The Primary Care Chronic Pain Program (PC-CPP) of the Women’s Primary Care Clinics at the VA Salt Lake City Health Care System (VASLCHCS) in Utah was the first VA primary care clinical service to incorporate patient participation in obtaining chronic opioid medications in the treatment of chronic noncancer pain. In addition, the program used a multimodality approach for chronic pain treatment and veteran education about the relationship between physical and mental health issues.
Treatment Complexity
Chronic, noncancer pain is a complex issue in the primary care setting. Diagnosis is difficult, patient education is time consuming, goals and expectations are often unclear, and the experience can be unsatisfying for the patient and the provider.1 These issues, combined with an estimated prevalence rate of 71% for moderate pain among veterans seen in primary care, present a unique challenge for the primary care provider (PCP), given the limited time available to spend with these complex patients.2 Comorbidity rates with mental health issues (eg, depression, anxiety, substance use disorders, etc), which range from 18% to 44%, add to the management challenges for PCPs.3
Veterans also pose unique challenges in pain care as they have a 2-fold greater risk of death from opioid overdose compared with that of the general population, and Utah has been shown to have the highest rate of veteran overdoses.4 Developing programs to help PCPs efficiently manage patients with chronic noncancer pain and mental health comorbidities was vital at VASLCHCS.
Before VASLCHCS established the PC-CPP, the treatment for chronic noncancer pain and related mental health comorbidities followed a biomedical model that separated physical and mental health with the treatment focus on pharmacologic management of symptoms by separate services. Consistent with the biomedical model, management of chronic noncancer pain commonly included long-term use of opioids.
Over the past 2 decades, the use of opioids for treating chronic noncancer pain has significantly increased, with more than 62 million opioid prescriptions dispensed in 2012.5 There are no longitudinal follow-up studies, however, beyond 16 weeks on the use of opioids.6 Further, patients who are prescribed increased opioids continue to report high levels of pain, poor quality of life, and functional disability.7 High-dose opioids also are associated with overdose deaths.
Likewise, PCPs in the Women’s Primary Care Clinics at the VASLCHCS struggled with decreasing opioid use, often because other interventions for managing pain and related mental health conditions in primary care were not readily available. Although the VASLCHCS has an effective specialty pain service caring for patients with complex pain issues, opioid morphine equivalent doses > 200 mg/d, and palliative care, patients with chronic noncancer pain treated in the primary care setting did not have a consistent treatment approach.
A chart review of women veterans seen in Women’s Primary Care Clinic (N = 122) revealed that the majority of patients lacked timely urine drug screening, state database queries, signed medication management agreements, and documentation consistent with state and national guidelines. Additionally, many patients lacked provider follow-through regarding alternative and adjunctive therapy consults, which were often discontinued after failed contact attempts or no-shows to scheduled appointments.
There also was a general consensus among the Women’s Primary Care Clinic PCPs that caring for patients with chronic noncancer pain was exhausting, time consuming, ineffective, and often straining on the patient-provider relationship, as evidenced in many patients’ request to change providers secondary to pain management. The PC-CPP was developed to help systematically facilitate safe opioid prescribing, manage chronic pain issues, and document evidence-based care among women veterans receiving treatment for chronic noncancer pain at the Women’s Primary Care Clinics at VASLCHCS while coordinating and following through with nonpharmacologic interventions.
Program Development
National, state, VA, and professional licensure guidelines for chronic noncancer pain treatment standards were reviewed with the goal of creating a program that was evidence based, would benefit the patient in terms of opioid prescribing and pain control, and improve function while identifying key elements of care and documentation that adequately covered the prescriber of retribution.1,8-10
Concurrent to a review of the guidelines was a review of the literature with the goal of identifying useful patient education and alternative interventions and chronic pain programs that were already established and might meet the clinic’s needs.10,11 These reviews provided direction for a generalized approach to caring for patients with chronic nonmalignant pain. They also clarified that although pain education programs existed nationally, a program that offered a holistic, reproducible, adherence-driven yet patient-centered approach to the patient prescribed opioids chronically in a primary care setting was lacking.