A feasibility study of a co-developed, multidisciplinary, tailored intervention for chronic pain management in municipal healthcare services

Abbreviation

GP

general practitioner

HLC

healthy life center

HPC

health promotion and coping

NSAIDs

non-steroidal anti-inflammatory drugs

OOC

orthopedic outpatient clinic

1 Background

Chronic pain is a major public health issue, affecting an estimated 30% of individuals worldwide [1]. The condition significantly impacts individuals socially and economically, often leading to depression, insomnia, impaired work capacity, and disrupted social relationships [2,3]. Thus, chronic pain is regarded as a complex biopsychosocial phenomenon that necessitates a comprehensive approach [4].

Effective chronic pain management requires thorough assessments to identify underlying causes and pain types, allowing for targeted treatment when possible and supporting patient self-management [5]. Self-management is crucial not only for improving functional abilities and quality of life despite pain but also for fostering active patient involvement in their treatment [6]. However, research indicates that multidisciplinary, self-management-based approaches are typically introduced only after pharmacological or surgical interventions have failed [7]. Many participants report living with chronic pain for up to a decade before seeking these interventions, suggesting that they are often viewed as a last resort rather than a first-line strategy [8].

There has been a strong emphasis and desire for immediate solutions in managing chronic pain, such as medication or surgery, which may lead both patients and clinicians to prioritize quick relief [9]. Consequently, evidence-based but effort-intensive approaches, including physical therapy and cognitive-behavioral strategies, tend to be underutilized [10]. This reliance on medication can overshadow non-pharmacological strategies that are supported by clinical guidelines [5]. Moreover, the growing dependence on opioids for chronic pain management raises concerns due to their limited long-term effectiveness and associated risks [11,12].

General practitioners (GPs) are expected to have a holistic understanding of patients’ medical histories, life circumstances, and prior treatments, enabling them to coordinate various interventions and treatments. As the primary point of contact in the healthcare system, GPs can ensure continuity of care, avoid duplication of efforts, and facilitate timely referrals to specialists or multidisciplinary teams [13]. However, GPs receive minimal training in chronic pain management, despite the high prevalence and impact of chronic pain [14].

Many patients report a lack of coordination and communication among specialists leading to treatment delays and a fragmented care experience [15]. For individuals with complex needs, a coordinated and integrated approach is essential, yet challenging to achieve in a fragmented healthcare system [16]. Systematic reviews of pain management courses have revealed modest improvements in function and pain intensity, underlining the urgent need for more personalized and multidisciplinary treatment options beyond what is typically provided in generic programs [17,18].

Considering these challenges, the aims of this study were to co-create and to evaluate the feasibility of a personalized, multidisciplinary, and coordinated intervention for chronic pain management within municipal healthcare services. Additionally, the study will provide insights into how such an intervention can be structured, along with information on the characteristics of participants seeking this type of treatment. This information will provide valuable insights into the target population’s needs, ultimately aiding in the refinement and implementation of the intervention. Consequently, the research questions are as follows: (1) What would a co-created, personalized, and multidisciplinary pain management intervention within municipal healthcare look like? (2) To what extent is the intervention feasible with regard to recruitment rates, participant retention, adherence to intervention components, and self-reported evaluation of perceived benefits? (3) What characteristics do patients seeking such a service exhibit?

2 Methods

This study followed the Medical Research Council (MRC) framework for developing and evaluating complex interventions [19]. Feasibility outcomes are reported in line with the CONSORT extension for pilot and feasibility trials [20]. The research consisted of two phases: (1) development of the intervention through a structured co-creation process involving key stakeholders and (2) a single-arm feasibility study.

2.3 Structure and content of the intervention

The co-created intervention consisted of two parts: a generic component that explains the phenomenon of chronic pain and provides education and self-help support, and a specific component that addresses individual needs (Figure 1). The two parts were delivered sequentially, with all participants completing Part 1 before entering Part 2. To ensure a sustainable approach that aligns with limited resources, the study evaluated the feasibility of integrating personalized and group-based care while incorporating existing courses at the HPC.

