The Role of Integrated Care in Managing Chronic Pain

The term “integrated care” encompasses a variety of approaches and models of blending mental health and primary care services. “Collaborative care” is a specific model of integrated care consisting of the following elements: team approach, population-based care, measurement-based treatment to target, evidence-based care, and accountability (18, 19). In the past 10 years, a number of studies have demonstrated that the concepts of collaborative care can be applied with success to managing chronic pain (20–23). Treating underlying psychiatric conditions alone has been shown to improve pain outcomes (24), and integrated care can provide quicker access to treatment and improved outcomes in a range of comorbid mental health conditions (25). Given the comorbidity of anxiety and depression with chronic pain, targeted depression and anxiety screening in individuals who are dealing with chronic pain provides an opportunity to intervene and treat problems that may hinder improvement in pain (9, 10).

Aside from simply treating underlying mood or anxiety disorders, integrated-care providers also have the opportunity to adapt their practices to better address chronic pain directly. The integrated-care psychiatrist can support the primary care practice in management of these patients through several strategies: expanding knowledge of pharmacologic treatment strategies pertinent to chronic pain; increasing awareness and availability of evidence-based psychological therapies; and incorporating coaching on healthy behaviors in the areas of self-management, exercise, and sleep.

Critical to achieving and demonstrating success in integrated care are the use of clinical outcome measures and treating to a target outcome. A 50% reduction in measured symptoms with a validated tool has been identified as the target for which to strive in behavioral health, and the treatment plan should be adjusted every 10–12 weeks if the goal has not been achieved (19).

When measuring pain outcomes, it is important to quantify not only pain severity but also functional status. The Brief Pain Inventory (BPI) is a valid and widely used instrument that has been utilized in a number of collaborative care studies (22, 26). It consists of four numerical rating scales of pain intensity (current, worst, least, and average in the past week), as well as measures of pain’s interference on functioning in seven areas (general activity, mood, walking ability, work, relations with other people, sleep, and enjoyment of life) (27). A one-point change on its 0–10 scoring scale has been considered clinically important (28, 29). The BPI’s generalizability among a wide variety of pain conditions and ease of use make it a recommended tool for treating pain in integrated practices, although other tools may be useful as well (30–33). The Patient Health Questionnaire (PHQ-9) (34) and Generalized Anxiety Disorder 7-Item Scale (GAD-7) (35) for depression and anxiety, respectively, or similar tools, should be incorporated into chronic pain treatment, given the importance of identifying and treating these disorders for those individuals with chronic pain.

The integrated-care psychiatrist has the opportunity to provide considerable assistance to primary care colleagues by becoming more familiar with psychotropic treatment options and dosing recommendations for common pain syndromes, including fibromyalgia, migraine headaches, low-back pain, irritable bowel syndrome, neuropathic pain, and others. Agents that may serve dual roles treating psychiatric and pain-related symptoms include serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and gabapentinoids (36–38). Recommendations regarding starting doses, titration plans, and treatments goals could be made to PCPs, with guidance provided on safety and monitoring parameters. Cross-titration schedules may be outlined when recommendations are made to switch pharmacologic classes (e.g., selective serotonin reuptake inhibitor to SNRI, or SNRI to TCA).

Additionally, a number of opportunities exist for integrated-care psychiatrists to assist in dealing with the changing landscape of opioid prescribing and its consequences. Despite there being few chronic pain conditions for which long-term opioid use is indicated, opioids are still commonly prescribed, and PCPs often care for or inherit patients on treatment regimens that are outside the recommended parameters of the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain (8). PCPs may have inadequate training or limited confidence to approach difficult conversations and management decisions around inappropriate long-term opioid use (39).

Beyond implementing screening tools such as the Screener and Opioid Assessment for Patients with Pain (SOAPP) or Opioid Risk Tool to identify patients at high risk of addiction (40, 41), integrated-care psychiatrists may serve as consultative support for PCPs who either have identified a need to address opioid use disorders or have recommended a change in pain management treatment with which the patient may not agree. These topics can be challenging to discuss with patients and the changes even more difficult to implement. In the first scenario, the role of the integrated-care psychiatrist may consist of a range of options, from directly providing or supporting substance use treatment in the primary care setting with medication-assisted treatment (42) to linking individuals with specialized addiction services. In the second example, when a treatment change away from opioids is recommended, the plan for an opioid taper may be met with patient reluctance, fear, or anger but also PCP concerns about her or his ability to adequately treat pain throughout the taper and maintain a therapeutic relationship. An integrated model to educate the patient and support the PCP in this endeavor can provide improved outcomes for the patient, including decreased pain interference, improved pain self-efficacy, and reduced perceived opioid problems, as was recently demonstrated by Sullivan et al (43).

The integrated-care psychiatrist should be familiar with psychotherapeutic approaches to treat pain but may or may not choose to become the evidence-based therapist for a practice. He or she may help facilitate access to psychological treatment either within or outside of the primary care practice by identifying appropriately trained therapists, facilitating training for existing providers, and incorporating treatments into collaborative models of care. Recent guidelines published by the American College of Physicians (ACP) emphasize nonpharmacologic interventions as first-line treatments for chronic low-back pain; therefore it is essential for integrated-care psychiatrists to be familiar with the evidence and connect patients with appropriate resources or treatments (44).

Self-management, which has demonstrated efficacy in managing chronic pain in primary care (64, 65), has been defined as a patient’s ability “to manage the symptoms, treatment, physical and psychological consequences and lifestyle changes inherent in living with a chronic condition” (66). Just as in dealing with other chronic medical conditions, helping patients develop long-term strategies to manage their pain-related difficulties can lead to improved functioning and reduced disability. Better understanding the concepts of self-management and how they have been applied in integrated settings will help the integrated-care psychiatrist incorporate them into models of care such as those involving care managers. It may also help them in advising PCPs on strategies for improving patient engagement in their care.

