Pain Management Best Practices Inter-Agency Task Force September 25, 2018 Meeting Summary – Day 1

Meeting and Task Force Member Introduction: 8:30 a.m. - 8:40 a.m.

Dr. Vanila Singh, MD, Task Force Chair, Chief Medical Officer (CMO) in the Office of the Assistant Secretary for Health (OASH), US Department of Health and Human Services (HHS)

• Comprehensive Addiction and Recovery Act (CARA) 2016, established the Task Force to identify gaps and inconsistencies and make recommendations for clinical draft report
• Task force will consider public comments, make modifications and considerations within scope of narrow charge, and finalize report.
• September is Pain and Sickle Cell Awareness Month

Dr. Singh introduced the Pain Management Best Practices Inter-Agency Task Force members and provided a brief biography for each member:

• Dr. Sondra M. Adkinson, PharmD
  • Dr. Adkinson is a Clinical Pharmacist with over 15 years of experience and serves as the Pharmacy Pain Program Manager and Pain School Facilitator at the Bay Pines Veterans Health Administration.
• Dr. Amanda Brandow, DO, MS
  • Dr. Brandow serves as the Chair of the American Society of Hematology and as an Associate Professor of Pediatrics at the Medical College of Wisconsin with over a decade of experience providing care for individuals with sickle cell disease (SCD) and acute and chronic pain.
• Commander René Campos, MBA
  • Commander Campos retired as Commander of the U.S. Navy after a 30-year career, and now represents active duty, Guard and Reserve, retirees, Veterans, survivors, and family members as the Senior Director of Government Relations at the Military Officers Association of America.
• Dr. Jianguo Cheng, MD, PhD
  • Professor
  • Department of Anesthesiology at Cleveland Clinic
  • Dr. Cheng is President of the American Academy of Pain Medicine, and has served on its Board of Directors since 2014 as Director-at-Large and Vice President for Scientific Affairs.
• Dr. Daniel Clauw, MD
  • Dr. Clauw currently serves as the Director of the Chronic Pain and Fatigue Research Center and as a Professor of Anesthesiology, Medicine, and Psychiatry at the University of Michigan.
• Dr. Jonathan C. Fellers, MD
  • Dr. Fellers is currently the Medical Director of the Integrated Medication-Assisted Therapy at Maine Medical Center and also serves on the Co-Occurring Disorders Service-Line Lead, Buprenorphine Prescribers Committee, Center for Psychiatric Research, and Leadership Committee.
• Dr. Howard L. Fields, MD, PhD
  • Dr. Fields was a founder of the UCSF pain management center, Professor Emeritus, and has made major contributions to understanding and treating neuropathic pain where his current research is focused on the neurobiology of opioid analgesia and reward.
• Dr. Rollin M. Gallagher, MD
  • Dr. Gallagher is Emeritus Investigator at the Veterans Affairs (VA) Center for Health Equity Research and Promotion, and he is currently the Director for Pain Policy Research, Primary Care, and Penn Pain Medicine at the University of Pennsylvania.
• Dr. Halena M. Gazelka, MD
  • Dr. Gazelka is currently the Director of Inpatient Pain Services in the Division of Pain Medicine at the Mayo Clinic and also serves as the Chair of the Opioid Stewardship Program and as an Associate Medical Director for Mayo Clinic Hospice.
• Dr. Nicholas Hagemeier, PharmD, PhD
  • Dr. Hagemeier is an Associate Professor and Co-Investigator of East Tennessee State University Gatton College of Pharmacy’s $2.2 million NIH-funded Diversity-promoting Institutions Drug Abuse Research Program.
• Dr. Michael J. Lynch, MD
  • Dr. Lynch currently serves as the Medical Director of the Pittsburgh Poison Center, an Assistant Professor for the University of Pittsburgh, Department of Emergency Medicine, and as an Adjunct Assistant Professor for the West Virginia University School of Medicine.
• Dr. John McGraw, MD
  • Dr. McGraw is a retired Colonel having served in both the U.S. Air Force and U.S. Army for a combined 34 years of commissioned service and is now currently serving as the Medical Director of OrthoTennessee, which is the largest orthopedic clinic in Tennessee with more than 100 providers.
• Dr. Mary W. Meagher, Ph.D.
  • Dr. Meagher is a Professor of Psychology and Neuroscience at Texas A&M University where her research focuses on the role of stress and emotion in health, with an emphasis on pain and inflammatory conditions.
• Dr. John V. Prunskis, MD
  • Dr. Prunskis is founder and co-Medical Director of Illinois Pain Institute and is a Clinical Professor at Chicago Medical School.
• Dr. Mark Rosenberg, DO
  • Dr. Rosenberg is Chairman of the Emergency Department at St. Joseph’s Health in New Jersey and leader and developer of the nationally recognized Alternatives to Opioids program (ALTO).
• Dr. Molly Rutherford, MD
  • Dr. Rutherford is Founder of Bluegrass Family Wellness, PLLC in Crestwood Kentucky, serving as a certified addiction specialist treating patients on the front lines of the opioid epidemic.
• Dr. Bruce A. Schoneboom, Ph.D.
  • Dr. Schoneboom is currently the Chief Learning Officer at the American Association of Nurse Anesthetists, and also Adjunct Faculty at Texas Christian University and Johns Hopkins University School of Nursing.
• Ms. Cindy Steinberg
  • Ms. Cindy Steinberg is the National Director of Policy and Advocacy at the U.S. Pain Foundation, and Policy Council Chair of the Massachusetts Pain Initiative and is a chronic pain patient herself.
• Dr. Andrea Trescot, MD
  • Dr. Trescot is the Past President of the American Society of Interventional Pain Physicians and currently serves as the Director of the Pain and Headache Center in Eagle River, Alaska.
• Dr. Harold K. Tu, MD
  • Dr. Tu is currently the Director of the Division of Oral and Maxillofacial Surgery at the University of Minnesota School of Dentistry, and Chairman of the Department of Dentistry at Fairview Hospital.
• Dr. Sherif Zaafran, MD
  • Dr. Zaafran was appointed as the current President of the Texas Medical Board by Governor Greg Abbott, and also serves the President of the Memorial Hermann Division of U.S. Anesthesia Partners in Houston.

