A Primary Care Approach to Managing Chronic Noncancer Pain
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ABSTRACT:
SUBMITTER: Clinton-Lont J
PROVIDER: S-EPMC6373717 | biostudies-literature | 2016 Dec
REPOSITORIES: biostudies-literature
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Project description:Objective:Family physicians in Canada receive little training in chronic pain management; concomitantly, they face increasing pressure to reduce their prescribing of opioids. Project ECHO Ontario Chronic Pain/Opioid Stewardship (ECHO) is a telementoring intervention for primary care practitioners that enhances their pain management skills. This qualitative study reports participants' experiences and assessment of ECHO. Design:An opportunistic sample of multidisciplinary primary care providers attending one of three residential weekend workshops participated in focus group discussions. Setting:University or hospital facilities in Toronto, Thunder Bay, and Kingston, Ontario, Canada. Subjects:Seventeen physicians and 20 allied health professionals. Methods:Six focus group discussions were conducted at three different sites during 2014 and 2015. Transcripts were analyzed using a qualitative-descriptive approach involving analytic immersion in the data, reflection, and achieving consensus around themes discerned from transcribed discussions. Results:Findings resolved into five main themes: 1) challenges of managing chronic pain in primary care; 2) ECHO participation and improvement in patient-provider interaction and participant knowledge; 3) the diffusion of knowledge gained through ECHO to participants' colleagues and patients; 4) ECHO participation generating a sense of community; and 5) disadvantages associated with participating in ECHO. Conclusions:Managing patients with chronic pain in primary care can be difficult, particularly in remote or underserved practices. Project ECHO offers guidance to primary care practitioners for their most challenging patients, promotes knowledge acquisition and diffusion, and stimulates the development of a "community of practice."
| S-EPMC5998945 | biostudies-literature
Project description:IntroductionPrimary care providers are frequently unprepared to manage chronic pain adequately due in part to insufficient professional training. This study evaluated the effect of a telementoring intervention on knowledge and perceived competence related to chronic pain management.MethodsThe study design was a cluster randomised controlled trial. Primary care clinics that were part of the University of Washington Medicine Telehealth network were the unit of randomization. Primary care providers comprised the intervention group (n = 23) and the control group (n = 18). Providers in the intervention group attended telementoring sessions through the TelePain programme and presented patient cases at the beginning and end of their enrolled patients’ 12-week study period. TelePain sessions included a didactic presentation and telementoring for specific patient cases by a panel of pain specialists from the disciplines of pain medicine, internal medicine, anaesthesiology, rehabilitation medicine, psychiatry, addiction medicine, nursing and complementary and integrative pain management. Providers’ baseline and end-of-study knowledge and perceived competence in managing chronic pain were assessed by three questionnaires: Knowledge and Attitudes Survey Regarding Pain, the KnowPain-12 and the Perceived Competence Scale.ResultsKnowledge (Z = –0.34, p = 0.97 (Knowledge and Attitudes Survey Regarding Pain) and Z = 0.49, p = 0.62 (KnowPain-12)) and perceived competence (Z = –0.74, p = 0.46) did not increase for providers in the intervention group compared with providers in the control group. These providers attended on average 12.5 sessions (range 0–31) while participating in the study.DiscussionFurther research is recommended to establish the effectiveness of this telementoring intervention.
| S-EPMC10802791 | biostudies-literature
Project description:BackgroundOpioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).MethodsThe clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.ResultsThe key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation.ConclusionsOpioids remain a treatment option for some selected patients with CNCP under careful surveillance.SignificanceIn chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.
