Integrated Chronic Pain Treatment and Training Project
- Need: To reduce prescription opioid misuse and overdoses in North Carolina.
- Intervention: The ICPTTP standardizes and streamlines chronic pain management in primary care clinics.
- Results: The ICPTTP reduced patients' average morphine equivalent daily dose, and 29% of patients successfully tapered off chronic opioid therapy.
Evidence-levelPromising (About evidence-level criteria)
In 2016, 1,956 North Carolinians died from drug overdoses. The state lost 1,567 lives in 2015 and 1,358 in 2014. Some of these deaths come from prescription medications, as overprescribing opioids has become a national issue. According to CDC data, there were 82.5 opioid prescriptions dispensed per 100 people in North Carolina in 2016, compared to a national average of 66.5 prescriptions.
Mountain Area Health Education Center (MAHEC) worked to prevent opioid misuse and overdose by educating patients and the larger community on safer alternatives to pain management. In addition to Asheville and Henderson at Blue Ridge Community Health Services, MAHEC's Integrated Chronic Pain Treatment and Training Project (ICPTTP) was implemented at Andrews Internal Medicine in rural Andrews, which serves the rural counties of Cherokee, Clay, Graham, and Macon.
MAHEC created the ICPTTP in order to stabilize and streamline chronic pain management in primary care clinics. Multidisciplinary care teams provided medication management and behavioral health services as well as trained primary care providers (PCPs) in chronic pain management. Care teams educated patients and suggested alternative pain treatments such as physical therapy and acupuncture.
MAHEC partnered with Project Lazarus, which provides community outreach and education about opioid misuse. The ICPTTP received funding from a Centers for Medicare & Medicaid Services (CMS) Health Care Innovation Award (HCIA).
"Core providers" trained other PCPs on chronic pain protocols so that pain treatment is safer and standardized. Providers also learned how to identify and prevent opioid misuse, in part through drug screenings. Providers offered:
- Education about the potency of opioid medications and the potential for misuse
- Group medical visits, which provided social connection and support for patients
- Ways for patients to change their perception of pain (ways to endure pain and stay active)
- Screenings to identify behavioral health issues such as prior substance use or trauma
- Referrals for patients who would benefit from more intensive treatment for mental illness or substance use
In 2016, the ICPTTP at MAHEC implemented an opioid tapering curriculum to reduce the number of patients on chronic opioid therapy (COT), average morphine equivalent daily dose (MEDD) per patient, and the number of patients on concomitant benzodiazepines (simultaneously taking opioids and anxiety medications).
As of 2017:
- Over 90% of ICPTTP patients remained engaged in care following the implementation of the opioid tapering curriculum in 2016.
- 29% of patients were successfully tapered off COT.
- Significantly more patients met the CDC recommendation of less than 50 MEDD.
- The total number of patients on concomitant benzodiazepines decreased.
From October 2012 to June 2015, the ICPTTP reached 376 patients. According to the HCIA Disease-Specific Evaluation: Third Annual Report:
- The MEDD decreased significantly.
- 25% of participants stopped taking opioids altogether.
- Patients who began the program with a lower MEDD were more likely to stop taking opioids.
- Patients reported improved functionality and relief from mental health issues such as anxiety.
- One program site reported fewer emergency department visits (and lower healthcare costs), as patients visited the pain clinic instead.
Program coordinators found that patients and providers were not aware of the lack of safety and efficacy of opioids for pain.
Since Asheville is a larger community, patients at the Asheville site had easier access to services such as acupuncture, yoga, and behavioral health providers than patients at the rural sites.
The sites were still able to implement the program despite differences in staffing. For example, some program sites relied on nurse practitioners (NPs) while two sites implemented the project without NPs. Larger sites could hire a behavioral health provider, while the Andrews location wasn't able to fill this position. Without a behavioral health provider, PCPs at some sites were still able to implement the chronic pain protocols but said they would have appreciated having someone trained in substance use treatment.
To develop the program across western North Carolina, MAHEC staff members provided buprenorphine waiver trainings for healthcare providers, trainings on treating pain and substance use disorders safely, and consultations for medication-assisted treatment. MAHEC also hosted Project ECHO clinics designed to educate and support rural health practitioners in the state and conducted community outreach initiatives throughout the region.
Pharmacy and prescription drugs
Prescription drug misuse
August 2, 2017
Date updated or reviewed
October 2, 2020
Suggested citation: Rural Health Information Hub, 2020. Integrated Chronic Pain Treatment and Training Project [online]. Rural Health Information Hub. Available at: https://www.ruralhealthinfo.org/project-examples/968 [Accessed 26 November 2020]
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