Federal representatives:

• Dr. Scott Griffith, MD, representing the Department of Defense.
  • Dr. Griffith is an active duty army physician at Walter Reed National Military Medical Center, the inaugural pain management consultant to the Army Surgeon General, and the national captain consortium pain management fellowship director.
• Dr. Sharon Hertz, MD., representing the FDA.
  • Dr. Hertz is currently the director for the Division of Anesthesia, Analgesia, and Addiction Products at the Center for Drug Evaluation and Research in Food and Drug Administration. She's also a board-certified neurologist and part of FDA's efforts to address prescription opioid abuse.
• Dr. Jan Losby, PhD, representing the Centers for Disease Control and Prevention (CDC).
  • Dr. Losby serves as the lead for the Opiate Overdose Health System's team in CDC'S Division of Unintentional Injury Prevention.
• Captain Chideha Ohuoha, MD, representing Substance Abuse and Mental Health Services Administration (SAMHSA).
  • CAPT Ohuoha currently serves as the director of the Center for Substance Abuse Treatment Center. In this role, he leads the development to develop, promote, and enhance programs and new approaches in the treatment of both alcohol and drug abuse.
• Dr. Linda Porter, PhD, representing National Institutes of Health (NIH).
  • Dr. Porter directs the Office of Pain Policy at NIH and is also the DFO of the Inter-Agency Pain Research Coordinating Committee. She has background in PT and neuroanatomy.
• Dr. Friedhelm Sandbrink, MD, representing the VA.
  • Dr. Sandbrink is the acting national program director for pain management in the Veterans Health Administration and is also a clinical associate professor in neurology at the Uniformed Services University of the Health Sciences.
• Dr. Cecilia Spitznas, PhD, representing Office of National Drug Control Policy
  • Dr. Spitznas is a senior policy advisor and provides policy analysis to the director of the White House Office of National Drug Control Policy.

Meeting Purpose and Objective: 8:40 a.m. - 8:50 a.m.

Dr. Vanila Singh, M.D., Task Force Chair provided a statement of purpose to the public and Task Force.

• Noted that the Comprehensive Addiction and Recovery Act (CARA) of 2016 or CARA established the Task Force to study and develop best practices for treating acute and chronic pain.
• The Task Force will also identify gaps and inconsistencies in current best practice guidelines and submit a final Report of recommendations to federal agencies and the United States Congress.

Opening Remarks by Congressmen Pete Sessions and Michael Burgess: 8:50 a.m. - 9:20 a.m.

The Honorable Pete Sessions (R-TX 32^nd):

• Thanked the Task Force for all their important work. Stated that the Task Force should “Take all the time you need and then make a quick decision”
• Noted that healthcare and law enforcement need (1) clear, succinct recommendations and (2) an identification of the origin of the problem
• Expressed that decision makers need to be informed on programs and solutions
• Requested that the Task Force address issues/pain associated with disability
• Noted that Congress and American people are looking for clear answers - delineate the real marketplace. There may not be one answer for all problems, but there can be answers to enable law enforcement and first line responders on how to deal with issues of substance abuse and addiction
• Requested clear responses and recommendations from the Task Force; Congress will take this response as guidance for creating policy solutions to the opioid epidemic.
• Emphasized the need for “clarity” in recommendations several times

The Honorable Michael Burgess (R-TX 26^th):

• Emphasized the importance of continuing the work on 42CFR Part 2 (Confidentiality of Substance Use Disorder Patient Records) - vote in the House was overwhelmingly in support for the bill; was left out of the Senate side for some reason.
• Emphasized need to avoid rapid and forced tapering; patient abandonment
• Noted the need for new and innovative ways to treat acute and chronic pain
• Also noted that different people require different treatment methods and guidelines (e.g. acute pain vs specific condition vs chronic pain)
• Sympathetic to patient needs for medication and treatment to continue their life; stressed access and availability

Public Comment: 9:20 a.m. - 9:50 a.m.

Kate Gilliard -

• American Physical Therapy Association (APTA) representative
• Noted that Physical therapists play a unique role in the prevention, wellness, and management of disease and disabilities for individuals across the age span.
• They also play an important role in the prevention and treatment of acute or chronic pain by providing strengthening and flexibility exercises, manual therapy, posture awareness, and body mechanics instruction.
• Stated the need to reduce co-pays for non-pharmacological treatment
• Emphasized integrated and multidisciplinary approach to treatment
• Emphasized the importance of addressing the cause of pain rather than the symptoms
• Recognized that opioid prescriptions can be necessary in treatment
• Recommended choosing safe alternatives to opioids
• Noted restrictive payer policies. APTA recommends the reduction or elimination of copays for non-pharmacological alternatives for pain (e.g., PT).
  • Ensure that patients have access to appropriate pain therapy treatment that is not limited by copays and/or outdated legislation
• The commenter also released a white paper on “Beyond Opioids How Physical Therapy Can Transform Pain Management to Improve Health.”

Heather Parsons -

• American Occupational Therapy Association (AOTA) representative
• Noted that the use of discipline-specific language was cause of concern in the Environmental Scan regarding functional restoration, which is approach involving multiple disciplines
• Requested that the Task Force adopt final report language that is fully inclusive of all providers in final recommendations, including occupational therapists
  • Careful and specific mention in Final Report could make difference in access

Dr. Connie Newman, MD -

• American Medical Women’s Association representative
• Pain and addiction susceptibility differences between sexes
• Special pain considerations for women in pain management
• Eliminate pain control as a measure of quality care by 3^rd parties
• Education of healthcare providers and everyone on sex-based differences in pain, benefits of non-opioid alternatives
• Safe storage and disposal of opioids and other medications
• Providers should be encouraged to discuss all treatment options with patient.
• Providers should also assess women with chronic pain to assess for psychological comorbidities.
• Family planning - women should be offered all options for contraception
• Opioid deaths increasing more in women than in men
• Women more likely to have conditions leading to chronic pain - may perceive pain more intensely; may also get more addicted more quickly
• Risk association with pregnancy and post-partum period

Richard Lawhern -

• Emphasized the demographics of chronic pain
• Published CDC data to indicate the minor association between prescription of opioids and death by opioids - the commenter argued against the association between prescribing and death and addiction.
• Beginning drug abusers and chronic pain patients who use opioids are different and should not be conflated with one another
• If patient’s life is stable enough to see a physician, they are almost never drug abusers (cited Dr. Nora Volkow article)
• Urged the Task Force not to restrict the availability of opioid analgesic therapy to people who need them

Kelly Devine -

• Pain patient perspective and person of recovery perspective
• Advised the Task Force to avoid patient abandonment and forced tapering
• Safe access to herbal medications that help chronic pain patients and withdrawals
• Suggested the Task Force increase Narcan (naloxone) dispensing
• Recommended art therapy as a possible treatment option
• Also recommended a combo-lock lid on opioid prescription bottles
• Child Protective Services (CPS) and stigma: mothers will often refuse treatment out of fear of having children taken away

