Chronic Pain in Primary Care

Bill H. McCarberg, MD

Disclosures

October 14, 2009

Question

The primary care physician is the point of service entry into our medical delivery system. This doctor is the one initially seen for almost every type of disorder. Why is our opioid policy so restrictive that most primary care physicians will not touch the needs of patients with chronic pain? This places an extreme burden on a dwindling number of chronic pain specialists.

Response from Bill H. McCarberg, MD
Assistant Clinical Professor, Department of Family Practice, University of California San Diego School of Medicine; Founder, Chronic Pain Management Program, Kaiser Permanente, San Diego, California

The primary care physician is usually the point of service entry into our healthcare system. This could be the family physician, internist, osteopath, pediatrician, gynecologist, or a variety of physician assistants and nurse practitioners. The initial work-up occurs at a primary care facility, and treatment is rendered. In most acute problems, with the help of the providers and the natural healing process of the body, the symptoms resolve. When the problem continues despite appropriate interventions or the condition is persistent (eg, diabetes, congestive heart failure), continuing care and management usually occur at the primary care level.

Seventy percent of patients with acute pain do not seek medical attention; the delay often results from the hope that they can manage the pain on their own.[1] Moderate to severe pain is still one of the most common reasons for primary care visits in the United States.[2,3] In a 2008 survey, more than 1 in 4 Americans reported an episode of pain during the previous year.[1] Acute pain is a protective, biological process resulting from trauma or injury to tissue, usually of rapid onset and limited duration with an identifiable source.[4,5] Acute pain is prevalent, resulting in disruptions in activities of daily living, work absenteeism, and reduced productivity.[1]

Inadequately treated acute pain also may lead to adverse physiologic changes, including cardiac dysfunction, impaired immunity, and the development of chronic pain.[6] Increased activity in peripheral and central nociceptive pathways can lead to plastic changes in neural circuits that perpetuate such acute pain symptoms as allodynia (painful responses to normally nonpainful stimuli) and hyperalgesia (increased sensitivity to painful stimuli), often after the initial insult has resolved.[7]

Pain remains undertreated, especially in the primary care setting. Even when patients make the decision to visit a healthcare professional, inadequate training and resources may prevent proper assessment of their condition.[2] Deficiencies in pain management related to patient gender, race, and socioeconomic status have been reported.[8]

The treatment of pain varies according to the cause. Determining the underlying problem and resolving the condition are usually adequate to treat acute pain. In persistent pain, lifestyle changes, medication, and adaptation are frequently needed. In both of these circumstances, opioids can be a valuable option. For any of us who have suffered with pain, the efficacy of opioids cannot be underestimated. The contribution of opioids to improved function, sleep, mood, and pain has been demonstrated in multiple trials.[9] Yet reluctance to use opioids in primary care is increasing.

Over the past 3 decades, there have been changes in opioid prescribing in the United States. With the establishment of pain medicine as a specialty and more understanding and knowledge about the mechanisms of pain, vast improvements were seen in patient comfort, acute pain recovery times, and functional improvements.[2] Observing a continuing unmet need in pain management, state medical boards developed intractable pain acts to encourage all providers to manage pain more effectively. Texas passed the first such act in 1989.[10] By following the guidelines stated in the intractable pain acts, providers were protected from state medical board sanction when prescribing opioids. Several states developed similar acts, and then the Federation of State Medical Boards created Model Guidelines for the Use of Controlled Substances for the Treatment of Pain. In 2004, these guidelines were updated to a Model Policy. Twenty-eight state medical boards have adopted the Model Policy verbatim, and 10 other states have adopted guidelines with similar language.[11]

Despite these advances, primary care physicians are increasingly hesitant to prescribe opioids. Reasons for this reluctance include compliance with treatment, the possibility of adverse effects or abuse related to analgesic medications, limited access to interdisciplinary care, and perceived regulatory scrutiny.[12,13]

As the therapeutic use of opioids has increased in recent years, so too has the misuse and abuse of these agents.[14] This has contributed to concerns among some clinicians and patients that opioid therapy will lead to addiction among pain patients,[15] although only a small percentage of pain patients actually develop iatrogenic addiction.[16] Some of this confusion may stem from inconsistent use of the terminology associated with opioid use, abuse, and addiction. Critical for understanding patient responses and behavior is recognizing the differences between such terms as addiction, dependence, and tolerance, which will lead to the development of appropriate treatment and referral plans.[17]

The public health is not best served by decreasing the medical use of opioids even with increases in prescription opioid misuse and abuse. This highlights the need for examination of the potential for inappropriate medication use as part of an individualized risk-benefit analysis that should be conducted for every patient being considered for opioid therapy. Risk for aberrant drug use depends more on genetic and psychosocial factors, including personal and family history of drug abuse, the presence of psychiatric disorders, and a potential patient agenda for euphoria and abuse, rather than the mere exposure to an opioid.[18]

The majority of patients who present to their primary care provider will be considered low risk and can be managed routinely in this setting.[19] Others with a known past history of substance abuse, or a psychiatric disorder may require consultation or referral to an appropriate specialist. Such an approach benefits the patient, the prescriber, and society as a whole by making this essential analgesic class available to patients in pain, while reducing the risk associated with the prescribing of opioids.

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