More than 50 million Americans suffer from chronic pain. Behavioral health conditions, including mental health and substance use disorders (SUD), are highly prevalent among those with chronic pain. In fact, 56% of U.S. adults with chronic pain have clinically significant anxiety or depression symptoms.
And yet, a “staggering” share of this group does not receive effective behavioral health care.
There is a business case for behavioral health providers to address chronic pain patients’ mental health needs by building interdisciplinary care teams and testing new technologies. However, significant work remains to educate, train and employ behavioral health professionals to effectively care for patients experiencing both behavioral health and chronic pain challenges.
Studies have demonstrated that patients with mental health and chronic health conditions have higher emergency room visits and hospitalization utilization and costs than their peers with chronic conditions only.
“Many people view chronic pain purely as a physical issue and fail to recognize the significant role mental health plays in pain perception and management,” Dr. Cleopatra Lightfoot-Booker, chief of clinical operations at behavioral health provider Forge Health, told Behavioral Health Business. “Similarly, some underestimate how chronic pain can lead to behavioral health conditions like depression, anxiety and SUD, perpetuating stigma and delaying comprehensive treatment.”
White Plains, New York-based Forge Health offers in-person and telehealth care for mental health conditions, trauma and substance use disorders in New Jersey, New York, Pennsylvania, Massachusetts and New Hampshire. MFO Ventures and HC9 Ventures have invested in the company.
Chronic pain and behavioral health conditions frequently overlap due to shared biological, psychological and social factors, according to Lightfoot-Booker, and the conditions can perpetuate the other. Chronic pain can lead to depression, anxiety and other mood disorders, as well as substance use disorders. Inversely, behavioral health conditions can exacerbate the perception of pain.
Despite the interplay between behavioral health concerns and chronic pain, patients with both conditions often fail to receive care.
Among people in need of mental health care without chronic pain, 72% receive treatment that meets their needs, according to Jennifer S. De La Rosa, strategy director at the University of Arizona Health Sciences’ Comprehensive Center for Pain and Addiction. For those with chronic pain and mental health care needs, only 44% receive treatment that meets their needs.
“Those with chronic pain have been left behind in the otherwise highly successful effort to advance the mental health of the U.S. population,” Jennifer S. De La Rosa, strategy director at the University of Arizona Health Sciences’ Comprehensive Center for Pain and Addiction, told Behavioral Health Business.
De La Rosa is also an assistant research professor of family and community medicine at the University of Arizona.
How chronic pain is currently treated in the behavioral health industry
While treating both mental health conditions and chronic pain is crucial, it is not without its challenges.
Patients often encounter stigma for having both conditions and may therefore be reluctant to seek care. Integrated care programs and dually-trained clinicians are also relative rarities, making it difficult for patients to find care when they do seek it out.
Providers can struggle to treat this population. The connection between physical and psychological symptoms complicates diagnosis and treatment. Additionally, clinicians are tasked with managing pain while minimizing the risk of opioid misuse.
Common misconceptions also complicate treatment.
“Providers, family members, and patients themselves often hold dualistic beliefs about pain, that there is “real” pain based in structural or biological problems, and mental pain which is both unobserved and of questionable legitimacy,” De La Rosa said.
Physical health providers often only broach mental health with patients after an inconclusive workup, De La Rosa said, leading patients to feel that their pain is “all in their head.”
The American health care system isn’t set up to easily integrate care.
“Treatment for this population is often fragmented, with pain specialists, mental health providers, and addiction specialists working in silos,” Lightfoot-Booker said. “Integrated programs that specifically address the overlap are not yet widespread, although their value is increasingly recognized. Some centers use interdisciplinary approaches, but these remain the exception rather than the rule.”
One such exception is Forge Health, according to Lightfoot-Booker. The hybrid care provider offers a continuum of care for patients with mild to severe needs, allowing patients to transition easily between levels of care as their conditions change over time. Forge’s programming integrates medication management, therapy and psychosocial, reducing fragmentation.
