>> GOOD MORNING. I'D LIKE TO WELCOME YOU ALL TO THE SECOND MEETING OF THE INTERAGENCY PAIN RESEARCH COORDINATING RESEARCH COMMITTEE AND I THINK WE HAVE VERY AMBITIOUS PLANS FOR THE MEETING AND HOPEFULLY WE'LL ACCOMPLISH EVERYTHING ON THE AGENDA BUT IF WE DON'T WE CAN SAVE IT FOR THE NEXT MEETING. I WANT TO START BY WELCOMING OUR NEWEST MEMBER, MYRA CHRISTOPHER, SHE'S THE PALLIATIVE CARE AT THE CENTER FOR PRACTICAL BIOETHICS, AN ORGANIZATION SHE'S LED SINCE ITS INCEPTION IN 1984, PRIOR TO THAT SHE SERVED IN THE ROBERT WOOD JOHNSON OFFICE FOR COMMUNITY STATE PARTNERSHIPS TO IMPROVE END OF LIFE CARE. SHE'S CURRENTLY THE PRINCIPAL INVESTIGATOR ON THE PAIN ACTION INITIATIVE AND NATIONAL STRATEGY AND WAS A MEMBER OF THE INSTITUTE OF MEDICINE'S PANEL WHICH DEVELOPED THE RECENT REPORT ON PAIN, RELIEVING PAIN IN AMERICA, A BLUEPRINT FOR TRANSFORMING CARE, EDUCATION AND RESEARCH. SHE'S RECEIVED MANY AWARDS FOR HER WORK IN CHRONIC PAIN INCLUDING THE AMERICAN PAIN ACADEMY MEDICINE AND THE AMERICAN ACADEMY PAIN MANAGEMENT HEAD-HEART AWARD. SHE REPLACES TINA, PRESIDENT AND CEO OF THE NEUROOPERATING GLOBALLYATHY COMMITTEE OVER THE SUMMER AND I WANT TO THANK TINA FOR ALL THE WORK SHE DID AS THE IPRCC AND THE WORKING GROUP. WE HAVE A VACANCY ON THE COMMITTEE DUE TO THE RECENT RESIGNATION OF TAMARA MILLER WHO IS WHERE A NATIONAL FIBROMYALGIA FOUNDATION. NOW DUE TO UNAVOIDABLE CONFLICTS 4 MEMBERS ARE NOT ABLE TO BE WITH US TODAY, TERRY KELLIE WHOSE HUSBAND HAD EMERGENCY GALLBLADDER SURGERY, BUT HE'S DOING WELL, WE HEAR, CHRISTINE MIAKOWSKY, MARY VARGAS, SHE MAY BE PARTICIPATING ON THE PHONE PART OF THE TIME AND DR. SMITH LET US KNOW HE WILL BE LATE. SO WE'RE GOING TO START WITH A SET OF SHORT UPDATES ON FEDERAL RESEARCH EFFORTS RELATED TO PAIN. WE WILL HEAR FROM NORA, DAVE, AND CARMEN AND WALLY SMITH IF HE GETS HERE ON TIME BUT THEN WE WILL SPEND MUCH OF OUR TIME ANALYZING THE IPRCC PAIN RESEARCH PORTFOLIO. THEY ARE IDENTIFYING CLINICAL PAIN RESEARCH AND MAKE RECOMMENDATIONS FOR FEDERALLY FUNDED PAIN RESEARCH. SO WE GATHERED TOGETHER, AN EXTRAORDINARY WEALTH OF INFORMATION ON THE PAIN RESEARCH BEING CONDUCTED AND SUPPORTED ACROSS THE FEDERAL GOVERNMENT AND TODAY WE'RE GOING TO DISCUSS OUR PRELIMINARY WORK IN EXAMINING THOSE DATA. WE THEN NEED TO FIGURE OUT HOW TO TAKE THIS, I THINK RATHER INDIGESTIBLE AMOUNT OF DATA AND TURN IT INTO SOMETHING THAT ACTUALLY WE CAN THINK ABOUT COACHINGLY AND USE IT TO AIRCRAFT DENTIFY GAPS. AND A SECOND GOAL WILL BE TO EXPLORE POTENTIAL OVERLAPS BETWEEN THE AGENCIES BECAUSE THERE'S SEVERAL AGENCIES WORKING ON BACK PAIN, SEVERAL AGENCIES WORKING ON THERAPEUTICS DEVELOPMENT AND WE MAY NOT GET TO THAT TODAY, BUT I THINK MAKING SURE THAT THE AGENCIES THAT ARE WORKING ON SPECIFIC PROBLEMS ARE DOING IT, RECOGNIZING THAT THEY'RE BOTH OR 3 OR 4 OF THEM WORKING ON THIS ISSUE AND MAKING SURE THAT THE EFFORTS ARE INTEGRATED WILL BE GOOD. SO, I WANT TO THANK ALL THE STAFF AT THE 6 FEDERAL AGENCIES FOR THEIR EXTRAORDINARY DEDICATION AND HARD WORK IN GATHERING THIS EXTENSIVE DATA SET OF FEDERALLY FUNDED RESEARCH AND IN HELPING US TO ANALYZE IT. SO THAT'S THE MORNING. THEN RIGHT AFTER LUNCH ASSISTANT SECRETARY OF HEALTH DR. HOWARD COE AND THE DEPUTY ASSIST APT SECRETARY FOR HEALTH WILL JOIN THE MEETING TO DELIVER THE EXPANSION OF THE CHARGE TO THIS COMMITTEE AND THERE'S TIME AFTER THAT CHARGE TO DISCUSS WITH DR. COE AND P A RIK BUT HOW WE'LL TAKE THAT NEW CHARGE ON. NOW THE AFTERNOON, AFTER DR. CO LEAVES WE'VE BEEN CHARGED WITH COMING UP WITH A SUMMARY OF ADVANCES IN PAIN RESEARCH SUPPORTED OR CONDUCT BY FEDERAL AGENCIES AND WE'LL TRY TO SPEND THE AFTERNOON DISCUSSING THOSE ADVANCES AND HOW BEST TO PUT THEM IN A REASONABLE SUMMARY AND ALSO TO DETERMINE WHETHER OR NOT WE WANT TO DO THIS ON ANNUAL BASIS. I PERSONALLY THINK THAT'S A GOOD IDEA BUT IF THE COMMITTEE NOT ENTHUSIASTIC ABOUT IT THEN WE SHOULDN'T GO FORWARD AND THEN THE LAST PIECE, MAJOR GENERAL TOM THOMAS WILL SHARE THE ARMY SURGEON'S GENERAL PAIN MANAGEMENT TASK REPORT SO IT'S A VERY FULL DAY. I WANT TO ANNOUNCE THAT DR. LINDA PORTER WAS RECENTLY MAIM--NAMED AS THE ADVISOR FOR THE IPC RC, LANED SITTING ON MY RIGHT RECEIVED HER Ph.D. FROM THE BOSTON SCHOOL OF ANATOMY AND MEDICINE, SHE WASOT UNIFORM UNIVERSITY OF HEALTH SCIENCES FOR 10 YEARS BEFORE JOINING NINDS, AS THE PROGRAM DIRECTOR RESPONSIBLE FOR OUR PAIN PORTFOLIO. WHEN SHE WAS THERE, SHE DIRECTED AN NI H FUNDED RESEARCH PROGRAM LOOKING AT SENSORY MOTOR ELEVATION AT THE CORTICALE LEVEL AND STUDIED VARIOUS EFFECTS OF MODULATORS ON DEVELOPING CORDICLE NEURONS AND PROTECTIVE INFLUENCE, AND SO, IN 2003 WE WERE VERY FORTUNATE TO RECRUIT LINDA FROM USES, TO COME TO NINDS AND SERVE ON OUR PROGRAM STAFF. SHE TOOK OVER OUR PAIN PORTFOLIO, PERIPHERAL CENTRAL MECHANISMS THAT MEDIATE PAIN, CENTRAL PROCESSING AND PAIN, DISEASE RELATED PAIN DISORDERS AND PAIN MANAGEMENT SO I'M DEDELIGHT THAD HREUPDA IS KWROEUPBING US ON HER NEW ROLE AND I WANT TO INDICATE EEXTEND MY APPRECIATION. [ APPLAUSE ] AND THANK PAUL SCOTT, THE DIRECTOR OF OFFICE OF SCIENCE POLICY AND PLANNING AT NINDS, HE DID A WONDERFUL JOB SERVING AS FOR THE COMMITTEE THIS PAST YEAR UNTIL LINDA ASSUMED THIS POSITION. NOW AS YOUR FIRST OFFICIAL JOB COULD YOU GET PEOPLE TO APPROVE THE MINUTES. >> I WILL DEFINITELY TRY. >> SO IN THE MAILING THAT YOU GOT A WEEK OR SO BACK, THERE WAS A COPY OF MINUTES FROM THE JUNE 28th MEETING, THE TELEPHONE MEETING AND WE HOPE YOU HAD A CHANCE TO LOOK AT IT. IF NOT, IF YOU COULD TAKE A LOOK AT THE HARD COPY THAT'S INCLUDED IN YOUR PACKET; IF FOLKS NEED A FEW MINUTES TO LOOK THROUGH IT. I THINK EVERYONE HAD A CHANCE TO REVIEW. YES MIKE. >> [INDISCERNIBLE]. >> PAGE 3 PARAGRAPH 2. OH THAT NEEDS TO COME OUT. WE'LL CORRECT THAT, THANKS MIKE. >> OTHERWISE YOU'RE OKAY. COULD I HAVE A MOTION TO APPROVE THE MINUTES. >> THANK YOU. >> SECOND? ANY DISCUSSION? OKAY. SO THE MINUTES ARE APPROVED. IF I COULD POINT OUT TO YOU THAT ALSO IN YOUR PACKET, WE HAVE RECEIVED 2 PUBLIC COMMENTS IN WRITTEN FORM, 1 IS FROM CHRISTINE WHOSE REPRESENTING THE AMERICAN ASSOCIATION OF NURSE AN ESTIMATE THAD THEY--THIVITYS, SHE WILL ALSO HAVE ORAL COMMENTS LATER IN THE DAY AND DAVID WEISEMAN ON BEHALF OF THE ADHESION SOCIETY, HAS WRITTEN COMMENTS. SO WHEN HAVE YOU A CHANCE, LOOK THROUGH THOSE, AND WE'LL TURN IT BACK TO STORY. >> [INDISCERNIBLE]. --DIRECTOR OF THE DIVISION OF INTRAMURAL RESEARCH CENTER FOR COMPLIMENTARY AND ALTERNATIVE MEDICINE, THIS WAS AN EXTRAORDINARY RECRUIT IN THIS ROLE, DR. BUSHNELL, WILL BE IN CHARGE OF OVERSEEING A PROJECT FOR THE BRAIN'S ROLE ON RECEIVING AND MODIFYING PAIN. TELL BE HIGHLY COLLABRATIVE AND WILL COMPLEMENT BASIC RESEARCH ACROSS THE NIH IN NEUROSCIENCE, IMAGING AND BEHAVIORIAL HEALTH. SHE'S ALREADY HERE, HER LAB IS SET UP. BEFORE COMING TO NIH, SHE WAS THE HERALD GRIFFITH ANESTHESIA AND PROFESSOR DENTIST OF NEUROLOGY IN MONTH REAL CANDAND WAS ALSO THE DIRECTOR OF THE MIGUEL EDWARD CENTER FOR RESEARCH ON PAIN. SHE RECEIVED NUMEROUS HONORS FOR RESEARCH ON PAIN AND LIFETIME ACHIEVEMENT AWARD FOR THE PAIN SHOET, AND THE FREDERICK KERR BASIC SCIENCE RESEARCH FOR THE AMERICAN PAIN SOCIETY. SHE HOLDS A Ph.D. IN M. A. AND EXPERIMENTAL PSYCHOLOGY FROM AMERICAN UNIVERSITY AND A BACHELOR'S DEGREE IN PSYCHOLOGY FROM THE UNIVERSITY OF MARYLAND. SHE BEGAN HER SCIENTIFIC CAREER IN 1976, ACTUALLY WITH RON DUBNER, AT NIDCR, EXPLORING THE PSYCHOLOGICAL ASPECTS OF PAIN PROCESSING AND WE THINK SHE'S A WONDERFUL ACISION TO THE PAIN RESEARCH COMMUNITY AND WE'RE DELIGHTED. JOSEY, WOULD YOU LIKE TO SAY ANYMORE? >> NO, STORY, YOU SAID IT VERY WELL. WE'RE DELIGHTED TO BE PART OF THIS GROUP, IT'S BEEN A COOPERATIVE ACTIVITY BETWEEN OURSELVES AND NEURIE SCIENCE INSTITUTES HERE AND THE SUPPORT FOR HER LAB WILL COME FROM NCAM, BUT SHE'S ABLE TO TAKE ADVANTAGE OF THE SUPERB NEUROSCIENCE RESOURCES ON THIS CAMPUS. MOST OF THEM IN NINDS, SO WE'RE VERY EXCITED ABOUT HER ARRIVAL. >> AND WE'LL BE A MEMBER OF THE PAIN CONSORTIUM AND HOPEFULLY WE'LL END UP COMING TO SOME OF THESE MEETINGS. >> SO THE NEXT UPDATE IS FROM DR. NORA VOLKOW, ABOUT THE ACTIVITY SHE'S SPEAR HEADING ON BEHALF OF NIH. >> GOOD MORNING, I ACTUALLY, I THINK THIS IS THE FIRST TIME I'M HEARING FROM THE EVERYONE, AND APPRECIATE BEING ABLE TO PRESENT THIS INITIATIVE. I COME FROM THE NATIONAL INTUITY ON DRUG ABUSE WHERE WE'VE BEEN INVESTED ON RESEARCH THAT RELATES TO PAIN THAT GOES FROM THE VERY BASIC UNDERSTANDING BECAUSE OF THE ROLE OF OPIOIDS BUT ALSO MORE RECENTLY, BECAUSE OF THE INCREASE IN THE USE OF PRESCRIPTION MEDICATION THAT HAS FORCED US IN A WAY TO TRY TO ADDRESS THE GAPS IN RESEARCH AND TREATMENT AND EDUCATION IN THE USE OF OPIATE MEDICATION AND THIS IS CERTAINLY IN MY BRAIN, WAS HIGHLIGHTED WHEN LAST YEAR, THERE WAS A FIRST PRESCRIPTION MEETING, ORGANIZE TO THE TRY TO BRING TOGETHER RESEARCHERS AND PROVIDERS OF TREATMENT FOR INDIVIDUALS SUFFERING FROM BRAIN, FROM THE PERSPECTIVE THOUGH OF THE CONCERN OF THE USE OF PRESCRIPTION MEDICATION. WHAT BECAME CLEAR IN MY BRAIN WAS THE NOTION AND I AM ALWAYS IN A VERY DIFFICULT SITUATION BECAUSE I HAVE TO PUT FORWARD A CONCEPT THAT WE DO HAVE A PROBLEM OF USE OF PRESCRIPTION MEDICATIONS, BUT AT THE SAME TIME WE HAVE THE REALITY THAT PAIN IS A VERY FADING CONDITION AND OPIATE MEDICATIONS ARE MANY INSTANCES THE BEST TREATMENT WE CAN OFFER TO PATIENTS. SO WHEN WE'RE IN THAT SITUATION WHERE WE HAVE POSITIVE METRICSICATION THAT HAS A TREMENDOUS VALUE AND ANOTHER 1 WE SEE THE DIVERSE AND ABUSE. SO WHEREVER I GO, I GET CRITICIZED BECAUSE THE PATIENT THAT ADVOCATES BECOME DEFENSIVE TOWARDS ME AND SAYS, WE CANNOT ADDRESS THE PAIN PROBLEM, IT'S AN IMPORTANT 1 AND THE OTHER 1 WHEN I SPEAK IN„i SUBSTANCE ABUSE FIELDS THEY SAY HOW CAN YOU BE SO SENSITIVE TO THE NEED FOR HAVING THESE PRESCRIPTION MEDICATION SO I HAVE NO WIN IN NO WAY. AND MY PERSPECTIVE HAS ALWAYS BEEN, WE NEED TO ADDRESS THAT THESE 2 THINGS ARE NOT EXCLUSIONARY. WE HAVE THE NEED FOR PROVIDING THE NEED FOR OPIATE MEDICATION AND THE OTHER HAND WE DO HAVE A PROBLEM OF DIVERSION. NOW THESE GO TO ALERT, I MEAN--IT GOES TO AN EMERGENCY SITUATION WHEN I WAS CALLING BY A CONGRESS PERSON AND I'M NOT GOING TO GIVE NAMES, JUST PUTTING THE THINGS ON THE TABLE AND THEY ASK ME, WE WOULD LIKE YOU TO ENDORSE A STATEMENT THAT THE USE OF OPIATE MEDICATION SHOULD BE REMOVED, NOT–r AS„i AN INDICATION OF CHRONIC PAIN. AND I SAID THERE'S ABSOLUTELY NO EVIDENCE THAT 1 COULD PUSH FORWARD FOR IS SUCH A MOVE. BUT THESE REALLY WAKE ME UP TO THE NEED THAT WE NEED TO BE PROACTIVE, IN TERMS OF PROVIDING EVIDENCE, CLEARLY, WITH THE WORD OF SCIENCES IN USE OF MEDICATION WITH THE OPIATE MANAGEMENT AND USE OF CHRONIC PAIN. IN ORDER FOR US TO AVOID TO BE IN THAT SITUATION, WHERE THERE IS INCREASING PRESSURE FROM GROUPS TO TRY TO CHANGE THIS INDICATION AND THAT'S ACTUALLY IN MY BRAIN, WHEN I CAME BACK AND I SAID WE NEED TO DO SOMETHING ABOUT IT, AND OBVIOUSLY THE PAIN CONSORTIUM IS THE IDEAL PLACE TO DO IT. THE IOM REPORT IN MY VIEW AS BEEN REAL INSTRUMENTAL IN HIGHLIGHTING UP THE AWARD AND CERTAINLY IN THE SCIENTIFIC COMMUNITY OF THE NEED THAT WE HAVE TO DEVELOP MORE SCIENCE AS IT RELATES TO OUR UNDERSTANDING OF PAIN, BUT ALSO TO BRING IT INTO TRANSLATION FOR THE PROPER SCREENING AND TREATMENT OF PATIENTS THAT ARE SUFFERING FROM PAIN. ALSO TO ME 1 OF THE THINGS I LOVE ABOUT THE IOM REPORT IS THAT IT BASICALLY SAYS WE HAVE TO TRANSFORM OF COURSE, VERY IMPORTANT. BUT THE OTHER ASPECT IS THAT IT DOESN'T RAISE THE NOTION OF PAIN. WHICH IS AN ASPECT WE HAVE NOT BEEN FOCUSING SO MUCH IN THE HEALTHCARE SYSTEM. YOU ALL KNOW, MANY OF YOU WERE PARTICIPATINGOT IOM REPORT BUT I LIKE TO BRING IT BECAUSE IT IS JUST A NUMBERS, THEY ARE JUST SO GIGANTIC, 110 MILLION INDIVIDUALS WITH CHRONIC PAIN AND COST CLOSE TO HALF A THRILLION DOLLARS PER YEAR FOR THE MANAGEMENT OF PAIN AND OF COURSE, THIS IS IN A SITUATION WHERE IT IS RECOGNIZED THAT THE MAJORITY OF PATIENTS SUFFERING FROM CHRONIC PAIN DO NOT HAVE RELIEF NOW. THAT LACK OF RELIEF AND WHAT THE NUMBERS ARE, ARE UNCLEAR BUT IT DOES REFLECT 2 ASPECTS OF T. 1 OF THEM A CULTURE THAT WE MAY HAVE, IN TERMS OF WHAT IS THE RESPONSIBILITY OF THE HEALTHCAR SYSTEM TO ADDRESS PAIN BUT I THINK THAT THE OTHER REALITY TO IT, IS THE FACT THAT WE DO NOT NECESSARILY HAVE ALL THE TOO TOOLS TO PROPERLY MANAGE PAIN. I THINK THAT IS A FAIR STATEMENT. THE OTHER THING WE NEED TO ALSO RECOGNIZE IS A PREVALENCE OF CHRONIC PAIN, IT'S INCREASING IN THE UNITED STATES, THIS ALSO SEEMS TO BE THE CASE IN OTHER AREAS OF THE WORLD. IN OUR COUNTRY, PART OF THE PROBLEM IS ASSOCIATED WITH INCREASED LONGEVITY AS WELL AS OTHER CONDITIONS LIKE EPIDEMIC THAT WE'RE SEE O GBA OBESITY AND AS WELL AS IMPROVEMENT OF SURVIVAL WITH TRAUMA. IN THE IOM REPORT, AGAIN I'M JUST SUMMARIZING RAPIDLY, THERE IS HIGHLIGHTING THE NEED NEAR COMPREHENSIVE TREATMENT PROGRAMS THAT INVOLVE THE PATIENTS AND SELVES TO TAKE RESPONSIBILITY AS WELL AS A HEALTHCARE SYSTEM THAT IS BETTER INTEGRATED. IT IS ALSO DISCUSSED THAT THEY ARE ALEGORITHMS FOR THE TREATMENT OF CHRONIC BRAIN THAT ARE NOT ALWAYS EFFECTIVE AND THEN THERE ARE ACTUALLY IN THE FIRST CHAPTER THERE IS 1, THE HIGHLIGHT THE POINTS THAT ARE IMPORTANT THAT ARE GOING TO BE DISCUSSED AND 1 OF THEM IS ACTUALLY DISCUSS THE CONFUND RUM, THEY USE THEIR W BASICALLY QUOTING THE CONUNDRUM OF THE USE OF OPIOIDS BECAUSE THIS RECOGNITION THAT THE HEALTHCARE IS RELYING MORE AND MORE IN THE PRESCRIPTION OPETRESSABLATE MEDICATION FOR THE MANAGEMENT OF BOTH ACUTE AND CHRONIC PAIN. THIS IS HIGHLIGHTED IN THESE SLIDES THAT SHOWS DATAB TAPE FRIDAY VERSE SPOTS. THE SIGNATURES THEUF KACCT TININE PATHWAY SPOT OF MEDICATIONS IN OUR COUNTRY AND YOU SEE THESE PRESCRIPTIONS IN ALLELES FROM 91, 1991 WHERE APPROXIMATELY 76 MILLION PRESCRIPTIONS ARE GIVEN IN THIS COUNTRY, NOT GIVEN HERE, THE 20 WELL 11 WHERE THAT HAS GONE FULLLY TO 2020. SO ALMOST A 3 FOLD INCREASE IN THE NUMBER OF PRESCRIPTIONS, THESE REFLECT SPECIFICALLY TO HYDROCO DONE AND OXYCODONE WHICH ARE THE MOST FREQUENTLY ABUSED OPIOID MEDICATIONS. HAD IS A SIGNIFICANT INCREASE IN THE NUMBER OF PRESCRIPTIONS THAT THOSE REFLECTS PART, THE MORE AGGRESSIVE RECOGNITION AND SCREENING OF PAIN AND IT'S TREATMENT. BUT IT ALSO DOES REFLECT IN PART, THE OTHER SIDE OF THE COIN WHICH IS THAT THIS MEDICATIONS ARE BEING DIVERTED AND ABUSED. MOST OF THEM ACTUALLY INTERESTINGLY ARE VERY FAR APART FOR THEIR USE FOR PAIN MEDICATIONS. PERHAPS WHAT I THINK ALERTED THE COMMUNITY ABOUT THIS ISSUE, IS THAT THIS INCREASE IN THE PRESCRIPTION OF OPIOID MEDICATIONS, THERE HAS BEEN A SIGNIFICANT INCREASE IN A NUMBER OF DETHS FROM OVERDOSES THAT HAVE BEEN ASCRIBED TO THE USE OF PAIN MEDICATIONS. IT'S BASICALLY CLOSE TO 4500 DEATHS IN THE UNITED STATES IN A GIVEN YEAR FROM OVERDOSES FROM PAIN MEDICATIONS AND THESE ARE FAR GREATER NUMBERS THAN THERE ARE DOSES ARE HEROINE, DON'T THE DEPTHS THAT ARE CAUSED BY COCAINE AND IN MANY STATES CLOSE TO HALF OF THE STATES THERE ARE MORE TKAEPGTS FROM OVERDOSES OF PAIN MEDICATIONS THAN THERE ARE FROM CAR ACCIDENTS. THIS ALERTED THE FDA, THE HHS, TO TRY TO RECOGNIZE AND TRY TO ADDRESS THESE PROBLEMS. NOW FROM THE PERSPECTIVE OF THE--THIS THESE RISKS, OBVIOUSLY LIKE ANYTHING ELSE, THESE GUYS LED TO SOME PHYSICIANS WHERE THEY ARE,--THESE ARE ASSOCIATE WIDE OPIOID MEDICATIONS ARE JUSTIFY INDEED TERMS OF THE EFFICACY OF OPIATES FOR THE TREATMENT OF CHRONIC PAIN. AND I THINK THAT THAT'S WHERE WE HAVE TO REALIZE THAT THERE'S NOT SUFFICIENT RESEARCH THAT HAS BEEN DONE WITH RESPECT TO THE CHRONIC--USE OF OPIATES FOR THE CHRONIC TREATMENT OF PATIENTS WITH PAIN. AND THE NOTION TO OF OPIOID MEDICATION DO HAVE--MAY AFFECT COMMUNITY FUNCTION, THERE MAY BE SEDATING FOR CERTAIN PATIENTS AND SOME HAVE COME UP AND THIS PAPER WAS INFLUENTIAL IN THE JOURNAL OF OF MEDICINE 2003 THAT SUGGESTS THAT PROLONGED HIGH DOSE OPIOID THERAPY MAY BE NEITHER SAFE NO EFFECTIVE. BUT THE BOTTOM LINE IS I DON'T THINK THAT WE CAN CONCLUDE LIKE THAT, THE BOTTOM LINE IS THAT WE DON'T HAVE SUFFICIENT STORIES AND THE STORIES THAT ARE THERE, ARE DONE WITH RELATIVELY SMALL NUMBER OF SUBJECTS AND OF A RELATIVELY SHORT PERIOD OF TIME. ANOTHER PAPER IN 2010 ALSO HIGHLIGHTS, MORE TOWARDS ADDRESSING THE ISSUE OF, WELL, WHAT ABOUT THE DOSES, WHAT ABOUT THE RISK FOR OVERDOSES AND COMES TO THE CONCLUSION THAT PARTICULARLY THE OVERDOSES AND DEATHS FROM OPIOIDS ARE ASSOCIATE WIDE HIGHER DOSES OF OPIOID MEDICATIONS. IF YOU LOOK AT THE LITERATURE THOUGH, WHAT IS ALSO CLEAR IS THAT THOSE FROM OVERDOSES FROM PAIN MEDICATIONS ARE USUALLY ASSOCIATED WITH COMBINATIONS, PARTICULARLY, NOTABLE ARE THE ASSOCIATIONS FOR EXAMPLE BETWEEN OPIOIDS AND DRUGS, OPIOIDS AND ALCOHOL, AND AGAIN, I EMPHASIZE BECAUSE WE HAVE SUPPORTED MANY MUCH THOSE STORIES, THAT MANY OF THE DOSES FROM OVERDOSE ARE FROM INDIVIDUALS THAT WERE ABUSING OTHER SUBSTANCES. AND MOST OF THEM AS I SAY, ARE OUTSIDE OF THE CONTEXT ON THE PROPER MANAGEMENT OF PAIN. SO ALL THESE LED US AS PART OF THE PAIN CONSORTIUM TO RECOMMEND AND SAY, SHOULD WE BE DOING A CONSENSUS CONFERENCE THAT ADDRESS THE USE OF FOCUS OF MEDICATIONS AND THE MANAGEMENT OF CHRONIC PAIN. IT'S CLEAR THAT THERE IS A GAP OF KNOWLEDGE. SO WE APPROACH THE NIH CONSENSUS DEVELOPMENT PROGRAM WHICH AT THE NIH, WHICH WAS START INDEED 1977 AND IT'S PURPOSE IS TO PRODUCE CONSENSUS STATEMENTS ON IMPORTANT AND CONTROVERSIAL TOPICS IN MEDICINE AND I CLEARLY, THIS 1 FITS THE BILL. THE CONFERENCE IS SPONSORED AND BY 1 OR MORE INSTITUTES, CENTER OR NIH OFFICE AND BY THE NIH OFFICE OF THE DISEASE PREVENTION AND THE GOAL IS TO EVALUATE THE AVAILABLE SCIENTIFIC INFORMATION AND DEVELOP A STATEMENT THAT ADVANCES UNDERSTANDING OF THE ISSUING QUESTION AND WILL BE USEFUL TO HELP PROFESSIONALS AND THE PUBLIC AT LARGE. SO IT SEEMS LIKE SPECIFICALLY, THE ISSUES OF OPIOIDS WERE PERFECT FOR THIS ENDEAVOR. IT HAS TO BE CLINICAL AND PUBLICLY HELD IMPORTANCE, GAP BETWEEN KNOWLEDGE AND PRACTICE AND AS WE KNOW, THERE'S 1 OF THE ISSUES THAT IS DISCUSS INDEED THE IOM BOOK IS THAT THE GUIDELINES ARE NOT NECESSARILY IMPLEMENTED IN MANY INSTANCES. THERE IS SCIENTIFIC INFORMATION FROM WHICH TO ANSWER SOME OF THE QUESTIONS. AND AGAIN IT'S AN ISSUE THAT IS CROSS CUTTING ACROSS VARIOUS NIH INSTITUTES AND PAIN ACTUALLY PERTAINS TO I WOULD SAY, TO ALMOST EVERY SINGLE INSTITUTE AT THE NIH. EXAMPLES OF CONSENSUS CONFERENCES ARE THE ROLE OF ACTIVE SURVEILLANCE IN THE MANAGEMENT OF LOCALIZED PROSTATE CANCER AND ANNOUNCING USE AND QUALITY OF COLORECTAL CANCER SCREENING AND VAGINAL BIRTH AFTER CESS ANIAR--CESSARRIAN. THE CONFERENCES ARE 3 TYPES: STATE OF SCIENCE WHICH IS THE DESIGNED TO FIND GAPS IN RESEARCH AND THESE SURBLLY ARE FOR TOPICS FOR WHICH THERE'S NOT SUFFICIENT KNOWLEDGE, CONSENSUS CONFERENCES, THESE ARE 2.5 AND THESE ARE CONFERENCES TO REVIEW THE SCIENTIFIC LITERATURE AND RESEARCH AND ANSWER SCIENTIFIC QUESTIONS. USUALLY BASICALLY THESE CONSENSUS CONFERENCE TAKE APPROXIMATELY 2 YEARS TO BE ABLE TO GATHER THE APPROPRIATE INFORMATION. SO WHEN WE WERE DISCUSSING THE IDEA OF HAVING A CONSENSUS CONFERENCE ON OPIOIDS AND PAIN, WITH THE OFFICE OF DISEASE PREVENTION, THEY OFFER A THIRD OUT THERE AND AN IDEA IN WHICH THEY CALL A WORKSHOP CONFERENCE, WHICH IS INTERMEDIATE BETWEEN THE STATE OF THE SCIENCE WHERE THERE'S LIMITED INFORMATION AND THE CONSENSUS CONFERENCE WHERE THERE'S SIGNIFICANT SCIENTIFIC KNOWLEDGE BECAUSE THEY FAILED THE DATA AVAILABLE FOR THE USE OF OPIOIDS FOR THE MANAGEMENT OF CHRONIC PAIN WAS NOT AT THE STATE THAT IT COULD COME UP WITH A CONSENSUS CONFERENCE THAT WOULD SERVE AS GUIDELINES BUT ON THE OTHER HAND THERE WAS SIGNIFICANT DATA SO THEY OPPOSE AND APPROVE THE CONFERENCE WHICH IS APPROXIMATELY, SHOULD TAKE 1 YEAR, 1 YEAR AND A COUPLE OF MONTHS IN ORDER TO BE ABLE TO DEVELOP THE SCIENTIFIC QUESTIONS WITH THE LITERATURE IS--SCIENTIFIC QUESTIONS THAT COULD BE ANSWERED WERE LITERATURE IS AVAILABLE OR ALTERNATIVELY, TO PROVIDE AN IDEA WHAT ARE THE GAPS AND THE RESEARCH NECESSARY TO ADDRESS THEM IN THE FUTURE. THE EFFICACY WAS APPROVE OFFICE OF DIVERSITY 2012, THE CONSENSUS CONFERENCE OR WORKSHOP CONFERENCE IS DONE WITH OTHER AGENCIES IN THIS CASE WHERE PARTNERING WITH THE FDA INVOLVEMENT WHO HAS BEEN ALSO VERY ACTIVE PARTICIPANT WITH RESPECT TO THE USE OF OPIOID MEDICATION. WE ESTABLISH A WORKING GROUP WITH MEMBERS FROM THE DIFFERENT INSTITUTES FROM--WITH PARTICULAR WITH PRESENCE IN THE PAIN CONSORTIUM AND THE PERSON THAT„i WAS PROPOSED TO SHARE THIS CONSENSUS, THE WORSHIP CONFERENCE IS ALAN WHO WAS USED TO BE DIRECTOR OF THE NATIONAL INTUITYS ON DRUG ABUSE WHO IS NOW CHIEF EXECUTIVE OFFICE AT THE AMERICAN ADVANCEMENT OF SCIENCE AND THESE ARE THE MEMBERS FOR THE WORKING GROUPS AND THE MAIN-HAD THE THE TASK FOR THESE MEMBERS WAS TO ACTUALLY IDENTIFY THE SCIENTIFIC QUESTIONS THAT WILL BE ANSWERED DURING THE WORKSHOP CONFERENCE. THERE WAS A PERIOD WHERE WE HAVE THE DIFFERENT INSTITUTES AND THE REPRESENTATIVES COME UP WITH QUESTIONS AND THESE ARE SUMMARIZED IN THE FOLLOWING SLIDES, 1 OF THE MOST IMPORTANT 1S, IS WHAT TYPE OF PAIN WOULD BENEFIT FROM THE USE OF OPIOID MEDICATIONS AND FOR EXAMPLES, WHICH ARE THE MOST AND LEAST EFFECTIVE OF THE TYPES OF PAIN, NEUROPATHIC, MUSK LO SKELETAL, BACK ACHE, HEADACHE. WHAT IS THE VALUE OF OOID MEDICATIONS IN CHRONIC PAIN THAT RESULT FROM PERSISTENT INSULT VERSES CHRONIC PAIN THAT PERSPITTIVE ALTHOUGH THERE'S NO EVIDENCE OF AN INSULT. SHOULD WE USE OPIOID M )Jju WHEN THE PAIN IS A RESULT OF THE MEDICATION ITSELF, LIKE THE IPGCR, THAT HAS BEEN REPORTED WITH THE USE OF OPIOID MEDICATIONS. SHOULD WE BE USING CHRONIC PAIN, CONTINUOUSLY OR SHOULD IT BE USED INTERMITTENTLY WHEN THERE IS A FLAIR UP OR A BREAK THROUGH PAIN. HOW DO WE PRESCRIBE IT IN ORDER TO ACTUALLY MAXIMIZE THE EFFICACY AND MINIMIZE THE SIDE EFFECTS. FOR EXAMPLE, CAN WE ADJUST PAIN MEDICATIONS ON THE VERY END--ON TAKING THE CIRCADIAN VARIATIONS. [INDISCERNIBLE] FORMULATIONS THAT ARE LESS LIKE LE TO CAUSE TOLERANCE, FOR EXAMPLE, SHORT VERSES LONGER ACTING OPIOIDS, CONTINUOUS VERSES INTERMITTENT PRESCRIPTIONS. ARE THERE WAYS OF COMBINING MEDICATIONS AND TREATMENT THAT CAN MINIMIZE THE TOLERANCE OR ADVERSE SIDE CENTER FOR EXCELLENCE ON AGINGS OF OPIOIDS ON FOR EXAMPLE, COMBINATION OF OPIOIDS WITH OTHER PHARMACOLOGICAL AGENTS WITH BEHAVIAL OR COMPLIMENTARY APPROACHES. ULTIMATELY RISK FOR ADDICTION ARE CERTAIN DOSES ARE GENES POPULATIONS MORE OR LESS LIKELY TO CAUSE ADDICTION, FOR EXAMPLE, SHORT VERSES LONG ACTING, IMMEDIATE RELEASE FORMULATIONS WHICH ARE USUALLY ASSOCIATE WIDE MORE REWARDING EFFECTS. AND HOW THE SEVERITY OR CONISSITY OF PAIN RELATE TO THE RISK OF ADDICTION OR HOW DOES SEVERITY OF PAIN RELATE TO THE EFFICACY IN THE MEDICATION AND ITS TREATMENT. HOW DO YOU CURTAIL THE USE OF OPIOID MEDICATIONS AND WHAT DO DO YOU IF A PATIENT STILL CONTINUES TO HAVE PAIN BUT IT'S ACTUALLY BECOMING ADDICTED TO THEIR PAIN MEDICATION. HOW DO YOU DIFFERENTIATE DID DID SHES OF PHYSICAL DEPENDENCE VERSES ADDICTION. POPULATION DIFFERENCES, HOW TO USE OPIOID MEDICATIONS, HOW TO USE MEDICATIONS IN ADOLESCENCE OR CHILDREN. HOW TO USE OPIOID MEDICATIONS, DIFFERENTLY IN MEN FROM WOMEN. AND WHAT ABOUT TRAINING, WHAT TRAINING IS AVAILABLE? WHERE ARE THE NEEDS FOR FURTHER TRAINING IN THE HELPER SYSTEM? AND IMPORTANTLY, WHAT SHOULD BE TOP AREAS OF RESEARCH FROM THE VERY BASIC ASPECTS TO THE AREAS OF TRANSLATION AND IMPLEMENTATION. SO THIS IS SUMMARIZED AND PROPOSED FOR THE WORKSHOP CONFERENCES, RISE I SAY THE PROPOSAL WAS ACCEPTED. THESE ARE THE QUESTIONS TPHAOEUGZINIZEATION--ORGANIZATIO N YOU HAVE ANY SUGGESTIONS THIS WOULD BE VERY, VERY, WELCOME, AGAIN FOR THESE CONFERENCE TO BE SUCCESSFUL 1 OF THE AIMS IS THAT WE PROPERLY IDENTIFY THE MOST RELEVANT QUESTIONS TO BE ADDRESSED. I'LL BE HAPPY TO ANSWER ANY QUESTIONS YOU MAY HAVE. THANKS VERY MUCH. [ APPLAUSE ] >> SO, THANK YOU NORA VOLKOW AS FAR AS GETTING THIS ORGANIZED AND COORDINATEDMENT 1 OF THE THINGS I WOULD LIKE AT IS THE ASSESSMENT AS WELL AS TREATMENT OF PATIENTS WITH CHRONIC PAIN AND WHAT I NOTED THERE WAS THAT PIECE DIDN'T SEEM TO COME OUT AS LOUD AND CLEAR, THE ASSESSMENT PIECE, 1. TWO, THE OTHER PART THAT I WAS ADDRESSING IS THAT YOU TALK ABOUT POPULATION DIFFERENCES BUT YOU DIDN'T TALK ABOUT OTHER SOCIAL DETERMINANTS, SIZE GENDER BUT YOU DID TALK ABOUT THESE ACROSS THE LIFE SPAN AND I WOULD THINK THAT THAT WOULD BE SOMETHING YOU MAY WANT TO ADDRESS AND THERE ARE A NUMBER OF PAPERS THAT REALLY SUGGEST THAT THERE ARE DIFFERENCES IN HOW--WHO GETS ACCESS TO OPIOID ANALGESICS FOR CHRONIC PAIN WITH PATIENTS, CERTAIN POPULATIONS BEING AT RISK FOR RECEIVING LESSER QUALITY CARE. AND THEN THERE'S THE LITERATURE THAT SUGZESTS THAT THERE ARE DIFFERENCES IN THE PHARMACOKINETIC OF HOW THESE DRUGS ARE METABOLIZED IN DIFFERENT POPULATIONS AND SOME OF THAT WORK HAS NOT BEEN EXPLORED AND SOME OF IT WON'T BE DONE BECAUSE OF SOME OF THESE DRUGS ARE OFFPATENT. SO I WOULD REQUEST THAT YOU POTENTIALLY LOOK AT SOME OF THOSE PARTICULAR ISSUES AS WELL. >> THANKS VERY MUCH FOR THE SUGGESTION. IT'S EXACTLY. THIS IS THE TYPE OF INPUT THAT WE WANTED ON FEEDBACK THAT WE WANTED. I MEAN BECAUSE AS I SAY, WE HAVE TO IDENTIFY WHAT ARE THE MOST RELEVANT QUESTIONS WHERE WE CAN ANSWER THEM FOR WHICH THERE IS SCIENTIFIC EVIDENCE AND DEVELOPMENTAL ENDOCRINOLOGY DEFINITIVELY--DEFINITIVELY THE ACCESS TO THE OPIDDOID MEDICATIONS AND DIFFERENCES IN RESPONSE IS 1 OF THE AREAS THAT--FOR WHICH THERE IS DATA. >> C VOLKOW THANK YOU VERY MUCH, THIS IS EXCITING. THE IOM COMMIT HE MADE A STRONG RECOMMENDATION THAT WE MADE A SHIFT FROM A BIOMEDICAL APPROACH TO A BIOPSYCHOSOCIAL OR INDGREATED APPROACH. O I'M WONDERING IF IT MIGHT BE POSSIBLE TO CONSIDER THE EFFICACY OF OPIOIDS AS A SINGLE MODALITY VERSES THE EFFICACY OF OPIOID IN A BIOPSYCHOSOCIAL APPROACH. SO WHEN THERE WERE OTHER TREATMENTS AS PART OF THE PLAN. >> THANKS, VERY MUCH AND DEFINITELY, THAT IS 1 THAT SHOULD BE INCLUDED. >> I WAS HOPING THAT ONE OF THE QUESTIONS ASKED IN THIS MEETING WOULD BE TO LOOK AT WHAT THE OTHER UNDERLYING MECHANISM IS CAUSING PAIN. BECAUSE I THINK WHERE WE HAVE TROUBLE IS COULDING WHAT THE UNDERLYING MECHANISMS OF CHRONIC PAIN ARE AND IF WE'RE GOING TO DETERMINE HOW OPIOIDS ARE GOING TO BE USEFUL, OR WHAT OTHER APPROACHES MIGHT BE USEFUL, WE NEED TO LEARN MORE ABOUT CHRONIC PAIN AND HOW--WHAT ARE THE UNDERLYING ASPECT IN NERVOUS SYSTEM AND ELSEWHERE THAT PLAY A ROLE IN CHRONIC PAIN. I THINK THAT SHOULD BE A PART OF THIS--OF WHAT YOU'RE DRESSING DURING THIS MEETING BECAUSE THIS IS A MEETING ON OPIOID AND CHRONIC PAIN. >> YEAH, NO, THIS IS DEFINITELY AND AGAIN, RIGHT? I MEAN ULTIMATELY, OUR UNDERSTANDING OF SPECIFICALLY WHAT ARE THE CHANGES THAT LEADS TO CHRONIC PAIN ULTIMATELY, WILL BE ABLE TO GUIDE TREATMENT AND OBTAIN TREATMENT AND UNFORTUNATELY, WE'RE NOT COMPLETELY THERE AND I THINK THAT IN THE AREA WHERE ARE THE RESEARCH GAPS, THAT MAY BE ONE OF THE ASPECTS THAT WILL BE HIGHLIGHTED AND AS YOU SAW, ONE OF THE SPECIFIC QUESTIONS THAT WAS IDENTIFIED, IS WHAT IS THE ROLE OF CHRONIC PAIN ON PAIN WHERE THERE IS STILL AN INSULT VERSES PAIN, CHRONIC PAIN WHERE THE INSULT IS NOT THERE AND THOSE TWO ARE VERY LIKELY TO BE DISTINCT AND UNDERLIE DIFFERENT NEUROPLASTIC CHANGES AND UNDERLIE DIFFERENT APPROACHES SO--I PREDICT THAT THAT WILL BE ONE OF THE HIGHLIGHTS OF THINGS IN TERMS OF WHERE RESEARCH IS NEEDED. UNFORT FAVORITELY, I DON'T THINK WE HAVE THAT DATA YET THERE. >> I AGREE, WE DON'T HAVE THE DATA. >> THANK YOU THIS QUESTION IS ACTUALLY TO DR. RAPPA PORT. AND ONE IS TO ASK TO WHAT EXTENT IS THE FDA USING THIS INFORMATION AND WORKSHOPS, YOU'REUNED AN INCREDIBLE AMOUNT OF SCRUTINY THESE DAYS TO PUT IT LIGHTLY. HAVE YOU THIS RESCHEDULING OF HEIGHT ROUGH ATOM CO DONE COMING UP THERE'S PETITIONS TO CHANGE THE SCHEDULING OF OPIOIDS IN GENERAL, HOW ARE YOU USING THIS INFORMATION WHICH IS WONDERFULLY PRESENT INDEED MAKING THESE DETERMINATIONS AND IN MOVING FORWARD. >> SO, WE HAD A WORKSHOP IN THE SPRING OF THIS YEAR PARTNERED WITH NIH, WITH THE PAIN CONSORTIUM ON THIS TOP IN GENERAL, I THINK IT WAS SORT OF A KICKOFF TO NIDA'S WORKSHOP AND BASICALLY WHAT IT WAS ARE OPIOIDS EFFECTIVE IN CHRONIC PAIN AND THAT'S THE QUESTION WE'RE RAISED AND WE'RE BEING ADDRESSED TO ASK IN THE LABELS BY RESTRICTING THE USE ONLY IN NONCHRONIC CANCER AND TO CANCER PAIN. I MEAN ONLY TO CHRONIC CANCER PAIN. ACTUALLY ONLY TO CANCER PAIN AND TERMINALLY ILL CANCER PATIENTS AND ACUTE PAIN. IT WAS VERY CLEAR TO ME, PRIOR TO THAT WORKSHOP THAT THERE WAS VERY LITTLE DATA BECAUSE WE WOULD REVIEWED WHAT'S AVAILABLE TO SUPPORT EITHER THE EFFICACY OR THE LACK OF EFFICACY AFTER 12 WEEKS. AND THAT'S WHAT CAME OUT AFTER A FULL DAY OF HAVING PAIN AND OPIOID EXPERTS IN THE COUNTRY TAKE ABOUT WHAT WAS KNOWN. SO WHAT WE ARE DOING IN FOLLOW UP TO THAT, IN ADDITION TO WORKING WITH NIDA ON DEVELOPING THIS NEW CONFERENCE, FIRST OF ALL, WE INITIATED A WORKING GROUP UNDER ACTION THAT IS CALLED RESOLVE AND IT'S GOING TO BE--WE'VE ALREADY MET, ACTUALLY WE BROUGHT 12 EXPERT CLINICAL TRIALISTS, ANALGESIC CLINICAL TRIALISTS TO DC, AND WE SPENT THE DAY HARBING OUT A PROTOCOL, SYNOPSIS FOR HOW TO STUDY CHRONIC--WHETHER OPIOIDS ARE EFFECTIVE IN CHRONIC PAIN AND THAT IS HAS BEEN DEVELOPED. IT'S CURRENTLY UNDER REVIEW AT THE CENTER, THE CENTER DIRECTOR'S LEVEL AND WE'RE LOOKING FOR FUNDING FOR THOSE SOURCES FOR THAT STUDY, NO STUDIES IS GOING TO BE PERFECT IN THIS SITUATION, GIVE ALL THE ANSWERS THAT PEOPLE ARE ASKING YOU WITH THIS IS ONE OF THE WAYS WE CAN ADDRESS THIS AND WE HOPE IT WILL SPUR MORE INVESTIGATION IN THE FUTURE. YOUR QUESTION--I CAN GO ON AND ON AND ON AND ON AND ON ABOUT THE THINGS WE'RE DOING TO ADDRESS THESE QUESTIONS AND I DON'T WANT TO TAKE UP ALL THE TIME TODAY TO TALK ABOUT THAT BUT UNDER ACTION WE'RE DOING A LOT OF OTHER THINGS TO ADDRESS SOME OF THESE QUESTIONS AND IF WE HAVE TIME LATER I CAN UPDATE ON SOME OF THAT. >> SO KIASK NORA DID YOU KNOW WHAT ACTION WAS DOING. >> SO IT SEEMS TO ME THERE COULD BE ONE OF THE OBJECTIVES OF THIS COMMITTEE IS TO MAKE SURE THERE IS CLOSE COLLABORATION BETWEEN THE DIFFERENT FEDERAL AGENCIES AND THIS LOOKS LIKE A PLACE-- >> WE ABSOLUTELY, I KNOW DR. THROB MORTON HAD SOME CONVERSATION WITH NI DA BEFORE WE ACTUALLY DEVELOPED THE SYNOPSIS OF THIS PROTOCOL BUT ONCE HE AND DR. WOOD COCK FINALIZE WHETHER THIS IS GOING TO MOVE FORWARD AND ACTUALLY GO ON DISCUSS SOURCES OF FUNDING, I THINK DR. VOLKOFF WILL BE PART OF THOSE PEOPLE'S APPROACH. >> I WOULD SAY THAT WE ALL HAD THE PAIN CONSORTIUM SHOULD BE VERY MUCH INTERESTED ON CARING THE DETAILS OF THE ACTION. ABSOLUTELY NOT JUST NIA. >> I THINK INHERENT IN MY QUESTION IS WHAT YOU FOLLOWED UP ON WHICH IS THAT I KNEW THERE WAS EFFORTS IN THE IF, DA AND I KNEW THIS WONDERFUL EFFORT, MY QUESTION WAS TO WHAT EXTENT ARE THE TWO GROUPS WORKING TOGETHER AND I THINK YOU JUST--WE JUST WENT THERE. >> SO I GUESS WHAT WE NEED IS TO HAVE ACTION COME TO A PAIN CONSORTIUM MEETING TO MAKE SURE THERE'S GOOD COMMUNICATION ON THE INITIATIVES. RIGHT SO WE HAVE REPRESENTATIONOT NIH ACTION AND WE ALSO HAD FDA REPRESENTATION THAT PUT TOGETHER THE WORKING GROUP CONSENSUS SO THERE HAS BEEN CONFLICT. >> SO THIS IS JUST A COMMENT AND YOU KNOW I THINK ONE OF THE COMMENTS THAT YOU MADE IN YOUR SLIDE PRESENTATION IS ABOUT THE PERCENTAGE OF PATIENT WHO IS ARE UNDER TREAT, POORLY ASSESSED AND TREATMENT TO PAIN AND I WANT TO MAKE CERTAIN THAT WE DON'T DO DAMAGE, PARTICULARLY TO THOSE PEOPLE WHO LIVE WITH CANCER WHO ARE DYING FROM CANCER, PERCEPTIONS ARE VALID UNTIL TESTED. AND SO, I JUST WANT TO GET THAT ON THE RECORD THAT THERE ARE PEOPLE WHO BENEFIT FROM OPIOID ANALGESICS, SOME OF THOSE PEOPLE HAVE CANCER, SOME OF THEM HAVE OTHER TYPES OF PROBLEM BUT WE JUST NEED TO MAKE CERTAIN THAT WE ARE MAKING SURE THE PATIENT IS INVOLVED IN THIS CONVERSATION. >> YEAH, AND I ACTUALLY COMPLETELY AND A HUNDRED% AGREE WITH YOU. THE LISTING WE WANT TO DO IS COME BACK WITH A WORSHIP THAT ACTUALLY LEAVES PATIENTS MUCH MORE UNPROTECTED THAN THEY ARE ALREADY THERE. THAT IS WHY EXPLICITLY IN TERMS OF THE QUESTIONS, COINCIDENT THINK THERE WOULD BE MUCH ISSUE WITH RELATED TO CHRONIC PAIN IN CANCER PATIENTS. I THINK A LOT OF THE ISSUE WILL OF THE QUESTION IS ON THE CHRONIC PAIN IN NONCANCKER PATIENTS, AND AGAIN, I THINK THAT'S WHERE WE HAVE TO BE EXTREMELY CAREFUL BECAUSE THE ISSUE WE DON'T WANT TO PUT EVERYTHING IN A BAG AND LIKE FOR EXAMPLE, CONTINUOUS, YES YOU BECOME TOLERANT BUT A LOT OF PARENTS WITH CHRONIC PAIN CAN TAKE IT FOR BREAK THROUGH PAIN SO THERE ARE DIFFERENT WAYS OF PRESCRIBING THIS OPIOID MEDICATION AND AND WE DON'T WANT TO THROW EVERYTHING WITH THE WASTE BASKET SO I THINK I AM, THE LEAST THING WE WANT TO DO IS COUNT FOR IT BAH WE CAN NOT, NOT DO IT BECAUSE THERE'S A LOT OF PRESSURE ALREADY. >> I'M NOT DISAGREEING WITH YOU. I THINK WE HAVE TO PROVIDE THE EVIDENCE. BUT I HAVE TO SAY, THERE ARE PATIENTS IF WE'RE THINK BEING TREATMENT AND WE'RE THINK BEING MULTIDISCIPLINARY TYPES OF TREATMENT, THERE ARE A NUMBER OF PATIENT WHO IS CAN'T GET PHYSICAL THERAPY AND/OR PSYCHOLOGICAL COUNSELING AND THINGS OF THAT NATURE AND ALL THEY MAY END UP HAVING IS OPILOT OPIUM TREATMENTS. >> OKAY, LAST COMMENT AND. >> THIS IS THE FOLLOW UP TO THIS DISCUSS AND ALSO WHAT SEAN WAS ASKING EARLIER AND