I WANT TO WELCOME EVERYBODY IN THE AUDIENCE AND THOSE LISTENING IN ON THE WEBCAST, AND THIS WILL BE VIDEOCAST FOR POSTERITY. IT IS, I THINK, A VERY IMPORTANT PRESENTATIONS THAT YOU'RE GOING TO HEAR ABOUT THIS AFTERNOON. AND THIS IS THE PRESENTATION OF THE DRAFT OF THE FEDERAL PAIN RESEARCH STRATEGY, WHICH IS PUT TOGETHER BY A TREMENDOUS TEAM OF EXPERTS TO VEL DEVELOP A LONG TERM STRATEGY TO ADVANCE THE FEDERAL PAIN AGENDA. ALL OF THOSE IN THE PAIN CONSORTIUM TAKE THIS SERIOUSLY IN DEVELOPING THEIR RESEARCH PLANS FOR THE FUTURE. JUST TO GO BACK AND TELL FOLKS HOW WE GOT TO WHERE WE ARE NOW, SO IN THE PATIENT PROTECTION AFFORDABLE CARE ACT OF 2010, THERE WAS A SECTION, SECTION 4305, ABOUT ADVANCING RESEARCH AND TREATMENT FOR PAIN CARE MANAGEMENT. THE SECRETARY HAD THE IOM CONVENE A CONFERENCE ON PAIN AND THEN ASKED THE SECRETARY TO ESTABLISH THE INTERAGENCY PAIN COORDINATING COMMITTEE TO COORDINATE ALL EFFORTS ACROSS FEDERAL AGENCIES AND THE OTHER DEPARTMENTS TO SUPPORT RESEARCH RELATED TO PAIN. LINDA'S OFFICE OF PAIN POLICY AND MYSELF HELP DIRECT THAT INTERAGENCY PAIN COORDINATING COMMITTEE, WHICH IS AN OFFICIAL FEDERAL ADVISORY COMMITTEE. AND SO THE RECOMMENDATIONS YOU'LL BE HEARING ABOUT WERE DONE IN CONCERT WITH THE IPRCC AND WILL BE PRESENED TO THE IPRCC, AND THE IPRCC WILL THEN DELIVER THOSE RECOMMENDATIONS TO THE SECRETARY AND WE AT NIH CERTAINLY ARE A PART OF HHS AS I SAID, MUCH OF THIS IS DIRECTED TOWARD US, BUT ACTUALLY TO ALL THE OTHER AGENCIES THAT FUND PAIN RESEARCH. WHAT CAME BEFORE THE FEDERAL RESEARCH STRATEGY IS THE NATIONAL PAIN STRATEGY, SO PEOPLE SHOULD BE FAMILIAR WITH THIS. THIS IS OUT AND HHS IS ENGAGED IN IMPLEMENTING THIS, THE PAIN STRATEGY, THE NATIONAL PAIN STRATEGY IS FOCUSED PRIMARILY ON DEVELOPING A COMPREHENSIVE POPULATION HEALTH LEVEL STRATEGY FOR PAIN PREVENTION, TREATMENT MANAGEMENT, EDUCATION, REIMBURSEMENT AND RESEARCH. THE RESEARCH SIDE OF THIS IS REALLY THE FEDERAL PAIN RESEARCH STRATEGY, WHICH WE'LL BE TALKING ABOUT, THE NATIONAL PAIN STRATEGY AS IT WAS DEVELOPED AND PRINTED AND DISSEMINATED HAS REALLY LEFT THE RESEARCH PART TO THIS SECOND PART, WHICH WE'LL BE DISCUSSING TODAY. THE NATIONAL PAIN STRATEGY DOES CONTAIN REALLY IMPORTANT AND INTERESTING GUIDELINES AND SUGGESTIONS FOR HOW TO SOLVE PAIN IN THE U.S. SO THE NATIONAL PAIN STRATEGY AS YOU KNOW LOOKS AT DISPARITIES, POPULATION RESEARCH, PREVENTION AND CARE, SERVICES AND PAYMENT, PROFESSIONAL EDUCATION AND TREATMENT, AND PUBLIC EDUCATION AND COMMUNICATION, AND AS YOU CAN SEE, THE SCIENTIFIC RESEARCH SIDE IS REALLY -- WAS LEFT FOR THE FEDERAL PAIN RESEARCH STRATEGY. THE FEDERAL PAIN RESEARCH STRATEGY, THEREFORE, FULFILLS THE IPRCC MANDATE TO FILL IN THAT GAP AND IDENTIFY THE CRITICAL GAPS IN BASIC AND CLINICAL RESEARCH ON THE SYMPTOMS AND CAUSES OF PAIN, AND MADE RECOMMENDATIONS TO ENSURE THE ACTIVITIES OF THE NIH AND OTHER FEDERAL AGENCIES ARE FREE OF UNNECESSARY DUPLICATION OF EFFORT, AND THEN WE'RE COMPLETING THE RESEARCH RECOMMENDATIONS OF THE IOM NATIONAL PAIN STRATEGY AND THE NATIONAL PAIN STRATEGY SECTION ON PAIN RESEARCH. SO THE AGENDA IS TO DEVELOP PHYSIOLOGICAL CLINICAL BEHAVIORAL PSYCHOLOGICAL OUTCOMES IN HEALTH SERVICES RESEARCH BE IN APPROPRIATE LINKS ACROSS THESE DOMAINS THAT ALIGN WITH THE NATIONAL PAIN STRATEGY. SO AS THIS WAS DEVELOPED, THERE WAS A PROCESS AND A STRUCTURE, AND THAT IS DIAGRAMMED HERE. THE EXPERTS WERE ASKED TO CONSIDER IN THESE DIFFERENT CATEGORIES WHAT ARE THE HIGHEST PRIORITIES FOR RESEARCH, SO THE FIRST ONE WAS PREVENTION OF ACUTE AND CHRONIC PAIN. THE SECOND ONE WAS ACUTE PAIN AND ACUTE PAIN MANAGEMENT. THE THIRD ONE WAS TRANSITION FROM ACUTE TO CHRONIC PAIN, AND THE FOURTH ONE WAS CHRONIC PAIN AND CHRONIC PAIN MANAGEMENT. WE THOUGHT THAT IT WAS REALLY IMPORTANT TO ADDRESS THE DISPARITIES IN PAIN, BOTH MANAGEMENT TREATMENT AND BIOLOGY, AND SO THIS WAS INCLUDED SPECIFICALLY IN THE FEDERAL PAIN RESEARCH STRATEGY. ACROSS THE LIFESPAN, FROM CHILDREN TO THE ELDERLY IS INCLUDED IN EACH OF THE INDIVIDUAL PILLARS OF THE PAIN STRATEGY. THE QUESTIONS ARE IN THE PUBLIC, TRYING TO DISTILL THE INFORMATION INTO THESE CATEGORIES THAT ARE RELEVANT TO THE PUBLIC, TRYING TO ANSWER QUESTIONS SUCH AS WHAT HAPPENS TO WHOM, WHAT'S THE SCIENTIFIC BASIS BEHIND WHO DEVELOPS CHRONIC PAIN VERSUS THOSE WHO DON'T, FOR INSTANCE, WHY AND HOW DOES IT HAPPEN, WHAT ARE THE BIOLOGICAL MECHANISMS THAT LEAD TO THE PROBLEMS THAT WE HAVE WITH CHRONIC AND ACUTE PAIN MANAGEMENT AND THEN HOW TO MANAGE PAIN. THESE QUESTIONS ARE LOOKED AT FROM THE BASICS AND THE IDEA THERE BEING TO TRY AND UNDERSTAND THE MECHANISMS THAT UNDERLIE PAIN THAT WILL THEN LEAD TO OUR ABILITY TO DEVELOP BETTER TREATMENT TO TRANSLATE THE DISCOVERIES FROM THESE DIFFERENT SCIENTIFIC AREAS TO TREATMENTS. SO YOU'LL BE HEARING IN THE NEXT COUPLE HOURS THE DISTALLATION OF THE FEDERAL RESEARCH PAIN STRATEGY, AND IT IS AVAILABLE TO READ ON THE WEBSITE OF THE NIH PAIN POLICY OFFICE, AND YOU CAN SEND YOUR COMMENTS TO THIS EMAIL ADDRESS SEEN HERE IN BLUE. COMMENT PERIOD IS OPEN BETWEEN MAY 25TH AND JUNE 6TH. SO WITH THAT, I'D LIKE TO AGAIN THANK EVERYBODY FOR COMEING, I REALLY WANT TO GIVE MY APPRECIATION TO THE PEOPLE WHO WORKED SO HARD OVER THE LAST YEAR ON THE NATIONAL PAIN RESEARCH STRATEGY, THE FEDERAL RESEARCH STRATEGY, AND I CERTAINLY SPENT A LOT OF TIME WITH THE DOCUMENT AND HAVE BEEN VERY IMPRESSED BY THE SCHOLARLY AND REALLY OBJECTIVE NATURE OF THE WRITING. SO THANKS VERY MUCH, AND I'LL HAND IT OFF TO LINDA. THANK YOU. >> I SHOULD BEGIN BY SAYING I'M NOT LINDA. NO, I'M ALLAN BASBAUM FROM UCSF, WE'VE CO-CHAIRED THE STEERING COMMITTEE, AND I'LL TALK A LITTLE ABOUT THE STRUCTURE OF THE FPRS OR THE FEDERAL PAIN RESEARCH STRATEGY EFFORT THAT HAS ACTUALLY BEEN GOING ON FOR CLOSE TO TWO YEARS. I'LL TRY TO SUMMARIZE WHERE WE ARE AND WHERE WE'VE GONE AND LATER ON WE'LL ACTUALLY HEAR SOME OF THE RECOMMENDATIONS. SO THE BOTTOM LINE IS, THE OBJECTIVE IS TO RELIEVE THE BURDEN OF PAIN WITH THE ULTIMATE GOAL OF DEVELOPING A PAIN RESEARCH STRATEGY TO THAT END. SO THIS JUST LISTS WHAT THE TASK HAS BEEN OVER THE LAST YEAR AND A HALF, AND I'LL DESCRIBE THE STRUCTURE OF THE ORGANIZATION, TO LOOK AT THE BACKGROUND THAT EXISTS. ONE IMPORTANT MESSAGE IS THAT IT WASN'T JUST TO IDENTIFY RESEARCH THAT HAS NEVER BEEN DONE BEFORE, BUT ALSO TO EMPHASIZE RESEARCH THAT'S EVEN ONGOING, TO EMPHASIZE WHAT RESEARCH THAT IS ONGOING THAT IS STILL IMPORTANT AND NEEDS TO BE CONTINUED. THAT'S AN IMPORTANT THING, BECAUSE IT WASN'T JUST AN EFFORT TO TRY TO FIND THINGS THAT HAVEN'T BEEN DONE YET. THE MOST IMPORTANT END POINT IS TO DEVELOP A SET OF PRIORITIES, RESEARCH RECOMMENDATIONS THAT WILL BE USED WE CERTAINLY HOPE BY THE FEDERAL AGENCIES THAT FUND PAIN RESEARCH AS THEY DEVELOP THEIR PORTFOLIOS. WALTER WILL SAVE ME SOME TIME BY SHOWING YOU THIS SLIDE WHICH WAS MEANT TO LOOK ACROSS THE CONTINUUM, AND AS YOU'LL SEE IN A MOMENT, THERE ARE FIVE TOPICS, AND FOR EACH OF THESE TOPICS, THERE IS A WORKING GROUP MADE UP OF ABOUT 12 MEMBERS WITH TWO CO-CHAIRS, WE'LL TALK ABOUT THAT IN A MOMENT. EACH ADDRESSING THESE ELEMENTS AND AS LINDA WILL TELL YOU, CLEARLY THERE ARE CROSS CUTTING THEMES THAT ARISE WHERE QUESTIONS OF RESEARCH THAT ARE NOT UNIQUE TO ONE PARTICULAR WORKING GROUP, AND LINDA WILL BEGIN BY SUMMARIZING THE CONCLUSIONS ABOUT THE CROSS CUTTING ELEMENTS BECAUSE CLEARLY TO SOME EXTENT, SOME PEOPLE MAY CONSIDER THOSE THE MOST IMPORTANT ISSUES, AND IT'S NOT A SURPRISE, PERHAPS, THAT THE NUMBER ONE CROSS CUTTING THEME ACTUALLY ADDRESSES THE OPIOID ISSUE, THE EFFORT TO COME UP WITH SOMETHING OTHER THAN OPIOIDS TO TREAT PAIN. AS WALTER SAID, THE WAY THE COMMITTEES, THE DIFFERENT WORKING GROUPS ADDRESS THE PROBLEM IS TO LOOK AT QUESTIONS, MECHANISMS, AND ULTIMATELY TREATMENT APPROACHES. NOW THIS IS THE STRUCTURE OF THE IPRCC AND HOW THE STRUCTURE WAS GENERATED. THE IPRCC IS MADE UP OF FEDERAL AGENCY REPRESENTATIVES, THAT'S THE NIH, THE DOD, THE VA, THE CDC, ET CETERA, WHO FUND PAIN RESEARCH. PATIENT ADVOCACY GROUPS, SCIENTISTS, CLINICIANS WHO HAVE BEEN WORKING AND OVERSEEING THIS EFFORT. THERE'S A STEERING COMMITTEE THAT WAS DEVELOPED BY THE IPRCC THAT OVERSEES THE WORKING GROUPS, AND LINDA AND I HAVE CHAIRED THE STEERING COMMITTEE, AND JUST A QUICK LOOK AT THE MEMBERS, IT'S A BROAD GROUP THAT REPRESENTS MANY DISCIPLINES, PH.D.s, MDs, CLINICIANS, ADMINISTRATORS, ET CETERA, AND THEIR TASK WAS REALLY LARGELY DONE THROUGH TELECONFERENCE CALLS, THEIR MOST IMPORTANT TASK IN SOME RESPECTS WAS TO HELP DEVELOP THE MEMBERSHIP OF THE WORKING GROUPS, SO THEY SUGGESTED NAMES, THE CO-CHAIRS OF THE WORKING GROUPS ALSO DEVELOPED -- IDENTIFIED SOME NAMES, AND WE CAME UP WITH A TERRIFIC GROUP OF ABOUT 60 MEMBERS OF THE GROUP, SO THIS IS A LARGE NUMBER OF PEOPLE. AND THEN I DON'T WANT TO FORGET THAT ON THE SIDE, AND I DON'T KNOW WHY IT'S ON THE SIDE, WITH BUT THIS IS WHERE THE ADMINISTRATIVE HELP FROM THE OFFICE OF PAPER POLICY FROM PAIN POLICY FROM NINDS AND ALSO FROM NIDCR, AND I THOUGHT IT WAS ABSOLUTELY CRITICAL TO SHOW YOU WHO THEY ARE, BECAUSE THEY MADE THIS WORK POSSIBLE. WITHOUT THEM, IT WOULD HAVE BEEN IMPOSSIBLE. SO A BIG THANK YOU TO THEM, AND THEN OVERSEEING THAT WHOLE EFFORT, AND IT'S BEEN REALLY A FUN EXERCISE TO BE WORKING WITH LINDA PORTER OVER THE LAST ALMOST TWO YEARS, SHE IS PRETTY REMARKABLE AS IS HER TEAM. THEN FINALLY THE WORKING GROUPS, I'M NOT GOING TO GIVE YOU THE NAMES OF ALL THE MEMBERS BUT THE COCHAIRS OF THE WORKING GROUPS, THE PREVENTION GROUP, DAVE REUBEN AND ROBERT GATCHEL, ARDEM AND CHRIS, AT TIMES THEY WENT OFF IN SEPARATE WAYS AND THEY ALWAYS CAME BACK TOGETHER AGAIN. THE TRANSITION GROUP FROM ACUTE TO CHRONIC, BOB DWORKIN AND TED PRICE, THE CONGRESS PAIN MANAGEMENT GROUP, SEDDON SAVAGE AND JIANREN MAO, AND CHERYL AND ROGER, THESE ARE REAR COMPLEX DETAILED DOCUMENTS. JUST TO GIVE YOU A LITTLE HIS TRER OF THE PROCESS, WHERE HISTORY OF THE PROCESS, WHERE IT ALL BEGAN, BACK IN 2015, WHEN THE IPRCC DELEGATED THE TASK AND TO INITIALLY THE STEERING COMMITTEE, SELECT WORK GROUP CO-CHAIR, WHICH WE DID, THEN TO DEVELOP THE COMMITTEE CHAIRS, THE COMMITTEES BEGAN TO WORK ON THEIR OWN. IT WAS REALLY QUITE AN IMPRESSIVE TASK, BECAUSE THERE WERE PRETTY MUCH WEEKLY AND ABOUT THE BIWEEKLY CONFERENCE CALLS WITH 10 OR 12 PEOPLE ON THE PHONE. LINDA AND I WERE USUALLY ON THOSE CALLS, SO THERE WAS A LOT OF INPUT FROM EVERYBODY. PERHAPS ONE OF THE MOST VALUABLE EFFORTS WAS THE INDIVIDUAL WORKING GROUPS MET IN EITHER CHICAGO OR DALLAS, AND SPENT AN ENTIRE DAY WHERE THEY TRIED TO CRYSTALLIZE THE IDEAS, AND THAT REALLY MOVED THE EFFORT FORWARD, GET BACK ON THE PHONE EVERY WEEK, AND EVENTUALLY THERE WAS -- AFTER ALL THE PRIORITIES WERE -- OR AT LEAST IDEAS WERE DEFINED, THERE WAS A MEETING OF THE CO-CHAIRS, A TERRIFIC MEETING OF THE CO-CHAIRS IN DALLAS, AN ALL-DAY MEETING WHERE, IN FACT, THINGS CAME TO FRUITION, THE CROSS CUTTING IDEAS WERE CRYSTALLIZED, AND THE DOCUMENT WAS THEN PUT FORTH WHICH COULD THEN BE SCORED, AND THE SCORING WAS A COMPLICATED TASK, INITIALLY THOUGHT TO BE SOMEWHAT OF A DELPHI PROCESS, BUT BASICALLY WE DID IT TWO WAYS WHERE EVERY PRIORITY THAT WAS IDENTIFIED BY THE DIFFERENT GROUPS WAS VOTED ON BY EVERYBODY ACROSS ALL THE FIVE WORKING GROUPS BUT THE RECOGNITION WAS THAT AN INDIVIDUAL WORKING GROUP WAS MUCH MORE COGNIZANT DID ABOUT THE PROBLEMS DISCUSSED IN THEIR OWN GROUP, SO THEY INDIVIDUALLY VOTED ON THOSE AS WELL AND MOVED THINGS UP TO THE TOP. WHAT'S LEFT ARE THE HIGHEST PRY OR ELEMENTS AND THAT'S WHAT'S IMPORTANT, IS THAT THERE ARE MANY OTHER IMPORTANT IDEAS THAT DIDN'T MAKE IT, SO EVERYTHING THAT'S LEFT IS, IN MY MIND, HIGH PRIORITY. THIS WAS EVENTUALLY DISCUSSED WITH THE STEERING COMMITTEE THAT MADE THEIR OWN RECOMMENDATIONS, AND HERE WE ARE SUBMITTED TO THE IPRCC. IT WAS A TREMENDOUS PROCESS, I LEARNED AND WORKED IN AREAS I KNEW NOTHING ABOUT, AND TODAY WE'RE GOING TO HEAR THE PRODUCT OF WHAT WAS A PRETTY IMPRESSIVE GROUP OF PEOPLE WORKING TOGETHER TO GENERATE WHAT I HOPE IS GOING TO BE THE NEXT FUTURE OF PAIN RESEARCH. I SHOULD EMPHASIZE, THERE'S AT LEAST TWO THINGS THAT HAVE YET TO BE DONE, OBVIOUSLY IMPLEMENTATION. THE STEERING COMMITTEE HIGHLY RECOMMENDED THAT WE IDENTIFY EACH WORKING GROUP A TRANSFORMATIVE TOPIC, KIND OF THE WHETHER OR NOT THE TECHNOLOGY EXISTS, BUT TO IDENTIFY SOMETHING THAT IS GOING TO REVOLUTIONIZE AND TRANSFORM PAIN RESEARCH. COME UP WITH THAT IDEA. AND ON THE OTHER HAND, THEY'RE ALSO ASKED TO IDENTIFY NEAR-TERM SUCCESS, WHAT IS GOING TO MAKE A DIFFERENCE IN THE NEAR TERM. THE FORMER MIGHT TAKE FIVE YEARS, THERE MIGHT BE REQUIRED TECHNOLOGY THAT DOESN'T EVEN EXIST YET, BUT IDENTIFY THE QUESTION AND THEN MAYBE WITH THE TECHNOLOGY WILL COME AND FOLLOW IT. SO THAT IS ON THE HORIZON THAT WILL COME AFTER THE RESULT OF WHAT YOU'RE GOING TO HEAR TODAY. AND WITH THAT, I WILL TURN IT OVER TO LINDA. THANK YOU. >> THANKS, ALLAN. I THINK THAT GIVES A GOOD ACCEPTS OF HOW MUCH EFFORT HAS GONE INTO THIS ON THE PART OF SO MANY DIFFERENT PEOPLE. IF THERE ARE FOLKS LISTENING FROM THE TASK FORCE, WE WANT TO SAY THANK YOU DIRECTLY, BUT WE WILL SEND THEM ALL A FOLLOW-UP THANK YOU TOO. A COUPLE OF NOTES BEFORE I REVIEW THE CROSS CUTTING PRIORITIES FOR WHAT WE'RE GOING TO DO OVER THE NEXT COUPLE HOURS, SOMEONE FROM EACH OF THE WORK GROUPS WILL GIVE YOU A QUICK OVERVIEW OF THE RESEARCH PRIORITIES THAT THEY HAVE SUBMITTED FROM THEIR INDIVIDUAL WORK GROUPS, AND THE RATIONALE AS TO HOW THEY GOT THERE. JUST A REMINDER THAT THESE RESEARCH PRIORITIES THAT ARE REMAINING ARE THE PRODUCT OF MANY, MANY MORE, SO WE'VE BEEN THROUGH THE PROCESS OF SORT OF THE RESEARCH GROUPS, NARROWING THINGS DOWN, TALKING ABOUT WHAT WAS MOST IMPORTANT, SOMETIMES MERGING THINGS, SOMETIMES TAKING THEM APART AND MAKING THEM MORE UNIQUE, AND SO WHAT STARTED AT SOME POINT WITH MAYBE A COUPLE HUNDRED PRIORITIES THAT WOULD BE SUBMITTED TO THE FEDERAL AGENCIES AND DEPARTMENTS, WE'RE DOWN TO JUST UNDER 50. WE TRIED TO THINK OF MANY WAYS TO NARROW THAT EVEN MORE AND REALIZED THAT EVERYTHING THAT'S LEFT IS REALLY IMPORTANT AND SO EVERYTHING WILL BE IN THE FINAL DOCUMENT. THE OTHER THING -- COUPLE OF OTHER THINGS I WANT TO MENTION IS, THIS IS A PUBLIC COMMENT PERIOD. THERE'S A MAILBOX OPEN, IT WILL BE OPEN FOR ANOTHER SEVERAL DAYS AFTER THE