A New Approach to Pain Management in Primary Care

FROM THE AMERICAN ACADEMY OF NEUROLOGY

BOSTON—Investigators reported favorable early results with the new Primary Practice Physician Program for Chronic Pain (4PCP) at the American Academy of Neurology annual meeting. This randomized, prospective study is evaluating a novel interdisciplinary approach to the management of chronic pain in primary care.

"Chronic pain remains undertreated and poorly understood by physicians, even though recent healthcare policy has recognized pain as the fifth vital sign," said Thomas Chelimsky, MD, professor of neurology at Case Western Reserve University in Cleveland. "Overall, 34 million Americans suffer from chronic pain, and most are significantly disabled."

During the first year of the 4PCP trial, physicians documented major improvements in several domains related to chronic pain. Notably, physicians improved the use of the most effective resources available for managing chronic pain. They also became more comfortable in dealing with chronic pain, its emotional consequences, and issues associated with opiate abuse.

Medical schools and residency programs "teach little" on this subject, Dr Chelimsky pointed out. And third-party payers mainly reimburse for technical procedures that are not evidence-based.

Among the most common reasons why physicians are unwilling to treat patients with chronic pain are:

• Fear of creating addiction
• Poor knowledge
• Service delivery constraints
• Concerns for patient motivation, adherence.

Dr Chelimsky and colleagues assembled a community-based interdisciplinary support team that included occupational, physical, and behavioral therapists. The primary care doctors attended semiannual workshops, which included didactic presentations and case-based active learning at the physician's office.

Established criteria are used to compare pain relief measures between 12 physicians in the intervention group and 12 physicians in a control group.

Results at 1 year showed that the intervention group improved more than the controls in:

• Managing the emotional consequences (78% vs 20%) and diagnosing the functional consequences (56% vs 20%) faced by patients with chronic pain.
• Feeling comfortable from a legal perspective prescribing opiates (45% vs 0%) and assessing drug-seeking behavior (63% vs 20%).
• Being satisfied with patients' response to treatment (75% vs 0%).

"It's a shame that our system reimburses nonevidence-based options for treating chronic back pain, like lumbar spine injections, lumbar surgery, and spinal cord stimulation, which have only a 20% to 25% early success rate and eventually fail in about 75% of cases," Dr Chelimsky observed. Additional data are expected in the next 6 months.