Pain Management in Primary Care

William C. Becker

Matthew J. Bair

Introduction

PREVALENCE OF PAIN IN THE UNITED STATES

Pain is the most common reason cited for patients seeking medical care, and pain accounts for up to 80% of total visits to physicians’ offices.¹^,² Although it is difficult to determine the prevalence of pain precisely, recent surveys suggest that 75 to 105 million Americans experience pain daily or intermittently.³^,⁴^,⁵ Given this widespread prevalence, the Institute of Medicine (now the National Academy of Medicine)⁶ and the U.S. Department of Health and Human Services,⁷ among other important stakeholder groups, have called primary care the foundation of pain treatment in the United States, a foundation that should be adequately trained to meet the challenge of delivering high-quality pain care.

ECONOMIC IMPLICATIONS OF CHRONIC PAIN

The National Academy of Medicine estimated the cost of pain to be approximately $565 billion dollars, making it one of the costliest conditions in the United States. Although the precise figure has been debated, there is little argument that the costs associated with pain treatment and the economic impact of missed days of work and unemployment and other societal costs are high and increasing.

Care management plans and disease management programs are abundant for other chronic conditions, such as asthma, hypertension, hyperlipidemia, and diabetes mellitus. Treatment strategies include case management, treatment algorithms, provider education, and patient support groups. In contrast, very little emphasis has been placed on studying and developing such initiatives for chronic pain conditions. Given the large allocation of United States health care dollars for treating patients with these conditions, it is time for the provider, payer, and policymaker communities to take notice; emerging models discussed at the end of this chapter may signal the beginning of a promising trend.

CHRONIC PAIN MANAGEMENT: THE STATUS QUO

With the onset of pain, most patients attempt self-care with over-the-counter products and/or self-help techniques (e.g., distracting activities, rest). When these methods fail to provide adequate relief, the patient generally seeks help from a medical professional. In many cases and particularly in health care systems with limited access to specialty care, the gatekeeping primary care provider is the first medical contact. The primary care provider recommends treatment and refers the patient for appropriate specialty care, such as a physical medicine assessment for low back pain.

When pain becomes chronic and specialty care is ineffective in improving the underlying condition, care management becomes more difficult. In a recent survey, only 34% of internists reported that they felt comfortable with their abilities to manage patients with chronic pain.² In a related article, Ballantyne and Mao⁸ wrote that the most difficult issue now facing physicians is “whether and how to prescribe opioid therapy for chronic pain that is not associated with terminal disease, including pain experienced by the increasing number of patients with cancer in remission.” In part, physicians are hesitant to prescribe opioids because they lack both the understanding of how to comprehensively assess pain and its common comorbidities and the knowledge of available pain therapies.

The varied presentations and manifestations of chronic pain may at times confound primary care providers. Physical exam and radiographic abnormalities are not predictive of pain severity or dysfunction.⁹ Many patients experience pain that may be constant and occurs for several years, and yet their life functioning is not changed in major ways. Conversely, there are other patients with similar structural abnormalities who suffer substantially more and cannot maintain their usual levels of activity.¹⁰ Patients whose lives are significantly disrupted by pain engage in behaviors that are maladaptive, anticipate more distress, amplify sensations associated with pain, spend more time resting, and complain of less ability to control pain.¹¹^,¹² It may be reassuring to providers to recognize that this same degree of variability is seen in virtually all chronic conditions as a manifestation of the complex interplay of biologic, psychological, and social factors.

At the same time, surveys evaluating the adequacy of pain treatment demonstrate that the current system is dysfunctional.¹³ Patients report that they are not asked about pain, that they are afraid to report pain to their primary care providers, and that they are often not offered treatment. In one survey, 22% of patients with pain reported being uncomfortable discussing pain with their personal physicians, 13% said they were denied pain medication or referrals to pain specialists, and 70% reported experiencing continued pain despite treatment.¹⁴ Much of these system problems can be attributed to the treatment of pain at the primary care level.

