Bill McCarberg, MD Director: Chronic Pain Program Kaiser Permanente San Diego, California Assistant Clinical Professor (

1. The Role of the Primary Care Physician in Pain Management Bill McCarberg, MD Director: Chronic Pain Program Kaiser Permanente San Diego, California Assistant Clinical Professor (Voluntary) University of California School of Medicine San Diego, California Chair - Managed Care Committee American Pain Society

2. Conclusions • 65 million chronic pain patients in the United States • 6000 pain specialists • Primary care must becomes more involved Boarded through American Academy of Pain Medicine or American Board of Medical Subspecialists

3. Chronic Disease Primary Care 86% 91% 92% 90% 89% 94% Others 14% 9% 8% 10% 11% 6% Condition ASCVD Stroke Hypertension Diabetes COPD Asthma Data based on 1996 Medical Expenditure Panel Surveys. Annals of Family Medicine Vol 2 Suppl 1 March/April 2004

4. Pain Specialist Nurses Psychiatrist Spine Surgeon Neurologist Pharmacist Physiatrist Social Worker Psychologist Anesthesiologist Occupational Therapist Physician Assistant Physical Therapist Interdisciplinary Pain Management Integrated Coordinated Interdisciplinary Primary Clinician

5. Annual Mean Cost Per Patient By Condition (Age-Adjusted) Stroke HIV Infection Dementia Cancer Heart Disease Pregnancy Multiple Sclerosis Diabetes Respiratory Disease Panic Disorder Gastrointestinal Disease Depression Anxiety Hypertension Arthritis Chronic Pain Group Health Cooperative of Puget Sound Health Affairs 16:3

6. Total Annual Costs By Chronic Condition(Number of patients x Mean cost per patient millions) Panic Disorder Multiple Sclerosis HIV Infection Anxiety Dementia Stroke Pregnancy Depression Cancer Arthritis Gastrointestinal Disease Diabetes Respiratory Disease Hypertension Heart Disease Chronic Pain Group Health Cooperative of Puget Sound Health Affairs 16:3

7. Managed Care Survey • How pain currently being managed • Impediments to pain management • Beliefs about opioid prescribing • Beliefs about treatment effectiveness

8. Managed Care Survey – Characteristics of Sample • 74 administrators from managed care • Size: 2,200 to 25 million covered lives Health Plan Employer Data and Information Set (HEDIS) does not yet include a measure for pain management.

9. Results of the Survey –Current Treatment • 2/3 of the sample did not have identified pain management programs • 59% acknowledged that there were no specific guidelines in place for handling pain • 75% acknowledged that they believed such programs could reduce costs

10. Rank Most Difficult Pain Problems Mean Rank Back pain 1.5 Headache 2.8 Fibromyalgia 3.2 Neck/Shoulder pain 4.2 Arthritis 4.4 Diabetic Neuropathy 4.8 Cumulative Trauma 4.8 Pelvic pain 5.1 Other 3.6

11. Results of the Survey – Non-pharmacological Treatments • 60% agreed there was good evidence to support the effectiveness of rehabilitation programs • Frequently deny payment for rehabilitation programs

12. Results of the Survey – Patient Education • 84% self-management is an important aspect of pain management • 11% believed that their organizations did a good job of educating patients about their pain

13. Chronic PainDisease Management • Chronic pain like other chronic diseases lends itself to disease management • Primary care best equipped for disease management

14. Legal • 5th Vital Sign • Joint Commission on Accreditation of Healthcare Organizations • Decade of Pain Control and Research • AB 487 • Litigation

15. Barriers to Treatment • Knowledge • Regulation • Bias

16. Primary Care Research • 56 physician questionnaires • 7 extensive interviews • Different cultures, gender, locations, ages

17. Primary Care Research • Some physicians’ reliance on outdated pain theories • Inadequate physician training • Biases concerning opioid use • Meanings attached to pain that affect its perception

18. Research - Issues • Chronic pain issues: • no standard chronic pain treatment • cannot deal with suffering connected with pain

19. Success in Chronic Pain Cases • Ability to live a meaningful life • Improved daily functioning • Goal modification from pain alleviation to lifestyle adaptation

20. Success in Chronic Pain Cases • Decreased somatic focusing • Acceptance that certain medications can decrease pain amplification • Diminished need for medications • Compliance

21. Physician- Patient Relationship • Importance of physician attitude of hope and compassion • Ongoing relationship between patient and health professional

22. Most physicians feel patients have pain but: • psychosocial factors are not understood by patients • possibility of addiction issues influences physician attitude • compensation issues • Physician tendency to underestimate high pain levels

23. Practice Issues • Limited time • Pain is one of many problems • Unrealistic expectations • Adversarial relationship • disability, handicapped, Internet

24. Pain Specialist Referral • Patients still have pain • Unusual drug combinations • Psychiatric issues unaddressed

25. Pain Specialist Referral • Tests, diagnosis and procedures we do not understand • feel incompetent to deal with pain • Behavior difficult to understand • What to do with worsening pain • Patient still has pain

26. Pain Specialist Referral • You were so happy that the pain specialist is seeing your patient • She has back pain with a “normal” MRI. She was using Vicodin® 2 qid with pain levels of 6/10.

27. Pain Specialist Referral • Multiple ESIs failed • A discogram was done showing internal disc disruption • Intradiscal electrothermal therapy (IDET) is partially successful

28. Pain Specialist Referral • The patient returns for your continued care on gabapentin, topiramate, nortriptyline, fluoxetine, a lidocaine patch • Morphine ER 120mg tid and Vicodin® 2 qid. Her pain level is 6/10

29. Primary Care and Chronic Pain • Only providers able to cope with the number of patients with chronic pain • Limited time but multiple, repeated exposures to patient and family • Seen patients in crisis • Aware of coping mechanisms • Know family members • Practicing disease management models and not threatened • Uniquely positioned to deal with health care and undertreatment of pain crisis

30. Conclusions • Pain specialists are the best trained to deal with complicated, complex chronic pain patients • In randomized clinical trials, interdisciplinary pain care always gives the best pain relief, functional improvement and cost

31. Conclusions • Interdisciplinary pain centers are closing nationwide due to lack of reimbursement • Primary care treats many complicated, complex medical problems • Primary care must learn to treat chronic pain patients