PMTF Day 1 pt 3 Subcommittee

DR. VANILA SINGH: So basically, what we wanted
to do is, in this subcommittee section where we discuss the three different modalities
that are in this subcommittee, knowing that two– the psychological intervention and complementary
alternative [INAUDIBLE] are in the other one. But these three, with the approaches to pain
management and the special consideration of special populations, wanted to open up. I think all of us here have had great deliberations,
long ones, over and over, over the summer. But some key highlight points that we had
brought forth that we want the public to know about, as they were not privy to those subcommittee
discussions. And I will ask everyone to have their name
tags sit up in that same fashion. And we’ll go, as much as possible, in the
order that it’s received. I will be moderating this. And I believe we have about one hour. Just under one hour. OK, John Prunskis, please go ahead. JOHN PRUNSKIS: Thanks, Dr. Singh. And I just had a question procedurally. In our discussions, do you want to go section
by section? What’s your determination of how the discussion
should be held? In other words, in looking at the draft document,
we have– Section 111 is Approaches to Pain Management in Acute Pain. Do you want to hear discussion on that, finish
that discussion, and then move on to the next gap? Or do you have a preference on how you’d like
our discussion today to proceed? I wanted to ask you. VANILA SINGH: Great question. Thank you. I think we’re going to integrate it. I anticipate that people are going to naturally
foray into one and the other. So it’s kind of open to what was discussed
in Subcommittee 1. JOHN PRUNSKIS: OK. VANILA SINGH: Thank you. JOHN PRUNSKIS: All right. Then, if I may, then I’ll proceed. Thanks again for your leadership. And thanks again for Matt, Dr. Gallagher,
and everybody on my committee. And for those members of the public, as was
mentioned before, this is still a draft living, breathing report, as Dr. Singh mentioned. So we’re not done yet. There’s a couple of things in the Gaps and
Recommendations. And I’ll go through these systematically and
quickly because I know many people here want to voice their opinions. And in deference to Dr. Singh’s request, I’ll
just go through them. So a couple of things that, if possible, might
be something to discuss are protection of physicians from prosecution or other sanctioning
if they’re using appropriate guidelines and ethical care. Other things– again, I’m going to get into
the weeds a little bit here. And I’m just going to go briefly into each
section. In the Acute Pain section is a reference to
ketamine. I’m not sure if that should be deleted. There’s, in Recommendation 1B, continuous
catheter is singled out as a regional technique. That might be subject to discussion as to
whether to leave it or keep it in. Under Medications, Recommendation 1A, where
it ends with, “Integrating the biopsychosocial model is recommended,” my suggestion would
be, “may be considered.” Moving down further to Gap 2, there are some
specific recommendations that, again, in some cases– I’m looking especially at Gap 2, Recommendation
2D. It states, “comprehensive, multidisciplinary.” One of the things that we’ve heard frequently
is the need for a comprehensive, multidisciplinary approach. But in our practice, for example, a lot of
times, we can address the pain problem without a multidisciplinary approach. And I just want to make sure that, somehow,
is not lost. Moving forward with other recommendations,
going forward to another gap about inadequately trained physicians. We mentioned certain boards, such as American
Board of Pain Medicine and American Board of Interventional Pain Physicians. And I think it’s just an oversight that we
actually didn’t mention the gold standard, which is the American Board of Medical Specialties
board certification process. VANILA SINGH: And, John, just because there
are 29 of us here, we’ve already done the commenting, editing portion days ago. This is more to enrich the discussion for
the public to understand what has led us to where we are. And so I think that’s the richer discussion,
not getting into technicalities of Req 1A or 1B. But rather, why is it that multidisciplinary
care may be appropriate in certain complex conditions? Where does that come from? Why is acute perioperative pain a good arena
to have a pre-op consultation when perhaps a patient may have chronic pain and may actually
be a complex patient to manage? Perhaps that situation where someone has already
been on opioids or [? on ?] on opioids and are about to have surgery, those types of
things. Why buprenorphine, which had come up in our
first public meeting, is something that we think should be considered earlier, rather
than later, for chronic pain patients. More on the subject matter, not the technical
editing, which we’ve already gone through, actually. JOHN PRUNSKIS: Well, as a point– I appreciate
those comments, Dr. Singh. Again, these are just suggestions. Maybe another way would be to go section by
section because I know that there are some– well, this is our first time together as a
group since we met months ago. And all of us, I know, take this very seriously,
and words really matter. They really matter. And it’s just a suggestion. It might be appropriate to take it section
by section, debate it, move on to the next section, because I haven’t heard from a lot
of my colleagues who may have concerns with some of the words. So it’d be difficult. VANILA SINGH: Why don’t why don’t we stick
to what– JOHN PRUNSKIS: Well, if I could just finish. VANILA SINGH: –your concern is. I think you’ve already had some time. I’d like to get everybody else a chance since
we only have an hour. And again, we have 29 members. I think you’ve made some of your points open
and available, a lot more than I anticipate everybody else is going to have. So we’ll come back, and let’s see how it opens
up, all right? JOHN PRUNSKIS: Just to end, what’s the– I
just need a clarification. What’s the process? So if one of our colleagues has a question
and wants to do a certain change, is there a vote up or down on a phrase, a sentence? VANILA SINGH: We are voting– JOHN PRUNSKIS: I’m not sure. VANILA SINGH: So as has been discussed in
our subcommittee meetings in the last few weeks, numerous times, we will be presenting
our recommendations. And people had a chance to weigh in on them. And that final document was sent. We are on a short timeline. And we will be voting on them tomorrow. For our public’s sake, we want them to be
able to think and understand about, perhaps, why sickle cell is something that was brought
up as an example as a disease in which it spans a lifetime of these folks, involves
a minority health issue, something that we wanted to address in detail. And that gives the public a better sense of
what we’re doing, rather than getting into the wordsmithing, which isn’t really what
the public meeting is for. That’s something that we’ve done on the side
already. So I hope that helps. I see– Dr. Clauw, did you have comments? DANIEL CLAUW: Yeah, and this is in response
to the public comments this morning from the person who was in charge of the occupational
therapists. I do think we have to modify our language
somewhat to be more inclusive of other types of therapists– OTs, recreational therapists,
art and music therapy. But there are a number of people that– I
think that we could call this umbrella “restorative therapy.” Maybe there’s a better semantic term. But I don’t think we in any way intended to
be that restrictive in the document. And we probably should edit it along those
lines. VANILA SINGH: And that’s a great point. And again, I think that was reflective in
the timing, knowing that once our report, with the recommendations, as we have it, gets
posted, we will trigger a 90-day public comment period where those modifications that make
absolutely great sense– because we know that it is a pretty extensive field of physical
therapy, restorative therapy, and whatnot that would be added. And I think we will make that a note for that
time period. Thank you. And I think, Dr. [INAUDIBLE]. SPEAKER 1: Good morning, everybody. And thank you for the opportunity to make
a few quick comments. First of all, to echo the comments that were
just made, I do appreciate the Task Force’s movement away from singular discipline language
in how we talk and how we write, and that our view broadens the field to multiple disciplines
and multiple perspectives. We had the physical therapists also echoing
that from the public comments, because language matters. We’ve talked a lot about stigmatization of
patients. But language can also marginalize others that
want to be part of the solution. And so I appreciate, as we continue to evolve,
that we continue to make that an important thing that’s in our consciousness. The other thing I just wanted the Task Force
to be aware of– the American Academy of Nursing has a campaign called Have You Ever Served? And the intent of the campaign is to highlight
that every provider that is doing an assessment or an evaluation of an adult patient should
probably be asking the question, “Have you ever served?” Because many of us who have served do not
necessarily want to talk about our experience, or are humbled by that experience, and may
not be forthright in bringing that information forward. And as we talk about special populations,
it may be on us, as providers, to ask that question– “Have you ever served?– to make
sure that we’re identifying those that may be part of a special population, the military
and the veterans population. So thank you for that. VANILA SINGH: Great comment. Thank you. [AUDIO OUT] –two, please. Or actually, Dr. Trescot first, and then Dr.
