Chronic Pain is a Chronic Condition, Not Just a Symptom.

Christine E Whitten, MD, is an SCPMG anesthesiologist in San Diego, CA. She is the Southern California Coordinator of Pain Management and the Clinical Lead for the CMI Chronic Pain Condition Group. E-mail: [email protected]. Kristene Cristobal, MS, is the Care Management Institute’s National Project Manager for Chronic Pain and the Project Manager for Culturally Competent Care. E-mail: [email protected]. Presented at the Kaiser Permanente Primary Care 2005 conference, Maui, Hawaii, March 20-25, 2005, as Whitten C, Evans C. Chronic pain management in primary care. Conservative estimates indicate that 60 million Americans suffer from some type of persistent or recurrent pain sufficient to significantly affect their lives. The Kaiser Permanente (KP) member population includes many patients with chronic pain, and this cohort is generally characterized by a high level of utilizing medical services. Compared with other conditions addressed by the Care Management Institute (CMI), chronic pain more adversely affects quality of life, functional status, and productivity. Recent measurement of the KP chronic pain cohort by CMI showed chronic pain in 5.1% of adult KP members. This incidence can be compared with the incidence of other conditions diagnosed in the KP population: diabetes, in 7.7% of the population; depression, in 6.5%; coronary artery disease, in 3.2%; persistent asthma, in 2.0%; and heart failure, in 1.6%. According to the recent CMI Annual Population Care Management Report, about a third of patients with moderate to severe impairment from a chronic condition would benefit from care management, and another third would benefit from case management (Figure 1). About 50% of these impaired patients require only support for self-care. As Figure 1 shows, patients who are moderately to severely impaired by chronic pain often demonstrate poor pain control, clinically significant deconditioning and physical impairment, and often a lack of coping skills. A state of learned helplessness may develop and substantially alter a person’s lifestyle. The population with chronic pain has a high incidence of comorbid conditions. For example, 27.7% of members with chronic pain also had documented depression during 2000, whereas 6.5% of all adult members had depression. Compared with utilization by nonafflicted KP members, utilization of resources by KP members with chronic pain is much higher. For example, this utilization • is 3.7 times higher than the HEDIS inpatient admission benchmark • is 2.7 times higher than the HEDIS emergency visit benchmark • includes four times more outpatient visits • produces pharmacy costs that are 3.5 times higher. Chronic pain is a chronic condition with its own pathological changes, its own set of clinical and behavioral characteristics, and its own subset of effective approaches to treatment regardless of etiology. To promote healing, we teach acutely injured patients to rest passively and to focus on their pain as a gauge of when to become more active. However, treating chronic pain in the same way you treat acute pain is a prescription for failure. Ironically, the patient clinical contributions