WELCOME TO THE SECOND LECTURE IN THE SPRING'S INTEGRATIVE RESEARCH LECTURE SERIES SPONSORED BY THE NATIONAL SENT FOR INTEGRATED COMPLIMENTARY H. OUR TOPIC IS MANAGING CHRONIC PAIN AND PRIMARY CARE AND I CAN THINK OF NO TOPIC MORE RELEVANT CURRENTLY, IT IS MY GREAT PLEASURE TO WELCOME DR. ERIN KREBS. DR. KREBS RESEARCH FOCUSES ON CHRONIC PAIN MANAGEMENT AND PRIMARY CARE, CONDUCTING HEALTH SERVICES RESEARCH AT THE MINNEAPOLIS VETERANS AFFAIRS CENTER FOR CHRONIC DISEASES OUTCOMES RESEARCH. SHE SHE'S ALSO ASSOCIATE PROFESSOR AT UNIVERSITY OF MINNESOTA AND INTERNIST WITH ACTIVE PRIMARY CARE PRACTICE AS WELL. DR. KREBS RECEIVED HER MEDICAL DEGREE AT THE UNIVERSITY OF MINNESOTA WHERE SHE ALSO COMPLETED HER RESIDENCY, SHE DID FELLOWSHIP TRAINING AT THE ROBERT WOOD JOHNSON CLINICAL SCHOLARS FOUNDATION AT THE UNIVERSITY OF NORTH CAROLINA. HER RESEARCH IS IF YOU BELIEVEDDED BY THE VA, OUR OWN INSTITUTE NCCIH AND THE PATIENT CENTERED OUTCOMES RESEARCH INSTITUTE, PCORI. AND MANY OF YOU MAY HAVE SEEN ABOUT SIX WEEKS AGO ON MARCH 8 DR. KREBS PUBLISHED A PAPER IN JAMA WITH HER COLLEAGUES THAT COMPARED EFFECTS OF OPIOID AND NON-OPIOID MEDICATIONS IN A GROUP OF PATIENTS AT THE VA CARE CLINICS WHO HAD MODERATE TO SEVERE BACK PAIN OR OSTEOARTHRITIS PAIN AND THOSE FINDINGS ARE INTRIGUING TO SHOW THAT NON-OPIOIDS WORKED BETTER OVER 12 MONTHS FOR PAIN RELATED FUNCTION RELATIVE TO THE OPIOIDS, AND THIS ARTICLE SURE MANY HAVE SEEN RECEIVED A LOT OF ATTENTION BY RESEARCH COMMUNITY, THE CLINICAL CARE COMMUNITY, OF COURSE THE MEDIA. AMONG DR. KREBS CURRENT PROJECTS SHE IS LEADING TWO OTHER CLINICAL TRIALS IN THE VA PATIENTS IN THE VA FOR PATIENTS RECEIVING LONG TERM OPIOID THERAPY FOR PAIN. AND JUST TO GIVE YOU A LITTLE BIT OF BACKGROUND ABOUT NCCIH, WE HAVE THE LEAD FEDERAL AGENCY FOR SCIENTIFIC RESEARCH ON USEFULNESS AND SAFETY OF COMPLIMENTARY AND INTEGRATIVE HEALTH PRACTICES. TWO TOP SCIENCE PRIORITIES ARE TO IMPROVE UNDERSTANDING OF PAIN AND IDENTIFY EFFECTIVE COMPLIMENTARY AND INTEGRATIVE HEALTH APPROACHES TO IMPROVE TREAT AND MANAGE PAIN AND PAIN IS THE NUMBER ONE REASONS AMERICANS DO TURN TO COMPLIMENTARY INTEGRATED HEALTH APPROACHES. PAIN AND OPIOID MANAGEMENT OF PAIN IS FRONT AND CENTER IN THE OPIOID CRISIS, NIH AND OTHER AGENCIES WITHIN THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ARE ALL COMING TOGETHER TO ADDRESS THIS CURRENT DEVASTATING PROBLEM THAT IS AFFECTING INDIVIDUALS, OUR COMMUNITY AND OUR COUNTRY. AND THREE WEEKS AGO NIH LAUNCHED THE HEAL INITIATIVE HELPING TO END ADDICTION LONG TERM, THAT INCLUDED MANY INITIATIVES NCCIH IS CONDUCTING INCLUDING PARTNERSHIP WITH THE VA AND THE DO D, DEPARTMENT OF DEFENSE AND THINKING ABOUT INTEGRATIVE NON-PHARMACOLOGICAL APPROACHES FOR THE MANAGEMENT OF PAIN. SO PRIMARY CARE CLINICIANS PLAY A CRIMINAL ROLE IN TREATING PAIN BUT THERE IS MUCH TO LEARN HOW TO BEST OPTIMIZE PAIN MANAGEMENT AND REDUCE RELIANCE ON OPIOID MEDICATIONS. DR. KREBS WILL SHARE HER PERSPECTIVE ON THIS CHALLENGE AS WE AS RELEVANT IDEAS AND RESEARCH FINDINGS FROM HER OWN RESEARCH. JOIN ME IN WELCOMING DR. ERIN KREBS. [APPLAUSE] >> HELLO. I'LL JUST APOLOGIZE IN ADVANCE, I'M GETTING OVER A COLD SO I HOPE I WON'T BE COUGHING DURING THIS TALK. SO JUST TO START WITH SOME DISCLOSURES, I'M SPEAKING FOR MYSELF, OBVIOUSLY NOT REPRESENTING THE US GOVERNMENT, THOUGH I AM A VA EMPLOYEE. I'LL JUST START WITH A FEW DEFINITIONS HERE. TODAY I'M TALKING ABOUT CHRONIC PAIN. CHRONIC PAIN IS TRADITIONALLY DEFINED MOST BASIC DEFINITION IS PAIN THAT PERSISTS FOR AT LEAST THREE TO SIX MONTHS. DEPENDING ON THE SPECIFIC DEFINITION CHRONIC PAIN IS THOUGHT TO AFFECT A FIFTH TO A THIRD OF U.S. ADULTS. SO OBVIOUSLY IT'S EXTREMELY COMMON. OF COURSE YOU CAN GUESS THAT A FIFTH TO A THIRD OF U.S. ADULTS DO NOT HAVE THE KIND OF LIFE LIMITING CHRONIC PAIN THAT IS THE FOCUS OF MOST OF OUR ENERGIES RIGHT NOW. MANY PEOPLE WITH CHRONIC PAIN ARE ABLE TO LIVE NORMAL LIVES, DESPITE THE PAIN. THE FOCUS OF THIS TALK AND MY RESEARCH IS REALLY PEOPLE WHO EXPERIENCE HIGH IMPACT CHRONIC PAIN. THAT'S DEFINED AS PAIN THAT'S SUBSTANTIALLY LIMITS LIFE ACTIVITIES, CHRONIC PAIN CONDITIONS, WE KNOW, ARE AMONG THE MOST COMMON CAUSES OF DISABILITY IN THE US. SO UNDOUBTEDLY A MAJOR PUBLIC HEALTH ISSUE. IN FACT, LOW BACK PAIN IS THE NUMBER ONE CAUSE OF YEARS LIVED WITH DISABILITY. SO WHEN I TALK ABOUT CHRONIC PAIN, I'LL DO SO IN A GENERIC FASHION. BUT KNOW THAT REALLY WHAT I'M TALKING ABOUT IS THIS KIND OF LIFE LIMITING CHRONIC PAIN, I'M SPEAKING GENERALLY BUT MOSTLY ABOUT THE COMMON CHRONIC PAIN CONDITIONS. BACK PAIN, NECK PAIN, JOINT PAIN, ARTHRITIS, THESE ARE THE THINGS THAT AFFECT MOST PEOPLE WHO DO HAVE CHRONIC PAIN DISABILITY IN THE US. MY SECOND FOCUS TODAY IS PRIMARY CARE. YOU ALREADY HEARD THAT I'M A PRIMARY CARE GENERAL INTERNIST. SO THIS IS REALLY WHAT INFORMS ALL OF MY WORK, I WOULD SAY. NOT EVERYONE REALLY NOSE WHAT PRIMARY CARE -- KNOWS WHAT PRIMARY CARE IS SO I'LL START WITH DEFINING IT. AND I WILL SAY THE PRIMARY AND PRIMARY CARE ISN'T JUST FIRST, IT'S NOT ABOUT TRIAGE, IT'S ABOUT THE MAIN APPROACH TO CARE. THE PRIMARY RESPONSIBILITY, THE MAIN FOCUS, PRIMARY CARE IS INTEGRATED, ACCESSIBLE HEALTHCARE, DELIVERED BY CLINICIAN WHOSE ARE RESPONSIBLE FOR ADDRESSING THE MAJORITY OF HEALTH NEEDS. AND DEVELOPING A SUSTAINED PARTNERSHIP WITH PATIENTS. AND PRACTICING IN THE CONTEXT OF FAMILIES AND COMMUNITY. BY DEFINITION, CHRONIC PAIN IS WHOLE PERSON-FOCUSED WHICH MAKES SENSE I THINK REALLY IMPORTANT FORUM FOR CHRONIC PAIN MANAGEMENT. INCREASINGLY PRIMARY CARE IS TEAM-BASED CARE. AT ONE POINT IN TIME PRIMARY CARE MAY HAVE BEEN DEFINED PRIMARILY BY SPECIALTY OF PHYSICIAN IN THE CLINIC, WHETHER IT'S FAMILY MEDICINE, GENERAL INTERNAL MEDICINE OR PEDIATRICS. BUT MORE AND MORE IN ADVANCED NEWER MODELS OF PRIMARY CARE LIKE THE MEDICAL HOME MODEL, OR IN VA, PATIENT ALIGNED CARE TEAMS, YOU HAVE THOSE PHYSICIANS SPECIALISTS WORKING ALONGSIDE AND TOGETHER IN TEAMS WITH OTHER CLINICIANS SUCH AS NURSE CARE MANAGERS, CLINICAL PHARMACISTS, PSYCHOLOGISTS, AND OTHER TEAM MEMBERS. I'LL JUST STOP AND MAKE A COUPLE MORE DISCLOSURES. FIRST AS YOU ALREADY HEARD, MOST OF MY VERGE FOCUSES -- RESEARCH FOCUSES ON OPIOIDS FOR CHRONIC PAIN AND MOST OF THE TIME I DO LECTURES I SPEND MY TIME TALKING ABOUT OPIOIDS FOR CHRONIC PAIN. SO IN CASE YOU'RE WONDERING WHY I'M GIVING AN INTEGRATIVE HEALTH SERIES LECTURE, I'M NOT GOING TO SPEND THIS HOUR TALKING ABOUT CHRONIC PAIN. I DO THINK IT'S IMPORTANT TO MAKE THESE DISCLOSURES BECAUSE WHAT I'M GOING TO TALK ABOUT IS A PROBLEM THAT WE HAVE WHICH IS I THINK OUR WHOLE WAY OF THINKING ABOUT PAIN CARE HAS BECOME VERY OPIOID CENTERED. I RECOGNIZE I'M A PRODUCT OF THAT OPIOID CENTERED APPROACH TO PAIN CARE, AND IN SOME WAYS THAT I PERPETUATE IT. BECAUSE I GO AROUND TALKING ABOUT OPIOIDS ALL THE TIME. AND THE MORE I DO THAT, I THINK THE MORE IT'S STRENGTHENS THAT CONNECTION IN EVERYONE'S MINDS, THAT IF WE'RE TALKING ABOUT PAIN, WE MUST BE TALKING ABOUT OPIOIDS. AND IF WE'RE THINKING ABOUT PAIN MANAGEMENT, WE MUST BE THINKING ABOUT OPIOIDS AS THE PRIMARY CORE WAY TO MANAGE CHRONIC PAIN. SO I WILL TALK ABOUT REFRAMING CHRONIC PAIN AWAY FROM THAT CONNECTION WITH OPIOIDS AT THE CENTER. FIRST I WILL TALK A LITTLE BIT ABOUT WHY WE NEED TO REFRAME. I'M SURE EVERYONE HAS SEEN A VERSION OF THIS SLIDE. IT IS AN OLD SLIDE, REALLY WHAT IT REPRESENTS IS THE BEGINNING OF WHAT WE NOW KNOW AS THE OPIOID EPIDEMIC. THE TOP LINE ON THE SLIDE SHOWS THE INCREASING OPIOID SALES FROM THE LATE '90s TO LATE 2000s. THIS SLIDE ENDS AROUND 2009 SO IT