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.
ABSTRACTObjectives: 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
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.
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.
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).
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.
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.
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).
Limited and inconsistent processes. Respondents noted limited or no processes for handling patients with chronic pain, whether in identifying and tracking patients along a care trajectory or in establishing consistent management approaches. Systematic approaches have been motivated by and focused on opioid reduction.
Transitions of care. Pain treatment across settings is often uncoordinated. It is challenging to follow up with patients after emergency department (ED) visits if they lack a primary care doctor to communicate with or if a pain center is not available or accessible. Pain approaches established in one setting may not carry through in others.
Pain Management Challenges
Opioid restrictions. Mandatory opioid restrictions and protocols for opioid prescribing may leave some patients with chronic pain without effective pain management or may prompt providers to avoid treating pain altogether. Due to the potential for misuse of narcotic medications, respondents noted that healthcare professionals may end up positioned as drug gatekeepers instead of trusted partners in pain management.
Resource constraints. Respondents stated that limited resources contributed to ineffective pain management. Primary care providers may not be able to provide a full complement of pain management services to patients.
Root causes. Respondents noted that the most effective chronic pain management addresses underlying causes and pathophysiology of pain, not just the symptom itself. This involves a detailed review of a patient’s medical history, current medications, mental and physical health, and social, financial, and other life stressors to develop a thorough understanding of the patient’s place on the pain spectrum. A detailed review can be difficult to obtain in a short patient visit and may require deeper investigation with other providers or psychosocial assessment.
Care variation. Approaches to treating chronic pain also varied, with limited guideline adherence or standardized approaches.
Lack of education. Many providers are not adequately trained in understanding pathophysiology or treatment of pain and the physiologic effects of both opioid and nonopioid treatments.
Lack of communication. Several respondents suggested that better communication among providers is needed, whether among inpatient providers or between inpatient and outpatient providers. In some cases, providers’ only connections may be through the electronic health record.
Complex experience of pain and pain management. Each patient’s experience of chronic pain is subjective, complex, and unique, which influences screening, diagnosis, treatment sought and received, and treatment effectiveness. Respondents indicated that patients with chronic pain may enter the care continuum at various points and proceed on various pathways, which may affect their experience of pain and treatment for it.
Perception of pain and therapeutic expectations. Respondents explained that reframing how patients use pain as a barometer for healing is challenging; it requires seeing pain as information to inform observations that may help avoid reinjury. It is crucial to discuss not only what treatment options may be available but also why certain ones may be more effective for long-term pain management.
Cost. Cost is often an issue in chronic pain management, as patients face insurance deductibles and other out-of-pocket costs.
Our findings, which include broad healthcare professional perspectives, mirror the complex and fragmented nature of US healthcare that is evident in studies with narrower interviewing frames.11-13 The lack of consistency noted in national reports and healthcare literature is evident in respondents’ discussions of barriers to comprehensive pain management. Our exploration identified a lack of comprehensive approaches to integrating systemwide pain management, from identifying patients with chronic pain to making treatment decisions to transitions of care. Importantly, this exploration also provides insights into gaps and challenges in chronic pain management beyond managing opioids. Respondents noted that opioids add further complexity to an already complicated pain management context.
Guidelines for chronic pain conditions echo complexities in pain management. Guidelines addressing general chronic pain, neuropathic pain, lower back pain, osteoarthritis, migraine, fibromyalgia, and other conditions have been published.7,14-25 Although specific treatments for various pain conditions differ, guidelines for the same condition often vary and complicate protocol consistency.26 Moreover, providers want input into guidelines or protocols for pain treatment: In our sample and in the literature,27 providers noted concerns about “cookbook” approaches if guidelines are mandated without allowance for provider autonomy, clinical expertise, and patient values. Responding to each patient’s unique pain experience and context in patient-centered ways while minimizing variation is a key tension in healthcare.28
As noted, pain management among our sample was largely limited to opioid reduction; respondents recognized the need to formalize chronic pain management approaches but lacked resources for doing so. Without clear system strategies, respondents recognized that pain may be managed differently at different touchpoints (eg, ED, inpatient, ambulatory). Management approaches that are solely focused on limiting opioids also have unanticipated consequences.29-31 Respondents remarked that restricting prescribing—without identifying underlying pathology, selecting appropriate treatment, and communicating treatment rationale—will not solve problems and can create new ones. Mandatory prescribing restrictions make some providers reluctant to treat pain or may leave some patients without options.32-34
