Guidelines for BH Involvement in Chronic Pain
I was hoping if you all could pass along any guidelines/best practices for BHCs to be involved in chronic pain workflows/policies in primary care, particularly CHCs.
Specifically, we are looking for research/recommendations on how *often* BHCs should meet with individuals who are receiving long-term opioids.
Appreciate any help!
David Bauman, PsyD
Behavioral Health Education Director
In the Department of Defense, anyone on a pain agreement or sole provider program was required to see the BHC at least monthly.
In some clinics we had the BHC appt before every medication refill so that meds could be adjusted regularly and so that the patients did not develop an expectation that meds alone will ever be the treatment plan.
If the patients stopped coming to PCBH appointments, their medications we're not refilled...until they followed up with the BHC.
All of these policies were included in the pain agreement and the patient signed it.
We also had case management on board and family members involved when feasible.
Like most sole provider programs we also had agreements (MOAs/MOUs) with local pharmacies that they would not refill these patients' pain medications at all or at least without calling us first to verify.
I hope this helps.
On Thu, Nov 16, 2017 at 11:42 AM, Greg Reicks wrote:
This is a great topic and I would like to explore further. We are trying to figure out how to use our BHCs in the most effective way with our chronic pain patients on opioids. I had thought about Kent's program of requiring these patients to see BHC in order to get her medications refilled, but I'm wondering if that is the wrong message. It seems that making this Requirement might lead to resentment which could make the BHC/chronic pain patient interaction less effective. I have heard of other clinics doing the same thing. What kind of outcomes are they getting? Reduction in opioids? Reduction in pain scores? Increased functional scores? Reduced disability?
Our experience with many of these patients is that they are "stuck" on what has been called "pill Island" and cannot seem to - or are unwilling to- get on the bridge to get off the Island. Many of these folks are not addicted per DSM criteria but certainly physically and psychologically dependent on these meds.
I agree, Greg, and that is the question that I am having, as well. In that, how do we use BHCs most effectively? Truthfully, if we required all of our long-term chronic opioid patients to see a BHC each month, the BHCs would only see chronic pain patients. Furthermore, if we make universal guidelines, not only is there potential for the patient to become resentful but also the medical providers who may feel that they are losing their ability to care for the patient.
I also struggle with the once per month idea due to it being fixed from the beginning. What if the patient is actually doing a lot better after a few visits with the BHC/PCP but is still on a small dose of pain medication? Does that patient still need to see the BHC every month?
Lastly, and this goes to Greg's point, what is the outcome of having it be every month? Further, is there research/guidelines supporting this? I have reviewed some of the research and it seems that it is suggested that BH be involved but does not quantify how often that should take place... Really appreciate everyone who has commented and looking forward to other's thoughts!
Greg and David, I appreciate your pause and I agree with you wholeheartedly. Forcing treatment is not helpful or sustainable.
And, the military context/culture in which these programs exist may paint a certain picture that heightens your concern. Even if we put aside the fact that addiction and "pseudo addiction" play a substantial role here...
Something I did not give ample attention to in my initial response is the idea that the programs must be communicated, marketed and run in a highly specific way. It is the key to the structure feeling forced versus supported.
My concern, which I'm sure is shared by all of you, is that the message we send to patients by focusing primarily on providing medications is: "Medications are the solution to your pain (and the goal of pain management is to decrease pain)." Whereas, the goal of evidence-based pain management is to improve functioning while (hopefully) minimizing pain. The concept of improving functioning and quality of life needs to be loud and out front in these programs that require behavioral health consultation.
Program design is one thing; implementation is a whole different animal.
I am sure you have seen some of the same pain management practice trends I have seen in the private sector. In some cases the PCP literally refuses to see any patients who need or request opioids. Tl
If the medical community (we) taught patients to use the opioids when we prescribed them, in my opinion, it's on us to re-educate them about what to do as we nation-wide tighten up and decrease opioid use.
PCPs have no time for that facilitation and education. That's where we come in - although nurses have also been very helpful for this.
Great conversation - let's keep the ideas flowing!
I provide BH services in a spinal and musculoskeletal institute, and all of our patients are dealing with chronic pain. We using a screening tool at intake to determine BH service necessity. If there is a positive screen, I provide a Health and Behavior Assessment, which is a basic in-room check in. I administer the PHQ-9 and/or the GAD-7. We use those results to determine what services we offer. Some patients need therapy services, others care management, and others are receiving MH services from outside providers. I also use a registry to track results and reassess as needed.
It was important to me when creating this program that we provide patient centered care and not required care. There’s plenty of billing to be done just with patients who WANT services.
The Substance Use Treatment Taskforce offered national practice guidelines. They were cited in a recent Open Minds post. Consistent with what I’ve been reading in this valuable thread, Recommendation #2 is for personalized diagnosis, assessment and care planning. I was thinking of offering a chronic pain management class for our long-term opioid patients who have refused evidence-based brief interventions. But, based on these guidelines I think I’ll stay away from mandates, at least until we have more research. I’d be happier if our clinic could get away from pain contracts altogether.
Patty Rebeck, Ph.D., Licensed Clinical Psychologist
I appreciate Ms Scarpate's approach. A pain patient with an organ/structural abnormality linked to their pain and with no evidence of depression, anxiety, ptsd or the prolonged impact of adverse childhood experience will have quite different needs than a patient whose pain seems
disproportionate to their organ/structure issue and who suffers from one or more psychosocial stressors or mental health conditions. A growing number of studies is showing the best outcomes are achieved when these contributing factors are addressed.