Managing pain in high-risk patients within a patient-centered medical home

ABSTRACT

Chronic pain remains a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy, and invasive and non-invasive interventions. The prevalence of chronic pain in the United States is staggering and continues to grow, and the personal and societal costs are not inconsequential. The etiology of pain is complex, and individuals suffering from chronic pain tend to have significant medical and psychiatric comorbidities such as depression, anxiety, and in some cases, substance use disorders. There is great concern regarding the burgeoning rate of prescription opioid misuse/abuse both for non-medical use and in pain patients receiving chronic opioid therapy. While there is ongoing debate about the "true" incidence of opioid abuse in the pain population, clearly, patients afflicted with both pain and substance use disorder are particularity challenging. The majority of patients with chronic pain including those with co-occurring substance use disorders are managed in the primary care setting. Primary care practitioners have scant time, resources and training to effectively assess, treat and monitor these complicated cases. A number of evidence- and expert consensus-based treatment guidelines on opioid therapy and risk mitigation have been developed but they have been underutilized in both specialty and primary care clinics. This article will discuss the utilization of new technologies and delivery systems for risk stratification, intervention and monitoring of patients with pain receiving opioid.

INTRODUCTION

The prevalence of chronic pain continues to rise in the United States causing individual suffering, contributing to morbidity, mortality and disability, and exacting burgeoning economic and societal costs. It has been estimated that over 116 million Americans suffer from chronic pain [1]. A recent Institute of Medicine report [2] projected the annual cost of chronic pain in the United States to be $560 to over $600 billion including healthcare costs ($261–300 billion) and lost productivity ($297–336 billion). To address the staggering personal and societal costs attributable to chronic pain, a recent Institute of Medicine (IOM) report on pain outlined the following guiding principles: effective pain management is a “moral imperative”; pain should be considered a disease with distinct pathology; there is a need for interdisciplinary treatment approaches; and the “serious problem of diversion and abuse of opioid drugs” must be addressed [2].

PRIMARY CARE AND CHRONIC PAIN MANAGEMENT

Much of the responsibility for incorporating these IOM principles for improved pain management will fall on primary care physicians (PCPs) as more than half of all chronic pain patients receive their pain care from non-specialist, primary care practitioners [3]. Specifically, primary care clinicians are confronted daily with the fundamental responsibility to alleviate suffering in their patients, effectively and efficiently, which often includes prescribing opioids to reduce or ameliorate pain. At the same time, all physicians are aware of the abuse liability of prescription opioids and thus, these practitioners are increasingly expected to balance their primary effort to relieve pain against exposing potentially vulnerable pain patients to the risks of opioid addiction and preventing greater access and availability of diverted opioids within the community. These care management problems are exacerbated by the fact that the great majority of PCPs have neither the time nor the training in pain management or addiction management to effectively balance these important responsibilities [4].

PRIMARY CARE AND THE “PATIENT-CENTERED MEDICAL HOME”

Complicating this call for more effective pain management is the fact that primary care practices themselves are changing. One of the key provisions of the recently passed healthcare reform legislation (i.e., The Accountable Care Act of 2010 [5]) is its emphasis upon the “patient-centered medical home” (PCMH). The medical home model was first described in 1967 by pediatricians attempting to define a model of care for managing children with chronic illnesses [6]. Subsequently, the Chronic Care Model (CCM) for chronic disease management was developed to improve health care outcomes based on the implementation of a chronic care management strategy derived from two decades of research in chronic care illness [7]. The PCMH was later described in an American College of Physicians position paper in 2005 [8], and joint principles of the PCMH were endorsed by the major primary care organizations in 2007. The major elements of the medical home are the use of a multi-disciplinary team to prevent emergence of predictable health problems, intervene early when problems develop, track and actively manage patient symptoms, and function using enhanced medical information (ie. electronic health record systems) and patient registries [7,8]. This form of prospective health management has been generally (but not universally) shown to improve the efficiency and effectiveness of management of several chronic illnesses [9]; and its expansion through the ACA 2010 is expected to provide assistance to currently beleaguered primary care physicians. Thus, the call for improved pain management methods by primary care practitioners comes at a time of great change in the very nature of primary care itself.