Zaafran, and then Dr. Tu. OK. ANDREA TRESCOT: Well, thank you again, Dr.
Singh, for allowing the participation in such an interesting and important document. As the representative for the American Society
of Interventional Pain Physicians, I do want to make just a couple of comments about the
role of interventions, both as a diagnostic tool– as we’ve said a couple of times, you
can’t treat what you can’t diagnose. And low back pain, as an example, is not a
diagnosis. And the physical therapy for a herniated disk
is very different than the physical therapy for a sacroiliac joint pathology. And to send someone to physical therapy early,
without a diagnosis, leads to inappropriate treatment that may actually be harmful in
the long run, and therefore, to put interventional pain management much, much, much earlier in
the treatment paradigm. It is not the treatment of last resort, but
rather the treatment of first resort or near first resort. The second has to do with the recognition
that all chronic pain started as an acute pain. And therefore, that early intervention preventing
the chronification of this acute pain is critical. And any delay in getting a diagnosis, in getting
effective therapy is going to increase the risk of that patient becoming a chronic pain
patient. And so the ER, the post-operative, all of
those arenas need to have a good understanding of what those interventional treatments might
involve. And that goes part and parcel to the education
and, as well, to the patients to understand what their interventional treatments are. Because interventional pain management and
pain management in general has been a black box. The pain clinic was, as I think I said before,
what my husband used to call the Hotel California. You can check out, but you can never leave. It was the, when all else fails, send them
to pain management, and get them out of my office. I never want to see them again. I never expect to get them back again. And so that is, unfortunately, sort of like
sending someone with gangrene to, now, the endocrinologist to get their blood sugar under
control, and then being surprised that there’s no good resolution of the problem. And for that reason, I think it’s also important
to recognize that the chronic pain patient is a special population in and of themselves. And I’m not sure we ever got that idea across–
that these patients respond to surgery, as an example, very differently than the virgin
patient. And therefore, this very close collaboration
between the surgeon and the perioperative team and the chronic pain specialist needs
to be really, perhaps, formalized better than it has been. And then the last thing I wanted to just mention
was much of what’s been looked at as pain management has been injections of materials–
local anesthetics, steroids, neurolytics, some neurolytic procedures– radiofrequency-cryo. But what we really, I think, got lost in the
wheat and chaff was the recognition of the stimulation aspects, both the noninvasive
and the invasive stimulations where we can do a local anesthetic injection that may last
a couple of hours. It may break a cycle. We can inject a steroid that may give days
to weeks of relief, where we can do a neurolytic that may give months to a years of relief. We’ve got the ability now to do invasive and
noninvasive treatments. The noninvasive being potentially patient-managed,
and the invasives that may have the potential for giving very long-term pain relief. And thank you. VANILA SINGH: Of course. And if I may say, that would also change what
we define as success. When someone’s having an acute flare on their
usual chronic pain, if you’re doing a procedure, and you get a few days out of it so the patient
can do some physical therapy and not lose too many days of work or lose their job, that’s
success. Versus some who will see, it should last a
year. So it’s the different situations and the maintenance
of the long-term issue, but also of the flares that happen and/or triggered by different
distress issues. ANDREA TRESCOT: Because you can’t rehab someone
who’s hurting. It’s very difficult to rehab somebody who’s
hurting. So if you give them just that period, that
push-start to get them some pain relief so that they can participate, that episodic treatment
doesn’t fix the problem. The rehabilitation does. But without that support through medications
and interventions, they’ll never be able to get to tolerate the physical therapy and rehabilitation. VANILA SINGH: Right. And I guess CRPS is probably one of the prime
examples of such a situation. Dr. Zaafran. SHERIF ZAAFRAN: Thank you, Dr. Singh. And actually, the conversation that I’m hearing
today, I think, validates quite a bit of what we had discussed over the last couple of weeks
in that there really is not one right answer. And there is not one single discipline that
is a solution to this problem. And I think, if you look throughout the document,
we did talk a little bit about making sure that the different components are emphasized,
especially in the Access to Care part, where I think we emphasized that a little bit more. But the idea of the multidisciplinary, multimodal
approach is important because, depending on the circumstance, it may just be intervention. It may just be the primary care physician
managing the acute flare-up. In many instances, it’s not one or the other. And hence, we came up with the whole “pain
navigator” and the “captain of the ship” concept in managing these complex situations as a
disease process and understanding that you have to deal with it in a horizontal fashion
and not in a vertical fashion. It’s not one or the other. It’s not physical therapy or intervention
or occupational therapy or your primary care provider. It’s really looking at all the different modalities
out there and trying to understand what, in totality, is going to help that specific patient. And one of the struggles that we had, at first,
was trying to delineate which of each discipline could actually be useful in treating pain. And we really couldn’t get to that answer
because it really wasn’t the answer. The answer was, it’s all of the above. And figuring out with one focused provider,
figuring out how to manage that patient through that process– how we can actually deal with
that chronic disease patient– which is what we’re defining chronic pain to be, within
a certain paradigm, through the process that they’re going through. Whether it be just managing their chronic
pain in a regular chronic condition, or whether it’s an acute flare-up in the perioperative
type of paradigm. So if you look throughout the document, I
think that theme is going to come up again and again and again in the standpoint of it’s
an all of the above– how you pay for it, how you manage it, how you treat it, how you
diagnose it, and how you manage that patient through that process. VANILA SINGH: Great point, because one of
the things is we knew access to treatment was a big deal coming from the public. So it wasn’t enough just to say, we need all
the tools in the toolbox, all the different modalities– even within PT, as Dr. Clauw
was saying, that there’s other restorative movement measures. So each of them have their detailed importance
and value. But what combination would really be dictated
by the individualized approach for that particular patient and bringing it together. And then sometimes learning the hard way that
certain patients may have sensitivities, or it doesn’t align with where their lifestyle
is. And so we recognize that there’s various treatment
modalities. But in order to enhance those or implement
them, the education had to be there for society, provider, and patient. The access to care issues had to be addressed,
particularly with opioids, when we’re saying, risk assessments, have a strong history, PDMP,
look at the records, risk stratify, all those sorts of things. That’s a complex, time-intensive, but very
important concept to keep patients safe, and also to not miss those times when it is indicated,
until we have better agents in the future. So it was looking at access to care, education,
and then the risk assessment, and how to do that, and then the stigma that often carries
a barrier. And putting those things in with the treatment
modalities, we thought, was the way to get this to actually occur and translate from
public policy to actual care. And then Dr. Tu. Thank you. Oh, OK. Dr. Lynch, then Dr. Tu. Thank you. MICHAEL LYNCH: Thank you, Dr. Tu. And thank you all. Just looking at this, it’s incredible. And thank you very much, Dr. Singh and Alicia,
for all your work. I think one of the things, when we’re talking
about multimodal therapy, sort of within the medications and the pharmacology– I’m approaching
