The Rural Pain Crisis

The Rural Pain Care Crisis: Strategies for Ameliorating Patient Suffering and Maintaining Provider Sanity Michael E. Schatman, PhD, CPE

Disclosure

Nothing to Disclose

Learning Objectives Recognize the complex factors that have caused the crisis in rural health care in the United States Identify the unique pain care issues of special populations in rural areas Describe how concrete strategies can be used to improve rural pain care practices Describe educational opportunities that will further enhance their clinical skills

Crisis in Pain Care 2008 – 3 articles with Jim Giordano elucidating the crisis in pain care in the US Giordano J, Schatman ME. Pain Physician 2008; 11:483-490.

Giordano J, Schatman ME. Pain Physician 2008;11:589-595.

Giordano J, Schatman ME. Pain Physician 2008;11:771-784.

Posited that ethical shortcoming were the cause of the sorry state of pain medicine 2012 – pain care has further deteriorated Ethical issues are still at the root of the problem

Crisis in Pain Care (cont’d) Disparities in pain care continue to grow The emphasis in the literature remains solely on racial and ethnic disparities Meghani SH, et al. Pain Med. 2012;13:5-28.

Even the research on geographic disparities emphasizes racial issues Green CR, Hart-Johnson T. J Natl Med Assoc. 2010;102:321-331.

Green CR, Hart-Johnson T. J Pain 2012;13:176-186.

Fuentes M, Hart-Johnson T, Green CR. J Natl Med Assoc. 2007;99:1160-1169.

Considering disparities other than racial puts academicians at risk of being branded “racist”

Crisis in Rural Pain Care Breuer et al. (2007) – published a landmark study in the Journal of Pain Breuer B, et al. J Pain 2007;8:244-250.

Findings: –The number of pain specialists practicing in the US is inadequate to meet the needs of the population –Many “pain specialists” are in academia, and do not provide clinical services –While the shortage is problematic nation-wide, it is worse in rural areas

Crisis in Rural Health Care (General) Globally, there is a close correlation between the concentration of qualified health care providers and key health outcomes World Health Organization (WHO) The World Health Report 2006 – Working together for health. Geneva: World Health Organization; 2006.

Physician shortage in rural areas: –The issue of the shortage of rural physicians has been in the literature for at least 87 years

Pusey WA. JAMA 1925;84:281-285.

–20% of our population live in rural areas, but only 9% of our physicians practice in rural communities US Census Data, 2010.

Crisis in Rural Health Care (cont’d) 95 PCPs per 100,000 residents needed; currently, there are only 55 per 100,000

National Advisory Committee on Rural Health and Human Services. The 2010 report to the Secretary: rural health and human service issues. Available at: http://www.hrsa.gov/advisorycommittees/rural/2010secretaryreport.pdf.

Rural applicants to medical schools are under-represented

Hensel JM, et al. Open Med. 2007;1:e13-e1.

Only 4% of recent medical graduates planned rural practice

Rabinowitz HK, et al. Acad Med. 2005;80:728-732.

As fewer medical students choose primary care residencies, the rural shortage has become more acute

Rosenblatt RA. Acad Med. 2010;85:572-574.

Crisis in Rural Health Care (cont’d) DO programs produce more rural physicians than MD programs

Chen F, et al. Acad Med. 2010;85:594-598.

As more DOs choose specialty training, this difference is likely to become less evident

Rosenblatt RA. Acad Med. 2010;85:572-574.

Physicians from rural areas are more likely to practice in rural areas

Zink T, et al. Acad Med. 2010;85:59-604.

Governments and medical schools need to collaborate to ensure that prospective students from rural areas are admitted

Rourke J, et al. CMAJ 2005;172:62-65.

Heavy-handed approach justified by the fact that all medical schools are publicly funded

Reinhardt UE. JAMA 2000;284:1136-1138.

Crisis in Rural Health Care (cont’d) Compulsory Service Programs –Used to reduce health care shortages in rural areas of many countries –Effectiveness has been established internationally Frehywot S, et al. Bull World Health Organ. 2010;88:364-370.

–Barely addressed as an option in the US –Physician/resident/medical student attitudes not likely to be positive –“assault on autonomy”

Nurses: The Key to Rural Pain Management

Rural Nursing Shortage Nurses are also in short supply in rural areas –e.g. 91% of rural hospital CEOs in Illinois reported a serious shortage in their hospitals

Glasser M, et al. J Rural Health 2006;22:59-62.

It takes rural hospitals 60% longer to fill nursing vacancies

Cramer M, et al. Nurs Outlook 2009;57:148-157.

While educational support has been found to help nurse retention, rural hospitals often lack the resources to provide such support

Molinari DL, et al. J Contin Educ Nurs. 2008;39:42-46.

Rural Nursing Shortage (cont’d) Implications of nursing shortage –Decreased patient safety

–Inferior patient outcomes –Higher levels of patient mortality

Effort to alleviate shortage

Unruh LY, Zhang NJ. Nurs Res. 2012;61:3-12.

Buerhaus PI. JAMA 2008;300:2422-2424.

Estabrooks CA, et al. Nurs Res. 2005;54:74-84.

–Government intervention needed –“There is reason, however, to argue that need for nursing care enters the realm of providing for the common good, a public safety issue, and therefore requires government intervention”

Fox RL, Abrahamson K. Nurs Forum 2009;44:234-244.

Shortages of Other Pain Care Providers Mental Health Professionals –Rural shortage is well-documented

Smalley KB, et al. J Clin Psychol. 2010;66:479-489.

Hough RL, et al. J Rural Ment Health 2011;35:35-45.

Half of all counties in the US don’t have a psychologist, psychiatrist, or social worker American Psychological Association. Caring for the rural community: 2000–2001 report. Available at: http://www.apa.org/rural/APAforWeb72.pdf.

Rural residents have been shown to have higher levels of depression, substance abuse, domestic violence, incest, and child abuse than residents of urban areas

Cellucci T, Vik P. Prof Psychol Res Pract. 2001;32:248-252.

Rural Mental Health Provider Shortage Suicide rates are higher in rural areas Eberhardt M, et al. Health, United States, 2001.

National Center for Health Statistics;2001.