With this as background, this article will review some of the major challenges associated with pain management (e.g. prescription opioid diversion, poisonings and overdose, role of substance abuse, etc.) and discuss how the emerging PCMH model of primary care delivery may affect the management of chronic pain.

PRESCRIPTION OPIOIDS, SUBSTANCE USE DISORDERS AND UNINTENTIONAL FATAL POISONINGS

Many veteran pain clinicians and various organized pain societies have supported the position that the majority of individuals with chronic pain can and should be managed safely with opioids, without posing significant risk of addiction [10–14] to individual patients in treatment. Put differently, most pain patients are not at risk for iatrogenic addiction. However, at the community level, there is concern regarding the escalating prevalence of prescription opioid abuse and the role of diverted, prescribed pain medication in fueling this escalation.

National statistics support these concerns. For example, the 2010 Substance Abuse and Mental Health Service Administration (SAMHSA) National Survey on Drug Use and Health (NSDUH) reported that the incidence of past month nonmedical use of pain relievers was considerably higher than that of stimulants, tranquilizers, or sedatives [15]. Also, the 2011 Monitoring the Future report [16] on adolescent drug use revealed that the use of narcotics other than heroin by 12th graders increased from 3.3% in 1992 to 9.2% in 2010. Similarly, emergency department visits related to narcotic pain relievers increased by 111% (160,000 visits) between 2004–2008 [17]. The National Center for Health Statistics reported that the number of fatal poisonings involving opioid analgesics more than tripled from 4,000 to 13,800 between 1999 and 2006 [18]. Opioids have become one of the most common classes of drugs responsible for overdoses—exceeding heroin and cocaine and following only alcohol, tobacco, sedatives, and psychotropic drugs [19]. There is a strong association between the rate of opioid-related fatal and non-fatal poisonings and opioid prescribing patterns [19,20] including maximum daily dosing [21]. While it is difficult to assess the number of opioid-related intentional overdoses, there is evidence to suggest that this is also noteworthy [22]. For example, between 2004 and 2008, emergency department visits for drug-related suicide attempts involving pain relievers increased by 58% [17].

PREVALENCE OF SUBSTANCE USE DISORDERS IN THE MANAGEMENT OF CHRONIC PAIN

Among patients with chronic noncancer pain (CNCP), the estimated prevalence of opioid addiction has ranged from 1 to 40% [14,23–26]. Beyond the problems in managing risk of addiction, there are the related risks of aberrant, disruptive, and problematic drug seeking behaviors in CNCP patients which is estimated as occurring in 3-62% of chronic pain patients receiving chronic opioid therapy (COT) [24,26–29].

Confusion regarding terminology may account for the difficulty in accurately determining the prevalence of true “addiction” in patients receiving COT [30,31]. The influential Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [32] outlines seven criteria defining substance dependence (addiction) including tolerance and dependence. Tolerance and dependence are particularity problematic criteria as the majority of patients receiving COT will naturally display signs of tolerance and dependence. The DSM-V (currently under development) has mitigated some of these diagnostic issues by excluding the criteria of tolerance and dependence in patients receiving prescription opioids. In spite of these proposed diagnostic changes, a recent study [33] compared the prevalence of prescription opioid use disorder (OUD) in chronic pain patients when assessed with both DSM-IV-TR and DSM-V diagnostic criteria among 705 patients receiving COT for CNCP. The prevalence of lifetime OUD based on DSM-V criteria was 34.9% (95% confidence interval [CI] = 30.5–39.5) which was similar to the prevalence of opioid dependence using DSM-IV-TR criteria (35.5%, 95% [CI] = 31.1–40.2). Logistic regressions revealed that regardless of criteria, OUD in this population was significantly predicted by history of opioid abuse (OR = 4.94; p < 0.001), higher opioid withdrawal symptoms (OR = 3.01; p = 0.008), and history of substance abuse treatment (OR = 1.62; p = 0.015).

