Rx15 clinical tues_200_1_bianchi_2saenger

Clinical Track:
FDA on Decreasing Opioid Risks and
VA on Exploring Non-Opioid Options
Presenters:
• Robert P. Bianchi, Vice President and Chief of Scientific
and Technical Affairs, Prescription Drug Research
Center
• Michael Saenger, MD, FACP, Lead Physician, Pain
Management, VISN 7, and Director, Empower Veterans
Programs, and Leader, Task Force for Opioid Safety,
Atlanta VA Medical Center
Moderator: Kelly J. Clark, MD, MBA, FASAM, DFAPA,
President-elect, American Society of Addiction Medicine
(ASAM), and Member, Rx Summit National Advisory Board

Disclosures
• Robert Bianchi and Michael Saenger, MD, FACP, have
disclosed no relevant, real or apparent personal or
professional financial relationships with proprietary
entities that produce health care goods and services.
• Kelly J. Clark, MD, MBA, FASAM, DFAPA –
Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US

Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

Learning Objectives
1. Explain a top-down and a bottom-up federal
response to the Rx drug abuse epidemic.
2. Evaluate abuse-deterrent opioids.
3. Advocate a framework for diagnosing and
treating chronic pain that de-emphasizes
opioids.

Government and Industry
Response to Rx Abuse
Robert Bianchi
Prescription Drug Research Center -
Chicago, IL
Atlanta GA - April 7, 2015

DISCLAIMER
• Robert Bianchi has disclosed no relevant,
real or apparent personal or professional
financial relationships with proprietary
entities that produce health care goods
and services.

Learning Objectives
• Government response to the Rx drug abuse
epidemic
• Industry Response to the Rx drug abuse
epidemic
• FDA Guidance to Industry
• In vitro testing to evaluate abuse-deterrent
opioids

Current Situation
• CDC has declared Rx abuse as an epidemic. More
americans abuse Rx than cocaine, heroin, inhalants
& hallucinogens COMBINED
• In 2013 approximately 43,982 overdose deaths
occurred, one death every 12 min*
• Of these deaths, 22,767 (51.7%) were attributed to
Rx drug abuse – 16,235 were attributed to opioids
– 6,973 were attributed to benzodiazepines*
*CDC Centers for Disease Control and Prevention. National Vital Statistics System
mortality data. (2015)

Insatiable Appetite - 2010
Rx abuse is the fastest growing drug problem in
the United States (5% of world population)
• 65% of the worlds supply of hydromorphone
(Dilaudid)
• 80% of the worlds supply of oxycodone
(OxyContin)
• US consumed 99% of the worlds supply of
hydrocodone (Vicodin)

What caused this phenomenon?
• Prescription drugs do not fall under the
clandestine cloud of illegal drugs such as heroin,
ecstasy or methamphetamine
• Prescription drugs are more available due to the
development of new products and increased
prescriptions
• Rx drugs are safe - FDA approved & Dr. prescribed
• Friends and family use them
• Drugs are frequently obtained free of cost

Contributing Causes
Doctor Shopping
Over prescribing
Stolen or forged prescriptions
Pharmacy thefts
Internet pharmacies
Pain clinics

Industry Response
• Develop consortium to explore options and
advise FDA
• Develop formulations that deter abuse
• Educate prescribers and patients
• Conduct research to develop new pain
medications

Government Response
• Increased monitoring of
– Manufactures
– Distributors
– Pharmacies
– Doctors
• Prescription Drug Monitoring Programs
• DEA “Take Back Program” 309 tons of Rx
medications from nine collection events
• Increased criminal investigations

Government Response
• Educational programs and publications for prescribers and
patients
• Requires sponsors to develop REMS
• FDA issued draft guidance to industry in Jan 2013,
describing how to demonstrate if an opioid formulation
contains abuse deterrent properties.
• April 2013 FDA allows labeling concession to Purdue for
reformulated OxyContin (physical or chemical properties
that deter IV and nasal abuse). Original formulation
available 1995-2010
• Encouragement to develop abuse resistant formulations
(ADF)

ABUSE DETERRENT OPTIONS
1. Physical/Chemical barriers – Physical barriers can
prevent chewing, crushing, cutting, grating, or
grinding. Chemical barriers can resist extraction of
the opioid using common solvents like water, alcohol,
or other organic solvents. Physical and chemical
barriers can change the physical form of an oral drug
rendering it less amenable to abuse (e.g., reformulated
OxyContin®)