The impact of mental disorders is greater in rural areas, due to a 3pronged problem of: –Accessibility –Availability –Acceptability of MH services – stigma in rural areas is strong Health Resources and Services Administration. Mental health and rural America: 1994–2005. Rockville, MD: HRSA; 2005.

Good luck finding a fellowship-trained pain psychologist

Shortage of Other Pain Care Providers Physical therapists –Shortage in rural areas well established Norris TE, Larson EH. In: Larson EH, et al. (eds.). State of the health workforce in rural America: profiles and comparisons; 2005. Wilson RD, et al. J Rural Health 2009;25:26-32.

–Shortage may become worse as we transition to the DPT as the entry-level degree for physical therapists

King J, et al. Physiother Res Int. 2010;15:24-34.

Causes of Shortages of Providers 1. Difficulties in recruitment and retention –Slower rural lifestyle may not appeal to young health care providers trained in urban settings –Limited financial incentives • Medicare and Medicaid account for 60% of rural hospital revenues Ziller EC, et al. Health Aff. 2006;25:1688-1689.

–Shortages  increased workloads  provider burnout Buykx P, et al. Aust J Rural Health 2010;18:102-109.

Causes of Shortages of Providers (cont’d) 2. More challenging patient population – Older United States Administration on Aging. Statistics on the aging population, 2007.

– A less medically compliant population Kaiser Commission on Medicaid and the Uninsured. The uninsured in rural America; 2003.

– A sicker, more at-risk population Center on an Aging Society. Rural and urban health. Washington, DC: Georgetown University; 2003.

– Tobacco use Vander Weg MW et al. Addict Behav. 2011;36:231-236.

– Certain classes of substance abuse Lambert D, et al. J Rural Health 2008;24:221-224.

– Obesity Jackson JE, et al. J Rural Health 2005;21,140–148.

– Poverty US Census Data, 2010.

Causes of Shortages of Providers (cont’d) 3. Other recruitment/retention issues: –Professional isolation –On call schedule –Employment opportunities for spouse –Raising a school-age child Hancock C, et al. Soc Sci Med. 2009;69:1368-1376.

4. No evidence of effectiveness of any specific retention strategy Wilson NW, et al. Rural Remote Health 2009; 9:1060.

Grobler L, et al. Cochrane Database Syst Rev. 2009;(1):CD005314.

General Issues - Rural Pain Prevalence –Significantly higher in rural compared to urban areas • May related to failure to treat acute pain in rural settings

Hoffman PK, et al. J Community Health Nurs. 2002;19:213-224.

–Recent systematic review indicates that farmers have higher rates of musculoskeletal disorders than non-farmers

Osborne A, et al. Am J Ind Med. 2012;55:143-158.

• Recently established as relating to daily exposure to whole-body vibration and mechanical shock

Milosavljevic S, et al. Ann Occup Hyg. 2012;56:10-17.

–Other “painful” rural careers include fishing and logging Francisco V, Ravesloot C. State of the Science Report, April, 2012.

Positives of Rural Pain Sufferers Social solidarity, close-knit relationships, and community commitments may increase potential for pain care in rural communities Work ethic

Robinson CA, et al. J Rural Health 2010;26:78-84.

–Recent study indicates that rural workers with LBP are more likely to continue to work than their metropolitan counterparts – “can do” attitude

Dean SG, et al. J Occup Rehabil. 2011;21:395-409.

–Rural workers suffering fractures on the job returned faster than urban workers

Young AE, et al. Scand J Work Environ Health 2008;34:158 –164.

Positives of Rural Pain Sufferers (cont’d) Rural workers injured on the job were likely to have a lower level of health care utilization when compared to urban workers –It has been surmised that rural workers are more active in their coping strategies, and less likely to see their injuries as disabling Young AE, et al. J Occup Environ Med. 2009;51:204-212.

–Rural culture appears to value self-reliance and independence Philo C, et al. J Rural Stud. 2003;19:259-281.

Hauenstein EJ, et al. Adm Policy Ment Health 2007;34:255-267.

Rural Pain The impact of rural residency among chronic pain sufferers is largely absent in the literature Recent qualitative study identified the them of “no place out here to get support” Tollefson J, et al. Int J Nurs Pract. 2011;17:478-485.

Recent study determined that low-literacy and culturally sensitive group CBT and education helps rural chronic pain patients – but doesn’t address the issue of where to find facilitators Thorn BE, et al. Pain 2011;152:2710-2720.

Shared Decision Making (SDM) (cont’d) “…a process by which patient and clinician work together to reach an informed decision by considering individual patient preferences and values as well as medical evidence” King VJ, et al. Med Decis Making 2012 [epub ahead of print].

Invaluable when clinician time in constrained and when information for patients may be of uncertain quality Foundation for Informed Medical Decision Making. Informing and involving patients in medical decisions: the primary care physicians’ perspective. Available at: http://www.informedmedicaldecisions.org/pdfs/FinalwhitepaperPCPSurvey.pdf.

Shared Decision Making (cont’d) Often involves using “Decision Aids,” eg, brochures, DVDs Costs will be counterpoised by physician incentives included in the Affordable Care Act Kocher R, et al. Ann Intern Med. 2010;153:536–539.

Most studies of SDM have been conducted in academic centers or large health systems in metropolitan areas O’Connor AM, et al. Cochrane Database Syst Rev. 2009;3:CD001431.

Shared Decision Making (cont’d) In a recent study of rural primary care practices, SDM was found by clinicians to be most useful when dealing with “hard” topics – the hardest of which was chronic pain King VJ, et al. Med Decis Making 2012 [epub ahead of print].

Research indicates that SDM increases levels of patient involvement, which is critical in self-management Elwyn G, et al. Fam Pract. 2004;21:337-346.

Ethically sound, as it enhances patient autonomy

Opioids and Rural Pain

Opioids and Rural Pain (cont’d) Rural opioid-related deaths are increasing more rapidly than those in non-rural areas Paulozzi LJ, Xi Y. Pharmacoepidemiol Drug Saf. 2008;17:997-1005.

Rural inhabitants more likely to have comorbid mental health issues and substance abuse disorders –Authors suggest that the lack of MH services results in rural dwellers self-medicating Simmons LA, Havens JR. J Affect Disord. 2007;99:265-271.

Opioids and Rural Pain (cont’d) Rural adolescents are significantly more likely to abuse prescription medications than non-rural adolescents Havens JR, et al. Arch Pediatr Adolesc Med. 2011;165:250-255.

