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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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The Role of Nonpharmacological Approaches to Pain Management PROCEEDINGS OF A WORKSHOP Lisa Bain, Sheena M. Posey Norris, and Clare Stroud, Rapporteurs Forum on Neuroscience and Nervous System Disorders Global Forum on Innovation in Health Professional Education Board on Health Sciences Policy Board on Global Health Health and Medicine Division PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and the Academic Collaborative for Integrative Health; Academy of Nutrition and Dietetics; Accreditation Council for Graduate Medical Education; Aetna Foundation; Alzheimer’s Association; American Academy of Nursing; American Association of Colleges of Nursing; American Association of Colleges of Osteopathic Medicine; American Association of Colleges of Pharmacy; American Board of Family Medicine; American College of Obstetricians and Gynecologists; American Council of Academic Physical Therapy; American Dental Education Association; American Medical Association; American Nurses Credentialing Center; American Occupational Therapy Association; American Osteopathic Association; American Physical Therapy Association; American Psychological Association; American Speech-Language-Hearing Association; Association of American Medical Colleges; Association of American Veterinary Medical Colleges; Association of Schools and Colleges of Optometry; Association of Schools and Programs of Public Health; Association of Schools of the Allied Health Professions; Athletic Training Strategic Alliance; Cohen Veterans Bioscience; Council on Social Work Education; Department of Health and Human Services’ Food and Drug Administration (5R13FD005362-02) and National Institutes of Health (NIH) (HHSN26300001 and 75N98019F00469 [Under Master Base HHSN263201800029I]) through the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s National Center for Medical Rehabilitation Research, National Center for Complementary and Integrative Health, National Eye Institute, National Institute of Mental Health, National Institute of Neurological Disorders and Stroke, National Institute on Aging, National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, NIH Blueprint for Neuroscience Research, and Office of Behavioral and Social Sciences Research; Department of Veterans Affairs (VA240-14-C- 0057); Eli Lilly and Company; Foundation for Chiropractic Progress; Foundation for the National Institutes of Health; Gatsby Charitable Foundation; The Institute for Integrative Health; Janssen Research & Development, LLC; Jonas Nursing and Veterans Healthcare; Josiah Macy Jr. Foundation; Michigan Center for Interprofessional Education; The Kavli Foundation; Lundbeck Research USA; Merck Research Laboratories; The Michael J. Fox Foundation for Parkinson’s Research; National Academies of Practice; National Association of Social Workers; National Board for Certified Counselors and Affiliates; National Board of Medical Examiners; National Council of State Boards of Nursing; National League for Nursing; National Multiple Sclerosis Society; National Science Foundation (BCS-1064270); One Mind; Organization for Associate Degree Nursing; Physician Assistant Education Association; Sanofi; Society for Neuroscience; Society for Simulation in Healthcare; Takeda Pharmaceuticals International, Inc.; University of Toronto; Weill Cornell Medicine–Qatar; and Wellcome Trust. Any opinions, findings, conclusions, or recommendations PREPUBLICATION COPY: UNCORRECTED PROOFS

expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25406 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. The role of nonpharmacological approaches to pain management: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25406. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence- based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/ about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

PLANNING COMMITTEE ON THE ROLE OF NON-PHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT1 DANIEL CHERKIN (Co-Chair), Kaiser Permanente Washington Health Research Institute (Emeritus) ANTHONY DELITTO (Co-Chair), University of Pittsburgh JOHN CHAE, Case Western Reserve University MEGAN DRISCOLL, University of Pittsburgh Medical Center KIM DUNLEAVY, University of Florida STEVEN GEORGE, Duke University ELIZABETH (LIZA) GOLDBLATT, Academic Collaborative for Integrative Health ALAN JETTE, Massachusetts General Hospital Institute of Health Professions ROBERT KERNS, Yale University JOHN KRYSTAL, Yale University ANNE MARIE MCKENZIE-BROWN, Emory University VITALY NAPADOW, Massachusetts General Hospital; Harvard University ROBERT SAPER, Boston University DENNIS TURK, University of Washington CHRISTIN VEASLEY, Chronic Pain Research Alliance Health and Medicine Division Staff SHEENA M. POSEY NORRIS, Program Officer ANNA FAHLSTROM, Research Assistant PHOENIX WILSON, Senior Program Assistant CLARE STROUD, Director, Forum on Neuroscience and Nervous System Disorders PATRICIA CUFF, Director, Global Forum on Innovation in Health Professional Education ANDREW M. POPE, Director, Board on Health Sciences Policy JULIE PAVLIN, Director, Board on Global Health 1The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY: UNCORRECTED PROOFS