In a pilot project from our center, we sampled 219 patients from a community primary care setting with CNCP receiving COT for 6 months or more to assess presence of “aberrant drug-related behaviors (ADRBs)” (e.g. “lost prescriptions,” demanding/threatening behaviors, etc.) that may be very disruptive to care management. In addition to collecting demographic and routine clinical measures, we also administered the Opioid Risk Tool [28], a measure of patient characteristics and behaviors designed to predict the probability of patients displaying ADRBs when prescribed opiates for pain. The ORT has high sensitivity (0.94) and specificity (0.91) within chronic pain populations when used to identify patients at risk for opioid abuse [28].

Within this clinical sample, 54% were judged at low risk, 21% at moderate risk, and 25% at high risk of abusing/misusing prescription opioids. Of particular interest among the 219 patients screened, 31.7% self-reported a history of substance abuse which has been the most reliable, and evidence-based predictor for developing prescription opioid abuse [25,34–36]. While no single study is definitive, other studies have also demonstrated similar rates of risk for abuse or addiction among CNCP patients receiving COT [23–27,37,38].

MANAGEMENT OF CONCURRENT PAIN AND SUBSTANCE USE DISORDER

While drug seeking and risk for overdose, abuse, and addiction are significant complicating problems of pain management, it is also the case that patients with a history of or current substance use problems may also have legitimate need for pain management. These patients concurrently afflicted with legitimate CNCP and substance use disorder (SUD) tend to have complex etiologies for their pain, substantial comorbidities, as well as poor outcomes from conventional medical treatment. Jamison et al [39] interviewed 248 methadone maintenance patients. The majority (61.3%) reported that they experienced chronic pain as a primary medical condition. The patients with pain reported a higher incidence of health problems, more psychiatric disorders, and a belief that they were undertreated for their pain. Nearly half (44%) of this population held the belief that prescription opioids contributed to the development of their addictive disorders. Poorly controlled pain in patients with SUD is also associated with higher incidence of relapse to addiction and poorer quality of life [40]. Patients in methadone maintenance programs who endorse a history of pain are more likely to report depression, anxiety, and suicidal ideation [41] and have a higher incidence of psychiatric comorbidities [42].

In summary to this point, it is clear that the majority of patients with chronic pain, including those with a history of SUD, are managed in a primary care setting where few practitioners have the time, resources, or training to effectively monitor and treat them [3,4]. At the individual patient level, patients with pain and SUD may be undertreated for pain, leading to increased risk for relapse to addiction and diminished quality of life. At the community public health level, failure to manage these patients properly may contribute to greater diversion of prescription opioids with the attendant problems of greater overdose incidents, new cases of addiction and elevated community health care costs.

FUTURE MANAGEMENT OF CHRONIC PAIN USING A CHRONIC DISEASE MODEL WITHIN A PATIENT-CENTERED MEDICAL HOME

Given the complexity of these patients’ individual needs and the significant public health concerns associated with their management, it is difficult to imagine adequate management by any single practitioner. This realization was among the factors promoting the recent healthcare reform legislation (i.e., Affordable Care Act of 2010 [5]). Within that legislation are important efforts to institute broader development and utilization of the PCMH, emphases upon multi-disciplinary team treatment; promotion of prevention and early intervention efforts, and particularly the active tracking and management of chronic conditions using electronic health record systems (EHRS) and patient registries [5]. It is expected that the combined features of the PCMH employing a chronic disease management model, especially the use of team management strategies through the EHRS and translating existing opioid guidelines into practice, will provide the kind of proactive patient management that these complex chronic pain patients need.

Electronic health record and computerized decision support systems

The purpose of EHRS is to improve patient safety and decision making, specifically, by having the computer system automatically provide reminders and alerts regarding the utilization of clinical guidelines in decision making (Computerized Decision Support System-CDSS). There have been recent reviews of the potential efficacy of computerized decision support features with mixed results. In a systematic review of randomized controlled trials by Roshanov et al [43], the effectiveness of clinical decision supports in the management of various chronic diseases was reviewed. The authors concluded that a small majority of clinical decision supports did improve care processes in chronic disease management and some led to improvement in patient health.

