Impact of a Novel Community-Based Biobehavioral Chronic Pain Team Training Program (4PCP) on Practitioner and Patient Outcomes

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Impact of a Novel Community-Based Biobehavioral Chronic Pain Team Training Program (4PCP) on Practitioner and Patient Outcomes ABSTRACT Although primary care medical practitioners (PCPs) provide the first and sometimes only line of treatment for patients with chronic pain, surveys show they are generally not comfortable with its management. This may reflect a dual shortcoming in their educational preparation. First the average medical school spends 0 to 6 hours on chronic pain, when pain organizations like the International Association for the Study of Pain (IASP) suggest 74 hours. Second, medical training is primarily oriented towards a biopharmacologic framework. While drugs may help the nociceptive component of pain, and anxiety or depression, they offer little to address the core emotional, cognitive and behavioral roots of chronic pain. This biopharmacologic mindset, that a drug might “do it all”, may have set a stage for today's opioid crisis. Managing these deeper chronic pain issues requires a biopsychosocial framework, that views a chronic pain syndrome as a brain disorder, reinforced by years of negative cognitive, emotional and behavioral habits, requiring retraining through physical & behavioral activation, and cognitive restructuring. However, since this framework and skillset are foreign to most PCPs, they remain ill-prepared to manage the totality of a chronic pain syndrome. In the 4PCP (Primary Practice Physician Program for Chronic Pain) pilot, we demonstrated that PCPs eagerly learned and implemented this new framework into their practice, increasing confidence with chronic pain management, reducing visit times, and improving patient pain. That study did not formally address opioids, though physicians tapered opioids spontaneously. We now ask 2 new questions: (1) Will a dissemination-ready, fully codified, intensive version of 4PCP produce better outcomes, sustained for 2 years? (2) Will practitioners find new confidence and skills in managing pain as a team and taper opioids? In 27 practices (4 practitioners each, 108 total) in 4 cities (Bozeman, Cleveland, Madison, Milwaukee) we will teach the new curriculum, 3 practices at a time every 2 months over 18 months, using a stepped cluster design. Practices will co-train with a paired psychologist and PT to build a clinical team. For each practitioner, we will identify 10 patients with chronic pain, ideally on opioids (1080 total) for patient outcomes. We will measure 3 types of outcomes before and for 2 years after the training intervention: (1) patient improvement; (2) the change in practitioner satisfaction with care rendered and practitioner burnout; (3) the change in opioid prescribing in the enrolled patients based on state records.