IROKO PAIN MANAGEMENT DIGEST

Transcription

1 IROKO PAIN MANAGEMENT DIGEST 2013 A

2 PAIN MANAGEMENT DIGEST Editorial Board Christina Barrington, PharmD Director Humana, Great Lakes Region Chicago, IL Christopher V. Goff, JD, MA Chief Executive Officer and General Counsel Employers Health Canton, OH Jeff Livovich, MD Medical Director National Policy and Operations Aetna Scottsdale, AZ Bill McCarberg, MD Kaiser Permanente, San Diego (retired) Adjunct Assistant Clinical Professor, University of California San Diego Neighborhood Healthcare, Federally Qualified Healthcare Clinic San Diego, CA Scott R. Taylor, BS Pharm, RPh, MBA Executive Director, Office of Industry Relations Geisinger Health System Danville, PA This 2013 Iroko Pain Management Digest is designed to serve as an educational resource for managed care organizations that seek a broader understanding of the issues surrounding pain management. The content of this report was prepared by ReCon Marketing Solutions, LLC, with the guidance of an editorial board, and it is based on independently conducted primary and secondary research. Iroko provided financial support for this report and the editorial board. The 2013 Iroko Pain Management Digest Produced by ReCon Marketing Solutions, Medford, NJ Managing Editor and Research Director - Marsha Fisher Editorial and Research - Meredith Scheiner Project and Market Research Director - Betsy Dennison Creative Director - Lin Kossak ReCon Management Sal Cofoni, salcofoni@reid-cofoni.com Dean Reid, deanreid@reid-cofoni.com

3 Table of Contents Introduction Managed Care Issues and Answers in Pain Management...2 Survey Methodology and Research...5 Chapter 1 Medical and Pharmacy Director Perspectives on Pain Management...6 Employer Survey: Interim Results...11 Chapter 2 Practices in Pain Treatment and Management: A Physician Survey...12 Chapter 3 Pain Management: The Patient Experience...17 Chapter 4 Issues and Answers for MCOs...22 Pennsylvania: Building a Foundation for Successful Treatment of Low Back Pain...22 New England: A Pharmacy Director-Driven Program to Address Opioid Risk...24 Ohio: Building State Policies and Procedures Through a Pain Management Task Force...26 Chapter 5 Treating Pain: Mixed Models and Modalities...27 New Treatments, New Goals...27 Current Multimodal Therapeutic Choices...28 Multidisciplinary and Interdisciplinary Care: A Focus on Outcomes...29 The Rehabilitation Institute of Chicago Center for Pain Management: Chronic Pain Program...29 Establishing Coverage for Multidisciplinary Pain Programs...30 Chapter 6 Building on Successful Pain Management Programs...31 University of Washington Center for Pain Relief: A Large Multidisciplinary Model...31 Washington: Addressing Opioid Risk...32 Missouri: A Medical Home Model Provides Comprehensive Pain Management for a Large Medicaid and Uninsured Population...33 California and Oregon: Evaluating Regional Pain Management Programs...34 Improving Clinical Trial Design and Interpretation...35 Appendix...37 References

4 PAIN MANAGEMENT DIGEST Introduction Managed Care Issues and Answers in Pain Management Prelude In the spring of 2009, a national managed care workgroup 1 gathered with an aim of building consensus among medical and pharmacy directors as to how their plans could achieve the following goals: Alleviate barriers to effective management of pain Create best practices in pain management within each participant s own organization Shift organizational perspectives to regard chronic pain as a chronic disease This workgroup agreed upon the barriers to achieving these goals, and suggested paths to follow in addressing the core issues: Barriers Lack of commonly accepted guidelines Tenacity and complexity of chronic pain Difficulty determining whether treatment is working Fragmentation of the healthcare system across pain treatment providers Paths to improvement Managed care plans need to partner with physicians to improve treatment and management of pain Patients with chronic pain need multidisciplinary treatment and multimodal medication plans The 2009 group had identified exactly those issues that remain troubling to medical and pharmacy directors today Improving Pain Management Pain management discussions have moved into the national spotlight, largely through the attention of national reports such as Relieving Pain in America from the Institute of Medicine (IOM) in 2011, but also because, over the past decade, there has been a shift in policies and coverage within health plans and a changing treatment paradigm within physician practices (Chapters 4, 5, and 6). The IOM estimated that more than 100 million adults (more than a third of the population), experiences some sort of chronic pain. 2 As the survey data in Chapters 1, 2, and 3 of this publication show, preferred treatments and coverage for those treatments vary across respondents. There are good reasons for the variability. First, an unusually diversified array of treatments and modalities are used for pain relief, not all of which are dependably effective across differentiated types of patients even when they have similar diagnoses. Second, the clinical trials used to bring new medications to the market focus on treatment of acute pain, although chronic pain is much more prevalent and more difficult to address clinically. This impedes development of evidencebased guidelines for chronic pain. In Chapter 6 we present the ways that researchers have begun to establish pain classifications to strengthen the rigor of clinical trials of pain treatments, but also to better evaluate treatments when used for patients with specific pain diagnoses. The most difficult problem in successfully achieving pain management s clinical goals is made clear in the IOM report, which contends that despite the currently available range of treatment options, pain remains undertreated across the country. National statistics and statistics from the Pain Management Digest survey groups confirm this view. Surveys from our managed care directors show that 50% of managed care organization (MCO) directors believe pain is being undertreated; only 17% believe it is appropriately treated. While 38% of our full physician sample believes that pain is appropriately treated, a third believe it is undertreated. The remainder of these survey respondents believe pain is overtreated. 2

