Complexity Model Urged for Chronic Pain

LAS VEGAS—Many physicians use a focused or unidimensional approach to pain management whereby they simply prescribe an opioid to relieve pain caused by a specific problem. Although this might be appropriate for acute pain, it might be inadequate for many patients with chronic pain, according to John F. Peppin, DO, FACP, of The Center for Bioethics, Pain Management and Medicine, Lexington, Kentucky.

Patients with chronic pain frequently have multiple concomitant problems that can affect pain level, and if these problems are not addressed, patients will not have their pain controlled, Dr. Peppin said. “We've got to be much broader in our approach to these patients,” he said.

Dr. Peppin and a colleague, Martin D. Cheatle, PhD, of the Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, spoke about the need for a different approach to chronic pain management in a Wednesday session titled, “The Complexity Model: A Novel Approach to Collaborative Pain Management.”

The complexity model, which Drs. Peppin and Cheatle and others have developed into a screening tool, incorporates categories of factors that might influence chronic pain, such as medical and psychiatric comorbidities, tobacco use, patient risk for drug abuse and diversion, number of chronic pain problems, number of past surgeries, tobacco use, head trauma history, body mass index (BMI), sleep disorders, and education level. The extent to which a patient fits into a particular category is given a point value ranging from 0 to 5. For example, within the category of medical comorbidities, moderate disease has a value of 2, and in the sleep category, the presence of severe insomnia for more than two years has a value of 3. These values are added to arrive at a final score. The higher the score, the greater the complexity of a patient's chronic pain, which is classified as low, moderate, or complex.

The tool is designed to help primary care physicians—the practitioners who handle the bulk of chronic pain patients—decide whether to treat the pain themselves or to refer a case to a pain specialist and to give pain specialists a better idea of the management approach needed for a particular patient. “We don't make any claims that this is easy,” Dr. Peppin said.

“We also don't make any claims that there aren't barriers to this approach, because there clearly are—reimbursement barriers, time constraints, etc. We also feel that this is the only way that we are going to get these patients adequately treated.”

When managing patients with chronic pain, clinicians should look for overlapping problems and conduct a complete history and physical examination, he said. Good documentation is essential in the complexity model, with the objectives of establishing a working diagnosis, identifying patients' pain problems and comorbidities, outlining a clear treatment approach, establishing patient goals, communicating clearly with patients' primary care physicians, and providing appropriate documentation for reimbursement.