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5 Articles in this Series
Introduction
An AIPM 2018 Preview with Clay Jackson, MD
Can Nutritional Management Make a Dent in Pain Relief?
Challenges Faced When Implementing an Integrative Care Model
The Role of Cannabis in Pain Care Today
When Pain, Opioid Use, and Mental Health Intersect

Challenges Faced When Implementing an Integrative Care Model

An AIPM 2018 Meeting Highlight featuring Robert B. Saper, MD, MPH

One of the first barriers—or stigmas—that pain practitioners may face when trying to establish an integrative care model is the concept that alternative medicine is to be “distrusted” or “ineffective.” Fortunately, there has been a growing rapprochement of complementary medicine and conventional medicine over the past two decades, which is crucial for allowing for integration to occur, explained Robert B. Saper, MD, MPH, director of integrative medicine and health disparities at Boston Medical Center and associate professor of family medicine at Boston University School of Medicine, at the AIPM 2018 Global Pain Clinician Summit. He offered ways to overcome this and other barriers, starting with accepting that, “It’s not about using only pharmacological therapies or only nonpharmacological therapies. Both must be integrated to optimize care.”

Source: 123RFAccessibility and affordability are just two of the barriers practices face when trying to offer integrative care.

Dr. Saper shared stories of chiropractors, for instance, who have been too easily dismissed by physicians in discussions about patients’ treatment plans. “We need to be multilingual” in order to best understand each specialty that offers something to pain relief and to pain management, he noted. In his view, a common mistake among practitioners of complementary therapies is to lead with their theory or mechanism by which their therapy is claimed to work, when having these discussions or even when lecturing. “Our knowledge of why these practices may work is largely rudimentary,” he explained. “If we want to integrate, we need to lead with terms that are understandable.” A better way to capture a conventional physician’s attention is with the evidence for effectiveness, he advised.

Fortunately, interprofessional education is becoming more common. There is an online curriculum out of the University of Arizona, he noted as an example, while also sharing an example from his community, where students from the New England School of Acupuncture are learning side-by-side with medical students at Boston University.

Dr. Saper went on to highlight four other major barriers facing the implementation of integrative care across pain management.

Other Major Barriers

Awareness

The first challenge is awareness. Approximately 35 to 50% of the reasons individuals give for non-use of complementary health practices such as acupuncture, chiropractic, yoga, and natural products are they “never thought about it, never heard of it, or do not believe in it,” said Dr. Saper. “We need to do more to educate patients about these options.” Take yoga, for instance, he said, where a common perception is that this ancient practice only involves young women who are super flexible; with this in mind, the practice may seem inconceivable to older, less flexible chronic pain patients facing mobility issues, fatigue, and other symptoms. Chronic pain patients may not understand how yoga can help with their back pain, for example, and that anyone can learn its practice.

On the provider side, the American College of Physicians released evidence-based back pain guidelines in 2017 that encourage non-pharmacological, noninvasive treatments, such as superficial heat, massage, acupuncture, and spinal manipulation as a first approach (see Qaseem et al, Ann Int Med, 2017). “Many physicians are not aware of this or brush it off because they don’t have the referral network in place or the professional on-site staff to carry out these approaches,” noted Dr. Saper.  He also pointed to the Institute for Clinical and Economic Review (ICER) consensus document on cognitive and mind-body therapies for chronic low back and neck pain, as an example of growing clinical awareness of the evidence for integrative therapies for pain.

Unfortunately, because there is no powerful financial body behind the implementation of integrative care, compared to new medications supported by industry, the road to wide implementation is steep, noted Dr. Saper. Soon enough, the integrative community hopes insurance companies will find complementary therapies for pain more attractive if they realize they can help reduce costs, he suggested.

Availability

When it comes to availability of integrative care, Dr. Saper used yoga studios throughout Boston as an example. He pointed out how these studios are primarily housed in higher income areas. “These services are not in the communities where patients need them the most,” he said. “The less educated, less wealthy, less well-insured often need greater access to care as well as patient education about their care options.”

Adding to this logistical challenge is the complexity and time it takes to set up billing and revenue structures to make reimbursement claims, he noted.

Accessibility

Accessibility is also a key factor and often goes hand-in-hand with availability. Many patients cannot miss time from work or have trouble accessing transportation to obtain needed care. Again, this factor varies across income areas, noted Dr. Saper. One approach his hospital has tried is to provide care through community programs, such as establishing networks with community health centers. In addition, his team makes available integrative practitioners to go to clinics where the need is greatest. “This type of fluid, mobile team provides greater access,” he said.

Affordability

Perhaps the most difficult and obvious barrier is affordability. When describing this last challenge facing integrative care models, Dr. Saper noted that most people zero in on this challenge right away. Progress has been minimal in this area, so even if a practice addresses the above three barriers, providing integrative care will not be easy without affordability.

“If a patient has little discretionary income,” he explained, “they are much less likely to spend it on an acupuncture treatment.” On a positive note, this is where self-efficacy and self-care may be put into play. “Giving patients the education and tools they need, and helping them to be confident in that the ability to self-manage their pain is one important step in this direction,” Dr. Saper concluded.

Real-Life Scenarios           

As part of the Q&A session after Dr. Saper’s talk, one audience member shared that at least 55% of her patients have chronic pain, opioid problems, and mental health challenges. She asked how clinicians can practically bring together an inter-professional team, rather than relying on one person to carry the load of leading the patient’s treatment plan. How do we build this cross-continuum of care, she posed, and then, where is the funding?

AIPM Executive Director Bob Twillman, PhD, responded, noting that in his experience, instead of calling in a verbal order to a resident, he might focus on sharing the assessment results and explaining why the treatment plan is what it is. “We need to aim for transdisciplinary care over multi- or inter-disciplinary care—we all need to be experts at what we do,” he said. “I need to be an expert on the psychology of pain why also understanding what the interventional options are and why and when they may be helpful to explain to the patient.”

Added Daniel B. Carr, MD, of Tufts Medical School: “Pain cannot be treated when some team members undermine others or when attending physicians deny their residents’ requests to carry out an order from another team member.” Andrey Ostrovsky, MD, of the Baltimore-based Concerted Care Group, chimed in as well: “We need a culture that awards interdisciplinary care – it’s not going to come from legislation. Furthermore, transdisciplinary care may alleviate silos and even turnover in specialties.” Read more about the intersection of chronic pain, opioid use, and mental health in this town hall overview.

It was pointed also out, with audience applause, that the bedside nurses and even cleaning crew often know more about what a hospital pain patient may be going through because they talk to the patients most. Several nurses in attendance at the AIPM summit made a point of noting how well trained they are in complementary practices, such as homeopathy and even cannabis use (see the American Holistic Nurses Association, among others), and are taking on increasing responsibilities to not only deliver this kind of care but also to explain its value to physicians.

 

Next summary: The Role of Cannabis in Pain Care Today
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