Welcome back to the Healing Pain Podcast with Trevor Lentz, PT, PhD, MPH

We have read studies on the implementation of integrated pain management programs, but do they apply in the real world? Join us as we explore the realm of integrated pain management programs with Trevor Lentz, PT, PhD, MPH. Dr. Trevor is a distinguished figure in physical therapy and an assistant professor in the Department of Orthopedic Surgery at Duke University School of Medicine. Driven by a commitment to enhancing care for those grappling with chronic pain, his research underscores the significance of non-pharmacologic treatments while addressing systemic healthcare hurdles. In this enlightening episode, Dr. Lentz joins Dr. Joe Tatta to unravel the essence of integrated pain management, drawing from real-world experiences and outcomes. Additionally, he dissects the pivotal implementation challenges faced by both providers and healthcare systems, delving into the unique and innovative strategies these programs employ under Dr. Lentz’s insightful guidance. Don’t miss out on this insightful conversation on the vital work of delivering integrated pain management programs.

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Implementation Of Integrated Pain Management Programs: What Do Real-World Experiences Tell Us? With Trevor Lentz, PT, PhD, MPH

In this episode, we’re honored to welcome Dr. Trevor Lentz, a prominent figure in the field of physical therapy and an assistant professor in the Department of Orthopedic Surgery at Duke University School of Medicine. Dr. Lentz’s extensive research has focused on improving the care provided to individuals suffering from chronic pain with a particular emphasis on non-pharmacologic treatments and addressing healthcare system barriers. Dr. Lentz has an impressive academic background holding a Master’s in Physical Therapy, a Master’s in Health Policy Management, and a PhD in Rehabilitation Science all from the University of Florida in Gainesville.

Additionally, he’s completed a postdoctoral fellowship in Musculoskeletal Outcomes Research at the Duke Clinical Research Institute and a faculty fellowship in Implementation Science at Vanderbilt University. His outstanding work has been recognized with funding from prestigious organizations such as the National Institutes of Health, the Foundation for Physical Therapy, The Duke Endowment, and the Center on Health Services Training & Research.

In this episode, we delve into the world of integrated pain management programs. We will explore the definition of these programs, learn about the real-world experiences and outcomes of these programs, as well as dissect the major implementation barriers that both providers and systems are experiencing. Dr. Lentz will also share with us the unique and innovative strategies these programs are employing to deliver integrated pain management as well as his insights on where this vital work is headed next. Without further ado, let’s begin, meet Dr. Trevor Lentz, and discuss integrated pain management programs.

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Trevor, thanks for joining me. Welcome.

Thanks, Joe. It’s great to be here.

A lot of people know your work from Duke and a lot of your work in psychologically-informed care. Probably most clinicians know your work from the OSPRO Yellow Flag. If people haven’t heard of that, they should google that and take a look at it. I also came across some great work that you did in May 2023 in The Journal of Pain that I want to make sure we point people to because you’re going to be talking about this for most of the episode here.

For those of you who are out there and want to open up your browser and take a look, we’re talking about a particular paper that Trevor wrote called Overcoming Barriers to the Implementation of Integrated Musculoskeletal Pain Management Programs: A Multi-Stakeholder Qualitative Study. First, thanks for the work. I know your whole team has put a lot of work into that but tell us how that work came about and what the purpose of it was.

It’s an interesting background for this particular project. We were funded through The Duke Endowment. If you all are not familiar with The Duke Endowment, they fund a lot of different types of work in particular around healthcare. They gave a lot of money to Duke University to try to understand how to better manage the opioid crisis. They were particularly interested in the opioid crisis in North Carolina and the US South. They had a number of different projects that they wanted to fund. We were one of those. A lot of the projects were geared toward addressing secondary and tertiary prevention as it relates to the opioid crisis, opioid misuse, and opioid use.

They’re trying to understand how we manage patients who are already on opioids and how we get them better options and access to buprenorphine and things like that to reduce some of those effects. Not a lot of those projects though were focused upstream. Ours was one of the few. As part of that portfolio, we’re focused on, “How do we prevent patients from being exposed to opioids in the first place? Maybe even more importantly, as we start talking about trying to reduce the prescription of opioids, what options do we give patients?” As we know, opioids can be effective for some patients. By pulling some of those things away, we need to be able to provide better options so that we’re not left with this other crisis of undertreated pain.

