Management Of Pain In Primary Care Research Articles

Quality indicators for osteoarthritis pain management in the primary care setting

BackgroundDevelopment of valid and feasible quality indicators (QIs) is needed to track quality initiatives for osteoarthritis pain management in primary care settings.MethodsLiterature search identified published guidelines that were reviewed for QI extraction. A panel of 14 experts was assembled, including primary care physicians, rheumatologists, orthopedic surgeons, pain specialists, and outcomes research pharmacists. A screening survey excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant for osteoarthritis in primary care settings. A validity screening survey used a 9-point Likert scale to rate the validity of each QI based on predefined criteria. During expert panel discussions, stakeholders revised QI wording, added new QIs, and voted to include or exclude each QI. A priority survey used a 9-point Likert scale to prioritize the included QIs.ResultsLiterature search identified 520 references published from January 2015 to March 2021 and 4 additional guidelines from professional/governmental websites. The study included 41 guidelines. Extraction of 741 recommendations yielded 115 candidate QIs. Feasibility screening excluded 28 QIs. Validity screening and expert panel discussion excluded 73 QIs and added 1 QI. The final set of 15 prioritized QIs focused on pain management safety, education, weight-management, psychological wellbeing, optimizing first-line medications, referral, and imaging.ConclusionThis multi-disciplinary expert panel established consensus on QIs for osteoarthritis pain management in primary care settings by combining scientific evidence with expert opinion. The resulting list of 15 prioritized, valid, and feasible QIs can be used to track quality initiatives for osteoarthritis pain management.

Chronic noncancer pain management: Integration of a nurse-led program in primary care.

Chronic noncancer pain is often excessively managed with medications (most notably opioids) instead of nonpharmacologic options or multidisciplinary care-the gold standards. To offer an effective alternative to pharmacologic management of chronic noncancer pain in primary care. Patients 18 years of age or older with chronic noncancer pain were referred by family physicians or nurse practitioners in a family health team (outpatient, multidisciplinary clinic) in Ottawa, Ont. A registered nurse used the Pain Explanation and Treatment Diagram with patients, taught self-management skills (related to habits [smoking, consumption of alcohol, diet], exercise, sleep, ergonomics, and psychosocial factors), and referred patients to relevant resources. A nurse-led chronic pain program, initiated without extra funding, was successfully integrated into a primary care setting. Among the participating patients in the pilot project, outcomes related to pain intensity, pain interference with daily living, and opioid use were encouraging. This program could serve as a model for improving chronic noncancer pain management in primary care.

Impact of Telehealth on Palliative Care and Pain Management in Primary Care

Primary health care focuses on the public's needs for a sustainable healthy existence without placing any financial burden on patients in order to ensure the highest degree of health and well-being and their equitable distribution. When pain management and palliative care are incorporated into primary healthcare, patients' quality of life and satisfaction improve. Palliative care includes supportive medical care for patients at any stage of disease with the goals of symptom relief, pain control, stress management, carer respite, and enhancing the quality of life. Globally, a wide range of technologies have been created to establish novel approaches to treating various chronic pain problems. Furthermore, utilising telehealth systems, which have been increasingly included in specialized palliative care over the past ten years and most recently during the COVID-19 pandemic, is one way to address the growing need for palliative care. Through the utilisation of a wide variety of public communication channels, telehealth can be employed for various primary healthcare goals. Telehealth is expected to be effective for conducting routine evaluations. reduced patient burden and missed appointments, as well as improved convenience and treatment of some chronic illnesses such as diabetes and hypertension. However, patients must get instruction and assistance in using this platform, with specific support made accessible for groups known to be at risk. Telehealth’s role in primary care needs further elaborated study. The purpose of this research is to review the available information about the impact of telehealth on palliative care and pain management in primary care.Primary health care focuses on the public's needs for a sustainable healthy existence without placing any financial burden on patients in order to ensure the highest degree of health and well-being and their equitable distribution. When pain management and palliative care are incorporated into primary healthcare, patients' quality of life and satisfaction improve. Palliative care includes supportive medical care for patients at any stage of disease with the goals of symptom relief, pain control, stress management, carer respite, and enhancing the quality of life. Globally, a wide range of technologies have been created to establish novel approaches to treating various chronic pain problems. Furthermore, utilising telehealth systems, which have been increasingly included in specialized palliative care over the past ten years and most recently during the COVID-19 pandemic, is one way to address the growing need for palliative care. Through the utilisation of a wide variety of public communication channels, telehealth can be employed for various primary healthcare goals. Telehealth is expected to be effective for conducting routine evaluations. reduced patient burden and missed appointments, as well as improved convenience and treatment of some chronic illnesses such as diabetes and hypertension. However, patients must get instruction and assistance in using this platform, with specific support made accessible for groups known to be at risk. Telehealth’s role in primary care needs further elaborated study. The purpose of this research is to review the available information about the impact of telehealth on palliative care and pain management in primary care.