5 Figure 1. The Pain Management Digest survey groups perception of how well pain is being treated across the United States Pain is usually undertreated Pain is appropriately treated Pain is usually overtreated 17% 38% 33% 23% 29% 33% 38% 38% All Physicians N=220 Pain Specialists n=47 MCO N=46 50% greater number of elderly patients (67%) and minorities (76%) depend on PCPs for pain management. 8 Health System Costs Resulting from Pain: In the US, persistent pain costs $560 to $635 billion annually. Research based on national medical expenditure data found that the costs of persistent pain exceed the economic costs of the six most costly major diagnoses cardiovascular diseases ($309 billion); neoplasms ($243 billion); injury and poisoning ($205 billion); endocrine, nutritional, and metabolic diseases ($127 billion); digestive system diseases ($112 billion); and respiratory system diseases ($112 billion). 2 Note from the researchers: Unlike these diagnosed conditions, pain affects a much larger number of people, by a factor of about four compared with heart disease and diabetes and a factor of nine compared with cancer. Thus, the per-person cost of pain is lower than that of the other conditions, but the total cost of pain is higher. 2 There are important social and economic consequences of undertreated pain: Unrelieved pain results in more emergency room visits, longer hospital stays, more outpatient visits, and missed work or job loss. 3,4 Over time, acute pain may transition to chronic pain and chronic pain can become an illness in itself. 5 Diagnosis and assessment of specific pain complaints are difficult, and treatment guidelines are sometimes inconsistent. Pain arises from multiple causes including surgery, injury, and disease, and each patient s pain is likely to present somewhat uniquely. Incidence of Pain: According to national medical statistics, the annual incidence of pain that lasts longer than a day stands at 26% among adults. 6 It s estimated that, annually, 25 million adults will experience acute pain, and 50 million will endure chronic pain for 3 months or longer. 7 Findings from a 2010 Massachusetts survey are typical of treatment patterns across the country. Investigators found that a quarter of the state s population experiences pain lasting more than 3 months. Primary care providers (PCPs) treat 60% of the Massachusetts patients with pain. An even Acute and Chronic Pain Pain management practice guidelines emphasize that it is crucial to treat acute pain appropriately to avoid its possible progression to chronic pain. 3,9 We make the distinction between the two types of pain in our survey reports and in interviews reported in this publication. Acute pain: Most people understand and expect acute pain as a result of injury. Acute pain is a normal sensation triggered in the nervous system that alerts us to the need to take care of ourselves. 2 Chronic pain: In surveys, from 10% to 20% of patients report having chronic pain when it is defined as persistent pain lasting at least 3 months. 10 In our surveys we defined chronic pain as lasting 3 months or longer. Physiologically, chronic pain results in many changes in the peripheral and central nervous system, which are thought to aid in its persistence. 11 More simply, a chronic pain continues when it should not. 12 National costs are sobering, but they do not reflect the costs of pain as MCOs and patients experience them. Pain treatment is not easy to track using claims data because pain is experienced across a range of reimbursement codes for other 3

6 PAIN MANAGEMENT DIGEST Key Recommendations From the Institute of Medicine 2 Recommendation 2.1: Improve the collection and reporting of data on pain. The National Center for Health Statistics, the Agency for Healthcare Research and Quality, other federal and state agencies, and private organizations should improve and accelerate the collection and reporting of data on pain. The effectiveness of treatment in reducing pain and pain-related disability, determined through research on the comparative effectiveness of alternative treatments (including in different patient populations), to identify people most likely to benefit (or not) from specific treatment approaches. Recommendation 2.2: Create a comprehensive population health-level strategy for pain prevention, treatment, management, education, reimbursement and research that includes specific goals, actions, time frames, and resources. Recommendation 3.5: Revise reimbursement policies to foster coordinated and evidence-based pain care. Payers and healthcare organizations should work to align payment incentives with evidence-based assessment and treatment of pain. Optimal care of the patient should be the focus. conditions. Pain itself is a symptom more often than a primary condition and is hidden within the claims system. Even appropriate treatment can lead to additional costs from treatment of side effects, from referrals that are not tracked as continuation of an existing condition, or from exacerbations over time. Patients pay directly for treatments that may not be covered by their insurance, and patients without insurance pay what they can, and then suspend therapy without resolution of pain. They may next appear at an emergency room. Some of those costs are presented in the introduction to Chapter 5 on page 27. Guidelines for Pain Management: MCOs continue to seek consistency in guidelines that address pain treatments so that they can confidently move forward with programs and coverage decisions that treat pain effectively and simultaneously manage the risk of opioid abuse. For that reason, medical and pharmacy directors are relying on guidelines such as the American Pain Society 2009 Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain 13 and the Washington State Medical Directors Guidelines. 14 These guidelines support MCO pharmacy programs that seek to identify patients at risk through the use of claims data. (Chapter 4) Physicians and pain specialists have welcomed broader opportunities to learn about evidence-based pain management procedures and medicines, and have pursued broadened avenues to obtain pain specialist credentialing. 2 Today Today, it is possible to believe that appropriate treatment of pain is, in fact, more easily found across the country than it was just a decade ago. Our interviews profile a range of successful pain management models from many regions. (Chapters 4, 5, and 6) And through our surveys, it is clear that a wide array of healthcare providers are expanding pain management services and are reaching more patients with treatment. A Thank You to Editorial Reviewers This monograph on pain was suggested, guided, and reviewed by the editorial board members listed on the inside front cover. Additional information about current practices is based on more than 20 interviews with board members and with the experts in pain management across the country. All interviewees reviewed our drafts of their comments. Our editorial board reviewed all text and edited or suggested changes to strengthen our information. We thank these knowledgeable and generous contributors who are furthering the science of pain management. Without them, our understanding of issues and answers would be much poorer. 4

7 Survey Methodology and Research Survey design and data analysis were performed by ReCon Marketing Solutions, LLC, Medford, New Jersey, a healthcare research and communications firm. ReCon designed 3 proprietary survey instruments with the direction and review of an independent editorial board. Surveys were developed to collect information from core stakeholder groups: managed care organizations (MCOs), physicians, and patients. The first 3 chapters of this publication report findings from those surveys. Secondary research and interviews with pain management physicians and payers were performed to verify the direction of data analysis and to report on initiatives in the field that the editorial board determined to be of interest to the key stakeholders. Recruitment and Fielding ReCon engaged Research Now to program and field the physician and patient surveys to their proprietary database. Potential MCO participants were recruited from ReCon s managed care database and received a link to the online survey. A forth survey (for employers) was fielded by the Employers Health Coalition to its members in order to add that stakeholder perspective. Because that survey was still in the field at the time this publication was completed, only interim data from July 28, 2013 are presented on page 11. MCO, physician, and patient surveys were in the field on an overlapping schedule from May 21 to June 2, Those who met qualification criteria and submitted a completed survey were reimbursed for their time. Respondents to all 4 surveys were assured that individual survey responses and the respondents names and company affiliations would be held in strict confidence by ReCon. The final report reflects blinded and aggregated data. Prequalification Criteria Respondents from the 3 core survey groups had to meet specific prequalifying criteria to ensure the integrity of their responses: Directors from MCOs were prequalified to have knowledge of their organizations policies and services regarding pain management Physicians were prequalified to be current practitioners and to be actively treating patients with acute or chronic pain Patients were prequalified to have been treated by a doctor or other healthcare provider for pain within the past 12 months and to have been treated with at least one type of prescription pain medication, such as a COX-2 inhibitor, non-steroidal anti-inflammatory drug (NSAID), opioid or opioid combination. Types of pain could include pain resulting from an operation or surgery, fibromyalgia, neuropathic pain caused by diabetes or other medical conditions, migraine headache, or musculoskeletal pain. Patients with cancer-related pain were not included in this survey sample because the causes and treatments of their pain are so different from other types of pain. Figure 1 shows the geographical distribution of each survey group. Figure 1. Regional* distribution of survey respondents 24% 24% 20% 33% MCOs (n=46) 22% 34% 21% 22% Physicians (n=220) Northeast Midwest South West 23% 27% 27% 24% Patients (n=211) Percentages may not total 100% due to rounding. *US Census regions are defined as follows: Northeast: CT, ME, MA, NH, NJ, NY, PA, RI, VT Midwest: IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI South: AL, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV West: AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY Data Analysis and Reporting ReCon collected, clarified, aggregated, analyzed and reported the resulting data using the Statistical Package for the Social Sciences. All data were blinded and aggregated across each full sample of respondents (denoted as ALL), as well as by specific demographic characteristics, as applicable to each survey population. The Pain Management Digest editorial board (page 1) reviewed the survey analyses and interpretations, and the final manuscript. Statements or opinions contained within the report reflect the responses of survey respondents and interviewees, and do not necessarily reflect those of our sponsor, Iroko Pharmaceuticals, LLC. 5

