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We examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among primary care providers (PCPs) who cared for high-risk patients in safety net health settings.
We recruited PCPs (n=61) through their HIV-infected patients who were enrolled in a longitudinal study on pain, use and misuse of opioid analgesics (Pain Study). We asked PCPs to complete a questionnaire about all of their patients in their practice on the prevalence of chronic pain and illicit substance use, use of opioid analgesics, confidence and satisfaction levels in treating chronic pain, and likelihood of prescribing opioid analgesics in response to clinical vignettes.
All PCPs cared for at least some patients with chronic pain, and the majority prescribed opioid analgesics for its treatment. All PCPs cared for at least some patients who used illicit substances. PCPs reported low confidence and satisfaction levels in treating chronic pain. The majority (73.8%) of PCPs were highly likely to prescribe opioid analgesics to a patient without a history of substance use who had chronic pain. The majority (88.5%) were somewhat to highly likely to prescribe opioid analgesics to a patient with a prior history of substance use but not active use. Most (67.2%) were somewhat to highly likely to prescribe opioids to a patient with active substance use.
In order to improve PCPs confidence and satisfaction in managing chronic pain, further work should explore the root causes of low confidence and satisfaction and also explore possible remedies.
Opioid analgesics are used widely for the treatment of moderate to severe chronic non-cancer pain (CNCP) . However, inconsistent evidence on long-term efficacy and rising rates of misuse and overdose has made this practice controversial [2–7]. Prior studies found that primary care providers (PCPs) feel inadequately trained, and lack satisfaction and confidence in providing effective CNCP treatment [8–10]. PCPs face uncertainty around the use of opioid analgesics for CNCP, and have to balance concerns about analgesics misuse, physical or psychological dependence, and regulatory scrutiny with the imperative to control pain [9, 11–14]. PCPs’ concerns are heightened among patients with co-occurring mental health and substance use disorders because these patients are more likely to misuse opioid analgesics than patients without these disorders [13, 15, 16]. Yet opioid prescribing is increasing among patients with mental health or substance use disorders because they are more likely to report CNCP refractory to non-opioid therapy .
The American Pain Society (APS)/American Academy of Pain Medicine (AAPM) Chronic Opioid Therapy Guidelines released in 2009 , compared to those released in 1996 , recommended more caution in the use of opioid analgesics for CNCP in patients with a history of mental health or substance use disorders. The 2009 guidelines suggest stringent monitoring and consultation with addiction, psychiatric, or pain management specialists for patients with co-occurring chronic pain, mental health or substance use disorders . While most primary care providers (PCPs) have limited access to addiction or pain specialists , those practicing in safety net settings (i.e., settings that primarily serve uninsured, Medicaid-insured, and other vulnerable populations ) may be more affected by the lack of specialists because patients in these settings have higher rates of mental health or substance use disorders than the general population [22, 23].
In this study, we examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among PCPs who cared for high-risk patients in safety net health settings. Through case vignettes, we assessed PCPs’ likelihood of prescribing opioid analgesics for patients with or without a history of substance use disorders. We conducted this study in 2008 and 2009, approximately a year prior to the release of the 2009 APS/AAPM Chronic Opioid Therapy Guidelines for CNCP . This was a time of increased awareness of complications associated with opioid use and misuse [7, 24–27].
We recruited PCPs through their patients who were enrolled in a longitudinal study on pain, and the use and misuse of opioid analgesics (Pain Study). Pain Study patients were recruited from the Research on Access to Care in Homeless (REACH) study, a cohort of HIV-infected indigent adults recruited from homeless shelters, single room occupancy hotels, and free meal programs using probability sampling . We offered enrollment in the Pain Study, regardless of pain status, to all active members of the REACH study between September 2007 and June 2008 (n=337); 296 completed enrollment activities. Of the 296 Pain Study patients, 272 remained enrolled at one year, and 269 of these participants provided informed consent to contact their PCPs. We recruited the PCP that each study patient identified (between 2008 and 2009), provided that he/she gave informed consent and the identified PCP met our definition (physician, nurse practitioner (NP), or physician assistant (PA) providing longitudinal, comprehensive care). We recruited and collected data from PCPs by mail, using a modified version of Dillman’s Tailored Design Method . Of the 269 Pain Study patients, 240 named a healthcare provider who fit our definition of a PCP and had confirmable contact information. We described more details on PCP recruitment previously . All study protocols were reviewed and approved by the University of California, San Francisco (UCSF) Institutional Review Board. We obtained a Certificate of Confidentiality from the National Institute on Drug Abuse.