A chatbot solution?
Digital mental health platform Wysa has taken another tack to chronic pain and mental health treatment.
Over the last five years, the provider has performed small clinical trials and usability studies on treating chronic pain and mental health with its AI-powered chatbot. In March, the company received a $3.4 million grant from the National Institute of Mental Health (NIMH) to further develop personalized pathways for patients with mental health conditions and chronic pain.
Thus far, Wysa’s studies have found “remarkable changes in reductions in anxiety and depression, reduction in pain interference and improvement in physical function,” according to Chaitali Sinha, chief clinical research and development officer at Wysa.
Wysa, which has offices in Boston, London and Bengaluru, India, has raised a total of $30 million from investors, including a $20 million Series B raise in July. The company operates an artificial intelligence-backed chatbot that can provide users with cognitive behavioral therapy techniques, meditations, breathing and mindfulness exercises.
Wysa’s chatbot has specialized content for treating patients with mental health needs and chronic pain. It helps them build habits that can support their treatment plan without giving any medical advice that might go against a doctor’s recommendations.
Through previous studies, Wysa has tweaked its programming to make its digital tool as easy to use as possible. For instance, older adults reported struggling to access the Wysa app because they forgot their Apple app store password. Wysa created a pathway to help patients contact the company directly to re-download the app.
Currently, the company is conducting “micro trials” to create personalized pathways based on a patient’s needs. For instance, a patient may struggle to type in the app if they experience pain in their fingers. The app could then change its communication mechanism to make it easier for the individual to use the techniques.
The digital tool could aid patients who may otherwise struggle to receive specialized care, Sinha said.
“Even in a really large hospital, you will have one single therapist who will be taking out of pocket, and that’s it,” Sinha told BHB. “There is no mental health resource to send them to, apart from giving them a pamphlet. That becomes a major issue, even if the provider recognizes that pain is something that is biopsychosocial.”
“Our work started exactly in that manner – an orthopedist reached out to us six years ago now and said ‘I think this is something that my patients might just benefit for all because I don’t have any options for them,”’ she continued.
Needed changes
The gap between needed care and accessible, impactful care for people with behavioral health and chronic pain needs can begin to be surmounted in several ways.
Integrated treatment, in which both mental health and chronic pain are treated simultaneously with a multidisciplinary team, can ensure patients receive holistic care for all their conditions.
Evidence-based therapies, including cognitive behavioral therapy, dialectical behavior therapy and medication-assisted treatment (MAT), are also needed. Patients should also be regularly reassessed throughout the course of treatment to monitor behavioral health conditions and pain levels, according to Lightfoot-Booker.
Ensuring sufficient access to evidence-based care requires a multi-pronged approach.
For one, more specialized training in treating chronic pain and behavioral health conditions is needed for clinicians in order to have an adequate supply of trained professionals.
Digital tools can be a helpful aid to a treatment plan when a clinician is seeking to avoid the use of opiates, expanding the available treatment modalities in a clinician’s “toolbox,” according to Sinha.
Systemic changes within the behavioral health industry could also improve the status quo for patients with mental health needs and chronic pain. Increased advocacy for integrated care reimbursement models, like integrated care add-on codes, is one avenue for the industry to improve care for this vulnerable population, according to Lightfoot-Booker.
“Within the industry, there would be a significant benefit for increased policy advocacy for reimbursement models that support integrated care,” Lightfoot-Booker said. “[By using integrated care add-on codes]behavioral health clinics would potentially bill standard IOP services while leveraging add-on codes for integrated behavioral health interventions, such as screenings for co-occurring mental health conditions or chronic pain management.”
The most impactful change may be the simplest, however. Clinical practice models should actively address patient self-stigma and previous experiences of pain invalidation.
“Patients agree that the most important thing any provider can say to someone living with persistent pain is “I believe you,”’ De La Rosa said. “These words are powerful medicine all by themselves.”
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