Quantifying implementation strategy and dissemination channel preferences and experiences for pain management in primary care: a novel implementer-reported outcome.

Precision implementation science requires methods to evaluate and select implementation strategies. This study developed and evaluated a novel measure of concordance between current and preferred dissemination channels (DC) and implementation strategies (IS) to guide efforts to improve the adoption of evidence-based management strategies for chronic pain. We conducted a one-time electronic survey of Pennsylvania primary care practitioners (PCPs) about current vs. preferred chronic pain management DC and IS use. Survey items were selected based on preliminary data, the Model for Dissemination of Research, and the Evidence-Based Recommendations for Implementing Change taxonomy of implementation strategies. We used Cohen's kappa (κ) to assess the agreement between participant-level current and preferred DC/IS. We calculated % preferred minus % experienced for each DC/IS and assessed the equality of proportions to determine whether this difference significantly departed from zero. We categorized DC and IS based on the degree of use and preference, to evaluate alignment. The current sample included 101 Pennsylvania PCPs primarily in urban (94.06%), non-academic (90.10%) settings who self-identified as mostly female (66.34%) and white (85.15%). The greatest difference between preferred and experienced DCs, or "need," was identified by participants as workshops, clinical experts, seminars, and researchers. Similarly, participants reported the greatest IS gaps as multidisciplinary chronic pain workgroups, targeted support for clinicians, and a chronic pain clinical champion. Participating PCPs had moderate DC concordance (kappa = 0.45, 95% CI = 0.38-0.52) and low IS concordance (kappa = 0.18, 95% CI = 0.13-0.23). DC and IS concordance were both greater than that expected by chance. We further identified well-aligned DC and IS, including professional organizations, briefs, and guidelines. We identified a novel implementer-reported outcome of dissemination channel and implementation strategy concordance that allows implementation scientists to quantify the magnitude of the gap between the current and preferred experience of implementers. This quantitative measure can help with the selection and evaluation of dissemination channels and implementation strategies. Future research should leverage this measure to understand the degree to which preference concordance influences clinical outcomes and performance.

Development and Testing of a Communication Intervention to Improve Chronic Pain Management in Primary Care: A Pilot Randomized Clinical Trial.

Effective communication skills are essential for optimally managing chronic pain and opioids. This exploratory, sequential mixed methods study tested the effect of a novel framework designed to improve pain-related communication and outcomes. Study 1 developed a novel 5-step framework for helping primary care clinicians discuss chronic pain and opioids with patients. Study 2 pilot tested an intervention for teaching this framework using standardized patient instructors-actors trained to portray patients and provide immediate clinician feedback-deployed during regular clinic hours. Primary care physicians were randomized to receive either the intervention or pain management recommendations from the Centers for Disease Control and Prevention. Primary outcomes were pain-related interference at 2 months and clinician use of targeted communication skills (coded from transcripts of audio-recorded visits); secondary outcomes were pain intensity at 2 months, clinician self-efficacy for communicating about chronic pain, patient experience, and clinician-reported visit difficulty. We enrolled 47 primary care physicians from 2 academic teaching clinics and recorded visits with 48 patients taking opioids for chronic pain who had an appointment scheduled with an enrolled physician. The intervention was not associated with significant changes in primary or secondary outcomes other than clinician self-efficacy, which was significantly greater in the intervention group. This study developed a novel framework and intervention for teaching clinician pain-related communications skills. Although the intervention showed promise, more intensive or multicomponent interventions may be needed to have a significant impact on clinicians' pain-related communication and pain outcomes.

