Doctor blames health system, opioid crisis for Tucson pain clinic's closure

The Integrative Pain Center of Arizona permanently closed Friday after 15 years in business — a move leaders say was fueled by a misguided health-system response to the opioid crisis.

The center’s recent financial setbacks could not be overcome in a system where U.S. health insurers are rewarding physicians for treating the symptoms of chronic pain rather than the root causes, center co-founder Dr. Bennet E. Davis said last week as he walked through his darkened north-side Tucson clinic.

Also, federal grant money to address issues of opioid misuse tend to focus on “downstream” treatment of symptoms, he said.

“It’s like treating diabetes by increasing funding for kidney transplants and amputations and treating blindness,” Davis said.

That flawed response is only further increasing the number of people becoming ill and dying from opioid overdoses, he said.

As deaths continue, he is worried that new dosage restrictions are too drastic and will further endanger people by pushing them into illicit drugs.

Davis is one of three co-founders of the local pain center, which had 2,000 patients in Southern Arizona, in addition to a telemedicine program consulting with primary care physicians across the United States.

“A lot of pain clinics, you just go in and get pain meds, but (Davis) was a firm believer in not just putting a Band-Aid on the pain,” said Nick Stavros, chief executive officer of Community Medical Services, which is the largest opioid addiction treatment program in Arizona and has two clinics in Tucson.

“If every pain clinic in the country ran like his, we probably wouldn’t be in the midst of an opioid epidemic,” Stavros said.

While there are some signs the health system is catching on to the idea of doing more integrative treatment for pain, Davis and his clinic co-founders say they aren’t able to stay in business until that happens.

“I don’t think the community was ready for what we did. We need to redesign health care where we have contextually appropriate treatment,” Davis said. “We are in a poorly managed trauma crisis, which has led to lots of things, including increased opioid poisonings.”

Setbacks

The center had some recent financial setbacks — a contract with a management company did not go well; there was a paperwork problem with Medicare that left them without reimbursements for several months; and referrals were down.

But the center could have weathered those issues if they’d had better support all along from health insurers and from the health system in general, including from primary-care doctors, Davis said.

“We ran on thin margins,” he said. “But the health system was doing its best to make it hard for us. Their focus is not on individual or population health. Their focus is networks and contracts.... There is a lot of pushback against clinics trying to do integrative care.”

The clinic was created in 2002 by Davis, clinical psychologist Cela M. Archambault and nurse practitioner Kathy J. Davis, who is not related to Bennet Davis. Their vision was to treat pain by integrating behavioral health with medical care to treat the whole patient, not just the symptoms. Interventions ranged from joint injections, nerve blocks and pain medication to cognitive behavioral therapy and acupuncture.

Before creating their own clinic, Kathy Davis, Dr. Bennet Davis and Archambault all worked together at the University of Arizona, where Dr. Davis ran the UA’s Arizona Pain Institute from 1995 to 2002.

Archambault, a clinical psychologist with a specialization in health psychology and pain management, said integrative care for pain was around in the 1980s and 90s, so it’s not a new concept. But inadequate funding for health psychology — a branch of psychology designed to change behavior to improve physical health — means not many clinics are offering it, she said.

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Insurance paid for about one-third of the cost of providing psychology services at the Tucson clinic, its leaders said. The founders used money from pain procedures to finance the gap and pay Archambault.

Davis could have made a lot of money by focusing on pain procedures, but he remained committed to creating a clinic he knew would help patients, as difficult as that was, said Steve Nash, who spent 22 years as executive director of the Pima County Medical Society and is now executive director of the Tucson Osteopathic Medical Foundation.

“It’s this combined team approach to work together to approach all the issues,” Nash said. “One in six of us is going to have a chronic pain episode at some point in our lives, whether it’s from surgery or injury.”

But to really get to the root cause of chronic pain, rather than throwing pills at it, isn’t the norm, Nash said. That’s where the Integrative Pain Center of Arizona stood out, he said.

Trauma care

Frequently, the root of chronic pain is unresolved childhood trauma, Davis said. That’s why all patients at the Integrative Pain Center of Arizona were given a 10-question screening for “adverse childhood experiences (ACEs).” Davis thinks more members of the medical community should be using the ACEs score tool, since a high ACEs score is connected with poor health outcomes.

“If you witness someone falling off a building and onto a sidewalk, it will rewire your nervous system, right then and there,” Davis said. “Your rewired nervous system will work differently.”

Davis estimates at least 25 percent of the pain center’s patients needed help with addressing unresolved trauma that typically occurred during their childhood development in various forms, including neglect, exposure to violence, or physical, sexual or emotional abuse. Trauma is bad at any age, but it’s worse for children because their nervous systems are still developing, he explained.

Such exposures impact brain development, brain structure, hormones and the immune system, said Davis. Studies have shown adverse experiences disrupt the release of dopamine in the nucleus accumbens, which is the pleasure and reward center of the brain; inhibit the prefrontal cortex, which is associated with impulse control; and alter the amygdala, which processes fear.

Once that developmental trauma is acknowledged and addressed with appropriate therapies, those patients don’t need downstream treatments for chronic pain like nerve blocks or opioids, Davis said.

Effective interventions can include nutritional help, exercise, physical therapy and therapies to rewire the nervous system such as somatic experiencing, Davis said. Somatic experiencing is an alternative treatment that focuses on body sensations as a way of resolving and healing trauma.

Illicit drugs

Davis is hopeful government health-insurance programs like Medicaid and Medicare will eventually have payment systems more supportive of integrative care in dealing with chronic pain.

And he was encouraged by the reaction to his talk about trauma and chronic pain, and by other presenters’ mentions of the subject, during last month’s first-ever Southern Arizona Opioid Abuse Prevention Symposium.

But it wasn’t soon enough to save his clinic. And he’s worried about the immediate future under government and insurance rules on restricting prescribing doses.

Limiting someone to a maximum 100 milligrams per day, for example, won’t work if they have been taking 600 milligrams or more per day — a common scenario, Davis said.

Those patients need a more gradual weaning off what Davis refers to as “pill island.” And patients need to be treated with trauma-informed care, not hard-line tactics that could re-traumatize them or lead them to use illicit drugs, he said.

“I think we’re just going to push them off of pill island into the water of getting it on the street,” he said. “The Mexican cartels are all over this opioid crisis. They know with the government shutting down access to opioids, these anxious people are going to want more drugs.”