Chronic pain management can be challenging, and a collaboration of DPH and Community Clinic Consortium doctors are working together to create a common set of guidelines, practices, and patient education forms that can be used across the safety net. In this way, patients with chronic pain can expect similar high-quality, comprehensive treatment no matter where they seek care. In addition, they can experience similar practices at different clinic sites, to minimize “doctor-shopping”.

Patients in the safety net may experience chronic pain for a variety of reasons: 

• workplace injury
• accidents
• degenerative or inflammatory conditions

Back pain in particular is epidemic in people with a history of manual labor. A significant subset of patients in the safety net have histories of substance abuse, and in some cases these habits developed as a coping strategy for dealing with pain. How can patients be managed compassionately and safely, allowing them to optimize function while minimizing risk of abuse and diversion?

The team includes medical directors from the Department of Public Health/Community Oriented Primary Care (Drs. Joseph Pace, Barbara Wismer, Daniel Wlodarczyk and Sushma Magnuson), San Francisco Community Clinic Consortium (Dr. David Lown), South of Market Health Center (Dr. Peter Berman), and General Medicine Clinic at San Francisco General Hospital (Dr. Claire Horton). They lead a team of providers who share the goal of improving the quality of life for chronic pain patients, and decreasing practice variation in the care of these patients.  The use of a chronic disease registry, i2i Tracks, assists coordinating the care of patients with chronic pain. In addition, they are developing a set of quality improvement measures for this population, which includes some of the following:

• Pain management agreements, including informed consent and treatment plan with written goals.
• Department of Justice Controlled Substance Review and Evaluation System (CURES) reports ordered on new patients. These reports show the names and prescribers of all recently filled controlled substances.  A new program allows registered providers to access this information online.
• Random urine toxicology screens, to identify recreational drug use.
• Routine assessments of pain levels, and effectiveness of treatment.
• Draft guidelines on how to respond to red flags and contract violations, so there is some consistency throughout the safety net providers, and to reduce doctor-shopping among patients with chronic pain.

Although many of these measures have been a part of provider practice, they have been inconsistently used or documented.

Currently, the team is working on standardized pain management guidelines and tools that can be used and adapted by any clinic site, and that will be available in a standard and low-literacy format, as well as in Spanish and Chinese.  For more information, contact provider.relations@sfhp.org.