>> GOOD MORNING, EVERYONE. I WANT TO THANK EVERYONE FOR COMING. I KNOW THIS IS A SPRING BREAK IN MONTGOMERY COUNTY SCHOOL SYSTEMS AND SO THANKS, EVERYONE, FOR SHOWING UP ON THIS MONDAY MORNING. MY NAME IS DAVID SHURTLEFF, I'M THE DEPUTY DIRECTOR OF THE NATIONAL CENTER FOR COMPLEMENTARY AND INTEGRATIVE HEALTH NATIONAL CENTER HERE AT NIH. IT'S MY PLEASURE TO WELCOME YOU TO THE SECOND 2017 NCCIH-SPONSORED INTEGRATIVE MEDICINE LECTURE SERIES AND ACTUALLY OUR SECOND PRESENTATION FOCUSED ON RESOURCES AND RESEARCH ON HEALTH ISSUES THAT AFFECT OUR MILITARY. AND NCCIH IS ACTUALLY HOSTING THREE EVENTS OVER THE COURSE OF A COUPLE OF MONTHS. IN MARCH, MANY OF YOU MAY HAVE HEARD DR. GEWIRTZ, WHO DISCUSSED HER RESEARCH ON DEVELOPING AND TESTING THE AFTERDEVELOPMENT, AFTERDEPLOYMENT ADAPTIVE PARENTING TOOL, WHICH IS VERY INTERESTING. TODAY I'LL INTRODUCE DR. KAREN SEAL IN A MINUTE ABOUT HER WORK. AND LATER THIS MONTH IN APRIL 25TH, YOU WILL BE HEARING FACEBOOK LIVE PRESENTATION FROM DOCTORS ERIC SCHOOMAKER AND CHESTER BUCKENMAIER ON THE FACEBOOK. THAT'S APRIL 25TH AT 1:00 P.M. SO I HOPE YOU'LL HAVE THE OPPORTUNITY TO HEAR THAT CONVERSATION AS WELL. JUST A LITTLE BIT OF BACKGROUND. FOR NCCIH RESEARCH AND MILITARY POPULATIONS IS A VERY HIGH-PRIORITY RESEARCH AREA FOR US. SINCE 2013, WE'VE HAD A GROWING PARTNERSHIP EFFORT WITH AGENCIES, INCLUDING THE VA, DEPARTMENT OF DEFENSE, AND SIX OTHER NIH INSTITUTES AND CENTERS, SUPPORTING RESEARCH ON NON-PHARMACOLOGICAL APPROACHES FOR THE MANAGEMENT OF PAIN AND ITS COMORBID CONDITIONS IN THESE POPULATIONS. SO NOW IT'S MY GREAT PLEASURE TO INTRODUCE DR. KAREN SEAL. DR. SEAL'S PROFESSOR OF MEDICINE AND PSYCHIATRY AT THE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO. THE WEATHER IS ABOUT THE SAME THERE AS IT IS HERE NOW. WHICH IS NICE. IN ADDITION, SHE'S ALSO AT THE SAN FRANCISCO VA MEDICAL CENTER. SHE IS A STAFF PHYSICIAN, DIRECTOR OF THE INTEGRATED CARE CLINIC FOR IRAQ AND AFGHANISTAN VETERANS AND DIRECTOR OF THE INTEGRATED PAIN TEAM CLINIC. DR. SEALS' RESEARCH FOCUSES ON UNDERSTANDING THE PREVALENCE AND PREDICTORS OF MENTAL HEALTH PROBLEMS IN MILITARY VETERANS AND DEVELOPING INTERVENTIONS TO OVERCOME BARRIERS TO MENTAL HEALTH CARE. DR. SEAL'S RESEARCH IS SUPPORTED BY THE NATIONAL INSTITUTE ON DRUG ABUSE AND THE VETERAN'S ADMINISTRATION. THIS MORNING, DR. SEAL WILL DISCUSS HER WORK ON THE OPTIONS FOR PAIN TREATMENT INTERVENTION STUDY, WHICH HAS BEEN TESTING A NOVEL INTERVENTION THROUGH OPIOID MEDICATIONS AND THE USE OF NON-DRUG STRATEGIES FOR PAIN MANAGEMENT IN VETERANS. SO PLEASE WELCOME DR. KAREN SEAL. [APPLAUSE] >> SO THANK YOU SO MUCH FOR INVITING ME TO SPEAK TODAY. IT'S MY PARTICULAR PLEASURE TO BE HERE AT NCCIH WE'RE DOING NCCIH GRAND ROUNDS BECAUSE I THINK I REALLY OWE NCCIH A DEBT OF GRATITUDE FOR THEIR SUPPORT IN REALLY MOVING ME INTO THIS FIELD OF PAIN MANAGEMENT, OPIOID RISK REDUCTION IN PRIMARY CARE FOR VETERANS. I REALLY APPRECIATE YOUR SUPPORT OF VETERANS. DR. BRIGS, DR. KRISTIN HUNTLEY, WHO HAD BEEN SUPPORTING MY WORK AT THE VA FOR YEARS NOW. THIS HAS BEEN GREAT FOR ABOUT THREE YEARS SO THANK YOU. I ACTUALLY WAS JOKING. I CHANGED THE TITLE SLIDE A LITTLE BIT TO INCLUDE PAIN AND OPIOID MANAGEMENT IN VETERANS IN PRIMARY CARE BECAUSE PEOPLE I THINK IT'S ALWAYS CONFUSING WHEN I'M INTRODUCED PEOPLE SAY OH, YOU'RE A PSYCHIATRIST AND I'M ACTUALLY REALLY NOT A PSYCHIATRIST. I'M A PRIMARY CARE INTERNIST AND MY MAIN FOCUS IS TRYING TO BRING LIGHT OF THESE INTEGRATED INTERVENTIONS INTO THE PRIMARY CARE ARENA. SO WITH THAT, I WILL MOVE FORWARD. I THOUGHT, SPEAKING OF WHICH, I WOULD JUST PAINT A LITTLE PICTURE HERE OF THE TYPE OF VETERAN THAT WE TEND TO SEE, PARTICULARLY IN OUR IRAQ AND AFGHANISTAN VET CLINIC. SO I AM GOING TO SHOW YOU A CASE, A NEW PATIENT, 28-YEAR-OLD IRAQ VETERAN. HIS LOWER BACK PAIN STARTED ABOUT THREE YEARS AGO FROM AN INJURY HE SUSTAINED IN IRAQ. OVER THE YEARS, HE HAS PROGRESSIVELY BEEN MAINTAINED ON HIGHER AND HIGHER DOSES OF OPIOIDS AND LONG ACTING OPIOIDS NOW TOTALING DAILY DOSE, WHICH IS HIGH, BUT I AM AFRAID TO SAY NOT THAT ATYPICAL. HE ALSO USES ADJUNCTS FOR PAIN MANAGEMENT. IBUPROFEN IN TOPICAL MEDS AND HE'S BEEN STEADILY ESCALATING HIS DOSE OF OPIOIDS AND HE FREQUENTLY RUNS OUT EARLY SO HE SAYS THAT WHEN HE RUNS OUT, HE REPORTS DRINKING ABOUT SIX BEERS A NIGHT TO RELIEVE HIS PAIN. HE DOES CARRY A DIAGNOSIS OF PTSD BUT HE'S NOT IN TREATMENT. BECAUSE OF HIS PTSD, HE HAS VERY POOR SLEEP, WHICH IS THE HALLMARK DIAGNOSIS OR SYMPTOM THAT WE COMING INTO PRIMARY CARE, EVEN IF THEY DON'T ACKNOWLEDGE THE PTSD. THEY TALK ABOUT THEIR POOR SLEEP AND HE HAS NIGHTMARES FREQUENTLY. HE NOW AVOIDS LEAVING THE HOUSE. HE USED TO BELONG TO A GYM, HE NO LONGER GOES TO THE GYM HE'S GAINED WEIGHT. THIS IS A VERY CLASSIC SCENARIO. HE NOW IS STARTING TO SHOW THE METABOLIC EX THAT HAVE. HE HAS HYPERTENSION. HE'S EVEN BORDERLINE DIABETES. HE SAYS THAT BECAUSE OF THE OPIOIDS AND OTHER REASONS AND HIS POOR SLEEP, HE'S NOW NODDING OFF IN CLASS TO THE POINT WHERE HE'S CONSIDERING DROPPING OUT OF SCHOOL. HIS BACK PAIN IS WORSE. HE'S CONSTANTLY OUT OF MEDS AND HE ACTUALLY IS REQUESTING, IF NOT SOMEWHAT DEMANDING FRANKLY AN INCREASE IN HIS OPIOID DOSE AND THIS IS THE FIRST TIME I'M MEETING THIS YOUNG VETERAN. SO YOU'RE HIS PCP WHAT DO YOU DO? YOU HAVE 50 MINUTES WITH THIS YOUNG VETERAN. EVERY BONE IN YOUR BODY REALLY WANTS TO HELP HIM AND YOU WANT TO RELIEVE HIS PAIN AND SUFFERING. BUT THERE ARE RISKS TO WHAT HE'S ASKING, AND SO THEREIN LIES THE CHALLENGE THAT WE FACE IN PRIMARY CARE. SO WHAT WE'RE GOING TO DO TODAY IS ACTUALLY START WITH THE FUNDAMENTALS, TALKING ABOUT PRIMARY CARE -- SORRY, TALKING ABOUT NEUROSCIENCE, EPIDEMIOLOGY, AND CO-MORBIDITY BECAUSE I FIRMLY BELIEVE THAT WHEN YOU TALK ABOUT DEVELOPING INNOVATIONS AND INTERVENTIONS, YOU VERY WELL TO GO BACK TO THE SCIENCE AND LOOK AT THE EVIDENCE. AND OUR UNDERSTANDING OF CHRONIC PAIN. WE'RE THEN GOING TO MOVE TO RESEARCH THAT I AND OTHERS HAVE BEEN DOING ON COLLABORATIVE CARE TO SUPPORT PAIN AND OPIOID MANAGE IN PRIMARY CARE AND LOOK AT HOW THAT RESEARCH IS ACTUALLY INFLUENCED THE IMPLEMENTATION OF OUR INTEGRATED PAIN TEAM CLINICS IN THE SAN FRANCISCO VA HEALTHCARE SYSTEM, NOT JUST IN OUR MEDICAL CENTER BUT ALSO OUR COMMUNITY-BASED OUTPATIENT CLINICS. AND THEN DISCUSS A LITTLE BIT OF THE FUTURE DIRECTIONS FOR WHAT I AM CALLING WHOLE-HEALTH PAIN CARE. SO WE'LL START WITH NEUROSCIENCE, EPIDEMIOLOGY AND CO-MORBIDITY SO I LOVE THIS FIRST SLIDE, BECAUSE I AM ALWAYS IMPRESSED THAT DAY CART IN THE 16TH CENTURY REALLY GOT THAT IF YOU STICK YOUR HAND INTO A FIRE THAT THE PAIN IS NOT IN YOUR HAND, AS WE STILL VERY FIRMLY BELIEVE. HE ACTUALLY UNDERSTOOD THAT THE EXPERIENCE OF PAIN IS ACTUALLY IN THE BRAIN. SO THAT HE REALLY RECOGNIZED THOSE ASCENDING BOTTOM-UP INPUTS, EXPERIENCED