8 PAIN MANAGEMENT DIGEST Medical and Pharmacy Director Perspectives on Pain Management Demographics Overall, 46 medical and pharmacy directors from managed care organizations (MCOs) responded to this survey. Most respondents (89%) represent managed care health plans, and 11% represent pharmacy benefit management organizations (PBMs). Most (68%) are pharmacy directors and 32% are medical directors. The organizations represented in this sample offer a range of plan designs, with 89% offering commercial benefits covering more than 134 million members. Many also offer managed Medicare (72%) and managed Medicaid (61%) plans. (Figure 1) Figure 1. Percentage of MCOs offering commercial, managed Medicare and managed Medicaid plans Overall Overall lives Lines of Business* N=46 N=198,903,799 Commercial (n=41) 89% 134,289,669 Managed Medicare (n=33) 72% 42,291,443 Managed Medicaid (n=28) 61% 22,322,687 *Responding organizations may operate more than 1 line of business. Note: The reporting of covered lives by health plans and PBMs may result in double counting of lives. Respondents were asked to provide information specific to each of these 3 lines of business when they were able to do so. Therefore, the total number responding to questions about commercial, Medicare, and Medicaid plan practices will vary. This is particularly evident in responses to questions regarding pharmacy benefit designs and drug management under those benefits. Introduction Pain Management Under Commercial and Government Benefits Perhaps no other condition is treated across a more fragmented healthcare system than that which serves patients with pain. Every region in the country has its own multiplicity of health care providers who offer medicinal, surgical, interventional, psychological, rehabilitative and physical therapies, as well as providers who offer complementary and alternative methods (CAM) to patients with pain. Referrals among these physicians and other care providers and among facilities is a daily part of doing business. Additionally, the range of medications being used for pain is expansive and multimodal, often combining use of nonopioid and opioid analgesics, as well as drug classes commonly referred to as adjuvant analgesic drugs, medications that are used to treat other conditions but have been found to be effective in treatment of pain patients (eg. antidepressants and anticonvulsants). 1 Contracting arrangements with these providers are as central to health plan profitability, as is the organization s ability to provide coverage for the most effective and highest quality healthcare possible while maintaining a healthy medical loss ratio (MLR). Moreover, tracking costs related specifically to pain treatment is notoriously difficult, primarily because of multiple coding issues. Also, office visits for pain evaluation and treatment are poorly reimbursed for PCPs. A recent review in the Clinical Journal of Pain said, The overwhelming problem for chronic pain management is how to realign the financial incentives with what is the best available care for the patient. 2 MCO Survey Results In the Pain Management Digest survey, a third of the organizations that responded (15 MCOs) reported having the ability to track costs across medical and pharmacy benefits, 6

9 CHAPTER 1 Medical and Pharmacy Director Perspectives on Pain Management Figure 2. MCO satisfaction with stated goals of therapy Completely dissatisfied Completely satisfied Goals of Appropriate Therapy Effective management of acute pain 2% 0% 7% 9% 11% 17% 15% 33% 7% 0% Effective management of chronic pain 4% 4% 20% 9% 22% 17% 20% 4% 0% 0% Effective management of pain during transition care between inpatient 2% 4% 9% 13% 22% 22% 22% 4% 2% 0% and outpatient services Reduced inpatient admissions due to pain 7% 0% 17% 20% 22% 9% 17% 7% 2% 0% Overall cost of healthcare consumed in association with pain management The risk of substance abuse associated with pain management 2% 7% 26% 20% 26% 9% 11% 0% 0% 0% 9% 22% 24% 15% 15% 9% 7% 0% 0% 0% Rated on a scale of 1-10, with 1 indicating completely dissatisfied and 10 indicating completely satisfied. Figure 2 lists common goals that a plan would value in designing pain management benefits and policies. Across the full scale, respondents responses cluster in midrange, but shaded boxes indicate that respondents satisfaction with achieving the stated goals is fairly positive for the first 3 listed and is negative regarding costs of care and management of opioid risks. and 40% of them can also track costs related to adverse events occurring from use of pain medications. These capabilities support initiatives that can improve care and reduce costs. However, very few (7%) of the responding MCOs have mechanisms in place that can help them evaluate the efficacy of pain treatments. Those who have begun to address evaluation of treatment say they have investigated mortality data, provider claims, member claims, and pharmacy board prescription monitoring reports. Others are looking at emergency visits, inpatient surgical practices, days in intensive care, and hospital readmissions. Across the healthcare system, plan directors are aware that pain management may not be delivered as well as it could be. Fewer than 20% of medical and pharmacy directors who responded to the Pain Management Digest survey believe that pain is appropriately treated. Not many plans have tried to correlate specific pain patients to specific cost and utilization data. Therefore, when asked to rank pain treatment according to its total costs to the plan, pain was thought to be least costly of 6 conditions. Diabetes was ranked most expensive, cardiovascular disease was next, and oncology, respiratory conditions, and mental health followed in that order. Nevertheless, when asked how concerned these organizations were with the total costs of pain management, 50% of respondents reported a high level of concern (8, 9, and 10 on the scale). In Figure 2, responses from this survey group show that only in the treatment of acute pain primarily addressed through medical benefits related to hospitals and surgical centers are plan directors relatively satisfied with the current practices. There is a high level of dissatisfaction with management of the transition between inpatient and outpatient services, concern about substance abuse risks, a broad disparity across the group as to satisfaction with chronic pain treatment, and awareness that treatment has not effectively reduced inpatient admissions. 7

