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The American Journal of Managed Care April 2020
High-Cost, High-Need Patients: The Impact of Reported Penicillin Allergy
Kimberly G. Blumenthal, MD, MSc; Nicolas M. Oreskovic, MD, MPH; Xiaoqing Fu, MS; Fatma M. Shebl, MD, PhD; Christian M. Mancini, BS; Jennifer M. Maniates, MA; and Rochelle P. Walensky, MD, MPH
Solid-Organ Transplant Recipients With Hyperglycemia on Admission Face Worse Outcomes
Amit Akirov, MD; Tzipora Shochat, MSc; and Ilan Shimon, MD
Incorporating Telemedicine as Part of COVID-19 Outbreak Response Systems
Kimberly Lovett Rockwell, MD, JD; and Alexis S. Gilroy, JD
The Patient-Driven Payment Model: Addressing Perverse Incentives, Creating New Ones
Mark Aaron Unruh, PhD; Dhruv Khullar, MD, MPP; and Hye-Young Jung, PhD
In Uncertain Times, Public Service Leadership More Important Than Ever: A Q&A With Sherry Glied, PhD
Interview by Allison Inserro
Spending Variation Among ACOs in the Medicare Shared Savings Program
Michael Anne Kyle, MSN, MPH; J. Michael McWilliams, MD, PhD; Mary Beth Landrum, PhD; Bruce E. Landon, MD, MBA; Paul Trompke, MPP; David J. Nyweide, PhD; and Michael E. Chernew, PhD
Collaborative Care Plans Reduce Subspecialty Consults: The Experience From a Safety Net Hospital
Arshag D. Mooradian, MD; Ronald Stone, RD, MBA; Carlos Palacio, MD, MPH; and Eric Stewart, MD
Response to “e-Consult Implementation Success: Lessons From 5 County-Based Delivery Systems”
Melissa D. Sexton, PhD, MDiv, LMFT; LaToya K. Williams, EdD, LCSW; and Lillianne Lewis Debnam, MD, MPH
Initiation of Triple Therapy Maintenance Treatment Among Patients With COPD
Yong Li, PhD; Jonathan Lim, MSc; Stephen Stemkowski, PhD; Shuchita Kaila, PhD; Andrew Renda, MD; and Asif Shaikh, MD
LACE+ Index as a Predictor of 90-Day Plastic Surgery Outcomes
Eric Winter, BS; Gregory Glauser, BS; Ian F. Caplan, BS; Stephen Goodrich, BS; Scott D. McClintock, PhD; Stephen J. Kovach III, MD; Joshua Fosnot, MD; Joseph M. Serletti, MD; and Neil R. Malhotra, MD
Outcomes of Liver Transplantation by Insurance Type in the United States
Maria Stepanova, PhD; Saleh Al Qahtani, MD; Alita Mishra, MD; Issah Younossi, MPH; Chapy Venkatesan, MD; and Zobair M. Younossi, MD, MPH
Primary Care Physician Practice Styles and Quality, Cost, and Productivity
Harold S. Luft, PhD; Su-Ying Liang, PhD; Laura J. Eaton, MD, MPH; and Sukyung Chung, PhD
Currently Reading
Healthcare Professionals’ Perceptions of Challenges to Chronic Pain Management
Cate Polacek, MLIS, MFA, ELS; Roni Christopher, DHSc; Michelle Mann, BS; Margarita Udall, MPH; Terri Craig, PharmD; Michael Deminski, MS, BSPharm; and Nila A. Sathe, MA, MLIS

Healthcare Professionals’ Perceptions of Challenges to Chronic Pain Management

Cate Polacek, MLIS, MFA, ELS; Roni Christopher, DHSc; Michelle Mann, BS; Margarita Udall, MPH; Terri Craig, PharmD; Michael Deminski, MS, BSPharm; and Nila A. Sathe, MA, MLIS
Healthcare professionals report pain management barriers across system, provider, and patient levels, highlighting the need to consider chronic pain as a chronic condition that warrants coordinated approaches.
ABSTRACT

Objectives:
To explore healthcare professionals’ perceptions of challenges to chronic pain management.

Study Design: Qualitative interview study.

Methods: Semistructured telephone interviews with healthcare professionals involved in chronic pain management and thematic analysis of transcriptions.

Results: Respondents (N = 16) described multiple challenges to chronic pain management: Management occurs in a complex care context complicated by the multidimensional, subjective nature of pain. A lack of systematic approaches fosters variation in care, and clinicians lack time and resources to manage pain holistically. Efforts to date have focused primarily on opioid reduction versus strategic approaches to manage chronic pain across the system.