Polydrug toxicity is a more common cause of accidental overdoses involving opioids in rural decedents Wunsch MJ, et al. Am J Addict. 2009;18:5-14.

Opioids and Rural Pain (cont’d) Research indicates that rural prescription opioid users are more likely to use benzodiazepines, medically and nonmedically Havens JR, et al. J Addict Med. 2010;4:137-139.

–Particularly significant given the frequency with which concomitant use of benzodiazepines are involved in opioid overdose deaths Webster LR, et al. Pain Med. 2011; 12(Suppl.2):S26–S35.

Opioids and Rural Pain (cont’d) The good news: A community based OD prevention program in rural NC resulted in a substantial reduction in opioid deaths

Albert S, et al. Pain Med. 2011;12(Suppl.2):S77-S85.

Successful Canadian rural primary care pilot program to decrease opioid deaths

–Educational workshops for physicians –Toolkits (e.g., risk screening measures, educational materials for patients) –Email support group for physicians –Access to videoconferencing services

Thinking outside the box works!

Srivastava A, et al. Can Fam Physician 2012;58:e210-e216.

Opioids and Rural Pain (cont’d) Bottom line: lack of access to other approaches to chronic pain may make COT more important in rural areas Aggressive risk mitigation – while important in all settings – may be even more crucial in rural areas By ignoring the predicament of the rural practitioner, we are ignoring the plight of the rural pain sufferer Ethical, as well as practical implications are apparent

Psychological Intervention The frustrating thing is that we know of its efficacy in rural populations – when available –CBT has been successfully adapted to low-literacy rural populations Day MA, Thorn BE. Pain 2010;151:467-474.

Kuhajda MC, et al. Transl Behav Med. 2011;1:216-223.

–Lends itself well to chronic pain treatment via internet Cuijpers P, et al. J Behav Med. 2008;31:169-177.

Special Populations in Rural Areas

Older Rural Adults Older adults are over-represented in rural areas United States Administration on Aging. Statistics on the aging population, 2007.

More likely to suffer from chronic pain than their nonrural counterparts Hoffman PK, et al. J Community Health Nurs. 2002;19:213-224.

Most are unaware of the existence of nondrug treatments that can be used for self-treatment to complement pharmacologic pain management approaches Vallerand AH, et al. Am J Pub Health 2003;93:923-925.

Older Rural Adults (cont’d) Recent research indicates that nurse-taught self-treatment strategies (eg, appropriate use of heat and cold, relaxation) are effective tools for older rural pain sufferers Fouladbakhsh JM, et al. Pain Manag Nurs. 2011;12:70-81.

Given the emergent literature on problems with opioids unique to seniors, teaching nondrug strategies is crucial!

Dublin S, et al. J Am Geriatr Soc. 2011;59:189-1907.

Miller M, et al. J Am Geriatr Soc. 2011;59:430-438.

Lynch T. Am J Manag Care 2011;17:S293-S298.

Rural African Americans Rural practitioners in certain regions will see a high percentage of African American patients Unlike urban areas – where Latinos are the largest minority population – rural African Americans outnumber rural Latinos

Johnson K. Reports on Rural America, 2006.

Trust issues among rural African Americans can make treatment complicated

Wiltshire JC, et al. J Natl Med Assoc. 2011;103:845-851.

Dilorio C, et al. J Community Health 2011;36:505-512.

Rural African Americans Despite 20th century migration of African Americans to northern cities, large rural populations continue to dwell in the southeast Johnson K. Reports on Rural America, 2006.

Although rural African Americans are particularly vulnerable to ill health, they are often overlooked in the literature Scott AJ, Wilson RF. Rural Remote Health 2011;11:1634.

Rural African Americans (cont’d) Higher prevalence of painful conditions in rural African American populations – barely investigated –Hip osteoarthritis Jordan JM, et al. J Rheumatol. 2009;36:809–815.

–Knee osteoarthritis Jordan JM, et al. J Rheumatol. 2007;34:172-180.

Assumptions often made from studies of racial prevalence in general population, which is problematic

Rural African Americans (cont’d) Strong empirical support exists for higher incidence of diabetes among rural African Americans Dabney B, Gosschalk A. In: Gamm LB, et al. (eds). Rural Healthy People 2010; 2007 (REVIEW).

Incidence of diabetes and higher rates of complications established for rural African Americans Clark ML, et al. South Online J Nurs Res. 2011;11:(April).

Research needed on rural racial differences in painful diabetic neuropathy

Rural Latinos The Latino population in rural areas grew at the fastest rate of any group in the 1990’s and post-2000

Johnson K. Reports on Rural America, 2006.

Clearly due to the large Latino populations in rural farming communities

U.S. Census Bureau. Current Population Survey, 2010.

Health care access situation is dire: –74% uninsured –72% have no PCP –51% need translator when going to a doctor

Duran M. Online J Rural Nurs Health Care 2012;12:49-54

Rural Latinos (cont’d) Qualitative study identified numerous barriers causing health care disparities: –Lack of and limitations of health care insurance –High cost of health care services –Communication with providers –Legal status/discrimination issues –Transportation issues Cristancho S, et al. Qual Health Res. 2008;18:633-646.

Rural Latinos (cont’d) Even palliative care in cases of cancer is difficult to access: –Geographic distance/transportation –Underinsurance –Language and literacy barriers –Fear of deportation Smith AK, et al. JAMA 2009;301:1047-1057.

Rural Latinos (cont’d) An important barrier to effective treatment for Latinos is a lack of adequate pain assessment tools and educational materials

McNeill JA, et al. Hispanic Health Care Int. 2003;2:73-80.

Likely more of an issue among rural Latinos, given lower levels of education, healthcare literacy

Institute of Medicine. Health Literacy: A Prescription to End Confusion, 2004.

Widespread translation and validation of assessment measures finally beginning to occur

Rural Latinos (cont’d) Many translated tools are still culturally-inappropriate Narayan MC. Am J Nurs. 2010;110:38-47.

Latino pain outcomes remain poor –Less satisfied with treatment than other ethnic groups Wallace AS, et al. Spine J 2009;9:721-728.