I CAN SPEAK ABOUT THIS BECAUSE IT'S PUBLICLY AVAILABLE THERE'S A CITIZEN PETITION THAT WAS SUBMITTED TO THE FDA TO THE COMMISSIONER FROM AN ORGANIZATION CALLED PHYSICIANS FOR RESPONSIBLE OPIOID PRESCRIBING THAT IS ASKING TO HAVE LABEL DEMANDING THAT LABEL CHANGES BE MADE THAT INCLUDE„i REMOVAL OF MODERATE AND THE INDICATION SO THAT IT ONLY BE FOR SPEAR PAIN. LIMITING THE DOSE OF I CAN'T REMEMBER, A LOW LEVEL AND LIMITING THE LENGTH OF TREATMENT FOR TPHAOEUPT DAYS FOR OPIOIDS. SO THRE IS A DOCKET OPENED FOR THAT. I KNOW SPECIAL OF ARE AWARE OF THAT AND HAVE WRITTEN INTO THE DOCKET AND THERE WILL BE PROBABLY BE A PUBLIC MEETING TO DISCUSS THE QUESTIONS THAT HAVE BEEN RAISED BY THAT CITIZEN PETITION AND I SHOULD ALSO MENTION AS OTHERS HAVE SAID THAT THERE'S A LOT OF CONGRESSIONAL INTEREST IN THIS, SO AS SEAN SAID WE'RE UNDER CERTAINLY--CERTAINLY NORMOUS PRESSURE RIGHT NOW--EFORMOUS PRESSURE RIGHT NOW TO ADDRESS THESE QUESTIONS THAT ARE BEING RAISED. AND IN RESPONSE TO DR. GREEN WHAT WE'RE TRYING TO DO IS MAKE SURE THAT WE HAVE DATA TO SUPPORT WHATEVER DECISIONS WE MAKE AND THAT'S WHY I THINK THE CONFERENCE THAT NIDA IS SPONSORING AND ANY OTHER ACTION OR UNDER SOURCES IS CRITICAL AT THIS TIME. >> ONE LAST KPHEBT. >> I JUST WANT TO SAY I THINK IT WILL BE HELPFUL IF WE RECEIVED A SHORT REPORT FOR EVERY MEETING OF THE IPRCCON HOW THIS IS PROGRESSING HOW THIS WHOLE ISSUE OF OPIOIDS AND THE ISSUE OF NONCONSER CHRONIC PAIN IS PROGRESSING SO THAT WE'RE UPTO DATE AND WE KNOW WHAT'S GOING ON BECAUSE THIS IS THE FIRST TIME THIS COMMIT HE HAS BEEN MADE AVAILABLE TO OF THIS CONSENSUS. >> WELL IT JUST GOT SET UP. >> YEAH. >> SO ONE OF THE--GOALS WE HAVE IS THAT THERE WOULD BE UPDATES AT EVERY ONE OF THESE MEETINGS IF ANYONEOT COMMITTEE HAS AN UPDATE THAT THEY THINK IS USEFUL, WE CAN PRESENT IT AT THE MEETING AND/OR POST IT ON THE WEB SITE BETWEEN MEETINGS. >> I CONTINUING WOULD BE VERY IMPORTANT THAT WE DID THAT IN THIS ISSUE FOR SURE. EMPLOY. >> OKAY, SO, THE NEXT TOPIC WE WANT THED TO LET YOU KNOW ABOUT WAS A PROGRAM AGAIN THAT NIDA'S LEADING ON NIH CENTERS OF EXCELLENCE IN PAIN EDUCATION. YOU KNOW NOTICE THAT EACH OF THESE TOPICS ADDRESSES SOMETHING OF INTEREST TO THIS COORDINATING COMMITTEE. >> GOOD MORNING, NO I DON'T NEED TO WALK AROUND, I WILL HOPEFULLY BE QUICK, DAVE THOMAS ON THE NATIONAL INTUITY OF DRUG ABUSE AND PAIN CONSORTIUM AND I WANT TO PRESENT AN UPDATE ON CENTERS OF PAIN EXCELLENCE AND PAIN EDUCATION. FIRST I WANT TO EXPLAIN A LITTLE BIT ABOUT THE PROBLEM THAT LED TO US THINKING WE NEED MORE PAIN EDUCATION AND I THINK I'M TALKING TO A CROWD THAT DOESN'T NEED TOO MUCH CONVINCING ON THAT BUT I WANT TO SHOW YOU ONE SLIDE FROM ONE SIDE FROM BETH MURENSON, LOOKING AT THE NUMBERS OF HOURS SPENT ON PAIN MEDICATION IN MEDICAL SCHOOLS AND IN THE UNITED STATES AND ALSO CANADA AND THE UNITED STATES, AND THE DARK BAR AND THE POINT HERE, AND YOU HAVE--ORDINATE IS THE NUMBER OF SCHOOLS BY THE NUMBER OF HOURS PAIN IS TAUGHT ACROSS THE FOUR YEAR EDUCATION AND THE REAL POINT HERE IS THAT THESE BARS ARE VERY HIGH. A LOT OF SCHOOLS GET BETWEEN ZERO AND 10, OR TEACH PAIN BETWEEN ZERO AND 10 HOURS OVER FOUR YEARS WHICH DOES NOT SEEM LIKE A LONG TIME. MEDIAN IS SEVEN HOURS, UNITED STATES, A LITTLE MORE IN CANADA, 14 HOURS, COMPARE THAT WITH VETERINARY SCHOOLS AT LEAST IN CANADA, THEY GET ABOUT 10 TIMES AS MUCH EDUCATION ON PAIN. SO, AGAIN, I DON'T HAVE TO CONVINCE YOU THAT WE NEED MORE PAIN EDUCATION IN MEDICAL SCHOOLS, NURSING DENTAL AND PHARMACY SCHOOLS BUT THIS IS JUST ONE STAGGERING STUDY THAT WAS RECENTLY PUBLISHED, ALSO PUBLISHED INSTITUTE OF MEDICINE RELIEVING PAIN IN AMERICA, SAME SORRY, CHAPTER FOUR, ALL ABOUT: WE NEED MORE PAIN EDUCATION IN AMERICA AND IN FACT, THE RECOMMENDATION FOR ONE, FOR TWO, FOR THREE ALL WERE TALKING ALONG THOSE LINES AND WE'RE VERY MUCH THINKING WHAT WE'RE PROPOSING FOR THE CENTERS OF EXCELLENCE. ONE SLIDE ON PRESCRIPTION DRUG ABUSE EPIDEMIC, NORA DID A GOOD JOB SUMMARIZING THAT. ALL I WANT THE TO POINT OUT HERE IS THAT PRESCRIPTION OPIATES, MORE PEOPLE ARE DYING FROM THEM NOW THAN COCAINE AND HEROINE COMBINED AND THE TREND IS GETTING WORSE. SO IT'S A DISTURBING PROBLEM AND WE'RE STUCK IN A SITUATION NOW WHERE WE HAVE HEALTH CARE PROVIDERS THAT HAVE MIN MILE PRIMARY EDUCATION IN PAIN ARE ASKED TO TREAT THE HUNDRED MILLION PLUS PEOPLE IN CHRONIC PAIN IN THE UNITED STATES PLUS THEY'VE GOT THE PROBLEM THAT THEIR STRONGEST PAIN KILLER AND KILLING A LOT OF PEOPLE. SO AT NIDA, THE GROUP IN COOPERATION WITH THE PAIN CONSORTIUM HELD A WORKSHOP ON THIS TOPIC. SOME OF YOU WERE PARTICIPANTS IN THIS WE HAD PEOPLE, ACCREDITATION PEOPLE, EXPERTS COME IN AND SAY WHAT CAN WE DO ABOUT THIS PROBLEM? AND THE SOLUTION WAS THAT WE NEED TO FIND PAIN CHAMPIONS. IF THE PAIN CONSORTIUM IS THE IPRCC, WHOEVER JUST SAYS, OKAY, IT'S TIME TO TEACH PAIN, EVERYBODY DO IT AND WE CREATE A CURRICULUM, IT'S NOT GOING TO GET DONE. THAT WAS THEIR CONCLUSION AND WHAT WE NEEDED TO DO IS TO FOSTER CHANGE FROM WITHIN AND THAT IS TO FIND THESE PEOPLE AND WE THOUGHT THESE PEOPLE ARE OUT THERE BUT WE NEED TO FIND THESE PAIN CHAMPIONS THAT WERE ALREADY IN THESE INSTITUTIONS AND KNEW THE LANDSCAPE, KNEW WHERE THEY COULD PUT PAIN IN, KNEW THE PEOPLE TO TALK TO AND PERSUADE WITHIN THEIR INSTITUTIONS TO CREATE PAIN CURRICULUM KNOW FROM WITHIN. THE SECOND RECOMMENDATION IS TO INFLUENCE ACCREDITATION WHICH IS WE DO HAVE PLANS ON DOWN THE ROAD TO DO THAT. WE CREATED QUITE AN ORGANIZATION WITH THE PAIN CONSORTIUM HERE THIS IS THE NIADA STAFF THAT ARE INVOLVE WIDE IT, PAIN CONSORTIUM WE HAD 10 DIFFERENT INSTITUTES AND OFFICES PITCH IN MONEY AND THAT WAS A HUGE AMOUNT OF COLLABORATION WITH THEM. THE REST OF THE PAIN SON SORTIUM IS HELPING US TO VARIOUS DEGREES BUT THESE ARE THE ACTUAL FUNDING INSTITUTES AND OFFICES, WE HIRED A CONTRACTOR, A CONTRACTING COMPANY, P A LADDIAN PARTNERS TO OVERSEE THIS BECAUSE I HAVE A CONTRACT WITH THEM. THEY HAVE A CONTRACT WITH THE VS OF EXCELLENCE THAT WE WERE PLANNING ON FUNDING. GOOD THING ABOUT THIS IS I SHOULD MENTION, IT'S ANOTHER ONE OF RON'S FORMER STUDENTS IS AT PALLADDIAN PARTNERS, SHE'S A PAIN EXPERT FROM YEARS BACK, BUT THEN SHE WENT ON TO EDUCATIONAL--PROMOTING EDUCATION SO SHE'S A REALLY GOOD PROJECT MANAGER OVER THERE AND THE WHOLE COMPANY'S BEEN VERY GOOD. SO THAT WAS THEN, THIS IS NOT MY REAL LUGGAGE BUT I'VE BEEN TRAVELING AROUND, I LOT OF YOU HAVE TALKED TO IN VARIOUS CONTEXTS, WE DID NOT GO OUT TRYING TO FIND--DID NOT SEND OUT A PETITION, IT WASN'T LIKE DO YOU AGREE WE NEED MORE PAIN EDUCATION, I'LL PUT YOU ON MY SUITCASE, THESE ARE GROUPS I'LL TALK TO IN A VERY SUBSEQUENT WAY, AND AND THEY GAVE A LOT OF GOOD ADVICE AND THEY WANT TO BE INVOLVE AND SOME ARE INVOLVE INDEED VARIOUS WAYS, BUT A LOT IS THEY GIVE US INPUT AND WHAT KIND OF THINGS WOULD MAKE GOOD PAIN EDUCATION. THEY UNDERSCORE THE NEED NEAR INTERDISCIPLINARY AND INTERPROFESSIONAL EDUCATION. TALK ABOUT CASE STUDIES, A LOT OF LEARNING, THESE DAYS IS NOT JUST--YOU LEARN A BUNCH OF FACTS AND NOW YOU KNOW HOW TO TREAT PEOPLE BUT IT'S A LOT OF SIMULATION AND YOU GO THRU A SIMULATED CASE AND YOU'RE BETTER PREPARED TO ACTUALLY DEAL WITH THE REAL CASE WHEN CONFRONT WIDE THEM. WE INCLUDED PHARMACY, WE DID NOT HAVE PHARMACY SCHOOLS INITIALLY, BUT WE INCLUDE THEM AND A BUNCH OF OTHER THINGS SO THE WHOLE PROJECT'S BEEN VERY ORGANIC AND I THINK IT'S GOTTEN BETTER BECAUSE OF THAT. THE END OF 2011, WE PUT OUT A CONTRACT FOR THESE CENTERS OF EXCELLENCE IN PAIN EDUCATION, WE GOT A LOT OF PUBLICITY FROM IT, IT WAS PUT ON THE FRONT PAGE OF THE NIH SITE LARRY TABAK WERE AT THIS AT THE HEALTH COMMITTEE MEETING LAST FEBRUARY BUT HE NOT ONLY, THE NIH PUT IN A BIG PARAGRAPH AND ENTERED IT INTO THE RECORD BUT PAIN EDUCATION WAS MENTIONED 33 TIMES AT THAT MEETING. SO IT STARTED TO BE CLEAR THAT IT WAS--IT WAS A VERY TIMELY EFFORT. THE LAST--THE FIRST INTERAGENCY RESEARCH COORDINATING COMMITTEE, FRANCIS COLLINS MENTIONED IT, AND THEN YOU GUYS HAD A BIG DISCUSSION ABOUT THE ACTUAL CENTERS OF EXCELLENCE IN PROMPT, TOO, SO IT WAS PLEASING FOR ME SITTING IN THE BACK THAT YOU HAD BECOME AWARE OF IT. IN MAY OF THIS YEAR WE FUNDED 12 ARE CENTERS OF EXCELLENCE, I'M SORRY THE TEXT IS SO SMALL BUT AFTER THEY FUNDED THEM, WE ALLOWED THEM TO RENAME THEMSELVES AND THEY PICKED PRETTY BIG NAMES. BUT HERE'S 12 CENTERS OF„i EXCELLENCE, HERE'S THE GEOGRAPHIC DISTRIBUTION, THEY'RE SPREAD ACROSS THE COUNTRY WHICH WE LIKE BUT THERE WERE A LOT IN THE EAST COAST BUT WE GOT A LOT OF APPLICATIONS FROM THE EAST COAST. INCIDENTALLY WE GOT A LOT OF INTEREST IN THIS PROGRAM, JULIE THIS YEAR, WE HAD OUR DAY AND HALF KICKOFF WHERE WE BROUGHT IN PEOPLE FROM THE VARIOUS CENTERS WE FUNDED ALONG WITH PEOPLE FROM THE MILITARY, THE AMERICAN PAIN SOCIETY AND THE GOVERNMENT THAT WERE INVOLVED TO HAVE INITIAL KICKOFF MEETING, HERE WE ARE AT THE KICKOFF MEETING. I SHOW THIS NOT JUST BECAUSE WE'RE ATTRACTIVE PEOPLE BUT BECAUSE, AS YOU CAN SEE, THE ENERGY THERE, IT KIND OF HAD TO BE THERE, BUT THERE WAS A LOT OF EXCITEMENT AT THIS MEETING ABOUT WHAT WE CAN DO AND WHAT'S ABOUT TO BEGIN. THESE PEOPLE DID NOT APPLY BECAUSE OF THE MONEY, THEY APPLY BECAUSE THEY WANT TO ACCOMPLISH IT AND BE PART OF THIS EFFORT. OKAY. THESE CENTERS HAVE THREE MAIN GOALS. THE OVERARCHING GOAL IS TO IMPROVE PAIN TREATMENT THROUGH EDUCATION. THE THREE SUBGOALS OF THAT ARE TO DEVELOP COURSES AT THEIR SCHOOLS, ACTUALLY GET MORE PAIN--IN THEIR CENTERS OF EXCELLENCE. DEVELOP A PAIN EDUCATION RESOURCE THAT CAN BE USED BY THE DIFFERENT CODES BY OTHER ORGANIZATIONS BECAUSE WE WOULD LIKE PAIN EDUCATION TO GO BEYOND THE BORDERS OF EXCELLENCE AND THEN TO DISSEMINATE AND EVALUATE WHAT WE ACCOMPLISHED. IN TERMS OF DAY ONE, GET COURSES INTO THESE SCHOOLS, THAT'S HAPPENING RIGHT NOW. THERE ARE 12 COPES, BUT 12 COPES ACTUALLY REPRESENTS A HUNDRED + TEACHING INSTITUTIONS AND THAT NUMBER'S INCREASING AS WE SPEAK. WE'RE ALLOWING THE COPES TO ADD MORE SCHOOLS TO THEM AS LONG AS THE SCHOOLS ADD SOMETHING TO THE PROJECT AND IT REPRESENTS 250 PLUS PARTICIPANTS SO THESE SCHOOLS ARE GOING TO BE TEACHING MORE PAIN AS A RESULT OF THIS PROJECT. SECOND PART IS THE DEVELOPMENT OF A PAIN RESOURCE PORTAL, THE BACKBONE IS GOING TO BE CASE BASED SCENARIOS. I DIDN'T BRING AN INTERACTIVE VERSION. WE'RE STILL IN DEVELOPMENT OF THESE AND--BUT WHAT THEY WILL HAVE IS YOU GO THROUGH A CASE WITH A PATIENT. THERE WILL BE VARIOUS RESOURCES THAT CAN BE USED IN ADDITION TO THE CASE, IT'S A GLOSSARIES, SO--WHEREAS THE CASE BASED SCENARIOS WILL BE THE BACKBONE OF IT, THERE WILL BE A LOT OF OTHER MATERIAL AND WE SEE THIS TOO AS ORGANIC THAT THAT AT THE END OF THE NEXT 23 MONTHS WHEN THE INITIAL CONTRACT IS DONE, THIS WILL BE UP AND RUNNING BECAUSE WE LIKE IT TO GROW AND EVOLVE OVER TIME AND WHAT THE PAIN CONSORTIUM IS DOING RIGHT MOW IS LOOKING OVER CASE STUDIES THAT WERE SUBMITTED BY THE VARIOUS COPES AND SEEING HOW THEY WORK TOGETHER. SORT OF LIKE WHAT YOU'LL DO IS A GAP ANALYSIS, TODAY, BUT ALSO LOOKING FOR REDUNDANCY. LIKE WE HAVE TOO MANY ON KNEE PAIN BUT WE ALSO HAVE A WHOLE LOT OF VERY, VERY, INTERESTING CASE STUDIES THAT WHEN YOU'RE READYING THEM NOT QUITE SURE WHERE HARE GOING TO GO. FOR EXAMPLE, NO TIME SHORT, BUT THERE'S ONE ON A 19 YEAR-OLD WOMAN WITH SICKLE CELL PAIN, SHE'S ON HIGH DOSE OPIATES AND HER PAIN'S BREAKING THROUGH LIKE CRAZY. WHAT TO DO? SHE'S IN THE EMERGENCY ROOM. THERE'S A TOOTH PAIN ONE THAT ENDS UP BEING BRAIN CANCER. BACK PAIN WITH INTESTINAL PROBLEMS WHERE OPIATES ARE PROBLEMATIC AND IN FACT, HAVE BEEN INS LAST WEEK WITH UNIFORM SERVICES AND EACH THOUGH THEY'RE NOT PART OF THE CENTERS OF EXCELLENCE, WE WOULD LIKE TO GETTATE LEAST ONE WOUNDED WARRIOR PAIN CASE IN THERE. AND THE LAST PART IS DISSEMINATION. WE WOULD LIKE TO GO BEYOND THE BORDERS, THIS IS WHERE WE MANDATE DISSEMINATION, IT'S HAPPENING NOW ANYWAY, THE SCHOOLS ARE ADVERTISING WHAT THEY'RE DOING, THEY ARE GETTING PRESSED, THEY ARE MAKING POSTERS AND SO, EVEN THOUGH THE FACT THAT WE HAD THE AVERAGE, THE PRESS WE GOT ON THIS INITIATIVE IS ADVERTISED IN THE FACT THAT WE'RE DOING THIS AND RAISING AWARENESS. SO, THIS IS MY LAST SLIDE. WE'RE TRYING TO OVERALL IMPROVE PAIN EDICATION, PAIN TREATMENT THROUGH EDUCATION. I'M SORRY. AND I THINK WE'RE OFF TO A GOOD START. SO I'LL ENTERTAIN QUESTIONS. >> GREAT, THANK YOU VERY MUCH. SO, DID YOU AND AND ANY OF THE COPES OBTAIN INFORMATION IN DEVELOPING THE CURRICULUM? >> DID THEY INVOLVE PATIENTS IN TERMS OF ASKING THEM WHAT THEY ... >> WELL YOU KNOW EDYOUICATING--EDUCATING PHYSICIANS ABOUT TREATING PAIN BUT AN INTERESTING PERSPECTIVE IS WHETHER OR NOT THE PATIENTS WHO COME TO THE PHYSICIAN HAVE HAD ANY INPUT. I MEAN THEY'RE PATIENT SCENARIOS, RIGHT? THEY'LL PROBABLY BE BROUGHT INTO THE SCENARIOS, A LOT OF IDEAS WITH THE COPES ABOUT DOING VIDEOS AND THE PORTAL OVER THE CASE STUDY, PORTAL I SHOWED YOU, THAT'S VERY AMENABLE TO VIDEOS AND PICTURES AND IT'S VERY INTERACTIVE, YOU KNOW MOVE THINGS AROUND. THE OTHER PART OF--PART OF THE IOM REPORT WAS PATIENT EDUCATION AND PATIENTS NEED TO BE MORE AWARE, MORE PART OF THE PROCESS OF THEIR OWN TREATMENT. THAT IS NOT SPECIFICALLY TARGETED AT THIS POINT IN THIS PROJECT NORIS THE CMEs, NOR ARE SCHOOLS BEYOND DENTAL PHARMACY NURSING AND MEDICAL SCHOOLS BUT I'D LIKE TO SEE THIS KEEP GOING OUT, GROWING. >> SO IT JUST WOULD BE INTERESTING WHEN THE CURRICULA GO UP IF THERE ARE CASE STUDIES ON NEUROPATHY OR VULVADINNIA, OR HEADACHE. IF PATIENT ORGANIZATIONS INVOLVED WITH THOSE PARTICULAR PAIN SYNDROME HAD AN OPPORTUNITY TO COMMENT. >> THEY COMMENTED TO ME. >> CERTAINLY CHRIS, I'M WAITING FOR HER QUESTION, BUT I'VE SAT DOWN WITH A WHOLE TABLE FULL OF PATIENT ADVOCACY GROUPS TALKING ABOUT THIS AND CHRIS, AND OTHERS SEPARATELY, WE WANT TO MAKE THEM HAPPY WITH WHAT WE PRODUCE, BUT WE ALSO WANT TO MAKE THEM HAPPY WITH THE END RESULT WHICH IS TO INCREASE PAIN COMPETENCY AND PEOPLE AND THAT'S--THAT'S THE END HOW I'LL FEEL GOOD ABOUT HELPING PATIENT SYSTEM THAT THEY GET BETTER TREATMENT. >> MIKE? >> COULD YOU TELL US, DO YOU HAVE ANY ADVANCE MEASURES OF WHAT WOULD BE A SUCCESS TO THE PROGRAM FIVE YEARS OUT? AND ALSO-- >> [INDISCERNIBLE]. >> WELL THAT'S PART OF IT, SURE, SURE. A LOT OF THAT IS BEFORE, AFTER, IT'S A SHORT TIME FRAME AND THEY CAN'T LOOK AT LONGITUDINALLY WHAT THE SUCCESS IS THEY ARE GOING TO LOOK AT COMPETENCIES HOW THEY--HOW THEY RESPOND IN SIMULATED SITUATIONS, THEIR ATTITUDES ORDER ITS PAIN AND WHAT BECAME REAL CLEAR IN THE WORKSHOP THAT WE DID KICKING THIS OFF, BUT A LOT OF IT WAS NOT JUST A LACK OF KNOWLEDGE ABOUT PAIN, BUT KIND OF DISMISSING PAIN, IT'S NOT THE PROBLEM. THESE CENTERS A NUMBER OF THEM HAVE IN THAT, AN ATTITUDEINAL CHANGE. THAT'S THE SHORT-TERM THAT'S WHAT WE CAN DO UNDER THE CONTRACT, BEYOND THAT THERE'S AN NIH PROGRAM THAT LOOKS AT MORE META-ANALYSIS OF CHANGE WHICH I TALK TO IN AND THEY'RE INTERESTED AND ONCE WE GET THIS UP AND RUNNING LOOKING AT A BIGGER SOCIETAL CHANGE BEYOND THAT AND THE COPES THEMSELVES WANT TO WORK TOGETHER AND LOOK AT CHANGE CROSS INSTITUTIONS SO THEY'RE KIND OF SYNCHRONIZING SOME OF THEIR METRICS SO THEY CAN LOOK AT CHANGES AT DIFFERENT COPES AND CONSISTENT WAYS. >> DO YOU HAVE PLANS TO EXPAND, AS A GREAT PILOT PROGRAM, BUT REALLY TO MAKE AN IMPACT, NATIONALLY, HOW MANY--HOW MANY OF THESE CENTERS ARE GUG TO NEED TO HAVE. I THINK THE HOPE WAS THAT IF GOOD CURRICULA WERE AT THESE CENTERS AND THERE'S 12, RIGHT THAT OTHER INSTITUTIONS WOULD PICK THEM UP AND THAT YOU WOULDN'T NEED TO HAVE A COPE AT EVERY MEDICAL SCHOOL OR KEPTAL SCHOOL OR WHATEVER. BUT--DENTAL SCHOOL OR WHATEVER. BUT WE'LL KNOW IN TWO YEARS IF THAT WORKS. I THINK ELIZABETH HAD A QUESTION ASK THEN MYRA? >> I NOTICE THERE IS A GREAT WASTE LAND OF THE MIDWEST THAT THERE WERE NO GRANTS MADE IN THE MIDWEST AND A CONSORTIUM OF 14 ACADEMIC INSTITUTIONS THEN, THE CITY WHERE I LIVE IN KANSAS CITY DID APPLY, IT WAS NOT GRANTED. HOWEVER, FOLLOWING THAT, WE HAD A VERY POSITIVE CONVERSATION WITH DONNA, MR. SMITH WHO WAS VERY HELPFUL BUT WE ASK HER TO QUERY THE LEADERSHIP AS TO WHETHER OR NOT THOSE ORGANIZATIONS THAT WERE NOT GRANTED MIGHT BE ABLE TO PARTICIPATE ON THEIR OWN. THAT THEY WOULD FUND THEMSELVES TO BE INVOLVED. AND WE NEVER HEARD ANYTHING BACK FROM THAT REQUEST, SO I'M JUST CURIOUS AS TO WHETHER THERE WAS ANY DISCUSSION? >> THAT IS THE TRAGEDY OF IT, AND I REMEMBER THE KANSAS, THEY PUT IN A GREAT COMPLICATION AND NUMBER OF OTHERS WHICH I DON'T I SHOULD MENTION SOME OF THE ONES WHO DIDN'T MAKE IT. >> DEFINITELY SHOULDN'T. >> BUT THAT IS AICAL--CHALLENGE TO GET THEM INVOLVED AND I'M AWARE OF THE DISCUSSION WITH KANSAS AND TRY IF FIGURE OUT HOW TO DID GET THEM INVOLVED, ONE OF THE WAYS WE COME UP WITH THAT WE SHOULD SHARE WITH KANSAS STEREO SOON BUT IT'S NEW, AND TO INVITE SCHOOLS TO PARTICIPATE, TO BE NOT CENTERS OF EXCELLENCE BUT BE PARTICIPANTS IN THE PROGRAM. WHAT CAN YOU OFFER? HOW CAN YOU BE INVOLVE WIDE OUR NETWORK AND THAT'S WHAT WE ASK FOR. WE ASK IF WE COULD ATTEND MEETINGS IF COULD BE LINKED INTO COMMUNICATION AND SO FORTH, BUT WITHOUT GRANT DOLLARS INVOLVED. I CAN'T SEE ANY REASON IF WE CAN'T DO THAT. IF IT'S SELF-FUNDED THAT WOULD BE A WONDERFUL WAY TO MAKE IT A BIGGER PROGRAM THAN WE COULD AFFORD AT THE TIME. >> ELESBETH DID HAVE YOU A COMMENT? >> I WANT TO GO BACK TO THE PATIENT ISSUE FOR A MINUTE FROM ANOTHER PERSPECTIVE. I NOTED IN THE ARMY SURGEON GENERAL TASK FORCE REPORT ON PAIN, THE POINT ABOUT THE DESIRABILITY OF HAVING PATIENTS BECOME ACTIVE AS OX POSE TO PASSIVE WITH RESPECT TO THEIR PAIN. AND IN OUR ORGANIZATION, WHICH IS A UNIQUE HEALTHCARE TRUST FUND, WE HAVE BEGUN WORKING ON THAT ISSUE THROUGH CHRONIC DISEASE SELF-MANAGEMENT AND CHRONIC PAIN AS AN INDICATION FOR PAIN MEDICATION PAIN MANAGEMENT PROGRAMS AND WE HAVE BEEN STARTLED BY THE VALUE. AND IT WOULD SEEM TO BE IMPORTANT ON WHAT IS BEING FOCUSED AND WHAT IS BEING THE CENTER OF ATTENTION IN THESE CENTERS. BECAUSE TO THE EXTHAT HE WENT THAT GETS ECINIZED AS A STRATEGY, IT HAS--IT HAS--YOU KNOW IN THE TRAINING PROGRAMS IT WILL HAVE WIDER DISSEMINATION. >> RIGHT. >> AND I--I AGREE THAT PART OF WHAT WE TRY TO DO WITH THE INTERPROFESSIONAL EDUCATION IS MAKE IT CLEAR THAT YOU'RE AN MD, YOU SHOULD BE WORKING WITH THE NURSES, WORK WITH THE PHARMACISTS AND MORE INTERACTION IN THAT--AND THAT INTERACTION SHOULD INCLUDE THE PATIENTS ISSUES BE NICE TO GET TO THE POINT WHERE PATIENT INVOLVEMENT WASN'T AS NECESSARY AS IT IS TODAY, IF THERE WAS BETTER PAIN EDUCATION OUTLET THERE. LIKE IF YOU'RE TAKING, OR FLYING ON A JET, YOU DON'T NECESSARILY HAVE TO KNOW HOW TO FLY AN AIRPLANE TO GO FROM POINT A TO POINT B. IF THE PILOT KNOWS WHAT HE'S DOING BUT GIVEN TODAY'S LANDSCAPE OF PAIN EDUCATION, THAT'S WAWE HAVE TO HAVE TO HAVE THE PATIENTS VERY INVOLVED AND IT DOES HELP THEM AT THIS POINT. AND CERTAINLY WITHIN THIS PROGRAM AN INTERACTION WITH THE PATIENT TALKING TO THEM, HAVING THEM BE PARTICIPANTS IT'S PART OF WHAT THE CASE STUDIES ABOUT. THEY'RE TALKING, SPENDING TIME, INTERACTING SO I THINK THAT IS INCORPORATED INTO THIS. >> SO I'M WONDERING IF IT--THE ISSUE OF SELF-MANAGEMENT OF PAIN HAS A LARGE ENOUGH EVIDENCE BASE THAT IT WOULD BE USEFUL TO THINK ABOUT A WORKSHOP ON THAT IT'S CERTAINLY SOMETHING WE'VE HEARD THAT YOU NEED TO HAVE PATIENTS ENGAGED AND THINKING ABOUT STRATEGIES TO MANAGE PAIN. SO WE COULD SYRUPLY DO HOME WORK. IT WILL BE VERY HELPFUL FOR ANY OF YOU WHO KNOW ABOUT SUCH STUDIES THAT WE COULD TAKE ADSRAPBT AVERAGE OF. >> WE'VE JUST DONE A META-ANALYSIS OF SOME OF THE CHRONIC DISEASE HEALTH MANAGEMENT, ARTHRITIS CELL MANAGEMENT BUT THERE'S EVIDENCE THAT DOES HELP REDUCE PAIN. SO, FROM A CDC PERSPECTIVE WHERE WE'RE TRYING TO ACTUALLY REDUCE THE POPULATION OF PAIN, THE TWO THINGS WE PUSH ARE THE CHRONIC DISEASE CELL MANAGEMENT PROGRAMS AND PHYSICAL ACTIVITY FOR PEOPLE WITH ARTHRITIS WHERE IT'S VERY GOOD, THAT HAPPENS. IT WOULD BE PART OF THAT CURRICULUM, TOO. >> I WAS GOING TO COMMENT ON THE LITERATURE AND CELL MANAGEMENT PAIN AND A GREATER EFFICACY, ONE OF THE THINGS THAT THE CENTERS OF EXCELLENCE ARE GOING TO BE DO SUGGEST HOW DO YOU ACTUALLY TEACH CELL MANAGEMENT TO A PATIENT THAT HAS PAIN AND AS WAS NOTED BY DAVID, THERE IS A DIVERSITY OF CENTERS OF EXCELLENCE. AND A NURSING INSTITUTE IS ONE OF THAT'S INVELV WIDE IT AND THAT ALSO EXPANDS WHO IS GOING TO BE DOING THE INTERVENTION, SO IT'S NOT ALWAYS THE PETITIONS BUT THE INVOLVEMENT OF OTHER HEALTHCARE PROVIDERS INTO THE MANAGEMENT OF PAIN INCLUDING THE TEACHINGS OF PATIENTS THAT ARE SUFFERING FROM PAIN WHICH WAS STORIES OR QUESTIONS ABOUT EDUCATION OF THE PATIENTS HOW DO YOU EDUCATE, IT'S NOT AUTOMATIC AND IT'S NOT SOMETHING FOR WHICH THERE IS SURRENT CURRICULUM. USUALLY WE CANNOT COVER EVERYTHING ON THERE, THE NORMAL LANDSCAPE OF THE OTHER THANS THANS--CHALLENGES THAT ARE THE ISSUES BUT WE'RE STARTING WITH SALIENT ISSUES WHERE WE CAN GENERATE KRUBG LUMTHAT WILL INSPIRE OTHERS TO USE IT AND EXPAND IT AND WE WANT A PROGRAM THAT EASE THE VOID OF ANY CONFLICT, SO AS WE GO ALONG WHAT WE HAVE SEEN IS THE NOTION OF HEALTHCARE CENTERS OR UNIVERSITIES THAT WANT TO PARTICIPATE EVEN THOUGH THEY MAY NOT GET FUNDING SO THAT'S EXACTLY WHAT WE WANT TO DO TO USE THESE TO ACTUALLY CAPITALIZE AND THEREFORE TAKE A MUCH STRONGER HOLD. >> ANY ADDITIONAL COMMENTS? >> I HAVE ONE. >> I FROM THE ARMY'S PERSPECTIVE, I SAY ARMY BUT THE MILITARY MEDICINE PERSPECTIVE, WE'RE SEE NOTHING OUR COHORTS OF WOUNDED WARRIORS PRIMARILY MOST OF THESE ARE SOLDIERS, 85-90%. AND THERE'S DIFFERENT WAYS WE'VE ATTACKED IT AND WITH OUR LONGER RANGE TREATMENT WITH WOUNDED WARRIOR TREATMENT, WE'VE SET UP PAIN MANAGEMENT SITES AND PAO*EUL TALK ABOUT THAL AFTERNOON, AND THEAD LEADING EDGE OF THE BATTLEFIELD, THE TRIP IS RESPONSIBLE FOR THIS, FIELDING THIS, THE REGIONAL ANESTHESIA CATHETERS SO WE'RE ABLE TO TAKE HOLD OF A TRAUMATICCASM TUEITATION AND PARTICIPATE NOTHING CARE BECAUSE HE WORKED IN A WAY THAT PEOPLE WENT THROUGH THE MEDICAL EVACUATION SYSTEM, WITHOUT BEING INTUBATED NECESSARILY THAT KIND OF THING AND PARTICIPATING THROUGH THE CONTINUUM OF CARE THROUGH THE WOUNDED WORIOR CATEGORIES--WOUNDED WARIAR SYSTEM AND WE ARE SEEING GROUPS THAT HAVE DECREASED INCIDENCE OF PTSD ASSOCIATED WITH THE PAIN. SO THE STUDIES TALK ABOUT SOME OF THOSE STUDIES RIGHT NOW THAT WE HAVE A COHORT OF CERTAINLY--WE COULD DO MORE WITH AND PEOPLE WANT TO BRING UP EDUCATION AND HOW YOU CHANGE CULTURE IS REAL REALLY WHAT WE'RE TALKING ABOUT AND DO YOU THAT THROUGH EDUCATION AND I'LL TALK ABOUT THAT MORE WITH THE TBI MANAGEMENT SYSTEM AND THINGS LIKE THAT SO I THINK THAT'S EXACTLY IT AND I KNOW YOU GUYS HAVE THE UNIVERSITY OF WASHINGTON IN YOURSELF AND WE'RE WORKING WITH ALEX AND HIS TEAM WITH THE ARMY. AND WE GET THE UNIFORM SERVICE UNIVERSITY WHICH IS A PRIME TARGET FOR POTENTIAL FOR EDUCATION BECAUSE WE HAVE TO GET IN THE TRAINING BASE. ONLY WAY TO CHANGE THE CULTURE WITH ALL THIS IS TO GET INSIDE THE TRAINING BASE. >> CAN I JUST IN TERMS OF UNIFORM SERVICES, WE WANT TO WORK WITH THEM AND IN TERMS OF COMMUNICATION, WE'RE FINDING WAYS AND BRIAN NEALY OVER THERE AND THEY WANT TO WALK WITH US AND THEY--WORK WITH US IN MEANINGFUL WAYS. >> ACTUALLY LATE THERAPY AND AFTERNOON, THE LIEUTENANT GENERAL WILL BE HERE, THE IMMEDIATE PAST ARMY SURGEON GENERAL WHO IS INSTRUMENTAL IN OUR EFFORTS, OBVIOUSLY GETTING AFTER THAT, HE WAS THE BOSS AND HE WAS OF INTEREST TO THE BOSS AND BECAME FASCINATING TO THE REST OF US. [LAUGHTER] , SO WE DID A LOT OF THESE THINGS UNDER HIS GUIDANCE, HE'S COMING THIS AFTERNOON BECAUSE HE'S HE'S NOW A FACULTY MEASURE OF ISSUES AND A PROFESSOR OF ISSUES IN THE SPARE TIME SO I THINK WE HAVE REAL POTENTIAL AND CONDITIONS MAY BE RIGHT. SO DON'T TELL HIM I SAID THAT BECAUSE IF HE COMES IN TODAY AND TELLS ME IF IT'S A BAD IDEA, I DON'T WANT TO BLAME HIM OR MYSELF. >> AND I THINK WE'VE HAD A LOT OF CONVERSATION ABOUT THIS, IT'S A GREAT EFFORT, A GREAT FIRST START. I THINK OUR CONCERN BOTH WITH THIS AND THE CONSENSUS CONFERENCE EARLIER IS THAT WE ALL KNOW IS THAT WE'RE LACKING EVIDENCE AND THAT WE'RE DEALING WITH PATIENT POPULATIONS THAT ARE VERY HETEROGENERATED AIC, WE'RE AT--RON AND I WERE AT A CONFERENCE LAST WEEK AT UNC AND I THINK DENNIS TURK PUT UP A SLIDE THAT SHOWED 80 DIFFERENT INTERVENTIONS THAT USED FOR FIBROMYALGIA AND THAT'S THE SAME IN ANY CHRONIC PAIN IN AMERICA WE'RE TALKING ABOUT. SO, WE HAVE CONCERNS, I GUESS A LITTLE BIT ABOUT EXACTLY WHAT'S GOING TO BE TAUGHT AND ALSO THIS DIVIDE BETWEEN TWA CLINICIANS FEEL ARE IMPORTANT AND WHAT PATIENTS FEEL ARE IMPORTANT IN OUR RESEARCH STUDIES, THE MAJOR INDICATOR OF SUCCESS IS THAT HE'S GOING DOWN ON A VAK SCORE ON A QTIP TEST WELL THAT'S NOT NECESSARILY WHAT'S MOST IMPORTANT FOR INVESTIGATIONS FOR TREATMENTS AND IF WE HAVE THIS OPPORTUNITY TO TEACH THROUGH THESE 12 CENTERS AND ALL ACROSS THE COUNTRY WE WANT TO MAKE SURE THAT WHAT'S BEING PUT OUT THERE IS REALLY MATCHING UP WITH WHAT PATIENTS FEEL ARE IMPORTANT AT THE END OF THE DAY. >> I'D LIKE TO MAKE A COMMENT ON THE PAIN EDUCATION PORTION, SO THE VA HAS A VERY ACTIVE PAIN EDUCATION COMPONENT AND IT'S TREATMENT STEPS, APPROACH TO PAIN, SO WE ALSO DO EVIDENCE BASED PRACTICE BUT ALSO PRACTICE BASED EVIDENCE WHERE WE'RE ACTUALLY MONITORING OUR CLINICIANS BEHAVIOR IN TERMS OF PRESCRIBING OPIATES AND THESE PAIN RELATED COMPOUNDS AND WE DETERMINE HOW THEIR BEHAVIORS CAN CHANGE OVERTIME IN TERMS OF THE PATIENT'S NEEDS AND YOU KNOW HOW THEY CAN WORK AS A GROUP TO INVOLVE THE PATIENT IN TERMS OF THE MANAGEMENT OF THE PAIN SO I JUST WANT TO MAKE THAT COMMENT. >> WHAT'S THE BEST WAY TO ENGAGE--[TONE ]--MILITARY AND PATIENTS AS THIS GOES FORWARD. OBVIOUSLY YOU AND THE VA CAN MONITOR WHAT PHYSICIANS ARE DOING. IT'S MUCH HARDER FOR THAT TO HAPPEN BUT THAT'S SOMETHING TO THINK ABOUT AND MAYBE A DISCUSSION AS THESE CURRICULA GET DEVELOPED WITH THE MILITARY WITH THE VA, WITH SELECTED PATIENTS TO LOOK AT GAPS. >> SEAN DID YOU HAVE A ... >> I WANT TO MAKE A COMMENT, DAVE, I KNOW THAT PRIMARY INTEREST FROM A PHYSICIAN STANDPOINT WAS TO BE TARGETING MEDICAL SCHOOLS AND WE DISCUSS TH-D BEFORE AND I'LL SHARE WITH YOU AND I WANT TO BRING UP AGAIN THAT THE SPECIALIST, THE PAIN MEDICINE FELLOWSHIP TRAINING THIS COULD ALSO PLAY A SIGNIFICANT ROLE IN INTEGRATING INTO THAT CURRICULUM, I'M A PROGRAM DIRECTOR AT STANFORD ALSO AND THEN THERE'S ABOUT 90 PROGRAMS IN THE COUNTRY THAT ARE YOU KNOW TRAINING QUITE A FEW PATIENT SPECIALISTS AND TO HAVE A CONSOLIDATED EDUCATIONAL CURRICULUM THAT CAN BE DRAWN UPON UPON FOR THE SUBSPECIALIST COULD BE OF INCREDIBLE VALUE AND I JUST WANT TO PUT IT OUT THERE THAT WE'RE HAPPY TO WORK WITH YOU FROM THAT CAPACITY. >> OKAY, THANKS, SEAN. >> JUST QUICKLY,„i I THINK THIS IS ALSO--SINCE PAIN IS SUCH AN INTERDISCIPLINARY AREA OF STUDY AND THESE CENTERS ARE VERY INTERFERON-GAMMA T-CELL DISCIPLINARY, I THINK IT'S A WONDERFUL OPPORTUNITY FOR US TO SEE HOW THE GENE SCIENCE PROGRESSS AND LOOK AT MODELS, IT WOULD BE GOOD BUT TO SEE WHICH MODELS WORK AND WHICH DON'T BECAUSE IF WE'RE EDUCATING IN THE CAREERS, IT WOULD BE A GREAT WAY TO GET STARTED IN THE INTERDISCIPLINEAR SCHETHAT WAY. >> FORTUNATELY WE HAVE NOT ALLOWED TO BE THE PERFECT TO BE THE ENEMY OF THE GOOD AND WE WENT AHEAD AND STARTED THIS PROGRAM WHICH LOOKS EXTREMELY PROMISING BUT THERE ARE LOTS OF NUANCES AND ADDITIONAL THINGS THAT WE CAN CONSIDER AS IT GOES FORWARD. SO I THINK IT'S A GREAT START AND CONGRATULATE YOU DAVE AND NIDA FOR GETTING US UNDERWAY. >> OKAY, SO IN THE PREVIOUS MEETING WE HAD A DISCUSSION ABOUT DISPARITIES IN PAIN TREATMENT, WE'VE HEARD ALREADY THIS MORNING THAT IT'S CLEAR THAT THERE ARE DISPARITIES AFTER THAT DISCUSSION NINDS TOOK ADVANTAGE OF THE FACT THAT ONE OF THE PROGRAM STAFFS WAS ON THE PLANNING COMMITTEE FOR THE HEALTH DISPARITIES MEETING TO BE HELD SHORTLY AND ARRANGED TO INCLUDE A SESSION ON PAIN AT THAT MEETING AND CARMEN AND WALLY ARE GOING TO BE PARTICIPATING IN THAT AND I THOUGHT IT WOULD BE HELPFUL IF WE COULD HAVE JUST A SHORT SUMMARY OF WHAT THE MEETING AND GOOD TIMING. SHORT SUM SUMMARY OF WHAT YOU ALL WILL BE PRESENTING AND DISCUSSING. >> SO, I'LL BE QUICK BECAUSE I KNOW WE'RE OVERTIME ALREADY. >> WELL I'VE GIVEN UP TRYING TO CONTROL THIS AGENDA WE'LL GET THROUGH TODAY WHAT WE GET THROUGH, I THINK THE DISCUSS HAS BEEN EXTREMELY INFORMATIVE AND I--WE--PLAN THESE MEETINGS NEED TO BE LESS AMBITIOUS ABOUT WHAT WE'LL GET DONE. >> OKAY. SO, FIRST OF ALL, IF YOU REMEMBER OR RECALL, IN THE ORIGINAL LEGISLATION THAT LEAD TO THE INSTITUTE OF MEDICINE REPORT AND OTHER THINGS, DISPARITIES IS HIGHLIGHTED. AND INSTITUTE OF MEDICINE REPORT THEY TALK ABOUT THIS TO A CERTAIN EXTENT, COULD HAVE BEEN MORE, BUT JUST SAYING AS MY COLLEGE KID WOULD SAY, JUST SAYING ... SO THE HHS SUMMIT ON DISPARITIES CAME UP AND I WOULD SAY THAT THAT WAS REAL INSPIR SPIRATION IN SAYING LET'S GET THIS IN. SO WE TOOK A WORKSHOP AND WE DID A PRECONFERENCE WORKSHOP AND A NUMBER OF YEARS AGO AND THAT WAS EXTREMELY WELL RECEIVED AT A SOCIETY MEETING AND BROKE THAT UP INTO TWO THINGS. THE FIRST ONE WAS REALLY SORT OF A STATE OF THE SCIENCE AND REALLY TRIED TO THINK ABOUT INTERPROFESSIONAL CROSS DISCIPLINE TYPE OF WORK. THAT ONE IS THE ONE THAT IS IN FRONT OF YOU WHICH IS CALLED RACIAL AND ETHNIC DIFFERENCES AND DISPARITYS AND PAIN CARE. AND SO, WE TRY TO GET PEOPLE A BIT OF A PRIMER AS IT RELATES TO DISPARITIES AND THE DIFFERENCES AND THE DATA, THE SECOND--SO THIS ONE WAS THE ONE THAT WAS ACCEPTED. SO THAT'S HERE FOR YOUR REVIEW. THE SECOND ONE WAS REALLY ONE THAT LOOKS AT HOW WE CAN THINK ABOUT THIS FROM THE STATE OF THE SCIENCE ALL THE WAY TO THE POLICY PIECE THAT ONE WE NEVER ACTUALLY EVEN HEARD BACK. IN FACT WE DIDN'T HEAR STORIES SMILING. >> [INDISCERNIBLE]. >> OKAY, THAT'S FOR THE TIE LATER. SO ESEBT SENTIALLY„i WE'RE EXCITED ABOUT THE WORN THAT IS ACCEPTED. OUR PLAN IS TO SUBMIT THE OTHER ONE AGAIN FOR NEXT YEAR. I THINK THIS IS--AGAIN IN STORIES, LEADERSHIP THAT REALLY--WE WERE--A LITTLE BIT PASSED THE DEADLINE AND LONIE HELPED US TO GET THIS TOGETHER SO I DON'T--I DON'T SEE HERE HERE BUT THE WE SENT HER THANKS FOR HER EFFORTS. AND SO, WE WOULD LOVE TO GIVE YOU AN UPDATE ON WHAT WE DO AT THE NEXT MEETING, WHERE WE WILL HAVE AN OPPORTUNITY TO HAVE DISCUSSES WITH OTHER PEOPLE IN THE DISPARITIES COMMUNITY. AGAIN, IT'S ONE OF THOSE THINGS IN WHICH PEOPLE, THEY GET IT. BUT WE THINK ABOUT DISPARITIES, CANCER, DIABETES, FIRST AND WE DON'T THINK ABOUT THE FACT THAT PAIN ACTUALLY IMPACTS PEOPLE AT LOTS OF DIFFERENT LEVELS, THE OTHER THING I WOULD SAY AND I SIT HERE LOOKING AT PATRICIA GRADY, THERE, HER BEAUTIFUL FACE, THE OPPORTUNITY IS, YOU KNOW WE ALSO, THE OTHER SYMPOSIUM IS MUCH MORE *EURBT PROFESSIONAL BECAUSE I WOULD JUST SORT OF STAND UP AND SAY, THAT NURSE VS PROVIDED A LOT OF LEADERSHIP TAZ RELATES TO PAIN CARE AND HELPING TO THINK ABOUT DISPARITIES IN CARE, SO WE LOOK FORWARD TO DOING THAT NEXT YEAR. >> WALLY YOU WANT TO ADD ANYTHING. >> I WAS *BT PREPARED TO TALK AND NOW I DON'T NEED TO. >> COME ON WALLY? [LAUGHTER] >> TAKE IT WHILE YOU CAN GET IT. >> OKAY. >> NOW YOU ONCE YOU FINISH SPEAKING YOU HAVE TO TURN OFF THE MICROPHONE BECAUSE THEY WON'T--[INDISCERNIBLE]--SO WE WERE DELIGHTED THAT WE COULD GET THIS ON THE AGENDA. WE THINK IT'S A VERY IMPORTANT ISSUE. MIGHT BE INTERESTING TO HAVE A SUMMARY MUCH WHAT'S DISCUSSED UP ON THE IPRCC WEB SITE AFTER IT'S BEEN HELD, MAYBE THE TWO OF YOU WITH THE LINEUS HELP, COULD PUT TOGETHER THE SUMMARY, SOEZ THOSE ARE THE UPDATES THAT WE WERE AWARE OF. I WOULD LIKE TO MAKE THIS A GENERAL PART OF THE MEETING. I THINK WE LEARNED VERY INTERESTING AND USEFUL THINGS AND HAD GOOD FEEDBACK SO IF FEDERAL AGENCIES OR NONFEDERAL MEMBERS HAVE EPIDATES, ACTIVITIES, INNICHIAATIVES THAT THEY WOULD LIKE TO EITHER HAVE PUT IMMEDIATELY UP ON THE WEB SITEY WE CAN DO THAT ALTERNATIVELY, WE WOULD LIKE TO SUBMIT THEM FOR INCLUSIONOT AGENDA, WE CAN DO THAT AS WELL. YEAH. OH. >> LANED HAS ONE, TOO. GO AHEAD. >> SO JUST AS AN UPDATE THE HEALTH DISPARITIES SUMMIT IS ALSO HAVING SOMETHING THAT IS FOCUSING ON RIP MARS, RESOURCE CENTER IN MINORITY AGING RESEARCH AND THERE ARE SEVERAL AGENCIES WHO PARTNERED AND SUPPORTED THEM AND THEY'RE TALKING ABOUT INVESTIGATOR DEVELOPMENT AND ONE OF THE THINGS THAT I CO-LEAD ONE OF THE COMWOEPBENTS OF OUR CENTER HAS FOCUSED ON TO A GREAT EXTENT IS PAIN. AND SO, ALTHOUGH WE'RE TALKING ABOUT INVESTIGATOR DEVELOPMENT, I MIGHT BE ABLE TO SLIP SOMETHING IN ABOUT PAIN. >> YES. >> OKAY, SO WE'RE TALKING A WHILE BACK AND COMPARING MEETINGS THAT WE'VE BEEN TO AND REALIZED THAT THERE HAVE BEEN WONDERFUL PAIN MEETINGS IN THE LAST MONTH PRESENTED AT SOME SORT OF HIGH PROFILE MEETINGS AND SO WE THOUGHT WE WOULD JUST BRING THIS TO YOUR ATTENTION AND THE AMERICAN NEUROLOGICAL ASSOCIATION MEETING EARLIER THIS MONTH, THERE WAS A SESSION ON ADVANCES AND HEADACHE PAIN RESEARCH TREATMENT CO CHAIRED BY ROBERT PESSINE AND CLIFFORD WOLF, IT ALSO FEATURED ROMY BERSTEIN AND ROY FREED MACHINE AND DAVID CORNBLAST, AND COVERED NEW INNOVATIONS AND OUR UNDERSTANDING OF THE PATHOGENESIS OF MIRROR MIGRAINE AND NEUROPATHIC PAIN. THEY LOOKED AT PAIN SIGNALING IN THE NERVOUS SYSTEM AND MALADAPTIVE PLASTICITY AND HOW THEY CONTRIBUTE TO THESE DISORDERS AND ALSO DID AN UPDATE ON A CLINICAL