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15 Articles in Volume 21, Issue #4
Advanced Practice Matters: Needs Assessment in Pain Management Training
Analgesics of the Future: Novel Capsaicin Formulation CNTX-4975
Ask the PharmD: How to Improve Medication Adherence in Chronic Pain Management
Behavioral Medicine: Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD
Case Report: Multimodal Management of Osteoarthritis
Commentary: The PCP's Role in Preventing Chronic Back Pain
Guest Editorial: Structural Racism in Pain Practice and How to Combat the “Hidden Curriculum”
Hypermobile Ehlers-Danlos Syndrome: An Update on Therapeutic Approaches for Pain Management
Male Clinicians as Allies in Women’s Leadership: What Your Female Peers Want You to Know
Meet the Women Changing Pain Medicine
Perspective: It’s Time to Advocate for Early Interventional Pain Management
Research Insights: Is Spinal Fusion Surgery Being Overused in Back Pain Care?
Tips from the Field: Treating Pain in an Under-Resourced State
Utilizing Music Therapy to Manage Chronic Pain
Woman to Woman: Leaders Share Advice for the Next Generation of Pain Medicine Clinicians

Tips from the Field: Treating Pain in an Under-Resourced State

Using Arkansas as an example, two pain management physicians share ways to break down barriers to healthcare access in under-served areas and provide patient-centered, systemic solutions.

Background

Arkansas, an under-resourced state that ranks 49th/50th in overall healthcare outcomes in the US, has many barriers to adequate palliative care and quality pain management. We have developed a collaborative presentation to identify many of these barriers and framed a way to approach them – both practically and logistically – on an individual and systemic level. Herein is a top-level review of our work and experience in providing pain management to an under-served patient population. 

 

Our goal is to help other pain practices reduce such barriers. Specifically, in looking at the data provided in the sidebar below, what can clinicians do to provide better healthcare in an under-resourced state like Arkansas? We will break down the barriers for each component to health outcomes and offer patient-centered and systemic solutions.   

 

Barriers to health outcomes continue to exist in under-resourced areas throughout the US. How clinicians can break down these barriers to provide patient-centered and systemic solutions. (Image: iStock)

 

Top Barriers to Pain Care in Under-resourced Areas

Literacy

Providers often assume that their patient can read and write but, in many cases, states have alarmingly low literacy rates. In 2012, 13.7% of Arkansans ages 16 years and older lacked basic literacy skills.1,2 It is important to recognize a patient’s level of literacy early in the relationship to avoid challenges to communication and unintentional poor compliance. 

How to overcome this barrier:

  • Incorporate a literacy evaluation your initial assessment questionnaires, such as: “What is your highest level of education?”
  • In the initial patient encounter, practice staff can discreetly ask, “Do you need help with understanding this form?” or “Do you need me to read through this form with you?" Remember, some of our patients have a hard time understanding written words.
  • A patient may feel embarrassed if they cannot read or write, and are unlikely to ask for help, thus, it falls on the provider to make any accommodations known and welcome
  • Normalize and be nonjudgmental. Pause frequently to ensure the patient understands what you are telling them
  • Prescription bottles can be color-coordinated and staff can explain in basic terms how to take them
  • For example, offices can use color-coded stickers. 
  • Some pharmacies will place medications into pre-portioned packets for patients based on when the medication is due.

Diet and Exercise

An area that has limited access to affordable and nutritious food is called a “food desert” – the US Department of Agriculture reported in 2010 that 23.5 million people live such locations, which are typically described as low-income, low-mobility areas. It is very difficult to provide effective nutrition counseling when patients cannot access or afford nutritious foods. We know that increased density of supermarkets decreases risks of type II diabetes, hypertension, and obesity.3

Physical exercise can also be limited. As an example, Arkansas also ranks 50th in the US for access to gyms. According to US Business Data, the state ranks 1st in the ratio of fast-food restaurants to gyms at 10.6 to 1.4 (More on the impact of food deserts on our sister clinical site EndocrineWeb.)

How to overcome this barrier:

Diet and physical activity can be hard to manage on an individual patient basis but there are ways to improve access. In our academic hospital, we have implemented a Culinary Medicine Program. Here, medical students meet every 6 weeks in a commercial teaching kitchen to understand how to improve their own diets and potentially influence the diets of future patients.  In addition, the hospital hosts a weekly farmers market, which allows patients to access high-quality whole foods after their clinic visits. 

We also recommend that patients consider calorie counting and/or food journaling. We also consider an open conversation with their physician about what a typical dinner looks like. Whether fast food or supermarket foods are more available to your population, it is reasonable to educate your patient on calories and making healthier choices at each type of location. There are many smartphone applications and YouTube videos that can help with exercise and offer free services. Practices can also individualize exercise programs and provide printouts to patients. 

See also, how providers can rebalance relationships with patients when privilege and idetnity come into play.

Tobacco Use

We know that tobacco use is associated with worse health outcomes and worse pain outcomes.5,6  In a 2018 CDC report, Arkansas ranked 48th, followed by Kentucky and West Virginia in tobacco use.

