In April 2021, our ‘pain management’ clinic made the decision to reframe itself as an integrated health clinic. Our objective was to discontinue all chronic opioid prescriptions by the end of 2021. Each provider was responsible for initiating discussions around opioid weaning with their patients. We instituted a policy of 10%–15% decrease in MME per month in accordance with current guidelines.4 This was required of all providers in order to maintain fairness and consistency for all patients regardless of their provider. Patients were informed of the clinic’s new policy and were given the option to receive a referral to alternative pain management clinic (other local clinic information was provided) versus continuing to receive care at our facility with a plan to wean opioids versus receiving a Suboxone prescription. In addition, in order to provide our patients on chronic opioid therapy (COT) with optimal support during the process of weaning opioids, we designed a three-part intervention. Our three-part intervention included (1) expansion of integrated pain modalities, (2) Suboxone therapy and (3) a community health worker (CHW) programme. Each component of this intervention will be discussed in the subsequent sections.
Expansion of integrated modalities
The first component of our intervention was to ensure the provision of alternative, non-pharmacological options for pain management. These therapies included cupping therapy, acupuncture, trigger point injections, osteopathic manipulation, cognitive behavioural therapy, joint injections, wellness groups and walk-in hours for alternative modalities.
Cupping therapy
At the time of our intervention, one provider was offering cupping therapy 7 to patients, and that provider subsequently trained other providers in the department to provide cupping therapy to their patients. Currently, three out of six providers are regularly providing cupping therapy. In October 2021, approximately 70 patients had participated in cupping for their chronic pain conditions.
Acupuncture
Acupuncture8 has level A evidence for efficacy in certain chronic pain conditions, and thus we wanted to ensure its availability at our centre. In September of 2020, our facility hosted a training for 20 providers in the department (including the six IHC providers) in auricular acupuncture. The training involved use of the National Acupuncture Detox Association (NADA) protocol9 for auricular acupuncture with the goal of expanding the number of providers who offer this service to their patients. By October 2021, over 80 individual patients had received at least one acupuncture session, with many regularly receiving treatments.
Trigger point injections/dry needling
Two providers in our clinic currently offer lidocaine injections and dry needling 10 services. As of October 2021, approximately 19 patients had received trigger point injections or dry needling for a number of chronic musculoskeletal conditions including ulnar tendinopathy, lower back pain, trapezius muscle spasm, occipital headache, etc.
Joint injections
One provider currently offers steroid-based joint injections including knee injections, carpal tunnel injections, de Quervain’s injections and acromio-clavicular joint injections.
Walk-in hours
In general, patients were being seen in the IHC on a monthly basis, and many expressed interest in getting more frequent treatments. In order to expand access to regular treatments, ‘walk-in hours’ were established on a weekly basis (every Wednesday evening) for patients to arrive without an appointment in order to receive acupuncture, cupping or osteopathic manipulation. On average, the clinic sees anywhere from two to eight patients during a weekly walk-in session.
Osteopathic manipulation
Currently, two providers, 1 doctor of osteopathic medicine (DO) and 1 allopathic physician (MD), offer osteopathic manipulation for various chronic musculoskeletal conditions including trapezius muscle spasm, low back pain, occipital headaches and tempomandibular joint pain, among others.
Yoga and meditation
Currently, one provider offers a weekly yoga and meditation group that is open to any patient at the health centre.
Wellness groups
In September 2020, the IHC started a weekly women’s wellness group open to any woman in the clinic. The group is currently run by one physician and has on average four to eight participants on a weekly basis. The group offers support as well as formal weekly education on multiple strategies for addressing pain and improving quality of life. Frequent topics covered include mindfulness-based stress reduction, nutrition, physical therapy, exercise and sleep, among others.
Suboxone therapy
The second component of our planned intervention was to offer Suboxone therapy to all patients as an alternative to chronic opioid therapy for pain control. Evidence is emerging about the efficacy of Suboxone as a medication for pain management in patients with and even without concurrent opioid use disorder11–13 that may be a safer option that COT long term. Therefore, we offered Suboxone as a safer and more evidence-based alternative for all patients on COT. All providers within the clinic were waivered to provide Suboxone. In order to ensure all providers were comfortable with Suboxone prescribing, CME time was provided to complete additional coursework in Suboxone prescribing and grand rounds were held on the topic of Suboxone. All patients were offered Suboxone as an alternative to COT. CHWs (discussed in the CHW program section) were assigned the task of following up with patients 48 hours after starting Suboxone by telephone. In addition, several Suboxone information sessions were held for patients in a group setting where providers, CHWs and current Suboxone patients were present in order to ask questions and provide information about Suboxone for those considering this therapy.
As of the fall of 2021, approximately 45 patients were on Suboxone, which was a 150% increase from the previous year (2020).
CHW programme
There is strong evidence for the use of CHWs, also called community navigators or health coaches, to improve patient care.14 Our health centre currently has a grant-funded CHW programme. Seven CHWs are employed by the health centre to help patients navigate care. In April of 2021, we integrated three CHWs into the IHC full time. Each of these health workers underwent a formal training in health and wellness coaching through the American College of Lifestyle Medicine.4 This training took place in several monthly sessions, better familiarising CHWs with basic motivational interviewing and health coaching training.
In May 2021, each CHW was assigned to cover the patients of two physicians. The CHW is present at all visits with the clinician so that physician and CHW were seeing the patient together as a team and patients began to see CHWs as part of the therapeutic team. The CHW is responsible for following up with patients after visits, providing ‘check-in’ phone calls, ensuring follow-up visits are scheduled and helping arrange transportation for patients in collaboration with the clinic’s case manager.