uso de opioides en tratamiento de dolor cronico

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National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic PainDavid B. Reuben, MD; Anika A.H. Alvanzo, MD, MS; Takamaru Ashikaga, PhD; G. Anne Bogat, PhD; Christopher M. Callahan, MD; Victoria Rufng, RN, CCRC; and David C. Steffens, MD, MHS

This National Institutes of Health (NIH) workshop was cospon-sored by the NIH Ofce of Disease Prevention (ODP), the NIHPain Consortium, the National Institute on Drug Abuse, and theNational Institute of Neurological Disorders and Stroke. A multi-disciplinary working group developed the workshop agenda,and an evidence-based practice center prepared an evidencereport through a contract with the Agency for Healthcare Re-search and Quality to facilitate the workshop discussion. Duringthe 1.5-day workshop, invited experts discussed the body of ev-idence, and attendees had opportunities to provide commentsduring open discussion periods. After weighing evidence from

the evidence report, expert presentations, and public com-ments, an unbiased, independent panel prepared a draft reportthat identied research gaps and future research priorities. Thereport was posted on the ODP Web site for 2 weeks for publiccomment. This article is an abridged version of the panel's fullreport, which is available at https://prevention.nih.gov/programs-events/pathways-to-prevention/workshops/opioids-chronic-pain/workshop-resources#nalreport. Ann Intern Med. doi:10.7326/M14-2775 www.annals.orgFor author afliations, see end of text.This article was published online rst at www.annals.org on 13 January 2015.

Chronic pain affects an estimated 100 million Amer-icans, or one third of the U.S. population. Approx-imately 25 million have moderate to severe chronicpain that limits activities and diminishes quality of life.Pain is the primary reason that Americans receive dis-ability insurance, and societal costs are estimated at be-tween $560 billion and $630 billion per year due tomissed workdays and medical expenses.

Although there are many treatments for chronicpain, an estimated 5 to 8 million Americans use opioidsfor long-term management. Opioid prescriptions anduse have increased dramatically over the past 20 years;the number of opioid prescriptions for pain treatmentwas 76 million in 1991 but reached 219 million in 2011.This striking increase has paralleled increases in opioidoverdoses and treatment for addiction to prescriptionpainkillers. Yet, evidence also indicates that 40% to70% of persons with chronic pain do not receive propermedical treatment, with concerns for both overtreat-ment and undertreatment. Together, the prevalence of chronic pain and the increasing use of opioids havecreated a “silent epidemic” of distress, disability, anddanger to a large percentage of Americans. The over-riding question is: Are we, as a nation, approachingmanagement of chronic pain in the best possible man-ner that maximizes effectiveness and minimizes harm?

On 29 and 30 September 2014, the National Insti-tutes of Health (NIH) convened a Pathways to Preven-tion workshop, “The Role of Opioids in the Treatmentof Chronic Pain.” The workshop involved a panel of 7experts, featured more than 20 speakers, and was in-formed by a systematic review conducted by the PacicNorthwest Evidence-based Practice Center (EPC) undercontract to the Agency for Healthcare Research andQuality (1). The EPC review addressed evidence aboutthe long-term effectiveness of opioids, the safety andharms of opioids, the effects of different opioid man-agement strategies, and the effectiveness of risk miti-gation strategies for opioid treatment.

CONTEXTThe expert panel considered in detail many contex-

tual issues that affect understanding about the dilemmaof opioid use and chronic pain (see the full report athttps://prevention.nih.gov/programs-events/pathways-to-prevention/workshops/opioids-chronic-pain/workshop-resources#nalreport ). Some of these are dis-cussed in the following paragraphs.

The burden of dealing with unremitting pain canbe devastating to a patient's psychological well-beingand can negatively affect their ability to maintain gain-ful employment or achieve meaningful professional ad-vancement. It can affect relationships with spouses andsignicant others; may limit engagement with friendsand other social activities; and may induce fear, demor-alization, anxiety, and depression.

