When to Call in the Cavalry— When and Why to Refer a Patient
The lack of pain specialists in many parts of the US has almost reached a crisis point, making the question of when and why to refer a patient especially timely. The recent Centers for Disease Control and Prevention (CDC) guidelines for opioid management suggest that clinicans should increase the frequency of follow-up visits when prescribing above 50 morphine milligram equivalents (MME) and consider offering concomitant prescriptions for naloxone (Evzio, Narcan), to be used in the case of accidental overdose. The guidelines also suggest to avoid, or carefully justify, prescribing above 90 MME and to consider a referral to a specialist.1
Unfortunately, these dosage ranges are commonly employed and exceeded in the complex chronic pain patient with multisystem pathologies, for whom few referral resources are available. This chapter offers some recommendations to deal with these complex cases, including how to confront challenges that arise when referring a patient for certain services before a basic treatment plan and medical regimen is in place.
Navigating Referral Tasks
Each primary care practitioner needs to determine the referral resources available in his or her community, as well as clearly establish basic medical regimens and protocols for chronic pain patients within the practice setting.
Each primary care practitioner also needs to identify and develop a list of available referral resources. Topping that list should be two types of pain specialists: medical management specialists and interventionalists. Additional resources include an addiction specialist, who provides addiction assessment, buprenorphine/naloxone (Bunavail, Suboxone, Zubsolv), and other addiction services, as well as physical therapy and psychological counseling services. Patients may also benefit from legal, spiritual, acupuncture, chiropractic, massage, and specialty exercises, dependent upon the practitioner’s personal choices and community availability.
Of note, the term “referral” is often misinterpreted. There are four basic modes of referral: (1) consultation in pinpointing the cause of the pain generator, if possible, or to obtain a second opinion for case management; (2) perform an ancillary specialty service; (3) co-management, in which the pain specialist takes over the medication management of the patient; and (4) take over of total case management, in which a specialist takes over the total care of the patient. Today, the most pressing issue in chronic pain management is the lack of referral resources for total care management of complex cases—especially for medication management. This issue affects all primary care settings to some degree.
A second opinion referral may be far easier to obtain than a takeover of care. A pain specialist who does medication management, for example, may be more willing to determine that the pain care rendered by the primary care physician is appropriate rather than be willing or able to take over total care. The most common ancillary specialty services in pain management are physical therapy, intervention (e.g., paraspinal corticosteroid injections), and psychological counseling. Referral for opioid use disorder, the current American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders-V term for “addiction,” usually necessitates buprenorphine treatment and nondrug elements of addiction treatment, such as a 12-Step program and addiction group therapy, and total take over of case management.2
Certain specific and common problems that are observed among chronic pain patients in primary care settings may warrant consultation or referral (Table 1). Some of these problems involve a degree of risk or danger, such as the patient who refuses to attempt nonopioid measures or patient continually requires more opioids. There could be a good reason for the patient’s opioid use, but medical justification to remain on long-term or lifelong opioids should require a pain specialist opinion. This would include a patient who has significant chronic pain that can’t be alleviated by other means, which includes the most common kinds of pain, such as “failed back syndrome,” osteoarthritis-related knee or back pain, as well as more complex cases, such as complex regional pain syndrome (RSD/CRPS), post-viral encephalopathy, or peritoneal adhesions.
Table 1. Common Problems That Warrant Consultation or Referral
- Patient uses 80 to 100 morphine milligram equivalents (MME).
- Patient uses multiple sedatives: benzodiazepines, muscle relaxants, anticonvulsant agents.
- Patient continually requires more opioids: verbal requests, early refills, emergency room visits.
- Patient uses non-authorized substances: illegal drugs, non-prescribed drugs in urine.
- Patient abuses or misuses medical regimen: sedation, non-functional,
3rd-party reports of misuse, missed appointments.
- Patient refuses nonopioid measures or reduction of opioid dosage.
What is vital is that the patient has already focused on improving function, lost weight, performed home exercise and physical therapy, quit smoking, etc. No matter what the source of the pain, if it persists under these circumstances, and their function is improved with opioids, then they are candidates for long-term opioids. Similarly, opioids may be warranted for a patient with genetic metabolic defects or pain that has centralized with neuroinflammation in the central nervous system.
The Complex Case: What to Do?
Many chronic pain patients are extremely complex. Their clinical condition may involve multiple biological symptoms. Some are tragically ill and may perish without specific analgesia or other medications. Many use as many as a dozen different medications a day. These patients may be psychologically needy and require a considerable time commitment. In many cases, specialty medical management outside the primary care setting is critical.
The most common complaint some pain specialists report hearing from primary care physicians is that, after referring a pain patient to a specialist with the expectation that he or she would take over medical management, the specialist simply sends the patient back to the referring doctor without even an opinion or practical recommendation for ongoing care. Sometimes the pain specialist recommends a single invasive procedure or proclaims the presence of hyperalgesia, for which the only answer is to stop all medications. Sadly, primary care physicians throughout the country have simply not been able to identify enough referral sources for the patients with complicated, chronic pain conditions. In these cases, the physician should openly discuss with the patient and family that he or she cannot identify a competent, caring referral source. The physician should then keep looking for a referral source, document the attempts in the medical record, and clearly outline that no source has been identified.