Chronic Pain Management in Primary Care

Bill McCarberg, MDFounderChronic Pain Management ProgramKaiser PermanenteSan Diego, California

Adjunct Assistant Clinical Professor University of CaliforniaSchool of MedicineSan Diego, California

PresidentWestern Pain Society

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The Problem

• 65 million chronic pain patients in the United States• 6000 pain specialists• 120,000 primary care providers

• The next major advancement in pain medicine will be in the training and expertise of the primary care provider - family medicine, internist, ob/gyn, pediatrics, nurse, nurse practitioner, physician assistant

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Barriers to Treatment

• Knowledge• Regulation• Bias

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Chronic Pain Conundrum

The most difficult issue now facing physicians “…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.”

Ballantyne JC, Mao J. N Engl J Med. 2003;349:1943-1953.

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Opioids in Chronic Pain• Strong push to use more opioids

– Federation of State Medical Boards– Medical Boards encourage use—Intractable

Pain Acts• Still controversial

– May Day Project– Increased use and awareness of prescription

drug abuse– Physician and, patient fear, bias,

misunderstanding— Rush Limbaugh– Regulatory oversight is real

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Opioid Analgesia—1990s

Old Teaching1. All patients get

addicted to narcotics2. Side effects limit

effectiveness3. Save until pain is

really bad - tolerance4. Pain is not life

threatening

New Thoughts1. Almost no one gets

addicted to opioids2. Side effects can be

managed3. Treat pain early -

tolerance is exaggerated4. Pain kills

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Opioid Analgesia—2000s

Old Teaching1. All patients should be given a trial

of opioids2. No ceiling effects for opioids3. High pain levels require opioids as first-line

agents4. Even addicts do

well on opioid therapy

New Thoughts1. In some patients, risks may be too high for

opioids2. As doses increase, effects lessen;

hypersensitization3. Pain levels alone do not dictate opioids4. Significant practice issues in monitoring

patients on opioids

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Practice Issues

• Limited time• Pain is one of many problems• Unrealistic expectations• Adversarial relationship

– Disability, handicap, Internet

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Top Concerns Among PCPs (N=248)

84.2

74.968

60.7

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0102030405060708090

100

Precriptionabuse

Addiction Adverseevents

Tolerance MedicationInteractions

Bhamb B, et al. Curr Med Res Opin 2006;22(9):1859-65.

n=208 n=185 n=150n=168 n=79

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

number of patients with chronic pain• Limited time but multiple, repeated

exposures to patient and family– Seen patients in crisis– Aware of coping mechanisms– Know family members

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Primary Care and Chronic Pain• Practicing disease management models

and not threatened• Uniquely positioned to deal with health

care and the undertreatment of pain

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Chronic DiseaseCondition

ASCVDStroke

HypertensionDiabetes

COPDAsthma

Primary Care86%91%92%90%89%94%

Others14% 9% 8%10%11% 6%

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

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Interdisciplinary Pain Management

Integrated Coordinated

Neurologist

Social Worker

Pain Specialist

Physical Therapist

Psychiatrist

Anesthesiologist

Physiatrist

Psychologist

Nurses

Spine Surgeon

Occupational Therapist

Pharmacist

Physician Assistant

Primary Clinician

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Legal• 5th Vital Sign

• Joint Commission on Accreditation of Healthcare Organizations

• Decade of Pain Control and Research

• AB 487

• Litigation

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• Cancer - homogeneous• Noncancer Pain - heterogeneous

Opioid Literature

16 Passik & Weinreb, 1998

• Analgesia (pain relief)

• Activities of Daily Living (psychosocial functioning)

• Adverse effects (side effects)

• Aberrant drug taking (addiction-related outcomes)