Health care providers, who are often poorly trainedin the management of chronic pain, are sometimesquick to label patients as “drug-seeking” or as “addicts”who overestimate their pain. Some physicians “re” pa-tients for increasing their dose or for merely voicingconcerns about their pain management. These experi-ences may make patients feel stigmatized or feel as if others view them as criminals and may heighten fearsthat their pain-relieving medications will be taken away,leaving them in chronic, disabling pain.

Some patients who adhere to their prescriptionsmay believe that their pain is managed adequately, butothers using opioids in the long term may continue tohave moderate to severe pain and diminished qualityof life. Although many physicians believe that opioidtreatment can be valuable for patients, many also be-lieve that patient expectations for pain relief may be

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unrealistic and that long-term opioid prescribing cancomplicate and impair their therapeutic alliance withthe patient.

Although some patients gain substantial pain relief from opioids and do not have adverse effects, thesebenets must be weighed against the problems causedby the vast number of opioids now prescribed and thefact that opioids are nding their way illicitly into thepublic arena. The Substance Abuse and Mental HealthServices Administration's 2013 National Survey on DrugUse and Health found that, among persons aged 12years or older who were abusing analgesics, 53% re-ported receiving them for free from a friend or relative(2). According to the Centers for Disease Control andPrevention, approximately 17 000 overdose deaths in-volving opioids occurred in 2011 (3). From 2000 to2010, the number of hospitalizations for addictionto prescription opioids increased more than 4-fold tomore than 160 000 per year. In 2010, one out of everyeight deaths among persons aged 25 to 34 years wasopioid-related (4). In a 3-year period (2003 to 2006),more than 9000 children were exposed to opioids.

Many historical factors have inuenced opioid use.All currently available extended-release opioids havebeen approved for treatment of chronic pain on thebasis of 12-week efcacy studies, although there aresafety data for extended-release opioids from studieslasting a year (mostly open-label studies). Many imm-ediate-release opioids came on the market without ap-proval from the U.S. Food and Drug Administration(FDA) for treatment of acute pain, but all received ap-proval in recent years. New opioids that were intro-duced on the market over the past decade, particularlythose with extended-release formulations, were attrac-tive to patients and clinicians, who perceived them assafe and effective despite limited evidence. Physicianshave little training in how to manage patients withchronic pain and appropriately prescribe medicationsfor them. Physicians are often unable to distinguishamong persons who would use opioids for pain man-agement and not develop problems with misuse, thosewho would use them for pain management and thenbecome addicted, and those who request a prescrip-tion because of a primary substance use disorder.

Given these complexities, the panel struggled tostrike a balance between the ethical principles of be-necence and doing no harm—specically, between theclinically indicated prescribing of opioids on one handand the desire to prevent inappropriate prescriptionabuse and harmful outcomes on the other. These goalsshould not be mutually exclusive, and in fact, ap-proaches that attempt to achieve both simultaneouslyare essential to advance the eld of chronic pain man-agement. The panel also grappled with making recom-mendations in the face of little empirical evidence andeventually formulated advice based on its synthesis of the EPC report (1), workshop presentations that fo-cused on clinical experience, and smaller trials and co-hort studies.

CLINICAL I SSUESPatient Assessment and Triage

Chronic pain is a complex clinical issue requiringan individualized, multifaceted approach. It spans amultitude of conditions, with varied causes and presen-tations. Persons living with chronic pain are oftenlumped into a single category, and treatment appro-aches are sometimes generalized without supportingevidence. In addition, although pain is a dynamic phe-nomenon that waxes and wanes over time, it is oftenviewed and managed with a static approach. For manyreasons, including lack of knowledge, practice settings,resource availability, and reimbursement structure, cli-nicians are often ill-prepared to diagnose, appropri-ately assess, treat, and monitor patients with chronicpain.

