Considerations in Treating Patients with Chronic Pain

Abstract

Without question, the medical management of chronic pain patients presents primary care practitioners with significant challenges. Often these patients do not improve to the point that they no longer require medication management and other routine medical services (1). These patients also generally take up a disproportionate amount of the practitioner's time at office visits, and they are often uninsured and/or have limited financial means. It is also well publicized that state and federal authorities, primarily the Texas Medical Board (TMB), have made the evaluation of medical treatment of chronic pain a focus of their policing authority (2). Unfortunately, the current form-over-substance approach of the TMB and other regulatory agencies may be a major reason for primary practitioners' flight from seeing chronic pain patients. In spite of the fact that TMB rules specifically provide that the substance of a practitioner's actions should trump the rules' documentation (form) requirements (3), this directive is frequently not followed by the TMB when evaluating medical treatment of chronic pain patients. Against these disincentives to handle chronic pain patients are sentiments that chronic pain is frequently undertreated and/or inadequately managed (4). These circumstances place primary care practitioners in a difficult and unenviable situation. Primary care providers are frequently the only health care provider a patient wants to see or can afford to see. Thus, primary providers are often a chronic pain patient's only hope. Most providers have a true desire to help these patients, but many times this desire is outweighed by the disincentives mentioned above. These circumstances have appeared to stratify primary care practitioners into three classes. The first is a small class of practitioners who have decided to fight for these patients. The second is a class of practitioners who want to do the right thing but are understandably intimidated by entities like the TMB and are not sure what to do. Those in the third group have decided that these patients are simply not worth the practical and regulatory headaches. The primary aim here is to provide some pointers to the second and third classes of providers so these patients will not become orphans, and to provide some insight to help protect the first class of providers.