IN THE BRAIN. FAST FORWARD TO THE 21ST CENTURY, WHERE WE ARE NOW, AND WE HAVE ADDED THE UNDERSTANDING THAT NOT ONLY ARE THERE ASCENDING INPUTS THAT ARE EXPERIENCED IN THE BRAIN BUT A NUMBER NUMBER OF FACTORS THAT AFFECT HOW WE, AS INDIVIDUALS, EXPERIENCE THE SAME STIMULUS. SO FOR INSTANCE, THE WAY WE EXPERIENCE PAIN IS AFFECTED BY OUR PRIOR EXPERIENCES WITH PAIN, OUR ATTENTION TO THIS, OUR EXPECTATION OF WHAT THE PAIN'S GOING TO FEEL LIKE. IF WE HAVE AN UNDERLYING MOOD DISORDER, SUCH AS PTSD, ANXIETY, DEPRESSION, ANY NEUROCHEMICAL MAKEUPS, NEUROHORMONAL RESPONSES TO PAINS ARE GENETICS, EPIGENETICS, AND HOW OUR BODIES ARE SENSITIZED EITHER CENTRALLY OR PERIPHERALLY TO EXPERIENCING PAIN. SO I LIKE THIS IMAGE BECAUSE IT REALLY SHOWS THE NATURAL HISTORY OF ACUTE-TO-CHRONIC PAIN. SO AS WE KNOW, ACUTE PAIN IS EXPERIENCED. THERE IS OBVIOUS TISSUE DAMAGE TO THE BODY. OUR NERVOUS SYSTEMS GO INTO A HEIGHTENED ON ALERT MODE IN ORDER TO PROTECT US FROM FUTURE PAIN EVENTS AND ALSO TO HELP US IN THE HEALING PROCESS. USUALLY AFTER ABOUT THREE MONTHS, 90 DAYS, ACUTE PAIN OR TISSUE DAMAGE RESOLVES. AND WE MOVE ON. HOWEVER, IN CHRONIC PAIN, CHRONIC PAIN IS A SITUATION, AS SOME OF YOU KNOW, WHERE SOMETHING GOES AWRY WITH OUR NERVOUS SYSTEMS. AND THE PAIN NO LONGER SERVES A USEFUL PROTECTIVE FUNCTIONS. OUR NERVOUS SYSTEMS REMAIN ON HIGH ALERT. AND OVER TIME, WE START TO SORT OF HAVE SEQUELAE FROM THE CHRONIC PAIN THAT RESULTS IN POOR FUNCTIONING AND POOR QUALITY OF LIFE AND THAT REALLY IS A CHRONIC PAIN SYNDROME. SOMETHING HAS GONE AWRY WITH OUR NERVOUS SYSTEMS AND OUR RESPONSE. SO THIS IS A BROCHURE THAT THE VA HAS ACTUALLY PUT TOGETHER AS A PART OF THERAPEUTIC NEUROSCIENCE EDUCATION. WHICH IS VERY EMPOWERING ACTUALLY FOR VETERANS AND THEIR PROVIDERS. WHICH REALLY GETS AT THIS CORE FUNDAMENTAL UNDERSTANDING OF CHRONIC PAIN AND SAYS THAT THERE ARE SEVERAL FACTORS THAT WE CAN INTERVENE ON, ESSENTIALLY TO HELP CHANGE OUR EXPERIENCE OF CHRONIC PAIN. AND SOME OF THOSE ARE OUR BEHAVIORS, SUCH AS SMOKING, DRINKING, OUR DIETS, CAFFEINE, THE KIND OF STRESS THAT WE'RE UNDER, OUR MOOD STATES, ANY MEDICATION THAT'S WE'RE ON THAT MAY BE EXACERBATING CHRONIC PAIN, POOR SLEEP. SO THESE ARE ALL THINGS THAT WE CAN ACTUALLY CHANGE, WHICH IN SOME WAYS, MORE CHRONIC PAIN IS NOT GOOD NEWS. THE GOOD NEWS IS THERE ARE THINGS THAT WE ACTUALLY MAY BE ABLE TO DO TO RELIEVE THE CHRONIC PAIN EXPERIENCE. SO NOW IN TERMS OF SORT OF LOOKING AT THE BROADER EPIDEMIOLOGY OF CHRONIC PAIN, I AM SURE YOU ARE FAMILIAR WITH THESE NUMBERS, BUT IT ALWAYS STARTLES ME THAT OVER 100 MILLION ADULTS IN THE U.S. SUFFER WITH CHRONIC PAIN, AND I REALLY, AS AN INTERNIST, AM ALWAYS INTERESTED TO SEE THAT CHRONIC PAIN FAR AND AWAY EXCEEDS THE PREVALENCE OF CORONARY HEART DISEASE AND DIABETES. SO IT REALLY IS ONE OF OUR BIGGEST PUBLIC HEALTH PROBLEMS IN THE UNITED STATES. 42% OF ADULT AMERICANS REPORT CHRONIC PAIN LASTING GREATER THAN A YEAR. THAT'S ALMOST A HALF OF ALL AMERICANS. IT IS THE SECOND MOST COMMON REASON FOR OUTPATIENT PRIMARY CARE VISITS, LOWER BACK PAIN BEING THE MOST COMMON AND IT'S THE LEADING CAUSE OF DISABILITY IN THE U.S. TODAY. IT LEADS TO POOR PSYCHOSOCIAL FUNCTIONS. YOU SEE PEOPLE NOT ABLE TO WORK. THE BREAKUP OF INTERPERSONAL RELATIONSHIPS, LEADING TO DIVORCE, POOR PARENTING, ET CETERA, AND CERTAINLY A POORER QUALITY OF LIFE. SO IT'S ALSO VERY EXPENSIVE PROBLEM. OVER $600 BILLION ANNUALLY ARE SPENT ON CHRONIC PAIN, EITHER FROM HEALTHCARE EXPENSES, LOST INCOME, OR LOST PRODUCTIVITY. SO IT'S A REALLY BIG PROBLEM. SO IN TERMS OF CHRONIC PAIN IN VETERANS, WHAT DO WE SEE? UNFORTUNATELY, VETERANS SUFFER DISPROPORTIONATELY FROM CHRONIC PAIN AND IT'S PROBABLY NOT THAT SURPRISING THAT THAT'S THE CASE, BECAUSE A LOT OF THE UNDERLYING MENTAL HEALTH PROBLEMS THAT THEY DEVELOPED AT THE SAME TIME THAT THEY DEVELOP THEIR ACUTE-TO-CHRONIC PAIN INJURY KIND OF MUTUALLY FEED EACH AND WE'LL LOOK THE THAT IN A MOMENT. UNFORTUNATELY, PHYSICAL VETERANS, 75% OF FEMALE VETERANS IN THE VA HEALTHCARE SYSTEM HAVE RECEIVED ONE OR MORE CHRONIC PAIN DIAGNOSIS, AND IN TERMS OF MALE VETERANS, 50% OF ALL MALE VETERANS FROM ALL ERAS HAVE RECEIVED ONE OR MORE CHRONIC PAIN DIAGNOSES. I THINK IT'S INTERESTING TO COMPARE THE TWO ERAS, VIETNAM TO IRAQ AND AFGHANISTAN. THAT'S VIETNAM VETERANS WERE DETERMINED, WERE OF COURSE OLDER AND WE SEE VERY HIGH PREVALENCE OF CHRONIC PAIN AND THAT POPULATION, THAT PLAYING IS AGING. THEY'RE IN THEIR 60'S, THE 70'S. WE HAVE OUR YOUNGER VETS WHO ARE SORT OF MOVING -- ACTUALLY, IT'S BEEN A DECADE SO THEY'RE IN THEIR EARLY 30'S. OVER 50% OF IRAQ AND AFGHANISTAN VETS WHO HAVE PTSD ALSO SUFFER CO-MORBID CHRONIC PAIN CONDITIONS AND UNFORTUNATELY OF THOSE WITH CHRONIC PAIN, THOSE VETERANS ARE TWO AND A HALF TIMES THE RISK, IF THEY HAVE PTSD, OF BEING PRESCRIBED OPIOIDS, WHICH OF COURSE IS A PROBLEM THAT WE FACE. OPIOIDS. NOW I ALLUDED TO THIS SORT OF MUTUAL MAINTENANCE PHENOMENA WITH CHRONIC PAIN AND PTSD. YOU COULD EASILY SUBGENERALIZED ANXIETY DISORDER, DEPRESSION. BUT ESSENTIALLY THIS IS A DOWNWARD VICIOUS CYCLE WHERE THE PTSD CREATES GREATER ANXIETY, WHICH HEIGHTENS THE PAIN PERCEPTION, WHICH CREATES GREATER DISABILITY WHICH THEN FEEDS AT VOIDANCE, HEIGHTENING THE ANXIOUS SIGHT AND YOU CAN SEE THIS IS JUST A CYCLE THAT, UNLESS IT'S INTERRUPTED SOMEWHERE, ACTUALLY KEEPS FEEDING AND REINFORCING THESE TWO PAIN CONDITIONS. OF COURSE, PTSD IS RARELY SEEN IN ISOLATION. KEEPS COMPANY WITH DEPRESSION, TRAUMATIC INJURY AND OTHER MENTAL HEALTH PROBLEMS. SO IT'S VERY COMPLICATED. ONE OF THE THINGS THAT I WAS FOCUSED ON -- I ACTUALLY CAME OUT OF THE PTSD WORLD AND STILL VERY FOCUSED ON PTSD WITH OUR IRAQ AND AFGHANISTAN VETERANS. VERY INTERESTED IN THIS PROBLEM OF COMORBID PTSD AND CHRONIC PAIN OVERUSE OF PRESCRIPTION OPIOIDS AND WE LOOKED AT OUR NATIONAL VA DATA AND FOUND THAT ACTUALLY THERE IS AN INCREASED RISK FOR ADVERSE OUTCOMES IN OUR VETERANS WITH CHRONIC PAIN WHO ARE USING OPIOIDS AND THESE ARE MORE WOUNDS AND MORE INJURIES, MORE OPIOID-RELATED ACCIDENTS AND OVERDOSES, SELF-INFLICTED INJURIES AND UNFORTUNATELY SUICIDES AND VIOLENCE-RELATED INJURIES, ALL AS CLINICAL ADVERSE OUTCOMES RELATED TO PRESCRIPTION OPIOID S IN THIS PARTICULAR POPULATION. SO MORE RECENTLY, AS A MENTIONED, PTSD IS RARELY SEEN IN ADMINISTRATION? OUR VETS. THEY OFTEN HAVE CO-MORBID DEPRESSION. MANY HAVE MODERATE TO MILD, WE ACTUALLY RECENTLY WENT BACK TO OUR NATIONAL DATA AND SORT OF REDID THIS ANALYSES LOOKING AT THE ASSOCIATION OF THESE COMORBID CONDITIONS WITH CHRONIC PAIN AND TRYING TO SEE THE RELATIONSHIPS THERE. SO IN THIS CASE WE LOOKED AT OVER 100,000 IRAQ AND AFGHANISTAN VETERANS AND WHAT WE FIRST -- WHAT I WANT TO POINT OUT FIRST IS THAT THERE IS ACTUALLY AN INDEPENDENT ASSOCIATION WITH MILD TBI, WAS ACTUALLY A QUESTION IF MY