The panel identied several important manage-ment issues for clinicians. First, they must recognizethat patients' manifestation of and response to pain willvary, with genetic, cultural, and psychosocial factors allcontributing to this variation. Clinicians' response to pa-tients with pain may differ because of preconceivednotions and biases based on racial, ethnic, and othersociodemographic stereotypes. Treating pain and re-ducing suffering do not always equate, and patientsand clinicians sometimes have disparate ideas aboutsuccessful outcomes. A more holistic approach to themanagement of chronic pain that is inclusive of the pa-tients' perspectives and desired outcomes should bethe goal.

Patients, providers, and advocates all agree thatopioids are an effective treatment for chronic pain for asubset of patients and that limiting, disrupting, or de-

nying access to opioids for these patients can be harm-ful. These patients can be safely monitored by using astructured approach that includes optimization of opi-oid therapy, management of adverse effects, andfollow-up visits at regular intervals.

The fact that some patients benet while others donot, or may in fact be harmed, highlights the challengeof appropriate patient selection. Data are lacking onthe accuracy and effectiveness of risk prediction instru-ments for identifying patients at highest risk for adverseoutcomes (such as overdose or development of anopioid use disorder). Yet, the panel heard from a work-shop speaker that longitudinal studies have demon-strated risk factors (for example, substance use dis-orders and comorbid psychiatric illnesses) that areassociated with these harmful outcomes, and somestudies show that patients who are at high risk are mostlikely to be prescribed opioids and higher doses of them.

Although evidence supporting specic risk assess-ment tools is insufcient, our consensus was that man-agement of chronic pain should be individualized andshould be based on a comprehensive clinical assess-ment that is conducted with dignity and respect andwithout value judgments or stigmatization of the pa-tient. The initial evaluation should include an appraisalof pain intensity, functional status, and quality of life, as


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well as an assessment of known risk factors for potentialharm, including history of substance use disorders andcurrent substance use; presence of mood, stress, oranxiety disorders; medical comorbidity; and concurrentuse of medications with potential drug–drug interac-tions. A redesign of the electronic health record mayfacilitate such an assessment, including integration of meaningful use criteria to increase its adoption. Finally,the incorporation of other clinical tools (such as pre-scription drug monitoring programs) into this assess-ment, although not well-studied, seems reasonable. Pa-tient characteristics can be used to tailor the clinicalapproach, with those screening at highest risk for harmbeing triaged to more structured and higher-intensitymonitoring approaches.

Treatment OptionsData to support the long-term use of opioids for

chronic pain management are scant. Workshop speak-ers stressed the need to use treatment options that in-

clude a range of progressive approaches that mightinitially include nonpharmacologic options, such asphysical therapy, behavioral therapy, and complemen-tary and alternative medicine approaches with demon-strated efcacy, followed by pharmacologic options, in-cluding nonopioid pharmacotherapies. The use of andprogression through these treatment methods wouldbe guided by the patient's underlying disease state,pain, and risk prole as well as their clinical and func-tional status and progress. However, according to aworkshop speaker, lack of knowledge or limited avail-ability of these nonpharmacologic methods and theready availability of pharmacologic options and the as-sociated reimbursement structure seem to steer clini-cians toward pharmacologic treatment, specicallyopioids.

The type of pain could inuence its management.Data were presented on 3 distinct pain mechanisms:peripheral nociceptive (caused by tissue damage or in-ammation), peripheral neuropathic (caused by dam-age or dysfunction of peripheral nerves), and central-ized (characterized by a disturbance in the processingof pain by the brain and spinal cord). Persons withmore peripheral nociceptive pain (such as acute paindue to injury, rheumatoid arthritis, or cancer pain) mayrespond better to opioid analgesics. Those with centralpain syndromes (for example, bromyalgia, the irritable

bowel syndrome, temporal-mandibular joint disease,and tension headache) respond better to centrally act-ing neuroactive compounds (such as certain antide-pressant medications and anticonvulsants) than toopioids. According to a workshop speaker, evidencesuggests that nonopioid interventions may better treatbromyalgia and that patients with even a few signs of the disorder are at risk for poor response to opioidsand a worse long-term course of pain. Speakers pre-sented evidence that nearly all chronic pain may have acentralized component and suggested that opioidsmay promote progression from acute nociceptive painto chronic centralized pain. However, several speakersand audience members cautioned against making

blanket statements about who is or is not likely to ben-et from opioids.

