THE CHRONIC PAIN PATIENT’S GUIDE
TO KENTUCKY’S REGULATIONS
Even though I’m on the lowest dose possible to keep my chronic pain under control I still worry this too will be taken away. At each appointment I get scared I will be told my doctor can no longer prescribe what little medication I do get. I appreciate the pain relief I do get, it means more to me than people can imagine.
~Samuel
October 1, 2014 at 7:47 PM
People with pain must recognize that they have a role to play in making sure these medications remain available, as needed, to all.
~Steven D. Passik, PhD
Abstract: This is a summary of how chronic pain patients can effectively prepare for a productive and meaningful visit with their Kentucky physician to address pain care options -especially when care involves the use or potential use of controlled substances. The goal is that patients and physicians will work together to maximize the therapeutic benefits and minimize the inherent risks to patients, physicians, and society.
Pain is the most common reason patients see physicians. We all feel pain, but everyone experiences pain in a unique way. There are many ways to treat pain, but treatment is best when tailored to the needs of the individual. Sometimes adequate pain treatment requires drugs (i.e. “controlled substances”) that expose users to risks of addictions, abuse and misuse. In these cases, patients and physicians must work together to minimize these risks.
It has been estimated that in the U.S. there is only one pain specialist for every 26,000 patients with chronic pain. Thus the majority of chronic pain treatment remains in the hands of primary care physicians.
Treating chronic pain can be straightforward when the primary focus is providing relief. But inescapable concerns about potential drug abuse and regulatory scrutiny can make treating chronic pain very complex and stressful for patients and physicians.
Most states have specific prescribing regulations that sometimes are inadequately communicated and poorly understood. This contributes to physician anxiety and adds to the physicians’ clinical, legal, and administrative burdens.
The patient-physician relationship must be a true partnership based on respect, trust, honesty, and clear communication. The following is a summary of what patients can do to help their physician partners.
*
The Chronic Pain Patient’s Guide to Kentucky’s Regulations
General Recommendations:
- Prepare answers to some basic medical history questions.
- Obtain copies of pertinent documents and medical records.
- Make a list of your healthcare providers along with their contact information.
- You may wish to store the data on a flash drive, CD/DVD or upload to a secure website for retrieval by your physician. Be advised, until you give these documents to your physician you are responsible for keeping them private.
- Bring a friend or family member with you for support, assistance with questions, and to help verify information.
For the initial visit prepare the following:
- Medical history
- Medical records
- Medications
- Substance use
- Social and family history
- Other medical issues
- Education and consent
- Ability to function
- Goals
- Questionnaires / mental health screen
- Medical history.
It begins with your “Chief Complaint.” This is where you tell your physician what hurts.
Chief complaint: My pain is _______________________
For example: “My pain is in my low back.”
Next, fill in some DETAILS about your pain:
(i) Cause. Based on what you know about your condition, what do you think is causing your pain?
Examples: a bad disk / pinched nerve / arthritis, etc. Be as specific as you can.
(ii) Location. Where does it start? Where does it go?
(iii) Quality. Sharp? Aching? Electrical? Sensitive to touch?
(iv) Symptoms. Numbness? Tingling? Weakness? Muscle wasting? Skin color changes? Swelling?
(v) Timing. Started when? Is it constant? Variable? Worse at certain times of the day? Lasts how long?
(vi) Aggravating factors. What makes it worse? Bending? Standing? Twisting? Being anxious? Working?
Housework? Sleep?
(vii) Relieving factors. What makes it better? Resting? Heat? Ice? Massage? Medication? Injections? Being
distracted? Sleep?
(viii) Pain scale. Rate your pain on a scale from: ZERO (no pain) to TEN (worst pain imaginable).
- Medical records.
Your physician may not need every record, but information about care related to your pain is useful and includes:
- Surgery reports related to your pain (back surgeries, etc.);
- Laboratory tests (blood tests, urine drug screens, etc.);
- Studies (x-rays, MRI, CT, EMG, etc.);
- Pain care treatments (epidurals, physical therapy, acupuncture, chiropractic, etc.);
- Consultations with specialists (surgeons, pain, chiropractic, mental health).
Make a list of your diagnostic tests, especially the most recent ones; include dates and contact information. Gather the reports. If you wait for your physician to get the reports faxed, your pain care could be delayed significantly. You may want to copy them onto a flash drive, CD/DVD, or to a secure website.