TRIAL FOR NEUROPATHIC PAIN THAT'S ONGOING AND SO STORY ATTEND THAD MEETING AND IT WAS A VERY, VERY, NICE MEETING. >> IT WAS A GREAT SESSION IT TO & TO MY KNOWLEDGE IT'S THE FIRST COMPOSEIUM, A WHOLE HALF DAY ON PAIN AT THE A. M. A. IN QUITE SOMETIME, IF NOT, EVER. SO NICE THAT THIS IS A SENIOR NEUROLOGICAL SOCIETY MEETING AND IT WAS VERY NICE THAT THIS WAS ACTUALLY INCLUDED. AND WE WERE ALSO REAL LE EXCITE THAD THE NEUROBIOLOGY OF PAIN WORKSHOP THAT THE ATTEND ANT FOR THIS WAS PHENOMENAL, IT WAS OVER--THEY HAD--THEY HAD DIFFICULTY GETTING PEOPLE INTO THE ROOM, I HAD TO PULL STRINGS TO GET INTO IT BECAUSE IT WAS OVERCOMMITTED. THIS IS THE NEUROATIVE BIOLOGY DISEASE WORKSHOP WHICH PROCEEDS THE NEUROSCIENCE MEETING BY A DAY EMPLOY CATHERINE BUSH AND WOLF CO CHAIRED THIS AND AND DAVEED WAX MAN SAYS THE JULIA, CATHERINE HERSELF AND AND CLIFFORD AND THE BASICALLY COVER TOPICS FROM MOLECULAR SIGNALING ALL THE WAY TO NEW TREATMENT TARGETS AND SILENCING THOSE PAINS. RON WAS INVOLVED IN THE AFTERNOON WHICH IS SET UP AS A SERIES OF WORKSHOPS, MOSTLY ATTENDED BY YOUNGER PEOPLE WHO ARE COMING INTO PAIN RESEARCH, WHERE THEY WILL DISCUSS SORT OF VERY INTERACTION, THIS INTERACTIVE DISCUSSION OF VARIOUS TOPICS RELATED TO PAIN AND PAIN RESEARCH. SO I THOUGHT IT WAS A WONDERFUL MEETING. THEY DID A TKPWRAT JOB AND I DON'T FINISH YOU WANT TO ADD ANYTHING TO IT, RON, BUT IT WAS GREAT. >> JUST COMMENT THAT IT WAS AMAZING THERE WERE OVER 300 YOUNG PEOPLE THERE. >> IT WAS 375. >> WOW. WOW. JUST ONE OF THE BEST ATTENDANCES AT A DISEASE-- >> THESE ARE GRADUATE STUDENTS AND POST DOCS AND YOUNG FACULTY. AND WHAT WAS VERY INTERESTING IN THE AFTERNOON IN THE WORKSHOP DISCUSSIONS WHICH WAS A SMALL GROUP DISCUSSIONS, BUT EACH PERSON GOT YOU UP AND TOLD US WHAT THEY WERE STUDYING AND SO MANY OF THEM ARE DOING RESEARCH THAT'S RELATED TO PAIN AND I THINK THAT BODES WELL FOR THE FUTURE. >> IT'S VERY CLEAR THAT ONE OF THE ISSUES HAS BEEN RECRUITING THE BEST AND BRIGHTEST STARTING INVESTIGATORS INTO THE FIELD OF PAIN RESEARCH AND THIS KIND OF MEETING CAN MAKE A HUGE DIFFERENCE IN THAT REGARD. >> SO THERE WAS ALSO A SPECIAL LECTURE DURING THE MEETING ITSELF, THE SOCIETY FOR NEUROSCIENCE MEETING BY DAVID JULIUS FROM PEPPERMINTS WHERE HE TALKED ABOUT PERIPHERAL RECEPTORS AND THE WONDERFUL WORK HE'S DONE OVER THE YEARS AND THE SOCIETY FEATURED BREAKING NEWS SEGMENTORSHIP SKILL FROM ACARRION ON HIS RECENT IMAGES STUDYING LOOKING AT CHANGES IN THE BRAIN, STRUCTURE AND FUNCTION WITH ACUTE AND SHORT-TERM AND LONG-TERM PERSISTENT LOW BACK PAIN AND THAT HE'S ACTUALLY SEEING IN THESE IMAGES STUDIES PREDICTERS FROM THE ACUTE POPULATION OF WHO WILL AND WHO WILL NOT GO ON TO CHRONIC LOW BACK PAIN. VERY EXCITING STORY. SO THE NEXT SLIDE--DO YOU MIND SWITCHING THIS WHILE I START TO TALK. SO WHAT ARE THE RECOMMENDATIONS OF THE IOM REPORT WAS TO LOOK AT THE REVIEW PROCESS FOR PAIN GRANTS THAT COME INTO NIH. AND SO, THIS IS A PROCESS THAT WE'VE UNDERTAKEN THAT'S UNDER WAY AND WE HAVE A LITTLE BIT OF INITIAL INFORMATION FOR YOU. WE KNOW THERE HAS BEEN SOME CONCERN ABOUT ACROSS THE COMMUNITY OF WHERE AND HOW PAIN GRANTS ARE REVIEWED, SO WE ARE BEGINNING TO LOOK AT THIS. WE'VE HAD VERY INTENSE AND HARD WORK BY SOME OF THE NIH STAFF WHAT WE PROPOSE IS THAT WE PUBLISH A LIST OF WHERE PAIN GRANTS ARE REVIEWED. AND SO, FROM THE ANALYSIS WHERE ALL THE PAIN GRANTS COME IN, WE HAVE FOUND THAT THERE ARE 46 STUDY SECTIONS THAT REVIEW UNSOLISITTED SO THESE ARE MOST OF OUR RPG GRANTS, RO-1S, ROTHRAORBGSs ET CETERA, THAT 46 DIFFERENT STUDY SECTIONS THAT COVER REVIEW OF PAIN GRANTS ACROSS THE CENTER FOR SCIENTIFIC REVIEW. ON AVERAGE, ABOUT 25% OF OF THESE GO TO THE STUDIES OF MULTIPLE ENDOCRINEAT O SENSORY AND CHEAPEE SYSTEM STUDY SECTION. SO THERE'S A BIT OF A CONCENTRATION THERE, AND SO WHAT THE PLAN IS, IS THAT OVER THE NEXT FEW WEEKS WE WILL PUBLISH THE FULL LIST OF STUDY SECTIONS THAT TAKE PAIN GRANTS ON THE NIH PAIN CONSORTIUM WEB SITE AND ALSO ON THE IPRCC WEB SITE SO THIS IS FYI FOR YOU APPROXIMATE ANYBODY HAS COMMENTS ON THAT, WE WOULD BE HAPPY TO TAKE THEM NOW. OKAY, THANK YOU. >> OKAY, SO WE ARE NOW GOING TO TAKE THE 9:30 BREAK AND IT WOULD BE GREAT IF YOU ALL COULD BE BACK HERE AT 10:15 I THINK WE CAN MAKE UP SOME OF THE TIME BY HAVING A SHORTER DISCUSSION THAN MAYBE THAN WE PLANNED ON MEN AND WOMEN TO DO WITH THE ADVANCES. OKAY, SO YOU HAVE 10 MINUTES >> OKAY, SO WE HAVE A SMALL CHANGE IN THE SCHEDULE. I HAVE TRADED THE THE SLOT THEY WAS GOING TO USE FOR PAIN RESEARCH ADVANCES FOR THE PRESENTATION OF THE ARMY SURGEON GENERAL'S PAIN MANAGEMENT TASK FORCE REPORT WE WANT TO MAKE SURE THAT THAT ACTUALLY HAPPENS AND MAJOR GENERAL THOMAS HAD TO LEAVE TO GET TO OTHER THINGS. SO RIGHT NOW I'M GOING TO START LOOKING AT THE OVERVIEW OF THE FEDERALLY FUNDED PAIN RESEARCH PORTFOLIO AND LINDA WILL BE PRESENTING THAT. OKAY, SO, MOST OF YOU HAVE FOLLOWED AT LEAST THE PRELIMINARY STEPS AND ACTIVE PARTICIPANTS IN GETTING THIS PORTFOLIO ANALYSIS OFF THE GROUND. SO WE HAVE FOR YOU THIS MORNING SOME--PRESENTATION OF SOME OF THE DATA IN A WAY WE HOPED WOULD BE HELPFUL TO DEBEGIN TO DIGEST THIS INCREDIBLY LARGE AND COMPLEX DATA SET. SO WE HAVE IN THE EXCEL SPREADSHEET EARLIER, THE PROGRAMS FEDERALLY FUNDED BY THE HRQ, THE D.O.D., THE D. D. A., THE NIH. THAT ARE RELATEDDED TO PAIN. SO WHAT I THINK MIGHT BE HELPFUL BEFORE I LAUNCH INTO THE SLIDES IS TO REMIND YOU MUCH THE PROCESS OF HOW WE GOT HERE. AT THE VERY BEGINNING OF THIS INAUR INAUGURAL MEETING WE DECIDED THAT IT WOULD BE BEST TO BREAK THIS DOWN INTO SMALLER COMPONENTS WHICH WE CALL BUCKETS AT THE TIME AND TO BE ABLE TO SORT OF PUT INTO SMALL GROUPS, AS A STARTING POINT, SORT OF AS A MEANS TO LOOK AT MORE DETAILED ATHAT WILL SIS OF THESE SMALLER GROUPS OF GRANTS AND SO IN ORDER TO DETERMINE HOW WE WOULD BREAK THOSE GROUPS DOWN, WE INITIALLY PUT TOGETHER A WORKING GROUP OF THE NIH STAFF. >> WHO WENT TO THE IOM REPORT AND THEY WENT TO AN OMNIBUS PROGRAM ANNOUNCEMENT THAT WE HAVE OUT THAT THE IOM ACTUALLY CITED THAT USED SPECIFIC SCREAMATTIC AREAS FOR SOLICITATIONS FOR RESEARCH ON PAIN, AND WE ALSO LOOK AT AN EARLIER SURVEY THAT WE HAD DONE IN 2002 FOR THE NIH ONLY PORTFOLIO. AND SO WE CAME UP WITH A LIST OF TERMS AND DEFINITIONS FOR THOSE TERMS THAT WE THEN PUT FORWARD TO THE OTHER AGENCY REPRESENTATIVES FOR THEIR INPUT, TOOK THEIR INPUT AND BROUGHT IT TO A WORKING GROUP OF THE IPRCC WHICH INCLUDED TINA, SEAN, RON, CHRIS, TRIP, MIKE AND WALLY SMITH AND SO WE HAD INPUT FROM THEM AS TO HOW TO SET THE DEFINITIONS FOR THESE SCHEMEATIC TOPICS TO SORT THE DATA WITH AND ALSO HOW TO GATHER THE DATA. THAT THEN CAME TO THE FULL COMMITTEE FOR DISCUSSION IN JUNE. SO WE'VE TRIED TO ROLL--WE TRIED AT THAT POINT TO ROLL IN ALL TOGETHER ALL THE RECOMMENDATIONS AND WE FIND THE DEFINITIONS BEFORE WE WENT TO ALL THE AGENCIES TO ACTUALLY ASK THEM TO COLLECT OUR DATA AND SO THE DATA COLLECTION PROCESS WHICH ALL THE AGENCIES ARE VERY FAMILIAR WITH BASICALLY CONSISTED OF TAKING THEIR ENTIRE RESEARCH PORTFOLIO AND BREAKING IT DOWN INTO THREE--WHAT WE WERE CALLING TEAR ONE VERY BROAD CATEGORIES OF BASIC CLINICAL AND TRANSLATIONAL RESEARCH AND TO BREAK DOWN INDIVIDUAL PROJECTS AS A PERCENTAGE OF THOSE THREE CATEGORIES IN 25% INCREMENTS. AND THEN FOR THE SECONDARY TIERS WHICH WERE MUCH MORE DISCREET, WE HAD I THINK 29 OF THEM ALTOGETHER, WE ASKED THEM TO BREAK DOWN EACH OF THE PROJECTS INTO PERCENTILES INTO INCREMENTS OF 25% TO EACH ONE OF THE MOST RELL SRAPT SECOND TEAR TOPIC AND IT IS DEFINITIONS WERE INCLUDED IN THE EXCEL SPREADSHEET AND ARE ACTUAL LOW WILL SHOW UP ON ONE OF THE SLIDES THAT COMES UP LATER. YOU HAVE THE SLIDE SET THIS YOUR PACKET. SO, AS A STARTING POINT, THEN, Ws DID SOME VERY SORT OF BASIC OVERVIEW KIND OF SLIDES FOR YOU AS TO THE BREAK DOWN OF THE AMOUNT OF THE PORTFOLIO THAT WAS CONTRIBUTED TO BY EACH OF THE FEDERAL AGENCIES INCLUDED IN THE PORTFOLIO ANALYSIS AND AS YOU CAN SEE FROM THIS SLIDE THAT THE NIH COMPOPE SEPTORS RELATIVELY LARGE--COMPOPE SENT RELATIVELY LARGE COMPARED TO OTHER AGENCIES AND IT'S VERY BROAD AND VERY DIVERSE. SO WE BROKE THIS DOWN INTO THE THREE TOP TIER, THE TOP TIER THREE CATEGORIES AND FOUND THAT WE'VE GOT ACROSS ALL THE AGENCIES 50% IS COATED AS CLINICAL RESEARCH, 35% IS BASIC AND 15% AS TRANSLATIONAL RESEARCH. AND AGAIN, THESE--THE DEFINITIONS FOR EACH OF THESE WERE GIVEN TO THE FOLKS WHO WERE CODING THESE GRANTS SO THEY'RE USING CONSISTENT DEFINITIONS TO MAKE THE DETERMINATIONS OF WHERE YOU GRANTS BELONGED. AS WE GOT FEEDBACK ALONG THE WAY FROM THE WORKING GROUP AND THE COMMITTEE MEMBERS, WE TRIED TO ADDRESS SOME OF THE QUESTIONS THAT WE HAD IN ADVANCE OF THIS MEETING AND SEAN HAD ASKED US IF WE WERE ABLE TO DETERMINE WHETHER THERE WAS ANY SHIFTING TREND IN THE BREAK DOWN OF THE THREE TOP CATEGORIES, AND AT THIS POINT, REALLY THE ONLY SORT OF TIME STAMPS THAT WE HAD WERE AN EARLIER PORTFOLIO ANALYSIS IN 2002 AND WE WERE ABLE TO COMPARE THAT TO THIS CURRENT TWEBT 11 ANALYSIS FOR NIH DATA, WE DIDN'T HAVE THE FEDERAL DATA AT 2002 FOR WHICH WE HAD COMPARABLE DEFINITION. SO FOR THIS ONE, YOU CAN SEE THERE'S A LITTLE BIT OF SHIFT MOVING INTO BASIC AND TRANSLATIONAL RESEARCH AND AGAIN THAL IS JUST THE NIH DATA. IT'S ALL WE HAD AVAILABLE AND NOT SURPRISING GIVEN A LOT OF THE INSTITUTES ACROSS NIH AND NOW NCATS, WHICH WAS ACTUALLY FORMED AFTER THIS YEAR'S DATA COLLECTION, AND HAS PUT A LOT OF EFFORT INTO EXPANDING THEIR TRANSLATIONAL PROGRAMS. SO THEN WE ALSO LOOKED AT THE BREAK DOWN OF THE THREE TOP TIERS BY THE DIFFERENT AGENCIES AND YOUR SLIDES KIND OF GIVE YOU A SENSE THAT THE INTERESTS ARE QUITE DIFFERENT IN THE RESEARCH PORTFOLIOS AS EACH OF THE AGENCIES, THE D.O.D., FDA, NIH ARE SPLIT AS FAR AS CLINICAL RESEARCH CDC HAD TRANSLATIONAL RESEARCH ON THE PORTFOLIO AND THE EPA IS A BIT OF AN EVEN DISTRIBUTION OF THE OTHER THREE. AND THIS MAY--WE'RE HOPING THAT ALL IN INFORMATION WILL BE HELPFUL AS WE MOVE FORWARD IN DETERMINING OUR GAPS AND OPPORTUNITIES TO MOVE FORWARD. AH DEGREE ASK THAT WE 85 YOU A SENSE BECAUSE THE NIH WAS SUCH A LARGE COMPONENT OF THE FEDERAL PORTFOLIO THAT WE GAVE YOU A SENSE OF THE DIFFERENT INSTITUTES, COMMITMENT TO FUNDING, PAIN RESEARCH GRANTS AND HERE YOU HAVE A BREAK DOWN OF THE NIH PORTFOLIO AS PERCENTAGE OF NUMBER OF GRANTS OF DOLLARS COMMITTED TO THE NUMBER OF GRANTS, SORRY BY EACH OF THE INSTITUTES, SO YOU CAN SEE THERE'S A LOT OF INSTITUTES THAT ARE INVOLVE SAID AND A LOT OF INSTITUTES THAT MAKE A MAJOR COMMITMENT TO IT. >> SO THE SECONDARY CODE WERE THE LIST EVER THE 29 DIFFERENT BUCKETS OR SECONDARY CODES THAT WE PUT TOGETHER AND YOU CAN SEE HERE THAT THE DISTRIBUTION ACROSS THE DIFFERENT BUCKETS WE SET UP WAS NOT VERY EVEN. THE FIRST ONE AND THESE ARE IN ORDER OF THE PERCENTAGE OF GRANTS IN EACH OF THOSE SECONDARY CODES. AND PLEASE STOP ME IF YOU HAVE ANY QUESTIONS OR COMMENTS AS WE GO ALONG BECAUSE THERE'S JUST A LOT OF INFORMATION IN THIS SLIDE SET. SO, THE FIRST ONE IS THE NEUROBIOLOGICAL TKPWHRAOEL MECHANISMS OF NO INCEPTION AND PAIN. THIS CATEGORY INCLUDES PREDOMINANT NUMBER OF BASIC RESEARCH GRANTS WHICH FROM YOUR EXCEL DATA SHEET, YOU CAN SORT THEM BY BASIC CLINICAL OR TRANSLATIONAL. AND BECAUSE THIS WAS A LARGE PERCENT OF THE PORTFOLIO, RON AND MIKE VOLUNTEERED TO TAKE A CLOSER LOOK AT THE GRANTS THAT ARE WITHIN THIS CATEGORY AND AFTER I FINISH UP, THEY'LL PRESENT TO YOU THEIR FINDINGS ON THE BREAK DOWN OF THAT PARTICULAR CATEGORY. SO WE THOUGHT THIS IS A GOOD STARTING PLACE TO START TO DISSECT OUT THESE CATEGORIES A LITTLE BIT AND LOOK AT MORE DETAIL AND WHAT'S IN THEM. >> NEXT UP WAS NONFARM KACCT LOGICAL MECHANISMS TREATMENT, FOLLOWED BY PHARMACOLOGICAL MECHANISMS IN TREATMENT, BIOBEHAVIORIAL AND SOCIAL MECHANISMS CAME UP FAIRLY HIGH, PAIN OUTCOMES ADDRESSMENTS MEASURES, THE FULL DEFINITIONS AGAIN ARE IN YOUR EXCEL SPREADSHEET AND THEN WE SORT OF HAVE A CLUSTER HERE AT FOUR% OF THE PORTFOLIO FOR GENETICS GENOMICS, AGAIN A FAIRLY BASIC COMPONENT. ANALGESIC DEVELOPMENT, MECHANISMS OF TREATMENT FOR TRANSITION SO THIS IS ACUTE-CHRONIC PAIN PHASES WOULD BE INCLUDED IN HERE; DEVELOPMENT AND SRALDATION OF ANIMAL MODELS AND THE UNIQUE POPULATIONS AND THIS REMINDS ME THEY FORGET TO MENTION FROM THE INITIAL ANALYSIS, NOT ONLY DID WE HAVE PRIMARY TEARS, BASIC, TRANSLATIONAL AND CLINICAL BUT WE ARE ALSO LOOKING AT NOW, WE HAD CHECK BOXES FOR THE SECONDARY WORKING CODE SYSTEM THAT THE FULL COMMITTEE FELT WE NEEDED TO PICK UP MORE INFORMATION FROM AND THOSE CHECK BOXES INCLUDED THINGS LIKE UNIQUE POPULATION, SPECIAL POPULATIONS, VETERANS, MILITARY, CHILDREN, AGING ET CETERA. AND SO, UNDERNEATH EACH ONE OF THOSE CHECK BOXES, WE CAN LOOK A LITTLE BIT MORE IN DETAIL AND PULL UP THAT INFORMATION. COMPARATIVE EFFECTIVE RESEARCH, TRAINING AND PAIN RESEARCH, PAIN EDUCATION, DEVELOPMENT AND DEVICE AND THERAPY DEVELOPMENT SYSTEMS CAME UP WITH A FAIRLY EQUAL PERCENTAGE. THE SECOND PAGE IS A CONTINUATION OF THE SECONDARY CODES BY TITLE AND HERE YOU'RE STARTING TO SEE WHERE EACH OF THESE HAD A SMALLER NUMBER OF THE OVERALL PAIN RESEARCH PORTFOLIO COMMITTED TO THE SPECIFIC TOPICS. SO I'M NOT GOING TO READ THROUGH THEM BECAUSE THEY'RE FAIRLY EVENLY SPREAD OUT BUT I'LL LEAVE THEM UP HERE FOR A SECOND IF YOU WANT TO QUICKLY READ THROUGH AGAIN THE SLIDE SET WILL GIVE YOU THE SAME INFORMATION. SO HERE IS THE LIST, CHECK LIST EXPANSION THAT I JUST MENTIONED AND WHAT WE'VE GIVEN YOU HERE ON THIS SLIDE IS THE NUMBER OF APPLICATIONS WHICH WERE CHECKED OFF FOR ONE OF THE SPECIFIC BOXES. SO FOR THE PAIN EDUCATION COMPONENT, WE WANT TO KNOW WHETHER THE EDUCATIONAL COMPONENT OF THE GRANT WAS FOR HOUSE AND PUBLIC, AND THE NUMBER THAT YOU SEE TO THE RIGHT SIDE OF EACH ONE OF THOSE TITLE SYSTEM THE NUMBER OF GRANTS THAT WERE CODED FOR THAT PARTICULAR GROUP. IN THE PAIN AND WOMEN'S MINORITIES HEALTH RESEARCH, WE ASKED THE CODERS TO CHECK OFF WHETHER THE GRANT WAS FOCUSED ON HEALTH RESEARCH IN WOMEN'S OR IN MINORITIES, AGAIN, THE NUMBER OF THE TKPWRAPTS ARE HERE. --GRANTS ARE HERE, UNDER UNIQUE POPULATIONS, PEDIATRIC 22 GRANTS ELDERLY 33, AND END OF LIFE, 22, DISABILITY, ONE AND MILITARY SIX. AND UNDER SEX AND GENDER DIFFERENCES, 22 APPLICATIONS, SPLIT FAIRLY EVENLY BETWEEN MALES AND FEMALES. SO DURING OUR CONVERSATIONS WITH THE WORKING GROUP, WE HAD DISCUSSED--WELL, ACTUALLY WE PRESENTED DATA ON THE DISEASE CONDITIONS LIST THAT WE GAVE TO THE CODERS, AND ASKED THEM TO CHECK OFF, OR ACTUALLY TO ADD THE--IT GETS COMPLICATED, I'M SORRY, TO NOTE WHICH CONDITION WAS MOST RELATED TO THE GRANT THAT THEY WERE CODING. IN ORDER TO CAPTURE AN IDEA OF HOW THE PORTFOLIO WAS DISTRIBUTED RELATED TO SPECIFIC PAIN CONDITIONS, THESE WERE NOT BROKEN DOWN BY THE SPECIFIC PERCENTILE OR INCREMENTS OF A GRANT. THIS WAS THE GRANT--THE GRANT IS LOOKING PRIMARILY FOR EXAMPLE AT OSTEOARTHRITIS PAIN SO THE WHOLE GRANT WOULD BE CODED FOR THAT PARTICULAR CONDITION. AND IS THERE ARE THREE PAGES HERE AND SO AS I GO THROUGH THE SLIDE, THEY ARE GOING IN DESCENDING NUMBER OF PERCENT OF PROJECTS COMMITTED TO THAT PARTICULAR PAIN CONDITION. SO OSTEOARTHRITIS PAIN, CANCER PAIN AND LOW BACK PAIN CAME UP AS THE TOP THREE AS PERCENTAGE OF PROJECTS THAT WERE PRIMARILY TARGETING THAT PARTICULAR PAIN CONDITION AND THEN WE HAVE NEUROPATHIC PAIN, IRRITABLE BOWEL, HEADACHES AND SICKLE CELL, OTHER MUSK LO SKELETAL PAIN AND SOME OF THESE CATEGORIES ARE FAIRLY BROAD BECAUSE WE HAD NOT ANTICIPATED CERTAIN CODES THAT PEOPLE WOULD ADD AS THEY WENT--CONDITIONS RATHER THAT PEOPLE WOULD ADD AS THEY WENT THROUGH THE GRANTS OR THEY DIDN'T QUITE FIT WITH THE CONDITIONS THAT WE HAD. SO SOME OF THESE ARE FAIRLY BROAD BUT ALSO INCLUDE SPECIFIC CONDITIONS UNDERNEATH IT. FOR EXAMPLE WE HAVE A NEUROPATHIC PAIN ONE BUT WE HAVE NEUROPATHY. SO THERE'S SOME OVERLAP, BUT ONE GRANT WAS ONLY COUNTED ONCE. AND HERE YOU SEE, ON THE SECOND PAGE OF THREE, THESE ARE ALL ABOUT ONE% OF THE PROJECTS SO THESE ARE ALL FAIRLY EVENLY DISTRIBUTED AND AGAIN I'M NOT GOING TO READ THROUGH THE LISTS. YOU HAVE IT IN FRONT OF YOU; AND THEN, ON THE FINAL LIST, WE HAVE THE REMAINDER OF THE PAIN CONDITIONS THAT WE HAD ON THE LIST, NOSE EXCEPTION WERE NOT INCLUDED BECAUSE A LOT OF THE GRANTS WERE NOT COMMITTED TO A PAIN CONDITION BUT WE'RE VERY SORT OF BASIC RESEARCH THAT COULD BE APPLICABLE TO MANY DIFFERENT PAIN CONDITIONS, WE ALSO HAVE NOT PAIN CONDITION SPECIFIC BECAUSE IT MIGHT HAVE BEEN A GRANT THAT WAS TARGETING MULTIPLE CONDITIONS OR WAS BASIC TRANSLATIONAL RESEARCH THAT COULD BE APPLICABLE TO A NUMBER OF CONDITIONS. SO THE WORKING GROUP SUGGESTED THAT IT MIGHT BE HELPFUL AS A PILOT TO LOOK AT THE BREAK DOWN BY PRIMARY AND SECONDARY CODE FOR SOME OF THESE SPECIFIC CONDITIONS AND SO, THE NEXT SEVERAL SLIDES START OUT WITH THE THREE TOP GROUPS, AS FAR AS DISTRIBUTION OF THE PORTFOLIO. SO FOROSTEOARTHRITIS PAIN, THIS SLIDE WILL SHOW YOU THE BREAK DOWN BETWEEN BASIC TRANSLATIONAL AND CLINICAL AND HERE, IT'S PRIMARILY CLINICAL. WE'RE SHOWING YOU DOLLARS AND PROJECTS WHICH DON'T EXACTLY MATCHUP BECAUSE SOME CLINICAL PROJECTS ARE MORE EXPENSIVE THAN BASIC PROJECTS. AND THEN IF YOU LOOK AT OSTEOARTHRITIS PAIN AGAIN ACCORDING TO HOW THESE WERE CODED FOR THE SECONDARY TIER, YOU'LL GET A SENSE THAT A LOT OF THE OSTEOARTHRITIS GRANTS WERE CONSIDERED RELATED TO NONPHARMACOLOGICAL MECHANISMS IN TREATMENT, A LOT OF THEM RELATED TO DIAGNOSIS AND CASE DEFINITIONS AND MECHANISMS OF AND CODED OF OSTEOARTHRITIS AND OA AND THEN, SORT OF A HANDFUL OF OTHER SECONDARY CODES THAT THE CODERS CONSIDERED THESE GRANT SAYS TO BE RELEVANT TOO. CANCER PAIN, WAS THE NEXT ON THE LIST AND HERE AGAIN, YOU SEE THE DISTRIBUTION IS EVEN MORE SO SWAYED TOWARDS CLINICAL RESEARCH AND THAT THERE'S A SMALL BIT OF TRANSLATIONAL AND HERE IS THE BREAK DOWN FOR THE CANCER PAIN GRANTS AS FAR AS THE SECTIONAL ANALYSISARY CODES--SECONDARY CODES GO FELT SO HERE WE HAVE A LOT DEVOTED TO UNIQUE POPULATIONS, NEUROBIOLOGICAL AND TKPWHRAOEL MECHANISMS, PHARMACOLOGICAL MECHANISMS OF TREATMENT, NONPHARMACOLOGICAL MECHANISMS OF TREATMENT. THERE'S A BIG EDUCATIONAL COMPONENT HERE FOR PAIN. THERE'S A LOT DEVOTED TO BIOBEHAVIAL BEHAVIOR AND AGAIN YOU CAN READ THROUGH THE LIST AS GUTMACHER THROUGH, AND I KNOW THIS IS A LOT TO DIGEST, WE'RE TRYING TO GIVE YOU AN IDEA OF WHAT THIS PORTFOLIO LOOKS LIKE AND THE LAST OF THE THREE THAT WE PILOTED, IS LO BACK PAIN, HERE WE SEE A BIT MORE IN THE BASIC PORTFOLIO THAN WE DID IN THE PRIOR TRANSLATIONAL, PROBABLY ABOUT THE FIRST TWO AND CLINICAL ACCOUNTS FOR A LITTLE BIT--A LITTLE BIT MORE THAN HALF, A LITTLE BIT LESS THAN 2/3RDS OF THE GRANTS THAT WE HAVE AND IF WE BREAK DOWN LOW BACK PAIN, ACCORDING TO THE SECONDARY CODE CATEGORIES, WE SEE THAT NONPHARMACOLOGICAL MECHANISMS IS SUBSTANTIALLY HIGH ON THE LIST AT 26% OF THE LOW PACK BANE GRANTS. AGAIN, BIOBEHAVIORIAL AND PSYCHOSOCIAL MECH NICHES FOR TREATMENT ARE VERY HIGH ON THE LIST. OUT COMES ASSESSLETS IS IMPORTANT, COMPARATIVE EFFECTIVENESS IS IMPORTANT AND THEN THERE ARE SOME, NEUROBIOLOGICAL MECHANISMS, LOOKING AT MECHANISTIC GRANTS AND THEN A PERCENTAGE DEVOTED TO THE LAST SEVERAL ON THE LIST. AND SO WHAT WE'RE TRYING TO DO IS SEND YOU SOME AND TO LOOK AT TO BEGIN TO DETERMINE HOW WE'RE GOING TO THINK ABOUT IDENT TIE WHAT WAS IN THE SPECIFIC CATEGORIES OR DEFINITIONS IN ORDER TO HELP US LOOK AT THE GAPS IN THE PAIN RESEARCH PORTFOLIO ONEER THING WE'RE A BIT CONCERNED ABOUT IS THAT THE GAP MAY NOT NECESSARILY MATCHUP TO THE SPECIFIC AREAS WHERE THERE'S NOT A LOT OF RESEARCH DOLLARS COMMITTED, WE PUT THESE DEFINITIONS, THESE CODES TOGETHER, PRIOR TO DOING THE PORTFOLIO ANALYSIS, IN THE HOPES THAT WE WOULD TARGET THE ONES THAT THE COMMUNITY FELT WAS MOST IMPORTANT BUT WE MAY NOT HAVE BROKEN THEM DOWN IN A WAY WHERE, THE BIGGEST IS THE MOST IMPORTANT AND NEEDS NO MORE RESEARCH, THERE'S NO GAPS IN THERE, THIS IS NOT WHAT THIS PORTFOLIO IS SUGGESTING AND IT MAY NOT BE THAT THE ONES WITH THE SMALLEST DOLLAR AMOUNTS ARE THE ONES THAT THE COMMITTEE FEELS ARE THE MOST IMPORTANT AS FAR AS GAPS AND NEEDS BUT THIS IS MEANT TO BE A TOOL TO HELP US GO TO A THAT POINT. SO-- >> SO MAYBE WE COULD STOP AND HAVE QUESTIONS, THE PLAN WAS THEN THAT RON AND MIKE WOULD TALK ABOUT HOW TO BREAK DOWN THAT 18% OF NEUROBIOLOGICAL AND TKPWHRAOEL AND THEN TO DEVELOP A PLAN FOR GOING FORWARD BECAUSE I DON'T THINK WE'RE WHERE WE WANT TO BE YET? SO GENERAL COMMENTS--SO FOR EACH OF THESE CATEGORIES YOU CAN GO IN AND LOOK AT ALL THE GRANTS THAT WERE CODE INDEED A PARTICULAR FASHION, GET A SENSE OF WHAT WAS IN THOSE BUCKETS. I DON'T KNOW HOW MANY HAD A CHANCE TO DO THAT BUT YOU COULD HAVE DONE THAT. SO GENERAL COMMENTS ON THIS 30,000 OVERVIEW? >> THIS IS LOVELY, I LOVE IT AND YES IT'S A LOT TO DIGEST AND YOU DO SEE PATTERNS THAT ARE USEFUL AND FOR ME GOING FORWARD, ONE OF THE THINGS MOVING FORWARD TO BE DONE OR ASK TO BE DONE IS TO START LOOKING COMPARATIVELY IS ACROSS THE DISEASE BUCKET ACROSS DISTRIBUTIONS SO YOU CAN DO THAT MANUELLY NOW AND SO IT'S TROUBLE AND TAKEN--THEY'S FINE TO START LOOKING AT SOME OF THESE DISEASES, THAT WOULD BE ONE CUT TO LOOK COMPARATIVELY ACROSS DISEASE BUCKETS TO SEE TRENDS. >> BY DISEASES YOU MEAN THE LOW BACK PAIN? THE SICKLE CELL? >> YES. >> AND AND YOU CAN LOOK, YOU DID ONE QUICK SCAN LOW BACK PAIN AND OSTEOARTRITIS IS A LOT IN SOME WAYS AND VERY DIFFERENT THAN CANCER. IF YOU JUST LOOK RIGHT NOW, YOU CAN SEE THATFUL. >> SO YOU'RE SAYING A SIMILAR ANALYSIS TO WHAT WE DID WITH THIS PILOT STUDY ACROSS ALL CONDITIONS WE HAD LISTED. >> RIGHT AND I'M NOT SURE I CAN TELL YOU EXACTLY WHAT I WANT TO SEE IN A GRAPH BUT I AM-- >> I THINK WHAT HE'S DOING IS SAYING THAT CANCER PAIN IS GOING TO BE ACUTE OR CONSEQUENCE OF NEUROTOXICITY, OF THE AGENTS WHICH IS GOING TO BE DIFFERENT FROM OSTEOARTHRITIS AND LOWER BACK PAIN WHICH IS GOING TO END UP BEING CHRONIC. >> YOU CAN SEE ALREADY THE WAY THE MONEY IS BEING SPENT IS DIFFERENT, POSSIBLY CORRESPONDING TO THAT BUT POSSIBLY NOT. SO THAT'S ONE CUT. >> OKAY, SEAN? >> ALSO WANT TO ADD MY THANKS FOR WHAT HAS TO BE AN INCREDIBLE AMOUNT OF WORK FOR YOU AND YOUR STAFF. >> WHOLE TEAM, EVERY AGENCY HAD PEOPLE CONTRIBUTING TO THIS, FERRETING OUT THE GRANTS, CODING THE GRANTS. THIS WAS A MONUMENTAL TASK AND NIH IS THE MAJOR BIOMEDICAL RESEARCH AGENCY SO THE BULK OF THE MONEY UNDERSTANDABLY IS THERE WHICH DOES NOT IN ANY WAY UNDERCUT THE IMPORTANCE OF THE CONTRIBUTIONS TO THIS RESEARCH PORTFOLIO THAT THE OTHER AGENCIES ARE MAKING. >> ALL THE STAFF IS GETTING A RAISE THEN. >> WELL, WE WORK FOR THE FEDERAL GOVERNMENT AND WE HAVEN'T HAD A RAISE IN SEVERAL YEARS. >> THAT'S JUST--THAT'S WRONG. >> BUT THANKS FOR THE OFFER. THE FIRST THING THAT COMES TO MIND AND I KNOW THAT MICHAEL AND RON ARE GOING TO TALK ABOUT THE BIOBEHAVIORIAL--THE MECHANISMS BUT WHAT STRIKES ME IS WHEN I LOOK AT LOW BACK PAIN AND GUTMACHER TO OSTEOARTHRITIS, THE NUMBER ONE IS PHARMACOLOGIC MECHANISMS IN TREATMENT AND I THINK THERE WOULD BE VALUE IN TRYING TO GET THAT BROKEN DOWN. THE FIRST ONE WAS LIKE FEAT% OR SO, AND THE LOW BACK PAIN WAS 26%, LARGE, LARGE, LARGE, AMOUNTS OF MONEY BEING SPENT IN THAT BUCKET ON TWO OF THE THREE TOP CATEGORIES. AND WHEN I LOOK AT NONPHARMACOLOGIC MECHANISMS, IT'S CLEARLY VERY BROAD. A MUCH MORE TECHNICAL TERM, I AGREE. >> BUT SEAN IS BRINGING TO LIGHT EXACTLY WHEY WAS TRYING TO GET AT. I NOTICED IT AS WELL. >> SO YOU COULD IMAGINE THAT THE TWO--IS THIS WHAT YOU'RE THINKING THOSE TWO PAIN CONDITIONS, PUT IN THE RESEARCH ON NONPHARMACOLOGICCAL INTERVENTION AND THEY THEIR COULD BE DUPLICATION AND WERE THEY TO BE ADDRESSED IN AGGREGATE OR ONE COULD INFORM THE OTHER, AND IF YOU WERE GOING TO HAVE A MEETING, YOU WOULD WANT TO HAVE A MEETING ON NONPHARMACOLOGICAL INTERVENTION THAT WOULD BRING TOGETHER BOTH THESTIO ARTHRITIS AND THE PACK BANE PEOPLE. >> I GOT IT. >> GOOD, THANKS. >> THAT'S NOT SOMETHING THAT OCCURRED TO US WHICH IS REALLY GREAT THAT THERE'S A WHOLE COMMITTEE DEALING WITH THIS. OTHER INITIAL THOUGHTS AND COMMENTS SO SHOULD WE GO TO RON AND MIKE'S PRESENTATION. HYDE LIKE TO MAKE A COMMENT. >> NO, I DON'T MEAN TO RUSH ANYBODY. >> THE COMMENT THEY WOULD MAKE IS THAT THE OBVIOUS DIFFERENCES IN„i THESE THREE CONDITIONS BETWEEN BASIC TRANSLATIONAL AND CLINICAL RESEARCH, CLINICAL RESEARCH IS THE MAJOR PART OF RESEARCH THAT SIMPLY PROJECT IN DOLLARS. BUT I THINK THAT THE OVEREMPSCIZZ, UNDEREMPHASIS ON THE BASIC SCIENCE BECAUSE THE TRANSLATIONAL RESEARCH AS IT WAS DEFINED, I ASSUME THAT THE PEOPLE WHO COATED THIS, COATED THEM BASED ON THE DEFINITION AND THE DEFINITION OF TRANSLATIONAL RESEARCH IS THE ONE THAT SAID, IS THE PROCESS OF DEVELOPING IDEAS, INSIDE--INSIGHTS AND DISCOVERIES AND INQUIRY OF THE TREATMENT OF PREVENTION AND DISEASE. SO CLEARLY THERE'S A BASIC RESEARCH COMPOPEINENT TRANSLATIONAL RESEARCH. SO THESE NUMBERS ON BASIC RESEARCH REALLY UNDERESTIMATE THE AMOUNT OF RESEARCH THAT IS RELATED TO THE BASIC CATEGORIES WHICH STILL, IS STILL A SURPRISINGLY LOW, I WAS SURPRISED TO SEE THE PERCENTAGE WHERE IT'S SO HIGH FOR THE CLINICAL RESEARCH AND RELATIVELY MUCH LOWER FOR THE BASIC SCIENCE AND THAT GOES FOR THESE THREE ITEMS. WONDERING WHETHER THIS WOULD--WENT THROUGH OTHER CONDITIONS. SO FOR OSTEOARTHRITIS, YOU HAVE 68% OF THE DOLLARS IN CLINICAL STUDIES, CANCER IS 79% AND IT'S A LOW BACK AND 64%. SO I JUST WANT TO POINT THAT OUT, IF YOU NOTICE THAT. >> AS WE PULL THESE UP, THEY MAY SHIFT MORE TOWARDS BASIC BUT KEEP IN MIND THAT A SIGNIFICANT NUMBER OF GRANTS IN THE PORTFOLIO WEREN'T ATTACHED TO A SPECIFIC PAIN CONDITION, PARTLY BECAUSE THEY WERE BASIC RESEARCH AND WEREN'T FOCUSED ON ONE AND SO, THE BASIC IS UPAROUND 35% IN TOTAL BUT IT'S NOT GOING ALL SHOW UP WHEN WE TARGET THE SPECIFIC PAIN CONDITIONS. OTHER COMMENTS? >> THIS IS MORE PRAISE. I'M HAPPY WITH THE NOMENCLATURE, THE WAY YOU CUT THINGS. I'M NOT SURE I COULD HAND TELEIF I HAD ANOTHER ONE. >> OKAY, THANKS SO RON AND MIKE? >> OF HOW WE DID THIS, THEN I'LL GIVE YOU THE DATA. >> SO DON'T LOOK AT ME. >> SO, THANK YOU. SO AS YOU HEARD, OUR PLAN IS TO BEGIN WITH SPEAKING ABOUT THE PROCESS AND MOVING ON TO THE DATA AND THE RESUTS AND THE PROCESS ACTUALLY IS PRETTY STRAIGHT FORWARD, WE BEGAN WITH 415 GRANTS FROM THE EXCEL SPREADSHEET AND OF THOSE WE COULD EVALUATE AND ASSIGN TO A PARTICULAR TOPIC, 85% OR 351 GRANTS. THOSE 15% THAT WE COULD NOT ASSIGN TO A TOPIC, EITHER DIDN'T HAVE AN ACOUCH ANNIEING ABSTRACT SINCE WE WERE PRETTY EARLY ON IN THE DEVELOPMENT OF THE EXCEL SPREADSHEET OR BECAUSE THE CONTENT OF THE GRANT ITS WAS PURELY ADMINISTRATIVE AND NONSCIENTIFIC SUCH AS WITH AN ADMINISTRATIVE CORE OR WITH A TRAINING GRANT OR INFREQUENTLY THE CONTENT OF THE GRANT WAS REALLY A HOMONYM OR UNRELATED TO THE MISSION OF PAIN AND THOSE SUSCEPTION, SO OUR CHARGE WAS TO SUBDIVIDE, TO CATEGORIZE TO A POINT OR ASSIGN TO A PARTICULAR TOPIC THE GRANTS AND CATEGORY NUMBER ONE AND TO DO THAT, WE ADOPTED THE SOCIETY FOR NEUROSCIENCE POST POSTER SESSION TOPICS USED @ AN NULL MEETING AND 18 OF THEM ARE SHOWN ON THIS SLIDE. TWO OF THEM WERE NOT ADOPTED BECAUSE THEY OVERLAP WITH THE SECONDARY CODE DEALING WITH ANIMAL AND HUMAN MODELS OF PAIN AND THOSE SUSCEPTION. AND I WOULD SAY IN GENERAL, RON AND I WERE SATISFIED USING THIS TOPIC LIST. WE THINK IT COULD BE IMPROVED BUT THERE WAS A BIT OF A TIME PRESSURE AND SO I THINK FOR THE PURPOSES EVEN IN RETROSPECT, I THINK THIS IS ADEQUATE. IF ONE WERE TO TAKE THIS FURTHER, AND USE IT FURTHER, I THINK THAT WE WOULD WANT TO REFINE IT. SO THIS IS THE LIST, OUR FIRST TASK WAS TO ASK THE QUESTION, HOW WELL DID RON AND I AGREE AS THE EVALUATOR FOR THE INDIVIDUAL GRANTS SO WHAT WE DID WAS TAKE 25 OF THE IDENTICAL GRANTS, REVIEW THEM INDEPENDENT OF ONE ANOTHER AND THEN CAME BACK AND COMPARED OUR SCORES AND WE AGREED IN ADVANCE THAT WE WERE SHOOTING FOR AN AGREEMENT OF CORRESPONDENCE OF 75-80% AND IF WE ACHIEVED IT, WE WOULD GO OUT AND DO THE REST OF THE 300 + GRANTS, IF NOT WE WOULD ANOTHER 25 UNTIL WE REACHED AGREEMENT AND IN FACT WE HIT IT ON THE FIRST SHOT. SO AFTER THE FIRST 25 WE WERE READY TO TAKE THE LARGER BULK OF THE LIST. WE ALSO AGREED THAT WE WANTED TO ASSIGN PER GRANT IF WE COULD, A SINGLE TOPIC, BUT SOMETIMES THIS HAS GOT TO BE VERY DIFFICULT AND RATHER THAN--WE SAID OKAY, LET'S USE THEN A MAXIMUM OF TWO TOPICS PURPOSE GRANT BUT WE DIDN'T WANT TO GET INTO THREE, FIVE ARE, OR 10. SO ONE TOPIC PER GRANT OR AT THE MOST, TWO. SO I TOOK THE FIRST 175 FROM THAT LIST OF 351, RON TOOK THE BOTTOM HALF WE READ IT BY TITLE, ABSTRACT, KEY WORDS, ANY OTHER INFORMATION WE CAN GET, SOMETIME WHAT'S WE WENT TO THE LITERATURE, AND WE DID THIS OVERA COURSE OF 10 DAYS OR SO. AND THEN WE CAME TOGETHER AGAIN. WE COLLAPSED OUR DATA AND THE DATA RON WILL DESCRIBE IF A FEW SECONDS, BUT I JUST WANT TO MENTION THAT RON'S DATA AND MY DATA ARE REALLY IN REMARKABLE AGREEMENT EVEN THOUGH WE WERE DEALING WITH TWO DIFFERENT LISTS WITHIN THAT 351. WHAT I MEAN BY THAT IS THAT WE AGREED IN NINE OF THE 10 MOST POPULATED TOPICS. OKAY IN AND THE FIRST FIVE THAT WE RANKED BASED ON THE NUMBERS WITHIN THE INDIVIDUAL TOPICS WERE RANKED ABSOLUTELY IDENTICALLY SO WE THINK THAT WITHIN THE CONSTRAINTS OF WHAT I MENTIONED ABOUT THE CHOICE OF TOPICS, ET CETERA THAT OUR DATA IS RELIABLE AND WORTHY OF PAYING ATTENTION TO IT, SO, NOW, RON, YOU'RE UP. >> THE DATA IS THE NEXT SLIDE. I THINK, THERE WE ARE. OKAY. SO THE TKPWRAPTS ARE RANKED HERE IN TERMS OF THE NUMBER OF GRANTS AND THE PERCENT OF THE TOTAL AND YOU CAN SEE THAT THIS CLEARLY IS MOST OF THE GRANTS, A GOOD PERCENTAGE NOT MOST, 24% OF THE TKPWRAPTS FARM COLLEGE AND PHYSIOLOGY CATEGORY. SO BUT WE WE DID INITIALLY IS WE DIVIDED INTO THREE GROUPS. THE COLORS ARE REPRESENTED THIS GROUP HERE WHICH ARE THOSE THEMES THAT WERE 20 OR MORE GRANTS AND THEN THE NEXT GROUP ARE THOSE THAT WERE BETWEEN NINE AND 19 THAT'S IN THE LIGHT BLUE AND THEN THIS GROUP HERE IS NINE TO 11. AND I THINK WHAT YOU CAN SEE IS THAT IF YOU LOOK AT THE FIVE HIGHEST CATEGORIES, THEY REPRESENT, I TOLD YOU MOST RECEPTORS OPIOID, 12% VISCERAL PAIN, 12% TRANSREDUCTION, 8 PERCENT REDUCTION, 6 PERCENT PROCESSING. SO CAN YOU SEE WHERE THE EMPHASIS WAS IN THESE GRANTS. NOW WE CAN ALSO COLLAPSE THESE THEMES INTO THOSE RELATED TO PERIPHERAL MECHANISMS AND THOSE RELATED TO CENTRAL MECHANISMS. IF WE DO THAT, WHAT WE FIND IS THAT 39% OF THE GRANTS ARE RELATED TO PERIPHERAL MECHANISMS, YOU CAN USE THIS CATEGORY HERE WITH NO SUSCEPTIBLES, THIS CATEGORY OF SENSORY TRANSDUCTION, THOUGH THEY WERE SENSORY TRANSDUCTION GRANTS, PERIPHERALEC INANISMS THAT WERE NOT DIRECTLY RELATED TO THE TEAM, AND THERE'S ALSO A CATEGORY OF WHERE IS IT,--LET ME SEE WHAT I HAVE HERE. THERE'S ALSO THE ONE ON NO SUSCEPT EPTERSOT MOLECULAR, AND THERE'S ALSO A CATEGORY OF--YEAH, SO PERIPHERAL, TRANSDUCTION PERIPHERAL, PLASTICITY MECHANISMS. >> DID YOU ENCRUDE VISCERAL PAIN IN THAT PERIPHERY. >> NO WE DID NOT CONSIDER VISCERAL PAIN IN THATTER 55RY, THAT WAS KEPT OUT, AND IF YOU ADD ALL THOSE UP, THEY REPRESENT 39% OF THE GRANTS. IF YOU COMPARE THAT TO THE--FOR THOSE THAT WERE ON CENTRAL MECHANISMS, HERE, HERE WE INCLUDE THE CATEGORIES OF SENSORY TRANSDUCTION, CENTRAL MECHANISM, CATEGORY OF RANGE IMAGES, DESCENDING MODULATION, THE CATEGORIES OF SPINAL CORD PROCESSING AND THOSE ARE THE CATEGORIES AND THAT TOTAL COMES OUT TO 16%. AND SO WHAT YOU CAN SEE IS DOING THIS ANALYSIS, THERE'S A TREMENDOUS EMPHASIZE IN THE PRESENT SPIRIT THAT'S RELATE--SUPPORT THAT'S RELATED TO MECHANISMS. IF YOU LOOK HERE THERE'S VERY FEW GRANTS THAT HAD VERY MUCH TO DO WITH CENTRAL PAIN OR AFFECTIVE OR COGNITIVE PAIN PROCESSING. AND I THINK THAT OUR CONCLUSIONS ARE ONE THAT I THINK WHAT WE COULD DO IS CLEARLY COMBINE SOME OF THESE CATEGORIES AND IT DOES--IT WOULDN'T CHANGE THIS ANALYSIS, BUT I THINK IT MIGHT BE EASIER TO GO FORWARD FUTURE ANALYSIS TO THIS BY REDUCING DOWN THE NUMBER OF CATEGORIES. AND BECAUSE THERE ARE A NUMBER HERE THAT ARE SOMEWHAT OVERLAPPING, AND I THINK IT WOULD BE WORTH WHILE TO REDUCE THE NUMBER OF CATEGORIES. SO THIS IS WHAT WE HAVE AND I THINK--I THINK IT WAS WORTH WHILE TO DO THIS BECAUSE WE WERE ABLE TO SEE WHERE--WHERE THE RESEARCH WAS ONGOING RESEARCH WAS AND ALSO THE RATHER STRONG EMPHASIS TODAY ON PERRIFFEERAL NECKANISMS OF PAIN ON THIS CATEGORY. SO THAT'S PRETTY MUCH WHAT WE HAVE, ANYBODY LIKE TO TAKE QUESTIONS AND HAVE DISCUSSION ABOUT PEOPLE HAVING IDEAS ON HOW WE MIGHT WANT TO PROCEED WITH THIS KIND OF ACINAL SIS. WITHIN THIS CATEGORY AS OPPOSE TO THE OTHER--THE OTHER CODE. SEAN WHAT YOU DO HAVE? >> YEAH I'M SURE WE ALL WANT TO SEND OUR THANKS OUT TO THE TWOF YOU, WE APPRECIATE THE LARGE AMOUNT OF WORK YOU PUT INTO IT. MIKE YOU ALLUDED WHEN YOU LOOKED OVER THE GRANTS THAT THERE WERE SOME GRANTS IF I UNDERSTAND THIS CORRECTLY THAT YOU DIDN'T FEEL WERE PAIN GRANTS THAT--AND SO I GUESS MY QUESTION TO YOU IS AS AS AN EXPERT RATERS, IT MAY GIVE US A SENSE OF HOW ACCURATE IS THE OVERALL BATCH RELATED TO PAIN WHAT PERCENTAGE DO YOU THINK REALLY ARE NOT PAIN GRANTS. >> SO COULD I JUST--THEY WERE WORKING WITH THE RCDC FRAME, RIGHT? NOT WITH OTHER FRAMEWORK? SO IT TURNS OUT MART OF THE LEGISLATION--PART OF THE LEGISLATION FOR REAUTHORIZING NIH REQUIRED THAT THERE BE A COMPUTER BASED WAY TO ASSESS FUNDING OF PARTICULAR AREAS AND THERE ARE A HUNDRED AND--HOW MANY