Self-management focuses on interactive collaboration between the patient and health care provider, in contrast to passive communication in which the patient receives information or directive care; personal responsibility is emphasized. Aspects of self-management programs overlap with other treatments, such as psychological treatments, and have a number of core features: building self-efficacy, self-monitoring, goal setting, action planning, decision making, problem solving, self-tailoring, and partnering with health care providers (64, 67).

In the Stepped Care for Affective Disorders and Musculoskeletal Pain trial, Kroenke et al studied a multistep intervention for patients with depression and musculoskeletal pain (21). They hypothesized that the combination of effective antidepressant treatment and a chronic pain self-management program would be more beneficial than would either alone. Step 1 consisted of working with a nurse care manager for 12 weeks to optimize antidepressant treatment, and step 2 consisted of six sessions of a self-management program delivered over 12 weeks with a focus on self-efficacy and social support to manage pain symptoms. The self-management intervention involved education about chronic pain. Clinically significant improvements in depression, pain severity, or both were noted in the intervention group at 12 months. A follow-up analysis demonstrated that those in the intervention group significantly increased time spent in self-management behaviors and reported greater self-efficacy in managing pain and depression. A dose-response relationship was noted between the number of pain self-management sessions attended and the improvement in depression and pain (68).

Overall evidence for self-management interventions for chronic pain is positive, and their ability to be delivered in discrete time periods makes them favorable for the integrated-care psychiatrist who is considering expanding treatment models for chronic pain.

Many of the studies discussed above utilized single-treatment strategies, but the complexity of chronic pain often necessitates combination treatment utilizing multiple approaches (78). Collaborative care delivered by care managers has shown great promise for delivering multidisciplinary chronic pain treatment and may be ideal in primary care settings as an alternative pathway for patients presenting to the PCP with pain. Psychiatrists may play integral roles in adapting these models to their own settings and serving in supervisory roles to other care team members.

The Study of the Effectiveness of a Collaborative Approach to Pain trial, by Dobscha et al, involved a multifaceted collaborative-care intervention with a psychologist care manager for chronic pain in primary care. After an assessment by the care manager and discussion with an internist, recommendations were communicated to the patient’s primary care providers, and the patients were offered a four-session workshop described as an activating intervention to manage chronic pain. The care manager then called every two months for the next year to reassess patients, review cases with an internist, and make treatment recommendations as needed. Statistically significant improvements in disability, pain intensity, and depression scores resulted, and gains were maintained in most domains at 12 months (20, 79).

Bair et al conducted an Evaluation of Stepped Care for Chronic Pain for veterans of the Iraq and Afghanistan conflicts (23). The intervention consisted of nurse care managers delivering 12 weeks of algorithm-based analgesic optimization and self-management strategies (step 1), followed by 12 weeks of CBT (step 2). Step 1 included education about chronic pain and encouragement to limit bed rest, resume activities, and perform recommend exercises, including walking. At nine months, decreases in pain, disability, and pain interference were seen.

Using a telecare collaborative strategy, Kroenke et al discovered that using automated symptom monitoring by phone, and nurse care managers to optimize nonopioid analgesics using algorithms, led to significantly more patients having improvement in pain outcomes at 12 months (22). The delivery by telephone suggests that the intervention may be more accessible to individuals, such as those in rural areas, with limited access to other treatments.

As is outlined in the above examples, a number of varied collaborative-care models have been shown to be effective for chronic pain. Utilizing interprofessional team members to assist in care delivery greatly expands access and enhances the care that can be provided by an integrated-care team in the primary care setting.

Integrated-care psychiatrists are well positioned to incorporate into integrated clinical practice the evidence-based pain management strategies outlined in this article. Doing so is becoming more financially viable to a wider range of practices as payment models supporting integrated care evolve, such as Accountable Care Organizations, value-based purchasing strategies, and other innovative models (80). An important milestone for sustaining integrated care occurred on January 1, 2017, when the Centers for Medicare and Medicaid Services implemented new rules for Medicare payments for collaborative care and other integrated behavioral health services. These changes allow practices to bill for services including psychiatric consultation and care manager activities, and other payers are expected to follow suit (81).

The menu of options for chronic pain integrated care includes psychological treatments, improved self-management strategies, and pharmacological treatments, which can be tailored to meet the needs, preferences, and resources of the patient and the practice. Depending on the setting, the integrated psychiatrist’s role in treating chronic pain may consist of serving as a source of information to the PCP, an advocate for a collaborative-care model, or a direct treating provider for psychiatric problems, chronic pain, or substance use disorders.

In the case of Mr. B (see Box 3), the integrated psychiatrist developed screening processes for depression in patients with chronic pain, reviewed progress and treatment plans with a NCM who was delivering self-management recommendations, made recommendations for pharmacological treatments, and helped link the patient with psychological treatment delivered by another member of the integrated-care team. The integrated-care team involvement would continue until a predefined treatment target (e.g., BPI and PHQ-9 score reductions) is achieved or a higher intensity of care is needed.

The current milieu of chronic pain management is fractured, expensive, and insufficient. Integrated-care psychiatrists can play a crucial role in improving not only our patients’ pain outcomes but also our primary care colleagues’ confidence in managing chronic pain. Assessing the needs of the primary care practice and the psychiatrist’s skill set will help determine which options for individual practices are most feasible and beneficial.