Relevant to the issue of pain management and opioid therapy, novel approaches have been proposed for improving the treatment of SUDs through using a harmonized EHRS that would integrate primary care with specialty addiction treatment [44]; and by adding community physician alerts when opioid therapy is prescribed for chronic pain [45]. In one application within the Veteran’s Administration system, an automated computerized decision support system was developed to embed the 2003 VA/DOD clinical practice guideline for opioid therapy for CNCP [46]. These efforts have not yet been evaluated but offer a potential blueprint for the application of this new technology to the field of opioid therapy in the CNCP population.

Opioid guidelines and translational implementation science

Due to the increasing concern regarding the rising abuse/misuse of prescription opioids, guidelines have been published to guide best practice in prescribing, managing, and monitoring prescription opioids. These guidelines have included the 2003 Veterans Administration/Department of Defense clinical practice guidelines for opioid therapy for CNCP [47] and the more recent 2009 Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain from the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) [48]. These expert consensus guidelines provide general parameters when prescribing opioids, but there has been no available working protocol as many of the recommendations have little empirical support. Additionally, these specific guidelines have not been adapted for the special needs of chronic pain patients with a history of SUD. As previously mentioned, there has been a recently published iterative process developed to specify and operationalize the 2003 VA/DOD guidelines into a computerized clinical decision support system [46]. This process involves formalizing the published guidelines and drawing upon content experts in pain management as well as end users (for example, PCPs). For patients with pain and SUD, the addition of addiction and translational researchers to this process is critical. The process begins with empirical evidence derived from the guidelines, but when this evidence is incomplete, expert clinical consensus or “community standard practice” is considered. This process is essential for obtaining logical, clinically acceptable, and reproducible clinical decisions and behaviors. Once the rules for the decision are specified, it is equally important to specify the conditions required to change the decision (i.e., using the same procedure to assure that changes follow from empirical data). Once these guidelines are translated into specific elements of care which can be agreed upon by all practitioners, it will be necessary to embed them within an EHRS.

Chronic disease management model and CNCP

A chronic disease management model emphasizing risk assessment, intervention monitoring and corrective action has been highly successful in treating a variety of chronic illnesses such as diabetes mellitus, hypertension, coronary artery disease, asthma, etc. There is compelling evidence that both pain [49] and addiction [50] are chronic diseases. Thus, it is reasoned that by applying the chronic disease management model to effectively and efficiently assess and manage patients with CNCP at risk for opioid abuse/misuse within a PCMH will have clinical utility and should reduce public health risks associated with this population. Here we outline the processes associated with applying fundamental components of a chronic disease management model for treating CNCP, including: risk assessment, stratification, intervention, monitoring, and ongoing treatment modification (see Fig. 1).

• Risk assessment

  In general medical practice, risk assessment is determined by certain biomarkers such as HbA1c, lipid levels, and blood pressure readings. Among patients with CNCP being considered for or already prescribed opioids, such markers would include the use of validated screening tools for the major risks for poor clinical response, potential for medication diversion, and development of aberrant behaviors.