- Medications.
(a) An accurate and current medication list is extremely important. Include the date, dosage, quantity, and directions. Bring the medicine bottles with you and/or labels, written prescriptions, etc.
Provide answers to these questions:
- Do you find your current medications to be effective?
- Are you taking them the way they have been prescribed for you?
- How long have you been on your current medications?
- When was the last time you had a medication change?
- Are they causing you any unacceptable side effects such as: sedation, fatigue, nausea, constipation, etc.?
(b) Your medication “journey.” It is extremely important for your physician to know (and document) how you got to this point. What medications did you use in the past? Did you try some over-the-counter medications? Non-controlled substance prescriptions? Gather records (medical, pharmacy, etc.) to show how your dosages have changed over time.
(c) If you have a prescribing “agreement” with another physician, bring a copy.
- Substance use.
It is vital to be forthcoming about any substance abuse or any substance abuse treatment involving you or any close relative (especially a mother, father, son or daughter). And report any drug-related arrests?
Do you drink alcohol? Do you smoke?
Remember to drink plenty of fluids before your visit in case you are asked to provide a specimen for a random urine drug screen.
- Social and family history.
Where do you live and with whom?
Is your home life a challenge?
What is your occupation? Are you disabled?
Where do you get money to live on?
How much formal education have you had?
- Other medical issues.
Are you dealing with any other medical issues such as: diabetes, heart disease, cancer, etc.? When was your last general medical evaluation?
Note: To receive long-term controlled substances for pain in Kentucky, it is mandatory that you have a yearly preventive health evaluation.
- Education and consent.
Show that you have educated yourself about controlled substances and prepare to document your “informed consent.”
(a) The Kentucky Board of Medical Licensure has posted educational points of emphasis on their website.
I have prepared an educational summary for both Kentucky and Indiana which is available here: http://goo.gl/IJ4I1l
Or download the Murphy Pain Center New Patient Package. Study the patient education sheet. Print it out. Sign it. And bring it with you.
Watch this outstanding video by Dr. Mike Evans that explains many of the pros and cons of the use of controlled substances for chronic pain care.
(b) Once you have been informed, you are ready to give your “informed consent.” You may download this document and bring it to your physician:
I have written an article about informed consent and treatment agreements, Are We In Agreement, available on my website: Confluential Truth.
- Ability to function.
Describe your current ability to participate in life’s activities. This will give your physician a baseline from which to judge your progress. You may visit the website for ICSI (Institute for Clinical Systems Improvement) and download and complete the form in Appendix C: Physical Functional Ability Questionnaire (FAQ-5).
- Goals.
Come up with some specific and realistic goals that might be attainable. Think of how you can show when you have achieved them. Within reason, think about what you would like to do that you cannot do now. Be prepared to demonstrate this to the physician; i.e. walk without a cane, bend to pick up something, rise from a chair unassisted.
Set goals that are SMART: specific, measurable, attainable, realistic, and track-able.
- Questionnaires / Mental Health Screen
Complete these “screening” questionnaires and bring them to your visit.
You may go to the Kentucky Board of Medical Licensure website, download these self-report questionnaires, fill them out, and bring them to your office visit.
- Opioid Risk Tool
- Patient Health Questionnaire (PHQ-9), mental health screen
You may also go to the website for ICSI (Institute for Clinical Systems Improvement) and download and complete these two forms:
Appendix A (Brief Pain Inventory); and
Appendix B (Patient Health Questionnaire PHQ-9)
*
If this all seems a bit overwhelming, you can begin to simplify matters by visiting the Murphy Pain Center website and downloading the “New Patient Package.” In it you will find policies, consent forms, agreements, educational materials, and a “New Patient Evaluation” form. These are the kinds of materials you will likely be filling out at your physician’s office visit. Having this information on hand can make your visit more productive.
In conclusion: Due to growing concerns about drug abuse, coupled with layer upon layer of regulations, physicians are becoming increasingly anxious about prescribing controlled substances for patients suffering in chronic pain.
This has been a summary of how a chronic pain patient can effectively prepare for a productive and meaningful visit with his or her physician to address pain care options -especially when care involves the use or potential use of controlled substances. The goal is that both parties will work together to maximize the therapeutic benefits and minimize the inherent risks to patients, physicians, and society.
