Pain Specialists Seek Help from Primary Care

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.