VIRTUOUS VERY MIXED ON THAT POINT. AND YOU CAN SEE HERE THERE IS A VERY CLEAR DOSE RESPONSE ACTUALLY. VERY LITTLE INTERACTION BUT PURE ADDITIVE RESPONSE AS YOU START ADDING AND STACKING THESE MENTAL HEALTH DIAGNOSES. YOU CAN SEE THAT THE VETERANS WHO ARE MOST AT RISK ARE THOSE WITH DEPRESSION, WITH PTSD AND MODERATE-TO-SEVERE TBI FOR HAVING CHRONIC PAIN. WE HAVEN'T PUBLISHED ON THIS -- THIS IS IN PRESS RIGHT NOW, THESE DATA. THIS DATA WE'RE LOOKING AT RIGHT NOW I WANTED TO GO A STEP FURTHER AGAIN AND LOOK AT THE ASSOCIATION IN THIS POPULATION WITH CHRONIC PAIN, LOOK AT RISKS FOR RECEIVING PRESCRIPTION OPIOID USE AND AGAIN WE FOUND AN INDEPENDENT ASSOCIATION WITH OUR VETERANS WHO HAVE MILD TBI, AND I THINK THESE DATA ARE ACTUALLY EVEN MORE DRAMATIC. CERTAINLY THE RELATIVE RISKS ARE BIGGER. AND ONE OF THE THINGS THAT IS PARTICULARLY STARTLING MIGHT BE HYPERBOLE BUT PRETTY CONCERNING IS OUR PATIENTS WITH MODERATE-TO-SEVERE TBI. WE GENERALLY DO SEE COGNITIVE IMPAIRMENT IN THAT GROUP AND OF COURSE THE USE OF OPIOIDS IN A GROUP OF PATIENTS IS REALLY CONTRAINDICATED. SO ONE OF THE THINGS THAT I NOTICED WHEN WE WERE DOING THESE ANALYSES IS THAT MODERATE-TO-SEVERE TBI IS REALLY A DRIVER OF RISK FOR RECEIVING PRESCRIPTION OPIOIDS. AND AGAIN WE HAVE THIS MORE OR LESS ADDITIVE PATTERN, SOME INTERACTION BUT MOSTLY AN ADDITIVE PATTERN WITH THE HIGHEST RISK FOR CHRONIC PAIN BEING IN THOSE VETERANS WHO HAVE DEPRESSION. PTSD AND MODERATE-TO-SEVERE T BI. JUST GROUP THAT YOU WOULD REALLY NOT WANT TO SEE PRESCRIBED, REALLY WANT TO SEE THEM GETTING NON-OPIOID ALTERNATIVES AND YET HERE WE ARE WITH ALMOST FIVE TIMES THE RECEIVE -- RISK OF RECEIVING OPIOIDS. PRETTY DISTURBING DATA ACTUALLY. -- WHY IS THERE THIS ASSOCIATION? THIS HAS BEEN FASCINATING TO ME AS JUST REALLY TRYING TO UNDERSTAND WHY ARE CHRONIC PAIN PATIENT WITH COMORBID HEALTH PROBLEMS ARE DRAWN TO OPIOIDS? WE CAN TALK ABOUT NEUROSCIENCE FOR HOURS. BUT ESSENTIALLY WHAT'S GOING ON -- AND THIS IS A VERY SUPERFICIAL EXPLANATION THAT I THINK ALMOST EVERYONE CAN UNDERSTAND EASILY -- OPIOIDS TEMPORARILY AMELIORATE MENTAL HEALTH SYMPTOMS. PROVIDERS KNOW IT. VETERANS ARTICULATE,T. SPECIFICALLY IN PTSD, OPIOIDS ATTENUATE THE TRAUMA-RELATED COGNITIONS, FEAR AND HYPERAROUSAL. OPIOIDS DAMPEN DOWN THAT NEUROHORMONAL STRESS RESPONSE THAT WE SEE IN A LOT OF THESE PATIENTS THAT THEY ARE DEALING WITH ON A CHRONIC BASIS. AND OF COURSE, OPIOIDS CAN TRANSIENTLY ALLEVIATE DEPRESSION. WHAT HAPPENS IN PRIMARY CARE -- AND THIS IS INADVERTENT, UNINTENTIONAL -- IS CHRONIC PAIN PATIENTS WHO HAVE THIS UNDERLYING EMOTIONAL ISSUES -- PTSD, DEPRESSION, ANXIETY -- ARE THOSE PATIENTS THAT EXPERIENCE A LOT OF DISTRESS RELATED TO THEIR CHRONIC PAIN. AND SO GENERALLY THESE ARE THE PATIENTS THAT DON'T INITIALLY ACCEPT THE NON-OPIOID ALTERNATIVES. THEY HAVE A LOT OF DISTRESS. THEY ARE DEMANDING AND PRIMARY CARE PROVIDERS DO WANT TO ALLEVIATE THAT DISTRESS IN ANY WAY THEY CAN AND SO INADVERTENTLY OVER YEARS AND BECAUSE WE WERE TAUGHT TEN YEARS AGO THAT WE HAD TO ALLEVIATE PAIN NO MATTER WHAT, EVEN IF IT INVOLVED PRESCRIBING OPIOIDS, WE ARE TRAINED TO PRESCRIBE OPIOIDS A DECADE AGO. THESE PATIENTS HAVE ENDED UP ON OPIOIDS TO RELIEVE THEIR EMOTIONAL DISTRESS. A LOT OF SELF-MEDICATION IS GOING ON AND THIS IS FEEDING SUBSTANCE USE DISORDERS THAT WE ARE NOW DEALING WITH TODAY. SO AS WE ALL KNOW -- AND I THINK DR. CRABS ARE WORKING ON THIS VERY QUESTION. TO DATE, THOUGH, THERE HAS BEEN NO EVIDENCE THAT PRESCRIBING OPIOIDS IS SUPERIOR TO OTHER ALTERNATIVES FOR THE TREATMENT OF CHRONIC PAIN. THERE IS NO EVIDENCE. WE'RE STILL LOOKING FOR IT. AND UNFORTUNATELY, THE USE OF OPIOIDS IN THE SETTING OF CHRONIC PAIN AND MENTAL HEALTH PROBLEMS ONLY SERVES TO EXACERBATE THOSE PROBLEMS. WE KNOW THAT THERE IS EVIDENCE. LOTS OF DIFFERENT STUDIES, SAYING THAT THE USE OF OPIOIDS ACTUALLY WORSEN PSYCHOSOCIAL FUNCTIONING AND QUALITY OF LIFE. AND WE KNOW THAT THE USE OF OPIOIDS DATA SHE'S IT INCREASES THE SERIOUS ADVERSE OUTCOMES IN THIS PARTICULAR POPULATION OF HIGH-RISK PATIENTS. AND UNFORTUNATELY, SHOWS THAT SERVICES ARE TWICE THE RISK FOR OPIOID OVERDOSES AS OTHER U.S. ADULTS. SO REALLY DRIVING THIS NEED TO COME UP WITH NON-OPIOID ALTERNATIVES. SO LOOKING AT THESE DATA, SEVERAL PROFESSIONAL ORGANIZATIONS AND BODIES HAVE COME UP WITH THE CONSENSUS TO ADVOCATE, CDC, DEPARTMENT OF HEALTH AND HUMAN SERVICES -- ARE NOW ADVOCATING FOR THE TECHNOLOGY AND I THINK THIS REALLY WAS A DRIVER IN YOUR PUTTING OUT THE RECENT FOA, THAT REALLY WHAT WE NEED IS A MULTIMODAL BIOPSYCHOSOCIAL APPROACH TO CHRONIC PAIN TREATMENT THAT'S FOCUSED ON IMPROVING THE EXPERIENCE OF INDIVIDUALS WITH CHRONIC PAIN AND ENHANCING THEIR FUNCTIONING AND QUALITY OF LIFE. SO REALLY WHAT'S RECOMMENDED, AS FIRST LINE, ARE NON-PHARMACOLOGICAL THERAPIES, JUST NON-OPIOID, SUCH AS EXERCISE AND COGNITIVE BEHAVIORAL THERAPIES. THOSE ARE TWO THAT ARE REALLY SEEN AS NOW THE MOST, SAFEST AND PROBABLY MOST EFFECTIVE FOR THE TREATMENT OF CHRONIC PAIN. AND THEN SECOND LINE IS THE CONSIDERATION OF THE USE OF NON-OPIOID ANALGESICS, ANTI-INFLAMMATORIES, TOPICAL MEDICATIONS, ANTI-CONVULSANTS. BUT WHAT WE'RE SEEING NOW REALLY IS A RESULT OF THESE GUIDELINES IS THAT PRIME CARE -- PRIMARY CARE PROVIDERS ARE FEELING PRESSURE FROM OUR PATIENTS TO REIGN IN THE USE OF OPIOIDS AND WHAT THIS ACTUALLY LOOKS LIKE IS A LOT OF PRIMARY CARE PROVIDERS ARE STARTING TO INITIATE TAPERS AND SIMPLY JUST CUTTING THEIR PATIENTS OFF OF OPIOIDS AND PATIENTS ARE ACTUALLY FEELING LIKE THEY REALLY DON'T HAVE ANY OPTIONS OR THEIR OPTIONS ARE LIMITED BECAUSE WE'RE REALLY IN A PERIOD OF TIME WHERE THERE IS A GAP. WE HAVEN'T FIGURED OUT HOW TO NECESSARILY IMPLEMENT WHAT THE IOM AND WHAT THE CDC, THE NATIONAL PAIN STRATEGY ARE CALLING FOR. SO WE'RE UNTIL THIS GAP WHERE PATIENTS ARE FEELING LIKE THEY HAVE NO OPTIONS. I HEAR PATIENTS SAYING IT'S LIKE THE RUG WAS PULLED OUT FROM UNDER ME. I'M CUT OFF AND ABANDONED. SO HERE -- THEY'RE REALLY FRUSTRATED. UNFORTUNATELY, ON THE SIDE OF THAT EQUATION, PRIMARY CARE PROVIDERS ARE FEELING VERY FRUSTRATED, TOO, BY A LACK OF GUIDANCE IN HOW THEY SHOULD PROCEED WITH THESE PATIENTS. AND A LOT OF THE JOB STRESS AND BURN WORKOUT THAT PRIMARY CARE PROVIDERS ARE EXPERIENCE THAWING HEAR ABOUT IS REALLY RELATED TO THE TREATMENT OF CHRONIC PAIN AND THE MANAGEMENT OF OPIOIDS IN CHRONIC PAIN PATIENTS. SO BACK IN 2014, YOU ALL HAD A CONFERENCE, THE NIH PATHWAYS TO PREVENTION OF OPIOIDS FOR CHRONIC PAIN AND REALLY WHAT YOU DETERMINED THAT THE TIME IN 2014 IS THAT CLINICIANS ARE OVERBURDENED AND HAVE INSUFFICIENT RESOURCES. AND YOU ADVOCATED OR RECOMMENDED THAT SYSTEMS OF CARE, NOT JUST THE INDIVIDUAL PROVIDERS BUT ACTUALLY THE SYSTEMS OF CARE MUST FACILITATE IMPLEMENTATION OF PAIN AND OPIOID MANAGEMENT GUIDELINES TO HELP THAT INDIVIDUAL