Clinical ManagementClinicians have little evidence to guide them once

they make the decision to prescribe opioids for chronicpain therapy. Data on selecting specic agents on the

basis of drug characteristics, dosing strategies, andtitration or tapering of doses are insufcient to guidecurrent clinical practice. Some clinicians may use opioidrotation, whereby they transition a patient from an ex-isting opioid regimen to another with the goal of im-proving therapeutic outcomes. However, this approachhas not been formally evaluated. The use of equianal-gesic tables (opioid conversion tables), which provide alist of equianalgesic doses of various opioids to guideclinicians in determining doses when converting fromone to another, was an issue of particular concern. Theequianalgesic dose is a construct based on estimates of relative opioid potency. Many opioid conversion tablesare available, and speakers noted the lack of consis-tency among them. Many studies that determinedthese equianalgesic doses were conducted in a sampleof the study population and using data points thatmay not be generalizable to patients presenting withchronic pain. The FDA has begun including data ob-tained from drug trials and postmarketing studies inpackage inserts to aid clinicians in switching betweenopioids, but many clinicians and pharmacists seem tobe unaware of this. Speakers discussed the concept of incomplete cross-tolerance, whereby providers mayneed to reduce the dose by 25% to 30% when convert-ing between opioids. Because of its longer half-life,methadone may require a larger reduction (up to 90%).

Determination and Assessment of OutcomesPatient assessments should be ongoing and should

include both positive and negative outcomes. Therange of items on such assessments might include painintensity and pain frequency, using both a short timereference as well as a longer time frame for compara-tive purposes; functional status, including effect onfunctions of daily living; quality of life; depression; anx-iety; potential misuse or abuse of opioid medications;potential adverse medical effects of opioids; and othermeasures that mimic items obtained during the initialclinical risk proling. These frequent reassessmentsshould guide maintenance or modication of the cur-

rent treatment regimen, and patients who do not meetthe mutually agreed-on clinical outcomes should beconsidered for discontinuation of opioid therapy. Al-though many speakers agreed on the need for an “exitstrategy,” there was less consensus and few data onhow one should be implemented.

Adverse Events and Side EffectsPotential harms include the risk for an opioid-use

disorder, increased risk for falls and fractures, hypogo-nadism with resultant sexual dysfunction, and myocar-dial infarction (1). Realistic expectations about potentialharms from various treatment options should be dis-cussed with patients as well as relatives and caregivers.


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Communication options should be available to discussevolving concerns; for example, adverse events andside effects might be monitored regularly and reportedto the clinician between regularly scheduled visits byusing the Internet or other communication channels.Risk Mitigation Strategies

Data on the efcacy of risk mitigation strategies,such as patient agreements, urine drug screening, andpill counts, are lacking. Although some speakers ex-pressed concern about the effectiveness of patientagreements, the use of such agreements and othercare support mechanisms might be an option as part of a comprehensive care management plan. Naloxone,which has traditionally been used to reverse heroinoverdose, was highlighted as a potential risk mitigationstrategy for patients who are prescribed opioids forchronic pain.Reducing the Next Generation of Long-TermOpioid Users

Speakers stated that a multidisciplinary team ap-proach that emulates the functions of a multidisci-plinary pain clinic would be desirable given the successof such models in treating the whole person and notmerely the pain condition, which may not be a simple,single entity. The use of a more effective chronic dis-ease care model based on a comprehensive biopsy-chosocial model of care may have implications for re-ducing the potential for a new generation of long-termopioid users.

