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

Discussion

The ultimate goal for patients of the MCPMC is to minimize disease progression, prevent an increase in pain, and improve adherence to treatment plans, including pharmacologic, interventional, and complementary components. According to the change in reported pain levels from the initial to the most recent assessment, most patients met the goal of preventing an increase in pain. There was a trend toward a decrease in reported pain, though it was not clinically or statistically significant. The follow-up PAQ measured varying changes in functional status and often demonstrated disease stabilization or progression, not improvement among patients. Forty-five percent of patients showed improvements, and 55% reported more difficulty performing daily activities. The median change between all 27 MCPMC patients was an overall decline in function of 2 points. This worsening in function over time would be expected for most of the chronic pain conditions.

In 2013, 9% of patients were initiated on SR opioids, making a clinic total of 33% of patients on SR medications. More than half the patients were on IR opioids as monotherapy, which is not an ideal treatment for chronic pain management. However, 81% of this group was on 15 mg MEDD or less. The use of SR opioids may or may not reduce abuse potential but can improve patient outcomes. Overall, there was an emphasis on using SR opioids when appropriate while continuing to improve patient outcomes. Over 61% of patients remained on the same opioid doses or were decreased over the course of 2013. There was also a significant use of adjuvant medications, primarily antidepressants, antiepileptics, and topical pain relievers. The most frequently prescribed non-opioid medication, excluding NSAIDs, was gabapentin. This medication has abuse potential and was treated as a controlled medication by the MCPMC during this period.

After enrollment in the MCPMC, patients used complementary and interventional treatments more consistently than prior to enrollment in the clinic. Treatments such as injections, acupuncture, OMT, and PT may reduce opioid medication consumption in the long term or slow the progression of disease for most patients. The improvement in QOL and lack of disease progression in these patients is not objectively measurable; however, the summative progress may be subjectively evaluated through reported pain levels and patient satisfaction.

For MCPMC patients who remained in the clinic, PT and acupuncture attendance was 70% and 75%, respectively. Although these were improvements in adherence for many MCPMC patients, the rates were still below the facility average completion rates of 80% and 81%, respectively. It could be argued that patients with acute pain are typically seen in PT for shorter periods and with fewer possibilities of missing appointments. Conversely, the single active MCPMC patient who attended OMT had a 100% completion rate compared with the average facility OMT attendance of 68%.

Other goals of the MCPMC consist of managing AEs, minimizing ED visits, monitoring for drug abuse and diversion, and improving adherence to pain agreements. The substantial 65% decrease in ED visits can be attributed to the patients’ participation in the MCPMC. Before enrollment, many patients would frequent the ED, because their PCP was not available. The cost savings from minimizing ED visits, provider and staff time, and resources is difficult to measure due to low rates of collections from insurance supplemental to IHS insurance yet is a significant benefit to the IHS facility.

Conclusions

Since the implementation of the MCPMC, patient outcomes have improved due to more consistent drug abuse and diversion surveillance of chronic pain patients rather than performing surveillance because of a suspicion of inappropriate medication use. Frequently using the pain agreement and monitoring parameters constructed a more trusting relationship between the PCP and the patient, and identified patients inappropriate for long-term opioid therapy. Identifying these patients was an unintentional, yet positive outcome.

Additionally, PCPs reported spending half the time with MCPMC patients vs general chronic pain patients. Patients who were not compliant with their pain agreements were discontinued from opioid therapy and were disenrolled from the clinic. Patients who have remained active have become more compliant with their pain agreements and treatment plans than they had been before enrollment. The MCPMC has ultimately relieved a significant burden from primary care and ED providers while improving outcomes and satisfaction of chronic pain patients.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.