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

Acupuncture, transcutaneous electrical nerve stimulation, and osteopathic manipulative therapy (OMT) were much less frequently suggested treatments, with percentages of patient referrals of 22%, 21%, and 6%, respectively. Sixty percent of patients referred to acupuncture attended the initial visit, 47% attended a second, and 40% attended 3 or more appointments. Of this group that attended at least 3 appointments, patients completed 75% of scheduled appointments, which was also below the facility averages of 86% in 2012 and 81% in 2013. Only 50% of patients referred to OMT attended the initial visit, of which these patients completed 100% of their scheduled appointments. This rate of attendance was above the facility averages of 60% in 2012 and 68% in 2013. Thirteen percent of patients were referred for interventional pain management and completed 1 of 3 types of injections (onabotulinumtoxinA, spinal, or intra-articular). There was a slight decrease in patients without complementary treatment referrals from 14% in 2012 to 13% in 2013.

Adherence

Pain agreement adherence was determined by assessing ED visits, urine toxicology results, and ACSPMPD search results. Sixty-one percent of the 67 MCPMC patients did not seek care in the ED, whereas 12% had 1 visit in 2013. This decrease in frequency of ED visits was significant compared with these same MCPMC patients from prior to participation in the clinic. The mean ED patient visits per year decreased from 5.1 to 1.8.

Urine toxicology tests were completed on 54 of the 67 MCPMC patients in 2013. Overall, urine toxicology reports were determined to be appropriate at the initial review 51% of the time, with 30% of patients having all of their reports completely appropriate. Of the 54 patients, 35% were disenrolled for inappropriate urine toxicology reports for the following reasons: negative for opioids, positive for opioids without a prescription, positive for amphetamines with additional confirmation testing, and positive for barbiturates without a prescription. Six percent of patients were discovered to have trace amphetamine results that were sent out for confirmation, but these reports were found to be negative, thus confirming an initial false-positive result.

Forty-eight percent of MCPMC patients tested negative for opioids at some point during the year when they were expected to have positive results. Of this group, 31% were prescribed morphine; the remaining patients were prescribed synthetic or semisynthetic opioids that are known to cause false-negative results: fentanyl (4%), hydrocodone (50%), and oxycodone (15%).⁹ Twenty-two percent of patients were disenrolled from the clinic for testing negative for opioids. The reason for disenrollment was often in conjunction with other behaviors that resulted in violations of their pain agreement. The remaining 78% reported running out of pain medications early and remained in the clinic. Two percent of patients were discovered to have a positive opioid result when it was expected to be negative. This group reported finding previously prescribed medications and subsequent results were appropriate, thus they remained in the clinic. Lastly, 2% of patients tested negative for barbiturates when it was expected to be positive. These patients reported running out of pain medication early as well.

The ACSPMPD was also used to assess pain agreement adherencee for all MCPMC patients. Six percent of patients were identified as seeking care from providers outside the IHS facility and receiving prescriptions for opioid medications, thus violating their pain agreements. Seventy-five percent of these patients were disenrolled from the MCPMC for this reason. PCPs referred the other 25% of patients, and the outside prescribers had performed procedures on them. These patients were reminded of their pain agreements, and no further violations were discovered according to the database. Each patient’s status in the MCPMC was evaluated on a case-by-case basis, and often decisions to disenroll or continue treating patients were based on the PCP’s clinical judgment.

Patient satisfaction was measured in the follow-up PAQ by asking 27 patients how they felt about their care, using a typical 5-point Likert scale. The 2 statements were, “I am pleased with the care that I have received for my pain,” and “I believe that I am receiving the best health care available.” Seventy percent of patients answered “strongly agree” or “agree” to the first statement, and 67% of patients answered the same for the second statement. Nineteen percent of patients answered “not sure” to the first statement, and 22% of patients answered the same for the other statement. Eleven percent of patients responded, “disagree” or “strongly disagree” to both statements.

In October 2013, 12 PCPs who had patients in the MCPMC completed an online survey regarding their perception of patient outcomes, time spent providing care to chronic pain patients, comparisons with general chronic pain patients, and satisfaction with the clinic. Most of the PCPs reported they spent 15 to 30 minutes on MCPMC patients compared with 30 to 60 minutes on general chronic pain patients each month. Most of the PCPs stated that they required ambulatory care clinic visits with chronic pain patients every other month, whereas MCPMC patients needed to be seen only quarterly. PCPs agreed that having their patients participate in the MCPMC resulted in better pain control, improved adherence to treatments, increased diversion and abuse surveillance, and better access to pain medications. Eleven of 12 PCPs stated that they were very satisfied with the MCPMC.