User perspectives on systematic data collection regarding back pain managed in general practice – a qualitative study

BackgroundBack pain is a main driver of disability and the most prevalent reason why people in Demark visit a general practitioner (GP). However, little is known about back pain management in primary care. For new strategies to be sustainable and to accommodate the recommendations for evidence-based practice, patients’ perspectives are paramount to complement clinical expertise and research evidence.This study aimed to identify recommendations for systematic data collection in a nationwide cohort regarding the management of back pain in general practice from the perspectives of GPs and patients.MethodWe applied an adapted exploratory sequential design using focus groups and individual interviews. Seven GPs and ten patients with back pain participated, and four focus groups and seventeen individual interviews were conducted. Data were analyzed using abductive reasoning.ResultsBoth GPs and patients with back pain found that 1) recruitment to a cohort should take place through the GPs, 2) the heterogeneity of patients with back pain and their need for individualized treatment and care should be considered, and 3) data from the cohort should feed into a flowchart or guideline to illustrate a generic patient pathway and visually assist both the patient and GP to obtain an overview and, thus, structure the patient pathway.ConclusionGPs and patients with back pain both considered the nationwide cohort with the overall aim to investigate back pain management as being extremely relevant in relation to improve t the patient pathway. User perspectives should be explored and integrated into health care interventions.

Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care

BackgroundThe US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process.MethodsThe objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager’s adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function.DiscussionThis research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions.Trial registrationClinicalTrials.gov, NCT05256394, Registered 25 February 2022.

Assessing the use of a clinical decision support tool for pain management in primary care.

ObjectiveGiven time constraints, poorly organized information, and complex patients, primary care providers (PCPs) can benefit from clinical decision support (CDS) tools that aggregate and synthesize problem-specific patient information. First, this article describes the design and functionality of a CDS tool for chronic noncancer pain in primary care. Second, we report on the retrospective analysis of real-world usage of the tool in the context of a pragmatic trial.Materials and methodsThe tool known as OneSheet was developed using user-centered principles and built in the Epic electronic health record (EHR) of 2 health systems. For each relevant patient, OneSheet presents pertinent information in a single EHR view to assist PCPs in completing guideline-recommended opioid risk mitigation tasks, review previous and current patient treatments, view patient-reported pain, physical function, and pain-related goals.ResultsOverall, 69 PCPs accessed OneSheet 2411 times (since November 2020). PCP use of OneSheet varied significantly by provider and was highly skewed (site 1: median accesses per provider: 17 [interquartile range (IQR) 9–32]; site 2: median: 8 [IQR 5–16]). Seven “power users” accounted for 70% of the overall access instances across both sites. OneSheet has been accessed an average of 20 times weekly between the 2 sites.DiscussionModest OneSheet use was observed relative to the number of eligible patients seen with chronic pain.ConclusionsOrganizations implementing CDS tools are likely to see considerable provider-level variation in usage, suggesting that CDS tools may vary in their utility across PCPs, even for the same condition, because of differences in provider and care team workflows.

Utilizing primary care to engage patients on opioids in a psychological intervention for chronic pain.

