Comprehensive, Multimodal, Interdisciplinary Approach to Chronic Non-Cancer Pain Management in a Family Medicine Clinic: Retrospective Cohort Review



 

Edward Kwon, MD1; Christopher Stange, MD1; Katy Reichlin, DO1; Hamilton Vernon, DO1; Akira Miyanari, MD1; Elizabeth Bier, DO1; Hind Beydoun, PhD, MPH2; Virginia Kalish, MD1

Perm J 2021;25:20.307

https://doi.org/10.7812/TPP/20.307
E-pub: 10/29/2021

Introduction: The complexity of chronic non-cancer pain in the setting of regulatory efforts to curb opioid usage presents a novel challenge for the medical community. Much of this burden falls on primary care clinics. We retrospectively quantified the reduction of opioid usage by patients in a multimodal, interdisciplinary, primary care clinic for chronic pain.

Methods: A multimodal, interdisciplinary, chronic pain clinic embedded in a large academic military family medicine clinic operated one-half day weekly to address referrals from within the clinic at large. Appointment times were longer than typical primary care appointments. The clinic was equipped with support staff, ancillary specialty providers, and non-pharmacologic complementary treatment resources. A retrospective cohort review was conducted on 78 patients referred to this clinic from March 1, 2015 (the inception date of the clinic) through December 31, 2015.

Results: Fifty-four of 78 patients met inclusion criteria. Overall mean morphine equivalent daily dosing (MEDD) dropped from 31.5 MEDD to 20.5 MEDD (p = 0.0005) 12 months post-intervention and from 31.5 MEDD to 9.5 MEDD (p < 0.0001) 36 months post-intervention. Four patients with a high mean baseline opioid dose of 185.2 MEDD dropped to 29.9 MEDD 36 months post-intervention. The mean 0-10 pain score decreased from 5.3 ± 2.2 to 4.0 ± 2.5 (p = 0.001).

Conclusion: A multimodal, interdisciplinary, primary care-based, chronic pain clinic equipped with extended appointment times, non-pharmacologic treatment resources, and specialty access can curb opioid usage. Leadership support for protracted appointment duration, complementary treatment resources, and interdisciplinary personnel is crucial to success.

INTRODUCTION

From the mid-1990s until recent years, chronic non-cancer pain management was dominated by opioid prescribing, resulting in irrevocable harm to vulnerable populations in the United States.1 Unintentional opioid analgesic overdose deaths skyrocketed.1 Research from 1990       to 2010 explored the cost benefit and effectiveness of multi-disciplinary programs for chronic non-cancer pain. However, no studies included opioid usage as a primary outcome and no studies included chronic non-cancer programs embedded within primary care.34 As the opioid crisis grew, guidance from public health authorities made a dramatic shift away from opioids as an effective treatment option for chronic pain and adopted opioid safety guidelines. The Centers for Disease Control and Prevention (CDC) published opioid prescribing guidelines in 2016.3 In 2017, the United States Department of Health and Human Services declared the opioid epidemic a public health emergency. That same year, the Federation of State Medical Boards updated their policy document providing guidance to state medical and osteopathic boards governing the safe and appropriate usage of chronic opioid analgesics.2 Two years later, in 2019, the CDC advised against rigid application of opioid prescribing guidelines and highlighted the importance of clinical judgement.4,5 Mounting pressure to curb opioid use, while simultaneously addressing the complexities of chronic pain management, presented a novel clinical conundrum for the medical community, with much of the burden falling on primary care. For many primary care doctors, these can be taxing cases due to time constraints and limited resources, contributing to clinician burnout and dissatisfaction.6,7

Chronic pain affects the whole person, mind and body.25 Persistence of pain results in central sensitization to varying degrees, adding to the complexity of management.26 Maladaptive lifestyle choices commonly coexist. An integrated, multimodal approach that includes psychosocial, non-pharmacologic and pharmacologic, as well as interventional management, is essential to address the entirety of the patient. Growing evidence supports an interdisciplinary approach as a vital tool to offer complex chronic pain patients.9–11 Multidisciplinary support, resources, and time with individual patients are needed to relieve the burden on patients and clinicians.8,9,16–23 While this multi-disciplinary approach to chronic non-cancer pain is not a novel concept, embedding such a program within primary care is. In addition, while it is important to evaluate cost, pain, and function as outcome measures, it is equally important to measure opioid use. We present a primary-care based, comprehensive, multimodal, interdisciplinary pain clinic that achieved a significant reduction in opioid dosage, coupled with a mild improvement in pain scores.

