Finding a new doctor for health checkups and general care can pose a challenge to anyone. But for people who take prescription opioid pills for their chronic pain, it might be far harder, according to a new study.
In fact, 40% of 194 primary care clinics contacted for the study said they wouldn’t accept a new patient who takes Percocet daily for pain from a past injury, no matter what kind of health insurance they had.
Another 17% of the clinics said they would want more information before deciding whether to take the patient; two-thirds of these said they would want the patient to come for a preliminary appointment before making a decision.
All the clinics in the study were accepting new patients at the time.
The findings, published in JAMA Network Open by a team from the University of Michigan, suggest that more patients who take opioids for chronic pain face could health care access problems than previous studies have suggested.
However, the team did find that larger clinics and those that offer safety-net coverage were three times more likely than others to accept patients who currently take opioids for chronic pain.
More than just pain care
For such patients, getting access to primary care goes beyond checkups, preventive care and management of medical conditions, says lead researcher Pooja Lagisetty, M.D., M.Sc.
Having a regular provider could enable them to receive other pain-relieving treatments, and if indicated, provide guidance in safely and gradually tapering their use of opioids.
Primary care providers can also equip patients who take opioids, or their loved ones, with a “rescue” drug to use in case of an opioid overdose, screen patients for signs of opioid use disorders, and treat such disorders if the patient is among the minority of people on long-term prescription opioid treatment who develop an addiction to the drugs.
Without access to such care, the researchers note, patients may turn to other means of obtaining opioids, outside of a prescription from a regular provider.
It also may lead to worsened health outcomes for their other medical issues like their diabetes or high blood pressure.
In fact, Lagisetty says, that’s what led her and her colleagues to launch the study with funding from the Michigan Health Endowment Fund. Lagisetty is a general internal medicine physician at Michigan Medicine, U-M’s academic medical center, and the VA Ann Arbor Healthcare System.
“Anecdotally, we were hearing about patients with chronic pain becoming ‘pain refugees’, being abruptly tapered from their opioids or having their current physician stop refilling their prescription, leaving them to search for pain relief elsewhere,” she says.
“However, there have been no studies to quantify the extent of the problem.
These findings are concerning because it demonstrates just how difficult it may be for a patient with chronic pain searching for a primary care physician.”
Calling around for care
The team did the study using a “secret shopper” method, to get a realistic sense of what clinics would tell someone who called to inquire about whether her parent could get an appointment as a new patient.
The first round of calls went to 667 randomly chosen Michigan clinics, to ask if they were accepting new primary care patients and other questions.
For the second round of calls, the researchers used the scenario of an adult child calling on behalf of a parent, so that the conversations did not need to include detailed information about the patient for the purposes of scheduling an appointment.
The callers also said that their “parent” was taking medications for high blood pressure and high cholesterol, two conditions that primary care providers play key roles in managing.
The researchers wanted to find out if type of insurance, size or type of clinic, or population density around the clinic played any role.
Half of the callers said their parent had Medicaid, the other half said they had Blue Cross Blue Shield coverage.
Nearly half the clinics were in rural areas, and nearly one-third had a single provider.
Nine percent were community health centers, which provide care to anyone regardless of ability to pay.
“Our results did not differ by insurance status, which was surprising because previous studies on primary care access have showed that patients on Medicaid tend to have lower access to primary care than those with private insurance,” says Lagisetty.
“This may indicate that providers and clinics are not making these decisions to restrict access based upon reimbursement.
Larger clinics and community health centers were more likely to accept new patients suggesting that they may be some system level factors that affect access to care.”
There was no difference in access between rural and urban areas.
Getting help for addiction issues
The researchers also looked at the availability of treatment for opioid use disorder at the primary care clinics.
Such treatment, which requires providers to get special training and permission from the federal government, involves counseling and prescriptions for medications that can block the symptoms of withdrawing from opioids.
Lagisetty has looked at the feasibility of primary care clinics offering such treatment, and differences in access to it.