Margaret Wilson -

• Advocated for the preservation of opioid therapy for patients
• Expressed that pain patients are not substance abusers nor addicts
• Suggested that patient autonomy is key for risk evaluation and treatment selection
• Avoid regulations that act on moralistic standpoint as opposed to factual standpoint
• Avoid forcing patients into alternative monotherapies - briefly mentioned cognitive behavioral therapy (CBT) and psychotherapy.
• “Moral War” against prescription opioids
•  Briefly mentioned iatrogenic harm

Trina Vaughn -

• Chronic pain patient on opioid therapy
• Mother of the commenter was profiled and dismissed from ER as a drug seeker
  • Later died from kidney failure and infection that was a direct consequence of this ER dismissal
• Stated that addiction is the problem; addicts need help, they may not want it
• Suggested that clinical decision making be put back in the hands of the providers
• Noted that street drugs are often sought after as an alternative to opioids
• Stop letting DEA raids from driving physicians out of practice
• Current CDC Guidelines are causing harm to those who need opioid medications
  • Reconsider and start over; give back legal opioids

Jackie Evans-Shields -

• Heron Therapeutics - commercial bio-tech company
• Discussed the importance of innovative approaches to acute pain management that prioritize development of non-opioid therapeutics
  • Incentivize environment of non-opioids in surgical setting
  • Incentivize use of innovate drugs and non-opioid technologies
• Discussed coverage for non-opioids
• Reduce patient exposure to opioids in the surgical setting
• Recommended “unpackaging” and paying for non-opioid prescriptions separately in non-surgical settings

Remarks: 9:50 a.m. - 10:00 a.m.

Dr. Paul R. Cordts, M.D., Assistant Director, Medical Affairs, Defense Health Agency, Department of Defense                      

• Pain Management and Opioid Safety - DoD Pain Management Strategy
• Overview of the Military Health System (MHS)
  • Opioids make up 4.5% of total MHS prescriptions
• Biopsychosocial approach - stepped care model of pain care
• Overview of MHS Pain Strategy
  • Project ECHO - overview of MHS Pain Strategy was originally developed on non-DoD program basis
  • Collaboration across the spectrum to develop the ECHO program
• Defense and Veterans Pain Rating Scale
  • Innovation is in the Quality of Life (QoL) questions added on to the 1-10 scale
    • Additional questions on activity, sleep, mood, and stress
  • Supplemental questions are more useful to clinicians - goal is not to eliminate all pain (not possible sometimes); by asking patients to describe pain as it relates to the 4 key areas; can help clinicians evaluate efficacy of pain management - focusing on improving patient QoL
• MHS Stepped Care Model
  • Figure of the model shown here (see slides)
• Pain Assessment Screening Tool and Outcomes Registry (PASTOR)
  • Assess efficacy of clinical interventions
  • Based on NIH investment in PRMOIS
  • Advanced analytics for assessing patient reported outcomes
  • Utility: ability to provide individual and population-level reports using scientific methods
• Pain management is the primary problem with opioid use and abuse as a symptom
• Need to include biopsychosocial aspects of pain in solutions
• Need to continue collaborative efforts

Subcommittee 1 Presentation: 10:00 a.m. - 11:35 a.m.

Dr. Vanila Singh, M.D., Task Force Chair, re-iterated the meeting purpose, objects, and public comments slides.

• Public Comment Analysis
  • Large majority of public comments concerned chronic pain, treatment access, decreased functionality
  • Stigma and prescription opioid use being conflated with addiction
  • Major contributor to suicide related comments was lack of functionality and QoL
  • CDC reports association between chronic pain and suicide increasing
  • Word-cloud that illustrates the complexity of pain as a disease and the associated co-morbid conditions; pain is not simply a symptom
• 60% of Subcommittee 1 topics discussed modalities in various settings
• Dr. Vanila Singh, M.D., Task Force Chair covered approaches to pain management and special populations
  • Limited pharmacologic options for pregnant women with pain; want obgyn involved earlier in pain care
  • Various disciplines, modalities and medications included in our approaches to pain management and medication recommendations and overviews of each of the special populations, including pregnant women, sickle cell disease and pediatrics
• Dr. Rollin Gallagher, M.D., M.P.H., discussed Subcommittee 1 gaps and recommendations
  • Compassion, need to improve care for patients experiencing pain
  • Discussed the chronification of pain from acute to chronic pain
  • Find out subpopulations of pain patients based on mechanisms of pain
    • Emphasized mechanism-based, multimodal medications
  • Noted the importance of a collaborative stepped care model of pain care and community system. This requires a system change and back-and-forth exchange of information from primary treating team and pain specialists.
  • Suggested a simple, condition-specific treatment algorithm to assist frontline providers in treating pain conditions
    • Starting with non-opioids is key
  • Make buprenorphine more easily available to frontline providers
  • Physical Therapy
    • Avoid overuse of medications
  • Interventional Procedures
    • Improve access to out-patient interventional procedures
    • Remove barriers to access for these treatment options
  • Pain is inevitable in life; can be a dominant force; impact on QoL; penetrates consciousness and erodes confidence.
  • Chronic pain in not unitary; it is derived from multiple conditions/sources.
  • Assessment of subpopulations along trajectories; chronification of pain; mechanisms.
  • Need to start with non-opioids if possible; if opioids, the dose/duration should be managed by physicians/providers; create safe use of opioids in our communities
  • Remove barriers to access treatment, including PT, interventional procedures, medication and consultation with experts in pain management, addiction and mental health specialists when appropriate.