The genesis of our project or the motivation behind it was, “How do we better manage people who have pain to try to reduce this exposure to opioid use?” They were particularly interested in integrated pain management programs. These are comprehensive programs that address the biopsychosocial issues related to pain. They wanted to understand, “What are some of the implementation barriers or programs like this? How do we overcome some of those barriers? What do these programs look like in real life? How do we create more of them so that more people have access to treatments that are safe, effective, and accessible?” What we set out to do was to try to get a better understanding of what these programs look like and some real-world experiences with their implementation.

I’m trying to think back. It was published in May 2023 but you and your team have worked on this for a while. I do remember back when the opioid crisis hit. One of the biggest concerns was, “We’re starting to taper people down or not prescribing these medications at all. What’s the alternative?” This paper speaks to that in some way because when you look at integrated pain management programs, they’re saying, “This could be an alternative or perhaps even exist alongside someone who is taking an opioid.” It’s an important work. Integrated pain management is not something that our audiences are unfamiliar with but there are different types of integrated pain management. Give us either your definition of it or what you looked at or recognized in the study that you did.

There are a variety of different ways that integrative or integrated pain management can be defined. Even throughout our project, there was a lot of confusion or questions about exactly how we would define that. The important part here is that we tried to take a relatively broad brush to this. We wanted to look across all of these different programs that were out there to manage pain. We didn’t want to define it too narrowly such that we could pick up on programs that were providing good pain care, and we could learn a lot from them.

The way that we operationally defined it is that they were programs that delivered care consistent with the biopsychosocial model. They tended to integrate two or more psychological, physical, or integrative services to address musculoskeletal pain typically within a structured program. These aren’t services being provided concurrently. It needed to be within the context of an integrated program where they were being delivered in some integrated way. That’s how we tried to define it. We were pretty loose in that definition as we were looking across a variety of different programs that we encountered.

Was it easy to find these programs? There are some debates. These programs used to exist more in the early ’90s and they have fallen out of suit. Your paper talks about that a little bit between the lines of trying to figure out, “Potentially, what are the barriers? Can we overcome them to bring them back in some way?”

In short, the answer is no. There are a number of programs out there that are fairly well-known but it was somewhat difficult to identify programs. By their nature, a lot of these are within large academic health systems or non-academic health systems in large part because of the resources that are required. We found some challenges in identifying a broad variety of different types of rural programs and programs that provide care in urban settings. A lot of them tended to be focused on academic health systems or other large health systems.

That’s where we found the challenge in identifying them. Most of our approach was to reach out to programs that we were familiar with or that people that we had talked to were familiar with and then ask them, “What are the programs in this space? Who are the people who are doing great work in the integrative or integrated pain management space?” We took it from there. We ultimately spoke to about 30 different programs across the US.

I mentioned the goal of our funder. A lot of them were in the Southeast but we also had pretty good representation out in the Midwest and the West, as well as a couple of programs up in the Northeast. We tried as best we could to get a representative sample, understanding that these are going to be concentrated within certain areas where those resources exist. Maybe we can talk about that in a little bit. That is one of the challenges in delivering this level of care for pain management. You have to have access to some of those resources and it creates challenges for delivering it in more rural settings.

Maybe you can give us an idea of what one of those programs looks like. Maybe you can name it or not. You mentioned it has oftentimes 1 or 2 psychological components and 1 or 2 physical components but as I read through your paper, I also saw chiropractic and acupuncture. I was wondering. Are those disciplines you saw within one program? Are you scattered throughout different programs?

We saw it scattered pretty well throughout a lot of different programs. A lot of the programs that we talked to depended on what stage of development they were in. Early on, these programs were typically focused on delivering 3 or 4 different types of treatments. For instance, acupuncture, chiropractic care, and cognitive behavioral-based therapies. As those programs grow, they start to offer more treatments. It could be reiki, physical therapy, mindfulness, and nutrition-based programs as well.

