A Primary Care Approach to Managing Chronic Noncancer Pain

Patient Distress

The SMA could be stressful for patients who felt they were being “punished” or who showed up more than 15 minutes late and had to reschedule the SMA. Having a mental health provider available was crucial for these situations.

Therapeutic Option Development

A cornerstone of the program was getting patients to participate in nonpharmacologic treatment options, which required a robust selection of programs. The VASLCHCS was fortunate to have many programs already available (Table 2), but this was not always the case for the VA community-based outpatient clinics (CBOCs).

Stakeholder Support

Before its start, PC-CPP was presented to the Pentad (a group of 5 individuals in the local facility who hold executive leadership positions) for approval. Tapering opioids can lead to feelings of hostility, frustration, or sadness for patients, so having the Pentad support for the program was crucial to address complaints made to patient advocates or senators. Provider support also was important to reinforce program rules. The PC-CPP inclusion criteria included only those patients whose PCP was agreeable to a taper when the patient did not comply with program expectations. This strategy helped to improve patient adherence with the PC-CPP and decrease patient arguments with clinic staff, as all patients are held to the same standards.

Staff

Finding willing staff can be a challenge. It is estimated that each site needed a program leader who can champion the program objectives and drive organization of staff, space, documentation, and consistency for the patients consulted to the PC-CPP. The goal is that the consistent, reproducible expectations for both the PCP and the patient will reduce overall workload for a clinic. Patients may test the firmness and conviction of the staff to the PC-CPP. Having staff who are able and willing to be firm on relaying information for adherence to the patient is vital.

Administrative Support

At a minimum, a medical support assistant was required to help with scheduling, reminder calls and letters, CPRS check-in/check-out, ensuring necessary forms are ready for the SMA, tracking adherence, and following-up on no-shows and rescheduling.

Documentation

The CPRS consult and note template titles required the approval of the template committee. Although the template is helpful, there is still a great deal that needs to be manually entered in the note, such as BPI scores, opioid risk scores, and chosen nonpharmacologic interventions scores of pain, function, and opioid risk as well individual comorbidities, diagnosis, and follow-up dates. Documentation is geared toward easy review for the PCP who should scan the document prior to renewing opioid medications. The PC-CPP consult became a message board. Once the patient attends the SMA, the designated staff will add a comment to the message board, identifying all dates attended, complete history of the patient’s intervention choices and rate of adherence, as well a follow-up SMA date and whether the patient should bring materials such as take-home tests.

Time Commitment

Program development carries a heavy time burden. One full-time equivalent clinician for 6 weeks for program development is needed. Time allotment is estimated to be the following:

• Medical provider—30 minutes per patient (chart review, documentation, consult resolution). With training, these duties could be completed by support staff
• Pharmacist—30 minutes per patient (chart review, UDS, Utah Division of Occupational and Professional Licensing, fill history). Additional time is needed for writing opioid tapers for qualifying patients
• Primary care mental health integration—a PhD spent 1 to 2 hours per SMA visit assisting patients who became distressed during the visit. Only once has a patient needed to be escorted to the emergency department for active suicidality. A PhD also spent 10+ hours per week running and managing the CBT for Chronic Pain Group
• Support staff—a registered nurse spent 4 hours each month preparing for the SMA (entering consults, ordering EMITs, purchasing snacks)

Conclusion

In this descriptive report, the authors presented an overview of a newly developed program to manage chronic nonmalignant pain and safe opioid prescribing in a primary care setting. A final report is pending. The intent with this interim report was to describe the PC-CPP at the VASLCHCS, its methods and protocols, and logistic considerations for other providers who are working with patients with chronic pain in a primary care model. Standard operating procedure and inclusion/exclusion criteria were included to help with clinical decision making for patients chronic pain for whom aberrant opioid-related behavior presents a problem.

The authors expect that the PC-CPP will provide more comprehensive assisted care, lending to decreased complications associated with accidental overdose, because since patients have been educated about risks for accidental overdose from chronic opioids and have the responsibility for their outcomes. The authors also anticipated that functional scores (as measured by the BPI) will increase despite lowering opioid doses because patients will use ancillary treatments for pain. The desired outcome is that patients will come to understand that pain control is best approached holistically rather than through opioid monotherapy.

There have been several recent initiatives within the VA to decrease opioid prescribing and increase patient safety. With this in mind, continued expansion of this program to CBOCs and male patients could be useful to providers. Also, this program was conducted in a small setting (Women’s Clinic), and there are many challenges with rolling out such a program in a larger clinic (eg, greater chance for provider disagreement, greater need for administrative staff support). Nonetheless, the benefits of close monitoring of prescription opioids and active encouragement to engage in nonpharmacologic therapies are substantial and deserve further advancement.