PCPs completed questionnaires in which they self-reported their age, sex, race/ethnicity (white, African American, Hispanic, or Asian/Pacific Islander), clinical training (physician, NP or PA) and years in clinical practice (4 to 9 years, 10 to 19 years, ≥ 20 years). For physicians, they reported their specialty (internists, family practice or other) and subspecialty (infectious disease (ID) or HIV specialist).
Although we recruited PCPs through their patients who were enrolled in the Pain Study, we asked them to answer questions on chronic pain management for all of their patients. Using a Likert scale, PCPs estimated how many of the patients in their panel had chronic pain (defined as ongoing pain that lasted ≥ 3 months). Of those with chronic pain, PCPs estimated for what proportion they had prescribed chronic opioid analgesics (defined as an ongoing prescription for the treatment of chronic pain (as opposed to use for self-limited problems). Of those on opioid analgesics, PCPs estimated for what proportion they had signed a pain medicine agreement. PCPs estimated what proportion of his or her patient panel had used illicit substances (crack/cocaine, methamphetamines, or heroin) during the past year. For all questions about their patient panel, PCPs selected among the following response categories: ‘none to very few,’ ‘some,’ ‘about half,’ ‘most,’ or ‘almost all to all.’
We asked PCPs, “Compared to a condition that you encounter and manage regularly in your practice (e.g. basic HIV care or hypertension management…) how confident are you in managing chronic pain?” We repeated the question stem to assess satisfaction in treating chronic pain. In doing so, we gave PCPs the opportunity to self-select a condition that they managed regularly in their practice with the assumption that PCPs who practiced in HIV-specific settings would recognize basic HIV care as something that they managed regularly and PCPs in general medicine practices would recognize hypertension as something they managed regularly. PCPs reported whether they were ‘much less,’ ‘slightly less,’ about equal,’ ‘slightly more,’ or ‘much more’ confident or satisfied in treating chronic pain.
To obtain information on PCPs’ attitudes toward using opioid analgesics to treat chronic pain, we presented PCPs with clinical vignettes of three different patients with moderate to severe chronic pain who had not responded to treatment with non-opioid analgesics or other therapies: a patient without a history of illicit substance use; a patient with a prior history of illicit substance use, but no active use; and a patient currently using illicit substances (Table 2). Before reading the clinical vignettes, PCPs read the following statement: “Many factors contribute to a clinician’s decision whether or not to prescribe opioid analgesics on an on-going basis to treat a patient’s chronic pain. Consider the patient profiles below, and indicate how likely you would be to prescribe an opioid analgesic in each case.” For each patient, PCPs reported if they were ‘highly unlikely’, ‘somewhat unlikely’, ‘neither unlikely nor likely’, ‘somewhat likely’, or ‘highly likely’ to prescribe opioid analgesics.
We calculated means (SD) for continuous variables and frequencies for categorical variables. We conducted bivariate analyses using the Chi-square statistic to determine if confidence and satisfaction levels varied by level of clinical training (physicians vs. NP or PA), years in clinical practice (4 to 9 years vs. 10 to 19 years vs. ≥ 20 years), and clinical practice characteristics (having none to some vs. half to all patients with chronic pain). For bivariate analyses, we collapsed responses for confidence and satisfaction levels as ‘much less to slightly less’ versus ‘equally to much more’. We conducted bivariate analyses to examine the association between PCPs’ likelihood of prescribing opioid analgesics to a patient with active substance use and PCPs’ clinical training (physicians versus NP or PA), clinic location (academic HIV specialty clinics, non-academic HIV specialty clinics, or general medicine community-based clinics), use of a pain agreement (none to some, about half, versus most to all), and confidence in treating chronic pain (much less to slightly less versus equally to much more). We dichotomized responses to the case vignettes as ‘highly unlikely to neither unlikely nor likely’ versus ‘somewhat to highly likely’ to prescribe opioid analgesics. All analyses were conducted using Stata, version 11.