  • Risk assessment screening tools
    Screening tools have been developed from the literature, identifying ADRBs suggestive of possible opioid misuse or abuse. There are two types of screening tools: one designed to prescreen patients being considered for opioid therapy; and the other to assess patients currently prescribed opioids [51]. Examples of prescreening tools include the Opioid Risk Tool [28], Screener and Opioid Assessment for Patients with Pain [52], Diagnosis, Intractability, Risk, Efficacy [53] and Drug Abuse Screening Test [54]. Tools used for monitoring patients currently receiving prescription opioids include Pain Assessment and Documentation Tool [55] and the Current Opioid Misuse Measure [56]. While these instruments are useful as one component of an assessment battery, they have methodological weaknesses including limited generalizability to other clinical settings, as they were primarily validated in pain clinics and apprehension regarding reliability in self-administered versus clinician-administered versions [57].
  • Urine drug screening
    Recent expert consensus clinical guidelines for the use of COT in CNCP [48] recommended those patients at high risk or who are engaged in ADRBs (strong recommendation, low-quality evidence) and patients at low-risk (weak recommendation, low-quality evidence) to have periodic UDS. Numerous studies have demonstrated that a significant percentage of patients receiving prescription opioids have abnormal UDS—defined as presence of illicit drug, absence of prescribed opioid, or presence of non-prescribed opioid—[24,25,34,37,38,58] ranging from 16% [34] to 44% [58]. UDS does not diagnose addiction, tolerance, or dependence but is commonly used to evaluate the potential for abuse and adherence in CNCP patients receiving opioid therapy. There is limited evidence that routine UDS reduces the rate of abuse or misuse [59] but it is another element of a sensible risk assessment strategy.
  • Mental health screening
    There is a high prevalence of concomitant mood disorders in patients with chronic pain [60,61], and opioids have anxiolytic and possible antidepressant properties. CNCP patients also experience frequent suicidal ideation [22,62–66]. For example, in one study [62], 153 adults with chronic pain were assessed for suicidal behavior. Nineteen percent reported current passive suicidal ideation, 13% were experiencing active thought of suicide, 5% had a plan for suicide, and 5% reported a previous suicide attempt. A number of validated tools for assessing depression and anxiety are available which vary in length and specificity [22]. The measurement of emotional functioning in chronic pain trials was evaluated by a consensus panel [67], and two measures of emotional functioning were recommended: the Beck Depression Inventory [68] and the Profile of Mood States [69].
    A balanced risk assessment strategy depends upon a combination of UDS and screening for ADRBs and mood disorders.

• Risk stratification

  Based on the initial risk assessment, patients can be categorized into low, moderate, and high risk for misusing/abusing opioids. Patients determined to be at low risk can be managed solely in primary care with less intense monitoring (i.e., less frequent office visits) and more moderate dosing of opioids. Patients at moderate risk will require closer surveillance, more limited access to opioids initially, and co-treatment with other specialists (such as behavioral health practitioners, addiction medicine practitioners). Patients judged to be at high risk should be referred to an integrated pain management program [70].

• Interventions

  For purposes of this paper we will focus on high-risk patients, which pose the most significant problem for PCPs. Ideally, patients at high risk for abusing/misusing prescription opioids would be most optimally managed in an integrated pain clinic. In practice, the majority of these patients are cared for in busy primary care clinics. Independent of their risk profile, a balanced approach of rational pharmacotherapy targeting pain, sleep and mood disorders, cognitive behavioral therapy, and exercise is essential for all patients suffering from chronic pain. However, access to these services is typically limited particularly in more rural settings which necessitate developing office-based and novel treatment delivery systems.