FORUM ON NEUROSCIENCE AND NERVOUS SYSTEM DISORDERS1 STORY LANDIS (Co-Chair), Director Emeritus, National Institute of Neurological Disorders and Stroke JOHN KRYSTAL (Co-Chair), Yale University SUSAN AMARA, Society for Neuroscience RITA BALICE-GORDON, Sanofi KATJA BROSE, Chan Zuckerberg Initiative EMERY BROWN, Harvard Medical School and Massachusetts Institute of Technology DANIEL BURCH, Pharmaceutical Product Development, LLC JOSEPH BUXBAUM, Icahn School of Medicine at Mount Sinai SARAH CADDICK, Gatsby Charitable Foundation ROSA CANET-AVILES, Foundation for the National Institutes of Health MARIA CARRILLO, Alzheimer’s Association E. ANTONIO CHIOCCA, Harvard Medical School TIMOTHY COETZEE, National Multiple Sclerosis Society JONATHAN COHEN, Princeton University ROBERT CONLEY, Eli Lilly and Company JAMES DESHLER, National Science Foundation BILLY DUNN, Food and Drug Administration MICHAEL EGAN, Merck Research Laboratories JOSHUA GORDON, National Institute of Mental Health HENRY T. GREELY, Stanford University RAQUEL GUR, University of Pennsylvania MAGALI HAAS, Cohen Veterans Bioscience RAMONA HICKS, One Mind RICHARD HODES, National Institute on Aging STUART HOFFMAN, Department of Veterans Affairs STEVEN HYMAN, Broad Institute of Massachusetts Institute of Technology and Harvard University FRANCES JENSEN, University of Pennsylvania GEORGE KOOB, National Institute on Alcohol Abuse and Alcoholism 1The National Academies of Sciences, Engineering, and Medicine’s forums and round- tables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. ix PREPUBLICATION COPY: UNCORRECTED PROOFS

WALTER KOROSHETZ, National Institute of Neurological Disorders and Stroke ALAN LESHNER, American Association for the Advancement of Science (Emeritus) HUSSEINI MANJI, Janssen Research & Development, LLC CAROLINE MONTOJO, The Kavli Foundation ATUL PANDE, Tal Medical STEVEN PAUL, Voyager Therapeutics, Inc. EMILIANGELO RATTI, Takeda Pharmaceuticals International, Inc. DOUGLAS SHEELEY, National Institute of Dental and Craniofacial Research TODD SHERER, The Michael J. Fox Foundation for Parkinson’s Research DAVID SHURTLEFF, National Center for Complementary and Integrative Health PAUL SIEVING, National Eye Institute NORA VOLKOW, National Institute on Drug Abuse ANDREW WELCHMAN, Wellcome Trust DOUG WILLIAMSON, Lundbeck STEVIN ZORN, MindImmune Therapeutics, Inc. Health and Medicine Division Staff CLARE STROUD, Forum Director SHEENA M. POSEY NORRIS, Program Officer PHOENIX WILSON, Senior Program Assistant BARDIA MASSOUDKHAN, Financial Associate ANDREW M. POPE, Director, Board on Health Sciences Policy x PREPUBLICATION COPY: UNCORRECTED PROOFS