Context: Chronic pain, one of the most prevalent issues encountered in primary care, is often treated with opioid prescriptions. Overuse of these medications can cause overdose and death, creating a dire need for alternative treatment methods. Psychological interventions are effective for improving pain and distress, yet are underutilized. Physicians report difficulty engaging patients already on opioids in these interventions; it is possible that offering this intervention in a primary care setting may alleviate this barrier. Objective: Determine whether opioid prescriptions are related to patients engaging in a brief psychological intervention for chronic pain management in primary care. Study Design: Secondary analysis of a pilot randomized clinical trial of a 5-session psychological intervention for chronic pain. Setting: Primary care clinic in an urban setting Patient Population: Patients with chronic pain (N= 220) were approached to enroll in a pilot randomized clinical trial (RCT) for a brief, psychological intervention for pain in primary care. Of these, 60 participated and 160 declined. Instruments: Electronic health records were reviewed to determine whether patients were prescribed opioids or pain medications at the time they were approached about the RCT. Main outcome: Comparing opioid prescriptions in enrollees versus non-enrollees. Results: There was not a significant difference between enrollees and non-enrollees in the rate of opioid prescriptions (18.3% vs. 20%, p= .78), the morphine milligram equivalent dose of opioids (M= 17.64, SD= 22.91 vs. M= 18.07, SD= 18.19; p= .95), or the rate of non-opioid pain prescriptions (33.3% vs. 40%, p = .37). When examining for gender differences, among women, there were similar rates between enrollees and non-enrollees in the rate of opioid prescriptions (23.4% vs. 17%, p = .36). However, no males with an opioid prescription enrolled, whereas 25% of men who did not enroll had an opioid prescription. Conclusions: Among all patients, opioid prescriptions were not related to enrollment in the RCT. This suggests that engaging patients who are on opioids in a psychological treatment for chronic pain, specifically in a primary care setting, may increase utilization. However, this may be true for women, but not men. Further work needs to be done to identify methods to increase psychological intervention engagement among all patients receiving opioids, but especially men.

Evaluation of pharmacist interventions as part of a multidisciplinary pain management team

Pharmacists have an important role within the healthcare system. They can offer some services to the patients including consultation, patient education and therapeutic management. Community pharmacists can assess the type and severity of pain, monitor treatment and guide medication regulation to improve the treatment of the pain. The involvement of pharmacists in nonprescription medication counseling about pain will increase the public’s ability to understand the risks and benefits of over-the-counter drugs. Aim and objects was to study and analyze professional abilities and role of pharmacy employees during the pain management. The survey was conducted among 285 employees of licensed pharmacies in Armenia with the help of questionnaires, the number of which was determined according to “The Survey System Version 11.0”. Survey data were entered and analyzed using SPSS software package. The study was quantitative investigation and the questionnaire was developed based on the World Health Organization standard questionnaire. As a result of our research, it became clear that pharmacists have pure, indistinct knowledge about adverse reactions of over-the-counter analgesics and pharmacy employees in the Republic of Armenia have incomplete knowledge and ideas about pain management. According to the study pharmacists’ information sources was not reliable and the use of these sources in professional pharmaceutical practice were not inappropriate. Involvement of pharmacists in primary care pain management is very important and pain management training of pharmacy staffs should be encouraged. Pharmacist should be a part of a multidisciplinary pain management team and for this reason comprehensive information on pain management as well as development of practical skills should be included in continuing education programs for pharmacists.

Pain Management in Primary Care: A Randomized Controlled Trial of a Computerized Decision Support Tool

BackgroundPrimary care providers manage most patients with chronic pain. Pain is a complex problem, particularly in underserved populations. A technology-enabled, point-of-care decision support tool may improve pain management outcomes. MethodsWe created an electronic health record (EHR)-based decision support tool, the Pain Management Support System–Primary Care (PMSS-PC), and studied the tool-plus-education in 6 Federally Qualified Health Center practices using a randomized, wait-list controlled design. The PMSS-PC generated “best practice alerts,” gave clinicians access to a pain assessment template, psychological distress and substance use measures, guidelines for drug and non-drug therapies, and facilitated referrals. Practices were randomly assigned to early vs delayed (after 6 months) implementation of the intervention, including technical support and 6 webinars. The primary outcome was change in worst pain intensity scores after 6 months, assessed on the Brief Pain Inventory-Short Form. Changes in outcomes were compared between the practices using linear multilevel modeling. The EHR provided clinician data on PMSS-PC utilization. ResultsThe 256 patients in the early implementation practices had significantly improved worst pain (standardized effect size [ES] = −.32) compared with the 272 patients in the delayed implementation practices (ES = −.11). There was very low clinician uptake of the intervention in both conditions. ConclusionsEarly implementation of the PMSS-PC improved worst pain, but this effect cannot be attributed to clinician use of the tool. Further PMSS-PC development is not indicated, but practice-level interventions can improve pain, and studies are needed to identify the determinants of change.

