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The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop (2019)

Chapter: 6 Education and Training of Health Professionals in Pain Management

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Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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:"6 Education and Training of Health Professionals in Pain Management." 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:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 53
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 54
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 55
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 56
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 57
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 58
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 59
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 60
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 61
Suggested Citation:"6 Education and Training of Health Professionals in Pain Management." 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.
×
Page 62

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

6 Education and Training of Health Professionals in Pain Management Highlights • Clinicians often receive inadequate pre- and post-licensure train- ing about pain and its treatment (Fishman). • Interprofessional education and collaboration are essential com- ponents of integrative medicine (Kligler). • Several organizations have developed free curricula, including competency-based curricula, to facilitate interprofessional educa- tion (Darnall, Fishman, Kligler, Thomas). • Addressing misconceptions and reducing stigma are important goals of interprofessional curricula (Thomas). • Immersion programs, internships, and fellowships offer creative approaches to promote interprofessional pre-and post-licensure training (Anderson, Baker, Fishman). • Turf, ignorance, and economics present barriers to the implemen- tation of collaborative, team-based, patient-centered, pain care in clinical practice (Goldblatt). • Many excellent models to promote collaborative practice exist in- cluding those that involve interfaculty education, intra-agency col- laborations and exchange programs. In addition, there are programs that address social factors (or the social determinants) that affect the pain experience (Goldblatt, Harrell, Kligler, Watt-Watson). NOTE: These points were made by the individual speakers identified above; they are not intended to reflect a consensus among workshop participants. 51 PREPUBLICATION COPY: UNCORRECTED PROOFS

52 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT Throughout the workshop, many participants emphasized the need to change health care practice to integrate nonpharmacological management of pain, with important implications for implementation and dissemination that need to be considered, said Kim Dunleavy, clinical associate professor and director of Professional Education and Community Engagement in the Department of Physical Therapy at the University of Florida. Every group that has looked at the problem of inadequate or inappropriate pain man- agement has recognized that clinicians receive inadequate pre- and post- licensure training about pain and the treatment of pain (IOM, 2011b), said Scott Fishman, Fullerton Endowed Chair in Pain Medicine and professor of anesthesiology and psychiatry at the University of California, Davis. Adding to this problem are interprofessional and interdisciplinary silos and the fact that while each discipline includes pain in its curricula, pain is not the primary focus of any of them, he said. Benjamin Kligler con- curred about the importance of interprofessional education and collabora- tion, noting that they are essential components of integrative medicine. Integrative medicine, he said, reaffirms the important relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and uses all appropriate therapeutic lifestyle approaches and disciplines to achieve optimal health and healing.1 One of the biggest barriers to interprofessional education and health care is physicians who resist the idea of working collaboratively with other practitioners, said Kligler. Belinda Anderson, founding director of the Institute for Health and Wellness at Monmouth University, added that immersion approaches might be far more effective than didactic approaches in bringing people from disparate professions together. Selling this idea to different profes- sions may require different strategies, she said. In addition to informing practitioners from the various professions about how and why a particular complementary approach may be beneficial, she said it is equally im- portant to let them know about the training and qualifications of the prac- titioners of that approach. Creative approaches are also needed to encourage CIH professionals to collaborate with mainstream practitioners, 1For more information about integrative medicine, go to imconsortium.org (accessed March 11, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

EDUCATION AND TRAINING OF HEALTH PROFESSIONALS 53 she said. Educating patients about self-care and these different therapeutic interventions is also important, said Anderson. With medical information increasing at such a rapid rate, data over- load presents a significant challenge for providers. Thus, building complex- ity and changeability into interprofessional education curricula through the use of big data approaches, artificial intelligence, and telemedicine is es- sential, said Anderson. Learning health care systems that provide feedback to practitioners about successful and unsuccessful interventions may also help change behavior and practice, said David Shurtleff. INTERPROFESSIONAL EDUCATION MODELS Fishman advocated a competency-based education model that em- ploys competencies as goals. He led an interprofessional project that in- cluded physicians, nurses, pharmacists, acupuncturists, physical therapists, and other health care professionals to build consensus about core compe- tencies for pain management. Based on the domains of the International Association for the Study of Pain Curricula, they developed and reached consensus about the competencies of the important goals for all students: Every student who graduates from a health professional program should know what pain is and how to recognize it and should understand how to safely and effectively treat pain within the scope of their practice. In addi- tion, he said, they need to understand how the patient’s context affects their pain (Fishman et al., 2013). Fishman said the model has been em- braced by many national and international professional organizations. Fishman and colleagues were invited by the National Board of Medi- cine Examiners to review the U.S. Medical Licensing Exam to see how well it aligned with the core competencies they identified (Fishman et al., 2018). He and his team were surprised to find that 15 percent of the ques- tions on the exam directly tested on pain. However, almost 90 percent of the questions that directly tested aspects of pain knowledge focused on recognition of pain. Fishman said that while recognizing pain is obviously important, without understanding pain or how to treat it safely and effec- tively, or the context in which it occurs, may create the conditions where clinicians reach for what is known and accessible, which typically means opioids and other pharmacological approaches. While he believes the Na- tional Board of Medicine Examiners will change the test as a result of this study, even more important is to convince accreditors of schools and li- PREPUBLICATION COPY: UNCORRECTED PROOFS

