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10 Articles in Volume 7, Issue #7
Burning Mouth Syndrome
Chronic Pain Program in a Primary Care Setting
Chronic Persistent Pain Can Kill
Education and Exercise Program for Chronic Pain Patients
Managing Pain in Intensive Care Units
Oxycodone to Oxymorphone Metabolism
Patulous Eustachian Tube: Part 1
Rational, Emotive, Ethical Approaches to Bio-psychosocial Pain Care
Smoking and Aberrant Behavior in Chronic Pain Patients
Structuring Opioid Therapy

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.

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.

Table 3. Pain Specialist In Primary Care Duties
Patient encounters number 15-25 per day.
Visit documentation, per pain template.
Review of tests and studies.
Records review.
Specialist, Behavioral Health, Pharmacy, E.R., PCP, and Pain Clinic coordination of care.
Pain Med refills, medication monitoring per DEA guidelines.
Michigan automated prescription service requests and reviews.
Impromptu appointments for med counts/drug screens.
Patient and staff education
Family meetings.
Facilitate referrals.
Disability/Insurance/Social Service Forms.
Handle patient problem calls.
Peripheral nerve block and trigger point injections.
Random charts reviewed and case discussion with supervising physician.

Primary Care Pain Program Structure

The structure of the pain program within the authors’ primary care setting provides that the pain specialist normally schedules 25 patients in a ten hour day and works under the supervision of the Chief Medical Officer, along with a dedicated medical assistant, an assigned phone nurse, and lab personnel on-site. The PCP refers a patient to her for pain management. The first visit is spent doing a chart review, history and physical, substance abuse risk assessment, reviewing and signing the informed consent and medication agreement, reviewing the pain program guidelines and expectations and obtaining the initial urine or serum drug screen. This is a scheduled forty minute visit. Subsequent visits are scheduled for twenty minutes and occur anywhere from weekly to a minimum of every three months. Once the patient’s treatment regimen and pain is stable, and there are no aberrant behaviors, the patient is considered for transfer back to the PCP for on-going pain treatment. The pain specialist reviews the treatment regimen and patient’s status with the PCP and receives approval before transferring the patient back to the PCP. The daily duties of the pain specialist are outlined in Table 3.

One of the first assignments for the pain specialist was to revise the informed consent/medication agreement. It details all the standard requirements for such an agreement as outlined by multiple pain resources on the internet and from the American Academy of Pain Management. Special effort was made to create a one page format easy to understand by patients with literacy issues. We then developed the pain program guidelines to give the patients and the PCPs a clear understanding of the program. The guidelines provide the patient with structure and stated expectations to promote patient-provider treatment coordination, participation, and trust. The guidelines cover the purpose of the program, evaluation and referral process, treatment modalities considered, treatment plan objectives, and documentation templates. They include the World Health Organizations Pain Treatment Three-Step Analgesic Ladder,10 guidelines for use and limitations of certain medications, adverse reactions to monitor, labs to obtain, information on opiate withdrawal, treatment plan compliance, refill policies, and controlled substance laws and regulations. Also included are guidelines on aberrant behaviors, substance abuse , lost or stolen medications, and when to obtain and how to interpret drug screens.

Documentation for the pain visit is more detailed and specialized than a routine clinic visit. The process begins with the patient completing a form in the waiting room outlining pain scores (highest and lowest since last visit), functional status, medication side effects, refills needed, and miscellaneous comments. We utilize an “Electronic Health Record” (EHR) with a template to follow the “Four A’s” documentation guidelines developed by Passik and Weinreb.11 We assess analgesia, adverse reactions, activities of daily living, and aberrant behaviors—as well as psycho-social issues, new findings, etc. The EHR allows us to view alerts and reminders on patients for such problems as literacy issues or aberrant behaviors. A hospital laboratory interface allows us to view lab results, usually the same day. Imaging studies, behavioral health and specialist reports are scanned into the EHR for review.