When patients are adequately prepared, physicians can feel more comfortable, and patients can more likely receive safe, effective, and proper pain care.
It is a partnership.
Note: For the purposes of this summary “controlled substances” refers to CSA scheduled drugs 2 – 4 (Schedule 5 drugs are exempt from Kentucky’s regulations).
Note: Kentucky’s regulations do not apply if the patient is being treated:
(a) in hospice or “end-of-life” treatment;
(c) for cancer pain or pain associated with the treatment of cancer;
(b) in a licensed hospital as inpatient, outpatient, or observation status
(d) as a registered resident of a long-term-care facility
(e) during a disaster or mass casualty situation
(f) as a single dose for a diagnostic test or procedure
So now that you know the pathway…
James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.
*
References and links pertaining to this article are provided in the comments.
*
Confluential Truth 
The Chronic Pain Patient’s Guide to Kentucky’s Regulations
*
*
General Recommendations:
1. Prepare answers to some basic medical history questions.
2. Obtain copies of pertinent documents and medical records.
3. Make a list of your healthcare providers along with their contact information.
4. You may wish to store the data on a flash drive, CD/DVD or upload to a secure website for retrieval by your physician. Be advised, until you give these documents to your physician you are responsible for keeping them private.
5. Bring a friend or family member with you for support, assistance with questions, and to help verify information.
For the initial visit prepare the following:
1. Medical history
2. Medical records
3. Medications
4. Substance use
5. Social and family history
6. Other medical issues
7. Education and consent
8. Ability to function
9. Goals
10. Questionnaires / mental health screen
*
*
*
1. Medical history.
It begins with your “Chief Complaint.” This is where you tell your physician what hurts.
Chief complaint: My pain is _______________________
For example: “My pain is in my low back.”
Next, fill in some DETAILS about your pain:
(i) Cause. Based on what you know about your condition, what do you think is causing your pain?
Examples: a bad disk / pinched nerve / arthritis, etc. Be as specific as you can.
(ii) Location. Where does it start? Where does it go?
(iii) Quality. Sharp? Aching? Electrical? Sensitive to touch?
(iv) Symptoms. Numbness? Tingling? Weakness? Muscle wasting? Skin color changes? Swelling?
(v) Timing. Started when? Is it constant? Variable? Worse at certain times of the day? Lasts how long?
(vi) Aggravating factors. What makes it worse? Bending? Standing? Twisting? Being anxious? Working?
Housework? Sleep?
(vii) Relieving factors. What makes it better? Resting? Heat? Ice? Massage? Medication? Injections? Being
distracted? Sleep?
(viii) Pain scale. Rate your pain on a scale from: ZERO (no pain) to TEN (worst pain imaginable).
2. Medical records.
Your physician may not need every record, but information about care related to your pain is useful and includes:
• Surgery reports related to your pain (back surgeries, etc.);
• Laboratory tests (blood tests, urine drug screens, etc.);
• Studies (x-rays, MRI, CT, EMG, etc.);
• Pain care treatments (epidurals, physical therapy, acupuncture, chiropractic, etc.);
• Consultations with specialists (surgeons, pain, chiropractic, mental health).
Make a list of your diagnostic tests, especially the most recent ones; include dates and contact information. Gather the reports. If you wait for your physician to get the reports faxed, your pain care could be delayed significantly. You may want to copy them onto a flash drive, CD/DVD, or to a secure website.
3. Medications.
(a) An accurate and current medication list is extremely important. Include the date, dosage, quantity, and directions. Bring the medicine bottles with you and/or labels, written prescriptions, etc.
Provide answers to these questions:
• Do you find your current medications to be effective?
• Are you taking them the way they have been prescribed for you?
• How long have you been on your current medications?
• When was the last time you had a medication change?
• Are they causing you any unacceptable side effects such as: sedation, fatigue, nausea, constipation, etc.?
(b) Your medication “journey.” It is extremely important for your physician to know (and document) how you got to this point. What medications did you use in the past? Did you try some over-the-counter medications? Non-controlled substance prescriptions? Gather records (medical, pharmacy, etc.) to show how your dosages have changed over time.
(c) If you have a prescribing “agreement” with another physician, bring a copy.
4. Substance use.
It is vital to be forthcoming about any substance abuse or any substance abuse treatment involving you or any close relative (especially a mother, father, son or daughter). And report any drug-related arrests?
