How primary care should manage chronic pain patients

In April 2010 the American Society of Anesthesiologists (ASA) published updated guidelines for the management of chronic pain. The guidelines were based on a review of recent scientific evidence as well as a survey of expert opinion. As I read through the guidelines, summarizing the efficacy of various therapies for chronic pain ranging from epidural injection to medication management, some of my most challenging clinical cases involving pain management came to mind.

The assessment of pain is recognized as integral to the care of every patient to the extent that pain, similar to blood pressure, is assessed at every encounter as a “vital sign” on a scale from 1 to 10. Reports of the “under-treatment” of pain by doctors are prevalent in the literature. Yet at the same time physicians are increasingly fearful to prescribe some therapeutic options, mostly chronic narcotics, because of the regulatory and legal concerns intrinsic in prescribing these medications, and because of their addictive potential.

The advent of Pain Medicine as a specialty in the past several decades has had a beneficial impact for the management of patients with chronic pain, but the reality is that most of these patients continue to be managed largely by their primary care physicians.

I remember the harrowing case of a patient in her thirties who was my patient. She had chronic abdominal pain, had been through unending diagnostic tests, referrals to pain centers and subspecialty consultation. In the end, I was left to manage her symptoms and had her on a multimodal regimen that included chronic narcotics. One weekend I received a call for the county coroner. This mother of five had been found by her husband dead from a presumed overdose. As it turned out, unbeknownst to me, she had recently visited a new pain clinic and was prescribed additional medications, which she had added to what I was already prescribing.

Another patient, a respected professional, after many years of caring for her and a good doctor-patient relationship, forged a prescription that I wrote and was caught at the pharmacy where arrest was threatened. On returning to me she was tearful and afraid that I would no longer care for her. I did, and she went on to come off of her chronic narcotics until she was diagnosed with metastatic cancer a year later, the diagnosis of which was possibly delayed given her long history of bone disease and chronic pain.

It is the impact of cases like these that cause physicians to question themselves, in a stare down with the Hippocratic Oath, “first do no harm,” and result in their reluctance to manage chronic pain. To a primary care physician the pain clinic might seem like an ideal solution. Similar to an anticoagulation clinic (for the management of patients on warfarin) the pain clinic would take over pain management, including the prescribing of medications, and provide a systematic approach, allowing primary care doctors to obviate themselves of this risky aspect of patient care.

The reality is, however, that there are currently too few pain centers to handle the numbers of patients with chronic pain. Moreover, the consultative and drug monitoring aspect of pain management is not nearly as lucrative as the procedural aspect of pain management. The result is that many pain centers act as a consult services, making initial treatment recommendations, including the assessment of whether a patient is a suitable candidate for a therapeutic procedure, but send the patient back to their primary care doctor for the ongoing medication prescribing and management. It’s rare that the patient is cured after the pain clinic consultation, and so begins the back and forth, trial and error process, as the primary care doctors picks up the management and tries his or her best to advocate for the patient.

In primary care we have a lot of work to do. This is highlighted by the fact that in my 12 years of clinical practice within an 18-member group of academic general internists we had no practice-wide strategy or protocol for managing patients with chronic pain issues. Though a variety of pain contracts had been proposed for implementation during the course of my employment within this group, we could never settle on one to adopt. Some of this seemed to occur as a result of insufficient time to develop a process for a systematic practice approach to pain management. However, there was also general acceptance of the view that each physician had his or her own unique style and standard, the art of medicine. Nonetheless, I think the lack of systemization led to cross-coverage issues and increased risk for both patients and physicians related to inconsistency in practice.

What is the answer? In my view chronic pain, similar to other chronic conditions, is best managed by a patient’s primary care physician within the context of a “medical home.” There needs to be more standardization of processes and protocols within primary care practices, with clear pathways of communication back and forth with procedural specialists, opportunities for group support for patients, and linkages to physical rehabilitation and psychological support services.

However, the development and management of such programs within the context of primary care will require more support from our healthcare system. Similar to other chronic health conditions, fee-for-service based reimbursement for primary care office visits at current rates is not adequate to support the care coordination necessary to deliver the highest quality and safest care to our patients.