METHODS

Study Design

This study was an Institutional Review Board-approved, single-center, retrospective cohort study conducted at a large family medicine residency clinic at Fort Belvoir Community Hospital, serving approximately 25,000 beneficiaries made up of active duty, family members of active duty, and military retirees. During the study period, one of three self-selected rotating faculty family physicians and one assigned rotating senior family medicine resident accepted consultative referrals for complex chronic pain patients enrolled in the family medicine clinic. One faculty family physician provided full-body acupuncture, and many faculty members and resident providers were proficient in auricular acupuncture. The clinical team included a clinical pharmacist, a psychiatrist, a licensed clinical social worker, a case manager, and a licensed practical nurse. In addition, two Complementary and Integrative Health (CIH) physicians intermittently joined the team to offer a personalized care plan using behavioral and holistic recommendations. Pain specialists, psychiatrists, physical therapists, and occupational therapists were available on a referral basis and via electronic communication or telephone consultation, if needed. Two physical therapists specialized in chronic musculoskeletal pain.

The embedded team, referred to as the “Family Medicine Integrative Chronic Pain Clinic” (FMICPC) met one-half day weekly, focusing on two structured, comprehensive assessments and one follow-up appointment. During a 15-minute team huddle, the patients for the day were reviewed. An array of assessment tools was completed during check-in. These included the Oswestry Disability Index, Opioid Risk Tool, Pain Self-Efficacy Questionnaire (PSEQ-2), and Patient Health Questionnaire-9 (PHQ-9). Most referrals were due to concern for prescription opioid use by the patient. These patients would complete an Opioid Risk Tool and receive an informational handout entitled “Taking Opioids Responsibly”.27 The prescription drug monitoring program data on the appointed patients were also reviewed.

The faculty and senior resident would simultaneously see one patient for initial consultation, with the clinical pharmacist or psychiatrist accompanying the resident depending on the anticipated needs of the patient. The faculty member precepted the resident after completing their own consultation and would then see one additional follow-up appointment. The remaining time was spent ensuring a comprehensive clinic encounter was documented in the medical record, performing complementary treatment modalities as needed, discussing the case with the care team, and ensuring the patient had a clear discharge plan of care. The other team members also conducted follow-up visits as indicated.

Ninety minutes were allotted for each comprehensive evaluation, with some of the time spent discussing the cases with the team. A thorough pain-focused history and exam included identifying chronic interacting conditions, such as depression or insomnia. Functional, psychosocial, and safety assessments were also done. Management addressed physical, behavioral, psychological, and pharmacologic treatment realms with goals of encouraging self-efficacy and stressing patient education. The physician might trial complementary treatments such as auricular acupuncture, dry needling, cranial electrical stimulation, and gua-sha (an instrument-assisted soft tissue release technique from East-Asia). Patients were returned to their primary care physician, while also offering follow-up in the FMICPC.

Study Population

All adult patient (≥ 18 years old) encounters in the FMICPC from March 31, 2015 through December 31, 2015 were retrospectively reviewed. Criteria for referral were that the patient had chronic non-cancer pain, defined as pain lasting for greater than 3 months. While most patients were on chronic opioids, this was not a requirement for referral. Referrals were reviewed by one FMICPC faculty physician for approval.

Data Sources and Collection

Data extracted from the electronic medical record by the clinical systems support department included demographic information, pre- and post-treatment opioid dosages, pre- and post-treatment benzodiazepine dosages, number of procedures, and number of clinic visits. Pre- and post-treatment clinical scale scores, urine drug screens, prescription drug monitoring checks, naloxone prescription data, and medication safety agreements were extracted by the clinical investigators. Clinical scale scores included 0-10 pain scale scores, the Oswestry Disability Index, PSEQ-2, and PHQ-9. All data were analyzed at baseline, 12 months post-intervention, and 36 months post-intervention.

