Pain Management on the Radar: Final Survey Results
Saturday, January 18, 2014
Posted by: Joy Ingram
by Lynn Gerlach, Development and Communication Manager
If the responses of 66 medical directors and other CHC clinicians are
any indication, we have some serious work to do in Region X to address
the issues – for clinicians and their clinics as well as for patients –
around complex chronic pain management. Our December survey results are
now tallied, and we are able to complete the preliminary sketch we
offered last month.
Considering that clinician satisfaction might be one good opening
indicator of a successful program, we begin with the fact that only 16%
of our member clinicians surveyed rate their personal satisfaction with
their clinic’s pain management program “outstanding” or “very
satisfied.” 62% rate their personal satisfaction with the program as
“somewhat satisfied,” and 22% are “dissatisfied.”
The survey did not ask respondents to explain the reason for their
personal satisfaction or dissatisfaction, but it did offer the very
satisfied ones an opportunity to describe the best practices their
clinics have developed. Their reports are now in the hands of the
steering committee for the annual Region X Spring Primary Care
Conference, which is designing relevant pain management sessions for
Saturday and Sunday, May 17 and 18, in Seattle.
Accurately reflecting the FQHC membership of NWRPCA by state , the
group responding was 38% medical directors, 20% non-administrative
physicians, 17% PAs, 17% ARNPs, and 8% behavioral health providers.
Two-thirds have been working in the same clinic for more than five
years, the largest group (36%) having been in place for more than ten
Current status of pain management programs
Asked to identify the type of pain management program their clinic
has, well over 90% indicated they treat complex chronic non-cancer pain
patients, most in programs that include opioid prescribing. Only four of
66 said they do not treat such patients, and one said the clinic treats
pain patients, but not with opioids. Two-thirds of respondents
indicated their clinic has either tried a few complementary approaches
to pain management or has a full multi-modal program in place.
The multi-modal approaches identified were quite consistently reported:
- 100% prescribe NSAIDS
- 96% prescribe opioids
- 87% employ integrated behavioral health
- 76% use physical and/or occupational therapy as treatment
- 48% use rehab and cognitive behavioral approaches
- 44% use complementary alternative medicine such as acupuncture, massage therapy, exercise class, Yoga or Tai Chi
Other modalities offered for chronic pain management include referral
to a local pain specialist, pain clinic consultations, chiropractic,
naturopathy, osteopathic manipulation, pain groups, substance abuse
assessments, micro current, ultrasound, topical compounds, OMT, pain
contracts, medical marijuana, antidepressants, gabapentin, and Quality
of Life classes.
A few respondents referred specifically to enforced dose limits and
restrictions on other medications. Representatives from three clinics
added a note that they have not been taking on new complex chronic pain
patients and are treating only those grandfathered in. A few noted their
desire to use physical therapy and acupuncture hampered by patient
inability to get coverage by insurance or Medicaid.
What training will help?
Given a dozen carefully selected options for future training,
respondents were asked to rate each option on a scale from “extremely
helpful” to “of no help at all.” The default rating, in the center
position, was “no opinion.” Eight of the twelve options were rated
either “extremely helpful” or “quite helpful” more than 75% of the time.
Top-rated was the opportunity to learn alternative approaches and
resources such as activation, relaxation and changing dysfunctional
thoughts. The second-most popular topics were approaches to encouraging
patients to adopt self-management strategies and techniques for talking
with patients who are requesting an increase in opioid dose.
Techniques for tapering dose and discontinuing opioids also rated as a
very helpful training topic. Respondents demonstrated a keen interest
in learning more about programs to augment the primary care visit (e.g.
group visits, behavioral health co-location, and pre-visit planning),
clinic policies and practices to reduce patient-provider or
patient-staff conflict, and issues in drug selection for complex chronic
Even the potential training topics that were not the highest rated
all fell consistently above “no opinion.” These included: learning to
establish a registry and population management; managing pain patients
new to the clinic; management of established patients considering
initiating chronic opioid therapy; and referring patients who are
addicted to opioids or have severe mental health problems.
The Spring Primary Care Conference steering committee will carefully
consider these responses in planning nine hours of CME training in
Seattle in May. In addition, NWRPCA will take this wealth of insight
under advisement in its continuing partnerships with University of
Washington, Group Health Research Institute, the MacColl Center for
Healthcare Innovation, and Swedish Family Medicine Residency.
Now tell us what you really think
At the conclusion of the 10-question survey, which was met with
uncharacteristic enthusiasm by physicians requesting an opportunity to
participate, the PCA offered respondents a chance to provide any
additional input they wished to present. Twenty providers took the time
to offer more, including this comment by a Washington physician:
“[Opioid prescribing] is the worst tool ever given to overwhelmed,
under-resourced and undertrained primary care staff with insufficient
time to see these complex patients.”
Another Washington provider asserted that “lower limits have been
proven to save lives in our clinic.” An Oregon clinician called for
“significant turnaround in recommendations to help manage chronic
non-malignant pain… [including] clinicians trying to engage clients
around the change in treatment recommendations… determining if this
therapy ‘is enabling improved function – is this patient better?’ as a
result of medication or therapy.”
From Oregon came this offer: “We also have a vigorous buprenorphine
program, and that helps us ‘clean up our own industry’s mess.’”
From Alaska, this insight: “Bigger
issues are lack of staff resources in terms of people and money to pay
for these people (behavioral health, physical therapy, addiction
specialists, pain specialists when needed) to be able to implement
better approaches. While we don't have the staff, it is hard to put best
practices (even when you learn or have learned about them) into
from Alaska: “Unfortunately our uninsured patients do not have an
option for referral to chronic pain management, and some of them end up
staying with us for that reason.” A third Alaska respondent described a
multidisciplinary “pain management review committee” available to each
clinician to make recommendations in difficult cases or when the risk of
opioid prescription appears to be too high.
Idaho came support for the concept of a multidisciplinary approach: “I
do believe that chronic pain issues should be treated. However I do not
believe that opiates are the appropriate choice for a vast majority of
our patients. If a clinic is going to use chronic opiates, a
multidisciplinary approach is mandatory. This should include mandatory
behavioral health evaluation, PT/OT, random urine drug screens for
compliance and documentation of no illicit substances (diversion and
abuse monitoring) and random pill counts in clinic by trained staff.”
Oregon provider took time to paint a full picture of the challenges
facing community health centers in relation to treating pain patients:
“I believe a major challenge lies in integrating management of chronic
pain into primary care, particularly in an FQHC environment with so many
patients who have multiple, complex medical issues, extensive
psychosocial comorbidities and difficulties, diminished resources, and
often a disconnect between the perspectives of the FQHC and the broader
medical community. I believe chronic pain needs be treated as though it
were a chronic mental health disorder, with which it shares multiple
similarities, and probably managed by dedicated providers.
Organizationally, a major issue is the burnout experienced by providers.
Extensive multi-modal approaches are desirable but not fiscally
obtainable in most cases.”
“This is a complex issue,” wrote another Oregon provider. “I feel
that we do well with the limited amount of time available to us. It
seems the biggest problem, as with everything these days, is that we do
not have enough time to address our patients’ problems appropriately.
Most patients at an FQHC are very complex. Thanks for addressing this issue.”
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