MEETING. WALTER PUT THE MAILBOX UP THERE. WE'VE GOT COMMENTS ON THERE TODAY THAT WE'RE GOING TO BRING UP DURING THE QUESTION AND ANSWER PERIOD. WE WILL ALSO TAKE QUESTIONS FROM THE IMMEDIATE AUDIENCE HERE. WHAT WE REALLY WANT TO DO IS TAKE CAREFUL CONSIDERATION OF THOSE QUESTIONS AND COMMENTS THAT COME IN, WE MAY POSSIBLY GO INTO A REVIEW OF THE DOCUMENT, BUT WE CERTAINLY WILL CAREFULLY MAKE SURE THAT WHAT'S NEEDED TO BE INCORPORATED INTO THE FINAL COPY GETS IN. THIS IS A DRAFT THAT YOU'VE BEEN LOOKING AT. FOR THOSE WHO WENT TO THE WEBSITE AND ACTUALLY READ THE DOCUMENT BEFORE YOU CAME, A NOTE THAT THERE ARE SOME MINOR CHANGES IN THAT DOCUMENT SINCE IT WAS POSTED ONLINE A WEEK AGO. THE ONE THAT I REALLY WANT TO MENTION IS THE DISPARITIES GROUP HAD SOME AMAZINGLY COMPREHENSIVE CAREFULLY THOUGHT OUT PRIORITIES THAT THROUGH OUR REVIEW PROCESS, THEY WERE ASKED TO SORT OF NARROW THOSE A LITTLE BIT MORE TO THE SCOPE OF VULNERABLE POPULATIONS. WE WANTED TO MAKE SURE THAT THE OVERALL MESSAGE WASN'T LOST AS THEY NARROWED THINGS A LITTLE BIT, SO WHAT YOU WILL SEE IN THE FINAL DOCUMENT IS SOME SLIGHT CHANGES IN A FEW OF THE DISPARITIES -- PRIORITIES THAT ARE IN THE DOCUMENT THAT'S ON SITE. WHAT YOU HAVEN'T SEEN YET IS THAT THERE IS A PREAMBLE BEING CONSTRUCTED THAT WILL GO WITH THIS DOCUMENT. SOME OF THOSE OVERARCHING PIECES OF THE DISPARITIES RESEARCH PRIORITIES THAT WERE REVISED WILL GO INTO THE PREAMBLE, ALONG WITH A LOT OF REALLY IMPORTANT CONCEPTS THAT CAME UP DURING THE COURSE OF THE DISCUSSIONS OVER THE YEAR AND A HALF, LIKE HOW DO WE DEFINE THE TRANSITION FROM ACUTE TO CHRONIC PAIN, WHAT'S THE DEFINITION OF THIS, HOW DO WE -- YOU KNOW, WHAT'S THE DEFINITION OF PRIMARY, SECONDARY, TERTIARY, SO THERE ARE A LOT OF THINGS THAT WILL END UP IN THE PREAMBLE THAT WILL HELP TIE THIS DOCUMENT TOGETHER. WE'VE BEEN KIND OF KEEPING A GROUPS FELT THAT WERE IMPORTANT THAT AS FAR AS DRIVING THE RESEARCH AGENDA NEEDED TO BE HIGHLIGHTED AND NOTED IN THAT PREAMBLE. SO FROM THERE, I WILL RUN QUICKLY THROUGH. THE CROSS CUTTING THEMES. SO I'M THE FEDERAL REPRESENTATIVE, I'M WITH THE FUNDING AGENCY, I DID NOT DEVELOP THESE CROSS CUTTING THEMES. THESE WERE DONE BY THE WORK GROUPS FROM OUTSIDE. THESE CROSS CUTTING THEMES EVOLVED PRIMARILY THROUGH THE PROCESS OF LOOKING AT OVERLAP IN THE PRIORITY OF THE WORK GROUPS, PARTWAY THROUGH THE STAGE OF COMPLETION. AND IT WAS CLEAR THAT MANY OF THE WORK GROUPS HAD RESEARCH PRIORITY THAT THEY SHARED OR VERY MECH MUCH OVERLAPPED WITH THOSE OF OTHER WORK GROUPS. SO AT THE FACE TO FACE CO-CHAIR MEETING THAT ALLAN MENTIONED, WE SPENT A LOT OF TIME DISCUSSING WHICH OF THOSE PRIORITIES -- SOME OF THEM WERE MERGED AND MOVED INTO ONE -- TWO FROM TWO GROUPS WERE MERGED INTO ONE AND PUT INTO ANOTHER WORK GROUP, BUT THESE CROSS CUTTING THEMES WERE COMMON THEMES THAT THREE OR FOUR OR FIVE OF THE WORK GROUPS FELT WERE IMPORTANT. SO THEY ENDED UP INTO A SEPARATE CATEGORY THAT I'LL RUN THROUGH NOW, BUT JUST BEFORE I GET THERE, GOING BACK TO THE VERY BEGINNING OF WHEN WE SET THIS PROCESS UP, WE PRESENTED THIS CONTINUUM OF PAIN THEMES TO THE IPRCC AND THEY SAID THERE REALLY IS -- THERE REALLY SHOULD BE NO DEFINED BOUNDARIES ACROSS EACH ONE OF THESE BOXES, BECAUSE THEY DO BLEND FROM ONE INTO THE OTHER CLEARLY AS FAR AS HOW THE RESEARCH SHOULD BE CARRIED FORWARD. AND SO I THINK THE CROSS CUTTING THEMES HELP TO KIND OF MERGE THESE BOXES TOGETHER AS WE GO ACROSS THE CONTINUUM OF THE PAIN AND THE DISPARITY RESEARCH PRIORITIES. THAT SAID, SO THE FIRST CROSS CUTTING THEME IN THE DOCUMENT IS THE TOPIC OF NOVEL DRUG DEVELOPMENT AND NON-PHARMACOLOGICAL TREATMENT DEVELOPMENT FOR PAIN. THE CURRENT DRUGS THAT WE USE ARE SORT OF RIDDLED WITH ADVERSE EVENTS, SOME ARE NOT PARTICULARLY EFFECTIVE. THIS FIELD HAS MOVED FORWARD VERY QUICKLY OVER THE PAST MANY YEARS, DEKAITS, EVEN, AND SO THIS AREA KIND OF CAME UP IN EACH ONE OF THE WORK GROUPS. SO WITHIN THIS THEME OF NOVEL DRUGS, THE PRIMARY RESEARCH PRIORITIES, ONE WAS TO DEVELOP SAFER OPIOID, NEW NON-OPIATE ANALGESICS, INCLUDING THE FIRST GENERATION OF DISEASE MODIFYING AGENTS. SECOND PRIORITY WAS TO EVALUATE EFFICACY, SAFETY, AND INTERACTIONS OF NEW THERAPIES. AND THE THIRD WAS TO EXPLORE BIOLOGICAL TARGETS. FOR THE FIRST ONE OF THESE, I THINK THAT THE INTERSECTION OF THIS PRIORITY WITH THE THREE UPCOMING WORKSHOPS THAT YOU'VE HEARD ABOUT FROM NORA VOLKOV AND WALTER EARLIER IN THE MEETING, I THINK THERE'S JUST A REALLY NICE ALIGNMENT BETWEEN WHERE THE NIH IS MOVING FORWARD AND WHERE THIS HIGH PRIORITY SET OF RESEARCH RECOMMENDATIONS IS. SO THAT'S GOOD NEWS FOR STARTERS. AND THEN THE SECOND OF THE CROSS CUTTING RESEARCH PRIORITIES IS TO DEVELOP SCREENING TOOLS AND OUT COME MEASURES FOR ASSESSMENTS ACROSS THE CONTINUUM OF PAIN. SO OBVIOUSLY THIS GOES FROM ACUTE THROUGH THE TRANSITION TO CHRONIC PAIN. AND EVEN FROM THE OUTSIDE COMMUNITY, AS SOON AS I MENTIONED THAT WE WERE DOING RESEARCH STRATEGY, PEOPLE WOULD SAY, FIRST QUESTION, ARE YOU DEALING WITH MEASURES AND ASSESSMENTS? AND SO CLEARLY, YOU KNOW, WE NEED BETTER TOOLS IN THIS AREA, ESPECIALLY GIVEN THAT PAIN IS SUBJECTIVE AND SO IT IS HARD TO FIND OBJECTIVE MEASURES THAT ARE USEFUL AND MEANINGFUL. THE OTHER ISSUE IN HERE IS THE ISSUE OF BIOMARKERS, SO ONE OF THE RESEARCH PRIORITIES WITHIN THIS OVERARCHING THEME IS THE DISCOVERY AND EVALUATION OF BIOMARKER INFORMATION. A BIG TOPIC OF CONVERSATION ACROSS THE DISCUSSIONS OF THE WORK GROUPS RANGING FROM WE DON'T HAVE BIOMARKERS TO WE DO HAVE BIOMARKERS IN THE MIDDLE WE NEED BETTER BIOMARKERS, AND THE BIOMARKERS REALLY RELATE NOT ONLY TO THE IDENTIFICATION OF PAIN BUT ALSO TO TREATMENT RESPONSE BEING VERY IMPORTANT, AND I THINK THAT'S ANOTHER TOPIC THAT WE'LL WILL PROBABLY COME UP IN THESE NEXT SET OF THREE WORKSHOPS ACROSS THE NIH. ONE BIG ISSUE HERE WAS THE STANDARDIZATION OF ASSESSMENT TOOLS, MAKING SURE THAT THE APPROPRIATE DOMAINS ARE ASSESSED TSH ARE INCLUDED AS PART OF OUR STANDARD OUTCOMES, AND THEN THE THIRD ONE ON THIS LIST IS TO DEVELOP SCREENERS FOR PREDICTER VALUES, VARIABLES OF PERSISTENT OR RECURRENT PAIN. CLEARLY I THINK THESE ARE ALL THREE REALLY IMPORTANT AREAS IN THE CROSS CUTTINGS. ANOTHER BIG TOPIC OF CONVERSATION, I THINK HERE AT NIH BUT ALSO IN THE RESEARCH PRIORITIES DEVELOPMENT IS THE FACT THAT THE UTILITY OF A RESEARCH NETWORK WITH THE NATIONAL REGISTRIES AND STANDARDIZED DATASETS WOULD REALLY BE IMPORTANT TO MOVE NOT ONLY CLINICAL DATA FORWARD BUT ALSO IF IT WERE TO INCLUDE PRE-CLINICAL COMPONENTS IN IT COULD BE AN INCREDIBLY VALUABLE TOOL. SO MORE SPECIFICALLY OVER THIS OVERARCHING THEME, THE PRIORITIES WERE TO DEVELOP THE RESEARCH NETWORK, THE RESEARCH NETWORK WAS ENVISIONED AS THE DATA COORDINATING CENTER, THE RESEARCH AREAS WITH DISCOVERY SITES FOR DIFFERENT CONDITIONS, THIS THEY WOULD I THINK RATE INCORPORATE PRE-CLINICAL AND CLINICAL RESEARCH, AND THAT THERE WOULD BE STANDARDIZED MEANS TO COLLECT THE DATA AND TO INTERPRET AND DISSEMINATE THE DATA, SO THE SPECIFIC RESEARCH PRIORITY BY TITLE WERE TO DEVELOP A NETWORK TO DETERMINE SIMILARITIES AND DIFFERENCES ACROSS PAIN STATES SO THIS WOULD REALLY BE A MEANS TO UTILIZE THE NETWORK AND DATASETS ONCE THEY WERE ESTABLISHED, TO STANDARDIZE THE COLLECTION AND EVALUATION SO AGAIN THE NETWORKS WOULD ALL HAVE STANDARDIZED DATA INPUT, COMMON DATA ELEMENT, MINIMUM DATASETS, AND THEN THE FOURTH IN THE LIST IS TO LEVERAGE AND EXPAND THE CURRENT DATA RESOURCES SO THE VISION WAS THAT THE TOOLS DEVELOPED COULD BE EXPANDED INTO HEALTHCARE SYSTEMS, AND THAT ELECTRONIC HEALTH RECORDS AND STANDARDIZED DATA COLLECTION THROUGH THAT MEANS WAS AN IMPORTANT COMPONENT OF THIS THEME. EFFECTIVE MODELS OF CARE OF DELIVERY FOR PAIN MANAGEMENT, SO AGAIN, THIS SPANS ACUTE PAIN MANAGEMENT THROUGH CHRONIC PAIN MANAGEMENT SO IT COVERS PRIMARY, SECONDARY, TERTIARY CARE. THE RATIONALE WAS THAT CARE IS NOT ALWAYS ACCESSIBLE, IT'S NOT ALWAYS PATIENT-CENTERED, INTEGRATION IS AN ISSUE, PAYMENT PROGRAMS DON'T NECESSARILY REFLECT CONSISTENCY OR COST-EFFECTIVENESS OR APPROPRIATE TO ACCOMMODATE THE NEEDS OF THE PATIENTS. SO WE KNOW THERE ARE SOME MODELS THAT ARE PROBABLY WORKING VERY WELL AND IN SOME AREAS THE V.A. HAS REALLY MOVED FORWARD WITH A STEPPED CARE MODEL, AND SO THIS IS ONE EXAMPLE THAT MIGHT BE TAKEN AS A MEANS TO MOVE FORWARD. SO THE SPECIFIC PRIORITY WERE TO DEVELOP, EVALUATE AND IMPROVE THE MODELS OF CARE, AND THIS WAS HIGHLIGHTED THAT THIS SHOULD BE IN DIFFERENT SETTINGS LIKE COMMUNITY SETTINGS AND HOSPITALS AND SO FORTH. TO WITHIN THOSE MODELS OF CARE, TO DETERMINE BENEFITS, RISKS AND COSTS OF TREATMENT, SO FOR THOSE TREATMENTS THAT WERE COST-EFFECTIVE, THEY SHOULD BE MOVED INTO THE MODELS. FOR THOSE WHICH ARE NOT, THEY SHOULD BE CONSIDERED AS LOWER PRIORITY. BUT AGAIN THE ISSUE IN DETERMINING THE RISK BENEFITS IS WHAT FITS BEST INTO INTEGRATED CARE. EXCESSIVE EFFECTS OF -- CHANGES IN APPROACH, IN THE VA SYSTEM, THE DOD SYSTEM, SOME OF THE LARGER HEALTHCARE SYSTEMS, THAT THIS LAST ONE WILL BE VERY IMPORTANT AS WE MOVE FORWARD. AND THEN THE LAST THEME HERE IS TO REALLY TAKE ADVANTAGE OF THE PRECISION MEDICINE METHODOLOGY TO BOTH PREVENT AND TREAT PAIN. I THINK THERE IS AN INCREDIBLE OPPORTUNITY WITH PRECISION MEDICINE BEING MOVED TOWARDS AN APPROACH FOR PAIN MANAGEMENT BECAUSE WE KNOW THERE ARE GENETICS, WE KNOW THERE ARE ENVIRONMENTAL INFLUENCES, ALL KINDS OF DIFFERENT FACTORS THAT CAN HELP US DETERMINE HOW TO TAILOR TREATMENTS TO INDIVIDUALS, HOW TO KNOW BETTER HOW INDIVIDUALS RESPOND TO DIFFERENT TREATMENTS, AND AS THERE'S A BIG INITIATIVE DEVELOPING ACROSS THE NIH TO MOVE TOWARDS PRECISION MEDICINE TECHNOLOGY IS EVOLVING SO IT'S IMPORTANT TO DEVELOP THOSE INITIATIVES' THEY MOVE FORWARD. SO I WILL STOP THERE, AND I THINK I HAVE A FEW MINUTES FOR QUESTIONS NOW, BUT THERE WILL BE A LONG QUESTION AND ANSWER SESSION WITH THE ENTIRE PANEL UP HERE LATER, AND THERE WILL BE REPRESENTATIVES FROM ALL THE WORK GROUPS WHO CONTRIBUTED TO THESE CROSS CUTTING THEMES AT THE PANEL SO IF YOU WOULD LIKE A BETTER MORE COMPREHENSIVE ANSWER, YOU CAN SAVE YOUR QUESTIONS ON THE CROSS CUTTING THEMES TILL THEN OR I CAN TAKE QUESTIONS NOW IF YOU LIKE. SO WE'LL WAIT ON THE QUESTIONS. SO WE'RE NOW GOING TO MOVE TO THE REPRESENTATIVE FROM THE PREVENTION TEAM. I'M GOING TO LET YOU INTRODUCE YOURSELF AND -- >> THANK YOU, LINDA. >> I'M A CHIROPRACTOR, EPIDEMIOLOGIST AND HEALTH ECONOMIST AND I'VE BEEN INVOLVED IN PAIN RESEARCH IN DIFFERENT SETTINGS, ACADEMIA, MANAGED CARE AND NOW I WORK FOR A PHARMACEUTICAL COMPANY, PACIRA PHARMACEUTICALS, AND PART OF THE PAIN PREVENTION GROUP. I'D LIKE TO START WITH JUST A SIMPLE STATEMENT OF THE PROBLEM. WE SPENT A LOT OF TIME DISCUSSING THIS. WE HAD A LOT OF DIFFERENT OPINIONS ON THE COMMITTEE, PHYSICIANS, RESEARCHER, BASIC SCIENTISTS, PHYSICAL THERAPISTS, WE WERE ALL TRYING TO DETERMIN WHAT WE COULD DO AS A GROUP TO REALLY MAKE A CONTRIBUTION TO PREVENTING ACUTE OR CHRONIC PAIN. STATEMENT OF THE PROBLEM IS, ALL PAIN BEGINS AS ACUTE PAIN. EVERYONE WILL EXPERIENCE ACUTE PAIN AT SOME POINT, SO EVEN THOUGH WE'RE DISCUSSING THE PREVENTION OF ACUTE PAIN, WE HAVE TO ACKNOWLEDGE THAT SOME PAIN IS INEVITABLE. SOME ACUTE PAIN WILL BECOME CHRONIC. COMORBIDITIES VASTLY INCREASE THE RISK OF THE TRANSITION FROM ACUTE TO CHRONIC PAIN, AND CHRONIC PAIN IS RESPONSIBLE FOR A LARGE PROPORTION OF THE MORBIDITY AND COST ASSOCIATED WITH PAIN OVERALL. SO WITH THAT AS OUR STARTING POINT, WE TRIED TO LOOK AT THIS FROM A PUBLIC HEALTH PERSPECTIVE. EACH DEEM YOL GISTS LIKE TOEP DEEM YOM GIS TS LIKE TO TALK ABOUT DIFFERENT LEVELS OF PREVENTION. YOU HAVE PRIMARY PREVENTION, SECONDARY PREVENTION AND TERTIARY PREVENTION. FOR EXAMPLE, PRIMARY PREVENTION FOR AN INFECTIOUS DISEASE WILL BE POPULATION-WISE VACCINATION. SO YOU PREVENT THE DISEASE FROM EVER HAPPENING IN THE FIRST PLACE. VACCINATION TO PREVENT CHICKEN POX. THAT DOESN'T ALWAYS WORK, SO SOME PEOPLE WILL STILL DEVELOP THE DISEASE. SECONDARY PREVENTION IS ABOUT MINIMIZING THE IMPACT THAT IT HAS ON YOU ONCE YOU HAVE IT. SO IN THIS CASE, YOU CAN TAKE SOME ANTIVIRAL MEDICATION TO TREAT CHICKEN POX ONCE YOU HAVE IT. TERTIARY PREVENTION IS A LITTLE BIT DIFFERENT, WHERE THE CONDITION OF INTEREST HAS HAPPENED, IT'S ALREADY HAD AN IMPACT ON YOU BUT YOU'RE TRYING TO PREVENT IT FROM HAVING AN IMPACT ON YOUR MORTALITY OR ON YOUR DISABILITY. SO IN THIS CASE, RECURRENCE OF SHINGLES, EVEN THOUGH YOU HAD THE VACCINE, EVEN THOUGH YOU HAVE THE DISEASE, YOU'RE JUST TREATING THE SYMPTOMS TO ALLOW YOURSELF -- NOW WHY I STARTED WITH INFECTIOUS DISEASE IS BECAUSE THIS MODEL WORKS VERY WELL IN INFECTIOUS DISEASE. YOU YOU A PLY THAT TO PAIN, IT'S LESS OBVIOUS. THE DISCUSSION INITIALLY WAS, IS IT REALLY POSSIBLE TO DO PRIMARY PREVENTION OF ACUTE PAIN? AND THERE ARE SO MANY DIFFERENT CAUSES OF ACUTE PAIN THAT WE STRUGGLED WITH HOW WOULD YOU IMPLEMENT A RESEARCH AGENDA TO PREVENT ACUTE PAIN. BUT THE BATTLE ISN'T ALL LOST, THE EFFORTS SHOULD SHIFT VERY QUICKLY TO SECONDARY PREVENTION. WE HAVE INTEREST AROUND LOW BACK PAIN OR NECK PAIN. IT COULD QUICKLY GROW OUT OF THE SCOPE OF THIS GROUP IF WE WANTED TO PREVENT NECK PAIN, AND ONE OF THE CAUSES WAS WHIPLASH, AND ONE OF THE CAUSES FOR WHIPLASH WAS MOTOR VEHICLE ACCIDENTS, AND THEN WE WOULD GET INTO ROAD SAFETY AND AUTOMOBILE DESIGN. IT'S TOO BROAD OF A SCOPE, SO WE HAD TO REALLY THINK ON A VERY PRACTICAL LEVEL WHAT CAN WE DO. THEN WE ALSO HAD TO DIFFERENTIATE OUR EFFORTS FROM THE REST OF THE GROUP BECAUSE WE ALREADY HAVE A GROUP THAT'S GOING TO DEAL WITH MANAGEMENT OF ACUTE PAIN. SO WE TRIED TO KEEP OUR FOCUS ON PREVENTION OF ACUTE AND CHRONIC PAIN. WE CAME UP WITH SIX RECOMMENDATIONS AND I'LL JUST GO THROUGH EACH ONE AT A TIME. NUMBER ONE, OPTIMIZE PUBLIC HEALTH STRATEGIES TO EDUCATE PATIENTS ON MANAGING PAIN. OF COURSE THERE'S NO VACCINE TO PREVENT THE DEVELOPMENT OF PAIN. METHODSTHERE ARE SOME STUDIES IN ACUTE LOW BACK PAIN, FOR EXAMPLE, THAT SHOW THAT ONCE YOU HAVE A LOW BACK PAIN, EVEN THOUGH YOU FEEL TERRIBLE, EVEN THOUGH MOVEMENT HURTS, THE BEST THING YOU CAN DO IS TO CARRY ABOUT YOUR NORMAL ACTIVITIES TO THE DEGREE THAT YOU'RE CAPABLE. WORST THING YOU CAN DO IS LIE DOWN FOR AN EXTENDED PERIOD OF TIME BECAUSE IT'S VERY HARD TO GET BACK UP AFTER THAT. SO THAT MESSAGE IS THE EQUIVALENT OF THE PRIMARY