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Chronic Pain Program in a Primary Care Setting

With a designated pain professional and appropriate safeguards, a pain management program can be successfully integrated into a multi-physician primary care clinic.
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About 50 million Americans live with chronic pain and four out of ten patients do not get adequate pain relief. The American Academy of Pain Management has proclaimed pain to be an epidemic.1 In the early 2000’s, the Joint Commission on Accreditation of Health Organizations (JCAHO) incorporated the concept ‘adequate treatment of pain is a patient right’ into their standards.2 Legal cases have been brought for the inadequate treatment of pain.3 The Federation of State Medical Boards of the United States, in the introduction to their “Model Policy for the Use of Controlled Substances for the Treatment of Pain” indicated that “the under treatment of pain is recognized as a serious health problem that results in a decrease in a patient’s functional status and quality of life.”4 Emergency rooms are inundated with patients seeking treatment for their chronic pain and represents a poor utilization of the community medical resources. There is a shortage of pain specialists with only one for every 21,000 patients.1 Meanwhile, untreated chronic pain impacts multiple aspects of the patient’s life, leads to depression, anxiety, irritability, emotional frustrations, social avoidance, relationship issues, loss of self esteem and lack of enjoyment of living and, occasionally, leads to suicidal ideation or attempts.5

With the above in mind, the pain program and its evolution is a priority within the authors’ clinic. It is clear that primary care providers must take a more active role in the treatment of chronic pain. Many primary care providers (PCPs) are comfortable treating acute pain due to its short course and usually identifiable cause, however they are much less comfortable treating chronic pain due to the myriad of complexities. Some of the concepts associated with chronic pain are difficult for the provider without advance training to understand and accept, such as pain without a clear etiology. Providers trained in pain treatment know that treating pain is morally and ethically correct, even without evidence from randomized control trials.6 Limitations to patients receiving adequate pain care include the failure of many PCPs to understand that pain transmission is microscopic at nerve endings, and macroscopic pathology is not necessary to explain pain and suffering.7 There is a need to also accept treating vague pain conditions such as fibromyalgia (which in light of emerging research, shows more scientific data supporting evidence for neural malfunction).8

There are multiple reasons many PCPs are reluctant to treat pain (see Table 1) and why patient access to pain treatment may often be restricted (see Table 2). In the authors’ community, for example, the tertiary pain clinic will not accept patients suspected of drug abuse, nor patients with untreated or poorly treated psychological problems such as depression, anxiety, malingering, or borderline personality disorders. They also do not accept a patient if the referring physician does not prescribe opioids. Further, they will not treat headaches which are non-cervicogenic in origin. In addition, some of the local specialists will not accept patients with any type of pending legal action, including a social security disability application. This leaves many chronic pain patients without necessary pain management.

Table 1. Primary Care Providers Reasons For Under Treatment Of Pain
Unclear understanding of dependence versus addiction versus pseudo-addiction
Inadequate knowledge of use of medications
Fear of diversion
Fear of regulatory scrutiny/sanction
Fear of getting reputation as “narcotic prescriber”
Fear of misuse/abuse of medications
Time consuming
Fear of harm to patient with side effects
Lack of pathology to prove etiology (i.e. fibromyalgia)
Comorbid substance abuse issues
Comorbid psychiatric issues
Prefer referral to pain specialist
Physicians bad past experience bias
Cultural/racial perspectives
Other health issues such as HTN and diabetes considered more important
Prejudice against use of opiates
Table 2. Limits To Accessing Pain Management
Lack of insurance or inadequate insurance
Primary care providers under treatment of pain
Long wait list at tertiary pain clinic
Failure to meet criteria set up by pain clinics
Literacy or educational barriers that limit patients ability to convey adequate history and symptoms
Transportation limitations

Pain Specialist In a Primary Care Clinic

Improved access to chronic pain care can be facilitated by utilizing a chronic pain specialist within a primary care setting. This individual must be a pain treatment advocate and should possess the scientific knowledge and clinical skills necessary to treat pain. They should also possess the sensitivity, empathy and determination to know how pain affects the individual patient. Finally, they should be dedicated to providing technically right and morally good care.9

Prior to hiring a pain professional, an informal investigation by Dr. Kohn (the clinic’s CEO and Chief Medical Officer) revealed that pain and pain-related complaints were placing an overwhelming burden on the local two Emergency Departments. In addition, the medical providers within the clinic—a Federally Qualified Health Center (FQHC) serving a majority of uninsured and underinsured patients in an economically distressed inner-city environment—were also frustrated by the demands of pain treatment, which resulted in longer visit times and increased stress to the providers and the patients. It was found that the differing providers’ comfort levels, experience, and training in treating pain precluded a standardized approach to pain treatment. The decision was made in 2005 to hire a pain specialist to help address the healthcare crisis of untreated pain. The pain program concept was welcomed by the other ten primary care providers in the office. With adequate support staff, three on-site behavioral health professionals, and the support of the Board of Directors, a very successful pain management program within a primary care setting has evolved.

The first author, Karel Schram, credentialed by the American Academy of Pain Management, was hired as a physician assistant having seven years of training and experience at a multidisciplinary pain clinic operated by board certified pain management anesthesiologists. Along with participation in frequent on-going pain education, Ms. Schram actively networks with local board-certified pain specialists along with well-known regional and national experts and has a strong passion for advocating appropriate pain management.

Last updated on: February 26, 2013
First published on: September 1, 2007