Setting
While pain medicine often takes place in primary care settings, some providers feel unequipped to provide care for individuals with chronic pain due to inadequate resources and expertise.
Barriers
Some providers in primary care settings have expressed unease in managing patients with chronic pain who they perceive to take up additional appointment time, may ask for increased medication dosing, or make excessive calls to their office.
Some primary care providers may refer patients to specialty pain clinics to take over the care of high-complexity patients with chronic pain due to feeling inadequately resourced or trained to manage their care. While these settings may be appropriate care settings for some individuals, they are often financially untenable for the uninsured or underinsured, limiting access to high-quality pain care.
Buprenorphine may be prescribed by a specialty pain clinic, which is often distinct from the individual’s primary care team. This can lead to a lack of communication between providers and settings that leads to confusion for both providers and care recipients regarding who is responsible for long-term management and oversight of opioid therapy.
Facilitators
In qualitative studies of primary care providers, some individuals stand out for their willingness to take on additional training and administrative roles to better integrate pain medicine best practices in their primary care delivery settings. Having additional administrative support and less of a demand for patient care may help improve a site’s overall ability to manage high-demand pain patients.
Providers have expressed that being in academic medical settings can help create a continued learning environment that enables greater comfort in managing patients with chronic pain. A general culture of continued learning, as well as specific access to more formalized educational opportunities and research experts, is critical for enabling confidence in up-to-date pain medicine practice. The UW TelePain program is an example of a real-world academic-community partnership that seeks to disseminate best practices to providers outside of the university setting.
A stepped care approach has been developed and explored in the literature, where primary care teams provide foundational pain care and have the option to refer patients for initiation and stabilization of buprenorphine treatment by a specialty pain care provider. This approach allows for a transition to long-term care back to primary care settings for chronic pain management. Stepped care allows for expert clinical decision making, close monitoring, and stabilization in specialized settings, taking the burden of treatment initiation off the primary care provider.