The 240 Pain Study patients identified 90 unique PCPs from 23 clinical settings. We contacted the 90 PCPs, and received responses from 61 PCPs (68.0% response rate). Some PCPs cared exclusively for patients who were HIV-infected in practices that focused only on HIV-infected patients and others cared for both HIV-infected and HIV-uninfected patients in general medicine practices. PCPs practiced in a variety of clinical settings, including: community clinics (30.8%), academic hospital-based HIV clinics (53.8%), non-academic hospital-based HIV clinics (7.7%), academic primary care clinics (1.5%), private practices (3.1%), or the Veterans Affairs Healthcare system (3.1%). There were differences in practice site between the PCPs who enrolled and those who did not enroll in the study. We enrolled 33 of the 37 eligible PCPs who practiced at an academic HIV-based clinic that was located at a safety net hospital . When we excluded this site, there were no differences between the enrolled and the un-enrolled groups by type of site . The mean age of PCPs was 47. (Table 1) The majority (81.9%) were physicians, 16.4% were NPs, and 1.6% were PAs. Among physicians, 80.0% were internists.
All PCPs reported having at least some patients in their current panel with chronic pain: 47.5% reported that some, 39.3% reported about half, 11.5% reported most, and 1.6% reported that almost all to all of their entire panel of patients had chronic pain (Table 1). The majority of PCPs reported prescribing opioid analgesics for at least some of their patients with chronic pain: 26.2% reported using opioid analgesics for some, 29.5% for about half, 29.5% for most, and 13.1% for almost all to all of their patients with chronic pain. PCPs used pain agreements to varying degrees among their patients on opioid analgesics: 26.2% of PCPs reported using agreements with none to very few of their patients, while 22.9% used them for almost all to all of their patients on opioid analgesics. All PCPs reported having at least some patients in their panel who they thought had used illicit substances in the past year: 36.1% of PCPs reported having some patients, 32.8% about half, and 22.9% most of their patients.
PCPs reported low levels of confidence and satisfaction in treating chronic pain compared to treating common medical conditions that they had encountered (Figure 1). Compared to managing a commonly encountered problem (e.g. hypertension or HIV infection), over half of the PCPs felt much less (18.0%) or slightly less confident (36.1%) when treating chronic pain (Figure 1A). Few (16.4%) PCPs felt slightly more or much more confident in treating chronic pain. The majority of PCPs reported feeling much less (47.5%) or slightly less (36.1%) satisfied; only one PCP felt much more satisfied when treating chronic pain (Figure 1B). There were no differences in confidence (p=0.9) or satisfaction (p=0.3) levels between physicians and NPs or PAs, or by years in clinical practice (p=0.9 for confidence and p=0.9 for satisfaction). In comparing PCPs who reported that about half, almost all, or all of their patients had chronic pain to PCPs who reported that none or some of their patients had chronic pain, we found no difference in confidence (p=0.2) or satisfaction (p=0.9) in treating chronic pain.
When presented with clinical vignettes about patients who had moderate to severe chronic pain that did not respond to non-opioid therapies, the majority of PCPs (73.8%) were highly likely to prescribe opioid analgesics to patients without a history of substance use (Table 2). For patients with a prior, but not active, history of illicit substance use, the majority of PCPs were somewhat (29.5%) or highly likely (59.0%) to prescribe opioid analgesics. Most PCPs were somewhat (39.3%) or highly likely (27.9%) to prescribe opioid analgesics for patients with active substance use. Few (3.3%) were highly unlikely to prescribe opioid analgesics to those patients who actively used illicit substances. There were no statistically significant associations between PCPs’ likelihood of prescribing opioid analgesics to a patient with active substance use and PCPs’ clinical training (p=0.3), clinic location (p=0.2), use of a pain agreement (p=0.6), and confidence in treating chronic pain (p=0.2).
