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7 Articles in Volume 6, Issue #8
Hyoid Bone Syndrome
Minimally Invasive Interventional Spine Treatment – Part 1
Mobile MRI—Imaging on Wheels
On the Role of Primary Care Within a System of Integrative Multi-disciplinary Pain Management
Pediatric Headaches
Practical Applications of Low Level Laser Therapy
Strength Testing in Pain Assessment

On the Role of Primary Care Within a System of Integrative Multi-disciplinary Pain Management

“…Circumstances sometimes occur to render a special consultation desirable; in consultations,…as the good of the patient is the sole object…the aid ought to be received with candour… and advice adopted if agreeable to sound judgment.”1

- Thomas Percival, Medical Ethics

The past two decades have borne great progress in understanding the complex pathophysiology of different types and manifestations of pain. As summarized by recent work in this journal, we have come to recognize nosologic distinctions between susceptibility to, and presentation of types of pain based upon genomic predisposition, and phenotypic-environmental interactions throughout the lifespan.2,3 As such, we may view certain types of pain as being part of a spectrum disorder that involves differential expression of severity, duration, tractability, and co-morbid neurological and/or psychiatric disorders. Significant to this understanding is knowledge of how neural systems selectively and differentially develop as a consequence of individuals’ experience(s)—essentially establishing each person as unique in cognitive pattern(s), behavior(s) and in response to disease and expression of illness.4 In this light, it can be seen that—through progressively pathological changes in the neural substrates of sensation, perception, cognition, emotion and behavior—pain can be expressed not merely a symptom or sign, but can become a manifest illness (maldynia) that reciprocally involves other physiological functions, both directly and indirectly.5

Thus, while research advances have led to a more complete understanding of pain, the failure to develop and maintain truly translational applications that are articulated within an economically supportive medical system have allowed for an increased prevalence of pain as illness.6 Our contemporary understanding of pain has demonstrated the pathological processes that occur from periphery to brain and, in so doing, acknowledged the reality of complex pain as a disorder capable of uniquely affecting biological, psychological, and social dimensions of each patient’s life. Yet, despite an increase in our knowledge of pain, we are faced with steadily decreasing resources to best treat this problem.

The complexity of maldynic pain cannot be addressed through simple, unifocal therapeutic interventions. To be sure, there has been much written explicating the need for multi-disciplinary approaches to treat the multiple systems affected by, and multiple dimensions of, chronic and maldynic pain.7 While such a conceptual depiction of the complexity of pain would seem to substantiate this multi-disciplinary approach, as a matter of fact, the majority of pain is addressed and managed in a primary care setting, despite the fact that defined limitations upon the scope of primary care practice cannot sustain the comprehensive treatment and care required by the complex pain patient. This does not reflect any distinct inaptitude of primary care as a specialty or practice, nor does it imply any incompetence on the part of the individual primary care physician. To the contrary, we believe that the market forces that have been imposed upon, and exist within the regnant medical culture have both disenabled primary care practice, and threatened the viability of truly integrative care of the patient with durable, intractable pain.

We maintain that these limitations illustrate 1) that the problem of maldynic pain requires a more expansive paradigm of care that enjoins and enables the primary care physician; 2) that the primary care physician, as the first and often most important step in a process of effective assessment and successful referral, must be empowered to act within a larger, multi-disciplinary network of pain practitioners, and 3) that policy must be established that recognizes the epidemiologic, social, and personal burden of pain, and which facilitates both a role for primary care and a larger context of pain medicine in which to function.

In this essay, we present what we feel are the most compelling complex issues arising from, and within, the effective management of durable, maldynic pain. We argue that these issues mandate a greater involvement of primary care in treating pain, not as a stand-alone approach, but as a sentinel toward affording proper, comprehensive care within an integrated system of multi-disciplinary pain therapeutics. We offer suggestions toward maximizing the effectiveness of such cooperativity, and address the need for healthcare policy to fortify this system.

