Ethical Considerations in Pain Management for the Primary Care Provider

An Interview with Michael Schatman, PhD, CPE

Michael Schatman, PhD, CPE, is the Executive Director of the Foundation for Ethics in Pain Care. He has been involved in multidisciplinary chronic pain care for 26 years and maintains a private practice in pain psychology. He is the editor of Ethical Issues in Chronic Pain Management and Chronic Pain Management: Guidelines for Multidisciplinary Program Development, and has written more than 60 articles and chapters on pain management. He is chair of the American Pain Society’s Ethics Special Interest Group and also serves on its Ethics Committee. Dr. Schatman serves on the editorial boards of Pain Medicine, The Journal of Pain, Pain Practice, Pain and Therapy, Journal of Pain Research, Advances in Therapy, and Psychological Injury and Law.

Wendy L. Williams, BSN, MEd:

Thank you for agreeing to this interview with about the ethical considerations in pain management for primary care providers. Tell us why ethics in pain management is important to you.

Michael Schatman, PhD, CPE: Ethics in healthcare is important to me, as it should be to all healthcare providers. We are entrusted with the welfare of patients and the public. James Giorodano, PhD, one of the editors of the book, Pain Medicine: Philosophy, Ethics and Policy, said it well in a 2006 Pain Physician journal article: “Deciding to enter the field of pain medicine, and thus to call one’s self a pain physician, is voluntary; the ethical obligations inherent to that act of profession are not.” I would extend this imperative to all clinicians treating people with chronic pain. This group of patients is a vulnerable population. Healthcare providers have a deontological imperative to care for the vulnerable among us. Any one of us could be on Wall Street making serious money, but one of the reasons we chose healthcare is because we want to ameliorate suffering. Our obligation to care for our patients is clear.

WW: What are the two most important ethical imperatives for primary care providers (PCPs) who treat pain?

MS: Due to the scarcity of pain specialists in our country, PCPs are the most accessible assets to people with chronic pain. All PCPs will encounter chronic pain patients and are obligated to treat them. PCPs have an ongoing relationship with their patients, which enables them to treat the biopsychosocial, or whole person, experience of chronic pain. Pain medicine needs to consider treatment through a biopsychosocial lens, rather than the traditional mechanistic lens. From this perspective, the primary care provider is more qualified to treat chronic pain patients than interventionists and surgeons, for example. It takes more than treating the pain per se, and PCPs are in ideal position to treat the whole person.

Next, I would say that PCPs need to understand and accept that it is going to be time-consuming and, at times frustrating, to treat chronic pain patients. There is a wide range of pain-related problems, and the effects of chronic pain are not merely physical; they can be experienced emotionally, financially, legally, vocationally, socially, sexually, spiritually, etc. Working through these issues with our patients is a huge investment of time and care and, I would say, ethically imperative.

WW: What barriers do PCPs face with regard to best practices in pain management ethics?

MS: Two barriers come to mind: time constraints and an ineffective traditional model of chronic pain care. As primary care practice becomes less remunerative, PCPs continue to be stretched thin. There is a dilemma: should PCPs take time to treat pain patients, or should they simply refer out to scarce pain specialists? Gary Brenner, MD, a Harvard professor and Massachusetts General Hospital pain specialist, notes that primary care providers may refer out and anticipate some sort of intervention when it may not be necessary – and to justify that visit, the pain specialist may provide treatment with a questionable evidence basis.

Rollin “Mac” Gallagher, MD, MPH, co-chair of the VA-DoD Health Executive Council Pain Management Work Group, notes that there is a sequential, linear approach to treating chronic pain patients that does not seem to work. Typically, pain patients present to primary care. The PCP tests medication approaches. If there is a sub-optimal result, the patient is referred to physical therapy (PT). If PT is not satisfactory, there is a referral to an available pain specialist. The specialist may provide injections or blocks (interventions). Should that approach fail, a referral will often be made to a surgeon. The patient may undergo surgery, but the outcome still might not be satisfactory. This model of care does not represent every chronic pain patient’s experience, but it is a road map for musculoskeletal pain that most providers will find familiar.

Dr. Gallagher proposes an alternative model in which the primary care provider represents the hub of a wheel and coordinates concurrent, multimodal care services. I advocate this approach as being efficacious and ethical. The sequential model does not work. Chronic pain care needs to be centered in primary care and should ideally be multi-modal and coordinated in its approach.

WW: How do referrals to specialty providers or services affect the ethical treatment of chronic pain patients?

MS: It is a PCP’s ethical imperative to understand which treatments have an evidence basis and which treatments do not. Current literature has found that the most efficacious chronic pain care consists of graded exercise (physical exercise that starts out slowly and builds up) and cognitive behavioral therapy. When PCPs refer out, they should know to whom they are referring. Making a referral to a pain specialist who either does injections/interventions, or who recklessly prescribes opioids, may not be the best answer for every patient. Dr. Chuck Rosen, a spinal surgeon and President of the Association for Medical Ethics, maintains that surgery for back pain may be an over-utilized option. Overall, it is key to become familiar with the evidence basis for best practices in chronic pain management.

WW: What are some practical ways that PCPs can build competency and confidence when it comes to ethical pain management practice?

MS: Some research estimates that nearly 40% of what PCPs see in daily practice is related to chronic pain, so pursuing continuing education for pain management is critically important. Currently, a handful of states require pain management education for re-licensure; these mandates underscore the view that continuing education in the pain management arena is important. Conferences like PAINWeek and PAINWeekEnds provide additional educational opportunities. PAINWeek occurs every September. PAINWeekEnds are regional conferences that are held regularly around the country; the American Society of Pain Educators, in collaboration with individual state pain initiatives, supports these conferences. These educational offerings are specifically geared toward frontline providers to help them improve their practices. Getting more education, and practicing pain assessment and pain care skills, will lead to increased competency.

PAINWeek (2013 calendar TBA; keep checking)
PAINWeekEnds (2013 calendar TBA; keep checking)