Studies on increasing rates of opioid misuse, mortality from overdose, and emergency department visits for opioid abuse have raised concerns about long-term opioid analgesic therapy for CNCP [4, 6, 7, 32, 33]. We conducted this study not long before the release of the 2009 APS/AAPM Chronic Opioid Therapy Guidelines for CNCP treatment , and during the time when concerns about opioid analgesics were gaining national attention [7, 24–27]. In surveying PCPs who cared for high-risk patients from a variety of clinical settings, including HIV-specific practices and general medicine practices located in safety net settings, we found that the majority of PCPs had experience treating chronic pain and prescribing opioid analgesics. Despite their experience treating chronic pain among patients with substance use histories, the majority of PCPs lacked confidence in and were dissatisfied with treating chronic pain. Through clinical vignettes, we found that the majority of PCPs reported a somewhat to high likelihood of prescribing opioid analgesics irrespective of patients’ concurrent use of illicit substances.
During the past two decades, PCPs were urged to be proactive about chronic pain treatment in all patients . Chronic pain is a common problem in primary care and is associated with significant disability [35, 36]. The increased use of opioid analgesics is in part due to clinicians’ responses to patients’ concerns of poorly controlled chronic pain and decreased quality of life . Rates of opioid analgesic prescribing increased dramatically, particularly among those who were underinsured, or with substance use and mental health problems . This occurred despite poor access to pain or addiction specialists and lower than expected use of adjuvant analgesics, like neuropathic pain medications .
In our study, most PCPs reported a somewhat to high likelihood of prescribing opioid analgesics for the treatment of chronic pain refractory to non-opioid therapy for patients with active substance use. Likelihood of prescribing opioid analgesics for patients with active substance did not vary by PCPs’ clinical or chronic pain management characteristics, suggesting a need for identifying other factors that might influence PCPs prescribing practices for high-risk patients. Few PCPs were highly unlikely to prescribe opioid analgesics to a patient with current or past history of substance use. In comparison, more than half of the PCPs surveyed in a prior study that was done more than a decade ago were either very unlikely (16.0%) to prescribe opioid analgesics to a patient with a history of substance use, or would never (42%) prescribe opioid analgesics to a patient with active substance use . Our study differs from the prior study in examining attitudes and practices of clinicians who practice with high-risk patients in urban settings; it is possible that the differences we observed were due to the variations in practice settings and in experience with managing patients with active substance use disorders.
Similarities and differences exist between our study and others that examined PCPs’ views on chronic pain management. As seen in prior studies [39–41], wide variations existed in the use of pain agreements. While we did not explore reasons behind this variation, previous studies found that the use of pain agreements differed by physician level of training, primary care specialty, and assessment of patients’ risk for alcohol or substance use disorders [39, 40]. While we assessed likelihood of prescribing opioid analgesics to patients with and without a history of substance use, prior studies determined factors associated with willingness to prescribe opioid analgesics. Some of these factors included confidence and satisfaction levels in treating chronic pain, concerns about patients’ physical dependence or tolerance, or regulatory scrutiny [8, 9, 11]. Similar to prior studies [8–10, 42], PCPs in our study had low levels of confidence and satisfaction levels in treating chronic pain. In one prior study, PCPs expressed high confidence and interest in treating chronic pain, but had low satisfaction levels in providing optimal pain management, suggesting the importance of system support for effective pain management . Inadequate education in pain management and concerns about prescribing opioid analgesics to patients with substance use histories were other reasons for the low confidence and satisfaction levels among PCPs surveyed in prior studies [8, 9, 14, 43]. While we did not examine causes of the low confidence and satisfaction levels among PCPs in our study, we speculate on a few reasons drawing on recent trends in opioid analgesics prescribing.