Interventions Incorporating Interdisciplinary Teaming to Improve Chronic Pain Management in Primary Care: A Systematic Review

Current chronic pain management recommendations emphasize leveraging interdisciplinary care models, which rely on communication, coordination, and collaboration among multiple providers. We aimed to identify key features of interdisciplinary teamwork and teaming processes that facilitate improved pain outcomes for patients experiencing chronic pain in primary care settings. We searched PubMed, EMBASE, CINAHL, and the Cochrane Library for English language, randomized studies published after 2009. Included studies had to report patient-reported pain outcomes (i.e. BPI total pain), include primary care as an intervention setting, and involve interactions between at least two providers and the patient over time. We assessed study quality with the Cochrane Risk of Bias tool. We qualitatively synthesized findings on intervention characteristics related to teamwork and teaming processes and patient pain outcomes. PROSPERO Registration: CRD42020191467. We included 13 randomized studies with 14 total interventions in our review, of which 7 reported one or more significantly improved pain outcome compared to controls over 6 to 12 months of observation. Most studies involved multiple primary care practices in the USA or Canada. Five studies were evaluated either within the Indianapolis Veterans Affairs Medical Center (VAMC) or the Portland VAMC. Other studies took place in primary care centers in Spain, Finland, the UK, and the Netherlands. Interventions with positive pain outcomes often described regularly scheduled patient contact, but there were few identified similarities about the communication, coordination, and collaboration processes among clinical intervention members. Care management and patient follow-up schedules were identified as key characteristics of teamwork or teaming in the interventions associated with improved pain outcomes. Despite widespread emphasis on interdisciplinary teams for pain management, high quality evidence about relevant team structures and teamwork and teaming processes remains limited. Care management and patient follow-up characterized primary care-based interventions involving teaming associated with improved pain outcomes.

Chronic non-cancer pain management in primary care.

Chronic non-cancer pain is a common, often undiagnosed condition in primary care across the world, with prevalence rates between 20% and 40%. To effectively address this problem, the primary care practitioner needs to have an organised, comprehensive approach to diagnosing and managing these patients within a biopsychosocial framework, in collaboration with members of the interdisciplinary team. The aim of this article is to provide the primary care practitioner with up to date information on the management of chronic pain. A case study is introduced to raise awareness of some of the complexities of dealing with the problem. A series of key questions are raised that address the various levels of complexity. Current evidence is used to guide the reader through these questions, covering a wide area of pain research as it pertains to primary care. The article concludes with five practice points that link the literature to clinical practice.

UC Davis Train-the-Trainer Primary Care Pain Management Fellowship: Addressing the Pain Management Education Gap.

Primary care providers are responsible for the majority of pain care and opioid prescribing, but they are often inadequately trained. Training current providers to address the crisis of excessive opioid prescribing and inadequate pain management is a substantial workforce problem that requires urgent action. This educational need is vast and requires a staged solution to amplify its effect. The University of California, Davis Train-the-Trainer (T3) Primary Care Pain Management Fellowship targets the most pressing topics related to pain management, including prescription drug abuse, responsible opioid prescribing, and substance abuse, as well as broad coverage of comprehensive pain management. It offers an innovative, scalable solution to address the education gap in pain management that, in part, fuels the opioid epidemic in the United States. The T3 Fellowship incorporates a competency-based curriculum and a hybrid educational model of in-person and distance-based learning and direct faculty-fellow mentoring to comprehensively train primary care providers in pain care and prepare them to train others. Since it was established in 2017, 2 cohorts (of 17 and 26 fellows) have completed the 10-month fellowship and a third cohort of 38 fellows started the program in September 2019. Pre- and postprogram surveys for the first 2 cohorts, and a 6-month postprogram survey for the first cohort, demonstrated fellows' improvement and sustained performance in pain competencies as well as increased recognition and understanding of pain and related topics. If adopted by other institutions and expanded across the country, the T3 Fellowship holds potential for developing an ever-growing legion of trained professionals who will locally fill the need for effective pain management, including appropriate opioid prescribing. Advancing this model will require further economic and feasibility studies to assess costs, resources, and other variables, as well as a robust comprehensive outcomes program.

