the measurementand treatment of pain. And as I’ll discuss shortly, we’re committedto implementing a stepped-care model of pain care. And we’re absolutely committed to the ongoingcollaboration with you on the task force and our internal and external partners. Next slide. This slide represents the breadth of our painstrategy in DOD.If you take a look at the center here, yousee an icon there that says, “echo.” It’s interesting that our overall pain strategywas founded on a non-DOD program. We’ve embraced the echo approach to provideclinicians at remote locations with the tools that are necessary for advanced pain management. Most of the highlights on this slide weredeveloped to support remote patients and providers who don’t have local access to pain specialists. Along the way to developing the MHS pain strategy,we’ve collaborated with our partners at the VA, along with many other state, federal,civilian, and academic entities. Next slide. So here’s a larger version of the defenseand veterans pain rating scale from the previous slide. We’re very proud of our collaboration betweenthe DOD and the VA that led to this product, which, by the way, we freely share with otherorganizations who can brand it for their own health care systems. But it’s not unlike others 0 to 10 pain scalesyou’re familiar with.The innovation here is the second part ofthe pain rating scale, the quality of life questions. Next slide. These supplemental questions are, in manycases, more useful to our clinicians. Our goal isn’t to eliminate all pain. In some cases, that’s just not possible. But we focus on these four areas from topto bottom– activity, sleep, mood, and stress. And by asking our patients to describe theirpain as it relates to these four areas, we’re able to help both our patients and cliniciansevaluate their care and the effectiveness of the care they’re giving for pain. And by framing pain in this manner, expectationscan move from zero pain to enhancing the quality of life for our patients. Next slide. So this slide’s a little bit busy, but itcaptures our comprehensive approach to pain management.On the horizontal scale, we have patient complexity. And on the vertical scale, we have care complexity. So in the lower left here, you see self managementor management by the patient themselves. And then in the upper right, you have tertiarylevels of care, often pain management clinics offering a wide spectrum of treatment options. We’ve rapidly evolved our approach in painmanagement over the last decade. Our pain clinics used to be staffed primarilyby anesthesiologists. Today, there are multi-specialty clinics thatcan address the biopsychosocial needs of our patients. So we’ve embraced this stepped care modelthat allows us to have a structured approach to pain management through the continuum carefrom self-care to our patients at our medical homes that you see there in light blue and,when necessary, to secondary and tertiary levels of pain care.Our goal is to help patients manage theirpain at the lowest care level necessary and to teach them the skills necessary to moveback down the continuum of care represented here. Next slide. We use a tool called PASTOR in specialty clinicsto assess the efficacy of our clinical interventions. It’s one of the areas where we’re lookingat patient-reported outcomes– if we could click again. PASTOR is based on the NIH investment in promise–and if we could click again. It provides the advanced analytics for assessingpatient-reported outcomes and produces clinical reports shown here on the right side of theslide– and if we could click once more. The power of PASTOR is its ability to provideboth individual and population-level reports using scientific methods.And next slide. So to summarize our approach– click. We consider pain management to be the primaryproblem with opiate use and abuse to be a symptom. Next slide. To get after pain management, we have to takea comprehensive approach that includes the biopsychosocial aspects of caring for patientswith pain, next click. And finally, we don’t have all the answers,and we count on our partnerships and collaboration to advance our understanding and holisticapproach to pain management. And next slide. And we have experts in the back here– I realizethis is a very quick update of what we do in Department of Defense, but wanted to highlighta couple of points there about what we’re doing. If you have questions or want more information,please reach out to Lieutenant Colonel Rosser, who’s in the back, who’s in charge of ourpain clinical community, as well as Dr. Buckenmaier, who’s the director of DVCIPM, our Defenseand Veterans Center for Integrated Pain Management. They’re both here today, and I want to thankyou for your time and attention this morning.