TOPICS, PAUL? 200-SOME-ODD THAT GET LISTED IN THE DISEASE CATEGORY. NOW, EVERYBODY AT NIH RECOGNIZES THAT THE CODING BY THIS COMPUTER ALLEGOR ALEGORITHMS IS REPRODUCIBLE BUT NOT A HUNDRED% ACCURATE. AND SO, FOR SOME OF THE ANALYSIS--BUT WE ARE REQUIRED TO TO USE THE RCDC NUMBERS, WE ARE NOT PERMITTED. IT IS NOT--IT IS FORBIDDEN FOR US TO USE OTHER KINDS OF CODING FOR ANY SORT OF PUBLIC PRESENTATION. BUT WHEN WE LOOKED--WHEN WE DID OUR ANALYSIS, WE ACTUALLY GOT RID--WE DID NOT COUNT A NUMBER OF GRANTS THAT WERE IN THE RCDC CODING AND WE RECOGNIZE THAT THERE WERE GRANTS THAT HAD NOT BEEN CODED BY RCDC THAT WERE PAIN RELEVANT. AND THE TOTAL DIFFERENCE, GRANTS--HELP ME OUT HERE LINDA. >> YEE, SO--YEAH, SO THE CODERS TOOK OUT EXTRA GRANTS THAT THEY CONSIDERED THAT RCDC HAD THAT WERE NOT PAIN RELATED. SO YOU WON'T SEE THOSE IN THE SUBCATEGORIES BECAUSE THEY WERE TOLD NOT TO CODE THEM SO THEY'RE NOT GOING TO SHOW UP IN THE TEAR ONE AND TIER TWO CHECK LIST CATEGORIES. THEY ALSO FOUND 48 GRANTS THEY CONSIDERED THAT SHOULD HAVE GONE IN AND DID NOT GO IN. SO IT COMES OUT, YOU KNOW KIND OF A BALANCE IS WHAT'S IN THERE THAT SHOULDN'T BE AND WHAT'S IN THERE--WHAT'S NOT IN THERE THAT SHOULD BE. >> IN FACT, WE'RE TALKING ABOUT A HANDFUL OF GRANTS, MAYBE ONE-TWO% OF THE ENTIRE POPULATION. SO IT'S REALLY WITHIN THE LEVEL OF NOISE, CERTAINLY WITHIN THE WIGGLE ROOM OF OUR DATA ANALYSIS. >> THAT'S HELPFUL TO KNOW. I WAS ALSO TRYING TO RECONCILE AN OBSERVATION THAT I THINK THE NUMBER I SAW WAS 386 MILLION IN PAIN GRANTS. IS THAT RIGHT AND I REMEMBER WHEN WE HAD THE REPORT TO THOSE OF US ON THE IOM COMMITTEE, THE NUMBER WAS 331, 332. >> THIS IS 2011. >> AND I WAS TRYING TO GET A FEEL FOR: IS IT THAT THERE HAS BEEN THAT BIG A CHANGE IN PAIN FUNDING? THAT'S A PRETTY BIG STEP FOR CHANGE. OR IS IT THE WAY THAT THE GRANTS ARE CATEGORIZED, THAT WAS IN PART BEHIND SOME OF THIS QUESTIONING. >> YOU WOULD HAVE HAD THE IOM NUMBER WOULD HAVE BEEN AN RCDC NUMBER, IT WOULD HAVE BEEN FROM 2009 AND THE DATA HERE FROM THE 2011 HERE DATA. AND THE RCDC FOOT PRINT DOES GET TWEAKED ON A PRETTY REGULAR BASIS EVERY COUPLE OF YEARS SO THERE MAY HAVE BEEN SOME ADJUSTMENT. SO I THINK, IT'S THINK IT'S PROBABLY NOT--I MEAN, WORRYING ABOUT THE SPECIFIC DOLLARS IS LESS IMPORTANT ALTHOUGH THE DOLLARS ARE ALWAYS IMPORTANT THAN THIS KIND OF DISTRIBUTION CATEGORIZATION. >> THERE'S ONE THING THAT I THINK--ONE PIECE OF INFORMATION THAT WOULD BE VERY HELPFUL TO REALLY INTERPRET THIS IMBALANCE BETWEEN THE SEBTERAL PERRIFFERY, AND THAT IS THE DENOMINATOR, HOW MANY GRANTS WERE SUBMIT THE DURING ANY PERIOD OF TIME OR SICKLE THAT WE'RE--CYCLE THAT WE'RE DRIVEN BY MECH NICHES AND I MY SUSPICION IS THAT IT WAS VERY UNBALANCED IN FAVOR OF PERIPHERY AND THAT WHAT YOU'RE LOOKING AT HERE IS A REFLECTION OF WHAT'S COMING IN AS MUCH AS ANYTHING ELSE. >> , YEAH THE LARGE PROPORTION OF THESE GRANTS THAT COME IN ARE UNSOLICITED. NOT ALL BUT A LARGE PERCENTAGE. >> [INDISCERNIBLE] >> THERE'S NO REASON TO THINK THERE'S ANY PARTICULAR BIAS IN REVIEW OR INSTITUTE FUNDING. BUT WE HAVEN'T LOOKED AT THAT, SO THERE COULD BE AND WE JUST DON'T KNOW. >> I WILL SAY, I DON'T KNOW HOW RON FEELS ABOUT IT BUT I WAS VERY IMPRESSED WITH THE QUALITY OF THE SCIENCE OR THE ABSTRACTS THAT I READ. SO I WOULD SAY THAT IT WOULD BE A TOUGH CALL TO COME UP WITH EXCELLENCE SCIENCE THAT MATCHED AND INSTITUTED ALL THE WAY INTO THE CENTRAL DIRECTION BUT HOPEFULLY THAT WILL BE A TREND BECAUSE IT'S I THINK IT'S AN IMPORTANT TREND. >> OKAY, OTHER COMMENTS? SO IT SEEMS FROM THE REALLY A GOOD ADDITIONAL INFORMATION THAT WAS OBTAINED FROM TAKING THIS 18% AND BREAKING IT DOWN THAT THAT WOULD BE OF BENEFIT IN SOME OF THE OTHER CATEGORIES WHERE A LARGE PROPORTION OF THE DOLLARS SIT. IS THIS--IS THAT IMPRESS THAT YOU ALL WOULD TAKE AWAY? >> SO YOU HAVE TO USE YOUR-- >> YEAH, IF WE GO BACK TO THE ORIGINAL SLIDES WHAT WE SEE IS, IF YOU GO--WHERE IS IT? AND WRITE AND SHOWS THE CATEGORIES. IF YOU TAKE THE FIRST FIVE CATEGORIES, THIS CATEGORY THAT WE JUST WENT THROUGH, THE NONFORM COO KHROPBLGICAL MECHANISMS CATEGORY, THE PHARMACOLOGICAL MECHANISMS CATEGORY, BIOSOCIAL MECHANISM AND PAIN OUTCOMES ASSESSMENT, YOU ARE DEALING WITH 39-51% OF THE GRANTS SO THE FIRST FIVE CATEGORIES ARE 51% OF THE GRANT AND I THINK IT WOULD BE WORTH WHILE TO DO IT FOR THE--FOR THE SUBDIVISION OF EACH OF THE OTHER FOUR THAT ARE LISTED TO SEE WHETHER WE CAN GENERATE WHAT WE MIGHT CALL GAPS OR CALL MAYBE UNDEREMPHASIS, MAYBE A BETTER WORD IS UNDEREMPHASIS. >> OPPORTUNITY FOR ADDITIONAL MONEY. >> BUT WE ALWAYS DEPENNED ON IT. >> YES, CARMEN. >> SO I DON'T KNOW IF WE'RE GOING TO GET TO THIS, BUT IT LOOKS LIKE FROM MY ANALYSIS THAT WE SORT OF ALSO UNDERINVESTED AS IT RELATES TO WOMEN AND MINORITY HELP, ARE THESE THINGS ON THE TABLE SO AS THIS IS--YOU KNOW YOU TOOK CARE OF THIS IN SCENE ONE. HAVE WE ACTUALLY LOOKED ACROSS THE SPECTRUM THAT RON AND MICHAEL PUT TOGETHER TO LOOK AT WHETHER SOME OF THIS HAS LOOKED ACROSS THE LIFE SPAN SO FROM THE PEDIATRIC POPULATION TO THE ELDERLY POPULATION TO THE LIFE CARE SOME OF THEM DON'T LOOK AT IT NICELY AND WE LOOK AT IT IN THE CONTEXT OF UNIQUE POPULATIONS AS WELL AS AREAS THAT WE THINK ARE PARTICULARLY IMPORTANT. ARE YOU FOLLOWING ME IN. >> [INDISCERNIBLE]. >> SO YOU BRING UP A VERY GOOD POINT, TRIP BECAUSE WE TALK ABOUT VETERANS HERE AND I WAS GOING TO SAVE THIS COMMENT HERE BUT ARE WE TALKING ABOUT VETERANS OR ACTIVE DUTY MILITARY. >> SO I THINK FROM MY PERSPECTIVE AND I'M JUST A MILITARY KID. THERE'S A DIFFERENCE. >> SO CARMEN SO JUST SO I UNDERSTAND, SO UNDERNEATH IT WE HAVE A CHECK BOX FOR GRANTS THAT WERE DEVOTED, WE'RE TARGETING UNIQUE POPULATIONS SO WHAT YOU WOULD LIKE TO SEE FROM THAT GROUP OF GRANTS IS HOW THEY BREAK DOWN ACCORDING TO THE DEFINITIONS. THAT'S EASY„i FOR US TO PULL OFF. >> YES. >> YEAH,. >> SO I GUESS WHAT I'M SAYING IS, WE'VE DONE THIS, WE KNOW THAT--SO I MEAN I'M JUST TALKING ABOUT THE DATA, I MEAN OVER 50% OF THE POPULATION ARE WOMEN. >> AND THIS NUMBER DOESN'T REFLECT THAT AS FAR AS WHAT WE'RE SUPPORTING. >> WE THAN WE'VE GOT TO INCREASE AGE AND DIVERSIFYING SOCIETY. THIS NUMBER DIDN'T REFLECT THIS. >> WE KNOW THAT 1 PERCENT OF THE POPULATION IS SERVING IN PLACES FAR AWAY. SO THE NUMBER DOESN'T FIT BUT WE ALSO KNOW THAT'S A HUGE PRIORITY FOR US. I'M CONFUSED ABOUT THE CONTEXT OF VETERANS, VERSES ACTIVE DUTY MILITARY AND SO, I THINK THAT NEEDS TO BE CLARIFIED. >> I WOULD AGREE WITH THAT. >> WE'RE LOOKING AT THE POPULATION, YOU KNOW LIKE YOU SAID, LESS MAN 1 PERCENT OF FOLKS ARE IN UNIFORM ANYMORE AND THAT'S YOUR ACTIVE DUTY POPULATION BUT WE ALSO CALL THE DUTY THAT'S MOBILIZED IN THAT POPULATION. IT'S ACTIVE DUTY AND IF YOU LOOK AT THE VETERAN'S POPULATION AND AS YOU MENTION, WE'VE GOT ABOUT 50% OF POPULATION IS FEMALE. SO WE'RE SHIFTING OUR POPULATION BECAUSE IT'S BEEN UNDERREPRESENTED BUT IN MANY CASES THERE'S A LOT OF OPPORTUNITY I THINK TO LET A TASK FORCE LOOK AT ACTIVITY, NUTRITION AND SLEEP. THOSE COMPONENTS WHERE WE'RE SPENDING 70 CENTS OF EVERY DOLLAR ON DISEASE AND CONDITIONS RELATED TO THOSE AREAS. AND I ALSO HAD GUYS LOOK AT ACTIVE DUTY COMPOPE SPENT THE OPPORTUNITY WE HAD BECAUSE WE HAD THE MOST OPPORTUNITY TO INTERFACE WITH THOSE FEMALES MORE THAN ANYONE ELSE AND AND THEY COME TO THE DOCTOR MORE OFTEN DURING THAT PERIOD OF TIME WHEN THEY'RE EXPECTING A CHILD, UP TO THE TIME OF DELIVERY AND POSTPARTUM SO THERE'S OPPORTUNITY TO AFFECT THEIR BEHAVIOR DURING THAT WINDOW. AND THERE'S THINGS I CAN PRESENT THE NEXT TIME ON THAT. >> BUT THIS ALSO GOES TO THE FACT THAT YOU KNOW, PEOPLE WHO ARE ACTIVE DUTY IN THE MILITARY DON'T USUALLY GO OFF BY THEMSELVES. THEY HAVE FAMILY MEMBERS AND SO OFTEN WOMEN ARE PART OF THAT CONVERSATION. SO I THINK THAT WE NEED TO REALLY TRY TO EXPLORE THAT. >> MOST OF THE HEALTHCARE DECISIONS FOR ACTIVE DUTY ACROSS THE FORCE, AS YOU KNOW. >> LINDA, THESE BUCKETS WE HAVE DISTRIBUTE THESE TOPICS TO AN INDIVIDUAL, WELL, TOPIC, IS THERE ANY QUALITATIVE SENSE BECAUSE I DON'T THINK THERE'S GOING TO BE QUANTITATIVE SENSE OF WHAT DEGREE IS THERE AN INTEGRATIVE APPROACH. WHAT PERCENTAGE OF THESE GRANTS COMBINE ON MAKING THE GENOMICS WITH PERIPHERAL SUSEPTIBLES WITH THERE'S A GREATER SYSTEMS IN WORKING TOGETHER AND WE DISKERITIZED THEM HERE EFFECTIVELY. >> SO ONE THING WE DID THAT WE LOOK AT THE CODERS TO BREAK THEM DOWN BY PERCENTAGE. SO WE COULD LOOK AT FOR EXAMPLE, THE SPECIFIC AREAS THAT YOU WANTED TO TARGET, UNLESS HOW MANY GENOMICS INCLUDED BASIC TKPWHRAOEL MECHANISMS AND THEY WOULD SHOW UP IN BOTH IF THEY HAD BOTH AT 25, 50, 75 OR A HUNDRED PERCENT SO WE COULD PICK OUT PAIRS FOR EXAMPLE. IT'S A LITTLE BIT COMPLEX BUT IT'S SOME EXTENT, THE MATRIX IF YOU DID THEM ALL ACROSS COMBINATIONS WOULD BE IMPOSSIBLE TO SORT OUT BUT IF THERE ARE SPECIFIC AREAS TO SEE WHERE THERE'S INTEGRATION. YOU CAN SEE WHERE WE TARGET THOSE AND PULL THAT OUT OF THE DATA SET THE WAY IT'S SET UP. WE HAVEN'T FOCUSED ON DATE BUT WE CAN. >> I'D BE VERY QUALITATIVE, SENSE OF ARE WE MOVING INTO MORE OF AN INTEGRATIVE APPROACH OR IS IT STILL-- >> HAD IS ONE CUT, ONE TIME POINT. SO YOU'RE NOT GOING TO GET, MOVEMENT CHANGE--IF WE TRY TO DO THIS EVERY YEAR, THE STAFF WOULD QUIT. MAYBE EVERY FIVE YEARS OR SOMETHING. >> SO DO HAVE YOU ANY PARTICULAR CROSS CUTTING GENOMICS PLUS WHAT? OR INTEGRATIVE--WHAT WOULD YOU LIKE TO SEE IN TERMS OF THIS? YOU DON'T HAVE TO GIVE ME AN ANSWER NOW BUT SO SO WORN OF THE THINGS THAT BECAME CLEAR TO US AS WE LOOK AT THIS IS THAT WE ACTUALLY NEED TO NOT JUST PUT THEM IN THE BUCKET BUT WE NEED TO ANALYZE, TO ANALYZE THE [INDISCERNIBLE] AND WHAT YOU'VE DONE HERE IS A GREAT START, POINT OFF A PLACE WHERE THERE'S IMBALANCE, BUT, THERE ARE OPPORTUNITIES TO THAT MAYBE HAVEN'T BEEN EXPLORED AND WHAT WE NEED TO DO NEXT IS TO ACTUALLY UNDERTAKE AN ANALYSIS AND PRODUCE A REPORT THAT ACTUALLY TALKS ABOUT THE DEFINITE TOPICS, WHEN'S IN THE TOPIC AND WHAT'S REFLECTED IN THE GRANT ASK AND WHAT'S REFLECTED IN THE GRANT PORTFOLIO AND WHERE ARE THE OPPORTUNITIES THAT MAY OR MAY NOT BE FULLY ADDRESSED AND THAT WOULD BE THE NEXT STEP TO DO HERE. AND I THINK THE QUESTION, WE COULD CUT THE DATA SEVERAL WAYS SO THE NONPHARMACOLOGICAL TREATMENTS WITH BACK PAIN AND AFTIO ARTHRITIS WOULD BE VERY GOOD TO POINT OUT AS A PLACE WHERE THERE IS SYNERGY. MY QUESTION IS WHETHER OR NOT THERE ARE MEMBERS OF THE COORDINATING COMMITTEE WHO WOULD LIKE TO PARTICIPATE AS MICHAEL AND RON DID IN HELPING US AS WE GET TO SOME OF THOSE WITH THIS ANALYSIS, OR WE WANT THE STAFF TO GO DOGMAs IT AND SEND IT OUT FOR YOURm WOULD YOU ALL LIKE TO PARTICIPATE IN THE ANALYSIS OR THE RESPONSE TO ANALYSIS THAT WE'VE DONE. >> SO ONE RECK RECOMMENDATION THAT OUR COLLEAGUES DID WAS TO SIMPLY TAKE THE TOP FIVE AND CUT THE DATA THAT WAY. SO THAT WAS--THE PROBLEM IS WE DON'T HAVE CATEGORIES FOR HOW TO CUT THE DATA,. >> THEY CAME UP WITH IT. >> THEY WENT TO THE SOCIETY FOR SCIENCE, A--BITS TRACT SESSION, IT WASN'T TOTALLILY-- >> RIGHT. >> --THESE THINGS WERE DEVELOPED WITH OTHER THOUGHTS IN MIND. >> SO WE DON'T HAVE EQUIVALENT THEMES FOR THE OTHER CATEGORY. >> FOR THE TOP FIVE. >> WE DON'T HAVE. >> SO WE NEED TO AT LEAST THE OTHER FOUR. >> FOUR OF THE FIVE TOPS. >> SO YOU WOULDN'T TRY TO APPLY THE SAME. >> NO, NO, NO. >> YOU WOULD END UP WITH OTHER NOT-- >> OTHER NOT ATTRIBUTED. >> THAT'S JUST ONE OF SEVERAL APPROACHES ONE COULD TAKE. >> SO ANOTHER APPROACH WAS-- >> I THINK MAYBE HAVE BEEN THREE NOW, SOUNDS LIKE SEAN HAS SLIGHTLY DIFFERENT APPROACH WAS TO ASK COMBINATION, SCHEMEATIC COMBINATION. >> I DON'T WANT TO PUT WORDS IN YOUR MOUTH, CROSS CORALLIZATION. >> YEAH. >> YEAH. >> SO I'M ARGUING THAT AT THE HIGHEST LEVEL, THE COMMITTEE SHOULD DEBATE AMONG THE APPROACHES FOR NOMENCLATURE AS TO WHAT WE WANT TO SEE BECAUSE I'M NOT SURE WE KNOW YET. >> WE CROSS--AND THEN, THE BACK PAIN SOFTIO ARTHRITIS NONPHARMACOLOGIC--[INDISCERNIBLE ]. >> I THINK YOU'RE COMBINING THE CONDITIONS THAT WE NEED TO SUBMIT THE CONDITION FROM THE SECONDARY CODE. >> SO I, GHEE THERE'S THE SECONDARY CODES, THE KINDS OF ANALYSIS YOU DID BUT FOR THE OTHER FOUR THEN THERE'S THE EXTENT TO WHICH THERE ARE HOW MANY GRANTS THAT ARE LOOKING AT PAIN PROCESSING AND THE CONTEXT OF GENOMICS AND THEN THERE'S THE ANALYSIS THAT YOU SUGGESTED WHERE DIFFERENT PAIN CONDITIONS MAY HAVE REAL SIMILARITIES IN THE APPROACHES THAT ARE BEING TAKEN. >> I'M ONLY ARGUING THAT WE DON'T WANT THE STAFF TO QUIT THIS YEAR. [LAUGHTER] >> YOU KNOW, IS IT GOING TO TAKE THAT MUCH. >> WELL, NO IT'S THERAPIST IS ACTUALLY THE FUN PART. >> YEAH. >> YOU COULD ARGUE THIS IS THE FUN PART. >> THIS IS WHAT-- >> THIS IS WHAT YOU BROUGHT US HERE FOR WAS TO SORT OF TRY TO HELP STEER THROUGH THE SCIENTIFIC--TO HELP FIGURE OUT HOW TO THINK THROUGH AND HOW TO CHARACTERIZE THESE THINGS. SO I'M URG ARGUING THAT WHERE'S WHERE OUR DISCUSSION SHOULD BE AT THE MOMENT BEFORE WE START DIFYING OUT WORK. >> [INDISCERNIBLE]. >> ONE IS GAPS AND THE OTHER IS DUPLICATION REDUNDANCY. >> [INDISCERNIBLE]. >> SO I WOULD ARGUE THAT THERE MIGHT BE SYNERGY APPROXIMATE POETIC POTENTIALLY COMPLEMENTARITY BUT WE DON'T KNOW THAT UNTIL WE LOOK AT IT YOU AND THERE COULD BE BENEFIT FROM THE MEETING WHERE THE AFTIO ARTHRITIS GUYS TALK TO THE LOW BACK PAIN GUYS AND THEY THINK OH MY GOD, WE DON'T NEED TO DO TWO CLINICAL TRIALS ON X BECAUSE WHAT-- >> [INDISCERNIBLE]. >> IT SEEMS TO ME THE ENORMOUS AMOUNTS OF THOSE FIVE MANDATES BUT I THINK IT'S NECESSARY. >> JOSIE DO YOU WANT TO SPEAK TO THE. >> SO, I HAVE SEVERAL THOUGHTS ABOUT THIS; ANOTHER CATEGORY WHERE I SEE POTENTIAL FOR GAPS HAS TO DO WITH THE EPIDEMIOLOGY AND OBSERVATIONAL DATA SETS THAT WE HAVE ON PAIN CONDITIONS AND THAT HASN'T BEEN HIGHLIGHTED AND WE HAVE BEEN TAKING THE LEAD TOGETHER WITH NIAMS AND PERHAPS OTHER PEOPLE HERE ARE PART OF THIS PANEL ON RESEARCH STANDARDS OR TERMINOLOGY IN PACK PAIN AND WE ARE ONE OF THE MAIN FUNDERS OF THE NONPHARMACOLOGIC WORK ON BACK PAIN. I THINK CATEGORIZING THIS WILL BE SOMEWHAT HELPFUL BUT I THINK IT'S REALLY IMPORTANT TO DECIDE UPON THE TERMINOLOGIES THAT ONE IS GOING TO USE TO BREAK THIS INTO BOXES, VERY CAREFULLY. BECAUSE THE BOXES MAY RESULT IN LOTS OF OVERLAPS THAT MAY CREATE A SENSE OF REDUNDANCY, DON'T YOU. I GUESS IT'S THAT'S ALL. >> MARTHA AND THEN SEAN. >> SO JUST HAVE A FEW COMMENTS ON IT. THIS IS ABSOLUTELY AMAZING IN TERMS OF TRYING TO WRAP OUR HEADS AROUND THIS IN ALL THE INFORMATION THAT'S LEER, BUT ONE OF THE THINGS I CAUTION IS IF YOU JUST LOOK AT THE TOP FIVE TO KEEP YOU--THE TOP FIVE,%% OF FUNDING THAT YOU MAY LOSE THE GAP IN THOSE THAT'S THE LEAST FUNDED, THAT MAY BE A MAJOR ISSUE AND SOMETHING THAT NEEDS TO BE EVALUATED AND DAMAGED SO I DON'T KNOW HOW TO HANDLE ALL THE INFORMATION AND NOT HAVE THE STAFF LEAVE NEXT WEEK. AND SO THIS IS AN ISSUE ON THAT AND THEN ON THE OTHER PIECE BEYOND JUST THE--WE JUST HAD A WHOLE PRESENTATION ON THE EDUCATIONAL SIDE AND THE WORKFORCE AND THE TRAINING AND THE GAPS THERE AND AREAS THAT WE NEED TO ADDRESS IN THAT AREA AS WELL. >> I WANT TO THROW OUT A CONCRETE PROPOSAL TO IDENTIFY A GAP AND THAT BEING AROUND THIS IDEA OF MULTISYMPTOM CONDITIONS AND THIS BRINGS TOGETHER THE IDEA OF WHAT WALLY ALLUDED TO WITH THE SYNERGY WITH THE OVERLAP AND WHAT YOU ARE MENTIONING WITH THE OSTEOARTHRITIS AND TO BRIEFLY EXPAND ON THAT, WE'RE PART OF THIS MAP GROUP THAT DAN CLAUSE IS RUNNING PELVIC PAIN AND ACTIVE CONDITIONS AND ONE OF THE MESSAGES THAT HAVE COME OUT OF THIS IS THAT WHILE WE'RE FOCUSING ON PELVIC PAIN THAT ONE OF THE BIGGEST PREDICTERS IS THE NUMBER OF BODY SITES THAT ARE CHECKED OFF ON A BODY MAP, THAT PEOPLE ARE COMING IN, THERE'S NO--VERY LITTLE CLASSIC PELVIS PAIN ONLY, IT'S PLUS NECK PAIN, PLUS BACK PAIN AND AT THE SAME TIME THIS OPERA GROUP HAS BEEN ON TND AND MANY OF THESE PATIENTS COME IN WITH MULTIPLE SYMPTOMS, SO WE'RE BEGINNING TO THINK THAT MAYBE IT'S AN ARTIFICIAL CONSTRUCT OF THERE'S JUST PELVIC PAIN OR IRRITABLE BOWEL SYNDROME THAT IT MAY BE LABELED UPON THE PHYSICIAN THAT YOU COME IN TO GET DIAGNOSED FIRST. AND SO, PERHAPS WE COULD LOOK AT THE GRANTS, DATA AND SEE TO WHAT EXTENT ARE WE LOOKING AT THESE TOGETHER AND IF WE'RE FINDING THAT WE ARE IN FACT LOOKING AT THESE CONDITIONS IN ISOLATION, THERE MAY BE AN OPPORTUNITY, A GAP HERE TO TRY TO DO STUDIES THAT LOOKS AT THEM IN AGGREGATE AND FIND THE TOOLS TO USE WITH MANY OF CONDITIONS, MECHANISMS TREMENDOUSLY OVERLAP AND THERE'S AN OPPORTUNITY TO EXPAND OUR SCIENCE. SO >> SO I THINK IT MIGHT BE INTERESTING TO TAKE THE PAIN CONDITIONS LIST AND PUT IN A BIN, THE PAIN CONDITIONS WHICH ARE--BECOME PART OF THIS CHRONIC OVERLAPPING PAIN CONDITION PHENOMENON AND SO JOHN KUZIAK RAN A WORKSHOP COUPLE MONTHS AGO ON CHRONIC OVERLAPPING PAIN CONDITION SPECIALIZATION OF SPECIFIC ENDOTHELIAL THERE IS SOME ATTENTION BEING PAID TO THAT BUT YOU COULD--YOU WOULD PROBABLY ARGUE NOT ENOUGH. SO I THINK THAT'S ENOUGH GOOD WAY TO THINK ABOUT THE WAY OF DISSECTING THE DATA AND ITKEFPTIFYING GAPS. --E DENTIFYING GAPS. >> MAYBE WE SHOULD HEAR FROM JOHN ABOUT THAT WITH THIS CONVERSATION WE'RE HAVING AND-- >> JUNE DO YOU WANT TO COME TO THE TABLE--I HATE TO PUT YOU ON THE SPOT. >> HE'S PREPARED. HE'S LIKE THE MARINES. >> THAT WAS FOR YOU. >> SO THE FIRST OF AUGUST THERE WAS A MEETING OVER CHRONIC OVERLAPPING PAIN CONDITIONS, IT WAS A DAY AND HALF WORKSHOP, CHAIRED BY DAN KLOW AT MICHIGAN AND BETH UNGER AT CDC. THERE WAS REALLY QUITE A BIT OF DISCUSSION ABOUT DIFFERENT CONDITIONS AND THOSE THAT ARE OVERLAPPING AND I'M IN THE PROCESS RIGHT NOW OF PREPARING A REPORT ON THAT. SOME THOSE WITH REGARD TO RECOMMENDATIONS THAT CAME OUT OF THAT MEETING AND I GUESS I CAN MENTION A COUPLE THAT SORT OF CAME TO THE FRONT AND ONE IS SOMETHING THAT SEAN IS GETTING AT IS THAT THERE WAS REALLY A BIG INTEREST IN THAT IN THE COMMUNITY THAT WAS THERE, TO REALLY LEVERAGE THE INFORMATION THAT IS AVAILABLE THROUGH THE MAP PROJECT AS WELL AS THROUGH THE OPERA COOPERATIVE AGREEMENT FROM OTHER INVESTIGATORS WHO ARE--WHO ARE PERHAPS JUST NOW LOOKING AT INDIVIDUAL CONDITIONS BUT WOULD LIKE TO BEGIN TO LOOK AT THE OVERLAPPING CONDITIONS. THERE WAS SOME OTHER--OTHER RECOMMENDATIONS REGARDING DEVELOPMENT OF ANIMAL MODELS OF THESE OVERLAPPING CONDITIONS THAT WE REALLY DON'T HAVE ANY OF THOSE AT THIS POINT. WHAT ELSE CAN I SAY. REALLY ALSO RECOMMENDATIONS FOR BOTH CLINICIANS AS WELL AS BASIC RESEARCHERS TO GET TOGETHER TO WORK IN MULTIDISCIPLINARY TEAMS BUT ALSO TO COME TOGETHER WITH REGARD TO COMMON TERMINOLOGY THAT EVERYBODY UNDERSTANDS AND AGREES TO USE IN DEVELOPING RESEARCH PROJECTS. SO AS I SAID I'M IN THE PROCESS OF WRITING THOSE UP IN A MORE FORMAL WAY AND THOSE WILL BE PRESENTED TO THE PAIN CONSORTIUM EXEC COMMITTEE AS WELL AS THE CHAIRS OF THE WORKSHOP AND THE ENTIRE WORKSHOP. >> I THINK THAT THIS WILL BE A VERY HELPFUL DOCUMENT THAT JOHN'S DEVELOPING. IN A RELATED THEME, THEY HAVE A YEARLYY TWO DAY RESTREET AND AN ISSUE THAT HAS BEEN DISCUSSED A LOT IN--FOR A POTENTIAL COMMON FUND FUND SUGGEST THE ISSUES OF WHAT ARE BEING CALLED CO-MORBIDITYS, AND ONE OTHER AREA OF GAP THAT I THINK IT WOULD BE VALUABLE FOR THIS GROUP TO EXPLORE MAY BE THE ISSUES OF PAIN TOGETHER WITH OTHER CONDITIONS, PLUS DEPRESSION, PAIN PLUS OBESITY, I THINK A LOT OF US ARE RECOGNIZING THAT OUR--WE DON'T WANT OUR ORGANIZATION TO DICTATE CROSS CUTTING AREAS THAT ARE REALLY IMPORTANT AND SO THIS IS AN AREA THAT I THINK ALSO NEEDS THOUGHT. >> OTHER COMMENTS? YES? RON? >> I THINK THERE'S AN OPPORTUNITY HERE WITH THE ANALYSIS THAT'S BEEN ALREADY DONE IS THAT WE CAN LOOK AT SOME OF THESE PAIN CONDITIONS THAT ARE REPRESENTED WITH VERY LOW PERCENTS AND SEE WHETHER THERE'S AN OPPORTUNITY THERE FOR MORE RESEARCH BECAUSE THERE ARE MANY OF THEM THAT ARE LESS THAN ONE% OR ONE% AND MAY BE AN OPPORTUNITY TO INCREASE THAT IN TERMS OF THEIR--THE NEEDS WITHIN THE POPULATION, THE SAME TIME WE ALREADY TALKED ABOUT--TALKING ABOUT OVERLAPPING PAIN CONDITIONS. WELL IF WE LOOK AT MANY OF THESE PAIN CONDITIONS, WE CAN TAKE SOME OF THEM AND SAY THESE ARE THE ONES THAT HAVE OFTEN THEIR OVERLAPPING ACROSS DIFFERENT CONDITIONS. LET'S GROUP THEM TOGETHER AND THEN SUBDIVIDE THEM INTO TERMS OF THE SECONDARY CODES AND SEE HOW THEY FALL OUT WITH NEW CODES AND NEW--IN BREAKING DOWN THE SECONDARY CODES. I THINK THAT WOULD BE AN EFFECTIVE WAY OF MAKING USE OF THE INFORMATION WE ALREADY HAVE AND EXTENDING IT FURTHER. >> SO WE HAVE AS A SECONDARY CODE, PAIN AND OTHER NONPAIN CO-MORBIDITYS WITH THINGS LIKE DEPRESSION, CHRONIC OVERLAPPING PAIN CONDITIONS AND THAT SECOND ONE FOR EXAMPLE, INCLUDES GRANTS THAT ARE ONLY LOOKING AT MULTIPLE PAEUBT CONDITIONS--PAIN CONDITIONS, IT'S SEPARATELY CODED FROM CONDITIONS THAT MIGHT SHARE COMMON MECHANISMS AND SO WHAT I'M HEARING IS THAT IF WE COULD KIND OF LOOK AT THAT DATA QUALITATIVELY AND SEE WHERE THERE MIGHT BE INTEGRATION BETWEEN THOSE AS WELL AS SECONDARY BREAK DOWN FOR THE SECONDARY CODES AND SO WE COULD PROVIDE THAT THE DATA PUT TOGETHER IN THAT WAY AND PERHAPS COULD GET INPUT FROM CERTAIN FOLKS ON THE COMMITTEE WHO ARE REALLY INTERESTED IN THAT PARTICULAR AREA TO LOOK AT IT AND KIND OF BEGIN TO INTERPRET WHERE THE GAPS MIGHT BE OR THE OPPORTUNITIES MIGHT BE IN THAT GROUPING. SO YOU KNOW WE CAN PROVIDE YOU WITH DIFFERENT WAYS TO LOOKA AT IT. >> SO I HEAR A LOT OF INTEREST IN ANALYSIS STRUCTURED IN SEVERAL DIFFERENT WAYS AND THAT THE IDEA OF USING A REPORT ON THE CURRENT PORTFOLIO AS A MECHANISM TO ASSEMBLE THOSE ANALYSIS IN A WAY THAT WOULD ACTUALLY BE INTELIGEIBLE TO THE COMMITTEE AND TO THE LARGER COMMUNITY AS A WHOLE. >> [INDISCERNIBLE]. >> WELL, WE KNOW THERE ARE OPPORTUNITIES BUT YOU'LL JUST REMEMBER WHAT DR. COLLINS SAID, IT'S THE BEGINNING OF WHEN HE CHARGED THIS COMMITTEE. WE ALL HAVE TO BE MINDFUL OF THE FACT THAT WE'LL BE LUCKY IF OUR BUDGET STAYS FLAT WHICH MEANS--WELL YOU KNOW WHAT THAT MEANS, HAVING OPPORTUNITY TO IDENTIFY MEANS THAT INSTITUTES AND OTHER AGENCIES CAN BE ATTENTIVE TO THOSE GAPS AND OPPORTUNITIES AS THEY PLAN FOR FUTURE YEARS AND INITIATIVES. AND I WOULD LOVE TO HAVE NIMHD BE MORE ENGAGED IN THIS. >> YOU TRY TO MAKE MY THUNDER. >> [LAUGHTER] >> BUT I THINK THERE IS SOME REAL OPPORTUNITIES FOR THE OFFICE OF RESEARCH AND WOMEN'S HEALTH. >> DIRECTLY. >> RIGHT, RIGHT. >> AND I THINK ALSO FROM THE NICHD, WE DO NEED TO THINK ABOUT THINGS THROUGHOUT THE SPAN. >> AND WE HAVE A REPRESENTATIVE FROM THE AGING INSTITUTE BACK THERE WHO'S LISTENING VERY CAREFULLY. >> SO YOU KNOW AGAIN I JUST THINK WE NEED TO THINK ACROSS THE LIFE SPAN. IF WE THINK ABOUT IN THE CONTEXT OF CANCER, MORE AND/OR PEOPLE ARE SURVIVING CANCER DIAGNOSIS, THEY ARE GOING TO EPD UP WITH CHRONIC PAIN. THERE ARE PEOPLE THAT HAVE BEEN EXPOSED TO TOXINS WHO END UP WITH CHRONIC PAIN SO WE NEED TO THINK ABOUT THIS. >> THE OTHER THING I THINK THAT IS AGAIN JUST COMPLEMENTS TO RON AND MICHAEL FOR DOING THIS WORK, IS THE OPPORTUNITY FOR PUBLIC PRIVATE PARTNERSHIP SO NIH MAY HAVE FINANCIAL CHALLENGES, I HEAR. >> WELL I THINK ALL DISCRETIONARY FUNDING, THE MILITARY'S ON THE BLOCK FOR THE SEQUESTER AS WELL. NTHAT'S RIGHT. SO THERE MAY BE OPPORTUNITIES IN PUBLIC/PRIVATE PARTNERSHIPS THAT'S WE HAVEN'T DISCUSSED. >> IF WE IDENTIFY THOSE GAPS WE MAY BE ABLE TO LEVERAGE OUR RESOURCES. >> THIS THAT--STANDARD IS AN EXCELLENT SEGWAY SO I THINK THAT WE„i HAVE SOME DIRECTION FROM THIS GROUP THAT WE'RE NOT GOING TO GET A COMPLETE PLAN PLAN TODAY GIVEN WE'VE ALLOCATED OTHER AGENDA ITEMS. WHAT I'D LIKE TO DO IS THAT THE TEAM WILL GATHER, WE'LL LOOK ASTERISKS THE SUGGESTIONS THAT HAVE BEEN MADE AND THEN CIRCULATE THEM TO THE COORDINATING COMMITTEE FOR INPUT AND IN RESPONSE TO THAT CIRCULATING, THE E-MAIL WE ACCEPTED OUT, IF YOU ALL WOULD PROVIDE US WITH ADDITIONAL SUGGESTIONS FOR ANALYSIS THAT YOU THINK WOULD BE GOOD AND WE'LL TRY TO RANK ORDER THEM BECAUSE WE'RE NOT GOING TO BE ABLE TO DO THEM ALL AT–r ONCE. SO I'M GOING TO CAN NOW IS TO ACTUALLY--DO NOW IS ACTUALLY MOVE US IF RON AND MICHAEL COULD--YOU WERE GOING TO DO SOME AGGREGATING OF THOSE DATA OR CHANGE DEFINITIONS, IF YOU COULD DO THAT AND LET US KNOW WHAT YOUR--ALMOST FINAL THOUGHTS ARE ON THAT, THAT WOULD BE GREAT. ONE OF THE OTHER THINGS WE WERE CHARGED TO DO WAS TO LOOK AT POTENTIAL REDUNDANCIES. I THINK IT'S MUCH MORE LIKELY THAN REDUNDANCY THAT WE WILL HAVE COMPLEMENTARITY THAN FEDERAL AGENCIES. AND LINDA HAD PREPARED FOR THE LAST MEETING A PRETTY NICE ANALYSIS OF WHERE THERE WERE OVERLAPS AND SHE CAN GO AHEAD WITH THAT PRESENTATION AND GET YOUR INPUT ON THAT AND ALSO FINISH THIS WITH THE ISSUE OF PUBLIC PRIVATE PARTNERSHIPS WHICH WE WOULD LIKE TO MAKE AN IMPORTANT PART OF THE NEXT MEETING. >> THANK YOU VERY MUCH FOR THE IMPORTANT DISCUSSION, I THINK THE GUIDANCE AND SUGGESTIONS YOU HAVE MADE WILL HELP US TURN THIS ALPHABET SOUP TURN THIS INTO MEANINGFUL SUMMARYS AND ANALYSIS. >> STORY COULD I ASK A THINKING FORWARD TO THE NEXT STEPS FOR THIS ONCE YOU HAVE A GAP ANALYSIS COMPLETED, NOT TO COMPLICATE THINGS FURTHER BUT AS LINDA MENTIONED BEFORE, WE MAY HAVE AREAS WHERE THERE'S A LOT OF SPENDING GOING ON RIGHT NOW. BUT IT'S STILL A KNOWLEDGE GAP WHERE OTHER AREAS WE HAVE VERY LITTLE SPENDING AND IT'S NOT AS BIG OF A KNOWLEDGE GAP. SO TO ME„V% ANALYSIS, WE ALL KNOW THERE'S GOING TO BE A LOT OF GAPS BECAUSE WE KNOW THAT WE KNOW VERY LITTLE. THERE'S NOT A LOT OF EVIDENCE SO THE QUESTION IS ACCIDENT IS TO COMPARE THE ACTUAL SPENDING GAP ANALYSIS TO THE KNOWLEDGE GAP ANALYSIS, TO SEE WHERE WE REALLY NEED ADDITIONAL EFFORTS IN TERMS OF PUTTING FORWARD A STRATEGIC PLAN. SO I THINK WE HAVE AN OPPORTUNITY TO EITHER END UP WITH AN END RESULT OF A REPORT THAT JUST BASICALLY GIVES THE GAP ANALYSIS, AND PEOPLE CAN USE IT THE WAY THEY WANT, OR TO TAKE THAT ONE STEP FURTHER AND COMPARE IT TO WHERE ARE THE MOST PRESSING KNOWLEDGE GAPS AND WHERE DO WE NEED TO STRATEGICALLY INVEST OUR MONEY FIRST BEFORE MOVING FORWARD. >> I THINK IDENTIFYING GAPS WILL BE THE NEXT STEP AND THEN KNOWLEDGE VERSES GAP AND JUST BECAUSE THERE IS A LOT OF MONEY INVESTED IN PERIPHERAL MECHANISMS, DOES THAT MEAN WE SHOULDN'T INVEST ANY MORE IN THAT, I THINK A NUMBER OF US WOULD SAY NO, SO ABSOLUTELY WE SHOULD MOVE FORWARD AND I THINK THAT THIS REPORT CAN BE A LIVING DOCUMENT. >> WE'RE NOT GOING TO DO ALL THE ANALYSIS IN THE NEXT THREE MONTHS AND AS WE DO SOME THERE WILL BE INPUT FROM THE COMMITTEE THAT WE SHOULD MOVE IT FURTHER IN THIS DIRECTION, OR COME SO IT'S GOING TO BE AN ONGOING PROCESS. THANKS CHRIS. >> SO HOPEFULLY THESE NEXT FEW SET OF SLIDES WILL HELP A LITTLE BIT. >> A LOT OF THE QUESTIONS THAT COME UP, ARE RELEVANT TO SOMEWHAT OF A QUALITATIVE LOOK THAT WE TOOK FROM THE INPUT THAT WE GOT FROM THE INAUGURAL MEETING FROM THE DIFFERENT AGENCIES THAT GAVE US A SENSE OF WHERE SOME OF THEIR PRIMARY RESEARCH INTERESTS LIE AND WE TRY TO LOOK AT THOSE WHERE WHERE THERE WERE AREAS SIMATICALLY IN POTENTIAL OVERLAPS IN ANY IN THE DIFFERENT AGENCIES. SO THESE FIRST FEW SLIDES GIVE YOU A SENSE OF WHERE WE FOUND THE PRIMARY AREAS OF OVERLAP. IT'S NOT COMPLETE. >> OR COMPLEMENTARITY. >> OVERLAP IS NOT THE RIGHT WORD. THANK YOU FOR REMINDING ME. IT'S AREAS WHERE THERE'S AREAS OF INTEREST, SYNERGISTIC, COLLABRATORY AND WOULD SERVE AS POTENTIAL OPPORTUNITIES FOR THE AGENCY TO HAVE TO WORK TOGETHER A LITTLE BIT MORE CLOSELY TO SEE WHERE SHARED INTERESTS WERE AND HOW THEY CAPITALIZE ON THAT. SO THEY DON'T NECESSARILY REPRESENT BIG AREAS OF A PORTFOLIO OF THE OVERLAPPING AGENCIES THAT ARE LISTED IN BLUE, BUT AREAS WHERE WE SAW INTERESTS IN MORE THAN ONE OF THE AGENCIES. SO, ONE--THE FIRST ONE I LIST HERE IS MOLECULAR MECHANISMS OF NERVE INJURY INDUCED PAIN. >> AND HERE WE THERE WERE PROJECTS IN THE DEPARTMENT OF DEFENSE AND THE NIH PORTFOLIO THAT HAD THIS SHARED INTEREST. >> CONSEQUENCES OF ACUTE TRAUM AND AND DISEASE THAT LEAD TO CHRONIC PAIN, AND CONSEQUENCES OF ACUTE PAIN AND TRANSITIONING INTO A CHRONIC SITUATION OR DISEASE CONDITIONS THAT TRANSITION TO CHRONIC PAIN. AND HERE THE CHRONIC NIH AND SECRET RAN'S ADMINISTRATION AND QUANTITATIVE LIVE, AND CHRONIC PAIN CONDITIONS IS NINDA AND THE DRUG DISCOVERY DEVELOPMENT AND PRECLINICAL TESTING OF NOVEL ANALGESICS AND ALTERNATIVES TO OPIOIDS INCLUDED HERE AS WELL AS ANALGESIC DELIVERY SYSTEM, I LUMP THESE INTO SOMEWHAT LARGER CATEGORIES THAT COULD BE BROKEN DOWN TO SIMPLIFY IT FOR THE PRESENTATION. DEPARTMENT OF DEFENSE, NIH, AND NV A. THE VA AND THE NIH HAD GRANTS THAT WERE SHARED INTEREST AND IF YOU NOTICE, I LUMP THESE INTO IF YOU REMEMBER FROM THE VERY FIRST SET OF THOSE OVERVIEW ANALYSIS FROM THE INAUGURAL MEETING WE CODED OUR GRANT SPWOS SIX CATEGORIES AND I PUT THEM TOGETHER AS MUCH AS I CAN HERE. BASIC AND TRANSLATION WERE SEPARATE CATEGORIES CLINICAL RESEARCH AND QUOTE INCLUDES CER COMPARATIVE EFFECTIVENESS RESEARCH IN THIS SLIDE. SO HERE WE'VE GOT FORMICOLOGICAL THERAPY EVALUATION, BEHAVIORIAL INTERVENTION ASK ADJUNCT THERAPIES FOR LOW BACK PAIN AND THAT ONE IS, RISING TO THE OPEN TOP OF AN AREA THAT YOU'VE SEEN IN MANY OF THE DIFFERENT AGENCIES AND EVALUATION OF PRESCRIPTION ANALGESICS AND PREVENTION AND MANAGEMENT STRATEGIES FOR OPIOID USE AND ABUSE. AND WHY--OH. THE FDA IS NOT ON THIS ONE BECAUSE IT'S UNDERNEATH A DIFFERENT CATEGORY AND WILL SHOW UP LATER BUT CLEARLY THIS IS A BIG INTEREST FOR THEM AND IT'S ON TRANSLATIONAL RATHER THAN CLINICAL RESEARCH. >> QUALITY ASSESSMENT, AND HERE THE NIH AND THE VA, TOOLS AND REGISTRIES AND THESE ARE THINGS THAT MIGHT SERVE AS A VERY IMPORTANT SHARE OF RESOURCE ACROSS THE ENTIRE FEDERAL PORTFOLIO, THE PORTFOLIO IN THE NINDH HAVE SOME THAT CAN BE SHARED POTENTIALLY WE CAN TALK ABOUT IT. EVALUATION THERAPIES FOR MUSCULOSKELETAL AND RQ AND THE NIH HAD INTERESTS THAT WERE SHARED AND THE EPIDEMIOLOGY AND HEALTH DISPARITIES WE'VE GOT TRENDS AND USE AND ABUSE OF PRESCRIPTION AND OVERTHE COUNTER ANALGESICS. USE OF THE— EMERGENCY ROOM AND HOSPITALIZATION ALSO INCLUDED MEDICAL SERVICES RELATED TO ANALGESIC USE. CDC, THE FDA, SURVEILLANCE OF HEALTH PRACTICES, RISK BEHAVIORS, RELEVANT TO CANCER PAIN AND ARTHRITIS, IT'S NOT THAT THEY'RE CONNECTED IT'S BOTH OF THESE ARE INCLUDED FROM SMALL COMMUNITY POPULATIONS TO THE OVERALL FEDERAL POPULATIONS, CDC AND THE NIH HAVE SHARED INTEREST HERE. SURVEILLANCE STUDIES OF HEALTH PRACTICES, RISK BEHAVIORS AND THE PUDDEN OF DISEASE, RELEVANT TO CHRONIC PAIN ADDITIONS IN ADULTS AND SPECIAL POPULATIONS SUCH AS VETERANS AND THE ELDERLY. AND AND CDC, NIH, TRACKING LONG-TERM OUTCOMESCOMES AND TO THE SPECIFICS THAT CAME UP, OR PTSD AND CHRONIC PAIN AS A CONSEQUENCE OF ACUTE TRAUMA FROM„i SEVERAL DIFFERENT INSTANCES SUCH AS AMPUTATION, D.O.D. AND V. A. AND DISPARITYS AND ACCESS TO AND DELIVERY OF SERVICES TO MANAGE ACUTE PAIN LOWER BACK PAIN AND CANCER PAIN AND ARTHRITIS. CDC, NIH AND THE VA, AND THE MECHANISM USED FOR TRAINING POTENTIAL DISSEMINATION, PAIN RELATED INFORMATION AND EDUCATION WAS ACTUALLY VERY DIFFERENT ACROSS ALL THE AGENCIES BUT THE INTERESTS WERE SHARED. SO AT NIH AND THE VA WE HAVE SPECIFIC GRANT MECHANISMS FOR CAREER DEVELOPMENT FOR CAREER DEVELOPMENT PER RESEARCH. AT THE FDA AND NIH WE HAVE DIFFERENT TYPES OF MECHANISMS FOR TRAINING FOR ADDITION MECHANISM SKILLS AND OPIOID PRESCRIBERS AND OPIOID USE AND PREVENTION. >> SO FROM WHAT AUDRY SAID THAT THE VA IS ON THAT LIST AND SHOULD BE ON THAT LIST AS WELL. IF THERE AREN'T GRANTS FUNDED BUT THAT'S SOMETHING YOU WORKED HARD ON. >> RIGHT. >> SO THAT'S PART OF THE HEALTHCARE SYSTEM. >> WE DON'T FUND THAT PART. >> FUNDED RESEARCH. BUT IT'S PART OF THE ONGOING PORTION OF THE HEALTHCARE SYSTEM. >> OKAY, GREAT. SO WE'LL ADD THAT HERE FOR YOUR INFORMATION SEND IT OUT WITH THE VA ADD ON AND INCLUDE INDEED THAT ONE. >> SO TRAINING AND ACUTE MAIN AND ANESTHESIA BETWEEN THE D.O.D. AND NIH, THESE MECHANISMS ARE DIFFERENT AND THEY PRACTICESICIDE--PROVIDE THE TOPICS FOR THESE. CURRICULUM TOOLS FOR CHRONIC PAIN AND MANAGEMENT. YOU HEARD ABOUT THE COPE, THE C. D. C. AND THE D.O.D. AND V. A. HAVE OTHER MECHANISMS TO GO FORWARD WITH THESE KINDS OF TRAINING, THIS TYPE OF TRAINING PAIN MANAGEMENT AND EDUCATIONAL WEB SITES, THERE ARE PROBABLY MORE THAN I THOUGHT IN THE PORTFOLIO ANALYSIS, BUT THESE THREE AGENCIES WERE THE ONES THAT WERE LISTED THERE. AND I THINK THOSE ARE IMPORTANT TOOLS AND VERY WIDE SPREAD, WORK SHOP SEMINARS, WHITE PAPERS, THESE ARE KIND OF ONGOING ACTIVITIES ACROSS ALL THE AGENCIES AND INSTITUTES, THE ONES THAT WERE EXISTS PREDOMINANTLY AND DOD AND VA. SO THE OTHER THING WE PICKED UP FROM THE PORTFOLIO ANALYSIS THAT THERE ARE A NUMBER OF DATABASES AND REGISTRIES THAT WERE LISTED IN THERE, I DON'T HAVE THE DETAILS ON WHAT EACH OF THEM ENCOMPASSES BUT THE POTENTIAL FOR SHARING THESE, THIS IS MORE JUST TO LIST THE IDEA THAT THEY EXIST, AND THERE MIGHT BE A POTENTIAL TO USE THEM AS SHARED RESOURCES AND RESOURCES AND FEW EXAMPLES AND WE CAN PULL OUT MORE DETAIL ON ANY OF THESE AND PERHAPS CREATE MORE OF A DEFINED EXPANSIVE LIST BY TALKING AMONGST THE FEDERAL AGENCIES. AND SO THE OTHER TOPIC THAT CAME UP IN OUR DISCUSSION CARMEN BROUGHT THIS UP IS THE POSSIBILITY FOR PUBLIC-PRIVATE PARTNERSHIPS AS WE MOVE FORWARD WITH THE RESEARCH PORTFOLIO. AND SO FROM THE ANALYSIS, I PULLED OUT SOME EXAMPLES OF SUCCESSFUL PUBLIC PRIVATE PARTNERSHIPS FROM EACH OF THE DIFFERENT FEDERAL AGENCIES. THEY'RE