CLINICIAN. BUT UNFORTUNATELY,, WE'RE IN A GAP AND THERE ARE A LOT OF BARRIERS TO ACTUALLY CARRYING OUT THOSE RECOMMENDATIONS. WE STILL DON'T REALLY UNDERSTAND HOW TO COMMUNICATE WITH OUR PATIENTS. THERE ARE REALLY NO GUIDELINES FOR WHEN YOU GET DOWN IN THE WEEDS OF THIS HOW WE TALK OUR PATIENTS. WE HAVE VERY LIMITED TIME IN PRIMARY CARE OUR PATIENTS. MOST VISITS ARE 20 MINUTES. WHEN I MENTION 50 MINUTES, THAT'S INITIALLY. WE DON'T REALLY -- WE HAVE KNOWLEDGE DEFICITS. THAT'S CROSS CUTTING ON BOTH SIDES AND PROVIDERS AND IN PATIENTS. THERE ARE REALLY NOT GOOD OPIOID ALGORITHMS AND IT'S THE IMPLEMENTATION PIECE THAT'S REALLY TOUGH AND WE DON'T HAVE THE ANCILLARY SUPPORT IN PRIMARY CARE. WE TALK ABOUT TEAM-BASED CARE AND WE'RE LUCKY IN VA TO HAVE THAT, BUT THAT ACTUALLY IS FAIRLY UNUSUAL FOR PRIMARY CARE SETTINGS AND IT'S NOT UBIQUITOUS THROUGHOUT THE VA. SO I WANT TO TELL YOU ABOUT THE RESEARCH THAT'S BEEN SUPPORTED BY NCCIH ON COLLABORATIVE CARE TO SUPPORT PAIN AND OPIOID MANAGEMENT IN THE PRIMARY CARE SETTING. SO THIS IS OUR OPTI STUDY. IT WAS FUNDED AS AN R 34 THREE YEARS AGO AND WE ARE, WE'RE GOING TO BE WRAPPING IN JUNE. WE STILL HAVE COMPLETED ENROLLMENT OF 100 PATIENTS BUT WE'RE STILL FOLLOWING SOME. SO EVERYTHING THAT I AM GOING TO PRESENT TODAY IS STILL PRELIMINARY BECAUSE WE STARTED ANALYSES BUT WE CERTAINLY HAVEN'T COMPLETED SINCE THE STUDY HAS NOT CONCLUDE. SO I WANTED TO -- BECAUSE THAN R 34, JUST PRESENT SOME ELEMENTS THAT WE DEVELOPED AND PILOT-TESTED IN THE COURSE OF IMPLEMENTING THE STUDY. SO THE VERY FIRST THING THAT WE TALKED ABOUT OR THAT WE DEVELOPED HERE ARE STANDARD PRIMARY CARE VISITS FOR PAIN AND OPIOID OPTIMIZATION USING TEMPLATED STANDARDIZED NOTES EMBEDDED IN OUR VA ELECTRONIC MEDICAL RECORD. SO THAT ESSENTIALLY PRIMARY CARE PROVIDERS WHO ARE VOLUNTEERING TO BE STUDY CLINICIANS IN THE STUDY COULD ACTUALLY PUP -- PULL UP OUR VA ELECTRONIC MEDICAL RECORD AND FOLLOW A TEMPLATED GUIDE FOR HOW TO CONDUCT THESE VISIT AND DON'T DISH REALIZE I SHOULD HAVE JUST GRABBED A SCREEN SHOT AND SHOWN YOU BUT WHAT DOYLE IS I WILL WALK YOU THROUGH A LITTLE BIT OF HOW WE ARE TRAINING AND TRAINED CLINICIANS TO DO THESE VISITS. WE HAVE WORKED WITH OUR PRIMARY CARE PROVIDERS WHO VOLUNTEER TO BE PART OF THE STUDY IN TRAINING THEM IN PAIN AND OPIOID-SHARED DECISION MAKING AND HOW WE ARE WANTING TO EMPHASIZE NON-OPIOID AND IN FACT COMPLEMENTARY INTEGRATIVE PAIN MODALITIES FOR THE PARTICIPANTS IN OUR OPT STUDY AND HOW WE WORKED WITH ANCILLARY PROVIDERS OR ALLIED STAFF SOCIAL WORKERS, PSYCHOLOGISTS, TRAINEES, HOW TO DO TELEPHONE MOTIVATIONAL COACHING TO SUPPORT THESE VISITS. SO THIS IS OUR OPTI DESIGN. IT'S A THREE-YEAR ONGOING PRAGMATIC DOUBLE BLIND PILOT RCT TO TARGET IS 100 AND WE DID ENROLL 100 THANKFULLY. AND WE WANTED TO PRIMARY EVALUATE THE EFFECTIVENESS OF STANDARDIZED PRIMARY CARE PAIN PLANNING PLUS MOTIVATIONAL THIS IS COMPARED TO PRIMARY CARE PAIN PLANNING WITH NEUTRAL TELEPHONE CHECK-IN. AND OUR MAIN AIMS WERE TO IMPROVE PAIN SEVERITY AND INTERFERENCE, REDUCE OPIOID RISK, AND ENHANCE THE USE OF NON-PHARMACOLOGICAL PAIN MANAGEMENT. SO CRITERIA, PRETTY GENERAL BUT WE INCLUDED ALL MALE OR FEMALE VETERAN PATIENTS AT THE SAN FRANCISCO VA HEALTHCARE SYSTEM AND THAT ALSO INCLUDES SOME OF OUR COMMUNITY-BASED OUTPATIENT CLINICS AND THEY HAD TO HAVE CHRONIC NON-CANCER FINER AT LEAST THREE MONTHS. THEY HAD TO BE PROSCRIBED ONE OR MORE OPIOID FORS AT LEAST THREE MONTHS AND THEY HAD TO HAVE ONE OR MORE HIGH-RISK OPIOID USE FACTORS, SUCH AS BEING ON HIGH DOSE, OPIOIDS, GREATER THAN 45, MORPHINE EQUIVALENCE DAILY, BEING CO-PROSCRIBED BENZA, BEING MODERATE-TO-SEVERE MENTAL HEALTH PROBLEMS, SETS AND WE EXCLUDED PATIENTS WHO WERE ACTIVELY SUICIDAL AND HAD SERIOUS MENTAL ILLNESS WHO WERE UNTREATED OR RECEIVING OPIOID FOR CANCER PALLIATION. SO OUR STUDY AND OVERVIEW. WE DID SOME PRE-SCREENING FOR BASIC ELIGIBILITY IF THEY APPEARED ELIGIBILITY. WE HAVE THEM UNDERGO A BASELINE ASSESSMENT. IF THEY WERE STILL ELIGIBLE, THEY WERE SCHEDULED TO SEE ONE OF OUR VOLUNTEER PRIMARY CARE CLINICIANS. I ACTUALLY WAS ONE OF THEM. FOR AN HOUR-LONG VISIT AND I AM GOING TO GO INTO GREAT DETAIL ABOUT THAT VISIT. AND THEN AT THAT TIME THEY WERE RANDOMIZED TO BE EITHER IN THE MOTIVATIONAL COACHING INTERVENTION OR IN A NEUTRAL CHECK-IN, I WAS BASICALLY BALANCE FOR TIME AND ATTENTION. THEIR FIRST VISIT WITH THE CARE MANAGER, WHO IS THE ANCILLARY ALLIED STAFF, WAS IN PERSON, FOLLOWED BY THREE TELEPHONE MOTIVATIONAL COACHING SESSIONS, IF THEY WERE IN THE INTERVENTION ARM, AND IF THEY WERE IN THE CONTROL ARM, THEY WERE FOLLOWED BY THREE NEUTRAL TELEPHONE CHECK-IN SESSIONS. AT THE END OF OUR INTERVENTION PERIOD AT 12 WEEKS, WE BLINDED EVALUATORS CONDUCTED AN ASSESSMENT AND THEY CAME BACK TO SEE THE PRIMARY CARE PROVIDER FOR A CHECK-IN ON THEIR PAIN CARE PLANS AND ALSO TO OBTAIN DRUG SCREENING AND TO CONDUCT AN ADDICTION BEHAVIOR CHECKLIST. THEN THERE WAS A PERIOD OF IF NO CONTACT FOR EIGHT WEEKS WHICH POINT WE REPEATED THE EVALUATION, BOTH WITH THE BLINDED EVALUATORS AND WITH THE PRIMARY CARE PROVIDERS. I AM GOING TO FOCUS ON THIS PRIMARY CARE VISIT AND WALK THROUGH WHAT WE'RE DOING, WHICH I THINK IS PROBABLY GOING TO TURN OUT TO BE THE MOST IMPORTANT ASPECT OF THIS STUDY AND CERTAINLY WHAT WE'VE ALREADY STARTED TO IMPLEMENT IN OUR INTEGRATED PAIN TEAM CLINIC. SO ESSENTIALLY, THE BASELINE PRIMARY CARE VISIT FOLLOWS THIS TEMPLATE VEMA, VALIDATE, EDUCATE, MOTIVATE, ACTIVATE. SO THIS IS WHAT WE'RE TRAINING THEM TO DO. AND THIS ESSENTIALLY IS REFLECTED IN THAT STANDARDIZED TEMPLATED NOTE IN OUR ELECTRONIC MEDICAL HEALTH RECORD. SO IN TERMS OF VALIDATING PAIN, IS BASICALLY DOING AN ASSESSMENT OF PATIENTS' PAIN AND SAYING ESSENTIALLY THAT WE FEEL YOUR PAIN, THAT WE VALIDATE IT. WE KNOW THIS IS HARD. AND WHAT WE DO IS WE START OUT BY USING DR. CRAB'S PEG SCALE THAT I AM SURE MOST OF ARE YOU FAMILIAR WITH, WHICH LOOKS AT PAIN SEVERITY OVER THE PAST SEVEN DAYS ON A SCALE FROM 0 TO 10 AVERAGING UP ALL PAIN IN YOUR BODY AND THEN LOOKS AT INTERFERENCE WITH ENJOYMENT OF LIFE AND INTERFERENCE WITH GENERAL ACTIVITY, GETTING AT PAIN'S INFLUENCE ON PHYSICAL FUNCTIONING BUT ALSO ENJOYMENT OF LIFE AND QUALITY OF LIFE. WE THEN ASSESS PAIN MANAGEMENT, TRYING TO ADOPT A NON-JUDGMENTAL STANCE IN DOING THAT. WE LOOK AT MEDICATION USE AND ALSO LOOK AT THE ADVERSE EFFECTS OF THESE MEDICATIONS. SO IT'S INTERESTING, OF COURSE YOU HAVE THE CHART. YOU HAVE A MED LINE -- LIST BUT WHEN YOU TALK TO PATIENTS ABOUT WHAT THEY ARE DOING, THERE IS A GREAT GULF OR DISPARITY BETWEEN THE PRESCRIPTION AS WELL AS THE NON-OPIOID ANALGESICS. THE THIRD BULLET, NON-PHARMACOLOGICAL PAIN MANAGEMENT STRATEGIES, IS MY PERSONAL FAVORITE BECAUSE USUALLY PATIENTS WILL ANSWER PARTICIPANTS IN THE STUDY I AM DOING PHYSICAL THERAPY. I WENT TO A