it as an emergency physician and a toxicologist, primarily. Obviously, I treat pain. But I also spend a lot of time treating side
effects of medications– opioids and others. And I think it’s important and it has been
addressed and discussed that we recognize that, certainly, opioids and their risks and
side effects are well-recognized. When we’re talking about mixing and combining
multiple medications, which oftentimes is going to be appropriate to treat the various
aspects of a painful condition, it’s going to be very important that people– physicians,
patients– understand the side effects, risks, interactions of those medications, the interaction
with over-the-counter and non-prescribed medications, making sure that providers are aware of what’s
going on outside of their office or outside of their control and how that may impact what
they’re prescribing. And misuse, diversion, and those types of
things with non-opioid prescribed medications and nonscheduled medications. And one of the things that, I think, I’m sure
a lot of people are wondering about was the inclusion of poison center services, which
I appreciate. Thank you, Matt, and others. Is really addressing those kinds of issues. I think many people, when they think of poison
centers, don’t necessarily think of it related to medications and these types of scenarios. But I just want to sort of highlight and give
a little bit of background because I think most people don’t fully understand what it
is that they do. But essentially, they’re available 24/7. Anybody can call without– it’s free, essentially,
for public callers. And they can really help to manage, inform,
preempt, and then respond to any adverse effects, interactions. Can I take this with that? What might this do? I’m experiencing this side effect. Is that dangerous or not? And I think that that kind of service, when
you talk about access to care– being available throughout the United States to the public,
but also to health care providers. And we see that we significantly reduce ER
visits, hospitalizations, length of stay, and those types of things through our services. So I think it’s a powerful service for that
aspect of it. Obviously, as has been mentioned, we’re not
going to treat pain through poison centers. But I think there is– as we see more people
on more pharmaceuticals and things like that, there will be more side effects. It’s a very large portion of hospitalization
and adverse medical events driving health care utilization as well as morbidity for
patients. So I appreciate the inclusion. I do think that there is value there as part
of the overall construct as an aid both to patients and to providers. So I appreciate that. And I look forward to kind of seeing that
inclusion in the final report. So thank you very much. VANILA SINGH: One thing I want to say– Dr.
Lynch, that was actually very informative for us to understand what poison centers actually
do and to put that out there, particularly in this time, with the 24-hour services, but
also the links to other means. And I think that, here’s our colleague, and
they do this. And so it’s kind of really about connecting
the dots. And we’re putting more money into these treatment
and recovery services and whatnot, but there’s so many items that exist. And then there was a report that Dr. Lynch
had shared that actually showcased the top agents that are involved in unintentional
and intentional death. And it’s actually very, very educational,
certainly in the respect that we are in now. And I think that was something that really
gave me– and helped reframe me. I’m certain we put that on the SharePoint. But if you haven’t received it, it is their
annual poison center– the American Poison Center report. MICHAEL LYNCH: Annual report, yeah. VANILA SINGH: Yeah. And it’s fascinating in terms of understanding
what the accidental overdose chemicals or medications are. And it really gives us kind of more context
to what we’re seeing with the opioid epidemic. Dr. Tu, thank you for being patient. HAROLD TU: Thank you. I want to acknowledge the comments from the
women’s section of the AMA. I do think that our report should reflect
that focus and give a wider area of interest. The second is that I think the one thing that’s
been overlooked in the report is, under the Special Population– Native Americans. Minnesota being the number one in overdose
deaths, they’re unique in the sense that they’re sovereign nations. And access to resources and care and acknowledging
guidelines, I think, are problematic. And the other area I want to touch upon is
I believe that the use of PDMP should be mandated. And I would recommend that the report directs
and adhered to that recommendation. So thank you. VANILA SINGH: Thank you, Dr. Tu. And if I can, I’m just going to note that
we have, in the Health Disparities in African Americans, Latinos, American Indians, and
Alaska Natives– on page 9, we address them, specifically socioeconomic and cultural barriers
that may impede patient access to effective multidisciplinary care in this particular
group. And there’s evidence of racial and ethnic
disparities in pain treatment and treatment outcomes in the US in this group. And few interventions have been designed to
address these disparities. It was really a strong point you’re making
that we also– we’ll hear from IHS, the Indian Health Services CMO, who also spoke to us
in our subcommittee meetings. But it is certainly an ongoing issue. So that– HAROLD TU: Thank you. VANILA SINGH: –is why we wanted to bring
attention to that in terms of developing programs to address it. And the other thing– on the women’s. In the Special Section, we do talk about unique
issues related to pain management in women, with the recommendations. And this is on page 8. 1156, where we get into the unique challenges
that face women regarding their physical and mental health interactions with the health
system and roles in society. We do also ask for further research to elucidate
further understanding of the mechanisms driving sex differences in pain responses and research
of mechanism-based therapies that address those differences. So not only do we want to find out what they
are, but then we want to actually implement them and then raise awareness about it, certainly
to our front-line doctor and colleagues. And then the fact that women may experience
increased pain sensitivity. Of note, OBGYNs may be one of the first health
care providers a woman with pain encounters. And yet they’re often not included as part
of the multidisciplinary team. So we wanted to bring that. And I think ACOG, again, also came forth. And now we heard from AMWA, who I had met
the president when I was speaking at the Veteran’s and Women’s Issues. So that was just the right timing. And so I’m happy to note that those are in
there. And certainly, take an added look. We’d love to hear more. Thank you. And there we go. Dr. Brandow. AMANDA BRANDOW: Hi. Thank you, Dr. Singh and Alicia and all the
members of the Task Force. I’d just like to touch on sort of the rationale
for highlighting two special populations that I think are very complementary. That is patients with sickle cell disease
and pediatric patients. As everyone knows, sickle cell disease is
an inherited genetic disorder, so it spans, as Dr. Singh eloquently stated, the lifespan. So children with sickle cell disease start
experiencing severe acute, painful events as early as six months of age and experience
these acute events– acute and chronic and chronic pain throughout the lifespan. So I think it’s important to consider a disease
that spans the life also in the context of pediatric patients. Many chronic pain conditions that affect children
go on to continue to affect adults with chronic pain. In fact, a lot of adults who suffer from chronic
pain originated with a chronic pain condition in the childhood age groups, such as sickle
cell disease, among other severe chronic pain conditions in pediatric and adolescents. And so I think it’s important to understand
how we deliver care in the context of young children and giving them appropriate comprehensive,
multidisciplinary pain care as they develop early strategies to manage and cope with their
pain. And untreated pain has already been pointed
out in the acute arena or the chronic arena in childhood– goes on to develop and persist
as chronic pain as these children age. And so to remember our small children and
our adolescents and young adults is extremely important. And delivering expanded care in the context
of sickle cell disease or other chronic pain conditions. There’s also disparities of care. And sickle cell disease, as we know, affects
a minority population who already have barriers and difficulty accessing care, both in the
