The Role of the Nurse
Practitioner in Primary Care
Pain Triage & Management
Objectives
 Define and apply models of care that can assist with
triaging pain management patients.
 Understand how the biopsychosocial approach can
impact pain management.
 Appreciate the role of the Nurse Practitioner with pain
management in primary care and multidisciplinary care
settings.
Health Care Reform
 Focus on collaborative teams, care coordination, cost
reduction, quality, and patient centeredness.
 Accountable Care Organizations (ACO’s), Patient
Centered Medical Homes (PCMH), Transitional Care
Management (TCM).
 These models focus upon primary care, coordination,
accessibility, quality, and patient safety utilizing nurse
practitioners and physician assistants. (Naylor, 2012, IOM 2011, Neilson,
et al 2012)
Nurse Practitioners
 Presence in healthcare grown 36% of non-metropolitan
visits 2008-2009. (MMWR, 2012)
 Between 1995 and 2009, the number of Nurse
Practitioners per primary care physician more than
doubled from 0.23 to 0.48.
 140,000 practicing NP’s in the US 2011.(www.aanp.org)
NP Educational Benefits
 Health Promotion
 Patient Education
 Interdisciplinary Collaboration
 Quality Assurance
 Healthcare Design
Research
 Greenfield S, Anderson H, Winickoff R, Morgan A, Komaroff A. Nurse‐protocol
management of low back pain-Outcomes, patient satisfaction and efficiency of
primary care. The Western Journal of Medicine. 1975; 123(5): 350-‐9.
 Garfin S, Kurz LT, Harlow SJ, Katz MM, Weisman M. Effectiveness of a nurse
practitioner in screening patients in a spinal disorders clinic. Spine. 1988;
13(1): 121-‐3.
 Sarro A, Rampersaud YR, Lewis S. Nurse practitioner‐led surgical spine
consultation clinic. Journal of Advanced Nursing. 2010; 66(12): 2671-6.
 Crosley L, Mueller L, Horstman P, Software assisted spine registered nurse
care coordination and patient triage one organization’s approach. Journal of
Neuroscience Nursing. 2009; 41 (4): 217-224.
 95% agreement in diagnosis and management plan
between NP’s and surgeons.
 Safely triaged red flags.
 Patient satisfaction exceeded 94%, superior in the NP
group and higher patient satisfaction scores.
 Patient access improved.
 Only 26% of 177 patients desired to wait to see the
surgeon
 NP’s demonstrate excellent care with other chronic
diseases.
 HTN study decreased blood pressure 44%, decreased
incidence end organ damage. (Hill et al, 2003)
 DM: study of planned chronic care visits by Kaiser
Permanente participants led by a nurse educator had
significantly lower glycated hemoglobin levels and lower
use of hospitals than controls.
(Sadur et
all, 1999)
Massachusetts RAND study (2009)
 Nurse Practitioners care for diagnoses at a lower cost
than physicians while maintaining quality and patient
satisfaction.
 They note that NPs provide more disease prevention
counseling, health education, and health promotion
activities than physicians, which can lead to down
stream health care savings.
2009 IOM Report on Nursing
 Nursing represents the largest sector of health
professionals more than 3 million USA.
 Shift toward team-based care.
 Affordable, quality care, patient centered, evidence
based, outcome based.
Chronic Disease SelfManagement
 Chronic illness is a leading cause of death and
disability globally. (WHO, 2011)
 Nearly 1 in 2 US adults lives with chronic illness such
as diabetes, heart disease, or arthritis and the
prevalence is rising. (National Center for Chronic Disease Prevention
and Health Promotion, 2009)
 Pain
(National Center for Health Statistics Report: Health,
United States, 2006, Special Feature on Pain)
Chronic Pain
 Back pain is the most common form of chronic pain at
27%
 Neck pain accounts for 15%
 Headache and migraine 15%
 Facial pain 4%
(National Center for Health Statistics Report: Health, United States, 2006, Special
Feature on Pain)
Patient Access
Patient Triage
 How do we get pain patients to the right provider at the
right time?
 Fairview health system (2013) used risk stratification
using the Keel STarT tool.
 R/O red flags Agency for Healthcare Research and
Quality (AHRQ) guideline.
The Keele STarT Back Screening Tool
! " #$%#$&'( ) * +, ', " - '!" #$%
&%
' ( ( ) #', #. %'/* +0'0- 12* $1- ', * ', " - '3* 44* 5 #$&'6+- 1, #* $17'
'
'
'
'
* +#" , - ( ( % . , - ( ( %
8'
9'
9' : /') ( . %'2( #$'" ( 1'#/ - ( " 0%
01' 2%
3 4%
!( , 5#6'( , '1* ; - ', #; - '#$', " - '4( 1, '<'5 - - %1'
!'
!'
<' ='" ( >- '" ( ? '2( #$'#$', " - '#718!0( - '* 0'2( 9) '( , '1* ; - ', #; - '#$', " - '4( 1, '<'5 - - %1'
!'
!'
@' ='" ( >- '* $4/'' " !) ( 0%
#71- $%
0+#$" 29( #') - . ( +1- '* 3'; /') ( . %'2( #$%
!'
