Table 1.

Expressed Needs in Referring to PASS

Expressed NeedDescriptionExemplar Quote
Safety in prescribing opioidsPCPs requested guidance around the safety in prescribing opioid analgesics as it relates to dosing and medication choice; performing a benefit vs risk assessment (as it relates to the patients’ other medical and psychological comorbidities and other prescribed medications); approach to tapering; and managing acute-on-chronic pain flares.“Is it appropriate to continue the patient’s current pain regimen unchanged? [This patient] is very functional on this regimen, but there are concerns about its safety as he ages and some intermittent aberrant drug testing, early refill requests, and hx of overdose in the year 2015.” (RefQ1)
Communication for difficult conversationsPCPs requested consultation guidance on navigating conversations related to patients’ goals of care, and how to engage patients and promote self-efficacy in their treatment plan particularly around nonopioid options and when changing the opioid plan or tapering, particularly connected to expressing their concern for addictive behavior.“This patient has not been interested in engaging in conversation about her regimen, her pain management, or pretty much anything else. She wants to see us as little as possible and get her medications. How do I approach that? How do I engage her? Or do I put up firmer lines if she stays unengaged?” (RefQ14)
Suggestions for nonopioid approachesPCPs requested guidance in offering nonopioid approaches to pain management, including both pharmacologic and nonpharmacologic options, in patients with or without known substance use disorders.“What are other nonopioid therapies I can use in this patient [with fibromyalgia] to improve pain control?” (RefQ33)
Comprehensive/biopsychosocial approachPCPs sought guidance on creating a plan in partnership with their patients that included addressing underlying psychological comorbidities that affect their chronic pain and/or addiction.“Do I make engagement with CHA Psych a condition of ongoing buprenorphine prescribing? Most importantly: I think part of the problem here is that she does not acknowledge the role of her mental health situation and opiate dependence in furthering her chronic pain—she continues to look for a physical cause of her pain, to focus on that, and to focus on oxycodone as ‘the only thing that helps.’” (RefQ23)
  • CHA Psych = Cambridge Health Alliance Department of Psychiatry; hx = history; PASS = Pain & Addiction Support Services; PCP = primary care provider; RefQ = referral question.