Abstract
OBJECTIVE: Chronic pain is an important cause of morbidity among adults worldwide. Its manage- ment presents a greater challenge in the unique demographic of Appalachia. “Physician reluctance to prescribe opioids” has been identified as a major barrier to effective management of chronic pain nationally. The aim of this study was to determine whether prescribers in Appalachian Ohio encoun- tered similar barriers as prescribers elsewhere.
METHODS: A 29-item questionnaire was distributed to all 1719 physicians practicing in 29 counties in Ohio designated as “Appalachia.” The questionnaire evaluated demographics, assessed aspects of pain management, and asked participants to rank a list of 11 perceived barriers to effective chronic pain management. RESULTS: The overall survey return rate was 25.9%. The average respondent was male, 51 years old, with 20 years of experience practicing medicine, spending 86% of the working week with patients. Most participants (72.5%) reported being involved with chronic pain management “several times each week” or more. Of the potential barriers, those identified as important were (1) patient reluctance to make lifestyle or behavioral changes, (2) inadequate access to pain specialists, (3) inadequate access to health care because of financial burden, (4) lack of an objective measurement of pain, and (5) physician reluctance to prescribe opioids.
CONCLUSION: Prescribers in Appalachian Ohio identified issues of patient behaviors and health care accessibility as important barriers, in addition to top barriers previously described in the literature. Further research must be done to determine whether these results are unique to Appalachian populations.
Corresponding Author(s)
Erin N. Remster, DO, Department of Internal Medicine, East Tennessee State University, 618 Hillcrest Drive, Johnson City, TN 37604.
E-mail address: eremster@yahoo.com.
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With today’s remarkable medical advancements, why does chronic pain remain a significant issue for patients and health care providers? Chronic pain has been described as “pain without biological value that has persisted beyond the normal tissue healing time,”1 usually recognized as lasting greater than three months. It causes substantial morbidity nationally, affecting the quality of life of at least 50 million Americans who have disabling chronic pain2 as well as those who live with and care for them. Chronic pain costs Americans more than $100 billion annually for medical expenses, lost income, and lost productivity.3 A diagnosis of chronic pain may stem from a wide variety of corresponding medical conditions including low back pain, osteoarthritis, headaches, peripheral neuropathy, sickle cell disease, neu- ralgias, myofascial pain, fibromyalgia, complex regional pain syndrome, and others.4 Regardless of the underlying diagnosis (and in cases where a cause cannot be deter- mined), many patients with chronic pain experience depres- sion, hopelessness, social isolation, alterations in mobility, and altered sleep patterns.5
Although the prevalence of chronic pain in Ohio mirrors estimates of the national average, Appalachian Ohio is a unique geographical area and home to a distinctive patient population (Fig. 1).6,7 Twenty-nine of Ohio’s 88 counties are included in the Appalachian region; this area includes 12% of Ohio’s total population (almost 1.5 million people in Appalachian Ohio in 2006).8 In 2007, the per capita income for Appalachian adults was $29,274 (20% lower than the national average), and the 2009 unemployment rate reached 12.1%, superseding the national average by almost 3%.9 This contributes to the fact that 14% of Appalachian Ohio adults are uninsured.10 With the economic recession of the past two years, financial hardship has affected patients nationally, resulting in even higher unemployment rates and greater disparity in areas that were already economically depressed, such as Appalachia. Research has identified that adults living in Appalachian Ohio are more likely to be living with a chronic disease, to have limited access to health care, and to be in poorer health overall than those living in other parts of the state.11 As a result, health care providers are required to manage sicker patients with lim- ited resources.