PREVENTION THAT WE'RE TALKING ABOUT, BUT IT'S APPLIED A LITTLE BIT DIFFERENTLY. WE'RE NOT PREVENTING THE ONSET OF BACK PAIN, WE'RE JUST TRYING TO TEACH PEOPLE WHAT TO DO ONCE THEY HAVE IT. SO WE NEED EDUCATION TO MATCH OUR EXPECTATIONS WITH REALITY. ACUTE PAIN WILL OCCUR. WE NEED TO -- PUBLIC PREVENTION SHOULD ALSO DEAL WITH DIFFERENTIATING HURT VERSUS HARM HARM. THE RECOMMENDATIONS FOR ALL SORTS OF PAIN PREVENTION HAVE TO DO WITH HEALTHY LIFESTYLE, MAINTAINING A HEALTHY WEIGHT, HEALTHY LEVEL OF STRESS. IF ONE WANTS TO PREVENT PAIN, A HEALTHY LIFESTYLE IN GENERAL SEEMS LIKE A GOOD PLACE TO START. FOR EXAMPLE, THERE WERE PUBLIC HEALTH CAMPAIGNS IN AUSTRALIA CALLED BACK PAIN, DON'T TAKE IT LYING DOWN. THEY BLANKETED THE COUNTRY WITH TELEVISION, PRINT ADVERTISEMENT, THEY HAD CELEBRITIES, PROMOTING THE IDEA THAT IF YOU HAVE BACK PAIN, YOU SHOULDN'T REST. WE HAVE MUCH MORE IMPLEMENTATION RESEARCH TO TAKE THOSE GOOD IDEAS AND MAKE THEM MORE PRACTICAL IN DIFFERENT SETTINGS. WE ALL ATBREE HEALTHCARE PROVIDERS SHOULD BE A SOURCE OF THE HEALTHCARE INFORMATION THEY RELY ON, BUT HOW DO YOU INCORPORATE THAT APPROACH INTO YOUR BUSY PRACTICE? IS IT SOMEBODY ELSE WHO DOES IT, IS IT AN APP, IS IT A VIDEO, IS IT A PHONE CALL? WE KNOW THAT GENERALLY SPEAKING IT WORKS, BUT HOW DO YOU MAKE IT STANDARDIZED? SO THAT WAS THE FIRST RESEARCH RECOMMENDATION. THE SECOND WAS AROUND EPIDEMIOLOGY OF ACUTE PAIN FROM HEALTHCARE PROCEDURES. I STARTED BY STATING THAT WE CAN'T PREVENT ALL INCIDENCE OF ACUTE PAIN BUT ACUTE PAIN FROM HEALTHCARE PROCEDURES SEEMS LIKE A GOOD PLACE TO START. THERE ARE ESTIMATES THAT APPROXIMATELY 50 TO 100 MILLION SURGICAL PROCEDURES A YEAR IN THE U.S., PROBABLY AS MANY DENTAL PROCEDURES, PROBABLY MORE MEDICAL PROCEDURE, ALL OF WHICH ARE ASSOCIATED WITH SOME DEGREE OF PAIN. AND IN THIS SETTING, A LOT OF THESE ARE PLANNED AHEAD OF TIME, THEY'RE ELECTIVE PROCEDURES AN THEY'RE HAPPENING IN A HEALTHCARE SETTING WITH HEALTHCARE PROVIDERS WITH RESOURCES TO IMPLEMENT STRATEGIES THAT ACTUALLY COULD PREVENT ACUTE PAIN. SO WE NEED BETTER RESEARCH TO UNDERSTAND THE RELATIVE SEVERITY OF THE PAIN ASSOCIATED WITH DIFFERENT TYPES OF PROCEDURES, AND ESPECIALLY IN VULNERABLE POPULATIONS LIKE INFANTS WHO ARE GETTING REPEATED PROCEDURES IN A SHORT TIME OR SURGICAL ONCOLOGY PATIENTS WHO ARE SUBJECT TO REPEATED MEDICAL PROCEDURES THAT ALL HAVE PAPER ASSOCIATED WITH THEM IN A SHORT PERIOD OF TIME. RELATED TO THIS IS WE NEED TO EVALUATE THE SAFETY AND EFFECTIVENESS OF MANAGEMENT OF ACUTE PROCEDURE ASSOCIATED PAIN. SO THERE ARE SOME TRULY PREVENTIVE MEASURES FOR ACUTE PAIN FROM SURGICAL PROCEDURES. FOR EXAMPLE, THERE ARE STUDIES SHOWING THAT IF YOU TAKE A NONSTEROIDAL ANTI-INFLAMMATORY DRUG A FEW DAYS BEFORE HAVING A WISDOM TOOTH REMOVAL, YOU'LL REDUCE THE PAPER AFTER THE TOOTH REMOVAL. SO IN PAIN AFTER TOOTH REMOVAL. PRIMARY PREVENTION APPEARS SOMEWHAT POSSIBLE BUT THESE PRACTICES ARE NOT WIDELY SPREAD, SO WE NEED BETTER IMPLEMENTATION RESEARCH TO HELP FIGURE OUT HOW DO WE MAKE THIS THE STANDARD OF CARE? HEALTHCARE PROVIDERS RIGHT NOW RELY ON OPIOIDS TO A GREAT DEAL TO MANAGE ACUTE PAIN FROM MEDICAL-SURGICAL PROCEDURES. WE ALL KNOW THE CONSEQUENCES OF USING OPIOIDS IN HOSPITAL SETTINGS, A LARGE NUMBER OF PATIENTS WHO TAKE OPIOIDS TO MANAGE THIS PAIN WILL GO ON TO HAVE ADVERSE EVENTS, AND THERE'S ALSO RESEARCH SUGGESTING THAT A LARGE NUMBER OF PATIENTS WHO RECEIVE OPIOIDS INTENDED FOR SHORT-TERM USE FOR THE MANAGEMENT OF ACUTE PAIN WILL GO ON TO DEVELOP CHRONIC LONG-TERM USE WITH ALL OF THOSE ASSOCIATED MORBIDITIES. SO WE NEED RESEARCH TO IDENTIFY THE OPTIMAL APPROACH TO MANAGING PROCEDURE-RELATED PAIN BASED ON DIFFERENT FACTORS. WE HAVE A LOT OF TOOLS AVAILABLE RIGHT NOW, BUT THEY'RE NOT BEING CONSISTENTLY USED AND WE DON'T KNOW HOW TO TAILOR THE APPROACH TO EACH PATIENT. AGAIN ON THIS SAME THEME, OPTIMIZE POST SURGICAL APPROACHES FOR ACUTE PAIN. THERE'S A SUBSTANTIAL AMOUNT OF EVIDENCE SUGGESTING THAT ACUTE PAIN THAT START WITH A HEALTHCARE PROCEDURE CAN RESULT IN CHRONIC PAIN. FOR EXAMPLE, CHRONIC POST THORACOTOMY PAIN, POST MASTECTOMY PAIN, POST LAMINECTOMY, SO THERE'S SOME INDICATION THAT SURGICAL PROCEDURE ITSELF IS LEADING TO AN INCREASE IN RISK IN THE DEVELOPMENT OF CHRONIC PAIN. AND ONCE THAT CHRONIC PAIN SETS SO WE NEED MORE RESEARCH TO DETERMINE WHAT ARE THE RISK FACTORS THAT WILL LEAD TO THAT CHRONIC POST SURGICAL, POST PROCEDURAL PAIN, AND WHAT ARE THE INTERVENTIONS THAT WE CAN USE TO MINIMIZE NOT ONLY THE SHORT-TERM ACUTE PAIN THAT'S FELT AFTER MEDICAL PROCEDURES BUT THE RISK OF DEVELOPING CHRONIC PAIN. ANOTHER RECOMMENDATION, WE NEED TO LOOK AT THE ASSOCIATION BETWEEN PATIENT AND INTERVENTION FACTORS AND PSYCHOSOCIAL INTERVENTIONS. BROADLY SPEAKING, ADDING A PSYCHOSOCIAL APPROACH TO ANY TYPE OF PAIN MANAGEMENT PROGRAM IS GENERALLY FELT TO BE BENEFICIAL. BUT VERY FEW PEOPLE AGREE ON WHAT THAT PSYCHOSOCIAL COMPONENT SHOULD BE. IS IT A BRIEF TALK, IS IT TRAINING PHYSICAL THERAPISTS AS WE HEARD THIS MORNING TO DELIVER A SLIGHTLY DIFFERENT APPROACH TO MANAGING PAIN. IS IT -- DOES IT NEED A LICENSED BHAIFL BEHAVIORAL HEALTHCARE PROVIDER, DOES IT NEED FIVE VISITS A WEEK, DOES IT NEED TO BE AN IN-PATIENT RESIDENTIAL PROGRAM FOR SEVERAL WEEKS AS IN MULTIDISCIPLINARY REHABILITATION? HOW DO WE TAKE THOSE COMPONENTS THAT WILL WORK AND HOW DO WE APPLY THEM TO DIFFERENT PATIENTS BASED ON WHAT THEY HAVE? IS A PSYCHOSOCIAL INTERVENTION DEVELOPED FOR DEPRESSION ALSO GOING TO WORK FOR ANXIETY, FOR CATASTROPHIZING, HOW DO WE TAILOR WHAT WE HAVE SHOWN TO WORK BASED ON DIFFERENT PATIENT FACTORS. AND FINALLY, WE NEED TO LOOK AT THE SAFETY AND EFFECTIVENESS OF EARLY INTERVENTIONS FOR TERTIARY PREVENTION. SO TERTIARY PREVENTION WOULD BE ANALOGOUS TO ACKNOWLEDGING THAT ONCE SOMEONE HAS A CERTAIN DEGREE OF CHRONIC PAIN, THEY MAY NEVER BE ABLE TO BE PAIN-FREE, BUT HOW DO WE MINIMIZE THE IMPACT OF PAPER ON OF PAIN ON THEIR DAILY LIFE, HOW DO WE IMPROVE THEIR FUNCTION, WHAT IS IT WE CAN DO TO KEEP THEM ENJOYING THEIR NORMAL SOCIAL ACTIVITIES? MULTIDISCIPLINARY REHABILITATION SEEMS TO BE THE ANSWER, BUT THERE'S HESITANCE ON MANY DIFFERENT STAKEHOLDERS ON INTRODUCING IT TOO EARLY. WHEN SHOULD YOU INTRODUCE THE ALONG THE CHRONIC CONTINUUM? WE WANT TO DO IT EARLY BUT NOT SO EARLY THAT THE COSTS ARE IMPRACTICAL FOR SOCIETY. AND THEN WE ALSO DON'T KNOW, CAN WE TAKE A GENERIC APPROACH TO MULTIDISCIPLINARY REHABILITATION AND USE IT ON EVERY PATIENT OR DOES IT REALLY NEED TO BE CUSTOMIZED FOR EACH PATIENT AND IF SO, HOW DO WE DELIVER THAT TYPE OF CARE? THOSE WERE THE SIX RECOMMENDATIONS FROM THE ACUTE AND CHRONIC PAIN PREVENTIONS AND I'LL TAKE QUESTIONS AFTER THE OTHER PRESENTERS. I'LL QIF IT GIVE IT BACK TO LINDA. THANK YOU. SO OUR ACUTE PAIN WORKING GROUP WAS CHAIRED BY CHRIS AND ARMEN, WE HAD A MIX OF CLINICIANS AND BASIC SCIENTISTS. AND I'LL BEGIN BY SUMMARIZING OUR STATEMENT OF THE PROBLEM. I THINK TO BEGIN WITH, I THINK FOR A LONG TIME, THOSE OF US IN PAIN RESEARCH SAID ACUTE PAIN IS NOT THE PROBLEM. SO WE'VE HAD A LITTLE BIT OF A BIAS THAT ACUTE PAIN HAS ALREADY BEEN SOLVEED, WE KNOW WE'VE HEARD IF OUR PATIENTS DON'T EXPERIENCE PAIN, I DON'T THINK THEY HEAL WELL BECAUSE IF THEY'RE DIABETICS, THEY DON'T HAVE MUCH PAIN FROM THEIR NEWER PA THEE AND NEUROPATHY, IF I KNOW THERE'S PAIN, I KNOW MY PATIENTS ARE GOING TO HEAL WELL. SO WE HAVE THESE BIASES TO OVERCOME THAT WERE SOLVED, WE NEED TO LIVE WITH IT. WE DO KNOW IT IS NECESSARY, SOME DISEASE DIAGNOSIS TRULY DO RELY ON PAIN. FOR THAT DIAGNOSIS. BUT WE ALSO WANT AVAILABILITY TO TREAT THAT. SO I HAVE BEEN WORKING IN ACUTE PAIN CLINICALLY FOR OVER 25 YEARS AS WELL AS BASIC SCIENCE IN ACUTE PAIN RESEARCH, SO I'M REALLY THRILLED TO BE ABLE TO PRESENT THIS. WHAT WE NEED TO DISCUSS TO FURTHER EXAMINE THE PROBLEM IS, AS WILL PROBABLY BE A THEME IN EVERYBODY'S DISCUSSION IS OUR TREATMENTS ARE ASSOCIATED WITH ADVERSE EFFECTS, AND THESE ARE ACUTE, CERTAINLY WE KNOW ABOUT THE ACUTE ADVERSE EFFECTS, WE'RE ALWAYS MANAGING SIDE EFFECTS OF OUR TREATMENTS, BUT I THINK WE'VE INCLUDED IN HERE GOING ON TO CONCERNS FOR MISUSE AND ABUSE, AND I THINK WE NOW RECOGNIZE AND I PRESENTED THIS LAST WEEK AT THE AMERICAN PAIN SOCIETY WHEN PEOPLE HAVE MAJOR SURGERY, THE NUMBER IS ABOUT 6% WHO CONTINUE ON OPIOIDS AFTERWARDS, AND I GUESS I WOULD SAY EVIDENCE FOR DEPENDENCE AT LEAST TO START WITH. WE ALSO RECOGNIZE ACUTE PAIN INCREASES THE RISK OF CHRONIC PAIN. I THINK THE SINGLE -- ONE OF THE BEST PREDICTER, I WON'T SAY THE SINGLE BEST PREDICT TER, IT DEPENDS ON THE SURGERY, BUT ONE OF THE BEST PREDICTERS FOR THE RISK OF CHRONIC PAIN IS THE SEVERITY OF ACUTE PAIN. MAY NOT BE CAUSING IT BUT IT'S A PREDICTER. POST THORACOTOMY PAIN SYNDROME IS AN EXAMPLE OF THAT. SO AGAIN IN THAT THEME OF TRANSITIONS, WE RECOGNIZE ACUTE PAIN IS IMPORTANT BECAUSE IT'S INVOLVED BOTH IN TWO LONG TERM PROBLEMS WHICH WE'LL HEAR MORE DETAILS ABOUT GOING FORWARD. I ALSO MENTIONED LAST WEEK AT THE AMERICAN PAIN SOCIETY, AND THIS CAME OUT THROUGH ONE OF THE APS WORKING GROUPS, THAT SOME OF THE BEST PREDICTERS OF SEVERITY, ACUTE PAIN, ARE PSYCHOSOCIAL FACTORS. BUT YET WE HAD LITTLE GOOD EVIDENCE OF HOW BEST TO USE BIOBEHAVIORAL TREATMENTS IN ACUTE PAIN, ANXIETY, DEPRESSION, CATASTROPHIZING, WANTING TO KNOW MORE INFORMATION ARE PREDICTERS OF SEVERITY OF ACUTE PAIN. SO WE RECOGNIZE WE'VE GOT CHRONIC PROBLEMS, WE'VE GOT TREATMENTS, WE PROBABLY ARE UNDERUTILIZING AND NEED TO KNOW HOW TO UTILIZE THEM BEST. AND THEN TO GO ON, I THINK IN A THEME WE'VE HEARD ABOUT THIS MORNING AGAIN, WE NEED ALTERNATIVE MEASURES AND TREATMENTS, AND I THINK ONE THING THAT CAME OUT OF THE ACUTE PAIN GROUP THAT THOSE OF US DOING ACUTE PAIN TALK ABOUT A LOT IS WE HAVE END POINTS OF GIVE ME A VAS SCORE AND I CAN GO ON TO THE NEXT PATIENT, AND WE REALLY -- AND EVEN ACUTE PAIN IS A MULTIDISCIPLINARY PROBLEM, AND WE NEED MULTIDIMENSIONAL ASSESSMENTS FOR ACUTE PAIN MEASURES OF DISTRESS, COGNITIVE IMPAIRMENT. THAT MIGHT BE RESULTS OF ACUTE PAIN. SO REALLY, THE BOX IS WIDE OPEN TO MOVE BEYOND THE NRS TO MOVE BEYOND THE VAS SCORE FOR ACUTE PAIN, AND AS WE'VE ALSO HEARD ABOUT, NEW TREATMENTS FOR ACUTE PAIN, IT MAY BE A MEDICATION OR IT MAY BE A NON-MEDICATION. THE ACUTE PAIN HAS GREAT HETEROGENEITY, AND THAT MAY BE IN TRANSDUCTION, I THINK BASIC SCIENCE IS STARTING TO MOVE AWAY FROM THAT 1NOCICEPTIVE TRANSDUCER, IT'S PROBABLY NOT THE CAPSAICIN RECEPTOR, BUT WE RECOGNIZE HETEROGENEITY IN TRANSDUCERS AND BASIC SCIENCE BECAUSE OF THIS HYBRID GROUP IN BASIC SCIENCE AND CLINICIANS. I THINK WE WANTED TO EMPHASIZE AS I JUST SAID, THERE'S GREAT HETEROGENEITY, PSYCHOSOCIAL CIRCUMSTANCES THAT IMPACT ACUTE PAIN. WE'VE GONE ON WITH MOLECULAR AND CELLULAR HETEROGENEITY THAT I'LL PROVIDE MORE INFORMATION ON. SO WE HAVE THIS CHRONIC PROBLEM, DEVELOPING A CHRONIC PROBLEM WITH MAY BE MEDICATION USE, IT MAY BE CHRONIC PAIN. THERE'S NO DOUBT WE'VE PROBABLY I THINK IN GENERAL WE'VE UNDERSTATED THE PSYCHOSOCIAL COMORBIDITIES AND THEIR TREATMENTS, AND WE'LL SEE FROM THE BASIC SCIENCE PROPOSALS WE NEED RESPECT FOR HETEROGENEITY IN MECHANISMS. THERE ARE MANY TYPES AND CAUSES OF ACUTE PAIN. I MENTIONED ACUTE ZOSTER FOLLOWED BY POST HERPETIC NEURALGIA. SURGERY, I ALWAYS TALK ABOUT SURGERY, MECHANISMS FOR SURGERY AND PAIN. WE RECOGNIZE A BURN IS MUCH DIFFERENT THAN A SURGERY, IS MUCH DIFFERENT THAN ZOSTER, ALL EXAMPLES OF HETEROGENEITY OF ACUTE PAIN. WE WANT TO RECOGNIZE HETEROGENEITY IN THE SIGNALING OF ACUTE PAIN FROM SIGNALING TO PSYCHOSOCIAL CIRCUMSTANCES. AND LIMITED UNDERSTANDING OF THE CIRCUIT LEVEL FOR MECHANISMS FOR ACUTE PAIN, AND IT SHOULDN'T BE HOT PLATE, IT SHOULD BE ACUTE PAIN AFTER INJURY, IF I CAN EDITORIALIZE OFF MY SLIDES HERE. AND THEN LACKING TAILORED INTERVENTIONS WITH THIS HETEROGENEITY IN MIND. SO SORT OF INDIVIDUALIZED MEDICINE THAT WE TALK ABOUT. SO WHAT ARE OUR RECOMMENDATIONS AND I THINK I MANAGED TO PUT THE BASIC SCIENCE RECOMMENDATIONS, WE HAVE A HETEROGENEITY IN OUR PROBLEM AND WE HAD A VERY DIVERSE GROUP. SO WHAT ARE THE MOLECULAR MECHANISMS FOR HETEROGENEITY IN ACUTE PAIN SENSATION. I THINK TYPICAL EXAMPLES OF THAT WOULD BE BURN PAIN VERSUS TRACT PAIN, PRACT PAIN, WHY FRACTURE PAIN, WHY ARE THEY SO DIFFERENT. IT MOVES TO THE CELLULAR LEVEL AS WELL. NOCICEPTORS THAT MAY SIGNAL PAIN FROM ONE ORGAN MAY HAVE A TOTALLY DIFFERENT TRANSDUCTION PROCESS THAN THAT FROM ANOTHER ORGAN. WE ASKED FOR AB AN UNDERSTANDING OF THE AUTONOMIC NERVOUS SYSTEM. I THINK THIS PARTICULARLY CAME INTO ACCOUNT IN HEADACHE, AND ACUTE PAIN, BUT AN UNDERSTANDING OF THE AUTONOMIC NERVOUS SYSTEM AND ITS ROLE IN ACUTE PAIN. AND THEN APPRECIATING THE CIRCUITRY OF INVOLVED IN AN ACUTE PAIN SENSATION AND MODULATION. TO THE CLINICAL SIDE, WE WANT BETTER ASSESSMENT PARAMETERS AND BIOPSYCHOSOCIAL PREDICTERS. I WAS STRUCK THIS MORNING BY A VERY SUBTLE CHANGE IN MOOD BEING A PREDICTER FOR NECK PAIN, NOT REACHING THE RADAR OR THE BAR FOR DEPRESSION. BUT WHAT CAN WE USE IN OUR ASSESSMENTS THAT ARE GOING TO IMPROVE OUR ACUTE PAIN MANAGEMENT. SO WE NEED A VARIETY OF THESE PREDICTERS AND ASSESSMENTS. THINK THE PREDICTERS -- WE HAVE BATTERIES OF PSYCHOLOGICAL TESTS BUT WE'RE NOT GOOD ENOUGH AT PREDICTING, AND I THINK AS THE GROUP SAID THAT, NOT ME. AND THEN TAKING ALL THAT TOGETHER, THE SAME ACEMENTS PARAMETERS AND BE PREDICTERS FOR ACUTE PAIN IN PATIENTS WHO CANNOT SELF-REPORT WAS AN AREA OF EMPHASIS FOR OUR RECOMMENDATIONS. BACK AGAIN, ONE OF THE MOST EFFECTIVE STRATEGIES TO PROVIDE INDIVIDUALIZED ACUTE PAIN MANAGEMENT OF COMPLEX PATIENTS. AN EXAMPLE OF A COMPLEX PATIENT MIGHT BE AN OPIOID TOLERANCE PATIENT. HOW ARE WE GOING TO OPTIMIZE THEIR TREATMENT, WE HAVE A LITTLE BIT OF DATA ON THAT THAT'S BEEN HELPFUL BUT THAT'S ONE EXAMPLE OF ONE OF OUR COMPLEX PATIENT, THE CHRONIC PAIN PATIENT WHO HAD SEVERE CHRONIC PAIN HAS AN OPERATION IN THAT AREA OF CHRONIC PAIN. IT MAY NOT RELIEVE THAT, LIKE A HIP REPLACEMENT MIGHT. AN MAY PRODUCE A COMPLEX SCENARIO. THINK A BUNCH OF CLINICIANS CHIMED IN THAT WE NEED MANAGEMENT PROGRAMS THAT BEGIN WELL PRIOR TO THE EVENT IF WE KNOW THE EVENT IS GOING TO HAPPEN OR AFTER THE EVENTS HAPPEN, WE NEED REALLY EFFECTIVE PAIN MANAGEMENT PROGRAMS. WE NEED MULTIDISCIPLINARY CARE, IT WON'T BE ONE GROUP THAT PROVIDES THIS BUT IT MAY BE A LOT OF GROUPS WHO