Do you drink alcohol? Do you smoke?
Remember to drink plenty of fluids before your visit in case you are asked to provide a specimen for a random urine drug screen.
5. Social and family history.
Where do you live and with whom?
Is your home life a challenge?
What is your occupation? Are you disabled?
Where do you get money to live on?
How much formal education have you had?
6. Other medical issues.
Are you dealing with any other medical issues such as: diabetes, heart disease, cancer, etc.? When was your last general medical evaluation?
Note: To receive long-term controlled substances for pain in Kentucky, it is mandatory that you have a yearly preventive health evaluation.
7. Education and consent.
Show that you have educated yourself about controlled substances and prepare to document your “informed consent.”
(a) The Kentucky Board of Medical Licensure has posted educational points of emphasis on their website.
Or download the Murphy Pain Center New Patient Package. Study the patient education sheet. Print it out. Sign it. And bring it with you.
Watch this outstanding video by Dr. Mike Evans that explains many of the pros and cons of the use of controlled substances for chronic pain care.
(b) Once you have been informed, you are ready to give your “informed consent.” You may download this document and bring it to your physician:
I have written an article about agreements, Are We In Agreement, available on my website: Confluential Truth.
8. Ability to function.
Describe your current ability to participate in life’s activities. This will give your physician a baseline from which to judge your progress. You may visit the website for ICSI (Institute for Clinical Systems Improvement) and download and complete the form in Appendix C: Physical Functional Ability Questionnaire (FAQ-5).
9. Goals.
Come up with some specific and realistic goals that might be attainable. Think of how you can show when you have achieved them. Within reason, think about what you would like to do that you cannot do now. Be prepared to demonstrate this to the physician; i.e. walk without a cane, bend to pick up something, rise from a chair unassisted.
Set goals that are SMART: specific, measurable, attainable, realistic, and track-able.
10. Questionnaires./ Mental Health Screen
Complete these “screening” questionnaires and bring them to your visit.
You may go to the Kentucky Board of Medical Licensure website, download these self-report questionnaires, fill them out, and bring them to your office visit.
• Opioid Risk Tool
• Patient Health Questionnaire (PHQ-9)
You may also go to the website for ICSI (Institute for Clinical Systems Improvement) and download and complete these two forms:
Appendix A (Brief Pain Inventory); and
Appendix B (Patient Health Questionnaire PHQ-9)
#
#
#
The Chronic Pain Patient’s Guide to FOLLOW-UP VISITS in Kentucky
*
Kentucky’s regulations say that in order to be prescribed “controlled substance” pain medications beyond three months, initially the patient must be seen at least once per month. Beyond that, the patient may be evaluated less frequently if the physician has determined: (a) the medications are at appropriate levels to treat the condition; (b) the medications are not causing unacceptable side effects; and (c) the patient is sufficiently monitored to minimize medication misuse or diversion.
You can help your physician by being prepared for the follow up.
Have answers to the following questions (and any supporting documents, reports, phone numbers, etc.) ready for review by your physician.
*
*
*
Since your last visit…
Understanding that complete pain relief is rarely possible, how well do you feel your medications are treating your pain?
Poorly?
Adequately?
Very well?
Fill out the Brief Pain Inventory: http://www.painedu.org/Downloads/NIPC/Brief_Pain_Inventory.pdf
Have you been taking your medications exactly like they have been prescribed?
Do you have your pills (and/or pill bottles) with you in case a “random” pill count is performed?
Have you taken any other pain medications that were not prescribed for you by this office for your current complaint?
Remember to drink plenty of fluids before your visit in case you are asked to provide a urine specimen for a random drug screen.
Have you used any other mind-altering or illegal drugs or substances?
Are you having any side-effects that you find unacceptable?
For example: sleepiness, fatigue, constipation, nausea, dry mouth, urinary problems, sexual problems, etc.
Has your pain changed?
Has it moved?
Are there any new pains or symptoms?
Are you having “breakthrough pain” between doses of your pain medications?
Do you know what “triggers” this? For example: housework, standing, working, walking, etc.
How are you handling this? For example: rest, ice, over-the-counter medications, TENS, massage, acupuncture, meditation, etc.
Has anything about your overall health changed?
A new diagnosis?
Injury?
Surgery?