[APPLAUSE] DR. VANILA SINGH: Thank you so much for thoseremarks. They very much actually touch on some issuesthat are already in our recommendations, namely the echo model, the concept to try to havethe lowest effective dose, or treatment plan, and have self-management so that there issome sense of self-empowerment, and really to get the collaboration of the various teammembers. So thank you for all that, and I know thatthere’s much more we can do. Because we got a little out of order, we’regoing to step back and give a little bit of the context of where we are right now sinceour first public meeting, where we actually got 2,500 public comments, and then severalhundred already in for this public meeting.And we thought it was essential. I personally wanted to see that real-timedata and what it showed us about what’s going on with our patients. So I thought it would be of great relevanceand interest to all of us. We’ve heard about this to some degree in oursubcommittee deliberations and discussions, but I also had our administrative team goand do further analysis, which they actually use machine learning to enhance the accuracyof what we’re about to see. So on this slide, I wanted to just take amoment to look at the comments that were made out of these 3,000 comments that came throughfor the first public meeting and the beginning of our second meeting. And you can see that 83% of people who wroteto us– these are not necessarily the 30 organizations– mentioned chronic pain as a primary issue. No surprise there. 78% or almost another 80% were concerned abouttreatment access, access to treatment, something that we address in subcommittees three. Because in order for us to identify gaps andinconsistencies and make recommendations, we understood that that means nothing if wedon’t address the barriers to getting those things actually in play.So access to treatment and our patients andtheir loved ones made that a point. 60% of those public comments talked aboutfunctionality or the lack thereof, relating either to lack of treatment access or otherreasons. But that was a significant issue. And when we get further in just a couple slidesabout suicide, that was actually one big trigger that led to suicide was the inability to functionwith activities of daily living, quality of life, or a loss of job– things that theysaw as part and parcel of their own self-identity and dignity. After that, we saw 40% of folks concernedin their comments about pain medicine, and pain management, and perhaps opioid use beingconflated with addiction. Now we know that both of them in their ownright are significant and real diseases and deserve compassion and scientific-based patientcare. Yet both are unfortunately being double-whammied,if you will, with the stigma that is affecting their ability to not only get treatment but,in fact, also hurts their ability to get support from friends and family and a societal understandingof that dramatic effect, often with an invisible disease that doesn’t get the same empathywhen somebody has a cast on, for example.The next was 30% mentioned provider disincentives,where they had a great relationship or a trusted relationship with their provider or physician. And the current environment, despite thattherapeutic alliance and no change and no indication of misuse, or abuse, or addiction,they were being either abandoned or forced tapered. And I can tell you from the letters that we’rereceiving the options in that desperate situation were either contemplation of suicide, completedsuicide, or resorting to the illicit drug market. 27% noted stigma, once again, which playsinto this, and almost an equal amount we’re concerned about suicide. And that number is something that we’ll talkabout in a minute, because there’s some more data that’s recent on chronic pain patientsand suicide.But the suicide, when looked at further, whichwe will in a slide, again, really was led by the lack of functionality, the inabilityto do and have a quality of life. And then, finally, 16% mentioned insurance,and 13% specifically mentioned the CDC guidelines. That was in a specific reference. There were other indirect inferences as well. And the next slide. So what we also noticed was the comments predominantlycame from the adult population, which we saw as ages 18 to 64. Ages 65 and above were the elderly or consideredelderly. They constituted about 12% of the comments. So over 80% were in the prime adult years. In terms of gender, where it was identified,80% were women, and just over 20% were men. One of the case studies that we pulled outthat showcased this was, I’m a normal American woman who’s 43 years old. I’m a wife, a mother, I used to volunteerand cook. “I was your typical soccer mom. Now, I can’t get through a single day withoutdebilitating pain.” She would probably come into the chronic highimpact pain category.”My doctors agree that I need the pain medicine,but they are all afraid to prescribe anything to me. And I had been warned in the past severaltimes that pain clinics are not a good solution. Now, I’m being told that my only option, thanksto this new law, but as the powers that be made these sweeping changes may have placedfear in doctors, and pharmacies, and inpatients. A law should not dictate