Researchers worldwide have identified reasons chronic pain remains under-treated. Several studies have classified specific barriers related to physicians, patients, and existing health care infrastructure.3,12,13 One major barrier to effec- tive pain management identified by physicians in current literature is “physician reluctance to prescribe opioid med- ication.”3,12,13 Researchers postulate that this stems from prescribers’ lack of training in assessment and treatment of chronic pain, fears about potential legal sanctions that may result from prescribing controlled substances, and negative attitudes regarding patients with chronic pain.12 Ponte et al evaluated the attitudes of West Virginian family physicians regarding pain; the entire state of West Virginia is included in the designation of “Appalachia.”14 They discovered that a majority of primary care physicians surveyed had reservations in prescribing opioid medications for noncancer pain, and reported that regulatory scrutiny influenced their prescribing behaviors.15 Their study also supported previ- ous data that identified a lack of knowledge in prescribing appropriate opioid medications and managing the side ef- fects of opioids.12,15
Patient-related barriers reported in the literature include issues of communication, fears of opioid addiction and side effects, as well as patients’ reluctance to report pain.16 Health care infrastructure barriers such as long travel times to see a physician, inadequate transportation, and lack of social and psychological support resources add further com- plications.3
The investigators previously reported a pilot study ex- amining barriers to effective chronic pain management in rural Appalachian Ohio.17 The pilot study was a 30-item questionnaire distributed to physicians and nurse practitio- ners attending a continuing medical education conference on pain management. Results consisted of responses from 22 providers in Appalachian Ohio regarding chronic pain management, including identifying perceived barriers to chronic pain management. The top barriers identified in the pilot study were: “inadequate access to pain specialists,” “physician reluctance to prescribe opioids,” “inadequate access to health care due to financial burden,” and “lack of an objective measurement of pain” as the most important barriers identified by the participants. Although limited by the small sample size, the pilot study suggested that barriers involving health care accessibility were important obstacles for this patient population.17 Based on the results from the pilot study, the objective of the research presented here was to expand the sample to help identify specific barriers Ap- palachian prescribers encounter in managing chronic pain patients. By understanding these barriers, we can begin to identify ways to better prepare health care professionals to care for their patients with chronic pain.
Methods
Sample
The sample for this study consisted of a convenience sample of 1719 physicians from Ohio’s Appalachian coun- ties obtained from the Ohio State Medical Board in May 2007. All allopathic and osteopathic physicians who were in active practice at the time of the study and had a license to prescribe medication were included. A survey was mailed to listed addresses and, if returned, data were compiled and the participant removed from the mailing list. Three weeks after the initial questionnaire and cover letter were mailed, a second questionnaire was mailed to participants who had not responded.18
Survey instrument
Demographics. The initial questionnaire consisted of 29 questions previously used and validated in the literature by researchers in other demographics (Appendix).3,12,13 The questions were then piloted by the investigators among a small sample of Appalachian Ohio providers before query- ing the larger sample.17 The participants voluntarily and anonymously answered questions regarding their demo- graphics, prescribing behaviors, use of a pain contract, com- fort levels in discussing chronic pain with their patients and other health care providers, familiarity with federal and state regulations, and how participants view their medical edu- cation in chronic pain management. All aspects of the study protocol were approved by the Institutional Review Board at Ohio University.
Barriers to pain management. Physicians’ perceptions of the barriers to chronic pain management were measured using 11 items rated on a 5-point scale, with higher numbers indicating the item was perceived to be a “more significant” barrier. Figure 2 lists the potential barriers respondents ranked in this study. The scale used for the items ranged from “Not at all Significant” to “Extremely Significant.” When the term significant is being used as it applies in relation to the survey scale, it will appear in quotation marks to differentiate from its use in the statistical context (i.e., statistically significant).
Results
Response
Forty-eight surveys (2.8%) were returned undeliverable and 77 surveys (4.5%) were returned blank for a variety of self-reported reasons (i.e., retired, not currently managing chronic pain patients, etc.). The final sample consisted of 413 usable questionnaires with an overall return rate of25.9%.
Demographics
Physicians practicing in 27 of Ohio’s 29 (93.1%) Appa- lachian counties were represented in the sample. About three-quarters (74.0%) of the respondents were male and the majority of respondents (68.9%) were allopathic physicians. The average respondent was 51 years old (SD = 11.4), had 20 years of experience practicing medicine (SD = 11.9), and spent 86% of the working week with patients (SD = 23.3). More than one-third of participants (n = 169, 41.7%) reported being involved with chronic pain “daily” or “more than once each day.”
Ranking of potential barriers
Descriptive statistics were calculated to characterize re- sponses for survey items that asked physicians to rate how “significant” they perceived 11 barriers to chronic pain management. In an effort to rank the items in order from “most significant” to “least significant,” the following data reduction technique was used: the scale responses not at all significant and minimally significant were collapsed to form the category “Perceived as a Less Significant Barrier” and the scale responses moderately significant and extremely significant were collapsed to form the category “Perceived as a More Significant Barrier.” The no opinion/not applica- ble responses remained unchanged to preserve the spirit and intent of the original survey. Survey items were placed in descending order based on the frequency of the physicians’ responses collapsed into the category “Perceived as a More effective management of chronic pain. Each of these top barriers will be explored here.