The Problematic Nature of Practical Pain Management

We hold that three interactive “dimensions” create a problematic course for pain management practice, namely the clinical complexity of pain, economic factors, and the current medico-legal climate (See Table 1). At the most fundamental level are those clinical issues that arise as a consequence of the complexity of pain. Pain is not a unitary entity; it can be a symptom of a primary or co-morbidity (vide infra), and as such can be acute and/or chronic. Moreover, chronic pain may reflect an unresolved or exacerbating peripheral pathology, or may be caused by neuropathic changes within, and sensitization of the peripheral and/or central neuraxes.8 Differential diagnosis is not uniformly straightforward and prompt discernment of the type, nature and cause(s) of pain are important to successful therapeutic intervention and management. Indeed, we argue that this may well be the tipping point in determining whether the subsequent course of care is effective and beneficial. Frequently, it is the primary care physician who first encounters the pain patient poised upon the slippery slope leading to maldynic pain, and who is therefore confronted with making a diagnosis that will insure the execution of apt care (whether it be rendered by intervention within the primary care setting or afforded by sound referral). Such diagnoses are frequently complicated by psychiatric pre- and co-morbidities.9 Epidemiologically, the prevalence of certain types of psychiatric disorders and conditions is relatively high within populations of patients presenting with particular types of pain.10

While it is certainly possible that certain psychiatric presentations may be directly reactive to the presence and duration of pain, the coincident patterns of pain and psychiatric manifestations are such that a more intricate relationship is becoming apparent, and we are only beginning to reveal possible mechanisms that subserve such effects.11,12 In many ways, this speaks to the need to appreciate pain as embedded within a larger clinical constellation of somatic, cognitive-emotional and behavioral features including, but not limited to, pre-dispositions to, and expression of mood, anxiety, somatic and substance use disorders.13 Genotypic variations may result in pleiotropic effects that alter CNS structure and function to pre-dispose individuals to (sensitivities for, and types of) pain, neuropsychiatric disorders, as well as altering the kinetics and dynamics of particular pharmacological agents.14,15 Furthermore, as a disease process, particular types of pain can induce neural remodeling to down-regulate endogenous pain modulatory systems, thereby exacerbating both pain and apparent need for escalating doses of analgesic (and/or psychotropic) drugs.16,17 Frequently, such mechanisms drive behaviors that seem to be recidivistic and are often clinically problematic to manage.18

Appreciation of the multiple variables that contribute to, and arise from, durable pain requires considerable inter-subjectivity as part of diagnostic intuition and a treatment approach that is based upon a longitudinal care-paradigm rather than a solely curative-model of medicine. Yet, these approaches should not and need not be mutually exclusive.19 The longitudinal care paradigm is a combination of curative as well as palliative therapeutics, each rendered as appropriate to the needs and best interests of a particular patient at a given time.

Table 1. Factors Contributing to Problematic Nature of Practical Pain Management

Clinical Issues

  1. Complex, chronic and/or maldynic pain syndromes
  2. Co-morbidity of pain and other medical conditions
  3. Co-morbidity of pain and psychiatric conditions/disorders (including addiction)
  4. Pharmacologic management
    (Poly-pharmacy, and/or issues of pharmacologic compliance)
  5. Special Needs Patients

Administrative-Legal Issues

  1. Restrictions in third party claims’ allowances
  2. Diagnostic discrepancy and causation issues
  3. Pending legal action in accident cases
  4. Concerns related to professional liabilities

Economic Issues

  1. Reimbursement issues
  2. Rationing of treatment and charges by third party carriers
  3. Market model restrictions to insure demand escalation

Diagnosis and treatment of this complex patient are difficult even for the well-trained pain specialist yet, as Rollin Gallagher, Director of the Center for Pain Medicine, Research and Policy at the University of Pennsylvania School of Medicine has noted, “…we have only a few thousand pain specialists…those often have fragmented training…and most primary pain care doctors have little focused training in pain management…”20