Latinos less likely to be provided with opioids than non-Latino Caucasians, despite Latinos’ lower rates of prescription drug abuse Young AM, et al. Harm Reduction J 2010;7:24.

Meghani SH, et al. Pain Med. 2012;13:5-28.

Rural Latinos (cont’d) Latino patients’ fears of addiction to opioids are greater than those of other racial and ethnic groups, actually making them opiophobic Juarez G, et al. Cancer Pract. 1998;6:262-269.

Thus, there should be a greater focus on assessing patients’ attitudes to opioids and lifestyle issues, and less on a formulaic approach to pain control Chiauzzi E, et al. Pain Pract. 2011;11:267-277.

Rural Latinos (cont’d) What works in treating this population?

–Interpreters have been empirically established as reducing disparities and improving care Moreno G, Morales LS. J Gen Intern Med. 2010;25:1282-1288.

• CMS funding for interpreters is available

–Less than 20% of physicians treating Spanish-speaking patients can communicate with in Spanish at an advanced level Chiauzzi E, et al. Pain Pract. 2011;11:267-277.

• Worse in rural areas, as Latino physicians are less accessible to Latino patients than in non-rural areas Saha S, et al. Health Aff. 2000;19:76-83.

Rural Latinos: Word of Caution Anglos often make the mistake of assuming that all Latinos are the same The vast majority of rural Latinos in the US are of Mexican background US Census Bureau. 2008 American Community Survey 1-Year Estimates.

Nevertheless, avoid the assumption If not of Mexican heritage, take the time to ask/learn about specific health care beliefs

Rural Native Americans Rural Native American population continues to grow Johnson K. Reports on Rural America, 2006.

1/3 live in rural settings U.S. Census Data, 2010.

Disproportionally poor, medically underserved Zuckerman S, et al. Am J Public Health 2004;94:53-59.

Little research on pain among rural Native Americans, although the body of literature is gradually growing

Rural Native Americans (cont’d) Higher prevalence of painful conditions in Native American populations

Jiminez N, et al. J Pain 2011;12:511-522.

Juvenile rheumatoid arthritis Adult rheumatoid arthritis

Mauldin J, et al. BMC Musculoskelet Disord 2004;5:30.

Ferucci ED, et al. Semin Arthritis Rheum. 2005;34:662-667.

LBP Deyo RA, et al. Spine 2006;31:2724-2727.

Neck Pain

Barnes PM, et al. Advance Data 2005;356:1-24.

Headache Rhee H. Headache 2000;40:528-538.

Rural Native Americans (cont’d) Assessment difficult due to tendency to use vague terms such as “ache” and “discomfort” to describe severe pain Kramer BJ, et al. Arthritis Rheum. 2002;47:149-154.

Among certain groups, there is a culturally-grounded unwillingness to discuss pain at all –There exists the conviction that it is the healer’s job to perceive and experience the sufferer’s pain Barkwell D. J Pain Symptom Manage. 2005;30:454-464.

Know the cultural norms!

Rural Native Americans (cont’d) Certain tribes harbor the disbelief that medication can alleviate pain Elliott BA, et al. J Cancer Educ. 1999;14:28-33.

Stephenson N, et al. J Natl Black Nurses Assoc. 2009;20:11-18.

Educate, educate, educate! Do not underestimate faith in Native healing!

–63% of rural Navajos relied upon it for tx of their RA Ferucci ED, et al. Arthritis Rheum. 2008;59:1128-1136.

Be aware that rural Native Americans are twice as likely to abuse prescription opioids Huang B, et al. J Clin Psychiatry 2006;67:1062-1073.

Rural Native Americans (cont’d) Does this greater likelihood of abuse justify undertreatment? No – it simply means that risk mitigation practices must be more stringent Finally – Don’t make the mistake of assuming that all rural Native American tribes conceptualize pain and its treatment in the same manner

Veterans Military veterans are over-represented in rural areas West AN, et al. J Rural Health 2010;26:301-309.

Chronic pain is extremely prevalent among veterans – particularly those returning from Iraq and Afghanistan Clark M, et al. J Rehabil Res Dev. 2007;44:179–194.

Lew HL, et al. J Rehabil Res Dev. 2007;44:1027–1034.

VA stepping up to the plate with the SCAN (Specialty Care Access Network) program – helping rural veterans with chronic pain

Rural Emergency Departments Rural inhabitants: –Less likely to have a PCP –Less likely to have insurance –Less likely to have adequate transportation –More likely to use EDs for their primary care needs –Results in rural EDs becoming increasingly overtaxed Lawson S, et al. ENA Annual Conference 2011.

Rural End of Life Pain Care Rural areas less likely to have Medicare-certified hospices –Lack of hospice correlates highly with shortage of physicians Campbell CL, et al. J Nurs Scholarsh. 2009;41:420-428.

–Also correlates with community wealth Silveira MJ, et al. J Pain Symptom Manage. 2011;42:76-82.

Significant barriers limit access to rural hospice and palliative care –Most notable are financial barriers Lynch S. Am J Hosp Palliat Care 2012;[epub ahead of print].

Rural End of Life Pain Care (cont’d) Interdisciplinary treatment teams are rare Hall P, et al. J Interprof Care 2008;22:73-79.

Palliative care needs to occur within the context of primary care in rural areas Also, more likely to be home-based More likely to see palliative volunteer networks than in non-rural areas Castleden H, et al. Health Place 2010;16:284-290.

Qualitative study: Rural palliative care providers were more focused on curative approaches rather than pain management Crooks VA, et al. J Mixed Methods Res. 2011;5:77-95.

Rural End of Life Pain Care (cont’d) Many rural providers find it difficult to find strong opioids, and when they do, they’re often more expensive than in other areas Francoeur RB. Risk Manage Healthc Policy 2011;4:97–105.

Many rural pharmacies don’t carry strong opioids due to the perception of low demand Baltic TE, et al. Cancer Pract. 2002;10(Suppl. 1);S39-S44.

Is the tail wagging the dog here?