10 PAIN MANAGEMENT DIGEST Figure 3. Estimated percentage of members who at any given point in time are on pain medication 59% 20% It is possible that plans underestimate their costs for pain treatment. Figure 3 indicates that nearly a third of respondents estimated that 20% to 50% of members are taking pain medications. IOM data sources claim that the prevalence of pain has made it the most costly condition in the nation (at $635 billion), with pain adding incremental costs to the healthcare system that range between $261 and $300 billion dollars annually. The remainder resulted from reduced productivity. 3 Pain management programs: The dissatisfaction level expressed by these respondents reflects the finding that very few have policies or programs in place to improve pain management through a structured approach. (Figure 4) While 7% 4% 4% 7% <10% 10 20% 21 30% 32 40% 41 50% Don t know Almost 80% of MCO directors estimate that, at any given point in time, from 10% to 30% of covered members are being treated for pain. over a third (35%) said that pain management is a part of their case management programs, only 4% (2 plans) have a program that is as structured as other disease management programs. An additional 9% believe they will have such programs within 2 years. Those MCO programs include medication management to reduce opioid abuse and diversion, and they offer addiction counseling. Also, they offer alternative treatments to compliment medication regimens that are not working well enough to reduce the pain. These include but are not limited to physical and behavioral therapies and complementary and alternative methods (CAM). In addition, MCOs actively provide ongoing patient and physician education through multiple methods, including personal case manager outreach and phone counseling. Considerably more MCOs offer pain management educational information to providers (18%) and members (30%), primarily through newsletters and mailings. Three MCOs reported having pain management programs specifically for geriatric members with pain. One of those MCOs is a managed Medicare plan. Although MCOs may not have programs of their own, a substantial number (41%; n=17) reimburse treatment from multidisciplinary/interdisciplinary pain programs, and an additional 7% have plans to do so within the next 2 years. Because there are no national accreditation criteria for pain centers, MCOs approach selection of and reimbursement Figure 4. Percentage of MCO respondents having active pain management programs Will have this capability Yes No within the next 2 years MCO has a care/case management program for pain management 35% 57% 9% MCO is aware of national guidelines for pain management 70% 30% * MCO has a structured pain management program, similar to other disease management programs 4% 89% 7% MCO offers provider education on pain management 18% 75% 7% MCO offers patient education on pain management 30% 68% 2% MCO has a specific program for geriatric patients with pain 7% 93% 0% MCO reimburses claims from multidisciplinary/interdisciplinary pain programs 41% 52% 7% *not applicable 8

11 CHAPTER 1 Medical and Pharmacy Director Perspectives on Pain Management Figure 5. MCO satisfaction with their current approach to addressing pain as a clinical issue 20% 20% 24% Figure 6. MCO satisfaction with the support the plan extends to PCP pain management practices 24% 24% 13% 13% 0% 0% 2% 4% 4% = Completely dissatisfied 10= Completely satisfied 17% 15% 9% 7% 4% 0% 0% 0% = Completely dissatisfied 10= Completely satisfied Rated on a scale of 1-10, with 1 indicating completely dissatisfied and 10 indicating completely satisfied. In Figure 5, it s clear that few MCOs (4%) are highly satisfied with their current approach to pain, and only 7% (in Figure 6) are satisfied with their organizations support of good pain management practices among PCPs. A solid majority, however, rated satisfaction between a 4 and 7 on the 10-point scale, indicating a moderate level of satisfaction. for such care in multiple ways (see below). Figures 5 and 6 indicate the level of satisfaction MCO managers report in their approaches to pain management. Analgesic medication management: This survey asked MCOs about their practices and opinions regarding coverage and value of COX-2 inhibitors, oral NSAIDs, topical and transdermal NSAIDs, long- and short-acting opioids, transdermal opioids, and buprenorphine products. Figure 7 summarizes respondents satisfaction with the medication s clinical efficacy, clinical safety, and cost. With the exception of oral NSAIDs, few respondents considered costs of these treatments to be satisfactory; 70% are Methods MCOs use to reimburse multidisciplinary pain programs as reported by survey respondents Plans contract directly with recognized centers in the coverage region Coverage after prior authorization and referral from a participating provider Pain centers are credentialed by the plan Pain centers and referrals are part of the plan s patient centered medical home model Each intervention generates a separate claim by code; not bundled; no daily charge Pain specialists and pain treatment facilities are within the provider network satisfied with costs of oral NSAIDs. Almost 40% were also satisfied with the costs of short-acting opioids. Overall, only a third of respondents reported a high level of satisfaction with clinical efficacy, and even fewer were satisfied with safety of the listed therapeutic agents. Overall, 30% to 35% were satisfied with the clinical efficacy of oral NSAIDs, long-acting opioids, short-acting opioids and transdermal opioids. Only 13% were satisfied with efficacy of COX-2 inhibitors. Only 26% expressed a high level of satisfaction with clinical safety of topical/transdermal NSAIDs and COX-2 inhibitors (rating them at 8, 9 or 10 on a scale of 1 to 10). Figure 7. Level of satisfaction by drug type Clinical Clinical Drug Type Efficacy Safety Cost COX-2 inhibitors 13% 26% 4% Oral NSAIDs 35% 15% 70% Topical/Transdermal NSAIDs 2% 26% 7% Long-Acting Oral Opioids 35% 4% 4% Short-acting Oral Opioids 30% 9% 37% Transdermal Opioids 24% 9% 2% Buprenorphine products 15% 11% 2% On a scale of 1-10, with 1 indicating complete dissatisfaction and 10 indicating complete satisfaction, these percentages of respondents responded with an 8-10 rating. 9

12 PAIN MANAGEMENT DIGEST Reasons for dissatisfaction are most often related to side effects associated with currently available medications. Consequently, the FDA in its post-marketing directive documents for prescribers and for patients are focused on safety and prevention of side effects. For example, when using prescription NSAIDs, patients are cautioned to take the medication exactly as prescribed, and use the lowest effective dose for the shortest duration consistent with the individual patient treatment goals. 4 In a different survey question about the value of pain medications, respondents were asked to rank the most valuable attributes of the three most prescribed pain medications (with 1 as the highest value and 3 as the lowest). COX-2 inhibitors: 1 clinical efficacy; 2 safety; 3 cost Prescription NSAIDs: 1 clinical efficacy; 2 cost; 3 safety Oral opioids: 1 clinical efficacy; 2 safety; 3 cost. Cost of pain medications to the plan: Almost all respondents (98%) believe that the value of prescription NSAIDs is highly commensurate with their cost. MCOs also value short acting opioids (87% of respondents). Other product types in this list were not viewed as having as high a value compared with their cost to the plan. In general, pain medications are not being highly managed by these MCOs. The majority focus on quantity limits, with oral opioids attracting the most attention: 71% of commer- cial plans and 64% of Medicare plans. COX-2 inhibitors are managed through quantity limits by 54% of commercial plans, and are also subject to step-therapy by 49%. NSAIDs are the least restricted of the three types of medications. Quantity limits were applied to NSAIDs by about 29% of commercial plans and 33% of Medicare plans. Oral opioids are restricted in terms of quantity limits but less restricted by prior authorizations or step therapy requirements. In a closer look at how cost was spread across a range of pain medications, respondents estimated the portion of spending each agent contributed to the total pharmacy benefit spend for pain medications. Opioids were considerably more costly than the other medications listed, and they are estimated to account for 41% of the total. Prescription NSAIDs at 18% of the total and COX-2 s at 11% compose about 30% of the total, with opioid combination products at 12% of the total. Buprenorphine products accounted for 10% of total spending. Other agents accounted for 9% and included antidepressants, neurologic pain products for migraine, other analgesic patches, anticonvulsants, and toradol. MCO respondents continue to struggle with multiple barriers that impede their ability to put policies in place to support effective, appropriate pain management for their members and generally improve quality of care delivered by providers who treat patients with pain. (See the Barriers reported by these respondents in the box on this page) Barriers to adequately evaluating pain management as reported by MCO survey respondents Pain is very subjective; not easily measurable Not enough data are captured to know how well members are being treated for pain No established clinical mechanism to evaluate effectiveness of treatment Chronic pain is highly complex and there are too few specialists Ambiguity of claims data Total costs are impossible to determine Plans are tertiary to care; no interaction with patient or provider High volume of patients with pain; broad range of indications; too much to address with current plan resources Pain in the Workplace: An Employer Coalition Survey A surprising finding in the results of the MCO survey was that only 1 of the 46 MCO respondents has a partnership program with its employer customers to improve pain management treatment practices. However, that respondent reported that the program has succeeded in making benefit design changes which prevent opioid abuse and, thus, is reaching a goal of reducing costs related to misuse. On page 11, the Pain Management Digest presents early results from a proprietary survey of employer benefit plan managers and medical directors who are members of a national employer coalition. 10