How are your other conditions? (Examples: diabetes, high blood pressure, depression, etc.).
Fill out the Patient Health Questionnaire (PHQ-9): http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf
Any labs, x-rays, or other studies?
Any consultations with any other healthcare professionals and/or specialists?
Have you seen or feel you need to see a mental health professional?
Has anything changed in your life that could affect your pain?
Job change? Family crisis? Insurance change? Etc.
When was your yearly preventive health screening and physical examination by your primary care physician?
Note: It is very important that your pain medicine prescriber is assured you have had this done.
Do you know when your physician last ran a KASPER report? (Kentucky All Schedule Prescription Electronic Reporting database) It is must be done at least once every three months. If you do not know, please ask. And ask to see it as well. You may find errors, in which case you will want to correct it.
What was/are your “functional” goal(s)?
Are you making progress? Can you provide confirmation? (Examples: pictures, note from physical therapy, gym membership, attendance at work, support from a friend or family member, etc.)
What other goal(s) would you like to achieve?
Fill out the Physical Functional Ability Questionnaire (FAQ5)
See below:
*
*
*
PHYSICAL FUNCTIONAL ABILITY QUESTIONNAIRE (FAQ5)
Name: _________________________________
Date of birth: ______________________
Today’s date: _______________________
*
Instructions: Circle the number (1-4) in each of the groups that best summarizes your ability.
Add the numbers and multiply by 5 for total score out of 100.
*
__________ Self-care ability assessment
1. Require total care: for bathing, toilet, dressing, moving and eating
2. Require frequent assistance
3. Require occasional assistance
4. Independent with self-care Family and social ability assessment
*
__________ Family and social ability assessment
1. Unable to perform any: chores, hobbies, driving, sex and social activities
2. Able to perform some
3. Able to perform many
4. Able to perform all Movement ability assessment
*
__________ Movement ability assessment
1. Able to get up and walk with assistance, unable to climb stairs
2. Able to get up and walk independently, able to climb one flight of stairs
3. Able to walk short distances and climb more than one flight of stairs
4. Able to walk long distances and climb stairs without difficulty Lifting ability assessment
*
__________ Lifting ability assessment
1. Able to lift up to 10 lbs. occasionally
2. Able to lift up to 20 lbs. occasionally
3. Able to lift up to 50 lbs. occasionally
4. Able to lift over 50 lbs. occasionally
*
__________ Work ability assessment
1. Unable to do any work
2. Able to work part-time and with physical limitations
3. Able to work part-time or with physical limitations
4. Able to perform normal work
*
__________ FIANL SCORE Physical Functional Ability (FAQ5)
Instructions: Circle the number (1-4) in each of the groups that best summarizes your ability.
Add the numbers and multiply by 5 for total score out of 100.
*
© 2005 Peter S. Marshall, MD. Permission for use granted.
Click to access chronicpain.pdf
*
*
*
PATHWAY TO PARTNERSHIP
THE CHRONIC PAIN PATIENT’S GUIDE TO KENTUCKY’S REGULATIONS
References and Links:
1. Dr. Jeffrey Fudin’s blog
http://paindr.com/patients-share-humanistic-side-of-living-in-pain-amid-lawmaker-opioid-hysteria/#comment-111498
2. About Steven D. Passik, PhD
http://www.practicalpainmanagement.com/author/12720/passik
3. Who Really Treats Chronic Pain? The Necessity of Pain Management in Family Practice By Michael E. Schatman, PhD, CPE | April 21, 2014
http://www.hcplive.com/publications/family-practice-recertification/2014/April2014/Who-Really-Treats-Chronic-Pain-The-Necessity-of-Pain-Management-in-Family-Practice
4. Sometimes adequate pain treatment requires drugs that expose users to risks of addictions, abuse and misuse. (e.g. Oxycontin “Black Box” warning):
http://app.purduepharma.com/xmlpublishing/pi.aspx?id=o
5. Most states have specific prescribing regulations http://sppan.aapainmanage.org/states
6. States’ Regulatory Report Card 2013 http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/prc2013.pdf
7. Pain Specialists Show Increasing Burnout
Prevention, Mitigation Programs Needed http://www.painmedicinenews.com/ViewArticle.aspx?d=Policy%2B%26%2BManagement&d_id=83&i=November+2014&i_id=1120&a_id=28644
8. Caring for Patients With Chronic Pain: Pearls and Pitfalls
Pain is the most common reason patients see physicians.
