The Impact of an Innovative Patient-Practitioner Therapeutic Community on the Management of Chronic Pain


Karen Peters, PhD; Barbara Gawehn, RN, LAc

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Northern California

Background: The opioid epidemic begs for advances in chronic pain treatment. Literature suggests chronic pain and addiction share motivational and reward circuitry. To date, there is no treatment model addressing this connection in the long-term management of chronic pain. Kaiser Permanente Santa Clara bridges the gap with an innovative model that combines standard multidisciplinary chronic pain management approaches with a modality commonly used in addiction treatment to motivate patients, the therapeutic community. Initial outcomes are very promising.
Methods: Using mixed methodology, a comparative analysis of utilization (Emergency Department visits, Primary Care office visits, benzodiazepine and opioid prescriptions) was conducted on 2 patient groups. One group (n = 286) completed the Region’s standard chronic pain treatment at Santa Clara: Level 2, 9 to12 sessions, years 2007 to 2011. The other group (n = 193) completed a therapeutic community-based program: The Pain Management Rehabilitation Program (PMRP) at Santa Clara, intensive phase/24 sessions with ongoing rehabilitation, years 2015 to 2017. Wilcoxson rank sum tests compared utilization, 1 year pre- and postintervention. A qualitative approach using constructivist-grounded theory compared 47 patients’ responses with program assessment questionnaires used in both models. Staff responses to the same questions were also analyzed.
Results: The reductions in utilization were greater in the PMRP group: Opioid prescriptions decreased 83%, compared with the Level 2 group at 34%. Benzodiazepines decreased 80% in the PMRP group, while they decreased 39% in the Level 2 group. Emergency Department visits decreased 52% in the PMRP, whereas they increased 15% in the Level 2 program. Group differences were statistically significant. In the PMRP primary care office visits decreased 21%. In the Level 2 group they decreased 14%, with no statistically significant difference between groups. Level 2 increased understanding of chronic pain yet patients wanted more time to interact and practice techniques. Disappointment that pain did not go away was common. PMRP participants voiced that belonging to an ongoing community that practices techniques eases suffering and increases motivation to self-manage pain. They reported changes in attitudes, humor returning, and appreciation for comprehensive care and practitioner enthusiasm. Practitioners echoed with comprehensive care and a practitioner-patient community as being peak career experiences.
Discussion: Reduction of opioid and benzodiazepine prescriptions, along with Emergency Department visits and Primary Care office visits, and ongoing participation in a patient-practitioner therapeutic community motivates patients to self-manage pain, thus decreasing costs and potential fatalities. Patient and staff narratives suggest community is an intervention that affects motivation and engenders understanding and support in a way that is inherently rewarding to patients and staff. We surmise that community membership is an interpersonal neurobiological intervention that therapeutically affects brain mechanisms common to chronic pain and addiction. Narrative themes point to it having a revitalizing effect, both upon patients’ lives and practitioners’ passion to provide care to this difficult population.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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