Original Article

Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey

Authors: Brenda Breuer, PhD, MPH, Ricardo Cruciani, MD, PhD, Russell K. Portenoy, MD

Abstract

Objectives: Chronic pain is a serious public health problem and is treated by diverse health care providers. In order to enhance policies and programs to improve pain care, we collected information about the distribution of pain patients among four major groups of pain management providers: primary care physicians (PCPs), pain physicians, chiropractors, and acupuncturists, and the variation in the attitudes and practices of these providers with respect to some common strategies used for pain.


Methods: National mail survey of PCPs, pain physicians, chiropractors, and acupuncturists (ntotal = 3,000).


Results: Eight hundred seventeen responses were usable (response rate, 29%). Analyses weighted to obtain nationally representative data showed that PCPs treat approximately 52% of chronic pain patients, pain physicians treat 2%, chiropractors treat 40%, and acupuncturists treat 7%. Of the chronic pain patients seen for evaluation, the percentages subsequently treated on an ongoing basis range from 51% (PCPs) to 63% (pain physicians). Pain physicians prescribe long-acting opioids such as methadone, antidepressants or anti-convulsants, and other nontraditional analgesics approximately 50–100% more often than PCPs. Twenty-nine percent of PCPs and 16% of pain physicians reported prescribing opioids less often than they deem appropriate because of regulatory oversight concerns. Of the four groups, PCPs are least likely to feel confident in their ability to manage musculoskeletal pain and neuropathic pain, and are least likely to favor mandatory pain education for all PCPs.


Conclusions: There is substantial variation in attitudes and practices of the various disciplines that treat chronic pain. This information may be useful in interpreting differences in patient access to pain care, planning studies to clarify patient outcomes in relation to different providers and treatment strategies, and designing a system that matches chronic pain patients to appropriate practitioners and treatments.


Key Points


* Chronic pain is highly prevalent, and is costly in terms of lost productivity.


* Primary care physicians, pain physicians, chiropractors, and acupuncturists vary in the way they treat chronic pain, and in their attitudes regarding such treatment.


* These variations underscore the need for planning studies that relate patient outcomes to different provider groups and treatments, and designing a system that matches patients to practitioners and treatments.

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References

1. Krames E. A case for establishing hospital divisions of pain practice. Pain Med 2000;1:212–216.
 
2. U.S. Bureau of the Census: DP-1. General Demographic Characteristics; Data Set: 2007 Population Estimates; Geographic Area: United States. Available at: http://factfinder.census.gov/servlet/QTTable?-ds_name=PEP_2007_EST&-qr_name=PEP_2007_EST_DP1&-geo_id=01000US. Last updated 2009. Accessed August 19, 2009.
 
3. Bond M, Breivik H. Why pain control matters in a world full of killer diseases. Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=2911. Last updated 2005. Accessed Ocober 30, 2009.
 
4. Stewart WF, Ricci JA, Chee E, et al. Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003;290:2443–2454.
 
5. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a US national survey. Spine(Phila Pa 1976) 1995;20:11–19.
 
6. Nguyen M, Ugarte C, Fuller I, et al. Access to care for chronic pain: racial and ethnic differences. J Pain 2005;6:301–314.
 
7. Coulter ID, Hurwitz EL, Adams AH, et al. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine (Phila Pa 1976) 2002;27:291–296.
 
8. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998;280:1569–1575.
 
9. Rosenberg EI, Genao I, Chen I, et al. Complementary and alternative medicine use by primary care patients with chronic pain. Pain Med 2008;9:1065–1072.
 
10. Konvicka JJ, Meyer TA, McDavid AJ, et al. Complementary/alternative medicine use among chronic pain clinic patients. J Perianesth Nurs 2008;23:17–23.
 
11. Legorreta AP, Metz RD, Nelson CF, et al. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Arch Intern Med 2004;164:1985–1992.
 
12. National Institute of Health and National Center for Complementary and Alternative Medicine: Acupuncture: An Introduction. Available at: http://nccam.nih.gov/health/acupuncture/introduction.htm#ususe. Last updated March 27, 2009. Accessed May 11, 2009.
 
13. American Chiropractic Association: General Information about Chiropractic Care. Available at: http://www.acatoday.org/pdf/Gen_Chiro_Info.pdf. Last updated 2009. Accessed May 11, 2009.
 
14. States using NCCAOM Examinations for Acupuncture Licensure. Available at:http://www.nccaom.org/diplomates/sfi_forms/States%20using%20Exams%20for%20Ac%205–14-08%20NEW.pdf. Last updated 2009. Accessed March 4, 2009.
 
15. SAS Institute Inc: Sample 24985: %SREGSUB macro provides additional capabilities for PROC SURVEYREG. Available at: http://support.sas.com/kb/24/985.html. Last updated November 8, 2007. Accessed December 31, 2009.
 
16. Smith M, Carber LA. Chiropractors as safety net providers: first report of findings and methods from a US survey of chiropractors. J Manipulative Physiol Ther 2007;30:718–728.
 
17. Lincoln D. AAAOM Action Alert: President's Corner, AOM in US Healthcare. Available at: http://www.aaaomonline.org/pressroom.asp?pagenumber=48288. Last updated March 14, 2009. Accessed April 21, 2009.
 
18. Target Audience-Chiropractors. Available at: http://www.mpamedia.com/products/dc.php. Last updated 2008. Accessed January 7, 2010.
 
19. Target Audience-Acupuncture. Available at: http://www.mpamedia.com/audiences/target_at.php. Last updated 2009. Accessed May 12, 2009.
 
20. Sadosky A, McDermott AM, Brandenburg NA, et al. A review of the epidemiology of painful diabetic peripheral neuropathy, postherpetic neuralgia, and less commonly studied neuropathic pain conditions. Pain Pract 2008;8:45–56.
 
21.  Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50:1129–1136.
 
22. Dobscha SK, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA 2009;301:1242–1252.
 
23. Meier DE, Beresford L. Dartmouth atlas data can support palliative care development. J Palliat Med 2008;11:960–963.