PAIN MANAGEMENT
FROM THE NACHC LENS

High-quality, equitable, patient-centered pain management that mitigates risk for opioid use disorder is a priority for the United States. However, patients often encounter fragmented systems of care and limited non-opioid options to treat their pain. There is now a growing evidence base for use of non-opioid pharmacological and non-pharmacological treatments for pain management, and health centers are exploring how to effectively integrate these approaches into their practices.

In this issue of the Care Teams Digest, we highlight two health centers that are leading the way in evidence-based integrated care to help patients treat and manage chronic and acute pain. 
Affinia Healthcare and Logan University Chiropractic Care: A Pain Management Alternative Partnership

In 2017, Affinia Healthcare, Inc., St. Louis, MO, partnered with Logan University’s College Chiropractic to add chiropractic care into its integrated health services. This partnership enabled the health center’s patient population, including many who are either recent immigrants or experience unstable housing, access to chiropractic care as a pain management alternative to opioid medication. It also gave chiropractic students an opportunity to work with community health center patient populations and address the many complex Social Drivers of Health that impact their health and health care.

“By having chiropractors integrated into the care team, primary care providers are able to better focus on primary health care issues and have the chiropractors engage with the patient on musculoskeletal issues or concerns,” shares Kelsey Lewis, DC, an Integrative Health Center Clinician and Logan University Adjunct Faculty. Dr. Lewis, along with two other chiropractors and a rotating student staff, care for thousands of patients annually across three Affinia Healthcare locations. 

“We'll definitely refer or even co-manage patients with other disciplines like primary care, orthopedics, rheumatology, and neurology,” says Dr. Lewis. For example, if a patient has high impact chronic pain and depression we will talk with the primary care provider about pharmacologic treatment options.” 

Chiropractic Care and Pain Management: An Integrative Approach
“Mental health and pain go hand in hand,” says Dr. Lewis who estimates that at least half her patients have chronic pain. “Pain is complex and it’s specific to each person who has it. As providers it is critical to recognize what is important to each patient and what is driving their pain.”
For patients who experience high impact chronic pain, their mental and physical health pain may limit their ability to engage in daily routines such as working or taking care of families. In these situations, Dr. Lewis can coordinate care with a medical doctor, a clinical pharmacist, and a behavioral health specialist. Together they work as a comprehensive pain management team ensuring the patient receives a holistic perspective and integrative treatment plan.

“Our main goal is for patients to be able to re-engage in activities that they've stopped doing,” says Dr. Lewis whose chiropractic care team takes the following four-prong integrative approach to pain management customized for each patient. This approach is aligned with recent World Health Organization (WHO) guidelines for non-surgical management of chronic primary low back pain in adults in primary and community care settings and includes:
  • education about the complex and biopsychosocial nature of pain
  • exercises to improve the body’s resiliency to movement
  • manual therapy, and
  • mind-body/relaxation therapies (i.e. meditation)
Making Impact
An observational study of 35 Affinia Healthcare patients recently published in the Journal of Primary Care and Community Health found that patients experienced improvement in spinal pain and disability with chiropractic care versus a multidisciplinary pain team, highlighting the critical role chiropractors can play in managing chronic pain.

According to Dr. Lewis, people who would otherwise not have the opportunity to receive conservative care for pain management (i.e. chiropractic, physical therapy, occupational therapy) through an integrative approach, now have greater access to it.

“Patients feel they are getting high value and personalized care, and the chiropractic care team has observed patients are reengaging in their daily life activities and are having more fulfilling lifestyles, despite their many daily pressures and stressors.” 
People’s Community Clinic’s Integrative Pain Management Program

The Integrative Pain Management Program (IPMP) at People’s Community Clinic (PCC), Austin, TX, aims to treat pain and improve patients’ functioning and quality of life while reducing the use of pain medication and other substances. Created in 2018 with support from a Health Resources & Services Administration grant, the program adapted evidence-based best practices and expanded upon its current mental health services while addressing the opioid epidemic.

“We wanted to build a program that addresses chronic pain and that prevented people from ending up on opioids,” says Sharad Kohli, MD, a family medicine specialist at PCC and the IPMP Medical Director.

IPMP offers an array of non-pharmacological strategies to help patients reduce chronic pain and improve their quality of life. “We had a lot of resources already in our clinic. We had a very robust integrated behavioral health model, nutrition services, a partnership with an acupuncture school to offer free acupuncture, and a medical legal partnership who were already addressing some of the upstream factors that could impact their health. We just needed to integrate all these pieces together and try to see what we can do,” explains Dr. Kohli.

The program, and PCC more broadly, equips patients with the necessary skills to manage their pain and advocate for themselves and their care needs. The IPMP care team includes primary care physicians, social workers, an SUD counselor, a nutritionist, yoga therapists, an acupuncturist and a care coordinator.