http://www.jaoa.osteopathic.org/content/113/8/620.full
9. The full text of Kentucky’s regulations are available on the KBML website:
http://kbml.ky.gov/hb1/Pages/House-Bill-1-Ordinary-Regulations.aspx
10. Kentucky Board of Medical Licensure Considerations for Urine Drug Screening
http://kbml.ky.gov/hb1/Pages/Considerations-For-Urine-Drug-Screening.aspx
11. The Kentucky Board of Medical Licensure has posted educational points of emphasis on their website:
http://kbml.ky.gov/hb1/Pages/Considerations-For-Patient-Education.aspx
12. Murphy Pain Center New Patient Package.
Click to access new-patient-package.pdf
13. Dr. Mike Evans’ video that explains many of the pros and cons of the use of controlled substances for chronic pain care. Vid video by Dr. Mike Evans
http://www.evanshealthlab.com//opioids
14. Informed Consent and Agreement for Opioid Therapy of Pain, by Seddon R. Savage, MD, MS
Click to access OpioidTxAgreement-2012Savage-Cheatle.pdf
15. “Are We in Agreement” – an article about informed consent and treatment agreements, available at:
https://jamespmurphymd.com/2014/02/19/are-we-in-agreement
16. Physical Functional Ability Questionnaire (FAQ-5).
Click to access ChronicPain.pdf
17. SMART Goals
http://www.practicalpainmanagement.com/resources/abc-pain
18. The Kentucky Board of Medical Licensure website has these self-report questionnaires:
(a) Opioid Risk Tool
(b) Patient Health Questionnaire (PHQ-9)
http://kbml.ky.gov/substance-abuse/Pages/default.aspx
19. The Institute for Clinical Systems Improvement website has these two forms:
Appendix A (Brief Pain Inventory); and
Appendix B (Patient Health Questionnaire PHQ-9)
Click to access ChronicPain.pdf
20. CSA scheduled drugs:
http://www.deadiversion.usdoj.gov/schedules
PHYSICAL FUNCTIONAL ABILITY QUESTIONNAIRE (FAQ5)
Name: _________________________________
Date of birth: ______________________
Today’s date: _______________________
Instructions: Circle the number (1-4) in each of the groups that best summarizes your ability.
Add the numbers and multiply by 5 for total score out of 100.
*
__________ Self-care ability assessment
1. Require total care: for bathing, toilet, dressing, moving and eating
2. Require frequent assistance
3. Require occasional assistance
4. Independent with self-care Family and social ability assessment
*
__________ Family and social ability assessment
1. Unable to perform any: chores, hobbies, driving, sex and social activities
2. Able to perform some
3. Able to perform many
4. Able to perform all Movement ability assessment
*
__________ Movement ability assessment
1. Able to get up and walk with assistance, unable to climb stairs
2. Able to get up and walk independently, able to climb one flight of stairs
3. Able to walk short distances and climb more than one flight of stairs
4. Able to walk long distances and climb stairs without difficulty Lifting ability assessment
*
__________ Lifting ability assessment
1. Able to lift up to 10 lbs. occasionally
2. Able to lift up to 20 lbs. occasionally
3. Able to lift up to 50 lbs. occasionally
4. Able to lift over 50 lbs. occasionally
*
__________ Work ability assessment
1. Unable to do any work
2. Able to work part-time and with physical limitations
3. Able to work part-time or with physical limitations
4. Able to perform normal work
*
__________ FIANL SCORE Physical Functional Ability (FAQ5)
Instructions: Circle the number (1-4) in each of the groups that best summarizes your ability.
Add the numbers and multiply by 5 for total score out of 100.
*
© 2005 Peter S. Marshall, MD. Permission for use granted.
Click to access chronicpain.pdf
Optimizing Pain Care Delivery in Kentucky & Elsewhere
James Patrick Murphy, MD, MMM
February 19, 2015
PROBLEM
1. Chronic pain affects 1.6 million Kentuckians
Chronic pain affects approximately 47% of adults in the U.S. Considering that Kentucky ranks 4th worst in terms of disability payments and 3rd worst in overall health, it is reasonable to estimate that at least 47% of Kentucky’s 3.4 million adults (i.e., 1.6 million) have chronic pain.