  • Office-based interventions
    If patients are actively abusing their prescribed opioids and or using illicit drugs, immediate referral for chemical dependency counseling and/or inpatient detoxification may be required. SAMHSA sponsors a webpage aiding practitioners in locating suitable treatment providers and facilities in their local region [71]. In addition. the Screening, Brief Intervention and Referral to Treatment (SBIRT) initiative was developed by SAMHSA and the Center for Substance Abuse Treatment as a comprehensive, integrated public health approach to promote early detection, intervention and if necessary, referral for treatment services for individuals with SUD and those individuals at risk for developing more serious SUD. SBIRT has been designed to be integrated into a system of services utilizing existing community resources. SBIRT consists of initial screening (systematic screening as part of normal clinical practice in patients at high risk for abuse), brief intervention (1–2 brief motivational conversations focusing on behavior change, avoiding risky behavior, etc), brief treatment (2–6 sessions of cognitive behavioral therapy or motivational enhancement therapy, and in the primary care setting may also include ongoing management of SUDs utilizing pharmacotherapy, for example, buprenorphine in opioid dependent patients), referral to treatment (patients identified as having more serious SUDs are referred to specialized diagnostic and treatment services), and integration and coordination of services (in communities where SUD services are fragmented or limited, SBIRT functions to coordinate existing services). In a large multi-site study using employing SBIRT [72] 459,599 patients were screened across a range of medical settings (emergency department, primary care, etc). Of the patients screened, the majority of the high-risk patients were offered some level of intervention (brief intervention, brief treatment or referral to specialty treatment). Of patients reporting baseline illicit drug use, rates of drug use at 6 months after SBIRT were significantly lower. These patients also reported improvement in general health (p < 0.001), mental health (p < 0.001), employment (p < 0.001), housing (p < 0.001) and criminal behavior (p < 0.001). The screening component and elements of brief interventions could be readily incorporated into a CDSS process.
  • Computer-assisted cognitive behavioral therapy for pain and SUD
    There is persuasive literature that supports the efficacy and cost effectiveness of cognitive behavioral therapy (CBT) in the treatment of patients with various pain disorders in both specialty pain management and primary care settings [73–82]. Similar findings support the use of CBT in the treatment of patients with SUDs [83–85]. The application of these treatments to additional populations has been facilitated by the advent of computer interactive technology that has been utilized to develop computerized methods for the delivery of CBT for a wide range of health and mental health problems including pain and SUDs. These interventions have ranged from stand-alone interactive software packages (e.g., COPE http://www.ccbt.co.uk/cope.html; Beating the Blues http://www.beatingtheblues.co.uk/) to adjunctive software packages that complement the treatment delivered by the treating professional.
    Of particular relevance is the development of CBT-based software packages that may assist providers in a busy primary care setting to provide truly interdisciplinary care within the constraints of both professional competence and limited resources. Evidence is accumulating that computer-based interventions represent a promising modality of treatment of mental health problems [86,87]. This is true even for patients presenting with complex challenges. For example, Kay-Lambkin and colleagues [88] found that a computer-based CBT intervention for co-occurring depression and problematic alcohol or cannabis use was similarly as effective as a face-to-face CBT intervention. Thus computer-based interventions which enhance coping with chronic pain and target management of SUD symptoms or problems can assist in the management of individuals identified to be at high risk, as well as in the management of those patients engaged in problematic behaviors. Furthermore, as Tew and colleagues [89] note, the utilization of technology can facilitate the implementation of the patient-centered medical home by increasing continuity and coordination of care within the medical team.
    CBT delivered via computer has been well accepted by patients. In a summary of outcome studies focused on computerized delivery of CBT published in 2002 [90], patients across a range of treatment conditions reported that, generally, patients viewed it positively. A more recent update [91] by the same group indicated no change in this stance—and given the ever-increasing embeddedness of technology in daily functioning, it is likely that computerized modalities of treatment and intervention will see similarly increasing levels of acceptance.
  • Telemedicine
    An additional method of service delivery that has achieved increasing levels of evidence and acceptance is telemedicine. For the purposes of this paper, we will distinguish face-to-face video interaction (telehealth) from the computer-facilitated interactions described above. In this approach, the provider provides face-to-face services through a direct, real time video link to a patient. These approaches have been successfully utilized in working with a wide range of health [92] and mental health problems [93] including pain management in adults and children [94,95]. Among the most dramatic examples of the use of telehealth technology for the delivery of services are the recent successes documented in the delivery of prolonged exposure treatment for PTSD via telehealth for Veterans of the Afghanistan and Iraq conflicts [96]. A key element to the success of this treatment requires the treating therapist to carefully monitor increasing and decreasing levels of distress in patients in order to successfully deliver the intervention. Accordingly, such a modality may be useful in monitoring and intervening with high-risk CNCP patients without requiring frequent in-office visits—a strain for patient and provider alike. An additional resource available in managing the high-risk patient is remote assessment of pain and other symptoms. These assessments can be conducted through the use of assessment and transmission devices placed in the patients home (e.g., Health Buddy, Smart phone applications) and programmed to prompt regular assessment of pain, depression, medication compliance, etc. The information is then transmitted to the physician’s office for evaluation and potential follow-up. These types of monitoring systems have been successfully used with a variety of conditions including depression and pain [97].

• Monitoring

  Monitoring of response to interventions is important to support maintaining current treatment strategies or applying corrective action to meet treatment objectives (abstinence from illicit drugs, pain control, etc). Patients at moderate or high risk for either abusing medications or relapsing will require a higher level of surveillance (more frequent office visits, pill counts, limited supply of opioids, etc) until these conditions stabilize. Monitoring should include a medical record audit to determine whether there have been any aberrant drug–related behaviors (ED admissions for pain, frequent phone calls to the clinic, doctor shopping, etc), and SUD screening with validated assessment tools. Routine UDS is recommended, particularly for the patients at high risk for abusing their medications [48]. There has been some dispute regarding the frequency and overall utility of UDS [59]. Random UDS may be reasonable in this patient population depending on the extent and type of aberrant behaviors. The practitioner should ensure that they are fully educated on the interpretation of UDS and have a plan established when UDS is suggestive of diversion, hoarding behavior, or addiction.

