Supporting Rural Primary Care Practices in Delivering Care for Chronic Pain

Through our Pain Management in Primary Care project, the Rural Center of Excellence on Substance Use Disorder (SUD) Prevention is working to increase access to evidence-based treatment for chronic pain in rural areas by equipping primary care practices with tools to manage the complexities of this care. Our goals include improving clinicians’ confidence in pain management, preventing the onset and progression of SUD, and reducing stigma related to chronic pain and SUD.

Our collaboration with a primary care practice in rural New York State to consult on pain-management questions and provide tools has inspired a number of educational resources—available soon through this page. We hope they will be helpful to rural primary care practices across the country that are looking for support in chronic pain management and SUD prevention.

We invite you to reach out to our Program Assistance with your thoughts, questions, and to discuss adapting tools to your rural community.

Care for chronic pain

Greater access to evidence-based care for chronic pain is needed, especially in rural communities. Prevalence data from 2023 indicates that nearly a quarter of adults in the U.S. experience chronic pain. Prevalence rates are more pronounced—above 30%—in rural areas.¹ Primary care practices are considered a foundational piece to the Stepped Care Model for pain management and are often the first line for treating chronic pain.² Yet they often have concerns about how to balance appropriate management of chronic pain and prescription of opioids, especially in rural areas.³ Additionally, rural practices experience heavy demands on their time, lack of behavioral health specialists in the area, limited access to alternative therapies for chronic pain (for example, physical therapy or acupuncture), and concerns about SUDs including opioid use disorder (OUD).⁴ With these prevalent challenges, patients may struggle to find the pain-management care they need close to home.⁵

Clinical practice guidelines recommend a multimodal approach for managing chronic pain—drawing on various treatments including opioid and non-opioid medications, procedures, and other therapies—and a multidisciplinary one—involving behavioral health experts and physical therapists, among other health professionals. However access to these comprehensive approaches is limited, and payment structures are challenging. In communities lacking the range of treatment options and expertise, a primary care provider may find that prescribing opioids is the only option available to effectively relieve a patient’s suffering.⁶ Rural residents are more likely to be prescribed opioid medication than urban residents, and they are less likely to use self-management approaches (e.g., relaxation techniques, exercise, and distraction) for chronic pain.⁷

Given the barriers to effective pain management in primary care in rural areas, our center aims to help clinicians apply a patient-centered, guideline-consistent approach by expanding the tools and techniques available to them and providing support as they navigate complex cases.

Adapting best practices for rural communities

In 2022 our center teamed up with a Federally Qualified Health Center (FQHC) serving rural areas of the Finger Lakes region in New York State on a pilot program to address the urgent need for chronic pain management care. Together we developed a process in which a multidisciplinary team from our center—a pharmacist, primary care physician, pain management specialist, and addiction medicine specialist—uses a case-consultation approach to provide support on pain management to the FQHC’s primary care providers.

Our partnering practice identified a champion in their system to be our main point of contact. The champion shares cases submitted by providers for review and discussion. Our multidisciplinary team provides recommendations on these cases, using the Centers for Disease Control and Prevention (CDC) 2022 Clinical Practice Guideline for Prescribing Opioids for Pain. To increase access to treatment options that are often not available in rural communities, the team also advises on best practices in non-opioid pain-management interventions that can be performed in primary care offices.

A collaborative process has helped ensure the program meets the FQHC’s needs and is adapted for the rural communities they serve. In addition, the advocacy of the champion can promote evidence-based care locally in the long term. We are actively looking to expand this program to other practices in rural New York.

To evaluate the impact of this collaborative pilot, we survey clinicians early on in our work together and then annually to assess their knowledge and level of confidence in managing patients’ chronic pain. Surveys include questions about stigma. In addition, our evaluation will look at practice-wide SUD screening and prescribing patterns.

Increasing clinician confidence

We are working to increase primary care clinicians’ confidence in providing treatment for chronic pain. Through case consultations, our team provides feedback on specific questions raised by providers in their practice. Along the way, common topics of interest have emerged and inspired educational presentations and tools. Subjects have included having conversations with patients about medication changes, prescribing buprenorphine for perioperative pain management, and using ultrasound machines to provide image-guided injections.

The insights of clinicians and our partnering practice’s champion have driven the development of rurally adapted resources. Tools coming soon on this page include:

• A video series about psychosocial approaches to managing pain

• Prescribing guidance for medications to treat acute and chronic pain, mental health, and/or OUD

• Guidance on pain-management procedures that can be performed in a primary care office

Focus on prevention

While increasing access to evidence-based pain management in rural communities, this pilot project aims to prevent SUD and OUD. It equips primary care providers to help prevent SUD on three levels:

• Primary prevention: Confidence with safe opioid-prescribing practices and non-opioid pain-management approaches to decrease unnecessary prescribing while ensuring access to needed care

• Secondary prevention: Comfort with screening for SUD in primary care to identify SUD early before it progresses

• Tertiary prevention: Readiness to help patients with SUD connect with recovery services and supports and avoid negative health consequences

A patient-centered approach

The project also promotes a welcoming and empowering environment for patients. It strives to address concerns and misconceptions around chronic pain and opioid therapy and overcome barriers to evidence-based care.

After decades of major changes in practice and policy, clinicians may have concerns about prescribing opioids for chronic pain, including when working with new patients who have been receiving opioid therapy for years. Decreasing or stopping long-term opioid therapy can lead to serious risks including increased overdose mortality and increased risk for mental health crisis. Clinicians are encouraged to approach care plans in a way that actively involves patients in decision making and avoids judgment.⁸

This patient-centered approach includes being mindful and careful about what the actual risks are for a specific patient. If a primary care provider feels uncomfortable because of negative associations around opioid prescribing, our team recommends returning to a focus on treating the unique patient. For some patients, opioid therapy can be safe and appropriate.

Primary care providers can also help empower their patients—discussing expectations for pain management and setting goals together, for example. Having functional goals that are important to the patient, such as being able to carry out regular activities at work or play with their children, allow us to see how treatment works in specific, meaningful ways.

Finally, word choice matters when providing care for chronic pain as well as for SUD. Avoiding stigmatizing terms when communicating with patients and families, colleagues, in documentation, and elsewhere is very important.⁹