Figure 1

Content and structure of the intervention. *General practitioners. **Orthopedic outpatient clinic.

To achieve a personalized and coordinated approach, participants engaged in three individual consultations: prior to the start of Part 1, during a mid-point consultation after completing Part 1, and in a concluding consultation following the completion of Part 2. The individual consultations served both to collaboratively identify intervention components personalized to each participant’s needs and preferences, and to provide ongoing follow-up by monitoring participants’ progress and addressing any challenges that emerged during the intervention. Participants were encouraged to invite their GP to participate digitally in the concluding consultation to facilitate knowledge transfer and support ongoing follow-up after the intervention.

2.3.1 Part 1: Generic pain management course

The first part of the intervention was designed as a generic pain management program for all participants delivered across six consecutive weeks, with one 3-h session scheduled per week. A total of 6 series were conducted, with group sizes ranging from 6 to 15 participants. The educational structure was organized into four brief segments, each lasting 30 min, followed by a 20-min break. Part 1 was facilitated by a multidisciplinary team that included a psychologist, a physiotherapist, and a GP with work experience from pain management clinics. By collaborating, the team was able to integrate psychological, physical, and medical insights, providing participants with comprehensive knowledge and strategies for managing their symptoms.

The group session followed a varied format, incorporating a combination of teaching, dialogue, practicing self-management strategies, and homework assignments. Key themes addressed throughout the sessions included self-compassion, self-care, mindfulness, and scope for action (physical, psychological, and emotional). Participants received a workbook that provided basic information on pain, an overview of the course schedule, and details regarding homework tasks. Weekly assignments included a reflective exercise for contemplation and a practical task designed to enhance their self-management skills.

2.3.2 Part 2: Personalized component

The second part of the intervention was individualized to address each participant’s unique symptoms. This part offered optional content, allowing participants to select between 0 and 2 additional courses. The choices included existing courses available at the HPC, fostering a multidisciplinary approach. Participants from the intervention attended these courses alongside individuals who were not part of the intervention, ensuring a diverse learning environment. The other participants were not informed that some attendees were entering the courses through an ongoing pain management intervention. The available options for participants included: depression coping, anxiety coping, stress coping, smoking cessation, nutritional guidance, sleep courses, alcohol guidance, guided physical activity, body-mind activity, and course in life skills.

Furthermore, peer support groups were introduced at the start of Part 2, with the first meeting professionally facilitated. The participants in these peer support groups were the same individuals as in Intervention Part 1, maintaining group continuity despite the differing content in Part 2. During the initial peer support meeting, group rules and meeting structures were established, and participants were encouraged to express their interests and needs. Subsequent meetings were user driven.

3 Results: Feasibility outcomes and participant characteristics

A total of 70 participants were recruited between November 2022 and December 2023. Among these, 11 individuals (16%) were sourced from OOC, while the majority, 59 participants (84%), were referred through their GP. Of the total participants, 57 (81%) completed Intervention Part 1, and 43 participants (61%) completed the entire intervention (see Figure 2). No adverse events were reported during the intervention period.

Figure 2

Overview of participant enrollment and dropout.

The cohort comprised predominantly of women, representing 51 participants (73%). All participants reported having chronic pain for at least 1 year. The majority (57%) of participants had endured pain for a duration of 1–4 years, while a significant proportion (43%) had been living with pain for 5–10 years. More than half of the participants (51%) reported chronic pain in multiple body regions. The most reported single locations were the back (15.7%), legs (8.6%), head/face (7.1%), and neck (7.1%). Other reported areas included the hips, shoulders, abdomen, and pelvic region, each with lower prevalence. Please refer to Table 1 for details.

At baseline, paracetamol was the most used daily medication, taken by 41% of participants. There was notable use of non-steroidal anti-inflammatory drugs (NSAIDs) and weak opioids, with both categories utilized by 26% of participants each. Other medications included antidepressants at 11% and sleeping medications at 13%, while a significant portion, 39%, reported not using any medication daily.