Rural End of Life Pain Care (cont’d) 2005 – Center to Advance Palliative Care released “Providing Hospice and Palliative Care in Rural and Frontier Areas” 188 page document Available at no cost at: http://199.237.254.34/pubs/pdf/Rural_Toolkit.pdf

Should be considered the bible of rural palliative care Emphasizes “pain management, symptom control and comfort care”

Center to Advance Palliative Care Notable points: –Adult children often leave rural areas to seek their fortunes, leaving their parents alone –Recognizes that care will likely be provided in the home –Offers strategies for partnering with nursing homes and pharmacies –Discusses strategies for financial viability in detail –Emphasizes the need for dual roles and cross-training

Center to Advance Palliative Care (cont’d) Encourages exploration of telemedicine in order to deal with limited physician resources Provides strategies for dealing with transportation and other geographic issues

Rural Medical Technology

Rural Medical Technology (cont’d) Lags behind non-rural areas –Electronic medical records are far less utilized Tucker M, et al. South Med J. 2012;105:72-77.

Rural patient discomfort with technology is a myth Warren JC, et al. Health Technol. 2011;1:99-105.

–Rural telehealth is being used successfully by the VA in pilot programs Luptak M, et al. Rural Remote Health 2010;10:1375.

Telehealth/Telerehabilitation Definition: “The clinical application of consultative, preventative, diagnostic and therapeutic services via 2 way interactive telecommunication technology” Wakeford L, et al. Am J Occ Ther. 2005;59:656-660.

Despite established empirical efficacy, it is underused for pain –New study: Medline search yielded 14,000 references for “telehealth”, and over 100,000 for “pain” but only 32 for “telehealth and pain” McGeary DD, et al. Pain Pract. 2012;12:[epub ahead of print].

Telehealth Research Chronic pain patients found to be satisfied with physician-nurse team telehealth sessions, with high rates of discontinuation of both NSAIDs and opioids Naylor MR, et al. J Pain 2010;11:1410–1419.

Found to be equally effective as “in vivo” rehabilitation for postTKA patients Russell TG, et al. J Telemed Telecare 2003;9(Suppl. 2):S44-S47.

Found to provide as accurate a measure of gait analysis as the traditional assessment Russell TG, et al. J Telemed Telecare 2003;9(Suppl. 2):S48-S51.

Telehealth Research (cont’d) One study found higher levels of pain patient satisfaction for a telehealth management program than for in-person tx (56% vs. 24% “highly satisfied”) Pronovost A, et al. Can J Anesth. 2009;56:590–596.

Significant improvement in psychosocial outcomes among FMS patients participating in an Internet-based selfmanagement program Williams DA, et al. Pain 2010;151:694–702.

Telehealth Research (cont’d) Successfully used in the provision of an exercise program for knee pain Wong YK, et al. J Telemed Telecare 2005;11:310-315.

Effective in increasing self-efficacy and reducing pain and depression among older adults with arthritis Pariser D, O’Hanlon A. J Geriatr Phys Ther. 2005;28:67-73.

Actually found to be more effective than in-person rehabilitation for post-shoulder joint replacement patients Eriksson L, et al. J Telemed Telecare 2009;15:215-220.

Telehealth Research (cont’d) Telephonic migraine management counseling for adolescents found to be equally effective as treatment with triptans Cottrell C, et al. Headache 2007;47:1293-1302.

Has been used to provide interactive biofeedback to hand trauma and pelvic floor dysfunction patients Morelli S, et al. J Telemed Telecare 2008;14:372-376.

Glazer HI, et al. J Reprod Med. 2002;47:728-730.

Found to be equally effective as in-classroom interventions for teaching mind-body wellness Rybarczyk B, et al. Behav Med. 1999;24:181-190.

Telehealth Research (cont’d) Effective for teaching self-regulation skills to chronic pain patients Appel PR, et al. Telemed J E Health 2002;8:361-368.

Being used to assess chronic pain and its relationship to affective distress, depressive symptoms, and pain catastrophizing Roth RS, et al. Am J Phys Med Rehabil. 2004;83:827-834.

Successfully used for anti-depressant management Fortney JC, et al. Gen Hosp Psychiatry 2006;28:18-26.

Telehealth Research (cont’d) CBT – A critical, evidence-based modality in chronic pain management Are cognitive psychotherapists readily available in rural areas? Systematic review demonstrated efficacy of CBT via telehealth for health conditions including chronic pain Cuijpers P, et al. J Behav Med. 2008;31:169-177.

Telehealth approach obviously essential for providing psychosocial component of rural palliative care Fann JR, et al. J Clin Oncol. 2012;30:1178-1186.

Telehealth Research (cont’d) Therapeutic Interactive Voice Response following CBT for chronic pain Automated system with 4 components: –Daily self-monitoring questionnaire –Didactic review of coping skills –Behavioral rehearsal of coping skills –Monthly behavioral feedback messages from CBT therapist

Decreased pain, improved coping, decreased likelihood of relapse Naylor MR, et al. Pain 2008;134:335-345.

Telehealth Research (cont’d) Pediatric pain – Internet-delivered family CBT for children and adolescents with chronic pain –Reduced pain –Increased function –Rated as acceptable by all parents and children in the study Palermo TM, et al. Pain 2009;146:205–213.

Online chronic pain education module for physicians as effective as in-person lectures for improving provider knowledge, attitudes, and beliefs about pain management Harris JM, et al. Pain Med. 2008;9:555–563.

Telehealth Research (cont’d) Interdisciplinary pain treatment – impossible in rural settings? Videoconferencing between interdisciplinary rehabilitation team members has been found to be clinically effective Careau E, et al. J Telemed Telecare 2008;14:427-434.

Health care follow-up in rural areas has been found to be problematic Pollard C, et al. J Rural Health 2009;25:77-84.

Once chronic pain patients have stabilized, videoconferencing has been determined to be an effective method for follow-up Elliott J, et al. Pain Manag Nurs. 2007;8:35-46.

Telehealth and Mental Health Care Rural areas –Telehealth services alleviate problems of: •Travel •Strong rural stigma regarding mental health services

Thereby increases the likelihood of more biopsychosocial pain treatment

Rural Telehealth Currently, its applications have been limited in the US – mainly to state initiatives –Programs partnering urban academic medical centers with community health centers to manage chronic disease states (including pain) through telehealth have shown promise Arora S, et al. Health Aff. 2011;30:1176-1184.

–The VA is emerging as a leader in rural telehealth Tuerk PW, et al. Telemed J E Health 2010;16:115-117.

–Affordable Care Act: Earmarks $11 billion over 5 years for such initiatives Adashi EY, et al. N Engl J Med. 2010;362:2047–50.

