Pain Management by Primary Care Physicians, Pain Physicians,
Chiropractors, and Acupuncturists: A National SurveyThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Southern Medical J 2010 (Aug); 103 (8): 738747 ~ FULL TEXT
Brenda Breuer, PhD, MPH, Ricardo Cruciani, MD, PhD, Russell K. Portenoy, MD
Department of Pain Medicine and Palliative Care,
Beth Israel Medical Center,
New York, NY 10003, USA.
OBJECTIVES: Chronic pain is a serious public health problem and is treated by diverse health care providers. In order to enhance policies and programs to improve pain care, we collected information about the distribution of pain patients among four major groups of pain management providers: primary care physicians (PCPs), pain physicians, chiropractors, and acupuncturists, and the variation in the attitudes and practices of these providers with respect to some common strategies used for pain.
METHODS: National mail survey of PCPs, pain physicians, chiropractors, and acupuncturists (ntotal = 3,000).
RESULTS: Eight hundred seventeen responses were usable (response rate, 29%).
Analyses weighted to obtain nationally representative data showed that:PCPs treat approximately 52% of chronic pain patients
chiropractors treat 40%
acupuncturists treat 7%
pain physicians treat 2%
Of the chronic pain patients seen for evaluation, the percentages subsequently treated on an ongoing basis range from 51% (PCPs) to 63% (pain physicians). Pain physicians prescribe long-acting opioids such as methadone, antidepressants or anti-convulsants, and other nontraditional analgesics approximately 50-100% more often than PCPs. Twenty-nine percent of PCPs and 16% of pain physicians reported prescribing opioids less often than they deem appropriate because of regulatory oversight concerns. Of the four groups, PCPs are least likely to feel confident in their ability to manage musculoskeletal pain and neuropathic pain, and are least likely to favor mandatory pain education for all PCPs.
CONCLUSIONS: There is substantial variation in attitudes and practices of the various disciplines that treat chronic pain. This information may be useful in interpreting differences in patient access to pain care, planning studies to clarify patient outcomes in relation to different providers and treatment strategies, and designing a system that matches chronic pain patients to appropriate practitioners and treatments.
Key Words: acupuncturists, chiropractors, pain management, pain specialists, primary care physicians
Key Points
Chronic pain is highly prevalent, and is costly in terms of lost productivity.
Primary care physicians, pain physicians, chiropractors, and acupuncturists
vary in the way they treat chronic pain, and in their attitudes
regarding such treatment.These variations underscore the need for planning studies that relate
patient outcomes to different provider groups and treatments,
and designing a system that matches patients to
practitioners and treatments.
From the FULL TEXT Article:
Background
Chronic pain is a serious illness in its own right, and has complex biological and psychosocial underpinnings. [1] Based on US census data for the year 2007 and a report by the International Association for the Study of Pain, chronic pain afflicts at least 45 million adults, and unrelieved pain is associated with more than 61 billion dollars in lost productivity annually. [24]
Access to adequate pain care is a public health imperative. Policies that encourage access have been challenging to develop, however, because of limited information about the current status of pain care delivery and the range of patient outcomes associated with different types of care. Policies that generate optimal access to care should be informed by an understanding of the current delivery of care, including variation in the credentials and training of health professionals and the types of care rendered. Characterizing this variation should help define the types of studies that would be needed to determine whether patients with different types of pain are seeking care from professionals who have the competencies to address their problems.
The lack of detailed information about the variation in pain care delivery in the United States is surprising, given the importance of pain as a major reason that patients seek medical attention. [5] It is known that a very small proportion of those with chronic pain see a physician who specializes in pain management, and that chronic pain patients commonly seek treatment from primary care physicians or clinicians who offer complementary and alternative medical (CAM) approaches. [6] In 1997, CAM treatments were used by approximately 45% of the US population. [7, 8] From 1990 to 1997, patient visits to CAM providers exceeded the total visits to all US PCPs.8 In a more recent study of patients with persistent noncancer pain who were receiving primary care at 12 US academic medical centers, 52% reported current use of CAM therapy for pain control. [9] In another study, 40% of 425 patients in a Texas hospital pain clinic reported that they used CAM at least once. [10]
In a 2004 report, the American Chiropractic Association (ACA) estimated that 21 million to 28 million patients receive chiropractic services each year. [11] In 2006, an estimated 3.1 million US adults used acupuncture. [12] Chiropractors are licensed by all 50 states, and 40 states require acupuncturists to be certified by the National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM); one additional state accepts this certification, and another state has its own state examination. [13, 14]
In an effort to improve pain management, we undertook a survey to ascertain critical data regarding its current status. We surveyed four groups who commonly treat painPCPs, pain physicians, chiropractors, and acupuncturists. Specifically, we wanted to estimate the distribution of pain patients among these four groups of pain management providers and explore variation in the attitudes and practices of these providers with respect to some common strategies used for pain.
