A Multidisciplinary Chronic Pain Management Clinic in an Indian Health Service Facility

To ensure that medication changes and other issues can be addressed when a prescriber is available, all subsequent visits are scheduled when patients are due for a pain medication refill. The MCPMC pharmacists chose not to pursue prescriptive authority but have privileges to order urine toxicology tests, make nonformulary requests, and refer patients for complementary treatments. Subsequent appointments are commonly scheduled 1 to 4 weeks apart or alternate with PCP appointments.

Related: Multidisciplinary Approach to Back Pain

During each appointment, data are collected to record changes in therapy and pain levels. Questions regarding general health and adherence to pharmacologic, interventional, and complementary treatments, exercise regimens, and specialty referrals are asked of all patients. Additionally, follow-up PAQs are completed every 6 months to track progress in therapy, pain control, treatment plan adherence, and patient satisfaction. To determine pain agreement adherence, the ACSPMPD is reviewed monthly, and urine toxicology tests and pill counts are performed randomly at MCPMC visits.

In October 2013, all PCPs who had patients in the clinic completed a survey to assess their perception of the MCPMC. Questions were related to their satisfaction with the clinic as well as their opinion of patients’ satisfaction. Other questions were related to their view of patient care and outcomes compared with those of the general chronic pain patients at the facility.

Results

As of January 2013, 106 patients had been referred to the MCPMC by 17 PCPs. Thirty-six of these patients were still actively participating in the clinic, while 25 were pending review. Of the remaining 45 patients, 30 were denied initial enrollment, and 15 were disenrolled from the clinic over the previous 2 years. Patients were determined to be inappropriate candidates and not enrolled in the clinic for the following reasons: referral not approved by the PCP, patient refused care, patient had not established care with a PCP, mental health issues, pediatric patient, oncology patient, and death prior to the initial review. Patients were disenrolled from the MCPMC clinic before 2013 for the following reasons: not participating in their treatment plan, illicit drug use, seeking care from other PCPs, suspected diversion, death due to a nonpain-related issue, and remained stable on the medication regimen and were released back to the care of their PCP.

In 2013, there were 47 new referrals to the MCPMC, resulting in a total of 153 referrals since the clinic’s 2011 inception. Over the course of 2013, 31 new patients were enrolled, 32 referrals were denied (15 of which remained from 2012), and 36 patients were disenrolled (Figure 1). At the end of 2013, 31 patients remained active, while 9 referrals remained pending review. A total of 67 patients participated in the MCPMC at some point during 2013 and were included in the data collection. Patients by diagnoses are displayed in Figure 2.

In 2013, patients were scheduled for a total of 337 MCPMC appointments, and 298 (88%) were completed by patients, a 17% increase above 2012. The mean show rate of PCP ambulatory care clinic appointments was about 70%. The completed MCPMC visits for 2013 correlates to about 6.8 MCPMC visits annually per patient. Of the 67 patients included in data collection, the mean total number of months active in the clinic was 12.5. The mean number of months active in the clinic in 2013 was 6.9.

Pain Assessment Questionnaire

In 2013, 27 patients (40%) were enrolled in the clinic for 6 months or more and completed a follow-up PAQ. Throughout 2013, MCPMC patients presented to the ED for care 76 times, which correlates to about 1.8 ED visits annually per patient. MCPMC patients also attended an appointment with their PCP on average 3.7 times per year and provided urine toxicology tests on average 4.3 times per year between MCPMC and PCP visits.

Data collected from follow-up PAQs in January 2014 provided information on the 27 MCPMC patients enrolled in the clinic for 6 months or more. This review indicated alterations in patients’ reported pain levels, functional status, patient satisfaction, and adherence to pain agreements from before and after enrollment in the clinic. Additional information was collected using the electronic health record to reveal the adjustments in treatment plans, including pharmacologic, complementary, and interventional treatments, along with adherence to these treatments.

Patients’ self-reported pain levels at the time of appointment and average pain levels since the previous appointment were documented at each visit for the 27 MCPMC patients. These 2 pain levels were then compared with the levels of the initial assessment and the most recent appointment. Results were inconsistent; however, slight trends were observed with the analysis. The mean change in pain reported at the time of assessment decreased 5.1%. The mean change in average reported pain since the previous appointment also decreased 6.9%. Statistical analysis was performed using the Wilcoxon signed rank test. Both decreases in reported pain were not clinically or statistically significant (P = .21 and P = .17, respectively). Eleven (41%) patients had improvement in average pain, whereas 10 (37%) had no change, and 6 (22%) reported increased average pain levels.