The front-line staff at 12% of the clinics in the study said their providers offered this kind of medication-based OUD care. Nearly 41% told callers they didn’t know if their providers were able to offer it.
What factors play a role in a clinic’s decision to take on new patients with chronic pain who take prescription opioids?
Lagisetty notes that patient advocates have placed blame on a 2016 chronic pain treatment guide from the Centers for Disease Control and Prevention, which they see as swinging the pain-treatment pendulum too far away from prescription opioids.
“I suspect this is only a small part of the problem,” says Lagisetty, who is a member of the U-M Institute for Healthcare Policy and Innovation. “States, including Michigan, have implemented many other policies that are only occasionally based on the guidelines, in an effort to restrict opioid prescribing.”
The Michigan team wants to study the factors responsible for this phenomenon further, and determine how much is related to recent guidelines and policies, how much is stigma against patients on opioid therapy, and how much is provider fear of legal repercussions.
“We hope to use this information to identify a way for us to fix the policies to have a more patient-centered approach to pain management,” says Lagisetty.
“Everyone deserves equitable access to health care, irrespective of their medical conditions or what medications they may be taking.”
In the spring of 2016, The New York Times featured an article on primary care clinics in West Virginia that had hired an anesthesiologist to treat patients with chronic pain outside of primary care, thus “relieving its primary care doctors and nurse practitioners of their thorniest burden.”
The article lauded the anesthesiologist/pain specialist, who is quoted as saying, “I’m part F.B.I. investigator, part C.I.A. interrogator, part drill sergeant, part cheerleader.”1
Is treating chronic pain no longer the job of primary care providers (PCPs)?
Chronic pain complaints are the second most common reason for outpatient primary care visits: over 100 million Americans suffer from chronic pain, more than the total number affected by heart disease, cancer and diabetes combined.
Painful conditions also burden the U.S. economy, costing $635 billion each year in medical treatment and lost productivity.2 Y
et, PCPs report discomfort in managing chronic pain, especially given mounting pressure to curtail patients’ use of opioids.3
Perhaps chronic pain management actually has become one of primary care’s thorniest burdens. After all, PCPs did not sign up to become FBI investigators, CIA interrogators, drill sergeants or cheerleaders—well, maybe cheerleaders….
At a time when patients are dying in record numbers from opioids prescribed for pain, perhaps PCPs should offload chronic pain management to specialists, as The Times article suggests.
Yet this would risk moving backwards toward an antiquated biomedical model of specialty pain treatment, paradoxically the same model that got us into this mess in the first place.
The biomedical model assumes a singular biological cause for chronic pain; we just need a diagnosis and then we can “cure” the pain.
This sets both provider and patient on a crash course of diagnostic testing, polypharmacy and procedures.
In the U.S., hundreds of billions of dollars are spent on specialty procedures and opioid pain medications for chronic pain, and while these therapies may be appropriate in certain settings, outcomes for chronic pain are not well substantiated.
On the contrary, at least in the case of chronic opioid therapy, there is growing evidence of serious harm.4
In contrast, the 2011 Institute of Medicine’s consensus report, the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (2016) and the Department of Health and Human Services’ National Pain Strategy (2016) have all called for a biopsychosocial approach in the treatment of chronic pain.
Similarly, the National Pain Strategy calls for an evidence-based multimodal and interdisciplinary treatment approach to chronic pain.5
The CDC Guideline specifically recommends avoiding the use of opioids in favor of exercise therapy, cognitive behavioral therapy and non-opioid medications as first-line treatments for chronic pain.6
But how is an individual PCP, or even a specialist, expected to implement guidelines that essentially call for a team-based approach to chronic pain? What insurance plan reimburses this?
In fact, the Veterans Health Administration (VHA), the largest publicly funded, fully integrated health care system in the U.S., has been a leader in addressing these gaps in implementation.
In 2009, the VHA introduced a Stepped Care framework in which patients receive biopsychosocial chronic pain care first within VA primary care, instead of routinely triaging patients with chronic pain to specialists.