!'
A'
=$', " - '4( 1, '<'5 - - %1B
'='" ( >- '0- ( ##( 0%
3 1- ( %
#!1' !4', " ( $'+1+( 4') - . ( +1- '* 3') ( . %'
2( #$'
!'
!'
C'
=, D
1'$* , '0- ( 44/'1( 3- '3* 0'( '2- 01* $'5 #," '( '. * $? #,#* $'4#%- '; #$- ', * ') - '2" /1#. ( 44/'
( . , #>- '
!'
!'
E' : 1- - 4+2, %
$718, 7$#'" ( >- ') - - $'&* #$&', " 0* +&" '; /'; #$? '( '4* , '* 3', " - ', #; - '
!'
!'
F' ='3- - 4', " ( , '3 4%
; " 9) %
/ " +2%
+#%
$( - - +; !( '( $? '+$<#%
2( =( - %
, 1+2, %
$1%
, ( $%
" 24%
; ( $$( - '
!'
!'
G' =$'&- $- 0( 4'='" ( >- '21$%
( 2>14( 0'( 44', " - ', " #$&1'='+1- ? ', * '- $H
* /'
!'
!'
I J''K>- 0( 44B
'" * 5 '; 1$7( - #13 ( '" ( 1'/* +0') ( . %'2( #$') - - $'#$', " - '!" #$%
&%
' ( ( ) #'
L * , '( , '( 44'
M4#&" , 4/'
: * ? - 0( , - 4/'
N- 0/'; +. " '
OP, 0- ; - 4/'
!'
!'
!'
!'
!'
8'
8'
8'
9'
9'
? 1$" !%
#91- ( %
5" !!%
@6A%
BBBBBBBBBBBBBBBBBB%
%
%
C8; %
C91- ( %
5DEF@6ABBBBBBBBBBBBBB%
%
Q 'R- - 4- 'S $#>- 01#,/'89T8GT8F'''
U+$? - ? ') /'V0, " 0#,#1'W- 1- ( 0. " 'S R
Low to medium risk
 Reassurance.
 Self-management: activity modification, ice, heat,
appropriate medication use, sleep.
 Stay active!
High Risk
 Send to non-surgical specialist.
 Results: 50 times LESS opioid prescriptions than PCP,
56% more appropriate imaging, better outcomes.
(American College of Physicians/American Pain Society Low Back
Pain Guideline Panel 2007)
Opioid Risk
 ORT: opioid risk tool.
 5 items, 1 minute to administer.
 Intended setting primary care.
 High degree of sensitivity and specificity for risk for
opioid abuse. (Webster & Webster 2005)
Contraindications to opioid
prescribing
 History substance abuse or prior prescription drug misuse.
 Unsanctioned dose escalation.
 Non-adherence to other recommendation for pain therapy.
 Unwillingness or inability to comply with treatment plan.
 Social instability.
 Unwillingness to adjust at risk activities resulting in serious reinjury requiring additional opioids.
(AHRQ Guideline for Chronic Pain)
Pain Management
≠
Opioid Prescribing
Surgery
Injections
· in the clinic
· xray-guided
Medications
·
·
oral
topical
Passive Therapies
·
·
·
·
some PT
manipulation
massage, acupuncture, reiki etc.
corset
Active Therapies
· some PT
· strategies
· Teachers
Diet,
Exercise,
Sleep,
· aerobic
· stretching
· strengthening
Self Image
·
·
·
·
hobbies
habits
psychological health
job
(Agency for Healthcare Research and Quality
Technical Brief – Multidisciplinary Pain Programs for Chronic NonCancer Pain
Published online July 28, 2010
(Final—September 30, 2011)
www.effectivehealthcare.ahrq.gov
Biopsychosocial Model
 Heads of workers compensation authority (HWCA)
accepted model for injury management.
 Proposes that biomedical explanations are often
insufficient in fully explaining ill health, damage to the
tissue body or structure.
 Individual’s pain perception differs according to
psychosocial variables.
 Cognitive behavioral approach—A problem solving
approach to facilitate achievement of defined goals by
breaking tasks down into achievable steps.
 Identify unhelpful beliefs.
 Challenge unhelpful beliefs.
 Introduce more helpful ways to think about/manage
barriers—problem solving approach.
 Equip for self-management—to apply problem solving
approach independently.
http://www.hwca.org.au
Pain Catastrophizing
‘Sur L’eau, novelist (1875).
“Migraine is atrocious torment, one of the worst in the
world, weakening the nerves, driving one mad,
scattering one’s thoughts to the wind and impairing
memory. So terrible are these headaches that I can do
nothing but lie on the couch and try to dull the pain by
sniffing ether.”
 Pain Catastrophizing is defined as “an exaggerated
negative mental set brought to bear during actual or
anticipated painful experience”.
 Elements of:
 Rumination: “I can’t stop thinking about how much it
hurts”
 Magnification: “I worry that something serious may
happen”
 Helplessness: There is nothing I can do to reduce the
intensity of my pain”
http://sullivan-painresearch.mcgill.ca/
Scores above 30
 70% remained unemployed.
