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

Data on alterations in functional status and ADL were also collected from the 27 MCPMC patients. These patients reported the perceived degree of difficulty, on a scale of 1 to 5, required to complete tasks and get through their day. A rating of 1 represented the ability to complete activities with no difficulty, whereas 5 represented an inability to complete the tasks. For each of the 19 tasks, the differences in scores from the initial to the most recent PAQs were recorded as either a positive or negative alteration for each patient, and the sum of these differences was recorded as an overall positive or negative change in function. A positive change in function indicated an improvement in function, whereas an overall negative change indicated a decrease in ability to complete daily activities.

Twenty-six percent of the 27 pa-tients had a cumulative positive change of up to 5 points, and 19% had a positive change of 6 or more points. Alternatively, 22% of patients had a cumulative negative change of up to 5 points, and 33% of patients had a negative change of 6 points or more. The greatest positive change was 15 points, the greatest negative change was 28 points, and the median change from the initial to the most recent assessments was a negative change of 2 points.

Adjuvant Medications

The pharmacologic component of the treatment plans consisted primarily of optimizing the use of adjuvant medications and SR opioids when appropriate, while minimizing the use of IR opioids and other controlled medications. Of the 67 MCPMC patients in 2013, 55% were on IR opioids alone, a slight increase from 46% in 2012 (Table 1). Eighty-one percent of patients in this group were on ≤ 15 mg of morphine equivalent daily dose (MEDD), which would have required at least a doubling of their dose to initiate the preferred formulary SR opioid, morphine SR tablets. Six percent of patients were on SR opioids alone, also a slight increase from 3% in 2012. Twenty-seven percent of patients were prescribed a combination of IR and SR opioids. Nine percent of patients had been recently transitioned to SR opioids while in the MCPMC, of which 1 patient was prescribed the medication as monotherapy. Twelve percent of patients were not on any opioid therapy throughout 2013.

Opioids were switched to an alternative opioid at some point during the year to minimize tolerance in 15% of patients, of which 9% were IR and 6% were SR opioids. Changes in opioid therapy from the beginning to the end of the year were recorded as a decrease, increase, or no change in MEDD. Doses were decreased for 16%, increased for 27%, and not changed for the remaining 45% of patients. The sum of these changes for the 59 patients on opioids was a decrease of 172 mg MEDD or, on average, a decrease of about 3 mg MEDD per patient. Throughout the year, 36 patients were disenrolled from the clinic, and a total of 941 mg MEDD were discontinued by patients’ PCPs. This resulted in a mean of about 26 mg MEDD discontinued per patient. These statistics demonstrate small trends in decreasing overall MEDD in MCPMC patients.

Adjunctive therapies were often used in 67 MCPMC patients in addition to their opioid medications. If possible, therapies for pain management were chosen to maximize the ability to benefit comorbidities, such as depression, anxiety, and insomnia, while also treating chronic pain. The most frequently prescribed class of medications was antidepressants with 63% of patients prescribed one or more: bupropion, serotonin-norepinephrine reuptake inhibitor, selective-serotonin reuptake inhibitor, and tricyclic antidepressants. The next top 3 medication classes after antidepressants were topical medications (54%), antiepileptics (48%), and muscle relaxers (42%). The single most frequently prescribed adjunctive medication was gabapentin (37%), an antiepileptic.

Complementary Treatments

Complementary treatment referrals were followed throughout 2013 and compared with referrals from 2012 (Table 2). Physical therapy (PT) and exercise programs continued to be the most frequently referred treatment programs within the facility. Fifty-two percent of 67 MCPMC patients did not attend any PT appointments as recommended, of which the majority were required to attend as a component of their pain agreement. Of the remaining patients referred to PT, 48% went to their initial visit, 40% attended a second, and 32% attended 3 or more appointments. Of the group that attended 3 or more appointments, patients completed about 70% of the overall scheduled appointments, which was below the facility averages of 75% in 2012 and 80% in 2013.