Clinical Review
Multidisciplinary Approach to Back Pain
Combining physical, psychological, and/or social/work interventions may help reduce pain and disability in patients with chronic low back pain.
The epidemic of opioid abuse, addiction, and overdose deaths across the U.S. has not forgone the reservations of American Indian/Alaska Native (AI/AN) tribes. Indeed, AI/ANs may be at increased risk for abuse of prescription opioids due to higher rates of reported illicit drug use and misuse of opioids. According to the 2012 National Survey on Drug Use and Mental Health, AI/ANs aged ≥ 12 years had the highest rates of illicit drug use (12.7%) with the national average being only 9.5%.1 In 2009, AI/ANs aged 12 to 17 years were found to have the highest rates of marijuana use (13.8%) and nonmedical prescription drug abuse (6.1%) compared with the overall U.S. averages of 6.9% and 3.3%, respectively, putting them at an increased risk for an opioid overdose.1,2
In 2010, the American Pain Society conducted a survey establishing that about 41% of American adults reported having chronic, recurrent, or long-lasting pain.3 People of AI/AN heritage may experience chronic pain at higher rates, as they were identified as having the greatest incidence rates of low back pain (35%), arthritis (25%), and obesity (40%), which are often significant contributing factors to chronic pain.4-6
These conditions suggest a need for intensified management of chronic pain among IHS patients. The authors’ IHS facility is a closed health-system network where pharmacists are integral components of the health care team throughout the ambulatory care, emergency, and inpatient departments.
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Given that medications play a central role in the treatment of chronic pain, pharmacists are appropriate leaders for chronic pain management teams. Pharmacists can improve patient outcomes by conducting pain assessments, managing adverse events (AEs), identifying optimal medication choices, determining equianalgesic dosing, and managing care through care protocols.7
The primary objective of the multidisciplinary chronic pain management clinic (MCPMC) is to manage complicated and postsurgical patients, using a multimodal approach. Primary care providers (PCPs), which include physicians, nurse practitioners (NPs), physician assistants (PAs), and pharmacist providers collaborate to meet this goal by minimizing disease progression, preserving activities of daily living (ADL), maintaing employment, preventing an increase in pain, using treatment plans that include pharmacologic, interventional, and complementary components, decreasing emergency department (ED) visits for chronic pain issues, improving pain agreement adherence, managing AEs, performing drug abuse and diversion surveillance, and using sustained-release (SR) opioids when appropriate. Sustained release opioids not only ease dosing schedules and increase adherence, but also improve sleep, functionality, and quality of life (QOL) for chronic pain patients.8
Methods
The MCPMC began enrolling patients in January 2011 and has continued to date. Inclusion criterion is the presence of pain lasting 3 months or more. Exclusionary criteria are the presence of malignant pain, aged < 18 years, pregnancy, unmanaged psychiatric disorders, and a referral not approved by a PCP. Referrals are accepted from providers throughout the facility, including the ED, which then require approval by the PCP before enrollment. The PCP continues to manage these patients through consultations with the MCPMC pharmacists following MCPMC appointments and at separate ambulatory care clinic appointments.
Currently, there are 2 pharmacists practicing in the MCPMC clinic in conjunction with other health care providers, including 5 physical therapists, 1 psychiatrist, 2 clinical social workers, and 15 PCPs, including NPs and PAs. Additionally in 2014, the clinic became a yearlong rotation in the PGY-1 pharmacy practice residency.
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After enrollment, a pharmacist reviews patients’ health records for past pain medications, interventional and complementary treatments, adherence to these treatments, recent ED visits and medications received, urine toxicology results, adherence to pain agreements, and the Arizona Controlled Substances Prescription Monitoring Program Database (ACSPMPD).
During the initial MCPMC appointment, a pain assessment questionnaire (PAQ) is completed with a MCPMC pharmacist. The questionnaire, designed specifically for the MCPMC, consists of a comprehensive pain assessment, including functional status and common comorbidities, such as anxiety, depression, obesity, and insomnia. Patients provide feedback on efficacy of past or current medications, and interventional and complementary treatments if applicable. Patients also rate their satisfaction with health care received and develop goals for their treatment and overall health.
A collaborative treatment plan is then developed with the patient’s PCP. Treatment plans often consist of increasing or starting interventional and complementary treatments, SR opioids, and adjuvant medications. Common adjuvant medications include nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptics, immunosuppressants, disease-modifying antirheumatic drugs (DMARDs), and topical agents. To maximize benefits of the medications, antidepressants are often prescribed for dual purposes among patients with comorbid conditions, such as anxiety, depression, and insomnia. Among obese patients, weight loss is encouraged, and patients may be referred to dietary counseling and exercise programs. Other intentions of the treatment plans are to decrease breakthrough pain and ED visits while attempting to decrease the use of immediate-release (IR) opioids. Treatment plans are executed in a stepwise approach over multiple MCPMC visits and may be modified throughout the course of the program.