CHIROPRACTOR. AND THEN IF YOU KEEP PROBING, WHAT YOU HEAR IS SOMETIMES AND WHEN I DO MY WOOD WORKING OR WHEN I GO TO THE SENIOR CENTER AND I GO DANCING, MY PAIN IS ACTUALLY BETTER. OR WHEN I GARDEN OUTDOORS, I AM MOVING. I AM OUTDOORS DOING SOMETHING I LOVE AND I NOTICE THAT MY PAIN IS BETTER. SO WHAT WE'RE DOING NOW IS WE ARE TRAINING OUR PCPS TO REALLY PROBE FOR THINGS THAT PEOPLE ACTIVITIES THAT PATIENTS ARE ENGAGING IN THAT ARE PATIENT-DIRECTED ACTIVITIES, THAT ARE ACTUALLY RESULTING IN PAIN REDUCTION. THEY ARE NON-STRUCTURED ACTIVITIES. BUT WE LOVE THOSE BECAUSE THOSE ARE PATIENT-DIRECTED AND WE WANT TO BRING THOSE OUT AND RECOGNIZE PATIENTS FOR ACTUALLY DOING THOSE THINGS TO HELP THEMSELVES. OKAY, SO WE ALSO EDUCATE PATIENTS. WE START OUT BY TELLING THEM THAT THERE REALLY IS NO EVIDENCE FOR THIS SUPERIORITY OF OPIOID OVER NON-OPIOID MEDICATIONS BUT THERE IS EVIDENCE FOR REDUCED QUALITY OF LIFE AND FUNCTIONING AND THEN WE LITERALLY GO THROUGH A CHECKLIST ACTUALLY THAT THE VA HAS DEVELOPED THAT LOOKS AT EVERY POSSIBLE ADVERSE OUTCOME OF OPIOIDS AND BY THE TIME WE'RE DONE WITH THAT CHECK, THEY'RE BEGGING US TO TAKE THEM OFF THE MEDICATION. BUT WELL OUR MALE PATIENTS, HE OFTEN -- YEAH, WE'LL TALK ABOUT CONSTIPATION WHEN WE GET TO HORMONAL EFFECTS AND TALK ABOUT LACK OF LIBIDO AND MALE MENOPAUSE, THAT'S WHERE OUR MALE PATIENTS DO TAKE PAUSE BECAUSE I LOT -- THEY ARE HAVING A LOT OF HORMONAL EFFECTS OVER YEARS FROM BEING ON CHRONIC OPIOID THERAPY. NOT TO MENTION, ADDICTION, PHYSICAL DEPENDENCE, WHICH WE POINT OUT AND I THINK IT'S VERY RELIEVING THAT ADDICTION DOES NOT EQUAL PHYSICAL DEPENDENCE THEY ARE TWO DIFFERENT ANIMALS. OF COURSE WE TALK ABOUT OPIOID OVERDOSE AND DEATH AS THE ULTIMATE ADVERSE OUTCOME FROM THE USE OF OPIOIDS. IT'S VERY IMPORTANT TO SET THE RIGHT EXPECTATIONS FOR WHAT WE CAN DO. SO OUR GOAL IS REALLY, WITH OUR CHRONIC PAIN PATIENTS IS TO IMPROVE THEIR FUNCTION AND QUALITY OF LIFE. WE SAY TO PATIENTS THAT WE ARE NOT EVER GOING TO FULLY ERADICATE THEIR PAIN. CERTAINLY WE CAN'T DO THAT. ONLY A PATIENT ACTUALLY CAN WORK ON THEIR PAIN. AND OUR ROLE IS REALLY TO FACILITATE THAT PROCESS AND TO ASSIST THEM IN HELPING THEMSELVES. WE ALSO EMPHASIZE THAT MEDS ALONE ARE NOT THE MAGIC BULLET. THEY REALLY ONLY CAN HELP WITH ABOUT 30 TO 50% OF THE CHRONIC PAIN COMPLAINT AT BEST. AND THAT REALLY ALLOWS US AND OPENS THE DOOR TO LOOKING AT NON-PHARMACOLOGICAL MODALITIES THAT ARE NEEDED IF WE'RE REALLY GOING TO OPTIMIZE PAIN MANAGEMENT. SO WE'RE SETTING THE STAGE. AND THIS IS WHAT WE WANT TO COMMUNICATE TO PATIENTS. WE DON'T WRITE IT ON THE BOARD BUT WE UNDERSTAND THAT THEY HAVE CHRONIC PAIN. WE CAN'T CHANGE THAT FACTOR. THEIR INJURY IN IRAQ OR ANYTHING. BUT WE CAN WORK ON THE SUFFERING PIECE. THAT THAT'S SOMETHING THAT, AS A PARTNERSHIP, WE CAN WORK ON TOGETHER. SO REALLY WHAT WE DO -- THIS IS THE MOTIVATE. THIS FRAMEWORK. THIS IS THE MOTIVATE PIECE AND I HAVE THE FAMILY OFF TO THE TO THE SIDE AND YOU'LL SEE WHY HERE. SO REALLY THIS IS WHERE WE HAVE TRAINED PRIMARY CARE PROVIDERS TO DO SHARED DECISION MAKING. AND YES, THIS IS SCRIPTED AND IN THE NOTE. REALLY THERE IS A FOCUS ON PATIENTS' VALUES AND SO PROVIDERS WILL NOTE DOWN WANT TO SPEND TIME TIME WITH GRAND CHILDREN. WANT TO BE INDEPENDENT. WANT TO TRAVEL. THESE ARE VALUES AND OVERARCHING FUNCTIONAL GOALS AND IN NORTHERN CALIFORNIA WE'RE HEARING I WANT TO CLIMB MOUNT CHASTA. WE'RE NOT ACTUALLY -- THOSE ARE A LITTLE HARD TO WORK ON IN THE OFFICE. SO REALLY WHAT WE'RE GETTING AT IS GETTING PEOPLE TO BE MAKING SMART GOALS AND I'LL TELL YOU ABOUT THAT IN A MINUTE. BUT THE QUESTIONS THAT WE USE ARE QUESTIONS THAT VA WHOLE-HEALTH PROGRAM IS REALLY ROLLING THESE QUESTIONS AND THIS FRAMEWORK OUT NOW TO ALL VA PROVIDERS TO ASK OUR PATIENTS WHAT MATTERS MOST TO YOU? WHAT DO YOU WANT YOUR HEALTH FOR? TO REALLY GET PATIENTS THINKING IN THIS WAY. AND SPECIFICALLY IN REGARD TO CHRONIC PAIN, WHAT WOULD YOU WANT TO DO IF YOUR PAIN WERE UNDER BETTER CONTROL? SO WE WRITE ALL OF THESE OUT AND REFLECT ALL OF THIS BACK TO PATIENTS. SO REALLY THAT GETS US TO OUR MOTIVATIONAL INTERVIEWING MOMENT SENSE OF DISCREPANCY. SO REMEMBER HEARKEN BACK TO THE 28-YEAR-OLD IRAQ VET WITH ALL OF HIS ISSUES. THIS IS WHERE YOU ARE NOW. AND ON THE OTHER HAND, YOU JUST TOLD ME THAT YOU REALLY WANT TO STAY IN SCHOOL, THAT YOU HAVE A WIFE. YOU HAVE KIDS. YOU REALLY WANT TO SPEND TIME WITH THEM. YOU WANT TO BE SUCCESSFUL IN YOUR LIFE AND HOW DO WE GET YOU FROM WHERE YOU ARE NOW TO WHAT YOU JUST TOLD ME IS IMPORTANT TO YOU AND WHAT YOUR GOALS ARE IN LIFE? AND THAT'S REALLY WHERE WE MOVE TOWARD READINESS FOR CHANGE. SO WE WANT TO SEIZE ON THAT MOMENT AND ACTIVATE THEM AND ONE OF THE ACTUAL SERIES OF SHARED DECISION AIDS AND ONE OF THEM IS THIS CAR WITH FOUR FLAT TIRES. IT'S NOT SOMETHING THAT'S SOMETHING WE DEVELOPED. IT WAS DEVELOPED BY THE AMERICAN PAIN ASSOCIATION BUT WE'VE SEIZED ON IT AND WE USE IT. AND BASICALLY, THIS IS WHAT WE USE ON PATIENTS BUT I NEED THESE OPIOIDS. THEY'RE GOING TO HELP ME AND MAKE THE CAR DRIVE FORWARD. NO. ACTUALLY IF YOU JUST FOCUS ON ONE TIRE AND PUMP UP THAT TIRE, YOUR OTHER THREE TIRES ARE STILL FLAT AND THE CAR WON'T BE FUNCTIONAL. AND THAT REALLY GETS US MOVING INTO THINKING ABOUT PAIN MANAGEMENT FROM A MULTIMODAL PERSPECTIVE. AND I'LL SHOW YOU THIS MENU THAT -- THIS IS ANOTHER SHARED DECISION AID FROM OUR OPTI STUDY THAT WE HAND PATIENTS AND LOOK AT TOGETHER AND THEY ARE PICKING OUT THINGS FROM EACH OF THE FOUR QUADRANTS, BEHAVIORAL HEALTH, PHYSICAL MODALITIES, PROCEDURE AND MANUAL THERAPIES, MEDICATION THAT THEY MAY ALREADY BE DOING, WHICH IS A MOMENT THAT WE CAN VALIDATE THEIR SUCCESS AND THEY WILL ALSO USE THIS TO THINK ABOUT OTHER MODALITIES THAT THEY WOULD LIKE TO ADD TO THEIR PAIN MANAGEMENT REPERTOIRE AND THAT'S MOVING US TOWARD PAIN CARE PLANNING. REPERTOIRE. ALL THOSE WONDERFUL THINGS THAT PATIENTS ARE DOING BUT THEY DON'T REALIZE THAT IT'S PAIN MANAGEMENT THE GARDENING AND THE BOWLING AND THE DANCING. SO THOSE THINGS ARE IN THE PAIN CARE PLAN AS WELL BUT THEY'RE NOT ON THIS LIST. THAT'S -- THIS IS A COLLABORATIVE PROCESS. THERE IS ONE FUNNY THING THAT IT'S NOT YOUR GOALS FOR YOUR PATIENTS. IT'S THEIR GOALS. SO WE HAD TO CHANGE THE WAY WE WERE WORKING WITH PATIENTS. WE WANTED TO EMPHASIZE SELF-MANAGEMENT GOALS, GOALS THAT DIDN'T NECESSARILY RELY ON THE CLINICIAN OR HAVING AN APPOINTMENT. AND WE WANTED TO USE THIS CONCEPT OF SMART GOAL PLANNING. GOALS THAT WERE ALIGNED WITH PATIENTS' VALUES. SO WHAT IS A SMART GOAL? FIRST OF ALL, A GOAL IS SOMETHING THAT A PATIENT IS NOT ALREADY DOING. THAT SEEMS OBVIOUS BUT IT'S ACTUALLY IMPORTANT THAT WE'RE ASKING PATIENTS TO STRETCH A LITTLE. IN THIS PAIN CARE PLANNING PROCESS. SMART GOALS IS A GOAL THAT'S SPECIFIC. IT'S MEASURABLE. IT'S ATTAINABLE OR ACHIEVABLE. IT'S