Chronic Pain Program in a Primary Care Setting
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.
| 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 |
| 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