Subcommittee 1 Discussion

• Dr. John Prunskis, M.D.
  • Noted the need for protection for physicians from prosecution (DEA) if they are using appropriate guidelines and ethical care
  • Noted from the recommendations and guidelines:
    • Acute pain: should reference to ketamine be deleted?
    • Continuous catheter - leave or keep in?
  • Sometimes pain can be addressed without a multidisciplinary approach
  • Suggested adding board of medical specialties
• Dr. Dan Clauw, M.D.
  • Agreed with the patient comments on modifying language to include OT (restorative therapy); noted that the Task Force did not intend for the language to be that restrictive.
• Dr. Bruce Schoneboom, Ph.D.
  • Appreciated the move away from single-discipline language
  • Expressed the importance of identifying service members in screening process
• Dr. Andrea Trescot, M.D.
  • Interventional treatment needs to be treatment of first resort or near first resort in treatment paradigm; can be diagnostic tool
  • Close collaboration between surgeon, perioperative physician, and pain specialists needs to be formalized
  • Education of public and other providers on interventional treatments needed
  • Need to re-focus on stimulation therapies; may break cycle of pain 
  • Episodic treatment does not fix problem, rehab does; but without medication and intervention support, patients will not be able to tolerate PT
• Dr. Sherif Zaafran, M.D.
  • Not one right answer, no one single discipline solution to the problem
  • Multidisciplinary and multimodal approach is important
  • Introduced the “pain navigator” and “captain of the ship” concept
  • Look at all different modalities out there to identify in totality what treatment will help the patient
  • Utilize all-of-the-above approach rather than an either-or approach
• Dr. Michael Lynch, M.D.
  • Multimodal therapy and medications and side-effects: recognize opioids and their risk and side effects, especially in mixing of medications
  • Physicians and patients should understand the risk of these medications, medication interactions, misuse and diversion
  • Poison center services may address many of these types of issues
    • Poison center services: 24/7, manage, help, respond, and preempt potential adverse reactions and side-effect consultation. This service should be made available service to public and providers nationwide.
    • Poison centers do not treat pain but can help mitigate increases in adverse reactions from medications and other substances
• Dr. Harold Tu, M.D., D.M.D.
  • Acknowledged public comment from the American Medical Women’s Association (AMWA) and noted that the Final Report should provide a wider focus to women in special populations
  • Also suggested the Task Force note the American Indian population
  • Stated that the use of PDMPs should be mandated
• Dr. Amanda Brandow, D.O.
  • Highlighted Sickle Cell Disease (SCD), disparities and pediatrics in special populations
  • Importance of SCD as a disease model that spans from pediatrics throughout life
  • Important to understand how we deliver care in the context of children
  • Deliver expanded care in context of SCD or other chronic pain conditions
  • Expand pediatric mental health services, especially for patients on Medicaid
  • Expand access to pain care in pediatrics and adolescent realms
  • Dr. Singh noted:
    • The need of pediatric pain specialists; there is difficulty in recruiting for pediatric pain fellowships
    • The importance of developing pediatric pain guidelines for opioid use; existing guidelines are almost exclusively for adults
• Dr. Andrea Trescot, M.D.
  • In reference to Dr. Brandow’s pain life course SCD comments, mentioned that her chronic migraine patients noted the beginning of their pain in childhood/adolescence -
  • Severe pain patients may need to go directly to more aggressive (i.e. opioid) therapies:
    • WHO ladder has perhaps created more problems, needs to be abandoned or extremely modified; perhaps it should be a pain wheel instead of a ladder
    • Entry of treatment depends on degree of pain the patient is experiencing (1-10 pain scale) - to prevent someone presenting in ER with extreme pain start with Tylenol
    • The ladder might delay pain control - need to rethink ladder effect in favor of a more global approach to pain management
• Ms. Cindy Steinberg
  • Wants to emphasize public comments in connection with SC1 content
    • Type, dose, and duration of therapy, including opioid therapy, should be determined by physician and the patient - strongly emphasized in the public comments
    • Emphasize provider individual treatment decisions and individual patient treatment needs
• Dr. Jan Losby, Ph.D.
  • In regards to occupational therapy/physical therapy:
    • Consider patient outcomes used to ensure that patients continue to receive access to care; maintenance in addition to improvement
    • Some patients lose access to treatment because there are not clear indications of improvement; consider outcomes
    • Dr. Singh: limitations in reimbursement of coverage and restrictions on reimbursements; other restrictions to access in maintenance
• Dr. Jianguo Cheng, M.D., Ph.D.
  • Emphasized patient-centered NOT treatment-centered care; each patient requires a different treatment plan; need to evaluate each patient and identify true need of each patient; individualized, multidisciplinary care is the best approach
• Dr. Rollin Gallagher, M.D., M.P.H.
  • Need for immediate access to these treatment
  • Experimenting with several options while patients lose function is not tenable
  • Re-emphasized the need for a patient-centered, collaborative care model, such as VA and DOD integrating pain specialist into primary care, where specialists in same facility
• Dr. Mark Rosenberg, D.O., M.B.A.
  • A lot of acute pain is treatment in Emergency Departments (ED) across the country
  • All chronic pain starts with acute pain
  • Suggested not rushing into opioid medication when unnecessary
  • For EDs, a treatment-trial of medications prior to discharge; that way you can give them the lowest-dose, least toxic, most effective medication first
    • Try to use alternatives to opioids first, if that works and the patient tolerates then we can discharge patients without exposing them to opioids when unnecessary
• Dr. Nicholas Hagemeier, Pharm.D., Ph.D.
  • There is a need for multidisciplinary care that is coordinated; not just checking all modalities off; intramodal; need to help all those work together better
• Dr. Friedhelm Sandbrink, M.D.
  • Need to ensure providers are informed and well educated about other modalities; provide access in the primary care setting; understand the fundamentals of PT and exercise modalities for so primary care to refer to all modalities with the greatest knowledge possible
  • Make sure PT is used in conjunction with medication
  • Psychological approach to begin prior to treatment therapies
  • Not sequential, but rather, an integrated process of the various modalities
• Dr. John Prunskis, M.D.
  • Diagnosis is critical
  • Electronic Health Records (EHRs) has side-effects of prescribing more opioids; physician burnout and additional time per day
• Dr. Sherif Zaafran, M.D.
  • Emphasized that EHRs and medication plan pathways within the EHR were developed by physicians at his facility so that it was standardized and user-friendly and easy to use by the physician to avoid this excess workload and consequent burnout
  • In pre-operative setting, patients gets pre-operative medications that are non-opioids; helps significantly in decreasing the amount of opioids that they actually end up needing intra- and post-operatively, helping with that preemptive pain control.
  • Pain Navigator: process of timing and intramodality approach requires a person to facilitate the sequence of patient management
  • Sequence of medication give: not an either-or, it’s an all-of-the-above approach
    • Start stepwise process quickly so that non-opioid modalities are utilized. This way when opioid modalities are used, they are used in a significantly less proportion. 
• Dr. Andrea Trescot, M.D.
  • Pain Navigator: noted that the Mayo Clinic may also have a template on some patient navigation system
  • Buprenorphine: need to allow ERs to initiate buprenorphine for patients in opioid withdrawals - especially with substance abuse/misuse; want to avoid simply providing the patient with more opioids; Medicaid prior authorization another barrier to care
    • This should be readily available; lowest barriers of any opioid
    • This should not require a special license for buprenorphine - there is a low risk profile for the medication
    • Patients remarkable response to buprenorphine for chronic pain; patients should not have to fail multiple other medicines, particularly medicines that are inappropriate when you're trying to limit their exposure to opioids.
• Dr. Molly Rutherford, M.D.
  • American Society for Addiction Medicine (ASAM) working to remove restrictions on buprenorphine but it has been difficult to get its pain indications
  • Dr. Rutherford noted that she has a limit of 275 pts to which she can prescribe buprenorphine for OUD
  • There are restrictions in Kentucky that prohibit prescribing buprenorphine for pain - can use patches but not tablets
  • People in recovery, people with substance use disorders, should be mentioned as their own special population
• Dr. Michael Lynch, M.D.
  • Limit on buprenorphine waiver is arbitrary and based on stigma; limits not only emergency physicians, but outpatient primary care providers
  • Buprenorphine is the third most diverted medication behind oxycodone and hydrocodone
    • When it is diverted it is generally used to self-treat addiction
  • Pain navigators: often, this will need to come from the payor side - reduce need for additional acute care which is expensive, and payors are looking to avoid; navigators can coordinate care as providers do not have time
• Dr. Mark Rosenberg, D.O., M.B.A.
  • Best practices in the Emergency Department:
    • Addiction is a disease; ER physicians need to treat addiction as a disease - not just shuffling of patients, only way to do this is through buprenorphine and to get patients started on a road to recovery
    • POWER ACT legislation: ER should provide patients in withdrawal with medication-assisted treatment (MAT) and a warm-hand off into the community to continue any treatment of dependency and addiction
    • Abandoned patients present to ER in acute pain and also withdrawal due to inability to get their required doses of opioids; have had great success reducing pain, getting patients out of withdrawal immediately and immediate conversion with Butrans patches; need to transition chronic pain patients to other medications that are less feared - talks about many pts experiencing significantly greater success after transitioning onto Butrans patches from opioids
    • Need to help define best practices; all comes down to the X-license and what the emergency and primary care physician can do
• Dr. Jonathan Fellers, M.D.
  • Danger of conflating comments of chronic pain and addiction
  • Can prescribe buprenorphine for pain without X-waiver; DEA has said this is okay to do but it’s off-label to do so. In some states there may be additional legislation due to individuals going over limits for pain in treating OUD
    • Harrison-Narcotic Act
  • Buprenorphine is a lot safer but we’re at danger of conflating OUD and withdrawal; buprenorphine can be used to treat pain as well as withdrawal
  • Off-label use coverage for buprenorphine will be a challenge
  • Patients with addiction and mental health problems are a unique population
• Dr. Scott Griffith, M.D.
  • Emphasized the importance of education
  • There is an absence of large well-designed trials for most common treatment and interventions; there is a need for large, well-designed studies
  • Regenerative treatment and other new treatment therapies
  • Challenge of EHRs - burden on physicians
  • TENS unit - delay in approval and delivery of TENS
  • Dr. Singh brought to attention that TENS are inexpensive self-care treatment
• Dr. Harold Tu, M.D., D.M.D.
  • Disagreed with Dr. Prunskis on EHRs and contribution to overprescribing
  • In his experience he has seen an 80% decrease in opioid-prescribing with EHRs
  • Assessment of prescriber behavior without the EHR is impossible both on the global and individual level
  • EHR is valuable tool, for prescribing, documentation, and assessment of prescriber behavior