13 CHAPTER 1 Medical and Pharmacy Director Perspectives on Pain Management Employer Survey: Interim Results* In an abbreviated analysis of this Employers Health Coalition survey, responses from 17 companies are reported, representing 88,140 employees and dependents enrolled in health benefit plans. Company size ranges from 154 to over 27,000 employees. Across this sample, employers pay an average 72% of the health plan premium for their employees. Survey results: Using pharmacy and medical claims data, respondents reported that cardiovascular disease ranks first in regard to its cost impact, followed by cancer and diabetes. Cost of pain ranked fourth, followed by respiratory conditions, and mental health. Relative prevalence of chronic conditions among plan members was reported as well, with diabetes ranking first, followed by hypertension, cardiovascular disease, pain, and allergies. Forty-seven percent of respondents estimated that 10% to 25% of medical claims represent procedures to relieve or manage pain, with 53% estimating the same percentage range for pharmaceutical claims for pain medications. (Figure 1) Figure 1: Estimated percentage of employers healthcare benefit claims related to pain management Less than 10% Between 10% 25% Between 26% 50% Greater than 50% Don t know 0% 7% 7% 7% 20% 20% 20% 20% 53% 47% The Employers Health Coalition, Inc. is a not-for-profi t 501(c) (3) organization founded in 1983 with offi ces in Ohio. It provides member organizations with products and services that help maximize the value of the health and wellness benefi ts delivered to its member organization s employees. Today, the coalition represents more than 300 member organizations with covered lives in 50 states. The impact of pain on employee productivity was also explored, and chronic low back pain and other joint, neck or muscular pain were judged to have the most negative impact. Migraine or other headache, and arthritis were reported in third and fourth position. When asked to report concerns relating to pain medications (COX-2 inhibitors, non-narcotic prescription pain relievers, opioids and fixed combination products with opioids), respondents were most concerned with employees use of opioids and opioid combinations (40%). They specifically cited concerns about safety, disqualifications for driving or operating machinery, and addiction. Gastrointestinal or renal side effects were concerns regarding COX-2 inhibitors and non-narcotic prescription pain relievers, followed by concerns about cost and overuse. When asked about concerns related to pain management within their companies, 80% said they are most concerned that employees having difficulties with narcotic medications may create safety issues within the workplace, 60% are most concerned with the costs related to pain management, and 53% are concerned that there may be overuse or abuse of narcotic pain relievers among covered members. A closely related issue is that these respondents say that they don t know how to assess the impact of pain-related effects on worker productivity while at work. Pharmacy claims Medical claims *Survey findings on this page come from an early analysis of partial responses (from 17 of a final 21 respondents). The survey was still in the field when this publication was written. 11

14 PAIN MANAGEMENT DIGEST Practices in Pain Treatment and Management: A Physician Survey Demographics Of the 220 physicians who responded to this survey, 27% practice in a primary care setting, and 14% practice in a multispecialty group. Forty-one percent are in a private or group single-specialty setting. (Figure 1) In the full, 220-physician sample, 47 respondents (22%) self-reported a primary or secondary specialty in pain medicine or pain management. (Figure 2 in boxed text) Fourteen percent of the full sample, and 21% of pain specialists, practice in a multispecialty group; 45% of pain specialists are in primary care practice settings; and 17% are affiliated with a pain management clinic. Figure 1. Practice affiliations, full survey group and pain specialists ALL PS Practice Settings N=220 n=47 Private practice, primary care 15% 30% Private practice, single specialty 21% 19% Group practice, primary care 12% 15% Group practice, single specialty 20% 15% Group practice, multispecialty 14% 21% Affiliated with a university or 19% 19% academic center Affiliated with a community hospital 22% 23% Affiliated with a major medical center 9% 9% Community clinic 6% 2% Pain management clinic 4% 17% Respondents were asked to select all that applied and percentages may total >100%. PS=Pain Specialist. Pain Specialists Physicians who specialize in pain management come to that clinical expertise by multiple routes: through practice experience, and through recognition and/or credentialing from a number of professional organizations. Physicians already board certified by the American Board of Medical Specialties (ABMS) in anesthesiology, physical medicine and rehabilitation, or psychiatry/neurology are also eligible to obtain a subspecialty certification in pain medicine. More recently, the American Academy of Pain Management has also offered an accreditation program that recognizes a specialty in pain management. The program credentials physicians as well as pain management centers that meet specific qualifications. 1,2 Figure 2. Percentage of respondents having a primary or secondary specialty in pain management or pain medicine 79% Among these physicians, reimbursement through commercial plans accounted for 42% of total income, with Medicare providing 25% and Medicaid providing 18%. Cash payments from patients to the physician practice stand at 8% overall and at 10% among the pain specialist subgroup. Introduction 12% 10% Primary specialty n=26 Secondary specialty n=21 Not a pain specialist n=173 As mentioned in the MCO survey, a major goal of pain management is to increase the numbers of patients with pain who receive appropriate, effective treatment, not only because patients benefit, but also because the health system itself benefits. First, such therapy reduces the strain that undertreated pain puts on services, and appropriate treatment that follows accepted guidelines is likely to reduce costs 12