my care. Only my doctor should.” Next slide. So this slide actually gets into the complexityof the disease of those patients who commented what we heard mentioned throughout– and again,this is with not only a person going through it, but also with the machine learning tohelp pull up repeated words.And you can see by the diagram, that thisis a very complex picture with many different words, including suicide, anxiety, neuropathicpain, multiple sclerosis, depression, a sense of feeling abnormal, loss of productivity,therapy, naive, endometriosis, post-operative pain, psychological issues, physiotherapy,fatigue, injury, disability, Parkinson’s disease, degenerative disease. And the common pain issues that were mentionedin this group of folks was arachnoiditis, specifically arthritis, specifically endometriosis,specifically complex regional pain syndrome, fibromyalgia, spinal stenosis, herniated disks–all of us have heard about these– migraines, pain after surgery, trigeminal neuralgia. These are the ones in which the public commentshad noted the exact specific cause of the chronic underlying disease. This doesn’t include the vast majority thatmentioned the chronic pain only, but didn’t get into what their underlying disease is. And I think this slide makes the case of thecomplexity of pain. We know now that at least 50 million peoplehave chronic daily pain. We know that almost 20 million have high impactdaily pain. And we know that it encompasses such a widespectrum of diseases along with co-morbidities. So it isn’t one disease that we’re lookingat.I sat on a task force that looked at justone disease. And you know, we spent all this time aboutit. What we’re trying to tackle are providingbest practice guidelines and emphasis on important items that will help shepherd and guide thesevery challenging conditions. But at the end of the day, it is the clinicianand the patient, and it is individualized treatment because there isn’t a Toyota Corollamodel here, where you may have anxieties, suicidal ideation, neuropathic pain, or MS,and other issues. And we can see that it is complex. And I think that’s something that has to bestated and emphasized. Next slide. So this slide basically gets into the issueof chronic pain in which the word suicide and reduced functionality were frequentlymentioned of the 13% of public comments that mentions suicide. Many of them, actually, refer to decreasedfunctionality as a trigger to considering suicide and, in some cases, unfortunately,in actually successfully completing suicide.There is a retrospective analysis that’s justbeen released of the National Violent Death Reporting Systems data, NVDRS. And I think that might be the next slide–that showcases that suicide– they try to do this in an interesting qualitative descriptivemanner, where they looked at suicides, and they were trying to see from 123,000, howcould they pick up if someone was trying to commit suicide, and did they succeed? And so they looked at the coroner’s notesto my understanding, as well as other measures. And what they found was the rate was increasing,certainly from 2003 to 2014, as you can see in the black line. And at the bottom dash line, that was theline that suicide was committed by those who died by opioid overdose. So the suicide was actually completed successfullybut with other non-opioid measures, meaning firearms and the like of other things. But it’s a growing issue, and these numbers,I will say, only go to 2014. We don’t know what is actually happening since2015, ’16, ’17, and ’18.But based on letters and concerns, I thinkthat it’s fair to say that it certainly hasn’t gone away. And it likely is either the same, but morelikely possibly worse. And next slide. So the commentators mentioned the CDC guidelinesand unintended consequences. In this specific comment, that patient statedthat, I am disabled and on Medicare. I have significant health issues and ongoingmoderate to severe chronic pain. I have been on opiates for over 10 years dueto the government crackdown on opioids and the CDC’S new guidelines that have been abruptlycut back on my medication. I’m forced to do expensive ongoing procedures,like radiofrequency ablation, which is burning of the nerves, joint and spinal injectionsto the point where I’m unable to pay for any more of these types of procedures. So what we know is, one is the patient ismoved towards invasive procedures, which is one thing, but that they’re not covered itis another thing.I have lost two good pain management doctorsover the years who dropped all their pain patients for fear of being targeted by theFDA or the DEA, and that they could lose their license or worse. Every time I lose a doctor, I am forced tostart all over again, trying to find another doctor to treat my chronic pain. And on the left side of the slide, or yourright side, it also mentioned that when the CDC guidelines were mentioned within that13%, 90% refer to treatment access as a result of the CDC guidelines. 