Pain, in all its manifestations, is an aspect of most illnesses, as well as a normal part of the aging process. As such, its treatment is an essential component of primary care. The treatment of pain, especially acute pain, may at times require the use of opioids, which have significant risks in addition to their benefits. After years of misguided provider education, millions of patients in our healthcare system are on opioids for inappropriate diagnoses and at inappropriate doses (legacy patients or the lost generation). Even the most skilled providers may at times need specialty care to assist in the management of these complex patients. This guideline will address the following questions:
What kinds of patients are most appropriate for specialty care?
What is the screening and evaluation expected for these high-risk patients?
What kind of oversight should exist to assure consistent and safe management of these patients?
Who is a pain specialist?
What kind of services should constitute a specialty-care clinic?
What are the expectations and long-term goals for such patients?
Patient Selection for Pain Specialty Care
- Patients on high doses (>90 mg MED) or unsafe drug combinations (e.g., benzodiazepines + opioids) who either refuse dosage reduction, exhibit substance-use disorder behaviors, or have significant behavioral conditions beyond the scope of the provider, may require referral to a pain specialty program or substance abuse program for evaluation or ongoing care.
- Any chronic pain patient beyond the expertise of the primary care provider.
- The Oregon Medical Board (or similar state boards), UW “Tele-Pain” (or similar regional peer education), can be excellent resources for helping manage difficult patients in lieu of specialty referral.
Screening and Evaluation
All patients being prescribed chronic opioids need screening for behavioral, respiratory, and other psychosocial risks because, by definition, the specialty-referral clients are at higher risk. A more thorough evaluation of such patients is to be expected:
- Ongoing functional evaluation: PEG, Oswestry or similar, monitored over time.
- Respiratory: S T O P B A N G or similar, with appropriate referral or further evaluation as necessary.
- Central sensitization screening including but not limited to Central Sensitivity Index, Pain Catastrophizing Scale (PCS), PHQ-15, etc.
- Validated addiction-screening tests such ORT/SBIRT/DAST-28, appropriate for age and history.
- Query of the PDMP initially and episodically.
- Evaluation for possible unforeseen sources of nociception, such as identification of ongoing
Pain specialists, accredited, self-identified, or working under the license of others, can succumb to lack of time and inadequate resources resulting in a loosening of appropriate safeguards in the management of chronic pain. A process of peer review can provide feedback at the expert level (and can be an educational resource for primary care) to assure quality and consistent care for complex, high-risk patients. This may include:
- Regularly scheduled multi-disciplinary meetings of healthcare professionals, including behavioral specialists, addiction counselors/specialists, pharmacy, case management, and more to facilitate case discussions. Review of treatment data (MED, functional improvement, adherence to risk stratification) in a transparent fashion by the participants is an expected component.
- A committee that could serve as a “brain trust” for others providing pain management in the community.
It is clear from the latest research that chronic pain is often, if not largely, a disorder of nociceptive perception and dysregulation.27 Chronic pain patients often represent a subset of the population with specific bio-psycho-social characteristics. This means that a pain specialty clinic needs to have a foundation of understanding and resource accessibility to care for individuals with historical trauma, substance-use disorder, catastrophizing, as well as an understanding of the pharmaco-dynamics of opioids. Chronic pain is often best viewed through the lens of chronic disease management rather than cure. Therefore, to be considered a pain specialty clinic for the purposes of referral and reimbursement, items 1 through 6 will need to be provided by the clinic staff.
A pain specialty clinic should include the following:
- Clinicians willing to be transparent and share de-identified treatment data.
- An organization with deeply embedded behavioral health experts to provide evidence-based counseling, education, and substance-use disorder treatment.
- Prescribers specifically educated concerning the use and abuse of opioids, or who can demonstrate their expertise through an objective testing process.
- The ability to provide buprenorphine to appropriate patients for the treatment of opioid-use disorder.
- The ability to provide referral and expert care for complex chronic pain patients. It should be the goal of pain specialty to develop and establish a treatment plan and return the patient to primary care. In extremely complex patient situations, pain specialty should provide direct care until exceptional care needs are addressed, managed, and a care plan is established; at which point the patient should be returned to primary care. It is expected that all providers participating in a patient’s care will employ common treatment goals and communicate regularly amongst themselves.
- The previously listed components are essential for quality chronic pain care. If they are not offered on site, then close collaboration, integration, and management of such services is expected.
Long-Term Management Goals
The evidence supporting long-term benefits of opioids is lacking, while the risks and harms are evident. Tapering opioids after long-term use can be challenging and may elicit preexisting conditions. Patients with underlying trauma, mental health disorders, co-existing benzodiazepine use, and substance-use disorders can be exceptionally challenging when tapering, and specialty care can provide additional structure, expertise and support.
- The OPG guidelines, including < 50 MED for most patients, with an absolute MED maximum of < 90 MED, are appropriate for patients managed by pain specialty, as well.
- It is understood that these complex patients may require additional services, support, and time to achieve those goals. Specialty care, by definition, will provide that level of expertise and care.