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

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  • stargirl65

    “the consultative and drug monitoring aspect of pain management is not nearly as lucrative as the procedural aspect of pain management. The result is that many pain centers act as a consult services,…, but send the patient back to their primary care doctor for the ongoing medication prescribing and management.”

    So basically, if you can’t make a lot of money doing procedures on the patient then you don’t want to see them? Dump it back on primary care, they are used to doing a lot for little? Come on, you either do it or you don’t. You don’t get to pick to do the things that pay well and dump the rest on someone else. I would never refer back to a pain clinic like that.

    • http://somebodyhealme.dianalee.net Diana Lee

      Unfortunately, I’m not sure many referring docs realize this is what is happening. They’re so busy and I think they probably don’t hear it so clearly stated by the patients when they come back. There is such shame associated with chronic pain, especially when you “fail” a suggested treatment.

  • http://somebodyhealme.dianalee.net Diana Lee

    Thank you for this article. What you describe has been my experience in seeking treatment for chronic migraines / chronic daily headache that haven’t responded to preventatives (yet, I hope). Pain management clinics were eager to do any variety of procedures and we tried them without success. Once that phase was over so was our relationship. They offered me no further advice or care, so it was back to my PCP and alternative practitioner. And thank god for her. I don’t know where I’d be without her constant care.

    I just wish we had a better way of measuring chronic pain. It’s very hard to apply the 1-10 scale when you’re in pain 24/7.

  • jsmith

    Most family docs don’t want these pts- a lot of work, a lot of stress, a lot of uncertainty. This state of affairs will continue indefinitely.

  • ninguem

    ASA guidelines for pain management.

    If it is paid well, we do it.

    If it pays poorly, is time consuming, or requires a form to fill out, it is appropriate for the primary physician.

    No surprise.

  • http://drpullen.com Edward

    The above comments reflect the frustration of primary care physicians and patients. There are more problems yet. The author makes little mention of the difficulty of sorting out the huge number of professional patients seeking prescriptions for opioids to sell illegally, the drug seeking patients doctor shopping to support their habit, and the liability of patient accidental overdose. I’ve addressed this is several posts:
    http://drpullen.com/2010/02/04/cant-find-a-doctor-to-prescribe-pain-meds/ and http://drpullen.com/2010/03/15/oxycontin-what-the-big-deal/ I find management of chronic non-malignant pain the least satisfying and most frustrating part of family medicine today.

  • http://www.drdialogue.com Juliet K. Mavromatis, MD

    Thanks for the comments. Dr. Pullen, I enjoyed reading “Can’t Find a Doctor to Prescribe Pain Meds” at http://www.drpullen.com. As I see it, my role as a primary care physician is to act as a patient advocate and “believer,” not to police whether or not patients truly have pain, or are drug-seeking or shopping for pain medications to sell on the street. My belief in this role is what creates some of the difficulty in questioning motivations of patients who others might suspect of dishonest intentions. However at the same time, I am concerned about promoting drug dependency, which clearly puts patients at risk for potentially devastating social and health consequences, including death from overdose. It would be easier to let a Pain Clinic with a well-systematized approach take over, but Pain Clinics come with all the deficiencies noted above. So it comes back to us in primary care to develop better approaches for managing patients with chronic non-malignant pain.

    • http://somebodyhealme.dianalee.net Diana Lee

      I hope you know how much patients like myself appreciate doctors like you who take that kind of attitude. It gets old being treated like a criminal because you have chronic pain. It can be very demoralizing and even make you start to question whether you are right to be seeking out help when it seems no one is willing to offer any.

    • greencat

      I respect what you say about being non-judgmental. I practice this everyday in assisting with diabetes, reproductive health etc. But these areas do not come with the governmental / legal overwatch that is there for narcotics. It only takes getting burned once…Good luck to you, you are trying your best!