Brief Cognitive Behavioral Therapy For Chronic Pain: Results From a Clinical Demonstration Project in Primary Care Behavioral Health.

Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen's d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen's d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.

Self-medication in pain management: The state of the art of pharmacists' role for optimal Over-The-Counter analgesic use.

Self-medication is associated with an important utilization of Over-The-Counter (OTC) analgesics. The medical outcome resulting from therapeutic options bypassing the physician prescription is a major issue. In that context, pharmacists are expected to play a crucial role. The main objective of this review was to analyse the state-of-the art of pharmacists' role in pain management self-medication. An expert multidisciplinary group dedicated to self-medication in pain was established. Selection of publications was performed from PubMedand EMBASE databases which was based on the use of "pain" and/or "self-medication" and/or "self-care" and/or "analgesics" and/or "painkillers" keywords, restricted to the past 10 years. A total of 480 papers were identified, 49 of which papers were considered relevant and finally kept for final discussion, on OTC pain management and pharmacist's role. Literature analysis demonstrates that OTC analgesics are generally safe when appropriately used. Risks associated with misuse or inappropriateness depend on patients' vulnerability (elderly, pregnancy) or behaviour. Social cognitive theory-based intervention and multimedia applications improve self-medication but do not replace health care professional advice Pharmacists' interventions may improve the benefits and safety of OTC analgesic medication, with a better management of pain. Considering the heterogeneity of patients' knowledge and behaviour reported worldwide, inappropriate use of OTC pain medication should not be underestimated. Community pharmacists are ideally placed to guide self-medication or recommend a medical advice when needed. Embedding pharmacists in primary care pain management is essential and pharmacist-led medication coupled with an appropriate training of pharmacy staffs should be encouraged. Analgesics are widely used without prescription, all over the world. They represent the largest market of OTC drugs, with an overall benefit/risk ratio favourable when appropriately used. Because of potential individual risks associated to the ailment or to the patient's behaviour, pharmacists' interventions have proven to optimize analgesic self-medication, provided that pharmacy staffs are both available and more specifically trained. In the future, in pain management, especially self-medication, pharmacists should play an increasing role and should be included in educational programmes and pain management guidelines.

An ethnography of chronic pain management in primary care: The social organization of physicians' work in the midst of the opioid crisis.

BackgroundThis study reports on physicians’ experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities.MethodsOur team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings.FindingsIn their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse.InterpretationOur findings show that care providers find the treatment of patients with chronic pain–especially those patients also experiencing poverty–to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients’ social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision.

Promoting an Interprofessional Approach to Chronic Pain Management in Primary Care Using Project ECHO

POSTER ABSTRACTChronic pain is a complex multidimensional condition that requires management with multiprofessional expertise. Healthcare professional training programs tend to adhere to curricula within their own discipline with very few interactions with other professions. Project ECHO (Extension for Community Healthcare Outcomes) is a model for interprofessional education, using tele-mentoring, case-base discussions and didactics. The goals are to improve competency and confidence in managing complex cases in primary care. This qualitative study was conducted among primary care providers from various disciplines who participated in Project ECHO Ontario Chronic Pain/Opioid stewardship. The results show that participating in ECHO resulted in personal and professional benefit, and increased understanding about their own roles and limitations, as well as other healthcare professionals’ roles. The participants described changes in their attitudes toward patients with chronic pain, and their colleagues from other professions. Non-physician participants were more likely to approach physicians to discuss their assessment and diagnosis as well as medications prescriptions. The interprofessional nature of the program was seen as positive, contributing to a modest increase in collaboration between healthcare professional groups. These results show that Project ECHO is successful in enhancing interprofessional care in primary care settings to manage complex cases of chronic pain.Introduction/Aim: Chronic pain is a complex multidimensional condition that requires management with multiprofessional expertise. Healthcare professional training programs tend to adhere to curricula within their own discipline with very few interactions with other professions. Project ECHO (Extension for Community Healthcare Outcomes) is a model for interprofessional education, using tele-mentoring, case-base discussions and didactics. The goals are to improve competency and confidence in managing complex cases in primary care.Methods: This qualitative study was conducted among primary care providers from various disciplines who participated in Project ECHO Ontario Chronic Pain/Opioid stewardship.Results: The results show that participating in ECHO resulted in personal and professional benefit, and increased understanding about their own roles and limitations, as well as other healthcare professionals’ roles. The participants described changes in their attitudes toward patients with chronic pain, and their colleagues from other professions. Non-physician participants were more likely to approach physicians to discuss their assessment and diagnosis as well as medications prescriptions.Discussion/Conclusions: The interprofessional nature of the program was seen as positive, contributing to a modest increase in collaboration between healthcare professional groups. These results show that Project ECHO is successful in enhancing interprofessional care in primary care settings to manage complex cases of chronic pain.

