Daniel Cherkin suggested in his concluding remarks that the field is in the midst of moving “from a thousand points of blight to a thousand points of light.” The points of blight are well recognized, he said, including the tremendous toll of the opioid epidemic, the continued suffering of people in pain despite the availability of treatment approaches that can relieve suffering, inadequate clinician training, poor understanding of evidence
regarding pain treatment effectiveness, continued focus on a biomedical rather than biopsychosocial approach to treating pain, poor access to effective nonpharmacological care, inadequate coverage of nonpharmacological treatments, and a shortage of qualified clinicians to deliver those treatments.
The cost of continued inaction is high, Cherkin said as he shifted his attention to the thousand points of light. First, he said, recognition of the essential role of education has resulted in efforts to improve pain curricula with a focus on team and collaborative care, expand the workforce in critical areas, and change licensure and accreditation policies. In addition, models are being developed to remove cost and access barriers and provide systems support to make it easier for clinicians to provide nonpharmacological care. Finally, many agencies are increasing research funding dedicated to improving the management of pain. Cherkin also highlighted the increasing focus on patients at the center of care management and the importance of empowering patients and supporting self-management.
Eric Schoomaker added that although people in the conventional health care world might see efforts to expand the use of complementary and integrative health approaches as an attempt to build an alternative universe, in reality the aim is to integrate emerging disruptive technologies, some of which are 4,000 years old, into conventional practice.
Cherkin predicted that the workshop would imbue participants with energy and confidence to take their good work in this area to the next level, knowing that they can call on other participants for advice, support, and collaboration. Anthony Delitto agreed, adding that workshop participants are already implementing many new ideas in the classroom, clinic, and community. Emerging models are ready for prime time, said Delitto, adding that he would like to see simulations give way to real-world studies in community environments.
David Elton noted that many innovative pilot studies are underway that are driven by employers. For example, some studies evaluating virtual reality with biofeedback in the office and at home to control pain (Gupta et al., 2018). Biometric data collected indicated that participants experienced better pain control and improved function at very low cost, he said.
Benjamin Kligler commented that pragmatic data and a big data approach will be needed to evaluate some combinations of approaches, such
as cognitive behavioral therapy plus acupuncture plus yoga, because it is unlikely that anyone would conduct a clinical trial to assess effectiveness of that combination. Elton said Optum Labs is working in this space to bring all stakeholders together with academic and industry researchers and provide data access to begin answering these kinds of questions. Margaret Chesney added that leveraging datasets in existing studies may also provide a head start in efforts to fill research gaps.
Another issue related to understanding the effectiveness of combined therapeutic approaches was raised by Elizabeth Goldblatt. When people experience difficult chronic pain, they frequently see multiple practitioners who may or may not be working together as a team. It is vitally important that health professionals communicate with one another to provide optimal care, she added. Roger Chou said there have been studies of coordinated care models at the Department of Veterans Affairs (VA); although implementing these models outside of VA settings has proven difficult. Elton said data from his large network suggests there are pockets of innovation where diverse providers are working together in natural networks to provide tightly integrated care. These approaches can be powerful, he said, but may be challenging to scale up in health systems where providers operate in silos.
Cherkin suggested convening a task force to identify key actions that would have the biggest, broadest, and quickest impact on removing major barriers, and then crafting a strategy to address those issues. Schoomaker agreed, adding that a campaign plan is needed to clearly define lines of efforts and principal tasks. A national campaign should include a substantial amount of public education, added Goldblatt. She and Belinda Anderson suggested reaching out and engaging big technology companies that are moving into the health care field in these efforts.
In the closing moments of the workshop, David Shurtleff urged workshop participants to take advantage of the major programs and initiatives already in place to help move these ideas forward.1
1 Shortly after this workshop, 30 new funding opportunities aimed at evaluating the full spectrum of strategies for pain management were announced as part of the NIH HEAL Initiative. For more information on the NIH HEAL funding opportunities, see https://www.nih.gov/about-nih/who-we-are/nih-director/statements/nih-needs-your-innovative-research-ideas-through-our-newly-announced-nih-heal-initiative-funding-opportunities (accessed February 7, 2019).
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