The Challenges and Benefits of an Interdisciplinary Approach to Pain Management: A Q&A with Cam Kneeland, MD
Cam Kneeland, MD
What services do you offer at your practice, and how many patients are treated for pain there?
The Montana Center for Wellness and Pain Management (http://bit.ly/x7Xm3u) is one of the most comprehensive interdisciplinary pain clinics in the country; we have nine different specialties practicing here. We practice medical pain management, and also interventional pain managementnerve blocks, injections, spinal cord simulators, intrathecal pumps, etc. We have an addictionologist physician on staff. We also have chiropractic, acupuncture, massage, a naturopath, and a physical therapist, as well as mental health specialists, including a psychologist and several licensed counselors. I wanted to pursue this in our community because, as I was going through my training, I recognized the need for a more complete approach to chronic pain management. I saw some of the failures with traditional pain management, and was exposed to new practice models that utilized multiple specialties and worked better. In looking around and talking to patients and seeing what they utilized and what helped them, I decided to approach the hospital here with a proposal for a comprehensive interdisciplinary pain care model and was fortunate that they agreed that it was a good idea. It’s been very successful so far.
We have about 4,000 active patients at the clinic. I personally see probably 350 patients per month. Probably 80% of the patients we see have a primary complaint of low back pain with or without leg pain. These are patients who have, on average, been suffering from this pain for three to five years and have gone through their primary care physician, a surgeon, and probably a neurologist before they get to us. They are, by and large, maintained on opioids when they come to us because that unfortunately is the chronic pain management paradigm for most of the country. When pain patients come to us, we try to do a couple of things. Number one is establishing an accurate diagnosis. We try to find the true source of their pain and then offer them a variety of treatment options beyond opioids because one of my passions is limiting the misuse and diversion of opioid medications. I think those drugs are incredibly over-utilized, and the good medical data does not support their use for chronic non-cancer pain.
Can you expand a bit on what you are referring when you point to “the failures of traditional pain management?” How is that tied in with the overuse of opioids?
I think that the traditional approach to the management of pain relies too heavily on opioid pain medications. It arose when data from studies showing that chronic opioid use in cancer patients was effective was applied to non-cancer chronic pain patients. That, combined with the lack of other options in many placesmental health counseling, interventional pain management, chiropractic, acupuncture, massage, and all of the other modalities that we have found to be effective for chronic pain led many providers to take the path of least resistance, which is to say that when patients would experience more pain they would be given more opioids to treat that pain. This may work for a limited period of time in many patients, but, in my experience, 95% of patients do not do well for more than a year on opioids as their primary modality of pain management.
In your view, is this inadequate approach to treatment compounded by a lack of provider education? What are some other contributing factors?
Oh, absolutely. I think we’re actually lacking a couple of things. Number one, there’s a lack of pain management specialists. In fact, the data that I’ve seen indicates that there’s one pain management specialist for every 33,000 people in the United States (http://bit.ly/lzIPcm). The second problem is that there is a lack of understanding and a lack of willingness to treat chronic pain on the part of primary care physicians and other first-line health care professionals. Education is absolutely critical for the primary care physician, not only in terms of how to treat chronic pain but when to refer to a specialist, and how to appropriately prescribe and safely monitor controlled substances. It’s actually getting worse because as the problems with opioid abuse and misuse are more widely understood, fewer primary care physicians, fewer pain specialists, and just fewer health care professionals in general are willing to even treat chronic pain. I’ve heard from some of my colleagues in the primary care field that malpractice insurance for doctors who prescribe schedule II controlled substances is so expensive that they’re not willing to do it based simply on that.
It can also be a challenge to deal with the patients themselves. These are very frustrated, often angry patients who have been through multiple evaluations, have often been treated by multiple providers, and have not had a lot of success. That makes many providers hesitant to treat those patients, or at least have those patients represent a significant percentage of their practice. Add to this the fact that the DEA and state regulators have been very inconsistent in the way they handle these cases, leading to a lack of consensus and uncertainty regarding safe prescribing practices. These and other factors have resulted in an increasing unwillingness to treat chronic pain.
What are some of the challenges associated with implementing an interdisciplinary care approach to pain management? Are there any that are unique to a rural state like Montana?