DOESN'T CAPTURE THE WAYS IN WHICH THE OPENOID EPIDEMIC HAS EVOLVED BUT I THINK THE WAYS IN WHICH IT STARTED IS REALLY RELEVANT RIGHT NOW. ALONG WITH THE INCREASE IN OPIOID SALES THAT YOU SEE, DUE TO EXPANDED INDICATIONS FOR OPIOIDS, OUR TENDENCY TO PRESCRIBE MORE OPIOIDS FOR MORE PEOPLE, MORE OFTEN FOR LONGER DURATIONS OF TIME IN HIGHER DOSE, YOU SEE THAT CONSEQUENCES THAT OCCURRED, THE INCREASE IN OPIOID OVERDOSE DEATHS DUE TO PRESCRIPTION OPIOIDS AND PRESCRIPTION OPIOID USE DISORDER TREATMENT ADMISSIONS. WHAT THIS CIRCLE REPRESENTS AT THE BOTTOM THERE IS MY FORMATIVE YEARS OF MEDICAL TRAINING. SO I WAS REALLY A STUDENT, A MEDICAL STUDENT, AND A RESIDENT DURING THE YEARS WHEN THIS TREND WAS TAKING OFF. THIS WAS A CHANGE THAT OCCURRED DURING MY TRAINING YEARS AND I HEARD THE MESSAGES ABOUT PAIN MANAGEMENT CHANGE DURING THAT TIME. IT WASN'T QUITE THIS WAY WHEN I START BUT THIS IS HOW I REPRESENT THE STATE OF PAIN CARE RIGHT NOW. YOU MAY OR MAY NOT BE ABLE TO TELL, RIGHT IN THE MIDDLE THOSE OPIOIDS, SO THIS IS MY ILLUSTRATION OF OPIOID-CENTERED PAIN CARE. CIRCLING AROUND OPIOIDS AT THE CENTER. WE HAVE OUR ORGANIZATION OF CLINICAL CARE. OUR HEALTH SYSTEMS, WE HAVE MEDICAL EDUCATION CONTINUING MEDICAL TRAINING, POLICY, AND THE WAY OUR CULTURE THINKS ABOUT OPIOIDS. THIS IS ALL CHANGED OVER THE LAST 20 YEARS BUT THIS IS WHERE WE ARE NOW. PROBABLY THE ONLY ASPECT ACTUALLY OF OUR SOCIETY THAT ISN'T -- THAT HAS BEEN LEFT BEHIND OR HASN'T FOCUSED ON OPIOIDS SO MUCH IS RESEARCH. I DON'T KNOW IF THAT IS BECAUSE WE AS HUMANS EVOLVED WITH OPIOIDS OVER THE YEARS, BUT BECAUSE WE HAVE KNOWN THESE DRUGS FOR MILLENNIA, WE HAVEN'T INVESTED ENOUGH IN UNDERSTANDING HOW THEY AFFECT US. BOTTOM LINE, WE JUST DON'T KNOW AS MUCH AS WE NEED TO KNOW ABOUT OPIOIDS. WHAT WE DO KNOW SUGGESTS THEY DON'T DESERVE THIS CENTRAL PLACE IN PAIN MANAGEMENT. SO HOW DID WE GET TO THIS PLACE OF OPIOID CENTERED PAIN CARE? I WON'T GO INTO GREAT DEPTH ABOUT THE DEBATES OF WHO IS TO BLAME FOR THIS. TRUTHFULLY, THERE'S PLENTY OF BLAME TO GO AROUND. BUT I'LL BRIEFLY TELL YOU STORY OF THE EXPOSURES THAT LED ME TO AT ONE POINT IN TIME IN MY CAREER PRACTICE OPIOID CENTERED CARE AND TO EVOLVE INTO SOMEONE WHO FOCUSED HER CAREER RESEARCH ON OPIOIDS, WHEN I STARTED OUT AS A PHYSICIAN AND TRAINING OF SOMEONE INTERESTED IN PATIENT CENTERED CARE AND PAIN MANAGEMENT. I THINK FIRST MOST IMPORTANT FOR MANY OF US, THE ARGUMENT FOR INCREASED OPIOIDS WAS BASED ON ETHICAL GROUNDS. THIS IS A GRAPHIC HERE ME TAKING LIBERTIES WITH TEN COMMANDMENTS, SO THOSE ARE AGAIN THOSED UPON OPIOID PILLS THERE. THE IDEA IS THIS WAS REALLY THE BASIS FOR THE CHANGE. IN THE LATE '90s WHEN WE PRESCRIBE OPIOIDS FREQUENTLY, IT WASN'T BECAUSE OF NEW STUDIES, NEW EVIDENCE, BUT BECAUSE WE HAD THIS NEW IDEA THAT WAS GAINING GROUND AND THAT WAS THAT PRESCRIBING OPIOIDS MORE WAS A COMPASSIONATE RESPONSE THE PUBLIC HEALTH PROBLEM OF CHRONIC PAIN BUT IT WAS REALLY A MORAL OBLIGATION TO ADDRESS PAIN AND WHAT WAS POSITIONED AS UNDERTREATMENT OF PAIN. THIS CONCEPT WAS PROMOTED BY AUTHORITATIVE ORGANIZATIONS. I'M JUST PICKING ON THE JOINT COMMISSION HERE. THEN KNOWN AS JACO. THEY RELEASED A COUPLE OF MONOGRAPHS THEY PREPARED WITH THE NATIONAL PHARMACEUTICAL COUNCIL THAT WERE REALLY FOCUSED ON UNDERTREATMENT OF PAIN, HOW SHOULD WE ASSESS AND MANAGE PAIN. IF YOU READ THOSE DOCUMENTS TODAY, THE IDEA THAT OPIOIDS ARE THE ANSWER REALLY PERMEATES THROUGHOUT THOSE DOCUMENTS. JUST TO SUMMARIZE, I THIS I THE MESSAGE, ACCESSSIVE CONCERN ABOUT ADDICTION AND REGULATORY SCRUTINY HELI CONTRIBUTE TO THE TREATMENT OF PAIN, ANALGESICS, ESPECIALLY OPIOIDS ARE UNDERPRESCRIBED AND UNDERDOSED FOR BOTH ACUTE AND CHRONIC PAIN. SO DEFINING THE PROBLEM OF CHRONIC PAIN IS ONE OF UNDERTREATMENT, UNDERPRESCRIBING, I THINK IS WHAT GOT US GOING IN THIS DIRECTION. THOUGH THE SCIENCE WASN'T THERE, AS A JUNIOR CLINICIAN I FOUND THESE ARGUMENTS TO BE FAIRLY PERSUASIVE DESPITE MY QUESTIONS ABOUT OPIOID EFFECTIVENESS AND HARMS. I THINK ONE THING I'M NOT TALKING ABOUT BECAUSE IT'S WELL KNOWN AT THIS POINT IS THAT REALLY THE EVIDENCE THAT WE HAVE FOR OPIOIDS FOR CHRONIC PAIN DOES NOT JUSTIFY THEIR CENTRAL PLACE IN HOW WE THINK ABOUT CHRONIC PAIN MANAGEMENT. WE KNOW OPIOID CENTERED CARE HAS GENERATED HARMS. BUT DESPITE THIS, I THINK WHAT WE HAVE FOUND -- SORRY, EXCUSE ME. I THINK THE FOCUS ON THE HARMS HAS BEEN THE HE CAN STREAM PATIENT HARMS. BUT WHAT WE HAVE SOMETIMES NOT THOUGHT ABOUT OR LOOKED AT AS MUCH IS TOLL OF OPIOID CENTERED CARE ON PATIENTS, ON PRIMARY CARE, ON MANAGEMENT OF CHRONIC PAIN ITSELF. SO DESPITE LACK OF GOOD EVIDENCE FOR OPIOIDS, TO TREAT CHRONIC PAIN, OPIOIDS ARE ALWAYS NOW THE ELEPHANT IN THE ROOM WHEN WE TALK ABOUT PAIN. IN MOST CLINICAL ENCOUNTERS I THINK THEY ARE IN PEOPLE'S MINDS AND AFFECTING OUR INTERACTIONS WITH EACH OTHER. I HAVE BEEN INVOLVED IN A SERIES OF PROJECTS THAT ARE QUALITATIVE STUDIES INVOLVING INTERVIEWS WITH PATIENTS, PHYSICIANS, AND ALSO OBSERVING CLINICAL VISITS. ONE OF THE STRONGEST THEMES IN THOSE STUDIES IS THAT PATIENTS REALLY WANTED PHYSICIANS AND CLINICIANS TO HEAR THEM, TO LISTEN TO THEM, AND TO UNDERSTAND THEIR PAIN. BEYOND A NUMBER OF PAIN INTENSITY AND BEYOND TALKING ABOUT MEDICATIONS. AND PATIENTS REALLY FEAR WHEN THEY TALKED ABOUT PAIN, THEY WOULD BE VIEWED AS SOMEONE WHO IS FAKING PAIN OR AS A DRUG SEEKER. ON THE PHYSICIAN SIDE, PHYSICIANS FELT CONFLICTED ABOUT TALKING ABOUT PAIN. AND WHETHER THEY CAN TAKE PAIN COMPLAINTS AT FACE VALUE, I THINK WE HAVE HEARD THE TERM BENEFIT OF THE DOUBT OVER AND OVER. PHYSICIANS WANTED TO BELIEVE THEIR PATIENTS AND SHOULD, YET ISSUES OF OPIOIDS AND CONFLICT AROUND OPIOIDS WERE ALWAYS IN THEIR MINDS. PHYSICIANS ALWAYS FELT IMBITTERED TO SEVERAL PEOPLE TOLD US, THEY FELT CONFINED TO THIS UNWANTED POLICING ROLE. WHEN THEIR GOAL WAS TO HELP PATIENTS, THEY FELT THAT INSTEAD THEY WERE FORCED TO FOCUS ON OPIOIDS AND REGULATION OF OPIOIDS, MANAGING THEM. THIS IS AN EXAMPLE FROM ONE OF THOSE STUDIES OF A PATIENT DESCRIBING PROBLEMS HE HAD WITH HIS PREVIOUS DOCTOR. I WAS TRYING TO GET PAIN MEDICINE, SHE THOUGHT I WAS A DRUG ADDICT I GUESS. THAT'S THE ONLY REASON I WANTED IT BUT THAT'S NOT THE TRUTH. I THINK THAT WAS WHAT CAUSED OUR COMMUNICATION PROBLEM. I THINK SHE WAS A DRUG -- I THINK SHE THOUGHT I WAS A DRUG ADDICT AND I JUST WANTED NARCOTICS. THAT'S THE IMPRESSION I GOT FROM HER. THIS WAS A PATIENT WHO SWITCHED DOCTORS AND THEN WITH HIS NEW DOCTOR WAS AFRAID TO BRING UP THE ISSUE OF PAIN MEDICATION BECAUSE HE DIDN'T WANT THE SAME THING TO HAPPEN ALL OVER AGAIN. IT WASN'T AT ALL CLEAR THAT HIS PRIOR DOCTOR HAD EVER SAID THAT SHE THOUGHT TESTIFIES A DRUG ADDICT OR INAPPROPRIATELY SEEKING MEDICATIONS BUT THESE DOUBTS REALLY PERMEATED THE RELATIONSHIP. ANOTHER WAY I THINK THAT THE OPIOID CENTERED CARE HAS TAKEN A TOLL ON PRIMARY CARE, IS IN OUR PIPELINE. THIS IS A STUDY OF FIRST YEAR MEDICAL STUDENTS WHO ARE ON THEIR PRIMARY CAROATION. I DIDN'T DO THIS BUT I THINK IT'S IMPORTANT, IT'S A GREAT STUDY. I HEAR ALL THESE ANECDOTES HOW PEOPLE CHOOSE ONLY SPECIALTIES, SPECIALTIES OTHER THAN PRIMARY CARE BECAUSE THEY DON'T WANT TO DEAL WITH CHRONIC PAIN OR OPIOIDS. THIS STUDY IS ONE OF THE FEW I THINK THAT REALLY CAPTURED WHAT THAT'S ABOUT. THE RESEARCHERS LOOKED AT FIRST YEAR MEDICAL STUDENTS' JOURNALS THEY WERE REQUIRED TO KEEP DURING THEIR PRIMARY -- AND THEY CODED THOSE JOURNALS IN TERMS OF THE CONDITIONS THAT THE STUDENTS SAW AND SORT OF THE EMOTIONAL VALENCE BEHIND THEIR COMMENTS. THEN THEY LOOKED AT THE COMMENTS THEMSELVES. WHAT THEY FOUND