Article Figures & Data
Tables
Characteristic N (%) Age (years) 55+ 21 (46) 40 to 54 18 (39) 25 to 39 5 (11) Not recorded 2 (4) Sex Female 25 (54) Male 21 (46) Race/ethnicity African American 28 (61) White 14 (30) Latino 3 (7) Not recorded 1 (2) Substance use (past or present)* Cocaine 30 (65) Alcohol 26 (57) Marijuana 21 (46) Methamphetamine 14 (30) Heroin 11 (24) Nonprescribed opioids 3 (7) ↵* Patients may have reported use of more than one substance
Pain as Time Drain: Clinician Perspectives Theme: Pain management takes time from other patients and health concerns “My pain management patients drain my time. I don't want to say ‘drain’ but it's true, at least that's how I feel. My perception is that they drain my time and that puts me behind in the rest of my schedule, because there's always a struggle… And that takes away from the other patients that I need to spend more time with.” “From a patient's perspective, pain and mental health and well-being are the most, are frequently the most pressing issues, and understandably so. But there also are other big things that could be going on with people from a health perspective that are important, too, and it all needs to fit into the time. That's hard.” Theme: Pain and opioid management are often fraught with conflict “[In] terms of trajectory with patients… either if I'm inheriting them or if I'm starting over with them, or even starting with these new patients, [I try] to establish some functional goals… I totally do not have time to do any of [it] but it's not an option [not to]. If you don't do it the whole relationship ends up being a disaster… because every time you see them you're just arguing about whether or not it's [the pain's] better, whether it [opioid medication] makes them better or worse…” Theme: The intensity and chronicity of patient suffering weighs on providers “[If] you ask anybody in [this clinic] what percentage of our patients are on chronic opioids, they'll tell you some completely inflated number… I think [it's] because [of] the psychologic[al] space that these [CNCP] patients take up in people's minds. And that's because nobody's suffering more than a person with chronic pain… so you develop these really passionate and intense relationships with people because… they're trusting you with their suffering and you want to help them. And sometimes we help people and they move in a positive direction and sometimes we don't… [The] other thing that would happen is… you're trying to get them healthier and they'd no-show to all your visits and they would always come to… their refill appointment.” CNSP, chronic noncancer pain.
Insurance, Inherited Patients, and the 15-Minute Visit: Contextual Factors Theme: Reimbursement structures limit time for pain management in the safety-net “I went to that [CME and] they [said], “You got to spend at least an hour [in] the first visit with each [CNCP] patient,” and all these internists were saying, “Okay, yeah, no problem.” And they're going to bill the patient for the time. I'm working in a Medi-Cal [Medicaid] clinic, I can't do that. So, I went, “Yeah, in an ideal world.” So, I heard all this stuff that I'm supposed to be doing, taking a complete history, complete addiction history… But I don't have time to do what I am supposed to do in terms of proper treatment, opioid treatment, so I cut corners a bit.” Theme: Thorough initial assessment is difficult in brief visits, but essential for future care “[Any] time I get a new patient who has pain it's like the first visit… as soon as I can get to the place where everything else feels stable enough for me to talk about the pain, that's all I'll do. Because I think that initial pain assessment is so important and often times lost to me when you inherit [another clinician's patient]… You need time to listen… it takes more than fifteen minutes often… I just see that as such an important initial step in coming up with good plans and setting up people for expectations.” Theme: Visit duration and availability pose challenges to pain management “[A] new patient for us should be a 30-minute visit but there's so many new patients sometimes that new patients will be put into a 15-minute visit. And even 30 minutes is not enough for a lot of complex issues… And, yes, we do often have a culture where we deal with one or two problems on one issue because we don't have the time and we'll bring them back [for a follow-up visit].” “It's very hard to get an appointment in the clinic [when] you want one, and so one defense mechanism that almost all the doctors there use is to see people more frequently than they actually need to because everyone's afraid of their patients falling through the cracks and that just makes the problem [of clinical availability] worse.” CNSP, chronic noncancer pain.
Patient Perspectives Theme: Patients sense that providers are rushed “Some providers actually care about what's wrong with a person. My new provider is like… I think he's overwhelmed with how many patients he has, but at the same time he still tries to listen to you. [He] doesn't just go, ‘Here you go, here's your [opioid], go, bye.’ You know, he does pay attention but I think he's really overwhelmed… you can just see it in his face.” Theme: Continuity is important for pain and opioid management “Every time I came to the clinic, it was always a new doctor. So, I would always have to explain my story all over again to a new doctor…. [My current clinician] said that she would take me. And so ever since then [my clinician] got me off of all my medicine… and I'm actually getting [better]… But with [the other doctors] I never got medicine [opioids], I got medicine twice and they're like, ‘Here, just take a couple,’ and that would be it. But for me it wasn't just, ‘Give me medicine to make the pain go away.’ I want help to make sure if there's something that they can do to make the pain go away without medicine. That's what me and [my clinician] are trying to figure out right now.” Theme: Patients feel stigmatized and burdened by time-intensive monitoring requirements “[If] the doctor know [sic] my background and I have chronic pains… I feel like [the clinicians] should call my meds in, I shouldn't have to come up there and get a prescription… I feel like that because it don't make no sense. It's basically you're going in there without an appointment but it seems like it is appointment because you have to sit in there and you have to actually wait to get it and you're not going in the back [to a clinic room]… So, you won't be able to say nothing to that doctor or anything, [and] you come back two weeks later to come to the doctor. I feel like they need to better up on, on serious people that really, really have chronic pain.”