Since 2009, interdisciplinary pain clinics have been implemented at a few VA medical centers throughout the country.
These interdisciplinary clinics co-locate and integrate PCPs, psychologists, pharmacists and/or physical therapists to provide multi-modal pain care, often directly in primary care, and preliminary results are promising.7
In July of 2015, the Integrated Pain Team (IPT) was established within primary care in the San Francisco VA Health Care System (SFVAHCS).
The mission of the IPT is to provide focused interdisciplinary, biopsychosocial pain care that also addresses the psychological comorbidities such as posttraumatic stress disorder (PTSD) and depression that are prevalent among patients with chronic pain, particularly veterans; these same patients have also been found to have higher rates of opioid use and misuse.8
The interdisciplinary IPT clinic integrates and co-locates pain-trained PCPs with a psychologist and pharmacist with expedited access to physical and recreational therapy. Other PCPs are encouraged to refer patients with complex chronic pain, irrespective of whether they are prescribed opioids, and over the course of weeks to months, IPT providers assume responsibility for pain care, including prescribing.
Specifically, IPT providers collaborate with the patient and the referring PCP to develop a multi-modal pain care plan that emphasizes the use of exercise, behavioral interventions and complementary and integrative modalities, while reducing reliance on pain medications, especially opioids.
On patient discharge, IPT providers conduct a warm handoff back to the referring PCP, which consists of detailed in-person or electronic recommendations intended to empower PCPs to assume long-term management of their patients’ chronic pain issues.
In fact, one important function of the IPT in primary care is to provide pain management education for other PCPs in the form of these recommendations as well as regular educational sessions, all of which is intended to increase PCPs’ self-efficacy in managing complex chronic pain complaints.
The IPT is physically located at the San Francisco VA Medical Center, where local patients may be seen in person.
The San Francisco-based team also conducts virtual interdisciplinary pain management visits for patients based at more rural VHA community clinics throughout northern California, using video telehealth technology.
As a case example, a PCP with a patient who has chronic pain and is co-prescribed high-dose opioids for pain and benzodiazepines for an anxiety disorder may refer the patient to the IPT.
IPT providers will engage in shared decision-making with the patient to develop a Pain Care Plan aligned with the patient’s personal values and goals, which might include strategies such as gentle exercise, yoga or another enjoyable hobby (e.g., gardening), cognitive behavioral therapy for pain, and non-opioid analgesics to reduce reliance on opioids.
At the same time, IPT providers may attempt to reduce opioid overdose risk by tapering either the opioid or the benzodiazepine, or both, perhaps suggesting a non-benzodiazepine medication to treat anxiety symptoms.
On discharge, IPT providers will share the patient’s Pain Care Plan with the referring PCP to promote continuity of care.
Of note, while there are numerous positive randomized controlled trials for chronic pain using cognitive behavioral therapy9 , 10 and exercise,11 , 12 to date, there has not been a comparative effectiveness trial evaluating the biopsychosocial IPT model against other models of pain care delivery (e.g., pharmacist collaborative pain management).
Moreover, there are no studies that evaluate the effect of an interdisciplinary biopsychosocial approach on neurohormones (e.g., cortisol), that may mediate the putative positive effects on chronic pain and mental health comorbidities such as anxiety that can exacerbate and perpetuate chronic pain.
To begin to fill this research gap, we have been conducting a quality improvement study of the IPT clinic based at the SFVAHCS.
Preliminarily, we examined 162 veteran patients: 81 patients enrolled in the IPT clinic compared to 81 matched control patients who were seen in usual primary care during the same time period.
We followed both groups for 90 days.
All patients had chronic pain, were prescribed opioids and were matched with respect to age, sex, number and type of psychiatric diagnoses, and baseline daily opioid dose.
We found that the mean daily opioid dose (measured by morphine equivalent daily dose [MEDD]) decreased by 41.2 mg in the IPT group after 90 days (from 108.7 to 67.6 mg), while the reduction in the control group was only 24.8 mg (102.3 to 95.5 mg).