Subcommitee 2 Presentation: 1:00 p.m. - 2:30 p.m.

• Dr. Molly Rutherford, M.D., highlighted key gaps and recommendations from the slide deck
  • Identified several gaps in psychological approaches section
  • No modality should be mandated
  • Recommend increasing access through alternative treatment delivery such as telemedicine or innovative telementoring programs, such as Project Echo
  • Risk Assessment: thorough history and work-up to assess potential use disorders
  • There is an average of seven minutes for primary care visits, which is tied to payments; this is a systemic problem
  • Physicians must lead effort to reduce stigma by treating all patients with compassion, listening to them, and avoiding language that contributes to stigma.

Subcommittee 2 Discussion

• Dr. Mary Meagher, Ph.D.
  • Availability of current, empirically supported treatment that have been validated by the VA should be made available to the general population, e.g. Pain Coach; can a stepped-care model be implemented to a general population?
  • Provide access to technologies the taxpayers have already invested in. Stated not much of an investment needed beyond what has already been made. Additionally, will behavioral coaching be released by the VA?
  • Take stepped care model from VA/DoD and try to make this accessible to the general population - good first step in making treatment options available broadly for rural PCPs and other providers without pain specialists
• Dr. Michael Lynch, M.D.
  • Mentioned that it is necessary to address the lack of time that is spent physicians and patients. This is a large issue. Complex pain treatment is not adequately reflected in reimbursement.
  • Interpretation of toxicology screens is something that needs to be taught
  • PDMPS as a tool to adjust care and assess for risk, not to withhold care
• Dr. John Prunskis, M.D.
  • Noted that the need for psychologists in his practice has decreased
  • Also noted the stigma that physicians face because of regulatory agencies
  • Spinal cord stimulation now requires a face-face visit with psychologist/psychiatrist; other more intensive procedures do not, this needs to be addressed
  • Make recommendation on spinal cord stimulation requiring some form of psychological screening and substitute out the psychological assessment requirement
• Dr. Daniel Clauw, M.D.
  • Noted that there is no clearinghouse for apps/e-health approaches - this could potentially serve as a gap and inconsistency
  • Need for a government entity to test the best in class e-health products to provide pain patients with inexpensive selfcare/management apps
  • Money is spent on development and testing, but investigators have not advanced these apps to the public - this “valley of death” for apps is where patients are unable to access or have no knowledge of these apps
• Dr. Sherif Zaafran, M.D.
  • Noted the stigma on patients and providers
  • Unintended consequences of how screening and monitoring and risk assessment information is used:
    • Do not use these techniques to drop a patient from care
    • Need to educate providers on what to do in these scenarios - refer them to the appropriate care arenas
    • Dr. Singh highlighted anecdotes and stories from patients who feel like they have no options, losing functionality, going into despair, suicidal, may enter illicit market where there is no quality control
• Dr. Friedhelm Sandbrink, M.D.
  • Noted the concern on reliance with pain psychologists for behavioral therapies
  • Ensure that PCPs know about the value of these modalities and incorporate into their best practices
  • Interactive voice response system and motivational interviewing
  • Other countries (Canadian, Australian) that have great access to these modalities and multimodal pain care - look at what other resources are out there and make them available (e.g. databases)
• Dr. Andrea Trescot, M.D.
  • Urine drug screens and toxicology tests are useful tools to help identify patients who are at particular risk, not to be used to dismiss/discharge patients; these screens allow to detect drugs not on PDMP; also allows physicians to ask “where did you get this” and address; also confirms one can see the drug metabolite so when they say it’s not working it supports trying something new
  • Need for other drug-use information to identify at risk patients
  • Patients can now buy pill stamps online
  • Telemedicine is currently not reimbursed in Alaska
  • CMS is taking E&M codes and compressing them; Dr. Trescot is getting reimbursed at a level 2 for a level 4 visit which is a disincentive
  • Briefly mentioned allowing physicians to dispose of excess medication
  • Dr. Singh highlighted time and resources needed for appropriate pain care and need for appropriate reimbursement for complex management, including opioids; safe storage and disposal education needed
• Cecelia M. Spitznas
  • PDMP check frequency should be same for everyone to prevent stigma
  • Concern for opioid medications causing death
  • Agrees with recommendation for physicians to be able to destroy medications which would require change in DEA policy
  • States education campaign on pain needs to be more specific; campaign aimed at stigma important
• Dr. Harold Tu, M.D., D.M.D.
  • Disagrees with the notion that physicians can dispose of excess medication, the DEA will simply not allow for that - physicians would risk their license for this
    • Also disagrees that this would decrease medication diversion
• Ms. Cindy Steinberg
  • Emphasized a pain awareness campaign and its possible contributions to reduction in prescribing
  • Also expressed the need for centralized patient education and resources (patient portal) that is funded
• Dr. Halena Gazelka, M.D.
  • Need for more multidisciplinary approach
  • Stigma of patients is damaging
    • Patients do not want to visit pain clinics - worried about perception as drug seekers
    • Patients also do not realize that there are other tools in the toolbox besides opioid therapies
    • Want patients to have the full spectrum of care available to them
• Dr. Dan Clauw, M.D.
  • Careful consideration about how we use psychological approaches
  • Much of what falls under CBT is not psychological
  • The stigma is reinforced by labeling CBTs as psychological
    • Various behavioral approaches do not need a trained psychologist
    • Recommended that the section header is amended
• Dr. Mary Meagher, Ph.D.
  • So long as the provider is trained and competent then the provision of behavioral therapies is fine, does not have to come from psychologist, such as social worker - there needs to be very specific standards for what a competent provider in behavioral health looks like
  • Suggested that the term “behavioral health” is less inflammatory than “psychological approaches”; to note behavioral health is studied by psychologists
  • Brief and early intervention maybe should be considered/recommended
• Dr. Rollin Gallagher, M.D., M.P.H.
  • Agreed with competency in training for behavioral health
  • Recommendation for implementation research with proven trails for behavioral and psychological interventions