CHALLENGES W ITHIN THE H EALTHC ARE S YSTEM

A major inuence on opioid prescribing is the evo-lution of the larger health care system and the currentstate of primary care. Pain is a multidimensional prob-lem ranging from discomfort to agony and affectingphysical, emotional, and cognitive function as well asinterpersonal relationships and social roles. Therefore,best practice models for chronic pain management re-quire a multidisciplinary approach similar to that rec-ommended for other chronic complex illnesses, such asdepression, dementia, eating disorders, or diabetes.Unfortunately, team-based approaches to care for painhave largely been abandoned. Instead, management of chronic pain has primarily been relegated to primary

care providers working in health systems not designedor equipped for chronic pain management. Primarycare providers often face competing clinical priorities inpatients with chronic pain because these patientsoften have multimorbidity and polypharmacy. Time-consuming but important clinical tasks, such as con-ducting multidimensional assessments, developingpersonalized care plans, and counseling, have givenway to care processes that can be accomplished morequickly and with fewer resources, such as prescriptionwriting and referrals. In the case of pain management,which often requires substantial face-to-face time,quicker alternatives have become the default option.As a result, providers often prescribe opioids for pain

even when other methods might be safer and moreeffective. Moreover, most practices do not have accessto experts in pain management, including specialtypain clinics, or alternative approaches to pain manage-ment.

Payment structures and incentives are also impor-tant system-level facilitators for excessive opioid use.Fee-for-service payment has traditionally focused onthe processes of medical care rather than the outcomesof care valued by patients. Current reimbursement forevaluation and management may be inadequate to re-ect the time and team-based approaches needed forintegrative treatment. In some instances, paymentstructures place barriers to nonopioid therapy, such asformulary restrictions that require evidence of failure of multiple therapies before nonopioid alternatives (suchas pregabalin) are covered. Other payment structures,such as tiered coverage systems, keep nonopioid alter-natives as second- or third-line options rather thanplacing them more appropriately as rst-line therapy.Other incentives encourage prescribing opioids forseveral months at a time rather than prescribingthem for a shorter period or using lower-volumeprescriptions.

Finally, fragmentation of care across multiple pro-viders and sites often leads to patients receiving pre-scriptions from multiple providers. This may lead to in-appropriate prescribing of not only opioids but alsounsafe drug combinations, such as opioids and benzo-diazepines. Up to 25% of patients with chronic pain re-ceive their medications in the emergency department,thus often effectively bypassing the primary care sys-tem. Patients may consult multiple specialists with rele-vant expertise in chronic pain, but these specialists mayprescribe opioids without the knowledge of primarycare providers.

R ESEARCH M ETHODS AND M EASUREMENTThe EPC report found that much of the available

literature was of poor quality or was not readily appli-cable to treating patients with chronic pain with long-term opioid therapy (1). Research on chronic pain iscomplicated by the heterogeneity of denitions,patient characteristics (such as age, sex, and race/ethnicity), causes, clinical presentations that includevarious comorbid conditions, and available opioids for

prescription. Some of the important methodologicalproblems are discussed in the following sections.

DenitionsExtrapolating ndings of studies examining the ef-

fects of opioids on acute pain to chronic pain is partic-ularly difcult. One of the central denitional problemsis dening acute versus chronic pain. Various durationsare used to dene the latter, including more than 3months, more than 6 months, and an arbitrary duration.The American Academy of Pain Medicine suggests thatchronic pain is best dened as pain that does not remitin the expected amount of time. This is clearly an indi-vidualized pain assessment, and although it may be






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needed to adequately answer the important clinicaland research questions. Until the needed research isconducted, health care delivery systems and cliniciansmust rely on the existing evidence as well as guidelinesissued by professional societies. Systems of care mustfacilitate the implementation of these guidelines ratherthan relying solely on individual clinicians, who are of-ten overburdened and have insufcient resources.

