by Sara L. Jackson, MD, MPH, Jane Huntington, MD, Debra B. Gordon, RN, DNP, Daniel Krashin, MD, Ivan Lesnik, MD, Jane C. Ballantyne, MD

Background
As our nation continues to struggle with the effects of widespread opioid addiction, primary care physicians who care for patients with chronic pain are increasingly being asked to expand the care they provide to include non-pharmacologic treatments.¹  Recent CDC guidelines recommend the careful consideration of new or continued opioid prescribing, employing risk mitigation strategies, and shared decision making for maintenance of high opioid doses.² This approach is new for any primary care physician, and may be particularly challenging for residents. Building in support for residents as they learn to manage patients with complex chronic pain is key to developing a primary care workforce ready to employ new strategies to care for these patients. It was our hypothesis that providing access to pain specialty attendings within the residency clinic would help to meet these training challenges.

Project Overview
Both the Family Medicine Clinic and the Adult Medicine Clinic, which are academic primary care residency clinics at Harborview Medical Center, a safety-net hospital in Seattle, invited a pain medicine specialist to two half-day clinic sessions each month. During these sessions, patients with chronic pain were scheduled for a visit with their faculty or resident primary care provider; or if that physician was unavailable, they were scheduled with another resident or the clinical pharmacist. The patient was evaluated in a co-visit with the primary care team and the pain medicine specialist, who modeled discussions with patients to foster a comprehensive approach to pain management with appropriate discussion, education and risk mitigation strategies. The specialists were available during the clinic for case conferences and informal discussions of evidence-based practices for care of patients with chronic pain. Residents were invited to formally and informally consult the specialist during the sessions.

The specialists became catalysts for comprehensive multi-disciplinary pain treatment, supporting residents and faculty and their patients in seeking new approaches to pain treatment while deemphasizing opioid use, referrals to peer-support groups, mental health care, physical therapy, and buprenorphine treatment were encouraged.

Impact
Faculty and residents at the clinics were sent an anonymous survey before the integrated sessions began and 1 year later to measure changes in their confidence in providing successful treatment for patients with chronic pain. Responses were analyzed using a t-test for equality of means. On a seven point scale, self-ratings of confidence and of clinic resources improved between 15% and 21%, all at significant levels (p<0.05); see Table 1 for detailed pre- and post-intervention survey results. 

Conclusions
Access to expert pain care within primary care residency clinics can benefit patients with chronic pain and can be an important educational resource for resident training. Residents working with pain medicine consultants learned to provide care for patients with chronic pain with comprehensive therapies that minimized exposure to opioids. As reimbursement moves towards quality measures, our model of integrating pain specialists within primary care medical homes could be realistic in residencies located in academic medical centers and integrated group practices. Residencies in rural settings, with less access to pain specialty care, could benefit from growing access to telemedicine specialty consultation.³

We conclude that close partnership between primary care providers and pain medicine specialists, especially in settings where residents are training, improves provider confidence and may even affect future practice as residents carry forward these experiences. This model demystifies the management of chronic pain by incorporating care for patients with chronic pain—like any chronic illness—in the primary care medical home. Integrating a pain medicine specialist in a primary care clinic several sessions a month may be a practical way to care for most patients with chronic pain, reserving pain clinics for only patients with the most complex and refractory disease. Residency clinics can lead the way in this care transformation.

Acknowledgement
We are grateful to our patients for trusting us to care for them, and we thank the Harborview primary care providers, pain medicine specialists, and staff for their engagement in improving the lives of people with chronic pain. 

References:

1. Schneiderhan J, Clauw D, Schwenk TL. Primary care of patients with chronic pain. JAMA 2017; 317(23):2367-2368. doi:10.1001/jama.2017.578.
2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 2016;315(15):1624-1645.
3. Shelley BM, Katzman JG, Comerci GD Jr, et al. ECHO pain curriculum: balancing mandated continuing education with the needs of rural health care practitioners. J Contin Educ Health Prof 2017;37(3):190-194.