  • http://paynehertz.blogspot.com Payne Hertz

    Chronic pain patients need to wake up and realize that they are in a no-win situation when it comes to getting their pain treated by the medical profession. The attitudes and practices of most doctors towards cp’ers are not based primarily on reason, logic or science, or even common sense and common decency. I firmly believe that medical folklore, bigoted stereotypes, hostility, dogma and pathological self-interest play a far greater role in determining how the majority of chronic pain patients get treated than an adherence to any rational and objective medical standard. When doctors accuse patients of being drug-seekers based on completlely arbitrary criteria like the clothes they wear, the number of concurrent chronic pain problems they have, or whether they ask for drugs by name, it is impossible to make the claim that they are being professional and objective. When “pain specialists” milk chronic pain patients like cows for every farthing they can extract and then abandon them when the milk runs dry, can anyone claim that pain patients are treated any better than farm animals?

    I don’t believe that there is a solution to the problem of pain patients who require pain medication to control their pain that involves the medical profession. The medical profession gained an exclusive monopoly over the prescription of these medicines just 100 years ago, Prior to that, they were freely available over the counter and you could buy morphine and laudanum in most grocery stores. At the time, those who opposed this monopoly warned that it would lead to exploitation of pain sufferers, as well as an epidemic of undertreated pain. They were right. That epidemic has persisted now for over 100 years, but it is only in the last 20 or so the medical profession has gotten around to noticing that undertreated pain was actually a major problem worthy of attention. Think about the implications of that. For 80 years, patients suffered horribly right under the noses of their doctors and nobody thought it was time to do something serious about it until 20 years ago. But the sea-change in attitudes that came about as the result of this ideological shift has been short-lived, and now doctors are largely going back to the standard practice of simply condemning, ostracizing and ignoring pain patients.

    It’s been 100 years. If the medical profession still refuses to grasp the seriousness and moral gravity of undertreated chronic pain then I fear it never will. If many doctors still prefer dogma, medical folklore and bigotry over science and basic humanity after 13 years of medical school, additional training is not likely to persuade them. 21st Century technology exists for the treatment of pain, but it is useless if it is administered by 16th Century minds. I don’t know about you, but I don’t have another 100 years to wait to see if the medical profession will ever straighten up and fly right.

    After 100 years of trying and failing to communicate to the medical profession that we are human beings with a right to be free from torture and chronic pain is a living hell that no civilized society should ever force its members to endure, I don’t believe further dialogue will be productive. Insanity, as they say, is doing he same thing over and over again and expecting different results.

    The only solution is to go back to the way things were in the 19th Century and allow patients to purchase and use pain medications without a prescription from a doctor. There was no epidemic of untreated pain in those days, and no epidemic of opiate drug abuse despite all the exaggerated drug war propaganda we are exposed to today that suggests legalization will destroy the country and lead to opium dens for preschoolers. Whatever you may feel about legalizing drugs, there should be no doubt in your mind that this is the only feasible way we, as chronic pain patients, will ever be liberated from a broken and barbaric system that does little but exploit us for financial gain.

  • http://www.heartlandclinic.org/plattecity David Voran

    I know this may sound bizarre but I’m getting more and more convinced that all narcotics ought to be over-the-counter and available to any adult.
    Before you go ape think about this. Right now lack of access to drugs forces many chronic pain patients to become professional patients and extract a large time cost in clinics and unnecessary tests for their medications. Worse, many of them might go outside the system and by off the street where they get who knows what.
    Street dealers and illicit drug dealers wouldn’t be able to compete at a price or purity point with Pharma and, even if they wanted to, would now have a legitimate outlet for their business and begin paying taxes.
    When patients over dose and show up in the ED we’d have a better idea of what’s in their system and could treat more effectively.
    Most importantly we’d get rid of a significant number of patients that are so time consuming helping relieve the current and impending primary care shortage.
    Finally, since it’s been my experience that far less than half of the patients I send to pain clinics come away with a satisfactory management of their pain, it might limit the growth and expansion of these procedural cash cows and reduce the overall cost of medicine.
    Think about it.