Some of it was dependent on what stage of development they were in but we saw, particularly in the programs that were pretty well-established, a large menu of different options that were available that included a lot of different complementary and integrative treatments. Off the top of my head, acupuncture tended to be one that was fairly common as chiropractic care, physical therapy, and some types of cognitive behavioral-based treatment as well.

We tended to see those most commonly. There were also things like nutrition and weight loss. We saw a medical-legal partnership, which was somewhat interesting as well, in an FQHC in Austin, Texas, People’s Community Clinic. There are a variety of different treatment offerings that were both more traditional management and then your complementary approaches as well.

Everyone is excited to hear all those disciplines and multimodal interventions coming together. However, I do think it’s important that we probably start to talk about some of the barriers because this is the reason why these are not widespread. There are barriers from providers, practitioners, payers, and other stakeholders. What’s the major implementation barrier that you discovered in the research?

In talking with the group that we did, we identified four main barriers. They tended to focus on issues of payment and reimbursement. That’s the one that’s probably the most salient. There’s organizational change. Changing the culture around pain management tends to be siloed. How do you get people to start working together who haven’t worked together in the past? It’s developing a business case. There’s the ongoing finance but there’s also the startup. How do you get one of these programs off the ground?

There are a number of regulatory hurdles, whether that is related to credentialing or other nuanced state-specific or payer-specific hurdles that are related to regulation. Those tended to be the four main categories that we outlined in the paper. When we look from a provider perspective, the major pain points for a lot of providers were things that we’re probably already familiar with like utilization management, prior authorization needs, and utilization reviews.

For these programs in particular, what we heard a lot of was that the inability to pay for multiple visits to different providers on the same day was a major issue because these are integrated. These are providers working in the same physical space. The fact that an insurance company wouldn’t pay for a patient to see multiple providers makes this incredibly difficult to do or at least very inefficient.

I mentioned organizational change. We heard a lot about the need to develop buy-in from different healthcare disciplines that aren’t used to working together. It wasn’t so much that there wasn’t the belief that these other disciplines would be helpful. It was a lack of familiarity. It’s physicians working with acupuncturists, physical therapists, and chiropractors. Traditionally, you would see those as people who are vying for the same patient population but here, they’re all working together. They may not truly understand what each of them does.

Bringing these disciplines together, getting them to develop rapport, and helping them to understand what each did was a challenge for most programs. It even came down to something as simple as getting everybody to document on the same electronic health record system. It’s the simple, practical, and pragmatic issues as well but the organizational or cultural change was the biggest issue for the providers.

If we think about some of the payer perspective, that came down to primarily reimbursement. It would be of no surprise to anyone that reimbursement isn’t often aligned well with services that we know to deliver the highest value. Particularly in this case, we’re talking about delivery of services that traditionally haven’t been reimbursed very well. How do you bring all of these together to create a program that is self-sufficient and solvent? That is a major problem.

I mentioned the startup funding. Most of these programs were started either through charitable donations and grants or one-time investments from healthcare systems but to keep that going is to keep that funding going. It was challenging for a lot of these programs. It came down to being able to demonstrate some eventual return on investment.

Some of that may have been through cost prevention, which is difficult to do. If you’re helping to manage a patient who has pain conservatively and that reduces the risk of some adverse event related to opioid use, a hospitalization, or an emergency room visit, sometimes it’s a little difficult to project those cost savings but that’s what a lot of these programs try to do.

There are also these non-financial returns. Reducing provider burnout is incredibly challenging sometimes. We talked with a lot of programs that were embedded in primary care. They’re not so much embedded in primary care but had referrals from primary care. For primary care providers, managing chronic pain can be incredibly challenging. Reducing burnout and having another option to send patients who have chronic pain helped to sell the value of a program like this.

Those were some of the major challenges that we tended to see in the implementation barriers. One of the others I’ll mention is related to quality measurement. Something that we heard from payers quite a bit is, “How do we measure quality? Is there a good quality measure that captures all of the different dimensions of high-quality pain management?” That’s an area that still has yet to be resolved but it’s something that we heard from a lot of payers.