Current Barriers to Rural Telehealth Usually about the money: irrespective of evidence of cost-effectiveness Current barriers include: –Limited reimbursement –Legal and regulatory barriers –Lack of public knowledge of available services Tracy J, et al. Telemed J E Health 2008;14:990-994.

Costs of Telehealth for Pain Identified as cost-effective Embraced by managed care

Cameron AE, et al. Telemed J. 1998;4:125–144.

Elliott J, et al. Pain Manage Nurs. 2007;8:35-46.

Palsbo SE, Bauer D. Manag Care Q. 2000;8:56-64.

More current research needed to understand the extent of potential savings Insurance reimbursement

McGeary DD, et al. Pain Pract. 2012;12:[epub ahead of print].

–For 60% of telehealth contacts qualifying for reimbursement, over 80% result in reimbursement amounts comparable with those generated by inperson contact

Whitten P, Buis L. Telemed J E Health 2007;13:15–23.

Costs of Telehealth for Pain (cont’d) Work will need to be done with Medicare and Medicaid in order to loosen up the CPT codes that they currently accept Start-up costs of Telehealth programs can be prohibitive, with equipment costs ranging from $3000 to $300,000 Within 3-5 years, however, there will be a significant savings as compared to in-person tx

Vo AH. The telehealth promise: better health care and cost savings for the 21st century.

AT&T Center for Telehealth Research and Policy. University of Texas Medical Branch Report, May 2008.

As private insurers will clearly benefit from implementation of improved rural health care technology, they should look at it as a worthwhile investment

Bahensky JA, et al. J Rural Health 2008;24:101-105.

Costs of Telehealth for Pain (cont’d) Even telephonic self-regulation training for patients with chronic pain is effective - and cheap!

Appel PR, et al. Telemed J E Health 2002;8:361–368.

“Creative” use of existing CPT codes may be necessary until the government intervenes McGeary DD, et al. Pain Pract. 2012;12:[epub ahead of print].

Setting up telehealth programs focusing on patient needs rather than “cool technology” will serve underserved rural pain patients best Rosser BA, et al. Telemed J E Health 2011;17:211–216.

Primary Care and Chronic Pain

PCPs and Chronic Pain Only 15% of PCPs “enjoy” treating chronic pain Potter M, et al. J Fam Pract. 2001;50:145-151.

Only 34% of PCPs are comfortable treating patients with chronic pain.

O’Rorke JE, et al. Am J Med Sci. 2007;333:93-100.

Generally, PCPs would rather refer chronic pain patients to specialists than treat them themselves Upshur CC, et al. Pain Med. 2010;11:1791-1798.

Obviously not practical in rural areas without access to pain specialists Despite advocacy for PCP and mid-level provider control of chronic pain, challenges exist

PCP Training in Pain Management Essentially non-existent in medical school Empirically established in study of internal medicine residents

Yanni LM, et al. J Opioid Manag. 2008;4:201-211.

Guidelines exist for family practice resident training in chronic pain management

–American Academy of Family Physicians. Recommended Curriculum Guidelines for Family Medicine Residents: Chronic Pain Management.

http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/chronicpain.Par.0001.File.tmp/Reprint286FINAL.pdf

No evidence to suggest that training programs adhere to the guidelines

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Chronic Pain and Primary Care PCPs complain that there is insufficient time to address clinical concerns in visits, although the length of visits increased from 18 to 21 minutes between 1997 and 2005 At the same time, the number of clinical concerns increased from 5.4 to 7.1 Average time spent for each clinical concern was reduced from 4.4 to 3.8 minutes Abbo ED, et al. J Gen Intern Med. 2008;23:2058-2065.

Chronic Pain and Primary Care (cont’d) Primary care – theoretically holistic and biopsychosocial in its approach This theoretical orientation suggests that primary care is the ideal setting for management of chronic pain Smith BH, Torrance N. Curr Opin Support Palliat Care 2011;5:137-142.

•The “time crunch” experienced by rural PCPs provides a barrier to addressing chronic pain patients’ myriad complex issues

Mental Health Issues Can chronic pain be treated effectively without addressing its psychosocial sequelae? Failure to address depression results in worse overall outcomes in chronic pain

Bair MJ, et al. Arch Intern Med. 2003;163:2433–2445.

Failure to diagnose mood disorders in unexplained chronic pain results in patient dissatisfaction and poorer outcomes

Aguera L, et al. BMC Fam Pract. 2010;11:17.

Assume that all patients with chronic pain are depressed to some degree This is a distinction between persistent pain and chronic pain

Schatman ME, Sullivan J. Psychol Injury Law 2010;3:182-202.

Mental Health Issues (cont’d) Depressed chronic pain sufferers have more clinical concerns to be addressed at primary care physicians’ visits than most other patients, and visits are accordingly longer Geraghty EM, et al. J Gen Intern Med. 2007;22:1641-1647.

Not investigated specifically in rural practice, but no reason to think that the results would not generalize

Limits of Responsibility

Must rural physicians become psychologists?

Biopsychosocial Primary Care 2009 study determined that 57% of PCP’s talk to their chronic pain patients about emotional issues Among those who do not prescribe opioids for chronic non-malignant pain, 73% address emotional issues Phelan SM, et al. Pain Med. 2009;10:1270-1279.

At a minimum, rural practitioners need to assess their patients with chronic pain for common emotional sequelae

Physician Assessment of MH Physicians need to consider a differential diagnosis of depression rather than ordering more expensive tests when treating unexplained medical conditions such as chronic pain Seelig MD, Katon W. J Occup Environ Med. 2008;50:451-458.

Physicians should utilize one of 3 tools that is highly valid and quick to administer and score (5-10 minutes)

Physician Assessment of Depression Beck Depression Inventory-2 (BDI-2) Beck AT, et al. The Beck Depression Inventory second edition. Boston: Houghton Mifflin; 1996.

Zung Self-Rating Depression Scale

Zung WW. Arch Gen Psychiatry 1965;12:63-70.

Center for Epidemiologic Studies Depression Scale (CES-D)

Radloff LS. Appl Psychological Measurement 1977;1:385-401.

Physician Assessment of Anxiety Anxiety disorders are highly prevalent in chronic pain, likely as much so as depression Gureje O, et al. Pain 2008;135:82-91.

