INNOVATIONS IN EDUCATION
Primary Care Provider Concerns about Management of Chronic Pain in Community
Carole C. Upshur, EdD,1Roger S. Luckmann, MD, MPH,1Judith A. Savageau, MPH1
1Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA.
BACKGROUND: Chronic pain is a common patient complaint in pri-
mary care, yet providers and patients are often dissatisfied with treat-
ment processes and outcomes.
OBJECTIVE: To assess provider satisfaction with their training for and
current management of chronic pain in community clinic settings. To
identify perceived problems with delivering chronic pain treatment and
issues with opioid prescribing for chronic pain.
DESIGN: Mailed survey to primary care providers (PCPs) at 8 commu-
RESULTS: Respondents (N=111) included attendings, residents, and
nurse practioners (NPs)/physician assistants (PAs). They reported
37.5% of adult appointments in a typical week involved patients with
chronic pain complaints. They attributed problems with pain care and
opioid prescribing more often to patient-related factors such as lack of
self-management, and potential for abuse of medication than to pro-
vider or practice system factors. Nevertheless, respondents reported
inadequate training for, and low satisfaction with, delivering chronic
CONCLUSIONS: A substantialproportion ofadult primary care appoint-
ments involve patients with chronic pain complains. Dissatisfaction with
training and substantial concerns about patient self-management and
about opioid prescribing suggest areas for improving medical education
and postgraduate training. Emphasis on patient-centered approaches to
chronic pain management, including skills for assessing risk of opioid
abuse and addiction, is required.
KEY WORDS: pain; primary care; vulnerable populations; physician
satisfaction; medical education.
J GEN INTERN MED 2006; 21:652–655.
confidence in their ability to provide effective treatment, and a
low level of satisfaction with their care of chronic pain pa-
tients.1–4Recent controversies over prescribing opioids for
chronic pain, and reports of diversion and abuse, have made
providers even more uncertain about how to appropriately
treat patients with chronic pain.2,5–8At the same time, dispar-
ities in pain treatment have been documented.9–15The current
tudies about primary care treatment of chronic pain re-
port providers feel they have inadequate training, limited
study was undertaken to determine if providers in racially and
economically diverse community clinic settings had similar
views as those found in prior provider surveys, and to deter-
mine their perceptions about the challenges of providing
chronic pain care.
The study was approved by the Institutional Review Board of
the University of Massachusetts Medical School. Participating
sites included 5 federally qualified health centers (FQHCs), 2
hospital-operated community health centers, and 1 hospital-
based practice. All sites served large numbers of uninsured
and Medicaid-insured patients, and with 1 exception, were
highly diverse in terms of patient ethnicity (nonwhites ranged
from 40% to 85% of all patients).
Survey questions were drawn from prior studies,1,3and
nominated by an advisory group consisting of primary care
providers (PCPs), researchers, and a board-certified pain spe-
cialist. The questions covered: problems related to chronic
pain management, issues in opioid prescribing, likelihood of
prescribing opioids, estimates of co-occurrence of psychoso-
cial conditions with chronic pain (e.g., depression, substance
abuse), and satisfaction with training and with care delivery
for chronic pain (Tables 1 and 2 show the questions about
treatment problems and issues in opioid prescribing). Ques-
tions were pretested by 3 PCPs and revised. The survey was
distributed along with a print-out of patient appointments for
a recent randomly selected week. Providers were asked to in-
dicate the number of listed patients who had a current chronic
pain complaint, and the type of complaint, regardless of the
reason for the appointment.
Characteristics of the Sample
A total of 111 of 178 surveys were returned, or 62.3% (range
for individual sites of 46.6% to 100%). Respondents included
67 attending physicians (60 family practice, 4 internal medi-
cine, 3 osteopathy), 19 nurse practitioners (NPs), 3 physician
assistants (PAs), and 22 family practice residents. The sample
was 55% female and 82% white. A mean of 37.5% of adult pa-
tients seen in the targeted week across all providers was re-
ported as having a current chronic pain complaint. About one-
fourth of patients had back pain (23.6%), followed by joint pain
(17.1%), headache (12.1%), generalized pain (7.8%), neck pain
Manuscript received August 31, 2005
Initial editorial decision October 7, 2005
Final acceptance January 24, 2006
The authors have no conflicts of interest to declare.
Presentations: Preliminary findings from this study were reported at the
following: Society of Teachers of Family Medicine, September 2003, At-
lanta GA; American Public Health Association, November 2003, San
Francisco, CA; American Public Health Association, November 2004,
Address correspondence and requests for reprints to Dr. Upshur:
Department of Family Medicine and Community Health, University of
Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA
1655 (e-mail: Carole.email@example.com).