VERY DIFFERENT. THEY'RE ALL DESIGNED VERY DIFFERENTLY, THE GOALS OF EACH ONE OF THEM VERY DIFFERENT. I THINK WE HEARD ABOUT THE ACTION AT THE INAUG.ERAL MEETING FROM BOB RAPPA PORT, THE OSTEOARTHRITIS INITIATIVE IS A HIGHLIGHT OF SLIDES FROM THE INAUGURAL MEETING, I THINK AUDRY TALKED ABOUT THE DONAHUE FOUNDATION AND MAY DAY FUND IN HER EARLY TALK, SO AGAIN, THESE ARE JUST GLIMPSES AT WHAT THE POSSIBILITIES ARE, THE DETAILS AREN'T HERE, BUT IT'S JUST THE IDEA THAT THOSE OPPORTUNITIES ARE OUT THERE TO REALLY OPTIMIZE THE ACTIVITIES THAT THEY DO? AND I THINK WE HAVE--IF THESE QUESTIONS PUT UP HERE TO DRIVE THE CONVERSATION A LITTLE BIT BUT I THINK FOR THE MOST PART, THEY COME UP IN THE EARLIER DISCUSSION. AND AGAIN AS WE GO FORWARD WITH IDENTIFYING GAPS AND AN AREA THAT SOME OF THESE QUESTIONS MIGHT BE IMPORTANT TO LOOK TO, TO REALLY OPTIMIZE THE RESOURCES THAT WE HAVE, NOT ONLY IN THE FEDERAL GOVERNMENT BUT ACROSS SOME OF THE FOUNDATIONS IN THE ADVOCACY GROUPS AND WAY WHAT'SY CAN WORK EFFECTIVELY FOR US. >> ASK CAN I ASK A QUESTION, AND I AM HESITANT TO ASK THIS QUESTION, BUT IS THERE ANY WAY--IS THERE A REPOSITORY OF INFORMATION REGARDING PRIVATELY FUNDED RESEARCH? , YOU BACK TO CHRIS' NOTION ABOUT NOT ONLY LOOKING AT GAPS AND SPENDING AND GAPS IN KNOWLEDGE, ALTHOUGH CLEARLY NIH AND THE FEDERAL GOVERNMENT IS ENORMOUSLY IMPORTANT IN THIS, YOU KNOW THERE'S LOTS OF OTHER RESEARCH BEING DONE AND SO, THAT'S MY QUESTION. >> IT'S A GOOD QUESTION AND VERY DIFFICULT. >> CERTAINLY ONE USEFUL RESOURCE IS CLINICAL TRIALS .GOV. WHICH IS A COMPLETE--A FEDERALLY FUNDED PART OF NATIONAL LIBRARY OF MEDICINE WHICH CATALOGS ALL CLINICAL TRIALS AND IS REASONABLY COMPLETE, LARGELY BECAUSE THE JOURNALS REQUIRE SUBMISSION OF A TRIAL, TRIALS ARE ONLY ONE KIND OF RESEARCH. I THINK IT'S VERY, VERY, DIFFICULT IN GENERAL AND ALMOST EVERY FIELD TO CAPTURE THE FUNDING THAT IS INSTITUTIONAL, MANY ACADEMIC INSTITUTIONS DO DIRECT SUPPORT OF RESEARCH AND THAT PROVIDED BY PRIVATE FOUNDATION. >> YEAH, AND THE PHARMACEUTICAL INDUSTRY RESEARCH THAT'S PRIMARILY ANALGESIC DEVELOPMENT, THEY APPARENTLY ARE SOME SOURCES TO FIND BITS AND PIECES OF THAT INFORMATION BUT TO GET A COMPREHENSIVE LIST TOGETHER IS PROBABLY A PRETTY ENORMOUS TASK. >> CHRIS DO YOU WANT TO OFFER SUGGESTIONS ABOUT, SHOULD WE MAKE AN UPDATE TO COLLECT INFORMATION FROM THE VOLUNTARY GROUPS THAT DO FUND RESEARCH? >> YEAH, I THINK THAT THE MAJORITY OF US INVOLVED IN DIRECTLY FUNDING RESEARCH WOULD HAVE NO PROBLEM ROUGH ATOMICIDING THAT INFORMATION. --PROVIDING THAT INFORMATION. >> YEAH, ACTION IS DOING SOME OF OF THAT ON THE CLINICAL SIDE IN TERMS OF DIDN'T SHE JUST RELEASE A DATABASE THAT HAS AN ACTIVE LIST OF--YEAH. AND YOU KNOW, FROM THE EXTENT OF FARM AI GUESS YOU WOULD HAVE TO HAVE CONVERSATIONS WITH INDUSTRY AS WELL WHETHER THEY WERE INTERESTED IN SHARING THAT INFORMATION OR NOT, BUT I THINK IT'S A GOOD POINT. >> THE HOWARD HUGH'S MEDICAL INSTITUTE, THE KOMEN FOUNDATION. >> RIGHT, RIGHT, RIGHT, RIGHT. >> I'M JUST WONDERING IF IF IT'S WORTH TAKING A PASS AT IT OR WHETHER IT'S TERMED WOULD YOU RATHER VILLAIN A FOCUS ON LOOKING AT THE DATA THAT WE'VE COLLECTED AND ANALYZEALIZING THAT OR COLLECTING INFORMATION ON PRIVATE FUNDING FOR BOTH. >> IF WE COULD COME UP WITH THIS AND NOT LABOR INTENSIVE, AND IF IT WEREN'T LABOR INTENSIVE IT PROBABLY WOULDN'T BE A COMPLETE SUMMARY. >> BUT HOW WOULD YOU RECOMMEND USING THAT DATA. >> THE REASON I BRING IT UP IS THAT THAT PRIVATE FUNDING CHANGES SEASONALLY, YEARLY SO WHAT HAPPENS IN 2012 MAY NOT BE PRESINENT WENT TO 13 SO I COULD SEE IT USING DURING NIH, DOD, IS THAT WHAT YOU'RE THENNING OF. >> I'M THINKING ABOUT THE CHARGE TO THE IOM COMMITTEE AND EXTEND THEM,. >> I THINK WE'RE LOOKING AND TRYING TO. >> AND AGAIN I THINK FEDERAL GOVERNMENT HAS A VERY IMPORTANT PIECE OF THAT, BUT MAYBE NOT EVEN THE MAJORITY OF IT. SO I DON'T KNOW IF WE CAN DO--IF THIS COMMITTEE CAN FULLY DO WHAT IT WAS TASKED WITH WITHOUT SPECIAL INFORMATION, SOME MORE INFORMATION. >> THIS COMMITTEE WAS FOCUSED ON FEDERAL, AGES AND-- >> BUT MY HAPPENING IS THAT IT'S ABOUT TO EXPAND INTO THE POPULATION HEALTH STRATEGY. >> AND TO WHAT EXTENT THEN DO YOU WANT TO PUT FUNDING OF PAIN RESEARCH BY NONFEDERAL AGENCY--WHERE ON THAT LIST OF THE PLANS WOULD YOU DEVELOP--A NATIONAL STRATEGIC PLAN, WOULD YOU PUT OBTAINING INFORMATION ABOUT NONFEDERAL FUNDING OF PAIN RESEARCH. >> I DON'T HAVE THE ANSWER, I JUST HAVE A QUESTION. >> RIGHT. >> SO I'M--YOU KNOW IF THE RESOURCES WERE INFINITE, THAT WOULD BE A WONDERFUL PIECE OF INFORMATION TO HAVE, BUT I'M NOT SURE HOW WE WOULD USE IT EXCEPT INSOFAR AS OPPORTUNITIES FOR PUBLIC PRIVATE PARTNERSHIPS BETWEEN FEDERAL AGENCIES AND PRIVATE ORGANIZATIONS WHICH THE NFL GAVE US 30 MILLION DOLLARS TO STUDY TBI, NOW THEY MIGHT ALSO BE INTERESTED IN KNEE PAIN, I DON'T KNOW, I'M MAKING THAT UP, I'M SORRY. >> SO IT OCCURS TO ME THAT YOU COULD DO A PRETTY SURFACE JOB OF WHAT WE'RE TALKING ABOUT SIMPLY BY LOOKING AT THE POLISHED PORTFOLIOS OF THE PLAYERS THAT YOU'RE INTERESTED IN. SO YOU WOULDN'T NECESSARILY CALL AND COLLECT THE IDENTICAL INFORMATION FROM EACH AGENCY THE WAY THAT EACH PRIVATENTITY THE WAY YOU COLLECTED INFORMATION HERE. BUT YOU WOULD SIMPLY HAVE A LISTING OF GRANTS AND THAT YOU WOULDN'T BE ABLE TO SUPPLY THE SAME NAMENCULATURE. I THINK WHAT YOU WOULD PREFER TO DO IS TO COME UP WITH A SET OF VOLUNTEERS VOLUNTARY ORGANIZATIONS OR FUNDING, NOT FEDERAL FUNDING AGENCIES AND ASK THAT THEY PROVIDE US WITH INFORMATION AND WE WOULD EITHER GET AN ANSWER OR WE WOULDN'T AND MEMBERS OF THE COMMITTEE COULD, I'M SURE BE VERY UPONFUL IN PROVIDING US WITH ORGANIZATIONS TO CONTACT. SO THAT WOULD BE ANOTHER HOME WORK ASSIGNMENT FOR YOU ALL. CARMEN? >> SO I GUESS MY CONCERN IS WHETHER IT'S IN OUR CHARGE TO GO OUT AND LOOK AT SOME OF THESE OTHER--IT'S ALWAYS NICE TO KNOW INFORMATION BUT I THINK WE HAVE TO REVISIT THE CHARGE. >> THE SECOND COMMENT I HAVE, SO I WOULD JUST SAY THAT WE WOULD GET AN ADIVISIONAL CHARGE THIS AFTERNOON FROM HOWARD COE WHICH COULD BE PROCEIVED IN INCLUDING-- >> I UNDERSTAND BUT I DON'T HAVE THAT CHARGE NOW. >> I'M JUST--JUST SAYING ... >> LET ME FINISH, PLEASE. >> THE OTHER THING, I GUESS WHAT I WOULD SAY IS THAT, YOU KNOW I'M NOT SEEING IN THE NFL, YOU READ MY MIND, THEY GAVE MONEY AND WHETHER OR NOT THAT'S AN OPPORTUNITY TO ACTUALLY HAVE SOME OF THAT RELY SORT OF INFILTRATE AND SUPPORT THIS INITIATIVE AND THE OTHER THING I'M NOT SEEING IN THE PARTNERS LINDA WERE--HRQ, THEY FUND A LOT OF PAIN. ARE YOU THINKING OF THAT IN THE CONTEXT OF THE NIH. >> I'M TALKING ABOUT IN THE OTHER SLIDES TOO. >> WE HAD THE NHRQ FUNDING. >> YES AND THOSE WERE ONLY AREAS OF SHARED INTEREST, CARMEN THEY'RE NOT PORTFOLIO GLIMPSE. >> OKAY, OKAY, OKAY, FINE. >> I JUST DIDN'T SEE THEM HERE IN THESE BASIC-- >> SO IF YOU GO BACK TO THIS, SECOND SLIDE, WE DO HAVE HRQ AND WE INCLUDED IN OUR PORTFOLIO ALL THE AHRQ FUNDING SO WE'RE NOT, EVERY RESPONSE TO FEDERAL AGENCIES BUT WE DO HAVE AHRQ. >> RON? >> I WAS JUST GOING TO REMIND US, WE DO HAVE A RECOMMENDATION TO EXPAND PARTNERSHIPS BETWEEN PUBLIC ENTITYS AND PRIVATE ENTHUSIASM IT ISS AND MAYBE WE COULD HAVE A SUBGROUP OF THIS COMMITTEE THINK ABOUT, VARIOUS POSSIBLE PARTNERSHIPS AND INVITE INDIVIDUALS TO JOIN US TO MAYBE COME TO A MEETING WITH US TO TALK ABOUT THESE KINDS OF POSSIBLE PARTNERSHIPS. >> ONE OF THE AGENDA ITEMS FOR THE NEXT MEETING WILL BE PUCK LICK/PRIVATE PARTNERSHIPS AND WE WOULD BE DELIGHTED TO HAVE SUGGESTIONS OF PEOPLE WHOM YOU THINK--WE HEARD ABOUT ONE LAST TIME WHICH WAS ACTION. I FORGOT WHAT WAS ON THE LIST. >> MARIA FRER WILL HAVE TAKEN OVER FOR THE HEAD OF THE FOUNDATION FOR NIH AND WE THOUGHT WE WOULD HAVE HER COME AND TALK ABOUT THE FOUNDATION FOR NIH. ALSO A NUMBER OF THE OTHER AGENCIES, FDA HAS AN EQUIVALENT FOUNDATION, THE SUPERIOR COURTA PROBABLY DOES, SO USE THAT AND THEN IF THERE ARE PRIVATE OTHER ORGANIZATIONS THAT YOU THINK WOULD BE GOOD TO INVITE, WE CAN CERTAINLY DO THAT AS WELL. >> SHOULD WE BE THING ABOUT-- >> WE THINK ABOUT BIG FARM APHARMACEUTICAL--YOU'RE LAUGHING, SMILING? >> [LAUGHTER] >> WE COULD DISCUSS WITH THE FNIH ACTIVITIES THAT THEY HAVE BEEN SUCCESSFUL IN ESTABLISHING PUBLIC PRIVATE PARTNERSHIPS WITH FARM SPA AND THERE ARE TWO EXAMPLES WHICH HAVE WORKED EXTRAORDINARILY WELL, IT'S THE ARTHRITIS INITIATIVE AND THE OTHER IS ADNY AND WE COULD SEE WHAT HER THOUGHTS IN GENERAL PHARMA IS MOVING OUT OF CNS DISORDERS AND I GUESS YOU WOULD THINK OF PAIN AS A NEUROSCIENCES THINK OF PAIN. >> [INDISCERNIBLE]. >> NO? >> WHAT IS HE SAYING? >> HE SAYS-- >> [INDISCERNIBLE]. >> WE IS CERTAINLY BRAINSTORM ABOUT HOW WE WOULD, BUT IN GENERAL THE PARTNERSHIPS THAT HAVE BEEN MOST SUCCESSFUL WITH PHARMA HAVE BEEN PARTNERSHIPS WHERE ONE OR MORE INSTITUTES ARE CENTERS IN A FEDERAL AGENCY HAVE A PROJECT, AN INITIATIVE WHICH PHARMA THEN JOINED SIMPLY GOING TO FARM AND SAYING, WE NEED MONEY HAS NOT WORKED UNTIL THERE'S A SPECIFIC PROJECT D. SO FAR. BUT THAT COULD CHANGE. BUT WE'RE NOW TALKING ABOUT IDENTIFYING THESE SO CALLED OPPORTUNITIES POSSIBLY. AND THEY MIGHT BE INTERESTED IN HEARING ABOUT THESE OPPORTUNITIES AND MIGHT BE INTERESTED IN PARTNERING WITH THEM. >> TO JUST REITERATE THE ADNY GOT MONEY FROM PHARMA AFTER THEY COMMITTED 40 MILLION DOLLARS FOR THE FIVE YEAR ADNE PROJECT AND IT WAS VERY CLEAR, THE ALZHEIMERS DISEASE, NEUROIMAGING INITIATIVE IS THE GOAL WAS TO COME UP WITH BIOMARKERS AND CSF BIOMARKERS THAT WOULD ENABLE MORE RAPID CONDUCT OF CLINICAL TRIALS AND EARLY DIAGNOT--METASTASINOSEIS OF PATIENTS WHO WERE GOING TO DEVELOP ALZHEIMER PATIENT HYMERS AND THEN ONCE THAT HAD BEEN ESTABLISHED AND NIA HAD PUT ITS MONEY ON THE TABLE, THEN PHARMA JOINED IN AND THEY HAVE FUNDED PROBABLY FOR EVERY DOLLAR THAT NIA HAS PUT IN, 50 SENTS. SO VERY NICE PROJECT. AND IT WAS VIEWED AS PRECOMPETITIVE, SO HAVING THOSE BIOMARKERS WOULD BENEFIT ALL PHARMA COMPANIES THAT HAD AN INTEREST IN ALZHEIMERS AND WE'RE TRYING TO ESTABLISH A RELATIONSHIP LIKE THAT FOR A PARKINSON'S DISEASE BIOMARKER INITIATIVE. >> PAIN MERCHANDISE PHARMA? >> WITH THE NUMBER OF PHARMACEUTICAL COMPANIES THAT ARE INTEREST INTERESTED IN ADVANCING, UNDERSTANDING AND OUR TREATMENT OF PAIN CONDITIONS? >> SO THEY MIGHT BE BUT I WOULD-- >> THEY EVER HEARD ABOUT THIS COMMITTEE AND WHAT THIS COMMIT SEE GOING TO DO? >> THEY MIGHT BE I WOULDED JUST SAY THAT THE COMPANIES THAT CONTRIBUTED TO THE ADNI PROJECT NEW THAT THEY WOULD USE THOSE BIOMARKERS IN APPROACHING THE FDA AS POTENTIAL OUTCOMES OF TRIAL. SO I KNOW IF THERE WERE AN ISSUE OF PAIN AND THE LEVEL DIAGRAM IN THE ONE-10 BUT DO YOU WANT TO SPEAK FROM THE FDA? >> WELL, FROM ACTIONS PERSPECTIVE, OUR PRIVATE PARTNER IS INCLUDE INDUSTRY AND THEY PUT IN A LOT OF MONEY TO ACTION BECAUSE THEY HAVE AN INCENTIVE TO DO SO TO GET BETTER CLINICAL TRIAL DESIGNS. >> THAT'S WHAT I WAS GOING TO SAY IS I THINK ONE MAJOR AREA THAT SPEAKS TO PROBABLY EVERYTHING WE'VE DISCUSSED THIS MORNING FROM THE CONSENSUS CONFERENCE, ON OPIOIDS TO PAIN EDUCATION SOMEWHERE WHERE THIS COMMITTEE CAN BE VERY EFFECTIVE IS THAT IT'S NOT THAT PHARMACEUTICAL COMPANIES DON'T WANT TO STUDY PAIN, IT'S JUST COMPLEXITY OF PAIN AND ETICSROGEN AITY OF--HETEROGENEITY OF PAIN AND COMORBID PAIN ARE MOST LIKELY GOING TO REFOND THEIR TREATMENT AND I THINK SAO*E THAT AS A WIN-WIN-WIN. IF WE'RE ABLE TO ADVANCE THAT TYPE OF RESEARCH, THAT'S VERY ATTRACTIVE TO PHARMA. IT MEETS OUR GOALS AND IT MEETS PATIENT GOALS. >> SO ONE QUESTION MIGHT BE WHETHER OR NOT ANY OF THOSE--THE POPULATION, THE MAP PROJECT OR MAXENER'S PROJECT MIGHT BE AN INTERESTING PROJECT FOR INDUSTRY TO CONTRIBUTE TO. >> I THINK IT'S ALL RIGHT HAPPENED. >> BUT NOT BY NIH. >> IT IS THROUGH THE NIH. >> NO BUT THE MONEY. >> THE NIH IS SUPPORTING BOTH OF THOSE. >> BUT WE'RE NOT GETTING MONEY FROM INDUSTRY TO EXPAND WHAT THOSE PROJECTS ARE DOING AND I THINK THAT THE FDA AND POTENTIALLY THE DEPARTMENT OF DEFENSE, ALTHOUGH YOU CAN TAKE MONEY FROM COMPANIES-- >> YOU CAN'T. WE CAN'T EITHER BUT THAT'S THE MECHANISM--AND WELL THE ACTION TO HAVE THE PRIVATE PARTNER. THEY DO THE FUNDRAISING. >> RIGHT, NOW MANY COMPANIES PARTICIPATED AND PUT MONEY INTO THIS ADNI? >> I'M GUESSING FIVE OR SIX. >> SO IT'S ABOUT EIGHT MILLION DOLLARS PER-- >> OVER FIVE YEARS. AND THEY JUST REUPED. >> THAT'S NOTHING FOR THIS BIG PHARMA. >> NO ESPECIALLY IF YOU HAVE A DRUG FOR ALZHEIMERS. UNFORTUNATELY THE MOST RECENT TRIALS HAVE NOT GONE WELL. >> NOT THE POPULATION AND-- >> NO, NO AND YOU'RE NOT GETTING THEM TOO LATE AND NOT EARLY ENOUGH SO EVERYBODY NEEDS TO THINK LOOKING FORWARD ABOUT WHAT YOU WOULD LIKE TO HAVE ON THE AGENDA FOR DISCUSSION OF PUBLIC PRIVATE PARTNERSHIP. >> SO IN THE SPIRIT OF THAT, WHAT IS THE INTEREST IN LABERATING WITH THE MACK FOR INSTANCE BIG EFFORT LOOKING AT PELVIC PAIN, I KNOW YOU KNOW DAN WELL AND YOU KNOW THE COLLEAGUES WHO DO TMD WITH OPERA AND THAT TYPE OF MODEL. >> YEAH, WELL, IF YOU TALK TO ANY OF THEM, THEY'LL TELL YOU THAT WE'VE BEEN TALKING TO THEM. WE WANT TO MAKE SURE THAT AS THESE LARGE PROJECTS GO FORWARD AND THERE'S A LARGE INVESTMENT NUMBER ONE IT'S NOT IMPLICCAATIVE, AND NUMBER TWO SINCE WE HAVE THE OPPORTUNITY TO DO THIS, LET'S ANSWER AS MANY RESEARCH QUESTIONS AS POSSIBLE. WE WOULD LOVE TO PARTNER WITH PROJECTS LIKE THAT AND OTHERS. I THINK THERE ARE SOME--I DON'T WANT TO SAY SOMEWHAT POLITICAL THINGS IN TERMS OF HOW FAR DIFFERENT INSTITUTES PROVIDE MONEY FOR DIFFERENT STUDIES AND WHAT THE MAIN FOCUS IS, AND I THEN IS AN AREA WHERE THE COMMITTEE SHOULD BE ACTIVE IN MAKING SURE THAT WE MOVE THAT FORWARD. >> YEAH, AND PART OF THAT IN THE SPIRIT OF THAT IS PATIENT ADVOCACY, YOU ARE TIED IN WELL WITH PHILANTHROPY AND WE HAVEN'T DISCUSS THAD BUT THERE'S A LOT OF RICH DONORS OUT THERE WHO ARE LOOKING FOR PROJECTS TO WORK WITH WITH TO DONATE TOO. DO YOU SEE THIS, AND YOU KNOW YOU *URPBT ACT WITH A LOT WITH--INTERACT WITH DONORS AND I DO LOCALLY, THESE TYPES OF THINGS THEY HAVE INTEREST. WITH THE LEVERAGING MODEL AND NIH WAS TOSSING IN THIS AMOUNT OF MONEY AND WOULD YOU BE INTERESTED IN-- >> ABSOLUTELY BUT MAYBE I'M JUST NOT IN THE KNOW, THERE'S NOT A LOT OF FOUNDATIONS THAT HAVE AN ACTIVE INTEREST IN FUNDING. >> AND FOUNDATIONS THAT HAVE SUPPORTED OTHER TYPES OF RESEARCH, AND INITIATIVES AND I'M NOT AWARE BUT OFTEN TIMES THE UNIVERSITY OR HOSPITAL DEVELOPMENT ALL OFFICE WILL CHANNEL THOSE DONORS TO CONTRIBUTE THE RESEARCH PROGRAM OF INDIVIDUAL INVESTIGATORS WITHIN THE INSTITUTION A NAMED CHAIR OR PROJECT SO WE HAVE A NEW MEMBER WHO JOINED US IF YOU CARE„i TO-- >> WE DO, YES, DR. LANDES, IT'S MY PRIVILEGE TO INTRODUCE DR. LAND IS, BUT HE'S STILL AS AUTHORITY OVER ME. GENERAL SCHUMAKER, IS A RESEARCH BY TRAINING AND HE HAS JOINED THE FACULTY HERE AT UNIFORM SERVICES, SO, SIR, THANK YOU VERY FAR MUCH AND APPRECIATE YOU BEING HERE. >> THANKS FOR THE INVITITATION. >> IS THERE ANYMORE DISCUSSION ON HOW WE'RE GOING TO ORGANIZE THE PUBLIC PRIVATE PART MERSHIP PIECE OF NEXT MEETING OR ANYTHING THAT WE WOULD LIKE TO PURSUE ON THE COOPERATION COLLABORATION ON SHARED INTERESTS BETWEEN FEDERAL AGENCIES? SO ONE THOUGHT WE HAD HAD WAS IF WE PICK THREE OF THOSE EXAMPLES OF SHARED INTEREST AND EXPLORED WHAT THE AGENCIES WERE DOING AND HOW IT WAS SYNERGISTIC OR COLLABRATIVE OR NOT, IT STRIKES ME THAT THAT--WHILE THAT'S INTERESTING, IT'S PROBABLY NOT AS IMPORTANT AS GETTING THE--BRINGING FURTHER ALONG OUR PROCESS OF WHAT'S IN THE PORTFOLIO, WHAT THE PROJECTS ARE AND WHAT THE AREAS ARE SO UNLESS SOMEONE FEELS STRONGLY WE SHOULD TAKE ON THAT TOPIC OF SHARED INTEREST, RIGHT AWAY, I WOULD BE INCLINED TO NOT PURSUE THAT RIGHT NOW. IF THAT'S OKAY WITH EVERYBODY ELSE HERE. >> GOOD, GREAT. >> MYRA? >> THIS STORY IS SOMETHING THAT I'M INTERESTED IN BUT I'M FINE WITHY DELAYING IT, I WOULD NOT BE FINE WITH JUST TAKING IT OFF THE TABLE. >> NO, NO, NO. >> IT'S A QUESTION OF PRIORITIZING WHAT WE'RE GOING TO INVEST MOST OF THE STAFF TIME IN, AND THE COMMITTEE'S TIME IN NEXT. >> I THINK ONCE WE LOOKED AT THE PORTFOLIO, THESE WILL BE MORE IMPORTANT TIMING WISE TO PULL THEM IN. >> OKAY, IT IS 10 AFTER 12. LUNCH IS SCHEDULED FROM 12:15-1:15. >> TODAY DR. HOWARD KOH AND DR. ANAN PEREKK. DR. KOH SERVES AS THE ASSISTANT SECRETARY OF DEPARTMENT OF HEALTH AFTER BEING NOMINATED BY BARACK OBAMA IN 2009. HE OVERSEES 14 PUBLIC HEALTH OFFICES AND IMPLEMENTATION OF AN ARRAY OF INTERDISCIPLINARY PROGRAMS INCLUDING SEVERAL RELATED TO DISEASE PREVENTION, HEALTH PROMOTION, REDUCTION OF HEALTH DISPARITIES. HE SERVES AS SENIOR PUBLIC HEALTH ADVISER TO THE SECRETARY. BEFORE COMING TO HHS DR. COH WAS THE FINEBERG PACK PROFESSOR OF PRACTICE OF PUBLIC HEALTHND SATIATE GAME FOR PUBLIC HEALTH PRACTICE AT THE HARVARD SCHOOL OF PUBLIC HEALTH. GRADUATED YALE COLLEGE, YALE UNIVERSITY SCHOOL OF MEDICINE; POST GRAB WAIT AT BOSTON CITY HOSPITAL AND MASSACHUSETTS GENERAL HOSPITAL AND WENT TO THE ROLE OF PROFESSOR DERMATOLOGY, MEDICINE PUBLIC HEALTH AT BOSTON UNIVERSITY. HE SERVED AS COMMISSION OF PUBLIC HEALTH MASSACHUSETTS FROM 1997 TO 2003, MANY HONORS FOR HIS ACCOMPLISHMENTS IN MEDICINE, PUBLIC HEALTH AND HAS DISTINCTION OF THROWING OUT THE CEREMONIAL FIRST PITCH ON TWO DIFFERENT OCCASIONS. AT FENWAY PARK DESIGNATED MEDICAL AL STAR BY THE BOSTON RED SOX AT NATIONAL PARK IN WASHINGTON D.C . ON BEHALF OF HHS. DR. PERECK IS DEPUTY ASSISTANT SECRETARY FOR HEALTH SCIENCE AND MEDICINE AT HHS, PROVIDES OVERSIGHT AND DIRECTION AND COORDINATION OF ACTIVITIES RELATED TO A RANGE OF EMERGING PUBLIC HEALTH AND SOCIAL AND SCIENCE ISSUES. WORKED ON A VARIETY OF HEALTH ISSUES INCLUDING QUALITY CARE IMPROVEMENT, CHRONIC CARE MANAGEMENT AND DISEASE PREVENTION AND HEALTH PROMOTION. PART OF THIS ROLE HE SERVEED IN THE HHS OFFICE OF THE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE SUPPORTING VARIOUS INITIATIVES RELATED TO BIOTERRORISM AND PANDEMIC INFLUENZA PREPAREDNESS. HE LED THE HHS MULTI-P BILL CHRONIC CONDITION STRATEGIC FRAMEWORK PROCESS WHICH COULD PROVE USEFUL FOR INFORMING WHAT A SIMILAR PROCESS SHOULD OR SHOULD LOOK LIKE FOR PAIN. COMPLETED HIS UNDERGRADUATE IN POLITICAL SCIENCE, GRADUATE SCHOOL TRAINING IN MEDICINE, PUBLIC HEALTH AT THE UNIVERSITY OF MICHIGAN RESIDENCY AT HOPKINS, THE RESEARCH HOPKINS CENTERS FOR MEDICARE AND MEDICAID SERVICE IN THE INSTITUTE OF MEDICINE, SO WELCOME. >> DR. LANDIS, THANK YOU SO MUCH AND WELCOME, EVERYONE, I WANT TO CONGRATULATE ALL FOR BEING PART OF THIS VERY IMPORTANT COORDINATING COMMITTEE AND TELL YOU THAT YOUR WORK IS CRITICAL TO PUBLIC HEALTH. IT'S CRITICAL TO THE MORE THAN 100 MILLION AMERICANS WHO ARE SUFFERING FROM CHRONIC PAIN. I'M DELIGHTED TO SPEND A COUPLE OF MINUTES WITH YOU WITH MY COLLEAGUE DR. PARECK, DEPUTY ASSISTANT SECRETARY AT HEALTH AND HUMAN SERVICES. LET ME TELL YOU OUR PERSPECTIVE ON THIS. THEN TURN IT OVER AND MAYBE WE CAN HAVE A CONVERSATION HOW WE CAN WORK BETTER TOGETHER AS A DEPARTMENT OF HEALTH AND HUMAN SERVICES ON THIS KEY ISSUE. LET ME START BY THANKING STORY LANDIS FOR HER LEADERSHIP AND SHE'S AN INCREDIBLY DEDICATED PROFESSIONAL AND I HAVE THE PLEASURE OF WORKING WITH STORY ON OTHER AREAS OF PUBLIC HEALTH PARTICULARLY EPILEPSY, THAT WORK IS GOING VERY WELL. NOT SURPRISING SHE HAS ALSO TAKEN ON THIS AREA BECAUSE SHE IS SOMEONE WHO WORKS HARD ON BEHALF OF SO MANY PEOPLE AND SO MANY AREAS. I ALSO WANT TO ACKNOWLEDGE DR. LARRY TABAK WHO IS NOT HERE BUT IS INCREDIBLY RESPECTED DEPUTY DIRECTOR FOR NIH. BETWEEN DR. LANDIS AND DR. TABAK, YOU HAVE CREDIBLE LEADERSHIP P REPRESENTED HERE. I JUST LEFT DR. COLLINS' OFFICE AND TOLD HIM THAT I WAS GOING TO BE ADDRESSING THIS COORDINATING COMMITTEE AND I WANTED TO START BY THANKING STORY AND LARRY FOR BRINGING US ALL TOGETHER. SO YOU HAVE A VERY IMPORTANT CHARGE COMES FROM THE AFFORDABLE CARE ACT. I KNOW YOU HAVE STARTED THE WORK OF WHAT WE COULD DO AS AN NIH-WIDE EFFORT. PART OF THAT WORK I KNOW IS DOING AN INVENTORY, IF YOU WILL, OF WHAT NIH IS DOING, AMONG VARIOUS AGENCIES. AND HOW IT OVERLAPS OR DOESN'T WITH PARTS OF HHS LIKE CDC, FDA, AHRQ AND DOD AND VA. I KNOW YOUR WORK ALSO CAME OUT OF THIS REPORT MENTION SEVERAL YEARS AGO RELIEVING PAIN IN AMERICA A BLUEPRINT FOR PREVENTION I CARE EDUCATION AN RESEARCH. DR. MACKEY AND MS. CHRISTOPHER ARE ON THIS COMMITTEE. WE WANT TO SPECIAL THANKS FOR SERVING THE IOM COMMITTEE AS WELL. IF I CAN SAY I GOT TO HEAR DR. PEZO, THE CHAIRMAN OF THE COMMITTEE PRESENT AT HHS SO GOT TO HEAR DIRECTLY FROM HIM ABOUT THE WORK OF THAT VERY IMPORTANT COMMITTEE. Y'ALL HAD A PRODUCTIVE MORNING ADDRESSING ISSUES BEFORE NIH ON THIS KEY PUBLIC HEALTH ISSUE AND TALKING MORE ABOUT COORDINATION AND CUBE COLLABORATION. I'M HERE AND BECAUSE ONE OF THE IOM'S CORE RECOMMENDATION WAS THE NEED TO, QUOTE, CREATE A COMPREHENSIVE POPULATION HEALTH LEVEL STRATEGY FOR PAIN TREATMENT MANAGEMENT AND RESEARCH, UNQUOTE AND EVEN THOUGH YOUR CHARGE IS FOCUSED ON RESEARCH AND THAT IS SO KEY AND SO CRITICAL, THAT WHEN YOU HEAR RECOMMENDATION LIKE THAT, IT MAKES ME THINK ABOUT CONNECTING WITH MANY, MANY OTHER GROUP, ADVOCATES, CREDENTIALING ORGANIZATIONS, OTHER PROFESSIONAL ASSOCIATIONS, INSURANCE PROVIDERS, HEALTHCARE PROVIDERS, STATE HEALTH DEPARTMENTS. I'M A FORMER COMMISSIONER IN MASSACHUSETTS SO I KNOW THE PERSPECTIVE FROM STATE LEADERS ON THESE ISSUES. FROM MEDICAID, WORKMAN'S COMP AND MANY, MANY OTHER STAKEHOLDERS. SO I'M HERE BECAUSE YOU HAVE STARTED IMPORTANT EFFORT TO COORDINATE ACROSS NIH. YOU HAVE SOME CRITICAL MASS HERE WHICH I APPLAUD YOU FOR. YOU ARE STARTING TO DO THIS INVENTORY WHICH IS GREAT. AND RECEIVING INPUT FROM A BROAD ARRAY OF ORGANIZATIONS. BUT I AM NOW HERE TO REQUEST ON BEHALF OF THE SECRETARY THAT THIS COMMITTEE EXPAND ITS ORIGINAL CHARGE BEYOND RESEARCH AND BEGIN TO THINK ABOUT DEVELOPING A BROADER PLAN THAT MEETS THE IOM'S CORE RECOMMENDATION OF CREATING A COMPREHENSIVE POPULATION HEALTH LEVEL STRATEGY FOR PAIN PREVENTION, TREATMENT, MANAGEMENT AS WELL AS RESEARCH. THIS IS NOT EASY. AND AS ALWAYS, IN THESE TOUGH TIMES WE DONE HAVE ADDITIONAL RESOURCES TO DO THIS. SO WE NEED TO TAKE LEADERS ASSEMBLED HERE AND BRING PERSPECTIVES FROM OTHER PARTS OF HHS TO SEE IF WE CAN WORK TOGETHER TO BEGIN ON THIS EXPANDED CHARGE. MY OFFICE, THE ASSISTANT SECRETARY'S OFFICE HAS BEEN0Cp INVOLVED IN A WIDE ARRAY OF STRATEGIC PLANNING ON AREAS LIKE TOBACCO, HIV, HEPATITIS, VACCINES, HEALTH DISPARITIES AND A LONG LIST ONE OF THOSE IS A PLAN ON MULTIPLE CHRONIC CONDITIONS. THAT'S WHAT DR. LANDIS HAD ALREADY MENTIONED. DR. PARECK TO MY RIGHT HELPED CRAFT A DEPARTMENT WIDE STRATEGIC FRAMEWORK ON MULTIPLE CHRONIC CONDITIONS, MCC FOR SHORT. EVERYTHING HAS AN ACRONYM IN GOVERNMENT. SO THE MCC STRATEGIC FRAMEWORK WAS ONE THAT STRUCK DR. LANDIS AND DR. TABAK AS A GOOD MODEL FOR THIS AREA OF PAIN. SO WHEN DR. TABAK AND DR. LANDIS ASKED IF WE COULD COME HERE, I SAID I WOULD ONLY COME IF DR. PARECK CAME TOO AND MAYBE GAVE OVERVIEW HOW THAT MCC MULTIPLE CHRONIC CONDITION STRATEGIC FRAMEWORK CAME TO LIFE AT THE DEPARTMENTFUL SOME OF THE ACCOMPLISHMENTS THAT FRAMEWORK HAS HELPED TO ACCELERATE AND SO IF YOU CAN JUST CHAT FOR THREE TO FIVE MINUTES ON THAT THEME AND THEN OPEN UP TO SEE HOW WE CAN HELP THIS VERY IMPORTANT BODY MOVE INTO THIS NEW AREA. IN TURN I WANT TO THANK ALL OF YOU BECAUSE THESE ARE VERY CHALLENGING ISSUES, THEY'RE NOT EASY. THEY CAUSE TREMENDOUS IMPACTS ON PEOPLE ACROSS THIS COUNTRY IN STAGGERING WAYS. SO WE NEED AS MANY TALENT AS POSSIBLE TO BRING TOGETHER THE BROADEST POSSIBLE INTERDISCIPLINARY APPROACH. THAT'S WHY WE'RE HERE TODAY. SO ANAN, TAKE OVER FROM HERE. >> GREAT. (OFF MIC) >> THANK YOU. THAT'S BETTER. I WANT TO THANK DR. COH FOR THAT INTRODUCTION. DR. LANDIS AS WELL, FOR CHAIRING THE INTERAGENCY PAIN RESEARCH COORDINATING COMMITTEE. I WANT TO THANK ALL OF YOU HERE, FOR YOUR DEDICATION AND COMMITMENT TO CHRONIC PAIN. THIS COMMITTEE HAS AN IMPORTANT FUNCTION TO COORDINATE PAIN RESEARCH TO ENSURE DUPLICATION IN RESEARCH IS MINIMIZED TO ENSURE FINDINGS ARE DISSEMINATED AND TO FILL GAPS AND ADDRESS GAPS. WHAT DR. COH HAS REQUESTED TODAY IS AS HE SAID, AN EXPANSION OF THE INITIAL CHARGE OF THE COMMITTEE AND I THINK WHAT WE CAN OFFER PERHAPS IN DISCUSSION ARE A COUPLE OF WAYS THAT THE ASSISTANT SECRETARY FOR HEALTH OFFICE CAN HELP THIS COORDINATING COMMITTEE THE BROADER CHARGE THE INSTITUTE OF MEDICINE LAID OUT. I WANT TO OFFER A FEW WORDS ABOUT ANOTHER INITIATIVE THAT THE DEPARTMENT LAUNCHED SEVERAL YEARS AGO AND DR. LANDIS REFERRED TO THIS TO EXTENT IT MAY PROVIDE INSIGHTS HOW WE ALSO APPROACHED A VERY COMPLICATED PUBLIC HEALTH CHALLENGE. THAT CHALLENGE IN REALM OF CHRONIC DISEASE IS THE PHENOMENON OF MILLIONS OF AMERICANS LIVING NOT JUST WITH CHRONIC CONDITIONS BUT MULTIPLE CHRONIC CONDITION. SO THUS ONE IN 4 AMERICANS FOR 75 MILLION FROM TWO OR MORE RECURRENT CHRONIC CONDITIONS. SO IN DECEMBER OF 2010, WE LAUNCHED THE DEPARTMENT OF FRAMEWORK IMPROVING THE HEALTH STATUS AN QUALITY OF LIFE OF THIS POPULATION. FOUR GOALS. ENHANCING HEALTH SYSTEMS CHANGE, EMPOWERING INDIVIDUALS, EQUIPPING PROVIDERS AN ENHANCING RESEARCH GOALS. 15 OBJECTIVES, 45 STRATEGIES WE HAVE SPENT THE LAST 18 MONTHS IMPLEMENTING BOTH PUBLIC AN PRIVATE SECTORS. BUT IT REALLY STARTED OFF IN 2009, 2010, WITH A YEAR-LONG DELIBERATIVE PROCESS OF TRYING TO UNDERSTAND THE EPIDEMIOLOGY, IS TICK CANCEL OF HAVING MULTIPLE CHRONIC CONDITIONS, ITS IMPACT ON MORBIDITY AND MORTALITY, IMPACT ON COSTS, AND HEALTHCARE COST ESTIMATED A QUARTER OF THE U.S. POPULATION THAT HAS MULTIPLE CHRONIC CONDITIONS EQUATES TO TWO-THIRDS OF ALL U.S. HEALTHCARE EXPENDITURES. THEN IT NECESSITATED ACROSS SERVICES INTERAGENT SIX ESSENTIALLY A COORDINATING COMMITTEE, WE CALL IT A WORK GROUP WITH INDIVIDUALS FROM ALL HHS AGENCIES TO BETTER UNDERSTAND WHAT WE'RE DOING FOR PEOPLE WITH MULTIPLE CHRONIC CONDITIONS AND WHAT ARE WE DOING, WHAT CAN WE DO BETTER. WHERE CAN WE WORK TOGETHER BETTER. IT ALSO INVOLVES A VERY IMPORTANT PUBLIC STAKEHOLDER ENGAGEMENT AND INFORMATION PROCESS WHERE WE PUBLISHED A DRAFT FRAMEWORK IN THE FEDERAL REGISTER, HAD HUNDREDS AND HUNDREDS OF COMMENTS FROM INDIVIDUALS AND PUBLIC HEALTHCARE ORGANIZATIONS ACROSS THE COUNTRY WHO THEN WEIGHED IN ON THE FRAMEWORK AND AFTER SORT OF A YEAR OF DELIBERATION WERE ABLElYÖ TO ISSUE AGAIN THIS FRAMEWORK FOR THE DEPARTMENT BUT DEVELOPED BY BOTH PUBLIC AND PRIVATE SECTOR STAKEHOLDERS REALLY FOR THE NATION TO ADDRESS THIS LARGE PUBLIC HEALTH CHALLENGE. FOR THE LAST 18 MONTHS THIS COORDINATING COMMITTEE OR WORK GROUP THAT WE HAVE HAS CONTINUED IN MEETING SORT OF EVERY MONTH WHAT WE DO IS REVIEW EACH OF THE OBJECTIVES IN THE MULTIPLE CHRONIC CONDITION STRATEGIC FRAMEWORK TO SEE IF IMPLEMENTATION IS PROGRESSING. WE HAVE BONA FIDE LEADS FOR EACH OBJECTIVE SO THERE IS AN OPERATIONAL MANAGEMENT STRUCTURE WHICH WE CAN REPORT ON. I WILL MENTION BRIEFLY WITHIN 18 MONTHS SOME OF THE ACHIEVEMENTS WE HAVE BEEN ABLE TO MAKE, WORKING WITH IN THE FIRST GOAL FOSTERING HEALTH SYSTEM CHANGE, THANKS TO THE AFFORDABLE CARE ACT WORKING WITH PUBLIC SECTOR PAYERS LIKE CMS. WE HAVE BEEN ABLE TO PUSH FORWARD NEW PAYMENT AND THEREFORRY ITEMS. WE HAVE BEEN ABLE TO WORK THROUGH PARTNERS SUCH ADMINISTRATION OF IMMUNITY LIVING. EXPANDING SELF-CARE AND SELF-CARE MANAGEMENT APPROACH, EVIDENCE BASED SELF-CARE MANAGEMENT APPROACHES FOR INDIVIDUALS WITH MULTIPLE CHRONIC CONDITIONS. WE HAVE BEEN ABLE TO WORK WITH PRIVATE SECTOR ENTITIES LIKE THE QUALITY FORUM DEVELOPED A MEASUREMENT FRAMEWORK TO BETTER UNDERSTAND WHAT THE FOCUS ON IN CARING FOR PEOPLE WITH MULTIPLE CHRONIC CONDITIONS. AND WE INVESTED HEAVILY IN RESEARCH TO BETTER FIGURE OUT WHAT WORK, WHAT DOESN'T WORK IN TERMS OF EFFECTIVE TREATMENT FOR HETEROGENEOUS POPULATION AS WELL AS BASIC EPIDEMIOLOGY TO FIGURE WHAT ARE THE SUB POPULATIONS IN THIS HETEROGENEOUS GROUP WE CALLED MULTIPLE CHRONIC CONDITIONS WE OUGHT TO FOCUS ON WHO ARE MOST -- AT HIGHEST RISK. SO JUST A COUPLE L OF KEY EXAMPLES. AGAIN, IT'S AN INITIATIVE THAT WORKS. BECAUSE ALL OF THE AGENCIES ACROSS THE DEPARTMENT ARE INVESTED. EXTERNAL STAKEHOLDERS LIKE NATIONAL COUNCIL ON AGING AND OTHERS REALIZE THE IMPORTANCE OF THIS AND STEPPED UP. IT'S IMPORTANT BECAUSE EVERYONE AND DR. KOH PUT IT BETTER THAN ANYONE, CAN RELATE TO. WE ALL KNOW AND HAVE FAMILY MEMBERS OR TREATED INDIVIDUALS WHO HAVE FIVE, SIX, SEVEN, EIGHT, NINE, CURRENT CONDITIONS AND THE COMPLEXITIES OF CARING THAT POPULATION WHICH IS INCREASING IS SOMETHING TO GRASP. SO THAT'S AN EXAMPLE OF A STRATEGIC PLANNING PROCESS THAT WORKED FAIRLY WELL. THERE'S NO PERFECT PROCESS, WE HAVE OTHER EXCEPTIONAL STRATEGIC PLANNING EFFORTS THAT THROUGH DR. KOH OVERSIGHT HAS LED. WHETHER TOBACCO, HIV AIDS, HEPATITIS, ALZHEIMER'S AS WELL. SO ALL COULD BE MODELS FOR THIS COORDINATING COMMITTEE AS YOU TAKE ON THE BROADER CHARGE BUT THAT'S ONE ASPECT WHERE WE CAN PERHAPS BE VERY HELPFUL TO ALL OF YOU. SO LET ME STOP THERE AND TURN IT OVER BACK TO DR. KOH. >> STORY, YOU WANTED SOME COMMENTS? THEN OPEN IT UP? >> I OPEN IT UP TO THE COMMITTEE. CARMEN. >> THANK YOU. GLAD TO KNOW DR. PAREK WENT TO A GOOD SCHOOL, VERY GOOD SCHOOL. BUT I WANT TO THANK YOU FOR YOUR TIME AND WILLINGNESS TO COME IN, BROADEN THE CHARGE. IT'S CERTAINLY A GREAT OPPORTUNITY, SO WE THANK YOU FOR THE OPPORTUNITY TO PROVIDE THAT LEADERSHIP. THE OTHER THING I WOULD POINT OUT IS THAT WHEN WE TALK POPULATION, HEALTH, IN A DIAGNOSIS, TREATMENT, ASSESSMENT, AS RELATES TO PAIN, IS THE WHOLE CONCEPT OF DISPARITIES SO THERE'S THE OPPORTUNITY TO LINK THESE COMMENTS, THOSE TWO ACTIVITIES. I WOULD ENCOURAGE US TO DO SO AND ENCOURAGE YOU TO GIVE RESOURCES NECESSARY TO DO THAT. WHETHER WE'RE TALKING ABOUT RACE, ETHNICITY, PRIMARY LANGUAGE OR OTHER TYPES OF SOCIAL DETERMINANTS. WHERE A PERSON LIVES, THAT SPEAKS TO THE QUALITY OF CARE FROM A COST PERSPECTIVE, A QUALITY PERSPECTIVE OR AN ACCESS PERSPECTIVE. >> WE WOULD BE HAPPY TO DO THAT, WE HAVE RACIAL ETHNIC HEALTH DISPARITY STRATEGIC PLAN THE SECRETARY AND I UNVEILED 18 MONTHS AGO. REDUCING ELIMINATING DISPARITIES —PA„ PART OF THE HEALTHY PEOPLE OVERARCHING GOALS. IT'S A MAJOR THEME THROUGHOUT THE AFFORDABLE CARE ACT. I OFTEN SAY THE MAJOR GOAL TO GET MORE TO INSURANCE IS A DISPARITIES INITIATIVE BECAUSE RACIAL ETHNIC MINORITIES MAKE A THIRD OF THE POPULATION AND HALF ARE UNINSURED. SO DISPARITY THEME RUNS THROUGH EVERY PUBLIC HEALTH CHALLENGE WE HAVE SO GLAD TO ADVISE ON THAT. AND WE HAVE PLACES LIKE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY PUTTING OUT DISPARITIES NATIONAL REPORTS FOR MANY, MANY YEARS. SO THOSE ARE THE WAYS WE CAN HEALTH CONNECT THIS VERY IMPORTANT GROUP CONNECT WITH THE REST OF THE DEPARTMENT AND TRY TO BRING IN APPROPRIATE AMBASSADORS TO HELP YOU. >> DR. KOH, SEAN MACKEY FROM STANFORD. APPRECIATE YOU BEING HERE. IT CLEARLY SHOWS THAT HHS IS INTERESTED IN THIS ISSUE AND COMMITTED TO IT. >> THANKS FOR BEING ON THE IOM COMMITTEE TOO. >> IT WAS HONOR. IT REALLY WAS. I WANT TO EXPRESS CONCERNS ABOUT THIS ADDITIONAL CHARGE. THERE WAS A LARGE NUMBER OF PEOPLE THAT CONTACTED ME VIA EMAIL FROM DIFFERENT PROFESSIONAL ORGANIZATIONS, PATIENT ADVOCACY, AND I DISCUSSED WITH OTHER MEMBERS WHO ARE ALSO ON THE IOM COMMITTEE WHETHER OR NOT THIS GROUP IS THE RIGHT ONE TO TAKE ON THAT INCREDIBLY IMPORTANT MISSION. THERE ARE CONCERNS THAT THE SCOPE AND BREADTH IS SO FAR BEYOND WHAT THIS COMMITTEE IS CHARGED WITH, NOT ONLY THAT, THIS COMMITTEE DOESN'T HAVE THE RIGHT MAKEUP, THE OPINION LEADERS ARE NOT HERE, THE COMMITTEE WAS PICKED TO ADDRESS RESEARCH ISSUES. ADS EVIDENCED BY RECOMMENDATION 5.1 IN THE IOM REPORT. I'M CONCERNED IF WE TAKE ON THE BROADER ISSUE OUR ABILITY TO ANSWER THAT RECOMMENDATION, OUR ORIGINAL CHARGE WILL BECOME FRAGMENTED. I'M ALSO CONCERNED WHETHER OR NOT WE HAVE THE RESOURCES HERE TO BE ABLE TO ADDRESS THIS PARTICULAR ISSUE. ON THE OTHER HAND, IF A DECISION IS MADE, I THINK WHAT YOU'LL FIND IS I'LL WORK MY BUTT OFF AND DO EVERYTHING I CAN TO DO THE BEST JOB POSSIBLE. I KNOW ALL THE PEOPLE HERE ARE GOING TO DO THIS SAME. BUT I WANT TO PUT BACK TO YOU WHETHER THERE'S ANY POSSIBILITY OR CONSIDERATION TO RETHINKING THIS AND PUTTING TOGETHER THE RIGHT KIND OF COMMITTEE TO BE ABLE TO ADDRESS THIS JUST THIS INCREDIBLY BROAD, IMPORTANT PROBLEM, THAT FACES AMERICA. I CAN SHARE THERE ARE SO MANY PEOPLE LOOKING IN ON THIS COMMITTEE RIGHT NOW AND THIS SITUATION TO FIGURE OUT WHERE HHS IS GOING. >> QUESTION IS FAIR. AS ONE WHO TACKLED MANY OF THESE CROSS DEPARTMENTAL PLANNING ISSUES ON BEHALF OF THE SECRETARY, EACH ONE HAS ITS OWN SET OF CHALLENGES. EACH ONE HAS ITS OWN STRENGTHS AND WEAKNESSES IN TERMS OF APPROACHES. THE IDEAL WAY IS TO GALVANIZE THE DEPARTMENT AND TAP INTO SOME WONDERFUL POT OF RESOURCES THAT WERE AVAILABLE AND DO THIS IN SOME EXTREMELY COMPREHENSIVE WAY THAT WOULD COME UP WITH A PLAN QUICK LINNED DRESS RECOMMENDATIONS THAT THE IOM PUT FORWARD. WE'RE IN A PERIOD, I WANT TO STRESS DR. MACKEY, WE HAVE HAD CONVERSATIONS WITH MANY INSIDE DEPARTMENT AND OUTSIDE DEPARTMENT ABOUT EXACTLY HOW TO DO THIS. SOME CONVERSATIONS WENT TO THE HIGHEST LEVEL. WE HAVE ONE OF OUR LEAD ADVOCATES HERE, MS. BEASLEY WHO CAME IN TO TALK TO US ABOUT HOW THIS COULD BE DONE. WE WEPT BACK AND FORTH HOW TO ADDRESS THIS ISSUE -- WENT BACK AND FORTH HOW TO ADDRESS THIS ISSUE. YOU KNOW FROM THE NEWS THE BUDGET ISSUES