As I journey toward my goal of nurse practitioner, I am becoming increasingly aware of the number of patients living with chronic pain. My clinical rotations have given me a front-row view of the lack of monitoring of patients living with chronic pain who are prescribed pain medications.
In some cases prescriptions for pain medications were simply written out and no urine testing was ever ordered. No contract was signed between the patient and provider to help the patient manage his or her pain-medication compliance.
Joanna L. Starrels, MD, an assistant professor of medicine at Albert Einstein College of Medicine of Yeshiva University in Bronx, New York, headed a study investigating the tracking of patients prescribed pain medications by primary-care providers. The researchers followed 1,612 patients from eight primary-care practices who had been prescribed pain medications from January 2004 through April 2008.
Starrels and colleagues found that patients who are given pain medications are often not tracked by the primary-care physicians who prescribed the drugs. Just 8% of the study participants underwent urine testing, only half made regular visits to their prescribers, and 23% received more than one early opioid refill. Patients at highest risk of opioid misuse were more likely to receive more than one early refill, but their office-based monitoring was no greater than for persons without any risk factors for opioid misuse.
The investigators concluded that primary-care physicians’ adoption of opioid risk-reduction strategies is limited, even among patients at increased risk of misuse (J Gen Intern Med. 2011; 26:958-964).
Another report, this one from Linda Garufi Clark, MD, and Carole C. Upshur, EdD, both with the family medicine and community health department at the University of Massachusetts Medical School in Worcester, sought to determine family-practitioners’ views of how to improve chronic nonmalignant pain (CNMP) management in primary care (J Am Board Fam Med. 2007;20:479-482).
Among 14 family physicians from six community practice sites, three community health centers, a rural health center and two hospital-owned practices, four overarching themes emerged across all groups and respondents:
1. The need for a physician practice guideline toolkit with a range of information, but particularly around opioid prescribing
2. The need for changes in the way patients obtain monthly medications
3. The need for improvements in patient self-management education and increased access to both providers and alternative interventions
4. The importance of a nurse care manager to collaborate with both providers and patients.
As the dynamics of our health-care system evolve, nurse practitioners and physician assistants will be called upon to manage the diverse needs of our patients, and some of those patients will be living with chronic pain. The clinical management of chronic pain will be complex and time-consuming. It will be important to maintain ongoing collaborations with physicians and coordinate care with specialists in order to promote safe and effective pain management for our patients.
Debra Clements Coats, RN, BSN, CRNP, is an oncology nurse and FNP student in Pennsylvania. She plans to work in internal medicine upon graduation.