RESULTS-FOCUSED AND IT'S TIME-FOCUSED. AND SOME EXAMPLES ARE GO TO PHYSICAL THERAPY ONCE A WEEK. ENGAGE IN A MEDITATION CLASS. GO TO AA MEETINGS TWO TIMES A WEEK. SODAS ARE A BIG DEAL AND CUT BACK ON SODAS FROM SIX TO ONE DAY. THESE ARE SMART GOALS THAT ARE VERY SPECIFIC. SO THIS IS AN EXAMPLE OF A PAIN CARE PLAN THAT WE WOULD HAVE DEVELOPED AND ACTUALLY ONE OF OUR PAIN CARE PLANS. WE SORT OF DIVIDE OUR PLANS TO OPIOID RISK REDUCTION ITEMS AS WELL AS NON-OPIOID STRATEGIES. ILL SURE I WOULD DO THAT BETWEEN IN THE FUTURE. BUT ESSENTIALLY IT'S THINGS LIKE USE ANTI-INFLAMMATORY AND THE TOPICAL PAIN CREAM INSTEAD OF THE MID-DAY OXY CODON. GET A KIT TO PREVENT AN OVERDOSE. AND WE ALREADY MENTIONED SOME OF THESE OTHER THINGS. SO I'LL JUST GO BACK TO THIS BECAUSE AS WE THEN WENT TO START TO LOOK AT SOME OF OUR PRELIMINARY RESULTS, WHICH I WILL PRESENT TO YOU, YOU CAN SEE WE HAVE 100 OF THESE. AND ONE OF THE CHALLENGES THAT WE'VE HAD REALLY IN LOOKING AT OUR DATA IS TRYING TO CATEGORIZE ALL OF THESE DIFFERENT GOALS SO THAT WE CAN FOLLOW AND DETERMINE WHETHER PATIENTS ARE ACTUALLY MEETING THEIR SMART GOALS NOT IN THE COURSE OF THIS STUDY. SO LIKE SAID, WE HAVE ENROLLED 100. WE'RE STILL FOLLOWING UP OUR LAST FOLKS. SO WE DID START TO PRELIMINARILY LOOK AT OUR DATA AND I AM GOING TO SHOW YOU THE RESULTS FROM A RANDOM SUBSAMPLE OF 44 TRIAL COMPLETERS. SO 89% OF OUR SAMPLE IS MALE. I APOLOGIZE THE VA LARGELY MALE. AND SO WE DID OUR BEST. BUT CLEARLY WE NEED TO LOOK AT MORE WOMEN. MEAN AGE OF 62. 40% ARE NON-WHITE ETHNIC MINORITIES. 57% HAD A DEBATE AND 70%. THESE ARE ALL PATIENTS WITH CHRONIC PAIN WHO HAVE HISTORY OF OPIOID MISUSE BUT 70 PERCENT OF THEM HAD MENTAL HEALTH COMORBIDITIES, INCLUDING DRUG AND ALCOHOL ABUSE ISSUES. SO WHAT WE FOUND WAS THAT IN PARTICIPANTS WHO RECEIVED -- THIS IS ALL PARTICIPANTS IN BOTH ARMS -- IN PARTICIPANTS WHO RECEIVED PAIN CARE PLANNING PLUS -- I'M SORRY. I'M TELLING BUT THE INTERVENTION ARM FIRST. IN PARTICIPANTS WHO RECEIVED PAIN CARE PLANNING PLUS FOUR MOTIVATIONAL COACHING SESSIONS ARE PAIN INTERFERENCE WAS SIGNIFICANTLY DECREASED BY 12 WEEKS AND WAS MAINTAINED AT 20 WEEKS. IN OUR CONTROLS WHO RECEIVED THE PCP-DELIVERED PAIN CARE PLANNING PLUS 4 NEUTRAL TELEPHONE CHECK-IN SESSIONS WE SAW NO SIGNIFICANT DECREASE IN PAIN INTERFERENCE UNTIL RIGHT WHEN WE HIT THE 20-WEEK MARK AND WE DID A WITHIN GROUP CHANGE THERE. WE HAVE NOT SEEN ANY SIGNIFICANT CHANGES YET IN THIS MEASURE CURRENT OPIOID MACE USE MEASURE INDICATING THAT THERE HAS BEEN NO CHANGE IN OPIOID MUSE USE IN EITHER ARM BY SELF-REPORT. BUT WE HAVE NOT LOOKED AT THE URINE DRUG SCREENS OT IN ADDICTION BEHAVIOR CHECKLISTS AND WE HAVE NOT LOOKED AT CHANGE IN THE ACTUAL DOSES THAT PATIENTS ARE ON IN TERMS OF THEIR OPIOIDS. SO AS I WAS MENTIONING, I SHOWED YOU THOSE PAIN CARE PLANS AND YOU COULD IMAGINE 100 OF THOSE AND HAVING TO ACTUALLY CATEGORIZE THOSE WERE A PROBLEM BUT YET AN OPPORTUNITY FOR OUR GROUP TO, I THINK, GO AS STEP FURTHER. IT WOULD BE -- I'D BE INTERESTED IN THE DISCUSSION TIME TO TALK ABOUT THIS. WHAT WE DID WAS WE CATEGORIZED OUR NON-PHARMACOLOGICAL BASE STRATEGIES INTO TWO AREAS. COMPLEMENTARY AND INTEGRATIVE HEALTH STRATEGIES AND NON-COMPLEMENTARY AND INTEGRATIVE HEALTH STRATEGIES WITHIN THOSE TWO CATEGORIES THERE WERE FURTHER SUBCATEGORIZATIONS INTO STRUCTURED AND PATIENT-DIRECTED ACTIVITIES BASED ON EVERYTHING I TOLD BUT THE OPTI STUDY. PSYCHE HOW THAT ACTUALLY BECOMES APPLICABLE. JUST BY WAY OF EXAMPLE. I WANTED TO GIVE YOU EXAMPLES OF WHAT PATIENT-DIRECTED ACTIVITIES WERE. SO STRUCTURED ACTIVITIES MIGHT BE TAKING A YOGA CLASS OR DOING ACUPUNCTURE, PATIENT-DIRECTED PATIENTS MIGHT BE MEDITATING AT HOME OR DEEP FLARES. NON-STRATEGIES COMPLEMENTARY INTEGRATIVE HEALTH STRATEGIES, EXAMPLES OF STRUCTURED PHYSICAL THERAPY OR ENGAGING IN COGNITIVE BEHAVIORAL THERAPY FOR PAIN. WALKING, GARDENING, ALL NON-PHARMACOLOGICAL BASED STRATEGIES. WE'VE DONE WORK ON DEVELOPING THIS TAXONOMY WHICH WILL ALLOW US TO LINES OUR RESULTS BETTER. SO WHAT WE DID FIND AND REALLY REALIZED THAT IT'S THAT BASELINE PRIMARY CARE VISIT THAT I THINK HAS BEEN REALLY IMPORTANT IN THAT IN 44 COMPLETERS BOTH ARMS THAT RECEIVED THE PAIN CARE PLANNING AT BASELINE DEMONSTRATED HIGH RATES OF ENGAGEMENT IN ONE OR MORE NON-PHARMACOLOGICAL PAIN MANAGEMENT STRATEGIES. IT'S REALLY QUITE A LOT ACTUALLY. BUT THERE IS NO DIFFERENCE BETWEEN OUR TWO ARMS. AND WHAT WE DID NOTICE IS THAT THOSE IN THE INTERVENTION AND THOSE RECEIVING TELEPHONE COACHING ACTUALLY WERE MORE LIKE, SIGNIFICANTLY MORE LIKELY TO ENGAGE AND MAINTAIN A COMPLEMENTARY INTEGRATIVE HEALTH MODALITY. SO THERE IS SOMETHING ABOUT THAT MOTIVATIONAL COACHING THAT'S HELPING MOVE PEOPLE A LITTLE BIT MORE IN THE REALM. BUT OBVIOUSLY WE HAVE A LOT -- WE HAVE TO COMPLETE OUR ANALYSIS THERE. SO I AM GOING TO, IN THE INTEREST OF TIME, SKIP OVER THIS. BECAUSE I THINK REALLY WHAT WE WILL NEED TO DO IS PRESENT OUR FULL ANALYSIS AND I THINK THAT WILL BE INTERESTING. THESE RESULTS WERE PRELIMINARY. I AM GETTING SHORT ON TIME SO I AM GOING TO GO THROUGH AND WHAT I WANT TO DO HERE IS GIVE YOU A BRIEF PEEK AT HOW THE OPTI STUDY THAT WAS CONDUCTED ACTUALLY INFORMED A LOT OF THE PRACTICES IN OUR INTEGRATED PAIN TEAM CLINIC WHICH STARTED ABOUT ONE YEAR INTO THE OPTI STUDY. SO I WAS ABLE TO DEVELOP A LOT OF THESE DIFFERENT STRATEGIES FOR THE OPTI STUDY AND IMPLEMENT THEM IN OUR INTEGRATED PAIN TEAM CLINIC AT THE SAN FRANCISCO VA. SO BRIEFLY OUR INTEGRATED PAIN TEAM IS AN INTERDISCIPLINARY CO-LOCATED TEAM OF PROVIDERS AND MD, NURSE PRACTITIONER, PAIN PSYCHOLOGISTS, PAIN PHARMACISTS WITH READY ACCESS TO PAIN, PHYSICAL THERAPY AND INTEGRATIVE NUTRITION. THAT IS EMBEDDED IN OUR PRIMARY CARE CLINIC AT THE SAN FRANCISCO VA WITH VIDEO TELEHEALTH OUT TO OUR RURAL COMMUNITY-BASED OUTPATIENT CLINICS IN RURAL NORTHERN CALIFORNIA. WE V TELL TO TREE OF THOSE ON DIFFERENT DAYS. OUR PATIENTS WHO ARE REFERRED ARE REFERRED BY OTHER COLLEAGUES AND PRIMARY CARE. WE HAVE A VERY LARGE PRIMARY CARE CLINIC. WHO ARE REFERRED FOR COMPLEX CHRONIC PAIN AND PROBLEMATIC OPIOID USE. AND FOR HAVING COMPLICATED MENTAL HEALTH CO-MORBIDITIES. THEY ARE THERE FOR SHORT TERM MANAGEMENT AND THEN WE ARE SUPPOSED TO OPTIMIZE PATIENTS' PAIN CARE AND REFER THEM BACK TO OUR PRIMARY CARE COLLEAGUES. SO OBVIOUSLY, WE USE BIOSOCIAL APPROACH. WE FOCUS ON ALL THE THINGS WE WERE IN OPTI IMPROVING FUNCTION AND QUALITY OF LIFE. I USE THAT FOR OUR PATIENTS WHO HAVE CHRONIC PAIN BUT PRETTY HEAVY DUTY OPIOID USE DISORDERS AS WELL. AND OF COURSE WE'RE USING MOTIVATIONAL INTERVIEWING AND SHARED DECISION OR IN PAIN CARE PLANNING, WHICH COMES DIRECTLY OUT OF THE OPTI STUDY AND IS NOW BEING USED FOR ALL OF OUR PATIENTS IN THE INTEGRATED PAIN TEAM CLINIC. NOW, ABOUT A YEAR AFTER THAT, WE WERE FORTUNATE TO RECEIVE MORE