Studies of chronic pain patients have found that up to 29% meet the DSM criteria for an anxiety disorder Asmundson GJG, Katz J. Depress Anxiety 2009;26:888-901.

Can be quickly and accurately measured by physicians using the Beck Anxiety Inventory Beck AT, et al. J Consult Clin Psychol. 1988;56:893-397.

Physician Treatment of Depression Systematic reviews suggest that it is best treated with a combination of psychotherapy and anti-depressants Hollon SD, et al. J Clin Psychiatry 2005;66:455-468.

Recent systematic review suggests that antidepressant therapy may be more effective than psychotherapy in isolation Cuijpers P, et al. J Clin Psychiatry 2008;69:1675-1685.

Encouraging for the rural practitioner lacking access to adequate MH services

Physician Treatment of Anxiety Combination of antidepressant and psychotherapy determined to be most effective

Struzik L, et al. Expert Rev Neurother. 2004;4:285-294.

Effect of adding CBT to antidepressants in treating anxiety is only marginal

Hoffman SG, et al. Int J Cogn Ther. 2009;2:160-175.

Learning which antidepressants are “deactivating” vs. “activating” is useful

Long term benzodiazepine use is unlikely to be the answer in chronic pain sufferers

Manthey L, et al. Br J Clin Pharmacol. 2011;71:263-272.

Rural PCPs as Psychotherapists 85% of psychological issues are now treated by PCPs with medications and/or counseling Cummings NA, et al. J Clin Psychol Med Settings 2009;16:31-39.

Brief PCP counseling is effective as a first-line treatment Haaga DA. J Consult Clin Psychol. 2000;68:547-548.

A brief course in motivational interviewing alters PCP behaviors with patients – Found to be more effective than simple advice-giving Rubak S, et al. Br J Gen Pract. 2006;56:429-436.

Motivational Interviewing (cont’d) Focuses on helping patients explore and resolve their ambivalence about behavior change MI is patient-centered: –Focuses on what the patient wants, thinks and feels –The patient does most of the talking –Directive only in that the physician “steers” the patient in the healthier direction

Motivational Interviewing (cont’d) Originally designed to involve 30-60 minute sessions Brief Motivational Interviewing (BMI) consisting of multiple brief (<15 minutes) interventions now considered more practical and effective in medical settings Rubak S, et al. Br J Gen Pract. 2005;55:305-312.

Motivational Interviewing (cont’d) Principles: –Express empathy –Develop discrepancy –Avoid argumentation –Roll with resistance –Support self-efficacy

Miller WR, Rollnick SR. Motivational Interviewing: Preparing People to Change Behaviour. New York: Guilford Press; 1991.

Motivational Interviewing (cont’d) Myriad studies support use for substance abuse/addiction Empirically supported when used in primary care for: –Increasing patient activity levels Brodie DA, Inoue A. J Adv Nurs. 2005;50:518-527.

Fortier MS, et al. Appl Physiol Nutr Metab. 2007;32:1170-1185.

–Improving diabetes self-management behaviors Rubak S, et al. Scand J Prim Health Care 2009;27:172-179.

Jansink R, et al. BMC Fam Pract. 2010;11:41.

Efficacy of MI (cont’d)  COPD self-management  Smoking cessation  Adherence with osteoporosis medications  Anti-hypertensive medication adherence  Obesity prevention in children  Modification of eating habits in adults  What do these applications have in common?

Self-management

Robinson A, et al. J Clin Nurs. 2008;17:370-379.

Lai DT, et al. Cochrane Database Syst Rev. 2010:CD006936.

Solomon DH, et al. Osteoporos Int. 2010;21:137-144.

Ogedegbe E, et al. Am J Hypertens. 2008;21:1137-1143.

Perrin EM, et al. Curr Opin Pediatr. 2007;19:354-361.

Resnicow K, et al. Am J Public Health 2001;91:1686-1693.

MI Efficacy with Chronic Pain Motivational interviewing associated with: –Compliance with chronic pain rehabilitation Thompson JM, et al. Can Fam Phys. 2009;55:1085-1088.

–Chronic pain coping Rau A, et al. Schmerz 2008;22:575-578,580-585.

–Improvement of pain level and functional impairment in fibromyalgia patients Ang D, et al. Clin Rheumatol. 2007;26:1843-1849.

–Increased self-efficacy and exercise in fibromyalgia patients Jones KD, et al. Arthritis Rheum. 2004;51:864-867.

MI and Chronic Pain (cont’d) Increased willingness to participate in chronic pain management workshops Habib S, et al. J Pain 2005;6:48-54.

Reducing prescription drug abuse risk Zahradnik A, et al. Addiction 2009;104:109-117.

Baigent M. Curr Opin Psychiatry 2012;25:201-205.

Reducing pain in MS patients Kratz AL, et al. Ann Behav Med. 2011;41:391-400.

Improving self-management skills and cancer pain Thomas ML, et al. Oncol Nurs Forum 2012;39:39-49.

Combined with PT, improves outcomes of LBP Vong SK, et al. Arch Phys Med Rehabil. 2011;92:176-183.

MI in Rural Settings MI found to be effective when applied in promoting health behaviors in rural settings

Perry CK, et al. J Cardiovasc Nurs. 2007;22:304-312. Beckham N. J Am Acad Nurse Pract. 2007;19:103-110. Greaves CJ, et al. Br J Gen Pract. 2008;58: 535–540. Ely AC, et al. J Rural Health 2008;24:125-132. Miller ST, et al. Women’s Health Issues 2010;20:43-49.

MI has been found to be effective in promoting health behaviors even when applied telephonically in rural populations

Bennett JA, et al. Nurs Res. 2008;57:24-32. Cosio D, et al. Sex Transm Dis. 2010;37:140-146.

MI and Latinos Found to be effective in increasing health behaviors among Latinos Interian A, et al. Cultur Divers Ethn Minor Psychol. 2010;16: 215–225.

Del Pilar Rocha-Goldberg M, et al. Ethn Health 2010;15:269-282.

Important based on findings that minority group members in rural areas are less motivated for wellness behaviors than are non-minorities American Heart Association. Heart Disease and Stroke Statistics – 2004 Update.