Interdisciplinary care means a group of different specialties and experts who are involved in patient care in an equal fashion, and share a single goal of improving patients’ quality of life. In our clinic, these specialties are all in one location. We all share the same medical record system, we meet weekly to discuss patients and share ideas and expertise, and we educate each other about how to provide the best treatment for our patients. There are two challenges with this that are fairly equal in severity. One challenge is economic: reimbursement is not very good for complementary pain therapies such as acupuncture, massage, to a certain extent chiropractic, and certainly naturopathic treatment. To have an economically viable clinic, you have to have a certain type of payer mix, either patients who are able to pay for these services out of pocket, or you have to be successful financially with other modalities (medical pain management, physical therapy, mental health, interventional pain management) to compensate for the money lost with the complementary services. The other challenge is finding providers from all of those other specialties who are excellent at what they do and who are willing to treat a large number of chronic pain patients.
In those regards, our challenge at our clinic is not unique. What is unique to a state like Montana is that it’s such a sparsely populated state and there are many, many patients out there who simply live too far away from the clinic to be able to regularly benefit from the complementary and specialty services we offer, so their only local option is the primary care traditional medical treatment of pain.
In your experience, are patients generally receptive to this interdisciplinary model of treatment?
The vast majority of our patients love it. Almost weekly I hear a patient say it’s about time that somebody started incorporating these other treatments into a pain clinic. The patients who are resistant or hesitant, by and large, have been patients who have become dependent on and/or addicted to controlled substances. When they come to us and are told that this is not the best way to treat their pain, they get angry or frustrated because they’re used to that particular modality. They are afraid that we’re going to take their medications away. Getting through the dependency and addiction aspect of traditional pain management has been our biggest challenge with the existing patient population that we inherited here. Unfortunately, the pain clinic that was here before us was extremely liberal with opioid prescribing, and we inherited 1,500-2,000 opioid-dependent patients. Our approach is almost a 180-degree change from what these patients were used to.
Was there a learning curve for you in dealing with the patient population you inherited?
Yes. The previous clinic actually had an addictionologist, who we brought into our clinic because a large number of patients were already being treated by that specialist. I had not anticipated being this heavily involved in this area of chronic pain management. It’s been somewhat by necessity because that was the environment that we inherited. It’s a very, very important part of chronic pain management if you have a large number of patients who are treated with opioids, because 10-15% of all patients who are maintained on opioids will develop problems with addiction or abuse.
The number of patients will be that high, even with proper risk management and monitoring?
No, that number includes all patients who are started on opioid medications and maintained on them for more than six months. It doesn’t necessarily include patients who go through rigorous screening or patients who are in an environment where their opioid use is closely monitored. It’s a general statistic for the risk of opioid abuse or addiction. Among the patients we inherited, it’s probably higher than that simply because they were maintained with a very liberal opioid prescribing policy. Our new patients’ risk is lower, because we use opioids as a last resort and monitor them very closely.
As part of that risk monitoring, do you use urine drug testing and opioid agreements?
Absolutely. Not only do we use those, we also use random pill counts and random urine drug screens. We use risk assessment tools and screening questionnaires. If we feel that someone is particularly high risk or we are unsure of their risk, we utilize the services of our psychologist to do a more formal evaluation for the risk of addiction and abuse. The policies that we’ve instituted in terms of screening and monitoring have been probably the most significant change from the previous clinic.
How strict are your policies regarding a positive test for non-prescribed substances? Do you adhere to the “one strike and you’re out” approach favored by some practitioners?
We’re not quite that strict. We give patients one chance and then if they have another violation, we will discuss their case at our weekly provider meeting to talk about whether we think that patient needs to be discharged, whether they should be placed on a no-controlled-substances list, or whether we need to modify the way they are prescribed or the way they’re monitored. We’ll give the patient one chance unless we have proof that the patient is diverting his or her medications or if the patient tests positive for an illicit substance like methamphetamines. In those cases, we don’t typically give them another chance.
Do you think doctors are asked to do too much when it comes to curbing the diversion and abuse of pain medications?