54 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT censing organizations to require that schools demonstrate they are educat- ing students with clear competency-based goals for comprehensive pain education within their curricula. Kligler and colleagues, with a grant from the Health Resources and Services Administration, established the National Center for Integrative Primary Healthcare (NCIPH)2 and developed a standardized curriculum in integrative primary health care. In developing this program, they looked at shared competencies across different professions, realizing right away that shared competencies exist because every one of those professions put the patient first. The 30-hour online course they developed, called Foun- dations in Integrative Health, identified a set of core competencies and developed educational materials in integrative health (Kligler et al., 2015). The Department of Veterans Affairs (VA) has developed a set of free ed- ucational materials for interdisciplinary pain teams and a course called Whole Health for Pain and Suffering.3 Beth Darnall, clinical professor in the department of anesthesiology, perioperative and pain medicine at Stan- ford University, added that the International Association for the Study of Pain also has free curriculum outlines available online. The National Institutes of Health (NIH) Pain Consortium’s Centers of Excellence in Pain Education (CoEPEs)4 has also developed modules to promote prelicensure training on pain, according to the David Thomas, leader of the program and health scientist administrator in the Division of Epidemiology, Services, and Prevention Research at the National Institute on Drug Abuse (NIDA). One goal of these modules is to address miscon- ceptions, such as the idea that pain is in your head, or that if you treat a disease the pain goes away. Through the presentation of case studies, the modules also hope to reduce the stigma around pain, including the com- mon belief that patients who present with pain are drug seekers or simply complainers. The case studies approach also provides opportunities to learn about how to manage specific types of pain, said Thomas. For example, at a sickle cell disease (SCD) meeting, Thomas heard the story of a woman coping with pain related to the disease. SCD, said Thomas, is a condition where racism and ignorance collide. The woman’s story led to the creation 2For more information about NCIPH, go to http://nciph.org/ (accessed February 6, 2019). 3For more information and to download a Whole Health for Pain and Suffering course brochure, go to https://wholehealth.wisc.edu/courses-training/whole-health-for-pain-and- suffering (accessed February 6, 2019). 4For more information about the CoEPEs, go to https://painconsortium.nih.gov/Funding _Research/CoEPEs (accessed February 6, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

EDUCATION AND TRAINING OF HEALTH PROFESSIONALS 55 of an interactive module on the collaborative management of pain associ- ated with SCD. Thomas said he believes that the gap in pain education results from society’s lack of caring for people in pain. Although empathy for people in pain goes down in medical school, he said, empathy can be taught, and can pay dividends in terms of sustaining clinician’s interest in caring for people in pain (Chen et al., 2012; Hegazi and Wilson, 2013). Addressing Gaps in Pain Education To address the education gaps both in pre-licensure and post-licensure training, Fishman said we need to make some of the current NIH research funding available to study the impact of the education gap on the current opioid crisis as well as the impact of retaining our students and clinicians. Accreditors also need to be brought on board. Otherwise, he said, there will be generations of clinicians on the front line, particularly in primary care, who have not received adequate training in pain management. To fill this gap, he and his colleagues at the University of California, Davis, have developed a fellowship program using telementoring for retraining pri- mary care clinicians; and to make this training more widely accessible have also instituted a “train the trainer” primary care fellowship. Health professions with curricula that cover all these competency do- mains still face challenges in training students to synthesize this infor- mation into a comprehensive way to treat patients with chronic pain, said Nancy Baker, associate professor of occupational therapy at Tufts Univer- sity. The best way to do this, she said, would be through internships; how- ever, such internships are rare, in part because there are few sites that focus on the treatment of chronic pain. In addition, when an occupational thera- pist does gain this expertise, there are few jobs available. This “catch 22” is a problem for many other health professions, said Baker. To address this challenge, she suggested creating post-professional training programs to provide additional training for therapists with excellent skills but little spe- cific training in pain. She and her colleagues at Tufts have created an online training course for working therapists to increase their understand- ing of chronic pain and how to treat it. Moving from Classroom to Practice In 2010, the Lancet Commission published a report on health profes- sionals for a new century, emphasizing the importance of patient-centered, collaborative, team-based care, said Elizabeth Goldblatt (Frenk et al., PREPUBLICATION COPY: UNCORRECTED PROOFS