CAN PUT TOGETHER EDUCATION AND MANAGEMENT PROGRAMS FOR PATIENTS, SO SOMEBODY COMING WITH -- AN EXAMPLE OF SOMEBODY COMING FOR A VERY COMPLEX SURGERY, LET'S SAY THEY'RE COMING FOR PANCREAS SURGERY AND WE DEVELOP A PAIN MANAGEMENT PLAN THAT INCLUDES PERHAPS MULTIMODAL AND AL JEEZ YA PLANS TO TAPER EXPECTATIONS ET CETERA. WE HAVE NO WAY OF PLANNING THESE OUT AND THEY'RE REALLY DONE IN SILOS. AND THEN TOOLS TO EDUCATE ACUTE PAIN PATIENTS. EDUCATION SEEMS TO BE QUITE EFFECTIVE FOR IMPROVING ACUTE PAIN MANAGEMENT, PATIENTS KNOW WHAT TO EXPECT IF THEY UNDERSTAND THE EXPECTATION, THEY SEEM TO DO BETTER. HOW CAN WE -- THERE'S A LITTLE BIT OF DATA ON THIS, HOW CAN WE -- WHAT CAN WE DO TO OPTIMIZE THESE. SO THAT SUMMARIZES OUR WORKING GROUP AGAIN HEADED BY CHRIS AND ARMEN, AND I'D BE GLAD TO ANSWER ANY QUESTIONS. [APPLAUSE] >> HELLO, I'M BOB DWORKIN, I WANT TO START BY ACKNOWLEDGING THE CO-CHAIR WHO WORKED WITH ME ON THIS WORKING GROUP AND THAT'S TED PRICE, TED PRICE CAN'T WITH BE US HERE TODAY, AND I ALSO WANT TO BEING A KNOWLEDGE THE INPUT AND HELP OF ALL THE OTHER MEMBERS OF THE WORKING GROUP AND PARTICULARLY GREG TERMIN, WHO IS HERE WITH US TODAY, AND AS YOU'LL SEE IN A MOMENT, I'M VERY GLAD THAT GREG IS HERE. AND SO OUR WORKING GROUP WAS TASKED WITH THINKING ABOUT WHAT ARE THE UNDERLYING MECHANISMS THAT ACCOUNT FOR THE FACT THAT SOME PATIENTS APPEAR TO TRANSITION FROM AN ACUTE PAIN CONDITION TO CHRONIC PAIN. AS YOU'VE ALREADY HEARD TODAY, ACUTE PAIN CAN BE CAUSED BY INJURY, BY TRAUMA, OBVIOUSLY BY ILLNESS, AND VARIOUS MEDICAL INTERVENTIONS. PERCENTAGE OF PATIENTS WITH ACUTE PAIN, THE PAIN DOESN'T RESOLVE, AND APPEARS TO BECOME CHRONIC. SO THERE'S A TRANSITION, AT LEAST IT LOOKS LIKE A TRANSITION TRANSITION, FROM THE ACUTE PAIN CONDITION TO CHRONIC PAIN. AND YOU'VE ALREADY HEARD ABOUT OBVIOUS EXAMPLES THAT WE ALL KNOW ABOUT OF THIS, NOT ALL PATIENTS WITH ACUTE LOW BACK PAIN DEVELOP CHRONIC LOW BACK PAIN BUT SOME DO. NOT ALL PATIENTS INITIATING CANCER CHEMOTHERAPY OF VARIOUS TYPES DEVELOP CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY BUT A MINORITY, IT CAN BE LONG LASTING. NOT ALL PATIENTS DEVELOP POST HERPETIC NEURALGIA BUT ABOUT 20% OF PEOPLE MY AGE DO. THEN PERHAPS MOST IMPORTANTLY, THOUGH WE COULD QUIBBLE ABOUT WHICH OF THESE EXAMPLES IS THE MOST IMPORTANT, NOT ALL PATIENTS UNDERGOING SURGICAL PROCEDURES OF VARIOUS TYPES DEVELOP CHRONIC POST SURGICAL PAIN, BUT A MINORITY DO. SOME SURGERY, PERHAPS THORACOTOMY, IT'S NOT A MINORITY, THERE ARE SOME STUDIES THAT SUGGEST 50% OR EVEN MORE OF PATIENTS THAT HAVE THORACOTOMY ARE STILL IN PAIN A YEAR LATER. BUT FOR MOST OTHER SURGERY, IT'S LESS THAT BE 50%, AND SOMETIMES DOWN ON THE ORDER OF 5 TO 10%, BUT IT'S ALMOST ALWAYS THE CASE THAT SURGERY CAN BE FOLLOWED IN SOME PATIENTS BY CHRONIC PAIN. SO WE STAY IN THIS SLIDE, A SIGNIFICANT PORTION OF INDIVIDUALS, THE PAIN DOESN'T RESOLVE, BECOMES CHRONIC, AND THIS IS A CRUCIAL SCIENTIFIC PROBLEM TO UNDERSTAND THE MECHANISMS INVOLVED IN THAT TRANSITION. NOW, GREG WAS RESPONSIBLE EARLY ON IN OUR WORKING GROUP FOE POSES WHAT IS AN INCREDIBLY IMPORTANT AND CHALLENGING QUESTION WHICH IS, I HOPE I'M GETTING THIS RIGHT, MAYBE WE'RE BARKING UP THE WRONG TREE, MAYBE THERE IS NO TRANSITION, MAYBE ACUTE PAIN AND CHRONIC PAIN ARE THERE FROM THE BEGINNING, AND THE PATIENTS WHO LATER -- AT SIX MONTHS OR 12 MONTHS FOLLOW UP STILL HAVE PAIN, HAD CHRONIC PAIN FROM THE GUNNING, THEY ALSO HAD ACUTE PAIN WHICH RESOLVED, BUT YOU DIDN'T KNOW THAT BECAUSE CHRONIC PAIN WAS WAS THERE FROM THE BEGINNING CONTINUED BUT OTHER PATIENTS WHO DON'T BRING THEIR ILLNESS OR INJURY OR MEDICAL INTERVENTION WHO DON'T HAVE CHRONIC PAIN HAVE PAIN THAT APPEARS TO RESOLVE AFTER WEEKS OR AROUND THE TIME OF HEALING. SO GREG RAISED THIS CHALLENGING QUESTION OF DO WE KNOW, CAN WE BE SURE THAT THERE IS ACTUALLY A TRANSITION AS OPPOSED TO THE POSSIBILITY OF BOTH ACUTE PAIN AND CHRONIC PAIN BEING THERE FROM THE BEGINNING IN SOME PATIENTS, THE MINORITY WHO DEVELOP -- WHO APPEAR REALLY TO DEVELOP CHRONIC PAIN. ONE OF THE THINGS THAT I THINK IS INTERESTING TO THINK ABOUT, AND I DON'T KNOW THAT OUR WORKING GROUP SPENT ENOUGH TIME ON IT, IS WHAT KINDS OF RESEARCH STUDIES WOULD IT BE POSSIBLE TO DO PRECLINICALLY AND CLINICALLY TO TRY TO DISTINGUISH THESE AT LEAST OP THE FACE OF IT TWO COMPETING HYPOTHESES, THAT THERE'S A KIND OF ACTIVE TRANSITION FROM ACUTE TO CHRONIC, AND THAT THERE'S NO TRANSITION, GREG'S HYPOTHESIS, THAT THEY'RE BOTH THERE FROM THE GUNNING AND IN PATIENTS WHO DON'T HAVE THE CROPPING FROM THE BEGINNING, THE ACUTE PAIN RESOLVES. WE DIDN'T SPEND ENOUGH TIME, I THINK IT'S FAIR TO SAY, TRYING TO COME UP WITH RESEARCH DESIGNS THAT WOULD ADDRESS THAT QUESTION. WE DID SPEND -- AND IF YOU HAVE ANY QUESTIONS ABOUT THIS VEXING ISSUE, ASK GREG AND NOT ME. SO THESE WERE OUR THREE HIGH PRIORITY RESEARCH NEEDS THAT THE WORKING GROUP IDENTIFIED. THERE WERE A COUPLE OF OTHERS BUT I THINK THERE WAS A CONSENSUS AMONG THE WORKING GROUP AND ALSO THE LARGER GROUP, THAT THESE RESEARCH NEEDS HAD THE HIGHEST PRIORITY, AND THE FIRST IS REALLY THE BASE UK SCIENCE PRE-CLINICAL NEED, WHICH IS WE NEED TO DO A LOT MORE TO UNDERSTAND THE MECHANISMS THAT ARE INVOLVED IN THE TRANSITION FROM ACUTE TO CHRONIC PAIN. ALSO THE POSSIBILITY THAT THERE ARE PAIN RESOLUTION MECHANISMS THAT MAKE RESOLUTION LIKELY, MORE LIKELY IN THE PATIENTS WHO, IN FACT, SUCCESSFULLY RESOLVE THEIR PAIN. I THINK OUR WORKING GROUP SPENT SOME TIME ON THIS AND IT'S IMPORTANT, RAISES THE WHOLE ISSUE OF DISEASE MODIFICATION. YOU KNOW IN THE PAIN WORK, WE HAVE SYMPTOMATIC TREATMENTS AND WE'VE ALL BECOME VERY ACCUSTOMED TO INTERVENING WITH OUR PATIENTS SYMPTOMATICALLY IN A KIND OF PALLIATING WAY, BUT WHAT ABOUT ACTUAL DISEASE MODIFICATION. THEY ARGUE AND I'M REALLY OVERSIMPLIFYING THEIR ARTICLE BUT IT'S IN PRESS AND I THINK AVAILABLE ON PAIN MEDICINE'S WEBSITE SO YOU CAN READ THE NON-OVERSIMPLIFIED VERSION YOURSELF. THEY ARGUE THAT WE HAVEN'T THOUGHT ENOUGH ABOUT DISEASE MODIFICATION WHEN WE THINK ABOUT CHRONIC PAIN. WE HAVEN'T THOUGHT ABOUT THE POSSIBILITY OF CURING CHRONIC PAIN OF REVERSING IT, ARRESTING IT, RETARDING ITS PROGRESSION, PREVENTING IT, AND I THINK AS THE FIRST RESEARCH PRIORITY NEED HERE MAKES CLEAR, THIS REALLY IS A CRUCIAL DEFICIT OF OUR FIELD THAT WE HAVEN'T LEARNED, WE HAVEN'T DEVOTED ENOUGH ATTENTION TO WHAT ARE THE MECHANISMS THAT PROMOTE PAIN AND PROMOTE PAIN BECOMING CHRONIC OR WHAT ARE THE MECHANISMS THAT INTERFERE WITH RESOLUTION OR THAT COULD PROMOTE RESOLUTION. SO THE SECOND RESEARCH NEED HERE, AND THESE MECHANISMS, OF COURSE THERE'S A WHOLE LOT OF MECHANISMS AND IT NOT MY AREA OF EXPERTISE, THESE ARE PERIPHERAL -- IMMUNE SYSTEM MECHANISMS THAT OFTEN INTERACT WITH THE NERVOUS SYSTEM MECHANISMS, ET CETERA, ET CETERA. SO MOVING ON TO THE SECOND OF THE THREE RESEARCH NEEDS, AND I THINK HERE, THERE'S SOME OVERLAP OF THE PREVENTION WORKING GROUP, WHICH IS THERE AREN'T AS MANY PROSPECTIVE CAREFULLY CONDUCTED LARGE SAMPLE SIZE STUDIES OF RISK AND PROTECTIVE FACTORS THAT EXAMINED THE TRANSITION FROM ACUTE TO CHRONIC PAIN. THERE ARE SOME, CERTAINLY THERE ARE STUDYS THAT HAVE LOOKED AT RISK FACTORS FOR THE DEVELOPMENT OF CHRONIC LOW BACK PAIN IN PATIENTS WITH ACUTE LOW BACK PAIN EPISODES, THERE ARE STUDYIES CERTAINLY OF RISK FACTORS FOR IDENTIFYING WHICH PATIENTS WITH SHINGLES WILL DEVELOP POST HERPETIC NEURALGIA, BUT THERE CAN BE MANY MOVE MORE OF THOSE STUDIES, THOSE THAT HAVEN'T DIRECTED ENOUGH ATTENTION TO PROTECTIVE FACTORS. I'VE BEEN MUCH MORE INTERESTED IN WHAT INCREASES THE RISK OF CHRONIC PAIN REARNL WHAT MIGHT DECREASE IT IN A PATIENT WITH ACUTE PAIN, MAKE IT LESS LIKELY. DOES SOCIAL SUPPORT MAKE THE DEVELOPMENT OF CHRONIC PAINLESS LIKELY? ARE MARRIED PEOPLE LESS LIKELY TO DEVELOP CHRONIC LOW BACK PAIN AFTER AN ACUTE PAIN INJURY THAN SINGLE PEOPLE, OF COURSE I'M UNSEUMING THAT SINGLE PAY ARE UNHAPPY, THAT PEOPLE ARE UNHAPPY AND THAT MAY NOT BE THE CASE. THE ONES THAT HAVE BEEN DONE HAVEN'T LOOKED AT MECHANISMS BY AND LARGE, YOU KNOW, WE'VE LOOKED AT DEMOGRAPHIC CHARACTERISTICS, CLINICAL CHARACTERISTICS OF PATIENTS, MAYBE GIVEN THE DEPRESSION INVENTORY, BUT THOSE STUDIES SHOULD BE DONE WITH GREATER ATTENTION TO UNDERLYING NEUROBIOLOGICAL MECHANISMS. THE NUMBER OF STUDIES THAT HAVE LOOKED AT THE DEVELOPMENT OF CHRONIC PAIN IN PATIENTS WITH ACUTE PAIN THAT HAVE DONE SKIN PUNCH BIOPSIES TO LOOK AT EPIDERMAL INNERVATION OR HAVE INCLUDED FMRI OR QUANTITATIVE SENSORY TESTING ALSO ARE FEW AND FAR BETWEEN. AND THEN, OF COURSE, THE PROOF OF THE PUDDING IS IN THE EATING. SO OUR LAST HIGHLY RECOMMENDED RESEARCH NEED IS TO DO CLINICAL TRIALS THAT TEST HYPOTHESES ABOUT THE MECHANISMS OF THE TRANSITION FROM ACUTE TO CHRONIC PAIN BY TRYING TO PREVENT IT. SO IF WE HAVE HYPOTHESIS THAT PEOPLE -- I DON'T KNOW -- SHINGLES PATIENTS WHO ARE HIGH IN CATASTROPHIZING, THIS IS PSYCHOSOCIAL HYPOTHESIS, ARE MORE LIKELY TO DEVELOP PHN. CAN WE DO A CLINICAL TRIAL, SHOULD WE DO A CLINICAL TRIAL WHERE WE IMPLEMENT AN ANTICATASTROPHIZING INTERVENTION STARTING AS SOON AS POSSIBLE& AFTER THE APPEARANCE OF A HERPES ZOSTER RASH, AND SEE IF IT REDUCES VERSUS SOME KIND OF CONTROL THE LIKELIHOOD OF POST HERPETIC NEURALGIA. NO ONE HAS DONE A STUDY LIKE THAT, KIND OF INTERESTING IF SOMEONE WANTED TO FUND IT. MIGHT IT BE THAT AN ANTI-NGF ANTIBODY, GIVEN A WEEK BEFORE ELECTIVE SURGERY OF WHATEVER TYPE, REDUCES THE RISK OF CHRONIC POST SURGICAL PAIN SIX MONTHS LATER. I WAS IN A MEETING WHERE THAT ISSUE CAME UP. NO ONE AT THE MEETING VOLUNTEERED TO DO THAT. SO WE NEED TO DESIGN CLINICAL TRIALS THAT TEST PUTATIVE MECHANISMS OF THE TRANSITION FROM ACUTE TO CHRONIC PAIN BY SEEING WHETHER INTERVENTIONS THAT ADDRESS THOSE MECHANISMS PREVENT CHRONIC PAIN. AND THAT WAS THAT FINAL HIGH PRIORITY RESEARCH NEED THAT OUR WORKING GROUP IDENTIFIED. THANKS VERY MUCH FOR YOUR ATTENTION. AND I'D BE HAPPY TO ANSWER QUESTIONS AN NOW OR LATER. [APPLAUSE] >> I'M SEDDON SAVAGE, CLINICIAN, A PAIN MEDICINE CLINICIAN, ALSO DO EDUCATION AROUND PAIN AND CHRONIC PAIN IN PARTICULAR, ESPECIALLY IN THE AREA THAT INTERFACES WITH SUBSTANCE USE, AND ALSO WORK ON ADVOCACY FOR PAPER POLICY. I HAVE BEEN VERY HONORED AND ONLY A LITTLE INTIMIDATED, THEREFORE, TO WORK WITH THIS ILLUSTRIOUS GROUP OF RESEARCHERS, MANY OF WHOM ARE ALSO CLINICIANS, AROUND DEVELOPING OUR RESEARCH PRIORITIES FOR CHRONIC PAIN. AND TO BRING A PERSPECTIVE FROM THE FIELD TO THAT, I WAS HONORED TO CHAIR THIS WORK GROUP WITH JIANREN MAO. WE SELECTED VERY CAREFULLY TO MAKE SURE THAT WE REPRESENTED THE DIVERSITY OF ISSUES IN RESEARCH AREAS EXISTING IN THE FIELD OF CHRONIC PAIN IN PARTICULAR. SO THAT WE HAD DIVERSE PERSPECTIVES TO BRING TO THIS EFFORT. AND ALSO WANTED TO THANK ALLAN BASBAUM AND LINDA PORTER FOR MAKING THIS A REALLY SEAMLESS PROCESS WITH A LOT OF ENERGY AND ACTIVITY. SO OUR PROBLEM, WE'RE ALL FAMILIAR WITH THE CHAL EPTION, I THINK, OF CHRONIC PAIN. WE HAVE TWO INTERSECTING CHRONIC HEALTH CONCERNS AND REALLY CRISIS. WE HAVE THE PREVALENCE OF CHRONIC PAIN WHICH THE IOM REPORT HAS TOLD US AFFECTS AT LEAST 100 MILLION AMERICANS, MANY OF THOSE WHO SUFFER FROM HIGH IMPACT CHRONIC PAIN THAT LEADS TO DISABILITY, AND MASSIVE ALTERATIONS IN QUALITY OF LIFE. THIS NUMBER IS EXPECTED TO GROW AS THOSE OF US WHO WERE BABY BOOMERS CONTINUE UNRELEAPTINGLY RELEAPTING LY TO AGE, A LARGE SEGMENT OF THE POPULATION. AT THE SAME TIME, WE ARE AWARE OF THE RISE AS OPIOIDS HAVE BEEN MORE AVAILABLE FOR THE TREATMENT OF PAIN, MORE AVAILABLE FOR MISUSE AND ASSOCIATED WITH RISING OPIOID USE DISORDERS AND RISING OPIOID OVERDOSES. SO LOOKING AT THESE PROBLEMS, WHAT DO WE NEED TO ADDRESS PAIN IN A WAY THAT WILL NOT CONTRIBUTE TO THIS SECOND PUBLIC HEALTH CHALLENGE.& SO WE'VE MADE SIMILAR SIGNIFICANT ADVANCES OVER THE LAST FEW DECADES. AS CONTEXT, WE'VE REALLY INCREASED OUR UNDER STANDING OF NOCICEPTIVE MECHANISMS OF PAIN AND NEUROPATHIC MECHANISMS OF PAIN WHICH CONTRIBUTE TO THE EXPERIENCE OF PAIN BUT ARE NOT THE WHOLE OF THE EXPERIENCE OF PAIN. THOSE HAVE OPENED NEW POTENTIAL TARGETS FOR PAIN ASSESSMENT AS WELL AS PAIN TREATMENT. WE'VE ALSO, OVER TIME, VALIDATED AND HEARD A LOT ABOUT THAT OVER THE LAST TWO DAYS, A VIEW OF PAIN AS A REALLY COMPREHENSIVE AND COMPLEX EXPERIENCE THAT INCLUDES BIOLOGCAL, PSYCHOLOGICAL BEHAVIORAL AND ENVIRONMENTAL SOCIAL -- AND SOCIAL COMPONENTS. SO WE UNDERSTAND THAT THERE ARE MECHANISMS CONTRIBUTING AND THEN THE CONTEXT, THE BIOPSYCHOSOCIAL CONTEXT OF THE INDIVIDUAL. ADD TO THAT AN APPRECIATION OF THE COMPLEXITY THAT IS AMPLIFIED WHEN INDIVIDUALS HAVE CO-MORBID MEDICAL CONDITIONS COEXISTING SYMPTOMS OF A VARIETY OF TYPES, AND ARE IN DIFFERENT DEVELOPMENTAL STAGES OF THEIR LIVES AND IN DIVERSE SOCIOCULTURAL CONTEXTS. SO CHRONIC PAIN IS VERY, VERY COMPLICATED. AND WE KNOW THAT IT CAN BE SHAPED BY DIVERSE INTERNAL AND EXTERNAL FACTORS. SO WE HAVE MANY KNOWLEDGE GAPS THAT HAVE PREVENTED OR TAKEN THIS INCREASING APPRECIATION OF THE COMPLEX VARIABLES AND IDENTIFICATION OF THESE VARIABLES AND TRANSLATING THEM INTO SAFE AND EFFECTIVE THERAPY. SO WHILE WE HAVE SOME EVIDENCE OF ADVOCACY AND OF EFFECTIVENESS IN CLINICAL SETTINGS OF DIVERSE TYPES OF TREATMENTS WHETHER THEIR INTERVENTIONALLY TREATMENTS OR OTHERS FOR VERY SPECIFIC PAIN CONDITIONS IN SPECIFIC ENVIRONMENTAL CONTEXTS, WE REALLY ARE LACK AGO CLEAR UNDERSTANDING OF THE EFFECTIVENESS OF THESE CONDITIONS ACROSS DIFFERENT PAIN CONDITIONS. AND HOW THEY INTERACT WITH OTHER THERAPIES AND INTERVENTIONS. SO WE ARE BEGINNING TO LEARN MECHANISMS OF ACTIONS AND INTERACTIONS AMONG THERAPIES, BUT OUR STRATEGIES AS WE CHOSE THEM REALLY HONORED THE FACT THAT THESE ARE AREAS WHERE WE NEED FURTHER GROWTH. SO I WANT TO ACKNOWLEDGE THAT WE STARTED OUT WITH 10 CHRONIC PAIN STRATEGIES AND FIVE OF THEM WHICH WE CONSIDERED VERY IMPORTANT PRIORITIES WERE INTEGRATED INTO THE CROSS CUTTING PRIORITIES THAT LINDA PRESENTED EARLIER. SO JUST TO MENTION BRIEFLY, SCREENING AND OUTCOMES MEASURES INCLUDING DEVELOPMENT OF BIOMARKERS, USING LARGE DATASETS, NATIONAL REGISTRIES AND DEVELOPMENT OF RESEARCH NETWORKS TO REALLY BE ABLE TO COPE WITH ALL THESE MANY VARIABLES USING THE LARGEST POSSIBLE POPULATIONS FOR STUDY. THEN CRITICALLY EFFECTIVE MODELS OF CARE DELIVERY BECAUSE ONCE WE IDENTIFY EFFECTIVE THERAPIES, HOW