Pain affects over 100 million Americans yearly, and approximately 10-15% experience persisting pain [1,2]. Chronic, or persistent, pain is categorized as any aversive physical discomfort that is consistently ongoing for at least three months [3]. Chronic pain has substantial deleterious impacts on daily functioning, maintaining gainful employment, personal wellbeing, and family and societal burden [1,4,5]. The evolution of persistent pain care shifted from multi-disciplinary pain treatment teams to patients’ primary care providers with the emergence of opioid medications and the limited financial viability of the multidisciplinary pain center in an American managed care environment [6]. Further transformational shift in persistent pain treatment has occurred due to the confluence of recent, multiple factors, including:

a) Escalations in overdose deaths from the opioid epidemic;

b) Research highlighting the limited benefits and heightened risks of opioid over alternative medications (e.g. nonsteroidal anti-inflammatory drugs or NSAIDS); and

c) Demonstrated improvements in functioning when psychosocial treatments are added to care [7-9].

 The recent recommendations of the Centers for Disease Control (CDC) advocating for reducing the utilization of opioid medications in non-cancer pain and the expanding interdisciplinary care offerings for pain have had downstream reverberations in reducing the utilization of opioids in the policies of insurance payers, pharmacies, care organizations, and provider practices [10,11]. The change in narcotic pain medication prescribing trends has reestablished a need to help people cope better with the distressing and functionally impairing symptoms of pain. Psychological interventions provide a potentially powerful option to help fill this glaring need, and can be readily deployed in the primary care environment, to ease burden on both patients and medical care providers [9]. Current models of persistent pain, including central sensitization, propose that the brain becomes hypersensitive to pain, and pain sensation can be heavily influenced by patterns of thinking, life stressors, and environmental cues [12]. Moselely has indicated that educating individuals with persistent pain on the biological, social/contextual, psychological, movement-oriented, and self-management aspects of ongoing pain can create a new internal understanding, leading to different pain attitudes, beliefs, and behaviors [13,14]. In the last two decades, there has been a rapid increase in the integration of behavioral health providers into primary care and FQHCs [15]. This co-location of services and shared care movement provides a prime opportunity for behavioral health clinicians to utilize evidence-based interventions with demonstrated effectiveness for improving patient’s daily functioning, symptoms of psychological distress and substance use, and self-management coping skills in response to pain [15,16]. Brief, evidence-based group treatments, such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy (ACT) and skills-based psychoeducation can be readily applied in the primary care environment to a broad spectrum of patients and can be tailored by clinicians to match patient needs [17-19]. A major challenge in primary care is to provide highly effective, dose-limited, evidence-based treatments to a subset of patients with a given need [20]. Group interventions, while a convenient and cost-saving format, can be challenging for primary care participants to attend, especially across an extended multi-session format [21]. This is particularly true for individuals with chronic pain, given the barriers experienced in daily functioning, discomfort, and financial resources that can limit appointment attendance [22,23].

 This study provides a retrospective program evaluation of one FQHC’s provision of a low-intensity (3 hours), evidence-informed, manualized psychoeducational pain group (The Pain Academy) to individuals prescribed narcotic pain medication at the health center. Previously, an Acceptance & Commitment Therapy pain group was offered for the FQHC’s persistent pain population, however there was limited attendance by those prescribed narcotic pain prescriptions, and those with opioid prescriptions demonstrated lower levels of pain-related functional improvement relative to those individuals not prescribed opioid medications [24]. The FQHC responded by developing The Pain Academy, a targeted psychoeducation group for individuals with persistent pain and ongoing opioid-based pain treatment. The Pain Academy sought to increase the baseline knowledge and familiarity about effective psychological tools for managing pain for this subset of FQHC patients prescribed narcotic pain medications, as well as aiming to improve pain-related functioning. The FQHC decided that all individuals with prescribed opioid pain medication would be referred to attend the program and it was added to their pain intervention plan. The Pain Academy was also unique because it was developed shortly before the announcement of the new CDC chronic pain guidelines and implemented as the FQHC’s medical providers were consequently reevaluating their pain medication prescribing practices to this population [10]. This retrospective program evaluation sought to review the outcomes of the Pain Academy after its completion. Most notably, this program evaluation examined:

