Bill McCarberg, MDDirector: Chronic Pain Program

Kaiser PermanenteSan Diego, California

Assistant Clinical Professor (Voluntary)University of California School of Medicine

San Diego, California

Chair - Managed Care CommitteeAmerican Pain Society

The Role of the Primary Care The Role of the Primary Care Physician in Pain ManagementPhysician in Pain Management

ConclusionsConclusions

65 million chronic pain patients in the United States

6000 pain specialists Primary care must becomes more

involved

Boarded through American Academy of Pain Medicine or American Board of Medical Subspecialists

Chronic DiseaseChronic Disease

ConditionCondition

ASCVDASCVD

StrokeStroke

HypertensionHypertension

DiabetesDiabetes

COPDCOPD

AsthmaAsthma

Primary CarePrimary Care

86%86%

91%91%

92%92%

90%90%

89%89%

94%94%

OthersOthers

14%14%

9%9%

8%8%

10%10%

11%11%

6%6%

Data based on 1996 Medical Expenditure Panel Surveys. Annals of Family Medicine Vol 2 Suppl 1 March/April 2004Data based on 1996 Medical Expenditure Panel Surveys. Annals of Family Medicine Vol 2 Suppl 1 March/April 2004

Interdisciplinary Pain ManagementInterdisciplinary Pain Management

Integrated Coordinated Interdisciplinary

Neurologist

Social Worker

Pain Specialist

Physical Therapist

Psychiatrist

Anesthesiologist

Physiatrist

Psychologist

Nurses

Spine Surgeon

Occupational Therapist

Pharmacist

Physician Assistant

Primary Clinician

Annual Mean Cost Per Patient By Condition Annual Mean Cost Per Patient By Condition (Age-Adjusted)(Age-Adjusted)

$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000

StrokeHIV Infection

DementiaCancer

Heart DiseasePregnancy

Multiple SclerosisDiabetes

Respiratory DiseasePanic Disorder

Gastrointestinal DiseaseDepression

AnxietyHypertension

ArthritisChronic Pain

Group Health Cooperative of Puget Sound Health Affairs 16:3

Total Annual Costs By Chronic ConditionTotal Annual Costs By Chronic Condition((Number of patients x Mean cost per patient millions)Number of patients x Mean cost per patient millions)

$0 $50 $100 $150 $200 $250

Panic DisorderMultiple Sclerosis

HIV InfectionAnxiety

Dementia Stroke

PregnancyDepression

CancerArthritis

Gastrointestinal Disease Diabetes

Respiratory Disease Hypertension Heart Disease

Chronic Pain

Group Health Cooperative of Puget Sound Health Affairs 16:3

Managed Care Survey Managed Care Survey

• How pain currently being How pain currently being managedmanaged

• Impediments to pain Impediments to pain managementmanagement

• Beliefs about opioid prescribingBeliefs about opioid prescribing

• Beliefs about treatment Beliefs about treatment effectivenesseffectiveness

Managed Care Survey – Managed Care Survey – Characteristics of SampleCharacteristics of Sample

• 74 administrators from managed care74 administrators from managed care

• Size: 2,200 to 25 million covered livesSize: 2,200 to 25 million covered lives

Health Plan Employer Data and Information Set (HEDIS) does not yet include a measure for pain management.

Results of the Survey –Results of the Survey –Current TreatmentCurrent Treatment

• 2/3 of the sample did not have identified pain 2/3 of the sample did not have identified pain management programsmanagement programs

• 59% acknowledged that there were no 59% acknowledged that there were no specific guidelines in place for handling painspecific guidelines in place for handling pain

• 75% acknowledged that they believed such 75% acknowledged that they believed such programs could reduce costsprograms could reduce costs

Rank Most Difficult Pain ProblemsRank Most Difficult Pain Problems

Mean RankMean Rank

Back pain Back pain 1.5 1.5

HeadacheHeadache 2.8 2.8

FibromyalgiaFibromyalgia 3.2 3.2

Neck/Shoulder painNeck/Shoulder pain 4.2 4.2

ArthritisArthritis 4.4 4.4

Diabetic NeuropathyDiabetic Neuropathy 4.8 4.8

Cumulative TraumaCumulative Trauma 4.8 4.8

Pelvic painPelvic pain 5.1 5.1

OtherOther 3.6 3.6

Results of the Survey – Non-Results of the Survey – Non-pharmacological Treatmentspharmacological Treatments

• 60% agreed there was good evidence to 60% agreed there was good evidence to support the effectiveness of rehabilitation support the effectiveness of rehabilitation programsprograms

• Frequently deny payment for rehabilitation Frequently deny payment for rehabilitation programsprograms

Results of the Survey – Results of the Survey – Patient EducationPatient Education

• 84% self-management is an important 84% self-management is an important aspect of pain managementaspect of pain management

• 11% believed that their organizations did a 11% believed that their organizations did a good job of educating patients about their good job of educating patients about their painpain

Chronic PainChronic PainDisease ManagementDisease Management

Chronic pain like other chronic diseases lends itself Chronic pain like other chronic diseases lends itself to disease managementto disease management

Primary care best equipped for disease managementPrimary care best equipped for disease management