56 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT 2010). Shortly thereafter, she said, the IOM published a report on the fu- ture of nursing—the largest segment of the health care workforce—which emphasized the need for all health professionals to practice up to their full scope of training (IOM, 2011a). Those seminal reports led to the formation of the National Academies’ Global Forum on Innovation in Health Profes- sional Education, while at the same time the Interprofessional Education Collaborative (IPEC)5 was getting starting with its 6 original members that has now expanded to 21, and includes the Association of Chiropractic Col- leges, said Goldblatt. To create inclusive and collaborative team-based, patient-centered pain care, all mainstream/conventional health professionals are now re- quired to receive training in interprofessional education and collaborative practice, according to Goldblatt. Practitioners of five CIH approaches— acupuncture/East-Asian medicine, chiropractic, naturopathic medicine, massage therapy, and direct-entry midwifery—are licensed and have ac- creditation bodies recognized by the Department of Education. Others such as yoga or Ayurveda medicine,6 while highly credible, are not yet licensed in the United States, said Goldblatt. Models are emerging to pro- mote integrated health care using blended classrooms and collaborative clinics where health care professionals can gain deep knowledge about other professions and learn how to work together. Goldblatt mentioned there is a wealth of information on the National Center for Interprofes- sional Practice and Education (NEXUS) website, which provides evi- dence-based resources across the education-to-practice continuum.7 Practitioners in medical and allied health professions also need to learn self-care since many of these professionals (e.g., dental hygienists, physi- cal therapists, and occupational therapists) suffer from chronic occupa- tion-related pain, said Monika Gross with the Poise Project and Alexander Technique for Pain Management. She also suggested creating a new class of health care professionals for persons skilled in advocacy and translation. 5For more information about IPEC, go to https://www.ipecollaborative.org/about- ipec.html (accessed February 6, 2019). 6Ayurveda medicine is the ancient Indian medical system that “relies on a natural and holistic approach to physical and mental health.” It “combines products (mainly derived from plants, but may also include animal, metal, and mineral), diet, exercise, and lifestyle.” For more information, go to https://nccih.nih.gov/health/ayurveda/introduction.htm (ac- cessed March 7, 2019). 7For more information about NEXUS, go to https://nexusipe.org (accessed February 6, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

EDUCATION AND TRAINING OF HEALTH PROFESSIONALS 57 Working as consultants to health systems, these individuals could help translate curricula from one institution to another. COLLABORATIVE PRACTICE: A TEAM-BASED APPROACH FOR PAIN MANAGEMENT Creating egalitarian collaborative teams to provide patient-centered care remains a challenge, said Goldblatt. Turf, ignorance, and economics (TIE) all present barriers, despite the benefits that collaborative, team- based care can provide for patients and often can reduce stress for provid- ers. Evidence of the benefits gained from collaborative practice can help build bridges across disciplines, said Goldblatt, adding that successful teams require respect and trust for all practitioners on a team and a clear understanding of the strengths and limitations each one brings. The importance of collaborative practice in the treatment of pain and addressing the opioid epidemic mirrors what became evident in the early years of the HIV/AIDS epidemic, said Margaret Chesney, professor of medicine at the University of California, San Francisco. Then, like now, there were dual epidemics—treating patients while at the same time stop- ping the spread of the disease—both of which demanded attention to a wide array of medical and social factors, said Chesney. Specialists in in- fectious disease, oncology, dermatology, pulmonology, and others were called in for their expertise; and psychologists were also needed to help patients manage the stress of coping with the disease. All providers be- came integral parts of the collaborative team, she said. Moreover, because adherence to the complex and individualized medication regimens was so important to prevent development of drug-resistant virus, patients were not only the center of the team, they led the team, said Chesney. It was “their adherence to care” that the tam needed to encourage. Wanting to avoid adding new medications to deal with the side effects of their antiviral treat- ment, patients began educating her and other clinicians about side effect management, including acupuncture, massage, dietary interventions, sup- plements and other nonpharmacological approaches they had sought out. The collaborative team also expanded to include communities, when it be- came clear that providing housing and other resources would also be neces- sary to stop the epidemic. Anderson added that including social scientists and psychologists on the team can be especially helpful in elucidating the importance of social determinants of health. PREPUBLICATION COPY: UNCORRECTED PROOFS