medical arena and the mental health arena, with very severe, limited access, specifically
for pediatric patients on Medicaid. And so I think, also, the other point for
consideration is an important collaboration that needs to be established between the disease
specialist– whether it be the hematologist, the neurologist, the gastroenterologist, the
rheumatologist– that’s managing their primary chronic disease, in partnership with pain
medicine, I think, is really important and cannot be underscored. So expanding access to pain care, both in
the pediatric and adolescent realm to partner with the primary disease specialist is really
important. Thank you. VANILA SINGH: Great points. And for any of those who want to have– the
actual page is 7. Page 7, where sickle cell disease, in section
1154, gets into some of the gaps, inconsistencies, and then our recommendations, which we’ve
highlighted, but in more specific detail. It really gets into what is needed in terms
of understanding the current options and then future research. When we looked into sickle cell, it was pretty
amazing at the dearth of clinical trials for other options. And so our hope is this spurs that on. And in parallel, perhaps, being a genetic
disease, maybe a cure sometime in the foreseeable future. But until then, of course, our patients are
here now, and they need to be addressed. And then, just specifically for unique issues
related to pediatric pain management, that’s on page 6. So it actually does overlap, certainly, with
the sickle cell issue. But once again, emphasizing the need for pediatric
pain specialists. I had mentioned this– that when we did a
request for information, I’d heard from many folks that they cannot recruit pediatric pain
fellowships that are going empty. And there’s so much involved in that. And so to help bring the workforce to that
level and incentivize it– or perhaps– there’s a lot of training for anyone who gets that
far. Usually, it’s– they’re pediatricians. And they go into anesthesia. And then they’re considering pain fellowship. So it’s, like, years and years. And the other thing was developing those models
of care that allow for the smooth transition. But we have one other thing that we wanted
to recommend– that’s in all that that had been put forth– was the development of pediatric
guidelines for opioid use. Because the guidelines that exist right now
are almost exclusively for opioids– for adults. Thank you. And so that’s something that’s very necessary,
if at all. And what other modalities and how best to
address that. Let’s see. Who else is– OK. Dr. Trescot and then Cindy. Yes. Thank you. ANDREA TRESCOT: So thank you for letting me
speak again for a minute. First of all, I’d like to echo what Amanda
said about the pediatric pain and becoming adult pain. As the time I worked at the University of
Washington in their headache clinic– and the name of my clinic is Pain and Headache
Center. It just stuns me how the vast majority of
my chronic migraine patients say their headaches started when they were five years old. And those untreated headaches continued. They do not get better. And they only got worse. The other thing that I wanted to comment,
though, is that we have, for many, many years, focused on the WHO ladder of pain treatment. And the assumption was that you started low
and moved up. And unfortunately, I think what that does–
it’s like saying, I’m going to put out a big fire by only using a little bit of water first. And if that doesn’t work, then I’ll go to
something bigger. Rather than recognizing that some of these
patients, especially the patients in acute pain or the patients who are in severe pain,
should not be first started on Tylenol, perhaps, but may need to go directly to more aggressive
treatments. And that instead of having a ladder, I have
seen a wheel or an arch, where the patient enters that treatment and escalates to more
or de-escalates to less based on their response to treatment. But that that WHO ladder has perhaps created
more problems and may need to be abandoned, or at least severely modified. And that it was an interesting concept at
a beginning, but it has actually hampered the treatment of the patient in pain. VANILA SINGH: Could you give an example of
that? Just for– because the ladder– yeah, we know
someone comes in. They have mild pain. It doesn’t get better. But one where it’s an acute flare and it’s
clearly at the higher level. It’s a 0 to 60 kind of thing. ANDREA TRESCOT: Right. So I guess the– and I’ve got a picture and
never presented it to the committee, at my own– I’m quite sorry I didn’t. But it was this idea of, if you even took
the 1 to 10 scale, that the entry of the treatment depends on the degree of pain that they’re
having. So someone with a pain who comes into the
ER writhing in pain perhaps shouldn’t be given just a prescription for ibuprofen. Now, there is a role for IV Toradol, as an
example. And having just been in the ER myself not
long ago, that was what I requested first. And 15 milligrams of Toradol did the trick. But that was my request. But for me to go to the emergency room for
the first time in 30 years with acute pain– not writhing, but got my attention. It, I think, delays getting the patient under
pain control so that then you can assess them. So just the recognition that perhaps we need
to rethink that ladder effect, and more a global or Venn diagram or some other way of
looking at the approach to pain management. VANILA SINGH: Understood. Well said. Cindy. CINDY STEINBERG: Sure. We’ll talk a lot more about the multidisciplinary
approach as we get into the other sections. And I just want to focus particularly on this
section, and in particular, the public comments that we have heard, and connect those with
something in this section. So I mean, 3,000 comments is an overwhelming
number of comments. And I want to thank Dr. Singh for very carefully
going through those. And those graphs that you showed were very
eye-opening and were very responsive to the many comments that we’ve heard. And so in this section, when we’re talking
about the need for opioid therapy after you’ve tried some other things, I want to really
thank the people that worked on this particular section for emphasizing that the type, dose,
and duration of therapy should really be determined by the treating physician and the individual
patient. I think that’s an important statement. It’s one that’s very responsive to the comments
that we have heard and the concerns. The fact that 78% of people talked about treatment
access, 42% conflation with addiction, 31% on provider disincentives– the number of
physicians that now feel like they’re in a tough position and are leaving pain medicine. And the overwhelming 25% discussing suicide. So I really think that that emphasis on provider,
individual treatment decisions, and individual need, when you’re talking about opioid dose,
opioid duration, and the type of opioid, is incredibly important and one that we are being
responsive to public comments with. VANILA SINGH: Thank you. Dr. Losby, please. Thank you. JAN LOSBY: Thanks, Dr. Singh, and Alicia,
and fellow Task Force members. Just a brief comment. I was reflecting on the comment we had around
occupational therapy as well as physical therapy. And then I was reflecting on, in May, when
we had our meeting and there was the pain patients. And they were sharing their stories. And one individual was mentioning that, yes,
she had access to occupational therapy or physical therapy. But because she was not then demonstrating
progress, her access to care was actually limited. So I would hope that there might be an opportunity
to incorporate not only access and reimbursement in the coverage, but to perhaps consider the
outcomes that are used for ensuring that an individual would continue to receive access
to care if, in fact, maintenance would be considered in addition to improvement. VANILA SINGH: Mhm. Yeah, that’s a great point. And I think, also, to tag along with that,
we had made some comment in that same meeting about the limitations in reimbursement and
coverage for PT being limited to once a year. Right. Is that sort of what– yeah. JAN LOSBY: To the number of visits, it would
perhaps be recognizing– it would be number of visits, and then if it’s maintenance as
a true treatment goal. VANILA SINGH: Right. Right. Maintenance and home therapy, and teaching
that, and having access to the facilities that would allow for the maintenance. Is it Dr. Cheng next? Dr. Cheng, and then Dr. Gallagher. Thank you. And then we’ll go to Dr. Rosenberg. JIANGUO CHENG: Well, thank you. I think, when we look at recommendations,
this all looks like all centered about the treatment– pharmacological treatment, non-pharmacological