We are often asked about the use of opioids in our pain practice. Much of our population is underserved and uninsured and have little to no resources. Therefore, due to financial and formulary limitations, methadone is commonly used. Methadone often provides pain control equal to or superior to other long acting opiates, but requires extreme care when prescribing. A thorough understanding of the pharmacokinetics is necessary due to its unusual metabolism and potential complications.12 Prescribing opioids involves a complex interplay of participants, including the provider, patient, family, and pharmacist, as well as insurance (cost), legal, regulatory, enforcement, and media considerations.13 We strive to use the best suited medications within existing formulary and cost restrictions. Despite the complexities of opiate management, our policy is that opiates can and should be used appropriately for selected patients

Pain patients with a history of current substance abuse problems can present a unique challenge. The literature notes “All chronic pain patients deserve the right to be treated with dignity and respect, and to receive adequate analgesia” and “Balancing the treatment of chronic pain with the risk of developing or exacerbation of an addictive disorder or diversion of medications remains a medical challenge.”14 The literature also shows that the overall prevalence of drug misuse in the pain population is 3.2% to 18.9%.15 This is comparable to the general population. We feel that by treating these patients with a rational, structured treatment plan and set guidelines we can improve their care and reduce our risk.16

Our methodology uses the “universal precautions” format as outlined by Gourlay, Heit and Almahrezi.17 These steps include making a diagnosis with an appropriate differential, conducting a psychological assessment that includes risk of addictive disorders, obtaining a signed informed consent/treatment agreement, doing ongoing pre- and post-intervention assessments of analgesia, and monitoring adverse reactions, functional status, and aberrant behaviors. We trial appropriate medications, including adjunctive and/or opioids. Periodically, we review the pain diagnosis, comorbid conditions (including addictive disorders), and thoroughly document our findings. We refer to behavioral health and/or substance abuse specialists for a DSM IV diagnosis, including drug misuse or abuse. On-going psychological treatment with these diagnoses is usually a requirement to remain in the pain program.

Drug Testing Policy

Drug screens are utilized as one of the tools to monitor compliance, misuse/abuse and diversion. The screen is obtained on the initial pain management visit, and as needed thereafter at the discretion of the provider. A drug screen should be obtained at least annually for a low risk, stable patient without aberrant behaviors. The aberrant behaviors we monitor are those frequently published by multiple pain management resources. We have learned that drug screen results are not always conclusive and that there are many factors to be considered in their interpretation. We record when the last dose of medication was taken. We ask for the “expanded” opiate screen with gas chromatography and mass spectrometry (GC/MS) confirmation, including methadone. Our non-expanded standard drug screen panel looks for codeine and morphine only (under opiates). It is important for the pain provider to have a clear understanding of the interpretation of the drug screens including what is checked for in the panel, cut-off values, and metabolites to expect (i.e. EDDP for methadone). The provider should develop a relationship with the toxicologist for clarification of the screen when necessary. A negative result is not always negative; it can fall below the cut off level which can then be determined with a lower cut off threshold. Although uncommon, there have been lab or transcription errors. By becoming very familiar with drug screening, the pain specialist reduces the risk of misinterpretation and becomes a valuable resource for the primary care provider.

Discussion

Our pain management program is loosely based on the federal chronic disease model we use for treating diabetes. Part of this model includes promoting patient participation and responsibility for their care. We currently offer a two week self-management group workshop that complements and extends the regular medical treatment. It is designed to teach patients the skills necessary to develop a self-management program. The program reviews the types and benefits of exercise, practice action planning and problem solving, and discusses how to use medications wisely. There is no charge to participants and it consists of a 2 1/2 hour session twice a week occurring at four month intervals. It is facilitated by trained on-site staff. This workshop is part of a research study conducted by the University of North Carolina at Chapel Hill and Stanford University.

Although this pain management program within our primary care setting is in its infancy, we have made great progress and continue to evolve. The program has proven to be a success as outlined in Table 4. Our goal is to achieve 50% pain reduction in 50% of our pain patients and our baseline audit shows success. We have also had positive dialogue with the DEA with regard to our program. We have increased our identification of, and referrals for, substance abuse treatment. We have found that once pain is appropriately treated, many patients cease their misuse of substances and abstain from overuse of alcohol or the use of illicit drugs.

