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CBD or CBT: What Types of Treatment do Pain Management Specialists Provide?

Stephanie Slat, BS – Research Associate, University of Michigan Medical School

Pooja Lagisetty, MD, MSc – Assistant Professor, University of Michigan Medical School

Goodarz Golmirzaie, MD – Clinical Lecturer, University of Michigan Medical School

Jennifer Thomas, BA – Project Manager, University of Michigan Medical School

Amy Bohnert, PhD – Associate Professor, University of Michigan Medical School


Introduction: Amidst rising concerns about the risks of long-term opioid use, comprehensive treatment for chronic pain has garnered attention from the medical community1. However, it is unclear to what extent pain management specialists currently provide multimodal treatments for chronic pain. Therefore, the aims of this study were to understand 1) the degree to which specific forms of treatment are offered by pain management clinics, 2) whether a patient’s long-term opioid prescription presented any barriers to receiving care, and 3) how wait times for appointments vary.
Methods: The study used an audit “secret shopper” survey methodology. A research assistant called pain management clinics across 9 states with varying rates of overdose and simulated a patient on long-term opioid therapy for chronic pain seeking specialty care. Callers asked a series of questions about clinic size, providers available, insurances accepted, and referral requirements. In addition, they assessed the treatments offered (e.g. procedures such as injections, cannabinoids, behavioral therapy, physical therapy, etc.). Callers also asked if the clinic would provide assistance with opioid tapering and if they had a provider who uses buprenorphine to manage pain or opioid use disorder. Finally, wait time until the first appointment was also collected.
Results: Of 366 eligible clinics, 187 (51%) were willing to accept patients with Medicaid insurance during the call. Additionally, 201 (55%) required a referral before accepting the patient, and another 84 (23%) noted they only required a referral when the insurance company dictated one was necessary. Nearly all clinics (355, 97%) stated they perform procedures, such as injections, 77% were willing to manage medications for pain, and only 38% offered physical therapy. A quarter (89, 25%) offered CBD or medical marijuana as treatment options in the 8 states where it was legal (n=355) while only 13% offered behavioral therapy. 246 clinics (67%) indicated that their providers would assist a patient with discontinuing opioids. 110 clinics (30%) stated they had a provider who prescribes buprenorphine. Clinics reported a median wait time to new appointment of 9 days (IQR 4-17).
Conclusion: For patients with chronic pain who may benefit from multi-modal pain treatment that includes behavioral therapy,2 few pain management clinics were equipped to provide this care. Interestingly a larger proportion of these clinics offered CBD, despite evidence for efficacy being less robust than for behavioral therapy.3 The focus on procedural pain relief may be particularly limiting in patients who have chronic pain with co-morbid substance use disorders. In addition, many clinics required primary care referrals and did not accept patients on Medicaid, further limiting access to treatment for disadvantaged populations. However, wait time for visits was relatively modest.

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