intervention. But I do hope that we do not get the impression
it’s treatment centered. It should be patient centered. What, by that, I mean is, in the Cleveland
Clinic, we see about 81,000 patients a year. So from largely encounter with large number
of patients, we learned something. Each patient requires different treatment
plan. For example, if the patient have intracranial
hypertension headaches, and you do not have to do many different treatment. Epidural blood patch will cure 95% of patients. So the lesson we learned is you have to evaluate
each patient and to identify the true need of that patient. And we emphasize multidisciplinary care because,
in many cases, any single one treatment is not sufficient and not effective. And why so many patients are on chronic opioids–
because we have tried many different things, and none of them have worked. That’s why they end up in this maintenance
opioid therapy. And just like any treatment, there’s always
responders and non-responders. For those responders who respond to treatment
with the improvement or maintenance of their function and quality of life, that’s the best
evidence to continue that treatment. So individualized care is the core or is best
practice. Even though the recommendation is centered
on different modalities of treatment, I want to emphasize that’s not the center of care. In the center of care is the patient. Thank you. VANILA SINGH: Great comments. Thank you. Dr. Gallagher. ROLLIN GALLAGHER: Yeah, I just wanted to follow
up Andrea Trescot’s great comments about the need for immediate access to these treatments. The idea that people will try a whole bunch
of things while a patient’s losing function, getting compromised in their work or family
responsibilities is just not tenable. We really actually need to have a collaborative
care model. We’ve talked about that. Dr. Prunskis has talked about his system in
Chicago, for example. VA and DOD has committed themselves to having
pain medicine specialist access for primary care providers so that they can really, on
the same day, walk down the hall with a patient to the pain clinic and get that patient seen
and turned around in the right direction. So I agree we don’t need the old ladder. And waiting, for people that have problems,
should not occur any longer. Health systems need to have a collaborative
model where there’s easy access to all these different treatments– patient-centered, as
Dr. Cheng has mentioned. Thank you. VANILA SINGH: Thank you. Great points. Dr. Rosenberg. MARK ROSENBERG: Thank you. My comments are related to something that
Dr. Trescot had said regarding appropriate first dose of pain medication so that the
patient doesn’t have to go through a trial of too little pain medication when they’re
having severe pain. Our goal is– most acute pain– or a lot of
acute pain is treated in the emergency departments across the country. And we know that all chronic pain starts with
acute pain. And our goal is frequently to keep opioid-naive
patients opioid naive and not rush into opioids when not necessary. So I think best practice for emergency departments
is to do a treatment trial of medications prior to discharging the patient. That way, you can provide them with the lowest
dose, least toxic, least addicting medication first, and see how well that works. For instance, somebody who comes in with a
severe kidney stone pain, which is frequently very, very bad, a dose of IV lidocaine may
be enough to alleviate their pain. And then just some Toradol or nonsteroidals
will be all they need after that. And once you can identify that, then you’re
not sending them home with opioids that are not necessary. So I think, just repeating, best practice
in the emergency departments is to really try to use alternatives to opioids first. And if we can get them to work and the patient
tolerate it, then we know what to discharge them home on. And we can avoid going to too high of a dose
of a possibly addicting medication. Thank you. VANILA SINGH: Thank you. I’m going to come back with a question about
buprenorphine. Please, go ahead, Dr. Hagemeier. Oh. Oh, sorry. Yes. FRIEDHELM SANDBRINK: So thank you again for– VANILA SINGH: I’m lost in my world here. [LAUGHS] FRIEDHELM SANDBRINK: No, that’s OK. So I think it was emphasized repeatedly that
it’s really not a single modality that typically, for a chronic pain patient, is a solution. And going through these different approaches,
medications, physical therapy, intervention procedures leaves us a little bit with the
impression that we need to stand up more of these providers, that somehow we’re all taking
part in the treatment of the chronic pain patient. But at the same time, there’s sometimes a
little bit of confusion. What is multimodal care? What is multidisciplinary care? Where does one start and really lead to? So I just want to emphasize that, while we
discuss these modalities in isolation, what we really need to do is to also make sure
that not only the providers are actually informed and well-educated about the other modalities
and the importance of the other approaches as well, but also that we try to provide access,
really, as much as in the front, in the primary care office, as possible. So that means that maybe for interventional
pain procedures, a primary care is skilled in doing trigger point injections, or battlefield
acupuncture, or acupuncture, acupressure. But also understands the fundamentals of physical
therapy and exercise modalities so they can truly educate the patient and lead them with
expertise in the right direction. And not just relies on another referral to
another provider who’s going to then schedule them down the road. The other emphasis– I want to make sure that
multimodal care really, if it’s interdisciplinary or intermodal, basically, I guess, in that
regard. That’s a new word– means that it’s coordinated. That means that, for instance, if somebody
is going to get an epidural steroid injection, that the physical therapy is tied in with
this, that it’s maybe going to be utilized– VANILA SINGH: Yes. FRIEDHELM SANDBRINK: –right afterwards. And that, maybe, a psychologist approach beforehand
is already initiated to address a catastrophizing and make the most out of those modalities
as we employ those. So it really becomes not just all those different
modalities. It’s just checking them off one by one. But rather, it’s not a sequential. It’s an integrated process that brings them
together, brings them as much to the front, to where the patients are, and where the primary
care providers are who need access to this but also need to develop as much as possible
within their own practice. VANILA SINGH: Great points. Again, referring to the newer, the intermodal,
because we’re always multidisciplinary, interdisciplinary, integrative, multimodal. Our point is we need to help them all work
better together. And your point is huge and well-taken. I think the last time– I had had, actually,
one of my patients– because we had people who couldn’t make it suddenly, last minute. And for him, it was trigger points followed
by PT that allowed him to sustain his functionality. And it can’t be overemphasized. Very good point. And then, Dr. Prunskis. JOHN PRUNSKIS: Thanks very much. And I’d like to– I’m going to echo what some
of the doctors here have said. Diagnosis is critical. Without a diagnosis– and it has to be personalized,
individualized, like our colleague Dr. Cheng said, and others said as well. A higher level of discussions. We’ve talked briefly in our subcommittee about
the fact that we know that the electronic health record has allowed– has inadvertently
had a side effect of those physicians who use it prescribing increased opioids. And as we’re talking about how we– there
is an importance in some of our patients who need multimodal, interdisciplinary approaches. Let us remember that physicians, right now,
are just stressed and have an extra three hours of day per work entering data into an
EHR. So it’s great to talk at a table about how
we need multimodal, multidisciplinary. But let’s also remember the physician who
is exhausted, has three hours per day extra work, who might feel well-intentioned and
want to use multimodal, multidisciplinary, but just doesn’t have the time. So thank you. VANILA SINGH: Great point. And I think that’s an issue that almost all
the medical organizations support. And we will be mentioning that, for sure,
in the report because of its impact on the time and resource that we are highlighting. Dr. Zaafran. SHERIF ZAAFRAN: Yeah, thank you. I was actually going to say something else
first. But I’m going to respond to that real quick
because it’s a very valid point. What I’ll tell you is that, in our institution,