76% referred to decreased functionality dueto those guidelines. And 58% referred to a provider disincentiveto take care of the patient due to the guidelines. The next slide. We have 30 professional organizations thatI’ve mentioned– the American Academy of Nursing, the American Association of Colleges of Nursing,American Association of Nurse Practitioners, the American Association of Oral and MaxillofacialSurgeons, the American Association of Orthopedic Surgeons, The American College of Addictionologyand Compulsive Disorders, the American College of Obstetrics and Gynecologists, the ADA,the American Massage Therapy Association, the American Psychological Association, theAmerican Society of Anesthesiologists, American Society of Hematology, Coalition to Optimizethe Management of Pain Associated with Surgery, The Federation of State Medical Boards, theInternational Chiropractors Association, the National Association of Specialty Health Organizationand the Physical Medicine Management Alliance, in addition to the NANS, the North AmericanNeuromodulation Society, Protecting Access to Pain Relief Coalition, and the Joint Coalition.And since then, we had folks who reached out. We heard from the President of AMWA, the AmericanMedical Women’s Association. We also heard from the AMA current presidentand the president-elect, as well as the numerous other medical organizations and stakeholders,many of them sharing the concerns of– for example, AANS share their concern of havingcomplex surgeries– that three-day limitations in acute pain medicines were just simply notadequate and were a hardship to their patients. So next slide. And so I think that that kind of covers whatwe were looking at in terms of breaking down the public comments, so we really understoodthat the vast majority were the hardships that the patients are now facing at an acceleratedrate.And so our recommendations that you all haveseen and what we’ve done is we’ve really tried to balance that with smart best practicesand really thread this needle. And with that, I think our next move is we’regoing to move to the Subcommittee 1 presentation. So what we’re doing is we’re going to presentall three subcommittee findings today. And we’re going to highlight those key pointsthat have been discussed and mentioned in our first public meeting throughout our subcommitteemeetings and in recent days that you’ve received, that we’ve had comments on, and have furtherwordsmithed and try to make more elegant.And I will– actually let me just grab my[INAUDIBLE]. And we’ll probably just do this down there. But since I’m up here, I’ll just mention it. So Subcomittee 1 was chaired by Dr. Gallagher. And the various topics in this subcommitteewere broken into approaches to pain management, medications, physical therapy, interventionalprocedures, and special populations. If you take the medicines, the physical therapyand interventional procedures, that gets into treatment modalities. And I wanted to add that the multi-disciplinaryapproach that we are putting forth also has two other modalities that come into it, andthat would be psychological interventions for co-morbidities or just to help along toget the best patient outcome. That’s addressed in Subcomittee 2. And the complementary alternative and integrativetreatment modalities is covered in Subcommittee 3. And the purposes of all this was really toeven the workload to the best of our ability. So Subcommittee 1, three of the five get intothe modalities. I will cover the approaches to pain managementin a high level manner that helps understand where our recommendations are for the public,and then also just briefly go through the special populations.Then, I will hand it over to Dr. Gallagher,who will take it from there and speak on the medicines, the physical therapy, and the interventionprocedures, and then we’ll have some discussion and deliberation. And just so folks know, our wonderful groupon Subcommittee 1 was not just Dr. Gallagher, but Dr. Adkinson, Dr. Brandow, Dr. Fields,Dr, Griffith, Dr. Sharon Hertz, Dr. McGraw, Dr. Porter, Dr. Prunskis, Dr. Peter Staats,Dr. Trescot, and Dr. Tu, all who presented excellent different perspectives and gaveus a really organic understanding of all these very things, which is why I think we cameup with some very good updates. So in terms of the next slide, this is a verysimplistic overview of our approaches to pain management.This is both for the acute and chronic painsetting. And what it’s really based on is the ideathat there’s patient individuality in terms of their preferences, their experiences, andtheir own underlying medical diseases– co-morbidities and whatnot. There’s also the settings, the perioperativesetting, or is it a chronic pain setting, such as sickle cell disease where someonehas a flare of that. Or is it a flare or multiple sclerosis? All these various settings will help whenwe have a collaboration and coordination of care.So in some cases, the patient has a primarycare doctor, a rheumatologist, a neurologist, or a hematologist. And