Data Analysis

Statistical analysis was conducted using STATA version 15 (STATA Corporation, College Station, TX) and Excel (Microsoft Corporation, Redmond, WA). Continuous variables were summarized using measures of central tendency (mean, median) and spread (standard deviation, interquartile range). Categorical variables were presented using frequencies and percentages. Differences between pre-treatment and post-treatment outcomes were evaluated using paired t-test or Wilcoxon signed-rank test, as appropriate. The primary outcomes were mean opioid doses calculated as morphine equivalent daily dosing (MEDD) using Centers for Medicare and Medicaid Services opioid conversion factors. Secondary outcomes were mean clinical scale scores and percentages of patients who had naloxone dispensed, urine drug screening, and medication safety agreements. Two-tailed statistical tests were performed at an α level of 0.05.

RESULTS

Study patients:

Seventy-eight patients were internally referred to the FMICPC. Twenty-four patients were excluded (Table 1). Of those excluded, 10 patients (13%) missed or canceled their initial appointment, and eight patients (10%) chose to only see the FMICPC CIH physician, bypassing the comprehensive visit. Baseline characteristics are included in Table 2. Chronic low back pain was the most common chronic pain condition. Thirty-four (63%) patients suffered from comorbid mental health conditions.

Table 1. Reasons for excluded patients (n = 24)

Reason n
No-show or appointment cancellation 10
Appointment limited to CIH physician 8
Patient died 1
No longer eligible for care (retired from the military within 12 months) 1
Left practice due to dissatisfaction within 12 months 1
Age < 18 years 1
Concern for opioid diversion 1
Hospitalization for opioid overdose within 12 months 1

CIH = Complementary and Integrated Health.

Table 2. Patient characteristics

  Value
Total patients 54
Age (years) mean ± SD 46.37 ± 12.69
Sex, n (%)  
 Male 20 (37%)
 Female 34 (63%)
Concurrent mental health diagnosis,a n (%) 34 (63%)
Location/etiology, an (%)b  
 Low back 31 (57%)
 Fibromyalgia 10 (19%)
 Knee 7 (13%)
 Neck 3 (6%)
 Hip 3 (6%)
 Shoulder 2 (4%)
 Complex regional pain syndrome 2 (4%)
 Rheumatoid arthritis 1 (2%)
 Migraines 1 (2%)
 Abdominal 1 (2%)
 Pelvic 1 (2%)
 Elbow 1 (2%)

a Concurrent mental health diagnosis includes post-traumatic stress disorder, anxiety, depression, adjustment disorder, and bipolar disease.

b Some patients presented with more than one etiology of their chronic pain. As a result, percentages total to greater than 100%.

SD = standard deviation.

Primary Outcome

At baseline, 45 of the 54 included patients (83%) were on an overall mean opioid dosage of 31.5 MEDD (morphine equivalent daily dosage). At 12 months post-intervention, 31 of the 54 included patients (57%) were on an overall mean opioid dosage of 20.5 MEDD (p = 0.0005), representing a 35% drop in overall mean opioid MEDD. At 36 months post-intervention, 23 of the 54 included patients (43%) remained on an overall mean opioid dosage of 9.5 MEDD (p < 0.0001), representing a 70% drop in overall mean opioid MEDD (Table 3). Furthermore, the total number of patients on chronic opioids decreased from 45 (83%) to 23 (43%) at 36 months post-intervention, representing a 40% decrease. Five patients on or transitioned to buprenorphine therapy were excluded from opioid dosage calculations given this medication’s view as a safe and effective method to treat chronic pain and opioid use disorder, despite its significantly higher morphine equivalent conversion factor.