GLOBAL FORUM ON INNOVATION IN HEALTH PROFESSIONAL EDUCATION1 CASWELL EVANS (Co-Chair), University of Illinois at Chicago College of Dentistry DEBORAH POWELL (Co-Chair), University of Minnesota MALCOLM COX (Co-Chair Emeritus), University of Pennsylvania, formerly Department of Veterans Affairs SUSAN SCRIMSHAW (Co-Chair Emeritus), The Sage Colleges FRANK ASCIONE, University of Michigan TIMI AGAR BARWICK, Physician Assistant Education Association DAVID BENTON, National Council of State Boards of Nursing JOANNA CAIN, University of Massachusetts School of Medicine KATHY CHAPPELL, American Nurses Credentialing Center STEVEN CHESBRO, American Physical Therapy Association AMY APARICIO CLARK, Aetna Foundation DARLA SPENCE COFFEY, Council on Social Work Education DARLENE CURLEY, Jonas Nursing and Veterans Healthcare JAN DE MAESENEER, Ghent University MARIETJIE DE VILLIERS, Stellenbosch University KIM DUNLEAVY, American Council of Academic Physical Therapy KATHRIN (KATIE) ELIOT, Academy of Nutrition and Dietetics ELIZABETH (LIZA) GOLDBLATT, Academic Collaborative for Integrative Health CATHERINE GRUS, American Psychological Association SUSAN HANRAHAN, Association of Schools of the Allied Health Professions NEIL HARVISON, American Occupational Therapy Association ERIC HOLMBOE, Accreditation Council for Graduate Medical Education ELIZABETH HOPPE, Association of Schools and Colleges of Optometry HOLLY HUMPHREY, Josiah Macy Jr. Foundation EMILIA IWU, Jonas Nursing and Veterans Healthcare PAMELA JEFFRIES, George Washington University 1The National Academies of Sciences, Engineering, and Medicine’s forums and round- tables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. xi PREPUBLICATION COPY: UNCORRECTED PROOFS

SANDEEP (SUNNY) KISHORE, Young Professionals Chronic Disease Network KATHLEEN KLINK, Veterans Health Administration CHAO MA, Peking Union Medical College ANDREW MACCABE, Association of American Veterinary Medical Colleges LAURA MAGAÑA VALLADARES, Association of Schools and Programs of Public Health LUCINDA MAINE, American Association of Colleges of Pharmacy BEVERLY MALONE, National League for Nursing MARY E. (BETH) MANCINI, Society for Simulation in Healthcare ANGELO MCCLAIN, National Association of Social Workers LEMMIETTA G. MCNEILLY, American Speech-Language-Hearing Association MARK MERRICK, Commission on Accreditation of Athletic Training Education DONNA MEYER, Organization of Associate Degree Nursing WARREN NEWTON, American Board of Family Medicine BJÖRG PALSDOTTIR, Training for Health Equity Network (THEnet) MIGUEL PANIAGUA, National Board of Medical Examiners RAJATA RAJATANAVIN, Mahidol University LUCY SAVITZ, Kaiser Permanente WENDI SCHWEIGER, National Board for Certified Counselors, Inc. & Affiliates NELSON SEWANKAMBO, Makerere University College of Health Sciences STEPHEN SHANNON, American Association of Colleges of Osteopathic Medicine JAVAID I. SHEIKH, Weill Cornell Medicine–Qatar SUSAN SKOCHELAK, American Medical Association ZOHRAY TALIB, George Washington University MARIA TASSONE, University of Toronto DEBORAH TRAUTMAN, American Association of Colleges of Nursing MICHELLE TROSETH, National Academies of Practice RICHARD (RICK) W. VALACHOVIC, American Dental Education Association CYNTHIA A. WALKER, Medtronic xii PREPUBLICATION COPY: UNCORRECTED PROOFS

ALISON J. WHELAN, Association of American Medical Colleges ADRIENNE WHITE-FAINES, American Osteopathic Association XUEJUN ZENG, Peking Union Medical College BRENDA ZIERLER, University of Washington Health and Medicine Division Staff PATRICIA A. CUFF, Senior Program Officer ANNA FAHLSTROM, Research Assistant DANIEL CESNALIS, Financial Associate JULIE PAVLIN, Director, Board on Global Health xiii PREPUBLICATION COPY: UNCORRECTED PROOFS