Respondents emphasized the need to understand underlying causes of pain to inform appropriate, holistic treatment decisions. Pain is multifaceted, yet it is often treated solely as a symptom, and it is difficult to track across the system because of deficiencies in administrative coding.35,36 Fortunately, the 11th version of the International Classification of Diseases includes comprehensive pain diagnoses,36 and the new coding incorporates severity and psychosocial factors (eg, fear, anger, relationships), which may help improve multimodal treatment, health research, and policy.36,37
Additional provider education is also key to improved management. A 2018 systematic review reported considerable variation in pain management content and learning time in global medical school curricula; in the United States, students received a median 11 hours of pain-related content, and 96% of US medical schools lacked compulsory dedicated teaching in pain medicine.38
Education is 1 element that may facilitate culture change at provider, patient, and system levels to promote shifts in pain management. Such change may include provider education in pain mechanics and assessment; holistic understanding of etiology, patient education, and engagement; and development of trusted therapeutic relationships, a need echoed in other reports.29,39-42 To develop system-supported therapeutic patient-provider relationships, realistic expectations must be set and followed by the health system, providers, and patients. All 3 must understand and work toward pain management strategies that look beyond reliance on medication to mask pain and include physical and psychological multimodal therapies.12
Change at the patient level necessitates that patients see beyond quick fixes and embrace preventive care such as weight loss and appropriate self-management.13,29 Patients also need education on their pain condition, mental health, and treatment options.42 Similarly, promoting societal awareness of social determinants of health and appropriately tailored interventions may help improve pain management.12,40
System-level changes include shifting the notion that pain is merely a symptom. The 2016 National Pain Strategy endorses a multidisciplinary, population-based, disease management approach to pain, noting that “…the care model must shift from the current fragmented fee-for-service approach to one based on person-centered care, better incentives for prevention (primary, secondary, and tertiary) and for collaborative care along the continuum of the pain experience....”12 Moving from fee-for-service to value-based payment arrangements that link payment mechanisms to quality and value in care may also change systems’ approaches to pain-related care, particularly patient-centered care and care coordination.43,44
A shift toward viewing chronic pain as a chronic condition versus a symptom also necessitates change in systematic approaches across the care continuum.45,46 For example, standardized assessments may help target pain management appropriately: Outcomes associated with different approaches are variable, and understanding pain characteristics and patient attributes that may affect response to specific approaches can optimize care.46-48 Selecting appropriate multimodal treatments may help prevent longer-term pain issues. Understanding patients’ perceptions of pain can engage them in care.49 And managing care transitions between hospital and outpatient settings can promote continuity, a potential issue in inpatient, ED, and ambulatory care settings.12,50
These findings should be interpreted in light of potential limitations. We interviewed a small number of participants, although the sample size aligns with exploratory qualitative research methods.51-53 The small participant number is mitigated by the breadth of perspectives represented in the interviews and surveys; however, generalizability of findings to the broader population of individuals who treat chronic pain, particularly in outpatient or primary care settings, is limited. Our findings, however, align with reports of issues in chronic pain management in the literature.
These findings underscore the need to consider chronic pain as a chronic condition that warrants coordinated care approaches, including standardized assessments; consistent, patient-centered outcome measures; and multimodal treatments that target both physical relief and underlying psychosocial factors. Chronic pain management occurs in a multifaceted care context complicated by the multidimensional, subjective nature of pain. Limited systematic approaches foster variations in care, and clinicians lack time and resources to manage pain holistically. Although comprehensive chronic pain identification and management approaches are nascent, efforts have focused primarily on opioid reduction versus strategic, systemwide approaches to manage chronic pain. Still needed is effective, systematic management of pain across settings that coordinates care and keeps the focus on each patient’s unique medical history and concerns.Author Affiliations: Premier Applied Sciences, Premier Inc (CP, RC, MM, NAS), Charlotte, NC; Pfizer Medical Affairs (MU, TC, MD), New York, NY.
Source of Funding: This qualitative research project and manuscript was funded by Pfizer. The project agreement ensured the authors’ independence in designing the study, interpreting the data, and writing and publishing the report, with additional input into the survey design and interview guide from Pfizer.
Author Disclosures: Ms Udall, Dr Craig, and Mr Deminski are Pfizer employees with stock options; Pfizer is a pharmaceutical manufacturer that has FDA-approved medications to treat pain or conditions associated with pain. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (CP, RC, MU, TC, MD, NAS); acquisition of data (CP, NAS); analysis and interpretation of data (CP, RC, NAS); drafting of the manuscript (CP, NAS); critical revision of the manuscript for important intellectual content (CP, RC, MM, MU, TC, MD, NAS); obtaining funding (RC, MU, TC); administrative, technical, or logistic support (RC, MM, MU); and supervision (RC, MM, MU).
Address Correspondence to: Cate Polacek, MLIS, MFA, ELS, Premier Applied Sciences, Premier Inc, 13034 Ballantyne Corporate Pl, Charlotte, NC 28277. Email: Cate_polacek@premierinc.com.REFERENCES
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