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8 Future Directions Highlights â¢ To address the education gap regarding pain and pain manage- ment, efforts are underway to improve pain curricula, expand the workforce in critical areas, and change licensure and accreditation policies (Cherkin). â¢ To make it easier for clinicians to provide nonpharmacological care, models to remove cost and access barriers and provide sup- port for clinicians are being studied (Cherkin). â¢ Pilot studies are underway to evaluate the effectiveness of multi- modal treatments, and pragmatic studies and big data approaches will also likely be needed (Elton, Kligler). â¢ Potential next steps include identifying actions that would have the greatest impact, developing a strategy to implement those ac- tions, designing a national public education campaign on pain and pain management, and engaging with companies moving into the health care field (Anderson, Goldblatt, Schoomaker). NOTE: These points were made by the individual speakers identified above; they are not intended to reflect a consensus among workshop participants. Daniel Cherkin suggested in his concluding remarks that the field is in the midst of moving âfrom a thousand points of blight to a thousand points of light.â The points of blight are well recognized, he said, including the tremendous toll of the opioid epidemic, the continued suffering of peo- ple in pain despite the availability of treatment approaches that can relieve suffering, inadequate clinician training, poor understanding of evidence 77 PREPUBLICATION COPY: UNCORRECTED PROOFS
78 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT regarding pain treatment effectiveness, continued focus on a biomedical rather than biopsychosocial approach to treating pain, poor access to ef- fective nonpharmacological care, inadequate coverage of nonpharmaco- logical 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 crit- ical 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 nonpharmaco- logical care. Finally, many agencies are increasing research funding dedi- cated to improving the management of pain. Cherkin also highlighted the increasing focus on patients at the center of care management and the im- portance 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 uni- verse, in reality the aim is to integrate emerging disruptive technologies, some of which are 4,000 years old, into conventional practice. POTENTIAL OPPORTUNITIES FOR MOVING FORWARD 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, add- ing 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 experi- enced better pain control and improved function at very low cost, he said. Benjamin Kligler commented that pragmatic data and a big data ap- proach will be needed to evaluate some combinations of approaches, such PREPUBLICATION COPY: UNCORRECTED PROOFS
FUTURE DIRECTIONS 79 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 pro- vide 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 practition- ers who may or may not be working together as a team. It is vitally im- portant that health professionals communicate with one another to provide optimal care, she added. Roger Chou said there have been studies of coor- dinated 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 inno- vation 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 substan- tial 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 work- shop participants to take advantage of the major programs and initiatives already in place to help move these ideas forward.1 1Shortly 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 Initi- ative. For more information on the NIH HEAL funding opportunities, go to 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 Feb- ruary 7, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS