Enhancing Pain Care: The Case for Complementary and Integrative Health Services within Federally Qualified Health Centers

Pain, including back and neck pain, is among the most prevalent and disabling health conditions in the United States, impacting nearly all adults throughout one’s lifetime.1 For nearly 25% of adults, this condition develops into a chronic complaint that affects how an individual lives, works, and plays.2 Furthermore, the burden of chronic pain disproportionately impacts individuals and populations with greater exposure to adverse social determinants of health. High-impact chronic pain—defined as pain that severely limits one’s daily life or ability to work—further compounds these inequities, making it both a priority for health care providers and a challenge for society.3 FQHCs play a vital role in meeting the pain needs for such vulnerable populations.

Industry-leading clinical practice guidelines from the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and the American College of Physicians (ACP) emphasize the use of nonpharmacological interventions as first- and second-line approaches for treating spine pain. These guidelines advocate for evidence-based nonpharmacological therapies such as spinal manipulation, acupuncture, massage, and mind-body treatments (e.g. yoga, tai chi) to address both acute and chronic spine pain.4 These treatments are routinely used within CIH disciplines, including doctors of chiropractic, acupuncturists, massage therapists, and naturopathic physicians.5

Yet, adherence to these clinical practice guidelines and the integration of CIH providers remains a challenge. For decades, back pain was the most common condition that initiated opioid prescriptions in the United States, which fueled the early stages of the opioid epidemic.6 Although the rate of prescription opioids has decreased from national highs, a recent study of health insurance claims data showed that 20% of individuals with acute back pain are still prescribed an opioid, against the recommendations of medical guidelines.7 Individuals prescribed opioids for pain face a 21–29% risk of misusing opioids and an 8–12% chance of developing opioid addiction.8 The ongoing regularity of prescribing opioids for pain poses a continued risk to patient health. This risk is magnified for Medicaid beneficiaries, as this population is more likely to receive opioid prescriptions than those on commercial insurance.9 Furthermore, adequate pain management for individuals in recovery of substance use disorder, and for those who prefer non-medication options, often lack access to evidence-based alternatives.

Despite growing recognition of the benefits of nonpharmacological approaches for pain management and overall wellbeing, access to (CIH) providers remains limited, particularly in historically marginalized and medically underserved areas.10 FQHCs routinely serve these communities and are well-positioned to bridge this gap. However, chiropractic care, the most commonly utilized CIH service, is available at only 10% of the nation’s FQHCs, leaving an overwhelming majority of patients with limited or no access to these essential services.11

FQHCs that have CIH providers integrated have recognized significant advantages for patients, FQHC provider teams, and overall clinic efficiency. Patient surveys consistently demonstrate high satisfaction rates among those receiving treatment from CIH providers.12 These positive outcomes are corroborated by feedback from FQHC providers and administrators. A study of FQHCs employing doctors of chiropractic revealed that incorporating chiropractic care reduced the burden on primary care physicians in addressing musculoskeletal complaints. Co-location of chiropractic services was reported to increase patient access, decrease patient wait times, enhance care coordination, and create efficient internal referral processes. CIH providers, with their specialized expertise in musculoskeletal pain management, effectively alleviate the clinical workload associated with common pain complaints, thereby enabling primary care providers to concentrate their efforts on addressing other comorbidities that impact patients’ overall health status. Similarly, this on-site integration reduces “leakage” that can negatively influence patient outcomes, care coordination, and facility revenue.

Beyond the broad improvements to patient care, integrating CIH is particularly helpful for supporting care of complex healthcare needs, such as co-occurring chronic pain and a history of substance or opioid misuse. In 2023, FQHCs reported providing substance use disorder services to nearly 300,000 patients and medications to over 200,000 patients with opioid use disorder.13

Notably, many of these patients also have co-occurring chronic pain, and research indicates that unmanaged pain can increase the risk of illicit drug use.14 For these individuals, CIH providers play a crucial role in delivering essential care to help manage their pain effectively, thereby reducing risks for drug recurrence. With many FQHCs delivering care to this patient population, improving chronic pain treatment to include integrated CIH providers can supplement or support existing OUD/SUD treatment teams to effectively address the complex relationship between substance use and co-occurring health conditions, including chronic pain.

The impact of chronic pain represents a challenging and costly situation for patients and communities. Through the integration of CIH services into FQHCs, patients can better manage the impact of their pain. Similarly, FQHCs choosing to deliver CIH services can better meet the needs of their patients through integrating these high-value services.

Prioritize Adherence to Clinical Practice Guidelines for Pain Management – Adopt and implement clinical care pathways that align with established pain management guidelines from the CDC, WHO, and ACP by prioritizing nonpharmacologic therapies as first- and second-line treatments for musculoskeletal pain.

Include CIH Providers Within FQHCs – Integrate CIH providers (e.g. doctors of chiropractic, licensed acupuncturists, massage therapists, and naturopathic physicians) on-site within FQHCs to expand access to evidence-based, nonpharmacological pain care.

Build Referral Networks to CIH Services Not Offered On-Site – Develop referral pathways with trusted community-based CIH providers to ensure continuity of care when services cannot be delivered within the FQHC.

Credential CIH Physician-Level Providers to Full Scope – Credential doctors of chiropractic at the physician level when eligible to maximize reimbursement opportunities under the Prospective Payment System (PPS).

Provide Interprofessional Education and Care Coordination – Facilitate regular interprofessional training for clinical teams about CIH modalities and establish care pathways that promote quality care coordination for patients.

Collect and Report Data on CIH Utilization and Outcomes – Systematically collect and analyze data on CIH services, including patient-reported outcomes, access, opioid prescribing rates, and service utilization, to measure clinical and financial impacts of CIH integration.

Pursue Grant Opportunities to Support CIH Integration – Leverage local, state, and federal grant opportunities—including opioid settlement funds, state block grants, and targeted public health initiatives—to pilot, expand, or sustain CIH services within FQHCs, especially in communities disproportionately affected by chronic pain and substance use.