Public Discussion: 2:30 p.m. - 3:00 p.m.

RADM Michael Toedt, M.D. Chief Medical Officer, Indian Health Service, U.S. Department of Health and Human Services

• Indian Health Services’ (IHS) Comprehensive Approaches to Pain Management
• IHS serves 573 federally recognized tribes
• 2.3 million eligible American Indians and Alaska Natives
• IHS follows different regions than HHS regions, introduces certain issues in regard to coverage, jurisdiction, etc.
• IHS relies on meaningful government partnerships
• IHS pain management addiction work group started in 2012, chartered committee in 2017
  • Goals are directly informed by HHS Opioid Pain Strategy
  • Goals include: (1) involving patient in care planning process, (2) increasing provider support, (3) increasing access to clinical decision-making tools
  • Lack of access to non-pharma modalities in tribal communities must be considered
• IHS Chronic Non-Cancer Pain Policy
  • Updated based on 2016 CDC guidelines
  • Recommendation for providers to complete training on abuse and alternative treatments for pain
• Team-based approach
  • Policy requirement to establish local pain management teams (depends on size and resources of each facility)
• Treatments must be individualized and have to be multidisciplinary
  • Importance of incorporation of culturally-specific therapies
  • Telemedicine, mindfulness, nutritional interventions
• Blending traditional medicine with new strategies
  • Qualitative evidence that integrated therapies improve patient outcomes for chronic pain patients
• IHS has created comprehensive training materials for treating pain and addiction that they’ve disseminated to their providers
  • Providers must complete training in first 6 months and refresher course every 3 years
• Tele-Echo clinic
  • Provider-to-provider consultation, allowing front-line clinicians to consult pain and addiction experts
• All IHS pharmacies report to state PDMP’s and IHS providers must register with state PDMP’s
  • Prescribers must monitor their own prescribing data as well as that of their patients
• 143% increase in Naloxone procurement in IHS
• IHS.gov/opioids has best practices for pain management as well as opioids
• Trainings can be found and Tele-Behavioral Center of Excellence website

Dr. Walter Koroshetz, M.D. Director, National Institute of Neurological Disorders and Stroke, National Institutes of Health

• Discussed the research being planned at NIH
• Silver-lining of opioid crisis is that it has brought more attention and funding to pain research space
• Emphasized the National Pain Strategy
• Personalizing treatment, because everyone is a bit different based on pain condition and patient’s personal background
• Do not look at pain as one thing, it is a compilation many different things
• Best practices for pain management differ across ages and cultures of patient
• Humans will go to great lengths to reduce their pain, safer and more effective treatments would go a long way
• Research infrastructure for pain does not compare to other diseases
  • More research would inform, with evidence, best practices patients and practitioners should consider based on their specific conditions (precision-medicine approaches to treat chronic pain)
  • Understanding resilience would be very important
• Treatments we have for chronic pain right now are inadequate
• Pain pathway vs. reward pathway in the brain
  • There is a lot of understanding about the opioid system at the molecular level
  • Effect of opioids are incredibly profound on both please and pain systems, disconnecting these effects would be very beneficial
• NIH HEAL Initiative (helping to end addiction long-term)
  • Supported by Congress
  • Safer more effective treatments to pain management and understanding/combating opioid addiction
  • Big push to build clinical trial infrastructure to test new treatments for pain conditions
  • Will fund discovery of novel targets in pain system and validating discoveries across species, ages, and types of pain
  • Similar pipeline for discovery of biomarkers
  • Acute to chronic pain transition signatures
  • One of the major impediments to discovery of new treatments is lack of predictability of animal models on human pain conditions
  • Setting up two clinical networks: EPPIC (Early Phase Pain Intervention Clinic Trial Network) and ERN (Effectiveness Research Network - best practices for pain management)
  • Data from these projects will go into a central database available to industry, academia, and the public
• Q&A from the Task Force
  • Large release of funds into the pain management world
    • Congress appropriated $500 million/year to HEAL initiative ($250 for pain, $250 for opioids, but can be allocated differently based on NIH’s discretion)
  • We will start to determine interventions to prevent chronic pain based on what we know about at-risk populations for chronic pain (based on genetics, psychological trauma, etc.)
    • ERN part of HEAL is doing exactly that
  • Tribal nations sovereign, undercounting of Native American opioid deaths
    • IHS providers are typically state-licensed providers, so they must follow state guidelines despite patients being part of their own sovereign nations
    • Tribal leaders say that are funded at 50% that of civilians
    • Concern for underrepresentation of Native Americans and Alaska Natives in all mortalities, including opioid deaths (racial misclassification)
• Ongoing work between CDC and IHS to improve death reporting and statistics
  • To what extend does there need to be implementation science to make policy decisions
    • Frightening to take any action without evidence to support it, absolutely need more implementation science
    • In the absence of science in certain areas, have to make best judgement weighing benefit and harm
    • When faced with a crisis you have to act, but acting without collecting data and you’ll never get out of the crisis
• Pragmatic trials - collecting data in the real world, less controlled than randomized control trial but data is probably more generalizable
• ERN Network is trying to implement pragmatic trials, bridging research and practice

Subcommittee 3 Presentation: 3:15 p.m. - 4:00 p.m.

