Improving Coordination and Communication among Providers on the Frontier of Pain Management (A Q&A with Kaye Norris, PhD, program director of the Montana Pain Initiative)

Kaye Norris, PhD, describes the recent history and current activities of the Montana Pain Initiative, a “grassroots, interdisciplinary organization dedicated to improving the quality of life of Montanans with pain by removing barriers to effective pain assessment and management through research, education, and advocacy.”

How was the Montana Pain Initiative formed, and what issues have you been working on?

In 2004, the American Cancer Society (ACS), which understood that undertreatment of pain was a major issue in oncology, partnered with the Life’s End Institute, a non-profit organization in Montana that was working to improve the quality of life of dying people and their families to address some of the issues around pain management in Montana. They asked the state legislators to create a resolution to form the Montana Pain and Symptom Management Task Force. After the resolution passed in 2005, the task force worked for two years to create a convenience sample survey and hand it out at health fairs, private practice offices, and various clinics around Montana to people who were experiencing pain. After analyzing the survey data and reviewing guidelines and research from national pain organizations, the task force developed a white paper in 2007 (http://bit.ly/voEN7s) that made 12 recommendations for improving pain care in Montana, one of which was to create the Montana Pain Initiative (MTPI). One of the first projects undertaken by the MTPI, with grant funding from the Alliance of State Pain Initiatives, was to evaluate the pain management policies and procedures of long-term care facilities, home health agencies, and critical access hospitals in western Montana. Over eight months, participants assessed policies and practices, conducted workshops and training, put together action plans, and then went back to their facilities and worked toward implementing the action plans. They came back after several months for more training and to share challenges and successes. Around then is when I became involved with the MTPI. In the meantime, we conducted a strategic planning retreat to put together the vision and mission statement, and a five-year strategic plan (http://bit.ly/vzIOZc). The planning group decided that the MTPI would focus on three areas: policy improvement, provider practice improvement, and patient advocacy.

In the policy arena, we have worked with the various regulatory boards in Montana to encourage them to adopt good pain policies—for example, the Montana state board of medical directors voted unanimously to adopt the model pain policy that was put out by the Federation of State Medical Boards. The other policy area we have been working on since the inception of the MTPI is to get a prescription drug monitoring program passed by the state legislature, which finally happened in April 2011 (http://bit.ly/gTzTqQ).

Read the text of the bill that created the Montana Prescription Drug Registry (http://bit.ly/f48Q4Q)

What were some of the challenges you had to overcome to get the prescription drug monitoring program approved?

The main concerns were over privacy issues. Montana is a frontier state, and is all about privacy. People were concerned about the risks of somebody hacking into the information in the database, or the possibility that the information would be sold. There were also concerns about the cost and who was going to pay for it, and how small pharmacies in the rural areas would participate. These concerns were fairly easily addressed at the end of the process, but it took a lot of upfront legwork to make it palatable to the legislators. The prescription abuse issue has gotten worse in the last few years, which made it easier to finally convince them.

We came at it from a patient safety perspective. It was never meant to be a law enforcement tool; law enforcement only has access to the database through a subpoena. It was also never meant to be a watchdog for the physicians and other prescribers. We had to make these points very clear to everybody. We ended up with a good bill that will help providers by creating a resource to help them decide if a patient is telling them the truth about their medications.

How would you characterize the current state of pain management education among primary care physicians in Montana?

They are as challenged as other providers around the country. Most physicians don’t receive enough pain management training in medical school, so improvement has to come through continuing education. Primary care providers are finding that managing people’s chronic pain is very challenging; with the concerns over opioid misuse, primary care providers are feeling the pressure of providing good pain management while also keeping opioids off the street. Plus, Montana is a huge, rural state, and we only have a few pain specialists here—a couple of years ago we counted only six in the whole state, and they’re concentrated in the urban areas. We have real challenges with access to pain specialists in our state for primary care providers who are out there on their own trying to figure out how to deliver good pain care.

The problem is that each patient’s pain experience is individual; everybody’s experience of their pain is different. Pain has a subjective mental component, as well as whatever physical manifestation might be happening. It’s not as straightforward as treating other diseases. One of the reasons why primary care providers are frustrated with the situation is because they don’t get paid to do the kind of individual care that is necessary for good pain management.

The Area Health Education Centers Program is designed to “enhance access to high quality, culturally competent healthcare through community-based interprofessional/interdisciplinary training, continuing education, and health careers outreach activities that will ultimately improve the distribution, diversity, and supply of the primary care health professions workforce who serve in rural and underserved healthcare delivery sites” (http://1.usa.gov/s8UKt5).

Motivating patients to take steps to manage their own care is another area in which primary care providers need additional education. People have to take responsibility for their own health. If patients who are experiencing chronic pain are not actively part of their care management, then things don’t work very well. Doctors haven’t been trained to facilitate this; they’ve been trained to prescribe, and prescribing alone doesn’t get it done with chronic pain. They need to learn to take a team approach in chronic pain management.

Have you identified particular approaches that are effective in providing this education?

Our major focus at MTPI is provider practice improvement, and our signature education component is our annual conference. We have organized five annual conferences focusing on improving pain management practices in Montana, responsible opioid prescribing, and delivering interdisciplinary care. Each year our conference has gotten better and better. We’ve also pursued other approaches, including projects to promote and support mentoring of primary care physicians in rural areas by pain specialists. A practitioner in one of Montana’s urban centers has access to a medical community in a way that a primary care provider out in, say, Ekalaka, Montana, isn’t going to. Enabling somebody in Ekalaka to do interdisciplinary care and consult with a pain specialist would require some kind of distance partnership. That is a model that I think would work really well, but there would need to be a reimbursement structure to pay the specialists for the time they spent mentoring.

Go here to view the conference brochure (http://bit.ly/tBEaVz) and handouts (http://bit.ly/u7QwMQ) from the recently concluded 2011 Montana Pain Initiative conference.

Is there a role for telemonitoring and other technology applications in this?

Yes. We need to move in that direction and I believe Montana is the perfect incubator for trying to figure out how to do really good interdisciplinary care in rural areas. However, seeking funding for that kind of project is challenging. The MTPI has not been connected to a university until recently, when I became the assistant director of the Western Montana Area Health Education Center (http://bit.ly/uhhvtn), a federally funded program whose mission is to improve health care access in rural areas. Now that I’m the assistant director, the MTPI is being sponsored in part by the Western Montana Area Health Education Center which, because it’s sponsored by the University of Montana, opens up the possibility of securing federal grant funding. Doing a demonstration project of interdisciplinary pain care in a rural area would be totally in line with the mission of the Western Montana Area Health Education Center.

Does the increased scrutiny on pain providers from state and federal regulators and law enforcement due to the ongoing problems with misuse and abuse of prescription pain medications present any difficulties for what the MTPI is trying to do?

It’s important that we do our work in a balanced way. We can’t ignore the issue of medication misuse and abuse. We’ve had to adjust our mission somewhat to account for that aspect of pain care. We’ve found in Montana that working very closely with the attorney general has been incredibly productive. Through participating in a dialogue and looking for ways to work together to serve Montana, he shifted his focus from exclusively looking at the law and order side of things, and we embraced more of his concerns. If we try to approach this problem in isolation, we’re always going to be at odds with each other, but if we work together we can better serve the pain population in our state.