INTERNAL MEDICINE RESIDENTSʼ MANAGEMENT OF CHRONIC NONMALIGNANT PAIN: DEFICITS AND INCONSISTENCIES.

Abstract

Background Primary care providers are faced with challenges when prescribing narcotic analgesics for patients with chronic nonmalignant pain (CNMP). Lack of evidence-based guidelines, variation in pain syndromes, and challenges in recognizing prescription drug abuse create inconsistencies in practice. Resident clinic populations can present unique challenges as well. The purpose of this pilot study is to (1) describe patients on narcotic analgesics for CNMP in a resident teaching clinic, (2) determine resident use of a multimodal approach to therapy, and (3) determine use of clinical tools to avert patient misbehaviors. Methods Thirty charts were randomly selected from approximately 1,000 patients in an internal medicine resident teaching clinic who had received Schedule II narcotic analgesics between July 1, 2003, and June 30, 2004. Exclusion criteria included patients (1) less than 18 years of age, (2) who had fewer than two visits during the study period, and (3) who had expired. Data sources include the outpatient clinic record, pharmacy records, and the electronic medical record. Results Data were available for 28 of the 30 charts reviewed. Although data were limited, the population was predominantly female (64%), white (68%), and unemployed or disabled (81%). Ninety-three percent of patients had a specific pain diagnosis, back pain and/or degenerative joint disease being the most common (79%). Eighteen percent had no other documented treatment modality for pain control other than narcotics. Although a majority of charts had a signed medication contract (80%), few residents documented an attempt to obtain prior records. Only 14% of patients had urine drug screening during the study period. Face-to-face clinic visits were infrequent; 25% of patients had less than quarterly assessments. Several “red flag” behaviors, including prior substance abuse and legal histories, were not well documented. Of the 32% of patients who had contract violations (90% were early refills), only 11% had documented consequences. Conclusions The results from this pilot study reveal significant deficits and inconsistencies in resident practice. Residents underuse non-narcotic therapies in patients on narcotic analgesics as well as clinical tools that provide consistency in monitoring use and for potential abuse. Important red flag behaviors were infrequently documented. When contract violations occur, few residents are documenting consequences. However, the frequent request for early refills may indicate inadequate treatment of pain. When prescribing narcotic analgesics for CNMP, deficits can lead to inadequate pain control and inconsistencies can lead to unrecognized prescription drug abuse. Standardized training in the management of CNMP is warranted.