IS THAT STUDENTS PERCEIVED AN INDELLABLE LINK BETWEEN PAIN AND OPIOIDS. PATIENTS HAD PAIN, STUDENTS THOUGHT OPIOIDS. THAT WAS ALWAYS IN THE BACKGROUND OF ALL OF THE CONVERSATIONS. STUDENTS PERCEIVE THE PAIN VISITS AS FAR MORE NEGATIVE THAN OTHER CHRONIC DISEASE VISITS. SO 75% OF THE COMMENTS RELATED TO PAIN WERE CODED NEGATIVE EMOTIONAL TYPE COMMENTS. IN IS A QUOTE FROM ONE OF THE STUDENTS IN THAT STUDY ON HIS PRIMARY CAROATION. I I HEAR ABOUT THE DIFFICULTY, IDENTIFYING THE DRUG SEEKERS FROM THOSE WITH TRUE CHRONIC PAIN, U HEAR ABOUT THE DIFFICULTY IN SETTING LIMITS. AFTER SPENDING TWO WEEKS IN CLINIC I HAVE ONE COHERENT THOUGHT. I'M NOT SURE HOW I FEEL ABOUT TREATING THESE PATIENTS OR HONESTLY IF I EVER WANT TO. REALLY AT THE EARLIEST STAGES OF TRAINING OUR STUDENTS ARE PICKING UP OUR NEGATIVE FEELINGS, OUR NEGATIVE COMMENTS AND EMOTIONS ABOUT CHRONIC PAIN, PRESUMABLY FROM PRE-ACCEPTTORS WHO ARE OVERWHELMED, FRUSTRATED, BY OPIOID MANAGEMENT. I JUST DOES NOT NEED TO BE THIS WAY, AND IT SHOULDN'T BE. SO THIS IS THE POINT WHERE I SHIFT AND I'M NOT GOING TO SPEND THE REST OF MY TIME TALKING ABOUT OPIOIDS. I HOPE I HAVE AT LEAST MADE A CASE THAT OPIOIDS CENTERED CARE IS NOT WHAT WE SHOULD BE DOING. I DO ACTUALLY SEE REASON FOR OPTIMISM. ONE THING ABOUT THIS CRISIS THAT WE HAVE IS THAT WE HAVE AN INCREDIBLE FOCUS ON PAIN MANAGEMENT RIGHT NOW. SO WE REALLY HAVE AN OPPORTUNITY TO THINK ABOUT HOW TO DO IT DIFFERENTLY. AND I THINK IN TERMS OF HOW WE SHOULD THINK ABOUT CHRONIC PAIN CARE, I THINK THE VISION THAT WAS SET OUT IN THE NATIONAL PAIN STRATEGY RELEASED BY HEALTH AND HUMAN SERVICES, A COUPLE OF YEARS AGO IS A GOOD PLACE TO START. I HAVE OBVIOUSLY BENEFIT SELECTED AND ABBREVIATED THIS, I THINK THEIR VISION RUNS FOR A WHOLE PAGE OF SINGLE SPACE TYPE BUT JUST TO PULL OUT WHAT I THINK ARE SOME OF THE CRITICAL FEATURES HERE IN TERMS OF HOW WE WANT TO START THINKING ABOUT PAIN CARE IN THE FUTURE. THE NATIONAL PAIN STRATEGY REALLY DOES CAPTURE THIS WELL, I THINK. PAIN CARE SHOULD BE PATIENT CENTERED, ACCOUNTING FOR INDIVIDUAL PREFERENCES, RISKS AND SOCIAL CONTEXT. IT SHOULD BE COMPREHENSIVE MEANING BIOPSYCHOSOCIAL NEEDS AND IT SHOULD BE MULTI-MODAL AND INTEGRATED USING EVIDENCE BASED TREATMENTS. SO THE REST OF THIS TALK I'M GOING TO FOCUS ON THESE THREE CONCEPTS THAT I THINK ARE PRETTY CORE TO HOW WE NEED TO REFRAME CHRONIC PAIN CARE. OF COURSE I'LL START WITH PATIENT SENTENCED CARE. IN OUR OPIOID CENTERED CARE ERA, I THINK PATIENT CENTERED CARE HAS UNDESERVEBLY GOTTEN A BAD NAME. SOMETIMES IT GETS A BAD RAP BEING TO BLAME FOR OPIOID OVERPRESCRIBING OR OPIOID RELATED CONFLICT. BUT I DON'T BELIEVE THAT THAT IS DESERVED AT ALL. I THINK IT'S A GREAT CONTRAST TO OPIOID CENTERED PAIN CARE. A COMMON DEFINITION OF PATIENT CENTERED CARE IS CARE THAT IS RESPECTFUL OF AND RESPONSIVE TO INDIVIDUAL PATIENT PREFERENCES, NEEDS AND VALUES. SO IT IS CLEAR THAT THIS IS NOT A CUSTOMER SERVICE ACTIVITY NOR ALTERNATIVE TO EVIDENCE BASED CARE. YOU CAN FOLLOW A GUIDELINE AND YOU CAN SAY NO TO PATIENTS IN A PATIENT CENTERED WAY. IN THE CONTEXT OF CHRONIC PAIN CARE, PATIENT CENTERED CARE CONSIDERS THE EVIDENCE OF POTENTIAL BENEFITS AND HARMS OF THERAPIES SO THE DATA, THE SCIENCE, AND THE CONTEXT OF PATIENTS VALUES AND GOALS IN THE CONTEXT OF PATIENT HEALTH STATUS AND LIFE STAGE. SEEKING TO UNDERSTAND THE PATIENT'S PERSPECTIVE IS THE MOST IMPORTANT TASK IN PATIENT CENTERED CARE. FROM I TOLD YOU EARLIER THIS WAS THE STRONGEST THEME OF RESEARCH, THE IMPORTANCE OF BEING LISTENED TO AND UNDERSTOOD WHEN IT COMES TO PAIN EXPERIENCE. THIS WAS A QUOTE FROM A PATIENT IN THE STUDIES WHO HAS BEEN OBLONG TERM OPIOIDS FOR QUITE SOME TIME. I THOUGHT SHE WAS SO INSIGHTFUL IN TERMS OF HOW SHE DESCRIBED OUR ISSUES, SHE SAID 99% OF THE CONVERSATIONS WE EVER HAVE, SHE'S SPEAKING OF HER AND HER DOCTOR, IS MY WEIGHT, BLOOD PRESSURES, WHAT NUMBER OF PAIN I'M IN. BUT THERE IS NO CONVERSATION ABOUT PAIN. IT'S MY PERSONAL BELIEF AND MY DOCTOR IS THE BEST I HAVE SEEN OVER FOUR DECADES IS THERE ARE AT A LOSS FOR THIS. I LOVE HOW SHE JUST GOT IT. THEY'RE NOT TALKING ABOUT IT BECAUSE THEY DON'T KNOW WHAT TO TALK ABOUT OR HOW TO DO IT RIGHT. ANOTHER WORD ABOUT PATIENT CENTERED CARE IS FUNDAMENTALLY INDIVIDUALIZED CARE, BUT I THINK IT'S ALSO IMPORTANT TO KNOW THAT IN GENERAL, WHAT PATIENTS WITH CHRONIC PAIN WANT IS OFTEN DIFFERENT FROM THE CLINICIAN PERCEPTION. I OFTEN HEAR CLINICIANS SAYING THAT PAIN PATIENTS ARE FOCUSED ON GETTING PAIN RELIEF, EXCLUSIVELY THEY'RE NOT SEEING THE BIG PICTURE, BUT ACTUALLY THERE'S RESEARCH SUGGESTING THAT PATIENTS WITH CHRONIC PAIN REALLY DO SEE CONNECTIONS BETWEN PAIN AND A VARIETY OF DOMAINS IN THEIR LIFE. AND THAT WHEN THEY THINK ABOUT PRIORITIES, FOR PAIN MANAGEMENT IN TERMS OF THE OUTCOMES THEY HOPE TO SEE FROM SUCCESSFUL PAIN MANAGEMENT, THEY'RE NOT JUST WANTING PAIN RELIEF. THEY'RE WANTING IMPROVEMENT IN ALL KINDS OF THINGS. PARTICIPATION IN FAMILY AND SOCIAL ACTIVITIES. ENJOYMENT OF LIFE, EMOTIONAL WELL BEING. IMPROVEMENT IN SLEEP AND FATIGUE AND PHYSICAL ACTIVITY AND EMPLOYMENT. SO PATIENTS IN GENERAL DO NOT CONSIDER PAIN IN ISOLATION. AND NEITHER SHOULD WE. AND THIS IS HELPFUL WHEN THINKING ABOUT CARE PLANNING. BECAUSE IF YOU LOOK AT THIS BIG PICTURE, THIS IS A BIG PICTURE THAT CALLS FOR MULTI-MODAL CARE FOR INTEGRATED COMPREHENSIVE CARE, NOT FOR OPIOID CENTERED CARE. I'LL MOVE ON TO TALK ABOUT COMPREHENSIVE CARE. WHICH IS DEFINED AS A CORE FEATURE OF PRIMARY CARE. IN THE CONTEXT OF PRIMARY CARE, COMPREHENSIVE CARE HAS BEEN DEFINED AS DEALING WITH ALL HEALTH PROBLEMS INCLUDING MENTAL AND PHYSICAL HEALTH AND OTHER PROBLEMS EXCEPT FOR THOSE THAT ARE TOO UNCOMMON FOR MAINTENANCE OF COMPETENCE. DR. STARFIELD, A PIONEER IN PRIMARY CARE PAIN HEALTH SERVICES OR PRIMARY CARE HEALTH SERVICES RESEARCH, SHE SPECIFICALLY DEFINED TWO UNCOMMON AS LESS THAN ONE IN ONE THOUSAND IN THE POPULATION. CLEARLY ALMOST NO CHRONIC PAIN CONDITIONS MEET THE CRITERIA OF TOO UNCOMMON TO BE DELL WITH. IN COMPREHENSIVE PRIMARY CARE COMPREHENSIVE CARE IS ENHANCED BY TEAM BASED MODELS OF CARE AS I MENTIONED EARLIER, NOT JUST PHYSICIANS BUT CARE MANAGERS, NURSES, PHARMACISTS, PHYSICAL THERAPISTS, PSYCHOLOGISTS WORKING TOGETHER. IMPORTANTLY COMPREHENSIVE CARE FOR CHRONIC PAIN CLEARLY REQUIRES CONSIDERATION OF PATIENT OVERALL HEALTH STATUS. THERE ARE MANY FACTORS THAT CONTRIBUTE TO COMPLEXITY. I WILL TALK A LITTLE BIT ABOUT COMPLEXITY AND I WILL START WITH THE BIOPSYCHOSOCIAL MODEL WHICH HAS BEEN ESTABLISHED AS THE PRIMARY FRAMEWORK WITH WHICH WE SHOULD UNDERSTAND CHRONIC PAIN IN ITS TREATMENT. THIS IS JUST A BRIEF REPRESENTATION OF SOME OF THE MANY BIOPSYCHOSOCIAL FACTORS THAT FOR INDIVIDUAL PATIENTS CONTRIBUTE TO DEVELOPMENT OF CHRONIC PAIN TO MAINTENANCE OF CHRONIC PAIN OR TO PERSISTENCE OF CHRONIC PAIN AND DEVELOPMENT INTO DISABILITY. WE OFTEN FOCUS ON JUST A FEW FACTORS,THAT ARE THE MOST OBVIOUSLY INVOLVED IN CHRONIC PAIN, WHETHER THAT BE THE INJURY THAT OCCURRED AT THE START OF THE PAIN, AN ANATOMICAL ABNORMALITY OR MENTAL HEALTH COMORBIDITIES. BUT REALLY, FOR INDIVIDUAL PATIENTS, SO MANY OF THESE THINGS CAN PLAY INTO THE CHRONIC PAIN EXPERIENCE. MANY OF THEM ARE TARGETS FOR MULTI-MODAL THERAPY. SOME ARE NOT MODIFIABLE BUT THEY'RE IMPORTANT TO UNDERSTAND. I THINK PRIMARY CARE AND THE LONGITUDINAL RELATIONSHIPS, THE LONG TERM RELATIONSHIPS WE HAVE WITH PATIENTS, WE HAVE AN ADVANTAGE HERE. BECAUSE UNDERSTANDING ALL THESE DIFFERENT FACTORS, ARE REALLY THE KINDS OF THINGS YOU GET TO KNOW ABOUT PATIENTS OVER THE LONG HAUL. YOU DON'T LEARN