Development of a pain management policy in and indigent clinic in Galveston, TX



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Millions of Americans suffer from nonmalignant chronic pain (NMCP), often with life altering consequences, such as loss of job function and expensive medical bills. Opioid prescription therapy has gained acceptance among medical professionals for the treatment of this pain and a substantial increase in the number of opiates prescribed has occurred over the last two decades6. Along with this increase in opioid prescribing have come increases in the number of unintentional overdoses and/or deaths secondary to opioids7. Physicians may feel reluctant to prescribe opioids on a continued basis due to the increased number of deaths due to unintentional opioid overdose as well as out of fear of causing a patient to become addicted to the medication (termed “opiophobia” in the literature3,8,9). Former or active drug use by patients and psychiatric co-morbidities further compound this complex topic. \r\n\r\nAt St. Vincent’s clinic, a student and nurse practitioner-run indigent primary care clinic in Galveston, Texas, practitioners have historically avoided prescribing opioids for pain management. It was at their request that a MPH student investigate the possible efficacy of a doctor-patient opioid contract in similar clinical settings and create a pain management protocol based on its effectiveness. Thus, this Capstone aims to 1) review the current literature on the effectiveness of opioid pain contracts in primary care clinics for patients on long-term opioid therapy for non-malignant chronic pain; 2) to review pain management guidelines at indigent clinics in the Houston-Galveston area, and 3) to create a pain management guideline for St. Vincent’s clinic. To do this, a PubMed search was conducted using terms related to opioid use in indigent primary care clinics. Studies that a) used an opioid contract as or in conjunction with an educational intervention for non-malignant chronic pain; b) that took place in primary care or pain management clinics in conjunction with primary care physicians; c) that analyzed characteristics of opioid contracts; and d) were commentaries and expert opinion on the use of pain contracts for non-malignant chronic pain for patients with and without a psychiatric history or a history of substance abuse were identified. Studies that did not use pain contracts and or discuss the use of opioid contracts for managing non-malignant chronic pain were excluded. Of the 103 papers screened, 13 were selected according to inclusion/exclusion criteria, including 8 observational studies using a doctor-patient opioid contract and 5 expert literature reviews from major peer-reviewed journals. Three of the 8 observational studies did not use an opioid contract for an intervention, but rather analyzed characteristics of the contracts.\r\n\r\nTheir recommendations were analyzed. Additionally, 30 indigent primary care clinics in the Houston-Galveston area were screened for their pain management practices. Seven informal interviews with the medical directors of these clinics were conducted (including one pain medicine specialist and one psychiatrist specialized in addiction medicine). Recommendations from both the literature review and interviews with practicing primary care practitioners were synthesized and a pain contract was created. The contract and recommendations were then presented to St. Vincent’s clinic directors for review and/or use.\r\n