2. Agonist/Antagonist combinations – An opioid
antagonist can be added to interfere with, reduce,
or defeat the euphoria associated with abuse. The
antagonist can be sequestered and released only
upon manipulation of the product. For example, a
drug product may be formulated such that the
substance that acts as an antagonist is not clinically
active when the product is swallowed but becomes
active if the product is crushed and injected or
snorted. (e.g., Talwin Nx®, Suboxone, Embeda®)

3. Aversion – Substances can be combined to produce
an unpleasant effect if the dosage form is
manipulated prior to ingestion or a higher dosage
than directed is used. (Oxecta oxycodone/niacin)
4. Prodrug – A prodrug that lacks opioid activity until
transformed in the gastrointestinal tract. Can be
unattractive for intravenous injection or intranasal
routes of abuse (e.g. Vyvanse amphetamine).

5. Delivery System (including depot injectable formulations
and implants) – Certain drug release designs or the
method of drug delivery can offer resistance to abuse. For
example, a sustained-release depot injectable formulation
that is administered intramuscularly or a subcutaneous
implant can be more difficult to manipulate.
6. Combination – Two or more of the above methods can
be combined to deter abuse.

FDA GUIDANCE
The Guidance describes four categories of
recommended studies for supporting and
evaluating claims of abuse-deterrence:
–Premarket studies:
•Laboratory Manipulation and Extraction
Studies (Category 1)
•Pharmacokinetic Studies (Category 2)
•Clinical Abuse Potential Studies (Category
3)
-Post marketing Studies (Category 4)

Laboratory Manipulation and
Extraction Studies
Evaluate various simple and sophisticated
mechanical and chemical ways a drug can be
manipulated.
(1) defeating or compromising the controlled release of
an opioid from extended-release formulations
(2) preparing an IR or ER formulation for alternative
routes of administration
(3) separating the opioid antagonist, if present, from the opioid
agonist, thus compromising the product’s abuse-deterrent
properties.

Extraction Studies
Evaluate resistance to manipulation
1. Ease of particle size reduction using commonly
available manual tools (spoons, hammer, mortar &
pestle) & electrical appliances (coffee grinder,
blender)
• 2. Effects of heat & cold on manipulation efficiency

Coffee mills used to grind tablets
• Shown lids have been used for approx 15 runs each
• Examples on broken blades from two mills
Photos by permission, Egalet, Copenhagen DK, 2010.

Extraction Studies
• For a product with potential for snorting, the
particle size distribution should be
established.
• For a product with potential for snorting, the
particle size distribution should be
established, using various tools.
Photo by permission, National Medical Services Laboratories (NMS) 2014

Extraction Studies
Evaluate extractability of intact &
manipulated product
1.Commonly available aqueous solvents that have potentially
relevant solvent characteristics (pH, polarity such as water,
alcohol, cola, vinegar, acetone, mineral spirits)
2.Conduct at elevated temperature & room temperature.
3.Conduct on stirred & soaked comparator & ADF
4.Conduct on in tact and ground material

Extractability

SMOKING ABUSE
• For a product with potential for smoking, the
vaporization temperature and degradation
temperature of the opioid in salt and base
form should be determined.

SMOKING APPARATUS

INTRAVENOUS ABUSE
• For a product with potential for intravenous
injection, the opioid concentration in a small
injection volume and the viscosity
(syringeability and injectability) of the
injection fluid should be determined.

INJECTABILITY
Photos by permission, Egalet, Copenhagen DK, 2010.

INJECTABILITY

DOSE DUMPING
• The ingestion of alcoholic beverages with
extended release opioids poses serious safety
concerns i.e. uncontrolled immediate release of
drug.
• The FDA now recommends in vitro drug release
studies to determine if alcohol causes enhanced
release of opioid using varying concentrations of
alcohol

DOSE DUMPING

IN-VITRO EXPERIMENTS
• Develop written protocols that produce statistically valid,
reproducible results.
– Include related comparator product
– Include controls
– Include quality assurance procedures
– All experiments must be conducted at least in triplicate
– Use graphs and charts to illustrate data
– Experiments should be conducted by an independent
laboratory that is blinded to the fullest extent possible in
addition to in house laboratory experiments
– Take photographs to illustrate results