Table 4. Benefits of Pain Program Within Primary Care Setting
Pain Specialist accountability for appropriate pain care.
Patient satisfaction/improved function.
Credibility of pain management treatment plans.
Reduce bottle-neck at tertiary pain clinic.
Standardized Pain Assessment Tools.
Standardized Pain Documentation.
Efficiency in patient encounters.
Structured guidelines for patients.
Reduce emergency room utilization and preserving community resources.
Dispel pain management myths (i.e. drug seeking versus pain relief seeking)
Provide staff education.
Champion pain management within the clinic.
Provide resource for primary provider’s questions with regard to pain and urine drug screen.
Reduce diversion and misuse.
Increased substance abuse treatment referrals and improved illicit drug use abstinence outcomes.
Risk management/decrease liability.

We have reduced hospital ER utilization and increased patient function. An illustration of this is a case involving Mr. H, a 46 year old male with chronic cervical and lumbar spine pain. He had a typical pattern of a patient whose pain was under-treated. He was unable to find a PCP to meet his pain relief needs. This led to his over-utilization of local urgent care centers and emergency departments. The patient became increasingly frustrated with his inadequate pain treatment and the way it affected his life. Shortly after we formally presented our program to the local emergency department, they referred Mr. H to our clinic for pain management. Once we developed and instituted an appropriate treatment plan for Mr. H, he was referred, evaluated and treated for his back pain and received lumbar surgery. He also utilized our behavioral health department to learn pain coping techniques. His pain and function have improved and he has now returned to work. He no longer uses the emergency departments for pain care. He is currently being evaluated for cervical spine surgery. The patient has repeatedly expressed his satisfaction and gratitude to us for acknowledging his condition and allowing him to “get his life back.”

Of course, we face continuing challenges. Managing this pain program in an inner city Community Health Center with only one pain provider is demanding. The patient need for services is tremendous and exceeds our current provider capacity. In addition, establishing a new pain management program in a primary setting requires more time, both clinically and administratively. Pain patients are complex and can be emotionally and physically exhausting for the provider. During the initial start-up phase of the program we had our share of “drug-seekers” that needed to be sorted out and that process is ongoing. There are also regulatory issues—such as the requirements for prescribing schedule II medications—that present some challenges to the clinical workflow. As a result, the pain specialist and supervising physician must coordinate closely on a daily basis.

Internal logistical complications occur when a patient comes for a pain visit, but then also has a non-pain related health complaint that also needs to be addressed (i.e. abscess, urinary tract infection, shortness of breath, high blood pressure, etc.). In a tertiary pain clinic setting, these patients are referred to their PCP for these problems. In our case, the patient is already in the PCP’s office with both pain and medical issues that need attention. Since most insurance companies do not pay for same day visits by multiple providers in the same physical location, the pain provider will often address the medical issues. This can be complicated and time consuming, and can delay the schedule. Occasionally, pain issues are deferred due to more pressing non-pain related concerns. Another big challenge is tailoring a treatment plan with limited resources. Some patients have no insurance for specialist referrals or treatments. Due to out of pocket costs, these patients may not utilize interventional pain modalities such as epidural steroid injections. Medication choices are limited, especially the anti-seizure meds effective for neuropathic pain or migraine prophylaxis. In many cases, use of physical therapy or a TENS unit is cost-prohibitive for these patients.

Part of the on-going process of our pain management program is to enhance our data collection and interpretation. Our goal is to better monitor guideline compliance such as pain intensity, pain interference, emotional distress, activity level and physical capacities, employment status, relationship outcomes, health care utilization, patient satisfaction, and drug related problems.3 We also want to increase our PCP pain management education through case conferences and poster presentations. A pain program brochure for the patient, which outlines the program’s guidelines in a concise manner, is being developed. Future plans include transferring some pain specialist duties to a case manager/registered nurse, further customization and efficient utilization of the EHR for this specialized program, and developing a chronic pain support group.

Conclusion

We have created a successful pain management program that is integrated into a primary care setting. The critical components to our success were:

  1. hiring a highly trained, respected pain management specialist,
  2. administrative leadership and Board of Director support of the pain program,
  3. a standardized approach for evaluation and treatment,
  4. orientation and on-going education of pain management to medical providers,
  5. and continued interpretation and monitoring of program outcomes.

We believe that this program is an efficient model and our hope is that this concept will be considered by others so as to benefit patients, practitioners, and clinics, as well as reduce hospital ER visits by patients seeking pain relief.

Last updated on: February 26, 2013
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