Seven Tips for Managing Pain Patients after they Return
from the Specialist
Bill McCarberg, MD
Founder, Chronic Pain Management Program, Kaiser Permanente
Pain Med News. 2004;2(6).
A specialty consult is often needed for a complex medical
problem such as diabetes or congestive heart failure. When
the patient is returned to the primary care provider, the
condition has been evaluated, the work up completed, treatment
initiated and the problem stabilized. If difficult or complex
treatment strategies are offered as in HIV or cancer, the
patient is often followed on a long-term basis by the specialist.
In chronic pain patients, the pain does not disappear after
specialty referral. Aggressive strategies maybe employed including
injections, complex drug regimens, and high dose opioid management,
yet the long term care responsibilities lie with primary care.
The differences seen in pain care vs. other specialty care
for complex problems result from many factors including unfavorable
reimbursement from 3rd party payers. To provide quality, continuing
care for these complicated pain patients, the following tips
1) Developing a relationship with the referral doctor will
help guide your future care. Make sure the specialist delineates
what is the best course to follow with a patient for their
continued care or during pain flares. Should breakthrough
medication be used, or should the patient return to the specialist
during these times of crisis? Discussing the treatment plan
with the specialist such that the expected course and follow
up arrangements will lead to consistent quality care. The
pain specialist will also understand what level of comfort
and expertise you have in dealing with these patients. Future
referrals will be returned at the appropriate time in treatment
and with the necessary care information.
2) All pain treatment is ultimately aimed at improving patient
function. When patients return with continued pain, certainly
ask about their pain, but concentrate on function. Be sure
to document pain levels and improved function in the chart,
and emphasize to the patient the need for functional gains.
3) When the specialist has exhausted all treatment strategies,
continued pain is often distressing and fearful for the patient.
Returning to the primary care provider can be particularly
stressing when cure is not achieved. Reassurance and compassionate
listening are often very therapeutic. When cure is not anticipated,
patients expect us to validate their discomfort, answer concerns
about alternative therapies, and not abandon care. Avoid statements
like: "there is nothing more I can do" for example.
Another referral to physical therapy or updating an MRI will
not likely help after specialty care is complete. You can
continue an impactful therapeutic relationship with simple
reassurance, caring and hope.
4) Keep patients active. Exercise in any form that is practiced
regularly improves function, sleep, sense of well being and
depression. Continue to ask about exercise in your patients
and encourage this active.
5) Interdisciplinary specialty care providers use a variety
of treatment strategies including medication, physical rehabilitation,
injections, activity modification, exercise etc. As with any
chronic disease, successful self-management is the key. Passive,
unmotivated patients expecting to be taken care of or cured
do not improve and are stressful for us to treat. Self-management
skills (relaxation, exercise, pacing, strategic rest etc.)
give better outcomes than passive therapies. Emphasize the
importance of self-management skills with your patients.
6) Psychosocial issues including depression and anxiety are
commonplace in chronic pain patients. Inadequate assessment
and treatment of the psychosocial comorbities occur even after
specialty evaluation due to many factors including reimbursement
strategies and managed care carve-outs for psychosocial services.
Be alert to these lingering problems. We all provide psychosocial
treatments for our patients; chronic pain patients require
a high index of suspicion.
7) Regularly scheduled appointments for chronic pain patients
are vital rather than waiting until a pain problem spirals
out of control and becomes much more difficult to treat. Even
if we have difficulty dealing with patients with, for example,
fibromyalgia, hoping that they will not make their own appointments
is unrealistic. Regularly scheduled appointments help keep
the complaint lists manageable. Patients may not be as anxious
or feel as abandoned if you welcome them with a regular appointment.
Even though this may sound like more work for you, the result
will be shorter, more productive interactions.
Chronic pain patients are suffering not just from pain but
fear, depression, and isolation among many other issues. Primary
care can use the pain specialist for help but the continuing
care will ultimately return to us. We must provide quality,
empathetic care for our patients. I believe we are uniquely
trained with broad medical knowledge and longevity with our
patients to be able to provide the best care.
Updated July 19, 2005