Multidisciplinary Approach for Managing Complex Pain and Addiction in Primary Care

A Qualitative Study

Randi G. Sokol, MD, MPH, MMedEd; Rachyl Pines, PhD; Aaronson Chew, PhD

Disclosures

Ann Fam Med. 2021;19(3):224-231. 

In This Article

Abstract and Introduction

Abstract

Purpose: Primary care providers (PCPs) may feel ill-equipped to effectively and safely manage patients with chronic pain, an addiction, or both. This study evaluated a multidisciplinary approach of supporting PCPs in their management of this psychosocially complex patient population, to inform subsequent strategies clinics can use to support PCPs.

Methods: Four years ago, at our academic community health safety-net system, we created a multidisciplinary consultation service to support PCPs in caring for complex patients with pain and addiction. We collected and thematically analyzed 66 referral questions to understand PCPs' initially expressed needs, interviewed 14 referring PCPs to understand their actual needs that became apparent during the consultation, and identified discrepancies between these sets of needs.

Results: Many of the PCPs' expressed needs aligned with their actual needs, including needing expertise in the areas of addiction, safe prescribing of opioids, nonopioid treatment options, and communication strategies for difficult conversations, a comprehensive review of the case, and a biopsychosocial approach to management. But several PCP needs emerged after the initial consultation that they did not initially anticipate, including confirming their medical decision-making process, emotional validation, feeling more control, having an outside entity take the burden off the PCP for management decisions, boundary setting, and reframing the visit to focus on the patient's function, values, and goals.

Conclusions: A multidisciplinary consultation service can act as a mechanism to meet the needs of PCPs caring for psychosocially complex patients with pain and addiction, including unanticipated needs. Future research should explore the most effective ways to meet PCP needs across populations and health systems.

Introduction

Primary care providers (PCPs) face unique challenges in managing complex patients who struggle with pain, addiction, or both. Pain-related complaints are the number one reason patients seek medical care,[1] and it is estimated that 11% to 40% of adults in the United States live with chronic pain.[2] From the perspective of a treating PCP, the subjective nature of pain makes it difficult to assess. Additionally, managing chronic pain requires a different treatment approach compared with managing acute pain. Acute pain involves tissue damage and subsequent recovery and potentially short-term use of analgesic medications. By contrast, chronic pain is now recognized as a biopsychosocial phenomenon,[3] in which initial tissue damage resolves but the patient continues to experience pain triggered by various psychological and social stressors; it requires a multimodal approach. Strategies that use a full range of therapeutic options—including pharmacologic options and nonpharmacologic options (eg, cognitive behavioral and physical/rehabilitation therapies)—have been shown to be most effective in treating chronic pain.[4–6]

The biopsychosocial paradigm represents a departure from the biomedical model that is more commonly used when addressing patients living with chronic pain. Previously, PCPs thought that treating chronic pain with pain medications alone, particularly high doses of opioids, could cure the problem, but they had poor understanding of the severity and frequency of potential risks.[7] We have since learned that treating chronic pain solely with opioids will not resolve the condition and could lead to increased rates of developing a substance use disorder.[8] In fact, the Centers for Disease Control and Prevention's recent recommendations state that opioids are not first-line therapy, nor are they the preferred treatment for managing chronic pain.[9] The opioid prescribing that began during the 1990s was associated with a parallel increase in opioid-related substance use disorders and opioid-related deaths.[8,10,11] As many as 1 in 4 patients treated with opioids for chronic pain in the primary care setting misuse their medications, and up to 10% will show signs of an opioid use disorder (OUD),[9] a relapsing brain disease characterized by compulsive and overwhelming involvement with the use of a drug, despite the harmful consequences.[12]

The progression from chronic pain to misuse to the development of OUD is compounded by the fact that this relationship is not clear or linear. Rather, the intersection between chronic pain and addiction is complex, and both disorders interact at multiple levels: patients prescribed opioids for chronic pain are at risk for developing OUD, while at the same time, patients with OUD are at risk from having severe chronic pain. Also, it is often difficult to diagnose the disorder, as a patient's misuse of opioids (such as compulsive use or dose escalation) may represent OUD, untreated severe pain (pseudoaddiction), or a combination of both. Furthermore, signs and symptoms associated with dependence (such as withdrawal) and tolerance (requests for higher doses of opioids because of diminution of their effects over time) might be confused with OUD (although this disorder additionally involves dysfunction and consequences) in patients taking prescription opioids appropriately.[12,13]

Hence, PCPs often find themselves at a difficult juncture as they simultaneously try to help their patient struggling with chronic pain while they also try to provide safe care that does not lead to development of OUD. Historically, medical education has not covered the treatment of pain and addiction; therefore, in the context of the ongoing opioid epidemic, PCPs may feel ill equipped to treat this complex patient population. Several studies of PCPs' views on chronic pain management demonstrate that they report low confidence and satisfaction levels in treating chronic pain.[14,15] Potential existing strategies to improve confidence levels include developing pain protocols for assessment and management; creating opioid management dashboards; providing PCPs with education around pain management and identification of substance use disorders; creating consistent practice-based approaches to prescribing opioids, such as standardized workflows and use of opioid-structured clinical teams for chronic pain management; and using telehealth consultations and enhanced on-site specialty resources.[15–17] Although such approaches may improve PCPs' confidence levels, little is known about the individual questions and concerns they wrestle with as they manage complex patients with pain, addiction, or both. Having a better understanding of their needs could help inform subsequent strategies that clinics use to support these clinicians.

Approximately 4 years ago, a multidisciplinary team of clinicians came together to address this problem at the Cambridge Health Alliance, an academic community health safety-net system that serves more 140,000 patients in the metro-north Boston area with 13 primary care sites and 3 affiliated hospitals. Modeling a new service after other multidisciplinary consultative services,[18] we formed the Pain & Addiction Support Services (PASS), a group consisting of a primary care physician, a psychiatrist, a psychologist, a pharmacist with pain expertise, an addiction expert, and a palliative care physician that takes referrals from primary care clinicians who are struggling with patient cases related to pain and addiction. For 1 hour every other week, the PASS team meets to review and discuss a case in real time with the PCP present to provide a multidisciplinary lens and to support the clinician based on his or her needs. The consultation is then written up as a clinical note and entered into the patient's chart.

After providing consultation services for more than 60 cases, the PASS team realized that many recommendations to the PCP involve addressing pain and addiction through a wider, nontraditional biopsychosocial lens. The team also recognized the needs of the PCPs addressed during the in-person consultation discussion (their actual needs) may have differed from what the PCPs initially thought they needed before the consultation (their expressed needs).

The PASS team therefore wanted to more formally evaluate the value that its multidisciplinary approach provides to PCPs in order to improve the rigor of the referral service and to offer more generalizable guidance to clinics in supporting these clinicians who take care of this complex patient population. This study aimed to answer 3 research questions. First, what needs do PCPs initially identify when managing complex patients with pain, an addiction, or both (ie, their expressed needs based on referral questions)? Second, after receiving consultation services from a multidisciplinary team that supports PCPs with pain and addiction cases, what needs do they identify as the most helpful (ie, their actual needs)? And third, what is the discrepancy between PCPs' expressed needs and actual needs, and what implications does this information offer primary care clinics in supporting their clinicians in managing patients with pain, an addiction, or both?

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