Conclusions: Comprehensive approaches to identify and manage chronic pain are nascent and, typically, narrowly focused on reducing opioid use. Respondents, however, recognized the importance of effective systematic management across inpatient and outpatient settings. These findings underscore the need to consider chronic pain as a chronic condition that warrants coordinated approaches to care such as standardized assessments; consistent, patient-centered outcome measures; and multimodal treatments that target both physical relief and underlying psychosocial factors.

Am J Manag Care. 2020;26(4):e135-e139. https://doi.org/10.37765/ajmc.2020.42841
Takeaway Points

Reported barriers to chronic pain management included a complex, variable care context; the multidimensional, subjective nature of pain; variation in approaches to pain; and limited resources to manage pain holistically. Most chronic pain management focuses on opioid reduction versus strategic management across the system.
  • These findings align with other reports of fragmented episodic care in the literature and underscore the need for a comprehensive disease management approach to chronic pain.
  • Comprehensive management—including understanding characteristics of pain and patients that may affect pain presentation, treatment selection, and response—can optimize care for patients and providers.
Non–cancer-related chronic pain is a significant problem for many Americans. In 2016, 50 million US adults (20.4%) reported experiencing daily pain in the previous 6 months and nearly 20 million (8%) reported pain that limits daily activities.1 Use of opioids to relieve pain is pervasive. The 2015 National Survey on Drug Use and Health reported that 37.8% of noninstitutionalized US adults used prescription opioids, 4.7% misused them, and 0.8% had a use disorder.2 The most common reason for misuse, reported by 63.4%, was physical pain relief.2 However, opioids may have limited effectiveness for relieving chronic pain and may have significant adverse effects.3-7

Given the broad scope of chronic pain and opioid abuse, developing multimodal solutions that provide effective chronic pain management based on pathophysiology is an increasingly important health priority. However, nonopioid pain relief approaches may be underutilized. Studies report limited provider confidence in managing pain8,9 and limited knowledge about use of opioids for chronic pain.10

We conducted a qualitative interview study to understand healthcare professionals’ perceptions of challenges, gaps, and opportunities in chronic pain management.

METHODS

Participants

Using email and telephone contacts, we recruited participants from health systems taking part in Premier quality improvement initiatives. We identified stakeholders with interest and experience in chronic pain management who were from both larger and smaller hospitals across the United States (purposive sampling). We included a range of perspectives (physicians, nurses, quality improvement personnel, pharmacists) to ensure broad representation and promote generalizability of findings. Participants did not receive compensation or incentives for participation. Pfizer funded the study; Pfizer personnel did not participate in interviews and had no input into data analysis. The Advarra institutional review board approved the project as exempt research (Pro00028336).

Data Collection

We conducted semistructured telephone interviews with healthcare professionals involved directly or indirectly in caring for patients with chronic pain to understand perceptions related to nonopioid pain management. We created an interview guide based on literature review and clinical practice experience. One of 2 members of the project team (C.P., N.A.S.) conducted each interview; all interviews were recorded (with participant consent) for further analysis.

Data Analysis

We conducted an inductive thematic analysis (content analysis) of interview data to understand respondents’ experiences in managing patients’ chronic pain and to identify themes. Team members (C.P., R.C., N.A.S.) coded and discussed an initial interview transcript to ensure alignment in approaches and preliminary codes. Two team members (C.P., N.A.S.) independently read and coded each transcript, assigning relevant codes using NVivo 12 software (QSR International, Melbourne, Australia). We developed the coding structure using pragmatic approaches, combining both bottom-up elements—developing codes from ideas and issues inherent in the data—and top-down elements, with issue identification informed by the a priori interview structure. We maintained an iterative codebook to record codes and operational definitions, and the team discussed differences to reach consensus on a final coding framework.

RESULTS
​​​​​​
Interviews (each approximately 40-60 minutes) were completed with 16 healthcare professionals who self-identified as being engaged in chronic pain management, from either a prescriber or nonprescriber perspective (Figure). Across interviews, respondents described complex contexts surrounding chronic pain treatment. Chronic pain management is complicated by the multifaceted nature of pain, the complex presentation of physical or mental health comorbidities and acute and chronic pain, multiple health system touchpoints, and consequences of opioid overuse and misuse. We describe challenges under system, pain management, provider, and patient domains. Details and quotes supporting each challenge appear in the eAppendix (available at ajmc.com).


 
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