a) Attendance and retention in a dose-limited treatment in usual primary care;

b) Magnitude of change in pain-related functioning;

c) Degree of change in pain severity, pain self-knowledge, and self-efficacy; and

d) Impact on patient and provider satisfaction. It was hypothesized the Pain Academy would likely have minimal impact on pain severity, however improvements would be observed in pain-related functioning, self-efficacy, and pain knowledge.

Participants

 Individuals who attended the Pain Academy program were drawn from one urban Federally-Qualified Health Center (FQHC). Inclusion criteria for participating in the Pain Academy was: (a) being 18 years of age or older; (b) having a persisting pain diagnosis; (c) actively being prescribed an opioid medication; and (d) sufficient comprehension and understanding of English to complete self-report questionnaires and participate in group. Attendance and completion of the Pain Academy was requested by the primary care providers of all FQHC patients receiving opioid medications, as part of their annual pain treatment plan. Those individuals that did not feel comfortable participating in group or were not sufficiently able to understand English were provided alternate non-Pain Academy options for pain education and support, and are not included in this programmatic evaluation.

Procedure

 An iterative process developed the group curriculum for the Pain Academy, between the integrated behavioral health consultant and the primary care providers at the practice, yielding an intervention utilizing psychoeducation and teaching self-management pain skills. The planning for the group started with a meeting with the FQHC’s primary care providers to discuss goals of the Pain Academy and educational topics the providers wanted including: (a) benefits and risks of opioids; (b) signs of opioid tolerance and dependence, and (c) potential adverse impacts of sharing and selling medication. The FQHC’s medical and behavioral health providers agreed that the group would be offered in three, one-hour classes over one year (e.g., 2017) to improve accessibility. This program intensity was decided upon based on interactive staff discussion on reasonable expectations, and deriving from previous group attendance patterns at the FQHC’s and conversations about group amenability, during clinical encounters, with existing patients experiencing persistent pain at the FQHC. The components of the three classes drew from the published literature on evidence-based psychoeducational and cognitive-behavioral interventions for persistent pain (Table 1). Each class of the Pain Academy utilized a psychoeducational approach of presenting information, skills training, and facilitating discussion on the topics may be applied in attendees’ lives. The program was manualized, with a detailed outlined providing patient and clinical instructions on each component of each class, available upon request from the lead author: there was no patient guide, but rather several handouts were provided for each class, as listed below. Class 1 utilized a team versus-team, quiz show format to “test” and provide knowledge about chronic pain, pain medications, and safety in medication use. This class also provided handouts on different types of pain, risks of opioid medication, and signs of opioid dependence. A brief video reviewed how persistent pain is best treated by multiple approaches, including medical, movement, pain modalities, and psychological. Class 2 provided an overview handout on therapeutic modalities for pain reduction (e.g., heat, TENS unit) and local pain-related resources covered or subsidized by the participants’ insurance companies, such as fitness centers, chiropractors and therapeutic massage offerings. This class also taught and provided “do-it-yourself” practice handouts on self-massage strategies, behavioral pacing, and reviewed the problem of pain catastrophizing and associated cognitive coping strategies. Class 3 focused on progressive muscle relaxation, visualization, distraction-oriented coping techniques, and prospectively developing individualized plans to address low, moderate, and high pain symptomatic days. A review of the proposed treatment package was shared with the team’s medical and behavioral health providers for feedback. Finally, a focus group was conducted with attendees of another concluding pain group to review goodness-of-fit of the Pain Academy format, handouts, and measures, and additional feedback.

                                                                       Table 1: The pain academy program curriculum