58 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT The Department of Defense’s (DoD’s) Pain Management Task Force, which was mentioned in Chapter 5, also recognized the importance of col- laborative practice, said Chester (Trip) Buckenmaier III, Colonel, U.S. Army (retired) and program director and principal investigator for the Uni- formed Services University of the Health Sciences Defense and Veterans Center for Integrative Pain Management (DVCIPM) under the Department of Military Emergency Medicine. The ultimate goal of collaborative practice, said Buckenmaier, is to enable an individualized process and team approach that bridges the different treatment silos. Keeping silos and connecting them with the patient at the center of the activity is important, he said, adding that, in the operating room, the silo of anesthesiology is essential. Combating prejudice against what are considered alternative treatment approaches can interfere with development of collaborative teams, noted John Chae, vice president of research at MetroHealth. Using as an example the field of physical medicine and rehabilitation (PM&R), he suggested that prejudice could be overcome with science. PM&R evolved to what is now a more mainstream approach in part because of the emergence of the biopsychosocial model as well as an embrace of science, he said. How- ever, Kligler noted a tension that exists between pushing for research using conventionally established methods of proof and the use of other types of research methodologies. Patient-Centered Outcomes Research Institute (PCORI), for example, has successfully promoted the use of alternative methodologies, he said. Collaborative Practice Models Several models of collaborative practice were presented at the work- shop. Some of these use case studies to discuss various aspects of pain management and treatment of opioid use disorder. Eric Schoomaker sug- gested that to explore management of opioid use disorder, a case involving traumatic amputation would be appropriate since wounded warriors are the most grievously wounded and do not want to be further disabled by opioids. Other models immerse patients in a well-functioning social group to leverage the importance of social, cohort, and kinship functions in man- aging chronic pain. Daniel Carr, past president of the American Academy of Pain Medicine and professor of public health and community medicine at Tufts University, suggested that these programs might inadvertently be providing something akin to family therapy. PREPUBLICATION COPY: UNCORRECTED PROOFS

EDUCATION AND TRAINING OF HEALTH PROFESSIONALS 59 University of Toronto Interfaculty Pain Curriculum Judy Watt-Watson, professor emeritus at the University of Toronto, described an interfaculty prelicensure pain curriculum8 at the University of Toronto that has been mandatory for students in six training programs since 2002: dentistry, medicine, nursing, pharmacy, occupational therapy, and physical therapy (Hunter et al., 2008; Watt-Watson et al., 2004). Phy- sician assistants were also recently added, she said. The 20-hour program is completed over 3 days through a combination of online modules, large and small multiprofessional sessions, and concur- rent clinically focused sessions that the students choose. Students are as- signed to an interprofessional group of 30 people that is further divided into 10-person interprofessional teams to discuss several patient cases and develop appropriate patient-focused pain management plans. A facilitator on each team guides the team to ensure respect for the role of the different professions in patient care as well as the need for collaboration and future referrals to colleagues outside of their own profession, said Watt-Watson. Meanwhile, students learn about the relationship between pain and the so- cial determinants of health. Watt-Watson noted that an outcome of the curriculum is that many of the health science departments are now including more pain content in their curricula. As a result, students’ baseline knowledge is greater and overall scores for pain knowledge and beliefs between pre-test and post- test assessments increased by only only 7 percent in 2018 as compared to 17 percent in 2002. Recently, they have conducted curriculum mappings to identify overlaps and gaps, which along with the many other evalua- tions, allow them to adapt the program in an iterative fashion. They also have published a pain interprofessional curriculum decision model to share with other institutions what they have learned through the develop- ment and evolution of this program, said Watt-Watson (Watt-Watson et al., 2017). SHOW/Crossroads Model At the Biomedicine Campus in Phoenix, Arizona, the student-led clinic Student Outreach for Wellness (SHOW) has partnered with Cross- 8 For more information, go to http://sites.utoronto.ca/pain/research/interfaculty- curriculum.html (accessed March 11, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