we actually were very forceful in making sure that how the electronic health record was
developed was actually developed by the physicians as far as it dealt with acute pain management. So when we talk about a multimodal approach,
we actually designed our medical plan pathways within the electronic health record to help
facilitate that so that you’re not spending more than a minute or two actually doing what
you would normally do 99% of the time, with a certain amount of modifications. And it helped standardize the way we did it. It helped facilitate it. In our pre-operative setting, every single
one of our patients gets pre-operative medications that are non-opioids because it helps significantly
in decreasing the amount of opioids that they actually end up needing intra- and post-operatively,
helping with that preemptive pain control. So I think the problem is that we, as physicians,
may not necessarily have been as engaged or have not been given the opportunity to be
as engaged in developing a lot of these modules within the EHR. A lot of times it’s, here, take it, and just
use whatever you have as a template, as opposed to us being directly engaged in how it’s being
developed. The other thing that I would just mention. I know a lot of folks talked about the fact
that it’s not one specific modality or another. We talked very specifically about the concept
of a pain navigator. And the whole purpose behind that was that
it’s very difficult for a patient to know, do I go to the physical therapist right after
I have my epidural steroid injection? Do I see the psychologist right beforehand? That whole process of timing in the quote,
unquote “intramodality” approach, sometimes you’re going to need to have that person that’s
going to help facilitate the sequence of how that patient is going to be managed that way. And the last point I would make, just from
the standpoint of the sequence of medications given, as I had mentioned earlier, it’s not
an either/or, but all of the above. I would just say that that non-steroidal anti-inflammatory
that was given to the patient, whether it worked or not– regardless if it didn’t work
very well, it probably decreased the amount of opioids that the patient might have eventually
needed afterwards. So the point is that even those medications
that you start off with, it’s not a matter of trialing whether it’s working or not. It’s actually starting that stepwise process–
not over a long period of time, but fairly quickly– so that you’re utilizing your non-opioid
modalities. And by the time you need the opioid modalities,
you’re actually using significantly less than what you normally would have needed to otherwise. VANILA SINGH: Great point. I see Dr. Trescot. Anybody else right now? Oh, and Dr. Lynch. There we go. Yeah, I’m just play– yeah. OK, so I don’t know which order– was it Lynch
first? Go ahead, Dr. Trescot. You start. ANDREA TRESCOT: Thank you very much. Just to make the comment to the navigator,
I think, having spent a rotation as a medical student at Mayo Clinic, one of the things
they did with their executive physicals was very much like this– that you can’t have
the– you had to have a bowel prep for this. And you couldn’t have your barium enema before
you had that. And it was all very well-organized so that
you didn’t have the conflicts. And so maybe Mayo has a type of template that
might help with that patient navigator. I also was going to make a comment. You had just briefly touched on the buprenorphine. And as a board certified addictionologist,
I would– and dealing with this in Alaska, which has a huge opioid problem. Allowing the ER to be able to initiate buprenorphine
in those patients who are in withdrawal because they took their opioids too much and are out
of their medicines– clearly with a substance abuse or misuse issue. So instead of giving them more opioids, instead
perhaps initiating them then on buprenorphine where they’re ready for an induction. The taking the patients who come in in an
overdose situation and being able to resuscitate them– but then not sending them home without
anything. And it breaks my heart to have patients coming
into the office who are, again, in that same situation that I see with the ER. They’re out of their medicines. I want to put them– or they’re admitting
to me that they have a– they’ve been doing street drugs. Or they have admitted to heroin use because
their urine popped positive. And then it’s going to take me three days
to get them buprenorphine approved from Medicaid from a prior authorization. Rather than have– this ought to be the lowest
barrier of any opioid. This should be a readily accessible. And I still don’t think I understand the need
for an X license in a medicine that has as– we don’t require an X license for methadone,
which is a great medicine, but potentially lethal. And yet we require a special license for a
medicine that has a very low risk profile to it. And then the last thing that I was going to–
well, I think that’s plenty. I’ve talked far too much today already. VANILA SINGH: Well, no. No, not at all. So first of all, yeah, buprenorphine having
the low abuse potential and the low– the respiratory depression issue, of course, makes
it– it’s a partial agonist. And the barriers that we hear about– so there’s
barriers to addiction and barriers to chronic pain. Many in the chronic pain community are stating,
look, we’re asked to fail fentanyl patches or other things with buprenorphine. And in some patients, it makes sense. So that is actually in our recommendations
for those who– sometimes you don’t, like– even though we see 100 million things, you
may not know. The real question that I think that is of
value is the growing question of buprenorphine in the ER, in the warm handoffs, and as a
possibility. And I know Mark knows that I’ve asked him
about it. But if anyone has any other thoughts– because
if Medicaid is limiting it to three days, then you’ve lost that opportunity right there. ANDREA TRESCOT: Absolutely. Because you have the patient who is, at that
point, motivated. They’re sick with withdrawal. And you can get them out of withdrawal. It’s that time when you have them by the short
hairs, as the expression would be. This is your only option. Here’s what you need to be doing. OK. And the tremendous relief from chronic pain. I have patients who were on Oxycontin, 80
milligrams, four times a day with pain scores of 7, 8, 9 who we transitioned to buprenorphine
with pain scores of 0 to 1. Patients who have just had a remarkable response
to buprenorphine for their chronic pain. And yet they, again, have had to fail multiple
medicines, particularly medicines that are inappropriate for these patients when you’re
trying to limit their exposure to opioids. A good example, to be able to do a buprenorphine
patch– which is a wonderful medicine as an initiation– I have to have somebody who fails
a fentanyl patch, which makes absolutely no sense because the buprenorphine patch is at
such a low dose there’s no equivalence whatsoever. Or to have failed morphine, as another example. So we put in, from a pharmacologic point of
view– and maybe the pharmacy background on the committee can respond to that. But the people who are making the policies
about buprenorphine are not looking at the pharmacodynamics and the– the pharmacodynamics,
particularly, of these partial agonists or medications prior to making criteria. And I’ve spoken to the medical director of
Medicaid in Florida till I’m blue in the face. And I cannot seem to get through to him the
need for this as an early intervention rather than as, potentially, a rescue. VANILA SINGH: OK. So just hold that thought. Dr. Tu, were you going to comment on that
topic matter? Do you mind if we just circle out that, and
we’ll come back? Because I know Dr. Rutherford has something. And Dr. Lynch, being on the buprenorphine
committee, would probably have some insight into it as well. So Molly first. MOLLY RUTHERFORD: OK. VANILA SINGH: And then Dr. Rosenberg after
Dr. Lynch. MOLLY RUTHERFORD: Oh, thank you for bringing
that up. That is an excellent point. So the American Society for Addiction Medicine
is working pretty hard to remove prior authorization requirements for buprenorphine. There’s still the problem of getting buprenorphine
approved for pain, however. In Kentucky, actually, within our medical
board, we have regulations that prohibit us from prescribing buprenorphine for pain. And that came about because, apparently, people
were– I mean, we can use the patches. We can use the sublingual that are specifically
FDA approved for that purpose. But we can’t use, say, the cheaper buprenorphine-naloxone
tablets or the buprenorphine tablets– which are much more affordable– because of this