THESE THINGS FROM AN INTAKE FORM OR FROM AN INITIAL ENCOUNTER. ANOTHER FEATURE -- THE FREQUENT COMPLEXITY OF CHRONIC PAIN IS THAT PATIENTS WITH CHRONIC PAIN ALMOST ALWAYS HAVE CO-EXISTING HEALTH PROBLEMS. PAIN TYPICALLY DOES NOT OCCUR IN ISOLATION. JUST TO FOCUS ON A FEW OF THE BIG ONES YOU CAN TALK ABOUT THIS FOR HOURS IN ITSELF. CLEARLY SOME OF THE MOST COMMON WELL STUDIED CO-EXISTING HEALTH PROBLEMS ARE DEPRESSION, ANXIETY DISORDERS AND INSOMNIA. DEPRESSION IS I THINK THE BEST STUDIED OF ALL OF THESE BUT THE ASSOCIATION OF PAIN WITH ANXIETY DISORDER SEEMS TO BE ABOUT AS STRONG AND INSOMNIA ALSO IS JUST INCREDIBLY PREVALENT IN PATIENTS WITH CHRONIC PAIN. THE RELATIONSHIP APPEARS TO BE BIDIRECTIONAL SO IT'S NOT THAT PAIN IS JUST UNTREATED DEPRESSION, OR THAT CHRONIC PAIN CAUSES DEPRESSION. BUT REALLY THEY'RE FEEDING INTO EACH OTHER. THEREFORE, THEY'RE TARGETS FOR THERAPY TOGETHER. PHYSICAL HEALTH CONDITIONS, I THINK IT'S TALKED ABOUT LESS BUT ARE JUST AS COMMONLY CO-MORBID WITH CHRONIC PAIN. AND IT'S A WHOLE VARIETY OF INDIVIDUAL PHYSICAL HEALTH CONDITIONS, BUT IT'S ALSO THE TOTAL BURDEN OF CHRONIC DISEASE. SO PEOPLE WHO HAVE A HIGHER BURDEN OF CHRONIC DISEASE ARE MUCH MORE LIKELY TO HAVE CHRONIC PAIN. ANOTHER INTERESTING ASPECT OF THIS IS THAT THESE ASSOCIATIONS BETWEEN PHYSICAL HEALTH CONDITIONS, MENTAL HEALTH CONDITIONS, CHRONIC PAIN ARE STRONGER IN PEOPLE WHO HAVE MULTIFOCAL PAIN. SO IT'S LESS ISSUE WITH A SIMPLE CHRONIC CONDITION BUT THE MORE PAIN CONDITIONS YOU HAVE THE MORE LIKELY TO HAVE THESE OTHER COMORBIDITIES. PATIENTS WITH CHRONIC PAIN USUALLY DO HAVE MULTIFOCAL PAIN. SO THIS FACT IS MISSED IN A LOT OF OUR RESEARCH AND WE NARROWLY DEFINE A POPULATION OF STUDY, AND OFTEN IN OUR CLINICAL CARE WE TEND TO ADDRESS THE PRESENTING COMPLAINT, BUT IF YOU REALLY GET INTO IT, YOU FIND THAT OFTEN PEOPLE HAVE A LOT OF PAINFUL CONDITIONS CO-EXISTING. I WILL SHOW YOU DATA A COHORT STUDY I'M LEADING IN VA, A STUDY OF VETERANS OF LONG TERM OPIOIDS, ABOUT 9200 PATIENTS. WHO HAVE BEEN TREATED WITH LONG TERM OPIOIDS FOR CHRONIC PAIN. WE EXCLUDED FOLKS WHO WERE IN AN END OF LIFE PALLIATIVE CARE CANCER SITUATION BUT OTHERWISE IT'S A PRETTY UNSELECTED SAMPLE. WE ASKED THEM WHERE THEY HAD PAIN IN THE PAST SIX MONTHS AND THIS FIGURE JUST SHOWS HOW FREQUENT ALL PAIN CONDITIONS WERE. THIS MORE THAN 9,000 VETERANS, 95% SAID THEY HAD BACK PAIN THAT WAS BOTHERSOME IN THE PAST SIX MONTHS AND MORE THAN THREE QUARTERS REPORTED HAVING NECK PAIN SHOULDER PAIN KNEE PAIN AND LOWER LEG PAIN SO REALLY JUST IMPRESSIVE MULTIFOCAL PAIN IN THIS POPULATION OF PATIENTS ON OPIOIDS. OFTEN PEOPLE ASK WHAT IS THE MOST COMMON THING PEOPLE ARE TREATED WITH OPIOIDS FOR AND I THINK BACK PAIN BUT BACK PAIN IS JUST THE MOST COMMON PAIN CONDITION. HUMANS HAVE BACK PAIN, 95% OF PATIENTS ON OPIOIDS HAVE BACK PAIN. WHEN YOU ASK A PATIENT WHAT THEY'RE GETTING OPIOIDS FOR, THEY'LL NAME A NUMBER OF DIFFERENT PAIN PROBLEMS THAT THEY SEE ARE THE REASON FOR THEIR OPIOIDS. WHICH ALSO ASKED THE SAME PATIENTS WHETHER THEY THOUGHT THEY -- WHETHER THEY WOULD ENDORSE HAVING WIDESPREAD PAIN ALL OVER YOUR BODY. NOT SURPRISINGLY YOU SAW THE PAIN LOCATION DATA, 81% SAID THEY HAD WIDESPREAD PAIN ALL OVER THEIR BODY. SO TALKED A LITTLE BIT ABOUT COMORBIDITY, AND MULTIFOCAL PAIN, I'LL ALSO MENTION PATIENT COMPLEXITY EXTENDS BEYOND THOSE CONCEPTS. AND BEYOND THE HEALTHCARE UTILIZATION AND OTHER WAYS WE SOMETIMES DEFINE COMPLEXITY. ONE DEFINITION OF COMPLEXITY IN PRIMARY CARE IS PERSON-SPECIFIC FACTORS THAT INTERFERE WITH DELIVERY OF USUAL CARE AND DECISION MAKING FOR WHATEVER CONDITIONS THE PATIENT HAS. SO NOT JUST THAT THE PATIENT HAS THE CONDITIONS, IT'S HOW WELL THEY'RE ABLE TO MANAGE AND COPE WITH THEM. STUDIES FROM PRIMARY CARE PHYSICIAN PERSPECTIVE SUGGEST PSYCHOSOCIAL ISSUES AND DISEASE SEVERITY ARE HOW WELL CONTROLLED CHRONIC DISEASES, ARE IMPORTANT DRIVERS OF COMPLEXITY, IN TERMS OF PRIMARY CARE PHYSICIAN VIEWPOINT ON WHETHER A PATIENT IS COMPLEX. COMPLEXITY IS REALLY A MULTI-DIMENSIONAL CONCEPT. AND I THINK IMPLICATIONS OF THIS THAT ARE WORTH NOTING IS THESE ARE THE PATIENTS WHO MOST OFTEN GET REFERRED TO SPECIAL ISES AND OFTEN NOT JUST ONE -- SPECIALISTS, OFTEN NOT ONE BUT MANY, AND REFERRALS TO A VARIETY OF DIFFERENT SPECIAL iS ISN'T NECESSARILY THE BEST APPROACH TO COMPLEXITY, WHEN YOU HAVE SOMEONE STRUGGLING TO MANAGE CO-MORBID DIVERSE CHRONIC PAIN CONDITIONS. IT'S REALLY THAT COMPREHENSIVE LONGITUDINAL CONTINUITY OF PRIMARY CARE THAT IS MORE VALUABLE FOR THESE FOLKS. SO IMPLICATIONS OF PATIENT-CENTER AND COMPREHENSIVE CARE, DECISION MAKING ABOUT PAIN THERAPIES SHOULD REALLY INCLUDE CONSIDERATION OF POTENTIAL POSITIVE OR NEGATIVE AFFECTS ONCO EXISTING HEALTH CONDITIONS SO NOT JUST CHRONIC PAIN BUT WHAT ELSE IS GOING ON WITH THIS PERSON AND HOW MIGHT OUR TREATMENTS FOR PAIN AFFECT THOSE OTHER CONDITIONS. CONTINUE ANNUITY OF CARE MAYBE PARTICULARLY IMPORTANT FOR PATIENTS WITH HIGH COMPLEXITY AND MORE COMORBIDITIES. THESE PATIENTS MAY ALSO BE BETTER SERVED BY PRIMARY CARE TEAM BASED CARE THAN REFERRALS TO A VARIETY OF DIFFERENT SPECIALISTS. SO FINALLY, I WILL TALK ABOUT INTEGRATED MULTI-MODAL CARE. SO WHAT IS MULTI-MODAL CARE, IT'S A WORD THROWN AROUND A LOT, IT'S BASIC DEFINITION IS THAT IT'S CARE THAT USES DIFFERENT TYPES OF THERAPIES, DIFFERENT TYPES OF APPROACHES TO ADDRESS A FULL RANGE OF BIOPSYCHOSOCIAL FACTORS INVOLVED IN PAIN. INTEGRATED MULTI-MODAL CARE IS CARE GUIDED BY COORDINATED TREATMENT PLAN. JUST BECAUSE SOMEONE DOES A LOT OF STUFF DOESN'T NECESSARILY MEAN THEY'RE GETTING MULTI-MODAL CARE, IT MAYBE PRETTY DISCONNECTED. IN TERMS OF DIFFERENT TYPES OF THERAPIES, THAT MIGHT BE COMBINED IN MULTI-MODAL CARE, EXERCISE BEHAVIORAL THERAPIES, MANUAL THERAPIES AND PHARMACOLOGICAL THERAPIES ARE EXAMPLES, I THINK IT'S WORTH NOTING POLYPHARMACY COMBINING DIFFERENT MEDICATIONS TOGETHER IS NOT MULTI-MODAL CARE. SOMETIMES THAT -- I HAVE SEEN THAT GET CONFUSED AND I THINK IT'S WORTH POINTING OUT TO DO MULTI-MODAL CARE, YOU SHOULD BE ADDRESSING BIOPSYCHOSOCIAL FACTORS, NOT JUST THE BIO PART. A FEW MORE WORDS ABOUT TERMINOLOGIES HERE BEFORE I IRRITATE ANYONE IN THE AUDIENCE. I'M SPEAKING AT AN INTEGRATIVE HEALTH LECTURE SERIES BUT WHAT I'M SAYING IS INTEGRATED CARE. AND I DO MAKE A DISTINCTION HERE, INTEGRATED CARE IS COORDINATED USE OF MULTIPLE APPROACHES OR CARE PROVIDERS. SO KIND OF MORE GENERIC, I THINK, THAN INTEGRATIVE CARE. WHICH IS TYPICALLY USED TO DESKYPE COORDINATED USE OF CONVENTIONAL AND COMPLIMENTARY THERAPIES TOGETHER. THAT BRINGS US TO WHAT IS COMPLIMENTARY THERAPIES. I GOT THIS DEFINITION OFF THE NCCIH WEBSITE. I THINK THE BEST PLACE TO GO, COMPLIMENTARY THERAPIES ARE DIVERSE HEALTHCARE APPROACHES, THAT HAVE BEEN DEVELOPED OUTSIDE OF MAINSTREAM WESTERN OR CONVECTIONAL MED -- CONVENTIONAL MEDICINE. SO DEFINED THE OPPOSITION TO& CLINICAL CARE WHICH IS ODD, I UNDERSTAND WHY WE MAKE THESE DEFINITIONS BUT I DON'T NECESSARILY LOVE THAT. THIS IS A DISTINCTION I DON'T TEND TO FOCUS ON IN LIFE. THIS IS WHO I AM. I'M A PRAGMATIST, I'M MUCH MORE INTERESTED IN WHAT WORKS THAN WHERE IT CAME FROM. SO I TEND TO LUMP COMPLIMENTARY AND CONVENTIONAL THERAPIES TOGETHER WITHOUT REGARD FOR WHERE THEY CAME FROM. AND I KNOW THAT THAT DOES BOTHER SOME PEOPLE. SO I'M GOING TO ACKNOWLEDGE THAT THAT'S MY BIAS. I TALK ABOUT NON-PHARMACOLOGIC THERAPIES, OBVIOUSLY THAT DOESN'T NEED A DEFINITION, IT'S KIND OF SELF-EXPLANATORY. THIS IS A TERM I ALSO DON'T LIKE THOUGH. BECAUSE IT'S DEFINED IN OPPOSITION TO PHARMACOLOGIC THERAPIES, SUGGESTING THAT THOSE OUGHT TO BE THE CORE. WHICH IS NOT SOMETHING I WOULD ENDORSE. I HAVEN'T COME UP WITH A BETTER WAY TO DO IT. SO I'M OPEN TO SUGGESTIONS DURING THE COMMENT PERIOD BUT MOSTLY I'LL TALK INTEGRATED CARE AND NON-PHARMACOLOGIC THERAPIES. I THOUGHT I WOULD SHOW YOU A LITTLE BIT ABOUT CURRENT USE OF NON-PHARMACOLOGIC THERAPIES IN VA. BEFORE DOING THAT, I WILL JUST TELL YOU FOR BACKGROUND ABOUT PATIENT REPORTED INVENTORY FOR ASSESSMENT OF PAIN HEALTH SERVICES USED AND PAIN SELF-MANAGEMENT THAT I DEVELOPED AS PART OF AN NCCIH FUNDED RO1. ALISSA IS THE PI ON THIS STUDY, I'M CO-PI. WE WORKED WITH HELP FROM NCCIH. THE NEED FOR THIS IS REALLY THAT THERE ISN'T ESTABLISHED I THINK INTERVIEW SOURCE FOR UNDERSTANDING USE OF COMPLIMENTARY THERAPIES IN THE NATIONAL HEALTH INTERVIEW SURVEY. CAM SUPPLEMENT. THAT'S DEFINED FOR TELEPHONE. AND WHAT WE NEEDED WAS SOMETHING THAT COULD BE DEPLOYED IN A SELF-REPORT FASHION ON PAPER IN PARTICULAR. GIVEN WHAT I HAVE ALREADY SAID ABOUT MY PRAGMATIC APPROACH TO THIS, I ALSO WANTED TO INCLUDE SOME KEY CONVENTIONAL THERAPIES THAT AREN'T NECESSARILY COVERED IN THE CAM SUPPLEMENT. WE NEEDED SOME BRIEF DESCRIPTIONS, TO IMPROVE PATIENT SELF-REPORTING AS WELL. SO THIS IS JUST A QUICK VIEW OF WHAT THIS INVENTORY LOOKS LIKE FOR ONE OF THE CONDITIONS, ACUPUNCTURE, WE ASKED PATIENTS IN THE PAST YEAR HAD THEY USED EACH CONDITION HERE WE DESCRIBED ACUPUNCTURE AS STIMULATION OF SPECIFIC POINTS OF THE BODY WITH THIN NEEDLES. I THINK MOST PEOPLE KNOW WHAT ACUPUNCTURE IS BUT SOME DESCRIPTIONS OF SOME THERAPIES I THINK WERE MORE IMPORTANT BECAUSE LESS LIKELY PEOPLE WOULD BE FAMILIAR WITH THEM. WE ASKED ABOUT WHY AND HOW OFTEN PEOPLE USE THESE THERAPIES. JUST TO SHOW YOU WHAT KIND OF RESULTS WE GOT, THIS IS A SAMPLE OF NATIONAL GUARD VETERANS OF RECENT CONFLICT. SO AFGHANISTAN, IRAQ, AND RELATED POST 9/11 CONFLICTS. WE LOOKED AT USE OF THESE THERAPIES IN PATIENTS WITH AND WITHOUT CHRONIC PAIN. HERE THE BLUE BARS ARE THE PATIENTS WHO HAD CHRONIC PAIN AND THE PURPLE BARS ARE THOSE WHO DID NOT. WHAT YOU SEE IS PRETTY SIMILAR ACTUAL USE OVERALL OF THE DIFFERENT THERAPIES. A LOT OF USE REGARDLESS OF PRESENCE OF CHRONIC PAIN. BUT PATIENTS WITH CHRONIC PAIN DIFFERED IN FEW WAYS, THEY USE MORE CHIROPRACTIC THERAPY AND MASSAGE, MORE STRETCHING AND STRENGTHENING EXERCISE AND A LITTLE LESS AEROBIC EXERCISE. THAN PATIENTS WHO DID NOT HAVE CHRONIC PAIN. THE PATIENTS WITH CHRONIC PAIN ARE ALSO WERE ABOUT TWICE AS LIKELY TO REPORT USE OF PSYCHOTHERAPY. WE LOOKED AT THIS GROUP ACTUALLY IN TERMS OF WHY THEY USED CARE. HERE THIS SLIDE SPECIFICALLY FOCUSES ON ACTIVE SELF-CARE APPROACHES. WHICH ARE PARTICULARLY THE ONES ON THE RIGHT SIDE OF THIS SLIDE SO THINGS LIKE MEDITATION, YOGA, TAI CHI AND EXERCISE THERAPIES. AT THE BOTTOM YOU CAN SEE THE THREE GROUPS, PATIENTS WITH NO CHRONIC PAIN, PATIENTS WITH CHRONIC PAIN WHO DID NOT HAVE FUNCTIONAL LIMITATIONS, AND THEN PATIENTS WITH CHRONIC PAIN RELATED FUNCTIONAL LIMITATIONS OR CHRONIC PAIN DISABILITY ALL THE WAY ON THE RIGHT. INTERESTING THINGS I THINK, YOU LOOK AT THE GROUP THAT HAS CHRONIC PAIN DISABILITY, IT'S NOT SURPRISING THAT THEY ARE MUCH MORE LIKELY FOR USING THESE APPROACHES TO MANAGE PAIN. INTERESTINGLY THEY'RE ALSO MORE LIKELY TO USE THIS APPROACH TO MANAGE OTHER CONDITIONS. I THINK THIS IS ACTUALLY A GOOD SIGN, SOME OF THE ACTIVE THERAPIES WE LOOK AT HERE SUCH ADS EXERCISE, MEDITATION ARE RECOMMENDED FOR A VARIETY OF HEALTH CONDITIONS, REALLY PLURIPOTENT THERAPIES. IN ADDITION TO PAIN SO THEY MAYBE USEFUL FOR OTHER PROBLEMS, DEPRESSION, DIABETES, HYPERTENSION. THIS SLIDE SHOWS REALLY RESULTS OF THE SAME INVENTORY WITH A DIFFERENT SAMPLE, THESE ARE SAME VA PATIENTS ON LONG TERM OPIOID THERAPY FOR CHRONIC PAIN THAT I SHOWED YOU EARLIER, THE SAME FOLKS WHO HAD THE MULTIFOCAL PAIN AND 80% WITH WIDESPREAD PAIN. HERE WE ASK SPECIFICALLY ABOUT THE USE OF THESE THERAPIES FOR PAIN, AND THE PATTERN LOOKS A LITTLE BIT DIFFERENT THAN THE NATIONAL GUARD GROUP. I THINK THE MOST OBVIOUS DIFFERENCES ARE THIS GROUP IS USING MUCH MORE PSYCHOTHERAPY AND MEDITATION, MINDFULNESS MEDITATION. THEY ALSO USING MORE BOTH TYPES OF EXERCISE. NOT AS MUCH IN TERMS OF MANUAL THERAPIES, CHIROPRACTIC AND MASSAGE. WHY THIS IS, I CAN'T TELL YOU YET, IT'S PRELIMINARY DATA. SO NOW I WILL STOP TALKING ABOUT WHAT PEOPLE USE AND TALK ABOUT THE EVIDENCE FOR MULTI-MODAL CARE TO DO SO, I WILL JUST BRIEFLY GIVE YOU SOME BACKGROUND ON OF VA STATE-OF-THE-ART CONFERENCE THAT WAS HELD, FOCUSING ON NON-PHARMACOLOGIC APPROACHES TO CHRONIC MUSCULOSKELETAL PAIN. THIS WAS PROMPTED BY A WHITE HOUSE SUMMIT ON THE OPIOID CRISIS AND VA AGREED TO TAKE THE LEAD ON ALTERNATIVES TO OPIOIDS. SO THERE'S THAT OPIOID CENTERED PAIN CARE CONCEPT COMING THROUGH AGAIN. THE GOALS OF THIS SODA WERE TO CONVENE RESEARCHERS AND CLINICAL EXPERTS TO EVALUATE EXISTING EVIDENCE, IDENTIFY APPROACHES WITH SUFFICIENT APPROACHES THAT USED BROADLY IN VA AND WHO IDENTIFY EVIDENCE GAPS OR FUTURE RESEARCH NEEDS. MENTION I CO-CHAIRED THIS SODA WITH BOB KERNS. WE FORMED WORK GROUPS AND TASKED THEM WITH REVIEWING EXISTING EVIDENCE IN THREE CATEGORIES OF NON-PHARMACOLOGIC THERAPIES. WE CATEGORIZED THESE THERAPIES FUNCTIONALLY IN TERMS OF WHAT THEY MIGHT SEEM LIKE TO PATIENT, WHAT THEY MAY INVOLVE PATIENTS DOING. CATEGORIZED AS MANUAL THERAPIES, EXERCISE OR MOVEMENT BASED THERAPIES AND BEHAVIORAL OR PSYCHOLOGICAL THERAPY, BLURRING THE LINES BETWEEN CONVENTIONAL AND COMPLIMENTARY. A MAIN OUTCOME WAS CONSENSUS ON MULTIPLE THERAPIES THAT WERE THOUGHT TO HAVE GOOD ENOUGH EVIDENCE IN CHRONIC MUSCULOSKELETAL PAIN THAT REALLY THEY DESERVE TO BE BROADLY IMPLEMENTED AT THIS POINT. ROLLED OUT IN VA AND AVAILABLE FOR OUR PATIENTS, AS SOON AS POSSIBLE. THERAPIES SHOWN ON THE SLIDE ARE THOSE CORE THERAPIES. WE IDENTIFIED IN THIS PROCESS A VARIETY OF CONSIDERATIONS AND QUESTIONS I THINK THAT ARE RELEVANT. FIRST ONE THING THAT WAS REALLY NOTABLE IN REVIEW OF ALL THESE THERAPIES IS THE EFFECT SIZE WERE SIMILAR, AND SIMILARLY MODEST, REALLY MEANING THAT THESE THERAPIES TENDING TO HAVE SMALL TO MEDIUM SIZE IMPROVEMENTS FOR PEOPLE WHEN THEY WORKED. AND THEY GENERALLY WORKED FOR LESS THAN HALF OF THE PEOPLE WHO TRIED THEM SO NOT ONE TREATMENT THAT IS BEST FOR ALL PEOPLE WHICH SHOULDN'T BE SURPRISING GIVEN WHAT WE KNOW ABOUT THE COMPLEXITY OF CHRONIC PAIN BUT I THINK SOME PEOPLE FIND THIS DISAPPOINTING. ALL TREATMENTS ARE NOT LIKELY EQUAL FOR INDIVIDUAL PATIENTS SO THAT BRINGS UP ISSUES OF TREATMENT SELECTION. FOLLOW-UP. I SHOULD NOTE BECAUSE WE'RE TALKING NON-PHARMACOLOGIC PAIN THE SAME IS TRUE FOR MEDICATIONS. SO ALL EVIDENCE BASED MEDICATIONS USED FOR CHRONIC PAIN TEND TO HAVE SMALL TO MEDIUM BENEFITS FOR A SUBSET OF PATIENTS WHO USE THEM. THESE THE SAME PRINCIPLE APPLIES. BECAUSE OF THAT A COORDINATED APPROACH TO CARE DELIVERY IS PROBABLY NEEDED IF WE WANT TO HAVE EFFICIENT AND EFFECTIVE MULTI-MODAL CARE AND NEEDED TO SUPPORT PATIENT ADVOCATION. ONE THING WE'RE CONCERNED IS ABOUT IS DIFFERENTIATING BETWEEN THE THERAPIES THAT ARE ESSENTIALLY PASSIVE, DELIVERED BY A PRACTICER AND THOSE THAT PATIENTS ENGAGE WITH AND CAN USE TO HELP THEMSELVES AT HOME. A COMBINATION OF THOSE TYPES OF THERAPIES MAY BE BEST. AND THERE ARE QUITE A FEW GAPS THAT ARE RELATED TO IMPLEMENTATION OF THESE THERAPIES. SO THEY MAY BE EFFECTIVE IN TRIALS BUT THE QUESTIONS THAT STILL NEED TO BE ANSWERED RELATE TO TREATMENT SELECTION, APPROPRIATE DOSING, MODE OF DELIVERY AND MAINTAINING BENEFITS FOR PATIENTS SO HOW WE'RE SUPPOSED TO DO THIS IN A COORDINATED FASHION SHOULD WE ACTUALLY DELIVER THIS