Dr. Sherif Zaafran, M.D.

• Having Cindy, a patient advocate and a patient herself, was a very useful voice on the Task Force keeping them centered on what will be most beneficial for the patients
• Key recommendations:
  • Consider and cover complementary alternative and integrative therapies when needed
  • Evidence that they work in conjunction with other modalities, but a lot still unknown especially as they apply to special populations
  • Conduct further research about CAIT to determine value, effectiveness, risk and benefits, etc.
  • CMS and private payers should implement innovate payment models to include CAIT
  • Education
  • Coordination of education efforts
  • National evidence-based pain awareness campaign - destigmatizes acute and chronic pain
  • Diverse, expert panel (including patients, patient advocates, and clinicians) to develop core competencies/other essentials for patient pain education
  • Recognize chronic pain as a category of diseases
  • Access to care
  • Medication shortages (especially of local anesthetics)
  • Reimbursement should be integrative and multidisciplinary
  • Increase training of pain management specialty providers
  • Increase federal funding

Dr. Bruce Schoneboom, Ph.D.

• CAIT - have not yet discussed medical marijuana
  • Task Force should recommend decriminalization at federal level and investment in research of medical marijuana as useful treatment of chronic pain
• Encourages Task Force to use language of Interprofessional Education
• Need to get rid of language like non-physician providers because it makes them feel non-valued in the work they do
  • Nurses are the largest provider group in this country, but ‘nurse’ is not mentioned in the Report - offer more comprehensive and inclusive language

Dr. Andrea Trescot, M.D.

• Opinion that none of these CAIT therapies have any evidence for their effectiveness
• Tremendous concern that with limited financial resources reducing coverage for proven-effective medicines but increasing coverage for non-proven therapies could be damaging
  • It’s a zero-sum game

Dr. Cece Spitznas, Ph.D.

• Federal government has been investing in studying effectiveness of cannabis plant, Dr. Spitznas can report back to committee on status of that research

Dr. Mark Rosenberg, D.O., M.B.A.

• He prescribes medical marijuana to end-of-life patients and has had remarkable success
  • Often not just for pain, for many kinds of suffering
  • More work must be done with marijuana to make it a schedule 2 drug
  • Decriminalization of medical marijuana is outside the scope of this committee

Dr. John Prunskis, M.D.

• Importance of health care practitioners to make proper diagnosis
• Educational efforts: encourage public to ask their provider for the specific diagnosis of pain
• ‘Online’ vs. ‘Mobile Phones’ reaches a broader audience

Dr. Linda Porter, Ph.D.

• Evidence for CAIT
  • Recently AHRQ did a review on a number of these modalities in the more common pain conditions
  • In recent conversations with CMS, they’ve taken a deeper dive
  • Many of these modalities have a lot of evidence, although not systematically across lots of pain conditions or over significantly long-term
  • In considering coverage of these modalities, CMS considers more benefits to patient rather than cost
• CMS considers promising evidence if there’s evidence that it works for patients over 65 years of age, even if there’s not yet evidence for other patient populations

Dr. Jianguo Cheng, M.D., Ph.D.

• Patient population for approaches mentioned will be very different than for traditional pain treatments, e.g. Tai chi high quality evidence works for fibromyalgia

Dr. Daniel Clauw, M.D.

• Shouldn’t look at this as a zero-sum game
  • Very powerful lobbies that want to do those things will fight the Task Force
• Coverage decisions are made on the merit of the therapy

Dr. Nicholas Hagemeier, Pharm.D., Ph.D.

• Access to treatment doesn’t necessarily mean people will take advantage because there’s a lack of trust
  • Not just lack of trust of providers, but also of pharmacists
• Has to do with stigma in the professions
• Need to allow every health profession to bring their best to the table, saying ‘physician and other’ doesn’t allow that

Dr. Mary Meagher, Ph.D.

• Echoing concerns about ‘physician’ language
  • Just use ‘provider’
  • All disciplines need to be respected and empowered
• CAIT do have convincing evidence, with similar effect sizes as Cognitive Behavioral Therapies, so don’t minimize those approaches

Dr. Molly Rutherford, M.D.

• In Kentucky, a lot of pain clinics are being targeted for fraud
  • Fraud is not unique to pain management space, is widespread of healthcare system due to complexities of billings
  • Contributes to stigma
• Empower patients with their money, if they had a card similar to a HSA so they could choose to spend money on different modality treatments as they want
  • HSA’s flexible spending accounts cover acupuncture

Dr. Friedhelm Sandbrink, M.D.

• Tai chi has phenomenal results
• Must study the evidence of these modalities in conjunction with other therapies (not used in isolation)
• Avoid the languages that these are ‘alternatives’, when really used in combination, can cause concerns in patients
• Education: all healthcare staff have to be educated to speak the same language supporting an integrated model
  • Validate patient’s pain and providing positive perspective about integrative treatment modalities at every level

Dr. Sherif Zaafran, M.D.

• Inclusive language
  • Everything starts with a formal diagnosis, then there’s lots of other people that contribute (e.g., physical therapist, nurse)
• Pain Management Clinics
  • Texas has licensed and non-licensed clinics
  • Physicians that provide opioids/other intense drugs to more than 50% of their patients classified as a pain management clinic
  • As a regulator, doesn’t want providers to think he’s trying to shut them down
  • Need to deconstruct stigma of going to a pain clinic, need to promote the narrative that it is a safe place where you can be directed to continued necessary treatment
• Subcommittees did a lot of work to make sure they came up with gaps and recommendations, subcommittee chairs consolidated info but didn’t really make any changes

Dr. Harold Tu, M.D., D.M.D.

• He, as a surgeon, no longer refers to himself as the “captain of the ship”, rather it is a team
• Report does not acknowledge dentists
  • Dentists are one of the largest prescribers of opioids, and are the leading prescriber among young people
  • Dental school only has 6 hours of pain management education
  • Request that this be edited and added to the Final Report

Formal Review of CDC Guideline: 4:00 pm - 4:45 pm

Dr. Vanila Singh, M.D., Task Force Chair

• Identified items that were lacking or inconsistent, and in other places items were identified and valued; ‘Gap’ was terminology used
• What's the best we can do where we are now and what we understand now for our patients in a patient-centered manner that will improve their ability given the millions of people who are affected, and what can we do to ensure that that happens?
• Some things have become better understood since passage of CDC Guidelines
• Some major criticisms of CDC Guidelines are present but have been lost or were not implemented
• CARA legislation directed Task Force to review CDC guideline

Dr. Sherif Zaafran, M.D.