FUNDING FROM VA QUERY TO CONDUCT QI IN THE INTEGRATED PAIN TEAM. I AM SO GOING TO GIVE YOU A QUICK PEEK AT SOME OF THOSE QI RESULTS THAT WE'VE GOTTEN FROM THAT FUNDING AND THAT STILL IS AN ONGOING PROJECT. SO OUR FIRST PROJECT WAS BASICALLY TO START ABOUT NINE MONTHS AGO WE STARTED DOING BASELINE ASSESSMENTS ON ALL PATIENTS COMING INTO OUR INTEGRATED PAIN TEAM CLINIC. MOSTLY AT THE SAN FRANCISCO VA PRE AND POST. THEY HAD THREE INTEGRATED PAIN TEAM VISITS WITH US. USUALLY PATIENTS COME AND STAY ANYWHERE FROM COUPLE OF WEEKS TO SIX MONTHS MORE OR LESS. AND WE DID NOTICE THAT IN THE INTEGRATED CLINIC, WE DID GET A DECREASE ON THE CURRENT OPIOID MICE MEASURE THAT WAS SIGNIFICANT EVEN IN THE SMALL NUMBER OF PARTICIPANTS AND THIS IS BY SELF-REPORT. WE NOTICED DECREASE -- INTERFERENCE, CATASTROPHIZING. WE HAVE NOT SEEN ANY IMPROVEMENTS IN OUR PAIN TREATMENT SATISFACTION MEASURE BUT IT'S A STRANGE MEASURE THAT WE NEED TO WORK ON. MAYBE OUR OUR PATIENTS ARE NOT SATISFIED WITH US IS JUST WHAT WE NEED TO ACCEPT. SO WE DID ANOTHER. WE HAD ANOTHER PART OF THIS QUALITY IMPROVEMENT PROJECT THAT ALLOWED US TO ACTUALLY COMPARE PATIENTS IN OUR INTEGRATED PAIN TEAM CLINIC WITH MATCHED CONTROLS, IF YOU WILL, IN USUAL CARE USING A VA OPIOID DASHBOARD. AND WHAT I AM GOING TO SHOW YOU HERE IS THREE IN SIX MONTHS WE FOUND HUGE DECREASES IN THE DAILY DOSE OF MORPHINE EQUIVALENT BUT IN THEIR OPIOID DOSES AT THREE MONTHS THEY HAD A 61% DECREASE IN OPIOID USE. AT SIX MONTHS OVER 100% DECREASE. WHICH THE ODDS RATIOS WERE STRIKING SHOWING THAT THE LONGER PATIENTS STAY WITH US IN THE INTEGRATED PAIN TEAM CLINIC, MOTOR LIKELY THEY ARE TO REDUCE THEIR DAILY OPOID DOSE AS WELL AS KIT DISTRIBUTION IN THE INTEGRATED PAIN TEAM FINALLY WE HAD SOME QUANTITATIVE DATA. THIS WAS A MIXED METHODS QI PROJECT. THE BOTTOM LINE IS BASICALLY OUR STAKE HOLDERS ARE VERY HAPPY WITH THE SERVICES IN THE CLINIC, PARTICULARLY BECAUSE IT REDUCES A LOT OF THESE EMOTIONALLY CHARGED INTERACTIONS BETWEEN PCPS AND PATIENTS AND WITH THE LARGER PRIMARY CARE TEAMS BECAUSE IT'S REALLY THE CLERKS AND THE NURSES OFTEN THAT GET THE BRUNT OF THE PATIENT CALLING ON THE PHONE COMPLAINING THAT THEIR OPIOIDS ARE NOT BEING FILLED. WHAT WE DID FIND -- AND THIS IS VERY IMPORTANT -- IS THAT I THINK OFTEN IS OFTEN UTILIZED BY CLINICIAN THAT'S DON'T HAVE HIGH SELF-EFFICACY IN TERMS OF THEIR ABILITY TO WORK WITH CHRONIC PAIN PATIENTS SO THEY REFER THEM AND WHAT'S HARD IS DOING THE WARM HANDOFF OF THE PATIENT BACK TO THOSE PRIMARY CARE PROVIDERS AND WE REALLY, AS A TEAM, WE NEED TO DO A BETTER JOB EMPOWERING PRIMARY CARE PROVIDERS AT LARGE OUR SYSTEM TO BE ABLE TO MANAGE THESE PATIENTS. SO THIS WAS REALLY IMPORTANT FOR US TO LOOK IN THE MIRROR AND SEE THESE DATA COME BACK. SO THIS IS LEADING ME TO FUTURE DIRECTIONS FOR WHOLE-HEALTH PAIN CARE. AND I LOVE THIS. SIR WILLIAM OSLER IS SORT OF LIKE DES CARTS. THEY GOT IT BACK THERE. THE GOOD PHYSICIAN TREATS THE DISEASE. THE GREAT PHYSICIAN TREATS THE PATIENT WHO HAS THE DISEASE. I LOVE THAT QUOTE. AND THIS BRINGS TO US OUR VA CIRCLE OF WHOLE HEALTH, WHICH I AM SURE YOU HAVE SEEN MANY, MANY TIMES. AND HOW WE USE THIS FOR THOSE OF YOU WHO HAVEN'T SEEN IT, IS REALLY WE START WITH ME AT THE CENTER. AND WE TRY TO CREATE MORE AWARENESS IN OUR PATIENTS OF THESE EIGHT DIMENSIONS OF WHOLE-HEALTH. WORKING YOUR BODY, ENERGY, STRENGTH, FLEXIBILITY, THINK TO YOURSELF. WE ASK OUR PATIENTS ON A SCALE FROM 1 TO 5 WHERE ARE YOU NOW WITH WORKING YOUR BODY, WITH YOUR SURROUNDINGS WITH YOUR PERSONAL DEVELOPMENT, WITH YOUR FOOD AND DRINK? WITH YOUR SLEEP? WITH FAMILY? FRIENDS, CO-WORKERS AND YOUR INTERPERSONAL RELATIONSHIPS, WITH YOUR SPIRIT AND SOUL. WITH FEELING LIKE THERE IS SOMETHING BIGGER THAN YOU OUT THERE? WITH THE POWER OF MIND? WITH THE ABILITY TO REDUCE YOUR OWN STRESS? WHERE ARE YOU ON A SCALE OF 0 TO 5? THEN WE ASK THEM WHERE DO YOU WANT TO BE? THAT'S ACTUALLY DOING THE PERSONALIZED HEALTH INVENTORY, WHICH TAKES US FORWARD, REALLY INTO SORT OF AN AWARENESS THAT'S FUNDAMENTAL TO HOW PATIENTS ARE ACTUALLY -- I'LL GO BACK -- GOING TO BE ABLE TO INTERACT WITH THEIR HEALTHCARE COMMUNITY, BOTH CONVENTIONAL PROVIDERS AS WELL AS COMPLEMENTARY INTEGRATIVE HEALTH PROVIDERS IN TERMS OF PREVENTION AND TREATMENT AND THEN HOW THAT'S GOING TO AFFECT THEIR RELATIONSHIP IN GENERAL IN THEIR COMMUNITIES. AND YOU CAN SEE THESE CIRCLES. SO WITH WHOLE-HEALTH, THE APPROACH DOES CHALLENGE BOTH THE BIOMEDICAL AND I WOULD SAY THE CHRONIC CARE MODEL, WHICH ARE FOUNDED MODELS. BOTH OF WHICH STILL REMAIN DISEASE-FOCUSED AND OVERRELIANT ON PRESCRIPTIONS AND THE MEDICAL SYSTEM. SO WHOLE HEALTH EMPHASIZES WELLNESS, IMPROVED FUNCTIONING AND QUALITY OF LIFE. BY PROMOTING THESE PATIENT-DIRECTED. REMEMBER THE BOWLING AND GARDENING, SELF-MANAGEMENT ACTIVITIES THAT ENGAGE BOTH BODY AND MIND AND HEALING AND DISEASE PROFESSION -- PREVENTION. SO WHOLE HEALTH PROVIDERS ARE COACHES AND REALLY IT TAKES A TEMPORARY, WHOLE HEALTH TEAM, CAN ACTIVATE PATIENTS THAT STARTING THIS PROCESS OF GREATER SELF-AWARENESS THROUGH THAT PERSONAL HEALTH INVENTORY THAT I JUST SHOWED YOU. DEVELOPING A PERSONALIZED HEALTH LAN, WHICH ACTUALLY THE PHP IS VA'S VERSION OF THIS BUT SOUNDS VERY SIMILAR TO OPTI, SO WE'RE ALL KIND OF CONVERGING AT THIS POINT REALLY FOCUSED ON ACHIEVING SMART GOALS. AND USING PERSONALIZED HEALTH COACHING TO HELP PATIENTS ACTUALLY ACHIEVE THEIR VALUES AND GOALS. SO I HAVE TO ADMIT THAT I DID RESPOND TO THE FOA THAT WAS PUT OUT THERE. AND I AM REALLY EXCITED ABOUT IT BECAUSE WE ARE PROPOSING TO BASICALLY TAKE THE BEST OF OPTI AND THE BEST OF OUR INTEGRATED PAIN TEAM CLINIC AND CREATE A WHOLE HEALTH TEAM APPROACH THAT REALLY EMPHASIZES COLLABORATIVE NON-PHARMACOLOGICAL PAIN SELF-MANAGEMENT THAT FOCUSES ON IMPROVING FUNCTIONING AND QUALITY OF LIFE. AND ESSENTIALLY WHAT WE'RE PROPOSING IS A HIGHLY PRAGMATIC RANDOMIZED CONTROL TRIAL THAT WOULD BE WHERE ELEMENTS ARE PILOTED FIRST IMPLEMENTED IN REAL PRIMARY CARE SETTINGS BUT IN FOUR DIFFERENT VA SETTINGS AROUND THE COUNTRY. AND WE WANT TO COMPARE TWO APPROACHES AND WE WOULD HAVE A PARALLEL PROCESS EVALUATION AS WELL AS BUDGET IMPACT ANALYSIS BECAUSE I THINK WE HAVE TO ACKNOWLEDGE THAT A WHOLE HEALTH TEAM IS A MUCH GREATER, MORE INTENSIVE INTERVENTION THAN WHAT IS STANDARDLY UTILIZED IN VA RIGHT NOW, WHICH IS MORE LIKE PRIMARY CARE GROUP EDUCATION OR INDIVIDUAL EDUCATION IN TERMS OF PAIN AND OPIOID MANAGEMENT. THAT'S REALLY WHAT WE'RE DOING FOR OUR PATIENTS RIGHT NOW. SO WE HAVE TO SEE IF, WHEN WE GET MORE INTENSIVE, THAT'S REALLY FEASIBLE, IF WE CAN AFFORD AND THEN IF WE CAN, WE WANT TO LEARN ABOUT THAT PROCESS SO THAT WE CAN THINK ABOUT SCALING IT AND DISSEMINATING IT WIDELY THROUGHOUT VAS IN THE COUNTRY. SO BACK TO OUR CAR WITH FOUR FLAT TIRES. FOR VETERANS WITH COMPLEX CHRONIC PAIN CONDITIONS, I