Rising rates of opioid analgesic prescriptions for chronic pain have resulted in unintended consequences. Non-intentional drug overdoses have increased since 1997 and were among the leading causes of accidental deaths in 2007 . Overdoses from opioid analgesics contributed to almost half of the 27,658 overdose deaths recorded in 2007 . The number of emergency department visits in the United States due to non-medical use of opioid analgesics increased from 144,644 in 2004 to 305,885 in 2008, an increase of 111% . Patients with co-occurring mental health and substance use disorders are at greater risk for these adverse outcomes than patients without them [32, 33]. In addition, they are more likely to suffer from poorly controlled pain [17, 46, 47]. PCPs low levels of confidence and satisfaction around treating chronic pain could stem from challenges in caring for patients with chronic pain who have co-occurring mental health and substance use disorders. Soon after the study period, new guidelines recommended prescribing opioid analgesics only “if [clinicians] are able to implement more frequent and stringent monitoring parameters” and in consultation with mental health or addiction specialists . While these guidelines were not released until after the study period, concerns that led to the new guidelines were gaining widespread attention [7, 24–27]. While there are widespread barriers to access to addiction and pain specialists , these barriers may pose particular challenges for PCPs practicing in settings that care for high rates of patients who have co-occurring chronic pain, mental health and substance use disorders [22, 23, 38]. In a related study, we surveyed 296 Pain Study participants and found that 91.2% had pain, of who 57.0% were on chronic opioid analgesics . More than half had depression or met criteria for a lifetime substance use disorder . Of those with pain, only 2% had seen a Pain Management specialist in the past 3 months . A lack of access to pain and addiction specialists may have contributed to the low confidence and satisfaction among PCPs in our study.
A multidisciplinary approach where PCPs were supported by a NP/pharmacist pain management team, and backed by a multi-specialist consultant team, was feasible among chronic pain patients at risk for substance use disorders at a Veterans Affairs medical practice . This model resulted in increased adherence by PCPs to urine drug testing and opioid treatment agreements, improved patient adherence to pain agreements, and better differentiation of patients who engaged in opioid misuse . While such multidisciplinary models hold promise, they need to be tested in safety net health settings, which see a disproportionate proportion of patients with co-occurring mental health and substance use disorders [22, 23].
Our study has limitations. Our sample of PCPs who cared for high-risk patients in safety-net settings from one urban region may not be generalizable to other PCPs who practice in settings with fewer high-risk patients. However, our findings may be applicable to PCPs who care for patients with similar levels of co-occurring chronic pain and substance use disorders. Because responses were self-reported, a potential for recall bias exists. PCPs’ estimates of chronic pain, illicit substance use, use of opioid analgesics, and use of pain agreements among their patients were not verified by a medical record review. We were unable to determine the reasons behind PCPs’ low satisfaction and confidence levels in treating chronic pain. The clinical vignettes in our study may have had low ecological validity. Despite our good response rate among PCPs, we had limited information on non-responders, and cannot assess the magnitude of selection bias. Because our study was conducted prior to the release of the 2009 APS/AAPM Chronic Opioid Therapy Guidelines for CNCP treatment, we are unable to determine whether the guidelines led to changes in attitudes toward and practices of treating chronic pain in high-risk patients.
We explored chronic pain management among PCPs who cared for high-risk patients in safety net health settings and who were practicing at a time when a shift in thinking occurred --from less to more stringent restrictions around the use of opioid analgesics for chronic pain. The dissatisfaction reported by PCPs in our study may be a reflection of the conflict between wanting to treat chronic pain and lack of resources to manage it appropriately among high-risk patients. To improve PCPs confidence and satisfaction levels in treating chronic pain, further work should focus on identifying the root causes of the low confidence and satisfaction levels experienced by PCPs, as well as potential solutions. Improving confidence and satisfaction levels among PCPs may also improve the quality of pain management care for all patients and especially those with co-occurring mental health and substance use disorders.
Funders: This study was funded by the Pain Study grant from the National Institute on Drug Abuse R01DA022550, and the REACH study grant from the National Institute of Mental Health R01MH54907. Dr. Vijayaraghavan was supported by the Department of Health and Human Services – Health Resources and Services Administration, Primary Care Research Fellowship grant D55HP05165. Dr. Vijayaraghavan is currently supported by a post-doctoral fellowship through the Cancer Prevention and Control Division, Moores UCSD Cancer Center, University of California, San Diego. The Tenderloin Center for Clinical Research was supported by the University of California, San Francisco (UCSF), Clinical and Translational Institute grant, NIH/NCRR UCSF-CTSI UL1 RR024131. The funders had no role in the design or conduct of the study or the preparation of the manuscript.
Conflict of Interest
Contributors: The authors would like to thank Jennifer Mattson, BA for her invaluable assistance in preparing this manuscript. We would like to thank all the patients and their PCPs for their contribution to this study.