• Reinforcement of a lot of guidelines that were there, clarification of some gaps
• Key recommendations can be found on slide
• Patient should be involved in decision-making process, especially in regard to medication tapering or escalation, otherwise the treatment is not going to succeed

Dr. Jan Losby, Ph.D.

• Appreciated the nuanced approach in using the word ‘gap’
• Concern that Task Force recommendations perpetuate some of the misinterpretations of the Guidelines themselves
• Guidelines have tapering information/avoiding involuntary tapering, which might have had challenges in implementation but do not reflect inaccurate wording in the Guidelines themselves

Ms. Cindy Steinberg

• Recommendations provide updates to CDC Guidelines and they make sense to her
• Have heard from thousands of patients about how the Guidelines have been interpreted as rule and not as guideline

Dr. Scott Griffith, M.D.

• Dosage information is useful

Reflections and Next Steps: 4:45 p.m. - 5:00 p.m.

Dr. Vanila Singh, M.D., Task Force Chair -

• Intent is to protect the integrity of this Task Force
• Millions of people are living with pain and will be affected by the work of the Task Force
• The Task Force has completed a tremendous amount of work over the summer
  • Everyone on the Task Force brought their unique perspective and contributed to the work they’ve done
• No one size fits all, instead patient-centered individualized care
• Greater understanding of the importance of behavioral health
• Opioids do have value in acute and chronic pain, want to help give their colleagues the tools to keep their patients safe and with the ability to work
• Discussed the VA, DoD, and the need to collaborate and share information
• Tools such as PDMP are important but not error-proof
• Abandoning or rapidly tapering patients leads to more problems
• NIH might help us with a portal, as Dr. Linda Porter mentioned
• Some changes in how to refer to all healthcare providers
• Heard from DoD for the first time, they are part of the Inter-Agency nature of the Task Force but did not make it to the last meeting
• What they recommend may translate to care that impacts millions of patients
• Posting of report will trigger the 90 days of the public comment period
• Will meet again, likely once by Webinar, then once again in a one-day public meeting, then will sunset in May 2019 (one year after first public meeting)

Remarks: 5:00 p.m. - 5:15 p.m.

Senator Bill Cassidy, MD (R-LA)

• All physicians deal with those in pain
• Worked in a public hospital for the uninsured
  • Pain patient and addict are both very desperate and often feel like they have nowhere to go
• As a gastroenterologist he treated a lot of patients coming out of addiction, shows that you can beat addiction
• How do you help a generation of folks avoid addiction?
• Senators very interested in helping fight opioid addiction and overdose deaths
  • Must educate congress who want to help but need content knowledge to inform public policy - need help from this Task Force
• He thanks the Task Force for their work, encourages the Task Force to reach out to him directly

Adjournment: 5:15 p.m.

• Ms. Alicia Richmond Scott, M.S.W., Designated Federal Officer, adjourned the meeting

Participants

PMTF Members

• Sondra M. Adkinson, PharmD
• Amanda Brandow, DO, MS
• Commander René Campos, MBA
• Jianguo Cheng, MD, PhD
• Daniel Clauw, MD
• Steve Daviss, MD
• Jonathan C. Fellers, MD
• Howard L. Fields, MD, PhD
• Rollin M. Gallagher, MD
• Halena M. Gazelka, MD
• Nicholas Hagemeier, PharmD, PhD
• Sharon Hertz, MD
• Jan Losby, Ph.D.
• Michael J. Lynch, MD
• John McGraw, MD
• Mary W. Meagher, PhD
• Linda Porter, PhD
• John V. Prunskis, MD
• Mark Rosenberg, DO
• Molly Rutherford, MD
• Friedhelm Sandbrink, MD
• Bruce A. Schoneboom, PhD
• Vanila M. Singh, MD
• Cecelia Spitznas, PhD
• Cindy Steinberg
• Andrea Trescot, MD
• Harold K. Tu, MD, DMD
• Sherif Zaafran, MD

Speakers and Briefers

• Jennifer Thurston**
• Julia Litten**
• Anna Alfa**
• Corey Gritter**

Government Attendees

• Vanila M. Singh, MD, HHS, PMTF Chair
• Alicia Richmond Scott, MSW, HHS, PMTF DFO
• ADM Brett P. Giroir, MD, Assistant Secretary for Health, HHS *
• The Honorable Pete Sessions, Congressman (R-TX)*
• The Honorable Michael Burgess, Congressman (R-TX)*
• Paul R. Cordts, MD, Assistant Director, Medical Affairs, Defense Health Agency, DoD*
• RADM Michael Toedt, MD, Chief Medical Officer, Indian Health Services*
• Walter Koroshetz, Director, National Institute of Neurological Disorders and Stroke, NIH, HHS*
• The Honorable Bill Sessions, Senator (R-LA)*
• Lucille Beck, PhD, Deputy Under Secretary for Health for Policy and Services, Veterans Health Administration, VA**
• VADM Jerome M. Adams, M.D., M.P.H., U.S. Surgeon General, HHS**
• Shari M. Ling, M.D., Deputy Chief Medical Officer, CMS, HHS**

Registered Public Comment Attendees

• Kate Gilliard*
• Heather Parsons*
• Dr. Connie Newman, M.D.*
• Richard Lawhern*
• Kelly Devine*
• Margaret Wilson*
• Trina Waughn*
• Jackie Evans-Shields

Support Staff

• Vanila M. Singh, HHS, PMTF Chair
• Alicia Richmond Scott, HHS, PMTF DFO
• Morgan Courbois, HHS
• Karen Foster, HHS
• Rachel Katonak, HHS
• Chanya Liv, HHS
• Rachel McCoy, HHS
• Monica Stevenson, HHS
• Ashley Watkins, HHS
• Diane Epperson, Booz Allen Hamilton
• Christina Berger, Booz Allen Hamilton
• Matt Aldag, Booz Allen Hamilton
• Jeffery Saeling, Booz Allen Hamilton
• Brendan Dolan, Booz Allen Hamilton
• Nicole Miko, Booz Allen Hamilton

* Spoke Day 1 Only
** Spoke Day 2 Only
(phone) Joined via phone

Certification

I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.

Dr. Vanila M. Singh, MD

Pain Management Best Practices Inter-Agency Task Force, Chair