15 CHAPTER 2 Practices in Pain Treatment and Management: A Physician Survey Figure 3. Percentage of patients seen annually whose chief complaint is pain 49% 25% 48% 22% 19% 1%-20% 21%-40% 41%-60% >60% 34% 30% 26% 28% 28% 21% 23% 14% 11% 10% 11% Percentages may not total 100% due to rounding. Acute Pain ALL N=220 Chronic Pain Acute Pain Chronic Pain Pain Specialist n=47 associated with using treatments that are not needed or are ineffective. Physicians are the pivot point between the patients and the insurer; and for pain patients, the first doctor to treat their pain is likely to be a primary care physician (PCP) Researchers agree that PCPs treat the majority of people who have chronic pain, 2,3 and a primary care practice is where most people first report a pain. This is the key point of entry to the health system. Consequently, the treatment offered by a PCP to a new pain patient is critical. 1 If a new pain complaint is resolved swiftly, it can make a difference in halting a possible progression to chronic pain. If an already chronic pain is addressed effectively, its impact can be reduced and may lead to fuller functionality. The number of pain specialists is increasing but is still inadequate to treat all patients who might benefit from a specialist consult. Between 2000 and 2009, only 3,488 physicians became ABMS board certified in pain medicine. 2 To meet the growing need for effective treatment of patients with pain, the US health system has begun a determined effort to broadly extend educational information about pain treatment to PCP practices with a particular focus upon physicians practicing in an Accountable Care Organization (ACO) or a patient-centered medical home. Medical schools, CME providers, some payer organizations, and physician-led pain management societies encourage publications and programs to expand the understanding of the clinical skills used in the treatment of pain. Survey Results Pain Management Practices Across this sample, physicians treat a mean 321 pain patients monthly. Pain specialists, not surprisingly, treat more; the mean monthly volume reported by them is 363 pain patients. As estimated across the full sample of specialty and PCP practices, pain is the most often treated condition, diabetes is next and cardiovascular disease is third. To determine if the volume and type of pain treated by the full physician sample differs from that of the pain specialist subgroup, physicians were asked to estimate the relative volume of acute pain patients and chronic pain patients as a portion of their full annual patient load. The graphs in Figure 3 show an interesting comparison: In the full physician sample, pain patients make up 20% of annual patient load, with acute pain and chronic pain being equally represented among those patients. In practices where patients with pain compose 21% to 40%, the split between acute and chronic conditions remains balanced in the full sample and in pain specialist practices. In practices that have very high percentages of pain patients (41% to 60% and >60%), the difference in volume between acute and chronic pain patients is wider, especially within pain specialist practices, which also have more chronic pain patients: Pain specialists: 39% acute and 55% chronic pain All practices: 25% acute and 39% chronic pain 13

16 PAIN MANAGEMENT DIGEST Figure 4. Percentage of pain patients being treated with 1 or more analgesic medications 60% 49% 30% 31% 13% 7% 7% 3% 1 2 to 3 4 to 5 more than 5 Number of different medications ALL N=220 Pain Specialists n=47 Treatment of Pain Typically, medication is a first-line treatment for most pain complaints, and if the first-line agent or its dose is not strong enough to address the pain, the prescribing physician might increase the dose or introduce a second medication, either alone or as a multi-drug approach. 2,4 In the full physician sample, 30% of patients are being treated with 2 or 3 medications. Only 10% take more than 3. However, twice as many patients of pain specialists take 4 to 5 or more medications. (Figure 4) Physicians frequently refer patients to other healthcare providers while continuing medication, and sometimes the patient may receive additional medications and referrals from those providers. (Figure 5) While 34% of pain specialists say they do not refer pain patients to other clinicians; two thirds do, and they most often refer patients with chronic pain issues. The full physician sample refers a higher percentage of pain patients to other clinicians than the specialists do; however, they also refer more patients with chronic pain than with acute pain. As described in later chapters of this report, current treatment guidelines have broadly recommended use of multidisciplinary programs for the treatment of intractable chronic pain, finding that patients are able to improve functionality and that overall healthcare system costs are reduced. (See page 28 Multimodal Approaches and pages 29 and 30 Multidisciplinary and Interdisciplinary Care). Therefore, it is fortunate that the majority of these physicians (72%) have the option to refer patients to a multidisciplinary pain clinic or another type of pain center within their region. According to survey comments, however, coverage of such services is not always dependable, and from 37% to 49% of respondents are unaware of whether Medicaid or Medicare benefits cover such treatments. Most physicians (80%) report that commercial insurers in their regions do cover treatments provided in pain centers. Figure 5. Referral patterns: referring pain patients to other clinicians What percentage of patients with acute or chronic pain do you refer to another provider? ALL PS N=220 n=47 I refer more patients with acute pain to specialists than those with chronic pain 16% 13% I refer more patients with chronic pain to specialists than those with acute pain 71% 53% Neither, I do not refer my pain patients 13% 34% Most common reasons for referral* ALL PS N=192 n=31 The patient s particular pain can be better treated by a different physician specialist 69% 42% Medication therapy alone has failed to effectively mitigate the pain 58% 36% A need for interventional or alternative therapies 50% 36% A need for physical rehabilitation therapy 44% 36% The patient needs psychosocial therapy 36% 16% *Ranked on a scale of 1-10, with 1 indicating the most common reason and 10 indicating the least common, these percentages of respondents responded with a 1-3 rating. PS=Pain Specialist. 14

17 CHAPTER 2 Practices in Pain Treatment and Management: A Physician Survey Figure 6. Percentage of patients who use other therapeutic modalities Figure 7. Percentage of physicians who often prescribe the following medications for pain patients Types of Therapy Physical or occupational therapy Exercise (e.g., yoga, swimming, walking program) 26% 23% 37% 37% Most Commonly ALL PS Prescribed Medications N=220 n=47 Prescription-strength NSAIDs 68% 64% Opioid Combinations 45% 49% Oral Opioids 35% 47% Tricyclic Antidepressants 31% 51% Serotonin-Norepinephrine Reuptake 31% 47% Inhibitors (SNRIs) Selective Serotonin Reuptake Inhibitors 30% 53% (SSRIs) COX-2 Inhibitors 29% 45% Anti-anxiety Medications 28% 38% Topical/Transdermal NSAIDs 26% 34% Steroid Injections and Spinal Injections 24% 45% Transdermal Opioids 16% 38% Antitryptics (MAOIs) 13% 38% Psychological/ psychiatric counseling Relaxation techniques Spinal manipulation (Chiropractic care) 17% 15% 12% 15% 12% 12% Acupuncture 8% 12% Herbal supplements 9% 8% ALL N=220 Pain Specialists n=47 Respondents were asked to select all that applied and percentages may total >100%. Physician respondents report that almost 40% of their patients take advantage of physical or occupational therapy programs. About a quarter of patients pursue some sort of exercise program, and 17% have psychological or psychiatric counseling. Use of other modalities is less likely. (Figure 6) Use of Prescription Medications Both the full sample and pain specialists prescribe prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs) more often than any other medications listed. (Figure 7) Combination opioids and oral opioids are also widely prescribed. On a scale of 1 to 10, with 10 as the most-often prescribed agents, almost 70% of physicians ranked their prescribing of NSAIDs at a 6 to 10; 45% ranked prescribing of opioid combinations at 6-10 and 35% rated prescribing of oral opioids at A slightly higher percentage of pain specialists also report prescribing these 3 types of pain medication most often. The specialists more On a scale of 1-10, with 1 indicating the least prescribed and 10 indicating the most prescribed, these percentages of respondents responded with a 6-10 rating. PS=Pain Specialist. NSAID=nonsteroidal anti-inflammatory drug. often prescribe adjuvant agents such as antidepressants and anti-anxiety agents, as well as a considerably higher use of COX-2 inhibitors. Use of guidelines: A majority of respondents reported that they refer to treatment guidelines when prescribing pain medications: 65% of the full sample and 83% of pain specialists. Most often they consult internal practice guidelines (44%) or guidelines from other physician groups (29%), state-required guidelines (41%), and national treatment guidelines (32%). Within these practices, half of surveyed physicians measure pain intensity at each visit; 66% of pain specialists do so. These physicians use multiple validated assessment tools that help assess the efficacy of treatment. Such tools measure the patient s perception of pain reduction, increased functionality, or improvement in psychosocial skills. 15

