Opioid Prescribing and Monitoring
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When to Call in the Cavalry— When and Why to Refer a Patient for Pain Care

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.

A potentially more feasible alternative to a full takeover is co-management, an emerging type of referral in which care is shared between a specialist and primary care practitioner. The specialist may see the patient every 3 to 4 months, for example, while the primary care practitioner attends to the patient between specialty visits. This strategy is highly recommended for primary care practitioners who do not have a ready referral for medical management of complex patients who may require high opioid dosages.

The deciding factor has got to be if the patient’s pain level and function is improving with the medication. Beyond maintaining the effective treatments, co-management also requires setting up an ongoing appointment schedule and trying new treatment ideas or therapies, when appropriate.

When to Refer for Interventions

The interventionalist belongs to a subgroup of physicians who specialize in invasive procedures that may produce curative or prolonged amelioration of pain. These procedures are highly technical and require great skill, special equipment, and expense. Included among such interventions in use today are epidural and facet corticosteroid injections or nerve blocks, radiofrequency nerve ablation, and neuromodulation (spinal cord stimulators), in which electrical implants stimulate the spinal cord or nerve roots. Interventionalists may also implant an intrathecal device for delivery of opioids or other analgesic medications.

When referring patients for any of these procedures, consideration must be made for the potential risks inherent with associated surgical incisions and deep tissue administration of corticosteroids, anesthetics, electrical currents, or electromagnetic energy.

A chronic pain patient should be referred to an interventionalist only after an outpatient medical treatment regimen or protocol is in place. For example, an epidural injection is usually not a first-line therapy and should only be considered after the patient is already in an ambulatory care program, which may consist of topical and oral analgesics, muscle relaxants, anti-inflammatories, bracing, and stretching or range-of-motion exercises. If a patient is not responding well to outpatient medical management, a referral to an interventionalist for an epidural or facet joint injection may be warranted. Interventions must be considered an adjunct and not a substitute for a basic, chronic medical management program.

Referral for a spinal cord stimulator or an intrathecal opioid administration device may be needed in select cases. They must only be done, however, if an established medical regimen or protocol proves ineffective in relieving pain, leaving the patient unable to function mentally and physically, or carry out activities of daily living. Before embarking on implantation, an integrated medical protocol should contain, at a minimum, topical or oral analgesic, including a neuropathic agent (anticonvulsant) and anti-inflammatory agent, bracing, physical exercises, and a nutritious diet. A successful medical management regimen should allow a patient to carry out activities of daily living, defined here as the ability to self-manage hygiene, diet, dressing, ambulation, and socialization.

Since opioids are associated with complications, including opioid-induced constipation and endocrinopathy (suppression of testosterone, cortisol, dehydroepiandrosterone, and other hormones), the primary care physician involved in co-management of a chronic pain patient will need to be able to treat these issues, or refer to a specialst.

When to Refer for Psychological or Psychiatric Services

Chronic pain patients can greatly benefit from psychology and/or psychiatric
evaluation and treatment. Pain and depression often go hand in hand. Depression is a common complaint of the patient suffering with chronic pain—and pain is a common complaint of patients with mood disorders and anxiety.3-6 In addition, chronic pain patients can face substantial emotional trauma, with disintegration of social, marital, and financial relationships. Hopelessness and reclusiveness are common.

The challenge for the primary care physician is sorting out the psychiatric syndromes from the underlying pain triggers. What the patient requires at this point is generally a more comprehensive evaluation of the underlying emotional issues—ideally involving both a psychiatrist and a psychologist.

Refractory chronic pain syndromes are best formulated through four perspectives: diseases, behaviors, dimensions, and life stories, according to Michael R. Clarke, MD, PHD, MBA.7 “In this approach to chronic pain, diseases are what people have; behaviors are what people do; dimensions are what people are; and life stories are what people encounter.”

Despite a tremendous need for pain-specific psychological and psychiatric help, there is a shortage of qualified psychologists or psychiatrists, especially in rural areas. The term “qualified” here doesn’t necessarily require academic training or certification, but rather the desire of individual psychologists and psychiatrists to self-train and voluntarily enter the pain care field. Pain practitioners should attempt to identify and utilize psychology and psychiatry professionals who wish to participate in pain care.

The role of the psychiatrist is to provide ›a psychiatric evaluation, and establish a psychiatric diagnosis and provide medication treatment, if need. The psychiatrist can be invaluable in helping deal with recalcitrant depression and other mental dysfunctions.

The role of the psychologist is to provide support, encouragement, and coping skills to deal with intractable pain. The literature supports cognitive behavioral therapies (CBT) for the treatment of patients with chronic pain. The central idea in CBT is that unhelpful thoughts and behaviors can contribute to negative feelings, and negative feelings can increase sensitivity to pain. CBT includes a range of strategies aimed at enhancing coping skills, increasing confidence and self-efficacy for managing pain, and changing how individuals behave in response to pain.

Conclusion

A shortage of pain clinicians in the US is a critical issue that contributes to a of referral resources for the complicated pain patient. To help, second opinions and co-management must be utilized. Pain practitioners should determine a specific etiologic cause of pain and enter the patient into an outpatient medical regimen or protocol before making any referrals. A standard outpatient regimen will include multiple integrated therapies, including topical and systemic analgesics, anti-inflammatories, anticonvulsants, bracing, nutrition, and physical measures, among other strategies. Once these measures are in place, a referral needs can be identified. Referrals for interventions and psychological services are ancillary to the basic ambulatory care regimen. Primary care practitioners should make an inventory of referral sources available and liberally use them to enhance the care of chronic pain patients.

Last updated on: April 29, 2019
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