The People’s Community Clinic’s Integrative Pain Management Program

Knowing that pain impacts a patient's physical, cognitive, and social well-being means that it's important to take an integrative approach to pain management. It's also important to recognize that depression is extremely common in patients suffering from chronic pain conditions.

High-quality, equitable, patient-centered pain management that reduces the risk for opioid use disorder is key. Yet, in the United States patients often encounter limited choices and even fewer non-opioid options to treat their pain. Health centers around the country are showing us the benefits of an integrated and patient-centered approach to pain management that includes behavioral health management. We'll share one example with you here.

People's Community Clinic's Integrative Approach

The Integrative Pain Management Program (IPMP) at People's Community Clinic (PCC), Austin, TX, is structured 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 practices and expanded its current mental health services to address 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 have a robust behavioral health model, nutrition services, a partnership with an acupuncture school to offer free acupuncture, and a medical-legal partnership that addresses some of the upstream factors that could impact a patient's health. We just realized we should integrate all these pieces together to see what we can do," explains Dr. Kohli.

The program, and PCC more broadly, equips patients with 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 experienced substantial trauma-related 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 includes 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 about options for managing their pain.

"…We've tied it all together with groups…The doctor and other health care team members become participants in the group and everyone just kind of talks from their own perspectives. There is more time to hear patient stories," shares Dr. Kohli.

Dr. Kohli 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 five 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

NACHCrecently released theIncreasing Equity in Pain Management, Substance Use Disorder Treatment, and Linkages to Care resource guide to help health centers do this work. This guide distills valuable insight from 25 experts in health equity, pain management, and substance use disorder treatment from various regions in the United States.

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