Management of Chronic Noncancer Pain by VA Primary Care Providers: When Is Pain Control a Priority?

Additional training opportunities for primary care physicians and better use of ancillary services may be needed to further improve care for chronic pain patients.
Published Online: February 15, 2008
Allison R. Mitchinson, MPH; Eve A. Kerr, MD, MPH; and Sarah L. Krein, PhD, RN

Objective: To examine how primary care providers (PCPs) prioritize management of chronic pain in patients with multiple chronic conditions and to determine PCP perspectives on chronic pain management and pain treatment resources.

Study Design: Survey mailed to a random sample of 500 Department of Veterans Affairs (VA) PCPs at VA medical centers and community-based outpatient clinics.

Methods: After reading a vignette describing a patient with multiple chronic conditions and chronic pain, PCPs were asked to identify the 3 most important issues to address during the visit. The survey also asked about the availability of services, and level of confidence and satisfaction with chronic pain management.

Results: A total of 279 eligible PCPs (57%) responded to the survey, 77% of whom identified pain control among the top 3 treatment priorities. PCPs who did not choose pain control were more likely to indicate that chronic pain patients should see a specialist (54% vs 35%, P = .006) and were less confident about using opioid analgesics (52% vs 72%, P = .002). Of the respondents, 86% reported psychology or mental health clinics were available at their clinic site; 71%, physical therapy; and 20%, multidisciplinary pain clinics. Most PCPs (74%) were satisfied with the quality of care they provide for patients with chronic pain but only 30% were satisfied with access to pain specialty services.

Conclusion: Additional training opportunities for PCPs and more effective use of ancillary services may be needed for further improvements in care for chronic pain patients.

(Am J Manag Care. 2008;14:77-84)

Many VA primary care providers (PCPs) identify chronic pain as a treatment priority even among patients with other important chronic health conditions.

Additional training opportunities for PCPs and better use of ancillary services may be needed to further improve care for patients with chronic pain.

In healthcare systems with constrained resources, developing strategies that use broadly available services, such as psychology clinics and physical therapy, in combination could be an important mechanism for supporting both PCPs and their patients with chronic pain.

The prevalence of chronic noncancer pain is high in primary care populations and causes significant morbidity.1-4 Pain interferes with activities of daily living and work and family life, and is associated with psychological distress.2,5-7 In addition, chronic pain results in increased health service utilization and costs.8,9 Studies suggest there is substantial variability in the way physicians treat chronic pain10,11 and that primary care providers (PCPs) often are not comfortable managing patients with this condition.12,13 Moreover, patients frequently have multiple conditions that compete for the attention and time of providers, and may increase the complexity associated with managing chronic pain.1 Consider, for example, Mr Smith, a 65- year-old man with diabetes, hypertension, and congestive heart failure, presenting to his PCP for a follow-up visit. Mr Smith also has chronic low back pain from an old injury. Over the past 6 months his back pain has worsened, but an extensive workup did not reveal any new pathology. His body mass index is greater than 30 and his blood pressure, low-density lipoprotein, and glycosylated hemoglobin (A1C) values all are stable but moderately elevated.

In the midst of multiple conditions and concerns, will pain be a priority that the PCP chooses to address at this visit, or will it be overshadowed by concern about better blood pressure or glycemic control? How will the PCP establish his or her priorities? Clearly, it is difficult to prioritize and address all of the concerns for a patient with multiple chronic conditions in the midst of limited time and resources.

Although several studies have examined PCP perspectives regarding chronic noncancer pain,10-12,14 we know little about how chronic pain fits within the context of treating patients with multiple or complex chronic conditions. The Department of Veterans Affairs (VA) healthcare system is an optimal setting to address this issue, given the high prevalence among its patients of both chronic pain6,15 and other chronic conditions.16,17 We surveyed PCPs practicing in the VA to assess the extent to which pain control is identified as a management priority in a patient with multiple chronic conditions such as Mr Smith, and to elucidate PCPs’ perspectives on chronic pain management and the resources available to facilitate pain management. Specifically, we examined (1) what PCP characteristics are associated with providers’ identifying pain control as a management priority during a complex clinic visit; (2) what resources are available to PCPs to help them manage chronic pain; and (3) VA PCP satisfaction with their ability to care for patients with chronic pain.

Sample Selection
In 2005, we conducted a written survey of 500 VA primary care clinicians. The study was approved by the VA Ann Arbor Healthcare System Institutional Review Board. A list of all primary care clinicians including physicians, nurse practitioners, and physician assistants who worked at least 1 day a week in primary care and had a panel size of ≥200 patients was obtained using data extracted from a VA national database. Five hundred clinicians providing care to veteran patients at VA medical centers or community-based outpatient clinics (CBOCs) were randomly selected to receive the survey. House officers were not included.