Table 3. Comparison of baseline and post-intervention opioid and benzodiazepine daily dosages

  Baseline 12 months post 36 months post
Number of patients on opioids, n (%) 45 (83%) 31 (57%) 23 (43%)
Opioid dose (MEDD), mean ± SD 31.5 ± 52.2 20.5 ± 48.6 9.5 ± 21.0
Opioid dose (MEDD), median (IQR) 15 (31.0) 0.94 (13.5) 0 (9.8)
Number of patients on baseline opioid dose 50-89 (MEDD), n (%) 5 (9%) 2 (4%) 3 (6%)
Opioid dose for patients with baseline 50-89 (MEDD), mean ± SD 68.2 ± 7.35 55.0 ± 42.6

28.4 ± 42.1

Number of patients on baseline opioid dose ≥90 (MEDD), n (%) 4 (7%) 5 (9%) 2 (4%)
Opioid dose for patients on ≥ 90 (MEDD), mean ± SD 185.2 ± 53.9 128.3 ± 120.1 29.9 ± 35.6
Number of patients on benzodiazepines, n (%) 14 (26%) 14 (26%) 9 (17%)
Benzodiazepine dose,a mean ± SD 20.8 ± 53.5 29.2 ± 68.8 27.7 ± 92.2
Benzodiazepine dose,a median (IQR) 0 (2) 0 (1) 0 (0)

Five of the 54 included patients were placed on Suboxone therapy and thus excluded from the opioid dose calculations. The paired t-test was used to examine mean change in opioid dose values from baseline visit to the 12-month and 36-month post-intervention visits. The Wilcoxon signed rank test was used to examine change in median values across time points.

a Benzodiazepine daily dosages were converted to lorazepam 1 mg equivalents.

IQR = interquartile range; MEDD = morphine equivalent daily dosing; SD = standard deviation.

Of the 54 included patients, 4 patients were on a baseline mean opioid dosage of 50-89 MEDD and an additional 4 patients were on a baseline mean opioid dosage of ≥ 90 MEDD. The most dramatic decrease was noted among the 4 patients with a baseline opioid dosage of ≥ 90 MEDD who presented with a baseline mean opioid dosage of 185.2 MEDD and dropped down to a mean opioid dosage of 29.9 MEDD 36 months post-intervention, representing an 84% reduction in mean opioid dosage (Table 3).

There was no significant change in benzodiazepine dosage from baseline to 12 months post-clinic visit (p = 0.94) or from baseline to 36 months post-clinic visit (p = 0.57).

There was a wide variation of multidisciplinary visits among the patients who dropped their opioid dosages, ranging from a mean of 0.2 to 2.0 over the 12-month period following the initial comprehensive assessment. The most frequently utilized interventions were behavioral health counseling and physical therapy, with a mean of 2.0 for each and maximum number of visits of 41 and 34, respectively (Table 4). The only interdisciplinary intervention significantly associated with an opioid dosage decrease at 12 months post-intervention (p = 0.04) was the CIH physician intervention, which focused on holistic health and healing. Thirty-three of the 54 included patients received this intervention.

Table 4. Number of Complementary and Integrative Health modalities, Complementary and Integrative Health physician visits, and specialty visits per patient with reduction in opioid dosage

  Number of visitsa
Auricular acupuncture, mean ± SD, max 1.3 ± 3.0, 15
Cranial electrical stimulation,b mean ± SD, max 0.2 ± 0.7, 4
Gua-sha, mean ± SD, max 0.2 ± 0.6, 3
Behavioral health, mean ± SD, max 2.0 ± 6.6, 41
Physical therapy, mean ± SD, max 2.0 ± 5.2, 34
CIH, integrative health, personalized health, mean ± SD, max 0.4 ± 0.6, 2
CIH, holistic health and healing, mean ± SD, max 0.5 ± 0.7, 3
Interventional pain specialist, mean ± SD, max 0.7 ± 2.2, 14

a Only includes number of visits within 12 months of intervention.

b Our team utilized α-Stim© as the type of cranial electrical stimulation.

CIH = Complementary and Integrative Health; max = maximum; SD = standard deviation.