Reviewers This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: ROGER CHOU, Oregon Health & Science University PENNEY COWAN, American Chronic Pain Association CARMEN GREEN, University of Michigan Medical School CATHERINE LIVINGSTON, Oregon Health Authority ERIC SCHOOMAKER, Uniformed Services University of the Health Sciences HEATHER TICK, University of Washington School of Medicine BOB TWILLMAN, Academy of Integrative Pain Management JUDY WATT-WATSON, University of Toronto Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by BRIAN STROM, Rutgers, the State University of New Jersey. He was responsible for making certain xv PREPUBLICATION COPY: UNCORRECTED PROOFS

xvi REVIEWERS that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS

Contents 1 INTRODUCTION AND BACKGROUND 1 Workshop Objectives, 2 Organization of the Proceedings, 4 2 WORKSHOP CONTEXT: LIVED EXPERIENCE, PROVIDER PERSPECTIVES, AND CURRENT PATTERNS OF USAGE 5 Lived Experience and Provider Perspectives, 6 Background on Pain and Nonpharmacological Pain Management, 8 3 EFFECTIVENESS, SAFETY, AND COST-EFFECTIVENESS OF NONPHARMACOLOGICAL AND NONSURGICAL THERAPIES FOR CHRONIC PAIN 15 Examining the Effectiveness and Safety of Nonpharmacological Approaches, 17 Cost-Effectiveness and Cost Savings from a Societal Perspective, 22 Potential Research Priorities Moving Forward, 24 4 EMERGING MODELS OF CARE 25 Stepped Care, Stratified Care, and Matched Care, 29 First Contact Care, 30 Care for Patients with Complex and High-Impact Chronic Pain, 31 Integrative Care, 32 Using Technology to Support Access, Self-Management, and Care Processes, 34 Multimodal Approaches to Pain Management, 36 Neuromodulation, 37 xvii PREPUBLICATION COPY: UNCORRECTED PROOFS

xviii CONTENTS 5 MAJOR CURRENT RESEARCH INITIATIVES AND PRIORITIES 41 NIH HEAL Initiative, 43 Patient-Centered Outcomes Research Institute, 48 Department of Veterans Affairs, 48 Department of Defense, 49 6 EDUCATION AND TRAINING OF HEALTH PROFESSIONALS IN PAIN MANAGEMENT 51 Interprofessional Education Models, 53 Collaborative Practice: A Team-Based Approach for Pain Management, 57 7 POLICIES TO ADDRESS BARRIERS TO THE USE OF EVIDENCE-BASED NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT 63 Barriers and Potential Opportunities to the Implementation of Nonpharmacological Care: Patient, Clinician, Educator, and Health Care System Perspectives, 64 The Payer Perspective: Insurance Coverage and Reimbursement, 70 8 FUTURE DIRECTIONS 77 Potential Opportunities for Moving Forward, 78 APPENDIXES A References 81 B Workshop Agenda 91 C Registered Attendees 101 PREPUBLICATION COPY: UNCORRECTED PROOFS

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Pain is a leading cause of disability globally. The dramatic increase in opioid prescriptions within the past decade in the United States has contributed to the opioid epidemic the country currently faces, magnifying the need for longer term solutions to treat pain. The substantial burden of pain and the ongoing opioid crisis have attracted increased attention in medical and public policy communities, resulting in a revolution in thinking about how pain is managed. This new thinking acknowledges the complexity and biopsychosocial nature of the pain experience and the need for multifaceted pain management approaches with both pharmacological and nonpharmacological therapies.

The magnitude and urgency of the twin problems of chronic pain and opioid addiction, combined with the changing landscape of pain management, prompted the National Academies of Sciences, Engineering, and Medicine to convene a workshop on December 4–5, 2018, in Washington, DC. The workshop brought together a diverse group of stakeholders to discuss the current status of nonpharmacological approaches to pain management, gaps, and future directions. This publication summarizes the presentations and discussions from the workshop.

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