Chronic Pain Management
Why is this important?
Chronic pain is both a common and challenging problem in primary care settings. Approximately 116 million Americans have chronic pain.  Pain accounts for up to 20% of all outpatient visits costing over $600 billion dollars per year in direct medical treatment and lost productivity costs.  Adequate treatment of pain is recognized as an essential dimension of quality medical care. The Institute of Medicine’s 2011 blueprint for “Relieving Pain in America,”  includes the following principles: effective pain management is a moral imperative; and that there is value in comprehensive pain treatment that includes interdisciplinary approaches with treatment effectiveness depending greatly on the strength of the clinician-patient relationship. The Mayday Fund Special Committee  on Pain and the Practice of Medicine’s number one recommendation is that “every American who suffers from chronic pain should have 24/7 access to a well-trained primary care provider who can offer – and coordinate – pain care that is high-quality, equitable, and cost-effective.” This is similar to a “strong” recommendation made by the American Pain Society and American Academy of Pain Medicine Opioids Guidelines Panel  – “patients on chronic opioid therapy (COT) should identify a clinician who accepts primary responsibility for their overall medical care. This clinician may or may not prescribe COT, but should coordinate consultation and communication among all clinicians involved in the patient’s care.” The US Department of Health and Human Services and World Health Organization (WHO) have disseminated clinical practice guidelines for the management of pain, however these guidelines are not universally followed.
The assessment and management of chronic pain is complex. Chronic pain by definition continues beyond the usual recovery period for an injury or illness. There are a myriad of conditions that result in “chronic pain” and thus, there is no single effective treatment modality. In addition, there is controversy regarding the effectiveness and safety of COT for the treatment of chronic pain. The increase use of COT for chronic pain has coincided with increases in prescription opioid misuse  and unintentional opioid events and deaths.  While the exact percentage of patients on COT who misuse prescriptions, have an opioid overdose event or death is not clear,  the thought of it creates a profound apprehension for prescribers, even when it may be both safe and effective for the patient. Chronic pain is managed primarily in primary care with only 5% of patients ever receiving consultation from a pain specialist . This is in part due to the paucity of pain specialists as there are only 6 board certified pain physicians per 100,000 adult patients with chronic pain.  Management of chronic pain is ideally suited for a Patient Centered Medical Home model that seeks to strengthen the physician-patient relationship by coordinating care.
How will these tools help?
The tools and resources described in this module may improve outcomes for patients and for the practice. Patient tools and resources will include various resources related to patient engagement in multi-modal treatments, including self-management techniques. The patient will learn how to set realistic and achievable goals to reduce pain and improve function while ensuring his/her safety. Practice tools and resources will help you increase the effectiveness and safety when caring for patients with chronic pain. These practice improvements will be achieved through the universal use of individualized chronic pain management plans. These plans will be based on evidence-based and/or guideline-recommended assessment strategies to measure baseline pain, function and opioid misuse risk, and monitoring strategies to measure and balance benefit versus risk. Documentation strategies will allow for documenting pain and functional improvement over time, as well as recognizing safety concerns such as early signs of opioid misuse (aberrant medication taking behaviors). A registry of patients suffering with chronic pain is the hallmark of the Patient Centered Medical Home. Chronic pain clinical registry outcomes evaluation, performed at the practice level, identifies opportunities for quality improvement initiatives. Pain intensity and functional level should be measured for treatment effectiveness. Medication safety would be targeted through standardized patient education and the use of informed consents. High cost testing (e.g., repeated imaging tests) and acute care utilization (e.g., emergency room visits) would be tracked to evaluate coordinated chronic pain care. Key elements of documentation would be tracked in order to ensure accordance with best practice standards. Finally, patient satisfaction of chronic pain care would be tracked as a target outcome.
1 Institute of Medicine. Relieving Pain in America: A Blue Print for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.
2 A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform. The Mayday Fund Website.
3 Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O’Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C, For The American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-130.
4 Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD; 2010.
5 Centers for Disease Control and Prevention. Drug-induced deaths - United States, 2003-2007. MMWR 2011;60(Suppl):1-114.
6 Bohnert AS, Vale, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. JAMA. 2011;305(13):1315-1321.
7 Breuer B, Pappagallo M, Tai JY, Portenoy RK. U.S. Board-Certified Pain Physician Practices: Uniformity and Census Data of Their Locations. J Pain. 2007;8(3):244-250.
This module is intended for the following practice staff:
- Physician Assistants
- Nurse Practitioners
- Registered Nurses
- Medical Assistants
- Practice Managers
The content of this module was written and many of the resources were provided by:
Daniel P. Alford, MD, MPH, FACP, FASAM, Associate Professor of Medicine and Assistant Dean of Continuing Medical Education, Boston University School of Medicine
Leanne M. Yanni, MD; Bon Secours Richmond Health System - Palliative Medicine; Richmond, VA
This module was made possible by funding from Endo Pharmaceuticals, Inc.
- 1.00 Attendance