The multidimensional suffering encompassed by chronic pain conditions, combined with their prevalence, demands a multidisciplinary approach to management. The direct impact that chronic pain has on physical distress, as well as emotional state, sleep, stress levels, and coping systems, highlights the importance of behavioral health integration. There is a bidirectional relationship between chronic pain and behavioral health conditions – with chronic pain conditions increasing the risk for the development of behavioral health problems and chronic pain being a symptom commonly experienced by individuals with behavioral health conditions. Social determinants of chronic pain (including poverty, unemployment, adverse childhood events such as abuse, and exposure to violence) necessitate the integration of social interventions with clinical interventions. Resultant psychological, social, and functional impairments related to the experience of chronic pain may exacerbate disability in this population (Kohrt, Griffith, & Patel, 2018).
Nicole Polashenski, DO
A person-centered approach includes timely access to behavioral health interventions, physical and behavioral health care coordination, addressing health-related social needs, and education around self-management strategies (Eaton et al., 2015). The approach incorporates behavioral health treatments, such as cognitive behavior therapy, trauma-focused psychotherapy, and behavioral activation, with psychosocial interventions to enhance social support. This approach targets the transdiagnostic features of chronic pain (impaired emotional regulation, sleep disturbance, avoidant coping, and demoralization) that can fuel further physical and emotional distress. It also addresses the physical, psychological, and social implications of living with chronic pain (Kohrt, Griffith, & Patel, 2018).
The variability in how individuals experience pain underscores the use of a biopsychosocial framework for effective management. Chronic stress states can make individuals more sensitive to the experience of pain and at higher risk for a host of maladaptive coping responses. Individuals with a history of trauma are at a particularly elevated risk of demoralization due to a cycle of aversion responses combined with motor, autonomic, and endocrine system activation, which can worsen both pain and psychological suffering. As the intensity and duration of such distress increases, the subsequent demoralization can impact the risk of suicide if it progresses to feelings of hopelessness, helplessness, and further despair. Psychotherapy can be a valuable tool in introducing hope and motivating positive behavioral change via various psychotherapeutic approaches (De Figueiredo & Griffith, 2016).
Community Care Behavioral Health Organization (Community Care), a nonprofit behavioral health managed care organization part of the UPMC Insurance Services Division, is committed to ensuring access to evidence-based behavioral health treatment and physical-behavioral health integration. Given that individuals who have serious behavioral health conditions are a medically vulnerable population, the integration of physical and behavioral health services is an existing focus and initiative to improve the physical health status of these individuals that can also be applied to populations experiencing chronic pain. Community Care’s Behavioral Health Home Plus model is a comprehensive approach to physical and behavioral health integration as part of treatment and recovery for adults with serious behavioral health conditions or opioid use disorder. The model incorporates wellness coaching, effective coordination, collaboration between physical health and behavioral health providers, and population health learning collaboratives. Case managers and certified peer specialists serve as “health navigators” to assist individuals in achieving health and wellness goals. The model supports whole-person care by creating an environment of wellness, activating individuals to better manage their overall health, and attending to social determinants of health. The model’s learning collaboratives disseminate education, tools, and resources to providers around topics that pertain to collaborative care, including the impacts of traumatic stress and social determinants of health on chronic pain. Community Care has also provided education around physical-behavioral health integration to Pennsylvania HealthChoices’ contracted Federally Qualified Health Centers (FQHC) via behavioral health-focused learning sessions, during which the topic of behavioral activation for individuals with chronic pain has been presented.
UPMC Community HealthChoices is one of three Managed Care Organizations (MCOs) that manage Pennsylvania’s Community HealthChoices program. Plan medical directors provide behavioral health case consultation for UPMC’s Community HealthChoices service coordinators to support individuals with complex physical and behavioral health needs, often including chronic pain. These are opportunities for case-by-case discussion around challenges in chronic pain management -including social determinants of health needs and social impairments associated with chronic pain, the importance of coordinated multidisciplinary care and emphasizing behavioral health interventions that promote engagement with the pain providers. Educational sessions are offered to UPMC Community HealthChoices providers by Community Care via a summer institutes series, and topics include the intersection of chronic pain and substance use disorders.
Digital applications offer opportunities to promote self-management strategies that can be uniquely valuable in chronic pain management. Community Care offers members access to a free mobile wellness application called RxWell that provides health coaching to support self-management strategies and improve overall wellness through several behavioral health and lifestyle program offerings. It also provides educational content and activities based on cognitive behavior therapy to increase resilience and promote behavioral change.
Pharmacological interventions for pain management, particularly reliance on opioid analgesics, can be fraught with risks, including diversion, addiction, and overdose. The opioid epidemic further highlights the importance of the implementation of mitigation strategies (Volkow & McLellan, 2016). UPMC Health Plan and Community Care provide opioid educational resources to providers. Pharmacy initiatives include provider outreach to promote evidence-based opioid prescribing, early prevention of opioid use disorder via identification of high-risk members and referral for various interventions, and overdose prevention strategies. This also includes a robust opioid/medication-assisted treatment (MAT) outreach program implemented by UPMC Health Plan Pharmacy. The program identifies members using high dose opioids where the risk of overdose and addiction is elevated, those with concurrent potentiators on board (thus increasing risk of overdose), those utilizing multiple providers/pharmacies, and other factors such as history of overdose or substance use disorder. Pharmacist interaction through the MAT program also screens for social determinants of health to make appropriate referrals to the UPMC Health Plan or community resources.
The UPMC integrated delivery and finance system supports the integration of comprehensive care. Across the insurance services division, UPMC Health Plan and Community Care provide access to comprehensive physical and behavioral healthcare, focusing care collaboration and incorporation of appropriate pharmacy interventions. The synergy of these components promotes the relief of the multidimensional suffering associated with chronic pain conditions.
Nicole Polashenski, DO, is Associate Medical Director of Community Care Behavioral Health Organization.
References
De Figueiredo, John M., and James L. Griffith. “Chronic pain, chronic demoralization, and the role of psychotherapy.” Journal of Contemporary Psychotherapy, vol. 46, no. 3, 5 Apr. 2016, pp. 167–177, https://doi.org/10.1007/s10879-016-9331-x.
Eaton, Simon, et al. “Delivering person centred care in long term conditions.” BMJ, 10 Feb. 2015, https://doi.org/10.1136/bmj.h181.
Kohrt, Brandon A., et al. “Chronic pain and mental health: integrated solutions for global problems.” Pain, vol. 159, no. 9, Sept. 2018, pp. S85–S90. Supplement 1, https://doi.org/10.1097/j.pain.0000000000001296.
Volkow, N. D., & McLellan, A. T. (2016). Opioid abuse in chronic pain — misconceptions and Mitigation Strategies. New England Journal of Medicine, 374(13), 1253–1263. https://doi.org/10.1056/nejmra1507771.
