I attended my first pain group the other day. Pain group at Fairmount Primary Care Center (FPCC) was instituted two years ago and consists of an hour-long monthly meeting for selected patients who are taking narcotic painkillers for chronic pain related to any number of underlying medical conditions. Medication of any kind tends to be at best a partial remedy for chronic pain, which by definition doesn’t just get better. In fact, the more patients either need or believe they need narcotics to manage their pain, the more likely they are to need and benefit from other things as well, like social support and behavioral strategies that can help them live their lives as fully as possible despite their pain.
Hence pain group—it’s social, and it includes attention to a variety of psychosocial and behavioral factors relevant to the management of chronic pain. It’s also required. Prescriptions for refills of narcotic medications are distributed at the end of pain group. No attendance, no prescription. There are actually two groups, one that meets on Thursdays and one on Fridays, so if you can’t make one meeting you can go to the other. And since pain group starts and ends on time (unlike individual appointments with the doctor), it’s easy to plan for. Patients receive a reminder phone call a week in advance, and prescriptions are printed in advance as well for those whose attendance is expected.
Eight patients were at pain group the day I attended—five women and three men, all seated around a cluster of tables in an upstairs conference room. Suzanne, the director of behavioral health, handed around portfolios and nametags belonging to each participant and then opened the meeting with a check-in consisting of a "pain log”—a sheet of paper, photocopied on both sides, on which each participant could rate on a scale of one to ten his or her experience over the past few weeks with respect to pain level and a variety of other factors: stress, exercise, activity level, sleep, appetite, mood, social interaction, alcohol use, financial concerns.
"Why do you think we do this?” Suzanne asked the group. "Why do we ask about these things?” "Because it’s all connected,” volunteered one participant. Yes, said Suzanne. Pain group can’t fix pain itself. But pain group can provide an opportunity to look at all these interconnected dimensions of life, to see how a person’s experience of pain might be affecting other things, and how other things might be affecting his or her pain. And it might be that deliberate changes in some of those other things—getting more sleep, for example, or more exercise—could lessen a person’s pain, or make it more tolerable.
So how was everyone managing? Answers varied. Some participants had days when they didn’t get out of bed, when it seemed that the best way to cope was simply to rest. Others found it important to be up and about, no matter what. Everyone was mourning a loss of some kind. A man who had worked all his life voiced his sense of uselessness at no longer being able to do so: "You feel like a stain on the wall.” A woman who had spent years raising children and grandchildren related a teenage grandson’s response to her efforts to get him to forego time with friends to watch a movie with her: "Grandmom, you gotta get a life!”
With each contribution to the conversation the resilience and resourcefulness of the group became more apparent. Disclosures were met with sympathetic nods and knowing smiles. More positive stories began to emerge—of efforts to "get a life,” to give back, to be involved. A group member who had lived on the streets for several years and is now stably housed serves dinner at a homeless shelter one night a week. "It makes me feel really good.” Another group member is active in her church. "When I’m there, I’m so busy I forget about my pain.” Too soon, the meeting was over. Participants were encouraged to set a goal for the next month ("Make it specific, so you can know whether you met it,” said Suzanne). Pain logs and goal sheets were returned to participants’ portfolios, prescriptions were distributed, and the group dispersed.
Pain group seems so obviously beneficial and empowering that it raises the question: why aren’t all patients who are living with chronic pain participating in such a group? Well, there are reasons. One is logistical—there is only one of Suzanne, and only so many groups that she can handle in a given week or month. But another reason is more purely human. Before the current arrangement was devised, Suzanne had tried unsuccessfully for years to have pain groups at FPCC. Then in 2009 she was in San Diego at the annual meeting of the CFHA, and shared her frustration with fellow CFHA member Patricia Robinson. "Do patients get their narcotics scripts at pain group?” Patricia asked. "No,” said Suzanne. "That’s why they don’t come,” said Patricia.
Suzanne came back to Philadelphia and sat down with the medical director at FPCC, who is also the provider whose panel includes the greatest number of patients with chronic pain. Together they created a clinical pathway for patients who in the medical director’s judgment either needed or stood to benefit most from pain group. That pathway included a new way of dispensing prescriptions for narcotic medication: at pain group, rather than in an individual medical visit. The hope was that both providers and patients would benefit: providers because they could feel safer prescribing narcotics to more adequately supported patients, and patients because they could develop more efficacious and integrative coping strategies.
It’s been a success, although not without challenges. At first, pain group seemed to some patients more like punishment than like care, and they responded with anger rather than with engagement. Only with considerable effort on Suzanne’s part did the first group settle down to the point that another provider could be involved and another group begun. Now, for providers, pain group has helped to facilitate a more collaborative relationship with patients, one in which it is clearer that both physician and patient have contributions to make to managing the patient’s pain. And for many patients, pain group has become a primary social outlet and the high point of their month.
The question does remain: why does there seem to be no way to get patients to come to pain group except to make their narcotics prescriptions contingent upon attendance? At the very least, this leaves out patients who aren’t yet at the point of needing narcotics, and who might never devolve to the point of needing them if they had the support of pain group. But if patients want pills and they don’t want groups, what do you do with that? It’s part of a larger question, namely, how is it possible to respect patients’ desires with respect to their own healthcare, while at the same time persuading them at least to try interventions that providers believe might be good for them?