9 Best Practices in Evaluating and Treating Pain in Primary Care
In the United States, there is a disconnection between the health care needs of patients and the behavior of the health care professionals and facilities from whom patients seek help. This is especially true when pain is a primary concern for the patient.1
The disconnection exists for many reasons—a fragmented health delivery system and misaligned financial incentives top the list.2 For example, health providers are paid better to do a lot of procedures, regardless of the outcome, than they are paid to develop and coordinate an effective care plan that results in an improved outcome. On the patient side, people will agree to more tests and procedures as long as they do not have to pay or have to pay only a small portion.
When pain is a presenting complaint, inadequate knowledge and skills, combined with misaligned attitudes and beliefs among health providers, compound the patient-provider disconnection. There are many more reasons for this disconnection; the list is long. Rather than belabor this point, I will seek to discuss what can be done to address these problems, who can do it, and how.
Driving the Change
It is time for health care providers to drive change! Here is how to do it: Drawing from the rich health care reform literature and our own experience, providers can sketch a vision for how we believe the system should work, and focus on our own behavior. Starting with a high-priority health problem like pain, our first step is to answer the question, “What does it look like when the behavior of health providers and health care delivery facilities is perfectly lined up with the best interests of people whose chief complaint is ‘I hurt’?”
In this article, I take the first step and answer that question with a set of 9 Best Practices for primary care pain evaluation and treatment that together describe a vision for “pain care in primary care, version 2.0.” In follow-up articles, I will engage leading thinkers and clinicians in the process, having them address each best practice in detail, starting with an understanding of what pain is. We also will review the common pain syndromes and challenges in primary care using the best practices as the foundation, starting with best practices for evaluation and treatment of low back pain and best practices for opioid prescribing in primary care.
Broad Impact of Pain
Pain is the ideal health problem to tackle now for several reasons. Chief among them is the sheer impact of pain on our public health and economy. In 2013, the Institute of Medicine estimated the annual cost of treating the 100 million Americans who suffer from chronic pain to be $600 billion dollars, a figure that is estimated to exceed the cost of any of our “priority health conditions.”3 Given the magnitude of the pain problem, as a society we should be appalled by reports declaring that chronic pain is so poorly treated in the United States that pain has become an economic and human catastrophe.1 One need not look far for evidence: Witness the prescription opioid crisis in America.4 Furthermore, the lessons we learn from implementing primary care pain care v2.0 are likely to be transferrable to other health conditions and, therefore, relevant to the larger effort to heal American health care.
Focus on Our Behavior
Why focus on health care provider behavior, when there is so much else wrong with health care? First, our behavior is one facet of the health care landscape (maybe the only one) that health care providers can control. Second, external efforts to control provider behavior are achieving mixed results. Third, our current behavior poses a significant barrier to better, safer pain care. And lastly, and most importantly, successful culture change always starts with individual behavior.
We will not be able to influence health professional behavior enough to solve the “pain problem” simply by improving pain curricula for primary care and specialists. As noted, the majority of our current crop of health care professionals have received inadequate training3 to develop the knowledge, skills, attitudes, and beliefs required to evaluate and effectively treat pain, to engage patients in more healthy behaviors, and to create and manage a coordinated and patient-centered care team for each patient.
My own teaching experience reflects this. I have found that many American health professionals who occupy key decision-making roles harbor fundamental misconceptions about “what pain is” that have led them to engage in behavior such as the wholesale treatment of emotional pain with opioids and which spur them to ask the wrong questions, such as “Is my patient’s pain real?”
Thus, although a recent,5 multidisciplinary expert panel proposed a comprehensive consensus teaching curriculum that is a tremendous step forward, the panel also concluded that “pain curricula must be judged on their ability to improve provider performance, and change in performance requires more than a good curriculum. To change health professional performance, we must establish clear and concise pain care performance standards that are comprehensive, enduring, and compelling enough to propel change in the health care culture.”5
Table 1 summarizes the 9 best practices for the treatment of pain in primary care settings. Designed with the following criteria in mind, each best practice must:
- Remain relevant despite progress in knowledge and technology. A best practice must draw on, but not have its relevance depend on, current understanding of the biology and psychology of pain, chronic illness, and health behavior
- Reflect current thinking about consensus pain curriculum guidelines
- Inspire health care professional training
- Remain relevant to a wide range of health care professionals and health care delivery scenarios
- Describe measurable behaviors clearly
- Be flexible and easily adapted to address cultural, ethnic, socioeconomic, and gender differences
- Facilitate better health care policy
- Embrace a commitment to patient-centered care
- Enhance value (better care and lower cost) in our health care system6
- Be transferable to other health conditions
1. Become Expert at Engaging the Patient
No standard definition for either “health care consumer engagement” or “patient engagement” exists, yet a general understanding of these terms is that they both mean enabling people to fully participate with health care professionals to maintain their own health and make informed health care decisions. The benefits that accrue from better patient engagement include less unnecessary care, greater patient satisfaction, and better adherence to care plans.7 When it comes to pain, if patients are engaged we envision them being more likely to tackle obesity, smoking, lack of exercise, and being more compliant about their analgesic pharmacotherapy.