Abstract
Background: Mounting evidence supports the use of integrative pain management (IPM) in primary care settings. There is limited understanding of primary care clinicians’ experiences, recommendations, and strategies for integrating IPM into clinical care.
Methods: A total of 97 clinicians were contacted via e-mail from a listserv maintained by the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region Practice and Research Network, a practice-based research network. A total of 23 clinicians completed a recruitment survey and 21 were contacted to schedule an in-depth interview. Interviews addressed knowledge of and approaches to IPM, barriers and facilitators integrating IPM into clinical care, and recommendations for future program design. Interviews were completed until saturation was reached and then were transcribed and subjected to thematic analysis. Participants were offered $100 for their participation in the interview.
Results: A total of 14 clinicians included 11 MDs, 1 PA, 1 LCSW, and 1 PharmD. Domains reported include strategies and perspectives on integrating IPM, system level improvements needed to increase access, clinical barriers to addressing chronic pain, and perceived patient level challenges. Key findings within these domains include the need for a paradigm shift in the approach to treating chronic pain, the importance of adaptability and flexibility, and challenges related to time, payment, and resource availability.
Discussion: As a specialty that focuses on whole-person, comprehensive care, family medicine is uniquely situated to integrate IPM into routine practice. Furthermore, ongoing collaboration with primary care clinicians such as behavioral health providers and pharmacists are synergistic toward these goals. However, challenges related to knowledge, comfort, payment, and resource availability must first be overcome within family medicine. This requires improving education on pain management in medical school and residency, increasing access to community referral networks with specialized knowledge in chronic pain, and expanding payments for nonpharmacologic and team-based care.
- Alaska
- Chronic Pain
- Community Health Services
- Complementary Therapies
- Idaho
- Integrative Medicine
- Montana
- Pain Management
- Practice-Based Research Networks
- Primary Health Care
- Public Health
- Qualitative Research
- Washington
- Wyoming
Background
One in 5 Americans live with chronic pain,1 leading to reduced functioning, negative health outcomes and increased health care utilization.2 While there is growing evidence supporting the use of integrative pain management (IPM) (eg, acupuncture, cognitive behavioral therapy, mind body practices, multidisciplinary rehabilitation etc.) to treat chronic pain,3–5 patients frequently do not have access to these services in primary care settings.6,7 Because chronic pain is a complex and multifaceted condition, it requires developing and implementing a new culture of holistic health care centered on knowledge of IPM's benefits, challenges, and integration strategies in primary care.8 In the 2022 Guidelines on Opioid Prescribing and Monitoring, the CDC recommends the use of IPM, stating that noninvasive nonpharmacological approaches have potential for improving an individual’s function and decreasing pain levels without added risk of serious harm.9 However, the majority of current medical education and quality improvement efforts around pain management focus on improving primary care clinicians’ knowledge and skills related to safe opioid prescribing rather than the use of IPM.8,10 In addition, there is limited understanding of clinicians’ experiences, challenges, and recommendations regarding IPM to inform future implementation efforts.11,12 Further research in this area is essential for improving patient care and outcomes and to help identify strategies for integrating these approaches into clinical care. We conducted in-depth interviews with primary care clinicians that treat chronic pain in 5 States across the Intermountain West and Pacific Northwest to understand clinician experiences referring patients for or offering IPM services; perceived benefits, barriers, and challenges providing these services; and suggestions for implementing IPM in primary care settings.
Methods
In April – June 2023, primary care clinicians were recruited using an e-mail listserv of clinicians specifically willing to participate in short surveys and interviews maintained by the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region Practice and Research Network, a practice-based research network with over 120 practices. A total of 97 clinicians were sent a recruitment e-mail containing information about the study and a link to sign up for a qualitative interview or decline participation. Participants interested in the study completed a brief survey that included their practice zip code, gender identity, racial/ethnic identity, graduation year from professional school, and contact information. Participants were then contacted through e-mail and scheduled for interview through a videoconferencing platform. Participants were given $100 gift cards for completing the interviews.
The interviews utilized a semistructured interview guide developed by a multidisciplinary team that included an acupuncturist/naturopathic physician, a family physician, and a medical anthropologist. The interview guide addressed topics related to knowledge of and comfortability with nonpharmacologic therapies, approaches to chronic pain management, facilitators and barriers to integrative pain management, and recommendations for future program design. The interviews were audio-recorded, deidentified, and transcribed.
We used Dedoose-9.0.46® for data management and thematic analysis.13,14 Descriptive statistics were used to summarize the questionnaire responses. A codebook was developed based on the semistructured interview guide by [authors]. Each transcript was coded by 2 reviewers to ensure consistent and accurate identification of themes. The team then met regularly to discuss the application of codes and to identify any discrepancies and reach consensus. The researchers then identified emerging themes and completed a narrative of the findings, supported with quotes. This study was approved by the University of Washington Institutional Review Board (STUDY00016872).
Results
A total of 97 clinicians from the listserv were sent the recruitment e-mail with an invitation to complete a survey. Of those, 23 primary care clinicians completed the recruitment survey indicating their interest in participation. Of those, 21 indicated they were interested in completing an in-depth interview and 2 participants declined to participate because they did not have a large panel of patients with chronic pain and the other was not interested in the topic. Of these, we completed interviews until we reached saturation at 14 interviews. Interviews ranged from 30 to 55 minutes in length. Participant characteristics are described in Table 1.
