Why Primary Care Doctors Need to Rethink Chronic Pain Treatment
Primary care physicians play a key role in caring for patients with chronic pain. But many clinicians — and insurers — fail to emphasize the value of nonopioid alternatives.
Pain affects more people in the United States than diabetes, heart disease and cancer combined. Between 50 million and 100 million adults in the United States have chronic pain conditions, according to estimates from the National Center for Complementary and Integrative Health.
But a failure to differentiate between chronic and acute pain can lead to all such complaints being treated as acute cases, often with unnecessary opioids prescribed — action that has helped fuel the nation’s opioid crisis.
It’s why two University of Michigan researchers say the health care industry must make systemic changes to properly care for patients with chronic pain.
“Opioids get a lot of attention from both patients and physicians, and they distract from what we really should be doing to manage chronic pain,” says Daniel Clauw, M.D., director of Michigan Medicine’s Chronic Pain and Fatigue Research Center.
“Opioids were a class of drugs that were never really shown to work for chronic pain and never really should have been used for chronic pain.”
Although such drugs may provide temporary relief, the aftereffects can be severe.
The tendency for physicians to prescribe — and sometimes overprescribe — opioids has left many Americans dependent on the drugs. A 2016 report by the Centers for Disease Control and Prevention found that as many as 1 in 4 people who receive prescription opioids long term for non-cancer-related pain subsequently struggle with addiction or misuse.
Shifting the conversation
Clauw and Jill Schneiderhan, M.D., an assistant professor in Michigan Medicine’s Department of Family Medicine, are calling on primary care physicians to take a more comprehensive approach to treating patients with chronic pain. They echoed these points in an editorial published last month in JAMA.
Schneiderhan, who has treated chronic pain for a decade, encourages her patients to focus on behavioral interventions such as exercise and a number of complementary and alternative therapies such as yoga, acupuncture, tai chi and mindfulness.
The key to persuading reluctant patients to eschew drugs in lieu of other options? “You have to first establish a therapeutic relationship,” says Schneiderhan, noting that connection helps facilitate a wider discussion. “Building trust is critical.”
She and Clauw also are encouraging insurance companies to adjust medical reimbursement rates to make them more conducive to the care of chronic pain patients.
Third-party payers, for instance, typically will reimburse for referral to subspecialists as well as expensive imaging studies and procedures. But they often do not reimburse for the extra time it takes a primary care doctor to care for patients with chronic pain — or for the nonpharmacological therapies that are increasingly recommended for their treatment.
The two physicians suggest a new methodology that emphasizes a patient-physician relationship with shared decision-making, nonpharmacological treatments and selective use of nonopioid analgesics.
More change needed
Challenges remain for all involved parties. Research has shown that chronic pain is a frequent component of many complex neurological disorders that are often tough for patients to understand.
“It’s sometimes very difficult to explain the nervous system to patients without them hearing ‘I think you’re making your pain up,’” says Schneiderhan.
Short appointments and a lack of supplemental support from health coaches and behavioral change specialists also make it challenging for physicians to adequately educate chronic pain patients.
Another barrier to proper care: relative value units, the method Medicare and nearly all health maintenance organizations use to calculate the volume of work expended by a physician in treating patients. With well-patient visits assigned a lower RVU than intensive surgical procedures, Schneiderhan and Clauw say the formula penalizes the kind of care chronic pain patients need from their physicians.
“If [Schneiderhan] were allowed to do this right and do this well, her RVUs would be abysmal,” says Clauw. “It would look as if she were very unproductive.”
As a result, the two say, fewer physicians are willing to see chronic pain patients who don’t need a surgical procedure, because the surgical procedures are reimbursed (and, in their opinion, even over-reimbursed).
In an attempt to offset these issues, Clauw facilitates two-hour patient education workshops that are designed to provide patients and their families with the latest information about pain syndromes and guidance on symptom management strategies.
Meanwhile, Clauw and Schneiderhan will continue to push for a cultural shift — work that encompasses patients and providers alike.
“Medical administrators and leaders have to get on board and acknowledge the appropriate ways to manage chronic pain patients, and insurance companies have to understand reimbursement needs to shift,” says Clauw. “But there also has to be a shift in thinking on the part of patients with chronic pain. They have to move away from the idea that there is a quick fix.”