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

Results

Sample Findings

Our sample consisted of 20 PCCs (18 physicians and 2 nurse practitioners) who represented 13 clinics within 3 Indiana health care systems. Note, 1 PCC and 4 patients were in Illinois. The PCCs had an average of 14 years practicing post medical school (range, 2 to 34 years). Gender was balanced with 10 men and 10 women. Sixteen of the participants identified as white, 2 as black, and 2 as Asian. None of the participants identified as Hispanic or Latino.

Analysis Findings

Seven themes emerged through our analysis of factors that influenced PCCs to change chronic pain management plans. Below, we describe the themes and illustrate them with participant quotes. Many of the quotes we highlight involve opioids. We found these quotes particularly relevant given the current opioid crisis in the U.S. For context, half of the event and action pairs (43/86) included an action related to opioids (ie, start, switch, or change dose). Furthermore, most of the event and action pairs (77/86) included an action related to medications (ie, start, stop, switch, or change dose). About a third of the event and action pairs (28/86) included some type of nonmedication action (ie, referral). It is important to note that over half (44/86) of the event and action pairs included multiple actions (ie, stopping 1 medication, starting another, and ordering a referral).

1. Change in Patient Condition

A change in patient condition was the most common reason cited for changing a pain management plan. Over half (52 of 86) of the event and action pairs reveal changes stemming from events such as acute injuries, new contraindications, or changes in symptoms.

For acute injuries, changes to pain management plans typically included short courses of muscle relaxants or steroids, temporary increases in opioid medications, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy referrals, and rest, ice, compression, and elevation. Similarly, recent surgeries tended to result in temporary increases in opioid medications.

New contraindications, such as reduced kidney function or increased blood pressure, typically resulted in the discontinuation of specific medications such as NSAIDs. In 1 example, a recent fall by an elderly patient prompted a PCC to reconsider sedating medications.

"I stopped her amitriptyline given these falls because that was something that she was not getting a lot of clinical improvement from but was another sedating agent."
—PCC 12, Pt 44

New symptoms typically led to exploration of pain etiology including new tests, imaging, and referrals to specialists. New symptoms also led to the addition of new medications. For example, numbness and tingling led to the addition of gabapentin and depression symptoms led to the addition of duloxetine.

"[ I] suggested duloxetine to improve his pain control related to sleep and perhaps allow him to [ avoid the] nighttime narcotic. After all, that decision is based on clinical suspicion and experience that there may be… some emotional component, after his spouse was gone."
—PCC 24, Pt 94

Worsening pain associated with the progression of a chronic disease, resulted in the most varied changes in pain management. PCCs tended to try new medications and interventions in hopes of reducing pain and increasing function. In these cases, PCCs were also more likely to report gradually increasing the dose of opioids over time.

2. Outcomes Related to Treatment

Another common reason cited for changing a pain management plan related to the effects of treatment. Fifteen of the event and action pairs revealed changes resulting from side effects, ineffective treatment, and effective treatment.

Side effects typically resulted in the discontinuation of the suspected treatment. For example, gastric upset frequently led to the discontinuation of NSAIDs. When treatments were ineffective, PCCs tended to discontinue the treatment and try something new. For example, when a patient reported that cyclobenzaprine did not help, the PCC switched to pregabalin. When a patient reported that tramadol did not help, the PCC switched to hydrocodone. In another example, an aging patient with declining health was on a high dose of opioids and not improving. The lack of improvement prompted the PCC to decrease the opioid.

"So, at some point, I did start cutting her back because, I mean, I was at a point where it clearly was not working. And I felt like continuing it was not going to be, you know, in her best interest…"
—PCC 2, Pt 5

When treatments were effective, PCCs often reduced other, less desirable, medications. In 1 case, as epidurals were introduced and pain was reduced, opioids were then decreased. In another case, the patient's weight loss opened up a new treatment option (knee surgery), which was ultimately successful, and led to the reduction of opioids.

