Seven Tips for Managing Pain Patients after they Return from the Specialist
Bill McCarberg, MD
Founder, Chronic Pain Management Program, Kaiser Permanente
Escondido, California
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 may help.

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