How to overcome this barrier:

First and foremost, it cannot be overstated how much influence you have as your patient’s physician. It is important to recommend smoking cessation and to offer support. A simple, “How can I help you cut down?” question can help. Equally as important, clinicians must offer solutions to cessation; success increases with patient buy-in, nicotine replacement, and counseling and support.7

Missed Appointments

Patients in under-served areas may claim language barriers, attitudes toward healthcare, the clinic’s working hours or wait times, lack of transportation, or misunderstanding as reasons for missing a visit.8-10 

How to overcome this barrier:

  • Be mindful and ask your patient upfront if they foresee any barriers to arriving to their appointments – if possible, utilizing an interdisciplinary team or collaborating with social workers can help provide solutions. 
  •  Schedule the patient’s next appointment before the end of your current appointment with input from the patient on their schedule. Some may prefer to align other appointments in town or at the same hospital, for the same day. 
  • Provide frequent reminders via phone, text, mail, and email.
  • For those with transportation challenges, be aware of transportation options for your patients. Medicaid Rides can be scheduled 48 hours in advance with the help of your social worker. 
  • Consider providing telehealth visits in between in-person visits for those patients who have difficulty traveling (more on this below). 

Telemedicine and Technology

While more populated, resourced states have excellent access to cellular technology and broadband, under-resourced states often do not have access to dependable internet or wireless service. This largely restricts the use of technology for telemedicine visits. 

How to overcome this barrier:

As an example, our institution placed regional high-quality primary care programs in each region of the state. Each site has two telehealth stations so patients can access specialty care throughout the hospital system, including care for chronic pain, high-risk OB, neurosurgical, and specialty orthopedics.

Access to Mental Health Care

As pain becomes more chronic, emotional factors play a more dominant role in dysfunction and suffering.11 Affective disorders, anxiety disorders, and substance abuse disorders are the three most common psychiatric conditions associated with chronic pain.12 The pain management community knows that, to fully treat pain, we must also treat any psychiatric components or comorbidities in order to see substantiative improvement in function and quality of life.  Unfortunately, in under-resourced states access to mental health professionals is limited.

How to overcome this barrier:

Start by increasing awareness of psychiatric illnesses across all levels of healthcare and to the patient themselves. It is important to normalize discussions – beginning with initial assessments – about mood and sleep during chronic pain evaluations. 

Adding a licensed therapist to your clinic can be extremely helpful as they can assist with Cognitive Behavioral Therapy (CBT) and other behavioral strategies that help to improve things like catastrophizing and sleep disturbance, which can exacerbate pain symptoms. We always provide patients living with chronic pain a sleep hygiene handout.

More on structural racism in mental health care on our sister clinical site, Psycom Pro.

Access to Specialty Care and Pain Management Clinics

In many rural states, such as Arkansas, there is a lack of specialty-trained chronic pain physicians and palliative care doctors. As a result, a larger burden is placed on primary care providers and clinics to manage complex pain patients.

How to overcome this barrier: 

In Arkansas, we have several outreach and teaching resources available to our rural colleagues, including a program called AR-Impact, a grant-funded, multidisciplinary pain treatment and education collaborative that meets weekly about pain treatment education. We also provide peer-to-peer resources through a 24/7 call center, where physicians across the state can call in to speak with specialists regarding pain and symptom management. In addition, pain physicians at our state university are taking a lead in educating medical students, residents, fellows, and faculty in appropriate pain management. 

The hope is that these combined programs will assist with primary pain management and allow for increased interest in further subspecialty training with both palliative care and interventional pain specialties. 

More on disparities in pain management from Dr. Goree in a special conversation.

Access to Adjunct Therapies

Patient access to complementary medicine is also crucial as these modalities can provide alternative or adjunct treatment benefits to medication management. CBT, as well as spinal manipulation, acupuncture, massage, yoga, functional restoration, and interdisciplinary rehabilitation have shown proven benefit in the treatment of chronic and subacute back pain, for instance.13,14 Unfortunately, southern states (eg, Arkansas, Oklahoma, Missouri, Mississippi, Alabama, Georgia) have very few, if any, physicians trained in these modalities, according to the Academy of Integrative Health and Medicine. 

Adding to this barrier are insurance issues – often, insurance companies do not cover complementary treatments (eg, yoga, massage, and acupuncture) or patients do not hold insurance coverage. 

How to overcome this barrier:

Take a special interest in knowing local resources for yoga practices, massage, or acupuncture.  There are several training programs and massage therapy schools that provide treatment and resources at a fraction of the cost.

Special Considerations During COVID-19

Across our nation, adjusting and adapting to COVID-19 restrictions has been a lesson in resilience and adaptability. The pandemic has affected many of our chronic pain and cancer-related pain patients in a variety of negative ways – further restricting access to care, delaying operations or procedures, causing job loss, and, at its worst, producing death and grief.

As a medical community, we must be mindful of how best to treat these patients and adapt in the previously stated ways. Thinking creatively and sharing practical solutions is how we will take care of our communities during this crisis.

We are open to collaboration – find us on Twitter (Carrie Hyde @CHydeMD and Johnathan Goree @DrJGoree) or email PPM’s editor to connect. Let us know the ways in which you are making changes in your clinics to adapt to barriers to effective care. 

Last updated on: September 2, 2021
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Guest Editorial: Structural Racism in Pain Practice and How to Combat the “Hidden Curriculum”
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