Featured Articles: Pain Management/Opioids

Pain Management on the Radar: Final Survey Results

Saturday, January 18, 2014   (0 Comments)
Posted by: Joy Ingram
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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 years.

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 pain management.

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 reality.”

Also 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.

From 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.”

One 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.”

NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

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