Opioids are clearly the best treatment for some pa-tients with chronic pain, but there are probably moreeffective approaches for many others. The challenge isto identify the conditions in patients for which opioiduse is most appropriate, the optimal regimens, the al-

ternatives for those who are unlikely to benet from

opioids, and the best approach to ensuring that everypatient's needs are met by a patient-centered healthcare system. For the more than 100 million Americansliving with chronic pain, meeting this challenge cannotwait.

From David Geffen School of Medicine at the University of

California, Los Angeles, Los Angeles, California; Johns Hop-kins University, Baltimore, Maryland; University of Vermont,Burlington, Vermont; Michigan State University, East Lansing,Michigan; Indiana University Center for Aging Research andRegenstrief Institute, Indianapolis, Indiana; and University of Connecticut Health Center, Farmington, Connecticut.

Note: A list of the workshop panelists, speakers, workinggroup members, and sponsors is provided in the Appendix(available at www.annals.org) .

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConictOfInterestForms.do?msNum=M14-2775 .

Requests for Single Reprints: David B. Reuben, MD, Divisionof Geriatrics, David Geffen School of Medicine at the Univer-sity of California, Los Angeles, 10945 Le Conte Avenue, LosAngeles, CA 90095.

Current author addresses and author contributions are avail-able at www.annals.org.

References1. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I,et al. The effectiveness and risks of long-term opioid therapy forchronic pain: a systematic review for a National Institutes of HealthPathways to Prevention workshop. Ann Intern Med. 2015;162:276-86. doi:10.7326/M14-25592. Substance Abuse and Mental Health Services Administration. Re-sults from the 2013 National Survey on Drug Use and Health: Sum-mary of National Findings. NSDUH series H-48. HHS publication no.(SMA) 14-4863. Rockville, MD: Substance Abuse and Mental HealthServices Administration; 2014.3. Warner M, Hedegaard H, Chen LH. NCHS Health E-Stat: Trends inDrug-poisoning Deaths Involving Opioid Analgesics and Heroin:United States, 1999–2012. Atlanta, GA: Centers for Disease Controland Prevention; 2014. Accessed at www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htm on 22 December 2014.4. Gomes T, Mamdani MM, Dhalla IA, Cornish S, Paterson JM,Juurlink DN. The burden of premature opioid-related mortality.Addiction. 2014;109:1482-8. [PMID: 25041316] doi:10.1111/add

.12598

Table. Panel Recommendations

Federal and nonfederal agencies should sponsor research to identifywhich types of pain, specic diseases, and patients are most likely tobenet and incur harm from opioids. Such studies could use a range of approaches and could include demographic, psychological, socio-cultural, ecological, and biological characterizations of patients incombinations with clear and accepted denitions of chronic pain andwell-characterized records for opioids and other pain medications.

Federal and nonfederal agencies should sponsor the development andevaluation of multidisciplinary pain interventions, including cost–benet analyses and identication of barriers to dissemination.

Federal and nonfederal agencies should sponsor research to developand validate research measurement tools for identication of patientrisk and outcomes (including benet and harm) related to long-termopioid use that can be adapted to clinical settings.

Electronic health record vendors and health systems should incorporatedecision support for pain management and facilitate export of clinicaldata to be combined with data from other health systems to betteridentify patients who benet from or are harmed by opioid use.

Researchers on the effectiveness and harms of opioids should consideralternative designs (e.g., n -of-1 trials, qualitative studies, implemen-tation science, secondary analysis, or phase 1 and 2 designs) inaddition to randomized clinical trials.

Federal and nonfederal agencies should sponsor research on riskidentication and mitigation strategies, including drug monitoring,before widespread integration of these into clinical care. This researchshould also assess how policy initiatives affect patient/public healthoutcomes.