2. The systemic burden of pain
It is not surprising that pain is the most common reason a patient seeks healthcare services. Nationally, the annual cost of pain is greater than the annual costs of heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion) and nearly 30 percent higher than the combined cost of cancer and diabetes. Considering Kentucky’s poor population health, it is obvious that effective and efficient pain care must be priority for any healthcare provider serving the state.
3. Kentucky in crisis
Unfortunately, as elsewhere in the U.S., pain care in Kentucky has been in a state of crisis. There is plenty of blame to go around (e.g., certain provider attitudes; knowledge gaps; cultural attitudes; geographic barriers; difficulties in accessing specialty care; regulatory and legal concerns; and reimbursement policies that obstruct patient-centered care) but one of the primary causes of this dysfunctional system is the fact that pain is treated in an uncoordinated sequential manner, rather than through an integrated approach.
There are more than 10,000 professionally active physicians in Kentucky, but according to the Kentucky Board of Medical Licensure website there are only 85 physicians listed as specializing in either Pain Medicine or Pain Management. This means that there is about one pain “specialist” available for referral for every 100 physicians; and about one pain specialist for every 19,000 Kentuckians with pain. Obviously, pain specialists cannot be expected to meet the needs of Kentucky’s pain; primary care providers can and must be willing to and comfortable with treating the majority of patients with pain.
As pain specialist, I have a working knowledge of how various pain care providers (i.e., single provider, group practice, multi-specialty healthcare system) approach pain management on a daily basis in Kentucky.
I have found that in most pain care delivery system there is a deficient understanding of what “Pain Management” really means, ranging from hospital anesthesiologist-based injection-only treatment to office-based practices with unclear expectations, capabilities, and/or willingness to assume long term care – especially when care involves controlled substances.
Often the patients referred to “Pain Management” are perceived by the referring physicians as being “treated” but not necessarily “managed.” As a consequence, these patients “bounce back” to Primary Care for ongoing medication management after procedural interventions have proven inadequate in alleviating pain. This is frustrating for Primary Care offices and patients alike, and can lead to over-representation of pain patients on the daily office schedule at the expense of other necessary practice goals, e.g., “belly pain,” hypertension, diabetes, new patient evaluations, etc.
In most current systems, referral to “Pain Management” is really not a specialist referral; treatment of chronic pain solely from a pharmacological, surgical, or interventional perspective is actually a “subspecialist” referral as the full scope of a patient’s pain-related problems are not addressed in such a practice.
SOLUTION
I recommend implementation of a pain care delivery system that addresses patient pain issues in a coordinated manner through an integrated biopsychosocial approach. This could be accomplished on a local basis by creating true multidisciplinary pain management clinics to act as consultant, management, and mediation centers. This is a traditional approach with economic viability determined by the same variables inherent to a Primary Care clinic. It might be costly and difficult to scale this service to cover the needs of a larger health care delivery system or to service remote satellite offices.
Another option that could achieve the same goals would be to establish a more centralized consultation service for assessment, triage, and specialty care when necessary. This approach optimizes the efficiency of system-wide existing services (i.e., pain specialists, primary care, surgical specialties, mental health, diagnostic services, etc.) while minimizing the investment necessary to create an entire new clinical product (i.e., a new pain clinic). This is also a model that could be scaled to service a whole health care network, including remote clinics.
