Implementation of A Multidimensional Pain Program in Primary Care to Improve Outcomes in Patients with Chronic Low Back Pain

Background: The United States is experiencing an epidemic of opiate overdoses. Primary care providers (PCPs) have inadvertently contributed, having written more that 259 million opioid prescriptions for pain in 2012. Pain is the most common reason veterans visit their PCP, and chronic low back pain (LBP) is the leading diagnosis evaluated. The current unidimensional pain scale uses a numeric score that corresponds to veterans’ perceived pain intensity, but not the effect pain has on their quality of life. The Defense and Veterans Pain Rating Scale (DVPRS) is a multidimensional pain assessment tool used to standardize pain assessment in the Veterans Administration (VA) health system, and improve care using the VA clinical practice guidelines (CPG). Aim: The purpose of this quality improvement (QI) project was to implement a multidimensional pain program (MPP) in which PCPs were educated to replace the unidimensional pain assessment tool with the DVRPS, increase veterans’ involvement in pain agreements, and follow the CPG to better manage pain with less opiate use. Methods: The project coordinator (PC) reviewed charts of 22 veterans with chronic LBP and assessed for baseline measures of reported pain levels, the amount of opioids used with a morphine equivalent daily dose (MEDD) calculator, frequency of referrals to the interdisciplinary services according to the CPG, and use of pain agreements. The PC educated the PCPs about pain, use of the DVPRS, and the CPG. After three months, the PC reassessed the following outcome measures: (1) use of the DVPRS, (2) frequency of appropriate referrals according to the CPG (3) change in pain scores, and (4) the MEDD of opiates prescribed. At the completion of the project, the staff were surveyed about the MPP and replacement of previous pain scales with the DVPRS. Results: The MPP at the chosen federal facility was associated with achievement of the specific aims: there was an increase in documentation of pain agreements, more referrals to appropriate specialists, and decreased MEDD. The PCP’s were in favor of continued use of the DVPRS to better align practice with the CPG.Key words: Pain management, pain assessment, fifth vital sign, numeric pain scale