•5th Vital Sign

•Joint Commission on Accreditation of Healthcare Organizations

LegalLegal

•Decade of Pain Control and

Research

•AB 487

•Litigation

Barriers to TreatmentBarriers to Treatment

• Knowledge

• Regulation

• Bias

• 56 physician questionnaires56 physician questionnaires

• 7 extensive interviews7 extensive interviews– Different cultures, gender, Different cultures, gender,

locations, ageslocations, ages

Primary Care ResearchPrimary Care Research

• Some physicians’ reliance on Some physicians’ reliance on outdated pain theoriesoutdated pain theories

• Inadequate physician trainingInadequate physician training

• Biases concerning opioid useBiases concerning opioid use

• Meanings attached to pain that Meanings attached to pain that affect its perceptionaffect its perception

Primary Care ResearchPrimary Care Research

Research - IssuesResearch - Issues

• Chronic pain issues:Chronic pain issues:– no standard chronic pain treatmentno standard chronic pain treatment

– cannot deal with suffering connected cannot deal with suffering connected with pain with pain

Success in Chronic Pain CasesSuccess in Chronic Pain Cases

• Ability to live a meaningful lifeAbility to live a meaningful life• Improved daily functioningImproved daily functioning• Goal modification from pain Goal modification from pain

alleviation to lifestyle adaptationalleviation to lifestyle adaptation

• Decreased somatic focusingDecreased somatic focusing• Acceptance that certain medications Acceptance that certain medications

can decrease pain amplificationcan decrease pain amplification• Diminished need for medicationsDiminished need for medications• ComplianceCompliance

Success in Chronic Pain CasesSuccess in Chronic Pain Cases

• Importance of physician attitude Importance of physician attitude of hope and compassionof hope and compassion

• Ongoing relationship between Ongoing relationship between patient and health professionalpatient and health professional

Physician- Patient RelationshipPhysician- Patient Relationship

psychosocial factors are not understood by psychosocial factors are not understood by patientspatients

possibility of addiction issues influences possibility of addiction issues influences physician attitudephysician attitude

compensation issuescompensation issues Physician tendency to underestimate high pain Physician tendency to underestimate high pain

levelslevels

Most physicians feel patients Most physicians feel patients have pain but:have pain but:

Practice IssuesPractice Issues

• Limited timeLimited time

• Pain is one of many problemsPain is one of many problems

• Unrealistic expectationsUnrealistic expectations

• Adversarial relationshipAdversarial relationship

–disability, handicapped, Internetdisability, handicapped, Internet

•Patients still have painPatients still have pain

•Unusual drug combinationsUnusual drug combinations

•Psychiatric issues unaddressedPsychiatric issues unaddressed

Pain Specialist ReferralPain Specialist Referral

•Tests, diagnosis and procedures we Tests, diagnosis and procedures we do do not understandnot understand

– feel incompetent to deal with painfeel incompetent to deal with pain

•Behavior difficult to understandBehavior difficult to understand

•What to do with worsening painWhat to do with worsening pain

•Patient still has painPatient still has pain

Pain Specialist ReferralPain Specialist Referral

• You were so happy that the pain specialist You were so happy that the pain specialist is seeing your patientis seeing your patient

• She has back pain with a “normal” MRI. She has back pain with a “normal” MRI. She was using Vicodin® 2 qid with pain She was using Vicodin® 2 qid with pain levels of 6/10.levels of 6/10.

Pain Specialist ReferralPain Specialist Referral

• Multiple ESIs failedMultiple ESIs failed

• A discogram was done showing internal A discogram was done showing internal disc disruptiondisc disruption

• Intradiscal electrothermal therapy (IDET) Intradiscal electrothermal therapy (IDET) is partially successfulis partially successful

Pain Specialist ReferralPain Specialist Referral

• The patient returns for your continued The patient returns for your continued care on gabapentin, topiramate, care on gabapentin, topiramate, nortriptyline, fluoxetine, a lidocaine patchnortriptyline, fluoxetine, a lidocaine patch

• Morphine ER 120mg tid and Vicodin® 2 Morphine ER 120mg tid and Vicodin® 2 qid. Her pain level is 6/10qid. Her pain level is 6/10

Pain Specialist ReferralPain Specialist Referral

Primary Care and Chronic PainPrimary Care and Chronic Pain•Only providers able to cope with the number Only providers able to cope with the number

of patients with chronic painof patients with chronic pain

•Limited time but multiple, repeated exposures Limited time but multiple, repeated exposures to patient and familyto patient and family

– Seen patients in crisisSeen patients in crisis

– Aware of coping mechanismsAware of coping mechanisms

– Know family membersKnow family members

•Practicing disease management models and Practicing disease management models and not threatenednot threatened

•Uniquely positioned to deal with health care Uniquely positioned to deal with health care and undertreatment of pain crisisand undertreatment of pain crisis

ConclusionsConclusions

• Pain specialists are the best trained to Pain specialists are the best trained to deal with complicated, complex chronic deal with complicated, complex chronic pain patientspain patients

• In randomized clinical trials, In randomized clinical trials, interdisciplinary pain care always gives interdisciplinary pain care always gives the best pain relief, functional the best pain relief, functional improvement and costimprovement and cost

ConclusionsConclusions

• Interdisciplinary pain centers are closing Interdisciplinary pain centers are closing nationwide due to lack of reimbursementnationwide due to lack of reimbursement

• Primary care treats many complicated, Primary care treats many complicated, complex medical problemscomplex medical problems

• Primary care must learn to treat chronic pain Primary care must learn to treat chronic pain patientspatients