In terms of medication used as needed, 70% of participants utilized paracetamol. Weak opioids were used on an as-needed basis by 47% of participants, while strong opioids were less frequently used, reported by only 6%. Additional as-needed medications included anxiolytics at 11% and sleeping medications at 16%, with 10% using other unspecified medications (Table 2).

At baseline, participants reported a mean EQ-5D-5L score of 0.65 and a median score of 0.67. The EQ-VAS score, with a mean of 48.8 and a median of 50 (Table 3).

In terms of alcohol consumption, 47% reported drinking once a month or less, while 34% consumed alcohol 2–4 times a month. Notably, none of the participants indicated drinking four or more times a week. Half of the participants reported consuming 1–2 alcohol units on a typical drinking day. Additionally, 44% of participants stated that they never consumed six or more units at a time, while 47% did so less than once a month (Table 3).

The data regarding insomnia, as measured by the BIS, indicated that a significant majority of participants (84%) experienced insomnia (Table 3).

In Part 2, participants could select up to two courses from the available options. The results revealed a diverse range of preferences: 26% selected stress management, while 23% selected physical activity and/or body-mind activity. Other areas of focus included sleep and nutrition, each chosen by 9% of participants. A few participants (5%) chose to address anxiety, while 7% opted for a course on depression. Only one participant selected the available course in life skills. Notably, no participants selected the alcohol counseling or smoking cessation course, and 23% participants did not opt for any additional courses. Please see Figure 3 for details of what they selected.

Figure 3

Distribution of selected courses (n = 43). Participants could choose 0–2 of the courses. The figure excludes alcohol use and smoking cessation, as none of the participants selected these options.

Among the 43 participants who completed the entire intervention and provided post-intervention evaluations, none reported no benefit from Course Part 1. A total of 26% (n = 11) reported some benefit, 12% (n = 5) were neutral, 49% (n = 21) reported good benefit, and 14.0% (n = 6) reported very good benefit.

For Course Part 2, 16% (n = 7) reported no benefit, 14% (n = 6) reported some benefit, 14.0% (n = 6) were neutral, 37% (n = 16) reported good benefit, and 19% (n = 8) reported very good benefit.

A vast majority of participants, 98% (n = 42), indicated that they would recommend the intervention to others with chronic pain, while only one participant (2%) stated they would not.

4 Discussion

The findings from this feasibility study indicate that the co-created intervention was both acceptable to participants and implementable within municipal healthcare services. Recruitment proceeded as planned, retention was 81%, with 57 participants completing Part 1 of the intervention, and 61% (43 participants) completing the full intervention and follow-up assessments. Adherence to the scheduled sessions was high among those who remained in the study, with participants attending both group and individual sessions as planned. The study cohort was predominantly female (72.9%), with an average pain duration exceeding 4 years, reflecting the chronic and long-standing nature of the condition. This demographic pattern aligns with existing literature reporting a higher prevalence of chronic pain among women, often compounded by fragmented and insufficient pain management services [25]. Evaluations, based exclusively on responses from those who completed the full intervention, suggest that the course was perceived as relevant and valuable by most participants.

At the core of this intervention was the integration of individual consultations and group-based care, complemented by the implementation of peer support groups. This approach may foster an environment conducive to shared experiences and emotional support among participants, which can lead to significantly improved treatment outcomes [26]. Additionally, the intervention provided participants with flexibility to select from a range of courses personalized to their individual needs, creating a potentially sustainable model that balances personalization with efficient use of available resources. Although resource utilization was not formally assessed in this feasibility study, the combined use of group-based education and individualized consultations may represent a resource-efficient approach to chronic pain management. This approach warrants further investigation in future controlled trials.

Initial consultations enabled participants to assess their specific requirements and set personalized treatment goals, followed by mid-point evaluations to monitor progress and make necessary adjustments to the treatment plan. Concluding consultations provided an opportunity to review the outcome and facilitate the transfer of knowledge to the patients’ GP. Despite the notable completion rates for Part 1 (81%) and the entire intervention (61%), dropout rates in interdisciplinary pain management interventions vary from 5 to 46% and may indicate challenges related to engagement or a lack of personalization [27]. Nonetheless, the completion rates suggest that our personalized approach successfully engaged participants throughout the intervention.