  The patient monitoring elements of the guidelines may be the most difficult to translate and implement but also among the most important components of the final protocol especially when opioids are prescribed to patients at high risk for abuse. An example of a nested protocol based on the APS-AAPM guidelines [48] for monitoring of patients when opioids are prescribed is outlined in Fig. 2. The nested protocol relies upon the use of a standardized assessment of ADRBs (Current Opioid Misuse Measure [56]) and UDS results to guide decision making when opioids are prescribed.

Fig 1.

Chronic disease model for managing pain in risky patients. ORT Opioid Risk Tool, SBIRT Screening, Brief Intervention and Referral to Treatment, SOAPP Screener and Opioid Assessment for Patients with Pain, CA-CBT Computer-assisted cognitive behavioral therapy, BDI Beck Depression Inventory, COMM Current Opioid Misuse Measure, UDS Urine Drug Screen, POMS Profile of Mood States

Fig 2.

Opioid monitoring algorithm

DISCUSSION

There is great concern regarding the potential of abuse and diversion of prescription opioids, and there has been considerable effort devoted to developing evidence- and expert consensus-based consensus guidelines for opioid therapy in the CNCP population. However, utilization of these guidelines has been poor even in patients with a history of substance use disorder [98]. The recent Institute of Medicine report “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” [2] challenges practitioners and researchers to develop novel and effective assessment and treatment interventions to alleviate suffering in the large population of chronic pain patients. The patients who suffer from both the disease of addiction and chronic pain are particularly vulnerable to under treatment and additional suffering. While the need is great in this patient population, there is a dearth of qualified pain clinicians to meet this need and a large number of patients seek and receive care for complex chronic pain presentations in primary care settings.

Recently passed healthcare reform legislation coupled with the development and implementation of health information technology, as well as the growing emphasis on EHRS and CDSSs provides an opportunity to meet this challenge. Translational and implementation science methods are an avenue to embed well-vetted guidelines and treatment protocols into EHRS with increased utilization and improved patient safety and treatment outcomes. Utilization of novel treatment delivery systems (SBIRT, computer-assisted CBT, telemedicine, etc) in concert with CDSS could provide a treatment arsenal for many individuals who would not normally have access to these interventions. Critical to the implementation of an effective program to assist and support a primary care physician in managing complex pain patients is the emerging PCMH model of practice. The utilization of the risk assessment screening tools to better identify patients at risk for substance abuse and intervene appropriately requires a model of treatment that is proactive and integrated. The PCMH model of care relies on the integration of available resources (and data sources) to better address the needs of the patient. The framework of the PCMH is ideal to apply and integrate the available and emerging technologies necessary to support the patient and provider in the management and treatment of individuals with chronic pain and potential (or actual) substance use disorders. This integration has the potential to both mitigate risk to the patient and reduce the societal impact of prescription opioid misuse/abuse and diversion.

Further development of the practical aspects of the implementation of the PCMH model in a variety of settings has yet to be accomplished. In addition, additional work postulating definable guidelines for the use and interpretation of data garnered in such integrated program require development, research, and refinement. More specifically, further research is required to streamline the EHRS and CDDS processes to facilitate and encourage utilization by PCPs and better understand the barriers to implementation. Rigorous outcome studies on the efficacy and effectiveness of CDSS in improving patient health and reducing health care costs are lacking and necessary to procure reimbursement for additional services and support the expense of new technologies. Promoting physician adherence to clinical guidelines is also critical as is addressing the educational needs of PCPs in the areas of pain and addiction.

Though a challenging amount of work remains, the increasing prevalence of complex chronic pain patients seen in primary care settings necessitates that additional resources be developed. Currently evolving models of care and technology to assist the practitioner have the potential to be integrated in a fashion to assist practitioner and patient alike.