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A Day of Consulting in Rural America

Due to a lack of pain specialists, primary care physicians in rural areas are being asked to manage increasingly complex pain patients.
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America’s growing shortage of pain specialists, and now primary care physicians, is affecting the availability of pain treatment in many rural communities. This has become true in one rural community in Chino Valley, Arizona, approximately 90 miles northwest of Phoenix, where the primary care physicians are being tasked to become experts in chronic pain management.

At the invitation of these physicians, I travelled from Los Angeles County to this community to query, observe, examine, and advise on their problematic chronic pain cases. It didn’t take much persuasion to get me to undertake this task of hands-on, face-to-face consulting in a rural clinic. Why? I wanted to see for myself if my suspicion was correct—that primary care physicians are being forced to manage some severe, complex pain patients with little or no help from pain specialists and academic centers. I also wanted to know if some in-clinic, on-site training should be done to facilitate pain treatment in the primary care setting.

In this article I describe the problematic pain cases I evaluated, along with my analysis and primary recommendations. Hopefully, these assessments will help others who may have similar cases. I also summarize some of my personal observations to describe the plight of primary care physicians who must now shoulder the majority of medical management of some very severe, complex chronic pain patients.

Chino Valley Medical Center

Chino Valley, Arizona, is a town of about 20,000 people located about 15 miles north of Prescott. The primary industry in town is agriculture. Like in many Arizona towns, there has been a large influx of retirees from other states who have settled in the area in recent years. The Chino Valley Medical Center is essentially the only healthcare provider in the community (Figure 1). Seven primary care physicians and a nurse practitioner attend the clinic. Some of the physicians have retired to the area and work part-time. Because the center is “everything” and the “only thing” for medical care in this rural community, all ages, clinical problems, and third-party payment plans are accepted. No patient is turned away because they do not have anywhere else to go.

The physicians in this center had become very frustrated with a few of their chronic pain patients, who had seen pain specialists in Arizona, Nevada, and California. These referrals usually resulted in an interventional procedure such as an epidural injection being performed, with the patient being returned to the clinic for medical follow-up. The physicians in Chino Valley voiced no problem with the average chronic pain patient who had run-of-the-mill, mild to moderate pain from arthritis or neuropathies but wanted help in assessing and managing many of these intractable cases.

Troublesome Cases

On August 1, 2013, I saw 8 patients with chronic conditions that required sophisticated pain management. I will briefly describe the patients’ medical history and current pain management regimens. The intent of this article is not to detail dosages and any extraordinary findings as in the usual case report but to portray these patients as having a specific problem that is typical of the problematic, chronic cases now seen in primary care. I make no claims that my recommendations were optimal or the best-practice possible. Like any consultation, I gave it my best shot at that particular time and place. Please know that I physically examined and queried every patient, because I firmly believe you can’t properly evaluate, much less provide advice and teach, unless you’ve done an age-old history and physical (H&P).

Case 1

What Else Besides Standard Care?

A 31-year-old woman sustained a severe leg burn in childhood and developed diabetes and systemic lupus erythematosis as a teenager and young adult, respectively. She had seen multiple pain specialists and currently was being followed by a rheumatologist located 90 miles away in Phoenix. Her current medical regimen consisted of an antidepressant, bedtime sedative, long-acting oxycodone, and a short-acting hydrocodone/acetaminophen compound for breakthrough pain (Table 1). She had been treated previously with topical lidocaine patches, tricyclic antidepressants, and non-steroidal anti-inflammatory drugs (NSAIDs). Her pain was primarily articular, affecting multipl joints. She described her pain as constant and said she could sleep for only about 3 hours at a stretch.

On physical exam, her pupil size was under 3.0 mm and slowly reactive, indicating good opioid response. Her blood pressure and pulse rate were normal. She felt she had a good quality of life—she was functional, driving a car, and carried out normal activities of daily living. She believed her pain treatment had been excellent, and she was grateful to her physicians and their “life-saving” care. She and her physician simply wanted to know if there was anything else that she might do to better her clinical condition. In particular, were there any measures that might be curative?

My Assessment

This patient had centralized pain (severe, intractable pain that started in the periphery and now resides in the central nervous system) and was receiving effective, standard pain care (Table 2). She had normal physical and mental functions, and a good quality of life. This case is typical of many chronic pain patients who are the beneficiaries of standard, symptomatic pain care. However, many patients want to know what can be done to enhance their care and permanently reduce their pain.

Since the patient had tried multiple pain treatments, the only thing I know that may achieve greater pain relief, reduce the need for opioids, and give some permanent relief is the use of hormone therapies (Table 3). First, I recommend a standard hormone panel that is widely available through commercial laboratories. If any hormones prove to be deficient, they should be replaced.1,2 Also, patients may wish to attempt a trial with the neurohormones, such as human chorionic gonadotropin and/or oxytocin. Hormone therapies are easy and inexpensive options to try in many of these worst-case scenarios.

For follow-up, I recommended monthly visits to the clinic and a focus on dietary supplements, stretching exercises, and emphasis on gaining an improvement in quality of life (and not necessarily complete elimination of pain). One might also advise the patient that she may require ongoing therapy with opioids or other analgesics. This should be done in consultation with her physician, who can properly monitor the patient for the emergence of side effects or aberrant behaviors. Often meeting with family members can allay fears of opioid misuse or abuse.

Last updated on: December 3, 2013
First published on: December 1, 2013