IN-VITRO EXPERIMENTS
aka KITCHEN CHEMISTRY
• Every product is different; therefore each requires a unique
set of experiments developed under the standardized tests to
assess tamperability.
• Sponsor knows product’s vulnerabilities and should develop
experiments in concert with abuse experts based on product
knowledge and current abuse methods of similar products
using commonly available chemicals and equipment.
• Standardized laboratory extractions must be developed for
each dosage form, e.g. tablets, capsules, patches, liquids, IR,
SR using solvents & equipment commonly available.
• Consider testing all dosage strengths

Summary
• No objective measure exists to measure
tamperability/extractability
• Each product/system requires unique experiments designed
to address vulnerabilities
• Use independent laboratory (NMS) & abuse experts
• Consider all modes of abuse & all strengths
• Include photographs, graphs & charts where appropriate
• No product has addressed multiple pill abuse
• No product has been proven to be tamper proof

Thank you
Robert P. Bianchi
Vice-President and Chief
of Scientific and Technical affairs
Prescription Drug Research Center
134 N. LaSalle Street
Chicago, IL 60602
312-726-8620 - Office
571-233-4780 – Cell
RBianchi@pdrcllc.com
RBConsulting700@AOL.com

Reframing
Medical Home Team’s
Diagnosis and Treatment of
Complex Chronic Pain
Michael Saenger, MD, FACP
Rx Drug Abuse Summit
April 7, 2015

Conflicts of Interest
• Michael Saenger, MD, FACP, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.
• Biases toward:
– Bio-psycho-social-spiritual framework of Health
– Self-empowered care
– Evidence Based Practice (EBP)
– Systems of care / Team-based care
• Patient Centered Medical Home
– Model for Improvement
• Changing, and testing to see if it is improvement

Learning Objectives
• Discuss how to apply a “Whole Health”
Framework i.e. Bio-Psycho-Social-Spiritual Model
of Chronic Pain rather than Bio-Medical one
• Review how to become a “Coach” for
Collaborative Self-Management and draw out the
Client’s Internal Motivation for Change
• Review how to apply “Retraining the Brain” /
“Neuroplasticity” Model to chronic pain
management.

That to which we give
attention, grows!

Mindful Moment,
IF You Feel Safe AND Choose To, Then:
• Practice of self-care
– Release tension in your muscles… through
Gently rolling your shoulders…
– Activate “Relaxation Response” through
Slowing and deepening your breathing

Client Scenario 1
35 year old woman with chronic pelvic pain is crying
in the exam room. She has already been told by a
Gynecologist and a Gastroenterologist that her
ultrasounds and scopes are normal.
Healthcare Team recommends:
A. Converting oxycodone IR to fentanyl patch
B. Adding alprazolam prn
C. Ordering MRI of pelvis
D. Understanding her goals and
more about her as a whole person

Client Scenario 2
30 year old man with phantom limb pain
“cannot sleep because of the pain”.
Healthcare Team recommends adding:
A. Zolpidem
B. Pregabalin
C. Topiramate
D. Mirror Therapy

Historical Swing
• From: “Not much we can do”, besides:
– TLC
– Grandma’s chicken soup
– Prayer
• To: Many new choices of:
– Pharmaceuticals and
– Procedures

“Find it and Fix it”
• “Reductionistic Science” Model
– Produces many advances in
• Diagnosis
• Therapy
– May miss complexity of Whole

Story of Pelvic Pain
• “Usual Care” = “Bio-Medical Model”
– Chief Complaint drives
• Subspecialty referral
(for “Diseased Part”) and
• Differential Diagnosis with
– Life threatening illnesses excluded with
» Advanced testing…
• Symptom management with
» Poly-pharmacy

Opioids
Symptom/
Disease
Focused
Care
Obesity
LBP
Depression
Anxiety
GERD
Neuropathy
Insomnia
HA
Appetite
Suppressant
SSRI
Benzodiazepine
PPI
Gabapentinoid
Z Drug
Triptan
$$
$Modified from VHA Office of Patient Centered Care and Cultural Transformation; Tracy Gaudet,
MD, Director; David Rakel, MD, US Director of Whole Health Clinical Education Program;
Used with Permission

