PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.
"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.
Sherry Boschert/IMNG Medical Media
Dr. Bill H. McCarberg
It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.
He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.
"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.
Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.
"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.
Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.
Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.
One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.
An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.
Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.
"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."
Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.