DO WE GET THEM INTO THE FIELD AND IMPLEMENT THEM EFFECTIVELY? THE DEVELOPMENT OF NOVEL DRUGS AND PHARMACOLOGIC TREATMENTS AND PRECISION MEDICINE METHODOLOGIES. SO THAT LEFT US WITH THESE FIVE CHRONIC PAIN RECOMMENDATIONS, AND I'M NOT GOING TO READ THROUGH THEM HERE BECAUSE I'M GOING TO MENTION EACH OF THEM BRIEFLY IN THEIR OWN SLIDE. SO FIRST DETERMINING THE MECHANISMS THAT SUSTAIN OR RESOLVE, NOTING THAT THE TRANSITION TEAM ALSO PUT THIS EMPHASIS ON SUSTAINING OR RESOLVING THE MECHANISMS, AND CONSIDERING WHAT INTRINSIC AND EXTRINSIC FACTORS CAN MODULATE THOSE MECHANISMS. SO ONE OF THE OBSERVATIONS THAT HAS BEEN REPEATEDLY MADE IS THAT THERE'S SUCH A HETEROGENEITY OF RESPONSES TO SPECIFIC TREATMENTS WITHIN CONDITIONS. WE FIND THAT MOST OF THE TREAT THAMENTS WE HAVE HAVE MODEST EFFECTS OVER PLACEBO AS WE HEARD AGAIN THIS MORNING, AND THAT IT'S OFTEN A SUBSET OF PATIENTS WHO ARE RESPONDERS RATHER THAN THE WHOLE CLASS OF PATIENTS WITH A PARTICULAR CONDITION, UNLIKE SOME OTHER MEDICAL COMPANIES THAT WE TREAT. SO THERE'S A HETEROGENEITY OF RESPONSE, AND A COMMONALITY OF RESPONSES OF SUBGROUPS ACROSS DIFFERENT CONDITIONS. SO THAT SUGGESTS THOUGH SOCIETY OFTEN THINKS OF PAIN CONDITIONS SPECIFICALLY, LOW BACK PAIN, NECK PAIN, PANCREATIC PAIN, DIABETIC NEUROPATHY, WE THINK OF DIFFERENT TYPES OF CONDITIONS BUT IN DESIGNING TREATMENTS, OUR TEAM FELT WE NEED TO BE THINKING DIFFERENT MECHANISTICALLY ACROSS THOSE DIFFERENT CONDITIONS, SO THE GENETIC, IMMUNE, INFLAMMATORY AND EPIGENETIC FACTORS THAT CONTRIBUTE TO CHRONIC PAIN, AND AS WELL AS LOOKING AT PERIPHERAL AND NEURAL FACTORS AND TRY TO DEFINE BETTER THE MODIFICATION OF THOSE MECHANISMS THAT LEAD TO THE SUBSETS OF RESPONDERS. THEN LOOKING AT WHAT INTRINSICALLY CAN BE MODIFIED THROUGH PERHAPS INTERNAL SELF MANAGEMENT STRATEGIES VERSUS EXTERNAL INTERVENTIONS OR PHARMACOLOGIC TREATMENTS. AND THE GOAL, OF COURSE, WITH ALL OF THIS FEEDS BACK ON ONE OF THE CROSS CUTTING GOALS OF PRECISION -- MORE PRECISE MEDICINE INTERVENTIONS TAILORED TO INDIVIDUALS. SO PRECISELY MATCHING OUR THERAPIES TO INDIVIDUAL PATIENTS. OUR SECOND PRIORITY WAS DETERMINING BITE DIRECTIONAL RELATIONSHIP BETWEEN COMMON COMORBIDITIES AND CHRONIC PAIN. WE KNOW THAT MANY IF NOT ALL OF OUR PATIENTS WITH CHRONIC PAIN HAVE SOME FORM OF CROW MORBIDITIES. OFTEN THEIR PAIN IS SECONDARY TO AN ECK SITION MEDICAL CONDITION. COMMON EXAMPLES, MALIGNANCIES, DIABETES, OBESITY, AND OTHERS, AND WE KNOW THAT WHILE THESE ENGENDER PAIN, PAIN CAN ALSO ENGENDER IMPACT THE COURSE OF SOME OF THESE DISEASES SO THERE'S A BI-DIRECTIONAL RELATIONSHIP. SLEEP DISTURBANCES, AMONG SITE, DEPRESSION, DYSFUNCTION AND REWARD OR RESPONSES TO SUBSTANCES, REWARDING SUBSTANCES AND CERTAINLY TRAUMA AND TRAUMATIC MEMORYIES CAN INFLUENCE THE DEVELOPMENT OF PAIN, THE INTENSITY OF THE EXPERIENCE OF PAIN, AND AT THE SAME TIME, PAIN CAN FEEDBACK AND INFLUENCE THE EXPERIENCE OF THESE. WE'VE ALL HAD PATIENTS, I'M SURE, WHO HAVE TOLD US IT'S HARD TO TELL WHEN THEIR PAIN BEGINS OR ANXIETY BEGINS OR THEIR POST-TRAUMATIC STRESS DISORDER. I'VE CERTAINLY HEARD THAT A LOT, THAT THERE SEEMS TO THIS BE CONFLUENCE AND INTERACTION BETWEEN THE SYMPTOMS. SO TERMING BOTH THE NEUROBUY LODGE CAM NEUROBIOLOGICAL AND PSYCHOSOCIAL MECHANISMS OF THESE BI-DIRECTIONAL INTERACTIONS CAN HELP US DISTINGUISH WHAT ELEMENTS ARE TRULY, IF THEY ARE, INDEPENDENTLY PAIN AND WHAT ARE INDEPENDENTLY THE CO-OCCURRING ISSUES AND THEN HOW THEY INFLUENCE ONE ANOTHER, AGAIN WITH AN END OF DEVELOPING MORE PRECISE AND INTEGRATED APPROACHES TO THE CARE OF OUR PATIENTS. OUR THIRD REMAINING PRIORITY IS UNDERSTANDING THE MECHANISMS OF CHILDHOOD PAIN. I SHOULD MENTION THAT FOR EACH OF OUR PRIORITIES, WE EMPHASIZE THE IMPORTANCE OF STUDYING THE PARTICULAR PRIORITY ACROSS THE LIFESPAN. AND WE CERTAINLY RECOGNIZE THAT FOR THE AGING POPULATION, MID LIFE POPULATION, CHILDHOOD AND ADOLESCENT POPULATIONS. THERE ARE SPECIAL ISSUES. BUT CHILDHOOD CHRONIC PAIN AS WE RECOGNIZE IS IMPORTANT IN MANY WAYS TO OUR UNDERSTANDING OF PAIN. BEYOND THE FACT THAT UNDERSTANDING AND BETTER TREATING CHILDREN WITH PAIN WILL RELIEVE SUFFERING IN THIS POPULATION. BUT CHILDHOOD CHRONIC PAIN DOES CONFER A RISK FOR THE DEVELOPMENT OF ADULT CHRONIC PAIN AS WELL AS THE EVOLUTION OF PSYCHIATRIC DISORDERS IN ADULTHOOD, AND WE KNOW INCREASINGLY HAVING INCREASING EVIDENCE THAT EARLY ADD VER EXPERIENCES CAN ALTER THE NEURAL SYSTEM AND POSSIBLY PREDISPOSE ONE TO THE DEVELOPMENT OF PAIN LATER IN LIFE AS WELL AS CO-MORBID DISORDERS, MOOD DISORDERS, SUBSTANCE USE DISORDERS AND OTHERS. SO CLEARLY FOCUSING ON THIS POPULATION MAY BE VERY HELPFUL FOR US. FOCUS WOULD BE LOOKING AT THE VARIOUS DEVELOPMENTAL STAGES AND ENVIRONMENTAL CONTEXTS, AND HOW -- WHAT THE RISKS ARE FOR THE DEVELOPMENT OF PAIN, AND DIFFERENT POINTS IN DEVELOPMENT. THIS IS SIMILAR WHEN WE LOOK AT THE DEVELOPMENT OF OBESITY, FOR EXAMPLE, WE KNOW THERE ARE DISCRETE TIMES IN CHILDHOOD WHEN A DEVELOPMENT OF OVERWEIGHT CAN LEAD TO OBESITY AS WELL AS OTHER TIMES DURING CHILDHOOD, SO ARE THERE SIMILAR VULNERABILITIES AT DIFFERENT DEVELOPMENTAL STAGES IN THE COURSE OF CHILDHOOD AND ADOLESCENCE, SO LOOKING AT THE NEUROBUY LODGE LO JIK, THE PSYCHOLOGICAL AND SOCIAL ENVIRONMENT, AND CERTAINLY THERE ARE DIVERSE MEASURES THAT NEED TO BE USED IN ORDER TO EXPAND OUR KNOWLEDGE IN THIS AREA. PSYCHOLOGICAL AND FAMILY ENVIRONMENTS, LOOKING AT PHYSIOLOGIC MEASURES OF PAIN AS WE INCREASE OUR DEVELOPMENT OF THEM, GENETIC AND IMMUNE MARKERS, BRAIN IMAGING AND OTHERS, SO BRINGING DIVERSE METHODOLOGIES TO BEAR ON THIS. SO NOT ONLY AIMING TO BETTER ADDRESS CHILDREN'S EXPERIENCE OF PAIN BUT TO TARGET OUR TREATMENTS AT DIFFERENT DEVELOPMENTAL STAGES, AND HOPEFULLY THIS WILL LEAD TO BETTER UNDERSTANDING OF PAIN MECHANISMS ACROSS ALL POPULATIONS. OUR FORT PRIORITY, DETERMINE SAFE AND EFFECTIVE KRON CHRONIC PAIN MANAGE. THAT SOUNDS LIKE THE WHOLE KIT AND KA BOO DELLBOODLE TO ME. BUT WE FOCUS THIS A BIT. THE REALITY IS THAT -- AND WE'VE HEARD A LOT OF THIS OVER THE LAST COUPLE OF DAYS THAT WE WIDELY ACCEPTED THAT MULTIMODAL TREATMENT APPROACHES, THAT USE THE BIOPSYCHOSOCIAL MODEL OF CARE APPEAR TO HAVE THE STRONGEST OUTCOMES IN TREATMENT, AND THAT IS A GOAL. BUT LESS UNDERSTOOD IS THE EFFECT OF INDIVIDUAL INTERVENTIONS THAT WE ARE USING WHEN WE PROVIDE SUCH WRAPAROUND TREATMENT. PARTICULARLY IN CROCK PAIN, CHRONIC PAIN, FOR MANY REASONS, WE HAVE RELATIVELY SHORT OUTCOMES DATA, SO WE HAVEN'T LOOKED AT THE LONGER TERM, IT'S VERY DIFFICULT TO SUPPORT STUDIES OF LONG TERM OUTCOMES, AND WE HAVE THEM ON SPECIFIC INTERVENTIONS. WE DON'T ALWAYS, AS WE MENTIONED BEFORE, CAPTURE THE RESPONSES OF SUBPOPULATIONS, SO WE MAY LOOK AT A LARGE POPULATION AND SAY, THIS IS NOT AN EFFECTIVE TREATMENT, BUT THEN THERE IS A SUBPOPULATION WHO STATISTICALLY WE COULDN'T CAPTURE, WHO ARE POTENT RESPONDERS TO A PARTICULAR INTERVENTION. SO WE IDENTIFIED THE NEED FOR SYSTEMATIC EVALUATION USING A KIE VERSE IT OF TRIALS LOOKING AT PRAGMATIC REAL WORLD STUDIES AND RANDOMIZED CLINICAL TRIALS AND OTHER APPROACHES, LOOKING AT THE LONG TERM EFFECTIVENESS OF BOTH PHARMACOLOGIC INCLUDING OPIOIDS AND NON-OPIOIDS AS WELL AS NON-PHARMACOLOGIC THERAPIES, AND LOOKING AT THESE ALONE AND IN SPECIFIC COMBINATIONS TRYING TO GET AT THE COMPLEMENTARITY OF MANY OF OUR TREATMENTS. THEN LOOKING TO DETERMINE MECHANISMS OF THERAPEUTIC AND NON-THERAPEUTIC EFFECTS. THE FINAL STRATEGY IS DETERMINING THE OPTIMAL USE OF SELF MANAGEMENT STRATEGIES FOR CHRONIC PAIN, AND I THINK MANY OF US BELIEVE AND I THINK THERE IS EVIDENCE TO SUPPORT IT THAT LIKE OTHER CHRONIC CONDITIONS, WHETHER THEY'RE ASTHMA, DIABETES, HYPERTENSION, CARDIOVASCULAR DISEASE, ONE OF THE KEY COMPONENTS TO LONG TER EFFECTIVE CARE ACCEPT CARE IS ENQAIJING TH E PATIENT IN AN ACTIVE AND INFORMED ROLE IN SELF MANAGEMENT. SO IT'S WIDELY DIRECTED AS A COMPONENT OF CARE BUT THERE ARE A LOT OF QUESTIONS STILL OPEN. WHAT IS THE EFFECTIVENESS AND THE EFFICACY OF FARIOUS VARIOUS DIVERSE STRATEGIES? THERE ARE MANY THINGS PATIENTS CAN DO TO SELF MANAGE FROM MOVEMENT THERAPIES TO CALMING RELAXATION THERAPIES TO HERBAL TREATMENTS, SOUND, PRESSURE, OTHER SELF IMPLEMENTED MODALITIES, SO SETTING EACH OF THESE AND FINDING IN WHAT COMBINATIONS THEY'RE EFFECTIVE, WHAT'S THE DOSING OF SPECIFIC TREATMENTS? I'M WORKING IN ASSOCIATION WITH A PROGRAM WHERE WE IMMERSE PEOPLE IN CBT ACT MINDFUL NUSS MET TAITION, YOGA, DAITION, MEDITATION, FOR FOUR WEEKS. I RECENTLY HEARD A PRESENTATION OF THREE HOURS SINGLE DOSE INTERVENTION OF ACT THAT HAD VERY SIMILAR OUTCOMES IN PEOPLE WITH CHRONIC PAIN. SO WHAT'S THE RIGHT COMBINATION, AND WHAT IS THE INTENSITY THAT WE NEED TO PROVIDE. IT MAY BE DIFFERENT FOR DIFFERENT POPULATIONS, OF COURSE, BUT -- AND THEN THE SYSTEMS ISSUES OF ENGAGING OUR PATIENTS AS WE HEARD I THINK YESTERDAY, MAYBE MAKING IT AUTOMATIC BEHAVIOR THAT ONE DOES SELF CARE, STRATEGIC SELF CARE. WHAT ARE COST-EFFECTIVE AND SUSTAINABLE DELIVERIES IS DELIVERY SYSTEMS , AND HOW CAN WE CREATE MEDICAL OR HEALTHCARE CULTURES IN WHICH PATIENTS ARE REAL PARTNERS AND THERE'S PATIENT-CENTERED -- WHERE THERE'S SHARED AT THE SITION MAKING AND SELF MANAGEMENT IS VIEWED BY ALL CARE PROVIDERS AS A CRITICAL COMPONENT OF CHRONIC PAIN MANAGEMENT AND CHRONIC ILLNESS MANAGEMENT. SO I'LL STOP THERE, I'M HAPPY TO TAKE QUESTIONS BUT I THINK WE'RE ON A ROLL OF AS A GROUP TAKING THEM LATER SO WE SHOULD PROBABLY MOVE ON UNLESS THERE'S A BURNING QUESTION. >> HELLO. YOU ARE STILL AWAKE OUT THERE? OKAY. SO I'M CHERYL STUCKY. I USUALLY TELL THE MEDICAL STUDENTS THAT I TEACH THAT MY NAME RHYMES WITH COOKIE, I MAKE GREAT CHOCOLATE CHIP COOKIES. SO JUST TO WAKE YOU UP, I AM A PROFESSOR AT THE MEDICAL COLLEGE OF WISCONSIN, SI WITH IN WHICH IS IN MILWAUKEE, NOT MAD SOB, AND I RUN A BASIC SCIENCE RESEARCH LAB LOOKING AT MECHANISMS THAT DRIVE ACUTE AND CHRONIC PAIN. I THINK THE REASON I MIGHT HAVE BEEN SELECTED FOR WORKING WITH THIS GROUP IS I HAVE DONE A LITTLE RESEARCH WORKING ON SICKLE CELL DISEASE WHICH AFFECTS A LOT OF AFRICAN-AMERICANS, ALSO WORKING ON SOME AGING AND PAIN. I WANT TO FIRST OF ALL THANK MY AMAZING AND TALENTED CO-CHAIR, ROGER FILLINGIM, AND BROKE OUR GROUP REALLY INTO SEVERAL SUBGROUPS, FIVE IN PARTICULAR, WHERE THERE ARE FIVE DIFFERENT DISPARATE GROUPS THAT WE IDENTIFIED THAT WE THINK MEET SPECIFIC AND SPECIAL ATTENTION SO FOR AGING ADULTS, WE HAD CARY REID, FOR RACE AND ETHNICITY, ADAM HIRSH, FOB SEX AND GENDER, LISA BEGG, FOR PEDIATRICS, LINDSAY COHEN, AND FOR SOCIOECONOMIC STATUS, WE HAD JAMES JACKSON AT THE LEAD. SO WHAT IS REALLY THE PROBLEM HERE AND WHY DID DISPARITIES GUESS GET CHOSEN AS A GROUP TO I HIGHLIGHT? BECAUSE THERE ARE ACTUALLY MAJOR AGE, SEX, GENDER, RACIAL AND ETHNIC, AND SOCIOECONOMIC GROUP DIFFERENCES IN THE DEVELOPMENT OF PAIN, AND ALSO THE PERSISTENCE OF PAIN CONDITIONS ACROSS THE LIFESPAN. SOME HAVE BEEN UNDERSTUDIED, AT WORST, SOME HAVE NOT BEEN STUDIED AT ALL. FOR EXAMPLE, SOCIOECONOMIC STATUS AND CHRONIC PAIN HAS RECEIVED FAIRLY LITTLE ATTENTION ATTENTION. SO WHAT ARE THE GROUPS WE'RE INTERESTED IN? SO FIRST OF ALL, SEX AND GENDER. NOW WE ALL KNOW THERE'S GROWING EVIDENCE THAT THERE ARE DIFFERENCES BETWEEN THE GENDERS AND SEXES AND THE AMOUNT AND INDENSE TENS IT ININTENSITY OF CHRONIC PAIN. WE KNOW FEMALES ON AVERAGE HAVE MORE CHRONIC PAIN PARTICULARLY FOR CERTAIN CONDITIONS. 'S WE HAVE BEGUN ELUCIDATING SOME OF THE MOLECULAR AND CELLULAR MECHANISMS UNDERLYING SOME OF THOSE DIFFERENCES BUT WE'RE JUST AT THE BEGINNING OF THE CURVE OF THAT TRAJECTORY. WE ALSO KNOW THERE'S A DIFFERENCE IN PAIN ACROSS THE LIFESPAN. WE KNOW THAT AS WE AGE, AND MANY OF US ARE STARTING TO FEEL THIS ACUTELY AND APPARENTLY, THAT WE FEEL MORE PAIN. AND YET AWJ POPULATIONS, WE HAVE LITTLE EVIDENCE, EMPIRICAL EVIDENCE OF THE MOLECULAR, CELLULAR, PSYCHOLOGICAL, SOCIAL FACTORS THAT AFFECT THE DEVELOPMENT OF THAT PAIN IN AGED POPULATIONS. THERE'S VERY LITTLE RESEARCH, BASIC RESEARCH ON AGE SUBJECTS, IN PART BECAUSE IT'S EXTREMELY EXPENSIVE TO HOUSE THESE ANIMALS OR TO BUY AGED ANIMALS. WE ALSO KNOW AT THE OTHER END OF THE AGING SPECTRUM, THE YOUNG AGE, VERY FEW CHILDREN ARE INCLUDED IN CLINICAL TRIALS. AND THERE'S ACTUALLY VERY LITTLE BASE UK RESEARCH BASIC RESEARCH ON PAIN MEMO NIRKS IN YOUNG KIDS OR SUBJECTS. THE OTHER ASPECT IS FOR PAIN TREATMENTS IN KID, HOW DO THOSE PAIN TREATMENTS AFFECT THIS DEVELOPING NERVOUS SYSTEM THAT GOES FORWARD AND CONTINUES TO DEVELOP? THERE'S VERY LITTLE UNDERSTANDING OF HOW THAT DEVELOPING NERVOUS SYSTEM IS AFFECTED BY PAIN TREATMENTS OR ANY OTHER PHARMACOLOGICAL TREATMENT. THEN THERE'S THE WHOLE ISSUE OF ETHNICITY AND RACIAL DIFFERENCES DIFFERENCES. WE KNOW CERTAIN TYPES OF CHRONIC PAIN AFFECT CERTAIN ETHNIC OR RACIAL GROUPS. SICKLE CELL DISEASE, 1 IN 400 AFRICAN-AMERICANS WILL BE BORN WITH SEVERE SICKLE CELL DISEASE. A FAIRLY HIGH PORTION OF HISPANIC PEOPLE WILL BE -- WILL SUF FRER SICKLE CELL DISEASE. BUT WE KNOW VERY LITTLE ABOUT THE DIRVESES IN THESE DIFFERENCES IN THESE ETHNIC GROUPS. SO WHILE RACIAL AND ET NIRK GROUPS ARE INCLUDED IN CLINICAL TRIALS, THERE ARE NOT SPECIFIC TRIALS OR SPECIFIC STUDIES THAT INVESTIGATE RACIAL OR ETHNIC-SPECIFIC TYPES OF PAIN DISORDERS. AND THEN THERE'S THE PIGGY BANK IN THE LIVING ROOM, RIGHT? THERE'S THE HAVES AND THE HAVE-NOTS. WE KNOW VERY LITTLE ABOUT HOW THESE DIFFERENT SOCIOECONOMIC GROUPS DEAL WITH CHRONIC PAIN. BUT WE DO KNOW IS THE HAVE-NOTS HAVE POORER ACCESS TO RESOURCES AS WE WOULD GUESS. THEY HAVE POORER HEALTH AND THEY HAVE POORER PAIN OUTCOMES. BUT WE KNOW VERY LITTLE TO ANYTHING ABOUT THE MECHANISMS THAT UNDERLIE THOSE DIFFERENCES. SO WHETHER AND HOW THE CHARACTERISTICS AND PATIENT PREFERENCES, BECAUSE THESE DIFFERENT GROUPS MAY HAVE DIFFERENT PREFERRED TYPES OF TREATMENTS, HOW DO THEY INFLUENCE THE SUSCEPTIBILITY TO CHRONIC PAIN, HOW DO THEY BENEFIT FROM THE TREATMENTS, AND THE RISKS, ALL OF THAT IS UNKNOWN. SO OUR GOAL WITH THIS GROUP, ULTIMATELY, IS TO DEVELOP PERSONALIZED MEDICINE FOR PAIN. SO I'D NEXT LIKE TO TALK ABOUT THE RECOMMENDATIONS FROM THE DISPARITIES GROUP. WHAT DO WE SUGGEST THAT WE DO? WE HAVE NINE RECOMMENDATIONS AND I'LL JUST BRIEFLY GO OVER THOSE NOW AND HIGHLIGHT I THINK SOME THE OF THE KEY FACTORS. THE NUMBER ONE RECOMMENDATION FIRST IS TO BETTER DEFINE THE