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10 Articles in Volume 15, Issue #1
Psoriatic Arthritis: Current Strategies for Diagnosis and Treatment
Traumatic Brain Injury: Evaluation, Treatment, and Rehabilitation
Pain Management in the Elderly: Treatment Considerations
9 Best Practices in Evaluating and Treating Pain in Primary Care
Rationale for Medical Management
New York State Enacts New Law to Prevent Drug Diversion
Editor's Memo: Acknowledging the Failure of Standard Pain Treatment
PPM Editorial Board Discusses Epidural Steroid Injections and Blindness
Ask the Expert: False Positive Amphetamine Urine Screens
Letters to the Editor: Pregnenolone, Acute Porphyria, Opioid Calculator, Arachnoiditis

9 Best Practices in Evaluating and Treating Pain in Primary Care

This article presents best practices for primary care evaluation and treatment of pain, which can form a platform for a new kind of patient-centered pain 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

Best Practices

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.

How engaged are patients now?

A recent national survey found that although 23% of respondents had adopted new behaviors related to their health care, they were not confident they could maintain them in the face of stress or a crisis. The remaining 77% of responses ranged from thinking they could remain passive recipients of care (12%), to not having basic facts or being able to understand their recommended regimens (29%), to having some facts but lacking the confidence and skills to act on them (36%).8 A similar analysis from the Medicare Current Beneficiary Survey found that only about 30% of older people report feeling that they possess both the motivation and skills to participate fully in their care.9 These statistics describe the “patient engagement gap,” which represents one of America’s largest opportunities to achieve a higher level of health care effectiveness. The New England Health Care Institute recently published a major research piece that calculated this opportunity at over $290 billion for the United States alone.10

What does patient engagement look like, ie, what behaviors should providers be looking for from patients? In 2010, the Center for Advancing Health11 proposed the following means of recognizing and measuring patient engagement:

  • Find safe, decent care
  • Communicate with health care professionals
  • Organize health care (make appointments and attend them, get tests done)
  • Pay for health care as needed
  • Make good decisions about treatment
  • Participate in treatment
  • Promote health
  • Get preventive health care
  • Seek health knowledge

What can health care providers do to promote patient engagement?

First, they need to remember that people don’t change behavior because of reminders or prodding; patients change behavior when it is beneficial to them, easier than the old way, and/or when it improves their life experiences. Second, establish a healing relationship with patients. Some of the steps to building healing relationships with patients are presented in Table 2. Promoting health literacy, shared decision-making, and providing access to health information (for example, patient access to their health record) also are described as effective measures in the patient engagement literature.12

2. Place Patient at Center Of Care Delivery

The Institute of Medicine defines patient-centered care this way:

“Health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.” 13

Patient-centered care replaces our current physician and health care institution (think hospital)–centered system with one that revolves around the patient (Figure 1). Effective care generally is defined by, or in consultation with, patients, rather than by health professional and health institution–dependent tools or standards. The goal is to do what is in the patient’s best interest, whatever it takes. There is room for disagreement between health professional and patient regarding what is and is not in the patient’s best interest in the patient-centered care model. A synthesis of the most commonly mentioned attributes of patient-centered care are presented in Table 3.14

Despite the recent prominence given to patient-centered care, and the growing evidence of its importance, the nation’s health care system appears to fall short of achieving it. For example, according to a recent Commonwealth Fund survey of patients in 5 countries (Australia, Canada, New Zealand, the United Kingdom, and the United States), one-third of sick patients in the United States leave the doctor’s office without getting answers to important questions.15 Across all countries in the study, one-third to one-half of respondents said their doctors sometimes, rarely, or never tell them about treatment options or involve them in decisions about their care.15

Perhaps the most crystalline example of a behavior shift from provider-centered to patient-centered pain care I have heard came from a primary care provider who described how much more effective she was when she stopped referring to herself in conversation with patients. Instead, she made it about the patient. She highlighted a single transformative experience; a discussion with a new patient who she felt was being prescribed too much opioid by a previous PCP. Instead of taking her usual approach, “I am not comfortable prescribing this amount of opioid” (which, she admitted, often provoked a discussion about just why she was not comfortable, a discussion that touched on regulatory pressures on her, and legal risk for her), she said “I do not think this amount of opioid is in your best interest in the long run.” A lively discussion of the patient’s best interests ensued, and that segued into discussion of the patient’s short-term and long-term goals. A number of unrealistic patient expectations emerged, and she was able to address those, instead of defending her position on prescribing opioids.

3. Build an Integrated Care Team Around the Patient

Care coordination has been identified by the Institute of Medicine as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the American health care system.16 The U.S. Department of Health and Human Services Agency for Health Care Research and Quality has assembled resources to help clinicians measure care coordination and learn about how to incorporate care coordination into routine primary care practice; details are available at http://pcmh.ahrq.gov/page/papers-briefs-and-resources.17 For the purpose of this series of articles, we are going to focus on team-based care for pain patients.