Compared with the previous pilot study, the investigators identified the same top barriers among prescribers, with one exception: the larger sample identified “patient reluctance to make lifestyle or behavioral changes” as the most important
Table 1 Identified barriers to chronic pain management in descending order
specialists Financial burden (patient) | 73.1% (409) | 3.81 (1.24) |
Lack of objective | 72.3% (404) | 3.77 (1.26) |
measurement of pain | ||
Physician reluctance to | 71.0% (407) | 3.69 (1.24) |
prescribe opioids | ||
Inadequate pain | 59.3% (408) | 3.34 (1.30) |
assessment | ||
Lack of transportation | 57.2% (409) | 3.31 (1.30) |
(patient) | ||
Federal/state regulations | 52.9% (408) | 3.23 (1.43) |
Inadequate access to | 50.1% (405) | 3.09 (1.41) |
primary care Patient fear of addiction | 40.4% (408) | 2.87 (1.21) |
Patient reluctance due to | 35.5% (408) | 2.72 (1.19) |
adverse effects |
Inadequate access to pain
barrier % (n) Mean (SD)
87.9% (406) 4.35 (0.95)
78.1% (406) 4.05 (1.21)
barrier. This was not ranked highly in the pilot study. Reasons for this may include that the pilot study was done in one town at a conference specifically regarding chronic pain issues; participants in the pilot were essentially self- selected and represented only one narrow geographical lo- cation. The results of this larger survey indicate that physi- cians queried see patient-related barriers as being a very important component in solving the puzzle of chronic pain. The existing literature suggests that the characteristics of chronic pain fall into physical, behavioral, and psycholog- ical dimensions.5 Because pain is a wholly subjective ex- perience, how an individual experiences pain and responds to it is complex and unique to the individual. Yet, theories suggest that pain is also a result of operant conditioning or learned behavior. Living with chronic pain adversely alters patients’ day-to-day patterns, which results in negative physical, psychological, and social effects. These include disruptions in eating and sleeping and alterations in mobil- ity. The psychological effects of these changes include de- pression, anger, anxiety, grief, hopelessness, and feelings of helplessness.5 In short, chronic pain initiates learned behav- iors that are often complicated by comorbid depression,
Significant Barrier.” To confirm the rank order of the items, means and standard deviations were calculated. The ranks derived from the frequency distributions and those derived using item means were identical (Table 1). It was hoped that two subscales could be extracted from these items: physi- cian barriers and patient barriers. However, inter-item cor- relation matrices revealed that the correlations between the items for each potential subscale were weak and would not result in sound psychometric scales. It appears that the barriers to chronic pain management are very complex and should be treated individually rather than collectively.
The most important barrier identified was “patient reluc- tance to make lifestyle or behavioral changes,” followed by “inadequate access to pain specialists,” “inadequate access to health care due to financial burden,” “lack of an objective measurement of pain,” and “physician reluctance to pre- scribe opioids.”
Discussion
This study examined the perspectives physicians have re- garding barriers to the effective management of chronic pain in Appalachian Ohio. It is clear that management of chronic pain provides challenges to health care providers as well as their patients. It was identified that prescribers in this demographic view elements of patient reluctance and health care inaccessibility, as well as physician barriers including reluctance to prescribe opioids, as important obstacles to requiring a holistic treatment approach that involves more than simply treating pain.
In some areas of Appalachia, poor health decisions have been identified as having a significant impact on communi- ties.19 In addition, many patients in Appalachian regions have difficulty accessing necessary medical care as a result of financial or transportation barriers. One can imagine that this arrangement can easily lead to missed appointments and lack of follow-through with physician recommendations. If responses to pain are also learned, we can understand how patients from specific demographics might share similar learned patterns of response to pain from family or other community members. As our current system functions, in Appalachia and elsewhere, there are many financial disin- centives toward making health improvements for patients, including disability payments and supplementation of food and housing costs. Presently, there is little motivation for patients to return to work, and there is only a paucity of jobs available. Why should people want to improve their health when it costs more money to do so? This remains a chal- lenge for providers and their patients nationally, and is closely intertwined within larger health care systems and state and federal programs.
