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


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

In This Article


Our study aimed to identify factors that influence PCCs to change existing pain management plans. The 7 factors we identified are depicted in Figure 1. In a related analysis, team members looked at the broader factors that influence sensemaking regarding chronic pain.[24] The sensemaking factors include external social/environmental factors, patient factors, and clinician characteristics. The factors we identify in this article fit neatly into those broader categories, lending support to our findings.

Figure 1.

What leads to changes in existing chronic pain management plans? Seven themes emerged in our analysis of factors that influenced changes to chronic pain management plans based on interviews with primary care clinicians from 2016 to 2018.

Chronic pain is notoriously difficult to treat due to frequent etiologic ambiguity and limited availability of efficacious and safe interventions.[2,6] These difficulties may be exaggerated in the primary care context, where PCCs have limited training in pain management, minimal available time, and concerns about legal issues related to pain medications.[3,7] New education and policy as well as point-of-care interventions, such as clinical process redesign, and clinical cognitive support tools may help clinicians navigate pain management more effectively and efficiently.

It is notable that when asked, none of the PCCs in our sample reported using cognitive support tools (or information from such tools) as a trigger for changing a pain management plan. This represents a potential leverage point as cognitive support tools could help PCCs identify and track factors that influence changes to pain management. We recommend future research to develop, implement, and assess the effectiveness of such innovations. As a step in that direction, we highlight an insight from each influencing factor and propose a related practice innovation (Table 1). These potential practice innovations are inspired by our findings. We do not intend to imply that our findings provide evidence regarding the utility of these broad innovations; rather, they are intended to inspire future research and exploration based on our understanding of the challenges described by PCCs and the decision strategies they report.

Our study has potential limitations. First, our sample consisted of PCCs, not pain specialists. However, PCCs treat most patients with chronic pain[3] and are arguably in greater need of cognitive support because they are less likely to receive formal training in pain management than pain specialists. Future investigations could look at the difference between what causes PCCs to change their pain management plans versus pain specialists. A second limitation is potential bias in selection of patients; it is possible that patients may have been selected to represent certain issues or their resolution. A third limitation is reliance on PCC recall of treatment events. Although we conducted our interviews within 3 days of the patient visit and encouraged PCCs to use their electronic notes to verify historic information, there is risk that recall is incomplete. While most of the participants did consult the electronic health record (EHR) at some point in their interview, we do not know how many of the excerpts used in this analysis were derived from information obtained in the EHR. Although retrospective accounts are vulnerable to errors in recall, the Critical Decision Method technique is designed to improve accuracy of recall and provides insight into the context and rationale behind decision making, not easily obtained via other methods.[22,25] Future investigations could validate our naturalistic observations with patient data. A fourth limitation involves the location and timing of our study. Our sample of US PCCs could have amplified a focus on opioids. In Europe, for instance, opioid treatment is relatively limited.[26] Future investigations could look at what influences non-US PCCs to change their pain management plans. Notably, the influence of pharmaceutical companies did not emerge in our themes. This is surprising given research that links opioid marketing to increased prescribing.[27] It is possible that marketing efforts influence the type of response but are not, by themselves, a trigger for action. Future investigations could track these themes over time to identify shifts in influencing factors. Future investigations should also include patients in the analysis process.