Putting into Practice: Implementing Chronic Pain Management Toolkit in Your Office The Centers for Disease Control and Prevention guidelines state: An estimated 20% of patients presenting to physician offices with non-cancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription. Chronic pain has been variably defined but is defined within this guideline as pain that typically lasts more than three months or past the time of normal tissue healing. Chronic pain can be the result of an underlying medical disease or condition, injury, medical treatment or condition, injury, medical treatment, inflammation, or an unknown cause. Physicians report multiple barriers to appropriately managing chronic pain, including lack of time, training, increased scrutiny on opioid prescribing, and fear of patients developing opioid use disorder. In addition to these concerns, several studies have reported increased physician burnout in the management of chronic pain from a lack of patient self-management skills. From Carole Upshur, EdD, and colleagues in “Primary Care Provider Concerns about Management of Chronic Pain in Community Clinic Populations”: “Despite the unfavorable reports about pain education and low satisfaction with pain treatment, PCPs did not identify provider expertise and health system factors (e.g., difficulty of diagnosis, lack of evidence-based guidelines) as the most important obstacles to treating patients with chronic pain. Instead, patient compliance and behavioral factors were rated as more problematic.” Using a systematic evaluation in chronic pain management, including implementing the resources found in the American Academy of Family Physician’s (AAFP) chronic pain management toolkit, allows for physical, mental, and functional evaluation of patients who suffer from chronic pain. After completing a thorough evaluation, a physician can determine appropriate medication and additional treatments and therapies that can be taken to improve selfmanagement skills. In March 2014, AAFP launched the Chronic Pain Toolkit, giving physicians multiple resources in one location that are easily accessed and downloaded. The Chronic Pain Toolkit is divided into five sections: • Pain Assessment gives an overview of appropriate strategies and diagnostic tools used to support chronic pain assessment in patients. • Functional and Other Assessments discuss supporting tools and methods for the diagnostic assessment of functional activity and other coexisting conditions, including the patient’s emotional and mental health, quality of life, and other psychosocial factors. • Pain Management provides details on strategies and considerations for effective management of acute and chronic pain. • Opioid Prescribing covers the prescribing of opioids as it relates to the treatment of chronic pain and includes information and resources on safe prescribing practices, risk mitigation and monitoring, opioid conversion and tapering tools, and specific resources for patients. • Opioid Use Disorders: Prevention, Detection and Recovery offers a brief overview along with resources in support of opioid use disorder prevention, recognition and assessment, and treatment and recovery. Application Determining which patients are appropriate for evaluation is key. The more inclusive the application of the pain management toolkit within a physician’s practice allows for clearer guidelines for staff and improves patient safety. Avoid common misperceptions that short-acting opioids or morphine milliequivalents (MME) less than 90 can be excluded from pain management evaluation because the patient is deemed lower risk. Protocols should be clear and nondiscriminatory, including all patients meeting the criteria for chronic pain. Barriers to Implementation Often cited as barriers for not managing chronic pain are the lack of time or familiarity with resources provided, patient behaviors, and increasing scrutiny over controlled substance prescribing. Overcoming these barriers can improve adherence and patient safety. By Darlene Petersen, MD, and Brian Hunsicker UtahAFP.org | 24
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