SEARCHING FOR SOLUTIONS

There have been tremendous advances in the knowledge of pain pathophysiology, the understanding of treatments for pain, and recognition of the value of an interdisciplinary approach to pain management. On the scientific front, there has been an explosion in pain research, and new pharmaceutical agents have become available for treating different types of pain. Complementary and integrative health therapies for pain management have gained recognition and an increasingly robust evidence base. Novel interventional techniques and surgeries have been introduced. Professional pain societies have sprung up, and training is now available to provide physicians and other health care professionals with expertise in pain management. Despite this unprecedented progress, pain care remains inadequate, and undertreatment of pain is still considered pandemic. The reasons for these continuing inadequacies are varied, but it is clear that new solutions must focus on primary care.

A New Approach to Chronic Pain Management

There are many different types of pain that it is difficult for a nonexpert provider to become familiar with and comfortable treating all pain conditions. Current categories for classifying pain include nociceptive versus neuropathic, acute versus persistent, cancer versus noncancer, and area of the body (headache, abdominal pain, chest pain). These categories are simplistic and helpful only in a general way.

We are accustomed to accepted, well-defined, objective measurements to assess the quality of care. For many other chronic conditions, there are standardized outcome measures. In patients with diabetes, we can measure hemoglobin A₁C levels. In patients with asthma, peak flow and the use of inhaled β agonists guide care. Treatment outcomes for pain are often subjective, confusing, and controversial. If a patient’s pain severity is better but function is not improved, is this outcome adequate? If the patient is satisfied with treatment but pain intensity levels remain high (e.g., an 8 on the 0 to 10 pain numerical rating scale), is this treatment sufficient? If the patient returns to work but is on high doses of opioids, is this acceptable? All of these questions frequently arise in the primary care and complicate treatment.

WHO TREATS CHRONIC ILLNESS?

When pain becomes chronic, a behavioral syndrome and comorbidities may emerge including depression, anxiety, helplessness, insomnia, deconditioning, and increased reliance on the health care system, what has been called “high-impact” chronic pain. At this point, chronic pain becomes a disease process that needs chronic disease management.¹⁵ Chronic back pain is not a diagnosis but rather a description of duration and location. In many cases, it is not possible to be more precise in the diagnosis of, for example, low back pain because even experts disagree on the underlying etiology.¹⁶ Neuroscience increasingly points to dysregulated neuroplasticity and central sensitization as common pathways to chronic pain,¹⁷ further underscoring the futility of “imaging” chronic pain in most cases. Providers would do well to learn to message to patients that a lack of imaging findings is important for ruling out sinister causes of pain (e.g., cancer) but does not mean the pain is not real.

Failure to be more precise in the diagnosis should not delay treatment or impede medical management. Treatment in primary care often involves uncertainty, as most of the conditions encountered cannot be diagnosed precisely: Viral illness, rash, or headaches are common, and the etiology unexplained. Chronic pain falls into the group of conditions that often defies definitive diagnosis and is suited to the primary care practice. A patient’s suffering can be ameliorated by nonpharmacologic interventions including patient education and self-management skills that may be combined with analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs).

All primary care physicians must treat patients with a variety of chronic diseases. In fact, most chronic illness is principally managed at the primary care level.¹⁸ Improvements in the medical management of asthma, hypertension, and diabetes have arisen from interventions implemented in primary care. Despite the lack of specialty training and through the use of practice guidelines, following treatment recommendations, conducting chart reviews, discussing shared experience, and providing expert assistance, primary care delivers excellent medical care. Management of persistent pain lends itself to the same paradigm.

WHY PRIMARY CARE IS INVOLVED?

Primary care is based on the elements of trust, therapeutic alliance, advocacy, continuity, care coordination, preventive care, and careful attention to quality of life/lifestyle issues. Motivating patients to strive for better health through exercise, diet, stress management, medication adherence, and disease monitoring is a common role played by the primary care provider—a role that requires the provider to adopt and maintain a nonjudgmental attitude.

