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1 Introduction and Background1 Pain is a leading cause of disability globally (Dahlhamer et al., 2018; Vos et al., 2015). 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 (Rudd et al., 2016). The substantial burden of pain and the on- going opioid crisis have attracted increased attention in medical and public policy communities, resulting in a revolution in thinking about how pain is managed, said Daniel Cherkin, senior investigator (emeritus) at the Kai- ser Permanente Washington Health Research Institute. This new thinking acknowledges the complexity and biopsychosocial nature of the pain ex- perience and the need for multifaceted pain management approaches with both pharmacological and nonpharmacological therapies, a recommenda- tion of the 2011 Institute of Medicine report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (IOM, 2011b) and the National Academies report Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use (NASEM, 2017). For example, Cherkin said the American College of Physicians re- cently recommended a dramatically new approach to managing back pain that begins with nonpharmacological treatments as first-line care (Qaseem et al., 2017). Nonpharmacological approaches are also emphasized in the 1The planning committeeâs role was limited to planning the workshop, and the Proceed- ings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be con- strued as reflecting any group consensus. 1
2 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT Centers for Disease Control and Preventionâs Guideline for Prescribing Opioids for Chronic Pain (Dowell et al., 2016), added Steven George, pro- fessor and director of musculoskeletal research at the Duke Clinical Re- search Institute. An important challenge is to find strategies to implement these guidelines effectively and efficiently in real-world practice, said Cherkin. Echoing the emphasis on implementation, Anthony Delitto, dean of the School of Health and Rehabilitation Sciences and professor of phys- ical therapy at the University of Pittsburgh, added that implementing what is known now could make a big dent in addressing the challenges associ- ated with pain management. Emerging models of care that provide inte- grated, patient-centered, evidence-based, multimodal, interdisciplinary care,2 with systematic coordination of medical, psychological, and social aspects of careâa concept promoted by the National Pain Strategyâhave been shown to decrease pain and increase function and will be important, said Robert Kerns, professor of psychiatry, neurology, and psychology at Yale University. The magnitude and urgency of the twin problems of chronic pain and opioid addiction, combined with the changing landscape of pain manage- ment, prompted the National Academies of Sciences, Engineering, and Medicineâs Forum on Neuroscience and Nervous System Disorders and its Global Forum on Innovation in Health Professional Education to con- vene a workshop on December 4â5, 2018, in Washington, DC. The work- shop brought together a diverse group of stakeholders to discuss the current status of nonpharmacological approaches to pain management, gaps, and future directions. WORKSHOP OBJECTIVES The workshop was designed to provide participants with an under- standing of the evidence currently available on the effectiveness and safety of nonpharmacological approaches to pain management, as well as infor- mation about emerging models of care for people living with chronic pain. In addition, the workshop explored barriers, opportunities, and policy changes needed to facilitate implementation of integrated systems of care that include nonpharmacological treatments (see Box 1-1). Workshop 2Defined in the National Pain Strategy as care provided by a team of health professionals from diverse fields who coordinate their skills and resources to meet patient goals.
INTRODUCTION AND BACKGROUND 3 BOX 1-1 Statement of Task An ad hoc committee will plan and conduct a 2-day public work- shop that will bring together key experts and stakeholders from gov- ernment, academia, industry, health professional societies, and disease-focused organizations to discuss nonpharmacological treat- ments and integrative health models for pain management, and their role within the broad landscape of approaches to pain management. Invited presentations and discussions will be designed to: â¢ Review the current state of evidence on the effectiveness of nonpharmacological treatments and integrative health mod- els for pain management, as well as available evidence on use patterns and patient interest. Examples may include acu- puncture, manual therapies, physical therapy and exercise, cognitive behavioral therapy, tai chi, yoga, meditation, and noninvasive neurostimulation. â¢ Consider multimodal approaches and potential synergies be- tween pharmacological and nonpharmacological approaches to pain management. â¢ Consider multimodal approaches and potential synergies be- tween devices and nonpharmacological approaches to pain management. â¢ Discuss research gaps and key questions for further research. â¢ Examine health professionsâ current approaches for educat- ing students, trainees, and practicing clinicians on nonphar- macological pain management, and discuss potential next steps to improve training and education within and across health professions. â¢ Explore policies, such as those related to reimbursement, that would enable broader dissemination and implementation of evidence-based nonpharmacological treatments when appropriate. The committee will develop the agenda for the workshop, select and invite speakers and discussants, and moderate the discussions. A proceedings of the presentations and discussions at the workshop will be prepared by a designated rapporteur in accordance with National Academiesâ institutional guidelines.
4 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT presentations primarily focused on chronic pain.3 There was limited dis- cussion of natural products (e.g., cannabis and vitamins)âan examination of their effectiveness as treatments for pain was not within the scope of the workshop. ORGANIZATION OF THE PROCEEDINGS Chapter 2 provides context to the workshop, including perspectives from people living with pain and from providers about how pain is cur- rently managed, and opportunities to reduce disparities. Chapter 3 exam- ines the evidence available for nonpharmacological approaches to pain management and discusses future research priorities identified by individ- ual workshop participants. Emerging models of care, including stepped, stratified, integrative, and multimodal care models, as well as the use of technology to encourage self-management, are discussed in Chapter 4. Chapter 5 highlights major current research initiatives supported by fed- eral agencies and a nongovernmental institute in the United States that fo- cus on pain management and reducing opioid use. Gaps in the education and training of health professionals in pain management are discussed in Chapter 6, along with opportunities to address these gaps within and across health professions to encourage the adoption and appropriate use of evi- dence-based approaches. Chapter 7 explores potential policy solutions to address barriers to the delivery of effective pain care. In Chapter 8, work- shop participants consider potential next steps needed to advance the inte- gration of evidence-based nonpharmacological approaches in pain care. 3Foran in-depth discussion about pain management for people with serious illness, see the forthcoming proceedings from the complementary workshop on Pain and Symptom Management for People with Serious Illness in the Context of the Opioid Epidemic, hosted on November 29, 2018, by the National Academiesâ Roundtable on Quality Care for Peo- ple with Serious Illness. For more information, see http://nationalacademies.org/hmd/ activities/healthservices/qualitycareforseriousillnessroundtable/2018-nov-29.aspx (accessed February 9, 2019).