The usefulness of self-management techniques in treat- ing chronic pain has been identified.20 These self-manage- ment tools focus on patient skill development and empower patients to actively manage their symptoms by developing effective strategies and communicating with their health care providers regarding their effectiveness.20 Recent research describes both inhibiting and facilitating factors to chronic pain self-management. Barriers included lack of social support, limited resources, and time constraints, de- pression, ineffective pain-relief strategies, as well as lack of individualized strategies for pain management and difficult patient-physician interactions. Facilitating factors included encouragement from the health care team, treatment of depression, improving social support and providing multi- ple strategies tailored to the patient’s needs.20 Although it cannot be determined by this research, incorporating self- management practices by eliminating identified barriers and making facilitating factors available may make it easier for patients to make lifestyle and behavior changes a part of their chronic pain management.
Participants in this study also identified issues of health care accessibility—“inadequate access to pain specialists” and “inadequate access to health care due to financial bur- den”—as important barriers to optimal pain management. For a patient in Appalachian Ohio, a visit to a pain specialist is more of a financial and logistical burden than a visit to a primary care provider, especially when these visits are com- plicated by pain. Of all 29 counties located in Appalachian Ohio, only 8 physicians identify themselves as “pain spe- cialists”: these physicians serve a population of more than
1.4 million people.7 These statistics certainly indicate that chronic pain must be managed in primary care out of ne- cessity.
The fourth ranked barrier identified in our study was “lack of an objective measurement of pain.” This is a ubiq- uitous problem for health care providers, because pain is a subjective experience, with no concrete measurement tools. For this reason, a holistic—and often creative—approach to assessment and treatment of chronic pain patients is neces- sary. Medical professionals have an obligation to individu- alize patient treatment options, which is of utmost impor- tance in dealing with chronic pain. By approaching each patient as a complete individual with inherent mechanisms for healing, providers can optimize treatment and improve the quality of life for most patients living with chronic pain. “Physician reluctance to prescribe opioids” remains an important barrier to treating chronic pain, noted by 71% of prescribers in this study, echoing results of similar previous studies.3,12,13 Although it cannot be determined from this study, perhaps with recent changes in medical education and the availability of continuing medical education in this area, physicians are becoming more confident in using opioid medications appropriately.
The major limitations of this study revolve around the fact that physicians were self-reporting, allowing us to eval- uate their opinions and perceptions, but not being able to objectively measure their experience with and knowledge of chronic pain. Also, further research needs to be done to identify whether these barriers are unique to physicians practicing in Appalachia or to those practicing in Ohio, in both, or in neither. The return rate was lower than expected, with several likely contributing factors. Physician informa- tion was obtained using a database from the Ohio State
Medical Board. Addresses provided are self-reported and updated by physicians; some provided home addresses and others provided office addresses, which may have limited response rate based on how mail is reviewed at each. An electronic version of the survey was not used, but may have provided a greater response rate.
Conclusion
Chronic pain management is a problem for patients and health care providers in Appalachian Ohio. Major barriers to effective pain management including patient behaviors, lim- ited access to pain specialists, financial burden of accessing health care, lack of an objective measurement of pain, and physician reluctance to prescribe opioids were identified in this study. Future research addressing the complexity of chronic pain, especially for unique populations such as Appalachia, is necessary. Applying results from this study in Appalachian Ohio to other Appalachian counties in other states may shed light on barriers unique to all of Appalachia, or identify trends among rural populations. Many osteo- pathic physicians are actively working in the Appalachian region, both as clinicians and educators, and play an impor- tant role in solving the puzzle of chronic pain. The problem here is complex, and a solution must be multifaceted. A holistic approach is needed not only from prescribers and their patients, but from legislators, medical educators, and state agencies to best serve patients in pain.
Acknowledgments
The authors thank the Ohio University College of Os- teopathic Medicine Department of Family Medicine and the Research and Scholarly Affairs Committee for their support of this research, Holly Raffle, Ph.D., from Ohio University’s Voinovich School of Leadership and Public Affairs for statistical analysis, and Ben M. Appleby for his assistance in creating the map of Appalachia.
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Remster and Marx Managing Chronic Pain in Appalachia 147
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