Secondary Outcome

The mean 0-10 pain scale score decreased from 5.3 to 4.0 twelve months post-intervention (p = 0.001). The PSEQ-2, PHQ-9, and Oswestry Disability Index scores did not reveal statistically significant changes from baseline, largely due to limited post-intervention completion rates of these questionnaires. Compliance with urine drug screening, prescription drug monitoring program checks, naloxone prescriptions, and medication safety agreements is summarized in Table 5. Each of these compliance rates were derived from the 45 initial patients who were on opioid pain medications. The compliance rates were higher in the high-dose opioid group.

Table 5. Urine drug screen, prescription drug monitoring program, Naloxone prescription, and medication safety agreement completion following the initial comprehensive evaluation

  Urine drug screen PDMP check Naloxone prescription Medication safety agreement
All patients on opioids, completion rate 42% 18% 33% 47%
Patients on ≥ 50 MEDD, completion rate 63% 25% 38% 63%

MEDD = morphine equivalent daily dosing; PDMP = prescription drug monitoring program.

DISCUSSION

It has been a decade since Dr Okie published her work conveying the “rising tide of deaths” associated with chronic opioid usage.1 Since then, chronic pain research has evaluated individual chronic pain therapies, such as biopsychosocial interventions, mindfulness-based stress reduction, acupuncture, interventional procedures, physical therapy, and buprenorphine. Research has also evaluated systems-based chronic pain models.8,9,17,18,21 However, few studies have investigated the integration of these interventions for chronic pain into a primary care setting utilizing extended appointment times. In addition, only a limited number of studies have utilized opioid usage as a primary outcome. We identified only five studies that evaluated primary-care clinic-level initiatives.16,19,20,22,23 Each of these initiatives focused on a multi-disciplinary approach to chronic pain and chronic opioid usage. Below, we also define an evolving array of terms in the literature used to describe strategies for chronic pain management.28–30

• Multi-disciplinary = juxtaposed specialties who practice within the boundaries of their fields29

• Interdisciplinary = coordination between specialties toward a common and coherent approach29

• Multimodal = a combination of multiple therapeutic components (sometimes used interchangeably with multicomponent)29

• Alternative = used in place of conventional treatment28

• Complementary = used together with conventional treatment, incorporating an individualized treatment plan with a philosophy that leverages the innate capacity to heal28

• Integrative medicine = conventional and complementary medicine brought together in a coordinated way.28

A weekly comprehensive integrated chronic pain clinic, embedded within our academic family medicine clinic, achieved a significant decrease in opioid usage coupled with a small improvement in pain scores. This is consistent with findings of a recent systematic review, which found that opioid tapers were associated with improved or maintained levels of pain.31 Furthermore, the 5 primary care-based studies also achieved an opioid dose reduction by taking a similar multi-disciplinary approach.16,19,20,22,23 Investing in such chronic pain programs embedded within primary care has great potential to curb opioid use and direct patients to safer, alternative treatment options. This interdisciplinary approach has been shown to improve chronic pain outcomes.10–15 As it has been over a decade since the healthcare community has identified chronic opioid use as a public health crisis, our efforts should now focus on combining specific therapies, systems-based concepts, and lessons learned into integrative, interdisciplinary models of chronic pain care. We believe that, through such models providing support to primary care, the practice of caring for chronic pain can brand into a more robust, truly comprehensive care experience.

The framework of our model required leadership support, extended appointment times, interdisciplinary teams, treatment resources, and physician training on integrative modalities (eg, auricular acupuncture, dry needling, cranio-electrical stimulation, and gua-sha). Communication and coordination between each discipline provided the vehicle, and a therapeutic alliance with our patients provided the core. While we were able to achieve a significant drop in opioid prescribing, superb clinical care depended on treating the whole patient, mind and body. Leadership support allowed our team the time and space to provide the comprehensive assessments and interventions—something that is not possible during our usual brief clinic appointments. This time investment ultimately translated into a significant reduction in opioid usage.