For PCPs treating patients with pain, team-based care coordination is the antidote to ineffective fragmented health care, provider isolation, and patient and provider frustration. My experience leads me to suspect that care coordination is likely to be shown to be the best practice for building an integrated team around the patient that is responsive to the patient’s needs and input, and is a powerful solution to health professional isolation, burnout, and knowledge stagnation. Many patients with pain see multiple health care professionals, and it is imperative that these professionals act and communicate as a unit, in coordination, to serve the patient’s best interests. An overlooked yet crucial component to care coordination is live conferencing, in which all key health care professionals have an opportunity to share information, define and agree upon a treatment plan, and identify which member of the team will be accountable for communicating with the patient on behalf of the treatment team.

The goal of this best practice is to transform fragmented health care delivery into a well-coordinated care team that speaks with one voice and listens with one mind (Figure 2).

4. Customize Care

There is evidence that “know your patient” rises to the level of the best practice recommendation. For example, psychosocial factors are more important than medical elements of the history, exam, imaging studies, etc, in predicting failure of back pain treatment.18

A search centered on research into the value of “know thy patient” will turn up a multitude of articles in the nursing literature but very little information pertaining to front-line therapy by primary care physicians. This is unfortunate because it is not possible to engage our patients and provide patient-centered care if we do not understand who we are dealing with. If a physician is treating a patient with knee pain and severe degeneration on x-ray, would it matter if there is a history of addiction disorder, criminal behavior, severe childhood developmental trauma? Would it matter if the patient had recently lost a spouse or a child? These are just a few of the questions that need to be answered before we can effectively treat pain.

Table 4 describes ways in which physicians can collect information about who a patient is.19 Combining an understanding of the patient with an understanding of what pain is will lead the PCP to truly patient-centered pain treatment recommendations.

5. Understand What Pain Is And Direct Care Accordingly

Compare the following definitions of pain from the International Association for the Study of Pain (IASP), one from 16 years ago and one from 4 years ago:

  • 1999: (Pain is) an unpleasant sensory and emotional experience associated with real or potential tissue damage, or described in terms of such damage.20
  • 2011: Many people report pain in the absence of tissue damage or any likely pathophysiologic cause; usually this happens for psychological reasons. There usually is no way to distinguish their experience from that due to tissue damage. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways (the wiring of the nervous system) by a painful stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a physical cause.3

In the later statements, the authors write “pain is always a psychological state,” and “many people report pain in the absence of tissue damage … usually this happens for psychological reasons.” The IASP is not talking about addiction. The IASP is saying that “I hurt” does not necessarily mean that there is a painful biological tissue pathology. It is imperative that PCPs understand the basic neuroscience and neuropsychology behind these statements, and the implications for treatment. For example, patients may present to us with complaints of pain, asking for specific medical pain treatments, yet the root cause may lie in developmental or adult trauma, anxiety, etc. Effective treatment requires that we address the root cause.

The following is a sobering blog post: “After enduring a terrible break-up I was so depressed that I wouldn’t eat, sleep, or leave the house for months. My sister introduced me to roxycodone and finally I felt normal again. Now I have been using just 30 mg of oxy or roxy daily to help cope with my anxiety for about a year or so. I don’t abuse it like most people do ... I don’t use it to get high … but just to feel happy and normal.”21

In my own medical practice, I have seen many patients just like this, who are not addicted yet started and continued on opioid analgesics because of confusion over what pain is; patients who “hurt all over” and whose goal for pain treatment is to “feel normal again.” In a future article, my series coauthors and I will engage leading pain neuroscientist colleagues to review current thinking about “what is pain.”

6. Make Function Primary Goal

Physical, social, family, cognitive, and work function, as well as the ability to sleep and exercise are examples of the tools we use to measure health and the impact of non-lethal disease on a person’s life. The World Health Organization measures the burden of disease using the disability-adjusted-life-year (DALY).22 This measure combines years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health. As we have already seen, pain is a major cause of “time lived in states of less than full health.” Since there is not good correlation between complaints of pain (the venerable 0-to-10 visual analog scale included) and degree of function loss,23 we have to use measures of function to grade pain severity in the clinic.

However, validated measures of patient function are not typically part of the PCP’s routine patient assessment.24 This has led to tremendous difficulty measuring pain, and, in particular, assessing the benefit or lack thereof of chronic opioid therapy for pain. Absent a consistent and well-validated way to follow results of therapy, treatment of pain patients with medications, procedures, and surgeries has become divorced from results.

There is no objective way to describe or measure pain; the closest approach is to measure how the patient functions in life. The good news is there are easy-to-use function assessment tools appropriate for the primary care setting, tools that are to pain what blood pressure is to hypertension management. My series coauthors and I will discuss how to use function as the primary outcome to evaluate pain and pain treatments in future articles.