really, the idea is to approach them asearly as possible with a multi-disciplinary approach that allows our colleagues to talkand come up with a plan. And that also gets everybody on the same page. You get the early referral, and you can startto discuss what treatment modalities are there, what common themes are there, and also havingthat value for a team conference. It takes time out of everybody’s days to gethigh-level different disciplines in these situations to come together. In the acute setting, in particular when it’sthe perioperative setting, a pre-op consultation, certainly for patients who have underlyingmedical issues like rheumatoid arthritis or perhaps MS, or Parkinson’s, or any numberof things, a pre-op consultation goes a long way in planning what the multimodal approachwould be, and that is something that we recommended.A multi-modal approach would be a considerationof perhaps pre-op medicines, such as Celebrex, or Gabapentin, or Baclofen, intra-op IV infusionsof Lidocaine or Ketamine. If the patient is having a big surgery andthey have chronic pain, ultrasound, guided nerve blocks, or continuous nerve block catheters,IV acetaminophen, IV NSAIDs, Toradol when indicated. But a consideration of all these things togive better patient pain care improve rehab immobilization, decrease the likelihood ofblood clots, and PEs, but also have the patient have less post-op nausea and vomiting andin early discharge, particularly, in the outpatient settings.So that’s just an example, but any numberor a combination of those tools to be considered for any of these patients, whether they’rein the perioperative, they may have chronic pain and they’re in the perioperative setting,or they may just be having a very challenging surgery and they’re in the perioperative setting. And for the chronic setting, we would loveour primary care docs front line, even for a one-time consultation to get a sense, ablueprint, and then establish their patient there, have a rapport, and work together.We found that team conferences allow for avery open dialogue about, what are the chances that there’s still an organic disease thathas not been looked into? What has worked? What is the patient relaying? So those are the overall approaches to painmanagement, which are much more eloquently stated in the recommendations. Next slide. The special populations are populations thatwe felt needed to be identified because of their special issues that surround who theyare or what they’ve done. With our veterans, certainly given their rolein active-duty situations, them having special injuries or potentially psychological issues,such as related to PTSD or high-impact injuries, and also with this understanding of long waitinglists and a potential referral out into the community, certainly I’ve been in that situationwhere we’ve had VA patients come to our clinic. We wanted to encourage that not only doesthe DOD to VA transition happen with better and smoother enhanced medical record and interoperablePDMPs and whatnot, but that also extend into the private community.With women, there being a high prevalenceof pain, a unique role that women often have is caretakers. And the higher sensitivity and other uniqueissues, such as fibromyalgia, endometriosis, issues in the peripartum period, chronic pelvicpain and all these issues be looked at with those eyes and to involve, as ACOG requested,having the OB/GYN who often functions as their primary care doctor, to be involved earlier. And we also know that when they are pregnant,which we get to later but I can cover now, there are very limited pharmacologic options. And in fact, ironically, opioids are probablyone of the safer options when you consider the various options that are available tothe non [? partuitent ?] patient.And so even in that case as well as in thenon-pregnant case, we wanted to get our obstetric and gynecologic colleagues involved earlierso that everybody is on the same page. With the pediatric population, I’ve heardthis throughout the country now, the shortage of pediatric pain specialists, the inabilityto get incentive for them to come into it as they have patients with congenital andgenetic issues, such as sickle cell disease, but many other issues– the need for morecenters, reimbursement for their services. And most important, a smooth transition fromthe pediatric youth stage to the adult stage. They get great attention often in this realm,but when they transition into the adult realm, there is fragmentation and loss of care.And so that smooth transition was somethingthat we heard a lot about. The workforce issues in that case will bealso addressed and Subcommittee 3, in terms of having a greater workforce for pediatricpain specialists, as well as other workforce issues for other specialists– geriatrics,a special group, these are folks who are at increased risk for falls and increased riskof medical co-morbidities, cognitive, decline renal impairment, as just some examples; developingguidelines in our aging population, which