REFERENCES:
Of the more than 10,000 professionally active physicians on Kentucky, only 85 are practicing in Pain Management or Pain Medicine. http://kbml.ky.gov/physician/Pages/Physician-Profile-Verification-of-Physician-License.aspx
Number of professionally active physicians in KY 10,757 http://kff.org/other/state-indicator/total-active-physicians
Kentucky ranks 47 (3rd from the bottom) in population health http://www.americashealthrankings.org/KY
Population of KY is (4.413 million) and 23.1% are under 18 76.9. Thus (77% 18 and over) 3.4 million adults. http://quickfacts.census.gov/qfd/states/21000.html
Kentucky statistics:
> Pct. of working age population with benefits: 8.1%
> Pct. with recurring neck and back pain: 34.8% (5th highest)
> 2011 labor force participation rate: 61.5% (10th lowest)
> 2011 unemployment rate: 9.5% (12th highest)
More than 19% of Kentucky’s population lived in poverty in 2011, a higher percentage than all but four states. Many people in Kentucky may not have the means to get well-paying work. Just 83.1% of people have at least a high school diploma, the sixth lowest percentage of all states. Meanwhile, just 21.1% of adults have at least a bachelor’s degree, the fifth lowest percentage of all states. As of 2011, just 61.5% of Kentuckians were considered to be in the labor force, among the lowest rates in the nation. In a well-publicized case, a Kentucky judge, David Daugherty, was accused in a civil suit filed in February of improperly approving Social Security benefits in order to help local attorney Eric Conn, arguably the most prominent disability lawyer in the region, receive millions of dollars from the federal government for handling these cases. http://247wallst.com/special-report/2013/05/20/states-with-the-most-americans-on-disability/3
Cost of Pain Care in the US:
We found that the total incremental cost of health care due to pain ranged from $261 to $300 billion. The value of lost productivity is based on three estimates: days of work missed (ranging from $11.6 to $12.7 billion), hours of work lost (from $95.2 to $96.5 billion), and lower wages (from $190.6 to $226.3 billion). Thus, the total financial cost of pain to society, which combines the health care cost estimates and the three productivity estimates, ranges from $560 to $635 billion. All estimates are in 2010 dollars.
Conclusion: We found that the annual cost of pain was greater than the annual costs in 2010 dollars of heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion) and nearly 30 percent higher than the combined cost of cancer and diabetes. http://www.ncbi.nlm.nih.gov/books/NBK92521
Chronic pain affects 47% of adults http://www.huffingtonpost.com/2012/04/30/chronic-pain-united-states-adults-age_n_1465222.html
Pain is the most common reason we access the healthcare system http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57
20% with chronic pain do not even seek help – “Silent Sufferers” http://www.mayoclinicproceedings.org/article/S0025-6196(11)61665-0/abstract
Pain management is frustrating and leads to physician burnout. http://www.painmedicinenews.com/ViewArticle.aspx?d=Policy+&+Management&d_id=83&i=November+2014&i_id=1120&a_id=28644
No physician who treats chronic pain solely from a pharmacological, surgical, or interventional perspective should be considered a specialist; he or she is merely a “subspecialist,” as the full scope of the patient’s pain-related problems are not addressed in such a practice. http://www.hcplive.com/publications/family-practice-recertification/2014/April2014/Who-Really-Treats-Chronic-Pain-The-Necessity-of-Pain-Management-in-Family-Practice
Barriers to pain care access:
Certain provider attitudes, insurance coverage, cultural attitudes of patients, geographic barriers, Gaps in knowledge, and reimbursement policies that obstruct patient-centered care. Difficulties in accessing specialty care. http://www.inthefaceofpain.com/advocacy-101/barriers-to-pain-management
Very well done. Written in terms that people (most) can understand. I am forwarding it to my pharmacist daughter. I am sure she will be quite interested also. Thank you for caring for and caring about people!
Dr. Murphy, Thank you for this well-written and very comprehensive post which helps to inform patients of how best to prepare for a visit. It’s unfortunate that even with all the preparation and apprehension that could go into a visit, providers are often intimidated by regulatory agencies, some of whom have spun out of control. It is so nice to see the dedication you have and true allegiance to your patients. The time commitment alone for preparing this comprehensive post is a testament to your kind heart and dedication. Keep up the stellar work – it is encouraging to patients and clinicians alike!
Thank you, Dr. Murphy, so much your exhaustive documentation!
It’s so useful to have a list to go by when starting on this journey. I know, because I didn’t have one 😦
I had to stumble through much confusion and frustration before I gathered enough information to understand what was needed and why. So, I would only like to emphasize that, especially with invisible or undiagnosed pain, an ongoing pain diary is absolutely necessary.
We know by now how unreliable memory is, so there’s no better “proof” of pain than weeks or months of daily pain level, medication, and activity logs. The more detailed and for longer, the better.
I started logging my pain/activity/medications for myself years ago to track my symptoms and results of the treatments I tried. They average about 2000 words per month, and with years of them I was able to get SSDI (without a lawyer!) with only a Fibromyalgia diagnosis, which is notoriously difficult.
I imagine there’s a huge difference between how a doctor feels facing a patient who can only tell them “I’ve been in a lot of pain for the last six months”, versus a patient who backs it up with a spreadsheet of pain level data from the last 6 months and a thick binder of daily logs.
Would you agree?