Primary care is uniquely positioned to provide care for patients with chronic pain. Of all specialties, primary care providers have the largest geographic distribution. Rather than clustering around medical centers in the largest cities, they are broadly distributed over diverse communities—from urban clinics to suburban medical centers to private practices in small towns and rural areas. Furthermore, primary care providers are trained in patient-centered communication, biopsychosocial assessment, and multimodal treatment planning, all core features of a high-quality approach to chronic pain.

By its very nature, primary care entails continuity by developing a longitudinal experience with patients. Each office visit enables the provider to achieve greater understanding of how individual patients are dealing with their persistent pain. Primary care providers are experienced in providing comfort and disease management for chronic conditions. When clinicians are challenged to broaden their definition of pain as a symptom and begin to view it as a chronic illness,¹¹ primary care is well equipped to deal with chronic pain.

When a patient’s pain becomes persistent and specialty care is either unavailable or ineffective as a treatment option, the providers can continue to play a key role by coordinating care, intervening when symptoms change, and constantly encouraging patients to make lifestyle choices as they do in all other chronic diseases: weight loss, sleep hygiene, anxiety/depression/mood management, physical activity, education, and judicious use of medications.¹⁹

From a cost and utilization perspective, primary care is the most appropriate setting for chronic pain management. Most types of health insurance, as well as Medicare and Medicaid, cover primary care visits yet may not cover long-term psychosocial treatment or interventional procedures. A classic 1995 study of low back pain examined 1,555 patients cared for by chiropractors, orthopedic surgeons, or primary care providers. Cost, work status, and time to restoration of baseline status were monitored. All groups achieved similar outcomes yet primary care was the least costly.²⁰ Risks of polypharmacy are better managed within the primary care structure because it is accustomed to dealing with multiple diseases and their treatments in a single patient.

TREATING CHRONIC PAIN IN THE PRIMARY CARE SETTING—WHY A CHALLENGE?

Training in Pain

Much of formal medical training occurs in hospitals where acute symptoms and life-threatening conditions are studied. Historically, very little practice has been offered in the management of chronic pain in the outpatient setting. Training in pain management may be limited to a brief session in a pharmacology or neuroanatomy course during medical school. As a consequence of this limited training, many residency-trained primary care providers are ill equipped and therefore uncomfortable treating patients with persistent pain.²¹ This may lead to inadequate assessment, substandard treatment planning, poor follow-up and monitoring, and generally poor quality of care.

However, the opioid crisis has prompted medical schools to re-examine pain management curricula and has spurred widespread calls for medical student and provider education to be cornerstones in addressing the crisis.

Disagreement among Experts—To Treat and Not to Treat

In recognition of the need to improve pain management, the Federation of State Medical Boards issued guidelines on the appropriate workup and treatment of persistent pain.²² Most states have adopted the Federation’s recommendations in the form of Intractable Pain Tratement Acts. The safe and proper use of opioids is the cornerstone of these acts, encouraging providers to assess patients’ pain and use medication when necessary. Increasingly, adequate pain relief is being viewed as
a patient’s right—and a clinician’s obligation—sometimes to the point of allowing the patient or family to take legal action against doctors for the undertreatment of pain. On the other hand, the opioid crisis has ushered in a new era of caution in treating pain.

The Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain in March 2016,²³ a landmark effort that garnered widespread publicity and spurned heated discussions of controversies related to guideline recommendations. For example, the CDC guideline contrasted significantly to the 2009 American Pain Society/American Academy of Pain Management’s Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain²⁴ as decidedly “opioid avoidant.” The CDC guideline promoted nonopioid analgesics and nonpharmacologic treatment options as preferred in the treatment of chronic pain, identified recommended limits in opioid doses prescribed, and advocated for heightened vigilance and monitoring for indications to taper down or discontinue opioids especially among patients already on long-term opioid therapy when benefits no longer outweigh harms. The CDC guideline also emphasized the lack of evidence demonstrating long-term efficacy of long-term opioid therapy in contrast to other treatments for chronic pain²⁵ and the growing evidence of potential harms, especially at higher doses.