Overall, the findings highlighted a diverse approach to pain management among participants, with paracetamol emerging as the most used medication, both regularly and on an as-needed basis. Specifically, paracetamol was utilized daily by 41% of participants and as needed by 70%, underlining its significance as a primary analgesic and emphasizing the importance of having accessible treatment options for chronic pain management. While 26% of participants also reported using NSAIDs, the low utilization of opioids (6%) likely reflects a cautious approach to opioid prescribing, considering the ongoing opioid crisis. This context stresses the timeliness of developing pain management interventions that minimize reliance on potent analgesics, in line with NICE guidelines [5].

Moderate health-related quality of life scores, as reflected in EQ-5D-5L and EQ-VAS assessments, indicated significant impairments among participants, highlighting the need for comprehensive pain management strategies that address not only physical but also psychological and social factors [28]. While alcohol consumption patterns suggested a low-risk profile, with infrequent use and a low prevalence of binge drinking, it is important to consider that participants may have underreported their alcohol intake. Research indicates that population surveys typically underestimate alcohol consumption by approximately 40–50% [29]. This potential for significant underreporting suggests that healthcare providers should approach alcohol assessment with caution. By leveraging a more accurate understanding of participants’ drinking habits, including the possibility of underreporting, interventions can be better personalized to meet individuals’ needs while considering their social habits.

In Part 2, participants had the opportunity to select areas for further support based on their personal needs and preferences, with choices made in consultation with the course facilitator during the mid-point session. The high prevalence of insomnia among participants (84%) highlighted a critical area for intervention, as sleep disturbances are known to exacerbate chronic pain and vice versa, significantly affect quality of life. Studies show that people with multisite chronic pain who also suffer from insomnia are at high risk for anxiety and/or depression, suggesting that insomnia symptoms play a key role in the association between multisite pain and common mental health problems [2,30]. Despite the widespread sleep issues, few participants chose sleep courses, possibly because they prioritized other concerns, such as mental health issues, which they may have viewed as more urgent. It is well-established that pain can lead to psychological distress [30], so it is not surprising that stress management was the most frequently chosen course among participants. Other courses, such as guided physical activity and body–mind activity, also attracted considerable interest, while anxiety and depression were less frequently selected. Notably, no participants selected alcohol counseling or smoking cessation, which aligns with the low risk for alcohol misuse indicated by the audit C questionnaire. A significant portion of participants did not select any additional courses, though the reasons for this are not reported.

5 Strengths and weaknesses

Chronic pain is a significant public health issue, and this feasibility study addresses the pressing need for new low-threshold treatment options. With 70 participants, the sample size was appropriate to address key feasibility outcomes such as recruitment, retention, adherence, and participant engagement, and provided preliminary data to inform the design of a future controlled trial. The cohort consisted of 73% women, which may provide insights into how the healthcare service functions specifically for this demographic, as women are overrepresented among those with chronic pain. The use of validated measurement instruments enhances the validity and generalization of our results.

The feasibility study offers valuable insights into chronic pain management, but it also has notable weaknesses. Future iterations could improve by incorporating design modifications such as the inclusion of a control group and strategies to reduce the current dropout rate of 39%. The dropout rate may suggest that the intervention was not relevant for all participants or that its content and duration were perceived as overly demanding. Furthermore, participants who completed part one may have felt satisfied with the outcomes they achieved, leading them to believe there was no need to continue to part two, which could result in their misclassification as dropouts. To gain a deeper understanding of the intervention’s impact, a larger follow-up study is recommended.

6 Conclusion

This feasibility study demonstrates the potential for addressing the complex needs of individuals experiencing chronic pain within a primary care context, reinforcing the necessity for personalized care. The findings emphasize the importance of evaluating the practical implementation of such an intervention, particularly considering limited resources and healthcare system infrastructure. This study also provided valuable insights into the organizational structure and resource requirements necessary to deliver the intervention effectively. Based on these findings, the results offer a promising foundation for designing a larger controlled trial to evaluate both the effectiveness and adaptability of this structured approach to chronic pain management within municipal healthcare services.