The true cost of pain management in your practice

This article is part of the Medical Economics Business of Health: Pain Management resource center.

The cost of chronic pain from loss of productivity and treatment is staggering. And its $635 billion annualized pricetag likely will climb as the U.S. population continues to age.

For physicians in primary care, pain remains the leading complaint received from patients. Although an estimated 116 million adult patients entering treatment rooms across the United States are believed to be afflicted with chronic pain that persists for weeks or even years, according to the Institute of Medicine, prescriptions are the second-most abused drugs in the United States.

And that is precisely the communications challenge for every primary care physician: balancing the legitimate need to help patients control pain versus protecting the public from abuse of prescribed medications.

According to Neil S. Skolnik, MD, professor of family community medicine at Temple University, Philadelphia, Pennsylvania, “It’s a fundamental challenge, because compassion drives us to want to treat patients’ pain adequately, and at the same time we need to protect both patients and other members of society from inappropriate prescribing of narcotic medicines.”

The U.S. Drug Enforcement Agency’s most recent proposal to make hydrocodone a Schedule II drug also is driving renewed attention to the use and misuse of pain medications. And a slew of position papers on the topic will be forthcoming, including one soon-to-be-released position paper from the American College of Physicians (ACP).

All of this activity is adding even greater importance for physicians to communicate with and educate patients, and monitor their pain.

Physicians add, there is an art and a method to appropriately assessing pain and achieving adherence with treatment modalities.

It starts with accurately diagnosing the cause of pain, developing a treatment and follow-up care plan, and closely monitoring patients for signs of abuse.

The pain contract

According to internist Gregory Hood, MD, of Lexington, Kentucky, a Medical Economics editorial board member, a communications tool gaining in popularity includes a pain contract if a prescription has the potential for abuse.

Santa Rosa, California-based consultant Keith Borglum, CHBC, from Professional Marketing and Management, agrees.

“Any time a patient gets a prescription for an abusable drug, they have to sign a pain contract. It says things like the patient won’t get duplicate prescriptions, won’t take more than the prescribed dose, will return for an appointment in ‘x’ number of days, won’t give the pills to anyone else,” says the Medical Economics editorial consultant.

According to Joshua Blum, MD, of the Denver Health and Hospital Authority, an opioid contract typically covers:

• signs of improper use of controlled substances (doctor shopping, selling meds, self-titration);

• defined terms of disciplinary action/termination;

• limitations for replacing medication;

• notifying the physician of relevant information pertaining to side effects, other medication changes, or a change in condition;

• monitoring for substance abuse;

• effects and side effects, including probability

• of physical dependence and consequences

• of withdrawal;

• adherence to dosing regimen;

• adherence with follow-up and specialty appointments; and

• the fact that medications need to be prescribed from a single doctor and pharmacy.

These contracts often spell out the rules for patients and can greatly enhance communication about the severity and potency of certain medications.

The interview

According to Skolnik, treating chronic pain successfully poses other challenges for physicians, especially as it relates to behavioral interviewing of patients. In fact, the physician should feel compelled to understand the level of pain a patient experiences as well as assess his or her ability to function at home or at work. Interviewing family members during the encounter to get another perspective is also quite helpful, Skolnik says.

The International Association for the Study of Pain (IASP), via Powell, et al., outlines one interviewing approach, including these questions:

• Provokes and palliates. What causes the pain? What makes the pain better? What makes the pain worse?

• Quality. Could you describe the pain? Is it sharp? Dull? Stabbing? Burning? Crushing?

• Region and radiation. Where is the pain located? Is it confined to one place? Does the pain radiate? If so, where to? Did it start elsewhere, and is it now localized to one spot?

• Severity. How severe is the pain?

• Time (or temporal). When did the pain start? Is it present all the time? Are you pain-free at night or during the day? Are you pain-free on movement? How long does the pain last?

The IASP also outlines additional questions that could help in the assessment of a patient’s pain:

• Is there a history of pain?

• What is the patient’s diagnosis and past medical history (for instance, diabetes, arthritis)?

• Is there a history of surgical operations

• or medical disorders?

• Has there been any recent trauma?

• Is there a history of heart disease,

• lung problems, stroke, or hypertension?

• Is the patient taking any medication

• (for instance, to reduce the pain; if so,

• did it help the patient?)

• Does the patient have any allergies

• (for instance, to food or medicines)?

• Does the pain hurt on deep inhalation?

• What is the patient’s psychological

• status (for instance, depression, dementia, anxiety)?

• What is the patient’s functional status, including activities of daily living?

Testing, follow-up

When it comes to monitoring prescription narcotics for misuse, periodic and random urine testing also is becoming more common. So, too, are background checks to available registries. Keep in mind, according to a 2008 paper by Turk D, et al., that your intuition may still miss 60% of abuse cases. And that oversight can even extend to observation and documenting prior history.

Therefore, periodic and random urine tests, in addition to scheduling return visits when it comes to prescription refills, definitely could be warranted.

Because of the potential for abuse, Borglum advises “that any renewal of an abuseable prescription requires a return visit.”

In his practice, Stephen S. Boyajian, DO, of Advanced Pain Consultants in Voorhees, Mount Holly, and Mercerville, New Jersey, takes the monitoring process one step further: For patients on chronic pain medications, “we might call them up in the middle of the month and ask them to come in to do a pill count. That way we know they are not taking their medication and selling it, or they’re not taking all their medication in the beginning of the month.”

Although the goal for physicians is to help patients and treat pain, this goal has been overshadowed by a concern and regulatory action focused on the potential for abuse, Skolnik says.

Keep in mind that patients in chronic pain take time to effectively manage, but doing so also can improve their lives in immeasurable ways. Most physicians agree that it’s a balance to provide effective treatment while limiting the possibility of abuse.

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