Evaluation of Chronic Pain Patient Healthcare Costs before and after a Tele-Education Intervention for Primary Care Providers in Underserved Communities

POSTER ABSTRACTIntroduction/Aim: Lack of formal training poses a significant barrier to effective chronic pain management in primary care. Project ECHO (Extension for Community Healthcare Outcomes) is a medical education model that uses weekly videoconferencing rounds and case-based learning to connect specialists with providers in resource-scarce areas. The Chronic Pain and Opioid Stewardship ECHO (“ECHO”) was launched in Ontario, Canada in 2014. We sought to describe the annual healthcare utilization costs of chronic pain patients before and after their case presentation at ECHO.Methods: We conducted a single-group before-and-after study using routinely-collected Ontario Health Insurance Plan administrative claims data between April 1, 2011 and March 31, 2018. Only the direct medical costs from the perspective of a public payer were considered.Results: Our sample consisted of 46 patients presented at ECHO between September 2014 and March 2018, representing 19% of all ECHO case presentations. The annual healthcare utilization costs per patient before and after ECHO were $2,385.54 and $2,027.91, respectively, representing a 15% decline. The largest decrease was observed in the frequency of hospital visits, while the frequency of assessment or consultation visits, use of diagnostic radiology services, overall healthcare encounters, and the number of unique billing physicians saw a slight increase in the post-ECHO period.Discussion/Conclusions: We observed notable savings in healthcare costs among patients presented at ECHO, despite a slight increase in utilization of certain healthcare services. Future studies should explore drivers of healthcare costs among ECHO patients to assess the cost-effectiveness of the program.

Patients’ and clinicians’ perspectives of co-use of cannabis and opioids for chronic non-cancer pain management in primary care

BackgroundThe prevalence of opioid-associated morbidity and mortality underscores the need for research on non-opioid treatments for chronic non-cancer pain (CNCP). Pain is the most common medical condition for which patients request medical cannabis. Limited research indicates that patients are interested in cannabis as a potential addition to or replacement for opioid medication. This analysis reports on CNCP patient and clinician perceptions about the co-use of cannabis and opioids for CNCP management. MethodsWe interviewed 23 clinicians and 46 CNCP patients, using semi-structured interview guides, from six safety-net clinics across the San Francisco Bay Area, and 5 key stakeholders involved in CNCP management. We used a modified grounded theory approach to code and analyze transcripts. ResultsCNCP patients described potential benefits of co-use of cannabis and opioids for pain management and concerns about dosing and addictive potential. Patients reported seeking cannabis when unable to obtain prescription opioids. Clinicians stated that their patients reported cannabis being helpful in managing pain symptoms. Clinicians expressed concerns about the potential exacerbation of mental health issues resulting from cannabis use. ConclusionClinicians are hampered by a lack of clinically relevant information about cannabis use, efficacy and side-effects. Currently no guidelines exist for clinicians to address opioid and cannabis co-use, or to discuss the risk and benefits of cannabis for CNCP management, including side effects. Cannabis and opioid co-use was commonly reported by patients in our sample, yet rarely addressed during clinical CNCP care. Further research is needed on the risks and benefits of cannabis and opioid co-use.