18 PAIN MANAGEMENT DIGEST Prescribing pain medications: A majority of physicians report that they follow recommended practices when prescribing opioids: 65% of the full sample and 81% of pain specialists say that they educate patients about opioid risks, and 55% also routinely administer urine drug tests and ask patients to sign a contract when an opioid is prescribed. (Figure 8) The factors that limit the level of prescribing the agents listed in Figure 9 are well established in the literature and among prescribers. In this survey, both the full sample and pain specialists agreed on which of the key factors in the drug profile cause the most concern and, thereby, limit their prescribing. A majority of prescribers considered abuse potential and the risk of opioid-induced tolerance to be the most limiting factors in their prescribing of opioids. No other characteristics of any pain medication agents caused so high a level of concern. Clinical safety and incidence of side effects regarding use of COX-2 inhibitors was a highly limiting factor for 30% of all respondents but of <30% pain specialists. Side effects was also a limiting factor when prescribing NSAIDs for >30% of all physicians and >40% of pain specialists. No doubt because of the limitations mentioned, relatively few physicians believe that the available drug therapies for pain are able to address the broad goals of pain therapy shown in Figure 10. Physicians ranked their satisfaction on a scale of 1 to 10 with 1 being completely dissatisfied, and 10 completely satisfied. Physicians reported a modest level of satisfaction with clinical efficacy, and they report that the patients they prescribe these drugs for have a lower level of satisfaction than the prescribers do. Figure 8. Physician practices when prescribing opioids Give patients educational information about risks associated with prescription opioid pain relievers Routinely administer urine tests to check for opioid abuse Ask patients to sign a pain contract or an opioid treatment contract when an opioid is prescribed for them ALL N=220 Pain Specialists n=47 39% 33% 55% 55% 65% 81% Figure 9. Limiting factors of COX-2 inhibitors, oral NSAIDs, oral opioids, and opioid combinations Drug classification ALL PS N=220 n=47 30% or more physicians identified the listed drug characteristics as the most limiting factors in prescribing the drug COX-2 Inhibitors Clinical safety/incidence of side effects 30% <30% Oral NSAIDs Clinical safety/incidence of side effects 36% 40% Potential, serious adverse events 33% 43% Patient tolerability <30% 34% Oral Opioids Clinical safety/incidence of side effects 35% 38% Potential, serious side effects 42% 51% Patient tolerability <30% 34% Abuse potential 72% 57% Opioid-induced tolerance 57% 45% Fear of prescribing 32% 40% Opioid Combinations Potential, serious side effects 38% 34% Abuse potential 56% 41% Opioid-induced tolerance 44% 38% On a scale of 1-10, with 1 indicating the least limiting and 10 indicating the most limiting, 30% or more respondents rated these at PS=Pain Specialist. Figure 10. Satisfaction with ability to affect broad goals of pain therapy ALL PS Goals of therapy N=220 n=47 Effective management of acute pain 35% 28% Reduced inpatient admissions due to pain 25% 28% Effective management of pain during transition care between inpatient and 16% 30% outpatient services The risk of substance abuse associated with pain management 14% 26% Effective management of chronic pain 12% 21% Overall cost of healthcare consumed in association with pain management 11% 23% On a scale of 1-10, with 1 indicating complete dissatisfaction and 10 indicating complete satisfaction, these percentages of respondents responded with an 8-10 rating. PS=Pain Specialist. 16

19 CHAPTER 3 Pain Management: The Patient Experience Demographics A total of 211 patients completed the full survey. Almost half (104 patients) were 60 years old or older. More than two thirds of the sample was female (71%) and 29% was male. Patient respondents to this survey were currently being treated or had been treated with a prescription pain medication within the past 12 months. They may have been treated in a physician s office, or in a clinic, hospital, or emergency department. Survey Demographics Patient Groups All=full sample (N=211) Types of Pain Musculoskeletal Pain (n=126) Neuropathic Pain (n=38) Post-surgical Pain (n=47) Definitions of pain as used in this survey Musculoskeletal Pain: arising from multiple sources such as but not limited to injury; back/neck pain; arthritis; muscle, bone, or joint pain. Neuropathic Pain: arising from fibromyalgia, migraine, or neuropathic pain caused by diabetes or some other chronic condition. Post-surgical Pain: arising from an operation, surgery or procedure that took place in a hospital, doctor s office, or clinic. While the majority of patients classified their pain as musculoskeletal, nearly a quarter of the sample reported having a pain that originated with a surgical procedure. Fewer (18%) reported having neuropathic pain. (Figure 1) Among the types of prescription pain medications these respondents have been taking, relatively few had been prescribed a COX-2 inhibitor, but almost 40% of patients have had an opioid prescription, and 51% have had an NSAID prescription at some time. (Figure 2) Figure 1. Percentage of patients reporting a pain complaint within the past 12 months, by type of pain 60% 63% Musculoskeletal Pain 23% 25% Post-surgical Pain 18% 12% Neuropathic Pain All N=211 Over 60 n=104 Figure 2. Percentage of patients having taken a prescription medication for pain over the past 12 months Opioid Combinations Prescription NSAIDs Opioids COX-2 Inhibitor 12% 14% 13% 9% 59% 55% 47% 51% 55% 50% 43% 37% 37% 40% 32% All N=211 Musculoskeletal pain n=126 Neuropathic pain n=38 Post-surgical pain n=47 81% Respondents were asked to select all that applied and percentages may total >100%. Opioid combination medications are commonly prescribed for a wide range of acute pain conditions, and 81% of respondents with post-surgical pain report having taken these agents. Overall, more than half of respondents have received prescription NSAIDs, and 59% have received an opioid combination medication. Most respondents were covered by insurance; 96% overall. Half were covered by an employer-sponsored health plan, 29% had Medicare with drug coverage, and 11% had 17