MULTI-MODAL CARE, THIS IS A BIG QUESTION AS WELL. AND DURING THE SODA IT BECAME CLEAR THAT THERE HAVE BEEN TRIALS OUT THERE ABOUT THIS, BUT ACTUALLY WE COULDN'T FIND ANY SYSTEMATIC REVIEW OR META ANALYSIS THAT HAD SUMMARIZED THAT EVIDENCE BASE. SO PART OF THIS PROCESS WAS ACTUALLY COMMISSIONING A NEW SYSTEMATIC REVIEW. BUT LOOK AT EFFECTIVENESS OF MODELS FOR IMPROVING DELIVERY OF MULTI-MODAL CHRONIC PAIN CARE WITHIN THE PRIMARY CARE SETTING. I'LL DISTINGUISH THIS FROM MULTI-DISCIPLINARY REHAB THERAPIES THAT ARE DONE IN SPECIALTY PAIN SETTING. THERE'S A WHOLE EVIDENCE BASIS AROUND THAT, THIS IS REALLY FOCUS ON HOW DO WE DELIVER THE MULTI-MODAL CARE IN A GENERALIST PRIMARY CARE SETTING. THE REVIEW WAS COMPLETED, FOUND EIGHT RANDOMIZED CONTROL TRIALS OF MOSTLY FAIR TO GOOD QUALITY. AND THESE TRIALS HAD A NINE TO TWELVE MONTH FOLLOW-UP, THAT'S THE GOOD NEWS. THE BEST EVIDENCE WAS FROM FIVE GOOD QUALITY TRIALS. THAT STUDIED MODELS WITH ONGOING TREATMENT MANAGEMENT WITH DECISION SUPPORT USUALLY IN THE FORM OF CARE MANAGER. THE BAD NEWS IS THAT EACH TRIALS STUDY DIFFERENT INTERVENTIONS. SO THE PRECISION OF THE EVIDENCE IS PRETTY LOW. THIS SLIDE JUST SHOWS A KEY FIGURE FROM THIS SYSTEMATIC REVIEW, DEMONSTRATING THAT ALL THESE THERAPIES WERE BETTER THAN USUAL CARE. BUT THEY DID DIFFER IN TERMS OF THE STRENGTH, THE SIZE OF THE EFFECT, THE DOTTED LINE KIND OF DOWN THE MIDDLE THERE IS, THAT'S BASICALLY A DOUBLE RELATIVE BENEFIT SO PATIENTS IN THE THERAPY WERE TWICE AS LIKELY TO IMPROVE AS PATIENTS NOT IN THE THERAPY. AND THE REVIEWERS SINGLED OUT A COUPLE OF TRIALS, THAT SEEMED TO BE POTENTIALLY THE MOST BENEFICIAL THOUGH THEY CAUTIONED ON DRAWING STRONG COMPARATIVE CONCLUSIONS, GIVING DIFFERENCES BETWEEN THESE STUDIES, THOSE I CIRCLED, THESE TWO THERAPIES DOUBLE THE BENEFIT FOR PATIENT USING THE MULTI-MODAL -- USING THE COORDINATED CARE APPROACH, VERSUS USUAL CARE WITH A NUMBER NEEDED TO TREAT OF ABOUT FOUR PEOPLE TO GET A CLINICALLY RELEVANT DIFFERENCE. I WILL TELL YOU ABOUT ONE OF THESE TRIALS, BOTH OF THOSE TRIALS WERE SINGLED OUT MOST LIKELY TO BE PROMISING WERE CONDUCTED AT THE INDIANAPOLIS VA AND LED BY KIRK CRONKI THERE, HE IS MY MEN TO AND I WAS AT THE INDIANAPOLIS VA AT THIS TIME, I HAVE GOT INTIMATE EXPERIENCE WITH THESE APPROACHES. THIS ONE IS TELECARE COLLABORATIVE MANAGEMENT OF CHRONIC PAIN AND PRIMARY CARE PUBLISHED IN JAMA FIVE YEARS AGO. AND THIS APPROACH HAD REALLY THREE KEY FEATURES. A NURSE CARE MANAGER WITH EXPERT PHYSICIAN BACK UP. THAT WAS ME AND CURT CRONKI IN THIS STUDY, A MEDICATION OPTIMIZATION ALGORITHM AND AUTOMATED TREATMENT MONITORING, EVALUATING PATIENTS ON A REGULAR BASIS WITH STRUCTURED MEASUREMENT OF PAIN AND DEPRESSION AND ANXIETY. IN A STUDY PAIN RESPONSE INTERVENTION GROUP WAS 52% COMPARED TO 27% FOR USUAL CARE WHICH FOR CHRONIC PAIN STUDY IS PRETTY GOOD. THIS IS MY OWN TRIAL THAT WAS PUBLISHED LAST MONTH, I MENTIONED EARLIER, iPUT IT HERE NOT THE TALK ABOUT FINDINGS OF OPIOIDS VERSUS NON-OPIOIDS BUT TO SAY THAT I USE THIS TELECARE COLLABORATIVE MANAGEMENT MODEL IN BOTH ARMS OF THE STUDY. SO IT WAS SOMETHING WE CONTROLLED FOR BUT I THINK IT WAS REALLY AN ACTIVE INGREDIENT. MY USE OF THIS IS PARTIALLY BECAUSE OF EVIDENCE BUT ALSO BECAUSE IT'S A JOY TO PRACTICE IN THIS COLLABORATIVE CARE APPROACH. THE KEY FEATURES OF THE CARE DELIVERY CARE APPROACH WE USED IN SPACE TRIAL WERE THE SAME AS THOSE IN THE SCOPE TRIAL, THERE'S ONE DIFFERENCE, AND THAT'S THAT WE USED A PHARMACIST CARE MANAGER INSTEAD OF A NURSE CARE MANAGER. AND I THINK WHEN YOU'RE TALKING OPIOIDS, WHETHER THAT'S AN INTERVENTION CARE THAT WAS TRYING TO OPTIMIZE OPIOID THERAPY IN A TRIAL OR WHETHER IT'S WHAT IS HAPPENING MORE OFTEN IN REAL LIFE PRACTICE NOW WHICH IS TRYING TO TAPER OPIOIDS, HAVING THAT EXPERTISE IN MEDICATION MANAGEMENT IN THE CARE MANAGER IS PRETTY HELPFUL. OTHERWISE IT WAS THE SAME CORE APPROACHES, MEDICATION OPTIMIZATION, AND TREATMENT MONITORING. THE MAIN RESULTS THAT HAVE GOTTEN ATTENTION TO REALLY THE DIFFERENTIAL RESULTSES BUT I WOULD LIKE TO POINT OUT THAT IN THIS 60% OF PATIENTS GOT BETTER. IN BOTH GROUPS, TRUE OPIOIDS WERE NOT SUPERIOR, THE SIZE OF OUR EFFECT WAS ATTRIBUTABLE IN LARGE PART SO THE CARE MODEL NOT JUST THE INDIVIDUAL DRUGS WE TESTED. IN TERMS OF MODELS TO DELIVER MULTI MODAL CARE THERE'S LOTS OF REMAINING QUESTIONS. THE BEST IS FOR INDIVIDUAL VA FACILITIES. SO DO THESE MODELS WORK OUTSIDE VA IN NON-INTEGRATED HEALTH SYSTEMS? HOW WELL CAN WE IMPLEMENT THEM ELSEWHERE? ALSO THESE MODELS HAVE NOT BEEN EXPLICITLY INTEGRATIVE OF OTHER CARE MANAGEMENT PROGRAMS. WE KNOW THERE ARE EFFECTIVE CARE MANAGEMENT PROGRAMS FOR DIABETES AND FOR OTHER CHRONIC CONDITIONS IN PRIMARY CARE. REALLY IT WOULDN'T BE CONSISTENT WITH PATIENT CENTERED COMPREHENSIVE CARE TO SILO CARE MANAGEMENT OF HEALTH CONDITIONS, HOWEVER THAT'S NOT HOW TRIALS ARE DONE. SO REALLY, FIGURING OUT HOW TO IMPLEMENT THIS IN WAY THAT INTEGRATES RATHER THAN SILOS CARE WILL BE IMPORTANT. THEN I THINK ACTUALLY THERE'S POSSIBILITY THERE BECAUSE MAYBE IN THE NON-PHARMACOLOGIC APPROACHES WERE INCLUDED IN MULTI-MODAL CARE HAVE BENEFITS BEYOND CHRONIC PAIN. SO I'M GOING TO WRAP IT UP, AND JUST SAY THAT I HOPE I HAVE GIVEN YOU A VIEW HOW THINGS COULD BE DIFFERENT. HOW WE CAN MOVE AWAY FROM OUR CURRENT OPIOID CENTERED PAIN CARE APPROACH AND THINK MORE ABOUT A PATIENT CENTERED COMPREHENSIVE INTEGRATED AND MULTI-MODAL CARE PROBLEM. NOT CARE PROBLEM. CARE MODEL. I LOOK FORWARD TO ANSWERING ANY QUESTIONS. THANK YOU. [APPLAUSE] >> THANKS SO MUCH. MY QUESTION IS ABOUT I THINK THE WORD IS OUT NOW PATIENTS WITH CHRONIC PAIN TO NOT NECESSARILY START OPIOIDS. BUT FOR PATIENTS THAT HAVE CHRONIC PAIN THAT HAVE BEEN ON OPIOIDS FOR A LONG TIME I THINK THERE'S VERY MUCH DEBATE ABOUT WHAT TO DO WITH THESE PATIENTS, HOW TO HELP THEM. TO WHAT EXTENT DO YOU THINK THEIR PAIN MAY ACTUALLY HAVE BEEN WORSENED BY OPIOIDS IN THE LONG TERM, THINGS LIKE OPPONENT PROCESS S TOLERANCE, DEPENDENCE, ET CETERA, IF SO, WHAT DO YOU THINK WE MIGHT DO ABOUT THAT? >> GREAT. SO THIS IS A GREAT QUESTION AND ONE THAT SINCE I'M TRYING NOT TO TALK ABOUT OPIOIDS ALL THE TIME I DIDN'T INCLUDE IT BUT THIS IS -- I WOULD SAY THAT OPIOID RELATED AEQUAT TRY GENIC ISSUES ARE AN ADDED AREA OF COMPLEXITY THAT HAS REALLY MADE CHRONIC PAIN MANAGEMENT MORE DIFFICULT. WE HAVE LOTS OF EVIDENCE THAT FOR SOME PATIENTS OPIOIDS CAN MAKE SITUATIONS WORSE. WE SIMPLY HAVE VERY LITTLE EVIDENCE IN THIS TERMS OF WHAT TO DO ABOUT THAT. AND RESEARCH IS ONGOING BUT THE WORLD ISN'T GOING TO WAIT FOR RESEARCH. SO I THINK REALLY THE MODEL I HAVE BEEN TALKING ABOUT IN TERMS OF PATIENT CENTERED COMPREHENSIVE INTEGRATED MULTI-MODAL CARE IS WHAT WE NEED TO APPLY TO THE CHALLENGE THAT WE HAVE IN PATIENTS WHO HAVE CHRONIC PAIN AND ARE STILL REALLY EXPERIENCING A LOT OF PAIN DESPITE OFTEN VERY HIGH DOSE, HIGH RISK MEDICATION REGIMENS OPIOID THERAPY, SO FOR THOSE PATIENTS, IT'S REALLY TRYING TO BE VERY PATIENT CENTERED IN OUR APPROACH AND COMPREHENSIVE IN OUR APPROACH. WE CAN'T JUST REMOVE OPIOIDS, WE NEED TO WORK WITH OUR PATIENTS TO DO IT IN THE BEST POSSIBLE WAY. AND TO APPLY OTHER APPROACHES. SO MY APPROACH FRANKLY WITH PATIENTS IS I DON'T KNOW IF YOU WOULD BE WORSE OFF OR BETTER OFF IF YOU WERE ON OPIOIDS. I DON'T. THERE'S NO WAY OF KNOWING THAT. BUT FOR AN INDIVIDUAL PATIENT, YOU CAN ADJUST THERAPY AND SEE WHAT HAPPENS. IF SOMEONE IS ON A VERY HIGH RISK REGIMEN, I WILL TAKE A GRADUAL APPROACH TRYING TO DECREASE THAT AND WE WILL RE-EVALUATE IN MY EXPERIENCE, IT'S GET STARTED BECAUSE IT'S SCARY FOR