Twice as many patients in the IPT clinic as in the control group (38 vs. 19 patients) reduced their daily opioid dose by 50% or more, representing a 2.6-fold increase in the odds of a 50% or greater reduction in daily opioid use (p = 0.004).
With follow-up extended to 180 days, the daily prescription opioid dose of the IPT group was 103% lower than that of the control group (p = 0.015); receiving care through the IPT clinic was associated with 3.6-fold increased odds of 50% or greater reduction in opioid use (p = 0.005).
In sum, these preliminary quality improvement data suggest that interdisciplinary team-based pain care in collaboration with primary care may be superior to usual primary care alone in reducing reliance on opioids for pain management.
This, in turn, may lead to greater reductions in patient harm, given the increased risk for opioid overdose associated with higher doses of opioids.
Regrettably, though, this groundbreaking interdisciplinary pain care model may be jeopardized by recent political developments, including recent election results.
In addition, several bills introduced in Congress (e.g., the Permanent Department of Veterans Affairs Choice Card Act of 2015, the Veterans Health Care Freedom Act, 2015), along with recommendations of the 2016 Commission on Care report,13 propose to channel the majority of veterans’ medical care (including pain care) to the private sector, where coordinated treatment is not the norm.
While creating limited networks and partnerships with private sector providers and organizations has the potential to enhance veterans’ options and access to care, the passage of these bills should not come at a cost of defunding and hence undermining the kind of advances our team-based approach demonstrates.
This would represent a disappointing step backwards given the wealth of evidence showing that the VHA outperforms private sector healthcare in outpatient care on almost all quality measures.14
The Integrated Pain Team clinic is one example of what’s at stake; these hard-won gains in interdisciplinary health services merit further support and dissemination throughout VA primary care and even to other healthcare systems.
As with chronic pain, lives may depend on coordinated team-based management and safe prescribing.
In fact, primary care-based integrated pain teams like those in the VA are rare in the private sector, mostly because biopsychosocial pain care is time-intensive and not reimbursed at the same high rate as specialty pain care, which commonly emphasizes procedures.
Interdisciplinary team-based care, while relatively easy to assemble in a fully integrated health system like the VA, is far less feasible in a more fragmented private sector healthcare system.
Yes, interdisciplinary team-based care takes more time up front than simply prescribing a pill, but in the long run, improved safety and efficacy of a team-based, opioid-avoidance approach may produce benefits for individual patients and populations alike.15
Moreover, team-based chronic pain care delivered in a primary care setting is consistent with the evidence-based, multi-modal strategies advanced by the CDC and other national health care agencies to reduce reliance on opioids and improve safe opioid prescribing.
In keeping with the CDC and other national guidelines, ancillary primary care staff in some VA centers assist in aligning pain care planning with patient values and goals and providing psychotherapy, physical rehabilitation and pharmacy support, ultimately exceeding what any individual PCP could provide.
In sum, many well-intentioned efforts to relieve chronic pain through specialty care have made people sicker, primarily by increasing over-reliance on opioids, further contributing to fragmented healthcare and soaring costs.
PCPs are best positioned to deliver biopsychosocial chronic pain care: they have long-term relationships with their patients and can consider patients’ values and goals in developing patient-centered pain care plans.
Nevertheless, PCPs need ancillary team support – “a village” – to implement this guideline-concordant care.
As a publicly funded health care system swimming upstream against a current toward privatization, the VA continues to pave the way toward primary care-based pain management, which is biopsychosocial in orientation and patient-centered. Providing interdisciplinary support to PCPs is critical to delivering high-quality chronic pain care in primary care, so that it never becomes PCPs’ “thorniest burden.”
More information: Pooja A. Lagisetty et al, Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids, JAMA Network Open(2019). DOI: 10.1001/jamanetworkopen.2019.6928
Journal information: JAMA Network Open
Provided by University of Michigan