“The greatest barrier to discovery
is not ignorance
but the illusion of knowledge.”
David Borstein

The Cycle of Chronic Pain in the Clinic
Modified from VA VISN 20 Chronic Pain Education for Providers;
Anthony Mariano, PhD; Used with Permission

Re-Framing
“All models are wrong, some are useful.”
George E. P. Box

Chronic Pain ≠ Acute Pain
Acute Pain, usually:
• Transient
• Simple
• Bio-Medical cause
• Curable
Complex Chronic Pain, usually
• Long lasting
• Complicated
• Bio-Psycho-Social-Spiritual
• Manageable, not curable

Chronic Pain often Driven by:
• Stress and Poor Coping Skills
• Deconditioning
• Central Sensitization
• Anxiety
• Depression
• Substance Use Disorder
– including Opioid Use Disorder
• Note that Sleep may be disrupted
by any of these

Whole Person Perspective
Explains Gap between
Objective Evidence and Subjective Pain

What is “REAL” Pain?
• “Pain” is what the Client says it is
• “Psycho-social pain” is “Real” pain
– But enabling “Chemical Coping”
worsens whole person problems

Break the Cycle of Frustration

Bio-Psycho-Social-Spiritual Model
Affects How to Diagnose Chronic Pain
• Initial thorough H&P and a few tests
• Assessments for
– Anxiety
– Depression
– Substance Use Disorders,
• including Opioid Use Disorder
• NOT additional CT/MRI… until
“real” “pain-generator” image captured

Affects How to Diagnose Chronic Pain
• Hear the Client’s Life Story
• Gather detailed Social History

Complex Chronic Pain
Diagnostic Clues:
• “Enigmatic” presentations to multiple PCPs
• Declining function over time
• Severe emotional distress and disability
not responding to conventional treatments
• Significant dissatisfaction with medical care

Affects How to Treat Chronic Pain
• Collaborative Self-Management

Collaborative Self-Management
• Chronic Care Model
• Primary Goal:
– NOT urgent nor complete pain relief
– Reduce suffering and disability
• Role of Healthcare Team
– Enhancing adaptive choices

Collaborative Self-Management
• Values Clients as people
– Identifies Functional Goals
– Supports addressing other life problems
• Challenges dysfunctional beliefs

Reframing Pain

“What do you want your Health for?”
• Re-centering
– Rather than: “On a scale of 0-10…?”;
• Moving from passive to active role
– Quarterback
• Drawing out intrinsic motivation for change
Tracy Gaudet, MD; VHA Office of Patient Centered Care and Cultural Transformation

Model of
Proactive Health and
Well-being
VHA Office of
Patient Centered Care and
Cultural Transformation;
Tracy Gaudet, MD, Director;
Used with permission
Circle of Health; What is:
- In balance?
- Out of balance?

VEMA Process
• Validation
– “We believe you have real pain”
• Education
– Shared model
• Motivation
– Enhanced: “Motivational Interviewing”
• Activation
– Offering new way to react to pain

“What you do
is more powerful
than any pill”
[or what is done to you]
Tracy Gaudet, MD; VHA Office of Patient Centered Care and Cultural Transformation

Facilitating Motivation
• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
• Challenge false beliefs
• Explore change
• Assist in “Action Plan”
• Reinforce adaptive action
• Reinforce gains; adjust goals
• Explore reasons;
reassess readiness to change

Roll with Resistance
• Avoid arguments
• “Yes… and…”
– Reflect back Client’s concerns
– Reframe the problem, avoiding false “dualism”
– Acknowledge difficulty
– Emphasize autonomy and responsibility

Pain is Inevitable;
Misery is Optional

Making Health Plan
• Responsibility for change is theirs
• Begin with small goals
• Start with social/recreational reactivation first
• Physical reactivation ≠ PT which “didn’t work”
– Encourage, “Think like an athlete”

SMART Goals
• Specific
• Measurable
• Achievable
• Realistic
• Timely
• Answering the 5 “Ws”: What, When, How…

Setting a Goal
SMART Examples:
• Walk in place for 5 minutes
before each meal
• Practice 3 minutes of slow
deep “belly” breathing at 10
and 2 each day
Not so smart examples:
• Get more exercise
• Relax more

Follow-up
• Inquire about progress towards goals
• Identify barriers
• Minimize focus on urgent pain relief
• Help establish new goals
• “You know you’re providing high quality pain care when
you spend very little time talking about pain”