It is too early to tell the full impact of the CDC guideline. However, the CDC guideline has already changed many providers’ approach to opioid therapy specifically and chronic pain care generally. More providers appreciate that high-quality pain care involves a combination of nonpharmacologic and pharmacologic options. Treatments where patients take an active role (e.g., yoga) are viewed as particularly valuable. Pain self-management skill building is considered low cost and effective and promotes less reliance on the health care system and that it may be in patients’ best interests to reduce or avoid taking opioids, especially long term. Avoiding long-term opioid therapy has been informed by consistent observational data and emerging randomized controlled trial (RCT) data that patients may experience accelerated decline in well-being and accrue a variety of bothersome and sometimes serious harms on long-term, and especially high-dose, opioids. That said, for individuals already on long-term opioid therapy for whom benefit is outweighing harm, the therapy (and ongoing close monitoring of it) should be continued. Involuntary tapering of patients not experiencing harm is not evidence based, not patient centered, and may have its own set of serious risks and unintended consequences.²⁶

Barriers to Treating Pain

Many barriers to the management of pain have been welldocumented in this text and others.²⁷ These obstacles relate to the medical system, providers, patients, and regulatory and governmental agencies, all of which are operant in primary care practices. At the same time, other obstacles are unique to primary care, making pain management more difficult even for the well-trained, conscientious provider.

Time Constraints

Primary care providers often perceive pressure to do more in less time, especially in light of cuts in reimbursement (Medicare, Medicaid, and other types of commercial insurance). Furthermore, the typical 15-minute office visits are crowded by other activities: telephone calls, add-on appointments, emergencies, hospital admissions, serving as preceptor for students or midlevel providers (i.e., interns, residents, nurse practitioners), and reviewing laboratory and x-ray reports.

Patient complexity is also a major contributor to time constraints. Patients may present with multiple medical issues at each visit—ranging from chronic conditions (diabetes, hypertension, and hypercholesterolemia), situational issues (insomnia, stress at work, menopausal symptoms), preventive care needs (immunizations, cancer screening), procedural needs (skin tag removal, knee injections), and other issues (medication refills, disability forms, jury excuses).

Comprehensive assessment and documentation of pain would be difficult in this setting even if the entire 15 minutes were available to address pain during the visit. To address these issues but still harness the wealth of resources that make primary care such a compelling foundational treatment setting, promising new care models described in the following discussion have emerged.

Lack of Guidelines Specific to Primary Care

A variety of well-recognized treatment algorithms and evidencebased guidelines exist for treating other chronic conditions encountered by primary care physicians (e.g., cancer,²⁸ neuropathy,²⁹ fibromyalgia syndrome³⁰). Although guidelines have been developed for some pain problems, there are relatively few specific recommendations for the treatment of persistent pain and rarely address the practical challenges to managing chronic pain in primary care.

Even when guidelines are available, studies show that often they are not followed by clinicians.³¹ This can be explained in part by the nature of chronic pain. When a patient’s chronic pain worsens, the cause is frequently undiscoverable, making it difficult to apply a guideline or to decide on a different treatment when so many therapeutic options have been ineffective.

Specialty Referrals

Referrals for patients with persistent pain may differ for other conditions in primary care practice. After referrals to specialists in other conditions, patients may return to the primary care provider after the medical issue has resolved or the chronic illness has an expected treatment course. Some examples include dysfunctional uterine bleeding is diagnosed and treated before referral back to primary care. The fractured bone is set and stabilized, rehabilitation is arranged, and the patient presents back to primary care with restored function. The patient with congestive heart failure has further diagnostic testing, medication adjustments, and returns to primary care when symptoms have improved and the patient is stable.

The workup and treatment of the patient with persistent pain, on the other hand, may be less amenable to these clear benefits and resolution of symptoms. The acupuncturist diagnoses an imbalance of energy or “chi” and treats with needles and herbs. The physiatrist may focus on muscle tightness and nerve injury and offers rehabilitative therapies. The interventionalist uses injections to alleviate radicular pain. The chiropractor focuses on structural imbalance of the skeleton and offers manipulation therapy.

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