Federal and nonfederal agencies and health care systems shouldsponsor research and quality improvement efforts to facilitateevidence-based decision making at every step of the clinical decisionprocess.

In the absence of denitive evidence, clinicians and health care systemsshould follow current guidelines by professional societies about whichpatients and which types of pain should be treated with opioids andabout how best to monitor patients and mitigate risk for harm.

The National Institutes of Health or other federal agencies shouldsponsor conferences to promote harmonization of guidelines of professional organizations to facilitate more consistent implementationof them in clinical care.





http://www.annals.org/http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2775http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2775http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2775http://www.annals.org/http://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htmhttp://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htmhttp://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htmhttp://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htmhttp://www.annals.org/http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2775http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2775http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2775http://www.annals.org/


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ical Ofcer, Metropolitan Jewish Health System (MJHS)Hospice and Palliative Care, Director, MJHS Institute forInnovation in Palliative Care, Professor of Neurology,Albert Einstein College of Medicine, New York, NewYork; David B. Reuben, MD, Chief, Division of Geriat-rics, Director, Multicampus Program in Geriatric Medi-

cine and Gerontology, Professor of Medicine, Divisionof Geriatrics, David Geffen School of Medicine at theUniversity of California, Los Angeles, Los Angeles, Cal-ifornia; Wendy B. Smith, PhD, MA, BCB, Senior Scien-tic Advisor for Research Development and Outreach,Ofce of Behavioral and Social Sciences Research, Of-ce of the Director, National Institutes of Health,Bethesda, Maryland; David J. Tauben, MD, Clinical As-sociate Professor, Department of Medicine, Chief (In-terim), Division of Pain Medicine, Medical Director,Center for Pain Relief, University of Washington, Seat-tle, Washington; David A. Thomas, PhD, Deputy Direc-tor, Division of Clinical Neurosciences and BehavioralResearch, National Institute on Drug Abuse, NationalInstitutes of Health, Rockville, Maryland; Judith Turner,PhD, Professor, Department of Psychiatry and Behav-ioral Sciences, University of Washington, Seattle, Wash-ington; Nora D. Volkow, MD, Director, National Instituteon Drug Abuse, National Institutes of Health, Rockville,Maryland; and Sharon Walsh, PhD, Professor of Behav-ioral Sciences, Psychiatry, Pharmacology, and Pharma-ceutical Sciences, Director, Center on Drug andAlcohol Research, University of Kentucky College of Medicine, Lexington, Kentucky.

Working GroupChairpersons: David A. Thomas, PhD, Deputy Di-rector, Division of Clinical Neurosciences and Behav-ioral Research, National Institute on Drug Abuse, Na-tional Institutes of Health, Rockville, Maryland, andRichard A. Denisco, MD, PhD, Services Research Branch,National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland.

Other members: Caroline Acker, PhD, AssociateProfessor and Head, Department of History, CarnegieMellon University, Pittsburgh, Pennsylvania; Jane C.Ballantyne, MD, Professor (retired), Department of An-esthesiology and Pain Medicine, University of Washing-ton, Seattle, Washington; Wen G. Chen, PhD, ProgramDirector, Sensory and Motor Disorders of Aging, Be-havioral and Systems Neuroscience Branch, Division of Neuroscience, National Institute on Aging, National In-stitutes of Health, Bethesda, Maryland; Edward C. Cov-ington, MD, Director, Neurological Center for Pain,Cleveland Clinic, Cleveland, Ohio; Jody Engel, MA, RD,Director of Communications, Ofce of Disease Preven-tion, Division of Program Coordination, Planning, andStrategic Initiatives, Ofce of the Director, National In-stitutes of Health, Bethesda, Maryland; Roger B. Fill-ingim, PhD, Professor, University of Florida College of