(7.5%), abdominal pain (6.8%), fibromyalgia (5.7%), and arm
pain (5.2%). Pelvic pain, neuropathic pain, and complex re-
gional pain syndrome were each reported at less than 5%.
Problems Providing Optimum Pain Relief
Respondents rated 11 possible problems in providing effective
pain treatment for their patients (Table 1). The majority of pro-
viders rated patient self-management, patient psychological
factors, and patient compliance as frequently or always pre-
venting optimal pain treatment. In contrast, much smaller
proportions of providers rated any of the 5 provider or system
factors as frequently or always implicated in failure to help
patients obtain optimal relief.
Use of Opioids
Providers were asked to rate their likelihood of prescribing op-
ioids for chronic pain when other treatments were ineffective
on a scale of 0=not at all likely to 4=very likely. Only 28.8%
rated themselves as highly likely to prescribe opioids (rating of
‘‘3’’ or ‘‘4’’). They also rated issues preventing prescribing op-
ioids for chronic pain (Table 2). Fear of the patient becoming
addicted, followed by fear of patients selling the opioids were
noted as the strongest reasons prevention opioid prescribing.
Few respondents indicated a large effect of law enforcement
scrutiny on their willingness to prescribe opioids.
Analyses were conducted to compare demographic char-
acteristics, and ratings of treatment problems, opioid issues,
and co-occuring patient psychosocial characteristics, for pro-
viders reported less likely to prescribe opioids (n=72, rating of
0 to 2), compared with those highly likely to prescribe opioids
(n=32, rating of 3 or 4). No significant demographic differ-
ences (gender, race, provider type, or practice site) were found.
However, there was a trend (P=.10) for a higher proportion of
attendings to be more likely to prescribe opioids (35.8%), than
residents (22.7%) or NP/PAs (13.6%).
In the analysis of treatment problems and opioid issues,
using t tests to compare mean rating scores on each item, pro-
viders less likely to prescribe opioids rated patient psychological
factors as a significantly greater problem than those more likely
to prescribe (2.91 vs 2.59, P=.019, ES=0.51), and reported a
higher rating for ‘‘difficulty coordinating or adding on pain man-
agement/treatment’’ (2.38 vs 1.97, P=.03, ES=0.50). They also
rated potential for patient addiction as more important in pre-
venting opioid prescribing (M=2.72vs 2.16, P=.004, ES=0.67).
However, analysis of patient co-occuring psychosocial charac-
teristicsfound acounter-intuitiveassociation betweenlikelihood
of prescribing opioids and estimates of the percent of pain pa-
tients who had substance abuse histories (w2=4.64, P=.031).
One-quarter of providers (25.8%) reporting higher likelihood of
prescribing opioids indicated that greater than 50% of their
patients with pain also had substance abuse histories, com-
pared with 9.6% of providers less likely to prescribe.
To further understand correlates of high versus low like-
lihood of opioid prescribing, a logistic regression was conduct-
ed with provider type (attending vs others), and the 4 variables
described above as significantly associated with opioid pre-
scribing as independent variables. Four variables remained
independently associated with likelihood of prescribing, 2
indicating increased likelihood and 2 indicating decreased
likelihood: (1) provider type (attendings more likely to pre-
scribe, odds ratio [OR]=5.3, P=.012; 95% confidence interval
[CI]=1.4 to 19.3); (2) rating a higher percent of patients with
substance abuse histories, OR=4.3, P=.013 (95% CI=1.4 to
13.8); (3) rating patient psychological factors as a greater prob-
lem, OR=0.36, P=.029 (95% CI=0.14 to 0.90); and (4) rating
potential for patient addiction as more of an issue, OR=0.31,
P=.002 (95% CI=0.15 to 0.64).
Satisfaction with Treatment and Training
Providers rated satisfaction with treating their patients with
chronic pain as quite low (M=1.90, SD=0.81), on a scale
Table1. Provider Ratings of Problems to Patient’s Achieving Optimal Pain Control (N=111)
ProblemHow Much do You Believe Each of the
Following Problems Limit Your Ability to
Achieve Optimal Pain Control for Your
Patients with Chronic/Persistent
Nonmaligant Pain Only
(e.g., Low Back Pain)?