ARE EXTRAORDINARY, WE'RE FACING A POTENTIAL FISCAL CLIFF AND THOSE SORTS OF THINGS. BUDGETS ARE BEING CUT B NOT ADDED TO. OUT OF SHEER PRACTICALITY WE HAD TO START WITH WHERE THERE WAS ACTION GOING ON AND WHERE THERE WAS CONCENTRATION OF RESOURCES. DR. LANDIS, TABAK AND I HAD A NUMBER OF CONVERSATIONS AND AFTER SOME TIE LOG ACTUALLY DR. LANDIS AND TABAK WHO STEPPED BACK AND SAID IF WE'RE DISCUSSING THIS AND NOTHING IS HAPPENING, THE LEAST WE CAN DO IS TAKE TOGETHER THIS NEW IPRCC AND PUT ITS RESOURCES OBJECT TABLE TO BEGIN -- ON THE TABLE TO BEGIN THE PROCESS. WE THOUGHT WE'D START HERE BECAUSE YOU HAVE AGENCIES OF NIH ALREADY HERE. YOU HAVE SOME OF THE ESSENTIAL ESSENTIAL STAKEHOLDERS REPRESENTED HERE. YOU'RE IN GOOD POSITION TO GET INPUT FROM PUBLIC AND PRIVATE ORGANIZATIONS. AND WE CAN HELP BRING IN OTHER PARTS OF THE DEPARTMENT, ONCE YOU IDENTIFY WHAT YOU THINK THOSE PARTNERS MAY NEED TO BE. YOU MAY COME TO A POINT AT SOME JUNCTURE THAT YOU DON'T THINK THIS IS THE RIGHT PLACE. THEN WE HAVE TO REVISIT. BUT IN AN IMPERFECT WORLD WE THOUGHT WE WOULD START HERE BECAUSE YOU HAVE MOMENTUM GOING ON AND COORDINATION GOING ON AT ONE OF THE BIGGEST AGENCIES IN THE DEPARTMENT TO BEGIN. SO THAT'S WHY WE'RE HERE. STORE RAY, YOU MAY WANT TO SAY MORE. (OFF MIC) >> I AM HONORED, I WAS ALSO HON IN ORDER TO SERVE -- HONORED TO SERVE ON THE IOM COMMITTEE AND HONORED TO BE HERE TODAY. I SHARE SOME OF SEAN'S CONCERNS. HOWEVER, I WAS VERY EXCITED WHEN I SAW THE EMAIL FROM STORY THAT THIS WAS LIKELY TO HAPPEN. WE ARE A YEAR AND A HALF OUT FROM PUBLICATION OF THE REPORT AND ONE OF MY REAL CONCERNS IS THAT IT IS GROWING WHOLE, IT IS LOSING HOME UM. AND -- MOMENTUM. I AGREE WITH WHAT DR. PAREK SAID ABOUT THE MULTIPLE CHRONIC CONDITION GROUP, THAT THE REASON IT WORKED WAS THAT OTHER STAKEHOLDERS KNEW THAT IT WAS TIME TO DO SOMETHING AND THEY WERE WILLING TO WORK COLLABORATIVELY WITH THE GROUP. I BELIEVE THAT IS VERY TRUE TODAY. THERE ARE MANY ORGANIZATIONS, MANY GROUPS AROUND THE COUNTRY, PROFESSIONAL SOCIETIES, ADVOCACY GROUPS, THINK TANKS AND OTHERS YEARNING FOR A PLACE TO INTERFACE WITH NIH, WITH THE DEPARTMENT. SO I THINK WE CAN MAKE THIS WORK. I'M LIKE SEAN, I THINK IT IS NOT WHAT WE HOPED FOR WHEN WE DRAFTED THE PLAN, MADE THE RECOMMENDATION BUT IT IS NOT A PERFECT WORLD. WE ARE ALL VERY AWARE OF THAT. I WOULD MAKE ONE OTHER COMMENT AND ASK OTHERS TO JOIN IN. I HEAR YOU TALKING ABOUT THIS AS STRATEGIC PLANNING. I WOULD ARGUE THAT THE IOM COMMITTEE SET GOALS UNIVERSEAL AND VERY PARTICULAR, VIA THE BLUEPRINT. SEEMS TO ME WHAT IS REALLY NECESSARY IS WE OPERATIONALLIZE THAT PLAN. I THINK THIS GROUP AND OTHERS THAT WOULD BE MORE THAN HAPPY TO COME AND PARTICIPATE IN WHATEVER WAYS CAN GET IT DONE. IT'S TIME THE GET IT DONE. >> ANOTHER ANALOGY I MAY SHARE BECAUSE DR. LANDIS IS AT THE HEART OF IT, WE HAVE HAD SOME VERY IMPORTANT CROSS GOVERNMENT CONVERSATIONS ABOUT EPILEPSY AND THE PUBLIC HEALTH ASPECTS OF EPILEPSY, THE EPILEPSIES, PLURAL. DR. LANDIS AND I HAVE HAD MULTIPLE CONVERSATIONS WITH EXPERTS LIKE YOURSELVES AND ADVOCATES AND OUTSIDE COLLEAGUES ABOUT THEIR ACROSS DEPARTMENT COLLABORATION ON EPILEPSY. SO YOU CAN SEE HOW THIS CONVERSATION GOES. THERE'S JUST SO MANY CRITICAL PUBLIC HEALTH ISSUES AND THE QUESTION HOW WE GET ANY FORWARD MOVEMENT IN AN IMPERFECT WORLD. IN THAT PARTICULAR CASE WE WERE ABLE TO FUND AN IOM STUDY AGAIN, WHAT WE DID WITH THAT, STORY AND I ARE PART OF THIS AND DAN JONES, DEPUTY PRINCIPLE IN MY OFFICE, WE HAVE A COORDINATING WE CAN REACH BY PHONE, WE HAVE THE IOM RECOMMENDATIONS AHEAD OF US AND SAY WHO IS DOING WHAT ACROSS THE DEPARTMENT ON THESE SET OF RECOMMENDATIONS AND WE'RE BUILT -- SLOWLY BUILDING A CROSS-DEPARTMENT COMMUNITY THAT'S COMMITTED TO MAKING THESE IOM RECOMMENDATIONS MOVE FORWARD. THAT GROUP HAS BEEN MEETING WITH NO BUDGET -- MOSTLY BY PHONE, SINCE THE RELEASE OF THE REPORT, BUT GAINING ENOUGH TRACTION THAT AT A NATIONAL MEETING IN CALIFORNIA IN DECEMBER THAT DR. LANDIS AND I ARE SPEAKING ABOUT, WE ARE READY TO GET UP AND TALK ABOUT SOME OF THE ACCOMPLISHMENTS THAT THE DEPARTMENT MADE BECAUSE THAT REPORT CAME OUT. IF WE CAN DO SOMETHING SIMILAR HERE WITH THE IOM PAIN REPORT, KNOWING IT'S NOT PERFECT BUT IT IS A BEGINNING, GET SOME MOMENTUM, GET BUY-IN ACROSS THE DEPARTMENT, STARTING WITH NIH, MAYBE WE CAN GET THROUGH FOR EXAMPLE THIS INCREDIBLE FISCAL CHALLENGE FACING US AT THE END OF THE YEAR, GET ON THE OTHER END AND ACCELERATE THE MOMENTUM IN THE NEW YEAR. THOSE ARE THINGS THAT COME TO MY MIND BECAUSE THERE'S NO ONE WAY TO DO THIS. LIKE YOU, WE FELT THAT IF WE DIDN'T COME TO THIS MEETING TODAY, THIS COULD SIT AROUND FOR WAY TOO LONG. THAT'S WHY MR. PAREKH MADE THE COMMITMENT TO COME HERE AND PUT ON THE TABLE. >> IF I CAN ADD A COUPLE OF TANGIBLE EXAMPLES OF HOW DR. KOH'S OFFICE CAN BE HELPFUL HERE. AGAIN, I THINK IT'S BRINGING KEY AGENCIES IN HEALTH AND HUMAN SERVICES TO THE TABLE. THE IOM RECOMMENDATION FOR EXAMPLE INCLUDES REIMBURSEMENT, TREATMENT, MANAGEMENT, REIMBURSEMENT PART OF THE POPULATION HEALTH STRATEGY. IT'S HARD TO TALK ABOUT SOME OF THOSE ISSUES WITHOUT THE LARGEST PAYER IN THE COUNTRY, AND CMS NOT AT THE TABLE. SO MAKING SURE CENTERS FOR MEDICARE MEDICAID SERVICES IS HERE WITH YOU AS YOU DELIBERATE AND HEARING FROM THEM HOW PERHAPS NOVEL PAYMENT AND DELIVERY MODELS CAN IMPROVE HEALTH OUTCOMES FOR PEOPLE WITH CHRONIC PAIN. THE RECOMMENDATION INCLUDES TRAINING AND WORK FORCE. AND P SO BRINGING HEALTH RESOURCE SERVICE ADMINISTRATION AND HRSA TO THE TABLE THAT FUNDS MANY WORK FORCE TRAINING PROGRAMS ACROSS THE COUNTRY TO HELP SUPPORT ALL OF YOU I THINK IS CRITICAL. THE ADMINISTRATION COMMUNITY LIVING WHICH FUNDS AND SUSTAINS SELF-CARE MANAGEMENT PROGRAMS ACROSS THE COUNTRY, THESE ARE KEY AGENCIES, NOT NECESSARILY REPRESENTED BY INDIVIDUALS CURRENTLY ON THIS COORDINATING COMMITTEE. BUT ENTITIES THAT WE CAN BRING TO THE TABLE SO Y'ALL CAN DRAW FROM THEIR INFORMATION TO CREATE THE BEST STRATEGY. WE TALKED ABOUT THE NETWORK OF OFFICE OF MINORITY HEALTH WE HAVE ACROSS THE COUNTRY TO ADDRESS DISPARITIES IN SUBGROUPS AND SUBPOPULATIONS. ALSO TO MAKE SURE THAT WHAT THIS COMMITTEE COMES UP WITH LINKS TO KEY PREVENTION INITIATIVES ACROSS THE DEPARTMENT. THE TWO LEADING PREVENTION INITIATIVES ARE HEALTHY PEOPLE 2020 AND THE NATIONAL PREVENTION STRATEGY. ENSURING THE GOALS AN METRICS WHEN WE TALK ABOUT PREVENTING CHRONIC PAIN ARE ALIGNED WITH THE METRICS OF HEALTHY PEOPLE 2020 AND GOALS OF THE NATIONAL PREVENTION STRATEGY ARE CRITICAL. SO THOSE ARE TANGIBLE CONCRETE RECOMMENDATIONS THAT DON'T TAKE A BUDGET. DON'T TAKE EXTRA DOLLARS BUT WAYS WE CAN BE SUPPORTIVE TO YOUR EFFORTS. >> SO JUST AS A FOLLOW-UP TO THAT. I APPRECIATE, I ASKED YOU A DIFFICULT QUESTION AND CHALLENGE THIS IDEA. I HOPE YOU UNDERSTAND WHERE IT'S COMING FROM. WE WANT TO DO THE BEST JOB WE CAN. >> I COMPLETELY UNDERSTAND. >> WE WANT THIS IOM REPORT -- >> AND I RESPECT THAT TOO. >> TO HAVE A LARGE IMPACT ON THE NATION BECAUSE THERE IS SUCH A LARGE PROBLEM. WE DO APPRECIATE -- I APPRECIATE, EEL TAKE OWNERSHIP BECAUSE I ASKED THE QUESTION. I APPRECIATE THAT THERE ARE BUDGET PRACTICALITIES. AND WE'RE BETTER OFF GETTING THINGS STARTED THAN WAITING FOR THAT IDEAL SITUATION THAT MAY NEVER ARISE. >> THANK YOU. THANK YOU. >> SO CARMEN, YOU WANT TO MAKE ONE LAST COMMENT? >> SO I WILL CONFESS THAT I WAS ACTUALLY SOMEWHAT RESPONSIBLE FOR THIS WHEN I WAS ROBERT WOOD JOHNSON HEALTH POLICY FELLOW AS FAR AS PUTTING IN SOME OF THE LANGUAGE FOR THIS PARTICULAR BILL. I WOULD ALSO REMIND FOLKS THAT THE IOM PIECE WAS ONLY PART OF THE PARTICULAR PIECE OF LEGISLATION. WHETHER OR NOT AND THE IOM AS MUCH AS I LOVE THE IOM, THEY WERE GIVEN A CHARGE. THEY DIDN'T GO THROUGHOUT THE ENTIRE PIECE OF LANGUAGE SO I WOULD ASK FOR YOUR GUIDANCE IN REGARDS TO OTHER THINGS THAT MAY HAVE BEEN LEFT ON THE TABLE. I CAN GIVE YOU SOME TIME TO THINK ABOUT THIS. THAT MAY ALSO BE WORTHWHILE AS FAR AS INCORPORATING INTO THIS PARTICULAR CHARGE. >> WE'RE OPEN TO HEARING ANY SUGGESTIONS, ANY IDEAS HOW TO MAKE THIS MOVE FORWARD. WE CAME TODAY TO TRY TO GET THIS LAUNCHED WITH YOUR GREAT EFFORTS EVERY TIME WE'RE ASKED TO BE INVOLVED IN STRATEGIC PLANNING ING, THE STORY IS DIFFERENT DEPENDING ON THE TOPIC. SO THIS ONE IS AN AREA WHERE WE FELT THIS COORDINATING COMMITTEE HAD SOME MOMENTUM AND WAS REALLY BRINGING COORDINATION ACROSS NIH WHICH IS SUCH A HUGE IMPORTANT AGENCY. SO WE THOUGHT TO START THERE, BUT WE WANT TO START HERE BUT KEEP LISTENING TO YOUR SUGGESTIONS, THOUGHTS, IDEAS, CRITICISMS. AND I'M VERY GRATEFUL TO STORY AND LARRY BECAUSE WE HAVE HAD MULTIPLE, MULTIPLE CONVERSATIONS ABOUT CAN WE DO THIS, SHOULD WE TRY TO DO THIS, IS THIS THE RIGHT FORUM AND WE DECIDEED IN IMPERFECT WORLD THIS IS THE PLACE TO START. STORY YOU MAY WANT TO CONCLUDE HERE BY -- >> WE ARE READY TO TAKE ON THIS ADDITIONAL RESPONSIBILITY. AS YOU CAN SEE. THERE'S SOME TREPIDATION. I WOULD SAY ONE OF THE MOST IMPORTANT THINGS WILL BE TO KNOW THAT WE HAVE THE SUPPORT OF THE DEPARTMENT AND THAT AS WE BEGIN TO MOVE FROM THE RESEARCH ENTERPRISE INTO REIMBURSEMENT AND OTHER ACTIVITIES THAT YOU WILL HELP US CONNECT UP WITH THE RIGHT PEOPLE AT THE DEPARTMENT. AND THAT THOSE PEOPLE WILL HAVE THE SAME COMMITMENT TO MAKING THIS COME TO FRUITION AS THIS COORDINATING COMMITTEE WILL. SO WE'LL BE IN TOUCH. >> AND WE'RE HERE TO HELP. >> GREAT. THANKS. >> AS I END LET ME GO AND THANK EACH AN EVERY ONE OF YOU. I KNOW WHETHER A HUGE COMMITMENT THIS IS, HOW IMPORTANT THIS TOPIC IS. WE'RE VERY INSPIRED THAT YOU EVEN EXIST, YOU WANT TO TRY TO DO THIS, AND AS MULTIPLE PEOPLE HAVE SAID, THE IOM MADE ITS RECOMMENDATION AND WE WANT THAT TO COME ALIVE AND MAKE A DIFFERENCE. WE FEEL WE CAN DO THIS IN PARTNERSHIP WITH YOU AND LEADERSHIP OF PEOPLE LINE STORY AN LARRY AS WELL. THANK YOU VERY MUCH. [APPLAUSE] >> STORY THIS IS A SIMPLE AND MAYBE SEEMINGLY TRIVIAL THING. DO WE CHANGE OUR ANYMORE NOW? >> NO. I DON'T THINK WE -- NO. THAT'S IN THE LEGISLATION. I DON'T THINK YOU CAN CHANGE OUR NAME I DON'T THINK WE CAN CHANGE OUR NAME WITHOUT CHANGING THE LEGISLATION. BUT I THINK WE CAN CERTAINLY DO A GOD JOB IF NOT OUTSTANDING JOB OF TAKING ON THIS ADDITIONAL RESPONSIBILITY. >> MAYBE WE COULD CREATE A TAG LINE. >> A TAG LINE. >> STORY, IS IT POSSIBLE -- I KNOW IT'S A CHARTER COMMITTEE BUT TO ADD AD HOC MEMBER WHEN WE NEED THEM? >> I THINK WHEN WE AGREED IN PRINCIPLE TO TAKE THIS ON, WE RECOGNIZED THAT PROBABLY THE BEST WAY TO GO FORWARD WOULD BE TO CREATE A WORKING GROUP OF THIS COMMITTEE, WHICH WOULD INCORPORATE SOME MEMBERS OF THE COMMITTEE AND ALSO WOULD INCLUDE A NUMBER OF REPRESENTATIVES FROM OTHER ORGANIZATIONS ABOUT HEALTH AND HUMAN SERVICES, TO FLESH OUT THE EXPERTISE AND KNOWLEDGE THAT WE DON'T HAVE ON THIS COMMITTEE. WHEN THEY'RE GONE WE'LL BEGIN TO FIGURE OUT WHAT WE'RE GOING TO DO NEXT. P >> SO WE ALL NEED TO TAKE A DEEP BREATH -- [LAUGHTER] >> SOME DAYS I LOOK AT THAT GLASS AND I THINK IT'S OVERFLOWING. SOLARRY TABAK HAS PROMISED US SOME ADDITIONAL SUPPORT TO HELP WITH THIS. WE'LL BE ABLE TO HIRE PROBABLY A CONTRACTOR OR ADDITIONAL PERSON. I'D LIKE TO SET UP A WORKING GROUP OF THIS COMMITTEE THAT WANTS TO BE BOOTS ON THE GROUND WORKING ON THIS EFFORT. THAT WORKING GROUP WILL REMAIN IN CLOSE COORDINATION WITH THE COORDINATING COMMITTEE. BUT I DON'T -- (OFF MIC) THE MISSION IS TO COME UP WITH A NATIONAL STRATEGIC PLAN. AS WAS DESCRIBED FOR THE MULTIPLE CHRONIC CONDITIONS THAT MEANS HAVING A DRAFT REPORT UP ON THE FEDERAL REGISTER WILL GET ALLKINE OF INPUT AND THEN THERE -- ALL KINDS OF INPUT. FOR THOSE WHO HAVEN'T SEEN IT, THERE IS A COPY OF THE DOCUMENT, YOU CAN PULL IT OFF THE WEBSITE. THIS IS NOT AN UNREASONABLE GOAL FOR US TO REACH, IT'S NOT PERHAPS AS DETAILED AS IT MIGHT BE. CERTAINLY DOESN'T HAVE A TIME LINE, CERTAINLY DOESN'T HAVE THE KIND OF TEETH THAT MAYBE WE WOULD LIKE. BUT HA I HEARD SAID WAS THAT ONCE THIS WAS DRAFTED AN REVISED AND ACCEPTED, THAT THE DEPARTMENT HAS WORKED VERY HARD ON IMPLEMENTING IT. WE HAVE TO COUNT ON THE DEPARTMENT WORKING AS HARD ON IMPLEMENTING -- (OFF MIC) >> NO. I'M THINKING YOU'RE GOOD ON THE PHONE. WE HAVE TO MAKE SURE THE DEPARTMENT WORKS AS HARD ON IMPLEMENTING WHATEVER WE COME UP WITH THEY HAVE APPARENTLY ON THIS. SO WE'RE GOING TO NEED LOTS OF PEOPLE FROM THE OTHER HHS AGENCIES WHO WILL BE WILLING TO WORK WITH US ON THIS. SO WHO -- (OFF MIC) >> RIGHT. THERE'S A SECOND -- WE CAN PASS AROUND AS LONG AS IT'S RETURNED TO ME. THERE'S A SECOND DOCUMENT WITH AN INVENTORY PROGRAMS ACTIVITY AND INITIATIVES FOCUSED ON IMPROVING THE HEALTH OF INDIVIDUALS WITH MULTIPLE CHRONIC CONDITIONS. I ASSUME WE WILL P PUT TOGETHER A SIMILAR DOCUMENT ON THE AGENCY PROGRAMS ACTIVITIES AND INITIATIVES RELATED TO PAIN IN THE DEPARTMENT. MY BET IS THAT WE WILL FIND THERE'S LOTS OF STUFF WE DIDN'T KNOW ANYTHING ABOUT THAT'S ALREADY GOING ON AND MAY NOT BE COORDINATED AS WELL AS IT MIGHT BE. SEAN. >> STORY, AND MICHAEL GETTING BACK ABOUT WHAT DOES THIS MEAN? THE WAY THE IOM REPORT CAME OUT, THIS INITIATIVE, THIS NATIONAL HEALTH LEVEL PLAN, IS REALLY MEANT TO BE THE GLUE THAT BRINGS TOGETHER THE OTHER IOM RECOMMENDATIONS, THE FOUNDATION UPON WHICH EVERYTHING IS THEN BUILT OFF OF. SO THE QUESTION IS, STORY, DO YOU HAVE A SENSE OF THE SCOPE OF WHAT WE'RE TAKING ON IN THESE NEXT SEVERAL STEPS? SHOULD WE BE THING BRAINSTORMING HOW TO PUT ALL THIS TOGETHER. AND DETHE FINEING WHAT THE SCOPE IS, DEFINING HOW BROAD THIS IS GOING TO BE. >> RIGHT. SO WE ARE GOING TO NEED TO DO ALL OF THAT. THE QUESTION IS DOES EVERYBODY AROUND THE TABLE RIGHT NOW WANT TO BE A PART OF THAT NITTY GRITTY BOOTS ON THE GROUND WORK OR DO YOU WANT TO DELEGATE TO A SUBSET OF THE MEMBERS OF THIS COORDINATING COMMITTEE RESPONSIBILITY FOR THAT ACTIVITY WITH THE UNDERSTANDING THAT THERE WOULD BE REGULAR REPORTS BACK TO THE PARENT COMMITTEE TO KEEP EVERYONE INFORMED AND ALLOW EVERYONE TO PARTICIPATE. SOME PEOPLE WOULD PARTICIPATE MUCH MORE DIRECTLY THAN OTHERS. ONE OF THE FIRST MEETINGS WOULD INVOLVE GETTING A BETTER UNDERSTANDING FROM DR. PAREKH ABOUT EXACTLY HOW HE GOT THIS OTHER DOCUMENT DONE AND TO LOOK AT THIS OTHER DOCUMENT AND DECIDE HOW GOOD A MODEL IS IT, WHAT ADDITIONS, WHAT SUBTRACTIONS DO WE WANT THAT AS A BLUEPRINT. SO HAVING -- SO THIS WILL BE A LOT OF WORK. AND MAY NOT BE CORE TO EVERYBODY'S INTEREST. SO JUST A SHOW OF HANDS TO SEE WHO WANTS TO BE ON THE WORKING GROUP. SEAN MYRA -- SOMEBODY WRITING THESE DOWN? CHRIS. OKAY. GOOD. (OFF MIC) >> MIKE, TO BE PERFECTLY HONEST, I DON'T THINK IT'S YOUR CUP OF TEA AND YOU SHOULD NOT IN ANY WAY FEEL THAT I AM DEMEANING YOUR COMMITMENT TO THE TOPIC OF PAIN. SO THERE ARE PEOPLE ON THE IOM COMMITTEE, PEOPLE HAVE EXPERIENCE, AND EVERYONE SITTING AROUND THE TABLE IS PART OF THE PROCESS. DO YOU WANT TO BE EATING THE CAKE WHEN IT'S BAKED OR DO YOU WANT TO BE GOING OUT AND CATCHING THE CHICKENS TO GET EGGS AND >> LOOKING AT THE MULTIPLE CHRONIC CONDITIONS DOCUMENT, IT HAS THESE FOUR CHAPTERS, FOSTERING HEALTHCARE AND PUBLIC HEALTH CHANGE. SELF-CARE, TOOLS FOR PROVIDERS AND THEN THE FOURTH IS RESEARCH. TO A CERTAIN EXTENT WE HAD ALREADY VIEWED NUMBER 4 AS OUR CHARGE. SO ONE WAY TO THINK ABOUT THE NEW SET OF TASKS IS WE'RE ASKING TO TAKE WHAT HAS GONE ON IN THE IOM AND MAP THE NON-RESEARCH PART AGAINST THIS POTENTIAL OUTLINE AND SEE HOW WELL IT WORKS. MAYBE SOME STICK WITH RESEARCH NUMBER 4 AND OTHER PEOPLE SAY WE HAVE INTEREST IN 1, 2 AND 3 AND WE'LL THINK ABOUT THAT. ONE, TWO AND THREE, NUMBER ONE IS FOSTER HEALTHCARE AND PUBLIC HEALTH SYSTEM CHANGE. TWO AND THREE INVOLVE SELF-CARE AND TOOLS FOR PROVIDERS. SO IF YOU GOOGLE MULTIPLE CHRONIC CONDITIONS YOU'LL PULL THE DOCUMENT UP. I THINK YOU COULD SIMPLY TAKE THAT DOCUMENT YOU COULD -- WE COULD IF WE CHEESE TAKE THAT DOCUMENT, SUBSTITUTE PAIN, FIX A COUPLE OF PARAGRAPHS AND BE DONE. I DON'T HAVE THE SENSE THAT ANY OF US WOULD BE COMFORTABLE DOING THAT. THE THING IS, SO MUCH WORK HAS ALREADY HAPPENED IN THE SETTING OF THE IOM THAT HAVING PEOPLE WHO KNOW THE IOM REPORT INSIDE OUT AND THINKING ABOUT THIS STRUCTURE AND HOW ONE MOVES BEYOND THE IOM REPORT SEEMS TO BE THE NEXT -- BUT WHAT I WAS TRYING TO SUGGEST IS IT'S NOT AS DAUNTING AS I HAVE MADE IT SOUND. >> RIGHT. WE DON'T HAVE TO START OVER. >> OKAY. >> SIMILARLY, THE REPORT IS STRUCTURED IN A VERY SIMILAR WAY. IF YOU JUST LOOK AT CHAPTER HEADINGS AND CROSS WALK WITH THE RECOMMENDATIONS AND CROSSWALK WITH WHAT WAS REFERRED TO AND THEIR OTHER GREAT EXAMPLES THAT WE CAN PULL FROM, THE MAY DAY REPORT THAT WAS PUBLISHED IN 2010, THIS IS A BIG TASK. BUT IT IS A REALLY IMPORTANT ONE AND I ACTUALLY BELIEVE WHAT JOCIE SUGGESTED IS A VERY GOOD ONE. I WAS COMPLETE CONFIDENCE IN THAT GROUP WITH REGARD TO THE RESEARCH. BUT AS I PROBABLY INDICATED WITH MY OTHER COMMENTS, HERE IS A WHOLE WORLD OUT THERE BEYOND NIH THAT IS ENGAGED IN THIS. >> WELL BEYOND THE VA, FDA, CDC. >> SURE. >> WE'RE JUST A SUBSET OF THE FEDERAL AGENCIES THAT NEED TO BE INVOLVED. >> BECAUSE THEY'RE NOT FOR PROFITS AND CORPORATE ENTITIES AND LOTS OF FOLKS WHO ARE WANTING TO MAKE THE (INAUDIBLE). >> RIGHT. I THINK WHAT WE'LL HAVE TO KEEP IN MIND IS THAT THIS GROUP WILL NOT BE RESPONSIBLE FOR IMPLEMENTING THAT PLAN. AND THAT WE WILL NEED TO HAVE IN MIND AS WE WRITE THE PLAN WHAT IS WHEREINABLE TO EXPECT TO HAVE IMPLEMENTED OVER WHAT TIME PERIOD. OKAY. RON. >> RECAPITULATE THE TIME AND EFFORT THAT WAS INVOLVED F THAT YOU SPENT IN TERMS OF THE IOM REPORT IN PREPARATION OF THAT REPORT. AND I SORT OF GET THE SENSE THAT WE'RE BEING ASKED TO DO THE SAME THING, THE SAME THING ASKED TO WRITE AN IOM REPORT ON MULTIPLE CHRONIC CONDITIONS. I DON'T QUITE UNDERSTAND (OFF MIC) >> IOM REPORT A -- (OFF MIC) >> SIMILAR TO THE IOM REPORT ON PAIN? >> (OFF MIC) >> THE IOM PAIN REPORT WAS DONE IN A SOMEWHAT UNUSUAL MANNER, THEY TAKE PLACE OVER ABOUT 18 MONTHS. OURS TOOK PLACE OVER SEVEN. SO WE HAD WITH ONCE A MONTH MEETINGS MOSTLY HERE AT THE NIH. AND THERE WAS -- THEY HAD AN INCREDIBLE STAFF. THEY HAVE APPROXIMATE INCREDIBLE STAFF THAT HELPS WITH THE CORE WRITING. WE DID A LOT OF E KITTING AND BASIC WRITING AS WELL. THERE WAS MANY HOURS WORTH OF WORK. IT'S LESS THE WORK CONCERNING TO ME, IT'S MORE GOING INTO THIS WITH A CLEAR SENSE OF WHAT WE'RE TRYING TO ACCOMPLISH AND DEFINING THE SCOPE AN GOALS AND MAKING SURE WE HAVE THE KEY PEOPLE HERE. 'S NOT WORRIED ABOUT NOT WORKING HARD. THAT 2-POINT MISSION IS TO UNITE A COMPREHENSIVE POPULATION LEVEL STRATEGY FOR PAIN MANAGEMENT AND RESEARCH. AGAIN, IT WAS MEANT TO BE THE CORE BASICALLY CHANGING THIS WHOLE NATION'S APPROACH TO THE MANAGEMENT OF PAIN EDUCATION, CLINICAL CARE, RESEARCH SO IT IS A BIG UNDERTAKING FROM THAT. WE NEED TO JUST DECIDE WHAT WE'RE GOING TO BITE OFF. >> HOW WE'RE GOING TO GET AS MUCH OF IT AS POSSIBLE DONE. WE WILL HAVE A WORKING GROUP. MAYBE WE SHOULD HIRE SOMEBODY AWAY FROM THE IOM. BUT FIRST STEP WE HAVE A NUMBER OF PEOPLE ON THIS COMMITTEE WHO WANT TO BE PART OF THE WORKING GROUP. WE WILL.X TALK TO DR. PAREKH ABOUT HOW HE PERCEIVES WHO AT THE DEPARTMENT WILL HAVE TO BE INTERACTIVE WITH, THEN WE'LL HAVE A CALL OF THE WORKING GROUP GROUP, WEAL ADD ADDITIONAL PEOPLE TO WORKING GROUP AND EACH THAT'S AGREED TO BE OPT WORKING GOWN CAN THINK ABOUT WHO ELSE TO HAVE ON THE GROUP. WE'LL GO AHEAD AND DO IT. I WOULD SAY IT BECAME INCREASINGLY CLEAR AND CHRIS IS AWARE OF THIS, THE DEPARTMENT SIMPLY DID NOT HAVE THE ENERGY OR RESOURCES TO TAKE THIS ON. EVERYTHING NAILS IT WAS IMPORTANT TO TAKE THIS NEXT STEP. AND THIS COMMITTEE HAS DONE SUCH A GOOD JOB, WE WERE THE OBVIOUS CHOICES. SO WE SHOULD TAKE IT AS A BADGE OF HONOR THAT WE HAVE BEEN ASKED TO DO THIS. AND PICK UP THE LOAD AND GO. CARMEN. >> SO I GUESS I'M PHILOSOPHY IF NOT NOW, THEN WHEN? WE'RE NOW. >> THAT'S MY POINT. SOME LEVEL YOU JUST GET ON WIT. SO THERE'S NOT A LOT OF MONEY, WE HAVE HEARD THAT BEFORE, WE HEARD ANYTIME MY HOUSEHOLD. IN MY MEDICAL SCHOOL. SEAN -- YOU'RE AT A PRIVATE SO MAYBE YOU HAVE MONEY. IT'S A JOKE. (OFF MIC) [LAUGHTER] >> I GUESS WE HAVE GOT GREAT LEADERSHIP, WE HAVE GOTTEN THE PROMISE OF RESOURCES. WE SORT OF DEFER TO WHAT WE DON'T KNOW. AND I SAY WE GET ON WITH IT. BUT WITH THAT BEING SAID, I WOULD SAY THAT WHERE WE TALKED ABOUT THE CHARGE OF HAVING PEOPLE LOOK UP WHO IS FUNDING PRIVATELY, I THEY IS ONE THING WE CAN NOW MOVE OFF THE TABLE. STORY, YOU POTENTIALLY COULD WRITE ONE BLATANT LETTER TO ASK SOMEBODY TO BE SEND US THE INFORMATION, NOT DISTILL IT BUT I THINK THAT GOING INTO -- >> THIS OBVIOUSLY TAKES PRECEDENCE. WE DON'T WANT TO IGNORE THE PORTFOLIO ANALYSIS WE HAVE BEEN DOING. WE DON'T WANT TO IGNORE THE ADVANCES BUT WE NOW HAVE THIS ADDITIONAL THING WHICH IS ON OUR PLATE. SO I DON'T WANT TO TO SAY ANYTHING MORE ABOUT IT BECAUSE WE HAVEN'T REALLY FIGURED OUT HOW WE'RE GOING MANAGE THIS BUT I HAVE GREAT VOLUNTEERS FROM THE COMMITTEE AND WE HAVE GOOD IDEAS ABOUT HOW TO START THE AMERICAN PAIN SOCIETY OFFERED THEIR ASSISTANCE. I KNOW MAYRA THAT YOU PUT TOGETHER APPROXIMATE ASCIENCE -- AN ALLIANCE OF DIFFERENT ORGANIZATIONS THAT ARE INTERESTED. SO IT MAY WELL BE WHEN PUSH COMES TO SHOVE WE FIND TOO MANY ASSISTANCE RATHER THAN NOT ENOUGH. >> WHAT YOU FIND IS EVERY ORGANIZATION WILL BE BEHIND THIS AND WILL BE HAPPY TO TO PROVIDE HELP. I THINK WHAT YOU SAID, IT'S SIFTING OUT FIGURING OUT HOW MUCH HELP DO YOU REALLY WANT. (OFF MIC) >> THANKS, DR. LAB DIS. -- LANDIS. S IN ARMY WE CALL THIS ADDING ANOTHER ROCK TO YOUR YOU CAN SACK. THAT'S WHAT THAT WAS. (OFF MIC) >> THERE YOU GO. BUT SINCE CARMEN STEPPED OUT I WAS IN THE AIR FORCE AND THEY JUST CALLED HARD. IT'S OKAY. WHAT I WOULD LIKE TO DO TODAY IS WE HAVE BEEN CHARGED WITH GIVING OVERVIEW FROM THE DOD PERSPECTIVE. WHEN I SAY THAT OFTEN TIMES I INTERCHANGE THE WORD ARMY OR ARMY MEDICINE. I DON'T MEAN TO BE EXCLUSIVE BECAUSE EVERYONE HAS A HAND WHAT IN WHAT WE HAVE BEEN DOING TO DATE. WE ARE THE BIGGEST SO THEREFORE OFTENTIMES I'M IN THE ARMY SO USE ARMY INTERCHANGEABLY. BUT I'M JOINED WITH (INDISCERNIBLE) FORMER ARMY SERGEANT GENERAL NOW AT THE UNIVERSITY UNIFORMED HEALTH SCIENCES AND COLONEL BUCKMIRE IS INVOLVED HEAVILY INVOLVED ARMY IF PHYSICIAN. HE'S A PAINIAC OR NEEDLE JUNKY. HE RUNS THE FELLOWSHIP AT PAIN MANAGEMENT AND ALSO IS PROGRAM DIRECTOR FOR THE DB SIPIM AND PROFESSOR UNIFORM UNIFORM UNIVERSITY. AS I MENTIONED. I'LL HIT EACH HIGHLIGHT. GENERAL SHOEMAKER WILL TALK ABOUT OUR PAIN MANAGEMENT TASK FORCE AND THE REPORT IS INCLUDED IN YOUR FILE TODAY. WE TOUCHED ON THIS THE LAST MEET BUG WE'RE GOING TO UPDATE YOU WHERE WE ARE TODAY WITH IMPLEMENTATION OF 109 RECOMMENDATIONS. THEN CLEAN UP WILL BE COLONEL BUCKMIRE WHO WILL TALK ABOUT DB SIP INITIATIVES. I DO HAVE BECAUSE I THOUGHT IT WAS IMPORTANT I HAVE A FILM CLIP OR TWO TO SHOW YOU. FIRST I WANT TO SHOW YOU A SLIDE HERE JUST AS A MARKER. THIS IS WHY WE EXIST. THIS IS WHAT WE DO IN ARMY OR MILITARY MEDICINE. OUR MISSION IS TO CONSERVE THE FIGHTING STRENGTH. AND NO ONE ELSE DOES IT BETTER THAN WHAT WE DO. FOR THE LAST 12 YEARS WE HAVE BEEN ENGAGED IN IRAQ AND AFGHANISTAN BUT WE HAVE BEEN DOING THIS FOR 237 YEARS. SINCE BEFORE WE HAD A NATION ARMY MEDICINE IS SERVING SHOULDER TO SHOULDER WITH OUR SERVICE MEMBERS AND DELIVERING GOOD MEDICINE IN SOMETIMES VERY BAD PLACES. YOU SEE A COUPLE OF IMAGES IF BEFORE YOU, POINT IS THAT COMBAT IS A OUR GREATEST CATALYST TO MEDICAL INN INVESTIGATION. ALL THE MAJOR ADVANCES IN MEDICINE YOU SEE COME FROM OUR WARTIME EXPERIENCE. WHETHER TALKING ABOUT WALTER REED OR GORGES FIGHTING AND CURING YELLOW FEVER OR JONATHAN LETTERMAN DESIGNING THE TENANTS OF PATIENT EVACUATION SYSTEM STILL IN USE TODAY BY THE WAY. OR DESIGNING COMBAT SUPPORT HOSPITAL, THOSE TENANTS ARE PRODUCTS OF THAT EXPERIENCE. NOW WE HAVE SURVIVAL RATES UNPRECEDENTED BECAUSE OF CAPABILITIES WE PUSHED TO THE TIP OF THE SPEAR BAYS SAY, THE LEADING EDGE OF THE BATTLEFIELD F. YOU'RE HURT IN AFGHANISTAN CHANCES OF SURVIVING ARE GREATER THAN 90%, 95% AND THE CHANCE OF SURVIVING HORRIFIC WOUNDS ARE GREATER THAN D. C. CXFC MAYBE THAT'S A BAD CHOICE. MICHIGAN. I'LL THROW MICHIGAN OUT THERE. THAT'S NO MISTAKING THAT IS BY DESIGN. OUR COMBAT MEDICS ARE THE BEST AT WHAT THEY DO. I MENTIONED EARLIER IN PASSING ONE INNOVATION WE HAVE, WE DON'T WAIT WAIT TO ADMIRE THE PROBLEM TO DEVELOP SOME KIND OF NEW DRUG ABOUT IT. WE HAVE -- IMPLEMENT INNOVATION AND CHANGE ALL THROUGH THE SPECTRUM OF OUR CARE. WE HAVE DEVELOPED WHAT I CALL A CHAIN OF CARE UNPRECEDENTED IN HISTORY OF WARFARE. TRIP WAS INSTRUMENTAL DEVELOPING OUR REGIONAL PAIN ANESTHESIA -- WHAT IS YOUR TERM? (OFF MIC) >> HIS NERVE BLOCK WHICH IS AMAZING. DR. SHOEMAKER WE SAW THIS IN PRACTICE. TRAUMATIC AMPUTATION. PERIPHERAL NERVE BLOCK IS PLACED THE GUY IS STILL CONVERSING AND TALKING KARAT BUT PAIN IS OBVIATEED TO THE POINT RATHER THAN BEING COMATOSE HE'S PARTICIPATING IN CARE AND HIS DEMAND FOR HIGHER LEVELS ONIATES MEDICATION WAS REDUCED OVER TIME BECAUSE OF THAT. THIS IS WHAT WE FOUND OVER TIME THE USE OF THESE TECHNIQUES AN PRACTICES. SO WE'RE LEARNING ALL THE TIME. WE ARE LEARNING ORGANIZATION WHAT WE DO IN THE MILITARY. THEN WE PUT INTO PRACTICE THOSE THINGS WE LEARNEDDED. THAT'S THE POINT. I WANT TO GO AHEAD AND -- (INDISCERNIBLE) >> WITHIN 24 HOURS PROBABLY. >> HEY, MOM. >> HEY, HOW ARE YOU? WHERE ARE YOU AT? >> I'M IN THE HOSPITAL. >> WHERE? >> I DON'T KNOW WHERE THE HELL I AM. I'M IN A HOSPITAL SOMEWHERE. I GOT HIT BY AN IUD TODAY. WHAT'S WRONG? HOW ARE YOU? >> I'M NOT TOO BAD CONSIDERING THE WAY THE VEHICLE -- >> CLEAR THE LAND RUN WAY 1 NINER LEFT AND THANK YOU FOR BRINGING OUR WARRIORS HOME SAFELY. >> IT'S A POWERFUL CLIP. IT CATCHES A COUPLE OF THINGS. NUMBER ONE YOU HAVE LESS THAN ONE-HALF OF ONE PERCENT OF FOLKS IN THIS COUNTRY THAT ARE SERVING IN UNIFORM. ANY TYPE OF UNIFORM AT ALL. SO REALLY SMALL SEGMENT OF OUR POPULATION, A LOT ON THEM FOR THE PAST 10, 12 YEARS, TREMENDOUS AMOUNT. THEY HAVE DONE A TREMENDOUS JOB. TO ADVANCE -- MEDICAL ADVANCEN'TS ARE NOT A MISTAKE, BUT A CONCERTED EFFORT FROM PROFESSIONALS. PEOPLE DOING AMAZING THINGS EVERY DAY. THIS IS A MAJOR LIMB AMPUTATION OVER THE PAST THREE YEARS, YOU CAN SEE A SEASONAL VARIATION TO THIS FOR SURE. PEAKS AND VALLEYS DEPEND ON THE SEASON. THERE'S A FIGHTING SEASON IN AFGHANISTAN, IRAQ, RIGHT NOW SINCE WE'RE OUT OF IRAQ, YOU CAN SEE THE LINE DOWN HERE OUT OF -- THIS IS OPERATION IRAQI FREEDOM. AFGHANISTAN IS STILL HOT AND HEAVY, IRRESPECTIVE WHAT YOU HEAR THERE'S A WAR GOING ON. AND THERE'S A SEASONAL VARIATION. WE'RE COMING TO THE WINTER SEASON WHERE FIGHTLING SLOW BUT THE IED REMAINS THE WEAPON OF CHOICE. WE DEFEAT A LOT OF THEM BUT THEY'RE HARMING SOLDIERS AND TREMENDOUS SEVILLEIANS OVER THAT THEATER. WE'RE APPLYING THE TECHNIQUES TACTICS AN PRACTICES WE LEARNED OVER THE LAST DOZEN YEARS IN OUR THEATER OF WAR EVERY DAY. SO WHAT IS A MAJOR LIMB AMPUTATION? A FINGER WOULD BE MAJOR. THEY DON'T COUNT DIGITS. WE'RE TALKING ARMS AN LEGS. MANY MANY CASES MULTIPLES. WE HAVE GUYS SURVIVING TRIPLE AMPUTATIONS NOW. AS A HOSPITAL COMMANDER, AS -- IN IRAQ AS A MATTER OF FACT, I HAD A COUPLE OF GUYS CAME THROUGH WITH TRIPLE AMPUTEES AN SURVIVED THAT. YOU NEVER USED TO HEAR THAT. THAT'S AMAZING. I THOUGH THROW THIS IN PART BECAUSE PAIN MANAGEMENT CAMPAIGN IS ANALOGOUS TO THE TBI PLAN WHICH WE DEVELOPED IN ARMY MEDICINE A COUPLE OF YEARS AGO AND GENERAL SHOEMAKER SITTING HERE TODAY WAS RESPONSIBLE FOR US GETTING AFTER THIS ONE WE SAW FOLKS WITH BLAST INJURIES, A LOT OF INJURIES HERE, THIS LINE HERE, THIS SOLID DARK LINE AT THE TOP IS THE INSTANCE OF MILD TRAUMATIC BRAIN INJURY. YOU EXPECT TO OVER THE YEARS BECAUSE WE'RE LOOKING FOR IT MORE. THAT'S THE FIRST TIME THERE'S BEEN ONE. THERE'S ENOUGH HEAD INJURIES WITH ASSOCIATED CAR ACCIDENTS IN STATE OF MICHIGAN, EVERY YEAR YOU COULD DO ALL RESEARCH THAT YOU WANTED TO. DAVE HOBBS AND GUYS FROM UCLA CAME TO US WHAT CAN YOU DO ABOUT IT. WE PUT TOGETHER A MANAGEMENT STRATEGY. 'S GOT WARTS BUT THE FIRST TIME ANYONE HAS DONE THAT. WE SHARED THIS IDEA WITH VARIOUS EVENT INSTITUTIONS AND NFL, ET CETERA, THIS IS THE BASIS FOR WHAT THEY'RE GOING AFTER BECAUSE PEOPLE ARE RECOGNIZING YOU HAVE TO CHANGE A CULTURE WITH RESPECT TO THESE INJURIES. SHAKING OFF OR GETTING BACK TO THE FIGHT, IT'S OKAY, NO GOOD. ESPECIALLY WITH REPETITIVE INJURY OVER TIME. CHRONIC INJURIES. THAT'S MORE RECOGNIZED BUT YOU'RE CHANGING THE CULTURE THROUGH EDUCATION. OUR STRATEGY WAS ACTUALLY CALLED EDUCATE TRAIN TREAT AND THIS IS A HIDDEN WOUND WE'RE DEALING WITH MORE AND MORE. YOU'RE TALKING RECOGNITION OF THESE WOUNDS WHETHER YOU CALL SOLDIER'S HEART OR SHELL SHOCK OR LATER THE NAME WAS CHANGE -- NAME WAS CHANGED THE POST TRAUMATIC STRESS DISORDER. THIS HAS BEEN AROUND A LONG TIME, NOT A NEW INJURY. WE'RE LOOKING FOR MORE, TRYING TO DESTIGMATIZE THE RECOGNITION AND TREATMENT IN OUR POPULATION AND WE'RE DOING -- WORKING ON THAT ALL THE TIME. PART OF COMPREHENSIVE BEHAVIORAL HEALTH CAMPAIGN PLAN WHICH WE HAVE INSTITUTED IN THE ARMY. I LIKE THIS VIN DIAGRAM BECAUSE WHAT THIS SHOWS YOU CO-MORBIDITY OR RELATIONSHIPS BETWEEN ALL THESE TYPES OF INJURY, THIS GETS BACK TO WHAT WE WERE TALKING EARLIER TODAY, WHAT AREAS TO FOCUS ON. I THINK THIS HIGHLIGHTS THE ISSUE FOR US, CERTAINLY IN THE MILITARY. THE RELATIONSHIP OF PAIN, RELATIONSHIP OF POST CONJUNCTION RELATIONSHIP OF PTSD. I WOULD ALSO THROW POLYPHARMACY, I COULD GIVE A FEW OTHER P WORDS IF YOU WANT TO BUT IT IS ABOUT THE PATIENT. BEFORE GENERAL SHOEMAKER RETIRED WE STARTED PATIENT CENTERED MEDICAL HOME APPROACH TO TAKING CARE OF FOLKS FOR THIS REASON. YOU CAN HAVE ALL THESE VARIOUS TYPES OF INJURIES BUT WE HAVE A SIGNIFICANT POPULATION IN OUR FORMATION HERE THAT HAS THE ENTITIES. SEPARATE SWIM LANES AND THEM DIFFERENTLY. I HAVE SOLDIERS THAT HAVE INJURIES, MULTIPLE INJURIES, MCC? HERE IS AN EXAMPLE FOR YOU. WE'RE TALKING THE SOLDIERS BUT SHARE THIS WITH THE NFL FOR A REASON. OUTSIDE FOOTBALL GIRL SOCCER PLAYER VERSUS THE MOST CONCUSSIONS IN OUR SOCIETY. SO WHAT WE DO IN THE MILITARY WILL BENEFIT ALL OF OUR SOCIETY THAT'S WHERE WE WANT TO GO. OUR FAMILY MEMBERS ALONG WITH THE SOLDIERS. WE'RE SEEING INCREASED BEDEMAND, INCREASED REQUIREMENT, IF YOU WILL, WE'RE AT THE BOW WAVE OF THIS WHOLE THING. AND WE'RE FACEING A TSUNAMI AND WE'RE FILLING SANDBAGS. IN OUR WORLD E EAR ADDRESSING THE REQUIREMENTS. WE IDENTIFIED THE REQUIREMENTS AND ATTACKING THOSE AREAS BUT THEY'RE NOT MUTUALLY EXCLUSIVE. THEY'RE INTERRELATED THAT'S THE POINT OF MY SLIDE HERE. I WANT TO STOP RIGHT HERE BECAUSE I WANT TO TRANSITION AND SHOW YOU ANOTHER QUICK CLIP, THEN I WAS GOING TO ASK GENERAL SKEW MAKER TO COME UP AND TALK ABOUT TO YOU AFTER THAT. THIS IS ABOUT FIVE MINUTE CLIP. THIS IS FROM THE ESCAPE FIRE FILM WHICH REP SENTLY CAME OUT, SOME MAYBE FAMILIAR BUT IT'S DEFINITELY PERTINENT TO WHAT WE TALK ABOUT TODAY. IF WE COULD TURN THE LIGHTS DOWN A LITTLE BIT. >> ALL I HEAR IS HOW WE GIVE PEOPLE MORE ACCESS O THE PRESENT SEMIAND HOW TO PAY FOR IT. THE PRESENT SYSTEM DOESN'T WORK AND IT WILL TAKE US DOWN. WE NEED A WHOLE NEW KIND OF MEDICINE. >> WE DONE HAVE A HEALTHCARE SYSTEM, WE HAVE A DISEASE MANAGEMENT SYSTEM. MANY HAVE A HARD TIME BELIEVING THESE CHOICES WE MAKE IN OUR LIVES EACH DAY MAKE A POWERFUL DIFFERENCE. >> THE AMERICAN HEALTHCARE SYSTEM IS GENERATING RIVERS OF MONEY FLOWING INTO VERY FEW POCKS. >> IN THE HEALTH INSURANCE INDUSTRY AT EXECUTIVE LEVEL WHAT'S MOST IMPORTANT IS WALL STREET'S EXPECTATION. THEY HAVE TO. THESE PRIVATE COMPANIES HAVE TO SERVE SHAREHOLDERS. YOU ALMOST FORGET WHAT YOU'RE DOING THE IS PROVIDE HEALTHCARE. >> THE HEALTHCARE SYSTEM IS UNSTABLE. WE'RE MORTGAGING THE FUTURE. NOT JUST HEALTHCARE. WE'RE TALKING THE HEALTHCARE OF THE NATION. >> THE COMMUNITY HEALTH CENTER WHERE I WORK, YOU NEED TO SEE MORE PATIENTS. WE'RE IN THE RED. SO IT SOUNDS LIKE YOU ARE FEELING OVERWHELMED RIGHT NOW. >> SORRY. >> DON'T BE SORRY. >> YOU END UP BEING THIS EVOLVING DOOR, YOU COULD NEVER GET O THE BOTTOM OF THINGS. >> WHEN YOU REWARD PHYSICIANS FOR DOING PROCEDURES INSTEAD OF TALKING TO PATIENTS, THAT'S WHAT THEY'RE GOING TO DO IS DO PROCEDURES. IF I SPENT FIVE MINUTES WITH YOU AND PUT IT IN ONE OF THESE, PROBABLY GET PAID 8,000 ON UP. 45 MINUTES ON AN ESTABLISHED VISIT WITH THE PATIENT TO TRY TO FIGURE OUT WHAT THE TRUE PROBLEM IS PROBABLY GET PAY $15. >> IT'S A COMPLETELY IRRATIONAL SYSTEM. >> 30,000 MEDICARE RECIPIENTS DIE EACH YEAR FROM CARE THEY DIDN'T NEED. >> THAT'S THE EQUIVALENT OF A JUMBO JET CRASHING EVERY WEEK. >> THE AVIATION INDUSTRY KILLED AS MANY PEOPLE WE WOULD BE UP IN ARMS. >> HOW DO WE COME TOGETHER THE ONLY WAY TO TREAT DISEASE IS GIVING DRUGS? >> MILITARY IS A MICROCOSM THE PROBLEM SOCIETY IS HAVING. >> SOLDIER'S USE OF PRESCRIPTIVE DRUGS TRIPLED IN FIVE YEARS. >> WHEN YOU DEPLOY THEY FEED YOU FEED YOU FEED YOU ALL THIS STUFF JUST TO KEEP YOU GOING. MISSION, MISSION, MISSION. >> >> MEDICATIONS I WAS ON. >> MOST OF THE DISEASE WE DEAL WITH IS LIFESTYLE RELATED AND PREVENTABLE. WE HAVE TO MOVE IN THE DIRECTION OF DISEASE THE PREVENTION AND HEALTH PROMOTION. >> WE PROVIDE INCENTIVES FOR PEOPLE TO ENGAGE IN HEALTHIER BEHAVIOR. >> WE HAVE IMPROVED THE HEALTH OF WORKFORCE, PRODUCTIVITY OF WORK FORCE AN BOTTOM LINE. >> MAKING MONEY AND DOING GOOD IN THE WORLD ARE NOT MUTUALLY EXCLUSIVE. >> WE'RE