"She was on the higher dose of medicine and was having a lot of problems, and then when she had her knee replaced last year, in the immediate postoperative period she needed more, but after that, after about a month or 2 after her surgery, her right knee pain got significantly better."
—PCC 20, Pt 71

3. Nonadherent Patient Behavior

Nonadherent patient behavior was also cited as a reason for changing a pain management plan. Nine of the event and action pairs revealed changes that were triggered by nonadherent patient behavior. In some examples, patients violated their opioid contracts by acquiring additional pain medication from other clinicians following surgery. In these cases, PCCs responded by reducing the opioid prescription and scheduling more frequent visits to monitor progress and discuss addiction. In some cases, such as when a patient used illicit drugs or acquired a legal substance illicitly, PCCs responded by weaning opioids or recommending treatment for substance abuse disorder.

"Then her substance abuse became clearly evident because she failed her regular urine [ toxicology test]. [ Opioids] were slowly weaned off."
—PCC 3, Pt 7
"And then [ she] did finally admit a couple of weeks after I initially met her that she had been buying them off the street. So, we got her into our Suboxone program and started her on Suboxone at that point. Which is for addiction, not so much for her pain, but… with her it is really all kind of mixed in with mental health and it is a complicated picture."
—PCC 22, Pt 88

In another case, a patient reported giving his opioids to his wife who was in pain. The PCC responded by reducing the opioid prescription and encouraging the wife to seek treatment for her own pain. The reduction was, in part, a recognition that the patient no longer needed as many pills if he was able to divert some to his wife.

4. Insurance Constraints

Concerns about insurance coverage also led to changes in pain management plans. Four of the event and action pairs revealed changes that were prompted by insurance concerns. In 1 case, a patient was doing well on celecoxib, but insurance stopped covering it, and the patient could not afford to pay for it out-of-pocket. The PCC switched to naproxen, but the patient did not respond to it as well as the celecoxib. Eventually, the patient started a new insurance plan and the PCC was able to resume celecoxib. In another case, a PCC tried to order pregabalin, but the insurance provider wanted the PCC to try other less expensive options first. Therefore, the PCC considered nortriptyline, but the patient worked in law enforcement and did not want any medications associated with depression on their medical record, leading to a further change to gabapentin.

"[ Insurance] basically wanted me to try cheaper medications beforehand. So, I backed off. We originally did nortriptyline, but because he's a [ law enforcement officer], he did not want anything associated with a… mental diagnosis like depression. So, we stopped—we never actually used the nortriptyline… we immediately switched him over to the gabapentin."
—PCC 8, Pt 35

5. Change in Guidelines, Laws, or Policies

In some instances, pain management plans were changed in response to new opioid prescribing guidelines, laws, and institutional policies. This occurred in 3 of the event and action pairs. Examples of changes to pain management plans included reducing opioids, avoiding opioids and benzodiazepines, and using other modalities of pain management.

"So, when the [ state] laws came down, I went to the conference downtown about it… Now the safety factor of giving benzos and opioids within last year with the CDC has gotten even bigger. Somewhere, I want to say along [ that timeline], I started weaning her off of benzos."
—PCC 5, Pt 26
"These days since we are cutting people, because of the new guidelines, you know, we're cutting people back on narcotics so much, I've been using a lot more of gabapentin, Lyrica, Cymbalta, that type of stuff, not just for neuropathy, but for even like osteoarthritis pain too."
—PCC 4, Pt 27

6. Approaches to New Patients

Some PCCs described rules of thumb that would trigger a change in pain management for new or transferred patients. This occurred in 2 of the event and action pairs. In both examples, PCCs described an opioid "threshold dose" for new patients. Opioids were reduced for new patients that exceed the threshold.

"Any patient of mine that is on 10 to 325, I've inherited, and I always try to wean them down to 1 of the lower doses."
—PCC 19, Pt 61
"I put her down to 30 and kind of took us away from that red flag dosing of narcotics and so I could get to know her better… we went ahead and did a pain contract even though the medications were not really high enough technically for a pain contract. I went ahead and did a pain contract to emphasize—and I kind of educated her about the dangers of the medications, risk of overdose and that it is habit forming, etc."
—PCC 8, Pt 32

7. Recommendations From Specialists

Specialist recommendations can also lead to changes in pain management plans. One event and action pair revealed a change that resulted from a specialist recommendation. In the following example, a neuroradiology specialist recommended a referral to surgery. The PCC followed the recommendation but had concerns with the proposed treatment.

"So the neuroradiology people had suggested we have her see pain doctors because they do things like pain pumps and stuff like that so I put in that referral, a neurosurgery referral, though I hate to have her have more back surgery… "
—PCC 11, Pt 41

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