There’s a lot there. I want to unpack a couple of those points to review for our audiences. It’s navigating coverage, payment reimbursement, potential organizational change, making a business case to stakeholders, and then overcoming regulatory hurdles. It sounds like that’s the meat of a study. I have one overarching question that I’m curious about. These are qualitative studies. You interviewed these stakeholders. They were insurance companies and various other stakeholders. Do you get the sense that they value integrated care in some way?

There is general agreement. I’ll put it this way. I don’t know if we talked to anybody that said, “This is a bad idea.” It’s the integrated part and the non-pharmacologic focus. Over the course of the entire project, we engaged over 100 different stakeholders. I don’t know if we ever heard at all that comprehensive pain care is not the way to go. Everybody that we spoke to is on board with the fact that pain management needs to change.

Pharmacologic management is the initial way of managing pain or even the primary way of managing chronic pain. There is a lot of debate, “How do you do that so that it meets the needs of every party?” It has to meet the needs of the payer, health system, provider, and patient. Unfortunately, those perspectives aren’t all aligned other than, “This is important. We need to figure out how to do it.” There’s a general agreement that this is a good idea.

There’s also something in your paper where you mentioned that there’s almost this paradox happening where things like medication, surgery, and interventions are covered quite readily and easily yet the things that we’re talking about here that make up an integrated pain management program oftentimes are not. I often wonder if we’re in this holding pattern until we figure out how to bring all these stakeholders together and make them “happy or satisfied” in some way both from a provider delivery perspective as well as from a value-based financial perspective.

That does need to align. Throughout our project, probably the closest that we saw to an example of that is a program at the University of Vermont. It’s a collaboration between the University of Vermont and BlueCross and BlueShield of Vermont. They have come up with a relatively novel bundled payment program for integrated pain management. It’s called the PATH program.

What they have done is come closest to aligning payer, healthcare system, provider, and patient perspectives, goals, and needs in developing this program where there is a fixed payment. There’s a bundle for a defined thirteen-week program where patients are coming into this program. It’s based on group visits. It’s a group-based program. They have cohorts that enter this program. It tends to work out well for both the payer and the healthcare system as well.

The thought is that we probably need more programs like that or at least more arrangements like that because that does bring a lot of those perspectives and those needs in alignment. Unfortunately, we don’t have enough of those but hopefully, with examples like what we’re seeing at the University of Vermont and BlueCross of Vermont, we will start to see more of those options. They’re showing pretty good outcomes as well for some of their initial cohorts.

That’s interesting for people to consider because you have to set aside the fee-for-service model to create a program like that. There are some experimental programs happening within the Medicare system, the MIPS but none of them have yet to take off the way we hoped they would. It sounds like the fee-for-service system could be a barrier to the implementation of integrated care in some way.

That’s probably the other thing that we had a pretty good consensus on. Not only that we need a better way to manage pain and we need to do it in a holistic way but fee-for-service is a major barrier. We heard that from payers as well. The way that is set up doesn’t incentivize this type of approach to pain management, at least not in a coordinated way. I do think that we need to move beyond that model to make this work. It requires a bit of risk from not only the payer but also the healthcare system side.

As a researcher, you have a lot of insight into some of the self-report measures that healthcare providers and researchers use. Some of these integrated management programs were trying to prove that, for example, there was less opioid use or fewer visits to the ER so you can prove that there are cost savings in the long-term. I’m wondering if you recommend people pursue that. Do you think it’s more feasible that you can take measures of quality of life, physical health, and mental health, and then use that to have discussions with interested stakeholders?

What we have heard from a lot of these programs is how difficult it is to measure, evaluate, and project some of these cost savings. We found that a lot of programs, particularly as they were starting up, tried to steer clear of that route. It was more to your latter statement about showing that there’s benefit from a quality-of-life standpoint of the patient and the provider, as well as the physician and people who are doing things that are well-aligned with what their goals are.

That’s probably where we tended to see a lot of these programs going because that’s something that you can also show pretty quickly or at least relatively easily if you compare it to how difficult it is to measure costs that there is some improvement in physical function, disability, quality of life, satisfaction, engagement, things that people like to do, improvements in pain coping, self-efficacy, or self-management, or even reduction in opioid use to some extent.