EPIDEMIOLOGY OF PAIN IN DISPARATE POPULATIONS. SO WHO GETS PAIN, HOW, AND IT'S THE STUDY OF INDIVIDUALS THAT GET PAIN. WE WANT TO INCLUDE KIDS, WOMEN VERSUS MEN, RACIAL AND ETHNIC GROUPS, OLDER ADULTS, AND THE SOCIOECONOMICALLY DISADVANTAGED PEOPLE. SO WHAT IS THE PREF LARYNX PREVALENCE, INCIDENCE, IMPACT OF PAIN, PATTERNS OF TREATMENT AND RISK FACTORS THAT PREDISPOSE DISPARATE POPULATIONS TO PAIN OR, AS DR. DWARK INSAID, THAT PROTECT OR GIVE RESILIENCE TO CERTAIN -- HELP THEM RECOVER FROM ACUTE PAIN. WE NEED TO UNDERSTAND THE SINGLE TYPES OF PAIN CONDITIONS AND OVERLAPPING, CO-MORBID TYPES OF PAIN. WE NEED TO UNDERSTAND THE CONSEQUENCES OF PAIN, BUT ALSO THE CONSEQUENCES OF THE -- AND THE EFFECTIVENESS OF SPECIFIC TYPES OF TREATMENTS FOR PAIN. THEN AS HAS BEEN MENTIONED SEVERAL TIMES, WE NEED TO UNDERSTAND AND STUDY DO LONGITUDINAL INVESTIGATIONS OVER THE LIFESPAN OF THE INDIVIDUAL AND STOP DOING THE STUDIES JUST ON 8 WEEK OLD MICE, FOR EXAMPLE, OR 8 TO 12 WEEK OLD MICE. WE NEED TO BE LOOKING AND CONSCIENTIOUS OF THE LIFESPAN. THE CHRONIC PAIN MECHANISMS MAY DIFFER WIDELY ACROSS THE LIFESPAN. SO WHAT ARE THE FACTORS THAT INCREASED RISK FOR PAIN OR INCREASED RESILIENCE TO CHRONIC PAIN? THEY INCLUDE CLINICAL, GENETIC, PSYCHOLOGICAL, METABOLIC, LIFESTYLE, AND ENVIRONMENTAL FACTORS. AMONG OTHERS. SO THE SECOND RECOMMENDATION IS TO DETERMINE POPULATION GROUP DIFFERENCES FOR OUTCOMES OF PAIN TREATMENTS FOR CHILDREN, WOMEN VERSUS MEN, SPECIFIC RACIAL AND ETHNIC GROUPS, OLDER ADUMENTS AND SOCIOECONOMICALLY DISADVANTAGED PEOPLE. WE NEED TO DETERMINE THE APPROPRIATE ASSESSMENT AND PERSONALIZED TREATMENT. WE NEED TO TERM WHETHER THE SAFETY, THE EFFICACY, THE COMPARATIVE EFFECTIVENESS OF ALREADY EXISTING PAIN& TREATMENTS, AND EMERGING PHARMACOTHERAPIES FOR ACUTE AND CHRONIC PAIN, WHERE THEY DIFFER ACROSS THESE DISPARATE POPULATIONS. WE ALSO KNOW THAT POPULATION GROUP DIFFERENCES WILL LIKELY DIFFER IN RESPOPSES TO RESPONSES TO THE NON-PHARMACOLOGICAL THERAPIES, SO FOR THAT, WE NEED TO DETERMINE LONG TERM SAFETY BENEFITS AND APPROACHES TO THESE NON-PHARMACOLOGICAL TREATMENTS, AND WE NEED TREATMENTS THAT CAN BE IMPLEMENTED AND DISSEMINATED WIDELY, PARTICULARLY WHEN YOU'RE THINKING ABOUT THE SOCIOECONOMIC GROUPS AND LOW STATUS GROUPS THAT NEED ACCESS TO THIS TYPE OF HEALTHCARE. THE THIRD RECOMMENDATION IS TO INVESTIGATE THE BIOLOGICAL, PSYCHOLOGICAL, AND SOCIAL MECHANISMS THAT CONTRIBUTE TO POPULATION GROUP DIFFERENCES IN CHRONIC PAIN. SO WE KNOW THE MURDER OF CHRONIC PAIN IS UNEQUALLY DISTRIBUTED ACROSS THE POPULATION. WE KNOW AGED PEOPLE SUFFER MORE CHRONIC PAIN, WE KNOW AFRICAN-AMERICANS HAVE A LIAR LIKELIHOOD SUFFERING FROM SICKLE CELL DISEASE. THERE'S AN URGENT NEED TO UNDERSTAND THE PIE BIOLOGICAL, PSYCH PSYCHOLOGICAL AND SOCIAL FACTORS THAT DRIVE THE DEVELOPMENT OF CHRONIC PAIN IN THESE POPULATION GROUPS. AN WE HAVE TO REMEMBER THAT EACH OF THESE FACTORS AGAIN WILL CHANGE OVER THE LIFESPAN OF THE INDIVIDUAL, SO IT'S SO VERY IMPORTANT TO THINK ABOUT THE ENTIRE LONGITUDINAL LIFESPAN WITH THESE TYPES OF STUDIES. AGAIN, WE NEED BASIC SCIENCE STUDIES, ALL THE WAY UP THROUGH THE CLINICAL STUDIES. WE NEED THE BASIC SCIENCE STUDIES, AND ALL THE WAY UP TO THE CLINICAL STUDIES. AND THIS SAYS HUMAN CLINICAL TRIALS START IN SIX MONTHS, BUT SOONER IF WE RUN OUT OF MICE. THE FOURTH IS TO IDENTIFY DEVELOPMENTAL PERIODS AND LIFE STAGES THAT CONFER RISK FOR OR PROTECTION AGAINST PAIN CONDITIONS. SO EXPOSURES TO NEGATIVE OR POSITIVE EVENTS IN ONE DEVELOPMENTAL PERIOD COULD HAVE NEGATIVE OR POSITIVE IMPACTS ON OTHER LIFE PERIODS. FOR EXAMPLE, A LOW SOCIOECONOMIC STATUS FOR A KID GROWING UP IN A POOR ENVIRONMENT WILL DECREASE ON AVERAGE THEIR PSYCHOLOGICAL AND THEIR PHYSICAL FUNCTIONING. AND THAT WILL ON AVERAGE LEAD TO INCREASED MORTALITY IN ADULTHOOD. SO DO THE EVENTS IN ONE DEVELOPMENTAL TIME PERIOD, STRESS OR ABUSE IN CHILDHOOD, DOES THAT PREDISPOSE THAT INDIVIDUAL TO PAIN OR RISK OF PAIN WHEN THEY'RE ADULTS OR AGED? ON THE FLIP SIDE, IF A CHILD GROWS UP IN A LOW SOCIOECONOMIC FAMILY BUT HAS A VERY STRONG, HEALTHY PARENT FIGURE, WILL THEY BE RESILIENT TO DEVELOPING CHRONIC PAIN IN LATER LIFE? THE FIFTH RECOMMENDATION SO TO CHARACTERIZE WITHIN GROUP VARIABILITY, SO WITHIN EACH ONE OF THESE FIVE SEPARATE GROUPS IN THE SPEERPS EXPERIENCE OF PAIN. SO RESEARCH DOCUMENTS THAT THERE ARE SIGNIFICANT WITHIN GROUP DIFFERENCES IN THE EXPERIENCE OF PAIN ACROSS AGE, SO WITHIN THE AGE, WITHIN GENDER, RACIAL AND ETHNIC AND SOCIOECONOMIC CATEGORIES. SO JUST TO IN A IF FUNNY WAY ILLUSTRATE WITHIN GROUP VARIABILITY, WE ALL KNOW THAT VULCAN ARE AT LEAST TWICE AS INTELLIGENT ON THE IQ SCALE AS HUMANS, BUT BECAUSE OF THE SPREAD AND WITHIN GROUP VARIABILITY, WE ALSO KNOW THAT SOME OF THESE VULCANS ARE ACTUALLY DUMBER THAN THE AVERAGE HUMAN, AND SOME OF THE HUMANS ARE ACTUALLY SMARTER THAN THE AVERAGE VULCANS. PERHAPS THOSE LEADERS OF OUR GROUP LIKE LINDA AND ALLAN. SO WE JUST HAVE HOMER SYSTEM& HERE HAVING A GUT REACTION IS HOW I E. THINKS, HE THINKS, USING HIS AUTONOMIC SYSTEM AND WE HAVE MR. SPOCK USING CONSCIOUS REFLECTION. SWOA NEED RESEARCH TO ELUCIDATE THIS WITHIN GROUP VARIABILITY IN THE EXPERIENCE OF PAIN IN BIOLOGICAL, PSYCHOLOGICAL AND SOCIAL FACTORS THIS, BASIC SCIENCE THROUGH CLINICAL RESEARCH. WHAT ARE THE RISK FACTORS AND WHAT ARE THE PROTECTIVE FACTORS WITHIN THESE DISPARATE GROUPS. OUR SIXTH RECOMMENDATION IS TO EVALUATE THE IMPACT AND THE LONG TERM CONSEQUENCES OF PHARMACOLOGICAL INTERVENTIONS FOR PAIN ACROSS THE LIFESPAN, AND SPECIFICALLY TO UNDERSTAND THE EFFECT OF THESE TREATMENTS ON THE DEVELOPING NERVOUS SYSTEM? INFANTS AND IN CHILDREN. THERE'S ACTUALLY LITTLE KNOWN ABOUT HOW PAIN TREATMENTS VARY IN EFFICACY ACROSS THE LIFESPAN. FEW STUDIES HAVE DOCUMENTED THE EFFICACY AND THE ADVERSE EFFECTS OF PHARMACOLOGICAL APPROACHES FOR PAIN IN INFANTS, CHILDREN AND ADOLESCENTS, SO VERY, VER IMPORTANT TO UNDERSTAND THIS. FORTUNATELY, LITTLE IS KNOWN ON THE PHARMICOLOGICAL TREATMENTS ON THE DEVELOPING NERVOUS SYSTEM. VERY FEW STUDIES HAVE DONE ANYTHING ON THIS AREA. SO WE SUGGEST THAT WE CONDUCT EYE QUALITY STU DISIS ON INDIVIDUAL AND MULTIMODAL PAIN TREATMENTS WITH LONG TERM FOLLOW-UP ACROSS THE LIFESPAN. SEVEN, HOW DO THE EFFECTIVE AND MOTIVATIONAL COMPONENTS OF PAIN CONTRIBUTE TO THE OVERALL PAIN EXPERIENCE AND FUNCTIONAL OUTCOMES IN DISPARATE POPULATION. SO MOST RESEARCH TODAY FOCUSES ON THE SENSORY DISKRIM NATIVE ASPECTS OF PAIN, THAT IS THE ACTIVATION OF NOCICEPTORS, THE FEEDING OF THAT INFORMATION AND IMPULSES INTO PAIN PATHWAYS GOING ON UP TO THE CORTEX, BUT WE, IN FACT, KNOW THAT PAIN IS INSTEAD A HIGHLY COMPLEX, AHIGHLY INDIVIDUAL EXPERIENCE, HIGHLY SUBJECTIVE, A PERCEPTIONAL PHENOMENON. IT IS AFFECTED BY OUR MOTIVATION, OUR EMOTIONS, OUR EMPATHY, OUR FEAR, OUR RELIEF FROM PAIN, OUR RELIEF FROM SOCIAL SETTINGS OR SOCIAL EXPERIENCES, OUR PAST EXPERIENCES, OUR ETHNIC CULTURE, SOCIAL SETTINGS AND VARIOUS ENVIRONMENTAL FAK FORS. AND SO THESE AFFECTIVE AND MOTIVATIONAL DIMENSIONS OF PAIN ARE REALLY WHAT BE UNDER LIE THE PERCEIVED UNPLEASANT NESES OF THE PAINFUL EVENT, AND THEY'RE PROCESSED IN QUITE SPECIALIZED AREAS OF THE BRAIN. SO ARE THOSE AFFECTIVE AND MOTIVATIONAL DIMENSIONS, ARE THEY ESPECIALLY INFLUENTIAL IN DISPARATE POPULATIONS? WE DON'T KNOW THAT BUT I THINK WE SHOULD FIND THAT OUT. AGAIN, THE AFFECTIVE AND MOTIVATIONAL ASPECTS THAT UNDERLIE THE UNPLEASANTNESS, LIKE WITH COGNITION, THE ATTENTION, THE DISTRACTION, THE HYPERVEG LENS, THE CATASTROPHIZING, THEY DEPEND ON CONTEXT. PAST EXPERIENCES. WHAT KIND OF TRAUMATIC EXPERIENCES HAVE WE ENCOUNTERED IN OUR LIFE AND HOW ARE THEY DEALT WITH? OUR EXPECTATIONS OF PAIN OR PAIN RELIEF, OUR SOCIAL EXPERIENCE WE EXPERIENCE PAIN IN. WHAT ARE THE CULTURAL BELIEFS AND CULTURAL NORMS AND THE EXPECTATIONS OF CULTURE AND HOW WE HANDLE PAIN. WHAT ABOUT OUR MOOD, HOW DOES DEPRESSION, ANXIETY, WHICH IS SO CO-MORBID WITH SO MANY DIFFERENT TYPES OF CHRONIC PAIN, HOW DOES THAT ACTUALLY AFFECT PAIN? OUR WORRIES. FOR EXAMPLE, PEOPLE WITH SOCIO -- IN LOW LOWER SOCIOECONOMIC STATUS SITUATIONS, THEY WOULD LIKELY HAVE A LOT MORE WORRIES THAN THOSE OF US IN HIGHER SOCIOECONOMIC STATUS AREAS, THEY'D HAVE WORRIES MONEY, HEALTHCARE, HOW ARE WE GOING TO HAVE A JOB, FEED THE KIDS. THOSE ARE LIKELY TO AFFECT THE OUTCOMES PAIN, THE FEAR, THE EMPATHY, THE RELIEF, THE ENVIRONMENT. DO WE HAVE ACCESS TO A LOT OF MONEY, ENOUGH MONEY OR NOT ENOUGH MONEY? TO WE HAVE ACCESSES TO HEALTHCARE, APPROPRIATE FOOD, A GOOD DIET, OR DO WE GET EXPOSED TO SECONDHAND SMOKE IN THE SECOND TO LAST, THE EIGHTH ONE, THIS HAS RECEIVED THE MOST ATTENTION SO FAR, THERE IS EVIDENCE NOW THAT REVEALS SEX DIFFERENCES AND PAIN RESPONSES AT THE MOLECULAR AND CELLULAR LEVEL. CHANGES IN HORMONES, ESTROGEN AND TESTOSTERONE, THOSE CHANGES OCCUR OVER THE COURSE OF THE LIFESPAN, BUT STILL SEX SPECIFIC MECHANISMS HAVE RECEIVED RELATIVELY LITTLE EMPIRICAL ATTENTION. AND THEY MAY DIFFER AT SPECIFIC LIFE STAGES. SO THOSE MECHANISMS MAY BE QUITE DIFFERENT IN A FEMALE CHILD THAN IN THE PREPUBESCENT ADOLESCENT THAN THE POST ADOLESCENT, AND THE ADULT. AND THE PRE OR POST POST-MENOPAUSAL WOMAN. THEY MAY DIFFER WITHIN ETHNIC GROUP, AGE, AND SOCIOECONOMIC STATUS. SO THIS IS JUST THE GUY SAYS MY BRAIN IS BIGGER THAN YOURS AND SHE SAYS DON'T BE AN IDIOT, DARLING. SO WE NEED TO NOT BE NAIVELY IDIOTS ABOUT IGNORING THESE DIFFERENCES. WE MUST TAKE INTO ACCOUNT THESE DIFFERENCES. LAST ONE, ADVANCED KNOWLEDGE OF THE RELATIONSHIP BETWEEN SOCIOECONOMIC AND PAIN. SOCIAL AND ECONOMIC FACTORS LIKE LACK OF INCOME, LACK OF WEALTH, OCCUPATIONAL RISKS, HAVING A BLUE COLLAR JOB WHERE YOU'RE CLIMBING LADDERS, ON YOUR BACK, LIFTING HEAVY LOADS DAY IN AND DAY OUT LIKELY WILL AFFECT YOUR DEVELOPMENT OF CHRONIC PAIN. EXPOSURES TO DIFFERENT ENVIRONMENTAL TOXINS, THE LIFESTYLE YOU LEAD, LOW EDUCATIONAL ATTAINMENT, AND ALL OF THESE RAILROAD FUNDAMENTAL CAUSES OF POOR HEALTH, FOR EXAMPLE, A PERSON WHO CANNOT AFFORD TO HAVE GOOD SHOES OR CHANGE THEIR SHOES OFTEN HAS POOR SOLES, IS LIKELY TO HAVE MORE ISSUES WITH FOOT PAIN, KNEE PAIN, BACK PAIN, THAN A PERSON WHO HAS ACCESS TO VERY GOOD QUALITY SHOES. SO DETERMINE THE EXTENT TO WHICH THESE FACTORS DRIVE ETHNIC DIFFERENCES IN PAIN AND ELUCIDATE THE BIOPSYCHOSOCIAL MECHANISMS THAT INFLUENCE THE DEVELOPMENT AND THE PROGRESSION OF PAIN AND RESPONSES TO TREATMENT. SO WITH THAT, WE HOPE THAT CLINICAL SCIENCE AND RESEARCH WILL ELUCIDATE THE MECHANISMS, BIOLOGICAL, IN THESE DISPARATE GROUPS, WE WILL THEN BE ABLE TO EDUCATE OUR RESEARCHERS AND OUR PHYSICIANS AND OUR PUBLIC TO BETTER PAIN TREATMENT AND ELIMINATE THE UNCONSCIOUS BIAS AGAINST THESE DISPARITIES. AND WITH THAT, I'D LIKE TO THANK YOU FOR LISTENING. [APPLAUSE] >> THANKS VERY MUCH FOR THE PRESENTATIONS. TIM HAD TO CATCH A PLANE SO WE'LL HAVE TO COVER FOR HIM IF QUESTIONS COME IN ON THE ACUTE PAIN GROUP. SO LET'S OPEN UP FIRST TO THE AUDIENCE FOR QUESTIONS, WE'VE RECEIVED A FEW QUESTIONS ALSO THROUGH OUR EMAIL BOX, AND SO I'LL PRESENT THEM TO THE GROUP AS WE GO THROUGH THIS SESSION. BUT PLEASE GO AHEAD. IF EVERYBODY AS YOU ASK YOUR QUESTIONS COULD INTRODUCE YOURSELVES, THAT WOULD BE GREAT. CORE WE GET THE FLOOR -- THE HALL MICS ON, PLEASE? THERE IT IS. >> BARB, NURSE PRACTITIONER, AND ASSISTANT PROFESSOR AT THE UNIVERSITY OF IOWA. I HAD A QUESTION THAT ACTUALLY WOULD APPLY TO CHRONIC PAIN AND DISPARITIES. YOU COVERED VERY WELL ACROSS THE LIFE PAN AND REFERRED TO LIFESPAN AND REFERRED TO THE CONTINUUM OF CARE WITH DOCUMENTATION, BUT WHAT I WAS WONDERING ABOUT WAS TAKING THE PATIENT THROUGH THE TRANSITIONS OF THE CONTINUUM OF CARE. SO BOTH FOR CHRONIC PAIN AND FOR DISPARITIES, HOW ARE THEY TRANSITIONING BETWEEN OUTPATIENT AND INPATIENT OR NURSING FACILITIES AND INPATIENT, AND GOING BACK AND FORTH? SO THAT'S ONE ASPECT THAT I THOUGHT WOULD BE IMPORTANT TO COVER. THE OTHER IS WE'VE -- I'VE SEEN THE TERM PATIENT CENTRIC AND PATIENT-CENTERED, BUT I THOUGHT A GOOD RESEARCH QUESTION WOULD BE, WHAT IS THE IMPACT OF PARTNERING WITH THE PATIENT ON OUTCOMES? >> I THINK THOSE ARE BOTH VERY IMPORTANT QUESTIONS, COMMENTS. I THINK THIS ISSUE OF TRANSITION TRANSITIONS IS PARTICULARLY IMPORTANT BECAUSE WE KNOW THOSE ARE THE GAPS WHERE WE OFTEN FAIL PATIENTS AND THERE'S A RE-EMERGENCE OF SYMPTOMS. I THINK THE EMPHASIS AND THE PLACE TO REALLY ADDRESS IT IN TERMS OF RESEARCH QUESTIONS IS ON THE CROSS CUTTING PRIORITY OF MODELS OF CARE. WE NEED TO DEVELOP BETTER PRIMARY CARE SPECIALTY RELATIONSHIPS, SURGEON TO PAIN CLINIC RELATIONSHIPS, AND YOU KNOW, WHETHER SHARED MEDICAL RECORDS GO A LONG WAY TO HELPING WITH THAT, SHARED PROTOCOLS AND DIFFERENT CLINICAL SITUATIONS CAN BE VERY HELPFUL. I AGREE IT NEEDS TO BE ADDRESSED. I THINK THE QUESTION NEEDS TO BE NARROWED SOME, THANK YOU FOR BRINGING IT UP, I DO THINK IT NEEDS ATTENTION. >> THE QUESTION WAS ABOUT PARTNERING WITH PATIENTS, AND TO DETERMINE WHAT THE OUTCOMES ARE WHEN YOU ACTUALLY PARTNER WITH YOUR PATIENTS. >> PARTNERING IN TERMS OF -- I HOPE THAT'S A GOAL OF ALL CARE. >> ENGAGING THE PATIENT IN DECISION-MAKING, DEVELOPING THE TREATMENT PLAN. >> THAT WAS SOMETHING WE ACTUALLY TRIED TO SPECIFY IN OUR -- TALKING ABOUT CHANGING THE CULTURE OF MEDICINE IN TERMS OF SELF MANAGEMENT, THE SHARED DECISION-MAKING WAS SPECIFIED AND ALSO WE DIDN'T USE THE TERM PARTNERING BUT I THINK IT'S A REALLY IMPORTANT CONCEPT, AND -- >> THANK YOU. >> JUST A COMMENT ON THE TRANSITIONING IN AND OUT OF PHASES ON HEALTHCARE ON ONE EXAMPLE, I THINK WE ACTUALLY NEED TO EDUCATE THE CAREGIVERS TO SOME OF THE CHALLENGES THAT CERTAIN DISPARATE PROP LAITIONS POPULATION S HAVE TO DEAL WITH, FOR EXAMPLE, MOMS OF KIDS THAT HAVE SICKLE CELL DISEASE, OFTEN THE PATIENT IS NON- -- IF THE KID IS NONCOMPLIANT, IF THEY DON'T SHOW UP, BUT THERE'S A LACK OF UNDERSTANDING OFTEN, THAT THE REASON THEY'RE NOT SHOWING UP IS THE MOM HAS FIVE KIDS UNDER THE AGE OF A AND HAS 5 AND CAN'T AFFORD CARE SO SHE CAN'T LEAVE THE OTHER FOUR KIDS HOME TO BRING THE KID WITH SICKLE CELL DISEASE TO THE CLINIC, SO EVEN JUST GREATER UNDERSTANDING OF WHAT THEIR ECONOMIC AND SOCIAL SITUATION IS IS. >> HI. I'M LIN DE BAR AT THE KAISER CENTER FOR HEALTH RESEARCH IN PORTLAND, OREGON. FIRST JU THANK YOU, THAT WAS -- IT'S CLEAR A LOT OF WORK WENT INTO THIS AND THOSE