Moreover, the economics of third party reimbursement within the current system of medical care does not enable the primary care physician to allocate the time or clinical efforts necessary to address maldynic pain, nor do these economics sustain viable resources such as multi-disciplinary pain centers (MPCs) to provide the comprehensive care that is required. Often, the third critical domain of medico-legal and administrative issues are a direct result of the escalating pressures to treat such patients within a context of diminishing opportunities for the provision of, and/or referral to, more appropriately expansive care. Taken together, such factors can lead to 1) the over-utilization of agents and/or procedures in an attempt to accommodate patient demands for enhanced care due to, or in compensation for, restricted capabilities incurred by time, fiscal support, etc., and/or 2) the under-treatment of pain due to such restricted capabilities, or as is more increasingly common, in response to the perception or realities of medico-legal sanction, and retribution. In the first case, patients’ fear of losing control of escalating pain, previous history of poorly managed pain, unavailability of continued care, and clinical abandonment are often instigative. In the second, it is often physicians’ fear of losing control over the clinical situation and of the professional and legal recriminations that could result.21 Clearly, the zero-sum nature of this situation is opprobrious to the sound practice of medicine — both technically and ethically.

 

“… (Pain) care is based on solid medicine, not fear.”22

Congressman Mike Rogers (R-MI)

As Gallagher has stated,23,24 if primary care is to regain any role in the care of complex durable pain, it is clear that such practice must exist as part of a larger fabric of pain medicine, and that the capabilities of pain management—as a field—must be empowered by economic and administrative support that establishes a balanced medico-legal system to enable a care environment that acknowledges, and responds to ongoing research. Obviously, this calls for a sea change. Toward this end, we posit that the effectiveness of primary care in treating the pain patient is sustained by revisions that must occur on three levels.

First, the primary care physician must be educated about pain. This must occur at four levels: 1) during the didactic, basic sciences component of the medical school years as part of an expanded curriculum that incorporates not only the scientific understanding of pain, but a more humanistic appreciation of the nature and impact of suffering as a primary focus of medicine qua medicine; 2) during the clinical clerkship phase of medical education so as to expose medical students to the realities of pain and the possibilities of pain medicine; 3) during the residency experience of any/all specialties that encounter pain patients within the scope of their practice(s)—most certainly including primary care, and 4) throughout clinicians’ careers through the provision of ongoing continuing education that allows integration of high-level knowledge to even the most “grass-roots” medical practice, such that an understanding of the issues of pain, necessities of treating pain patients, limitations of particular practice(s), and networks for referral can be established.25

Table 2. Specific Objectives of a Comprehensive, Integrative Multidisciplinary Pain Management Network

 
  1. Continuity of patients’ pain care enhanced through collaboration with primary care physicians
  2. Use of an integrative, multi-disciplinary approach with broadly based medical resources with enhanced capacity for treatment(s)
  3. Treatment that accommodates both curative and healing paradigms
  4. Provision of both outpatient and in-patient pain management care
  5. Provision of individualized pain management, based upon specific needs of each patient
  6. Outsourcing partnerships with mental health programs to address psychiatric factors and psychological dimensions of pain
  7. Outreach social service and educational programs to accommodate social and economic factors
  8. Establishment of outcomes’ database(s) at the local, state and national levels
  9. Facilitated cooperation with third party payers based upon prudent utilization of programs within the network.

Second, primary care must exist within an infrastructure of pain medicine that facilitates referral to and maintenance of MPCs.26 The general mission of this network of pain medicine would be to provide continuity of pain care, using an integrative, multi- or, more accurately, trans-disciplinary approach that accommodates broader-based medical resources to provide a greater capacity for long-term treatment, management and palliative care, rather than the fragmentary, single practioner-based system as is being currently utilized.25 In this way, the MPC would provide expert knowledge to, and/or implement pain management beyond the limitations imposed upon the primary care physician. The primary care physician could elect to collaborate with the MPC to co-manage each patient. Such informative and deliberative partnering between primary care physician, MPC clinicians, and the patient would allow for the most erudite, patient-focused resolution of clinical equipoise and the provision of the best care. This tri-partite relationship would also reduce the potential for adversarial interactions involving third-party carriers (e.g. - non-substantiation of re-imbursement for medical services needed), and regulatory agencies (e.g. legal sanctions, vide infra) that have become increasingly intimidating, and which have contributed to under-treatment of pain via “defensive” medical practice. In this latter regard, it is frequently issues surrounding longitudinal pharmacologic management of the pain patient that constitute the basis for such a defensive stance. Indeed, pharmacologic management is a special challenge when treating the patient who presents with multiple co-morbidities that include substance abuse or addiction.27 But rather than distancing such patients from the care they require, this networked model would afford resources to implement precautions (e.g., drug interactions, tolerance, etc), treatment, and special monitoring by enjoining professional specialists to focus upon the needs of each patient, as required. Specific objectives of this networked system of comprehensive pain care are described in Table 2. The grounds and basis for referral to the MPC reflect the complexity of pain, and the need for primary care to function cooperatively with other disciplines and medical specialties to provide effective and ethical care on a variety of levels for each person in pain. As such, Level I management would consist of pain care that could and should be administered within the primary care setting. Level II care would be trans-disciplinary, focusing upon pain as disease process and illness and is the purview of the MPC. Level III care would be dedicated to those specific pain conditions that require sub-specialty treatment(s) for ongoing management (e.g., neurology, rheumatology, etc.).