Participant Characteristics
Domains reported in Table 2 include strategies and perspectives on integrating IPM, system level improvements needed to increase access, clinical barriers to addressing chronic pain, and perceived patient level challenges. Key findings within these domains include the need for a paradigm shift in the approach to treating chronic pain, the importance of adaptability and flexibility, and challenges related to treatment expectations, time, payment, and resource availability.
Key Findings and Example Quotations for Strategies and Perspectives on Integrating IPM
Discussion
Clinicians in this study identified a range of strategies and perspectives useful for integrating IPM into primary care settings. Akin to implementing other forms of complementary or integrative approaches,15 our analysis underscores the need to embrace a paradigm shift when using IPM to treat chronic pain. This in part means embracing holistic notions of mind-body interconnectedness,16 addressing pain as a joint manifestation of physical, emotional, and social dysregulation,17 and focusing on multi-pronged interventions that aim to manage pain flare ups rather than attempt to identify and “cure” or “fix” an underlying issue through medically focused diagnostics, imaging, and interventions.18 Within this paradigm, treatment plans should be carefully tailored to individual patient needs and preferences,19 which often requires introducing patients to multiple different modalities to identify those most suitable or effective at alleviating pain and improving functionality. Building on previous studies documenting patient-level challenges,20 our analysis suggests that marked differences across populations in coping ability and capacity to engage in IPM modalities (due to personal coping styles, resource disparities, and the extent and severity of pain) will intimately shape this process.21 In response, clinicians using IPM must proactively seek to understand and incorporate each patient’s personal pain history into treatment plans, including previous attempts at treatment, the impact of pain on their quality of life, and associated mental/emotional correlates.22 An awareness of and sensitivity to personal trauma histories and cultural differences should likewise be developed to improve the acceptability and effectiveness of treatment plans.23
Despite mounting interest in the use of integrative modalities among clinicians and patients,24 and a growing evidence base supporting their use in chronic pain care,3,4 our study suggests that access to these services is still severely limited in primary care settings and throughout the wider community. While lack of access is often attributed to insurance coverage limitations and the absence of reimbursement for more naturalistic or complementary forms of care,25 clinicians in our study also identified a lack of community referral networks with specialized knowledge in chronic pain management as a constraining factor.26 Despite often greater insurance coverage for behavioral health and physical therapy services, clinicians in our study expressed concern that these providers may lack the requisite skills or capacity to provide chronic pain focused care. For example, physical therapy clinics may too exclusively focus on time-limited postsurgical rehabilitation services, and behavioral health clinicians who are too overwhelmed caring for an overload of depression and anxiety related issues may lack the necessary expertise or bandwidth to care for patients with chronic pain. To address these barriers, models of care that integrate improved payment with team-based approaches to chronic pain are needed.27 While the National Institutes of Health’s HEAL Initiative is beginning to fund studies that examine such models,28 greater collaboration with payors and policy makers as these models of care emerge is essential.29
Relatedly, while most of the clinicians in this study had experience with or were inherently motivated to use IPM approaches in their practice, they reported that a large personal investment was required to cultivate these skills, as education on IPM benefits, its evidence base, and implementation strategies is severely lacking in most medical school and residency training programs.30 Expecting to gain proficiency in the many diverse IPM modalities may be unrealistic during undergraduate and graduate medical education.31 However, an introduction to the key principles and paradigms of IPM could feasibly be incorporated into curricula alongside existing opioid related topics, thereby spurring interest in, and the likelihood of pursuing supplementary education on IPM through future CME related activities.32 In addition, incorporating an integrative medicine course into family medicine residencies may further help family physicians gain knowledge about IPM resources and approaches.33,34
The primary limitation to our study is whether the perspectives of those we interviewed are representative of the diverse settings and populations in which primary care clinicians work across the country. Because we recruited from a sample of clinicians expressing interest in IPM, there could also be the potential for self-selection bias. To minimize this limitation, we sampled across 4 different States and diversified our sample with non-MD clinicians working in diverse primary care settings.
As a specialty that focuses on whole-person, comprehensive care of individuals, families and communities,35 family medicine is uniquely situated to lead this paradigm shift for our patients who have chronic pain. Furthermore, ongoing collaboration with primary care clinicians such as behavioral health providers and pharmacists are synergistic toward these goals. Finding ways to implement sustainable programs for chronic pain management that use a paradigm shift to conceptualize chronic pain through a comprehensive and integrative lens will help reduce morbidity and improve function for the large portion of adults in the US suffering from chronic pain. Further, as the country continues to contend with a severe opioid epidemic - much of it historically driven by primary care pain management practices - ensuring equitable access to IPM services in primary care is crucial for mitigating further opioid misuse and overdose death.36,37
Notes
This article was externally peer reviewed.
Funding: This study was supported by the Osher Center for Integrative Health and the National Center for Advancing Translational Sciences of the National Institutes of Health (UL1TR002319).
Conflict of interest: None.
To see this article online, please go to: http://jabfm.org/content/38/2/366.full.
- Received for publication May 2, 2024.
- Revision received September 20, 2024.
- Accepted for publication October 21, 2024.
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