  • LastoftheZuchinniFlowers

    While I confess I have NOT yet read the ASA position statement I WILL say this: there are anesthesiologists who run pain management clinics who are caring, above board and who retain their patient in a therapeutic relationship for as long as the patient requires. My husband sees such a practitioner. He recently left his rather large, unweildly and perhaps too adversarial anesthesia group and opened his own offices. He is committed to treating pain both medically AND surgically and adheres to all DEA regs via opioid contracts and best practice protocols. There is no bullshit, however, within his practice from what I can see as a family member of a patient. IF you run out early, or IF you deviate from the contract (different pharmacies, different doctors, etc), is grounds for dismissal from the practice. My husband (former military pilot with chronic pain from having pulled too many ‘Gs’ over his career and with regional pain syndrome and multiple HNPs, now retired) will have maybe one or two epidurals per year and from time to time requires an opioid (oxycodone 5mg) to avoid disabling pain. Both treatment modalities work very well and while he along with his pain doctor have tried other (complementary) approaches, these two work best for HIM. I feel very lucky to have this physician caring for my husband. However, I do suspect that he is a rarity in this newly burdgeoning field. Lets face it, we (the baby boomers) are starting to hurt all the time for various reasons. Why fall apart when relief is available? We are still active and wish to remain so and if major laminectomies can be avoided, why not? The mind set our parents had vis a vis ‘pain’ should be abandoned, i.e. ‘stop complaining, suck it up, crybaby, etc.’ These attitudes have no place in the current medical approach. There are NO prizes given out for who tolerates the most pain in silence (which was hard for my tough guy-fighter pilot Marine officer to comprehend. And, while malingerers do exists – many CP pts are on the level and simply seek adequate treatment. I do not refer to the late Friday aft. ED pts. who show up with the complaints of global, indeterminate pain syndrome or who pinch fingerstick blood into their urine crying ‘kidney stone’ in search of Percs. These types are an unquestionable PIA to ANY ER doc. So, While the issue is yet to be solved (may never be solved in the current climate of ‘what to do with the patient in chronic pain), I DO NOT AGREE that CP pts should EVER be managed in their primary care doctors office. My husband is not and his PC would NOT appreciate the idea, and NOR WOULD I if I was the physician in Primary CARE. Such practoces are astonishingly TOO BUSY and with 15 minutes alloted for a re-visit or 30 for a CPE, there is NO TIME and more importantly NO RESOURCES for the paperwork required and the vigilance needed to maintain a CP in the manner which best serves them AND complies with the DEA regs required to keep everything Kosher. It is a COP OUT from the ASA to suggest that this should be the standard of care.

  • hashmd

    Now there is a “consensus report” from the Pain Management society that opiods for chronic, non-malignant pain is not optimal. So that puts Family Medicine doctors like me hung out to dry for prescribing long-acting opoids in whatever dose it takes to manage the pain (sometimes a whole lot in certain patients).

    I had a very good friend lose his license in Southern California for running a chronic pain practice. All it took is an overagressive district attorney and being targeted by the DEA.

    I may be next on the list for overprescribing narcotics for some of my chronic pain patients. After years of trying surgical, then non-surgical methods of pain control, there is little left to do. If they accuse me, I have to go back and defend the practice of all the failed surgeries, injections, stimulators, Physical Therapy, etc. that may have been tried years ago by providers that are no longer around. I would fail miserably and therefore lose my livelihood.

    I do it, but I can’t afford to advertise the fact because I would become too high profile for the next young federal or district attorney trying to grab headlines for taking down another doctor “illegally” overprescribing narcotics.

  • http://www.linkedin.com/in/achievementstrategies Marie

    Another sorry state of affairs in medicine where everyone is decrying the situation but no one is doing anything about it.

    I have chronic pain from MS, pain that is insidious and constantly shifting, just like the disease itself. Unfortunately for me, I also fell two years ago and fractured my shoulder. Three surgeries, a shoulder replacement, buckets of narcotics and consults with three well-regarded pain management specialists and I still can barely use my arm. My pain is nearly as bad as the day I broke it. And no one knows why.