is growing with an emphasis on non-pharmacologicalapproaches and also education for our doctors and our patients; ethnic diversity, whichhas often cultural barriers, people with different cultures may view pain as different, may viewpsychological interventions as having a different meaning– and so to really develop interventionprograms that delve into better and improved culture competency and communication.Sickle cell disease, we’ve talked about. This is a genetic disease. It really spans the lifespan of a patientfrom childhood to adulthood, primarily affecting a minority population, as the African-Americanpopulation, requiring a new set of guidelines to help folks understand this, as they’vebeen afflicted and adversely affected more often than not as drug seekers, a call formore research. Admiral [INAUDIBLE], who will be speakinglater, has taken a particular interest as a pediatric critical care doctor, and theyactually are talking about a cure for this, for this 100,000 patient population. But at the end of the day, considering exemptionsfor this population, given the vaso-occlusive crisis is a very different mechanism and alsoconsidering better reimbursement methods. There’s also some detail on outpatient infusioncenters and whatnot that would make much of the high cost and emergency visits and whatnotdecrease.And I think we covered pregnancy briefly. So with that, I’m going to come back down. And Dr. Gallagher is going to pick up in moredetail about medications and physical therapy, as well as interventions. So, OK. DR. ROLLIN GALLAGHER: Thank you, Dr. Singh, forthe opportunity to participate in this vitally important task force that we all believe willhelp guide our health system and our country forward towards improving pain managementfor all of us. I’m going to take a couple of minutes beforeI address our specific recommendations to make some remarks of my own. You know, pain, as we’ve heard from our terrificpublic testimony as well as from all of you, is inevitable in life and can be a dominantforce. As Albert Schweitzer once said, pain is amore terrible Lord of mankind than even death itself. And we know that from the suicides, from theoverdoses, and also from the terrible loss of quality of life of all of our tens of millionsof sufferers.As many in this room and many Americans acrossthis country can attest, pain penetrates our consciousness and gradually erodes our confidencein the happiness and satisfaction we can attain from our daily lives with our work, our families,and our communities. I want to thank Dr. Singh particularly forher outstanding leadership in herding us cats all around the table and around the countryin this mission. Fantastic job– I mean, amazing– 24/7, itseems– and being willing to get information and perspective from everybody. You know, we need to pull together. The last couple of times we were able to getsomething passed in Congress. And thanks to Congress for doing this, forrepresenting the people in pain, where by getting a group like this but a smaller group,not as well represented but still representative of many constituencies together and get theVeterans Paying Act and Military Paying Act passed, which then led to the NIH, IPRC, andIOM report, and the National Pain Strategy. So all these things working together, collaboratingas a group, really gets things done.And Congress, of course, responding to people,their constituents have really made this happen. So thank you to our congressmen who presentedtoday and, again, for the leadership in getting us to do this. I’d like to also thank Lizzy Richmond forhelping herd us cats. Did a great job of getting us to do our joband getting us to our meetings on time, multiple committee meetings– nights, weekends, workingon things to deadlines. Also to Booz Allen for their support in refiningour work. And then to my subcommittee, terrific groupof professionals around the table here who really were responsive to requests for information,for editing what we did, et cetera, and particularly to my co-chairs Shariff [INAUDIBLE], and MollyRutherford, who, in the last few weeks, did some real marathon sessions over the phonelate into the night to refine our recommendations. I’d also like to shout out particularly HowardFields, who’s not here today, but he did a very detailed, massive work in reviewing theCDC guidelines and helping us to move forward with that as a foundation but also lookingat the gaps and making recommendations to fill those gaps.You know, we’ve been out this a long time,both of us, for decades. In the early ’80s, Howard was working as aneuroscientist, a neurologist at UCSF, the University of California San Francisco, lookingat pain transmission and modulation and the central nervous system, spinal cord and brain. In the meantime, I had an NIH grant to teachbiopsychosocial medicine to medical students, and residents, and practicing physicians inVermont at the University of Vermont. But what happened to both of us is we startedtaking care of pain