July 1, 2013 – For those living with chronic pain, finding a primary care provider can be difficult. The same is true for patients with a history of chemical dependency.
And for people at the intersection – those who've developed an addiction to opiate painkillers after taking the medication for chronic pain, or for those with a history of opiate abuse who are dealing with an injury or illness that causes pain – there are even fewer places to go.
“Places like Old Town [Clinic] get more of these referrals, kind of as a last resort,” said Ed Blackburn, executive director of Central City Concern, the social services agency that runs the Old Town Clinic, which sees exclusively low-income patients, many of them uninsured or on the Oregon Health Plan. Most of their patients are either homeless or in transitional housing.
One of the reasons so many patients with a combination of opiate addiction and chronic pain get referred is because Central City has unique expertise in dealing with these issues. Since 2008 its patients have been able to enroll in a complex chronic pain program that includes support group meetings where patients talk about recovery issues and learn pain management techniques. Patients in the pain management program also sign a contract with the care team, with terms specific to their needs. If a patient is prescribed opiates and relapses, his or her case is referred to the controlled substances review committee to determine another course of treatment.
Both Blackburn and Dr. Rachel Solotaroff, Central City's medical director, acknowledge that a complex program incorporating pain management and addiction treatment would be difficult to replicate in most primary care settings, though incorporating access to behavioral health care is a recurring theme in discussions about coordinated care.
What Solotaroff and other stakeholders – including Dr. Nimisha Gokaldas, medical director of addiction and mental health services for Multnomah County – are urging instead is more widespread use of the drug Buprenorphine (in the brand-name formulation Suboxone) for patients dealing with pain and chemical dependency issues.
The drug has been approved and is used to treat either chronic pain or chemical dependency. Pilot projects involving the use of Suboxone in primary care settings – after patients graduated from another treatment program – have shown high rates of success.
But the first hurdle is getting primary care providers to start seeing patients with complex pain or addiction histories.
“There's just not a high tolerance around that level of complexity with chronic pain,” Solotaroff said. One patient she worked with at Central City had a contract with her primary care provider and was dropped because her dentist prescribed her pain medication – even though her medical records showed that she'd called her provider for a consultation about the prescription.
“The culture has to change around the fear around taking some of those clients,” Gokaldas said.
Both Gokaldas and Solotaroff said many primary care providers receive precious little education about addictions or mental health issues, and so the inclination is to punt to providers or agencies that have more expertise – so the anxiety around dealing with patients with addiction histories is understandable.
“You can't just say to everyone, This is what you're going to do now. You have to say, let me show you that this is not the bogey man you think it is,” Gokaldas said. “We're really not asking primary care providers to go beyond their scope. We want them to be able to say, 'This is one more piece in my arsenal to help my clients.'”
Image for this story by MT Vision (CC BY-NC-ND 2.0) via Flickr.
Christen McCurdy can be reached at [email protected].
