Many Cincinnatians are in pain, but a multi-disciplinary team at UC Health is giving hope to those who are suffering.
Last year, Dr. Tiffiny Diers and Dr. Jill Boone won the Care Innovation Award, which is sponsored by the University of Cincinnati and UC Health. Their winning idea was the Chronic Pain Group Visit — an innovative approach to helping people manage their pain holistically rather than relying solely on pharmaceuticals. The CPGV program teaches chronic pain patients alternative ways to manage their pain in a group setting.
Dr. Diers is an associate professor of internal medicine and pediatrics at the UC College of Medicine. Dr. Boone is a professor of pharmacy practice at UC’s James L. Winkle College of Pharmacy. Their combined expertise in clinical medicine and pharmacology make them an ideal pair to lead the CPGV project.
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Dr. Tiffiny Diers“Our goal has been to improve management of chronic pain in partnership with patients,” says Diers. “Primary care doctors are not necessarily trained in pain medicine, nor do we have a multi-discipline approach to pain medicine. Coupled with short visits, it makes it easier to write a prescription rather than take a more integrative approach.”
To tackle the issue, the CPGV meets once a week in the Hoxworth Clinic at UC Medical Center. The first 15 minutes of each meeting are dedicated to one-on-one clinical interaction where a patient’s vitals are recorded. This initial interaction also gives patients an opportunity to discuss their specific pain challenges in depth, rather than summarize their overall physical state. Then the patients, doctors and other experts have two hours to discuss methods for pain relief.
“Patients get the benefits of different perspectives of caretakers,” Boone says.
The alternative methods of pain relief range from progressive muscle relaxation and sleep hygiene to chair yoga, massage, acupuncture and nutrition. The group setting also lets patients encourage each other to try new modalities of treatment.
Acupuncture is one form of therapy that’s new to many patients, and most were hesitant to try it. Diers says that once one patient is willing to try an alternative method like acupuncture, other patients will often feel more encouraged. Providers also “took a needle” to lead by example and maintain equity in the group. Boone says that through these group efforts, acupuncture is now one of the more popular therapies among patients.
Martyn Thomas is a licensed acupuncturist working with patients in the CPGV program. Thomas explains how beneficial acupuncture can be for chronic pain patients.
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Pain management groups encourage patients to try alternative remedies like acupuncture. “We stimulate nerves which are the control mechanisms of muscle," he says. "By stimulating nerves, muscles can relax. If the muscles relax, the pain subsides." He notes that while he understands hesitation on the part of the patients, the results speak for themselves.
“The needles that I use are the thinnest needles I can buy — thinner than a human hair. They don’t really hurt that much. It’s pretty much instant relaxation of the muscles. Most people notice it right away. You can see their expression change on their face.”
The CPGV also has the benefit of exposing patients to therapies that often aren’t covered by insurance.
“The people we treat there would never have access to acupuncture treatments,” Thomas says. “My hope is that there will be cheaper clinics that use acupuncture.”
Thomas also uses his time at the CPGV to teach patients acupressure they can practice at home.
Becoming your own best care provider
Empowering patients to understand themselves and their pain is an important mission of the program. Rather than surrender to a pill regimen, patients are learning ways to take charge of their bodies and help themselves.
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Dr. Jill Boone“It’s a recognition that there are multiple zones of expertise,” says Boone. “There really is the expertise of the patients and what they know about their bodies. Patients learn from each other, become a partner with their provider and ultimately have better control over their disease state.”
Cathy Schwendenman understands the importance of the relationship between doctors and their patients. As a chronic pain patient herself and a member of the Patient Family Advisory Council, she believes input from patients is critical for comprehensive pain care.
“There are certain things you don’t know unless you’ve been through it,” says Schwendenman, who has suffered from chronic back pain for more than 20 years.
The council is made up of patients and their families who consult with doctors quarterly for unique perspectives on care. Schwendenman says Dr. Diers and Dr. Boone sought her expertise as a chronic pain patient and invited her to assess the CPGV.
“Doctors and patients just need to know that there are alternatives out there,” says Schwendenman.
CPGV resident physician Dr. Erin Connolly says she got involved after noticing that chronic pain was one of the chief complaints from her patients.
“As doctors, we are initially trained with medicine to help the pain,” says Connolly. “It was obvious that medicine was not the end-all-be-all.”
She says the typical 20-minute allotment for clinic visits are inadequate to address the real causes and possible solutions to a patient’s pain.
“Mind and body are one and very much interconnected,” says Connolly. “You need to get to the crux of what’s driving their pain. When they get stressed, their pain is 10 times worse. It isn’t just about the medicine, it’s about really delving into the cause of their pain and what we can do to help manage it besides increasing the dose of their meds.”
As a resident physician, Connolly says that the theory behind the CPGV is helping to shape her developing practice. “I’m learning to use every modality to help patients deal with their pain."
Alternative methods meet the heroin crisis head on
While the primary goal of the CPGV is to help patients better manage pain, the group’s work could also have implications for Ohio’s heroin epidemic.
“We have an incredibly sad situation of opioid misuse and heroin abuse,” says Boone, adding that providers need to make sure they are introducing options beyond opioids to minimize the risk of patients becoming addicted. “It’s clearly a national crisis, and Ohio is among the states with the worst problems. At least initially, a lot of concern from the opioid epidemic came from prescriptions.”
According to a March 2017 report from the Cincinnati Health Commission, people who abuse opioid painkillers are 40 times more likely to get addicted to heroin.
The author of that report and the director for the Family Health Division at the Cincinnati Health Department is Dr. Jennifer Mooney, who says Cincinnati’s geography is one reason our city is at the epicenter of the epidemic. “Pill mills” — pain clinics that distribute opioid painkillers as a solution for chronic pain — were once popular in the regions surrounding Cincinnati.
“Instead of taking a holistic approach, there were lots of different pharmaceutical ways to address pain,” says Mooney. “[Doctors] were told pain was a vital sign. If we’re not addressing people’s pain, we’re ignoring a vital.”
Diers says pain management is challenging in conventional care. National and local studies show a third of patients are in chronic pain, and 18 percent are on a controlled medication. The use of controlled substances creates tension in the patient-provider relationship, with patients often becoming defensive about their need to be on a controlled substance and providers negotiating a desire to alleviate suffering without contributing to a potential problem.
“UC Medical Center has been willing to innovate with highly vulnerable patients,” says Diers. “We need to have other things in our toolkit. We’re learning together.”