patients– patients with pain. And that drew us into a career in pain, justlike it did most of you around the table. We felt compassion. We felt the need to improve the care, andwe all got involved in it.So I want to thank all of you who have beendoing this for so many, many years and all those who we represent out there– the multiplethousands of providers, researchers, educators, et cetera, around the country who have puttheir heart and soul into this mission. You know, we’ve been saying for decades thatour education and training of pain, more money for pain research. Well, now, we have the focus.Congress has approved us. They want us to do this work. And so it’s great to be able to go forward. Finally, a special shoutout to my colleaguesin federal medicine– Tripp, Dr. Mark, Kevin Galloway, Scott Griffith, and others who havebeen– Dr. Spivak, who have worked with the VA people and Dr. Sam Brink and I over thelast 10 years or so to come up with a stepped-collaborative care model, which you heard Dr.Kurtz givean amazing, great presentation of earlier today. So thank you all. So let’s talk about medications. We have a whole bunch of recommendations forthis particular subcommittee. So we had to summarize these recommendationsinto a few key points here, particularly looking at, as Dr. Singh has presented to us– multiplepopulations. Chronic pain has been tended to be seen assort of a unitary thing, but study chronic pain. Well, chronic pain is multiple different conditions,and different populations. Pain itself– it starts with an acute painfrom an injury or a disease, and there’s a trajectory over time. And we have to look at our subpopulationsof patients along that trajectory and find out where they are in what we call the chronificationof pain– acute pain to chronic pain, and then to a complexity of chronic pain– andfind out where these subpopulations are based on their mechanisms. What are the mechanisms that determine ourmedication use? It’s very important to differentiate differentmechanisms for pain– neuropathic, diabetic neuropathy, post-war injury pain from a severewound to the leg arm or in extremity. It is very different in terms of its managementthan suceptive pain from a disease or myofascial pain from inflammation in the muscles andjoints to central pain, like fibromyalgia, sensitisation, where there’s pain from theperiphery that gets the brain plastically changing.We have to identify all those different processes. And then, the activators of pain– stress,depression worsens the pain response, et cetera. So these things all have to be identifiedin the individual patient and managed very specifically with mechanism-based, multi-modalmedications. We also need to embed this kind of approachto patients in a collaborative stepped-care model of pain care. And that requires a system change. It means that our primary care providers needto be, first of all, educated and trained and resourced to be able to provide most ofthe care, but with easy access to pain specialists, to mental health specialists, to psychologists,physical and occupational therapy, et cetera.The partners they have in their communityto take good care of pain is a public health issue. And it has to be a collaborative care model,where there’s a back-and-forth transfer of information between the specialist, the painmedicine specialist, and the primary care team up front so that we’re really providinga community support system. And there has to be work with, of course,the community itself, the pharmacists, and the mental health providers, et cetera, theaddiction specialist, so that our patients are really covered.And that’s really critical. How do we get there? Well, the VA and DOD actually made that change. And we’ve created a model called the stepped-carecollaborative care model in our organizations. We’re now implementing that widely under Dr.Sam Brink and others’ leadership. I want to say that we need simple algorithmsfor helping our front line providers manage the common pain conditions. Deborah Weinier at University of Pittsburghput together a tremendous set of about six different political practice guidelines forlow back pain in older adults. As an older adult, I appreciate the fact thatI know that my primary health clinician is going to be– have these algorithms to differentiatemy low back pain from radiculopathy, from SI Joint, disease from the depression thatmay be activating– whatever it is, whatever the cause, she’s got these algorithms verynicely laid out, and we need to develop those to support our education programs for primarycare and to help them make good decisions going forward.Next slide. So we need to start with nonopioids, if wecan. Obviously, mechanism-based, multimodalitymedications are important. It’s not one size fits all. Let’s figure out the mechanism. Let’s try the nonopiods if we can to see ifthat actually works. And we can use these IV. We can use them transdermally, and when wecan use them orally. So let’s start that way. But if opioids are being