| S-EPMC8248186 | biostudies-literature
Project description: Not available
| S-EPMC9809977 | biostudies-literature
Project description:BackgroundLittle is known about how primary care clinicians (PCCs) approach chronic pain management in the current climate of rapidly changing guidelines and the growing body of research about risks and benefits of opioid therapy.ObjectiveTo better understand PCCs' approaches to managing patients with chronic pain and explore implications for technological and administrative interventions.DesignWe conducted adapted critical decision method interviews with 20 PCCs. Each PCC participated in 1-5 interviews.ParticipantsPCCs interviewed had a mean of 14 years of experience. They were sampled from 13 different clinics in rural, suburban, and urban health settings across the state of Indiana.ApproachInterviews included discussion of participants' general approach to managing chronic pain, as well as in-depth discussion of specific patients with chronic pain. Interviews were audio recorded. Transcripts were analyzed thematically.Key resultsPCCs reflected on strategies they use to encourage and motivate patients. We identified four associated strategic themes: (1) developing trust, (2) eliciting information from the patient, (3) diverting attention from pain to function, and (4) articulating realistic goals for the patient. In discussion of chronic pain management, PCCs often explained their beliefs about opioid therapy. Three themes emerged: (1) Opioid use tends to reduce function, (2) Opioids are often not effective for long-term pain treatment, and (3) Response to pain and opioids is highly variable.ConclusionsPCC beliefs about opioid therapy generally align with the clinical evidence, but may have some important gaps. These findings suggest the potential value of interventions that include improved access to research findings; organizational changes to support PCCs in spending time with patients to develop rapport and trust, elicit information about pain, and manage patient expectations; and the need for innovative clinical cognitive support.
| S-EPMC7728906 | biostudies-literature
Project description:The study assessed 12-month chronic pain (CP)-related health care utilization and costs among chronic noncancer pain (CNCP) patients who initiated various long-term opioid treatments. Treatments included monotherapy with long-acting opioids (mono-LAOs), mono-therapy with short-acting opioids (mono-SAOs), both LAOs and SAOs (combination), and opioid therapy initiated with SAO or LAO and switched to the other class (switch). Using MarketScan® claims databases (2006-2012), we identified CNCP patients with ≥90 days opioid supply after pain diagnosis and continuous enrollment 12 months before pain diagnosis (baseline period) and 12 months after opioid start (post-index period). Outcomes included CP-related health care utilization and costs. Among CNCP patients (n=21,203), the cohort distribution was 74% mono-SAOs, 22% combination, 2% mono-LAOs, and 2% switch. During follow-up, the average daily morphine equivalent dose was highest in mono-LAO patients (96.4 mg) compared with combination patients (89.8 mg), switch patients (64.3 mg), and mono-SAO patients (36.2 mg). After adjusting for baseline differences, the mono-LAO cohort had lower total CP-related costs ($4,933) compared with the mono-SAO ($8,604), switch ($10,470), and combination ($15,190) cohorts (all: P<0.05). Mono-LAO patients had greater CP-related prescription costs but lower medical costs than the other cohorts during the follow-up period, including lower CP-related hospitalizations (1% vs 11%-20%), emergency department visits (4% vs 11%-18%), and diagnostic radiology use (21% vs 54%-61%) (all: P<0.001). Use of pain-related medications and other treatment modalities was also significantly lower in the mono-LAO cohort relative to the other cohorts. CNCP patients using long-term monotherapy with LAOs had the lowest CP-related total health care costs in the 12 months after opioid initiation compared with mono-SAO, switch, or combination patients despite higher opioid daily doses and higher prescription costs. Future research accounting for severity and duration of pain would aid in determining the optimal long-term opioid regimen for CNCP patients.
| S-EPMC5533567 | biostudies-other
Project description:Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.
| S-EPMC6731975 | biostudies-literature
Project description:BackgroundGuideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper.MethodsTwenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology.ResultsThe benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use.ConclusionsThese data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.
| S-EPMC4823143 | biostudies-literature
Project description: Not available
| S-EPMC2882451 | biostudies-literature
Project description:Major depression is common in the primary care setting. In the final article of this series, we illustrate the approach to the management of depression in primary care. Psychotherapy has been shown to be as effective as antidepressants for mild to moderate major depression. The common myth that antidepressants are addictive should be addressed. Antidepressants should be started at a subtherapeutic dose to assess tolerability, then gradually increased until a minimally effective dose is achieved. Apart from pharmacotherapy and psychotherapy, management of depression should include managing stressors, engaging social and community support, dealing with stigma and discrimination, and managing concomitant comorbidities. A strong therapeutic relationship and empathic listening are important between the primary care physician and patient.
| S-EPMC5563525 | biostudies-other