law. And the reason was the worry over doctors
who are treating addiction going over their limit– because we’re limited. I’m an addiction specialist. I’m limited to 275 patients that I can prescribe
buprenorphine for opioid use disorder. And so, I guess, people were saying that they
were prescribing for pain in order to get beyond that limit, which is an arbitrary,
ridiculous limit, and for another committee another time, I guess. So those are the obstacles that we’re seeing. And then, before you even mentioned that,
I was going to bring up that we do mention people in recovery, people with substance
use disorders under Psychological Approaches. I see them as a special population as well
because I know that people who are in recovery still have reasons, they still have surgeries,
they still have pain. They are very fearful of taking opioids for
pain, often. And so that’s just something I wanted to bring
attention to to represent my patients who are in recovery. VANILA SINGH: And makes the case for the perioperative
consultation all the more important to come up with the plan. Dr. Lynch, and then Dr. Rosenberg. MICHAEL LYNCH: Thank you. Yeah, so I originally was going to be talking
about something else. But I want to respond to this. So, sort of, at our institution, I lead our
efforts for the ED buprenorphine initiation and so forth. And I definitely want to echo that. I think that the X waiver, in particular,
is arbitrary and sort of based in stigma more so than something useful. It definitely limits not only emergency physicians,
but outpatient primary care providers. I think it sort of sets it in its own category,
as opposed to allowing it to be part of your treatment of medical illness, whether it be
pain, addiction, both. And from the emergency department side, there’s
very good data that says if we get it started, engagement rates, illicit drug use, and so
forth are better. But we can give a single dose and bring people
back on three days to give them single doses. But we can’t prescribe it without doing the
extra licensing. And I know one of the concerns is diversion. And that’s often talked about. It’s a highly diverted medication. And I think the third most diverted, last
I saw from DEA. And I’m not ever condoning or saying diversion
is appropriate. At the same time, higher than that is oxycodone,
hydrocodone, where there are no limits, nothing. And I’m not advocating that we put special
licensing on those medications. I’m simply pointing out that when it’s diverted,
it’s typically used to self-treat addiction and rarely used for recreational reasons. So that’s an important concept. And it needs to be discussed. But I think the existence of an X waiver essentially
limits care in a lot of different ways, starting in the emergency department, but also primary
and outpatient care. One other quick topic on the navigator and
that concept. VANILA SINGH: Please, go ahead. MICHAEL LYNCH: I think where I see it– and
to get to Dr. Prunskis’ point, I think that often will probably need to come from the
payer side. Because the idea is that by improving care,
functional outcomes, you’ll reduce the need for unscheduled and acute care, which is obviously
much more expensive and payers are always looking to avoid. And so I think the navigation part plus what’s
covered and how they can access it would sort of be housed there anyway. So I think that that would be the appropriate
place for that to come from to assist the physician, who can lead and identify that
through whatever mechanism, but not necessarily be the one arranging and coordinating it,
which is not really practical. Just a couple of thoughts. VANILA SINGH: Thank you for that. Dr. Rosenberg. MARK ROSENBERG: Yeah, if I may, a couple comments
regarding best practice in the emergency department for two cases. One, when a patient presents after getting
naloxone, and now they’re currently in withdrawal. And those who are coming in as pain orphans
who are chronic pain orphans, who are also in withdrawal, if I may. So those two areas. Addiction is a disease. We all know that. Emergency physicians need to treat addiction
as a disease. So when somebody comes in in withdrawal because
of dependency or addiction, they need to manage it, not just shuffle them out to the next
emergency department. The only way and the best practice to manage
that is giving buprenorphine and to get patients started on a road to recovery. We’ve had a lot of success doing that at many
hospitals across the country. And there’s even an act now that’s just passed
the Senate, and passed the House already, which is the POWER Act, which says that emergency
departments should provide patients who are in withdrawal with medical-assisted treatment
and provide them with a warm handoff, if possible, into the community so that they can continue
their treatment for dependency and addiction. So this is best practice. And I’m glad this was brought up. But what we’re seeing is also more and more
patients who are coming in who are abandoned by pain centers or their pain physician. And they’re presenting to the emergency department
not only in pain and acute pain from being– but also in withdrawal from not being able
to get adequate doses of their opioids that they had been on for a long period of time. We’ve had a great amount of success of giving
them some bupe, getting them out of withdrawal if they have a significant COWS score, and
then putting them on the Butrans patch right there in the emergency department. We’re able to then follow them over the next
couple days to see how they’re doing. We’ve had tremendous success in converting
them immediately. So I believe there’s some opportunity here
for those who are in chronic pain to really be transitioned onto a different medication
that people aren’t quite as fearful of. I was very lucky in the cases that I had to
transition them to family medicine, who was able to continue their Butrans patches. And we’ve had some people who now, months
later, are doing extremely well, when they were in high doses of opioids prior to this. So I think there’s an opportunity there, not
only in the emergency department, but in primary care. VANILA SINGH: Well, it makes the case of points
of contact– where they come in, and what can we do at that moment? Not just, perhaps, naloxone, but in fact,
something that’s longer term. And I think it just highlights that those
are opportunities. And maybe– I don’t know. Do you think that they would need specific
guidelines to consider who might be appropriate, that there is a warm handoff treatment facility,
those sorts of things? MARK ROSENBERG: I’m not sure that there’s
great established protocols, only because each community is different and the resources
in each community are a little bit different. But I think we can define what best practice
is. And then really look at different opportunities
in different communities, how we can make it work. And it all comes down to the X license and
what can the emergency physician do? One interesting point is the X license is
only required if you’re giving medical-assisted treatment to somebody. But if you’re treating somebody for pain with
a partial agonist, then you are able to prescribe bupe for somebody for pain, even if you don’t
have an X license waiver. VANILA SINGH: It’s an interesting point. Dr. Tu, thank you for– oh, is– OK. Yeah, there we. OK. OK, there first. JONATHAN FELLERS: So I take care of a lot
of patients with buprenorphine. And I think we might be at danger of one of
those concerns of the comments of conflating chronic pain and addiction in this area. So the point is well-made by Dr. Rosen that
the fact is that you can prescribe buprenorphine for pain without an X waiver. And the DEA has said that that is OK to do. It is off-label to do so. And it doesn’t apply. I do understand that, maybe in some states,
they may have added additional legislation because of concerns for people going over
the limit for prescribing buprenorphine, ostensibly for pain, but actually treating people with
opioid use disorder for it. You can’t prescribe any other opioids for
someone with opioid use disorder. That’s the reason there is an X waiver. That goes back to the Harrison Narcotic Act. And for the longest time, we could not treat
anyone with addiction with any narcotic medications, until methadone came out, and then with the
X waiver. VANILA SINGH: And methadone is [INAUDIBLE] JONATHAN FELLERS: Yeah, it’s an exception
as well. So that was back in the ’70s when– we had
a heroin epidemic back then as well. And so buprenorphine is a lot safer. But I think we are at danger of conflating
the two, saying someone who presents in withdrawal from having stopped their opioids– of course