ALL SALARIED BUT WHAT WE DO FOR A PATIENT IS DEPENDENT ON WHAT THE PATIENT NEEDS, NOT FINANCIAL INCENTIVES. >> THE SURGEON GENERAL DIRECTED WE ESTABLISH THE TASK FORCE TO LOOK AT ALTERNATIVES TO NARCOTICS. >> TWO AND A HALF MONTHS OUT OF COMBAT, I WAS SKEPTICAL. SO SKEPTICAL. I AM A COMPLETELY NEW PERSON. >> BY ACCEPTING THE FACT THE HEALTHCARE SYSTEM IS BADLY BROKEN WE CAN SEEK OUT THE ESCAPE FIRES THE POTENTIAL SOLUTIONS AN CREATE A SUSTAINABLE PATIENT CENTERED SYSTEM FOR THE FUTURE. >> IF YOU DON'T TAKE CARE OF YOU, NOBODY ELSE WILL. >> YOU CAN DO THAT. YOU CAN. >> >> I WOULD LIKE TO -- WE MENTIONED THE PAIN TASK FORCE AND THE TBE TASK FORCE AND ACTUALLY THE INDIVIDUAL WHO DIRECTED WE GET AFTER THOSE THINGS IN ARMY MEDICINE AS GENERAL SCHUMAKER. PLEASE WELCOME HIM. >> IT'S A PRIVILEGE TO BE HERE TODAY AND TO LISTEN ON THE DISCUSSION I HEARD IN THE LAST FEW HOURS HERE. I COMMEND Y'ALL FOR YOUR WILLINGNESS TO TAKE ON THE CHALLENGE PUT IN FRONT OF YOU IN PART, I CAN SPEAK WITH SOME EXPERIENCE, GRADUATE OF PRETTY GOOD MEDICAL SCHOOL AND GRADUATE SCHOOL AS WELL, I DON'T THINK I WAS EVER I WAS PREPER PAIRED TO THE DEGREE NECESSARY TO TAKE ON WHAT IS SHOWN AS MICROCOSM OF AMERICAN HEALTH AND HEALTHCARE CHALLENGES THAT ARMY AN MEL TEAR MEDICINE REPRESENT. FOR THOSE NOT FAMILIAR WITH US AROUND THE TABLE, LET ME EXPLAIN THAT MILITARY HEALTHCARE IS ONE OF THE LARGEST INTEGRATED HEALTHCARE SYSTEMS IN THE COUNTRY TODAY. ARMY MEDICINE EMPLOYS 75,000 EMPLOYEES, ABOUT HALF IN UNIFORM. WITH AN OPERATING BUDGET OF $14 BILLION. WE HAVE ABOUT 400 UNITS FIXED AND DEPLOYABLE AROUND THE WORLD. P AND THAT NUMBER ABOUT HALF THE TOTAL NUMBER OF MEDICAL PERSONNEL. AFTER THE PERSONNEL IN ARMY UNIFORMS ARE UNDER THE COMMAND AND CONTROL OF THEIR DEPLOYABLE UNITS IN COMBAT. AIR FORCE AN NAVY MEDICINE ARE SIMILAR IN STRUCTURE, SLIGHTLY DIFFERENT IN HOW THEY APPLY THEMSELVES AND IN THE SIZE OF THE MISSION THAT THEY HAVE BEEN FACED WITH. GIVEN NATURE OF GROUND COMBAT WE'RE INVOLVED IN. TOM HAS DONE A GOOD JOB OF LAYING THE FOUNDATION WHAT WE FACED WITH MY COMING IN TO THE POSITION OF THE ARMY SURGEON GENERAL. I PRECEDED THAT BY BEING COMMANDER OF WALTER REED ARMY MEDICAL CENTER IN NORTH ATLANTIC REGIONAL MEDICAL COMMAND, ABOUT A THIRD OF THE COUNTRY FROM FORT DRUM TO FORT KNOX. FORT DRUM NEW YORK TO FORT KNOX, KENTUCKY, INCLUDING WALTER REED AND NATIONAL CAPITAL REGION. IN 2007. WHEN I TOOK COMMAND OF THE MEDICAL COMMAND AND BECAME THE ARMY SURGEON GENERAL SO THAT I WAS IN A POSITION TO BE ADVISER TO THE LEADERSHIP OF THE ARMY AND THE DOD AND THE COMMANDER OF FIXED FACILITIES AND MEDICAL CENTERS, CLINICS, LABORATORIES, HEALTH AGENCIES WITHIN THE ARMY. IT WAS VERY APPARENT TO US FROM THE NUMBERS THAT YOU JUST HAVE SEEN AND TRENDS WE HAVE SEEN THAT AS A MICROCOSM OF AMERICAN HEALTH AND HEALTHCARE CHALLENGES -- HEALTHCARE CHALLENGES WE WERE STRUGGLING TO KEEP ABREAST OF MANAGEMENT OF PAIN. NOT JUST PAIN AMONG SOLDIERS WOUNDED IN COMBAT OR INJURED IN DEPLOYED ENVIRONMENTS WHICH IS FAR OUTSTRIPPED BY THE WAY THE NUMBER OF COMBAT WOUNDS. AS IN ALL WARS, AND IN ALL CONTINGENCYIES, INJURIES TO THE COMBATANT MOSTLY COME FROM ILLNESS AN INJURY RELATED TO AN ENEMY WEAPON. THEY INVOLVE CRUSH INJURIES, LIFTING INJURY, EXPOSURE TO INFECTIOUS DISEASE, PNEUMONIA, DI SEN TEARS, THINGS LIKE THAT. THAT WAS TRUE OF WASHINGTON'S ARMY AND TRUE OF THE ARMY AND NAVY AIR FORCE MARINE CORPS TODAY. BUT A MAJOR PART OF THE CHALLENGE REINVOLVED HOW WE WERE MANAGING PAIN. JUST AS A MICROCOSM OF THE AMERICAN LANDSCAPE, WE WERE STRUGGLING BUZZ WE ARE A SUBSET OF YOU. WITH ALL OF THE CHALLENGES THAT YOU FACE. HIGHLY BALKANIZED CARE PROCEDURALLY ORIENTED. FIXATED ON MEDICINE, NOBODY ILLUSTRATEDDED BETTER THAN THAT YOUNG SOLDIER BEING EVACUATED BACK FROM EASTERN AFGHANISTAN IN THE IF YOU HAD A CHANCE TO SEE IT HAD JUST SURVIVED THE LOSS OF 15 OF 25 OF HIS COMBAT FRIENDS, WAS SUFFERING FROM WOUNDS, PHYSICAL WOUNDS BUT MORE IMPORTANTLY PSYCHOLOGICAL WOUNDS. WHAT YOU SEE IS HIS TRANSITION BACK INTO LIFE IN AMERICA WHERE HE WHEN FROM BEING MANAGED WITH ARRAY OF NARCOTIC AN PSYCHOTROPIC DRUGS TO BEING COUNSELED IN GUIDED IMAGERY AND USE OF ACUPUNCTURE AND THINGS THAT HE IN A SELF-DEPRICATING WAY LAUGHS ABOUT. HE TALKS ABOUT FACT THAT I'M JUST A GRIP FROM THE BAYOU OF LOUISIANA AND MY FRIENDS WHO ARE OUT THERE HUNTING GATORS AND SUCKING DOWN BUDWEISER WOULD LAUGH TO THINK OF WHAT I'M DOING HERE BUT THIS STUFF IS WORKING. AND IT'S GETTING ME OFF THIS. IN THE LAST SCENE OF THE MOVIE YOU SAW HIM CATCHING A CAB, THE NATIONAL AIRPORT HE'S ON HIS WAY BACK TO FORT CAMPBELL. SO WE ARE FACED WITH WHAT AMERICA IS FACED WITH HOW DO YOU TAKE PEOPLE WITH ACUTE AND CHRONIC PAIN AND ENHANCE THEIR QUALITY OF LIFE, THEIR FUNCTION. HOW DO YOU TAKE 300 AMPUTEES AS WE HAVE DONE OVER THE LAST 12 YEARS AND KEEP THEM IN UNIFORM. WE REDEPLOYED 45 AMPUTEES INTO COMBAT. HOW DO YOU DO THAT AND KEEP THEM FUNCTIONAL? HOW DO YOU KEEP A SENIOR OFFICER LIKE LIEUTENANT GENERAL (INDISCERNIBLE) WHO INJURED HIMSELF IN SO MANY COMBAT AND TRAINING JUMPS THAT HE WAS ON A TOXIC COMBINATION OF NARCOTICS TO THE POINT OF WITHDRAWING AND GET HIM OFF OF THAT, HE'S NOW A SPOKESMAN FOR US IN MANAGEMENT OF PAIN BY OTHER TECHNIQUES AND OTHER TOOLS AND MODALITIES OTHER THAN SIMPLY NARCOTICS OR PROCEDURES. WHAT I CHALLENGE THE GROUP TO DO AND TOM IS SELF EFFACING BUT IS THE CHAMPION FOR THIS, IS TO COME UP AND WHAT YOU SEE HERE. WE WERE FORTUNATE TO BE HEAD OF IOM LAUNCHING THIS. I HOPE IOM MEMBERS HERE TAKE ADVANTAGE OF WHAT WE TRIED TO DO SETTING OFF MINES IN THE MINE FIELD FOR THIS PROCESS BUT WE PUBLISHED TASK FORCE REPORT ABOUT A YEAR AFTER IT WAS CHARTED THROUGH THE WORK OF MULTI-DATE PLENARY TEAM THAT INCLUDED OTHER SERVICES, SPREAD RANS ADMINISTRATION WHO PLAY AN ACTIVE ROLE IN THIS, SOME VERY,VERY ENGAGED GROUPS WITHIN THE COMPLIMENTARY AN ALTERNATIVE MEDICAL COMMUNITY IN THE UNITED STATES LIKE THE SAMWELLI INSTITUTE, THE BRAY WE WOULD COLLABORATIVE AND OTHERS. WHEN THEY REPORTED OUT TO ME IN THE SUMMER OF 2010, I DID ESSENTIALLY WHAT I HEARD THE ASSISTANT SECRETARY DO TO YOU. I SAID THIS IS FINE AND GOOD. THIS WILL BE ANOTHER ONE OF MY REPORTS THAT I'LL PUT ON MY SHELL OF AND TAKE WITH ME WHEN I RETIRE FROM UNIFORM. BUT NOW I'M GOING TO ASK YOU TO IMPLEMENT THIS. I WANT TO SEE A CAMPAIGN PLAN THAT MAKE THIS IS OPERATIONAL. AND TAKE THESE 109 RECOMMENDATIONS AND TURN THEM INTO PRACTICAL EXECUTABLE REALISTIC PLANS. THAT'S WHAT STRATEGIES ARE. WE'RE SUPPOSED TO BE ABLE TO DO STRATEGIES. THAT'S KIND OF WHAT YOU PAY US TO DO IN UNIFORM TO DEFEND YOU, SO IT SEEMED NATURAL TO ME THIS GROUP ESPECIALLY SINCE WE OWNED THE TERRAIN THAT WE WERE TRYING TO INFLUENCE SHOULD BE ABLE TO DO WHAT Y'ALL ARE GOING TO HAVE TO STRUGGLE DOING ON A MUCH LARGER SCALE ACROSS A MUCH MORE DIVERSE LANDSCAPE OF STAKEHOLDERS AND OTHER PLAYERS. DO I DO IT THIS WAY? >> YES, SIR. WHAT I CAME UP WITH IS FOUR LARGE AREAS INTO WHICH THESE 109 RECOMMENDATIONS COULD BE AGGRAVATED THAT INVOLVE CHANGING THE CULTURE WHILE FOCUSING ON THE INDIVIDUAL, THE PERSON, THE PERSON IN PATIENT CENTERED SYSTEM QUITE FRANKLY INCREASINGLY TRYING TO MOVE TOWARD A PERSON CENTERED TO KEEP PEOPLE FROM BECOMING PATIENTS IN OUR SYSTEM, THAT WAS OUR GOAL. THAT IS WHAT THE KEY -- THAT IS THE ESSENCE OF CONSERVING THE FIGHTING STRENGTH TO KEEP PEOPLE SAFE, HEALTHY, PROTECTED, EVEN WHEN SADDLED WITH CHRONIC INJURY, ILLNESS OR DISEASE AND KEEP THEM FROM BEING PATIENTS WITHIN OUR SYSTEM. PROVIDE THE TOOLS AND THE INFRASTRUCTURE THAT WE REQUIRE. AND SET THE STAGE FOR RESEARCH THAT WOULD CLOSE GAPS IN OUR UNDERSTANDING OF THINGS. ONE THING I HAVE LEARNED OVER 30 YEARS IN THE ARMY, INFORMATION DOES NOT AGGREGATE SPONTANEOUSLY INTO KNOWLEDGE AND SEND THE KNOWLEDGE PYRAMID INTO WISDOM BY ITSELF. YOU CAN GATHER INFORMATION AND DO STUDYING UNTIL THE COWS COME HOME BUT IT HAS TO BE WITH AN EXECUTABLE PLAN FOR IT TO MAKE A DIFFERENCE. REDUCE UNWARRANTED ADMINISTRATIVE AND MEDICAL VARIATION AND PRACTICEs. WE HAVE BEEN TOLD REPEATEDLY BY WINBERG GROUPS AND OTHERS THAT WE COULD REDUCE UNTOWARD EFFECTS OF OUR TREATMENTS, IMPROVE COST ACCOUNTABILITY AND OVERALL IMPROVE HEALTH AND CLINICAL OUTCOMES IF WE WERE TO REDUCE UNWARRANTED VARIATIONS IN ADMINISTRATIVE AND CLINICAL PRACTICE. THAT'S WHERE THE FOCUS OF THE LAST AREA WAS. WHAT THE GROUP DID WAS TO COME UP WITH WHAT WE RECOGNIZE VERY, VERY DENSE CHART BUT WHAT WE RECOGNIZE IS A SET OF OBJECTIVE BASED LINES OF EFFORT THAT ATTACK EACH MAYOR TASK WE LOOK TO AND HAVE INTERNAL TO THEM A SERIES OF ENABLING TASKS F YOU GET IT RIGHT YOU GET PART OF THE LINE OF EFFORT CORRECT SO AS WE AGGREGATE A SERIES OF GOAL AND INTERMEDIATE ACHIEVEMENTS, WE ARE MOVING THE WHOLE LINE OF EFFORT TOWARD THE (INAUDIBLE). AND THAT'S ESSENTIALLY THE STRATEGY. I KNOW THIS IS A LOT TO CHEW ON RIGHT NOW, I'M GOING THE CHANGE THE SLIDE BEFORE YOU HAVE AN OPPORTUNITY TO LOOK AT IT TOO CAREFULLY. FILLED WITH ACRONYMS LIKE TRANSITION UNITS RIGHT HERE. THIS IS THE UNIT, THAT COLLECT IT IS LARGEST POPULATION OF MOST SEVERELY INJURED ILL POTENTIALLY DISABLED OF OUR SOLDIERS NUMBER IN THE RANGE OF 8 TO 10,000 ACROSS THE ARMY RIGHT NOW. AND ARE POSITIONED WHERE OUR HOSPITALS ARE. THIS WAS OUR PLAN. A PART OF THAT WAS TO IMPLEMENT A SERIES OF GEOGRAPHICALLY BASED HIERARCHY OF CARE, IF YOU WILL THAT WOULD BE PROVIDED. ONE OF THE REAL PROBLEMS, I CREDIT MY OWN WIFE WITH A LOT OF INSIGHT INTO THIS. I'M AN INTERNIST BY TRAINING WHO DID A RESEARCH HEMATOLOGY FELLOWSHIP AT DUKE AN Ph.D. IN HUMAN GENETICS, MY BACKGROUND IS IN SORT OF THE ACADEMIC SIDE OF THINGS. WHAT I OBSERVED IN -- I USE MY WIFE AS AN EXAMPLE WITH HER PERMISSION, FORMER ARMY NURSE, ATHLETE IN COLLEGE WHO DID A LOT OF INJURY TO HER BACK PLAYING TENNIS AND RUNNING LONG DISTANCES, SUCH THAT BY THE TIME SHE WAS IN HER 30s WAS ALMOST INCAPACITATED BY RECURRENT EPISODES OF BACK PAIN, NOT AN UNCOMMON PROBLEM IN AMERICA TODAY. TO HER CREDIT SHE RESISTED PROCEDURES AND NARCOTICS AND SHE LOOKED AS OFTEN AS SHE COULD FOR OTHER SOLUTIONS. THAT ULTIMATELY RESULTED IN HER FINDING ACUPUNCTURE ON TOUR WE DID IN GERMANY AROUND THE TURN OF THE MILLENNIUM WHICH SHE TRANSITIONED BACK TO ONE IN THE UNITED STATES. ABOUT THE TIME SHE WAS (INAUDIBLE) FOR ACUPUNCTURE WHICH I'M STILL SURPRISED BY, THAT ACUPUNCTURE WORKS, I'M A SKEPTIC ABOUT MANY OF THESE THINGS. AND SHE TRANSITIONED TO YOGA AND BECAME AN INSTRUCTOR AND NOW THERAPIST AND NOW IS WORKING ON A PROTOCOL LOOKING AT YOGA AS A TOOL TO HELP MANAGE CHRONIC PAIN. BUT WHAT WE DISCOVERED IS WE MOVED AROUND THE ARMY AND GLOBE, THESE SERVICES ARE HIGHLY VARIABLE THE AVAILABILITY TO PATIENTS. EVEN INEN ARMY THAT WEAR IT IS SAME UNIFORM, FIRE IT IS SAME AMMUNITION AN DRIVES THE SAME VEHICLES AND HAS A LOT OF STANDARDIZED DOCTRINE, MUCH AS I THINKrB- PATIENTS EXPERIENCED WE EVEN IN A HIGHLY STANDARDIZED PRACTICE ENVIRONMENT HAVE VERY NON-STANDARDIZED APPROACHES TO CARE. VERY NON-STANDARDIZED ACCESS TO THOSE CARE -- TO THAT CARE EVEN WHEN AVAILABLE OR WHEN IT'S PROVEN TO BE EFFECTIVE. SO ONE OUR PLANS HERE IS TO STAND UP UNDER THE AUSPICES ANALYSIS BY DR. BUCKMEYER HERE A SERIES OF REGIONALLY BASED INTEGRATED PAIN MANAGEMENT CENTERS, SOME WHICH ARE FULLY CAPABLE NOW, ONE IN EUROPE, ONE DOWN IN FT. GORDON, GEORGIA, AUGUSTA, GEORGIA, SECOND LARGEST CITY IN GEORGIA AND CENTRAL TO THE REGION WHERE 60% OF THE ARMY LIVES IN FORT STEWART, FORT BENEFITING, FORT JACKSON AND OTHERS. OUT IN TRIPLER IN HAWAII AND MADIGAN. YOU'LL SEE A CLIP IN A FEW ABOUT THE MADIGAN CENTER. BELOW THIS IN A TIER OF HERB LOPPED APPROACH, OTHERS AT -- ECHELONED, SAN ANTONIO, TEXAS WHERE WE HAVE A LARGE TROOP OF POPULATIONS, HERE IN THE WASHINGTON D.C. AREA AND FORT BRAGG, NORTH CAROLINA AND SMALLER COMMUNITY BASED SYSTEMS WHICH HAVE ECHELONED CARE T NOT SOPHISTICATED SCALE OF INTEGRATED PAIN MANAGEMENT CENTERS BUT ALONG THE SAME LINES. IN PARTNERSHIP WITH COMMUNITY ASSETS AND COMMUNITY PARTNERS, THIS GETS BACK TO YOUR CIVIL FEDERAL PARTNERSHIP THAT YOU TALKED ABOUT EARLIER I BELIEVE. IN ORDER TO PROVIDE A GIVEN STANDARD OF CARE THAT'S ALL EVIDENCE BASED, THAT I COULD TURN TO AS THE LEADER HEALTH OFFICER, THIS IS ONE OF THE BIG CHALLENGES THAT I HAD IN TAKING THE REPORT AND GOING OUT AND TALKING TO THESE CENTERS, HOW CAN WE SPEAK FORCEFULLY AND CREDIBLY TO THOSE DEPENDENT UPON US THAT THE CARE IS FULLY INTEGRATED, THAT REFLECTS THE NEEDS THAT YOU HAVE AS AN INDIVIDUAL PATIENT AND THAT CAN BE REPLICATED WHEREVER YOU MIGHT BE SENT OR FIND YOURSELF ASSIGNED THROUGHOUT THE ARMY AND THE WORLD. THAT'S BEEN THE GOAL OF THE PAIN MANAGEMENT CAMPAIGN. I SEE, I SEE WITHIN THIS EFFORT OPT DEPARTMENT OF DEFENSE PROVIDING A TEMPLATE FOR YOU EXPERIENCIALLY TO LEVERAGE, I THINK THAT WE WOULD FEEL AWFULLY INADEQUATE IF WE DIDN'T PROVIDE IN SUFFICIENT DETAIL TO YOU SOME OF THE PROBLEMS THAT WE FACED IN TRYING TO WORK WITH STAKEHOLDERS AND TRYING TO BRING TOGETHER THE INTEGRATED APPROACH THAT WE HAVE TRIED TO DO BECAUSE I THINK WHEN I HEAR WHAT YOU'RE DOING AND YOUR HARTER, IT SOUNDS AWFULLY SIMILAR IN PARALLEL WITH WHAT WE FACE IN THE ARMY. THERE IS ONLY A SMALL POPULATION, ONLY 5% CARE PROVIDERS IN THE COUNTRY AND TRAINEES IN MEDICINE AND NURSING AND OTHER SPECIALTIES, WE REPRESENT A PLACE WHERE YOU MIGHT BE ABLE TO GARNER SOME IMPORTANT LESSONS. I HOPE YOU CAN DO THAT. I'LL TAKE QUESTIONS AT THE END OF OVERALL PRESENTATION. I THINK WE TRANSITION NEXT TO YOU? >> WE'RE INTERESTED IN HAVING THE PATIENTS PETE THEM WHERE THEY'RE AT, (INAUDIBLE) AND RESTORE THAT FUNCTION. >> I WANT TO BE ABLE TO WRESTLE WITH MY KIDS. OR I WANT TO BE ABLE TO PLAY BASEBALL AGAIN, AND HIKE IN THE MOUNTAINS AGAIN. >> I WENT FROM BEING ON HEAVY MEDS TO WHERE I'M DOWN TO TAKING BARELY ANY PAIN MEDS ANY MORE. >> IT WAS A GUNSHOT WOUND RECEIVEED IN COME BAT, IT TORE A LOT OF MUSCLE BONE, STUFF THAT CAN'T BE REPLACED BUT STILLACHES A LOT. >> I WAS VERY GUARDED GOING TO THE DRIVING RANGE FOR THE FIRST TIME. JUST TO TAKE THAT FIRST SWING. I ENDED UP HITTING 140 BALLS THE FIRST TIME I WENT TO THE DRIVE RANGE BECAUSE I FELT SO GOOD. KNOWING THAT I COULD DO IT WITHOUT HURTING MYSELF. FIRST TIME I HAVE SEEN THE CHIROPRACTOR, I WALKED OUT AND FELT LIKE A NEW MAN. I WAS LIKE OKAY, I WAS EVEN DANCING IN THE HALLWAYS. IT WAS FUNNY. >> I SAW AMAZING PROGRESS, PROGRESS THAT I DIDN'T -- THAT I THOUGHT I WAS BEYOND. ALL THE WAY DOWN TO SIMPLEST THINGS LIKE BEING ABLE TO TIE MY SHOES WITH ONE HAND. IT WAS SOMETHING I GAVE TIE UP, LEAVE THEM TIED UP, I WOULD NEVER UNTIE MY SHOES BECAUSE I COULDN'T TIE THEM BACK. >> WE ALL RECOGNIZE THE VALUE THAT EACH OF US BRINGS TO THE TABLE. I THINK OUR PATIENTS HELP US UNDERSTAND THAT. OUR PATIENTS ALSO WILL TALK HOW IMPORTANT EVERY SEGMENT WAS. >> I BROUGHT MY WIFE IN, DAY ONE, THEY INTRODUCED THEMSELVES TO HER, TOLD HER EVERYTHING THEY WERE GOING TO TRY TO DO TO ME IN THE NEXT SIX WEEKS. TOLD HER SHE COULD COME BACK ANY TIME SHE WANTED TO. VERY FRIENDLY, VERY FAMILY ORIENTED, AND THE PEOPLE THEMSELVES ARE GREAT PEOPLE TO BE AROUND. >> PROFESSIONALLY SATISFYING TO WORK TOGETHER AS A TEAM. WE JUST HAD OUR WEEKLY TEAM MEETING WHERE WE DISCUSSED EACH PATIENT ENROLLED IN THE SIX WEEK FUNCTIONAL RESTORATION PROGRAM. AND WITH EACH PATIENT WE ASK EACH MEMBER OF THE TEAM HOW ARE THEY DOING THIS WEEK. >> IT'S NOT JUST YOU GO TO ONE DOCTOR AND THEN YOU GO TO ANOTHER DOCTOR. THE DOCTORS COMMUNICATE WITH EACH OTHER AND LET IS WHAT I WANT TO DO, THIS IS WHAT I WANT TO DO, COMBINED. IT'S AWESOME. EVERYBODY HERE WAS SO FRIENDLY. EVEN LIKE HAVING DEPRESSION ISSUE, COMING HERE, HAVING A BAD DAY, THE SECOND YOU WALK IN HERE EVERYBODY WAS JUST MADE YOU SMILE. NO MATTER WHAT KIND OF DAY YOU HAD. I ALWAYS LOOK FORWARD TO COMING IN HERE. ALWAYS. (OFF MIC) WHILE WE MAY NOT REPRESENT THE LARGEST INVESTMENT IT'S A SIGNIFICANT INVESTMENT AND WE'RE CERTAINLY THE SECOND LARGE EPARTNER. WHEN YOU INCLUDE THE VA WHICH I DO, (INAUDIBLE) VERY CLOSELY WITH THE VA. WE HAVE NOT MADE A MOVE WITHOUT CONSULTING WITH THE VA, WE SEE IT AS A CONTINUUM OF CARE NOT JUST THE POINT OF INJURY THROUGH THE ROLES OF CARE, TIME FOR ME TO RETIRE, I THINK BECAUSE IT STARTED AT LEVELS OR ECHELONS THEN LEVELS THEN ROLES. BUT THE ROLES OF CARE INTO THE COMMUNITY, IT ISN'T JUST THE VA, IT IS THE IMMUNITY. SO I SEE US AS PARTNERS IN THIS. YOU SAW THE PAIN TASK FORCE DOCUMENT IN THE IOM REPORT, ONE THING THAT WARMED THE COKE RELATES OF MY HEART IS THE LANGUAGE WAS SO RECOGNIZABLE AND THINKING ALONG THE SAME LINES, AND WE ARE REFLECTION OF YOU. THE DIFFERENCE ABOUT THE HILL TEAR IN MY AND THE POINT IS WE CAN GO TO SOME OF THE NASTIEST PLACES ON THE PLANET AND DO THE SAME MEDICINE THAT YOU HAVE IN YOUR OWN FACILITY. I DON'T GET TO MAKE DECISIONS WHY WOE WE DON'T GET (INAUDIBLE) VIRGIN ISLANDS OR BAHAMAS TO FIGHT WARS. I DON'T MAKE THOSE DECISIONS BUT SAFE IN THE KNOWLEDGE THAT NO MATTER WHERE IT IS COKE THE SAME THING THAT YOU DO AND WE DERIVE STANDARDS FROM YOU. SO WE'RE IN THIS TOGETHER WHEN I GIVE LEKTURE WHAT IS WE'RE DOINGENING THE MILITARY, I REP MIND THE CIVILIAN AUDIENCES THAT STANDARDS ARE COMING FROM THEM, THAT THIS IS A PARTNERSHIP TOGETHER, PROVIDING OUT THERE. I DON'T HAVE THE BAR GRAPH BUT OURS FROM THE EFFORT OF WHERE WE'RE CONCENTRATING ARE SIMILAR BETWEEN THE NIH AND THE DOD. AS FAR AS TRANSLATIONAL RESEARCH, CLINICAL RESEARCH, WE DO HAVE (INAUDIBLE) RESEARCH. THAT'S ANOTHER COLLABORATIVE EFFORT FLOWING OUT TO THE NATION'S UNIVERSITIES. MUCH STUFF THAT WE HAVE ACCOMPLISHED WE COULD NOT HAVE ACCOMPLISHED WITHOUT CIVILIAN ACADEMICS. (INAUDIBLE) IF YOU'RE OUT RUNNING WITH US LIKE GENERAL SHOEMAKER WAS RECENTLY YOU SEE THE PURPLE SHIRTS THAT WE WE ARE, SO WE'RE THE BROKERS BETWEEN ARMY, NAVY, AIR FORCE AND VA TO DO THESE THINGS. WHILE THE NAVY CALLS IT SOMETHING DIFFERENT, READINESS RESTORATION FUNCTIONAL RELIEF OF PAIN AND RESEARCH, THERE ARE FOUR PROGRAMS ESSENTIALLY THE SAME THING. THE SAME THING WE'RE DE DESCRIBING AS FAR AS THE IPNC. 'S A (INAUDIBLE) BETWEEN DIVERSE IDEAS. FIVE YEARS AGO IF I TALKED ABOUT ACUPUNCTURE AS A PAINIAC OR MASSAGE OR YOGA THERE WOULD BE SNICKERING. THERE'S NO SNICKERING ANY MORE. A LARGE PORTION OF RESEARCH PORTFOLIO RIGHT NOW IS SPECIFICALLY LOOKING AT ACUPUNCTURE OR YOGA IN OUR SYSTEM THIS IS WHO WE ARE. WE STARTED OUT AS A CONGRESSIONAL SPECIAL INTEREST UNDER CONGRESSMAN (INAUDIBLE) OUT OF WALTER REED. TEN YEARS AGO. IT WAS FRUSTRATING TIME PERMLY BECAUSE A LOT OF PEOPLE WERE NOT LISTENING. MANY PEOPLE IN THIS AUDIENCE CAN UNDERSTAND THAT FORTUNATELY FOR ME LEADERS WE HAVE HERE TODAY BEGAN TO SEE THE SAME PROBLEM. SO THE FIRST TIME PEOPLE WEREN'T NECESSARILY LAUGHING AT US, THIS IDEA (INAUDIBLE) SOME OTHER DISEASE AND IF WE FIXED -- THE SOLDIER FIXED THE BONE SEWING UP THE WOUND FROM THE AMPUTATION, THAT HAND WILL TAKE CARE OF ITSELF BUT AFTER 11 YEARS OF CONFLICT WE BEGAN TO SEE THAT WASN'T NECESSARILY THE CASE. WE HAD A BIG ISSUE. I'M JUST A LOWLY COLONEL SO I DON'T RATE ANY NICE FILMS YOU GOT TO SEE BUT WHERE I AM IS IN THE TRENCHES TRYING TO DO RESEARCH, I WANTED TO TELL YOU IS IT'S DIRECT RESEARCH. THIS IS THE BUDGET AND IT'S RELATIVELY SIGNIFICANT IN THE SINCE THAT WE HAVE A GROUP OF PEOPLE, 25 EMPLOYEES THAT FOCUS ON THIS FOR (INAUDIBLE) WHAT I WANT TO BE CLEAR WHO WE WHERE NOT THOUGH IS (INAUDIBLE). WE LOOK AT THE BETH EVIDENCE, A LOT COVER COMING FROM THE NIH AND OTHER UNIVERSITY AROUND THE NATION AND WE MAKE RECOMMENDATIONS SO ARMY, NAVY AN AIR FORCE COLOR THAT POLICY FOR THEIR OWN SERVICES. WE DON'T MAKE THOSE DECISIONS. WE PROVIDE TOOLS. THESE ARE TWO AREAS THAT WE CAN EXPAND. WE HAVE CLINICAL ACTIVITY, WE HAVE A SERVICE IN CHRONIC PAIN SERVICE OVER AT WALTER REED ACROSS THE ROAD. I THINK IT IS A MODEL AND HAS BEEN A MODEL FOR (INAUDIBLE) AROUND THE NEIGH. PAIN EDGE CASE IS CERTAINLY -- EDUCATION IS A FOCUS BUT WE HAVE NO BUDGET, BENEATH OTHER OF THESE ACTIVITIES. THAT'S A REAL ISSUE. WE'RE IN NEGOTIATIONS RIGHT NOW, UNIFORM SERVICES UNIVERSITY, TO TRY TO IMPROVE UPON THESE TWO ISSUES AND TO GET THE ALIGNMENT THAT I NEED IN THE LEADERSHIP PARTICULARLY WITH GENERAL SHOEMAKER TO TROY TO HELP THOSE THINGS ALONG. YOU SAW THOSE LINES OF EFFORTS, OUR PROBLEMS ARE VERY SIMILAR TO WHAT YOU'RE EXPERIENCING AS A CIVILIAN SYSTEM. I HAVE A LOT OF PEOPLE THAT WILL ALSO COME UP TO ME AND I NEVER GET ANYBODY ARGUING ABOUT MY LECTURES SAYING ALL (INAUDIBLE) IS A BUNCH OF MALARKY, YOU DON'T NEED TO DEAL WITH ANY OF THIS. THE FRUSTRATING THING I DO GET IS PROFESSIONALS COMING UP TO ME AT MEETINGS SAYING I AGREE WITH EVERYTHING YOU'RE SAYING BUT IF I SUGGEST MAKING SOME OF THESE CHANGES TO MY GROUP TOMORROW I WOULD BE ON THE STREET THE NEXT DAY. THAT IS WHERE I THINK THE MILITARY CAN PROVIDE A MODEL THE GET DATA TO SHOW THE ECONOMICS OF THIS WILL WORK AS YOU CHANGE NATURAL POLICY. THAT GOES TO PROBABLY ONE OF THE MOST IMPORTANT ISSUES WE'RE WORKING ON RIGHT NOW. THERE'S NO WAY YOU'RE GOING TO MAKE ENOUGH CARBON COPIES OF PEOPLE LIKE MYSELF TO GO TO PLACES IN THE MILITARY WE NEED THESE SERVICES. IT'S NOT GOING TO HAPPEN. MOST OF THE PAIN IN THE MILITARY IS TAKING CARE OF BY PEOPLE LIKE ME. OR YOUR SYSTEM TAKING CARE OF PRIMARY CARE SO THE FOCUS IN THIS SYSTEM HAS BEEN ON PRIMARY CARE. HOW DO WE EMPOWER THOSE PROVIDERS FROM AN EDUCATIONAL STANDPOINT. I CAN TELL YOU WHEN WE DID OUR PAIN TASK FORCE EFFORT THE NUMBER ONE THING WE WERE IN OUR OWN RESEARCH, NOT GIVING ENOUGH PAIN EDUCATION TO DO THIS RIGHT. AND THEN THEY P WANT THE CURB SIDE CONSOLE. PEOPLE COME TO ME ACROSS THE WAY AND SAY WHAT WOULD YOU DO FOR THIS? WE TALK ABOUT IT. IT'S NOT MY PLAN, I'M JUST TELLING WHAT I WILL TO AND THEY WEPT ALONG FOR THEIR PATIENT AND THEY DO WHAT THEY'RE SUPPOSED TO DO. IT'S A WONDERFUL SYSTEM. WE CAN NOT REPLICATE THAT IN EVERY PLACE PLACE WE DO MEDICINE. BUT WE CAN LEVERAGE MODERN TELECOMMUNICATION BUT NOT HAVE ME TALK TO THE PATIENT AT THE DISTANT SITE THAT'S NOT MAKING MY DAY BETTER AND THERE'S NO WAY I WOULD HAVE ENOUGH TIME IN MY DAY TO CAKE CARE OF ALL THOSE PEOPLE. BUT IF WE BUILD KNOWLEDGE NETWORKS, NODES AROUND CENTERS OF EXCELLENCE WHERE WE KEEP OUR SPECIALISTS, FOLLOWING A MODEL THAT (INAUDIBLE) HAD TO DO, THEY HAD FOUR PAIN SPECIALISTS IN NEW MEXICO. GUESS WHERE THEY WERE? (INAUDIBLE). ALBUQUERQUE. THEY HAD ALL THIS VAST STATE TO DEAL WITH. THEY KNEW FROM A DISEASE STANDPOINT, WITH HEPATITIS C THEY TRIED TO DISPERSE THERE WAS NO WAY TO GET THOSE PATIENT TO TRAVEL HUNDRED OF MILES TO GET THE CARE THEY NEED SOD THEY BUILT A KNOWLEDGE NETWORK OF TELECOMMUNICATIONS, NODED OUT IN THESE PRIMARY CARE PEOPLE, MEET ONCE WEEKLY, THEY TALK ABOUT THEIR CASES. EVERYBODY IS LISTENING IN AN LEARNING AT THE SAME TIME. BUT THE EXPERTS BACK AT UNIVERSITY OF NEW MEXICO ARE NOT TAKING CARE OF THE PATIENT. THE PERSON WHO SHOULD BE TAKING CARE OF THE PATIENT, THE ONE IN THEIR ARCO, THE AREA OF OPERATION, PRIMARY CARE SPECIAL IST, IS TAKING CARE OF. THEY PUBLISHED IN THE NEW ENGLAND JOURNAL. THEY TOOK A PRIMARY CARE IF PHYSICIAN AND GOT THEM TO TREAT A PATIENT IN THIS DISTANT SITE USING THIS SUPPORT NETWORK. WITH AS MUCH SUCCESS SPECIALIST. WE CAN DO THE SAME (INAUDIBLE). FROM OUR PRIMARY CARE IF PHYSICIANS. THEY DON'T KNOW HOW TO MANAGE A PATIENT WITH THOSE (INAUDIBLE). THEY DON'T KNOW HOW TO DO INTEGRATED MEDICINE. THEY DON'T KNOW WHO TO TALK TO WHEN THEY HAVE A DIFFICULT PATIENT. WE INITIALLY SAW THAT IN OUR WARRIOR TRANSITION BY IMBEDDING PHYSICALLY A PAIN SPECIALIST IN THAT UNIT. WHILE THIS WORKS ACROSS THE STREET THAT'S NOT GOING TO WORK EVERYWHERE WE NEED TO DO GOOD PAIN MEDICINE. THAT'S ONE OF OUR BIG INITIATIVES RIGHT NOW. THIS IS AN EXAMPLE OF HOW WE'RE DOING RESEARCH. WE HAVE A PAIN TASK FORCE DOCUMENT, 109 RESIGNATIONS BY NUMBER. EVERY TIME I TURN TO RESEARCH PROJECTS NOW, I ASSOCIATE THE RECOMMENDATION BY NUMBER AND IT'S A GREAT WAY TO GO FORWARD WITH THE RESEARCH PROJECT SO MY LEADERSHIP AND PEOPLE DOING MY REVIEWS UNDERSTAND THE 27,000-FOOT VIEW PLAN, THE PAIN TASK FORCE DOCUMENT TIE TRIKING TO FOLLOW WITH RESEARCH TO PUSH THOSE LINES OF EFFORT FORWARD. WE WENT AROUND THE NATION AN INTERACT, NOT HERE TO CRITICIZE THE NRS. 'S A WONDERFUL RESEARCH TOOL THAT WE HAVE BEEN USING A LONG TIME BUT A LOT OF CLINICIANS ARE SAYING IT'S NOT VERY VALUABLE BEYOND JUST PATIENT INTERACTION. I CAN'T COMPARE SYSTEMS, I CAN'T REALLY ANSWER QUESTIONS WHETHER THIS THERAPY IS BETTER HAHN THAT THERAPY. IT'S NOT REALLY APPLICABLE IN ALL SITUATIONS. SO WE HAVE GIVEN THIS TASK, WE DEVELOPED THIS SYSTEM. THESE CASES WE STARTED THIS RESEARCH HAS BEEN ACCEPTED FOR PUBLICATION, PUT OUT IN PAIN MEDICINE DECEMBER. WE HAVE THE BASIS RATING SCALE, WE INITIALLY DID THE STUDY WITH COPYRIGHT ISSUES. WE WEREN'T ABLE TO USE THIS SEW WITH DEVELOPED YOU ARE OWN (INAUDIBLE) BASIS. WE (INAUDIBLE) WHERE PEOPLE DON'T SPEAK THE LANGUAGE, DON'T UNDERSTAND THE COLORS OR THESE BARS BUT THEY CERTAINLY UNDERSTAND THE PHASES. SOLDIERS, A MEDIC DOESN'T CARE (INAUDIBLE) IN PAIN IS 9 OR 2. HE WANTS TO KNOW DO I NEED TO TREAT, DO I NEED TO SUPPLEMENT, AM I GOOD TO GO. WHITE'S WARM AND FUZZY TO SAY PAIN IS WHERE THE PATIENT SAYS IT IS, THAT WASN'T SERVICING US AS FAR AS TRYING TO COMPARE SYSTEMS SO WE DECIDED DOD (INAUDIBLE) HARD TO DO ANYTHING. FUNCTION A.M. LANGUAGE ASSOCIATED WITH THAT NUMBER SO WE CAN STIMULATE THE CONVERSATION IN A DIRECTION THAT MAKES SENSE. IT WAS HARD TO HAVE THE SAME CONVERSATION WITH A SOLAR COMING IN, JUST (INAUDIBLE) WATCHING THE TELEVISION AND TALKING TO HIS FRIEND AND THEN SAID HE CANNOT CAMPAIGN. WE NEEDED TO RESET THE BAR IN THIS CONVERSATION. WE ALSO NEEDED MORE INFORMATION. I MENTIONED EARLIER THE INITIATIVE ON THE GENERAL ACTIVITY SLEEP AND NUTRITION. TWO OUT OF THREE APARTMENT BAD FROM A PAIN PERSPECTIVE. HOW IS THE PAIN AFFECTING ACTIVITY? THEIR SLEEP, THEIR MOOD AND STRESS? I CAN TELL YOU IN THE SYSTEM, THIS REVOLUTIONIZED THE WAY ACUTE PAIN MEDICINE, MY SPECIAL AREA, THAT'S WHAT I DO. REVOLUTIONIZED THE CONVERSATION WE WERE HAVING WITHIN PATIENTS. WE NOW SINCE WE STARTED ASKING THESE QUESTIONS ABOUT ACTIVITIES SLEEP FOOD INDUSTRY WE WERE ABLE TO TREND THESE NUMBERS -- TRIM THESE NUMBERS. WE CAN FOLLOW A PATIENT AND NOTICE CHANGES, FOR EXAMPLE, WHEN THEY HAVE ANOTHER SURGERY. WE STARTED NOTICING RIGHT AWAY WHERE I PERCEIVE WED HAD A PROBLEM WITH SLEEP IN OUR PATIENT POPULATION, BUT NOW WE HAD DATA THAT WAS AN ISSUE. THERE WERE 7 OR GREATER ON THE SCALE AND HALF OF THE SERVICE SO NOW WE WERE HAVING CONVERSATION ABOUT THREE. MORE IMPORTANTLY WE WERE HAVING CONVERSATIONS ABOUT MOOD AND STRESS. FAMILY MEMBERS WOULD COME OUTSIDE THE ROOMS AFTERWARDS AND SAY YOU'RE THE ONLY DOCTORS IN THE HOSPITAL. THE ONLY TEAM. THE PAIN FOLKS THAT ARE ASKING ABOUT THESE ISSUES AN INCORPORATING INTO THEIR CARE. WITHIN CARE IT'S APPROXIMATE INITIATIVE TO SHOW -- AN INITIATIVE TO SHOW HOW THEY TRANSLATE. INSTEAD OF ASKING THESE QUESTIONS AND WASTING TIME IN THE MORN, VALUABLE PATIENT TIME TALKING TO THE PATIENT, WHAT THE IF WE CALL THEM ON THEIR CELL PHONE? OR OTHER ELECTRONIC DEVICE? ALL THIS HAS BEEN FIGURED OUT AN WORKED OUT SO WE CAN DO IT AND QUERY THEM ABOUT THIS INFORMATION AT 8:00 O'CLOCK IN THE MORNING DOWNLOADED FROM THE WEBSITE AND LINK TO TALK TO THE PATIENT ABOUT THOSE RESULTS. RIGHT FROM THE BEGINNING RATHER THAN COLLECTING THE DATA. THOSE ARE THE THINGS WE'RE DOING. THEN (INAUDIBLE). NOT ALL THESE THING, THIS IS THE LAST SLIDE THAT I HAVE H. WE SEE THIS AS THE MOST IMPORTANT INITIATIVE. IT'S ALREADY A COLLABORATION BETWEEN DOD AND NIH. WE'RE LEVERAGING THE $100 MILLION THAT P REPRESENTS PROMISE NIH NORTHWESTERN. (INAUDIBLE) IS A PLACE HOLDER FOR THIS RESEARCH OUTCOMES REGISTER. IT'S NOT GOOD ENOUGH TO HAVE PATIENT CARE ALGORITHMS IF YOU DON'T HAVE THE DATA THAT'S BACKING UP THOSE ALGORITHMS. I HAVE NO BETTER INFORMATION TODAY THAT A GIVEN PATIENT WITH BACK PAIN WITH CERTAIN PARAMETERS THAT ACUPUNCTURE IS BETTER OR WORSE THAN SPINAL CORD STIMULATION THAT'S EXQUISITELY FRUSTRATING. WE HAVE THE EXPERIENCE OF PROVIDERS IN THEIR OWN LOCALES BUT THAT'S BREEDING THE EXTREME VARIABILITY WE HAVE IN OUR SYSTEM. IF WE HAD DATA WE WOULD THEN BE ABLE TO SAY TO OUR SYSTEM, A PATIENT WITH WITH THESE PARAMETERS, WITH THESE OUTCOMES IN THIS REGISTRY, THIS IS A TREATMENT ALGORITHM THAT WORKS OUT MOST OF THE TIME. >> WE'RE NOT REALLY PICKING YOU UP ON THE MIC. >> YOU'RE NOT PICKING ME UP? THAT'S AMAZING. I'LL START BACK RIGHT HERE. APPRECIATE IT. >> THE OTHER THING I WANT TO POINT OUT IS ALL THE FOLKS THAT ARE ALREADY INVOLVED IN THIS. CERTAINLY NIH, THE MANY UNIVERSITIES, AND THE BRAVE COLLABORATIVE INTEGRATIVE MEDICINE OUTCOME STUDY WORKING WITH (INAUDIBLE), WORKING WITH BRA WELL AND RESEARCH AN INTEGRATION AND SERVICES F THIS EFFORT IS THE FIRST ENTERPRISE IT SOLUTION THAT THE THREE SERVICES ARE WORKING TOGETHER WITH FROM THE BEGINNING RATHER THAN THE TRADITIONAL WAY OF DEVELOPING WITHIN YOUR OWN SERVICE AND SOCIALIZING IT WITH THE OTHER SERVICES AND LET THEM THROW A MISDEMEANOR BALL AT IT. EVERYBODY IS RECOGNIZED FROM THE BEGINNING HOW IMPORTANT THIS IS. WHERE I THINK WE HAVE A REAL OPPORTUNITY HERE IS CERTAINLY WITH OUR OWN IOM INITIATIVE, RECOGNIZING THAT THIS SORT OF DATA DRIVEN EFFORT, THIS DATABASE ON THE NATIONAL LEVEL BEING ABLE TO COMPARE WHAT WE'RE DOING IN THE MILITARY TO WHAT YOU'RE DOING IN SILVAIAN SECTOR AN STANFORD RIGHT NOW, WITH SEAN MACKEY'S SHOP, THAT'S WHERE THE REAL MONEY IS, SO WHILE WE DO LOTS OF OTHER RESEARCH IN THOSE VARIOUS AIR IAS, BEING ABLE TO COLLECT THE DATA TO INFORM AND DRIVE WHAT YOU'RE RECOMMENDING IS KEY AND ESSENTIAL FOR US TO MOVE FORWARD. WITH THAT I THINK I'LL TURN IT BACK OVER TO GENERAL THOMAS FOR QUESTIONS. >> THANKS. I'LL HOLD OFF IF THERE'S QUESTIONS OR COMMENTS FROM THE GROUP HERE. >> SO THESE WERE WONDERFUL PRESENTATIONS. AT NCAM AS PART OF THE NIH HAVE BEEN ENTHUSIASTIC ABOUT THESE ACTIVITIES HAPPENING WITH OUR MILITARY POPULATIONS. WE HAVE ONE FUNDING ANNOUNCEMENT THAT WE PUT FORWARD LAST YEAR FOR SUPPLEMENTAL FUNDING AND ANOTHER ONE THAT'S IN THE WORKS ENCOURAGING COLLABORATIONS BETWEEN NIH AND INVESTIGATORS WORKING IN MILITARY HOSPITAL SETTINGS, THESE ARE VA OR DOD. BUT THESE ARE INCREDIBLY IMPORTANT REAL WORLD EXPERIMENTS HAPPENING AND WE'RE EAGER TO HELP IN EVERY WAY WE CAN. >> THANK YOU. I THINK ONE THING I HAVE NOTICED WHEN YOU WORK WITHIN THE AGENCY IT'S ALMOST LIKE WORKING WITH NATO. THE SEPARATE NATIONS, SEPARATE OS, ENTITIES. THE COMMON LANGUAGE AS WE HAVE IN AFGHANISTAN WITH 50 NEIGHS IN NATO COALITION, THE COMMON LANGUAGE IS MEDICINE. THE GLUE THAT HOLD IT IS GUYS TOGETHER ALL WANT WHAT WE GOT BECAUSE WITH WE TIER BEST IN THE WORLD WHAT WE DO. THAT'S THE COMMONALTY WE SHARE HERE. THAT'S NOT NONETHELESSNIST ROOM THAT IS NOT PASSIONATE ABOUT WHAT YOU DO. THAT'S WHY YOU'RE HERE. YOU WANT TO MAKE A CHANGE, MAKE A DIFFERENCE. WE HAVE THE OPPORTUNITY TO DO THAT NO. CXFC I KNOW THERE'S COMPETING REQUIREMENTS, THERE'S NEVER ENOUGH MONEY AND ALWAYS OTHER CHALLENGES. WITH US IT SHOULDN'T BE TRIBAL WARFARE. WE'RE AFTER THE SAME GOALS HERE. WE REALLY ARE, WE CAN MAKE A DIFFERENCE. WE ARE MAKING THE DIFFERENCE. THE MILITARY IS UNIQUELY POSTURED BECAUSE WE'RE TASK ORGANIZED NO TO GET AFTER A PROBLEM AND DO IT. WE IDENTIFY THE PROBLEM EARLY ON BECAUSE WE HAVE TO. BECAUSE THE SOLDIER'S LIVES DEPEND ON IT. SO WE CAN ADDRESS IT THAT WAY. IF YOU LOOK AT THESE EFFORTS AS CREATING THE POTENTIAL FOR CREATING IRREVERSIBLE MOMENTUM, THAT'S WHAT WE WANT TO GET AFTER. IT'S NOT THAT WE CAN'T AFFORD THIS, THE REALITY IS WE CAN'T AFFORD NOT TO DO THIS. >> I'M ONE OF THE CO-CHAIRS OF THE PROMISE CONSORTIUM AND I KNOW PROMISE IS EXTREMELY EXCITED AT THE PASTOR INITIATIVE AND HOW THAT'S LEVERAGING THE PROMISE INVESTMENT. BUT I WAS VERY PLEASED TO SEE HOW MUCH DOES PAIN INTERFERE WITH YOUR SET OF FIVE QUESTIONS, FOUR QUESTIONS. I THINK THAT IS AN INCREDIBLY IMPORTANT COMPLIMENT TO DIRECT ASSESSMENT OF PATIENT REPORTED PAIN. >> SO I HAVE BENEFITED FROM MILITARY MEDICINE BUT IT WAS AIR FORCE. FYI. >> IS THIS STILL THE MILITARY JUST BOND -- [LAUGHTER] >> I LOVE YOU TOO. MY GRANDFATHER WAS NAVY. FIRST OF ALL I WANT TO THANK EACH AND EVERY ONE OF YOU FOR YOUR SERVICE. I DON'T THINK WE SAY THAT ENOUGH AND FOR THE SERVICE YOU PROVIDE SO SO MANY YOUNG MEN AND WOMEN AND OUR WAY. THERE IS ONE REAL OPPORTUNITY. THE OPPORTUNITY IS ONE OF THE THINGS THAT I SEE WITH MILITARY MEDICINE IS OUR WARRIORS HAVE ACCESS TO SOME OF THE BEST HEALTHCARE IN THE COUNTRY. MULTI-DISCIPLINARY CARE. I I THINK THERE ARE ALSO IN THE CIVILIAN SECTOR, PEOPLE DON'T HAVE ACCESS TO PSYCHOLOGICAL COUNSELING. PHYSICAL THERAPY, ACUPUNCTURE, AND I THINK WHERE YOU COULD DO THE CIVILIAN SECTOR A GREAT DEAL OF SERVICE, THERE'S REALLY DOCUMENTING THAT SUCH THAT PARTICULARLY WITH OR NEW CHARGE JUST WANTED TO MAKE YOU SMILE, STORY. >> I'MING BEGINNING TO SEE THE GLASS IS HALF FULL, WE CAN DECIDE WHAT WE THINK THE DEPARTMENT SHOULD DO AND TELL THEM. THEY ASKED US TO DO THAT. ACTUALLY PRETTY EMPOWERING IF YOU THINK ABOUT IT. >> I'M SITE SO DOESN'T TAKE MUCH. BUT I WOULD SAY THAT THAT WOULD BE ONE OF THE THINGS THAT YOU REALLY COULD DO FOR US. THAT CONSISTENTLY AS A PRACTICING PAIN MEDICINE IF PHYSICIAN AND RESEARCHER, WE HAVE DIFFICULTY GETTING PATIENTS ACCESS TO QUALITY