No, I don’t. I think that doctors have traditionally done too little in this area. We are the source of the vast majority of pain medications and as such, we need to be the primary gatekeepers of the distribution of these medications. I think that health care professionals have done far too little in the past in terms of properly screening patients, in terms of understanding the role of opioids in non-cancer pain, and in terms of the effective monitoring of their use and misuse.
Does that all come back again to lack of training and lack of reimbursement for the time required to provide comprehensive care?
It does. I think it also comes from a lack of understanding of the severity of the problem. For example, in Montana, the abuse and misuse of prescription medications kills more people each year than motor vehicle accidents. And Montana is one of the least safe states in which to drive. In this state, over the past three years, medical marijuana has been the hot topic in the media, and yet the misuse of prescription medications is much, much more dangerous and a much greater issue, in my mind. I think if there were a better understanding of the severity of the problem, it would become a higher priority for health care professionals to change their practices. In the last couple of years it’s finally become something that is more regularly seen in the media, but I still think that there’s a significant lack of exposure to this topic among health care professionals.
Will the Montana Pain Initiative and the prescription drug monitoring program that was recently approved in your state help out in that regard?
The efforts of the Montana Pain Initiative (http://bit.ly/yATulu) to educate providers have been very significant. They’ve done a very good job with that. I’m extremely excited about the drug monitoring program (http://bit.ly/wzZGoz) that will take effect and will hopefully, significantly reduce the work that we have to do to find patients who are doctor shopping and misusing or diverting their medication. Those are both very positive steps.
Is it a challenge even for experienced pain management practitioners to identify patients who are doctor shopping and drug seeking?
It’s a tremendous challenge, and there’s no good answer for it. Even using the best screening tools that we have available and utilizing our experience and clinical acumen to get an idea of who may be drug seeking, it is and will always be a significant challenge. It’s harder to identify the patients upfront than it is to identify them after they have entered treatment, when you can use effective monitoring tools such as random pill counts, random drug screens, and the prescription drug monitoring program. Things are improving as we study this patient population more and as we develop better screening tools.
Which screening tools that you use in the clinic have you found to be particularly effective?
There’s one called the SOAPP-R for opioid-naive patients (http://bit.ly/pS6vy9). That’s a two-page survey that has been validated in this patient population as being very predictive of the risk of addiction and abuse. There’s another one called the Current Opioid Misuse Measure, or COMM (http://bit.ly/x8TDuY), for patients who are currently maintained on opioids. It is similar to the SOAPP-R and also has been validated in this patient population to predict abuse and addiction. Those are the two screening tools that we use most often. If we have a patient who scores high or a patient for whom we’re unsure of the risk, we’ll refer them to our mental health specialist, who will use more in-depth screening tools, personality assessments, and things of that nature. But those two, the SOAPP-R and the COMM, both of which are available for free and are very easy to administer and score, have been effective for us.
How important is the patient education aspect of pain management? What are some of the approaches that have worked the best for you?
It’s incredibly important because most patients come to us having a poor understanding of both the diagnosis and the treatment of chronic pain. They need to be educated regarding the proper expectations. In other words, it’s very unusual to eliminate all pain in a chronic pain state, so patients have to have reasonable expectations regarding how much of their pain is going to be eliminated. They have to understand that our goal is to improve their quality of life as much as possible, and that may be by getting rid of 20% of their pain but allowing them to function better, allowing them, through counseling or other services, to modify their lifestyle such that they are happier, if not in significantly less pain. It’s something that takes time. We rely quite a bit on our mental health professionals with our counseling services to work with the patient to understand that there are limits to the amount of pain relief that can be achieved in many cases. But there are almost no limits to the improvement that can be made from the standpoint of coping with their pain, changing their perspectives, and allowing them to move forward with their lives.
Are we moving in the right direction in terms of payers, providers, and regulators getting on the same page regarding effective pain management?
We’re moving in the right direction in terms of our understanding of how best to treat chronic pain, but we aren’t moving in the right direction in terms of the ability to afford the type of treatment that’s needed for chronic pain. There’s good data that shows that using multiple modalities to treat chronic pain is effective, and yet we have increasing pressures from the government and from insurance companies to prevent patients’ access to those modalities. That’s a problem. I think that the clinical data and provider education are improving, but it’s still a financial challenge for some patients and providers to access those modalities, and in many ways it’s getting worse.