Presented at the Kaiser Permanente Primary Care 2005 conference, Maui, Hawaii, March 20–25, 2005, as Whitten C, Evans C. Chronic pain management in primary care. Conservative estimates indicate that 60 million Americans suffer from some type of persistent or recurrent pain sufficient to significantly affect their lives.1 The Kaiser Permanente (KP) member population includes many patients with chronic pain, and this cohort is generally characterized by a high level of utilizing medical services. Compared with other conditions addressed by the Care Management Institute (CMI), chronic pain more adversely affects quality of life, functional status, and productivity.1 Recent measurement of the KP chronic pain cohort2 by CMI showed chronic pain in 5.1% of adult KP members. This incidence can be compared with the incidence of other conditions diagnosed in the KP population: diabetes, in 7.7% of the population; depression, in 6.5%; coronary artery disease, in 3.2%; persistent asthma, in 2.0%; and heart failure, in 1.6%. According to the recent CMI Annual Population Care Management Report,3 about a third of patients with moderate to severe impairment from a chronic condition would benefit from care management, and another third would benefit from case management (Figure 1). About 50% of these impaired patients require only support for self-care. As Figure 1 shows, patients who are moderately to severely impaired by chronic pain often demonstrate poor pain control, clinically significant deconditioning and physical impairment, and often a lack of coping skills. A state of learned helplessness may develop and substantially alter a person's lifestyle. Figure 1 Illustration shows levels of care needed by patients impaired by chronic medical conditions. Percentages indicate proportion of patients with indicated level of need and are taken from the 2002 Annual Population Care Management Report3 of the Kaiser Permanente ... The population with chronic pain has a high incidence of comorbid conditions. For example, 27.7% of members with chronic pain also had documented depression during 2000, whereas 6.5% of all adult members had depression. Compared with utilization by nonafflicted KP members, utilization of resources by KP members with chronic pain is much higher. For example, this utilization2 is 3.7 times higher than the HEDIS inpatient admission benchmark is 2.7 times higher than the HEDIS emergency visit benchmark includes four times more outpatient visits produces pharmacy costs that are 3.5 times higher. Chronic pain is a chronic condition with its own pathological changes, its own set of clinical and behavioral characteristics, and its own subset of effective approaches to treatment regardless of etiology. To promote healing, we teach acutely injured patients to rest passively and to focus on their pain as a gauge of when to become more active. However, treating chronic pain in the same way you treat acute pain is a prescription for failure. Ironically, the patient with chronic pain should not focus on pain but instead should focus on adequate pain control to allow improved functioning and independence. Care plans should aim to simplify medication regimens, decrease pain-related behavior, increase patient and family coping skills, improve sleep, restore daily activities (such as household chores and social engagements), and resume vocational activity. Use of a multimodal approach has proven highly effective in both the KP Northern California Regional programs4 and the KP Northwest Region's Vohs Award-winning program.5 Help your patients with chronic pain to return to improved function and independence by following four basic principles of pain management. These principles include good communication between patient and clinician support for the active role of the patient in treatment optimal medication management use of a multimodal approach (Figure 2).6 Figure 2 Multimodal model of care for the whole patient shows modalities that should be included in a coordinated, multimodal, multidisciplinary treatment plan. Self care by the patient is central to the success of this—or any—treatment plan. However, the degree of appropriate intervention in each category varies with acuity. The KP CMI Chronic Pain Workgroup developed evidence-based guidelines, models of care, and tools for use by clinicians and members to help primary care practitioners to effectively manage chronic pain in their patients. These tools can be found online at http://cl.kp.org/pkc/national/cmi/programs/chronicpain. The earlier you identify and treat a higher-risk patient, the more likely you will be to prevent development of pathologic changes, and the better the clinical outcome will be.
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Nov 1, 2008
Lorraine Mcmain 
Open Access