 70% described themselves as totally disabled.
 66% met dx for moderate depression. (BDI-II)
 Higher risk for chronicity with higher levels of pain and
emotional distress.
 Pain catastrophizing may be the result of trauma
 Major losses, severe accidents, abuse, PTSD.
(Peterson & Moon,1999)
 Pain catastrophizers are unsuccessful in using
cognitive attention diversion coping strategies to
reduce pain.
(Sullivan et al, 1997)
Hyperalgesic State
 Increased sensory flow pain signals.
 Increased sensitivity to pain.
(Melzack, 1990)
 Neuroimaging: prefrontal, parietal, anterior cingulate
cortex, thalamus more activated.
(Seminowicz & Davis, 2006)
Interventions
 Importance of reducing pain catastrophizing is a key
factor to successful interventions for chronic pain.
(Spinhoven et al 2004, Sullivan et al, 2005)
 Multidisciplinary program 40% reduction in
catasrophizing scores. (Jensen et al 2001)
 Education, activity resumption and instruction on selfmanagement skills characterize content in
multidisciplinary pain programs. (Gatchel et al, 2007)
 Progressive Goal Attainment Program 10 week
program with cognitive behavioral interventions to
increase activity and minimize psychological barriers in
work related injuries.
 62% return to work (RTW) rate in those absent > 6
months.
 78% RTW rate for those absent 3 to 6 months.
 Reductions in catastrophizing were related to an
increased RTW.
(Sullivan & Stanish, 2003)
Example:
 CLBP “medical symptom stress cycle”.
 Anxiety can lead to behavioral changes that exacerbate
the pain the patient experiences.
 Treatment could include biofeedback and relaxation
techniques.
 Goal is to reduce the anxiety associated with the pain.
(Gatchal, et al, Spine J. 2008 ; 8(1): 40–44. doi:10.1016/j.spinee.2007.10.007)
Case Study One
 35 year old male, seen 2010 specific complaints, LE sciatica
since 2003. Received treatment in the military stabilized with
physical therapy baseline by 2004. Worsening LE symptoms
seen 2010.
No significant medical co-morbidities.
PFSH: mother alcohol and prescription abuse.
Physical exam: Decreased dermatome left L-5, decreased
heel walking right. Positive SLR right. Muscle atrophy right
calf.
Dx: MRI mod stenosis L-4-5, HNP with tear L5-S1.
Treatment
 Counseling for PTSD.
 Physical therapy.
 Sleep cycle disturbance. Reaction to amitriptyline.
 Spinal epidural with 90% improvement of symptoms.
Re-visit 2014
 Circles all descriptors on pain questionnaire.
 Does not localize pain.
 Gained 40 lbs, BMI 40.
 No exercise.
 PTSD ongoing.
 Sleep better not working 3rd shift, but interrupted by
pain.
 Physical exam: poor core strength, difficulty bridging,
turning supine to prone, guarding, LROM significantly
reduced.
 No new diagnostics.
Treatment
 Counseled for nutrition and weight loss.
 Physical therapy: active modalities rather than passive.
 PTSD discussed relationship to chronic pain.
 Consider SNRI, neurontin, lyrica (previously negative
response to Elavil).
Case Study 2
 50 year old female, chronic widespread pain since 2010,
MVA 2009.
 PMHX: FMS, Sadness, depression, headaches seen by
neurology, GERD, cholecystectomy.
 ROS: sleep cycle disturbance pain, new urinary
incontinence.
 Previously had cognitive behavioral therapy for pain.
 DX: MRI 2012 mod spinal stenosis C5-6, severe foraminal
narrowing, EMG 2010 EMG neg radic.
Record Review
 Psychological counseling: relaxation techniques and
CBT.
 “Hides in her home because she feels she is negatively
judged as a stay at home mother.”
 “Chronic pain has become her whole world.”
 “Because she doesn’t bring a paycheck, she does not
deserve pleasure.”
R/O Red Flags
 Exam: Positive hoffman’s right, DTR’s increased lower
extremity, positive clonus, increased RLE tone and
difficulty tandem walking.
 New urinary incontinence.
 MRI cervical spine ordered.
 To be continued….
Nurse Practitioner in Primary
Care Triage
 Utilize models of care to r/o red flags.
 Understand the Keele STarT method for triaging patients.
 Initial treatment: stay active, reassurance, physical therapy.
 Prescribe non-opioid medications as first line agents.
 Follow responsible opioid prescribing, review risk/benefits.
 Complex patients with psychosocial concerns refer to
specialist.
Nurse Practitioner in
Multidisciplinary Pain
 Assist the primary care provider in neurological, musculoskeletal
assessment.
 Order diagnostic imaging when needed.
 Recommend future treatments.
 Create a plan of care for complex patients that involves:







Physical conditioning.
Psychological counseling, CBT.
Vocational Rehabilitation, social integration.
Adjustment to disability.
Medication adjustments.
Workers compensation management.
Surgical vs. conservative treatment.