Factors That Influence Changes to Existing Chronic Pain Management Plans

Julie Diiulio, MS; Laura G. Militello, MA; Barbara T. Andraka-Christou, JD, PhD; Robert L. Cook, MD, MPH; Robert W. Hurley, MD, PhD; Sarah M. Downs, MPH; Shilo Anders, PhD; Burke W. Mamlin, MD; Elizabeth C. Danielson, MA; Christopher A. Harle, PhD

Disclosures

J Am Board Fam Med. 2020;33(1):42-50. 

In This Article

Abstract and Introduction

Abstract

Background: The objective of this qualitative study is to better understand primary care clinician decision making for managing chronic pain. Specifically, we focus on the factors that influence changes to existing chronic pain management plans. Limitations in guidelines and training leave clinicians to use their own judgment and experience in managing the complexities associated with treating patients with chronic pain. This study provides insight into those judgments based on clinicians' first-person accounts. Insights gleaned from this study could inspire innovations aimed at supporting primary care clinicians (PCCs) in managing chronic pain.

Methods: We conducted 89 interviews with PCCs to obtain their first-person perspective of the factors that influenced changes in treatment plans for their patients. Interview transcripts were analyzed thematically by a multidisciplinary team of clinicians, cognitive scientists, and public health researchers.

Results: Seven themes emerged through our analysis of factors that influenced a change in chronic pain management: 1) change in patient condition; 2) outcomes related to treatment; 3) nonadherent patient behavior; 4) insurance constraints; 5) change in guidelines, laws, or policies; 6) approaches to new patients; and 7) specialist recommendations.

Conclusions: Our analysis sheds light on the factors that lead PCCs to change treatment plans for patients with chronic pain. An understanding of these factors can inform the types of innovations needed to support PCCs in providing chronic pain care. We highlight key insights from our analysis and offer ideas for potential practice innovations.

Introduction

Up to 100 million adults in the United States are affected by chronic pain, leading to an economic cost that exceeds that of heart disease.[1] Due to an undersupply of specialist pain management physicians, primary care clinicians (PCCs) are mainly responsible for pain management care for chronic noncancer pain.[2,3] Despite their important role in managing pain, PCCs have limited training in pain management.[3,4] Even with training, chronic pain management is complex due to its biopsychosocial nature, etiologic ambiguity, lack of effective treatments, and limited PCC time.[2,4–7] Several best practice guidelines have been created to assist clinicians in treating pain.[8–10] However, studies have demonstrated a low level of guideline adherence for a variety of reasons.[10–15] Furthermore, little is known about how interventions should be tailored for individual patients rather than for the average patient.[6]

Limitations in guidelines and training leave PCCs to use their own judgment and experience in managing the complexities associated with treating patients with chronic pain. Several studies have looked at the effects of demographic factors on opioid prescribing for chronic pain.[10,16–21] Chen et al[17] indicated that a patient's specific pain diagnosis plays an important role in prescribing opioids. Turk and Okifuji[21] found that behavioral manifestations of pain, especially nonverbal communication, and reports of functional disability, were important factors in pain management decisions. However, to our knowledge, few studies have examined the factors that lead PCCs to change already existing chronic pain management plans.

Our study extends prior research by employing naturalistic methods to explore PCC decision making for managing chronic pain. We use concrete examples of specific patients, described from the PCC's first-person perspective, to elucidate the factors that influence changes to existing chronic pain management plans. Understanding these factors is important because they can be used to ideate innovations aimed at supporting PCCs on the front lines of chronic pain care.

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