A lot of the programs that we saw were focused on making the argument that this improves people’s lives. That in and of itself has a lot of value. For a lot of these programs, that was an effective argument. It wasn’t all about the dollars and cents necessarily. There needed to be some value that the administration saw in keeping this program around. That’s the easiest way to show it.

I want to connect some of your previous research to this particular study, the OSPRO Yellow Flag, which I point people to quite frequently for measuring psychological risk factors. If people dig into your research in that tool, it provides not only the vulnerabilities or the risk factors but potentially also resiliency factors. Both of them are important in pain care. It’s interesting. There may be more or some data building around resilience factors or the resilience factor approach.

When you look at these programs, are they targeting vulnerabilities and risk factors for treatment? Are they targeting building resilience in people through more of a wellness perspective? Oftentimes the complementary and integrated approaches tend to be focused more on wellness whereas something like traditional CBT may be focused more on the vulnerability of depression.

A lot of the programs that we talk to naturally recognize that chronic pain isn’t necessarily something that you solve or get rid of. The overwhelming approach to management for a lot of these programs is about building resilience and self-management skills. A lot of them integrate cognitive behavioral-based addressing, pain-coping skills, and things like that. It’s probably a little bit of both but many of these programs will talk with patients about this. It’s not so much solving your pain or fixing your pain, which we know is not something that we’re likely able to do but it’s about living better with your pain. It’s building up that resilience and quality of life despite the fact that you have pain.

What we saw was a lot of work focused on, “How do you improve wellness and quality of life? How do you do the things that you want to do to improve your well-being despite the fact that you have pain?” I do think it was a little bit of both but a lot of them were forward-looking in the sense that we need to build resilience as opposed to only addressing the coping issue.

Where would you like to see this work go in the future? Do you already have other studies planned or next steps to broaden this?

There are a couple of different areas. I talked a little bit about the quality issue. That seems to me that one of those areas is the low-hanging fruit. It’s getting some consensus around quality measures. What exactly defines these programs? A lot of the payers that we talked to said, “We don’t even know what integrated pain management is. How do you define it? We understand what an episode of physical therapy looks like or an episode of chiropractic care. We know what an injection looks like but what exactly does an episode of integrated pain management look like?”

With some of these questions they brought up, it seems like this is something that we could potentially tackle moving forward. This project in particular has geared our audience to healthcare systems, payers, and providers to some extent but it’s more about policy. What do we need to do from a policy perspective? My role as a researcher has traditionally been about collecting and analyzing data but in this case, it’s as important to try to disseminate this information and make sure that it’s getting out in front of the people that need to see it.

I’ll point audiences to some case studies that we have done alongside this paper. There are four different case studies that we have done on different programs that provide pretty good examples of how exemplary integrated pain management programs look in different settings. We probably need even more of these proof-of-concept examples so that this can be done efficiently.

It can be cost-effective in particular in showing these collaborations or these payment arrangements between payers and healthcare systems to make these programs work, whether it’s a bundled payment program or some other value-based arrangement. The more that we can show that this type of approach works and that it can be cost-effective across a variety of different settings is important.

The final thing I’ll say about future work in rural settings is, “How do we improve the accessibility of these types of services and treatments?” We started this study as COVID-19 was hitting. A lot of these programs were shifting toward telehealth. Everybody was trying to figure out how to do that effectively. Some programs did that effectively. Some programs couldn’t deliver physical therapy, chiropractic care, and certain services because they were not able to do that via telehealth. There were opportunities to use telehealth to reach more rural audiences but there were also challenges associated with that as well like, “Do you have access to the internet out in more rural areas?” That’s an area that has a great opportunity for future research and one that I would like to explore.

It’s important when large portions of our population don’t have access to a mental health provider or physical therapist. That telehealth component can be important. As a pain researcher, you’re also a physical therapist. I want to make sure we look at this from a physical therapy lens to get your opinion or gauge your opinion on the growing trend of primary care physical therapy in the realm of policy if we were able to potentially expand that in the ways that we have seen in the military if you think that would have a positive impact on not only developing these programs but also our role as practitioners within these programs and potentially even leading these programs.