considered, the dose,the duration, the type of opioid needs to be made by the practicing physician and withthe help of, of course, colleagues who look at risks and co-morbidities, et cetera, butwith the sole purpose of really helping the patient manage their pain safely and effectively.This model requires a collaborative multi-modaltreatment plan, with the physician and the patient, the patient being educated and informed. In the VA, for example, we established a informedconsent procedure for all patients who are on long-term opioids. Why? Because there’s a responsibility for takinggood care of the patient but always having them totally informed about the options andthe ways opioids are going to be used. We need to create safe use of opioids in ourcommunities. There are poison center services and communities. We develop those. We need to inform the public of their availabilityand get our community resources doing this kind of work– and also to educate our patientsabout safe management of opioids in their homes. Finally, in terms of medications, we haveto remove barriers to access the good medication use and to consultation with our experts inpain management, but also in people who look at risk factors, such as addictionologistand mental health specialists. And we need to make buprenorphine more easilyavailable to front line providers so we can move along in that direction.Next slide, please. Now physical therapy, of course, spans theentire spectrum of pain management– from recovery from the acute injury. We all know about our incredible operationsnow for joint replacement and how physical therapy is such a critical part of gettingpeople back to functioning as soon as possible. But also, after the acute injuries are over,there are going to be flares. There are going to be setbacks. And physical therapy needs to be availableand accessible to our patients once the flare happens so they can get back to functioningback to their jobs, et cetera and not have the flare bring them down, have them losetheir jobs, and lose their functioning, and have secondary consequences of complex chronicpain. An then finally, at the end of this trajectory,when patients do have complex chronic pain are dysfunctional, we need to have physicaltherapy and occupational therapy immediately available to help with the revisitation backto function and to reverse some of the neuroplasticity in the central nervous system, but also someof the weakness in the impairments that are caused by inactivity caused by chronic pain.So there are clearer indications and benefitsto the treatment of chronic pain syndromes, specifically with the use of OT and PT. We’ve heard from OT today already, aquatherapy,TENS of course, and then movement-based modalities, including tai chi, pilates, yoga et cetera. There should be minimal barriers to accessthese treatments. They’re safe. They really help patients avoid overuse ofmedications and function in their daily lives– and harm free. Self-administered therapies should be easilyfreely available to all of our patients out there to avoid overuse of medications. Finally, next slide. I want to speak briefly about interventionalprocedures, which are really important and have not been accessible. Evidence-based interventional procedures havenot been accessible to many of our patients due to insurance barriers, coverage, and justthe fact that we don’t have enough well-trained pain medicine doctors around the country inmultiple– in all the different areas of the country geographically.So we need to develop well-researched, evidence-basedpain guidelines for interventional pain procedures and how they work with other treatments. A nerve block or a procedure may help thepain right now, but then you have to get the patient into physical therapy and deal withthe catastrophizing of the fear that goes along with pain often and work those two thingstogether. And that’s really critical in the way we’veoutlined our recommendations. We need a consistent insurance coverage. So if a patient has a flare up– they’ve hada good result from a procedure but they have flare up in two or three months at work fromthe ergonomic stresses of their job. We need to be able to get them back in, quicklyrelieved, into physical therapy if they need it, and then back on the job. We also need access to improved access tothe outpatient centers for interventional procedures, pain medicine programs that aren’tin the hospital. Why? Because their more accessible to patients. They don’t have to drive to a city, a majorhospital, park, get to the OR, and get their procedure.They can do this in an outpatient settingclose to home– closer to home and more conveniently. We need to move those barriers to access. I think that’s my last slide, right? So now, I guess we’re going to open it upfor discussion of the group, right? DR. VANILA SINGH: So thank you, Dr. Gallagher. Produced by the US department of Health andHuman Services at taxpayer expense.
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