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

Discussion

Key Findings

It is important that primary care clinics have a rich understanding of PCPs' needs in managing complex patients struggling with chronic pain, an addiction, or both. This understanding ensures that they can provide appropriate resources and guidance that promote safe and thoughtful decision making when caring for this patient population. In this study, we identified PCPs' expressed needs before referral to PASS (our multidisciplinary pain and addiction consultation team), their actual needs after the consultation, and the discrepancy between these sets of needs, all of which have implications for macro level clinical approaches to supporting PCPs.

As exemplified by the heuristic map (Figure 1), although PCPs were largely aware of their needs (evidenced by generally good alignment of their expressed and actual needs), they had numerous needs in managing this complex population that they did not recognize before their consultation that warrant attention, so they can receive the appropriate level of support. These additional needs include psychological support of the PCP, who appreciated having emotional validation and gaining a sense of control in challenging cases; an outside entity to take the burden off the PCP of being the sole decision maker and to provide a new lens with which to view the case; and nuanced communication strategies (in areas such as boundary setting and reframing visits around patient values and functional goals).

Relevant Strategies

Our findings support prior literature and also offer new insights that can provide system-level guidance. Consistent with previous literature, clinics should provide concrete protocols and best practices on safe prescribing of opioids, around such topics as dosing parameters, opioid-tapering regimens, adjuvant medication options, and referral services for nonpharmacologic treatment modalities (eg, acupuncture, physical therapy, aqua therapy). This approach aligns with current recommendations supporting the development of standardized, clinicwide, evidence-based protocols and education to support clinicians in managing patients with pain, an addiction, or both.[15–17]

When standardized protocols and guidelines are unable to fully meet PCPs' needs, however, clinics should offer approaches that recognize the multifactorial components of pain and addiction care, which often do not have a specific, linear, or clear solutions. We propose 4 potential strategies.

A first strategy is to provide a venue for nonjudgmental, emotional validation in managing complex cases that inherently provoke frustration and exhaustion. In our study, a multidisciplinary consultation service filled this role. Our team's sheer empathy with the PCP—acknowledging how difficult the case was—was highly valued by many referring physicians. The consultation service we provided was a departure from the traditional consultation model. Rather than making recommendations solely directed at the patient, our consultation team reviewed the case with the PCP present and made recommendations directed at the PCP in their care of the patient. We found that inviting the PCP to attend these multidisciplinary discussions (either by telephone or in person) prompted identification of this need that would otherwise have gone unmet, and we therefore recommend that PCPs have the opportunity to directly engage in discussion with a consulting team. This approach also serves as a mechanism to connect PCPs to individual clinicians on the consultation team, who can then provide further support around the case after the consultation ends. Although this model can be helpful in providing PCPs with the emotional validation and communication strategies that they need, it might also be frustrating for some clinicians who simply want concrete answers or protocols. Peer-to-peer or small-group formats as described by Balint[21] may also play a similar role in providing emotional validation around difficult cases.

A second strategy is to create opportunities that support comprehensive case reviews. Having more "eyes" reviewing a case can affirm the PCP's decision-making process, ensure that the PCP is not missing important management components, and help take the burden off him/her to be the sole decision maker in the management plan, thereby allowing the PCP to maintain a relationship with the patient. Again, although we provided a consultation service for this process, clinics unable to offer this time- and resource-intensive type of service may develop other venues for physicians to receive outsider review and support of cases in a routine and scheduled way, such as building case discussion into clinician meetings or partnering clinicians to regularly share difficult cases. Clinicians should also let their patients know ahead of time that they are planning to discuss the case with a referral service and/or other clinicians to promote patient buy-in about decisions moving forward. This practice also sends a message to patients that the PCP cares about them and is dedicating extra, explicit time to reviewing the case and seeking other clinicians' thoughts and recommendations.

A third strategy is to provide PCPs with very concrete language suggestions to navigate difficult conversations, such as boundary setting, building the patient's sense of self-efficacy, and focusing on functional outcomes, values, and goals. These interpersonal skills are not commonly requested in referral questions or incorporated into consultation recommendations because they are a departure from the concrete "what" to do and rather represent "how" to implement a plan. In our study, this aim was accomplished by integrating scripted language into consultation notes to guide the PCP in their subsequent implementation of the recommendations.

A fourth strategy is to create systems and structures that simplify the process of seeking additional guidance and support. For example, lengthy forms to a referral service might be a deterrent to completing a referral; therefore, asking that the PCP submit a single question or building time to discuss patient cases into scheduled clinician meetings can foster regular conversations without creating extra work for the PCP.

Future Directions

Future research should build off each of the needs we identified to more fully understand how best to nurture them. For example, although PCPs identified a need for support around framing difficult conversations with patients, scripting language may be only a first step to addressing this need; physicians may require additional individual coaching and role modeling to effectively meet this need. Future research should also seek to identify how clinician needs may vary across patient populations and health care systems. This information will guide the provision of services and resources allocated to appropriately meet these needs. Further, longer-term studies should track whether consultation service support affects patient-oriented outcomes over time, such as improvement in patients' pain control experience and quality of life, and reduction of inappropriate opioid prescribing, OUD prevalence, and opioid-related overdoses.

Conclusions

To help meet PCPs' needs in caring for complex patients with pain, an addiction, or both, it is important that clinics provide concrete guidance around opioid, nonopioid, and nonpharmacologic management while using a biopsychosocial framework; offer clinician training around specific communications skills; and create venues for comprehensive case reviews that provide emotional validation for difficult cases. A multidisciplinary consultation service that reviews cases and provides recommendations through discussions directly with the referring PCP offers a mechanism for this type of support. Future research should explore how the needs of PCPs caring for this patient population differ across health systems and effective ways to meet these needs.

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