Survey Development and Administration
The survey was developed by the investigators and included the clinical vignette in Table 1, as well as questions about resources, satisfaction, attitudes, and confidence in treating chronic pain. Survey items related to provider attitudes and confidence were adapted from published studies, including work by Green et al and others,11,12,14,18,19 and other generally available pain surveys (see, eg, To establish face validity, the questionnaire was pretested by several general medicine physicians and questions that were unclear were refined based on their feedback.

Each randomly selected clinician was mailed a cover letter, informational brochure, and a copy of the survey. Both the study survey and informational brochure were titled “Real World Clinical Strategies for Patients with Chronic Conditions.” In the brochure the project was described as focusing broadly on treating patients with multiple chronic conditions, including diabetes, heart failure, and chronic pain. To encourage participation, a $10 gift card was included with the initial survey. Following a modified Dillman technique,20 all clinicians received a reminder letter approximately 1 week after the mailing and those who did not respond initially received a second survey 2 weeks after the reminder letter. The return envelopes were marked to allow us to track which clinicians responded to the initial mailing, but the surveys were unmarked so once the survey was removed from the envelope all responses were anonymous.

The primary outcome for our analysis was whether pain control was among the top 3 priorities to be addressed during a complex patient visit. Specifically, we asked providers to read a clinical vignette describing a patient presenting with multiple chronic conditions and a complaint of chronic pain (Table 1). Then, the PCP was asked to select from a list the most important, second most important, and third most important issue to address at the visit. The list included blood pressure control, glycemic control, cholesterol control, pain control, volume status, smoking cessation, weight loss, screening tests, exercise, and an option allowing the clinician to write in other issues.

Information to characterize respondents’ perspectives about chronic pain management also was collected as part of the study survey, including scope of practice, opinions about pain management, and confidence with using opioids to treat chronic pain. The extent to which providers felt that they were operating outside their scope of practice when treating patients with chronic noncancer pain was assessed using a single question: “In the past year, how often were you expected to manage or treat chronic pain conditions that you felt were beyond your scope of practice or training and experience?” Providers who responded sometimes, often, and very often were categorized as practicing beyond their scope of practice. Opinions about pain management were assessed by asking respondents to indicate their level of agreement with several statements about pain management on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). These statements included “Most patients with chronic noncancer pain should be treated by a provider who specializes in pain management” and “I did not receive adequate training in chronic pain management principles.” Respondents who rated the item a 4 or a 5 (vs 1, 2, or 3) were categorized as agreeing with the statement. Finally, we measured confidence in using opioids to treat chronic noncancer pain by asking respondents to rate their level of confidence on a 5-point scale ranging from 1 (not at all confident) to 5 (extremely confident). We dichotomized confidence so that respondents who rated their confidence as a 4 or 5 (vs 1, 2, or 3) were categorized as confident.

Also of interest was the availability of services for managing chronic pain and the extent to which PCPs were satisfied with their ability to care for patients with chronic pain. Respondents were provided with a list and asked to indicate which pain-related services (eg, physical therapy, specialty pain clinics) were available at their clinic site. Respondents also were asked to think about their ability to care for their patients with chronic noncancer pain and rate their level of satisfaction on a 5-point scale ranging from 1 (mostly dissatisfied) to 5 (mostly satisfied). Specifically, we asked them how satisfied they were with the length of appointments, quality of care, ease of obtaining specialty referrals, and the accessibility of medications for treating chronic pain. For each of the satisfaction items, respondents who rated the item a 3, 4, or 5 (vs 1 or 2) were categorized as being somewhat or mostly satisfied.

Lastly, we collected information to characterize the respondent sample, including age, provider type, sex, years in practice, number of patients seen per half day, average amount of time allotted for return visits, and practice site (VA medical center or CBOC).

Data Analysis
We calculated means and standard deviations for continuous variables and frequency distributions for categorical variables to summarize responses to questions on the survey. Chi-square tests and t tests were used to compare the association between prioritization of pain control, provider demographic characteristics, and PCPs’ perceptions about managing chronic noncancer pain. To assess service availability, in addition to presenting results for the sample overall, we also stratified responses by the respondents practice’ location (VA medical center vs CBOC). CBOCs were created to expand access to primary care services, so we expected the availability of on-site specialty services to be more limited at these clinic locations. Analyses were conducted using SAS software, version 9.0 (Cary, NC) and Stata statistical software, release 10.0 (College Station, Tex).

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