No at All or
Patient self-management problems (e.g., time for relaxation, exercise, family responsibilities
such as care for young children)
Patient psychological factors (e.g., depression, anxiety)
Patient compliance with treatment recommendations
Patient occupational factors (i.e., can not change jobs, can not make work accommodations)
Patient is invested in secondary gains of illness
Language barriers (e.g., patient’s first language is different from provider’s)
Provider and practice system problems
Difficulty coordinating or adding on chronic pain management/treatment with management
of other chronic diseases (e.g., diabetes, asthma, obesity)
Lack of evidence-based guidelines
Time/tracking systems for regular follow-up
Difficulty assessing pain levels
Time for a careful differential diagnosis
Upshur et al., Provider Concerns About Chronic Pain Management
where 0=not at all satisfied and 4=very satisfied. However, a
higher proportion (37.5%) of providers who rated themselves
as more likely to prescribe opioids also rated themselves as
highly satisfied with their pain care (satisfaction rating of 3 or
4), while only 16.7% of providers who were least likely to pre-
scribe opioids rated themselves as highly satisfied (P=.03). On
a scale of 0=insufficient, 1=adequate, 2=good, and 3=very
good, the mean rating of chronic pain education for NP/PA
programs was 0.5 (SD=0.80), for medical school 0.35 (SD=
0.67), and for postgraduate medical education 0.7 (SD=0.84).
The majority of attending physicians rated their medical
school education (81.5%), and residency training (54.7%),
about chronic pain treatment as insufficient. Residents rated
their undergraduate and graduate medical education on
chronic pain as somewhat better, with less than half rating
each as insufficient (47.6% and 42.1%, respectively).
Primary care providers in our study reported that over one-
third of adult appointments in a typical week involved a patient
with chronic pain. While this finding is not a true prevalence
estimate, it does indicate that providers in community clinic
settings encounter a large number of patients with chronic
pain symptoms. At the same time, as reported in prior studies,
providers in this study feel poorly prepared by their profes-
sional training for, and dissatisfied with, treating patients with
Despite the unfavorable reports about pain education and
low satisfaction with pain treatment, PCPs did not identify
provider expertise and health system factors (e.g., difficulty of
diagnosis, lack of evidence-based guidelines) as the most im-
portant obstacles to treating patients with chronic pain. In-
stead, patient compliance and behavioral factors were rated as
more problematic. Thus, in addition to improving basic knowl-
edge about chronic pain management, providers likely will also
need training in patient-centered care approaches that
address the compliance and behavioral problems they perceive
as so problematic.
Finally, respondents did not identify law enforcement
scrutiny as an important issue preventing opioid prescribing
as other studies have reported.1,2,4Instead, rated more impor-
tant were the risks of addiction, medication diversion, and
targeting of patients by illegal users. Surprisingly, providers
more willing to prescribe opioids also identified a larger pro-
portion of the chronic pain population as having substance
abuse histories. This finding could mean providers who pre-
scribe opioids for chronic pain are more careful to take sub-
stance use histories, or understand substance use as a
self-medicating avenue for patients to address their chronic
pain. Nevertheless, further study is needed to determine the
validity of these provider perceptions, their effect on opioid
prescribing, and to assess the real risk of addiction in patients
with chronic pain who are prescribed opioids in community
Taken as a whole, the concerns about optimal chronic
pain treatment in community clinic settings identified in this
study support continuing calls for more provider education
and practice change. This study has also identified that pro-
viders believe that patient behaviors are significant barriers to
effective pain treatment. Thus, the findings suggest that pro-
vider education should focus on patient-centered approaches
to managing chronic pain, and on addressing provider con-
cerns about substance abuse and addiction.
The authors wish to thank Heidi Shah, MD; Nick Apostoleris,
PhD, William Shaw, PhD, Robert I. Cohen, MD, Gonzalo Ba-
cigalupe, EdD, and Gail Sawosik, MBA, for their assistance in
survey design and implementation, and in manuscript review.
In addition, many thanks are due to the providers and admin-
istrators of the participating clinical sites in Massachusetts: Barre
Family Health Center, Barre; Community Health Connections,
Fitchburg; Family Health Center, Worcester; Family Medicine
University Campus, Worcester; Great Brook Valley Health Cen-
ter, Worcester; Greater Lawrence Health Center, Lawrence;
Table2. Issues that Would Reduce/Prevent Willingness to Prescribe Opioids for Chronic Pain (N=111)
Issue For Each of the Issues Listed Below, Indicate How
Much Each One Might Prevent You From Initially
Prescribing Opioid Medication to Patients with
Chronic/Persistent Nonmaligant Pain Who Have
not Responded to Other Measures
No or a Small
Effect on my
A Large Effect or
Would prevent me
Potential for patients to become addicted to opioids
Potential for the patient to sell the opioid on the illegal market
Potential that patient may be targeted by illegal users to get patient’s prescription
Side effects of opioids
Safety of opioids (e.g., respiratory depression)
Provider or practice system issues
Unsure of appropriateness of opioids
Lack of systems to monitor patient compliance (e.g., contracts, blood/urine tests)
Regulatory/law enforcement monitoring of opioid prescribing
The hassle and time required to track and refill prescriptions
Upshur et al., Provider Concerns About Chronic Pain Management
Hahnemann Family Health Center, Worcester; Holyoke Health Download full-text
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