The Four A’s of Treatment Outcomes

17 After Portenoy, in press.

Aberrant BehaviorProbably more predictive

• Selling prescription drugs• Prescription forgery• Stealing or borrowing another

patient’s drugs• Injecting oral formulation• Obtaining prescription drugs from

non-medical sources• Concurrent abuse of related illicit

drugs• Multiple unsanctioned dose

escalations• Recurrent prescription losses

Probably less predictive• Aggressive complaining about need

for higher doses• Drug hoarding during periods of

reduced symptoms• Requesting specific drugs• Acquisition of similar drugs from other

medical sources• Unsanctioned dose escalation 1 – 2

times• Unapproved use of the drug to treat

another symptom• Reporting psychic effects not

intended by the clinician

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Substance Abuse Issues Complicate Pain Treatment

• Trust issues

• Differentiating between analgesia and other effects of opioids

• Dysfunctional family issues

• Legal issues

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What is the Risk of Addiction?

• Boston Collaborative Drug Surveillance Project: Porter and Jick, 1980. NEJM• 4 cases of addiction in 11,882 patients with no prior

history of abuse who received opioids during inpatient hospitalization

• Dunbar and Katz, 1996. JPSM• 20 patients with both chronic pain and substance

abuse problems on chronic opioid therapy

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What is the Risk of Addiction?

• Dunbar and Katz, 1996. JPSM– Nine out of 20 abused medication– Of the 11 who did not abuse the medications, all were

active in recovery programs with good family support

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<1% ~ 45%

LOWShort-term exposure to opioids in

non-addictsPorter and Jick

HIGHLong-term

exposure to opioids in addicts,

Dunbar and Katz

Where is your patient?

Spectrum of Risk of Addictionor Aberrant Behavior

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Can You Define Addiction?

45 year old female with achiness everywhere, disabled, poor sleep, daytime fatigue, having trouble functioning at home. 4 Vicodin a day used to work, now 8 Vicodin does not help the pain.

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Can You Define Addiction?55 year old male with back pain, S/P a two level laminectomy followed a year later by a fusion and the pain continues. He is out of town and runs out of his Percocet®. He develops nausea, tremors, diarrhea, a low grade fever and begins to hallucinate.

24 Weissman DE, Haddox JD. Oploid pseudo addiction- an iatrogenic syndrome. Pain 1989;36:363.

Pseudo-Addiction

Pattern of drug seeking behavior of pain patients receiving inadequate pain management that can be mistaken for addiction– Cravings and aberrant behavior– Concerns about availability– “Clock-watching”– Unsanctioned dose escalation

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Addiction

• Neurobiologic disease– genetic, – psychosocial– environmental factors

• Characterized by: – Impaired control over drug use– compulsive use, – continued use despite harm– craving

Consensus DocumentThe American Academy of Pain MedicineThe American Pain SocietyThe American Society of Addiction Medicine

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DSM-IV Substance Dependence

• Tolerance• Physical dependence/withdrawal• Used in greater amounts or longer than intended• Unsuccessful attempts to cut down or discontinue• Much time spent pursuing or recovering from use• Important activities reduced or given up• Continued use despite knowledge of persistent

physical or psychological harm

Sees and Clark, J Pain and Symptom Management 1993

3/7 required for diagnosis5/7 common in non-addicted pain patients

27 (Passik & Portenoy 1996)

Differential Diagnosis of Aberrant Drug-Taking Attitudes and Behavior

• Addiction

• Pseudo-addiction (inadequate analgesic)

• Other psychiatric diagnosis• Encephalopathy• Borderline personality disorder• Depression • Anxiety

• Criminal Intent

PAIN MANAGEMENTTREATMENT PLAN AGREEMENT

COVER SHEET

Date initiated: _______________

Purpose: The purpose of this Agreement is to prevent misunderstandings about certain medicines I will be taking for pain management. This is to help both my doctor and me to comply with the law regarding controlled medications.

I understand that this Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this Agreement.

