Group-based Integrative Pain Management: A multi-level approach to address intersectional stigma and social isolation in diverse primary care safety net patients with chronic pain

PROJECT ABSTRACT
Background: The proposed study seeks to address chronic pain disparities in racially diverse,
socioeconomically disadvantaged individuals by optimizing multimodal pain management provided in primary
care safety net clinics. Multilevel barriers exist in primary care settings where socioeconomically disadvantaged
patients are most often treated. Lack of access to multimodal and nonpharmacologic care at the organizational
level, and provider bias and other forms of discrimination at the interpersonal level contribute to unequal
assessment, treatment, and quality of pain care. Stigmatization cross-cuts all levels and is closely linked with
social isolation common among individuals with chronic pain. Group-based models are a promising multilevel
approach to increase access to non-pharmacologic therapies, address time constraints that contribute to
disparities in pain care, improve interpersonal communication, and provide social support among safety net
patients with chronic pain. Methods: This study uses mixed methods and a pragmatic 2x2 randomized
factorial trial to test two group-based models: integrative group medical visits (IGMV) and group acupuncture.
The study tests the hypotheses that compared with usual care, each study intervention improves pain
interference and social isolation (primary outcomes), and that the two combined have synergistic effects
mediated by increased social support and decreased impact of intersectional stigma among safety net patients
with chronic pain. Study interventions include 12 weekly sessions based on existing protocols tested in primary
care safety net settings. IGMV includes pain education, social and behavioral support, and mind-body
approaches (meditation, yoga). Group acupuncture uses responsive manualization, allowing for a standardized
yet individualized treatment. During the R61 phase, a panel of national experts and patient stakeholders will
refine and optimize the structure, process, and content of IGMV aimed at reducing social isolation and
intersectional stigma as part of pain management. Interventions will be piloted in 40 English or Spanish
speaking patients with chronic pain at two primary care safety net clinics. Study procedures will be tested and
adapted for a larger scale trial. In the R33 phase, 360 participants will be recruited from two safety net clinics
and randomized to IGMV, group acupuncture, both, or neither. Aim 1 is to determine the effects of study
interventions on pain-related outcomes (primary outcomes: pain interference and social isolation). Aim 2 tests
social support and stigma as intervention mediators. Aim 3 examines patient experiences with pain
management, patient-clinician relationships, and clinical care in primary care safety net settings using
qualitative methods. Significance: Multilevel approaches are need to advance health equity in pain
management. The proposed study will contribute to knowledge of group-based integrative pain management
co-located in primary care to address disparities in pain care for socioeconomically vulnerable populations.

Grant Number: 4R33MD018333-02
NIH Institute/Center: NIH
Principal Investigator: MARIA CHAO