    The pain management guys treated me like a hot potato, none of them willing to commit to either a diagnosis or treatment plan. One doctor says its neurological. Another says its orthopedic. Another says all treatment bets are off because of MS. One did suggest a protocol of 100 mg of neurontin along with percocet 10 four times a day!!!! hahaha I want pain relief, not a coma!

    You have to understand I am a quiet, undemanding patient who simply wants to feels better, who never took anything more than ibuprofen until I was diagnosed with Transverse Myelitis, related to what turned out to be MS. I engage in no histrionics, no drug seeking, no drama, no tears, just a respectful request for help.

    I am also a woman who had four children with no medication, including having two babies at home. I can handle pain. But I’ve never experienced anything like this.

    So my choices appear to range from doing nothing to drugging myself into oblivion. At 55 I cannot pick up my grandson, put up my hair, scratch an itch on my other arm. Thank goodness for my orthopedist, neurologist and PCP. They all have expressed commitment to sticking with me through this ordeal. But the reality is I may be facing a lifetime of debilitating pain that no one in the specialty is willing to fully address.

  • DCPharm

    Going on 3 years chronic pain, and over subjected to “interventions” that don’t work! Every pain clinic I go to wants to be in the procedure business (follow the money). After bad experiences, I trust only one doc with “procedures,” but he doesn’t do the long term pain meds because he doesn’t want his practice to consist of DEA regs. I am having an impossible time finding someone to just manage my pain meds.. I am not a criminal or addicted to drugs (some people think that anyone that takes pain meds for 3 years is addicted). Also, I had to change PCP to go to someone that at least understands pain, as my original PCP wouldn’t give me anything when my disc originally herniated & my pain level was consistently 9! I realize that I have not offered solutions here, the main one I can think of is more collaboration between physicians & pharmacists. My husband, a pharmacist, always contacts physicians for suspected doctor-drug shoppers…. and he gets very mixed responses.

  • LastoftheZuchinniFlowers

    At the risk of putting anyone on the spot I am only going to say this: undertreatment of pain is neglect. I believe that a practice which advertises itself as being in the business of ‘pain management’ certainly needs to offer procedures which should offer some if not total relief to its patients. Epidurals for HNPs are highly effective but often in sets of three and they are costly but covered procedures under many insurance plans. We must all agree that the reason for this mess is the patient who is seeking narcotics and not those of you posting here. The narc seeker does NOT belong in the ER, nor does he/she belong in the PCPs office (for pain management). The patient in chronic pain belongs in the office of the pain management specialist. It is NOT fluff to say that this field requires a knowledgeable physician (anesthesiologist) who has true compassion BUT who will also have a firm grip on his practice. I am sad to read that so many needy people are going without the care that they need but I do not know what to do about it. PCPs cannot pick up this additional patient burden. The reasons why have been set forth in previous posts. I suppose that if someone is truly suffering and NOT getting the care they truly need a carefully worded letter with full disclosure released to access their medical records would be in order and should be sent to the state board of medicine/anesthesia to ask for help. I don’t think that ANY doctor who puts him/herself in the role of a ‘pain management’ specialist will wantonly neglect a patient’s pain. Getting referred to or gaining entry to these practices is usually the hardest part. Once you are a patient and known to the practice – THEN you can usually expect reasonable and consistent care. I wish you all well.

  • greencat

    I appreciate that patients have pain, but dealing with chronic pain is a minefield…Have seen several docs get in trouble for “over-prescribing” narcotics….This has sent a real chill through all of us…On the other hand, doling out the pills and infantalizing the patient was no help either. We have a lot to offer, and most of us will not jeopardize ourselves if there is any potential for abuse…Pain management is tough, but you cannot dump yet another thing on primary care in out 15 minute windows…

  • http://cottagepainclinic.com Masorteam

    So sad! When there is a non invasive chronic pain therapy, without side effects not being widely prescribed by MD’s. The abstract is on PubMed. It you would like a copy of the paper, submit the request on your letterhead.