WERE GREAT PRESENTATIONS. MY QUESTION REALLY IS I THINK FOR EVERYBODY IN THE PANEL AND LINDA HAD MENTIONED THAT ONE OF THE CROSS CUTTING THEMES WAS PAIN RESEARCH NETWORK AND ALSO HAD MENTIONED THAT THAT MIGHT BE A WAY TO FA STILL TATE BOTH CLINICAL AND PRE-CLINICAL WORK. I JUST WAS INTERESTED IN PEOPLE'S REFLECTIONS ON HOW YOU SEE SOMETHING LIKE THAT FACILITATING THE KIND OF RESEARCH PRIORITIES THAT YOU WERE POSING, HOW IT COULD BE STRUCTURED, WHAT COULD WORK THROUGH THAT KIND OF PROCESS, SO JUST MORE GENERALLY YOUR REFLECTIONS ON THAT AS ONE MECHANISM TO PROMOTE THIS RESEARCH. >> I'M VERY INTERESTED IN CLINICAL TRIALS SO WHEN I THINK ABOUT THIS KIND OF THING, I THINK ABOUT NETWORKS OF SITES THAT CONDUCT CLINICAL TRIALS AND THERE'S A VERY LONG AND DISTINGUISHED HISTORY OF THAT, BOTH IN ONCOLOGY AND IN NEUROLOGY, AND NEUROLOGY, FOR EXAMPLE, THE PARKINSON'S STUDY GROUP, THE HUNTINGTON'S DISEASE STUDY GROUP AND ONCOLOGY AS I THINK EVERYONE HERE KNOWS, THE COOPERATIVE AND COLLABORATIVE ONCOLOGY GROUPS AROUND THE COUNTRY, AND WE HAVE ABSOLUTELY NOTHING LIKE THAT FOR PAIN. THAT WOULD FACILITATE THE CONDUCT OF CLINICAL TRIALS. I WON'T SPEAK TO THE OTHER KINDS OF NETWORKS THAT YOU COULD HAVE THAT WOULD ENCOURAGE OBSERVATIONAL STUDIES OR PRE-CLINICAL STUDIES, BUT CERTAINLY WE HAVE NOTHING FOR CLINICAL TRIALS AND IN OTHER THERAPEUTIC AREAS, THEY'VE BEEN OF IMMENSE VALUE. >> THE OTHER THOUGHT WAS LARGE SHARED DATABASES IN NATURAL CLIB CAL SET THATION WEREN'T NECESSARILY SET UP TO BE RESEARCH NETWORK BUT IF WE USE THE SAME DATA COLLECTION AND HAVE SHARED OUTCOMES AND INTALK AND OUTCOMES DATA, AT MANY, MANY DIFFERENT MEDICAL CENTERS ACROSS THE COUNTRY AND SHARED MEDICAL RECORDS, YOU COULD REALLY ASK QUESTIONS LATER ON AND DO RETRO RETROSPECTIVE STUDIES ON A MUCH DIFFERENT SCALE THAN WE'RE DOING THEM NOW. I THINK AN EXAMPLE THAT'S EMERGING, ACQUIRED DATABASES, ONE WOULD BE AN EXAMPLE THAT HAS THE POTENTIAL TO BE USED IN THAT WAY. >> THIS IS A GREAT SET OF PRESENTATIONS AND A VERY WELL CONSIDERED APPROACH TO RESEARCH STRATEGY. ONE OF THE THINGS I'M WONDERING ABOUT IS THAT I THINK THE FUND MENTAL PROBLEM RELATED TO PAIN IN THE NERVOUS SYSTEM IS THAT THE NERVOUS SYSTEM IS NOT REALLY DESIGN TODAY ADAPT TO A CHRONIC PAIN PROBLEM. UNTIL WE DESIGN INTERVENTIONS THAT WILL PREVENT THE INPUT FUNCTION FROM COMING IN, STOPPING PAIN FROM GETTING IN TO THE NERVOUS SYSTEM, IT'S GOING TO BE VERY DIFFICULT TO UNRAVEL SOME OF THESE MUCH MORE COMPLICATED ASPECTS SUCH AS FEAR, CATASTROPHIZING, I'M WONDERING -- TO STOP THE PERIPHERAL GENERATOR AND SEE HOW THAT IMPACTS MANY OF THESE OTHER FACTORS. WHO IS THAT DIRECTED TO? >> I WANT TO ADDRESS THAT, MIKE. SO I DON'T DO PRE-CLINICAL RESEARCH SO I HOPE THAT YOU OR ALLAN OR SOMEBODY ELSE IN THE ROOM COULD ANSWER THE FOLLOWING QUESTION FOR ME. HAS ANYONE DONE A KIND OF RODENT MODEL PERHAPS OF NEUROPATHIC PAIN WHERE IF YOU ATTENUATE THE ACUTE PAIN AT THE INITIATION OF WHATEVER RODENT MODEL YOU'RE USING, PERHAPS WITH AN OPIOID, DOES THAT SHORTEN THE COURSE OFF THE CHRONIC PAIN IN YOUR RODENT MODEL? I'VE ACTUALLY WONDERED ABOUT THIS QUESTION FOR ALMOST 20 YEARS, DOES KIND OF ATTENUATING ACUTE PAIN IN A RODENT MODEL SOMEHOW IMPACT ON THE CHRONIC PAIN IN A RODENT MODEL, BECAUSE THAT WOULD OBVIOUSLY HAVE ENORMOUS IMPLICATIONS FOR HOW WE TREAT ACUTE PAIN IN PEOPLE. AND I JUST DON'T KNOW WHETHER ANY OF YOU GUYS HAVE DONE THAT STUDY. >> I HAVEN'T DONE THAT STUDY BUT THE MODELS -- THE NERVE INJURY IS STILL THERE AND REMAINS THERE FOR THE DURATION OF THE LIFE OF THE ANIMAL. SO IT'S A LITTLE DIFFICULT. >> BUT THAT'S ACTUALLY -- MAYBE YOU'RE ANSWERING MY QUESTION. IS IT THE NERVE INJURY THAT CAUSES THE CHRONIC STIMULUS EVOKED PAIN AND, THEREFORE, YOU'RE SUGGESTING THAT WHATEVER ACUTE PAIN THE ANIMAL IS AND THAT THERE'S NO BENEFIT OFON- TREATING IT. >> SO THERE'S BEEN -- ALLAN, YOU CAN GET INTO THIS AS SOON AS I COMMENT ON A COUPLE STUDIES IN HUMANS. A WHILE BACK, MARSHALL DEVOR SHOWED THAT PEOPLE WITH LONG-STANDING PHANTOM LIMB PAIN, THAT YOU COULD ATTENUATE THE PHANTOM LIMB PAIN BY BLOCKING FIRING OF THE DORSAL ROOT BEGAN GLEE ON THROUGH LOCAL INSTALLATION OF LIDOCAINE. AND EVEN EARLIER THAN THAT, THEY' NET ADVERTISED THE AND THE PAIN RESOLVED INSTANTLY. WHICH IS A WAKEUP CALL, WHAT DO YOU DO? BECAUSE ALL OF THAT STUFF, THESE CHRONIC PROBLEMS ARE BEING DRIVEN BY SOME SORT OF ECTOPIC FIRING IN THE PERIPHERY. ALLAN, PITCH IN HERE. >> I'M SMILING BECAUSE THIS ISSUE CAME UP IN THE LAST COUPLE OF DAYS AND I HAD AN INTERESTING DISCUSSION WITH GREG ABOUT JUST THAT POINT. THE ANSWER TO THE FIRST QUESTION IS YES, ESPECIALLY DURING THE GOOD OLD DAYS OF PREVENTIVE ANALGESIA WHERE THE PROPOSAL WAS MADE THAT AT LEAST PREOPERATIVE OR INTRAOPERATIVE PAIN MANAGEMENT OR LOCAL ANESTHESIA OR OPIATES, INITIALLY THE FIRST STUDY WAS IN PHANTOM LIMB PAIN DEVELOPMENT AFTER OPERATIVE AMPUTATION SUGGESTED THAT YOU COULD REDUCE OR PREVENT THE DEVELOPMENT OF CHRONIC PAIN. THAT HAS SORT OF NOT BEEN SUBSTANTIATED, ALTHOUGH IT'S KIND OF LIKE CHICKEN SOUP, THE ANESTHESIOLOGISTS SAY IT CAN'T HURT, AND THERE WERE ANIMALS STUDIES DONE THAT SUGGESTED THAT YOU COULD MIMIC THAT PHENOMENON. IT'S A LITTLE MORE DIFFICULT TO TELL BECAUSE OF THE DURATION OF THESE CONDITIONS, AND THINK HERE WE GO BACK TO ONE OF THE MAJOR RECOMMENDATIONS IS THE NATURE OF THE PRE-CLINICAL MODEL. TO WHAT EXTENT DOES THE PRE-CLINICAL MODEL MIMIC THE MODEL. WHETHER IT'S IDENTICAL TO THE CLINICAL MODEL IS NOT THE POINT, THE QUESTION IS WHETHER IT'S PREDICTIVE OF UTILITY OF SOME INTERVENTION. IF IT IS PREDICTIVE, IT DOESN'T MAKE A DIFFERENCE IF IT'S IDENTICAL TO THE CLINICAL MODEL AT ALL. SO THOSE STUDIES DO NEED TO BE DONE. I HAPPEN TO AGREE STRONGLY THAT THERE IS A PERIPHERAL DRIVER IN MANY CONDITIONS, MAYBE NOT ALL, BUT IT'S NOT THE ONLY CONTRIBUTOR. >> IT'S CERTAINLY NOT. >> THAT'S RIGHT. >> BECAUSE ANYTHING COMING IN FROM THE PERIPHERY HITS THE SENSITIZED CNS. BUT MANY OF THE PREEMPTIVE THINGS, LET'S SAY N SURGERY, OUR POSTER THAT WAS UP EARLIER TODAY BLOCKING THE PRIMARY AFFERANCE, THAT LASTED FOR THE DURATION AND THE ANIMAL RECOVERED BASICALLY PI THE TIME BY THE TIME THE ANALGESIA WORE OFF. SO THESE KIND OF LONG TERM INTERVENTIONS I THINK WILL ANSWER MANY QUESTIONS. >> THANK YOU. >> SOMEWHAT RELATED TO THAT, WE TALKED ABOUT DENTISTRY EARLIER TODAY OR YESTERDAY. THE FACT IS DENTISTS HAVE BEEN DOING THAT FOREVER. LOCAL ANESTHETIC INJECTION PRIOR TO A PROCEDURE. AND IT WOULD BE INTERESTING TO SEE TO WHAT EXTENT, NOW THERE ARE SOME INDIVIDUALS, I'M SURE, WHO HAVE DENTAL PROCEDURES THAT GO ON TO HAVING A CHRONIC PAIN CONDITION, BUT I DON'T KNOW WHAT THE NUMBERS ARE, AND I HAVE NO IDEA HOW THAT CORRELATES OR IS PARALLEL TO WHAT HAPPENS IN, SAY, POST KNEE REPLACEMENT OR POST HIP REPLACEMENT, ET CETERA, MY GUT FEELING IS IT'S PROBABLY A LOT LOWER AND IS IT BECAUSE THEY'RE REALLY GOOD AT WHAT THEY DO? >> I WANT THE TO MAKE A COMMENT ON THAT AS WELL, I THINK FROM A CLINICAL PERSPECTIVE, ANYBODY WHO'S PRACTICED AS AN INTERVENTIONALIST HAS HAD PATIENTS WHO JUST DRAMATICALLY WHEN YOU GET THE PAIN GENERATOR AND YOU BLOCK IT FOR A FEW HOURS, IT JUST STOPS THE PAIN, IT DOESN'T COME BACK. I THINK MOST PEOPLE WHO HAVE DONE CLINICAL PRACTICE HAVE ANECDOTES LIKE THAT, AND YES WE SEE SO MANY PATIENTS THESE DAYS GOING FROM TRIAL OF TRIAL OF TRIAL OF DIFFERENT PROCEDURES AIMED AT BLOCKING THE GENERATOR OF THE PAIN AND THEY'RE STILL SUFFERING WITH PAIN. SO CLEARLY IT IS -- IT MAY BE A SUBPOPULATION, HOW DO WE DEFINE THAT GROUP OF PEOPLE WHO ARE GOING TO RESPOND OR THE EXACT SUBSTRATE THAT'S GOING TO RESPOND TO THAT KIND OF TREATMENT, SO I DO THINK IT'S AN AREA THAT -- BECAUSE IT'S TRAUMATIC WHEN IT HAPPENS, I THINK. AGAIN, IT'S ANECDOTE, BUT PRETTY COMPELLING. SO THANK YOU FOR BRINGING THAT UP. >> HI, MY NAME IS JULIAN PHILLIPS. FORGIVE ME, I'M NOT QUITE AT YOUR LEVEL OF ABILITIES, I'M JUST A SIMPLE PERSON. I HAVE RSD, COUPLE OF THINGS, REALLY. FIRST TO PROFESSOR DWORKIN, TO YOUR POINT ABOUT THE CONTINUUM GOING FROM, I GUESS, NO PAIN TO PAIN TO ACUTE PAIN, TO CHRONIC& PAIN, WHETHER THERE IS SOMETHING THAT SAYS THERE ISN'T THE CONTINUUM, AND YOU JUMP STRAIGHT TO CHRONIC PAIN, WOULDN'T REFLEX SYMPATHETIC DYSTROPHY BE JUST THAT? I MEAN, I DON'T -- OBVIOUSLY I RECALL BEING IN ACUTE PAIN WHEN I INITIALLY DISLOCATED THE RIGHT RING FINGER OF THIS HAND, BUT IT OBVIOUSLY WENT ALMOST DIRECTLY TO ACUTE PAIN BECAUSE I NEVER GOT OUT OF -- SORRY, CHRONIC PAIN BECAUSE I NEVER GOT OUT OF THE ACUTE PAIN. BEYOND THAT, I JUST WOULD LIKE TO THANK EVERYBODY HERE FOR ALL YOUR WORK BECAUSE OBVIOUSLY I'M A RECIPIENT OF -- OR WOULD LIKE TO BE A RECIPIENT OF EVERYTHING THAT YOU'VE DONE AND DO, AND IT'S NICE TO HEAR YOU GUYS NOT TRYING TO STIGMA ADVERTISE THE LIKES OF ME WHO UNFORTUNATELY HATE IT AS MUCH AS I DO, HAVE BEEN TAKEN AND DO TAKE OPIATES. IT WOULD BE NICE FOR YOU TO -- NOT FOR YOU TO BE ABLE TO BUT WHEN YOU GET TO THE POINT THAT YOU CAN KEEP THE LIKES OF ME AWAY FROM THESE HORRIBLE MEDICATIONS, THERE WAS SOMETHING ELSE I WAS GOING TO ASK, BUT THAT'S GONE OUT OF MY BRAIN, THAT'S NOW GOING TO TBI AS WELL. FOR WHICH I APOLOGIZE. >> I'D LIKE TO RESPOND TO THE FIRST POINT AND HOPE SOMEBODY ELSE RESPONDS TO YOUR COMMENT ABOUT OPIOIDS. I ACTUALLY THINK THAT RSD CRPS, I DON'T KNOW IF GREG AGREEs, MIGHT BE A KIND OF PERFECT EXAMPLE OF THE HYPOTHESIS THAT FOR SOME PATIENTS, THE CHRONIC PAPER IS THERE FROM THE PAIN IS THERE FROM THE BEGINNING, AND OTHERS DON'T HAVE THAT FROM THE BEGINNING AND THE CONSEQUENCES OF THE INJURY RESOLVE QUITE QUICKLY. AND SO I TAKE YOUR POINT THAT I THINK IT'S FASCINATING AND SPEAKS TO THIS POSSIBILITY THAT PERHAPS FOR SOME PAIN CONDITIONS, THERE IS NO TRANSITION AND YOU'VE GOT TWO PROCESSES AT THE BEGINNING OF THE ILLNESS OR THE INJURY AND IT'S A CHRONIC PROCESS AND AN ACUTE PROCESS AND I CAN'T WAIT TO ASK GREG AFTER WE'RE DONE TODAY WHETHER HE AGREES. AND I WILL PASS ON THE OPIOID. >> GREG, DO YOU WANT TO COMMENT ON THAT FIRST THING AND I'M HAPPY TO COMMENT ON THE OPIOIDS. >> SO I JUST WANT -- I'M GREG FROM THE UNIVERSITY OF WASHINGTON. I JUST WANT TO MAKE IT CLEAR, I'M A BIG FAN OF THE IDEA OF PLASTICITY IN THE NERVOUS SYSTEM, AND MY FIRST NIH GRANT WAS ABOUT LTP AND MECHANISMS THAT MAY BE ACUTE TO CHRONIC, BUT AS FAR AS I CAN TELL, ACUTE PAIN IS NEITHER NECESSARY NOR SUFFICIENT FOR CHRONIC PAIN. AND THERE ARE MANY PATIENTS THAT I TREAT WHO HAVE CHRONIC BACK PAIN WHO GET BACK SURGERY, AND YOU ASK THEM ABOUT THEIR PAIN AND THEY SAY, YES, I HAVE BACK PAIN, BUT IT'S COMPLETELY DIFFERENT THAN THE CHRONIC PAIN. AND SO I GUESS WHAT I WAS REACTING TO ON THE COMMITTEE, I THINK IT'S A VERY INTERESTING HYPOTHESIS, THE ACUTE TO CHRONIC TRANSITION, BUT THE IDEA OF PERSISTENT PAIN MAY LEAVE OUT A COMPONENT OF ACUTE PAIN AND CHRONIC PAIN BEING VERY DIFFERENT IN TERMS OF WHAT PATIENTS SENSE. IT'S NOT REALLY PERSISTENT PAIN. IT'S SOMETHING DIFFERENT. AND WHETHER THAT DIFFERENT STARTS MOST OF THE ANIMAL MODELS, WE'RE TALKING, FROM MY LONG TERM POTENTIATION STUDY, IT WAS SECONDS, AND I WAS MAKING EXTENSIONS THAT MEANT CHRONIC PAIN, EVEN THE ANIMAL MODELS, YOU KNOW, YOU'RE TALKING ABOUT A FEW HOURS TO A FEW DAYS, AND SO LIKE ALLAN WAS SAYING, IT'S ALL ABOUT THE MODELS AND WHETHER THEY'RE PREDICTIVE AND I JUST THINK I'VE YET TO SEE GREAT EVIDENCE THAT THERE IS A TRANSITION, PER SE, AND NOT THAT I HAVE A HYPOTHESIS, IT'S RESEARCH SO AS SOON AS YOU'VE GOT A DOG MA, YOU'VE GOT TO TRY AND FIGURE OUT, WHAT'S WRONG WITH THAT DOGMA TO LOOK FURTHER. >> THE OTHER POINTS -- SORRY. THE OTHER POINT I WAS GOING TO ASK ABOUT, I HAD FORGOTTEN, WAS THAT NOMENCLATURE OF CRPS AND RSD AS AN EXAMPLE. TO ME, AND I DON'T KNOW THAT IT MATTERS REALLY, BUT I SORT OF GET TICKED OFF USING A POLITE PHRASE WHEN PEOPLE SAY THAT RSD IS NOW CRPS, BECAUSE CRPS IS JUST ALL ENCOMPASSING. A MIGRAINE IS CRPS. IT'S COMPLEX, IT'S REGIONAL, AND IT'S A PAIN. RSD, TO ME, IS A COMPLEX REGIONAL -- NOT SPECIFICALLY -- IN MY CASE IT WENT FULL BODY BUT ORIGINALLY IT WAS REGIONAL. SO TO ME, IT JUST SEEMS THAT PEOPLE WITH RSD, AS IT USED TO BE, HAVE ALMOST BEEN FORGOTTEN ABOUT SORT OF THING AND HAVE BEEN BULKED IN WITH EVERYBODY ELSE. NOT THAT I WANT TO BE SOMEBODY DIFFERENT, BUT IT JUST DOESN'T -- I DON'T KNOW, MAYBE I'M -- I'VE GONE -- >> I'M NOT A CLINICIAN BUT I WAS ACTUALLY ASKED YEARS AGO TO GIVE A LECTURE ON THE HISTORY, SOMEONE SAID YOU'RE OLDER THAN ANYBODY IN THE FIELD SO YOU CAN GIVE A LECTURE OF THE HISTORY OF NEUROPATHIC PAIN. NO, THEY WERE REFERRING TO ME. SO I DID GO BACK IN TIME AND IT'S JUST INTERESTING, THE EVOLUTION OF THE NAMES, AND I DON'T BELIEVE THAT THE PEOPLE IN THE FIELD BY ANY WAYS ARE DIMINISHING THE SIGNIFICANCE OF THE CONDITION THAT YOU HAVE. IF YOU GO BACK TO THE 19TH CENTURY, IT WAS REALLY THE ORIGINALLY CAUSED CAUSEALGIA DURING THE CIVIL WAR, THEN IT EVOLVED AND THEN THE TERM REFLEX SYMPATHETIC DYSTROPHY. I THINK THE REASON THAT NAME CHANGED IS BECAUSE THERE WERE QUESTIONS ABOUT THE EXTENT TO WHICH THERE'S A SYMPATHETIC COMPONENT. REFLEX SYMPATHETIC DYSTROPHY APPLIES A VERY SPECIFIC PATHOPHYSIOLOGY AND IT'S NOT ENTIRELY CLEAR THAT THAT'S WHAT'S GOING ON, SO THE COMPLEX REGIONAL PAIN SYNDROME WHICH IS -- IT IS OVERLY ALL ENCOMPASSING, IS MEANT TO INCLUDE REFLEX SYMPATHETIC DYSTROPHY BUT NOT TO DEFINE THE ETIOLOGY WHEN, IN FACT, YOU DISONT KNOW WHAT IT DON'T KNOW WHAT IT IS. >> HI. I WAS GOING TO RESPOND TO YOUR COMMENT ON RELATED TO OPIOIDS. AND FIRST TO REALLY THANK YOU FOR YOUR COMMENTS. I THINK THAT'S WHY WE'RE ALL HERE, WE WISH WE HAD BETTER PURE PURER TREATMENTS THAT COULD JUST REVERSE WHAT YOU'VE BEEN GOING THROUGH. SO WE'RE ALL WORKING ON IT. OPIOIDS ARE THE MOST POWERFUL PAIN RELIEVING MEDICATIONS WE HAVE AT THIS POINT IN TIME. THEY'RE CLEARLY A DOUBLE EDGED SWORD, BOTH FOR SOCIETY AT LARGE AS WE WELL KNOW, AND SOMETIMES FOR INDIVIDUALS WHO MAY FEEL BETTER INITIALLY AND ACTUALLY OVER TIME FIND THEY FEEL WORSE AND WE'RE REALLY STUDYING THE FACT THAT OPIOIDS -- ONE OF THE EXPERTS IS SITTING RIGHT NEXT TO YOU, PEGGY COMPTON, HAVE THE PROCESS WHERE AT THE SAME TIME, THEY RELIEVE PAIN, THEY MAY ACTUALLY STIMULATE A FORM OF NEUROPATHIC PAIN, AND ALSO HAVE OTHER SIDE EFFECTS. SO THAT DOESN'T ALWAYS OCCUR, AND I JUST WANT TO COMMENT THAT ANYONE WHO'S USING