MI and African Americans Trust issues among rural African Americans call for a more person-centered approach to pain management MI is certainly person-centered MI has been found to be effective in promoting health behaviors among rural African Americans Miller ST, et al. Women’s Health Issues 2010;20:43-49.

MI and Native Americans Study indicated that Native American response to MI was actually better than that of non-minorities Authors surmise that “the client-centered, supportive, and nonconfrontational style of MI may resemble the normative communication style of Indian populations, at least in the American Southwest, thereby representing a culturally congruent intervention” Hettema J, et al. Annu Rev Clin Psychol. 2005;1:91–111.

Example of Brief Motivational Interviewing

Nurses – The Key to Rural Pain Care While there is a rural nursing shortage, nurse practitioners provide a higher percentage of the care in rural settings than in non-rural areas Hooker RS, et al. Health Aff. 2002;21:174-181.

Relative availability ay be due to enjoyment of the autonomy they can exercise in rural settings Kaplan L, et al. J Nurs Pract. 2009;5:169-175.

Rural Nurse Practitioners Nurse practitioners within primary care practices have been found to offer more holistic care than physicians Seale C, et al. J Adv Nurs. 2006;54:534-541.

“Coaching” to promote health is a nurse practitioner educational competency mandated by the National Organization of Nurse Practitioner Faculties National Organization of Nurse Practitioner Faculties. Domains and Competencies of the Nurse Practitioner Education. Washington, DC: Author, 2000.

Nurses as Pain Managers The key skills of nursing include: –The use of effective communication –The assessment, planning, intervention and evaluation of clients’ physical, psychological, social and spiritual needs –The provision of support, empathy, reassurance and encouragement –Education and the provision of information

Nurses as Pain Managers (contâ&#x20AC;&#x2122;d) ď&#x201A;§These skills enable patients to cope more effectively with pain, its associated disability and the consequential reduced quality of life ď&#x201A;§They are routine functions of nurses involved in the treatment of patients with a variety of chronic conditions Richardson C, et al. J Clin Nurs. 2006;15:1196-1202.

What makes nurses such good pain managers?

Nurses as Pain Managers (cont’d) Nurses are “tuned in” to the needs of chronic pain patients British study – Nurses’ perceptions of which treatment components were most important were more congruent with those of the patient compared to other multidisciplinary treatment team members Brown CA, Richardson C. Eur J Pain 2006;10:13-22.

Nurses as Motivational Interviewers Myriad studies – generally in the primary care context – demonstrate that nurses are extremely effective at providing MI intervention Jansink R, et al. BMC Fam Pract. 2010;11:41.

Robinson A, et al. J Clin Nurs. 2008;17:370-379.

Brodie DA. Int J Nurs Stud. 2008;45:489-500.

Beckham N. J Am Acad Nurse Pract. 2007;19:103-110.

Waldrop J. Adv Nurs Pract. 2006;14:23-27.

Bennett JA, et al. Res Nurs Health 2005;28:187-197.

Brodie DA, Inoue A. J Adv Nurs. 2005;50:518-527.

Sims J, et al. Br J Gen Pract. 1998;48:1249-1250.

Specific Rural Nursing Interventions Exercise counseling by nurses has been found to be effective Tompkins TH, et al. J Am Acad Nurse Pract. 2009;21:79-86.

Rural women – more sedentary than urban women –More fear of injury –Safety issue of fear of unattended dogs Wilcox S, et al. J Epidemiol Community Health 2000;54:667-672.

Exercise issues unique to rural settings need to be addressed

Specific Rural Nursing Interventions (cont’d) Prescription adherence is poorer among rural patients Wroth TH, Pathman DE. J Am Board Fam Med. 2006;19:478-486.

–Financially-driven Carlton EL, Simmons L. Rural Remote Health 2011:11:1599.

Prescription assistance programs are effective Kripalani S, et al. J Hosp Med. 2008;3:12-19.

Counseling is needed to convince rural pain patients to take advantage of them Nurses are effective educators/advocates/counselors in PAPs Korber SF, et al. Oncol Nurs Forum 2011;38:44-50.

Summary and Conclusions As bad as our national pain care crisis might be, the rural pain care crisis is more daunting Problems with provider shortages need to be addressed through aggressive government intervention Not happening soon Other challenges of rural pain care include rural pain patient age, compliance issues, lifestyle issues, lack of education, and poverty

Summary and Conclusions (cont’d) Yet rural residents bring strengths to the table: –Social solidarity –Community commitment –Close-knit relationships –Work ethic

A Shared Decision Making approach is imperative – rural passivity is a myth

Summary and Conclusions (cont’d) Extra care needs to be exercised when using opioids with rural pain patients Extra care needs to be exercised when using opioids with all patients Special populations – seniors, African Americans, Latinos, Native Americans, and veterans – need to have their pain treated with special consideration and sensitivity

Summary and Conclusions (cont’d) Rural primary care providers need to develop expertise in palliative care, as quality end-of-life pain treatment is likely unavailable Providers should familiarize themselves with “Providing Hospice and Palliative Care in Rural and Frontier Areas” High tech approaches to pain management – particularly telehealth – represent a huge part of the solution to the rural pain care crisis

Summary and Conclusions (cont’d) Funding for telehealth is on its way – particularly within the Affordable Care Act Rural primary care providers cannot afford to ignore their moral imperative to become more effective pain managers Doing so will necessitate adopting a biopsychosocial perspective Screening for and treating comorbid depression and anxiety represents a good start

Summary and Conclusions (cont’d) Seeking training in Brief Motivational Interviewing will provide you with an incredibly powerful tool in promoting pain self-management http://www.motivationalinterview.org/ Nurses remain the key to improving rural pain care: –More time –More flexible –More biopsychosocial in training and practice

Closing Thoughts (cont’d) A recent article considered whether geographic disparities in palliative care constitute a serious violation of social justice Pesut B, et al. Nurs Philos. 2012;13:46-55.

Shouldn’t the geographic disparities of all pain care be considered a violation of social justice? Tools exist to help the rural practitioner and patient, but they are still somewhat sparse

Closing Thoughts (cont’d) Would justice not be served if the government were to “level the pain care playing field”? In the mean time, keep doing your best with what you have Treating pain is difficult everywhere Practitioners doing it in rural areas are the true “champions of pain”

Rural Physicians Can Be Heroes

Thank You