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Wednesday Oct 26, 2016

Team-based Care Aids Response to Pain Crisis

We've all been there. A new patient comes to see you and says he needs medication for chronic pain. It is one of the few situations when we must not only diagnose a patient's physical condition but also consider -- and judge -- what we know about his character. Does this person have legitimate pain or is he merely seeking drugs?

It's a challenge, balancing our obligation to relieve pain and suffering with the need to prevent abuse and misuse.

Now imagine that scenario multiplied over and over again.

In July, the Washington State Medical Commission suspended the license of the medical director of the Seattle Pain Centers, which subsequently closed its eight locations in the state after it was linked to at least 18 deaths in five years. It has been estimated that those clinics have treated 25,000 patients in the past eight years, including 8,000 patients who are currently using opioids(www.seattletimes.com).  

Now those patients need help.

Other pain clinics have taken on hundreds of new patients, but they lack the capacity to meet the giant swell of demand(www.seattletimes.com). So ERs and primary care clinics also are being inundated by these patients.

My clinic has primary care patients who also were patients of the shuttered pain clinic. Many have come back to us seeking meds until they can get in elsewhere, some are asking for new referrals to pain specialists, and others simply want us to manage their chronic pain.

Pain specialists already were in short supply before the state took action. Patients now face longer waits, and some face limited options based on payer networks.

One reason my practice has been able to handle the situation is our team-based approach. We have registered nurses who serve as care managers. In this case, they can offer patients education and coaching. They also assist our physicians in making referrals to pain specialists, and they help obtain the records and data we need to appropriately re-evaluate our patients' conditions.  

In addition, we have clinical pharmacists who work with us in caring for these patients, including by assisting us in pulling data from the state's prescription drug monitoring program. They also speak with patients about potential side effects, risks and interactions with their other medications, as well as assessing risks for abuse potential.

Some of the new patients came to me taking extremely high doses of pain medications. I tell them I'll take over their pain management, but not at that dose, and I offer a plan to taper their meds to a more reasonable and safe level. Some are comfortable with that. Some aren't and look for another doctor.

I've also offered alternatives to medications, as well as complementary treatment options. Having moved from Nevada to Washington last year, I've experienced a different culture in the Pacific Northwest. Many payers here are willing to cover services such as acupuncture, massage therapy and physical therapy that can help patients become less reliant on medication alone for treatment.

I also was pleased to see the Washington State Medical Association(wsma.org), the King County AFP and the Washington AFP step up with resources and tools to help physicians during this crisis. The AAFP also has chronic pain resources for members.

As an immediate measure in the aftermath of the state's action, the University of Washington TelePain program(depts.washington.edu) agreed to assist primary care health professionals who were taking Seattle Pain Center patients on high-dose opioids during their scheduled weekly teleconferences. My own medical group's physical medicine and rehabilitation physicians assisted in providing us the most up-to-date opioid tapering pathway, as well as working with us to discuss plans of care and available resources.

We're taught that patients come first. These patients were caught in a crisis they didn't create. It will take teamwork to ensure they get the care they need.

Helen Gray, M.D., is an employed family physician in Kirkland, Wash., working in a regional medical center.

Posted at 12:33PM Oct 26, 2016 by Helen Gray, M.D.

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