Prepare for “Bad Days”
• Exacerbations are “predictable ebb and flow”
of chronic pain
• Stress may precipitate Bad Day
– “Be prepared”
– “Be proactive”

We all can be Good “Therapists”,
Using “3 P’s”
• Pause: Relaxation Response
– When “Foaming in” or…
• Be Present: Attentive
– When “Crossing Threshold”
• Then Proceed
– With Whole Health Care
– Including those skills of our particular profession
http://www.fammed.wisc.edu/mindfulness/pip/pause

Roles for Primary Care Team:
• Affirming Client’s
– Worth (their story; their significance)
– Innate strengths to move toward Health
• Side-stepping non-value added care, which is:
– No better than standard care (or harmful or …)
– Passive
• Offering
– Motivational Enhancement
– Safe and effective options which promote Health

Using Re- Education in
Neuropsychology: “Re-Train the Brain”
The Hunter Group; used with Permission: http://www.youtube.com/watch?v=4b8oB757DKc

That to which we give
attention, grows!
“Neurons that fire together, wire together”
Donald Hebbs; “The Theory of Hebbian Learning”

From Where is Pain Coming?
Walter Reed Medical Center; http://www.youtube.com/watch?v=YL_6OMPywnQ

Re-Training the Nervous SystemStrainonBody
Tissue Damage
Graphic thanks to Neil Pearson, Jennifer Gansen and others
Sensitized
Nervous System
Alarm
Desensitized
Nervous System
Alarm
Deconditioned
Exercise Capacity
Reconditioned
Exercise Capacity

Neil Pearson’s “Exercise Guidelines”
for Stretching or Exercising
1. Go to “the Edge” for particular exercise;
2. Ask 2 questions
a. Am I safe? (if “yes”, then)
b. Will I pay for this later? (if “no”, then)
3. While at “the Edge”, keep
a. Body calm
b. Breathing calm
c. In touch with pain (not too much nor too little)
http://www.youtube.com/watch?v=gN-WwxfPIZo Modified; Used with Permission

Mindfully Aware
• I (We) cannot do:
– Everything
– Everything today
• I (We) can:
– Play significant role as Coach
– Educate re: range of safe and effective options

Collaborating with Other Coaches
Who Excel in:
• Motivational Enhancement
• Assessment and therapies for:
– Psychological care
– Movement needs
– Existential/Spiritual care
– “Biological” and other needs

Re-Framing our Care
FROM: TOWARDS:
Bio-Medical Model Bio-Psycho-Social-Spiritual Model
Symptom-driven Seeking Deeper Meaning / Values
Provider-driven Coaching / Motivational Enhancement
“Pharmaceuticals & Procedures” Activating Innate Healing
"Done to you" "You do"
Reactive Proactive / Reflective and Aware
1:1 Appointments Group Education and Support

Pendulum Balance
• Reductionistic AND Holistic Science
• Bio-Psycho-Social-Spiritual Model

Web Resources
Chronic Pain Overview for Clients
• Understanding Pain: What to do about it in Less than Five Minutes
http://www.youtube.com/watch?v=4b8oB757DKc
https://www.youtube.com/watch?v=MI1myFQPdCE
https://www.youtube.com/watch?v=jIwn9rC3rOI
• Low Back Pain – Mike Evans
http://youtu.be/BOjTegn9RuY
• Four Flat Tires – American Chronic Pain Association
http://www.theacpa.org/a-car-with-four-flat-tires

Web Resources
Deep Breathing & Exercise for Clients
• Deep Breathing Exercise for Relaxation Response: Breathe2Relax-Demo
http://www.youtube.com/watch?v=YdsipKCACac
• Neil Pearson’s Exercise Guidelines
http://www.youtube.com/watch?v=gN-WwxfPIZo
• Leslie Sansone (first 5 minutes) Starting Walking at Home
http://www.youtube.com/watch?v=ykPr0t2KutY&feature=youtu.be

Web Resources
Motivational Story for Clients
• Never, Ever Give Up. Arthur's Inspirational Transformation!
http://www.youtube.com/watch?v=qX9FSZJu448