PEOPLE BUT ONCE PEOPLE START REDUCING THEIR DOSE, THEY EITHER FEEL BETTER OR THEY DON'T FEEL WORSE. JUST FEELING THE SAME ON A LOT LESS MEDICATION IS A VICTORY FOR MANY PEOPLE, SO THAT'S ALL WE CAN DO RIGHT NOW. >> ERIN. THIS IS A GREAT PRESENTATION. CERTAINLY THE EARLY PART OF YOUR TALK THAT REALLY EXPLAININGS THE FACTS HOW WE GOT HERE. I'M VERY DISTRACTED BY THE COMMENTS, THE UNFORTUNATE COMMENTS AND FEEDBACK FROM MEDICAL STUDENTS, OR PARTITIONERS IN THE PIPELINE AND PERHAPS WANTING TO CONVEY SOME SENSE OF OPTIMISM THAT THIS CAN CHANGE WITH COORDINATED CARE, HOW TO BEGIN WITH THIS IN MEDICAL SCHOOLS, AS AN INTERNIST I DIDN'T RECEIVE TRAINING IN MEDICAL SCHOOL OR RESIDENCY OR FELLOWSHIP. AND THE MANAGEMENT OF PAIN AND SPECIFICALLY THE PAIN OF ADDICTION THAT CERTAINLY IS CONCURRENT IN MANY OF THESE FOLKS WHO HAVE BEEN TREATED WITH OPIOIDS FOR SUCH A LONG TIME. SO WHAT ARE YOUR THOUGHTS HOW WE FIX THIS IN THE TRAINING PROCESS AND CLEARLY NEED TO ENGAGE OTHER PRACTITIONERS WHO MUST BE INVOLVED IN THIS COORDINATED CARE? >> I THINK FIRST HAVING A SENSE OF COMPETENCY OR MASTERY OF A CONCEPT REALLY HELPS MAKE SOMEONE FEEL COMFORTABLE. AND IT MAKES IT MORE PLEASURABLE. I REMEMBER IN MY RESIDENCY TRAINING I DID THREE MONTHS ON THE BONE MARROW TRANSPLANT WARDS. THAT PROBABLY WOULD HAVE BEEN BETTER SERVED FOCUSING ON SOMETHING LIKE CHRONIC PAIN, I FELT REASONABLY COMPETENT IN SOME ASPECT OF BONE MARROW TRANSPLANT AT THE END OF MY RESIDENCY, WHICH IS SILLY IF YOU THINK ABOUT IT. OBVIOUSLY THAT'S PLENTY DIFFICULT. WE JUST SIMPLY NEED TO EXPOSE OUR STUDENTS AND OUR TRAINEES MORE TO THE FUNDAMENTALS AND ALSO TO CLINICIAN WHOSE ARE ACTUALLY DOING IT WELL AND GETTING GOOD OUTCOMES. UNFORTUNATELY WE PERPETUATE THE PROBLEM BECAUSE WE HAVE CLINICIANS WHO ARE OVERWHELMING, UNDERPREPARED GETTING BURNED OUT AND THEY ARE THE ONES DOING THE ROLE MODELING AND CLINICAL TEACHING ON THIS. SO SOMEHOW WE HAVE TO COUNTER THAT. I FIND A LOT OF JOY IN STREETING PEOPLE WITH BOTH CHRONIC PAIN AND WITH ADDICTION. AND YOU DO HAVE SUCCESS AND THAT IS WONDERFUL, ESPECIALLY WHEN YOU HAVE WORKED WITH SOMEONE FOR YEARS, IT'S GREAT TO SEE THEIR LIFE GETTING BETTER. IF STUDENTS DON'T EVER SEE THAT, IF ALL THEY SEE IS THIS KIND OF DISTRUST AND GRINDING DIFFICULTY IN PRACTICE, WE'RE NOT GOING TO CHANGE THIS. >> CERTAINLY THE CLINIC SYSTEMS WITHIN THE V ASH,, THERE'S AN OPPORTUNITY FOR RESIDENT CLINICS AND TCM AND YOU SAID -- IF THE TCM SYSTEM WORKS AND CAN BE IMPLEMENTED. THERE CERTAINLY IS AN OPPORTUNITY FOR EXPOSURE. >> BOY DOES TEAM BASED CARE MAKE A DIFFERENCE TOO. WE LEARNED SO MUCH FROM OUR COLLEAGUES IN PHYSICAL THERAPY OR PSYCHOLOGY AND MAYBE THINK ABOUT THE SAME PROBLEMS DIFFERENTLY, I THINK A TEAM BASED APPROACH OFTEN IS REALLY CO-EDUCATION OF THE PRACTITIONERS. >> I WANT THE THANK YOU. I LOVE WHAT YOU HAVE BEEN TALKING ABOUT BEING PAIN PALLIATIVE CARE INTEGRATED MEDICINE FOR YEARS AND I STARTED PROBABLY TEN YEARS BEFORE YOU. AND STUDIED ESSENTIALLY WITH RUSS PORTNOY SO OUT OF THE THE WHOLE OPIATE MODEL, EVERYBODY GETS OPIATES, PROBABLY GAVE HIGHER DOSES TO CHRONIC BACK PATIENTS THAN ANYONE SO I GET IT WHERE WE CAME FROM AND WHERE WE GOT HERE. THE TCM MODEL IS CRITICAL IN MEDICINE. MUCH OF WHAT WE DO HERE. I THINK PART OF THE ISSUE WE'RE GOING TO HAVE IS WE NEED TO THINK AS A -- WHERE IN GREAT INSTITUTIONS. WHERE IN THE FEDERAL GOVERNMENT WHICH IS WHERE -- LIKE WE HAVE MODELS FROM WE CAN SHOW WHAT'S GREAT BUT THIS IS HOW MEDICINE GETS TO BE EVERYWHERE IN THE COUNTRY. I ALSO THINK SOME OF THE THINGS WHERE THERE AREN'T HUGE DIFFERENCES BETWEEN THE DIFFERENT THINGS, WE HAVE ALL THE DIFFERENT MODALITIES FROM BRACHY TO COGNITIVE BEHAVIORAL TO HYPNOSIS, TO ACUPUNCTURE AND I ALWAYS SAY AND WE GIVE COMBINATIONS AND I SAY IT DOESN'T MATTER WHAT WE GIVE OR THE COMBINATIONS, IT'S THE FACT WHAT WE'RE DOING IS WE'RE TOUCHING PATIENTS IN DIFFERENT WAYS, THAT THEY HAVE NOT BEEN TOUCHED. IT'S TOUCHING PEOPLE, CARE THEY DON'T GET IN OTHER PARTS OF MEDICINE. AND THAT'S ESSENTIALLY WHAT WE'RE DOING WHEN WE ARE DOING THIS. I THINK THE ONLY OTHER THING I WOULD ADD WITH THE BIOPSYCHOSOCIAL MODEL COMING OUT OF A MORE PALLIATIVE CARE MODEL IS BIOPSYCHOSOCIAL AND SPIRITUAL. IF WE DON'T LOOK AT SPIRITUAL WITH MEANING AND PURPOSE TO PEOPLE, THAT ALSO ADDS TO THE TOTAL PAIN PICTURE. BUT THE LECTURE WAS EXCELLENT. REALLY ENJOYED IT. >> THERE'S A FUNDAMENTAL SKILL THAT MEDICAL STUDENTS DON'T LEARN. THAT'S HOW YOU -- HOW DO YOU LEARN -- HOW DO YOU TALK TO YOUR PATIENTS TO UNDERSTAND WHAT IS IMPORTANT TO THEM. WHAT THEIR VALUES ARE. AND HOW DO YOU THEN TRANSLATE THAT WORKING WITH THE PATIENT INTO CONCRETE GOALS OR FORWARD MOVING STEPS. THIS IS NOT ROCKET SCIENCE. IF YOU CAN LEARN THOSE JUST WAYS TO EXPLORE, HOW DO YOU EXPLORE THOSE VALUES, UNDERSTAND WHAT'S IMPORTANT, AND THEN HELP TALK TO -- FIGURE HOW TO TALK TO PATIENT TO MOVE THINGS FORWARD. THAT CHANGES THE CONVERSATION ABOUT SO MANY ASPECTS. >> AND THAT'S WHAT WE DO IN PALLIATIVE CARE. TO ME PALLIATIVE CARE IS FROM DAY ONE OF ANY CHRONIC ILLNESS WHICH IS EVERYTHING INCLUDING CHRONIC PAIN. IT'S LEARNING HOW TO SPEAK. I THINK SPENDING THREE MONTHS IN BONE MARROW TRANSPLANT WAS VERY VALUABLE BECAUSE YOU CAN LOOK AT, IT DOESN'T MATTER, THAT'S WHEN I SAY TO STUDENTS, IT DOESN'T MATTER WHAT DISEASE THEY HAVE. YOU DON'T FOCUS ON -- SOME OF THE DISEASES HERE I STILL DON'T KNOW THE DISEASE AND I THINK IT'S GREAT THAT THERE ARE SCIENTISTS STUDYING THAT. IT'S THE PERSON YOU'RE LOOKING AT. WHETHER IT'S BONE MARROW TRANSPLANT OR SICKLE CELL OR CHRONIC BACK PAIN, IS THE PERSON YOU'RE LOOKING AT. >> ABSOLUTELY. THANK YOU. >> HELLO. I HAD TWO QUESTIONS. THE FIRST ON THE PHARMACOLOGIC TREATMENT FRONT. DO YOU SEE NON-OPIOID DRUG TREATMENTS ON THE HORIZON THAT YOU THINK WOULD BE A PROMISING REPLACEMENT, ON THE NON-PHARMACOLOGIC FRONT, I AT LEAST PERSONALLY APPRECIATED WHAT YOU SAID, NOT -- CARING MORE ABOUT WHETHER SOMETHING WORKS THAN WHERE IT COMES FROM. DO YOU THINK WE WOULD BE BETTER OFF WITH LOTS OF DIFFERENT NON-DRUG TREATMENTS WHETHER THEY'RE COMPLIMENTARY MEDICINE OR OTHERWISE IN THE TOOLBOX TO TRY LOTS OF DIFFERENT THINGS TO PUT INTO HERE INTEGRATED CARE MODEL, DO YOU THINK WE WOULD BE BETTER OFF FOCUSING WITH SMALL NUMBER OF OTHER NON-PHARMACOLOGICAL THINGS WITH SOLID EVIDENCE BASE? >> THANK YOU. MY ANSWERS TO YOUR TWO QUESTIONS ARE RELATED. SO FIRST OF ALL, I THINK WE ACTUALLY HAVE A LOT OF IMPERFECT THERAPIES THAT WORK QUITE WELL FOR INDIVIDUAL PATIENTS. SO BOTH ON THE PHARMACOLOGIC SIDE AND THE NON-PHARMACOLOGIC SIDE I THINK WHAT WE NEED IS REALLY OPTIONS, AND WE NEED MODELS OF CARE THAT ALLOW US TO TRY THINGS, REASSESS, AND CHANGE IF SOMETHING ISN'T WORKING OR CAUSING MORE HARM THAN BENEFIT. BECAUSE THERE IS NO ONE THING, WE NEED TO BE MORE ORGANIZED THAN OUR APPROACH TO TREATMENT THAN IF WE SIMPLY HAD A SINGLE ANSWER. KIND OF THAT FALSE HOPE THAT OPIOIDS WAS GOING TO FIX EVERYTHING, WE CAN JUST FOCUS ON INCREASING OPIOIDS, I DON'T THINK WE'RE GOING TO HAVE -- I -- OPIOIDS DIDN'T FULFILL THAT PROMISE BUT NOTHING ELSE IS GOING TO EITHER. PERSONALLY I DON'T HOLD OUT THE HOPE WE'RE EVER GOING TO BREAK THE MODERATE EFFECT SIZE FOR ANY TREATMENT -- ANY ONE TREATMENT FOR CHRONIC PAIN, I THINK IT'S SIMPLY TOO COMPLEX A PROBLEM AND PATIENTS ARE TOO INDIVIDUAL IN THEIR EXPERIENCE AND RESPONSES AND ALL THE THINGS THAT GO INTO IT. PAIN IS KIND OF -- IT IS A SYMPTOM OF MANY THINGS AND CHRONIC PAIN IS A COMMON PATHWAY FOR MANY THINGS. HONESTLY I THINK WE HAVE A FAIR MAXIMUM OF MODESTLY GOOD PHARMACOLOGIC OPTIONS. IT