Third, such programs must be supported, developed and maintained in ways that reciprocally allow for 1) financial subsidies to renew the growth of MPCs to meet demographically identified need(s) and afford patients the fiscal latitude to access and utilize such expanded resources appropriately, and 2) development of a system of medico-legal initiatives and statutes that both protect and enable patients and physicians within a re-established probity of the physician-patient relationship, thereby assuaging patients’ fears of inaccessibility to care, and physicians’ fears that they will be unable to render such care because of economic, administrative, and/or legal restrictions. But here too, it is best to proceed with caution since policy that merely acknowledges the impact of pain, but does not enact programs that are specifically implemented toward affecting positive therapeutic outcomes might only serve to worsen the social and personal problem of pain.28

In Conclusion

We have attempted to depict the complex nature of pain, complications and difficulties impending upon the role and ability of primary care to treat the pain patient, and the need for re-integration of primary care practice within a larger context of pain medicine. In summary, we offer the following suggestions:

  1. The primary care physician should provide, and be qualified (literally by virtue of dedication, education, training, and experience) to guide Level I management of the pain patient.29
  2. Referrals to the MPC by the primary care physician should reflect the prudent judgment that at least Level II consultation, if not treatment, is required.
  3. Policy should be in place to insure that patients return to the primary care physician (i.e.- Level I care) following Level II consultation or required treatment, unless otherwise indicated (i.e.- progression to a Level III program; but see also 5, below).
  4. The primary care physician can elect to participate with clinicians of the MPC in providing continuity of care to the extent that the primary care physician feels competent and/or amenable.
  5. Level III care (ongoing pain-related specialty and sub-specialty treatment) can be provided in collaboration with referring Level I or II clinicians, as needed and/or desired, and represents the appropriate type and extent of care required based upon the nosology, severity, and/or co-morbidity of pain and other conditions (e.g., neurological, psychiatric, orthopedic, rheumatologic, etc.)

Of course, we recognize that all multi-disciplinary pain centers are not model programs — each has limitations and many have failed. At times, these failures were due to excessive utilization, replication of tests and procedures, and/or the use of a regimented, non-individualized approach to pain care. Other times, the MPC may have been clinically successful, but socio-economic factors contributing to escalating medical costs and diminished reimbursement led to their demise as pain centers or were absorbed into, or overtaken by, larger health service corporations.30

To avoid this scenario, we feel that our proposal cannot be static, but must reflect a cycle of understanding and progress. Collaboration should be developed between primary care providers and MPCs that is guided by community needs and local cooperation. Referrals by primary care physicians, and the treatment options that are available and provided within the MPC should be individualized. Multi-disciplinary pain centers should also contribute to research databanks that seek to continually assess clinical outcomes. As new information is gained from these outcomes’ findings, and other areas of research, it must be incorporated into education, and translated into therapeutics.31 Systems and policies for the furtherance of such research, and the delivery of progressively advanced care must be equally fluid, and must reflect not only utilization of healthcare resources in pain medicine in ways that are right, but the sound dedication to treating pain in ways that fulfill healthcare’s role as a public good.

Last updated on: March 25, 2014
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