Caring for patients with complex needs

Develop policies and resources to ensure that patients who develop opioid use disorder and/or who need mental/behavioral health resources are identified and provided with appropriate care, either in the primary care setting or by outside referral.

Why is this important?

Chronic pain can be complicated by other conditions that require special attention, namely mental/behavioral health conditions, opioid use disorder (OUD), and/or other substance use disorders. Insufficiently addressed mental/behavioral health conditions can interfere with successful pain management. For patients with opioid use disorder, the full agonist opioids used to treat pain (e.g., oxycodone, hydrocodone) are rarely the best choice and often the wrong medication for their pain. Medications such as buprenorphine, naltrexone, and methadone are needed for patients with opioid use disorder. Patients with other substance use disorders require assessment and treatment for their disorder in addition to treatment for their chronic pain. Identifying additional and appropriate resources for these patients and creating systems to connect patients to these resources is essential for an effective chronic pain management plan. Some of these resources might be developed or brought “in-house” within the primary care clinic setting, others will need to be identified in the local community and linkages established to them. Through implementing opioid management improvements using the Six Building Blocks, clinics become more aware of the existence of opioid use disorder. Clinics find that offering buprenorphine treatment on-site allows them to provide their patients a full spectrum of care.

Example activities

  • Select and consistently use tools to identify patients with complex needs.
  • Develop a approach to connect patients to mental/behavioral health resources, either integrated in the primary care setting, in the community, or through telehealth.
  • Develop an approach to connect patients with OUD to treatment, either internally through waivered providers or externally through an identified medication treatment for OUD facility.

Self-Assessment Questions Resources