60 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT roads, the largest substance abuse recovery residential center in the South- west, to provide community-based interprofessional direct care and health promotion services,9 said S. Liz Harrell, chief medical officer of integrated care at Crossroads and Doctor of Nursing Practice Faculty at the Arizona State University College of Nursing and Health Innovation. SHOW provides a learning laboratory that uses an interprofessional team-based approach to deliver care to vulnerable populations, said Harrell. The program is run by students and guided by interprofessional faculty from 12 different professional programs. Crossroads has been operating since 1960, originally as a halfway house before transitioning to become a residential substance use treatment program. Their recognition of the need for additional primary care services led to the partnership with SHOW, said Harrell. The SHOW/Crossroads clinic is expected to open in 2019 and will use an interdisciplinary team approach that focuses on ho- listic restoration. Other Innovative Programs to Promote Interprofessional Care Kligler described an exchange program between students from the Al- bert Einstein College of Medicine and the Pacific College of Oriental Med- icine, which gives students the opportunity to learn about each other’s practices and how they can be used in a complementary fashion to improve patient care (Anderson et al., 2012). Kligler also mentioned an acupunc- ture fellowship at Beth Israel in New York that trained licensed acupunc- turists to work in inpatient hospital settings. In interviews conducted with the acupuncturists, physicians, and nurses, Kligler said he and his col- leagues found that when nurses and physicians saw the benefits to their patients, they recommended acupuncture even if they did not know how it worked. The acupuncturists, meanwhile, felt like outsiders in conventional health care settings, and had to learn more about how hospitals function, said Kligler. The VA also has some excellent programs in complementary and in- tegrative care, added Kligler. For example, the Empower Veterans Pro- gram10 brings together social work, chaplaincy, physical therapy, and 9For more information, go to https://showazgeneral.wixsite.com/showazclinic (accessed March 11, 2019). 10To learn more about the Empower Veterans Program, go to https://www.atlanta.va.gov/ services/Empower_Veterans_Program.asp (accessed February 6, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

EDUCATION AND TRAINING OF HEALTH PROFESSIONALS 61 teachers of mindfulness in a 10-week program for veterans with high im- pact chronic pain. Participation in the program has yielded improved pain outcomes, decreased opioid use, and decreased suicidal thinking, said Kligler. Another innovative program called Central City Concern in Portland, Oregon, addresses the social determinants of physical and mental illnesses as well as addiction among the homeless through a comprehensive ap- proach that provides naturopaths, acupuncturists, chiropractors, working with a variety of mainstream health care providers while also offering housing, job training, and job placement, said Goldblatt. Models have also been developed for sustaining both education and care delivery programs after initial grant funding runs out, said Harrell. Given that there is no business model for care programs, she is in the pro- cess of building such a model that others can use to replicate. On the edu- cation side, Watt-Watson noted that sharing specific curriculum content can be challenging because of copyrights held by the universities where the curricula were developed. Michele Maiers, executive director of research and innovation at Northwestern Health Sciences University, summed up the discussion by citing the need to customize models of interprofessional and transdiscipli- nary education to the specific needs of the communities served, including the learning communities. Moreover, she said, in planning for the future it will be important to consider the next generation of health care providers. Most of them are millennials who are recognized as being highly collabo- rative with extensive communication networks, said Maiers, adding that they also want to be part of creating new models from the ground up. Leslie Davidson, chair of the department of clinical research and lead- ership at the George Washington University School of Medicine and Health Science and an occupational therapist who specializes in traumatic brain injury and neurology, added that pain is not a sensation, but a per- ception which can be described as a complex phenomenon attributed to the confluence of ever-shifting internal and external variables. Conse- quently, the treatment of pain is equally complex, with patients at the cen- ter requiring a collaborative approach from practitioners with a range of skills. Davidson said, implementing collaborative practice requires practitioners to consider multiple aspects of a patient’s pain experience. For example, pain may be particularly debilitating for different reasons depending on the cur- rent circumstances and life stressors of the individual. PREPUBLICATION COPY: UNCORRECTED PROOFS

62 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT She cited a recent book titled Not for Long: The Life and Career of the NFL Athlete by Robert W. Turner II, an assistant professor in her depart- ment, who described how the lives of professional football players are af- fected by years of playing the sport. The pain they experience every day and the functional limitations imposed by the pain, frequently lead to de- pression that may increase their sense of pain and hopelessness, said Davidson. Other important considerations include the roles, priorities, and the sense of purpose or meaningful activity of the person who experiences pain. It is critical for those who participate on their care team to understand how the person expresses their pain, how pain can be treated to increase their quality of life, and whether the pain is acute, sub-acute, or chronic, said Davidson. She added that it is essential that the care team understands and explores what situations or activities are most painful, and the pa- tient’s level of readiness to participate in a treatment plan. David said, With this more complete understanding of the patient’s pain ex- perience a treatment plan can be devised, that may include occu- pational therapy, physical therapy, sleep hygiene, cognitive behavioral therapy (CBT), yoga therapy, nutrition, maintaining and activity journal, intimacy counseling, meditation, and other approaches. Simplification of the pain experience is a surefire way to set up a recipe for treatment failure. 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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