LEVEL 1 PAIN MANAGEMENTTREATMENT PLAN AGREEMENT

I, _______________________ hereby acknowledge that my physician, __________________ has informed me that ___________which is being prescribed for my diagnosis of ________________ involves possible risks. These risks are listed on the cover sheet of this treatment plan agreement. Because of the potential problems of dependency and/or overuse, I agree to use this medication no more frequently than _________________ unless specified by future agreement with my physician. I will inform any health care providers that treat me that I am taking the medication(s) listed above, and that I have a Medication Agreement with my doctor. I will seek refills of the above medication from _______________ .

LEVEL 2 PAIN MANAGEMENTTREATMENT PLAN AGREEMENT

I, __________________________________ hereby acknowledge that my physician, (Patient name)

_______________________________, has informed me that s/he is concerned with (Physician name)my prescription drug usage. S/he has advised me of available counseling for

this issue. I will seek refills of the medication listed below from

_______________________________ or his/her representative at the medical (Physician name)

office at _________________________________, and not from any other provider. (Location) I am aware taking this medication involves certain risks, and these risks are listed onthe cover sheet of this treatment plan agreement.

I will not use any illegal substances, including, but not limited to marijuana, cocaine, methamphetamines, or heroin.

I will not share, sell, or trade my medication with anyone.

I will inform any health care providers that treat me that I am taking the medicationslisted below, and that I have a Medication Agreement with my doctor.

I will not attempt to obtain any controlled medicines, including opioid (narcotic) pain medicines, narcotic cough medicines, controlled stimulants, or antianxiety medicines from any other source.

I will safeguard my pain medicine from loss or theft. “lost” or “ stolen” medications suggest medication abuse and the medicine may not be replaced.

I agree that I will use my medicine as prescribed, and will not take more thanprescribed. I understand that use of my medicine at a greater rate than prescribed may result in my being without medication for a period of time. I understand that if this occurs I may experience withdrawal symptoms.

I hereby agree that I will use _______________________________________________ Name of drug(s)

______________________________________________________________________

no more frequently than __________________________________________________ sig or other range (e.g., #tablets/day, #tablets/month)

______________________________________________________________________

unless specified by future agreement with my prescribing physician. I am taking

this medication to treat my problem of ____________________________________. (Diagnosis or problem, e.g., chronic back pain)

I agree that refills of my prescriptions for pain medicine will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends. I understand that it is desirable to make refill requests one week before they are due.

I am aware that communication will occur in such a manner as to discourage any other physicians from dispensing medication to me except in cases of emergency.

I agree to follow these guidelines, and that they have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered.

I understand that if I break this Agreement, my doctor may stop prescribing these pain-control medicines and no further such medications may be prescribed by Kaiser Permanente physicians or filled at Kaiser pharmacies.

I understand that should I fail to abide by the above usage plan that my membership in the Kaiser Permanente Health Plan may be subject to termination.

Follow-up issuesI agree to schedule and keep appointments with prescribing physician as instructed.

I agree to schedule and keep appointments with consulting health care providers, laboratory tests and diagnostic tests as recommended by prescribing physician.

I realize that all of the medications have potential side effects, and I will have the recommended laboratory studies required to keep the treatment as safe as possible.

I agree to attend Chronic Pain Management Program classes.

Compliance issuesI agree that I will submit to a blood or urine test if requested by my doctor to

determine my compliance with my program of pain control medicine.

I will bring all unused pain medicine to every office visit.

Adding more restrictions:I understand that I must request medication refill 7 (seven) days in advance.I agree to use _______________________________________ Pharmacy, located at

________________________, for filling prescriptions for all of my pain medicine.

I understand that I will only get 1 (one) week's supply of medication at one time.

I understand that only I am allowed to pick up my medications, and that I will be asked for a photo identification.

My signature below indicates that a copy of this document has been givento me.

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Conclusions

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

• Interdisciplinary pain care gives the best pain relief, functional improvement, and cost

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Conclusions

• Interdisciplinary pain treatment has become a single provider working with multiple specialists