THINK IT'S REALLY URGENT THAT WE DEVELOP PRAGMATIC APPROACHES TO WORKING WITH THESE PATIENTS THAT ARE SELF-DIRECTED MULTIMODAL AND REALLY FOCUS ON IMPROVING THEIR HEALTH AND WELLNESS OVERALL AND IT REALLY REFLECT WHAT MATTERS MOST TO THEM IN THEIR LIVES BECAUSE ULTIMATELY THAT IS WHAT THEY WILL DO. AND I WILL LEAVE YOU WITH THIS QUOTE BETWEEN STIMULUS AND RESPONSE THERE IS A SPACE. AND IN THAT SPACE, IS OUR POWER TO CHOOSE OUR RESPONSE AND IN OUR RESPONSE IS OUR GROWTH AND OUR FREEDOM. SO THANK YOU VERY MUCH. [APPLAUSE] >> WONDERFUL WORK. WE HAVE ROOM FOR A LITTLE LONGER. SO GIVE US FIVE MINUTES FOR SOME QUESTIONS BEFORE WE DISBAND, QUESTIONS FOR DR. SEAL. >> THANK YOU VERY MUCH. I LOVE YOUR CAR TIRE AND I WAS LOOKING AT HOW YOU BROKE DOWN THE FOUR TIRES AND I THOUGHT IT WAS VERY INTERESTING BECAUSE WHEN WE ARE THINKING ABOUT -- -- [INAUDIBLE] BECAUSE BODY-DRIVEN INTERVENTIONS AND THEN YOU HAVE BEHAVIORAL -- [INAUDIBLE]. I AM WONDERING ARE YOU SUGGESTING THAT FOR ANY SUCCESS OF PHARMACOLOGICAL, I WONDER WERE -- IN WHICH CASE WE ALMOST HAVE TO THINK ABOUT THE DIFFERENT KINDS OF MIND-BODY INTERVENTION. COULD BE INTEGRATED TO BE BIGGER. THEY HAVE TO CARRY OUT ALL THREE OF THEM. IS THERE ANY EVIDENCE FOR THAT OR MAYBE YOU ARE STILL WAITING FOR IT? WHERE YOU COULD TARGET ONE OF THE TIRES OR TWO OF THE TIRES OR >> THREE TIRES IF IT'S A TRICYCLE. >> I THINK WE NEED A MECHANIC HERE. I DON'T KNOW WHAT WOULD MAKE THAT CAR GO. I DON'T THINK THERE IS ANY EVIDENCE THAT I AM AWARE OF THAT YOU NEED ALL FOUR TIRES FILLED. AND WE PUT THAT OUT THERE BECAUSE REALLY PATIENTS ARE SO FOCUSED ON THE MEDICATION PIECE, REALLY COMING RIGHT TO THE BIOMEDICAL MODEL. AND SO WHAT WE'RE REALLY TRYING TO DO IS HAVE THEM ACTUALLY SEE A VISUAL IN WHICH THEY COULD IMAGINE DOING A BEHAVIORAL HEALTH INTERVENTION OR EXERCISE FOR THEIR CHRONIC PAIN OR ACUPUNCTURE, WHICH WILL BE A PROCEDURE, A MASSAGE, WHICH ARE EVIDENCE-BASED, RIGHT? SO EACH OF THESE COMPONENTS HAS EVIDENCE. ILL NOT SURE -- I THINK THERE IS EVIDENCE WE KNOW THAT LIKE SAID WITH MEDICATION, NOT ONE OF THESE PARTICULAR THINGS IS GOING TO BE FULLY EFFECTIVE WITH SEVERE CHRONIC PAIN SO I THINK THERE IS EVIDENCE THAT YOU DO HAVE TO HAVE A MULTIMODAL APPROACH. AND WE DON'T REQUIRE PATIENTS HAVE AN ACTIVITY IN ALL FOUR QUADRANTS WE WANT THEM TO BE MOVING TOWARD MULTIMODAL AND NOT JUST ONE. >> DR. RYDER? >> SO I AM WONDERING WAS THERE AN IMPACT OF THE OPIOID SAFETY INITIATIVE IN TERMS OF IMPROVEMENT FOR THE OPTI STUDY? WAS THAT IMPACT AT ALL? AND THEN IF YOU HAVE TIME, HOW DO YOU ADDRESS ALCOHOL PROBLEMS WITHIN THE STUDY WHEN PEOPLE SAY WELL, ALCOHOL REALLY HELPS MY PAIN A LOT. IT REALLY HELPS MY PAIN THE MOST. HOW DO YOU ADDRESS THAT? >> SO IN TERMS OF FOR THOSE OF YOU WHO AREN'T AWARE THE OPIOID SAFETY INITIATIVE. VA HAS A LARGE INITIATIVE THAT BASICALLY SUPERSEDES ALL OF THIS AND IS REALLY DRIVING PRIMARY CARE FLOWERS WANT TO START TAPERING OPIOIDS, REIGNING IN AND SO WE WERE ABLE TO ADVERTISE THE OPTI STUDY AS POTENTIALLY A SOLUTION FOR SOME OF THEM TO REFER THEIR PATIENTS, EVEN THOUGH IT'S RANDOMIZED TO TWO DIFFERENT ARMS SO REFER THEIR PATIENTS TO ACTUALLY GET SOME OF THE HELP THEY NEED SO THEY COULD BE IN BETTER COMPLIANCE. SO I THINK THE DOVE TAILING WAS FRANKLY HELPFUL AND WE STRUGGLED A LITTLE BIT INITIALLY WITH RECRUITMENT BUT IT DID PICK UP AND THAT WAS ONE OF THOSE VERY NICE ECOLOGICAL MOMENTS WHERE WE HAD THE ENVIRONMENT HELPING OUR STUDY. IN TERMS OF ALCOHOL, ALCOHOL IS A BIG PROBLEM FOR US. AND A LOT OF THE SMART GOALS, SOME OF THE SMART GOALS ACTUALLY RELATE TO ALCOHOL. WE ALSO REFER, FOR TREATMENT, SO IF A PATIENT IS DRINKING AND THEY'RE NON-TREATMENT YES, ATTEMPT TO REFER FOR ADDICTION SERVICES. AT OUR VA, WE'RE VERY LUCKY IN THAT A LOT OF THOSE ARE GROUNDED IN HARM REDUCTION. SO SOMEBODY CAN BE DRINK COMING STILL GO TO A LOW-THRESHOLD GROUP, WHICH SOME OF THEM HAVE STARTED TO GO THROUGH THROUGH THE OPTI STUDY. >> A BIG CHALLENGE THAT YOU ARE CLEARLY DESCRIBING IS THE EDUCATION OF THE PRIMARY CARE PROVIDER. WHAT ARE YOUR STRATEGIES FOR BUILDING THE SELF-EFFICACY OF THE PCP, AS YOU DEVELOP THIS NETWORK OR WHOLE-HEALTH APPROACH? >> YEAH. WELL, THAT'S A REALLY GOOD QUESTION. SO THESE DATA JUST CAME TO US FROM OUR QI STUDY FOR OUR SHRINK AND WE HAVE BEEN GIVING SEMINARS, TALKS, WORKING WITH INDIVIDUALS, BUT THAT IS A CHALLENGE. WE'RE STRUGGLING WITH HOW WE CAN DO IT BETTER ON A LARGER SCALE. AND I THINK IT'S JUST MORE AND MORE. BUT IT'S ALSO THE AS WE WORK WITH INDIVIDUAL PCPS PATIENT IS FINDING WAY TO GIVE THOSE PATIENTS AND DO BETTER WITH WHAT'S CALLED THE WARM HANDOFF. IT'S ONE-BY-ONE IN OUR SYSTEM BUT THAT IS REALLY TELLING THEM WHAT OUR APPROACH IS AND HELPING THEM CARRY FORWARD IN TERMS OF LONG TERM MANAGEMENT AND NOT JUST SO AFTER -- SORT OF SAYING HERE IS THE PATIENT BACK BUT BEING WILLING TO ALSO HOLD THEIR HAND IN THE JOURNEY AS THEY START THE LONG TERM MANAGEMENT THAT HAVE PATIENT TO GIVE THEM THEM SORT OF LOWER-LEVEL SUPPORT WITHOUT FULLY TAKING OVER PRESCRIBING. >> SO ONE LAST QUESTION FOR MY OWN EXPERIENCE AS A PRIMARY CARE PROVIDER WAS IN NEW YORK CITY IN THE 70'S WHEN WE WERE IN THE MIDDLE OF A HEROIN EPIDEMIC AND METHDONE MAINTENANCE FIRST ARRIVED. WHAT ARE YOUR THOUGHTS ABOUT THE CO-MANAGEMENT OF OPIOID USE DISORDER AND CHRONIC PAIN AND MEDICATION-ASSISTED THERAPY, IT'S METHDONE? >> THAT'S A REALLY GREAT QUESTION. AND I ALSO STARTED OUT THIS WHOLE JOURNEY WORKING WITH PATIENTS AT NEEDLE EXCHANGES WHO WERE ADDICTED TO HEROIN. THAT'S HOW I GOT INTO THIS AND I WAS SHARING WITH DR. RYDER THAT I WAS AT NEEDLE EXCHANGE. IT'S INTERESTING HOW A LOT OF US COME TO THIS. I AM A FIRM BELIEVER IN THE FACT THAT SOME PATIENTS WHO HAVE CHRONIC PAIN AND OPIOID USE DISORDER ACTUALLY NEED TO BE ON ASSISTED THERAPY AND PARTICULARLY IN OUR PATIENTS WHO ARE ON OVER100 MORPHINE EQUIVALENCE DAILY DOSE WHO BECOME PHYSICALLY DEPENDENT AND WHO HAVE DEVELOPED ADDICTION TO THE MEDICATION I THINK ARE BEST SERVED WITH EITHER METHDONE AND NOW SUBOXONE. AND WAY THAT WE REALLY LOOK AT THIS IN TERMS OF A FRAMEWORK IS FOR INTEGRATED PAIN TEAM, WE TAKE PATIENTS WHO WITH A CAPITAL P, WHERE CHRONIC PAIN IS REALLY THE BIGGEST ISSUE AND ADDICTION, AS LITTLE A, MIGHT BE SECONDARY TO THE CHRONIC PAIN. AND IN THOSE PATIENTS WHO HAVE CHRONIC PAIN AND DO HAVE OPIOID MISUSE ISSUES, WE WILL DISCUSS THE USE OF SUBOXONE AS A MEDICATION-ASSISTED THERAPY. IF WE HAVE A PATIENT WHO COMES TO US THAT REALLY IS LITTLE P, BIG A ADDICTION, THOSE PATIENTS HONESTLY I THINK ARE BETTER MANAGED IN AN ADDICTION-FOCUSED SETTING AND SO WE WILL ROUTINELY SEND THOSE PATIENTS TO OUR ADDICTION SERVICES AND WE WILL FOLLOW ALONG SECONDARILY TO MANAGE THEIR CHRONIC PAIN. >> OKAY. WELL THANK YOU AND THAT'S -- LET'S ALL THANK DR. SEAL FOR HER WORK AND HER WONDERFUL TALK.