Discussion
Our data help shed light on the obvious question that arises in light of the extremely small number of pain physicians and the very high prevalence of chronic pain: who treats these large numbers of chronic pain patients? We found that a very small percentage of chronic pain patients are treated by pain physicians. The group that treats the greatest proportion, PCPs, prescribes opioid medication less frequently than they themselves view as appropriate because of concerns of regulatory oversight, and have the least confidence in their ability to treat neuropathic and musculoskeletal pain. This lack of confidence is noteworthy given the high prevalence and impact of these categories of chronic pain. [3, 20]
Twenty-one percent of PCPs and 21% of chiropractors reported that they practice in a rural area, compared to only 9% of pain physicians. This may partly explain why having a rural practice, rather than an urban/suburban practice, was a predictor for each of these two professional groups of treating their chronic pain patients on an ongoing basis they must compensate for the shortage of pain physicians.
Clinicians often refer patients to others within their own specialty. Pain physicians, who include specialists in neurology, anesthesiology, physiatry, and psychiatry, among others, may refer to other pain specialists when multidisciplinary input is needed. Some pain physicians may feel uncomfortable about prescribing long-acting opioids, perhaps when higher doses seem indicated, and they may want input from a more experienced colleague. Consistent with this explanation are data showing that, because of concern with regulatory oversight, 16% of pain physicians prescribe long-acting opioids less frequently than deemed appropriate. Older pain physicians, who may have more experience, are less concerned with regulatory oversight. Those with less confidence in their ability to manage neuropathic pain are more likely to refer patients to other pain physicians.
Given the significant correlations between the number of chronic pain CME hours and confidence in treating neuropathic and musculoskeletal pain, along with prescribing patterns of analgesic medications, the high prevalence rates of those who are negative about education and those who prescribe in a limited way raise concern about the overall level of competency in the treatment of chronic pain among PCPs.
Our study had limitations; the most important are related to the generalizability of our findings. We have mentioned the limitations of the master mailing lists from which our samples were drawn, and the problem associated with the possibility of one patient being treated by multiple clinicians.
Of note, those who responded to our survey might have been more likely to be interested in pain management. This, however, would imply that the differences we noted among the study groups were conservative.
While our overall response rate was only 29%, previous reviews found that surveys with very low response rates may provide a representative sample of the population of interest, whereas surveys with high response rates may not. [21] Further, there are numerous prior reports which addressed some of the same issues that we did, and the consistency of their findings with ours lends support to our observations that were not previously reported. First, our finding that approximately 2% of all chronic pain patients are reportedly treated by pain physicians, whether or not on an ongoing basis, agrees favorably with the survey findings of Nguyen et al [6] that only 5% of respondents had ever consulted a pain physician. Second, we found that chiropractors treat approximately seven times more chronic pain patients than do acupuncturists; the reports of others indicate a similar ratio. [11, 12] Third, our demographic characterization of acupuncturists and chiropractors is similar to those reported by others. [13, 18, 19] (Though we cannot be certain that the responses of younger acupuncturists who were underrepresented because of the way that sample was chosen would have been similar to those of the older acupuncturists in our sample). Finally, our findings regarding the relationship between pain management CME hours and prescribing patterns of PCPs are consistent with those of others. [22]
Conclusion
Concern about variation in US health care delivery has been increasing, and the data from this survey suggest that this variation extends to the management of chronic pain patients. [23] Our survey, however, was not designed to link any of the results to patient outcomes. Future research needs to include information from health care providers, both physicians and nonphysicians, who treat a very large proportion of patients with chronic pain, and we must match syndromespecific patient-reported outcomes to the professional groups that provide the care. Access to competent pain care will require definition of best practice and appropriate patient selection within each provider group, education to reduce variation once best practice is clear, and opportunities for patients to see specialists if generalist or modality-specific care is not satisfactory.
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