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.

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.

Identifying patients with complex needs 123 456 789 101112
1. Policies, clinic-selected screening tools, and workflows to identify opioid misuse, diversion, addiction, and to recognize mental/behavioral health needs… …do not exist. …partially exist. …exist, but are only partially implemented. …exist and are consistently implemented.

Opioid use disorder resources 

123 456 789 101112
2. Opioid use disorder treatment… …is difficult to obtain reliably. …exists but isn’t timely or convenient. …is available and is usually timely and convenient. …is readily onsite or available from an organization that has a referral protocol or agreement with our practice setting.
Opioid use disorder training 123 456 789 101112
3. Training on diagnosing opioid use disorder… …has not been offered to clinicians. …has been offered to clinicians, but there was limited participation. …has been offered and the majority of clinicians participated. …is consistently offered with widespread, regular participation.
Behavioral health resources 123 456 789 101112
4. Mental/behavioral health services… …are difficult to obtain reliably. …are available from behavioral health specialists but aren’t timely or convenient. …are available from behavioral health specialists and are usually timely and convenient. …are readily available from behavioral health specialists who are onsite or who work in an organization that has a referral protocol or agreement with our practice setting.
Stigma Training 123 456 789 101112
5. Training on addressing stigma surrounding opioid use disorder and mental/behavioral health needs… …has not been offered to clinicians and staff. …has been offered to clinicians and staff, but there was limited participation. …has been offered and the majority of clinicians and staff participated. …is consistently offered with widespread, regular participation.

Caring for Complex Patients resources

Assessment and treatment

Opioid Use Disorder (OUD) diagnosis form: A form outlining the criteria to diagnose OUD using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.

Developing a Buprenorphine Treatment Program for Opioid Use Disorder in Primary Care: A resource that guides primary care organizations and providers in developing a buprenorphine treatment program for opioid use disorder (OUD).

SAMHSA Medication-Assisted Treatment webpage: This webpage includes information, such as how to find MOUD/MAT and how to get waivered to prescribe buprenorphine.

PCSS Online MOUD Waiver Training: This 8-hour training will assist physicians and physician assistants (PAs) who wish to apply for a waiver to prescribe buprenorphine for the treatment of opioid use disorders.

Online webinars on assessing and treating OUD:

Identification, Counseling, and Treatment of OUD: An 8-hour training from Harvard Medical School that focused on current best practices in identification and treatment of OUD.

Collaborative Care Approaches for Management of OUD: An 8-hour training from Harvard Medical School that focuses on collaborative care strategies which include: provider roles and regulatory requirements; patient evaluation and patient education; transitioning between medications; potential misuse, relapse, and safer use; and caring for pregnant women and other special populations with OUD.

SUD 101 Core Curriculum: This training series from PCSS offers 22 modules that provide an overview of evidence-based practices in the prevention, identification, and treatment of substance use disorders and co-occurring mental disorders.

Case consultation resources:

Preventing overdose

Naloxone information from SAMHSA: Naloxone is a medication to counter opioid overdose.

Preventing an opioid overdose tip card: A tip card by the CDC on how to prevent an opioid overdose and what to do in the event of an overdose.

Opioid overdose response handout: A printable handout from the Center for Opioid Safety Education on what to do in the case of an overdose.

WA naloxone standing order resource: The purpose of this standing order is to facilitate wide distribution of the opioid antagonist naloxone so people in Washington can provide assistance to persons experiencing an opioid-related overdose.

Mental/Behavioral Health

Integrating Behavioral Health and Primary Care Playbook: An AHRQ guide to integrating behavioral health in primary care and other ambulatory care settings to help improve health care delivery to achieve better patient health outcomes.

The Behavioral Health Specialist: Guidance on how to integrate a behavioral health specialist into the primary care team.

Stigma

Reducing Stigma: A resource addressing stigma and harm reduction for patients with opioid use disorder from Alberta Health Services, which includes language suggestions.

Guiding Principles for Addressing the Stigma on Opioid Addiction: A resource from Johns Hopkins offering evidence-based guiding principles that should inform all activities intended to reduce the stigma surrounding opioid use disorder.

Changing Language to Change Care: A PCSS Learning Module on Substance Use Disorder.