Dentistry, Director, University of Florida Pain Researchand Intervention Center of Excellence, Gainesville, Flor-ida; Joseph T. Hanlon, PharmD, MS, Professor of Med-icine and Health Scientist, Division of Geriatric Medi-cine, University of Pittsburgh, Pittsburgh, Pennsylvania;Christopher M. Jones, PharmD, MPH, Lieutenant Com-

mander, U.S. Public Health Service, Team Lead, Pre-scription Drug Overdose Team, Division of Uninten-tional Injury Prevention, National Center for InjuryPrevention and Control, Centers for Disease Controland Prevention, Atlanta, Georgia; Margaret Kotz, DO,Director, Addiction Recovery Services, Department of Psychiatry-Adult, University Hospitals Case MedicalCenter, Professor, Psychiatry, Professor, Anesthesiol-ogy, Case Western Reserve University School of Medi-cine, Cleveland, Ohio; Deborah Langer, MPH, SeniorCommunications Advisor, Ofce of Disease Prevention,Division of Program Coordination, Planning, and Stra-tegic Initiatives, Ofce of the Director, National Insti-tutes of Health, Bethesda, Maryland; Elinore F.McCance-Katz, MD, PhD, Chief Medical Ofcer, Sub-stance Abuse and Mental Health Services Administra-tion, Rockville, Maryland; David M. Murray, PhD, Asso-ciate Director for Prevention, Director, Ofce of DiseasePrevention, Division of Program Coordination, Plan-ning, and Strategic Initiatives, Ofce of the Director,National Institutes of Health, Bethesda, Maryland; Eliza-beth Neilson, MS, RN, Senior Communications Advisor,Ofce of Disease Prevention, Division of Program Co-ordination, Planning, and Strategic Initiatives, Ofce of the Director, National Institutes of Health, Bethesda,

Maryland; Ann O’Mara, PhD, RN, Head, Palliative CareResearch, Community Oncology and Prevention TrialsResearch Group, Division of Cancer Prevention, Na-tional Cancer Institute, National Institutes of Health,Bethesda, Maryland; Wilma Peterman Cross, MS, Dep-uty Director, Ofce of Disease Prevention, Division of Program Coordination, Planning, and Strategic Initia-tives, Ofce of the Director, National Institutes of Health, Bethesda, Maryland; Bob A. Rappaport, MD, Di-rector, Division of Anesthesia, Analgesia, and AddictionProducts, Center for Drug Evaluation and Research,U.S. Food and Drug Administration, Silver Spring,

Maryland; David B. Reuben, MD, Chief, Geriatric Divi-sion, Director, Multicampus Program in Geriatric Medi-cine and Gerontology, Professor of Medicine, Divisionof Geriatrics, David Geffen School of Medicine at theUniversity of California, Los Angeles, Los Angeles, Cal-ifornia; Wendy B. Smith, PhD, MA, BCB, Director forResearch Development and Outreach, Ofce of Behav-ioral and Social Sciences Research, Ofce of the Direc-tor, National Institutes of Health, Bethesda, Maryland;Michael Von Korff, ScD, Senior Investigator, GroupHealth Research Institute, Group Health Cooperative,Seattle, Washington; Paris A. Watson, Senior Advisor,Ofce of Disease Prevention, Division of Program Co-


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ordination, Planning, and Strategic Initiatives, Ofce of the Director, National Institutes of Health, Bethesda,Maryland; and Jessica Wu, PhD, Health Scientist, Ofceof Disease Prevention, Division of Program Coordina-tion, Planning, and Strategic Initiatives, Ofce of theDirector, National Institutes of Health, Bethesda,

Maryland.

SponsorsNIH Ofce of Disease Prevention (David M. Murray,

PhD, director ), NIH Pain Consortium (Story Landis, PhD,chair ), National Institute on Drug Abuse (Nora D.Volkow, MD, director ), and National Institute of Neuro-logical Disorders and Stroke (Story Landis, PhD,director

).


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