While all interventions were utilized as a part of a comprehensive management plan for each patient, the CIH physician intervention focusing on holistic health and healing was the only individual intervention that was significantly associated with a decrease in opioid dosage at 12 months post-intervention (p = 0.045) (Table 4). This intervention was comprised of a spiritual, healing approach to the patient. Mindfulness, Reiki (a hands-on energy healing technique), and self-care were emphasized components. Otherwise, there was no significant association between a single pain intervention and opioid dosage decrease. Of the modalities and interventions offered to each patient, there was not one overriding preferred treatment. Rather, we believe the offering of multiple options allowed an avenue for open discussion into the biopsychosocial manifestation of pain expression and management and the risks of chronic opioid usage. Despite the variety of treatment options offered, each patient ultimately received only a handful of these treatment modalities (Table 4). Our findings support the concept that chronic pain management should not be “one size fits all” but rather, an individualized approach.

Lastly, compliance to new opioid regulatory measures was relatively low (Table 5). All FMICPC encounters included in this retrospective review occurred in 2015, which preceded the CDC guidelines and Virginia Board of Medicine regulations governing chronic opioid use as a part the treatment of chronic pain. Since publication, our clinic has adopted a stricter commitment to compliance with these measures.

Study Limitations

Our study involved a small sample from a military academic hospital with universal access to medical care. As a result, our findings may not extrapolate to most communities in the US, especially in areas where there may be a higher rate of opioid misuse and healthcare disparities. In hindsight, racial, ethnic, and language data, as well as sexual orientation and gender identity data collection at onset of the treatment, may have provided insight into health inequities in pain management within our clinic and hospital.

Another study limitation is its retrospective design. While we did see a significant reduction in pain by patient report, other measures did not show a statistically significant change, possibly affected by a low rate of post-intervention reporting. Secondly, we are unable to determine if our observed reduction in opioid use was entirely due to our interventions or due to background factors such as heightened awareness of the limited benefits and considerable harms of chronic opioid use. While we acknowledge this, we also chose 2015 as our study year as it preceded the CDC chronic pain guideline (2016),3 the Defense Health Agency Pain Management and Opioid Procedural Instruction (2018),32 and the Virginia Board of Medicine regulations governing chronic opioid usage for chronic non-malignant pain (2018).33

CONCLUSION

An integrative, interdisciplinary, primary care-based clinic equipped with extended appointment times, treatment resources, and interdisciplinary access can provide the comprehensive care needed to adequately treat chronic pain and curb opioid usage. The medical community should begin to translate chronic pain research into integrative, interdisciplinary clinic initiatives embedded within primary care.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Funding Statement

The authors received no financial support for the research, authorship, and/or publication of this article.

Acknowledgments

The authors would like to acknowledge the following individuals for their support, contributions, and/or clinical expertise throughout this project: 1) Dr Wayne Jonas and Dr George Ceremuga (Complementary and Integrative Health), 2) Dr Janice Lee (PharmD), 3) Dr Christopher Spevak (pain specialist), 4) Melissa Bartnick, LCSW, 5) Dalis Irish, RN (case manager), and 6) Leah Beaumont, LPN and Fabiola Irizarry, LPN. The authors would also like to acknowledge Mr Andrew Kim (Clinical Systems Support Department) for his work extractingthe requested data.

Disclaimer

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, Department of the Navy, Department of Defense, or the US government. This document was created free of branding or market affiliations. The author is operating solely as a contributor.

Author Affiliations

1Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA

2Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA

Corresponding Author

Edward Kwon, MD (eddiekwon6@yahoo.com)

Author Contributions

Edward Kwon, MD, served as primary investigator and author. Virginia Kalish, MD, served as the senior author, providing intellectual oversight and advice. All authors participated in acquisition of data, provided intellectual contribution, ensured the integrity of data, and reviewed the manuscript for final approval.

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Keywords: integrated, interdisciplinary, multimodal

AbbreviationsCIH = Complementary and Integrative Health; FMICPC = Family Medicine Integrative Chronic Pain Clinic; MEDD = morphine equivalent daily dosing; PDMP = Prescription Drug Monitoring Program; PHQ-9 = Patient Health Questionnaire-9; PSEQ-2 = Pain Self-Efficacy Questionnaire

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