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Helping a Rural Community Manage Chronic Pain Medication

This is a story from the Spring 2020 Issue of our magazine, written by Glenn Kotz, MD, and Jarrid Rollins, LCSW.

Few things are as frustrating as when a chronic pain sufferer comes into the office for an early refill on their main medication. The negotiation over how much medication to refill needs to be balanced with the risk of a painful cycle of withdrawal or worse – the patient resorting to street drugs to manage their pain. Despite this frustration, listening to what your patient needs, and what fears might be constraining their choices in their community, is important to safeguarding their long-term health.

In the Roaring Fork Valley, south of Glenwood Spring, CO, our clinic, Midvalley Family Practice (MVFP) has been running an innovative program to provide more resources for people to access chronic pain management. While there are resources in the region to help, from federally qualified health centers to scholarship programs that help people identify and pay for residential treatment, a shockingly high number of residents in the area struggle with misusing substances. In one study, 31% of respondents self-reported addiction struggles, and we know that self-reported studies underreport use. Such a high addiction rate suggests that having access to services is simply not enough to address addiction in a meaningful way. More worryingly, it is strongly correlated with “deaths of despair,” which are attributable to a decline in psychosocial well-being over time. It has reached crisis levels in rural communities.

We began the pain relief group (PRG) 5 years ago as a space to listen and learn about the needs of those wrestling with chronic pain and, hopefully, find some new pathways for addressing substance misuse. In the PRG, participants learn from each other – building solidarity over a shared struggle is integral to healing both the body and the mind. An open group with long sustaining members and deep bonds, the group protects and advocates for itself in the community, with insurance companies, and in other settings where patients struggling with chronic pain need support. The PRG helps doctors as much as patients — mch like our patients struggling with chronic pain, healthcare professionals can burn out on the deaths of despair that we see affect our patients. Fortunately, the physician’s office can be the place where change begins not only for the patient but for the community.

MVFP is an integrated care clinic that serves individuals and families in the Roaring Fork Valley and serves as a key entry point in a recovery-oriented system of care. We serve a wide swath of diverse individuals, from those on Medicaid and Medicare to privately insured folks. While MVFP refers patients to many organizations for added support, we often hear them express confusion about where to seek help for themselves or family members struggling with substance use and opioid use disorder. We set out to radically change these dynamics in the Roaring Fork Valley with support from a year-long Rural Communities Opioid Response Program (RCORP) planning grant.

We wanted to bring a strategic plan to the Roaring Fork Valley about how to address the growing opioid crisis in the western Rockies. We teamed up with regional health connectors and recruited organizations doing the work, but the centerpiece of our program is reaching individuals in the community who had struggled with addiction. The strategy of seeking those in recovery has been an incredible lesson in the power of listening and just how far off experts can be.

Concordantly, MVFP held 4 listening sessions with those in recovery to understand the needs of the community. One of the surprising results from those sessions was how misinformation amongst Latinx immigrants can lead to skepticism of addiction recovery. For years, the refrain in the RFV was that we needed more bilingual counselors to reach those seeking recovery who were limited English speakers. While this is certainly the case, many of the migrants participating told us that in some areas of Mexico people called treatment and rehab “torture,” which made them initially skeptical of seeking help for addiction.

If we hadn’t taken the time to listen to this community, we would not have known that some people faced social pressure about treating addiction – an insight that can help us design more effective interventions.

These few examples highlight a question that every provider must ask: how should I listen? Clearly, listening is important and inherent to our work helping both the individual and the community, but there are effective ways to start listening as well as systematic ways to join the qualitative and the quantitative into a coherent approach to addiction. First, establish a way of listening that you can easily adapt to different groups, from size to cultural. We used world café as it organizes discussion in small groups and encourages those less inclined to share in a large group to open up. The information gathered in these groups is then collected, categorized and studied, and sent out to create an impactful message.

Too many people in our community are unaware of how to get help, despite many providers saying they have an open-door policy for people seeking treatment. Providers need to get outside of the clinic mentality and understand that health and life goes on outside, meeting people where they are instead of waiting for them to come into clinic. In doing so, we have found new ways to provide help to our community.