When working with each individual patient, IPMP care teams:

  • consider all possible biopsychosocial causes of the patient’s pain
  • talk with the patient about what tools can address those root causes, and
  • ask the patient to choose where they would like to start

If a patient is not ready to engage in pain treatment due to other unmet needs, such as housing, immigration status, or an SUD, the IPMP team connects them to additional support. 

Relational Health and Trauma Responsive Care Incorporated into all Patient Services
Many patients served by the IPMP are uninsured or underinsured, and many patients have experienced substantial trauma related to adverse childhood experiences, racism and discrimination (including medical mistrust), and/or poverty. Many patients’ experiences with pain are rooted in trauma which happens on a relational level, so the IPMP centers this in its approach to care. This involves:

  • building supportive and trusting relationships among patients and providers,
  • fostering a sense of community and belonging among patients in the program,
  • empowering patients to make choices about their care, and
  • providing a safe space for patients to try new things, including new modalities of pain treatment.

Tying It All Together with Group Medical Visits
Group medical visits are a critical component of the IPMP. Groups are held in English and Spanish and are based on an eight-week curriculum, which covers information including nutrition and anti-inflammatory diets, stress and trauma, health-harming legal needs, exercise and movement, and sleep. Each week the topics are chosen by group members. These groups have been impactful for patients as they learn from one another and learn more about options for managing their pain.

“…We've tied it all together with groups…The doctor and other members of the health care team become participants in the group where everyone just kind of talks from their own perspectives. There is more time to hear patient stories,” shares Dr. Kohli. He believes that groups help patients feel heard and validated and offer connection and adds, “When they get in a room with other people who have the same experience, they feel like they can connect with someone and there's a community that forms. And community can be healing.”
Best Practices for integrative Chronic Pain Management

To ease the opioid crisis and bring about optimal and equitable health for patients, a task force convened by the U.S. Department of Health and Human Services recommends that healthcare organizations use a biopsychosocial, multidisciplinary, multimodal approach to chronic pain within 5 treatment categories:

  • Medications: Opioids and nonopioids, such as acetaminophen, NSAIDs, anticonvulsants, musculoskeletal agents, antidepressants, and antianxiety medications
  • Restorative therapies: Treatments by physical and occupational therapists, such as therapeutic exercise, cold and heat, therapeutic ultrasound
  • Interventional approaches: Image-guided and minimally invasive procedures, such as trigger point injections, neuromodulation, and sympathetic nerve blocks
  • Behavioral approaches: Counseling to address the psychological, behavioral, and social aspects of pain, such as cognitive behavioral therapy, and acceptance and commitment therapy 
  • Complementary and integrative health: Mind-body behavioral interventions, osteopathic and chiropractic manipulation, acupuncture, massage, movement (e.g., yoga, tai chi), and spirituality
TRAINING
Million Hearts® Learning Lab: Your Patient Needs a Statin – How Do You Get Them

Join the next Million Hearts® Learning Lab for a discussion on actionable activities care teams can take to increase statin therapy prescribing in high-risk groups.

Date and Time: March 7, 2024, 1:00 to 1:45 pm ET
 
Speakers:
Laurence S. Sperling, MD, FACC, FAHA, FACP, FASPC
Executive Director, Million Hearts®; Founder of Preventive Cardiology at the Emory Clinic; Katz Professor in Preventive Cardiology at the Emory University School of Medicine; Professor, Rollins School of Public Health in Global Health
 
Danielle E. Oryn, DO, MPH
Chief Medical Informatics Officer, Petaluma Health Center
Chief Medical Officer, Aliados Health

Click the image below to register today:
RESOURCE
NEW! Increasing Equity in Pain Management, Substance Use Disorder Treatment, and Linkages to Care: A Resource Guide for Health Centers

Looking for the latest guidance on effective pain management strategies that also reduce patients risks for substance use disorders (SUDs) and create meaningful linkages for care?

This guide offers actionable strategies and resources to help your care team offer effective pain management while reduce health disparities and advance health equity among minoritized and stigmatized people.
Happy 2024! As we start a new year and look to reset our personal and professional priorities, consider incorporating mindfulness as a way to reconnect with, and nurture yourself.

Practicing mindfulness involves breathing methods, guided imagery, and other practices to relax the body and mind and help reduce stress.

Ready to get started? Try Body Scan Meditation from the comfort of your bed at the start or end to your day when your house is quiet and calm. To begin, follow these three steps:
  1. Lie on your back with your legs extended and arms at your sides, palms facing up.
  2. Focus your attention slowly and deliberately on each part of your body, in order, from toe to head or head to toe.
  3. Be aware of any sensations, emotions or thoughts associated with each part of your body.

Aim to practice mindfulness every day for about six months. Over time, you might find that mindfulness becomes effortless.
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