they’re going to have tolerance and they’re going to experience withdrawal. That does not necessarily mean that they have
an opioid use disorder. You can treat withdrawal with buprenorphine. But that would be treating the tolerance. But you can treat the pain with buprenorphine
as well. The issue of getting, I guess, Medicaid to
pay for that off-label use, that is a problem because it is not FDA approved for that use. We do have the Butrans patch and those other
sublingual forms that are incredibly expensive, if you look at them compared to the other
options. And I just wanted to also say that I am very
aware that the patient with addiction and mental health problems is probably a unique
population too. And we were aware of that. And it’s well-addressed in the next section
that we’re going to come to. But I do think there are specific– that population
has unique requirements too and requires a whole care too. And so I don’t want the public to have the
impression that we’re not aware of that, that it’s not included as a special population,
because it is addressed in the next session. VANILA SINGH: Absolutely. Thank you for making that point. That’s important to keep the confusion away
and be as clear as possible. Doctor, please go ahead. SCOTT GRIFFITH: So I just wanted to make a
couple comments on education and research about what we’ve been talking about. And it sort of ties in. Pain is the most common– I’m an ACGME fellowship
director. And pain is the most common presenting complaint. So one of the points I want to make about
education is that we need to do it all the way through, from medical school to primary
care providers to our various team members. And when you look at our system that we had
shown up there with the stepped care, that’s a big part of that. Because while certain forms of education could
be bad– we don’t need people doing weekend courses and doing interventions. We do need people understanding the breadth
of pain caring, doing those pieces. The number of subspecialists is very low. Like in my system, for the Army, I kind of
have– I help decide some of the career choices for those folks. So it’s a relatively small community. And if you look at other specialties, at least
in our system– and I think there’s some truth to that, at least in certain areas, outside
the military as well. There are a very few number of specialists. So you look at cardiology, another prominent
thing. The number of specialists in that area would
be much higher. So it’s not only nice to have that. It’s critical that we educate all of our team
members that there were probably some things we did bad. But when I or Dr. Singh were young anesthesiologists
with subspecialty training in pain, we weren’t necessarily only ineffective in certain reasons
because of the intervention we chose or the medication we chose, but also because our
teams that we lead or are members of now are a lot bigger and more robust. And that’s probably what’s making a difference
in being able to do this. And when you look at why we’re saying some
of these things about what we’re saying about education, I think that the evidence of what’s
happened over these– in my case, around 20 years– is supporting that, yes, we do need
to do more education because a lot of those initiatives– my colleagues back over there
have been working very hard on– have only really been getting out to primary care in
the last few years, the Primary Care Pain Champions, the increased education to all
primary care providers. So I think that’s important for us to think
about. Likewise, with research, when we look at emerging
technologies, we need to think about the next pain treatments and not only the ones we work
at now. We’ve had some problems. We have lots of studies, but not necessarily
large, well-designed trials for our most common interventions. And I’m talking about [INAUDIBLE] treatments
that I’m involved with research, with Steve Cohen and others, on myself. And with epidural steroids, our most common
treatment– even with those treatments that are the most commonly used in the country,
there’s probably still a need for studies that are large enough, well-designed enough
to really answer the questions we still have. But as we look at regenerative techniques
and these new kinds of treatments, whether it be PRP, stem cell based therapies, we need
to keep that in mind and not repeat the problems we’ve had with small studies that don’t answer
the question in the past. And I just wanted to bring those things up. Neuromodulation, I think we’ve had some success
with. Some of those studies are better designed. Some of the things that we’re able to do with
neuromodulation, I think are a result of understanding the limitations of the way we studied that
in the past. So I wanted to bring up those, going back
to the idea of explaining why we said some of those things. And in those cases, I felt like those two
things needed to be said for those reasons. I worked, actually– strangely, in a way–
on some of the physical therapy writing for this. But I work closely with physical therapists. And Andrea and I put together some of those
pieces. And one of the things that has come up a couple
times is the challenge of electronic health records, the burden on physicians and others
of doing this kind of paperwork. And one of the things we came up with was
the TENS unit. So I think that for something like a TENS
unit where– at least in my system, you have to do several very well-worded sentences to
be able to get that approved. And if that goes well, that might take several
weeks before the patient gets it, when most of us realize you can order that online tonight,
and it should be there– depending on your subscription– within a day or two. [LAUGHTER] So we’re hoping that we move more towards
that, particularly on these inexpensive treatments that people can use for self-care. And that’s why we said that and why we believe
that, even understanding that, cumulatively, those kinds of treatments can add up to a
significant cost. By the same token, putting barriers to people
getting to those treatments, adding a lot of bureaucracy can add cost as well. Thank you. VANILA SINGH: Thank you. And I think that emphasizes, again, the self-management
aspect, also the more need for research. Perhaps the registries are also growing and
giving us some more data in those areas that we’ve looked at in neuromodulation, with stem
cell therapy, regenerative medicine. There’s a lot of areas that are, right now,
being looked at. And so you’re right. We don’t want to make the same mistakes as
in the past. We’re going to end with Dr.– well, we have
Dr. Rosenberg, too? Nope. We’re going to end the session with Dr. Tu. And then we’ll have a lunch break. And then we’ll come back to the afternoon
of Subcommittee 2, 3. And then we do have Senator Cassidy, who has
been good enough to agree to come at 5 o’clock. So just hold on to that. Thanks. HAROLD TU: So I want to disagree with my learned
colleague Dr. Prunskis that the contention that electronic health records actually increase
opioid utilization. In point of fact, that’s not been our experience. When we implemented the mandated protocol,
non-opiate protocol, we implemented with the electronic health record as well as e-prescribing. Unique to dental education, dental students
begin prescribing pain management in their junior year. And so that really caused them to challenge
them for thoughtful and clinical judgment in terms of pain management. And in fact, we’ve documented that we’ve seen
an 80% decrease in opiate prescriptions in the last two years. So I think the notion that the electronic
record, even as onerous as it can be, is really a tool and a valuable tool, both for the prescribing
part, but also documentation, and also assessment of prescriber behavior. Without the electronic health record, I would
say it’s impossible to document how prescriber behavior changed, both on a global level and
on an individual level. JOHN PRUNSKIS: If I may, briefly, I’m not
sure about the dental world. But in the medical world, it’s fairly well-documented. So I’m not– HAROLD TU: Well, I’m a physician as well. So– JOHN PRUNSKIS: I understand. I’m not debating the dental world. I’m just reflecting what’s in the literature. VANILA SINGH: OK. So on that point, we have 55 minutes for lunch? ALICIA RICHMOND SCOTT: Yeah. We’re going to break until– at 1:00, Dr.
[? Jhawar ?] is going to come and speak and give just a few remarks before we have the
Subcommittee 2 presentation. So we will break for lunch now. But I would like to ask, for the Task Force
members, we’re going to start promptly at 1:00. SPEAKER: Produced by the US Department of
Health and Human Services at taxpayer expense.

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