OIP YOIDZ AND BENEFITING FROM THEM SHOULD NEVER HAVE TO APOLL JAIZ FOR FEEL ASHAMED FOR THAT. I THINK THAT -- >> THAT'S A REALLY GOOD POINT. >> I THINK IT'S VERY IMPORTANT. BECAUSE THEY'RE BEING SO DEMONIZED NOW. >> ABSOLUTELY. AND I DON'T KNOW WHERE THAT'S COME FROM COMPLETELY, BUT UNFORTUNATELY, WE SOMEHOW COMBINED TWO PROBLEMS. WE'VE COMBINED ADDICTION, WHICH IS BY ITSELF AN END OF ITSELF, A HORRIBLE DISEASE, AND PAIN, AND WE'VE PUT THEM TOGETHER, TRYING TO SOLVE TWO PROBLEMS WITH ONE STONE. AND IT JUST DOESN'T WORK. AND THEY NEED TO BE SEPARATED, AND LIKE SOMEBODY SAID BEFORE, ADDICTION IS THERE. IT DOESN'T MATTER WHETHER IT'S -- RIGHT NOW IT'S OPIATE, BUT TOMORROW IT'S GOING TO BE, I DON'T KNOW, SOMETHING ELSE. SO ANYWAY, I'LL GET OFF MY SOAP BOX. >> THANK YOU VERY MUCH. >> THANK YOU. >> FOR YOUR COMMENTS. >> HI. THIS IS JAMES FRICTON FROM MINNESOTA. THANK YOU VERY MUCH FOR YOUR HARD WORK AND INCLUSIVE COMPREHENSIVE REPORT. A QUESTION I VR ABOUT FROM MY BOTH RESEARCH IN CLINICAL EXPERIENCE IS THAT THE MOST COMMON CONDITION THAT I SEE IN THE CLINIC AND IN RESEARCH IS MYOFASCIAL PAIN, AND I'M WONDERING WHY THERE HASN'T BEEN A SIGNIFICANT AMOUNT OF FOCUS BOTH FROM A BASIC SCIENCE AND A CLINICAL SCIENCE RESEARCH ON THE MOST, YOU KNOW, COMPLICATED, I SUPPOSE, AND PREVALENT CONDITION, PARTICULARLY SINCE IT'S SO RESPONSIVE TO BOTH TREATMENT AND SELF MANAGEMENT TRAINING. >> THAT IS AN EXCELLENT QUESTION. IN THE BASIC SCIENCE FIELD, MANY OF US THAT LOOK AT THOSE BASIC MECHANISMS TEND TO FOCUS ON THE SKIN BECAUSE THE SKIN IS EASY TO ACCESS. IT'S EASY TO QUANTITATIVELY STIMULATE. ON THE OTHER HAND, IT'S ACTUALLY QUITE HARDER TO STIMULATE EVEN DEEP MUSCLE TISSUE QUANTITATIVELY TO GET TO THE ENDINGS, THE NERVE ENDINGS, AND I THINK MANY OF THOSE NERVE ENDINGS ARE ACTUALLY, AS YOU SAID, IN THE FASCIA, THOSE NOCICEPTORS, BUT GETTING THOSE, FOR EXAMPLE, TRYING TO LABEL FACIAL AFFERENCE, IT'S ACTUALLY QUITE CHALLENGING TO DO BECAUSE THE TISSUE IS SO THIN. SO WE ALSO NEED -- THERE'S A GREAT NEED TO DEVELOP BETTER MODELS FOR MUSCLE AND FASCIAL AND DEEP PAIN. >> MYOFASCIAL PAIN IS OFTEN A COMPONENT OF OTHER PAIN, SO SOMEBODY WHO HAS NECK AND SHOULDER PAIN, SOMEBODY HAS LOW BACK PAIN, SOMEBODY HAS HEADACHE PAIN. SO I THINK OFTEN WE DON'T SINGLE OUT MYOFASCIAL PAIN AS AN ENTITY BECAUSE IT'S A COMPONENT OF MANY, MANY PAIN SYNDROMES, AND CERTAINLY AGREE, ABSOLUTELY, MOVEMENT THERAPIES, CALMING THERAPIES, SELF-MANAGEMENT, I THINK IT'S WHY BECAUSE IT IS SO RESPONSIVE TO THOSE THERAPIES, IT'S WHY ACROSS THE BOARD FOR THESE OTHER IDENTIFIED CONDITIONS THAT SELF MANAGEMENT CAN BE SO EFFECTIVE. BUT PEOPLE DON'T USUALLY SAY I HAVE MYOFASCIAL PAIN. THEY SAY I HAVE SHOULDER PAIN OR I HAVE LOW BACK PAIN. >> IT'S SO COMMONLY MISDIAGNOSED IN PRIMARY CARE AND IN OTHER SPECIALTY CARE IN FAVOR OF JOINT PROBLEMS, NEUROPATHIC PAIN, MIGRAINE, WHEN IN ACTUALITY IN MANY SITUATIONS IT'S RESPONSIVE TO FAIRLY SIMPLE TREATMENTS, BUT WHEN IT BECOMES CHRONIC, THEN YOU HAVE THE CENTRAL SENSITIZATION, ALL THE COMPLEXITY ASSOCIATED WITH THAT MAKES IT SO MUCH MORE DIFFICULT SO IT SEEMS LIKE ONE OF THE EDUCATIONAL SORT OF EFFORTS THAT WE NEED TO MAKE IS TO REALLY TRAIN ANYBODY AND EVERYBODY IN THE HEALTH PROFESSIONS ABOUT THE CONCEPT OF MYOFASCIAL PAIN, FIBROMYALGIA TO SOME EXTENT AND THE WHOLE IMPORTANCE OF THE SOFT TISSUES OF THE BODY. >> I THINK THAT'S A VERY IMPORTANT POINT. BECAUSE IT IS A CROSS CUTTING TYPE OF PAIN AS NEUROPATHIC PAIN IS. THANK YOU. >> I THINK IF TIM BRENNAN HAD OPINION HERE, HE WAS WITH THE ACUTE PAIN GROUP, THAT WAS A CONVERSATION THAT WAS HELD THERE, AND THEY SAY IN ONE OF THEIR PRIORITIES THAT CUTANEOUS PAIN HAS BEEN -- CUTANEOUS NOCICEPTORS HAVE BEEN THE FOCUS OF RESEARCH FOR DECADES, BUT WE'RE MISSING NOCICEPTIVE INPUT, HETEROGENEITY DIFFERENT, NOCICEPTORS DIFFERENT BETWEEN DIFFERENT TISSUES INCLUDING MYOFASCIAL. SO IT'S BEEN TARGETED IN THE PRIORITIES A RECOGNIZE THAT THIS IS STILL A GAP AREA. >> JUST TO FOLLOW UP ON THAT, WE COULDN'T AGREE MORE. THE OTHER AREA THAT IT WAS FELT IS IGNORED NOT NECESSARILY ON THE CLINICAL SIDE BUT CERTAINLY ON THE FUND MENTAL SIDE IS VISCERAL PAIN, WHICH ARE PREVALENT, EXTREMELY PAIN PAINFUL FOR INDIVIDUALS OBVIOUSLY, WHETHER IT'S CANCER PAIN, PANCREATITIS, AND YET THEY'RE POOR MODELS. AGAIN, AS CHERYL MENTIONED, IT'S DEEP TISSUE, OFTEN INACCESSIBLE. LEARN ABOUT A VISCERAL PAIN IN A MODEL SYSTEM WOULD BE TREATED DIFFERENTLY WHEN IT OCCURS IN A PATIENT, ARE THE MECHANISMS DIFFERENT, PEOPLE ASK WHY DID YOU SUDDENLY -- WHEN I SAY "YOU," THE WORKING GROUPS MENTIONED AUTONOMIC NERVOUS SYSTEM, IT'S LIKE, AUTONOMIC NERVOUS SYSTEM IN PAIN, WHAT A CONCEPT. IT'S BEEN IGNORED, AND THE PHYSICIANS ARE STIM LAIGHT THE VEGUS NERVE FOR NOT ONLY PAIN BUT EPILEPSY AND DEPRESSION AND THEY HAVE ABC LUTLY NO IDEA HOW IT WORKS, HOW MUCH OF IT IS A PLACEBO, HOW EFFECTIVE IS IT, YOU KNOW NOTHING ABOUT MECHANISM SO THERE'S AN OPPORTUNITY TO REALLY GET AT COMPLETELY UNDERSTUDIED AREAS. >> THANK YOU. >> SO I'M GOING TO ACTUALLY TAKE ONE OF THE COMMENTS AND QUESTIONS THAT CAME IN THROUGH THE MAILBOX AND POSE THAT TO THE GROUP. WE HAD A COUPLE QUESTIONS THAT RELATED TO IMPLEMENTATION RESEARCH. ONE READS WE ALREADY KNOW SO MUCH THAT DOES WORK, BUT CAN'T APPLY IT IN OUR HEALTH SYSTEMS EFFECTIVELY BECAUSE FL HEALTHCARE POLICY, THE ECONOMICS OF THE HEALTHCARE SYSTEM, AND SO HOW CAN WE IMPROVE THIS THROUGH BETTER IMPLEMENTATION RESEARCH? DOES ANYBODY WANT TO JUMP IN THERE? >> THERE'S SO MANY COMPONENTS TO THAT. I MEAN, A TRANSFORMATION OF OUR HEALTHCARE SYSTEM, PRIMARY CARE MEDICAL HOMES FOR ALL, CARE COORDINATION. I THINK, AGAIN, IT COMES UNDER DEVELOPING OUR MODELS OF CARE, BUT MY PERCEPTION IS, WE'RE TRYING TO PATCH TOGETHER CENTERS THAT PROVIDE GOOD CARE IN A SYSTEM THAT HAS MANY, MANY BARRIERS BUILT INTO IT. I DON'T HAVE AB EASY AN EASY ANSWER. >> I DON'T KNOW IF THIS IS QUITE AN ANSWER TO THE QUESTION, BUT LET ME JUST RECOUNT, I'VE MENTIONED THIS TO OTHERS, I WAS AT A MEETING IN EUROPE NOT TOO LONG AGO THAT I HELPED ORGANIZE AND I HAD INVITED JAIN BALLENTINE, WHO MANY YOU HAVE KNOW, WHO IS SOMEBODY WHO IS A STRONG ADVOCATE AGAINST THE USE OF OPIOIDS FOR NON-CANCER PAIN, NON-POST OP. FOR ALL THE REASONS WE UNDERSTAND, THE PROBLEMS OF BUT WHEN SHE BEGAN HER TALK, WITHIN FIVE MINUTES, SHE WAS STOPPED BY THE AUDIENCE, THERE WERE ABOUT A THOUSAND PEOPLE IN THE AUDIENCE WHO SAID, WHAT ARE YOU TALKING ABOUT, THIS ISN'T A PROBLEM HERE? IT LED TO A DIALOGUE. SHE NEVER FINISHED HER TALK BUT IT WAS A WONDERFUL DISCUSSION BETWEEN JAIN AND THE AUDIENCE ABOUT THE FACT THAT THE HEALTH SYSTEM IS SO DIFFERENT IN EUROPE, AND THERE WAS SOME REFERENCE TO THE ISSUE OF NATIONAL REGISTRIES, THE ABSENCE OF NATIONAL REGISTRIES FOR OPIOIDS IN THE STATES, SOME STATES HAVE REGISTRIES WHERE THERE'S A RECORD OF PRESCRIPTIONS BUT THERE'S NO NATIONAL REGISTRY, AND WON WONDERS, SO THERE'S A SIMPLE SOLUTION TO IMPLEMENTATION WHICH IS THE CASE IN EUROPE WHERE YOU CAN'T WRITE A PRESCRIPTION SOMEBODY ELSE IS GOING TO KNOW ABOUT IT EVEN IN ANOTHER COUNTRY BECAUSE IT CROSSES BORDERS, SO THERE'S AN ELEMENT THAT WE CAN THROW AT IT AND WONDER WHY IT DOESN'T EXIST AND EVERYBODY BELIEVES 50% OF THE PROBLEM OF MISUSE COMES FROM PRESCRIPTION MEDICATIONS. >> THINKING BACK ON THE DISCUSSIONS THAT THE PREVENTION GROUP HAD, I CAN'T RECALL AN INSTANCE WHERE SOMEONE WAS TALKING ABOUT THE NEED FOR AN INTERVENTION THAT DIDN'T EXIST ALREADY. MOST OF OUR DISCUSSIONS WERE CENTERED AROUND WE KNOW EDUCATION WORKS, WE KNOW EXERCISE IS HELPFUL, WE KNOW BIOPSYCHOSOCIAL REHABILITATION IS HELPFUL, WE KNOW -- ET CETERA, THE QUESTION IS WHY ISN'T THIS MORE WIDELY USED? I AGREE, IT REALLY IS A MATTER OF IMPLEMENTATION, AND I THINK THE PREVENTION GROUP FELT THAT ACUTELY. WE KEPT ON BATTING AROUND IDEAS, WE KNOW THIS WORKS, WHY ISN'T IT CONSTANTLY DONE, AND THE SILLY EXAMPLE OF TAKING IBUPROFEN A DAY OR TWO BEFORE YOU'RE GETTING A TOOTH EXTRACTION, WHY ISN'T IT DONE? BECAUSE ORAL SURGEONS DON'T CALL THEIR PATIENTS. ONE OR TWO DAYS BEFORE THE PROCEDURE. THERE'S NO SIMPLE MECHANISM FOR CALLING AND TELLING THEM START TAKING THIS THREE TIMES A DAY UNTIL YOU COME IN TO MY OFFICE. THAT SEEMS LIKE LOW HANGING FRUIT. I AGREE IMPLEMENTATION RESEARCH REALLY SHOULD BUILD UPON WHAT WE KNOW ALREADY, BUT PERHAPS ONE OF THE BARRIERS IS ALSO THAT IMPLEMENTATION RESEARCH ISN'T SEEN AS SEXY OR QUITE AS INTRIGUING AND DEVELOPING NEW THERAPIES. SO MAYBE IMPLEMENTATION RESEARCH ITSELF SHOULD BE PROMOTED SO THAT PEOPLE COULD BE REWARDED FOR WHAT WE ALREADY KNOW AND JUST TRYING TO MAKE IT MORE EASILY ACCESSIBLE. >> THANKS, SIMON. SO ONE MORE QUESTION IN HERE THAT WAS PRETTY INTRIGUING AND GOES BACK A LITTLE BIT TO ALLAN'S COMMENT ON THE INTERNATIONAL ISSUE OF OPIOIDS NOT BEING A CONCERN IN EUROPE. SO IT READS A LITTLE PREAMBLE HERE, I WOULD SUGGEST ADDING A PRIORITY TO ENGAGE IN CROSS NATIONAL COMPARATIVE RESEARCH DETERMINED WHETHER OTHER ADVANCE INDUSTRIAL COUNTRIES OF SIMILAR LEVELS OF PAIN ANDOR SIMILAR SOCIAL DISPARITIES IN PAIN AS WE DO IN THE U.S., DO PATTERNS OF PAIN PREVALENCE, DISTRIBUTION, PROGRESSION LOOK SIMILAR CROSS NATIONALLY OR DO SOME COUNTRIES SEEM TO BE DOING BETTER? IF OTHER COUNTRIES ARE DOING BETTER, WHAT CAN WE LEARN FROM THEIR TREATMENT OR POLICY REGIMENTS TO IMPROVE HEALTH DOMESTICALLY. SO I THINK ALLAN TOUCHED UPON ONE. MAYBE THERE ARE SOME OTHER THINGS THAT WE SHOULD THINK ABOUT, TALK ABOUT? >> I CAN THINK OF ONE EXAMPLE, THE CONCEPT OF ENHANCED RECOVERY AFTER SURGERY, ERAS, ORIGINATED IN EUROPE, APPROXIMATELY 20, 25 YEARS AGO, AND IT WAS AN ANESTHESIA GROUP WHO LOOKED AT WHAT WE CURRENTLY DO TO PATIENTS WHO ARE UNDERGOING SURGERY, AND IT'S NO -- NO FOOD, NO LIQUIDS FOR SOMETIMES 18, 24 HOURS BEFORE, KEEP THEM COMPLETELY IMMOBILE FOR DAYS AFTERWARD, PEPPER THEM WITH ALL SORTS OF MEDICATIONS, AND THEN ON THE OTHER HAND, WE COMPLAIN WHEN THEY STAY IN THE HOSPITAL TOO LONG. SO THEY LOOKED AT THIS DIFFERENTLY AND SAID HOW DO WE GET SOMEONE IN A HOSPITAL AS QUICKLY AS POSSIBLE, AND THEY STARTED DOING THINGS LIKE EAT AND DRINK UNTIL BASICALLY RIGHT BEFORE THE SURGERY. AND THEN WE'RE NOT GOING TO FORCE FEED YOU WITH ALL THESE OTHER THINGS, WE'RE GOING TO GIVE YOU OPTIONS, WE'RE GOING TO GET YOU TO STAND UP THE DAY OF SURGERY, WE'RE GOING TO DO PHYSICAL THERAPY THREE TIMES A DAY, EVEN IF YOU DON'T FEEL LIKE IT, AND ALL OF A SUDDEN, PATIENTS WHO USED TO STAY IN THE HOSPITAL 10 OR 12 DAYS ARE NOW GOING HOME AFTER TWO DAYS AND THE OUT IT IS COMES ARE VERY COMPARABLE. AND THAT'S NOW COMING INTO THE U.S., AND THAT JUST IS AN EXAMPLE OF WHERE WE COULD LEARN FROM WHAT'S BEEN DONE ELSEWHERE, AND I KNOW ERAS IS RAPIDLY BEING ADOPTED IN ALL SORTS OF PROCEDURES IN THE U.S., BUT THERE ARE PROBABLY OTHER EXAMPLES OUT THERE WHERE WE COULD APPLY WHAT OTHER COUNTRIES ARE DOING. >> I THINK THERE'S ALWAYS SOMETHING TO BE LEARNED FROM STUDYING ANY PHENOMENON ACROSS DIFFERENT POPULATIONS. EVEN WITHIN OUR OWN COUNTRY, WE KNOW THAT A LOT OF MEDICAL PRACTICE IS REGIONAL, IT'S NOT NECESSARILY BASED ON SCIENCE, AND IF WE LOOK IF HE REGIONAL VARIATIONS IN PRACTICE, MANY AREAS CAN LEARN FROM EACH OTHER, SO CERTAINLY STUDYING ACROSS NATIONALITIES, SOMETHING COULD BE LEARNED. THE USE OF EPIDEMIOLOGIC DATA OFTEN CAN GIVE US IDEAS FOR MORE SPECIFIC STUDIES, I THINK. >> I BELIEVE THERE'S EVIDENCE IN, FOR EXAMPLE, LATIN COUNTRIES THAT THERE IS LESS OF AN ISSUE WITH CHRONIC PAIN AND AGED POPULATIONS BECAUSE IT SEEMS TO BE THE AGED FOLKS JUST EXPECT THAT THEY WILL HAVE CHRONIC PAIN, AND IF YOU ASK THEM ABOUT IT, YEAH, I HAVE CHRONIC PAIN, BUT IT'S JUST PART OF MY LIFE. I JUST DEAL WITH IT. SO TO SOME EXTENT, I THINK THERE MIGHT BE A WAY WE COULD INCREASE AWARENESS IN AGED POPULATIONS THAT THERE WILL BE A LEVEL OF PAIN THAT THEY WILL HAVE TO GET USED TO BUT IT NEEDS TO BE MANAGED AND YOU CAN LEARN TO BECOME AND BE FUNCTIONAL WITH A CERTAIN LEVEL OF CHRONIC PAIN. >> ONE MORE POINT AND THEN I THINK WE'LL CLOSE OUT THE QUESTION SESSION UNLESS ANYONE HAS A BURNING ONE. CARE GIRS. DID WE MISS THAT IN THE SET OF RESEARCH PRIORITIES? IT'S IN ACUTE PAIN THAT CAREGIVERS SHOULD BE EDUCATED ALLEGES WITH THE PERSON THAT THEY'RE HELPING OUT, BUT ARE THERE OTHER AREAS THAT MAYBE IT SHOULD HAVE BEEN MORE EMPHASIZED AND WASN'T? >> I DON'T THINK WE ADDRESSED IT IN CHRONIC PAIN. I THINK WE SHOULD CLEARLY. AND THE WHOLE CONCEPT OF CHRONIC PAIN AS A FAMILY CONDITION SIMILAR TO OTHER CHRONIC ILLNESSES, SUBSTANCE USE DISORDERS, MEDICAL DISORDERS THAT ARE DISABLING, THEY ARE FAMILY ISSUES AND THE FAMILY NEEDS TO BE BROUGHT IN, SO YES, THANK YOU TO WHOEVER BROUGHT THAT UP. >> [INAUDIBLE] >> YES, ABSOLUTELY. ABSOLUTELY. >> CAREGIVERS WOULD CERTAINLY BE AN IMPORTANT PART OF THE AGED POPULATION IN OUR GROUP, AS WELL AS THE PEDIATRIC PAIN GROUP. SO WE APPRECIATE THAT COMMENT VERY MUCH. >> SO THANK YOU VERY MUCH TO THE PANEL. ALLAN, YOU HAVE THE RESPONSIBILITY OF CLOSING REMARKS ACCORDING TO OUR AGENDA, SO WE WILL LET YOU FINISH UP THE DAY. >> IT'S BEEN A REALLY INTERESTING EXPERIENCE FOR ME TO WORK WITH EVERYONE ON THIS EFFORT. I THINK THE PRODUCT IS EXCITING. IT'S MEATY. AND THE REAL QUESTION NOW IS WHERE DOES IT GO FROM HERE. I WAS WAITING FOR SOMEBODY TO ASK WHAT'S NEXT, SO I'M GOING TO BE THE PERSON WHO ASKS WHAT'S NEXT, I'M NOT LOOKING FOR AN ANSWER, BUT OBVIOUSLY OUR DREAM AND HOPE IS THAT THIS IS GOING TO LEAD TO RESEARCH BEING DONE IN DIFFERENT DISCIPLINES ACROSS THE COUNTRY, THAT'S GOING TO MAKE A DIFFERENCE. THAT MEANS THE AGENCIES THAT SUPPORT PAIN RESEARCH WILL LOOK AT THESE RECOMMENDATIONS. SOME OF THEM ARE ALREADY IN THEIR PORTFOLIO, OTHERS ARE CLEARLY NOT, AND THE HOPE IS THAT THEY'RE GOING TO TAKE THESE RECOMMENDATIONS SERIOUSLY TO BUILD THEIR PORTFOLIOS. IT'S BEEN A TERRIFIC EFFORT AND I WANT TO PARTICULARLY THANK LINDA, IT'S BEEN WONDERFUL WORKING WITH YOU, AND I LOOK FORWARD TO SEEING THE IMPLEMENTATION OF THESE RECOMMENDATIONS. >> MANY THANKS ON BEHALF OF ALL THE TASK FORCES FOR THE WORK THAT BOTH OF YOU HAVE DONE. >> THANK YOU VERY MUCH, AND THANK YOU BACK TO ALLAN FROM LINDA. >> COOL ADMIRATION. >> ALL RIGHT. THANKS ALL VERY MUCH. WE STILL HAVE THE MAILBOX OPEN, SO IF YOU HAVE COMMENTS FOLLOWING THIS DISCUSSION, PLEASE FEEL FREE TO SEND THEM IN. THANK YOU. [APPLAUSE]