7. Practice Lifestyle Medicine as Foundation of Pain Medicine

Lifestyle medicine is about reducing stress, improving sleep quality, maintaining a healthy diet and weight, exercising, and quitting smoking. For example, exercise therapy is effective (level A evidence) at decreasing pain and improving function in adults with chronic low-back pain, particularly in populations visiting a health care provider.25 In addition, epidemiologic studies show that smoking is a risk factor for chronic pain26 and a major factor contributing to the failure of back pain treatment.27 Disturbed sleep is a key complaint of people experiencing acute and chronic pain, and sleep and pain interact in complex ways that, ultimately, impact the biological and behavioral capacity of our patients.28 There is an abundance of evidence suggesting that dietary management of pain is possible.29 Obesity has been shown to be an independent risk factor for painful osteoarthritis of weight-bearing joints.30 In fact, obesity has been shown to promote a global inflammatory state within the body, which may well prevent patients with painful illness from improving until they lose weight.31

There are encouraging developments in this area that promise to provide us with the opportunity to learn how to apply lifestyle medicine principals to treatment of painful illnesses. For example, there are new specialty societies, such as the American College of Lifestyle Medicine, “the first national specialty society for clinicians emphasizing the use of lifestyle interventions in the treatment and management of disease.” Future articles will expand on this theme.

8. Become Proficient at Evaluating Pain, Stratifying Risk, Treating Pain, and Documenting Care

Training for PCPs in the following areas has, by and large, been inadequate:

  • the basic history and physical components of evaluating common painful conditions
  • screening for risk factors that would predict failure of medical therapy due to psychosocial, environmental, cultural, and age-related factors
  • treating common painful conditions at the primary care level; and documenting pain evaluation and treatment.

Future articles will present guidance on evaluating and treating common painful conditions, such as low back pain and headache, at the primary care level, in the context of the 9 best practices.

9. Refer for Right Care at Right Time

According to a recent study, PCPs are referring more patients to specialists than ever before.32 In fact, the rate almost doubled in the 10-year period between 1999 and 2009. If we, as health care providers, are to pursue better quality pain care, we must disrupt the current trends in how and when patients are referred for pain treatment.

More and more often, we see the burden of pain care being transferred to the most expensive provider who least knows the patient and has even less time to spend with the patient than the PCP. Wholesale referral to “someone else, anyone else, to prescribe opioids” must be replaced by referrals that support best practice care. Multiple simultaneous referrals increase cost and confusion, unless the PCP plans to forge the multitude of specialist voices into a coherent treatment team.

In a recent conversation with the developer of a popular referral management system, I was surprised to hear him lament an unanticipated consequence of that program. He told me that since his referral software has made it so quick for PCPs to find specialists who are in the patient’s health plan network, PCPs using his program have abandoned the search for the provider who produces the best results. In other words, software designed to reduce the provider effort and hassle required to navigate the health plan network morass has amplified the negative effect that narrow insurance networks can have on patient access to the best quality of care. These trends need to be replaced by a system in which referrals are customized to the patient and directs patients to the most capable and effective health professionals for their particular circumstances.

We must have a primary care cadre that makes the best use of the health professionals who play an important role in the treatment of pain. The medical home concept includes creating the right interdisciplinary pain care team for each patient. For patients with painful illness, this can include behavioral medicine specialists, physical therapists, complimentary/alternative professionals, nutrition and weight loss specialists, surgeons, pain clinicians, physical medicine specialists, neurologists, rheumatologists, and more.

As PCPs develop strong working relationships with key health professionals in the physical medicine, behavioral medicine, and complementary medicine fields to help them diagnose and manage their patients with pain, their job will get easier, their results will improve, and medicine is likely to become rewarding again. In future articles, my series coauthors and I will solicit feedback from a range of health professionals—from massage therapists to physical therapists, from Oriental medicine practitioners to behavioral health specialists—to discuss who to refer to, for what, and when.

Summary

This article presents 9 best practices for primary care evaluation and treatment of pain, which can form a platform for pain care transformation consistent with the Institute for Health Care Improvement Triple Aim:

  • Improving the patient experience of care (including quality and satisfaction)
  • Improving outcomes, meaning the health of populations
  • Reducing the per capita cost of health care.33

We cannot expect to simply wake up one day and adopt all 9 best practices, not in the current health care environment (10-min visits, pay for volume instead of quality, health plan restrictions that serve the health plan not the public, etc). The best practices approach targets the entire health care delivery system, because the whole system needs to change if providers are to perform at their best level. Nonetheless, each health care practitioner can lead by example and implement aspects of the best practices now. Furthermore, the dialogue with our medical directors, business managers, health plan representatives, and colleagues can start now, as well.

Each best practice is but a link in a chain. Effective pain treatment cannot occur if any of the links are missing or broken. But if the chain is intact, we believe that we will see reduction in costs, improvement in patient and provider satisfaction, and reduction in disability related to chronic pain. We also suspect that the 9 best practices are transferrable to other health conditions.

In the next article of this series, my coauthors and I will present a review of the latest on “what is pain?” In follow-up articles, we will address the best practices in more detail, with attention to both the role of the individual health provider and the role of the health system in implementing best practices. Finally, we will dedicate space to address key health conditions, such as back pain, in the context of the 9 best practices.

 

Last updated on: May 12, 2015

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