Other Web Resources for Clients
• The American Chronic Pain Association
http://theacpa.org/
• Conditions A to Z
http://theacpa.org/conditions
• Communication Tools (self rating logs…)
http://theacpa.org/Communication-Tools
• Mirror Box Therapy
http://healthskills.wordpress.com/2009/03/05/youtube-mirror-box-
videos/

Web Resources for Clinicians
• “Paths to Recovery” / “Retraining the Nervous System”; Neil Pearson
http://www.lifeisnow.ca/
• The American Chronic Pain Association
http://www.theacpa.org/

Other References
• The Pain Survival Guide: How to Reclaim Your Life. Turk. American
Psychological Association 2005
• Pain Management for Older Adults – A Self-Help Guide. Hadjistavropoulis.
International Association for the Study of Pain. 2008

What CAM to offer?
i.e. Integrative Health Therapy Options
• Complementary Medicine options for cLBP
– “Bridge” – useful short term
• Massage
• Spinal Manipulation
• Acupuncture
– “Active” – Client learns self management tools
• Alexander technique – “retrain the brain”
• Mindfulness – non-judgmental acceptance
• Yoga, Tai Chi ... movement training like Alexander
http://www.psychiatry.org/practice/professional-interests/addiction-psychiatry/learning-the-evidence-behind-alternative-complementary-chronic-pain-management---
emphasis-on-chronic-low-back-pain----part-two
http://www.psychiatry.org/practice/professional-interests/addiction-psychiatry/learning-the-evidence-behind-alternative-complementary-chronic-pain-management-
emphasis-on-chronic-low-back-pain----part-one

Away from therapies:
Dangerous
Ineffective
Passive
High Dose Opioids
Benzodiazepines
Chronic “Muscle Relaxants”
Chronic “Sleep Medications”
Transition From

Transition To
Dangerous
Ineffective
Passive
Towards therapies:
Safe
Moderately effective
Self-efficacious
Deep Breathing
Relaxation
Alexander Technique
Yoga / Tai Chi
Mindfulness

“Bridging Therapies”
For Those Needing Temporary Help
Dangerous
Ineffective
Passive
Towards therapies:
Safe
Self-efficacious
Saenger, APA PCSS-O Webinars, Evidence for CAM for Chronic LBP,
parts 1&2, 2013;
Saenger, American Chronic Pain Association Chronicle, June 2013;
Heckman, Heckman, Saenger and Marconi, HIV Specialist, Dec 2013
Temporary “Bridging” Therapies
E.g. while tapering opioids; Using
Acupuncture or
Spinal Manipulation or
Massage

Goal: Thriving Self-Management
Towards therapies:
Safe
Self-efficacious
Deep Breathing
Relaxation
Alexander Technique
Yoga / Tai Chi
Mindfulness

Re-Learning, Inter-Professionally
Really ALL in Patient Centered Medical Home…:
Clerk, LPN, Social Worker, Clinical Pharmacist,
Psychologist , Dietician …

Building Collaborative Relationship
• Set realistic expectations during initial meeting
• Take their concerns seriously
• Acknowledge their frustration with prior tx
• Listen to their story, not just their symptoms
• Express empathy for urgent pain relief
• Recognize current situation is unacceptable
• Commit to the relationship

Personal Meaning of Pain
• Disabling beliefs
• Psychosocial factors
• Factors maintaining pain
• Factors influencing medical utilization
• How is person currently managing?
• How ready is the person for self-management?

Story of Pelvic Pain, Revisited
• “Model of Illness”
• “What do you believe is:
– Causing this _____?
– Going to happen?
– Needed to find this?
– Needed to manage this?

“Draw me your story”
• Consider “homework” of one page drawing
“My Life”
Pain (1)
Began
Pain (1)
Worsened
Significant
Life Event 1
Significant
Life Event 2

Special Thanks to:
• “Tony” Mariano, PhD;
– VHA VISN 20
• Tracy Gaudet, MD;
– VHA Office of Patient Centered Care and Cultural Transformation
• “Mac” Gallagher, MD;
– VHA National Director for Pain Management
• Neil Pearson, MSc, BScPT, BA-BPHE, Cert MDT;
– Life is Now
• Ilene Robeck, MD;
– VHA VISN 6
• Anne Tomolo, MD, MPH;
– Atlanta VA National Quality Scholars Program
• Nadine Kaslow, PhD;
– American Psychological Association; Grady Health System; and Emory University

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