Consider the following scenario, which may seem familiar to many primary care physicians.

Your patient, Betty, is a pleasant, middle-aged woman who is overweight and out-of-shape. You have been her primary care physician for more than five years and everyone in the practice likes her. As she has aged and gained weight, back and joint injuries she suffered in her early twenties have become more bothersome. The more pain she has the less active she is, which adds to her weight issues. NSAIDS became less effective a couple of years ago and she began losing sleep because of her discomfort. You put her on stronger pain medications and sleep aids, which have helped her continue to function.

• Your medical record documentation should be a clear and concise re-creation of the circumstances of each visit or phone call and include:
  • An up-to-date history and physical exam, wherein you indicate whether or not the patient has a history of substance abuse.
  • A medication tracking sheet, located in a prominent place in the chart; this list should be kept up to date with all medications the patient takes, including over-the-counter remedies and all prescription renewals (this type of tracking is also available in electronic records).
  • Discussions with the patient about her pain, the treatment plan, medication risks and benefits, and alternative treatments offered or provided.
  • The patient’s progress, or lack thereof.
  • The specific name of the drug(s) prescribed, indication(s) for use, dosage, and instructions for use for all medications ordered.
• All long-term or chronic pain patients should be reviewed on a regular basis. The New Jersey Board of Medical Examiners (BME) requires this to be done, at a minimum, every three months. The Board has wide-ranging regulations relating to pain management practice.[1]

  
  At each review, consideration should be given to changes in medication, reduction in dosage, and/or alternative treatments. This review, your discussion with the patient, and your decision rationale, should be documented in the chart.
• Since this is a long-term care plan that you and your patient have worked on together, you may want to consider developing a written agreement of conduct which a patient can sign regarding her medications and any other areas of the treatment plan (such as exercise or therapy) that she is responsible for. In this way she may be more vested in remaining adherent to the treatment plan, and you will have specific issues to discuss with her in terms of her behavior.
• If your examination and testing indicates a possible need for more in-depth pain management than is available in a primary care practice, you should refer patients to a pain management specialist for specialized interventions.
• Also, if your examination and testing indicates that the patient may be drug seeking, you should refer her to an addictions specialist or drug dependence clinic. This is usually not the first conclusion that you draw, and it may not be welcomed by the patient, but if this is potentially the issue, your referral must be firm, not a suggestion. This type of care, like all of the others discussed, is for the patient’s benefit.

Treating the patient with long-term pain is difficult and complex. It is not care that should be handled on a visit-to-visit basis; it requires a careful plan and active participation on the part of the patient.

This article has focused on responding to the patient who is identified as having chronic pain. Each practice should take steps to identify these patients on a timely basis so that an appropriate care plan can be instituted early in their treatment. Basic steps include:

• Medication tracking lists which, when appropriately used, are very effective in spotting patterns of drug use that require review.
• Routine chart reviews.
• Making sure all narcotics and depressants are renewed only by the physician, not an office staff member.