This nomination encompasses several different aspects of the treatment of acute and chronic pain. As access to buprenorphine and methadone is very limited, this nomination instead focuses alternatives to treating pain and assisting the provider with managing withdrawal syndromes and sobriety, which is beyond existing guidelines (Kampman and Jarvis, 2015) Questions: 1- Efficacy of treatment options beyond opiates for acute pain and not limited to acetaminophen and NSAIDs but including off-label use of prescription medications, over the counter medicines and adjuvant interventions 2- Efficacy of treatment options beyond opiates for chronic pain including but not limited to prescription medications (approved and off-label uses), over the counter medicines and adjuvant interventions 3- Efficacy of treatment options for pain for those with high risk of adverse outcomes: pediatric patients, those with co-morbid history of substance abuse or other mental health diagnoses 4- Efficacy of treatment options for withdrawal syndromes from both prescription and illicit opiates as well as medications to assist with continued sobriety

Pain recognition and appropriate management is a component of basically every specialty (Institute of Medicine). As is becoming more readily recognized at every level, from the clinician s office to Congress, the United States has a problem with appropriately managing opiate medications and concurrently a rapidly increasing problem with illicit substances (Volkow, 2016). While this is a multi-factorial problem, clinicians need to have guidelines on alternatives to opiate medications that are evidence based. These alternatives include prescription, over the counter and adjuvant therapies/interventions, which are beyond the guidelines recently released by the Centers for Disease Control (2016). This proposal is also complementary to the research currently proposed by the Patient Centered Outcomes Research Institute (2016), which focuses on interventions to reduce opioid prescribing, In contrast, this proposal is geared towards efficacy of treatment alternatives and withdrawal protocols.

Patients have come to expect to be pain free from any condition they may suffer. While this is not necessarily an accurate or appropriate mindset, administrators and others have latched on to this metric as a way to grade medical entities and providers (Baker, 2016; Centers for Medicare and Medicaid Services, 2014; Stempniak, 2016). Providers need to have the skills necessary to assist patients with evidence based alternatives to the standard treatment of using opiates for severe acute and chronic pain. This will allow for decreased reliance on highly addictive substances with limited long term data. Moreover, providers need the resources to help reduce or stop the use of habit forming medicines by limiting withdrawal symptoms and improving chances at maintaining abstinence from opiates, both prescription and illicit.

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