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

Results

Figure 1 shows a heuristic map of the study results, depicting expressed needs, met needs, and discrepant needs. We discuss findings for each of these 3 sets of needs below.

Figure 1.

Heuristic map of results.
PCP = primary care provider.
Note: Shading indicates a need that was identified only after the consultation and was not listed in the expressed needs for the referral.

Expressed Needs Before the Consultation

Among the 66 referral questions extracted from referrals to PASS before consultation, PCPs expressed 16 needs. In order of frequency, PCPs expressed a need for expertise on safety in prescribing opioids, communication for difficult conversations, nonopioid options, and a comprehensive/biopsychosocial approach. Table 1 shows related themes and exemplar quotes. Many of the expressed needs highlighted the fact that PCPs lacked addiction knowledge and were unsure of when opioid prescribing or regimens were indicative of OUD.

Actual Needs met by the Consultation

From the 14 interviews, PCPs described 8 unique needs that were met by the PASS consultation. On average, they described 7 needs in their interview. Table 2 shows each need, the number of PCPs who identified that need, and an exemplar quote. The most common needs met by the PASS consultation included interdisciplinary expertise, communication strategies and skills, comprehensive review of the case, need to feel more control with the patient, confirmation of the current plan, and emotional validation that this was a challenging case. Among the co-occurring needs identified, most often, PCPs described the need to feel more control and the need for interdisciplinary expertise, which may suggest that they required more knowledge in order to feel greater control of their case.

Discrepancy Between Expressed and Actual Needs

Many of the PCPs expressed needs in their referral questions—expertise in addiction knowledge, safe prescribing of opioids, nonopioid treatment options (both pharmacologic and nonpharmacologic), communication strategies for difficult conversations, and a comprehensive biopsychosocial approach to patient management—that aligned with their actual needs described after the consultation—interdisciplinary expertise, communication strategies and skills, and a comprehensive review of the case. This overall good alignment suggests that many PCPs felt that their needs were met by the PASS consultation service.

On the other hand, several PCP needs emerged that were not initially anticipated but were later identified as important after the PASS consultation, including needs for confirmation of their medical decision-making process, emotional validation of the challenging nature of the case, feeling more in control of the case, and having an outside entity take the burden off the PCP to make management decisions while offering a fresh, unique lens. Additionally, the nature of the communication strategies identified by the PCPs' referral questions differed from that described as most helpful after the consultation. Many PCPs initially expressed wanting help with conversations around goals of care, patient engagement, changing the opioid plan, and expressing concern around addictive behaviors. They then later—after the PASS consultation—also reported benefiting from communication strategies around boundary setting and reframing the visit to focus on the patient's function, values, and goals. They also found it helpful when the consultation note contained word-for-word scripting of potential conversations.

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