20 PAIN MANAGEMENT DIGEST Medicare without drug coverage. Commercial coverage was less prevalent among those over 60 years old (39%). Six percent of the full sample and 9% of those over 60 had military or Veteran s Affairs (VA) benefits. Only 4% of this sample had Medicaid benefits. Many were currently being treated with pain medications, and 54% of the full sample was also taking medication for anxiety and/or depression. Just over 30% had been treated for a cardiovascular condition and 19% were treated for diabetes during the previous 12 months. Introduction The impact of persistent pain is profound. It affects patient s lives and it affects the healthcare system that continues to cover costs related to pain that is not successfully treated. In a 2006 survey from the American Pain Foundation (APF), Voices of Pain, more than half of the national respondent group reported that they had no control over their pain even though they were currently being treated. More than 75% were depressed, and only 14% were satisfied with current medications. 1 Older patients are known to be even more deeply compromised by pain than younger adults. 2 In the Pain Management Digest survey, 70% of respondents have suffered from pain-related sleeplessness, 60% report a reduction of their daily functionality, and 39% are depressed. Thus, the patient experiences reported in our survey are similar to those in the APF survey, showing that for people with chronic pain, control over their pain and their lives becomes an elusive goal. 1 Typically, guidelines for pain management recommend a stepped approach in prescribing medications. These are consistent with directives from the FDA to use the lowest effective NSAID dose for the shortest duration consistent with the individual patient treatment goals, 3 and with guidelines for older adults from the American Geriatrics Society, 4 which recommend initiating pain medications with low doses followed by careful upward titration, including use of frequent pain assessments for dosage reassessment. (See Appendix on page 37) For example, acetaminophen is commonly used as initial treatment for musculoskeletal pain; NSAIDs (other than COX-2 inhibitors) are also a common first choice and may be preferred for patients with chronic inflammatory pain. NSAIDs are also deemed to be helpful as an effective shortterm option in addressing breakthrough pain. Opioid treatments are reserved, if possible, for intractable pain. 4 Our survey asked patients what analgesics they are taking and what their experience is in using these common pain medications: NSAIDs, COX-2 inhibitors, opioids, and opioid combinations. Survey Results The patient experience: Despite the fact that 96% of this patient sample has healthcare coverage and access to a range of therapies, a majority of surveyed patients with chronic pain reported that their pain had not been completely resolved with treatment. Nevertheless, when respondents were asked if they experienced a difference in their level of pain before and after treatment, 62% reported having the highest level of pain possible before treatment. Only 17% had so high a level of pain after treatment began. Treatment made a positive difference. Figure 3. Characteristics of patients being treated for an active pain complaint Musculo- Neuro- Postskeletal pathic surgical ALL Pain Pain Pain N=163* n=99 n=33 n=31 Patients with an active continuing pain complaint 84% 85% 85% 81% Number of times patients visited a healthcare provider for the same pain complaint over the previous 12 months Once 11% 12% 12% 7% 2 to 4 50% 51% 46% 52% 5 to 8 25% 23% 30% 23% 9 to 12 3% 4% 0% 3% Weekly 4% 3% 6% 3% Monthly 5% 4% 6% 7% Patients who are currently taking prescribed pain medications 89% 91% 88% 84% *At the time surveyed, 163 of the total 211 patient respondents were experiencing an active pain condition and were being treated for it. 89% of those were being treated for a continuing pain. 18

21 CHAPTER 3 Pain Management: The Patient Experience At the time of this survey, 77% of responding patients were currently in treatment for pain. Of those, 84% were being treated for a continuing pain complaint. (Figure 3) Over the course of a year, 50% had seen a healthcare provider 2 to 4 times for the same complaint. Twenty-five percent to 30% had visited the healthcare provider 5 to 8 times over the 12 months. Among patients who reported having experienced chronic pain (a pain that lasted more than 3 months), a minority of the group had been treated to a resolution of that pain. From 53% (those with post-surgical pain) to 74% (those with musculoskeletal pain) reported that their pain had not been fully resolved. (Figure 4) Most were treated in a doctor s office: 58% of the full sample. Seven percent were treated in a rehabilitation or multidisciplinary pain center, and 8% had treatment in a surgical center or an emergency department. Figure 4. Time to pain resolution for patients who have previously had or currently have a pain complaint that lasted longer than 3 months a chronic pain 11% 7% 8% 5% Time to Resolution 11% 11% 7% 8% 8% 4% 5% 5% 5% 17% 11% 11% Impact of pain: Among the many pain-related issues that patients reported, the most troublesome for a majority of respondents are sleeplessness (70%), low energy (62%) and reduced daily functioning (60%). Depression affects 39% of these patients, and 33% say they worry about taking additional medications. When they reported such symptoms to their healthcare provider, as almost 90% did, physicians suggested multiple treatments. Patients were advised to take another prescription medication (53%) and/or use physical therapy (48%), chiropractic help or complementary and alternative methods (17%). Some were referred to psychological/psychiatric counseling (10%). (See Chapters 5 and 6 for more discussion of multimodal therapy) About 40% of this sample is employed, and even among those patients who worry about effectiveness on the job, not many have missed workdays because of pain, and most were in treatment. In this sample, 82 patients were employed at the time of the survey (38% of the full sample). Figure 5 shows the workdays lost due to their pain. Prescribed pain medicines: Most patients (85%) receive information about their prescribed pain medications directly from the prescriber. Usually the information is delivered in a person-to-person conversation (78%); however, about half of these patients receive written instructions from the prescriber, either as an accompaniment to the conversation or in lieu of it. ALL N=181 Musculoskeletal Pain n=108 Neuropathic Pain n=37 1 to 3 weeks 1 to 3 months 3 to 6 months 6 to 12 months ALL N=181 Musculoskeletal Pain n=108 Not Yet Resolved 69% 74% 70% Neuropathic Pain n=37 Post-surgical Pain n=36 53% Post-surgical Pain n=36 Figure 5. Percentage of working patients who have lost workdays due to pain Musculo- Neuro- Post- Length skeletal pathic surgical of Time ALL* Pain Pain Pain (days) N=82 n=56 n=14 n=12 None 44% 46% 36% 42% 1 to 5 29% 29% 29% 33% 6 to 10 11% 13% 7% 8% More than 10 16% 13% 29% 17% *These data represent a subset of the full sample. Only those respondents who currently had a job responded to this survey question. 19