In short, I support that. This could probably be an entire other episode about this topic. It is a great opportunity for physical therapists to be embedded. It does open up opportunities for us to take on a larger role in these types of pain management programs. When you look at these programs, they have embedded physical therapy with either primary care providers or specialists. In many cases, they’re right there front and center in treating patients on day one, which is important.

It becomes even more important when you have people outside of the integrated pain management context where a lot of these are more patients with chronic pain with the acute pain avoiding hopefully the exposure to opioids and providing options like physical therapy early on. We have a much better understanding that the timing of access to non-pharmacologic care including specifically physical therapy is important. It has a meaningful impact on what happens down the line for a lot of these folks. It has implications for trying to keep people out of or outside of the need for chronic pain management but it also gives us a good opportunity to function in a role that’s much more front and center.

We have a program. It’s not so much a chronic pain management program but there is one like that at Duke. It’s called the Joint Health Program for people with osteoarthritis, a common chronic pain condition. In that program, physical therapists operate as a quarterback helping to oversee the assessment and management of these patients and are responsible for referring out to other different types of services like nutrition and psychologically-based treatment. There are a lot of different models out there. We’re starting to see more of those. They do create value. It is an opportunity for us to get more involved in chronic pain management.

The value is a big piece. As a profession, we have to get better at learning ourselves and then educating the public and stakeholders. I want to make sure to point everyone to overcoming barriers to the implementation of integrated musculoskeletal pain management programs. You can find it in the May 2023 in the Journal of Pain. Trevor, I want to thank you for being here. Thank you for your work in pain management and physical therapy. Let people know how they can learn more about you and follow your work.

I’m on Twitter or X at @TrevorLentzPT. You can also Google my name at Duke and it will bring up a Duke Scholars page, which has some of my work on there. I do want to acknowledge the group that I worked with on this project. We do have a website where a lot of the information on this entire project is sitting. It’s freely available. We were very intentional about making sure that there were no paywalls that would restrict access to all of this work.

Duke Margolis Center for Health Policy is the group that I worked with on this. Rob Saunders, Jonathan Gonzalez-Smith, Katie Huber, and Will Bleser are a great group of health policy experts who helped us on this project, and also Christine Goertz who’s here in the Department of Orthopedic Surgery with me. We do have a page that has all of this information on it. It’s pretty easy to find on Google, Duke Margolis Center for Health Policy pain management project with my name. You should be able to find that. Thank you.

If you missed that, you can let your fingers do the googling. I want to thank Trevor again for joining us. Make sure to share this episode with your friends and family on Facebook, LinkedIn, Twitter, and Instagram where everyone is talking about pain management and integrated pain care. I’ll see you next time.

Important Links

• Dr. Trevor Lentz
• OSPRO Yellow Flag
• Overcoming Barriers to the Implementation of Integrated Musculoskeletal Pain Management Programs: A Multi-Stakeholder Qualitative Study
• The Duke Endowment
• Joint Health Program
• @TrevorLentzPT – Twitter
• Duke Margolis Center for Health Policy

About Trevor Lentz

Trevor A. Lentz, PT, PhD, MPH is an Assistant Professor in the Department of Orthopaedic Surgery at Duke University School of Medicine, a member of the Duke Clinical Research Institute, and core faculty in the Duke-Margolis Center for Health Policy.

His work focuses on improving care for people with musculoskeletal pain by 1) developing tools to evaluate psychological distress and behavioral needs in clinical practice, 2) re-designing pain care models to improve access to non-pharmacologic treatments, and 3) identifying and addressing health system barriers to high value care.

He has received funding from the National Institutes of Health (NIH), Foundation for Physical Therapy, Focus on Therapeutic Outcomes (FOTO), the Duke Endowment, and the Center on Health Services Training and Research (CoHSTAR).

Dr. Lentz received his Master of Physical Therapy (MPT), MPH in health policy and management, and PhD in rehabilitation science degrees from the University of Florida in Gainesville. He completed a postdoctoral fellowship in musculoskeletal outcomes research at the Duke Clinical Research Institute and a faculty fellowship in implementation science at Vanderbilt University.