PSYCHOLOGICAL COUNSELING, QUALITY PHYSICAL THERAPY. SO SOMETIMES ALL YOU'RE LEFT WITH IS OPIOIDS. THEY'RE ONE PART OF THINGS WE HAVE IN THE TOOLBOX. I'M IMPRESSED BY STORIES OF PEOPLE WHO HAVE BEEN ORINGLY INJURE -- HORRIBLY INJURED. THEY'RE NOT TAKING OPIOID ANALGESICS. THERE'S YOUNG MOTIVATED PEOPLE BUT I WOULD POINT THAT OUT. THE OTHER THING, I NOTICE BY LOOKING AT SLIDES THAT YOU TALK ABOUT ACUTE AND CHRONIC PAIN MANAGEMENT BUT WORK HAND IN HAND WITH THE VA AND CERTAINLY SOME YOUNGER SOLDIERS AND FAMILY MEMBERS HAVE CANCER PAIN SO I THINK THAT THAT IS AN OPPORTUNITY WITHIN THAT SLIDE, AND YOU MIGHT GIVE US A MOMENT OR TWO HOW YOU ADDRESS THOSE ISSUES. >> I'LL SAY RIGHT OFF THE BAT. IT'S OFTEN MISUNDERSTOOD THAT AGAIN, I HAD TO KEEP COMING BACK TO THE FACT THAT MILITARY HEALTHCARE IS A MICROCOSM OF AMERICAN HEALTHCARE. MILITARY ELIGIBLE POPULATION IS 9.2 MILLION. DEMOGRAPHICS IS ALMOST IDENTICAL TO DEMOGRAPHICS OF THE U.S. IF LOOKED ATLANTA MOST MAJOR MEDICAL CENTERS. IF YOU GO TO A FORT EXAM BELL, KENTUCKY OR FORT STEWART, GEORGIA, WHERE OFF CLUSTERING OF YOUNGER SOLDIERS AND YOUNG FAMILIES, YOU WOULDN'T SEE THAT. WHERE WE HAVE A HALF A MILLION MILITARY BENEFICIARIES RANGING FROM NEWBORNS OR PREGNANT MOTHERS TO RETIREES AN RETIRING FAMILY MEMBERS SO THE SAME SPECTRUM OF CHALLENGES THAT YOU ALL FACE. WHETHER ONCOLOGIC PAIN, POST HER PETTIC PAIN, DENTAL PAIN, ALL ARE -- IT'S A SHARED PROBLEM THAT WE HAVE WITHIN THE MILITARY. THE OTHER THING WE ENCOUNTER THAT'S OFTEN MISUNDERSTAND AS WELL THOUGH WE HAVE THE FLEXIBILITY AND I WAS GIVEN A FAIR AMOUNT OF LATITUDE TO EXPERIMENT WITH NEAR TERM SUCCESS IN SAY INTEGRATED PAIN MANAGEMENT AT THE EXPENSE OF A TRADITIONAL MODEL OF REMUNERATION, WE STILL HAVE TO ADHERE TO A U.S. MODEL HOW HEALTHCARE IS PAID FOR. I WAS BET BEATEN UP BY THE ENCOUNTERS YOU SAW, INSURANCE COMPANIES AND OTHER PEOPLE HELD BY A PARTICULAR BOTTOM LINE REQUIREMENT. AND IT'S AS UNNEVERRING FOR US IN THE BRAVE WELL COLLABORATIVE MEETINGS FOR EXAMPLE THAT PRODUCTMIER BROUGHT TOGETHER TO HEAR FROM INSTITUTIONS THAT SAY WE CAN CUT LENGTH OF STAY, WE CAN CUT POST SURGICAL PAIN, WE CAN IMPROVE PATIENT SATISFACTION BUT WE CAN'T MAKE IT PROFITABLE. IT'S AS METASTASIS IF -- WE HAVE THE SAME PROBLEM. AS IF WE'RE DOING THE BEST CAKE WE CAN IN THE CRACKS OF THE SIDEWALK BETWEEN EVERYTHING ELSE WE'RE DOING. THAT SOMETHING THAT HAS TO CHANGE, PART OF THE CULTURAL THAT HAS TO CHANGE IN AMERICAN HEALTHCARE. >> BUT YOU'RE DOING SOMETHING UNIQUE YOU'RE SENDING PEOPLE BACK THE WORK. THAT DATA, HOW YOU DO THAT IS A VERY IMPORTANT STORY. >> I AGREE FOR YOU, MANY OF US WHO SERVE FOR MANY YEARS IN UNIFORM IT'S ONE OF THE THINGS THAT KEPT US IN UNIFORM. I NEVER HAD TO APOLOGIZE FOR KEEPING PEOPLE HEALTHY. I NEVER HAD TO LINK INJURY PATTERNS WITH PREVENTION TECHNIQUES. WE HAVE A PATTERN OF WOUNDING AND COMBAT, LET'S REDESIGN THE VEHICLES SO IT DOESN'T ALLOW US TO WOUND THE NEXT SOLDIER. MAKE SURE IS BODY ARMOR COVERS. MAKE SHOWER THEY EXERCISE IN A REASONABLE WAY SO THEY DON'T SUFFER A HEAT INJURY OR COLD INJURY. BY THE SAME TOKEN, KNOWING AS THE NAVY DEMONSTRATED, IF YOU CAN PROVIDE PROMPT CARE FROM THE POINT OF INJURY ON CONTINUUM BACK TO THE REHABBENT CENTER YOU CAN REDUCE POST TRAUMATIC STRESS BY 50%. NOW WE HAVE CROSSED TO THE INTERSECTION SAYING WAIT A MINUTE, WE'RE MANAGING A COMPLETELY SEPARATE PROBLEM BY PROMPTLY ATTENDING TO A PRODUCT OF INJURY. LET'S SEE WHAT WE CAN DO TO OPTIMIZE THAT. >> I WANT TO THANK YOU FOR THE SERVICE YOU PROVIDED TO THE COUNTRY AND TO IOM COMMITTEE. WE WERE TREMENDOUSLY BENEFITED BY THE WORK THAT YOUD HA DONE AHEAD. I HAVE A QUESTION, YOU MAY HA JUST ANSWERED IT AND A COMMENT. IN THE IOM REPORT, WE USE THE TERM BIOPSYCHOSOCIAL PAIN MANAGEMENT WHICH IS A MOUTHFUL, I CAN'T GET IT OUT. OR WE USE INTEGRATED PAIN MANAGEMENT. I NOTICE YOU'RE USING INTEGRATIVE AND YOU ALSO USE INTERDISCIPLINARY PAIN MANAGEMENT. WE HAVE BEEN TRYING IN MY WORK SUBSEQUENT TO THE WORK IN THE IOM REPORT TO PUSH THE NOTION OF INTEGRATIVE PAIN MECHANIC MANAGEMENT LARGE PART BECAUSE OF YOUR WORK AND WE HAVE HAD SIGNIFICANT PUSH BACK ABOUT IT FROM TRADITIONAL BIOMEDICAL PROVIDERS. THEY ARE AFRAID OF THE LANGUAGE. PART OF THE IT HAS TO DO STORY WHAT PEOPLE SAID TO ME. YOU'RE JUST TALKING CAM. THERE'S NO EVIDENCE FOR CAM. SHOW ME YOUR EVIDENCE AND WE'LL TALK ABOUT IT. BUT I'M JUST CURIOUS AS TO WHETHER OR NOT INSIDE MANY MILITARY YOU HAD SIMILAR PUSH BACK OR BECAUSE OF THE WAY THINGS WORK IN THE MILITARY, YOU WERE JUST ABLE TO DRIVE THE NAME CHANGE, THE LANGUAGE. I THINK THE LANGUAGE IS VERY IMPORTANT. (OFF MIC) (OFF MIC) SO WHILE LANGUAGE IS VERY IMPORTANT, I DO THINK YOU HAVE TO CONSIDER THAT -- THE AUDIENCE THAT YOU'RE TALKING TO. WE HAVE BEEN USING THE TERM INTEGRATIVE MEDICINE BECAUSE MANY OF OUR PROVIDERS DON'T LIKE THE WORD CAM BECAUSE OF THE SOME OF THE NEGATIVE CONNOTATIONS DEVELOPED FOR THAT. AND THERE'S A WONDERFUL LIST, WISH I HAD IT, OF THE 38 DIFFERENT COMPLIMENTARY ALTERNATIVE MEDICINE TECHNIQUES THE VA CAME OUT WITH IT. PURGINGS ON THERE. IT'S A WONDERFUL LIST. WE'RE NOT TRYING ALL 38. FROM THE GET GO. WE HAVE FIVE SPECIFIC ONES THAT WE FEEL LIKE ACUPUNCTURE AND YOGA, HAVE ENOUGH DATA TO SUPPORT THEIR USE BUT WE'RE GO NOT GOING TO STOP THERE. NOT WILLING TO WAIT FOR THE LAST WORD ON YOGA. BEFORE WE ACCEPT THE DATA THAT EXISTS AN INTEGRATE THAT INTO OUR SYSTEM. BUT AT THE SAME TIME WE'RE DEVELOPING SYSTEMS LIKE FASTER PROMISE, LIKE THE NEW DVPRS PAIN SCALE SO AS WE'RE INTEGRATING THE NEW IDEAS INTO OUR SYSTEM, WE'RE GOING TO FIND OUT WHERE THEY FIT DATA TO SUPPORT THEM. IT'S IN THE A BLANK CHECK. IT'S THE MILLENNIA OF ACUPUNCTURE. I WROTE AN EDITORIAL RESPONDING TO CRITICISM FROM THE AIR FORCE OFFICER LAMENTING ACUPUNCTURE IN THE MILITARY ESSENTIALLY SUGGESTING THAT WE WERE PLACING SOLARS IN HARM'S WAY. WE'RE TALKING WHAT WE CALL BATTLEFIELD ACUPUNCTURE WHICH IS A (INAUDIBLE) WE DON'T SAY (INAUDIBLE) BECAUSE THAT AIN'T COOL. EVERYBODY WANTS A PIECE OF THAT. AND I ASK THE QUESTION INNOCENTLY HAS ANYBODY DIED FROM A-- USING KETAMINE ON THE WARDS. PEOPLE SAY HOW DO YOU JUSTIFY USING KETAMINE ON THE WARD? IT IS UNSAFE. I'M LIKE WAIT A SECOND. THE NARCOTIC DEATHS I EXPERIENCED AS A IF PHYSICIAN HAVE NEVER BEEN FROM KETAMINE, THEY HAVE BEEN FROM A MAGNITUDE ERROR BY AN UNFORTUNATE PROVIDER LATE AT NIGHT PROGRAMMING MACHINE WRONG WITH NARCOTICS. YOU PROGRAM THE MACHINE WRONG WITH KETAMINE YOU HAVE A PATIENT THAT SEES A FEW WHITE HE WILLN'TS BUT THEY'RE ALIVE. SO THESE ARE THE DISCUSSIONS THAT WE NEED TO HAVE AS A COMMUNITY, TO RESET THE BAR OUT THERE. THERE'S PEOPLE ARE DESPERATE FOR THIS DIRECTION. IT'S NOT THAT THE NURSES DON'T WANT US TO USE THE NEW IDEAS OR THAT PEOPLE ARE RESISTANT. THEY WANT A BODY LIKE THIS TO SAY THIS IS WHAT YOU SHOULD BE DOING. THAT IS ALL WE'RE DOING IN THE MILITARY. NOT A BLANK CHECK FOR ACUPUNCTURE, YOGA OR KETAMINE. IT'S DEVELOPING A SYSTEM AND COLLECTING THE DATA THAT SAY THIS IS THE BEST PRACTICE IN THAT SITUATION. THANK YOU. >> QUICK COMMENT. I'M HEARING I THINK TWOA+s THINGS, I BELIEVE. FIRST THE LANGUAGE ASSOCIATED WITH WHATEVER THE FINAL PRODUCT THAT Y'ALL COME UP WITH. AND I THINK ONE OF THE ADJECTIVES THAT HAS TO DESCRIBE THAT IS INTEGRATED. IT HAS TO BE AN INTEGRATED SYSTEM. IT CAN'T BE ONE -- >> INTEGRATED OR INTEGRATIVE? >> T E D. I HAS TO BE FULLY INTEGRATED ACROSS THE CONTINUUM OF CARE AND ACROSS THE MODALITIES THAT ARE AVAILABLE. IN THE CASE OF INTEGRATIVE HEALTH AND MEDICINE, I'M PROBABLY THE LEAST PERSON THAT SHOULD MAKE ANY PUBLIC COMMENT BECAUSE I'M NEWEST ENTRY INTO THIS FIELD. BUT MY OWN PERSPECTIVE I LIKEN THESE PRACTICES, I LIKE THE TERM INTEGRATIVE, HEALTH AND MEDICINE IN CONTRAST TO COMPLIMENTARY, BECAUSE NUMBER ONE, I THINK COMPLIMENTARY AND ALTERNATIVE IS MARGINALIZES IN SOMEWHAT DENIGRATING WAY. NUMBER TWO, MY SENSE IS, MY BIAS IS THAT THESE REPRESENT MANY OF THEM THOUGH THERE ARE THOUSANDS OF YEARS OLD, THEY REPRESENT I THINK WHAT DR. CHRISTIANSON WOULD CALL DISRUPTIVE TECHNOLOGIES. WE'RE REDISCOVERING AGE OLD LESSONS IN WHAT WOULD BE DISRUPTIVE OF THE WAY WE CURRENTLY DO MEDICINE, THAT AND HEALTHCARE IN GENERAL IN THAT THEY'RE TEAM BASED. THEY INTEGRATE AROUND THE PATIENT AND THREE DIMENSIONS ENTERGRAYTIVENESS THAT I LIKE IS THEY INTEGRATE THE TEAM, OTHER MODALITIES THAT ARE MORE CONVECTIONAL AND ACCEPTED AND IF NOTHING ELSE PAID FOR AND INTEGRATE THE INDIVIDUAL. THEY INTEGRATE THE PERSON. I THINK THAT'S WHAT OUR PATIENTS ARE TELLING US. THEY FEEL UNINTEGRATEED IN A WAY WE APPROACH THEIR CARE. THAT'S THE COMMENT I WOULD MAKE. >> I'LL JUMP ON AND BEAT THAT HORSE. AS A SURGEON, MY TRAINING AND HINGES WE NEVER WOULD TALK TO ACUPUNCTURIST O CHAI PRO FACTOR, COULDN'T CONCEIVE IT. NOW WE HAVE CLINICS WITH WITH THESE FOLKS WORKING SIDE BY SIDE SO YOU MAY HAVE BIOFEEDBACK, YOU MAY HAVE ACUPUNCTURE, YOGA THERAPY, ET CETERA. IN THE SAME CLINIC. WE SEE IT WORK. BECAUSE I HAD A FRIEND WHO WAS A CLASSICALLY TRAINED ANESTHESIOLOGIST, BUT HE ALSO WAS ACUPUNCTURIST AND I HAD HIM TRAIN LINE MEDICS AND IF PHYSICIAN ASSISTANTS AN DOCS ON ACUPUNCTURE TECHNIQUES BECAUSE SAW IT WORKS SO FOR THAT ACUTE MANAGEMENT, IT MAKES YOU A BELIEVER. YOU SEE THE OPPORTUNITY NOW OVER TIME TO -- IT IS A TEAM SPORT. WE ARE TRAIN AD CERTAIN WAY BUT WE HAVE TO KEEP AN OPEN MIND AND MOVE THIS THING FORWARD. WE FOUND OVER TIME THAT EVEN HAS A PIECE TO THIS. IF IT'S WORKING, I'M ALL FOR IT. >> JOCIE. >> AS HEAD OF DIRECTOR OF THE CENTER FOR COMPLIMENTARY ABOUT ALTERNATIVE MEDICINE, THIS LANGUAGE COMPLEXITIES ARE VERY FA WHERE I WILL YARR TO US. -- FAMILIAR TO US. IN OUR ORIGINAL MANDATE IT SAID WE WERE CHARGED TO STUDY THE DEGREE INTEGRATION OF THESE PRACTICES INTO CONVENTIONAL CARE. IN OUR CURRENT STRATEGIC PLAN FOR THE NEXT FIVE YEARS, PAIN IS VERY CENTRAL, IT'S ABOUT A THIRD OF THE EXTRAMURAL FUNDING. AND WE ARE FOCUSING ON THOSE PRACTICES WHICH SHOW POTENTIAL FOR INTEGRATION. WE'RE FOCUSING ON THE BUILDING OF THE EVIDENCE BASE. THAT'S WHY THESE WONDERFUL REAL WORLD EXPERIMENTS AN EXPERIENCES FROM THE MILITARY ARE SO IMPORTANT TO US. I WILL ADD IF YOU GO TO THE COCHRAN COLLABORATIVE, A GOOD PLACE TO LOOK AT STATUS OF EVIDENCE BASE YOU'LL FIND THAT THERE ARE ABOUT 300 REVIEWS ON COMPLIMENTARY HEALTH PRACTICES. MOST CONCLUDE AS MOST COCHRAN REVIEWS OF STANDARD AND ALTERNATIVE MODALITIES THAT THE EVIDENCE BASE ISN'T ADEQUATE. CERTAINLY THE EVIDENCE BASE FORESTERROID INJECTIONS FOR BACK PAIN IS IN FACT NOT ADEQUATE. BUT IN -- CERTAINLY IN A NUMBER OF AREAS WE ARE SEEING THE VALUE OF THE MIND AND BODY APPROACHES TO PAIN. AS DEVELOPING THE PIECES OF AN EVIDENCE BASE. AND THAT'S HOW WE TRYING TO INVEST THE TAXPAYER DOLLAR IN THIS AREA. >> I WANT TO BE CLEAR, I'M A HUGE PROPONENT OF INTEGRATIVE MEDICINE. MY ISSUE IS REALLY ABOUT USING LANGUAGE TO MOVE THE CONGRESS SEPTEMBER FORWARD, IT'S NOT ABOUT THE VALUE OF AN INTEGRATIVE APPROACH. >> I THINK IT IS IMPORTANT TO DISTINGUISH THAT SMALL SUBSET OF PRACTICES, WHICH ARE OF INTEREST FOR INTEGRATION INTO CONVENTIONAL CARE. IT IS NOT THE BREADTH AND SPECTRUM OF EVERY HEALTH PRACTICE KNOWN TO MAN. >> OKAY. ANY FURTHER COMMENTS OR ISSUES OR QUESTIONS? I WANT TO THANK YOU ALL -- >> JUST ONE. WE HAVE BEEN TALKING TODAY KNOWING WHAT I DO ABOUT WHAT'S GOING ON ACROSS THE COUNTRY, CERTAINLY THERE'S AREA IN PAIN TO IMPROVE PATIENT CARE THAT DOESN'T INVOLVE RESEARCH BUT IN ORDER TO IMPROVE PATIENT CARE IN THE END WE NEED TO ADVANCE RESEARCH. WHILE WE WORK TO UNDERSTAND BASIC UNDERPINNINGS OF PAIN AND HETEROGENEITY AND COMPLEXITY OF PAIN, THERE'S MANY PROGRAMS INCLUDING THE MILITARY SEAN MACKEY'S GROUP, UNIVERSITY OF WASHINGTON AND OTHERS MOVING FORWARD WITH MEASUREMENT BASED CARE AND COLLECTING INFORMATION ON OUTCOMES AND TYING THAT BACK INTO CLINICAL PREDICTORS. WE HAVE THE THIS MASSIVE POPULATION OF PEOPLE THAT WE'RE TRYING TO HELP. AND THEY CAN'T WAIT 40 YEARS. AS GENERAL THOMAS SAID WE CAN'T AFFORD NOT TO DO THIS. SO JUST REALLY, AGAIN, THIS AREA BEING ONE THIS COMMITTEE CAN BE REALLY IMPACTFUL ON IS COLLECTING PATIENT REPORTED OUTCOMES, UNDERSTANDING PHENOTYPES, GETTING MEASUREMENT BASED CARE, MODELS OUT THERE AND DATA ON THAT VERY QUICKLY TO START TRYING TO GUIDE CLINICAL CARE AND ADVANCE ALL OF THE THINGS THAT WE WERE CHARGED WITH BY DR. COH. >> GREAT. SO I WOULD LIKE TO THANK Y'ALL FOR THIS WONFUL PRESENTATION OF YOUR EFFORTS IN PAIN MANAGEMENT IN THE ARMED SERVICES AND LOTS OF THINGS TO LEARN FROM WHAT YOU HAVE BEEN DOING. [APPLAUSE] >> I THINK WE'D LIKE TO TAKE A SHORT BREAK. MAYBE 10 MINUTES, AND THEN THE LAST PIECE ON THE AGENDA IS DISCUSSION OF THE PAIN RESEARCH ADVANCES AND WHAT THEY ENDED UP BEING AND WHAT WE WANT TO DO WITH THEM AND HOW TO THINK ABOUT THEM GOING FORWARD. AND ONE PUBLIC COMMENT. THANKS. >> I KNOW A NUMBER OF YOU HAVE AIRPLANES TO CATCH, RUT GLENN THE COMMITTEE MANAGEMENT PERSON WHO RUNS THIS TOLD ME THAT FOR THE OPEN MEETING WE NEED TO HAVE A QUORUM OF MEMBERS AND WE'RE GETTING CLOSE TO HAVING LOST A QUORUM. ONE THING WE WERE ASKED TO DO IN OUR CHARGE WAS TO DESCRIBE THE ADVANCES IN PAIN RESEARCH. WE WENT AHEAD AND COLLECTED ADVANCES AND VOTED BUT I THINK IT'S WORTH IT NOW TO STEP BACK AND ASK WHO DO WE THINK IS THE INTENDED AUDIENCE FOR THESE ADVANCES, HOW THEY SHOULD BE PRESENTED, PUBLICATION PAPERS WITH RELEVANT STATEMENTS, A MORE INFORMATIVE SUMMARY, SICK CANCEL AND LIKELY CONTRIBUTION. -- SIGNIFICANCE AND LIKELY CONTRIBUTION. BALANCING THEM THEMEICLY AND POSTED ONLINE AND HOW OFTEN THE LIST SHOULD BE UPDATED. I WANTED RAISE THOSE QUESTIONS BEFORE WE TALK ABOUT WHAT THE RESULTS ARE OF THE EFFORT THAT WE HAVE HAD SO FAR. SO INITIALLY THERE WERE 131 ADVANCES COMMITTED. THAT COVERD THE LAST SEVERAL YEARS SO IT'S NOT SURPRISING THERE WERE THAT MANY. 11 OF THE MEMBERS OF THE IPRCC VOTED LAST WEEK AND WE BROUGHT IT DOWN TO 20 ADVANCES, WHICH IS A MANAGEABLE NUMBER. INTERESTINGLY, AND ENCOURAGELY SEVERAL ADVANCES HAD MULTIPLE VOTES. IN ADDITION TO ADVANCES THAT EVERYBODY EVERYBODY SUBMIT AND VOTED ON THERE WERE WRITE IN ADVANCES, THINKING ABOUT THE UPCOMING ELECTION WHERE THERE'S AN OPPORTUNITY TO WRITE IN PEOPLE MIGHT WANT IN OFFICE. THERE ARE THREE ONGOING STUDIES HIGHLIGHTED BY MEMBERS. SO IN ORDER TO HELP ORGANIZE THIS DISCUSSION WE GROUPED SOME OF THEM TOGETHER AND I'LL SHOW YOU THOSE GROUPINGS T. THERE WERE A NUMBER OF ADVANCES WHICH SEEM TO BE MOLECULAR. I OUTLINED THEM HERE. THERE WERE OTHER ADVANCES. THINKING ABOUT -- THE STRUCTURE OF DELTA OPIOID RECEPTOR BOUND TO NOW TRENDLE, WE REALED, THIS WAS MENTIONED IN ONE OF THE DISCUSSIONS THAT IN FACT THIS WAS AN AMAZING YEAR FOR STRUCTURES OF OPIOID RECEPTORS, FOUR WERE RESOLVED THIS YEAR. YOU CAN SEE THE LIST BELOW. THIS IS ABOUT IMPORTANT FINDING BECAUSE OPIOID STRUCTURES WERE NOVEL FOR DISCOVERY OF NOVEL OPIOIDS. IF YOU WERE LUCKY YOU FIND ONE THAT RELIEVES PAIN BUT LESS POTENTIAL FOR ABUSE. THESE HAD BEEN VERY DIFFICULT TO RESOLVE BY X RACE CRYSTALOGRAPHER. IN FACT TRANS-NIH WERE NEEDED TO DEVELOP TECHNIQUES. THERE WAS A MAJOR ROADMAP PROJECT TO HELP RESOLVE STRUCTURES OF MEMBRANE PROTEINS WHICH MADE A HUGE DIFFERENCE. IN ADDITION THE THAT INDIVIDUAL INSTITUTES FUNDED STRUCTURE STUDIES. THIS IS THE ONE THAT WAS ACTUALLY IDENTIFIED SPECIFICALLY AS AN AD VANCE. EVEN MORE INTERESTING IS NOBEL PRIZE IN CHEMISTRY WAS (INDISCERNIBLE) FOR STUDIES OF G PROTEIN COUPLED RECEPTORS. FRANCIS COLLINS IS QUOTED HAVING SAID HALF THE MEDICATIONS INCLUDING BETA BLOCKERS, ANTI-HISTAMINES AN PSYCHIATRIC MEDICATIONS, AFTER THESE RECEPTORS, BOTH ANYONE WAS ONE OF THE INSTITUTES THAT FUNDED COVELKA. WE CLASSIFIED SEVERAL AS SYSTEMS NEUROSCIENCE, AN INTERESTING PAPER THAT SHOWED IF YOU TAKE NEURAL PRE-CURSORS FROM FOREBRAIN GABAERGIC YOU COULD INTEGRATE TYPE ADULT SPINAL CORD AND INJURY INDUCED NEUROPATHIC PAIN. WE HAVE HEARD DISCUSSED THIS CORTICAL L STRIATAL FUNCTIONAL PRODUCTIVITY PREDICTS CHRONIC BACK PAIN AND ANOTHER INTERESTING PAPER AT PATTERNS OF HOW MANY BRAIN ACTIVITY THAT DISTINGUISH PAIN FROM NON-PAINFUL THERMAL STIMULATION. WE KIND OF GROUPED SPECIFIC CONDITIONS AND SPECIAL POPULATIONS TOGETHER. SO INCREASING PREVALENCE OF KNEE PAIN AND KNEE OSTEOARTHRITIS, RELATIONSHIP BETWEEN VULVA DIDN'TIA AND CHRONIC PAIN CONDITIONS, CHRONIC PAIN, MUSCULOSKELETAL PAIN, RARE ANDETH IN IN THIS CASE DISPREPPIE -- DISPARITIES IN PAIN, SEX DIFFERENCES AND SEX PAIN. SO VERY INTERESTING COLLECTION OF PAPERS THAT THE GROUP THOUGHT WERE IMPORTANT ADVANCES. THEN LOOKING AT TRANSLATIONAL THERAPEUTICS AND TREATMENT, A NUMBER OF ADVANCES HERE THAT WE ALSO -- THE GROUP ALSO THOUGHT WERE IMPORTANT TO HIGHLIGHT. THE THREE WRITE INS WERE THE ACTION IMPACT PROJECT THAT WE HAVE HEARD ABOUT FROM THE FDA, TWO NETWORKS, THE MAP NETWORK AND OPERA STUDY, WE ALSO HEARD ABOUT TODAY. I THINK ALL THINGS CONSIDERED THAT THESE WOULD BE -- THOUGH NOT INDIVIDUAL PUBLISHED PAPERS ON THESE, THAT IT WOULD BE GOOD TO ALSO ACKNOWLEDGE THE CREATION OF THESE NETWORKS AND IMPACT ACTION ACTIVITY AS ADVANCES. THEY HAVE A BUNCH OF PUBLISHED PAPERS. BUT I'M THINKING NOT SO MUCH AN INDIVIDUAL PAPER BUT THE CREATION OF THE STUDY. FOR THE INITIATIVE. WE COULD LIST THE PAPERS. IN GUIDING OUR THINKING ON THIS, WE LOOKED TO THE INTERAGENCY AUTISM COORDINATING COMMITTEE, THAT'S ANOTHER FA DA CONSTITUTED COMMITTEE THAT WAS LED WITH -- PUT IN LEGISLATION, RUN BY NIMH, THEY ACTUALLY HAVE AN -- THEY ARE MANDATED TO HAVE AN ANNUAL PROCESS TO COME UP WITH INDIVIDUAL PUBLICATIONS THAT REPRESENT SIGNIFICANT ADVANCES. ABOUT 60 ARE NOMINATED. THEN THEY SELECT THE SAME WE SELECT THESE, 20, AND THEIR PLAIN LANGUAGE SUMMARIES ARE DEVELOPED AND GROUPED. IN OUR CASE WE GROUPED THEM BY THE KIND OF SCIENCE IN THE INTERAGENCY AUTISM COORDINATING COMMITTEE. THEY GROUP THEM ACCORDING TO A SET OF QUESTIONS THAT THE INTERAGENCY AUTISM COORDINATING COMMITTEE HAS USED AS A WAY TO FORMULATE THEIR STRATEGIC PLAN. SO THEY HAVE WHAT SHOULD I BE CONCERNED IF MY CHILD IS NOT DEVELOPING NORMALLY. HOW CAN I UNDERSTAND WHAT'S HAPPENING. WHAT CAUSED THIS ETIOLOGY OF AUTISM. WHICH TREATMENTS AND INTERVENTIONS HELP. SO I DON'T THINK WE'RE AT A POINT WHERE WE HAVE SEVEN -- SET OF QUESTIONS THAT AS THE INTERAGENCY AUTISM COORDINATING COMMITTEE DOES BUT CERTAINLY AT A POINT WHERE WE COULD THINK ABOUT HAVING AN ANNUAL PROCESS, IDENTIFYING ABOUT 20 ADVANCES IF THAT'S THE APPROPRIATE NUMBER AND HAVING LAY LANGUAGE SUMMARIES WE WOULD PUT UP ON THE INTERAGENCY PAIN RESEARCH COORDINATING COMMITTEE WEBSITE. THE HOPE WOULD BE THE LAY LANGUAGE SUMMARIES WOULD BE LAY ENOUGH THAT THEY WOULD BE INFORMATIVE NOT JUST TO THE SCIENTIFIC COMMUNITY BUT THE BROADER LAY COMMUNITY. SO I WOULD LIKE TO PROPOSE WE KEEP THE 20 NOMINATED AND THE THREE INITIATIVES PROGRAMS AND THAT STAFF BE RESPONSIBLE FOR WRITING UP LAY LANGUAGE SUMMARIES. WHICH WOULD THEN BE POSTED ON THE INTERAGENCY PAIN RESEARCH COORDINATING COMMITTEE WEBSITE AND THAT A YEAR FROM NOW, OR WHEREVER IT WOULD BE A YEAR FROM WHEN WE STARTED, MAYBE IN JUNE WE BEGIN THE PROCESS AGAIN OF LOOKING AT ADVANCES. CARMEN. >> THIS IS GREAT. WITH THAT BEING SAID I ACTUALLY THINK THAT WE COULD POTENTIALLY ALSO LOOK BACKWARDS A BIT AND SEE WHAT SINCE WE'RE STARTING ANEW, WHAT ARE THE MOST IMPORTANT PAPERS IN THE PAIN ARENA? SOME WAS COVERED IN THIS MEDICINE REPORT BUT THEY DIDN'T LAY IT OUT IN THAT FRAMEWORK. BUT I THINK THAT THAT WOULD BE A GREAT PLATFORM TO WHICH TO GO FORWARD. THEN SORT OF SAY IN THE LAST THREE YEARS THESE ARE THE PAPERS BECAUSE IT WAS LAST THREE YEARS IS WHAT WE'RE TALKING ABOUT. THAT -- AND MOVING FORWARD EACH YEAR. >> SO THE QUESTION IS DO WE WANT TO HOLD UP PUT -- HOLD OFF PUTTING THESE UP TO GO BACK AND GET A HISTORICAL PERSPECTIVE ON THE PAIN FIELD OR PUT THESE UP AND OVER THE COURSE OF THE NEXT YEAR PICK A SEMINOLE PAPER EACH MONTH AND PUT IT UP ON THE WEBSITE. >> WELL, I GUESS THAT'S WHY YOU'RE THE CHAIR. [LAUGHTER] >> MADAM CHAIRWOMAN. >> THANK YOU, ACTUALLY I'M GOING TO GO SIT DOWN NOW. >> I MEAN, I THINK THE BALL IS MOVING. THE TRAIN HAS LEFT THE STATION AND WE HAVE OTHER WORK TO DO BUT I DO THINK THAT ONE OF THE THINGS WE NEED TO DO IS RESPECT THE HISTORY. THOSE PEOPLE WHO -- I MEAN THESE MOLECULAR ADVANCES, THESE CLINICAL POPULATIONS, I DON'T THINK IT WOULD TAKE US A HUGE AMOUNT OF TIME. BUT I THINK THAT THAT WOULD BE AN IMPORTANT PLACE TO BEGIN WITH WITH. >> SO HOW ABOUT IF WE SOLICIT FROM THE MEMBERS OF THE COMMITTEE AND FROM THE NIH INSTITUTE A LIST OF SEMINOLE PAPERS IN PAIN RESEARCH THEN WE GO THROUGH THE SAME PROCESS WE WENT THROUGH HERE, WE GET SOME CONSENSUS ON WHAT REPRESENTS THOSE SEMINOLE PAPERS. AND WE WHEN THAT'S READY POST THOSE. ONE OF THE THINGS THAT I KIND OF LIKE THE IDEA OF IS HAVING A WEBSITE THAT'S ACTUALLY DYNAMIC. GOOD. THANK YOU FOR THE WORD. THERE'S STUFF GOING UP ON A REGULAR BASIS. SO THAT WE DON'T JUST HAVE A FLURRY OF THINGS THAT GOT PUT OFF ONCE WE HAD A MEETING BUT THERE'S A CONSENSUS OF SEEING ADDITIONAL MATERIALS PUT UP ON A REGULAR BASIS. >> YOU GUYS ARE THE PAIN EXPERTS. YOU TELL ME. HOW FAR DO YOU WANT THE GO BACK? I DON'T WANT TO GO BACK TO THE GREEKS. (OFF MIC) >> NO, NO, NO, THAT'S NOT ENOUGH. YOU NEED TO SUBMIT A PAPER. RIGHT. THOSE ARE CLASSIC PAPERS. IT WOULD BE INTERESTING IN THAT REGARD TO HAVE THE SHARINGTON PAPER AND THEN WHAT THE IMPLICATIONS OF THAT DISCOVERY AND DESCRIPTION HAVE MEANT FOR THE PAIN FIELD. WOULD THAT BE -- WOULD THAT -- >> WHAT MIGHT BE MORE FUN AND INCLUSIVE TO THE COMMUNITY, IS OFFER THE IMMUNITY THE OPPORTUNITY TO NOMINATE. >> WE COULD PICK A COUPLE OF CLASSIC PAPERS OR WE COULD PUT UP THE PAST THREE YEARS ADVANCES AND ASK ANYONE WHO READS THE SITE TO SUBMIT CLASSIC PAPER SOUNDS A LITTLE -- I MEAN WE'LL FIGURE OUT SOME WAY -- >> SEMINOLE PAPERS. >> AND ASK COMMUNITY TO PUT HEMP, ASK THE PUBLIC TO CONTRIBUTE. VERY GOOD IDEA TO GET ENGAGEMENT FROM THE SCIENTIFIC COMMUNITY ON THIS. WE WILL GO WITH THE ONES 20 PLUS THREE WRITE WRITHE INS. WE'LL PUT THEM UP AS SOON AS THE LAY LANGUAGE SUMMARIES ARE DONE. THANK YOU VERY MUCH. AND WE CAN EVEN PUT THEM -- WE DON'T HAVE TO PUT THEM AT ONCE, WE COULD PUT FIVE, ONE FROM EACH -- ONE FROM EACH CATEGORY. PUT UP THE NEXT FOUR, SO WE DON'T HAVE TO WAIT UNTIL -- RIGHT. OKAY. ANY FURTHER DISCUSSION? I KNOW I PUSHED THAT THROUGH BUT SEEMS LIKE A REASONABLE STRATEGY. THIS WAS REALLY IMPORTANT UNTIL WE GOT THE NEW ASSIGNMENT. (OFF MIC) >> A YEAR FROM NOW WE'LL HAVE ADVANCES FROM THE PAST YEAR. WHAT WAS THE LAST PAPER? WHAT WAS THE LAST PAPER THAT GOT ADDED TO THIS LIST? 2012. SO A YEAR FROM THE LAST PAPER WE'LL BE GIN THE PROCESS AGAIN. SO EVERY YEAR WE'LL SOLICIT. >> THIS IS AN AMUSING POINT. WHEN I READ THE FOUR PAPERS IN NATURE, I THOUGHT THIS WAS A LAND MARK. AND SO I QUICKLY WEPT TO THE CITATION INDEX HUNDREDS, TURNS OUT THERE'S SIX 12 CITATION -- CITATIONS. LITERATURE CITATION TO CLASSIC PAPERS TAKES A LONG TIME FOR PAPERS TO GET PUBLISHED. >> FOR THAT WE WANT THE AGGREGATE OF THE FOUR PAPERS. >> ABSOLUTELY. >> CO-AUTHOR ON TWO. >> YES, I KNOW THAT. I KNEW THAT. I THINK WE FUNDED THAT WORK. OKAY. SO NOW I ASK IF THERE'S ANY NEW BUSINESS, ANY ADDITIONAL BUSINESS AND IF NOT THEN WE HAVE A PUBLIC COMMENT. CAN I ASK THE PLAN WITH REGARD TO WHAT IS THE MEETING OR GETTING WORK DONE? >> WE WILL END OFF HAVING >> WE HAVE THE DECIDE DO WE WANT A MEETING EVERY SIX MONTHS. THAT'S A PHYSICAL PEOPLE COME HERE, MEET EVERY SIX MONTHS. I THINK THIS THAT'S SMILE, RUTH. A REASONABLE SCHEDULE. WE HAVE A LOT OF WORK THAT'S GOING TO NEED TO BE DONE BETWEEN THOSE MEETINGS. AND SO WE WILL HAVE PHONE CONVERSATIONS TO DEAL WITH THAT. WITH OUR NEW CHARGE WE'RE GOING TO END UP PUTTING TOGETHER A WORKING GROUP AND WE HAVE VOLUNTEERS FOR THE WORKING GROUP. WE WILL AFTER WE HAVE TALKED TO DR. PAREKH AND GOTTEN ADDITIONAL INFORMATION, HIS THOUGHTS HOW TO GO FORWARD WITH THIS NEW CHARGE, WE WILL TALK TO THE WORKING GROUP AND GET SUGGESTIONS FROM -- FOR ADDITIONAL PEOPLE BEYOND THE IPRCC TO PUT TOGETHER ON THAT WORKING GROUP. AND SEND OUT A SUMMARY OF ALL THE THINGS WE AGREED TO. RON. >> THIS MORNING WE DISCUSSED A NUMBER OF POSSIBILITIES WHERE TO GO FORWARD WITH THE PORTFOLIO. >> THAT'S NOT GOING TO SLOW DOWN ONE IOTA. >> MAYBE THERE SHOULD BE A SUBGROUP WORKING GROUP. >> PORTFOLIO, WE COULD DO THAT. >> WORKING GROUP TO COME UP SORT OF RECOMMEND HOW WE SHOULD GO FORWARD >> SO I THINK EVERYBODY, THE WORKING GROUP DID AN EXCELLENT JOB IN HELPING US PUT TOGETHER THE PORTFOLIO ANALYSIS. I WOULD LIKE TO HAVE THE WHOLE COMMITTEE OFFER SUGGESTIONS ON HOW WE WILL CONTINUE TO PURSUE THE PORTFOLIO ANALYSIS AND GAP INDENTIFICATION. WE WILL SEND OUT A SUMMARY OF THE ANALYSES THAT WE HEARD TODAY THAT YOU THOUGHT WERE REALLY IMPORTANT. IN ADDITION TO THAT, WE WILL EXPECT SOME OF YOU MAY SAY NEVER MIND WE DON'T THINK THAT'S SO IMPORTANT OR GEE, IT WOULD BE GREAT IF WE DID THIS OTHER THING. >> WHO MAKES DECISIONS ON PRIORITIES WHICH ARE GOING FORWARD. >> WE COULD HAVE A VOTE IF YOU WOULD. LET'S SEE HOW MANY SUGGESTIONS WE HAVE. SEE HOW MANY SUGGESTIONS WE HAVE. THE QUESTION -- A QUESTION FOR YOU ALL IS DO WE WANT TO WAIT UNTIL FOR COMPLETE ANALYSIS OR POST ANYTHING OR POST THINGS AS WE GO ALONG? I DON'T THINK WE POST TO THE -- I DON'T THINK WE WANT TO POST DATA WE HAVE BECAUSE IT'S MOSTLY JUST NUMBERS. >> MAKE A DECISION WHERE WE ARE SIX MONTHS FROM NOW. >> YEAH. I AGREE, BEFORE THEN. >> WE HAVE GOT PEOPLE AND EVERYBODY IS INTERESTED IN THIS AND EXCITED ABOUT IT. I THINK THE ANAL SITS THAT YOU TWO GUYS DID WAS VERY INFORMATIVE. WE MAY SOLICIT OPINIONS FROM A SUBSET OF YOU ABOUT SOME OF THE SPECIFIC TOPICS, SECOND, THIRD, FOURTH AND FIFTH MOST FUNNED AREAS ABOUT HOW -- FUNDED AREAS HOW TO CREATE CATEGORIES. WE NEED TO LOOK AT IT A LITTLE BIT FIRST. ONE WE ACCEPT OUT OUR UNDERSTANDING OF WHAT PEOPLE HAVE ASKED US OR SUGGESTION WE DO, SOME MIGHT VOLUNTEER TO CREATE CATEGORIES FOR OTHER TOP ICS. >> RIGHT. RIGHT. >> WE HAVE VERY GOOD NOTES. WE HAVE THREE PEOPLE WHO HAVE BEEN TAKING NOTES SO I THINK WE WON'T HAVE LOST ANYTHING. >> SO WE HAVE AN ORAL STATEMENT FROM CHRISTINE ZEMBRICKY WHO IS BEHIND ME. SHE'S FROM THE AMERICAN ASSOCIATION OF NURSE ANESTHETISTS. >> GOOD AFTERNOON, EVERYONE. MY NAME IS CHRISTINE AND I'M A CERTIFIED REGISTERED NURSE ANESTHETIST. ON BEHALF OF THE AMERICAN ASSOCIATION OF NURSE ANESTHETISTS I WANT TO THANK YOU FOR THE OPPORTUNITY TO AUDIT THIS MEETING. IT WAS ABSOLUTELY -- (OFF MIC) >> IT WAS A PLEASURE TO BE HERE AND EVERY PERSON HAD SUCH A VITAL CONTRIBUTION TO THE MEETING. IT WAS A GREAT LEARNING FOR ME. I APPRECIATE THE OPPORTUNITYING TO HERE. THE AMERICAN ASSOCIATION OF NURSE ANECESSARY ANESTHETIST Z RECOGNIZES THE NEED FOR TRANSPORTATION IN THIS FIELD AND COMMITTED TO DOING WHATEVER WE CAN TO LEND EXPERTISE AN ACTIVE PARTICIPATION IN THE PROCESS. SO TO TELL YOU ABOUT THE AMERICAN ASSOCIATION OF NURSE ANESTHETISTS AND PAY PRACTICE, RESEARCH PERSPECTIVE AND EDUCATION. AND TAKE LESS THAN FIVE MINUTES SO THAT EVERYBODY CAN LEAVE. THE AMERICAN ASSOCIATION OF NURSE ANESTHETISTS IS PROFESSIONAL ORGANIZATION FOR CERTIFIED REGISTERED NURSE ANESTHETISTS WHICH I AM ONE OR CRNAs. WE REPRESENT MORE THAN 45,000 NURSE ANESTHETISTS AND NURSE ANESTHESIA STUDENTS IN THE COUNTRY. WE ARE ADVANCED PRACTICE REGISTERED NURSES, AND WE ARE TRAINED AT THE MATSERS OR DOCTORAL LEVEL AND ADMINISTER OVER 33 MILLION ANESTHETICS IN THE UNITED STATES OF AMERICA. WE HAVE BEEN PROVIDING ANECESSARY THEE SHAH AN MANAGING PATIENT PAIN FOR OVER 150 YEARS. NOW THAT I TOLD YOU ABOUT THAT, I WOULD LIKE TO TELL YOU ABOUT NURSE ANESTHETIST PAIN PRACTICE RESEARCH PERSPECTIVE AND EDUCATION. WITH RESPECT TO PAIN PRACTICE, THE INSTITUTE OF MEDICINE STATES THAT THERE ARE MANY MORE HEALTHCARE PROFESSIONALS NEEDED TO ASSESS AND TREAT PAIN. ESTIMATE THE TOTAL NUMBER OF CERTIFIED CURRENTLY PRACTICING IF PHYSICIANS TO BE BETWEEN 3 AND 4,000. NUMBER OF NURSE ANESTHETISTS PRACTICING IS EQUALLY SMALL. HOW FAR THE ONLY NUMBER THAT MATTERS TO THE PATIENT IS ONE PERSON TAKING CARE OF ONE PATIENT. THAT'S VITAL TO THE PATIENT RECEIVING CARE. THAT'S IMMEASURABLE. IN MANY RULE AREAS TALKING TO THE SQUARE STATES THEY DON'T WANT TO BE CONSIDERED RURAL STATES THEY TELL ME THEY ARE ACTUALLY FRONTIER STATES. CRNAs ARE THE ONLY HEALTHCARE PROVIDERS PROVIDING PAIN SERVICES. IN THESE SMALL COMMUNITIES. PATIENTS WOULD HAVE THE TRAVEL HUNDREDS OF MILES TO SEEK ALTERNATIVE CARE. THESE REMOTE AREAS REFERRING IF PHYSICIANS DEPEND ON THE NURSE ANESTHETIST AND CHOOSE TO USE THEM TO TAKE CARE OF PATIENTS. THE PATIENTS CHOOSE TO RECEIVE THEIR CARE FROM NURSE ANESTHETISTS, RATHER THAN ALTERNATIVE DRIVING 200-MILES DISTANCE TO RECEIVE CARE SOMEWHERE ELSE. CHRONIC PAIN MANAGEMENT SERVICES TO ALL TYPES OF PATIENTS, ACCORDING TO A 2012 CASE STUDY ANALYSIS BY THE LOOP GROUP OF FOUR INDIVIDUAL PATIENTS FROM ALL DIFFERENT PARTS OF THE UNITED STATES, REPRESENTING DIFFERENT GEOGRAPHIC LOCATION, THE DIRECT MEDICAL CLASS OF ALTERNATIVES TO THAT CARE, WOULD BE UP TO 130% HIGHER. SO THAT'S JUST A LITTLE BIT ABOUT PAIN PRACTICE. AND I THINK IT'S RELEVANT TO MY COMMENTS ABOUT RESEARCH. RELATIVE TO PAIN RESEARCH BETH DATA ARE NEEDED TO SHAPE THE TRANSITION TO EFFICIENT CARE SYSTEMS, THAT ADDRESSES POPULATION DISPARITIES RURAL CARE AND GEOGRAPHIES DOES PRESENT DISPARITIES FOR PATIENTS. AND RESEARCH THAT FOCUSES ON PEOPLE UNDERDIAGNOSED AND UNDERTREATED. THE AMERICAN ASSOCIATION OF NURSE ANESTHETISTS WELCOMES TO ASSIST NIH WITH THE COLLECTION OF PAIN INCIDENCE, PREVALENCE AN TREATMENT AS WELL AS OUTCOME OF TREATMENTS WITH 24% ALL U.S. COUNTIES SERVED ONLY BY MUST ANESTHETISTS AT THE SOLE PROVIDER OF ANESTHESIA SERVICE THERE'S A TREMENDOUS OPPORTUNITY, A WEALTH OF INFORMATION TO BE GARNERED THROUGH OUR PRACTICE. AND IT REALLY A NEED FOR A COLLABORATIVE AND DIRECTED NATIONAL EFFORT TO RESEARCH TO THIS AREA OF DISPARITY. SO WE STAND AT THE READY TO WORK COLLABORATIVELY WITH OTHER PROFESSIONAL GROUPS AND THE NIH TO USE THAT INFORMATION IN A WAY THAT IMPROVES PATIENT CARE ACROSS OUR NATION. A FEW WORDS ON PAIN EDUCATION. ACCORDING TO THE INSTITUTE OF MEDICINE REPORT ON PAIN EDUCATION CENTRAL TO ACHIEVE NECESSARY CULTURAL TRANSFORMATION AND APPROACH TO PAIN. DUE TO ADVANCED EDUCATION TRAINING AND EXPERIENCE NURSE ANESTHETISTS ARE ADDRESSING THIS PUBLIC HEALTH CHALLENGE BUT WE MUST DO MORE TO ADVANCE COMPREHENSIVE PAIN EDUCATION INCLUDING KNOWLEDGE OF PREVENTION WHICH I THINK MANY OF US THAT ARE DON'T FOCUS ON PREVENTION AND MORE ON TREATMENT AND MORE ON THE OUTCOMES OF THAT TREATMENT. AND WE REALLY NEED TO DO MORE IN THAT AREA. AS A KEY STAKEHOLDER THE PROFESSION OF NURSE ANECESSARY THEEIA EXPAND AND ADVANCE EDUCATIONAL OPPORTUNITIES FROM FOUNDATIONAL KNOWLEDGE AND POST GRADUATE STRAINING AND SPECIALTY TRAINING IN PAIN. HOW FAR, WE RECOGNIZE THAT ALL OF US MUST WORK TO IMPROVE THE EDUCATION IN PAIN MANAGEMENT AND TREATMENT INCLUDING SOME OF THE THINGS TALKED ABOUT TODAY AS FAR AS PATIENT SELF-MANAGEMENT, ALTERNATIVE METHODS OF REDUCING PAIN AND PREVENTION OF PAIN. SO I DON'T THINK ANY OF US ARE WHERE WE WANT TO BE WITH THAT RIGHT NOW. IN CLOSING PAIN IS A SIGNIFICANT PUBLIC HEALTH CHALLENGE IN WHICH SUBSTANTIAL DISPARITIES EXIST. SERIOUS RATES OF INADEQUATELY TREATED PAIN ARE MOST COMMON IN VULNERABLE POPULATIONS SUCH AS THOSE IN RURAL COMMUNITIES WHERE NURSE ANESTHETISTS ARE ESSENTIAL PAIN CARE PROVIDERS. OUR PROFESSION ALONG WITH OTHER GROUPS HAVE POTENTIAL TO EFFECT WIDE-REACHING CHANGES TO DELIVERY OF PAIN CARE. WE REACH OUT TO YOU TODAY O OFFER OUR FULL SUPPORT AND EXPERTISE TO WORK COLLABORATIVE LY WITH THIS GROUP AS WELL AS OTHERS IN THE PAIN COMMUNITY AND OTHER PROFESSIONAL ORGANIZATIONS TO DEVELOP A POPULATION LEVEL PAIN PREVENTION AND MANAGEMENT STRATEGY WITH FOCUS ON PAIN CARE, RESEARCH AND EDUCATION. THANK YOU FOR THE OPPORTUNITY TO PROVIDE THIS COMMENT. DO YOU HAVE ANY QUESTIONS? >> THANK YOU VERY MUCH. QUESTIONS? >> IS YOUR PRACTICE PREDOMINANTLY OUTPATIENT OR INPATIENT? >> CRNA PRACTICE IN ALL SETTINGS. THEY PACK IT IS ACUTE PAIN CARE IN HOSPITAL SETTINGS AND SURGICAL CENTERS AND CHRONIC PAIN MANAGEMENT IS MORE AN OUTPATIENT COMMUNITY-BASED SETTING SO COULD BE IN A PAIN CLINIC. IT COULD BE IN AN YOU HAVE ON BLAY OFFICE SETTING OR ACUTE CARE SETTING LIKE HOSPITAL OR AMBULATORY SURGERY CENTER. >> THAT WAS A YES OR A NO? >> I'M SORRY, WHAT WAS THE QUESTION? >> THE PREDOMINANTLY WAS THE KEY WORD. >> CHRONIC PAIN MANAGEMENT IS PRACTICED PREDOMINANTLY IN THE OUTPATIENT SETTING AND ACUTE PAIN MANAGEMENT IN INPATIENT SETTING. >> OKAY. TO THE POINT, WOULD YOU SAY THE MAJORITY OF SOCIETY ARE INPATIENT FOCUSED OR OUTPATIENT FOCUSED IN >> MAJORITY OF SOCIETY? >> THE MEMBERS OF YOUR ORGANIZATION. >> THE MAJORITY OF OUR MEMBERS PRACTICE ACUTE CARE SETTING PROVIDING ANESTHESIA SERVICES. >> THANK YOU VERY MUCH. WE ALSO PUT IN YOUR FOLDERS A LETTER WE RECEIVED FROM THE AMERICAN ACADEMY OF PAIN MANAGEMENT, AMERICAN CANCER SOCIETY WHICH IS PROPOSING AN INITIATIVE -- A RESEARCH INITIATIVE, WHICH WE DIDN'T GET THROUGH REGULAR CHANNELS BUT THOUGHT WE WOULD -- SINCE WE KNEW ABOUT IT PRINT IT OUT AND PUT IT IN YOUR FOLDERS. IT'S AT YOUR DESK. >> THANK YOU ALL VERY MUCH, I APPRECIATE THE HARD WE HAVE DONE TODAY AND WE'LL START LOOKING FOR THE MEETING THE DATE FOR THE NEXT MEETING. THANKS.