WOULD BE NICE TO HAVE A FEW NOR Z BUT I DON'T THINK WE'LL HAVE ANY DRAMATICALLY BETTER. >> GREAT TALK, THANK YOU. ONE THING I THINK ABOUT HERE IS THAT IN THIS PATIENT CENTERED BIOPSYCHOSOCIAL APPROACH, THE PATIENT ALSO PLAYS A LARGE ROLE AND ONE THING I'M WONDERING IS HOW PATIENT EXPECTATIONS ABOUT TREATMENT MIGHT PLAY INTO THIS. THOUGH PATIENTS ARE AWARE OF THE OPIOID CRISIS, THERE'S ALSO SOME ASPECT OF IF I'M IN A LOT OF PAIN, AND YOU GET PRESCRIPTION I CAN DO SOMETHING ABOUT THIS PAIN IN AN HOUR WHERE I CAN PICK UP THE PAIN MEDS IN THE PHARMACY, WHEREAS IF YOU TRY THIS OR THAT THAT CAN GO LONGER AND GIVEN DEMANDS ON PHYSICIAN TIME AND PHYSICIANS DON'T WANT TO BE PRIMARY CARE PHYSICIANS, IT COULD BE A LONGER PROCESS. SO HOW DOES ONE NAVIGATE EXPECTATIONS WITH PARABLES ABOUT THIS TYPE OF TREATMENT? >> EXPECTATIONS ARE HUGE. ,HUGELY IMPORTANT THAT'S THE PITFALL OF OPIOID CENTERED CARE. THERE'S AN EXPECTATION THAT OPIOIDS ARE HIGHLY EFFECTIVE AND IF YOU THINK MY PAIN IS REAL YOU GIVE ME THE GOOD STUFF. I'M NOT TRYING TO PUT THAT ON PATIENTS, WE ALL IN THIS CULTURE AT THIS MOMENT, ARE GUILTY OF THINKING THAT WAY SOMETIMES. BUT ONE THING ABOUT THAT, THE SPACE TRIAL I MENTIONED WHERE WE COMPARED OPIOIDS WITH NON-OPIOID THERAPY, WE DID A QUALITATIVE FOLLOW-UP STUDY TO UNDERSTAND THE EXPERIENCE OF PATIENTS IN THAT STUDY. I HOPE IT WILL BE IMPRESSED IN LITERATURE REVIEW BUT IT'S INTERESTING TO LOOK HOW THOSE TRANSCRIPTS HOW PATIENTS EXPERIENCE THIS AND HOW THEY CAPABLE TO THE STUDY WITH HUGE EXPECTATIONS FOR THE BENEFITS OF OPIOIDS. SOME OF THESE PATIENTS WERE REALLY AFRAID OF TRYING OPIOIDS BUT THEY ALL THOUGHT THEY WERE BETTER THAN OTHER MEDICATIONS. WHEN PERSONAL EXPERIENCE DIDN'T JIVE WITH THAT IT WAS INTERESTING TO HEAR HOW THEY WERE THINKING ABOUT IT CHANGE. CLEARLY WE HAVE A CULTURE PROJECT IN TERMS OF MODIFYING EXPECTATIONS ON THE BIG PICTURE LEVEL ABOUT WHAT CHRONIC PAIN IS. AND WHAT EFFECTIVE APPROPRIATE TREATMENT FOR CHRONIC PAIN IS, THAT'S A BIG PICTURE THING T. ON THE INDIVIDUAL PATIENT TIME YOU'RE RIGHT. SOME OF THESE NON-PHARMACOLOGICAL THERAPIES IN PARTICULAR REALLY YOU SEE THE BENEFITS SIX TO 12 MONTHS DOWN THE ROAD WHICH IF YOU HAD PAIN FOR TEN YEARS, IS ACTUALLY NOT TOO BAD BUT THAT'S NOT SATISFYING TO MANY PEOPLE. THAT'S WHERE MULTI-MODAL CARE COMES IN. MEDICATIONS, AND SOME OF THE MANUAL THERAPIES PROVIDE PRETTY IMMEDIATE RELIEF. MAYBE THEY'RE NOT SO SUSTAINABLE IN THE LONG RUN. SO COMBINING THOSE SHORT TERM AND LONGER TERM VIEWPOINTS CAN BE A GOOD WAY TO GO. THANK YOU. >> VERY GOOD PRESENTATION. I'M FROM MINNEAPOLIS, MINNESOTA, I'M A PHYSICAL MEDICINE REHAPPEN PODIATRIST PRACTITIONER THERE. I THINK THE MANAGEMENT OF CHRONIC PAIN, THE MANAGEMENT IS REALLY THE MOST IMPORTANT PART, IT'S NOT LIKE A CURE OF CHRONIC PAIN AND THE MANAGEMENT IN THE PHYSICAL MEDICINE, WE USE THE MULTI-MODAL TEAM APPROACH BECAUSE WE DEAL WITH DISABLED PEOPLE AND THE DISABILITY MANY TIMES IS PERMANENT. THEY HAVE TO BE TAUGHT RESPONSIBILITY TO TAKE CARE OF IT AND MANAGE. SO IT'S MORE LIKE TEACHING THEM WHAT TO DO. IN THAT CONTEXT, I'M WONDERING LIKE DIFFERENT PAIN PEOPLE EXPERIENCE THAT YOU SHOW, YES, BACK PAIN IS THERE ON THE TOP OF THE LIST BUT IS NOT JUST THE BACK PAIN THE SPINAL PAIN BECAUSE A LOT OF TIMES THE LEG PAIN, SHOULDER PAIN, THEY ARE RELATED TO THE SPINAL PAIN. SO I'M WONDERING WHERE DO -- LET'S SAY LIKE THE HEALTHCARE PEOPLE THAT ARE -- SAY LIKE HEALTH CLUBS AND NON--- IN NON-MEDICAL SETTING, PEOPLE USE THE CORE STRENGTHENING AND USE YOGA AND TAI CHI AND THESE THINGS, BUT THEY TOOK RESPONSIBILITY AND PAID FOR THE HEALTH CLUB, THEY GO THERE, THEY EXERCISE, THEY FEEL BETTER. IS THERE ANY ROOM FOR RESEARCH IN THAT TYPE OF APPROACH? AND NOT EXACTLY LIKE IN PHYSICAL THERAPY, WHERE TREATMENTS ARE -- THIS MANY MASSAGE SESSIONS ARE PAIRED THEN YOU'RE GONE AND YOUR PAIN IS BACK. >> THANK YOU FOR BRINGING IT BACK TO THE BIG PICTURE. THIS IS THE WHOLE SPECTRUM. WE HAVE A PROJECT TO DO IN TERMS OF PAIN. THAT IS STARTING WITH PREVENTION AND GOING ALL THE WAY TO HELPING FOLKS WITH REALLY SEVERE DISABILITY. CLEARLY WE CAN'T DO THIS ALL IN THE SAME SETTING. IT'S A PRIMARY CARE COMPREHENSIVE CARE WE SHOULD BE DOING ALMOST EVERYTHING. AT LEAST '09 0% T COMMON STUFF. BUT THE VERY DISABLED FOLKS DO NEED MULTI-DISCIPLINARY HIGH END REHAB PROGRAMS. AND THE REST OF US WHO HAVEACHES AND PAINS, WE NEED TO GET TO THE GYM. SO THERE IS REALLY A PUBLIC HEALTH AND IMMUNITY ASPECT TO THIS. PART OF IT IS LEARNING HOW TO MANAGE THINGS. I RECENTLY TALKED TO A PATIENT WHO IS WRITING BOOK ABOUT HIS ACTUAL PAIN EXPERIENCE. HE WANTS TO GET OUT HEALTH EDUCATION, IN ELEMENTARY SCHOOLS, HEALTH ED, IF SOMETHING HURTS, WHAT DOES THAT MEAN? WHAT IS YOUR BODY TRYING TO TELL YOU, HOW TO TAKE CARE OF YOUR BODY, HOW DO YOU DO THAT BODY MAINTENANCE. >> I'LL TRY TO BE QUICK WITH THIS ONE. THAT WAS A FABULOUS TALK, I'M A POST BACK GOING TO MEDICAL SCHOOL IN THE FALL. I'M ON A TEAM LOOKING AT CHRONIC PUBLIC PAIN IN WOMEN WITH ENDOMETRIOSIS. YOU'RE ABSOLUTELY RIGHT, HAVING STRONG MENTORSHIP IN TRAINEES, SO THEY SEE HOW TO PROVIDE CARE FOR PATIENTS WITH CHRONIC PAIN IS VERY VALUABLE. IT'S ALSO VALUABLE FOR US HERE WITH THE PRIVILEGE OF BEING AT NIH WHERE THE CARE THE PATIENTS RECEIVE IS FREE. THEY SPEND HOURS AS CLINICS BEFORE THEY ENROLL AND WE SPEND A YEAR FOLLOWING THEIR PAIN. SO NOT ONLY DO I SEE HOW THEY PROGRESS OVER THE YEAR, BUT THEY BENEFIT FROM THAT HANDS-ON FAIRLY EXPENSIVE PHYSICIAN CARE THAT'S COMPLETELY COST FREE FOR THEM. HOW DOES THIS INTEGRATED MULTI-MODAL CARE TRANSLATE INTO PRIVATE SECTOR WHERE INSURANCE COMPANIES AND PRIVATE CLINICIANS ARE LOOKING ARE AT HOW MUCH MONEY CAN WE MAKE FROM THIS OR HOW ARE WE REIMBURSING THIS? >> THANK YOU. I'M NOT TERRIBLY PREPARED TO FIX THE HEALTH SYSTEM OR LACK THEREOF THAT WE HAVE IN THIS COUNTRY, BUT THESE ARE IMPORTANT ISSUES. I THINK WE DO NEED TO THINK ABOUT WHAT WE ARE PAYING FOR, WHY WE ARE DOING SO. WHY DO WE PAY FOR EPIDURAL INJECTIONS IN PEOPLE WHO HAVE CHRONIC BACK PAIN, WE HAVE RANDOMIZED PLACEBO CONTROL TRIALS THAT DEMONSTRATE NO BENEFIT THERE. WE'RE PAYING BIG BUCKS FOR THIS STUFF. SOMEHOW, WE NEED TO RE-- WE NEED TO RE-EVALUATE WHAT WE'RE PAYING FOR. AND I THINK SOMETIMES IT'S JUST THAT THE COSTS TO THE SYSTEM DON'T OR THE SOCIETY DON'T GET ASSESSED, IT'S JUST COST TO VERY COMPLEX. I MEAN, I THINK THOUGH IN TERMS OF ROLLING THINGS OUT, PART OF THIS IS BRINGING IT MORE INTO THE PRIMARY CARE SETTING AND DOING MORE OF THAT TEAM BASED CARE. SO IN A COLLABORATIVE CARE PHYSICIAN OR TOP PAID PERSON IN THE TEAM WHO HAS FACE TO FACE OR TELEPHONE CONTACT WITH THE PATIENT. AGAIN, IT DOESN'T HAVE TO BE ALL FACE TO FACE BUT THERE WE HAVE A CHALLENGE SO WE'LL ENSURE IT'S PAY FOR PHONE VISIT WITH PHARMACIST INSTEAD OF FACE THE FACE VISIT WITH A PHYSICIAN, IT SEEMS LIKE THEY OUGHT TO. SO ONE THING ABOUT THE OPIOID CRISIS, WE HAVE A LOT OF LEGISLATORS A LOT OF POLICY MAKESSERS WHO WANT TO MAKE A DIFFERENCE RIGHT NOW. AND I GET A LOT OF CALLS FROM PEOPLE ASKING ABOUT WHAT DO WE NEED TO DO TO GET DOCTORS PRESCRIBE LESS OPIOIDS, HOW DO WE TURN THIS ON A DIME. WE CANNOT UNBAKE THAT CAKE. WE CAN'T JUST ROLE BACK TIME 20 YEARS AGO. BUT IF WE WANT TO MOVE FORWARD SOME OF THAT ENERGY COULD BE APPLIED TO IMPROVING HOW WE PAID FOR AND ORGANIZE PAIN CARE. I THINK THAT'S WHERE THE PAY OFF IS. IN THE LONG RUN. SO THERE IS MY PLUG FOR ADVOCACY, IF YOU EVER HAVE AN OPPORTUNITY TO SUGGEST WHAT MIGHT MAKE A DIFFERENCE FOR FUTURE PATIENTS. THAT WOULD BE IT. >> THANK YOU. >> THANK YOU VERY MUCH. [APPLAUSE]